Predictors of poor outcome in neonates with bacterial sepsis admitted to the University Hospital of the West Indies

To determine factors that affect outcome in neonates with culture-proven sepsis, the charts of all neonates with culture-proven sepsis admitted to the University Hospital of the West Indies between January 1995 and December 2000 were reviewed retrospectively. Neonates who survived without developing any complications (favourable outcome group) were compared with those who died and/or developed severe complications during the course of treatment (poor outcome group). Chi-square tests were done to determine factors associated with poor outcome; univariate and multivariate logistic regression analyses were also performed. One hundred and thirty-five neonates had culture-proven sepsis, of which 89 (66%) were term infants and 46 (34%) were preterm. Male to female ratio was 1.6:1. One hundred and twenty-six (93%) survived and 9 (7%) died. Case fatality rates were higher for premature infants (15%) than for term infants (2%). Twenty-four (18%) of the neonates with culture proven sepsis had a poor outcome. Gram negative organisms accounted for 19 (70%) of the cases with poor outcome. Prematurity (p < 0.001), very low birthweight (p < 0.001) and female gender (p < 0.05) were factors associated with poor outcome. Strategies aimed at decreasing morbidity and mortality in neonates with sepsis must include measures that will decrease the incidence of prematurity and low birthweight.

Hypernatraemic dehydration in exclusively breastfed infants: a potentially fatal complication

There have been several reports in the literature about hypernatraemic dehydration and severe malnutrition in exclusively breastfed infants. The authors report a series of four such cases admitted to the Newborn Special Care Unit of the University Hospital of the West Indies over a seven-year period. All four were term infants who had weight loss of greater than 20% of their birthweight, serum sodium levels greater than 175 mmol/L, metabolic acidosis and pre-renal failure at presentation. Three of the infants had seizures shortly after presentation. One of the infants died soon after admission to hospital, the three others had normal neurological development clinically at the time of last review.

Neonatal sepsis in Jamaican neonates

AIM

To determine the incidence and causative organisms of bacterial sepsis in neonates at The University Hospital of the West Indies.

METHODS

A retrospective review of all neonates with culture-proven sepsis admitted to the hospital between January 1995 and December 2000 was conducted. Incidence rates and antimicrobial susceptibility patterns were determined.

RESULTS

There were 4702 admissions to the neonatal unit during the study period. Of these, 135 had culture-proven sepsis and 115 were inborn, giving an incidence of 6.7/1000 live births. There were 89 positive blood cultures, 51 positive urine cultures and two positive CSF cultures. The single most common organism was Klebsiella spp (28%). Other organisms included Escherichia coli (16%), group B Streptococcus (11%) and Enterobacter spp (10%). The aminoglycoside resistance rate of Klebsiella spp was 46% and seven isolates had multiple resistance to antibiotics. There was a case fatality rate of 6.7%.

CONCLUSION

Physicians involved in newborn care at The University Hospital of the West Indies need to recognise the important role Klebsiella now plays in neonatal sepsis and its contribution to neonatal mortality. Empirical antibiotic regimens for gram-negative sepsis must take into consideration the high rates of aminoglycoside resistance that are now prevalent.

The impact of the establishment of a neonatal intensive care unit on the outcome of very low birthweight infants at the University Hospital of the West Indies

A retrospective analysis of the outcome of inborn very low birthweight infants admitted to the neonatal unit of the University Hospital of the West Indies pre- (period 1) and post- (period 2) establishment of a neonatal intensive care unit was conducted. During the study, 250 infants were admitted to the neonatal unit, 132 (53%) during period 1 and 118 (47%) during period 2. There was improved survival during period 2 when 81 (69%) infants survived compared to period 1 when 73 (55%) survived (p = 0.02). This increased survival was due to an increase in survival of infants weighing 750-999g in period 2 when 17 (65%) infants survived compared to 9 (29%) in period 1 (p < 0.05). There was an increase in the number of infants ventilated in period 2, 39 (33%) compared to 12 (9%) period 1 (p < 0.001). Infants who were ventilated in period 2 were less likely to die than those ventilated in period 1 (OR 0.05, CI 0.01, 0.66). After controlling for gender, weight, gestational age and ventilation, infants born in the second time period were less likely to die than those born in the first time period (OR 0.33, CI 0.14, 0.76). The establishment of a neonatal intensive care unit has resulted in improved survival of very low birthweight infants; further improvement in survival of these infants will be dependent on increased accessibility to surfactant therapy, initiation of total parenteral nutrition and availability of trained personnel.

Student self-assessment in a paediatric objective structured clinical examination

OBJECTIVE

The objective structured clinical examination (OSCE) has been recognized not only as a useful assessment tool but also as a valuable method of promoting student learning. Student self-assessment is also seen as a means of helping students recognize their strengths and weaknesses, understand the relevance of core learning objectives and to take more responsibility for each stage of their work The authors sought to evaluate the accuracy of medical student self-assessment of their performance in the paediatric clerkship OSCE and thus obtain preliminary data for use in programme strengthening.

DESIGN AND METHODS

A self-administered questionnaire was completed by successive groups of students immediately after the OSCE at the end of each clerkship rotation. Students assessed their performance at each station, using a performance rating scale. Performance data were summarized using descriptive and non-parametric tests. Basic statistical analysis of the Likert items was conducted by calculatingfrequencies, means and standard deviations. Regression analysis was used to correlate self-reported rating and actual performance in each station. A p value of < 0.05 was considered significant. Eighty-one students (92%) completed the questionnaire.

RESULTS

Fifty-eight (72%) of the students achieved greater than minimum competence in their overall scores. Significant positive correlation (p < 0.05) between student self-rating and actual score was noted- among the following stations: technical skills, cardiovascular examination, assessment of dysmorphism, dermatology, communication and photographic interpretation stations. Students overestimated their performance in the gastrointestinal examination, radiological and arterial blood gas interpretation. Students underestimated their performance in the following: respiratory system, examination of the head, developmental and nutritional assessment.

CONCLUSIONS

The findings highlight the perceived strengths and weaknesses in clinical competence and self-assessment skills and provide direction for programme training needs.

Importance of radiation time and dose factors on outcome for childhood medulloblastoma*

The purpose of this study was to investigate the relationship of posterior fossa radiation therapy duration (PFRTD) and relapse-free survival (RFS) following adjuvant craniospinal RT for childhood medulloblastoma. A retrospective audit was performed assessing all children aged <18 years managed with adjuvant craniospinal RT for medulloblastoma in Australia and New Zealand in 1980-1993. Children receiving prolonged (>180 days) pre-RT chemotherapy were excluded. Data were obtained for potential prognostic factors in domains of patient, tumour and treatment factors. Radiation therapy time factors assessed were PFRTD and time interval from surgery to commencement of RT (SRTD). The end-point assessed was RFS and analysis was performed using Cox regression and Kaplan-Meier survival. One hundred and eighty-nine children were identified from 10 oncology units, with data available from 182 children for analysis. Median follow up was 5.3 years. Seventy-three per cent of children presented with disease confined to the cerebellum; 13% had initial neuraxis disease. Macroscopic resection was described in 54%; 42% received adjuvant chemotherapy. Median RT dose and RT duration to PF was 55 Gy and 45 days, respectively. Seventy-eight relapses occurred with a 10-year actuarial RFS of 58.2% (standard error +/- 4%). On univariate analysis, increasing PF dose (P = 0.002), age >5 years (P = 0.006), and more thorough extent of surgical resection (P = 0.043) were associated with improved RFS; PFRTD (P = 0.20) and SRTD (P = 0.51) were not associated with RFS. On multivariate analysis, although both PF dose (P = 0.004) and extent of surgery (P = 0.045) remained strongly significant, RT duration was now associated with RFS (P = 0.049). Other factors assessed that did not reach significance were patient age, local tumour extent, presence of internal shunt and use of chemotherapy. The importance of local treatment factors was confirmed in this audit with established prognostic factors such as primary tumour macroscopic resection and adequate PF RT dose being associated with RFS. A treatment time effect is weakly suggested, although less significant than RT dose delivered.

Comparison of face-to-face and videoconferenced multidisciplinary clinical meetings

A trial of videoconferencing of multidisciplinary breast cancer clinical meetings between three public hospitals was conducted in an attempt to increase attendance by medical staff at the meetings, and thus facilitate multidisciplinary care for breast cancer patients. The videoconferences were compared with the previously existing face-to-face clinical meetings through questionnaires, attendance, number of cases discussed and anthropological analysis. Although more people attended the videoconferences than the face-to-face meetings, most of the participants in the trial preferred the face-to-face meetings to the videoconferences. The mean number of cases discussed at the videoconferences was significantly less than the mean number of cases presented at the face-to-face clinical meetings. The face-to-face meetings were informal, spontaneous and conducive to open discussion. In contrast, the videoconferences were formal and regimented. Multidisciplinary case discussion can be facilitated by videoconferencing. Some of the negative experiences we encountered could be overcome with changes in meeting format. Our experience may help others in setting up a successful multidisciplinary team via videoconference.

[Postmenopausal hormone replacement therapy and cardiovascular risk: role of conjugated equine estrogens and medroxyprogesterone acetate]

Atherosclerosis is a chronic systemic inflammatory disease of the vasculature that accounts for the majority of morbidity and mortality in women. The incidence of atherosclerosis is low in premenopausal women and increases after ovariectomy. Experimental studies demonstrate inhibitory effects of natural estrogens on the progression of atherosclerosis. In contrast, results from recent hormone replacement trials using conjugated equine estrogens and medroxyprogesterone acetate in postmenopausal women showed no effects or even an increase in cardiovascular morbidity and mortality such as thrombosis or stroke. Therefore, conjugated equine estrogens alone or in combination with medroxyprogesterone acetate should not be recommended for the prevention or treatment of cardiovascular disease. Optimizing the risk factor profile such as cessation of smoking, normalizing body weight and blood pressure, regular physical activity, and statin treatment of patients with coronary artery disease remain important treatment options.

Recent upsurge of tuberculosis in paediatric admissions at the University Hospital of the West Indies

These case reports describe the clinical course of eight children who were admitted to the University Hospital of the West Indies, Kingston, Jamaica, between July 2000 and November 2001 because of a diagnosis of tuberculosis. This represented an increase in the incidence of the disease in children at this institution. The purpose of this report is to make healthcare workers aware of the resurgence of tuberculosis. The diagnosis of paediatric tuberculosis is challenging and requires a high index of suspicion in the presence of suggestive clinical and laboratory findings. The diagnosis should not be limited to the immunocompromised patient, as in this report the majority of the patients were HIV negative.

Angiotensin-converting enzyme inhibitor therapy prevents upregulation of endothelin-converting enzyme-1 in failing human myocardium

In this study, we investigated the role of the renin-angiotensin system in expression of the endothelin system in atrial myocardium of patients with congestive heart failure. Atrial myocardium of control patients without angiotensin-converting enzyme (ACE) inhibitor therapy and heart failure patients without or with ACE inhibitor therapy undergoing aorto-coronary bypass surgery was studied. Endothelin-converting enzyme-1 (ECE-1) expression and endothelin-1 peptide level was upregulated in myocardium of heart failure patients without ACE inhibition. ACE inhibitor therapy prevented upregulation of ECE-1 and endothelin-1 in failing myocardium. Prepro-endothelin-1 and endothelin receptor A expression were not affected by heart failure. Endothelin receptor B was downregulated in heart failure patients. Our data demonstrate an upregulation of ECE-1 mRNA expression in failing human myocardium. Inhibition of the renin-angiotensin system by ACE inhibitor treatment prevents upregulation of ECE-1, suggesting that angiotensin II regulates ECE-1 expression in vivo.

[Ileus of the small intestine in intestinal marginal-zone B-cell lymphoma of mucoid-associated lymphoid tissue (MALT)]

HISTORY AND ADMISSION FINDINGS

A 67-year-old man had complained of diffuse abdominal pain and constipation for 4 days without indication of any underlying disease. On admission there was no evidence of weight loss, fever or nocturnal sweating.

INVESTIGATIONS

Physical examination revealed signs of an acute abdomen with high-pitched bowel sounds and diffuse abdominal guarding. The X-ray showed ileus of the small intestine which required emergency laparotomy. An obstructing conglomerate tumour was present in the area of the ileum, ca. 80 cm proximal to the caecum. It was removed by partial resection of the small intestine.

DIAGNOSIS

Ileus of the small intestine with a low-malignant marginal zone B-cell (non-Hodgkin) lymphoma of MALT type (mucoid-associated lymphoid tissue).

TREATMENT AND COURSE

Postoperative staging indicated no further manifestation of the lymphoma. As no radical operation in resecting the tumour had been performed, combined radio- and chemotherapy was undertaken.

CONCLUSION

Marginal B-cell lymphomas of the small intestine are only rarely seen in central Europe. Despite its usually slow growth this non-Hodgkin lymphoma of low malignancy can produce an acute mechanical ileus without prodromal symptoms. A multimodal therapeutic approach is often employed, but there are no established treatment strategies.

Endothelium and atherogenesis: endothelial therapy revisited

Atherosclerosis, a chronic systemic disease of the vasculature with an inflammatory component, is the primary cause of cardiovascular morbidity and mortality in industrialized countries. Impairment of vascular endothelial cell function in atherosclerosis and in conditions associated with increased cardiovascular risk are important determinants of disease progression. Reduced endothelium-dependent relaxation in the coronary and systemic circulation due to decreased bioavailability of nitric oxide (NO) and increased release of oxygen-derived free radicals promotes the adhesion of leukocytes, thrombosis, inflammation, cell proliferation, and increases in vascular tone. In addition to decreases in bioactive NO, enhanced production of the 21-amino acid peptide endothelin-1 contributes to the progression of atherosclerosis. This paper discusses mechanisms and therapeutic approaches to improving endothelial pathways in atherosclerosis. Restoration of endothelium-derived NO bioactivity through inhibition of the renin-angiotensin system, the endothelin system, or statin therapy improves vascular function in experimental hypercholesterolemia, hypertension and heart failure. These treatments may also have therapeutic benefit for patients at risk or with overt atherosclerosis, and are likely to reduce vascular and myocardial complications of this disease.

The lonely crowd in Minnesota: a psychometric approach to the study of the modern American character

The Historical study of the American character has been hobbled for several reasons, many of which are summarized by David Stannard in “American Historians and the Idea of National Character: Some Problems and Prospects.” Stannard emphasizes that America has always been too complex a sociocultural system to have produced a uniform national character or a typical personality. He notes that cultural anthropologists have not found psychological uniformity even in small, preliterate communities. If scholars would study the variety of the nation's psychological characteristics instead—if they would search for the modal personality (most frequently occurring type) and the distribution of other personality types rather than only the basic personality type—then, at least in Stannard's opinion, they would avoid oversimplification, the most serious conceptual error. But even this more realistic approach retains methodological problems that are so serious that he suggests historians concentrate on understanding “deeds and events” and leave the study of national character and characteristics to the social and behavioral scientists. (Philosophers of history might deny that the study of deeds and events is less troublesome than the study of national character, but that is another matter.)

The therapeutic potential of endothelin receptor antagonists in cardiovascular disease

Endothelin (ET)-1, a 21-amino acid peptide, is the predominant isoform of the endothelin peptide family. ET-1 is ubiquitously expressed and stimulates vasoconstriction and cell proliferation. Enzymes such as endothelin converting enzymes (ECE), chymases, and non-ECE metalloproteinases contribute to the synthesis of ET-1, which is regulated in an autocrine fashion in vascular and nonvascular cells. Endothelin ET(A) receptors mediate vasoconstriction and cell proliferation, whereas ET(B) receptors are involved in the clearance of ET-1, inhibition of endothelial apoptosis, release of nitric oxide and prostacyclin, and inhibition of ECE-1 expression. Most cardiovascular diseases, such as arterial hypertension, atherosclerosis, restenosis, heart failure, idiopathic cardiomyopathy, pulmonary hypertension, and renal failure are associated with local activation of the endothelin system. Experimental studies and first clinical trials suggest that ET-1 is importantly involved in the functional and structural changes in the cardiovascular system, and that many of the actions of ET-1 are mediated through pressure-independent mechanisms. Endothelin antagonists promise to be successful as a new class of drugs for the treatment of cardiovascular diseases.

Postmenopausal oestrogen replacement therapy and atherosclerosis: can current compounds provide cardiovascular protection?

The natural oestrogen, 17 beta-oestradiol, has been implicated in protection from atherosclerosis, a chronic systemic vascular disease with an inflammatory component accounting for the majority of morbidity and mortality in Western countries. Despite the protective effects of 17 beta-oestradiol in premenopausal women and experimental evidence demonstrating inhibitory effects of oestrogen on atherosclerosis progression, it is currently unclear whether hormone replacement therapy can affect cardiovascular morbidity and mortality in postmenopausal women. The recent advances in understanding the mechanisms of oestrogen action demonstrated roles for different oestrogen receptors and oestrogen metabolites in the pathogenesis of vascular injury and endothelial cell dysfunction. However, their respective role in the process of atherogenesis remains yet to be elucidated. Moreover, the availability of novel drugs with tissue- and/or receptor-specific actions will help to understand the role of oestrogen in cardiovascular diseases. Several ongoing large-scale clinical trials using opposed or unopposed replacement therapy with natural or synthetic oestrogens, or selective oestrogen receptor modulators (SERMs) will resolve the question whether the drugs currently available have therapeutic potential to interfere with the progression of atherosclerosis and its complications.

Smoking and symbolism: children, communication and cigarettes

Health promotion, with its concern with empowerment and autonomy, must recognize the agency of its target population. Based on 85 in-depth interviews with 10- to 11-year-old children throughout Northern Ireland, this paper argues that it is necessary to focus on the social relations of children if we are to understand and prevent childhood smoking. Addressing the complex issue of childhood agency, it is argued that regardless of various restrictions to their choices, children can act intentionally in constructing their identities. Instead of viewing the smoking children as communicating with the adult world, we focus on smoking as negotiation of status within the children's culture. Such negotiations utilize symbolism derived from and shared with the 'adult world'. It is important that those analyzing children's lives understand children's ideas and behaviour on their own terms. We must make sure that the very concepts in which the children's experiences are put are appropriate ones. It is suggested that the metaphor 'rite of passage' and terminology such as peer 'pressure' versus adult 'influence', commonly used to analyse the children's smoking behaviour, may actually conceal important aspects of childhood agency.

Endothelin in atherosclerosis: importance of risk factors and therapeutic implications

Endothelin (ET)-1, a potent vasoconstrictor peptide, is primarily released abluminally from endothelial cells and exerts its biological effect through the activation of specific ET receptors. Endothelin subtype A receptors (ET(A)) are involved in constriction and proliferation of vascular smooth muscle cells, whereas endothelin subtype B receptors (ET(B)) on endothelial cells mediate the formation of nitric oxide, which acts as vasodilator and inhibits platelet aggregation. Cardiovascular risk factors such as hypertension and aging, as well as hypercholesterolemia, which are precursors of atherosclerosis, and elevated ET-1 levels are found. The best approach to determine the contribution of endogenous ET to vascular structural and functional alterations can be achieved by chronic inhibition of ET receptors with ET receptor antagonists. Recent studies showed favourable effects of selective ET(A)-antagonists on vascular alterations in different experimental models of hypertension, hypercholesterolemia and atherosclerosis, suggesting that activation of the local ET system importantly contributes to endothelial dysfunction and vascular remodeling, mainly through ET(A) receptors. Chronic blockade of ET(A) receptors may be a new therapeutic approach for the treatment of atherosclerosis and its risk factors.