Understanding the impact on intensive care staff workflow due to the introduction of a critical care information system: a mixed methods research methodology

The Intensive Care Unit (ICU) is a complex and dynamic tertiary care environment that requires health care providers to balance many competing tasks and responsibilities. Inefficient and interruption-driven workflow is believed to increase the likelihood of medical errors and, therefore, present a serious risk to patients in the ICU. The introduction of a Critical Care Information System (CCIS), is purported to result in fewer medical errors and better patient care by streamlining workflow. Little objective research, however, has investigated these assertions. This paper reports on the design of a research methodology to explore the impact of a CCIS on the workflow of Respiratory Therapists, Pediatric Intensivists, Nurses, and Unit Clerks in a Pediatric ICU (PICU) and a General Systems ICU (GSICU) in Northern Canada.

Newborn screening for methylmalonic acidurias--optimization by statistical parameter combination

With the introduction of tandem mass spectrometry, newborn screening for disorders of propionate metabolism became widely available. However, there is controversy whether population screening for these disorders should be performed. The most widely used primary metabolite C(3) itself has a poor specificity or lacks 100% sensitivity for milder forms and/or defects of cobalamin metabolism. Strategies to improve specificity have included the calculation of metabolite ratios (e.g. C(3)/C(2)) or second-tier strategies with analysis of methylmalonic acid or 2-methylcitric acid from the primary screening specimen. We report the results of a new statistical approach to identify parameter combinations that allow for 100% sensitivity as well as increased specificity. The promising results of this alternative approach will have to be substantiated on larger data sets.

Autologous non-myeloablative haematopoietic stem cell transplantation for refractory systemic vasculitis

OBJECTIVE

For patients with systemic vasculitis (SV) refractory to conventional therapy, new treatment strategies aimed at aggressive induction of remission and relapse prevention are being sought. We herein report our single-centre experience in treating four patients with refractory SV employing non-myeloablative autologous haematopoietic stem cell transplantation (HSCT).

METHODS

Four patients with refractory SV (two with neurovascular Behcet disease, one with neurovascular Sjögren syndrome, and one with Wegener granulomatosis) were involved in an Institutional Review Board (IRB) and US Food and Drug Administration (FDA) approved phase I clinical trial of high dose chemotherapy and autologous HSCT. Peripheral blood stem cells were mobilised with cyclophosphamide (Cy) and granulocyte-colony stimulating factor (G-CSF). Conditioning regimen consisted of Cy 200 mg/kg and rabbit anti-thymocyte globulin 5.5 mg/kg intravenously (iv).

RESULTS

All four patients tolerated HSCT well without transplant related mortality or any significant toxicity. At median follow-up of 28 (range 22-36) months all patients were alive. Three patients (one with Behcet disease, one with Sjögren syndrome, and one with Wegener granulomatosis) entered a sustained remission at 6, 6 and 24 months, respectively, after transplant. They had significant decrease in disease activity and disease or treatment related damage, as measured by the Birmingham Vasculitis Activity Score and Vasculitis Damage Index, respectively. All three patients who achieved remission discontinued immunosuppressive therapy at the time of transplant and have not required treatment since. One patient with Behcet disease and positive for human leukocyte antigen (HLA)-B51 has not improved after HSCT.

CONCLUSION

We suggest non-myeloablative autologous HSCT is an alternative therapy for select patients with SV refractory to conventional immunosuppressive therapies.

Implementation of extended neonatal screening and a metabolic unit in the State of Qatar: developing and optimizing strategies in cooperation with the Neonatal Screening Center in Heidelberg

Qatar is a country in the Gulf area and member of the Gulf Cooperation Council states. The country is populated by original Qatari tribes that amount to about 200,000 people and about 600,000 expatriates mainly from Arabic and Asian countries. Inbreeding over centuries and high rates of consanguinity in the Qatari population and in some groups of expatriates, in addition to large family sizes and rapid population growth, have contributed to a high frequency of autosomal recessive disorders. In December 2003 Hamad Medical Corporation in Doha and the University Children's Hospital of Heidelberg, Germany, started an extended state-wide neonatal screening programme for metabolic and endocrine disorders, with the laboratory situated in Heidelberg, Germany. All aspects of the screening process had to be adapted to the unique situation of the laboratory being 6000 km from the birthplace of the neonates. Within 32 months, samples of 25,214 neonates were screened. In 28 cases an endocrine or metabolic diagnosis was identified (incidence 1:901, in Germany 1:1728). In particular, a variety of monogenic metabolic diseases were prevalent, with 19 patients detected giving an incidence of metabolic diseases of 1:1327 (Germany 1:2517). Each euro spent on the screening programme saved more than 25 euros in health and social costs. The programme revealed a high incidence of treatable inborn metabolic diseases in the population of Qatar. A reliable screening for classical homocystinuria showing a unique incidence of >1:3000 and for sickle cell disease has now been added.

A Comparison of the Expression and Metabolizing Activities of Phase I and II Enzymes in Freshly Isolated Human Lung Parenchymal Cells and Cryopreserved Human Hepatocytes

The pulmonary and hepatic expression and catalytic activities of phase I and II drug-metabolizing enzymes were compared using human lung and liver tissue, and lung parenchymal cells (LPCs) and cryopreserved hepatocytes. Cytochrome P450 gene expression was generally lower in lung than in liver and CYP3A4 expression in lung was negligible. Esterase gene expression was similar in lung and liver. Expression of all sulfotransferase isoforms in lung was similar to or higher than that in liver. Lung tissue expressed low levels of UGT. However, the expression of UGT2A1 in lung was higher than that in liver. There was a range of catalytic activities in LPCs, including cytochrome P450, esterase, and sulfation pathways. Phase I activities were generally less than 10% of those determined in hepatocytes. Rates of ester hydrolysis and sulfation in LPCs were similar to those in hepatocytes. When measurable, glucuronidation in LPCs was present at very low levels, reflecting the gene expression data. The metabolism of salbutamol, formoterol, and budesonide was also investigated. Production of salbutamol-4-O-sulfate and budesonide oleate was observed in LPCs from at least two of three donor preparations studied. Formoterol sulfate and low levels of formoterol glucuronide were detected in one of three donors. In general, drug-metabolizing capability of LPCs is low compared with liver, although some evidence for substantial sulfation and deesterification capacity was observed. Therefore, these data support the use of this cell-based system for the investigation of key routes of xenobiotic metabolism in human lung parenchyma.

Combining galiximab with the chemotherapeutic agents fludarabine or doxorubicin improves efficacy in animal models of lymphoma

3040

Background: Galiximab, a primatized monoclonal antibody that binds with high affinity to CD80 and mediates antibody- dependent, cell-mediated cytotoxicity in vitro, is currently under investigation for the treatment of follicular non-Hodgkin’s lymphoma (NHL). In a phase I/II monotherapy study, galiximab produced an overall response rate of 11%, and tumor reductions were observed in 46% of patients. Initial clinical trials also demonstrate that galiximab is well tolerated and suggest that combining galiximab with rituximab (anti-CD20) provides clinical benefit. These results are consistent with preclinical studies in murine lymphoma xenograft model systems, which demonstrate the superiority of combination therapy. Methods: To further define the therapeutic potential of galiximab, the Raji subcutaneous and the SKW disseminated lymphoma murine xenograft models were used to define the in vivo efficacy of galiximab alone or in combination with fludarabine or doxorubicin. Similar studies were performed with rituximab. Results: In the Raji model, both galiximab and rituximab exhibited maximal inhibition of the growth of preestablished (150-mg) tumors at a dose of 3 mg/kg/wk. Interestingly, higher doses of galiximab (but not rituximab) showed reduced inhibition. Galiximab (3 mg/kg/wk) inhibited tumor growth alone (P<0.0001 vs. control) and showed significantly enhanced activity when combined with fludarabine (50 or 100 mg/kg daily for 5 days; P<0.0002 vs. galiximab alone and P<0.003 vs. fludarabine alone). Similar results were observed with rituximab. In the SKW model, treatment with galiximab (5 mg/kg/wk for 6 doses) significantly enhanced survival compared with a control (P<0.0001) or doxorubicin (2.5 mg/kg/day for 3 doses; P<0.0001). Studies combining fludarabine or doxorubicin with both galiximab and rituximab are ongoing. Conclusions: Studies in animal models of lymphoma indicate that galiximab may provide clinical benefit when used in combination with chemotherapeutic agents such as fludarabine and doxorubicin, and provide a rationale for the investigation of these novel chemoimmunotherapy combinations in clinical trials.

No significant financial relationships to disclose.

Influence of dietary pattern on the development of overweight in a Chinese population

OBJECTIVE

To examine dietary factors predisposing to overweight and obesity, taking into account age, gender, education level and physical activity.

DESIGN

Longitudinal population study.

SETTING

Community living subjects in Hong Kong.

SUBJECTS

One thousand and ten Chinese subjects participating in a territory wide dietary and cardiovascular risk factor prevalence survey in 1995-1996 were followed up for 5-9 years.

MEASUREMENTS

Body mass index (BMI) was measured. Information was collected on factors predisposing to development of overweight and obesity (age, gender, education level, physical activity, macronutrient intake, Mediterranean diet score and food variety), and the predisposing dietary factors examined, adjusted for other confounding factors, using logistic regression.

RESULTS

The 5-9-year incidence of overweight is 22.6% (BMI > or =23 kg/m2, 95% confidence interval (CI)=15.0-30.1%) or 11.5% (BMI > or =25 kg/m2, 95% CI=7.3-15.7%), and for obesity (BMI >/=30 kg/m2) is 0.6% (95% CI=-0.2-1.4%). The corresponding figures for women were 14.1% (95% CI=8.8-19.5%), 9.7% (95% CI=6.0-13.4%) and 3% (95% CI=1.3-4.8%). After adjusting for confounding factors (age, sex, education and physical activity), increased variety of snack consumption was associated with increased risk of developing overweight (BMI > or =23 kg/m2) in the Hong Kong Chinese population over a 5-9-year period.

CONCLUSION

Increased variety of snack consumption may predispose to weight gain over a 5-9-year period.

Absorption, tissue distribution, metabolism and elimination of taurine given orally to rats

Three biodisposition studies with taurine were performed in male and female adult rats at dosages of 30 and 300 mg/kg. A single oral dose of (14)C-taurine was rapidly absorbed, distributed to tissues and excreted unchanged in urine. Elimination of radioactivity from intracellular pools was slow. Pre-treatment of animals for 14 days with unlabelled taurine did not significantly affect the fate of (14)C-taurine. At the higher dose there was more extensive excretion combined with a lower percentage of the dose in the carcass, indicating the possibility of saturation of the tubular reabsorption mechanism for taurine. Daily administration of unlabelled taurine for 14 days did not result in an increase in total taurine in the brain. The data indicate that exogenous taurine rapidly equilibrates with endogenous body pools and that any excess is rapidly eliminated by the kidneys.

Characteristics of the m2000 automated sample preparation and multiplex real-time PCR system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae

We evaluated a new real-time PCR-based prototype assay for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae developed by Abbott Molecular Inc. This assay is designed to be performed on an Abbott m2000 real-time instrument system, which consists of an m2000sp instrument for sample preparation and an m2000rt instrument for real-time PCR amplification and detection. The limit of detection of this prototype assay was determined to be 20 copies of target DNA for both C. trachomatis and N. gonorrhoeae, using serially diluted linearized plasmids. No cross-reactivity could be detected when 55 nongonococcal Neisseria isolates and 3 non-C. trachomatis Chlamydia isolates were tested at 1 million genome equivalents per reaction. Concordance with the Roche Amplicor, BDProbeTec ET, and Gen-Probe APTIMA Combo 2 tests was assessed using unlinked/deidentified surplus clinical specimens previously analyzed with these tests. For C. trachomatis, concordance for positive results ranged from 93.7% to 100%, while concordance for negative results ranged from 98.2% to 100%. For N. gonorrhoeae, concordance for positive and negative results ranged from 91.4% to 100% and 99.3% to 100%, respectively. A workflow analysis of the prototype assay was conducted to obtain information on throughput under laboratory conditions. At 48 samples/run, the time to first result for both C. trachomatis and N. gonorrhoeae was 4.5 h. A total of 135 patient specimens could be analyzed in 8.9 h, with 75 min of hands-on time. This study demonstrated the technical and clinical feasibility of the new Abbott real-time PCR C. trachomatis/N. gonorrhoeae assay.

Neonatal screening for glutaric aciduria type I: strategies to proceed

Acute encephalopathic crisis in glutaric aciduria type I results in an unfavourable disease course and poor outcome, dominated by dystonia, feeding problems, seizures and reduced life expectancy. A conditio sine qua non for the prevention of irreversible brain damage is timely diagnosis and start of therapy, i.e. before the onset of neurological disease. As there are no specific clinical signs or symptoms that allow a reliable detection of these patients before the manifestation of encephalopathic crises, neonatal screening programmes for glutaric aciduria type I have been established in some countries using analysis of glutarylcarnitine in dried blood spots by tandem mass spectrometry. This article summarizes recent strategies, pitfalls and shortcomings of mass screening for glutaric aciduria type I, focusing on the relevant risk of missing patients with a mild biochemical phenotype (i.e. low excretors). Furthermore, it evaluates a binary strategy--using glutarylcarnitine as primary variable and glutarylcarnitine/acylcarnitine ratios as secondary variable--to improve the diagnostic sensitivity and specificity of neonatal screening for glutaric aciduria type I. An optimization of diagnostic as well as therapeutic procedures must be achieved before screening for glutaric aciduria type I can be regarded as reliable and beneficial for all patients.

Cell viability effects of triamcinolone acetonide and preservative vehicle formulations

AIM

To assess the effect of triamcinolone acetonide and preservative vehicle formulations on human retinal pigment epithelium (ARPE19) cells over a range of concentrations.

METHODS

Triamcinolone acetonide, in its trade and preservative free formulations, along with the preservative vehicle were added to ARPE19 cell cultures in various concentrations (0.01-1.0 mg/ml). Cell viability was assessed using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay at day 5 after exposure. Functionality of the cultured ARPE19 cell line was confirmed by exposure to a previously characterised toxic agent, tamoxifen.

RESULTS

The ARPE19 cell line behaved as predicted with exposure to tamoxifen. All formulations caused significant reductions in ARPE19 cell viability at the highest concentrations (1.0 mg/ml for triamcinolone preparations and undiluted vehicle). Cell viability was reduced to the greatest degree in trade formulation triamcinolone, less so by the vehicle, and least by preservative free triamcinolone. At lower concentrations no significant effect on cell viability was observed, although cell viability was found to be inversely proportional to increasing concentration of all tested reagents

CONCLUSIONS

Both the trade and preservative free formulations of triamcinolone acetonide as well as the vehicle result in cell loss at in vitro concentrations of 1 mg/ml. Although this represents theoretical vitreous concentrations achieved with current widespread therapeutic use it probably does not indicate the actual exposure of cells in their biological milieu. That cell viability was reduced most in the trade formulation suggests a possible potentiated inhibitory toxic effect of triamcinolone acetonide and vehicle at higher concentrations.

Giving them a good start: informatics support of newborn screening and clinical care

Newborns are a vulnerable population: Exposed to dramatically changing environmental conditions, potentially suffering from impairments that cannot realistically be diagnosed during pregnancy, with the risk that unfavorable conditions escalate fast. We have investigated informatics methods and tools to make screening for congenital diseases and containment of critical processes that start in the first days safer and more efficient. This poster present a set of three different methodological approaches that all aim at comprehensive improvement of neonatal care.

High-dose vitamin E supplementation does not diminish ribavirin-associated haemolysis in hepatitis C treatment with combination standard alpha-interferon and ribavirin

BACKGROUND

Ribavirin is associated with haemolytic anaemia. Antioxidants have been reported to decrease severity of this anaemia.

AIM

To determine effect of vitamin E supplementation on ribavirin-associated haemolysis in chronic hepatitis C treated with standard alpha-interferon and ribavirin.

METHODS

Fifty-one naive chronic hepatitis C patients were randomized to receive either alpha-interferon/ribavirin therapy (control) or therapy plus vitamin E 800 IU b.d. with 24-week follow-up. Alanine aminotransferase ALT, haemoglobin and reticulocyte percentage were monitored. Symptoms and health-related quality of life were also monitored at each visit.

RESULTS

Forty-seven subjects were treated (27 vitamin E /20 controls). Thirteen withdrew because of adverse effects or non-compliance. Groups were similar in demographics, genotype and baseline lab indices. Comparison with baseline, treatment and follow-up values showed a significant haemoglobin and ALT reduction in both groups. There was no significant difference in haemoglobin and reticulocyte percentage between groups. Sustained viral response was not significantly different between vitamin E (11/18) and control (6/16) groups. Three patients required ribavirin dose-reduction in the vitamin E group compared with two controls. Health-related quality of life during and end-of-treatment was not different between groups.

CONCLUSIONS

Vitamin E supplementation alone during standard alpha-interferon and ribavirin therapy does not appear to diminish ribavirin-associated haemolysis.

Eclampsia, hippocampal sclerosis, and temporal lobe epilepsy: Accident or association?

BACKGROUND

Up to 30% of patients with temporal lobe epilepsy (TLE) have no identifiable risk factors.

OBJECTIVE

S: To report nine patients with TLE who had a history of eclampsia as the only risk factor for epilepsy and to investigate whether this possible association existed in a larger cohort of women with surgically treated TLE.

METHODS

The clinical data, video-EEG, neuroimaging, and neuropathology of 195 consecutive women undergoing anterior temporal lobectomy (ATL) were reviewed. Risk factors for TLE, age at epilepsy onset, and occurrence of pregnancy were identified in each patient.

RESULTS

Twenty-six women had no identifiable risk factors or seizures following a pregnancy. Nine of the 26 women had a history of eclampsia. The median age at the time of eclampsia was 16 years, and the latent period between the occurrence of eclampsia and onset of epilepsy ranged from 1 month to 2 years. The clinical, EEG, MRI, and neuropathologic findings were typical of hippocampal sclerosis (HS) and other than age at onset were no different from those of noneclampsia ATL patients. At mean follow-up of 57 months, seven patients were seizure-free and the other two markedly improved.

CONCLUSION

Eclampsia may be a risk factor for TLE and HS.

Extended experience in the use of laparoscopic ultrasound to detect pelvic nodal metastasis in patients with cervical carcinoma

OBJECTIVE

To evaluate the use of laparoscopic ultrasound (USG) to detect pelvic nodal metastasis in patients with early stage cervical carcinoma.

METHODS

Laparoscopic USG was used to search for pelvic lymph node metastasis in stage Ia2 to IIa cervical carcinoma patients before radical hysterectomy. Suspicious lymph nodes identified by laparoscopic USG were removed laparoscopically for pathological confirmation by frozen section. If nodal metastasis was diagnosed, radical hysterectomy would be cancelled but enlarged lymph nodes were removed preferably by laparoscopic approach before closing the abdomen. These patients were treated with radiotherapy after recovering from the surgery. By comparing the laparoscopic USG and pathological findings of lymph nodes removed with or without radical hysterectomy, diagnostic accuracy of laparoscopic USG was determined.

RESULTS

Ninety-three patients were recruited and the final analysis included 90 patients. Laparoscopic USG found suspicious lymph nodes in 17 patients and nodal metastases were confirmed pathologically in 14 of them. Three patients with macroscopic and five patients with microscopic pelvic nodal metastases were missed by laparoscopic USG. The accuracy, sensitivity, specificity, positive and negative predictive value of laparoscopic USG in detecting pelvic lymph node metastasis were 87.8%, 63.6%, 95.6%, 82.4%, and 89%, respectively. Macroscopic metastatic nodes were successfully removed laparoscopically in 11 out of 14 patients and laparotomy was required for the other three patients.

CONCLUSIONS

Laparoscopic USG can be performed with no major morbidity. This technique is sensitive in detecting macroscopic but not microscopic metastatic pelvic lymph nodes. Removal of macroscopic metastatic nodes identified via laparoscopic USG via laparoscopic approach could be accomplished in majority of patients.