Impact of nuchal translucency credentialing by the FMF, the NTQR or both on screening distributions and performance

OBJECTIVE

In the USA, both The Fetal Medicine Foundation (FMF) and the Nuchal Translucency Quality Review Program (NTQR) have operated education, review and credentialing for physicians and sonographers for the measurement of nuchal translucency (NT). We sought to assess differences in the distribution of NT measurements based upon the system from which the operator obtained their education, review and credentialing.

METHODS

398 311 NT measurements by 1541 sonographers who had performed ≥ 50 exams from July 2008 to June 2010 were grouped by organization. Differences between grouped measurements were assessed using analysis of variance of log(10) NT multiples of the median (MoM), with sonographer and organization as factors.

RESULTS

MoM values were significantly lower (P ≤ 0.001) and SD was significantly higher (P < 0.001) for the NTQR group compared with the FMF group or those sonographers credentialed by both. The percentage of individuals with negative bias ≥ 10% was greater for the NTQR group (P < 0.001). The difference was less but still significant (P = 0.009) when bias was adjusted for by the overall median for the organization.

CONCLUSIONS

Although NT MoM measurements were significantly lower and had a wider variance when obtained by the NTQR group, our data cannot distinguish between bias in training or the attributes of the participating sonographers in each program. With these large numbers, it is unlikely that patient characteristics could explain the discrepancy in distributions. Ongoing efforts to monitor sonographer performance with remediation for poor performers may reduce discrepancies between organizations.

Analgesia during radial artery cannulation: comparison of the effects of lidocaine applied by local injection or iontophoresis

We compared the effect of lidocaine injection with lidocaine iontophoresis for pain relief during radial artery cannulation prior to induction of anaesthesia. Patients were allocated randomly to one of two groups. Group 1 (n = 15) received iontophoresis for 10 min prior to cannulation, using 4% lidocaine 4 ml. Group 2 (n = 15) received local infiltration of 1% lidocaine 1 ml using a 25G needle. Pain scores were recorded immediately after cannulation using a 10-cm visual analogue scale (VAS). There was no difference in mean (SD) pain scores [group 1: 2.2 (1.5) cm; group 2: 2.3 (2.7) cm; 95% CI of difference -1.8 to 1.5 cm]. Lidocaine delivered by iontophoresis is an effective and painless method of providing analgesia for radial artery cannulation.

Universal newborn screening for Hb H disease in California

Newborn screening is an accepted public health measure to ensure that appropriate health care is provided in a timely manner to infants with hereditary/metabolic disorders. Alpha-thalassemia is a common hemoglobin (Hb) disorder, and causes Hb H (beta4) disease, and usually fatal homozygous alpha(0)-thalassemia, also known as Hb Bart's (gamma4) hydrops fetalis syndrome. In 1996, the State of California began to investigate the feasibility of universal newborn screening for Hb H disease. Initial screening was done on blood samples obtained by heel pricks from newborns, and stored as dried blood spots on filter paper. Hb Bart's levels were measured as fast-moving Hb by automated high-performance liquid chromatography (HPLC) identical to that currently used in newborn screening for sickle cell disease. Subsequent confirmation of Hb H disease was done by DNA-based diagnostics for alpha-globin genotyping. A criterion of 25% or more Hb Bart's as determined by HPLC detects most, if not all cases of Hb H disease, and few cases of alpha-thalassemia trait. From January, 1998, through June, 2000, 89 newborns were found to have Hb H disease. The overall prevalence for Hb H disease among all newborns in California is approximately 1 per 15,000. Implementation of this program to existing newborn hemoglobinopathy screening in populations with significant proportions of southeast Asians is recommended. The correct diagnosis would allow affected infants to be properly cared for, and would also raise awareness for the prevention of homozygous alpha(0)-thalassemia or Hb Bart's hydrops fetalis syndrome.

Analgesia for circumcision in a paediatric population: comparison of caudal bupivacaine alone with bupivacaine plus two doses of clonidine

BACKGROUND

Clonidine is often used to improve the duration and quality of analgesia produced by caudal epidural blockade, although the optimum dose of clonidine with bupivacaine remains uncertain.

METHODS

We compared the effect of clonidine, 1 and 2 microg x kg(-1), added to bupivacaine (1.25 mg x kg(-1)) with that of bupivacaine alone in 75 male children undergoing elective circumcision.

RESULTS

There was a trend towards increasing duration of analgesia with increasing dose of clonidine [group B (bupivacaine) 280.7 (171.6) min, C1 (bupivacaine + clonidine 1 microg x kg(-1)) 327.8 (188.3) min and C2 (bupivacaine + clonidine 2 microg x kg(-1)) 382.0 (200.6) min], although this difference was not statistically significant. Mean time to arousal from anaesthesia was significantly prolonged with clonidine 2 microg kg(-1) (group C2 21.3 (13-36) min, group C1 14.0 (6-25) min and group B 14.4 (2-32) min. Supplementary analgesic requirements and incidence of adverse effects were low, with no differences between the groups.

CONCLUSIONS

For paediatric circumcision, under general anaesthesia, the addition of clonidine 2 microg x kg(-1) to low volume (0.5 ml x kg(-1)) caudal anaesthetics has a limited clinical benefit for children undergoing circumcision.