Multicenter study evaluating target attainment of anti-Factor Xa levels using various enoxaparin prophylactic dosing practices in adult trauma patients

STUDY OBJECTIVE

Enoxaparin is standard of care for venous thromboembolism (VTE) prophylaxis in adult trauma patients, but fixed-dose protocols are suboptimal. Dosing based on body mass index (BMI) or total body weight (TBW) improves target prophylactic anti-Xa level attainment and reduces VTE rates. A novel strategy using estimated blood volume (EBV) may be more effective based on results of a single-center study. This study compared BMI-, TBW-, EBV-based, and hybrid enoxaparin dosing strategies at achieving target prophylactic anti-Factor Xa (anti-Xa) levels in trauma patients.

DESIGN

Multicenter, retrospective review.

DATA SOURCE

Electronic health records from participating institutions.

PATIENTS

Adult trauma patients who received enoxaparin twice daily for VTE prophylaxis and had at least one appropriately timed anti-Xa level (collected 3 to 6 hours after the previous dose after three consecutive doses) from January 2017 through December 2020. Patients were excluded if the hospital-specific dosing protocol was not followed or if they had thermal burns with > 20% body surface area involvement.

INTERVENTION

Dosing strategy used to determine initial prophylactic dose of enoxaparin.

MEASUREMENTS

The primary end point was percentage of patients with peak anti-Xa levels within the target prophylactic range (0.2-0.4 units/mL).

MAIN RESULTS

Nine hospitals enrolled 742 unique patients. The most common dosing strategy was based on BMI (43.0%), followed by EBV (29.0%). Patients dosed using EBV had the highest percentage of target anti-Xa levels (72.1%). Multiple logistic regression demonstrated EBV-based dosing was significantly more likely to yield anti-Xa levels at or above target compared to BMI-based dosing (adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 2.29-5.62, p < 0.001). EBV-based dosing was also more likely than hybrid dosing to yield an anti-Xa level at or above target (aOR 2.30, 95% CI 1.33-3.98, p = 0.003). Other pairwise comparisons between dosing strategy groups were nonsignificant.

CONCLUSIONS

An EBV-based dosing strategy was associated with higher odds of achieving anti-Xa level within target range for enoxaparin VTE prophylaxis compared to BMI-based dosing and may be a preferred method for VTE prophylaxis in adult trauma patients.

An Interprofessional Precision Health Model for Assessment of Caregiver Impact on Polypharmacy in Elderly Intensive Care Unit Patients: A Team-Based Proposal

Elderly critical care patients are one of the largest growing patient population groups according to Medicare data. More than 51% of elderly patients are discharged on inappropriate medications that have the potential to cause harm or interact adversely with other medications. Precision health has the potential to prevent adverse drug events and prescription of inappropriate medications. The purpose of this literature review was to define the concept of precision health and determine the state of science regarding interprofessional models of precision health for assessment of caregiver impact on polypharmacy in elderly intensive care unit patients.

Incidence of rebound salicylate toxicity following cessation of urine alkalinization

INTRODUCTION

Management of patients with salicylate toxicity frequently requires urine alkalinization to enhance excretion of salicylate. One strategy for determining when to stop urine alkalinization is to wait for two consecutive serum salicylate concentrations to be less than 300 mg/L (2.17 mmol/L) and declining. When alkalinization of the urine ceases, a rebound in serum salicylate concentration can occur from tissue redistribution or delayed gastrointestinal absorption. Whether this can lead to rebound toxicity is not well understood.

METHODS

This was a single-center, retrospective review of cases with a primary ingestion of acetylsalicylic acid reported to the local poison center over a five-year period. Cases were excluded if the product was not listed as the primary ingestion or if there was no serum salicylate concentration documented after discontinuation of intravenous sodium bicarbonate infusion. The primary outcome was the incidence of serum salicylate rebound to a concentration greater than 300 mg/L (2.17 mmol/L) after discontinuation of intravenous sodium bicarbonate infusion.

RESULTS

A total of 377 cases were included. Of these, eight (2.1%) had a serum salicylate concentration increase (rebound) after stopping the sodium bicarbonate infusion. All these cases were acute ingestions. Five of the eight cases had rebound serum salicylate concentrations that were greater than 300 mg/L (2.17 mmol/L). Of these five patients, only one reported recurrent symptoms (tinnitus). Prior to stopping urinary alkalinization, the last or the last two serum salicylate concentrations were less than 300 mg/L (2.17 mmol/L) in three and two cases, respectively.

CONCLUSIONS

In patients with salicylate toxicity, the incidence of rebound in serum salicylate concentration after cessation of urine alkalinization, is low. Even if serum salicylate rebounds to supratherapeutic concentrations, symptoms are often absent or mild. Routine repeat serum salicylate concentrations after urine alkalinization is stopped may be unnecessary unless symptoms recrudesce.

The Effect of Simulation-Enhanced Orientation on Graduate Nurses: An Integrative Review

The purpose of this review is to examine the state of science of simulation-enhanced orientation and its effect on graduate nurses (GNs).

BACKGROUND

GNs are essential to the alleviation of staffing deficits, mitigation of patient safety events, and provision of clinically adept care. Successful transition from academia to clinical practice is often influenced by factors that compromise retention, increase attrition, and impair professional development.

METHOD

The method used was an integrative literature review.

RESULTS

There is a paucity of research in the literature regarding the effect of simulation-enhanced orientation on clinical competency, confidence outcomes, and other benchmarks of professional development that may influence retention or attrition.

CONCLUSION

This integrative review confirmed the paucity of research of qualitative and quantitative outcomes of simulation-enhanced orientation on GNs. Stakeholders of organizational and educational institutions may find this review valuable, as it highlights the necessity for additional research. [J Contin Educ Nurs. 2021;52(3):150-156.].

Hemolysis after subcutaneous deoxycholic acid overdose

This report describes a case of hemolysis in a patient injecting deoxycholic acid and benzyl alcohol for aesthetic benefit without medical supervision. The concentration and dose injected by the patient resulted in a 10-fold overdose of deoxycholic acid in comparison to the FDA-recommended dosing for the approved indication. Providers should be aware of medically unsupervised use of DCA and other injectables and the potential risks associated with this practice.

Impulsivity and self-control in elementary school children and adult females: Using identical task and procedural parameters

Results of studies examining the relationship between impulsivity and age are limited because different tasks, procedural parameters, and different reinforcers have been used with different aged participants. Thus, the current study sought to rectify these differences in two experiments with children (42, ages 5-12) and adults (69 college-aged females) using the same task with identical procedural parameters. In the Self-Control Video Software Task (SCVST; Forzano and Schunk, 2008; Forzano et al., 2014) participants repeatedly choose between larger, more delayed and smaller, less delayed access to viewing video cartoons. No differences in impulsivity were found between adults and children. No age or gender differences were found among children. Differences in task and procedural parameters are identified as important in their implications for research on impulsivity.

Machine Learning Algorithm Helps Identify Non-Diagnosed Prodromal Alzheimer's Disease Patients in the General Population

BACKGROUND

Recruiting patients for clinical trials of potential therapies for Alzheimer's disease (AD) remains a major challenge, with demand for trial participants at an all-time high. The AD treatment R and D pipeline includes around 112 agents. In the United States alone, 150 clinical trials are seeking 70,000 participants. Most people with early cognitive impairment consult primary care providers, who may lack time, diagnostic skills and awareness of local clinical trials. Machine learning and predictive analytics offer promise to boost enrollment by predicting which patients have prodromal AD, and which will go on to develop AD.

OBJECTIVES

The authors set out to develop a machine learning predictive model that identifies prodromal AD patients in the general population, to aid early AD detection by primary care physicians and timely referral to expert sites for biomarker confirmation of diagnosis and clinical trial enrollment.

DESIGN

The authors use a classification machine learning algorithm to extract patterns within healthcare claims and prescription data three years prior to AD diagnosis/AD drug initiation.

SETTING

The study focused on subjects included within proprietary IQVIA US data assets (claims and prescription databases). Patient information was extracted from January 2010 to July 2018, for cohorts aged between 50 and 85 years.

PARTICIPANTS

A total of 88,298,289 subjects aged between 50 and 85 years were identified. For the positive cohort, 667,288 subjects were identified who had 24 months of medical history and at least one record with AD or AD treatment. For the negative cohort, 3,670,254 patients were selected who had a similar length of medical history and who were matched to positive cohort subjects based on the prevalence rate. The scoring cohort was selected based on availability of recent medical data of 2-5 years and included 72,670,283 subjects between the ages of 50 and 85 years. Intervention (if any): None.

MEASUREMENTS

A list of clinically-relevant and interpretable predictors was generated and extracted from the data sets for each subject, including pharmacological treatments (NDC/product), office/specialist visits (specialty), tests and procedures (HCPCS and CPT), and diagnosis (ICD). The positive cohort was defined as patients who have AD diagnosis/AD treatment with a 3 years offset as an estimate for prodromal AD diagnosis. Supervised ML techniques were used to develop algorithms to predict the occurrence of prodromal AD cases. The sample dataset was divided randomly into a training dataset and a test dataset. The classification models were trained and executed in the PySpark framework. Training and evaluation of LogisticRegression, DecisionTreeClassifier, RandomForestClassifier, and GBTClassifier were executed using PySpark's mllib module. The area under the precision-recall curve (AUCPR) was used to compare the results of the various models.

RESULTS

The AUCPRs are 0.426, 0.157, 0.436, and 0.440 for LogisticRegression, DecisionTreeClassifier, RandomForestClassifier, and GBTClassifier, respectively, meaning that GBTClassifier (Gradient Boosted Tree) outperforms the other three classifiers. The GBT model identified 222,721 subjects in the prodromal AD stage with 80% precision. Some 76% of identified prodromal AD patients were in the primary care setting.

CONCLUSIONS

Applying the developed predictive model to 72,670,283 U.S. residents, 222,721 prodromal AD patients were identified, the majority of whom were in the primary care setting. This could drive major advances in AD research by enabling more accurate and earlier prodromal AD diagnosis at the primary care physician level , which would facilitate timely referral to expert sites for in-depth assessment and potential enrolment in clinical trials.

Urban Emergency Department Response to Measles Outbreak

In the last year, New York City has had more than 600 confirmed measles cases. For each patient with measles, numerous neonates, unimmunized children, and susceptible adults can be exposed to the highly contagious virus. Working in an emergency department amid such an outbreak presents several challenges because of the crowded nature of the environment, the imperative for rapid identification and isolation of infected patients, and identification of vulnerable individuals who have been in the vicinity when a patient with measles presents. In this report, we discuss our process in navigating these challenges, collaboration with the city's health department, postexposure prophylaxis for individuals exposed in the hospital and the community, and prevention initiatives.

Placental Cytomegalovirus Infection

In the United States, cytomegalovirus is the most common congenital viral infection and the number 1 cause of nonhereditary sensorineural hearing loss. The vast majority of infants may be asymptomatic, especially if cytomegalovirus is contracted later in the pregnancy, and some symptoms may have a delayed onset. Therefore, it is important for the pathologist to identify the common histologic findings to help confirm the diagnosis so the child can be followed for late sequelae. Histologic examination of the placenta is important in live births and in cases of intrauterine fetal demise. Chronic lymphoplasmacytic villitis and fibrotic, avascular villi are the most common findings. When present, Cowdry A intranuclear and basophilic intracytoplasmic inclusions are characteristic. Immunohistochemistry for cytomegalovirus can highlight these inclusions as well as the associated eosinophilic debris. In addition, polymerase chain reaction or viral culture on placental or fetal samples can be performed for confirmation.

Primary carcinoid tumor of the bladder

Transitional cell carcinoma is the most common type of bladder cancer in the United States. This case report discusses the finding of primary bladder carcinoid tumor (also called well-differentiated neuroendocrine tumor) in a woman with gross hematuria. With only 15-20 reported cases, primary bladder carcinoid is rare and the approach to treatment is unclear. There have been two muscle-invasive cases reported which required more extensive treatment plans. The patient presented in this case underwent complete transurethral resection of the tumor with the recommendation of surveillance cystoscopy every 3 months.

A clinical study of Aicardi syndrome in Northern Ireland: the spectrum of ophthalmic findings

PurposeAicardi syndrome is a rare disorder, affecting ~1 in 100 000 live births. Chorioretinal lacunae feature alongside agenesis of the corpus callosum and spasms in flexion to make up a diagnostic triad. Recently ophthalmic findings such as microphthalmia and optic disc anomalies have been recognised in association with Aicardi syndrome. This population study aims to determine the presence of ocular findings and identifies some novel associations in these patients.MethodsA retrospective review of charts for seven patients with Aicardi syndrome was carried out.ResultsThe incidence of Aicardi syndrome in Northern Ireland was found to be 1 in 110 000 live births. Four patients who had microphthalmus also had iris abnormalities; two patients with bilateral microphthalmus had partial aniridia and two patients with unilateral microphthalmus had iris coloboma in the same eye. Optic disc abnormalities were found in 11 eyes of six patients. Two patients were found to have areas of fibrovascular proliferation with a thickened white ridge and avascular zone beyond. Both of these patients developed retinal detachments.ConclusionsOur review of patients with Aicardi syndrome in Northern Ireland has revealed some novel clinical findings, including aniridia in two cases. We also found a higher than previously reported rate of excavated disc anomalies of 50% in our cohort. We found two cases of peripheral retinal dysplasia, which has not been previously reported. This finding was associated with microphthalmus and severe optic disc abnormalities, and we feel this warrants early EUA to enable early treatment and hopefully result in better visual prognosis.

Bevacizumab compared with diode laser in stage 3 posterior retinopathy of prematurity: A 5 year follow up

We conducted a prospective randomized study to compare outcomes of intravitreal Bevacizumab versus diode laser in thirty eyes of fifteen premature babies with zone 1 or posterior zone 2 retinopathy of prematurity (ROP). We recorded complications, regression/reactivation of ROP, visual outcome, refractive error and systemic complications. The Bevacizumab treated eyes showed rapid regression of the ROP with resolution of plus disease and flattening of the ridge at 48 hours post injection. In 3 Bevacizumab treated eyes, reactivation occurred and were treated with laser (3 eyes) or a further Bevacizumab injection (1 eye). Of the diode laser treated eyes, one showed progression and was treated with Bevacizumab. At 5 year follow up, good outcomes were observed in both treatment groups. Hoever, less myopia was found in the Bevacizumab compared with the diode laser treated eyes.

MouseMine: a new data warehouse for MGI

MouseMine (www.mousemine.org) is a new data warehouse for accessing mouse data from Mouse Genome Informatics (MGI). Based on the InterMine software framework, MouseMine supports powerful query, reporting, and analysis capabilities, the ability to save and combine results from different queries, easy integration into larger workflows, and a comprehensive Web Services layer. Through MouseMine, users can access a significant portion of MGI data in new and useful ways. Importantly, MouseMine is also a member of a growing community of online data resources based on InterMine, including those established by other model organism databases. Adopting common interfaces and collaborating on data representation standards are critical to fostering cross-species data analysis. This paper presents a general introduction to MouseMine, presents examples of its use, and discusses the potential for further integration into the MGI interface.

Implementation of the court visitor program in a clinical nursing curriculum

The State of Texas has more than 19,000 individuals who lack the physical or mental ability to provide for their need for shelter, financial management, or physical care. These individuals have been designated as wards of the court and placed under guardianship. Texas probate courts appoint individuals known as court visitors to make annual visits to wards of the court to assess their well-being under guardianship. Although the 10 statutory probate courts have court visitor programs, many county courts do not. This article describes the details of a service-learning experience using an online distance educational program to train undergraduate nursing students in a mental health course to become court visitors. This information may be useful to others looking for nontraditional clinical experiences and service-learning opportunities for undergraduate nursing students.

Training in the private sector: what works and how do we increase opportunities?

In Australia 61% of elective surgery takes place in private hospitals where current opportunities for surgical education and training (SET) are limited. The situation will shortly be compounded because of the large increase in local medical graduates, many of whom will aspire to be surgeons. How and where to train these extra surgeons to meet the expanding needs of the community must be addressed. Two models of private sector training are reviewed both of which involved combined training in both private and public sectors. Two second-year (SET 2) positions were created from one public hospital SET position by using the private sector for 3.5 days per week for 3 months of a 6-month rotation. The second model was applicable to post-fellowship training with a fairly even split between public and private sector responsibilities. In the first year, four registrars shared the two 6-month rotations for the SET 2 position. Trainees did the required minimum procedures (range 109-139) with primary operating targets of 20-25% (range 21-32%). The post-fellowship position in colorectal surgery was greatly enhanced by the private sector involvement with regard to operating experience as well as meeting part of the remuneration of the trainee. Successful models for training within the private sector in Australia can be found. To expand training in the private sector there will need to be a cultural shift in the perceptions of surgeons, patients, administrators, and trainees. Funding for posts may be available to those private hospitals that can meet the Royal Australasian College of Surgeons' accreditation standards for posts and hospitals.

Merkel cell carcinoma metastasis to the iris in a 23 year old female

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine malignancy which predominantly affects elderly caucasians. The pathogenesis is poorly understood but ultraviolet light and immunosuppression have both been implicated. MCC most commonly arises on sun exposed areas of the head and neck or extremities and has a propensity for local recurrence and regional lymph node metastasis. It may present as a violaceous or non specific firm nodule or as a small plaque. Histological diagnosis can be difficult and electron microscopy or immunohistochemistry are frequently required in addition to light microscopy. Management is stage dependant and frequently involves wide surgical excision with or without chemotherapy or radiation therapy. Early diagnosis and complete surgical excision is associated with a favourable prognosis. However, aggressive tumours with regional recurrence or distant metastases result in a median survival of 9 months. Reports of primary MCC of the eyelids have been reported in the literature. Intra-ocular metastases to the choroid and ciliary body have also been reported.

Postcataract surgery outcome in a series of infants and children with Down syndrome

AIMS

To report the visual and refractive outcome and complications in children with Down syndrome undergoing cataract extraction.

METHODS

The case notes of 18 infants and children with lens opacities and Down syndrome who underwent cataract extraction between January 1981 and August 2006 were reviewed.

RESULTS

Over the 25-year study period, 7% (33 eyes) of paediatric eyes undergoing cataract extraction had Down syndrome. The average follow-up time was 11.2 (SD 7.5) years with a range of 2.5 months to 25 years. 25 were congenital, and eight were developmental lens opacities. 40% of patients attained a postoperative BCVA between 6/9 and 6/18. There was a large myopic shift of -7.96 (4.7) D for aphakes and -8.06 (7.4) D for pseudophakes with an average increase in axial length of 3.58 (3.14) mm. There was a 30% incidence of posterior capsular opacification (PCO) overall, 38% in eyes without a primary posterior capsulotomy. Five eyes developed aphakic glaucoma, one eventually necessitating an enucleation. Two patients had retinal detachments on follow-up.

CONCLUSION

Cataract extraction in our population of children with Down syndrome is a safe and effective procedure with a very encouraging visual outcome.

Golf--recognising the risk of severe eye injury

Golf related ocular injuries are uncommon but frequently result in severe injury necessitating removal of the eye. As golf increases in popularity, it is vital that awareness is raised among both players and spectators regarding the potential hazards. We determined the nature and frequency of golf related eye injury at our unit from 1990 to 2007. Patient age, nature of injury, management and visual outcome were documented. 10 patients (7 adults, 3 children) sustained golf related eye trauma over this time. 7 cases involved injury inflicted by a golf ball and 3 by a golf club. 7 eyes required enucleation or evisceration. Visual acuity in the remaining 3 eyes ranged from 6/6 to less than 6/60. Golf related ocular injuries while uncommon, frequently have devastating consequences. Public awareness must be raised in order to promote greater safety on the golf course.

Changing pattern of childhood blindness

All children under the age of 16 who fulfilled the criteria of blindness and low vision as defined by WHO were included in the study. These children were recruited from 1990 to 2004 from all the Ophthalmology Departments of Ireland, National Council of Blind and Visually impaired. Data was collected from history, detailed ocular examination and investigations including CT, MRI, ultrasound and chromosomal analysis. The prevalence of blindness in 2004 was 0.05% compared to 0.02% in 1989. The aetiologies were divided in (1) genetic, (2) prenatal, (3) perinatal, (4) childhood categories. The genetic group was 33% of the total, (15.63%) had albinism (11%) had retinal dystrophies. The perinatal group of 27% optic nerve hypoplasia, structural anomalies like microphthalmos, anophthalmos comprised of 15.85% and cataract (5.47%). The perinatal group was 26%, cortical blindness (17.45%), ROP (5.5%) and the childhood group comprised of 12.4% of the total. The overall prevalence of childhood blindness and low vision was shown to have increased compared to 1989. The most significant observation was the decrease in childhood blindness due to ROP, owing to the early diagnosis and treatment and an increase in brain blindness due to cortical disease and disability. This has been shown in other studies and is due to increased survival of preterm neonate.

Long chain fatty acid oxidation defects in children: importance of detection and treatment options

BACKGROUND

Mitochondrial beta oxidation plays a major role in energy production. Long chain fatty acid oxidation defects include deficiency of the trifunctional protein (rare) or more commonly defects of the long chain 3-hydroxy acyl-CoA dehydrogenase enzyme (LCHAD). These long chain defects have variable presentations, they may present in the neonate or infant with sudden death, hepatopathy (Reyes disease), hypoketotic hypoglycaemia, rhabdomyolysis, myopathy, cardiomyopathy and with late complications such as peripheral neuropathy, pigmentary retinopathy, retinal degeneration and progressive visual loss. The correct diagnosis at presentation is not only life saving but also allows for the appropriate dietary and other intervention, which may have major effects on outcome.

AIM

Three case reports of patients with long chain fatty acid oxidation defects who have shown significant benefits from treatment are reported.

CONCLUSIONS

These paediatric presentations illustrate the clinical heterogeneity of long chain fatty acid oxidation defects and opportunities for effective management if correctly diagnosed.

The in vitro pharmacology of the peripherally restricted opioid receptor antagonists, alvimopan, ADL 08-0011 and methylnaltrexone

This study characterized the pharmacology of the peripherally restricted opioid receptor antagonists, alvimopan, its metabolite, ADL 08-0011, and methylnaltrexone. The activities of the compounds were investigated with respect to human or guinea pig opioid receptor binding and function in recombinant cell lines and mechanical responsiveness of the guinea pig ileum. Alvimopan and ADL 08-0011 had higher binding affinity than methylnaltrexone at human mu opioid receptors (pK (i) values of 9.6, 9.6, and 8.0, respectively). The compounds had different selectivities for the mu receptor over human delta and guinea pig kappa opioid receptors. ADL 08-0011 had the highest mu receptor selectivity. With respect to their mu opioid receptor functional activity ([(35)S]GTPgammaS incorporation), methylnaltrexone had a positive intrinsic activity, consistent with partial agonism, unlike alvimopan and ADL 08-0011, which had negative intrinsic activities. Alvimopan, ADL 08-0011, and methylnaltrexone antagonized inhibitory responses mediated by the mu opioid agonist, endomorphin-1 (pA (2) values of 9.6, 9.4, and 7.6, respectively) and by U69593, a kappa opioid agonist (pA (2) values of 8.4, 7.2, and 6.7, respectively). In morphine-naive guinea pig ileum, methylnaltrexone reduced, while alvimopan and ADL 08-0011 increased, the amplitude of electrically evoked contractions and spontaneous mechanical activity. In tissue from morphine-dependent animals, alvimopan and ADL 08-0011 increased spontaneous activity to a greater degree than methylnaltrexone. The data suggested that alvimopan-induced contractions resulted predominantly from an interaction with kappa opioid receptors. It is concluded that alvimopan, ADL 08-0011, and methylnaltrexone differ in their in vitro pharmacological properties, particularly with respect to opioid receptor subtype selectivity and intrinsic activity. The clinical significance of the data from this study remains to be determined.

A comparison of the pharmacological properties of guinea-pig and human recombinant 5-HT4 receptors

BACKGROUND AND PURPOSE

5-HT(4) receptor agonists are used therapeutically to treat disorders of reduced gastrointestinal motility. Since such compounds are evaluated in guinea-pigs, we cloned, expressed and pharmacologically characterized the guinea-pig 5-HT(4) and human 5-HT(4(b)) splice variant, which share 95% homology. The functional properties of guinea-pig 5-HT(4(b)) receptors were compared with native receptors in guinea-pig colon.

EXPERIMENTAL APPROACH

Membrane radioligand binding and whole cell cAMP accumulation assays were used to determine the affinities, potencies and intrinsic activities (IA). Contraction of the guinea-pig distal colon longitudinal muscle myenteric plexus preparation (LMMP) was monitored to evaluate functional activity.

KEY RESULTS

pK(i) values for guinea-pig and human recombinant receptors, and guinea-pig striatum 5-HT(4) receptors, were in agreement, as were the potency and IA values for guinea-pig and human 5-HT(4) receptors expressed at a similar density ( approximately 0.2 pmol mg(-1) protein). Tegaserod was a potent (pEC(50)=8.4 and 8.7, respectively), full agonist at both guinea-pig and human 5-HT(4) receptors. In contrast, in the LMMP preparation, tegaserod was a potent, partial agonist (pEC(50)=8.2; IA=66%).

CONCLUSIONS AND IMPLICATIONS

Close agreement between the pharmacological properties of guinea-pig and human 5-HT(4) receptors support the use of guinea-pig model systems for the identification of 5-HT(4) receptor therapeutics. However, the mechanisms underlying the different agonist properties of tegaserod in recombinant and isolated tissue preparations, and the extent to which these impact the clinical efficacy of tegaserod as a prokinetic agent, remain to be determined.

Taxane-resistant lymphoepithelial-like carcinoma: Excellent response to VIP chemotherapy

BACKGROUND

Lymphoepithelial-like carcinoma is a rare tumour type. The optimal treatment for this disease is not known. No effective therapies are described in the literature.

AIMS

This report describes a case of lymphoepithelial-like carcinoma and documents a therapeutic strategy which has proved effective.

RESULTS

The patient was initially treated with a common platinum-based chemotherapy regimen incorporating a taxane (Carbplatin and Docetaxel). Disease stabilization initially occurred but the patient soon progressed. The patient was then treated with VIP chemotherapy and had a complete response.

CONCLUSION

VIP chemotherapy appears to be an effective therapeutic strategy in lymphoepithelial-like carcinoma.

Long term functional and structural outcomes of laser therapy for retinopathy of prematurity

AIMS

To assess the long term functional and structural outcomes of premature babies who received diode laser photocoagulation for threshold retinopathy of prematurity (ROP).

METHODS

25 patients (43 eyes) treated with laser were recalled for assessment at a mean follow up of 11 years. A further seven patients (14 eyes) with subthreshold ROP, which had regressed spontaneously without laser treatment, were also examined. All children underwent distance acuity, near acuity, contrast sensitivity (CS), and colour vision assessments followed by a dilated fundal examination and cycloplegic autorefraction.

RESULTS

The laser treated eyes had a mean distance visual acuity of 0.37 logMAR, a mean near visual acuity of 0.39 logMAR, a mean contrast sensitivity of 1.49 log CS units, and a mean spherical equivalent of -2.10D. An unfavourable distance visual acuity outcome occurred in five eyes (13.5%). An unfavourable near visual acuity outcome was also noted in the five eyes (13.5%) with poor distance visual outcome. 7% had an unfavourable structural outcome. On comparison with the control group, there was no significant difference in near acuity, CS, refraction, or colour vision between the two groups. However, there was a statistically significant difference in terms of distance visual acuity (p = 0.03).

CONCLUSIONS

Laser treated eyes with favourable structural outcome have a good visual outcome. The results show a long term benefit from diode laser photocoagulation in preserving distance and near vision in eyes with threshold ROP.

Diode laser versus cryotherapy in treatment of ROP

Advantages of laser therapy

RetCam image analysis of optic disc morphology in premature infants and its relation to ischaemic brain injury

AIMS

To assess optic disc characteristics in premature infants with and without ischaemic brain injury and to evaluate the role of optic disc morphology in dating the injury.

METHODS

RetCam fundal images, cranial ultrasounds and magnetic resonance imaging (MRI) of 109 premature infants were analysed. The study cohort was divided into subgroups depending on the presence or absence of periventricular leucomalacia (PVL) and intraventricular haemorrhage (IVH). The control group consisted of infants with normal neuroimaging at term and 2 years of age. Using the image analysis software of the RetCam, optic disc diameter (ODD), optic disc area (ODA), and optic cup area (OCA) were measured at 33-34 weeks gestational age. As serial cranial ultrasonography had been performed, it was possible to date the brain injury in those infants with periventricular white matter (PVWM) damage.

RESULTS

Although there was a trend towards reducing ODD, ODA, and OCA with increasing severity of IVH, only the IVH 4 group differed significantly from the controls for these parameters (p = 0.002, p = 0.02, and p = 0.04, respectively). 44.4% of infants with grade 4 IVH had small discs. Only one patient had a large cup in a normal sized disc; this patient had IVH 4. In patients with PVWM damage, the median time of insult was 27 weeks in those with small discs and 28 weeks in those with normal discs. This difference was not significant (p = 0.23).

CONCLUSIONS

Premature infants with IVH 4 have an increased incidence of optic nerve hypoplasia. We found no association between disc morphology and timing of brain injury.

Ahmed valve drainage implant surgery in the management of paediatric aphakic glaucoma

BACKGROUND

Paediatric aphakic glaucoma presents months or years after cataract surgery in children and is a major long term complication. The results of surgical treatment are poor and many children require multiple and repeat procedures with poor visual outcomes.

METHODS

13 children (19 eyes) had Ahmed valve implantation surgery, nine of the children had previous procedures such as cycloablation or trabeculectomy. Mitomycin was used at surgery in some patients and valve needling with Healon GV and 5-fluorouracil in some blebs after surgery. SF(6) gas was also used at the time of surgery in most children to reform the anterior chamber.

RESULTS

12 of the children (18 eyes) achieved intraocular pressure control of 15 mm Hg or less with a valve alone or with additional medical therapy.

CONCLUSION

Ahmed valve implantation surgery alone or in combination with medical therapy is successful and safe in the management of paediatric aphakic glaucoma.

Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems

BACKGROUND

Adherence to hand hygiene standards is poor. Approaches and systems to improve hand hygiene practices warrant testing.

OBJECTIVE

To compare the frequency of use of manually operated and touch-free dispensers of sanitizer for hand hygiene.

METHODS

Manual and touch-free dispensers of alcohol sanitizer were placed in the emergency department and an intensive care unit of a large pediatric hospital for two 2-month periods for each type of dispenser. Counting devices installed in each dispenser and direct observations were used to determine actual frequency of and indications for hand hygiene.

RESULTS

The touch-free dispensers were used significantly more often than were the manual dispensers. The means for the number of episodes of hand hygiene per hour were 4.42 for the touch-free dispensers and 3.33 for the manual dispensers (P=.04); the means for the number of episodes per patient per hour were 2.22 and 1.79, respectively (P=.004); and the means for the number of uses of the dispenser per day were 41.2 and 25.6, respectively (P=.02). However, the overall compliance rate was 38.4% (2136 episodes of hand hygiene per 5568 indications for hand hygiene).

CONCLUSIONS

The type of dispensing system influenced hand hygiene behavior. Nevertheless, overall hand hygiene compliance remained low. In order for interventions to have a major effect on hand hygiene, multiple factors must be considered.

Nosocomial transmission of Mycobacterium tuberculosis in a children's hospital

An infant was admitted for evaluation of respiratory distress and tracheomalacia. After several weeks of hospitalization, both the infant and her mother were diagnosed with culture-positive pulmonary tuberculosis (TB). Sixteen pediatric patients and 293 health care workers were evaluated for exposure to Mycobacterium tuberculosis. Tuberculin skin test conversions occurred in 6.7% of patients and 1.9% of pediatric health care workers. While nosocomial transmission of TB is relatively rare in children's hospitals, this report highlights the differences between TB control efforts in pediatric vs. adult facilities, including the importance of screening the adult visitors of children admitted with suspected TB.

Guidelines for the medical management of Irish children and adolescents with Down syndrome

Down syndrome (DS) is the most common chromosomal cause of developmental disability in Ireland. Children with DS have a high incidence of associated treatable medical disorders where early intervention carries a better outcome. Currently there are no agreed protocols for the screening and management of children and adults with DS in Ireland. A cross-sectional study of 394 children and adolescents was undertaken in the Eastern Regional Health Authority (ERHA) to assess the medical needs of children and adolescents with DS, in order to develop medical management guidelines. This study provides evidence-based data that children and adolescents with DS have a high incidence of treatable medical disorders, which supports the need for the medical management guidelines presented.

A retrospective review of visual outcome and complications in the treatment of retinoblastoma

The aim of this study was to look at the visual outcome and treatment complications of children diagnosed with Retinoblastoma during the years 1985-2003 inclusive. A retrospective review of all patients records was performed. Patient characteristics, treatment methods and complications were recorded. Twenty eight children presented to Temple street Hospital between 1985-2003. Six of these infants had bilateral tumours. The mean age at presentation was 23.7 months. Sixty-nine percent presented with Leucocoria, of these 33% also had a squint. The mean duration of symptoms was only known in 58% and this figure was approximately 19.8 months. Enucleation was performed in 24 eyes of 24 patients. Three patients required adjuvant chemotherapy post enucleation. Two eyes was treated with external beam radiation and one eye with plaque radiotherapy. One eye (second eye) was treated with systemic chemotherapy and radiation. Five eyes of three patients were treated with systemic chemotherapy followed by adjuvant Argon laser, cryotherapy and diode laser to each eye.The complications of each treatment group was recorded. The visual outcome in the salvaged eyes was favourable. There were no deaths recorded. Though chemotherapy with adjuvant local treatments provide adequate treatment for early tumours, enucleation still plays a major role in the treatment of Retinoblastoma. The total eye salvage rate in this study was 29% with an enucleation rate of 90% in unilateral cases and 33% in bilateral cases. Sixty-six percent of bilateral eyes affected were salvaged. Seventy-one percent of tumours were diagnosed after a parent noticed a gross abnormality of the eye. This highlights the possible need for screening for retinoblastoma in the infant population.

Drugs driving--standardized field sobriety tests: a survey of police surgeons in Strathclyde

OBJECTIVE

To determine the opinion of police surgeons within Strathclyde Police to the proposed introduction of Standardized Field Sobriety Tests (SFSTs) in the assessment of suspect drivers.

METHOD

25 police surgeons who attended a full day training programme in respect of 'Drugs and Driving' received a questionnaire relating to the tests. Following analysis of the responses, an identical questionnaire was posted to all 101 registered police surgeons in Strathclyde, resulting in a 45% response and results compared.

RESULTS

Of the conference attendees, 54% of doctors were satisfied with the tests, while 46% expressed reservations. Each test was considered separately, however the Walk and Turn Test and the One Leg Stand Test caused the highest levels of concern from at least 50% of the doctors. POSTAL RESPONSES: 52% were satisfied with the tests, however 48% expressed concerns. Again, the Walk and Turn Test and the One Leg Stand Test were by far the tests causing most concern.

CONCLUSIONS

a significant percentage of police surgeons in Strathclyde have expressed concerns regarding the SFSTs. Irrespective of length of experience and postgraduate qualification, the tests most contentious are the Walk and Turn Test and the One Leg Stand Test.

LASIK surgery in children

AIMS

To report success in the treatment of high myopia in children with LASIK. To report the visual results, complications and postoperative management of children with high myopia.

METHODS

Six children (seven eyes) with high myopia were included in this series. Preoperative and postoperative refraction, visual acuity, and pachymetry were compared.

RESULTS

Six children with high myopia ranging from -5.00DS to -16DS were treated. There were three males and three females. Five children had improved refraction and visual acuity post-LASIK. Age ranged from 2 to 12 years. Five of the children had unilateral amblyopia preoperatively. One had bilateral high myopia.

CONCLUSION

High myopia in children may be treated safely and effectively with LASIK.

Hospital Transmission of Community-Acquired Methicillin-Resistant Staphylococcus aureus among Postpartum Women

Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are being increasingly observed in patients who lack traditional risk factors. We described 8 postpartum women who developed skin and soft-tissue infections caused by MRSA at a mean time of 23 days (range, 4-73 days) after delivery. Infections included 4 cases of mastitis (3 of which progressed to breast abscess), a postoperative wound infection, cellulitis, and pustulosis. The outbreak strains were compared with the prototype CA-MRSA strain MW2 and found to be indistinguishable by pulsed-field gel electrophoresis. All were spa type 131, all contained the staphylococcal chromosomal cassette mec type IV, and all expressed Panton-Valentine leukocidin and staphylococcal enterotoxins C and H. The route of transmission was not discovered: the results of surveillance cultures of samples obtained from employees of the hospital, the hospital environment, and newborns were negative for the outbreak strain. We report that MW2, which was previously limited to the midwestern United States, has spread to the northeastern United States and has become a health care-associated pathogen.

Minimal response of circulating lipids in women with polycystic ovary syndrome to improvement in insulin sensitivity with troglitazone

We hypothesized that the administration of troglitazone (TGZ), an insulin-sensitizing agent of the thiazolidinedione class, would improve dyslipidemia associated with insulin resistance in polycystic ovary syndrome (PCOS). Three hundred and ninety-eight women with PCOS in a multicenter, double-blind trial were randomly assigned to 44 wk of treatment with: placebo or troglitazone (150, 300, or 600 mg/d). We examined the responses of circulating lipid and lipoproteins [total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and triglycerides (TTG)] by treatment arm, and the influence of glycemic parameters on baseline levels and response to treatment. There was a high prevalence of abnormal baseline lipid parameters, as defined by National Cholesterol Education Program guidelines [total cholesterol, > or = 200 mg/dl (35%); LDL-C, > or = 130 mg/dl (31%); HDL-C, <35 mg/dl (15%); TTG, >200 mg/dl (16%)]. Baseline models showed that parameters of insulin action had poor predictive power on lipid parameters. There was no significant response of any of the circulating lipids to treatment with either placebo or one of the troglitazone arms (after correction for multiple analyses). There were favorable, but nonsignificant, trends in HDL-C (increase) and LDL-C (decrease) and a trend toward decreased circulating TTG in the 300- and 600-mg TGZ dose treatment arms, both in an intention to treat analysis (n = 375) and in study completers (44 wk; n = 152). There also was a minimal treatment effect noted when only subjects with abnormal baseline levels were examined, and responders differed little from nonresponders in terms of indices of insulin action. There is a substantial prevalence of clinically recognized dyslipidemia in the population of women with unrecognized PCOS without type 2 diabetes. Treatment with an insulin-sensitizing agent may have minimal impact on circulating lipids. Further surveillance and treatment of abnormal lipid levels may be necessary in these women.

Troglitazone decreases adrenal androgen levels in women with polycystic ovary syndrome

OBJECTIVE

To determine whether amelioration of insulin resistance in polycystic ovary syndrome (PCOS) with the insulin sensitizer troglitazone (TGZ) decreases circulating adrenal androgens (AAs), as reflected by DHEAS levels.

DESIGN

Prospective, randomized, double-blind clinical trial.

SETTING

Multicenter study.

SUBJECT(S)

Three-hundred five women with PCOS.

INTERVENTION(S)

Subjects were randomly assigned to receive either placebo (PBO; n = 73) or TGZ in doses of 150 mg/day (TGZ-150; n = 78), 300 mg/day (TGZ-300; n = 77), or 600 mg/day (TGZ-600; n = 77) for 20 weeks. Blood was sampled before (week 0) and at week 20 of treatment.

MAIN OUTCOME MEASURE(S)

DHEAS, insulin, and glucose levels were determined in the blood samples.

RESULT(S)

There were no differences in age, body mass, or racial composition among the groups. Our results indicate that basal insulin declined in a dose-related fashion. Likewise, TGZ administration caused a dose-related decrease in DHEAS levels. To detect extreme effects, we subsequently subdivided patients receiving PBO or TGZ-600 into tertiles according to initial DHEAS levels. Patients receiving PBO in the lowest (n = 27) and highest (n = 22) DHEAS tertiles experienced a 16.8% +/- 62.0% and a -11.1% +/- 17.4% change in DHEAS levels during the study, respectively. Alternatively, patients with PCOS receiving TGZ-600 in both the lowest (n = 29) and the highest (n = 23) DHEAS tertiles experienced a drop in DHEAS levels (-18.7% +/- 27.2% and -26.4% +/- 17.2%, respectively), a significant difference from PBO.

CONCLUSION(S)

In conclusion, improving the insulin resistance-related hyperinsulinemia of PCOS with TGZ results in a decrease in DHEAS levels, regardless of initial DHEAS level. Whether the observed suppression is the direct result of decreased insulin levels or whether it reflects other direct and indirect effects of TGZ remains to be determined.

Should parents assess the interpersonal skills of doctors who treat their children? A literature review

Medical consultations in which doctors display good interpersonal skills are associated with a wide range of positive health outcomes. Obtaining the perceptions of patients, or parents in paediatric settings, regarding the interpersonal skills demonstrated by their doctors could provide feedback on doctor behaviours that influence health outcomes. It could also offer an alternative to more traditional methods of assessing interpersonal skills, such as using standardized patients. Patient perceptions of doctor interpersonal skills are most commonly obtained through patient-completed satisfaction questionnaires. A literature review was conducted with the aim of examining the potential role of parent perceptions in the evaluation of paediatric interviews. Studies identified were reviewed for information regarding the rationale for obtaining parent perceptions, the reliability and validity of measures used, the association between parent evaluations and specific doctor interview behaviours and the acceptability and feasibility of obtaining this information. Practical applications of the information obtained from parent evaluations were also sought. There was considerable support for the inclusion of patient evaluations in the assessment of the interpersonal skills of medical students and doctors. Reliable and valid measurement of patient evaluations can be obtained and patients are willing to provide this information. A clear association between specific doctor interview behaviours and parent satisfaction ratings was demonstrated. However, the important issue of feasibility and acceptability to doctors and medical students of obtaining patient perceptions of interpersonal skills, was not addressed. Patient evaluations of the interpersonal skills displayed by their doctors should be a component of clinical skills assessments. Information obtained from parents relating to the care of children could provide feedback to doctors regarding their personal interviewing style. In order to make full use of the information obtained from parents, there is a need for further study to establish the sensitivity of parent evaluations and methods to facilitate the process of obtaining this information.