Food insecurity and glycemic goals among Medicare beneficiaries with type 2 diabetes

OBJECTIVE

To examine the association between food insecurity and achieving glycemic goals among Medicare beneficiaries with type 2 diabetes.

METHODS

This study analyzed the nationally representative 2019 Medicare Current Beneficiary Survey of 1340 beneficiaries aged ≥65 years with type 2 diabetes. The binary dependent variable was whether beneficiaries' blood glucose was at target (A1C ≤ 7.5% or average fasting blood glucose of ≤140 mg/dL, all/most of the time). Food insecurity, a binary variable, was adapted based on the USDA's food security questions. A survey-weighted multivariable logistic model, adjusted for sociodemographics and comorbidities, was conducted to estimate predictive margins for comparing prevalence of having above-target blood glucose levels across groups.

RESULTS

Of study beneficiaries, 20.9% reported not achieving glycemic targets. The predictive marginal prevalence of having higher than target blood glucose levels was significantly greater in females over males (23.8% [95% confidence interval [CI], 20.1-27.4] vs 17.6% [14.3-20.9]); those with less than high school education over those with college education (31.0% [23.6-38.3] vs 18.6% [14.8-22.3]); and those reporting food insecurity over their counterparts (33.4% [24.5-42.3] vs 19.1% [16.6-21.7]).

CONCLUSIONS

Sociodemographic disparities related to achieving blood glucose goals were observed. Screening for food insecurity and related interventions should be considered for at-risk beneficiaries with diabetes.

Dissatisfaction of Out-of-Pocket Costs and Problems Paying Medical Bills Among Medicare Beneficiaries With Type 2 Diabetes

Purpose

The purpose of the study was to examine the relationship between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills among Medicare beneficiaries with type 2 diabetes.

Methods

The 2019 Medicare Current Beneficiary Survey Public Use File, a nationally representative sample of Medicare beneficiaries aged ≥65 years with type 2 diabetes, was analyzed (n = 2178). A survey-weighted multivariable logit regression model was conducted to examine the association between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills, adjusted for sociodemographics and comorbidities.

Results

Among study beneficiaries, 12.6% reported problems paying medical bills. Among those with and without problems paying medical bills, 59.5% and 12.8%, respectively, were dissatisfied with out-of-pocket costs. In the multivariable analysis, beneficiaries who were dissatisfied with out-of-pocket costs were more likely to report problems paying medical bills than those who were satisfied. Younger beneficiaries, beneficiaries with lower incomes, those with functional limitations, and those with multiple comorbidities were more likely to report problems paying medical bills.

Conclusions

Despite having health care coverage, more than one-tenth of Medicare beneficiaries with type 2 diabetes reported problems paying medical bills, which raises concerns about delaying or forgoing needed medical care due to unaffordability. Screenings and targeted interventions that identify and reduce financial hardships associated with out-of-pocket costs should be prioritized.

Failure to fail - Perspective from junior faculty preceptors on the challenges of evaluating underperforming students in the experiential learning environment

INTRODUCTION

Preceptors serve as the gatekeepers between individuals progressing from student pharmacist to independent practitioner. This responsibility is challenging if a student is not progressing as required and is at risk of failure. In this article, we will review the potential consequences and barriers of "failing to fail" a student, share the emotions that come with the decision, and suggest actions that may aid in preceptor decision-making.

COMMENTARY

A preceptor's failure to fail a student has a global impact on many parties including the student, their future employer and patients, the preceptor, and the school or college of pharmacy. Despite supportive factors, preceptors may experience an internal struggle about the ripple effect of failing or not failing an experiential student.

IMPLICATIONS

Underperformance in the experiential setting is a complex issue that remains largely unseen due to "failure to fail," a concept that should be researched further in the pharmacy setting. Empowering preceptors, particularly newer preceptors, to assess and manage failing students is possible through increased discussion around the topic and focused preceptor development programs.

Implementing a choose your own adventure activity to improve insulin decision making

INTRODUCTION

The objective of this educational activity was to evaluate the impact of a virtually simulated Choose Your Own Adventure (CYOA) activity on pharmacy student knowledge and confidence of insulin management.

METHODS

An online CYOA activity was created using TypeForm, version 2 (TypeForm SL) for a third-year pharmacy school diabetes elective with 16 enrollees over two course offerings. Through use of interactive storytelling, students used critical thinking skills to make decisions in six simulated patient's care including initiation, counseling, conversions, and titration of multiple types of insulin. Instructor-created surveys were administered to students before and after the activity to assess satisfaction, confidence, and knowledge.

RESULTS

Ten students (62.5%) completed the activity and both pre- and post-surveys. Average total scores on the five-question insulin knowledge quiz improved significantly from 46% to 68% (P = .02). High satisfaction scores were recorded for each item in the post-survey. Student confidence improved in all aspects related to insulin management (P < .001). No differences in knowledge, confidence, or satisfaction were found between students who completed the activity in an in-person vs. virtual classroom.

CONCLUSIONS

CYOA activities can be successfully implemented in an in-person and virtual pharmacy classroom using a digital platform. Students viewed the CYOA activity as an enjoyable, low-stakes learning tool to increase confidence in their decision making. This small study did find knowledge improvements, but further research is needed to fully establish the validity of the knowledge assessments and ensure knowledge gains are sustainable.

Comparison of the Usability, Accuracy, Preference, and Satisfaction of Three Once-Weekly Glucagon-Like Peptide 1 Receptor Agonist Pen Devices in People With Type 2 Diabetes

AIM

This study's aim was to compare the time and accuracy of use and participants' satisfaction and preferences with pen devices for the once-weekly glucagon-like peptide 1 (GLP-1) receptor agonists dulaglutide, exenatide XR BCise, and semaglutide.

MATERIALS AND METHODS

In this triple crossover, open-label, simulated injection study, GLP-1 receptor agonist pen devices were compared, with time and accuracy of use and participants' satisfaction and preferences as primary outcomes. Participants had type 2 diabetes and were naive to GLP-1 receptor agonist therapy. Participants watched instructional videos for each device, demonstrated administration, and then provided feedback after each demonstration. Investigators tracked errors and omissions of demonstration steps for accuracy and time. Differences across devices were compared using univariate mixed models, adjusting for multiple comparisons.

RESULTS

Of the 60 participants, 50% were male, a majority (65%) were Caucasian, and most (65%) had adequate health literacy. Participants rated the dulaglutide device easier to use than those of exenatide XR BCise or semaglutide (P <0.001 for each). Participants expressed greater satisfaction with the dulaglutide device compared with those of exenatide XR BCise or semaglutide (P <0.01 for each). Most participants (75%) preferred the dulaglutide device overall; however, many participants (61%) preferred the size and portability of the semaglutide device. The dulaglutide device took less time to use than the exenatide XR BCise or semaglutide devices (69 vs. 126 and 146 seconds, respectively; P <0.001 for each). Participants were less accurate when using the dulaglutide device.

CONCLUSION

Most participants preferred the dulaglutide device. The dulaglutide device took the least amount of time to demonstrate; however, demonstration accuracy was lower.

Evaluation of an escape room approach to interprofessional education and the opioid crisis

BACKGROUND

The use of an escape room in education helps promote communication, teamwork, and leadership amongst interprofessional learners in a unique and engaging manner; however, it is unknown if this method can change clinical knowledge related to the opioid crisis and interprofessional attitudes. Our objective was to evaluate the use of an interprofessional escape room activity to increase clinical knowledge related to the opioid crisis and to change attitudes toward interprofessional collaboration.

INTERPROFESSIONAL EDUCATION ACTIVITY

The session was developed as part of an interprofessional program at University of Colorado Anschutz Medical Campus. In this educational escape room activity, teams of interprofessional students solved six puzzles to gain knowledge of the opioid crisis. Knowledge gains were assessed using a pretest and posttest, while changes in interprofessional attitudes were assessed using the Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) instrument.

DISCUSSION

Of the 88 total participants, 70 students from six different health professions completed both the pretest and posttest and were included in the analysis. Knowledge of the opioid crisis improved, particularly in identifying signs of opioid overdose. Overall, SPICE-R ratings increased, which was driven by improvement in understanding professional roles and responsibilities.

IMPLICATIONS

The use of an interprofessional escape room as an educational method was effective in increasing some aspects of opioid crisis related knowledge and enhancing attitudes toward interprofessional collaboration. The educational model is applicable to various topics and interprofessional groups.

Bridging health disparities: a national survey of ambulatory care pharmacists in underserved areas

Background

There is a shortage of primary care medical providers, particularly in rural communities and communities of racial and ethnic minority groups. Clinical pharmacists can help fill gaps in care among these vulnerable populations.

Objective

To identify characteristics of ambulatory care pharmacists that pursue and maintain employment within underserved areas.

Methods

An original survey was distributed nationwide to ambulatory care clinical pharmacists in underserved settings. Respondent characteristics were analyzed using descriptive statistics.

Results

Of the 111 completed surveys, a majority of respondents were White, non-Hispanic, female, with English as their only spoken language. A majority of pharmacists completed a clinical experience or specialized training focused on underserved care prior to their position. The top three motivators for pharmacists accepting their clinical position as well as staying at their job were passion for caring for underserved populations, the presence of a faculty appointment, or the freedom and flexibility of advanced clinical roles.

Conclusions

With a large majority of our respondents identifying as White and unilingual, there remains a large opportunity to increase diversity in the clinical pharmacy ambulatory care workforce caring for underserved populations. There is an observed correlation between early experiential or specialized training in underserved care and pharmacists pursuing employment in these areas. Thus, one potential long-term strategy to diversify and grow the ambulatory care clinical pharmacist workforce in underserved settings is for clinical practice sites to partner with colleges of pharmacy to recruit and maintain quality individuals who can meet the needs of diverse patient populations as well as expand student and resident training opportunities in underserved settings.

Inelastic electron tunneling via molecular vibrations in single-molecule transistors

In single-molecule transistors, we observe inelastic cotunneling features that correspond energetically to vibrational excitations of the molecule, as determined by Raman and infrared spectroscopy. This is a form of inelastic electron tunneling spectroscopy of single molecules, with the transistor geometry allowing in situ tuning of the electronic states via a gate electrode. The vibrational features shift and change shape as the electronic levels are tuned near resonance, indicating significant modification of the vibrational states. When the molecule contains an unpaired electron, we also observe vibrational satellite features around the Kondo resonance.

Electrical Characterization of Metal-Molecule-Silicon Junctions

Direct assembly of molecules onto silicon surfaces is of particular interest for potential employment in hybrid organic-semiconductor devices. In the study we report here, aryl diazonium salts were used to assemble covalently bound molecular groups on a hydride-passivated, oxide-free n-type Si(111) surface. The reaction of 4-(trimethylsilylethynyl)benzenediazonium tetrafluoroborate generates a molecular layer of 4-(trimethylsilylethynyl)phenylene (TMS-EP) on the n++-Si(111) surface. The monolayer modifies the electrical properties of the interface and exhibits nonlinear current-voltage characteristics, as compared with the ohmic behavior observed from metal-n++-Si(111) junctions. The result of current-voltage measurements at variable temperatures (from 300 to 10 K) on samples made with the TMS-EP molecule does not show significant thermally-activated transport, indicating that tunneling is the dominant transport mechanism. The measured data is compared to a tunneling model.

Exciton-mediated hydrosilylation on photoluminescent nanocrystalline silicon

A novel white light-promoted reaction using photoluminescent nanocrystalline silicon enables the hydrosilylation of alkenes and alkynes, providing stabilization of the porous silicon without significant loss of the photoemissive qualities of the material. Photopatterning and lithographic fabrication of isolated porous silicon structures are made possible. Experiments and observations are presented which indicate that the light promoted hydrosilylation reaction is unique to photoluminescent silicon, and does not function on nonemissive material. Hydrosilylation using a reactive center generated from a surface-localized exciton is proposed based upon experimental evidence, explaining the photoluminescence requirement. Indirect excitons formed by light absorption mediate the formation of localized electrophilic surface states which are attacked by incoming alkene or alkyne nucleophiles. Supra-band gap charge carriers have sufficient energy to react with nucleophilic alkenes and alkynes, thereupon causing Si-C bond formation, an irreversible event. The light-promoted hydrosilylation reaction is quenched by reagents that quench the light emission from porous silicon, via both charge transfer and energy transfer pathways.

Penetrating missile injuries of the brachial plexus

We studied a consecutive series of 58 patients with penetrating missile injuries of the brachial plexus to establish the indications for exploration and review the results of operation. At a mean of 17 weeks after the initial injury, 51 patients were operated on for known or suspected vascular injury (16), severe persistent pain (35) or complete loss of function in the distribution of one or more elements of the brachial plexus (51). Repair of the nerve and vascular lesions abolished, or significantly relieved, severe pain in 33 patients (94%). Of the 36 patients who underwent nerve graft of one or more elements of the plexus, good or useful results were obtained in 26 (72%). Poor results were observed after repairs of the medial cord and ulnar nerve, and in patients with associated injury of the spinal cord. Neurolysis of lesions in continuity produced good or useful results in 21 of 23 patients (91%). We consider that a vigorous approach is justified in the treatment of penetrating missile injury of the brachial plexus. Primary intervention is mandatory when there is evidence of a vascular lesion. Worthwhile results can be achieved with early secondary intervention in patients with debilitating pain, failure to progress and progression of the lesion while under observation. There is cause for optimism in nerve repair, particularly of the roots C5, C6 and C7 and of the lateral and posterior cords, but the prognosis for complete lesions of the plexus associated with damage to the cervical spinal cord is particularly poor.

A novel leukocyte adhesion deficiency caused by expressed but nonfunctional beta2 integrins Mac-1 and LFA-1

In the leukocyte adhesion deficiency (LAD)-1 syndrome, there is diminished expression of beta2(CD18) integrins. This is caused by lesions in the beta2-subunit gene and gives rise to recurrent bacterial infections, impaired pus formation, and poor wound healing. We describe a patient with clinical features compatible with a moderately severe phenotype of LAD-1 but who expresses the beta2 integrins lymphocyte function- associated molecule (LFA)-1 and Mac-1 at 40%-60% of normal levels. This level of expression should be adequate for normal integrin function, but both the patient's Mac-1 on neutrophils and LFA-1 on T cells failed to bind ligands such as fibrinogen and intercellular adhesion molecule (ICAM)-1, respectively, or to display a beta2-integrin activation epitope after adhesion-inducing stimuli. Unexpectedly, divalent cation treatment induced the patient's T cells to bind to ICAM-2 and ICAM-3. Sequencing of the patient's two CD18 alleles revealed the mutations S138P and G273R. Both mutations are in the beta2-subunit conserved domain, with S138P a putative divalent cation coordinating residue in the metal ion-dependent adhesion site (MIDAS) motif. After K562 cell transfection with alpha subunits, the mutated S138P beta subunit was coexpressed but did not support function, whereas the G273R mutant was not expressed. In summary, the patient described here exhibits failure of the beta2 integrins to function despite adequate levels of cell-surface expression.

LFA-1-mediated adhesion is regulated by cytoskeletal restraint and by a Ca2+-dependent protease, calpain

The activity of integrins on leukocytes is kept under tight control to avoid inappropriate adhesion while these cells are circulating in blood or migrating through tissues. Using lymphocyte function-associated antigen-1 (LFA-1) on T cells as a model, we have investigated adhesion to ligand intercellular adhesion molecule-1 induced by the Ca2+ mobilizers, ionomycin, 2, 5-di-t-butylhydroquinone, and thapsigargin, and the well studied stimulators such as phorbol ester and cross-linking of the antigen-specific T cell receptor (TCR)-CD3 complex. We report here that after exposure of T cells to these agonists, integrin is released from cytoskeletal control by the Ca2+-induced activation of a calpain-like enzyme, and adhesive contact between cells is strengthened by means of the clustering of mobilized LFA-1 on the membrane. We propose that methods of leukocyte stimulation that cause Ca2+ fluxes induce LFA-1 adhesion by regulation of calpain activity. These findings suggest a mechanism whereby engagement of the TCR could promote adhesion strengthening at an early stage of interaction with an antigen-presenting cell.

Total shoulder replacement in rheumatoid disease: 7- to 13-year follow-up of 37 joints

We made a prospective study of 58 consecutive Neer II total shoulder replacements in 49 rheumatoid patients. Cemented glenoid and press-fit humeral components had been used. After a mean follow-up of 9.5 years (7 to 13), 11 patients (15 shoulders) had died, one shoulder had been arthrodesed and five patients (five shoulders) had been lost to follow-up. Of the remaining 37 shoulders 29 were painfree or had only slight discomfort, four had pain on unusual activity, and four had moderate or severe pain. There were satisfactory improvements in the mean range of active elevation (53 degrees to 75 degrees) and external rotation (5 degrees to 38 degrees); satisfactory performance of the activities of daily living had been maintained throughout follow-up. Radiographs showed loosening in ten shoulders of nine glenoid and nine humeral components but of these only three had significant symptoms. Three loose glenoid components and two loose humeral components required revision. We consider that the Neer total shoulder replacement provides a reasonable medium to long-term outcome in rheumatoid arthritis, but recommend that the humeral component should be routinely cemented.

Fractional allele loss data indicate distinct genetic populations in the development of non-small-cell lung cancer

Allelic imbalance or loss of heterozygosity (LOH) has been widely used to assess genetic instability in tumours, and high LOH on chromosome arms 3p, 9p and 17p has been considered to be a common event in non-small-cell lung cancer (NSCLC). We have investigated allelic imbalance in 45 NSCLCs using 92 microsatellite markers on 38 chromosome arms. LOH of 38% was observed on 3p using nine markers, 58% on 9p using 15 markers and 38% on 17p using five markers. Fractional allele loss (FAL) has been calculated for each tumour (FAL is the number of chromosome arms showing LOH/number of informative chromosome arms) and a median FAL value of 0.09 was obtained in the 45 NSCLCs studied. The LOH data were examined on the basis of FAL scores: low FAL (LFAL) (0.00-0.04), medium FAL (MFAL) (0.05-0.13) and high FAL (HFAL) (0.14-0.45) based symmetrically around the median FAL value of 0.09. Tumours with HFAL values showed a very clear polarisation of the LOH data on chromosome arms 3p, 9p and 17p, such that 80% showed loss on 3p, 80% on 9p and 73% on 17p. These incidences of LOH were significantly higher than would be expected, since overall genetic instability in these HFAL tumours ranged from 14% to 45% LOH. Nine of the 14 patients in the LFAL group were found to have no LOH on 3p, 9p or 17p, but five of these had LOH at other sites: i.e. LOH on 5p, 5q, 8p, 13q, 16q and 19q. These results indicate that LFAL patients form a new subset of NSCLC tumours with distinct molecular-initating events, and may represent a discrete genetic population.

T cell adhesion to intercellular adhesion molecule-1 (ICAM-1) is controlled by cell spreading and the activation of integrin LFA-1

Many leukocyte integrins require activation before they can adhere to their ligands. For example, stimulation of T cells enables the integrin LFA-1 to bind to ligand. This study compares two well known protocols for inducing T cell LFA-1 mediated adhesion to intercellular adhesion molecule-1 (ICAM)-1. We how that treatment with high concentrations of the divalent cation Mg2+ induces a high affinity state of LFA-1, which is reflected in the binding of soluble ICAM-1 and correlates with the expression of the epitope recognized by mAb 24. The second stimulation protocol with the phorbol ester phorbol-12,13-dibutyrate (PDBu) does not induce a high affinity state of LFA-1, and in this situation, adhesion is dependent on cell spreading and intracellular events involving protein kinase C, [Ca2+]i, and actin polymerization. These low affinity LFA-1 receptors are responsible for the initial contact with immobilized ligand because, unlike the Mg2+-stimulated receptors, adhesion is not blocked by soluble ICAM-1. Finally, we used a third method of inducing LFA-1-mediated adhesion by stimulation of T cells through the TCR/CD3 complex. This procedure, which is considered to be a more physiologic trigger for LFA-1 activation, resembles the phorbol ester protocol in that high affinity LFA-1 receptors are not induced and cell adhesion depends on involvement of the cytoskeleton and cell spreading.

T cell adhesion to intercellular adhesion molecule-1 (ICAM-1) is controlled by cell spreading and the activation of integrin LFA-1

Many leukocyte integrins require activation before they can adhere to their ligands. For example, stimulation of T cells enables the integrin LFA-1 to bind to ligand. This study compares two well known protocols for inducing T cell LFA-1 mediated adhesion to intercellular adhesion molecule-1 (ICAM)-1. We how that treatment with high concentrations of the divalent cation Mg2+ induces a high affinity state of LFA-1, which is reflected in the binding of soluble ICAM-1 and correlates with the expression of the epitope recognized by mAb 24. The second stimulation protocol with the phorbol ester phorbol-12,13-dibutyrate (PDBu) does not induce a high affinity state of LFA-1, and in this situation, adhesion is dependent on cell spreading and intracellular events involving protein kinase C, [Ca2+]i, and actin polymerization. These low affinity LFA-1 receptors are responsible for the initial contact with immobilized ligand because, unlike the Mg2+-stimulated receptors, adhesion is not blocked by soluble ICAM-1. Finally, we used a third method of inducing LFA-1-mediated adhesion by stimulation of T cells through the TCR/CD3 complex. This procedure, which is considered to be a more physiologic trigger for LFA-1 activation, resembles the phorbol ester protocol in that high affinity LFA-1 receptors are not induced and cell adhesion depends on involvement of the cytoskeleton and cell spreading.

Shotgun wounds of the limbs

Shotgun blasts may cause devastating injuries in civilian trauma practice. We have reviewed 23 consecutive patients with 28 deliberate shotgun wounds to limbs treated over a 4-year period. Wounds were categorized using the Red Cross wound classification. Twenty wounds were high-energy transfer grade 2 and 3 injuries: eight involved only the soft tissues (five category 2ST, three category 3ST), 10 wounds involved fractures (two category 2F, seven category 3F, one category 3VF), and three wounds involved major vessel injury (two category 3V, one category 3VF). Category 2ST and 3ST wounds were managed successfully with thorough wound excision of devitalized tissue, fasciotomy, and early wound closure. The more complex category 3F, 3V and 3VF wounds required a multidisciplinary approach to their management. Three lower limbs (category 3F, 3V, and 3VF wounds) with associated major nerve injury were amputated at the first operation; there were no cases of secondary amputation. Of the salvaged limbs, those with category 3F injury at or below the level of the elbow or knee had poor functional results.

Gulf war wounds: application of the Red Cross wound classification

The Red Cross wound classification was applied to 63 casualties requiring surgery in the recent Gulf war. The majority of wounds affect only soft tissue, caused predominantly by antipersonnel fragments. Bullet wounds were fewer but tended to be more severe, often involving a fracture or vascular damage. We recommend minor modification to the classification to include scoring of significant neurological injury. Further, we feel that by recording the distribution of all wounds as well as scoring the casualty's two worst injuries, the incidence and pattern of multiple wounds are ascertained, which is useful in military surgical research. We believe that the Red Cross wound classification is valuable in assessing a wound as part of a secondary survey, but that this wound score has little part to play in triage. It may help to decide management of individual wounds in clinical practice and is useful for recording the nature of wounds for future analysis.

Effects of a videotape feedback package on the peer interactions of children with serious behavioral and emotional challenges

Peer interactions are among the greatest challenges experienced by children who have severe emotional and behavioral problems. This study evaluated an intervention package designed to increase the ratio of these children's desirable to undesirable interactions. The package included three principal components: (a) observation of videotapes following regularly scheduled peer activity sessions; (b) self-evaluation of the children's peer interactions observed on the videotapes; and (c) delayed feedback and reinforcement for desirable peer interactions. Five students from two elementary schools participated. Multiple baseline designs and one reversal were used to evaluate the effects of the intervention package. The results showed that the intervention produced lower levels of undesirable peer interactions and higher ratios of desirable to undesirable interactions for all participants. The results are discussed in regard to their conceptual and applied implications and in terms of specific directions for future research.

Penetrating missile injuries in the Gulf war 1991

During the recent Gulf war 63 patients with penetrating missile injuries (including 29 Iraqi prisoners of war) underwent operation in a British Army Field Hospital. Their injuries and initial operative management are reported. Fifty-one casualties (81 per cent) suffered an average of nine wounds (range 1-45) due to fragmentation weapons, and 12 casualties sustained bullet wounds. All wounds were explored following the established principles of war surgery. The extremities were involved in 48 patients (76 per cent). Eight compound long bone fractures were managed with external skeletal fixators applied at the time of initial operation. Laparotomy was performed on seven patients, one of whom died. The average duration of operation was 77 min for shrapnel wounds and 85 min for bullet wounds.

Ciguatera fish poisoning: treatment with intravenous mannitol

Intravenous mannitol was given to 16 patients with acute ciguatera fish poisoning requiring hospital admission. Thirteen patients (81%) presented with sensory and neuromuscular symptoms; paraesthesiae and pain and weakness in the lower limbs were predominant features. Mannitol had little effect upon gastrointestinal manifestations, but a marked reduction was observed in the expected duration of neurological symptoms. Although these results are empirical and uncontrolled, they suggest that mannitol infusion may be effective in altering the clinical course of acute ciguatera fish poisoning.

Tension pneumothorax complicating pulmonary hydatid disease in childhood

The case of a 3-year-old girl with bilateral pulmonary hydatid disease presenting as a tension pneumothorax is described. This is a rare but serious complication of hydatid disease in the pediatric age group which may arise as a result of rapid growth of the cyst in the lung and low resistance to its expansion. Prompt relief of the pneumothorax with intercostal drainage is advocated, followed by early surgical removal of any suspected cyst to avoid further complication.

Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial

One hundred and thirty-seven consecutive acute superficial abscesses were randomly allocated to incision, curettage and primary suture without parenteral antibiotics (64 cases) or to conventional treatment with incision, drainage and dressings (73 cases). Wound healing was faster; 7.0 days: 25.1 days (P less than 0.01, Wilcoxon's rank sum test), the number of hospital visits was smaller; 3.8 visits: 11.1 visits (P less than 0.01) and the time off work was shorter; 4.0 days: 14.1 days (P less than 0.01) in the group treated by primary closure compared with those managed conventionally. In this study no complications attributable to the withholding of antibiotics occurred. Incision and primary closure of abscesses is safe and more economic than conventional drainage. Routine antibiotic cover is not necessary.

Infection after abdominal surgery: five year prospective study

A total of 1504 consecutive abdominal operations were studied prospectively over a five year period. The incidence of wound (2.8%) and intraperitoneal (0.8%) infections was low compared with contemporary reports. It is difficult to justify modifying existing practice on the basis of small controlled clinical trials when information from accurate audit discloses results superior to those of experimental studies.