Chemical kinetics of silver diammine fluoride in demineralization and remineralization solutions-an in vitro study

Introduction

Silver Diammine Fluoride (SDF) is a clinical minimal intervention to manage dentin caries. Its chemistry in demineralization conditions has been investigated widely, but far less in remineralization conditions. The aim was to investigate and compare the chemical reactions when SDF is added to remineralization and demineralization solutions.

Methods

0.01 ml SDF (Riva Star) was added to deionized water (DW); demineralization (DS = pH4) and remineralization (RS = pH7.0) solutions. The time sequence of concentrations of NH4+, F-, and Ag+ were measured using ion selective electrodes (ISEs) every 2 min. The pH was also measured. Precipitates were characterized using x-ray Diffraction (XRD) and, 31P and 19F nuclear magnetic resonance spectroscopy (NMR).

Results

The concentrations of NH4+ and Ag+ showed decreasing trends in DW (-0.12 and -0.08 mM/h respectively), and in DS (-1.06 and -0.5 mM/h respectively); with corresponding increase in F- concentration (0.04 and 0.7 mM/h respectively). However, in RS, NH4+ concentration showed little change (0.001 mM/h), and Ag+ and F- concentrations were negligible. XRD results showed that precipitates (in RS only) contained AgCl, and metallic Ag. NMR showed that fluorapatite/carbonated fluorapatite (FAP/CFAP) were formed. The pH increased after SDF addition in all three solutions.

Discussion

SDF dissolved to release NH4+, F- and Ag + . In DW and DS, NH4+ combined with Ag+ to form diamminesilver, causing an increase of F- and pH. In RS, F- reacted with Ca2+ and (PO)43- to form FAP/CFAP, and Ag+ reacted with Cl- to form AgCl/Ag. These suggests why SDF is effective in managing dentin caries.

Characterization of chemical reactions of silver diammine fluoride and hydroxyapatite under remineralization conditions

Introduction

Silver Diammine Fluoride (SDF) is a clinically used topical agent to arrest dental caries. However, the kinetics of its chemical interactions with hydroxyapatite (HA), the principal inorganic component of dental enamel, are not known. The aim was to characterize the step-wise chemical interactions between SDF and HA powder during the clinically important process of remineralization.

Methods

Two grams of HA powder were immersed in 10 ml acetic acid pH = 4.0 for 2 h to mimic carious demineralization. The powder was then washed and dried for 24 h and mixed with 1.5 ml SDF (Riva Star) for 1 min. The treated powder was then air-dried for 3 min, and 0.2 g was removed and stored in individual tubes each containing 10 ml remineralizing solution. Powder was taken from each tube at various times of exposure to remineralization solution (0 min, 10 min, 2 h, 4 h, 8 h, 24 h, and 10 days), and characterized using Magic Angle Spinning-Nuclear Magnetic Resonance (MAS-NMR) spectroscopy.

Results and discussion

19F MAS-NMR spectra showed that calcium fluoride (CaF2) started to form almost immediately after HA was in contact with SDF. After 24 h, the peak shifted to -104.5 ppm suggesting that fluoride substituted hydroxyapatite (FSHA) was formed with time at the expense of CaF2. The 31P MAS-NMR spectra showed a single peak at 2.7 ppm at all time points showing that the only phosphate species present was crystalline apatite. The 35Cl MAS-NMR spectra showed formation of silver chloride (AgCl) at 24 h. It was observed that after the scan, the whitish HA powder changed to black color. In conclusion, this time sequence study showed that under remineralization conditions, SDF initially reacted with HA to form CaF2 which is then transformed to FSHA over time. In the presence of chloride, AgCl is formed which is subsequently photo-reduced to black metallic silver.

Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis

Importance

Modulation of intestinal microbiome by administering probiotics, prebiotics, or both may prevent morbidity and mortality in premature infants.

Objective

To assess the comparative effectiveness of alternative prophylactic strategies through a network meta-analysis (NMA) of randomized clinical trials.

Data Sources

MEDLINE, EMBASE, Science Citation Index Expanded, CINAHL, Scopus, Cochrane CENTRAL, and Google Scholar from inception until May 10, 2023.

Study Selection

Eligible trials tested probiotics, prebiotics, lactoferrin, and combination products for prevention of morbidity or mortality in preterm infants.

Data Extraction and Synthesis

A frequentist random-effects model was used for the NMA, and the certainty of evidence and inferences regarding relative effectiveness were assessed using the GRADE approach.

Main Outcomes and Measures

All-cause mortality, severe necrotizing enterocolitis, culture-proven sepsis, feeding intolerance, time to reach full enteral feeding, and duration of hospitalization.

Results

A total of 106 trials involving 25 840 preterm infants were included. Only multiple-strain probiotics were associated with reduced all-cause mortality compared with placebo (risk ratio [RR], 0.69; 95% CI, 0.56 to 0.86; risk difference [RD], -1.7%; 95% CI, -2.4% to -0.8%). Multiple-strain probiotics alone (vs placebo: RR, 0.38; 95% CI, 0.30 to 0.50; RD, -3.7%; 95% CI, -4.1% to -2.9%) or in combination with oligosaccharides (vs placebo: RR, 0.13; 95% CI, 0.05 to 0.37; RD, -5.1%; 95% CI, -5.6% to -3.7%) were among the most effective interventions reducing severe necrotizing enterocolitis. Single-strain probiotics in combination with lactoferrin (vs placebo RR, 0.33; 95% CI, 0.14 to 0.78; RD, -10.7%; 95% CI, -13.7% to -3.5%) were the most effective intervention for reducing sepsis. Multiple-strain probiotics alone (RR, 0.61; 95% CI, 0.46 to 0.80; RD, -10.0%; 95% CI, -13.9% to -5.1%) or in combination with oligosaccharides (RR, 0.45; 95% CI, 0.29 to 0.67; RD, -14.1%; 95% CI, -18.3% to -8.5%) and single-strain probiotics (RR, 0.61; 95% CI, 0.51 to 0.72; RD, -10.0%; 95% CI, -12.6% to -7.2%) proved of best effectiveness in reduction of feeding intolerance vs placebo. Single-strain probiotics (MD, -1.94 days; 95% CI, -2.96 to -0.92) and multistrain probiotics (MD, -2.03 days; 95% CI, -3.04 to -1.02) proved the most effective in reducing the time to reach full enteral feeding compared with placebo. Only single-strain and multistrain probiotics were associated with greater effectiveness compared with placebo in reducing duration of hospitalization (MD, -3.31 days; 95% CI, -5.05 to -1.58; and MD, -2.20 days; 95% CI, -4.08 to -0.31, respectively).

Conclusions and Relevance

In this systematic review and NMA, moderate- to high-certainty evidence demonstrated an association between multistrain probiotics and reduction in all-cause mortality; these interventions were also associated with the best effectiveness for other key outcomes. Combination products, including single- and multiple-strain probiotics combined with prebiotics or lactoferrin, were associated with the largest reduction in morbidity and mortality.

Impact of 2019 Novel Coronavirus (2019-nCov) Pandemic and Lockdown on Parents and Caregivers in Ontario, Canada

The COVID-19 pandemic has impacted parents' and children's well-being. This study aimed to evaluate the impact of the COVID-19 pandemic and its preventive measures on children's well-being and their parents' anxiety level. Parents/caregivers were invited to respond to a self-administered survey. The primary outcome was to assess the rate and severity of parental anxiety during the pandemic/lockdown. Four hundred and thirty parents completed the survey. Ninety-two (21%) and 10 (2%) parents reported that their children gained or lost weight during the pandemic, respectively. Eighty-one (19%) parents reported a regression in their children's developmental milestones, particularly in toileting, speech, and social interaction. The GAD-7 mean scores increased by 2.9 points (95% CI [2.5, 3.25]; P < .001) in comparison with prepandemic scores. Adjusted multivariable analysis showed that having children with psychological conditions and a maternal education level less than a university degree were significantly associated with higher parental anxiety.

Quality and credibility of clinical practice guidelines recommendations for the management of neonatal hypoglycemia. A protocol for a systematic review and recommendations' synthesis

INTRODUCTION

Hypoglycemia is one of the most frequent metabolic conditions in neonates. Clinical practice guidelines (CPGs) influence clinical practice as high-quality CPGs facilitate the use of evidence in practice. This proposed study aims to systematically identify and appraise CPGs and CPG recommendations (CPGRs) for treating neonatal hypoglycemia (NH).

METHODS AND ANALYSIS

We will conduct searches in MEDLINE, EMBASE, CINAHL, Cochrane Library, LILACS (Latin American & Caribbean Health Sciences Literature), and Epistemonikos. Authors will search CPGs-specific databases and grey literature. Two reviewers will independently perform the titles and abstract screening, full-text review, and data extraction. Two appraisers will assess the quality of the CPGs and their recommendations using AGREE II (Appraisal of Guidelines Research and Evaluation) and AGREE-REX (Appraisal of Guidelines Research and Evaluation-Recommendations Excellence) instruments. Scores of ≥ 60% in the rigour of development domain will be considered for defining high-quality with AGREE II tool. CPGRs with scores >60% in the three domains will be used to determine high quality with the AGREE REX tool. We will perform a synthesis of the CPGRs to identify the consistency among the CPGRs and the methodological quality of primary studies that support them.

ETHICS AND DISSEMINATION

The results will help us to identify the methodological and quality gaps in the existing CPGs for the treatment of NH. Our findings will be submitted to peer-review journals and presented at academic conferences. Based on the study design, approval from the institutional ethics board is not required for this project.

TRIAL REGISTRATIONS

Systematic Review Registration Number (PROSPERO): CRD 42021239921.

Medications for the treatment of pulmonary arterial hypertension: a systematic review and network meta-analysis

BACKGROUND

There is no consensus on the most effective treatments of pulmonary arterial hypertension (PAH). Our objective was to compare effects of medications for PAH.

METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Clinicaltrials.gov from inception to December 2021. We performed a frequentist random-effects network meta-analysis on all included trials. We rated the certainty of the evidence using the Grades of Recommendation, Assessment, Development, and Evaluation approach.

RESULTS

We included 53 randomised controlled trials with 10 670 patients. Combination therapy with endothelin receptor antagonist (ERA) plus phosphodiesterase-5 inhibitors (PDE5i) reduced clinical worsening (120.7 fewer events per 1000, 95% CI 136.8-93.4 fewer; high certainty) and was superior to either ERA or PDE5i alone, both of which reduced clinical worsening, as did riociguat monotherapy (all high certainty). PDE5i (24.9 fewer deaths per 1000, 95% CI 35.2 fewer to 2.1 more); intravenous/subcutaneous prostanoids (18.3 fewer deaths per 1000, 95% CI 28.6 fewer deaths to 0) and riociguat (29.1 fewer deaths per 1000, 95% CI 38.6 fewer to 8.7 more) probably reduce mortality as compared to placebo (all moderate certainty). Combination therapy with ERA+PDE5i (49.9 m, 95% CI 25.9-73.8 m) and riociguat (49.5 m, 95% CI 17.3-81.7 m) probably increase 6-min walk distance as compared to placebo (moderate certainty).

CONCLUSION

Current PAH treatments improve clinically important outcomes, although the degree and certainty of benefit vary between treatments.

401 Squamous Cell Carcinoma Surgery During a Global Pandemic – a Single UK Tertiary Centre Experience

Aim

Method

Results

Conclusions

Outcomes of long-term von Willebrand factor prophylaxis use in von Willebrand disease: A systematic literature review

BACKGROUND

Von Willebrand Disease (VWD) is a common inherited bleeding disorder. Patients with VWD suffering from severe bleeding may benefit from the use of secondary long-term prophylaxis.

AIM

Systematically summarize the evidence on the clinical outcomes of secondary long-term prophylaxis in patients with VWD and severe recurrent bleedings.

METHODS

We searched Medline and EMBASE through October 2019 for relevant randomized clinical trials (RCTs) and comparative observational studies (OS) assessing the effects of secondary long-term prophylaxis in patients with VWD. We used Cochrane Risk of Bias (RoB) tool and the RoB for Non-Randomized Studies of interventions (ROBINS-I) tool to assess the quality of the included studies. We conducted random-effects meta-analyses and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

We included 12 studies. Evidence from one placebo controlled RCT suggested that VWD prophylaxis as compared to no prophylaxis reduced the rate of bleeding episodes (Rate ratio [RR], .24; 95% confidence interval [CI], .17-.35; low certainty evidence), and of epistaxis (RR, .38; 95%CI, .21-.67; moderate certainty evidence), and may increase serious adverse events RR 2.73 (95%CI .12-59.57; low certainty). Evidence from four before-and-after studies in which researchers reported comparative data suggested that VWD prophylaxis reduced the rate of bleeding (RR .34; 95%CI, .25-.46; very low certainty evidence).

CONCLUSION

VWD prophylaxis treatment seems to reduce the risk of spontaneous bleeding, epistaxis, and hospitalizations. More RCTs should be conducted to increase the certainty in these benefits.

Gynecologic and obstetric management of women with von Willebrand disease: summary of 3 systematic reviews of the literature

von Willebrand disease (VWD) disproportionately affects women because of the potential for heavy menstrual bleeding (HMB), delivery complications, and postpartum hemorrhage (PPH). To systematically synthesize the evidence regarding first-line management of HMB, treatment of women requiring or desiring neuraxial analgesia, and management of PPH. We searched Medline and EMBASE through October 2019 for randomized trials, comparative observational studies, and case series comparing the effects of desmopressin, hormonal therapy, and tranexamic acid (TxA) on HMB; comparing different von Willebrand factor (VWF) levels in women with VWD who were undergoing labor and receiving neuraxial anesthesia; and measuring the effects of TxA on PPH. We conducted duplicate study selection, data abstraction, and appraisal of risk of bias. Whenever possible, we conducted meta-analyses. We assessed the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. We included 1 randomized trial, 3 comparative observational studies, and 10 case series. Moderate-certainty evidence showed that desmopressin resulted in a smaller reduction of menstrual blood loss (difference in mean change from baseline, 41.6 [95% confidence interval, 16.6-63.6] points in a pictorial blood assessment chart score) as compared with TxA. There was very-low-certainty evidence about how first-line treatments compare against each other, the effects of different VWF levels in women receiving neuraxial anesthesia, and the effects of postpartum administration of TxA. Most of the evidence relevant to the gynecologic and obstetric management of women with VWD addressed by most guidelines is very low quality. Future studies that address research priorities will be key when updating such guidelines.

Surgical management of patients with von Willebrand disease: summary of 2 systematic reviews of the literature

von Willebrand disease (VWD) is the most common inherited bleeding disorder. The management of patients with VWD who are undergoing surgeries is crucial to prevent bleeding complications. We systematically summarized the evidence on the management of patients with VWD who are undergoing major and minor surgeries to support the development of practice guidelines. We searched Medline and EMBASE from inception through October 2019 for randomized clinical trials (RCTs), comparative observational studies, and case series that compared maintaining factor VIII (FVIII) levels or von Willebrand factor (VWF) levels at >0.50 IU/mL for at least 3 days in patients undergoing major surgery, and those with options for perioperative management of patients undergoing minor surgery. Two authors screened and abstracted data and assessed the risk of bias. We conducted meta-analyses when possible. We evaluated the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We included 7 case series for major surgeries and 2 RCTs and 12 case series for minor surgeries. Very-low-certainty evidence showed that maintaining FVIII levels or VWF levels of >0.50 IU/mL for at least 3 consecutive days showed excellent hemostatic efficacy (as labeled by the researchers) after 74% to 100% of major surgeries. Low- to very-low-certainty evidence showed that prescribing tranexamic acid and increasing VWF levels to 0.50 IU/mL resulted in fewer bleeding complications after minor procedures compared with increasing VWF levels to 0.50 IU/mL alone. Given the low-quality evidence for guiding management decisions, a shared-decision model leading to individualized therapy plans will be important in patients with VWD who are undergoing surgical and invasive procedures.

Evaluation of a Modified SBAR Report to Physician Tool to Standardize Communication on Neonatal Transport

OBJECTIVE

SBAR (situation, background, assessment and recommendation) is a structured format for the effective communication of critically relevant information. This tool was developed as a generic template to provide structure to the communication of clinical information between health care providers. Neonatal transport often presents clinically stressful circumstances where concise and accurate information is required to be shared clearly between multidisciplinary health care providers. A modified SBAR communication tool was designed to facilitate structured communication between nonphysician bedside care providers operating from remote sites and physicians providing decision-making support at receiving care facilities. Prospective interventional study was designed to evaluate the reliability of a "SBAR report to physician tool" in sharing clinically relevant information between multidisciplinary care providers on neonatal transport.

STUDY DESIGN

The study was conducted between 2011 and 2014 by a dedicated neonatal transport service based at McMaster Children's Hospital which provides care for approximately 500 infants in Southern Ontario annually. In the preintervention phase, 50 calls were randomly selected for the evaluation and 115 consecutively recorded transport calls following adoption of the reporting tool. The quality of calls prior to and after the intervention was assessed by reviewers independently. Inter-rater agreement was also assessed for both periods.

RESULTS

Inter-rater agreement between raters was moderate to perfect in most components of the SBAR "report to the physician tool" except for the assessment component, which showed fair agreement during both preintervention and postintervention periods. There was an improvement in global score (primary outcome) with a mean difference of 0.95 (95% confidence interval [CI]: 0.77-1.14; p < 0.001) and in cumulative score with a mean difference of 8.55 (95% CI: 7.26-9.84; p < 0.001) in postintervention period.

CONCLUSION

The use of the SBAR report to physician tool improved the quality of clinical information shared between nonphysician members of the neonatal transport team and neonatal transport physicians.

KEY POINTS

· Long-Accurate and concise information sharing is crucial for decision-making in neonatal transport.. · Information sharing between multidisciplinary teams can be enhanced by using a commonly understood information sharing template.. · The SBAR report to physician tool improves the quality of information shared between multidisciplinary team members in neonatal transport..

632 Analysing Laser Doppler Images - A Modified Approach to the Assessment of Burn Depth

Aim

To establish a method of quantifiably determining burn depth from Laser Doppler (LD) images of burns.

Method

NICE advises for LD scanning to be utilised for the assessment of intermediate depth burns, where there is doubt about burn depth following experienced clinician examination. However, these scan images do not provide a quantifiable measure of burn depth. LD determines burn perfusion, with deeper burns appear blue, and superficial burns appearing red. We retrospectively studied LD images from 110 patients over the course of 2019. Using Adobe Photoshop, Histogram software, we highlighted the burns using the selection tool, and determined the proportion of the burn that was deep/poorly perfused. We then correlated these results with time till recovery.

Results

Burns with a poorly perfused region of larger than 20%, had a proportional increase in time till full recovery. This proportional increase was also reflected in burns with a 30% and 40% poor perfusion. Burns with less than 20% of poor perfusion were found to recover at the same rate as superficial burns. This novel method for the measurement of burn depth will allow for the examining plastic surgeon to make a decision on treatment based on concrete and quantifiable burn depth data.

Conclusions

We have demonstrated the initial validity of a novel method for the quantifiable measurement of burn depth. Further study is required, to establish the validity of this novel approach to the quantifiable detection of burn depth.

636 Optimising Operative Capacity for Hand Trauma - An audit

Aim

Assess compliance with departmental and BSSH guidelines for hand trauma. Optimise operative capacity within the department. Promote minor ops experience among the junior doctors.

Method

Retrospective review of the overbooked patients seen in the Hand trauma Unit (HTU) in August 2020 using the eTrauma system and time to operation using the Lorenzo patient record system.

Results

Overall Local Compliance rates

Overall BSSH Compliance rates

Main area of non-compliance was waiting time for tendon operations, with a 30% breech rate (&gt;5 days waiting time).

Conclusions

Interventions before re-audit: On call junior doctor to be based in HTU for the whole day- will allow for minor procedures (nail beds and skin lacerations) to be done at bedside. The above will free up capacity in the minor ops theatre for tendons.

Histopathological alterations in gills, liver, kidney and muscles of Ictalurus punctatus collected from pollutes areas of River

Abstract Untreated sewage and industrial wastes from Faisalabad city are disposed to River Chenab through Chakbandi Main Drain (CMD). The present project is planned to investigate the effects of this freshwater pollution on the body of fish Ictalurus punctatus. The specimens of this fish species were collected upstream and downstream of the entrance of CMD into River Chenab. Fish gills, liver, kidney and muscles from dorsolateral regions of fish were subjected to histopathology. Farmed fish and fish from upstream areas were used as control. Fish collected from polluted experimental sites showed significant damage in selected organs. Gill tissues showed an abnormality in the form of an uplifting of the primary epithelium, fusion, vacuolation, hypertrophy, and necrosis. While liver tissues subjected to hepatocytes degeneration, necrosis, mitochondrial granular hepatocyte, and sinusoids dilation. Kidney tissues indicated increased bowmen space and constricted glomerulus and degenerated nephrons. Edema, necrosis, and atrophy were observed in muscle tissues of fish from polluted areas. Fish from the upstream area showed fused gill lamellae, inflammatory cell infiltration, hypertrophy and vacuolation in hepatocytes. Kidney tissues indicated the presence of nuclear tubular cells, destructive renal tubules, hemorrhage, and necrosis at tubular epithelium. Intra myofibril spaces were also observed in muscles. Specimens of control fish indicated no variation in gills, liver, kidney, and muscles. The present study revealed a strong correlation between the degree of tissue damage and environmental contamination. Present findings also compel global warnings to protect our water bodies and fish to rescue the human population.

Intensive versus less-intensive antileukemic therapy in older adults with acute myeloid leukemia: A systematic review

To compare the effectiveness and safety of intensive antileukemic therapy to less-intensive therapy in older adults with acute myeloid leukemia (AML) and intermediate or adverse cytogenetics, we searched the literature in Medline, Embase, and CENTRAL to identify relevant studies through July 2020. We reported the pooled hazard ratios (HRs), risk ratios (RRs), mean difference (MD) and their 95% confidence intervals (CIs) using random-effects meta-analyses and the certainty of evidence using the GRADE approach. Two randomized trials enrolling 529 patients and 23 observational studies enrolling 7296 patients proved eligible. The most common intensive interventions included cytarabine-based intensive chemotherapy, combination of cytarabine and anthracycline, or daunorubicin/idarubicin, and cytarabine plus idarubicin. The most common less-intensive therapies included low-dose cytarabine alone, or combined with clofarabine, azacitidine, and hypomethylating agent-based chemotherapy. Low certainty evidence suggests that patients who receive intensive versus less-intensive therapy may experience longer survival (HR 0.87; 95% CI, 0.76-0.99), a higher probability of receiving allogeneic hematopoietic stem cell transplantation (RR 6.14; 95% CI, 4.03-9.35), fewer episodes of pneumonia (RR, 0.25; 95% CI, 0.06-0.98), but a greater number of severe, treatment-emergent adverse events (RR, 1.34; 95% CI, 1.03-1.75), and a longer duration of intensive care unit hospitalization (MD, 6.84 days longer; 95% CI, 3.44 days longer to 10.24 days longer, very low certainty evidence). Low certainty evidence due to confounding in observational studies suggest superior overall survival without substantial treatment-emergent adverse effect of intensive antileukemic therapy over less-intensive therapy in older adults with AML who are candidates for intensive antileukemic therapy.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Efficacy and Safety of EMLA Cream for Pain Control Due to Venipuncture in Infants: A Meta-analysis

: media-1vid110.1542/5852339542001PEDS-VA_2018-1173Video Abstract CONTEXT: The eutectic mixture of lidocaine (EMLA) cream has been used to reduce the pain during venipuncture in infants.

OBJECTIVE

To determine the efficacy and safety of EMLA in infants <3 months of age requiring venipuncture in comparison with nonpharmacological interventions in terms of pain reduction, change in physiologic variables, and methemoglobinemia.

DATA SOURCES

Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and gray literature were searched from inception to August 2017, without language restrictions.

STUDY SELECTION

We selected randomized controlled trials in which researchers compared EMLA with nonpharmacological interventions.

DATA EXTRACTION

Two reviewers independently performed abstract screening and full-text review, and extracted the data and assessed the risk of bias.

RESULTS

Ten randomized controlled trials (907 infants) were included. EMLA revealed little or no effect in reduction of pain (standardized mean difference: 0.14; 95% confidence interval [CI]: -0.17 to 0.45; 6 trials, n = 742; moderate-quality evidence) when EMLA was compared with sucrose, breastfeeding, or placebo. In comparison with placebo, EMLA revealed a small-to-moderate effect on increasing methemoglobin levels (mean difference: 0.35; 95% CI: 0.04 to 0.66; 2 trials, n = 134; low-quality evidence). There was an increased risk of blanching of the skin in the EMLA group (relative risk: 2.63; 95% CI: 1.58 to 4.38; 2 trials, n = 123; I² = 84%, very low-quality evidence).

LIMITATIONS

Our results may not be applicable to older infants.

CONCLUSIONS

EMLA reveals minimal benefits in terms of reduction of pain due to venipuncture procedure in comparison with placebo and no benefit in comparison with sucrose and/or breastfeeding. Moreover, it produced an elevation in methemoglobin levels and skin blanching.

Comparative Effectiveness of Prophylactic Therapies for Necrotizing Enterocolitis in Preterm Infants: Protocol for a Network Meta-analysis of Randomized Trials

Necrotizing enterocolitis (NEC) is a common and devastating disease with high morbidity and mortality in premature infants. Current literature on the prevention of NEC has limitations including lack of direct and indirect comparisons of available therapies. We will search MEDLINE, EMBASE, Science Citation Index Expanded, Social Sciences Citation Index, CINAHL, Scopus, ProQuest Dissertations and Theses database, and grey literature sources to identify eligible trials evaluating NEC preventive therapies. Eligible studies will (1) enroll preterm (gestational age <37 weeks) and/or low birth weight (birth weight <2500 g) infants, (2) randomize infants to any preventive intervention or a placebo, or alternative active or nonactive intervention. Our outcomes of interest are severe NEC (stage II or more, based on Bell's criteria), all-cause mortality, NEC-related mortality, late-onset sepsis, duration of hospitalization, weight gain, time to establish full enteral feeds, and treatment-related adverse events. Two reviewers will independently screen trials for eligibility, assess risk of bias, and extract data. All discrepancies will be resolved by discussion. We will specify a priori explanations for heterogeneity between studies. For available comparisons between treatment and no treatment, and direct comparisons of treatments, we will conduct conventional meta-analysis using a random effects model. We will conduct a network meta-analysis using a random effects model within the Bayesian framework using Markov chain Monte Carlo methods to assess relative effects of eligible interventions. We will assess the certainty in direct, indirect, and network estimates using the Grading of Recommendations Assessment, Development and Evaluation approach.

Guidelines for feeding very low birth weight infants

Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.

Modeling of wastewater quality in an urban area during festival and rainy days

Water pollution during festival periods is a major problem in all festival cities across the world. Reliable prediction of water pollution is essential in festival cities for sewer and wastewater management in order to ensure public health and a clean environment. This article aims to model the biological oxygen demand (BOD(5)), and total suspended solids (TSS) parameters in wastewater in the sewer networks of Karbala city center during festival and rainy days using structural equation modeling and multiple linear regression analysis methods. For this purpose, 34 years (1980-2014) of rainfall, temperature and sewer flow data during festival periods in the study area were collected, processed, and employed. The results show that the TSS concentration increases by 26-46 mg/l while BOD(5) concentration rises by 9-19 mg/l for an increase of rainfall by 1 mm during festival periods. It was also found that BOD(5) concentration rises by 4-17 mg/l for each increase of 10,000 population.

Standardizing umbilical catheter usage in preterm infants

BACKGROUND AND OBJECTIVE

Absence of guidelines on umbilical arterial catheter (UAC) and umbilical venous catheter (UVC) use and inability to predict the hospital course may sway the frontline staff to overuse umbilical catheters in preterm infants. Our objective was to evaluate the feasibility of implementing guidelines standardizing the use of umbilical catheters and its impact on the incidence of sepsis and resource use.

METHODS

All inborn infants delivered at <33 weeks' gestation and admitted to the NICU were included in this quality improvement study. The primary outcome was proportion of infants receiving umbilical catheters. Secondary outcomes were central venous catheter (CVC) use and central line-associated bloodstream infection (CLABSI).

RESULTS

The proportion of infants receiving UACs and UVCs was significantly lower in postintervention (sustainment) phase than in the preintervention phase (93 [42.3%] vs 52 [23.6%], P = .0001) and (137 [62.6%] vs 93 [42.3%], P = .0001), respectively. There was no corresponding increase in the proportion of infants receiving peripherally inserted central catheters (PICCs) or surgical CVCs (SCVCs) during the sustainment phase. There was a significant reduction in the proportion of infants receiving CVCs (UVC, PICC, and SCVC) in the sustainment phase. The incidence of CLABSI was similar in the preintervention and sustainment phases.

CONCLUSIONS

Implementation of guidelines standardizing the use of umbilical catheters in the NICU is feasible. Fewer infants were exposed to the risk of UVC or UAC, and fewer resources were used.

Glass ionomer cements: effect of strontium substitution on esthetics, radiopacity and fluoride release

OBJECTIVE

SrO and SrF2 are widely used to replace CaO and CaF2 in ionomer glasses to produce radiopaque glass ionomer cements (GIC). The purpose of this study was to evaluate the effects of this substitution on release of ions from GIC as well as its effect on esthetics (translucency) and radiopacity.

MATERIALS AND METHODS

Cements were produced from ionomer glasses with varying content of Sr, Ca and F. The cements were stored in dilute acetic acid (pH 4.0) for up to 7 days at 37°C. Thereafter, the cements were removed and the solution was tested for F(-), Sr(2+), Ca(2+), and Al(3+) release. Radiopacity and translucency were measured according to BS EN ISO 9917-1:2003.

RESULTS

Ion release was linear to t(1/2) suggesting that this is a diffusion controlled mechanism rather than dissolution. The fluoride release from the cements is enhanced where some or all calcium is replaced by strontium. Radiopacity shows a strong linear correlation with Sr content. All cements were more opaque than the C0.70 0.55 standard but less opaque than the C0.70 0.90 standard which is the limit for the ISO requirement for acceptance.

SIGNIFICANCE

This study shows that the replacement of calcium by strontium in a glass ionomer glass produces the expected increase in radiopacity of the cement without adverse effects on visual properties of the cement. The fluoride release from the cements is enhanced where some or all calcium is replaced by strontium.

Biochemical Parameters in Women with Polycystic Ovary Syndrome in Ajman, UAE

Aims: Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 5 -10% of women and is a major cause of anovulatory infertility. Prevalence varies among population based on genetic and environmental factors. Etiology of PCOS remains unknown but hyperandrogenism and insulin resistance have both been associated with PCOS. The aim of this study was to measure levels of Homocysteine and other biochemical parameters in women diagnosed with PCOS attending Gulf Medical College Hospital & Research Centre (GMCHRC), Ajman, UAE. Methods: Young women, aged between 18 and 35 years of age, diagnosed with PCOS (N =37), not on any treatment, attending GMCHRC were included in the study. Biochemical parameters were measured using standard procedures. Laboratory normal reference ranges were used for comparison. Results: 54 % of the women with PCOS were overweight or obese according to the Body mass index (BMI) and 51% had a waist circumference >88cm. Fasting and postprandial Glucose and Insulin levels and HOMA-IR were within the normal reference range indicating that no Insulin resistance was seen in these women. 40% of the women had a serum total Cholesterol level above 200 mg/dL, while Low Density Lipoprotein (LDL) Cholesterol was above and High Density Lipoprotein (HDL) cholesterol was lower than the desirable value. Serum Triacylglycerol was within the normal reference range. Serum Testosterone, Estradiol, Prolactin Thyroid Stimulating Hormone (TSH) and Plasma Homocysteine level were found to be within the normal reference ranges. Homocysteine levels correlated with Testosterone, total Cholesterol and LDL cholesterol levels. Conclusions: BMI was high in 54% of the women. No Insulin resistance was seen in these patients. Hormone levels and Homocysteine were within normal reference ranges. Dyslipidermia was observed. These findings differ from reports in literature where Insulin resistance, Hyperandrogenism and high Homocysteine levels have been associated with PCOS. NJOG 2011 Nov-Dec; 6 (2): 7-10 DOI: http://dx.doi.org/10.3126/njog.v6i2.6748  

Severe hypernatremic dehydration and metabolic acidosis due to neonatal intestinal microvillus inclusion disease

Neonatal microvillus inclusion disease (MID) is a congenital secretory diarrhea diagnosed by morphological enterocyte abnormalities on histology. The secretory diarrhea associated with MID occurs within the first few hours of birth and is exacerbated by enteral feeding. Affected newborns will die of dehydration and acid-base disturbances if MID is not rapidly recognized and treated with massive intravenous fluid replacement and gut rest. We report a case of a 4-day-old neonate presenting with 18% weight loss, hypernatremic dehydration and metabolic acidosis. Despite aggressive fluid resuscitation (206 ml/kg for the first 24 h), the dehydration and metabolic acidosis were only minimally improved. The diapers were found soaked with clear, non-odorous fluid on repeated examinations. Persistent secretory diarrhea was suspected. Stool electrolytes analyses showed a high NaCl content typical of secretory diarrhea and intestinal biopsy with electron microscopy was diagnostic of MID.

The effect of ultrasound on the uptake of fluoride by glass ionomer cements

Ultrasound has been shown to improve the set of glass ionomer cements (GICs) and also other cement properties. In particular, the release of fluoride is enhanced. These cements also can take up fluoride ion from liquids. The aim of this study is to investigate the effect of ultrasound on this cement property. Two commercial dental restorative GICs were used together with a modified commercial material and an experimental material based on a F-free glass. All three commercial materials came in capsules which were mixed as makers directed, the experimental material was mixed as in previous papers. Mixed cement was placed polyethylene moulds to create 3 × 2 mm thick discs. These were either allowed to standard set for 6 min or set with ultrasound for 55 s. 18 samples were made for each material/set. Three samples were placed in 4 ml of 0.2% NaF solution for 24 h at 37°C. The cylinders were removed and the F concentration of the solutions measured by ISE using TISAB decomplexant. F uptake was determined by difference from the original NaF concentration. The two conventional GICs showed reductions of 17.4 and 8.5% for ultrasound compared to standard set whereas the modified material increased by 32.3% and the experimental one by 20.6%. It is suggested that the effect of ultrasound may increase the surface area of the residual glass particles in the GIC which would increase F uptake. In GICs where considerable F ion is released into the cement matrix by the enhanced reaction caused by ultrasound this may be sufficient to reverse the former effect producing the reduced uptake observed.

The effect of ultrasound on the setting reaction of zinc polycarboxylate cements

The set of glass ionomer cement (GIC) is accelerated by application of ultrasound. Although GIC has somewhat displaced zinc polycarboxylate cement (ZPC) in dental applications the latter is still extensively used. Like GIC, it provides direct adhesion to tooth and can provide F release, but is more radiopaque and biocompatible than GIC. The aim of this study is to examine the effect of ultrasound on the setting of ZPC using Fourier transform infra red spectroscopy and any interaction with SnF(2) addition. ZPC with and without SnF(2) addition (+/-S) at luting (L) 2:1 P/L ratio and restorative (R) 4:1 P/L ratio consistencies. Ultrasound is applied to the cement using Piezon-Master 400, EMS, Switzerland at 60 s from start of mixing for 15 s. The ratios of absorbance peak height at 1,400 cm(-1) -COO(-) to that at 1,630 cm(-1) -COOH were measured and compared those obtained for the cement not treated with US. These values were taken at the elapsed time at which no further change in spectrum [ratio] was observed at room temperature [10-20 min]. The US results are taken at 2 or 3 min. No US: R/+S (1.09), R/-S (1.2), L/+S (1.07), L/-S (1.04); US: R/+S (1.50), R/-S (1.64), L/+S (1.38), L/-S (1.05). The results show all four ZPC formulations are very sensitive to ultrasound whether with or without SnF(2). Reducing US to 10 s produces lower initial ratios but these increase up to 10 min when very high ratios (>2) are obtained. Previous studies with restorative GICs found that 40-55 s US was needed to produce the effect found with 15 s on ZPCs. ZPC powder is more basic than GIC glass; this may account for ZPC's greater sensitivity to US. Ultrasound may provide a useful adjunct to the clinical use of ZPC both as luting agent and temporary restorative.

Kinetics of fluoride ion release from dental restorative glass ionomer cements: the influence of ultrasound, radiant heat and glass composition

To compare the effect of ultrasonic setting with self curing on fluoride release from conventional and experimental dental glass ionomer cements. To compare hand mixed and capsule mixing and the effect of replacing some of the reactive glass with zirconia. In a novel material which advocated using radiant heat to cure it, to compare the effect of this with ultrasound. To evaluate the effect of ultrasound on a glass ionomer with fluoride in the water but not in the glass. 10 samples of each cement were ultrasonically set for 55 s; 10 controls self cured for 6 min. Each was placed in 10 ml of deionised water which was changed at 1, 3, 7, 14, 21, 28 days. The solution fluoride content was measured using a selective ion electrode. All ultrasound samples released more fluoride than the controls. Release patterns were similar; after a few days, cumulative fluoride was linear with respect to t(1/2). Slope and intercept of linear regression plots increased with ultrasound. With radiant heat the cement released less fluoride than controls. The effect of ultrasound on cement with F in water increased only slope not intercept. Zirconia addition enhances fluoride release although the cement fluorine content is reduced. Comparison of capsule and hand mixing showed no consistent effect on fluoride release. Ultrasound enhances fluoride release from GICs. As heat has an opposite effect the heat from ultrasound is not its only action. The lesser effect on cement with fluoride only in the water indicates that of ultrasound enhances fluoride release from glass.

Capecitabine therapy in advanced gall bladder cancer: A phase II study

14153

Background: Thymidine phosphorylase (TP) activity is found at higher levels in gall bladder cancer (GBC) tissues than in adjacent healthy tissues. GBC is relatively sensitive to 5-FU. TP activated capecitabine (CAP) mimics the continuous infusion of 5-FU. In view of drug potentiality this present study was initiated. Our aim was to evaluate the therapeutic efficacy and safety of CAP in previously untreated GBC patients (Pts). Methods: It was an open-labelled, single-centred, non-randomised and prospective study. Outcome measures were response rate and type of response for efficacy measurement and safety was measured by adverse events & laboratory blood values (LBV). All LBV were within reference range at baseline. The patients had no prior chemo/ radio therapy or a family history of malignancy; adenocarcinoma (stage III–IV); age 40–70 yrs; male/female: 16/ 30; KPS ≥ 70%. 46 pts were treated with 306 cycles (min 3–max 12) of CAP at a dose of 2500 mg/day in two divided doses from day 1–14 followed by 1-week rest. Results: Median age was 50 yrs. Hand foot syndrome occurred in 17.39% pts, diarrhoea (grade 3 & 4) 21.75% and both 15.21%, all toxicities were manageable. Mean LBV before and after CAP therapy were hemoglobin: 11.38–0.35 g/dl (95% CI, 10.66–2.10); total count of WBC: 9,260–580/mm3 (95% CI, 8,680–9,840); platelet count: 251,000–2,000/mm3 (95% CI, 227,000–275,000) and serum bilirubin: 1.17–0.33 mg/dl (95% CI, 0.5–1.84). The LBV between baseline and after CAP therapy were not statistically significant. Partial response was found in 12 pts (26.08%), stable disease in 26 pts (56.21%), and progressive disease in 8 pts (17.39%). Mean KPS value after therapy was 76% (95% CI, 69–84). Conclusion: This clinical experience indicates that CAP is a convenient choice in phase II chemo naïve GBC pts not adversely affecting haematological values.

No significant financial relationships to disclose.

CD4+ Th1 and CD8+ type 1 cytotoxic T cells both play a crucial role in the full development of contact hypersensitivity

The role of CD4(+) vs CD8(+) T cells in contact hypersensitivity (CHS) remains controversial. In this study, we used gene knockout (KO) mice deficient in CD4(+) or CD8(+) T cells to directly address this issue. Mice lacking either CD4(+) or CD8(+) T cells demonstrated depressed CHS responses to dinitrofluorobenzene and oxazolone compared with wild-type C57BL/6 mice. The depression of CHS was more significant in CD8 KO mice than in CD4 KO mice. Furthermore, in vivo depletion of either CD8(+) T cells from CD4 KO mice or CD4(+) T cells from CD8 KO mice virtually abolished CHS responses. Lymph node cells (LNCs) from hapten-sensitized CD4 and CD8 KO mice showed a decreased capacity for transferring CHS. In vitro depletion of either CD4(+) T cells from CD8 KO LNCs or CD8(+) T cells from CD4 KO LNCs resulted in a complete loss of CHS transfer. LNCs from CD4 and CD8 KO mice produced significant amounts of IFN-gamma, indicating that both CD4(+) and CD8(+) T cells are able to secrete IFN-gamma. LNCs from CD8, but not CD4, KO mice were able to produce IL-4 and IL-10, suggesting that IL-4 and IL-10 are mainly derived from CD4(+) T cells. Intracellular cytokine staining of LNCs confirmed that IFN-gamma-positive cells consisted of CD4(+) (Th1) and CD8(+) (type 1 cytotoxic T) T cells, whereas IL-10-positive cells were exclusively CD4(+) (Th2) T cells. Collectively, these results suggest that both CD4(+) Th1 and CD8(+) type 1 cytotoxic T cells are crucial effector cells in CHS responses to dinitrofluorobenzene and oxazolone in C57BL/6 mice.

Effects of acute and subchronic administration of typical and atypical antipsychotic drugs on the neurotensin system of the rat brain

The acute and subchronic effects of a variety of doses of a prototype typical (haloperidol) or one of several atypical antipsychotic drugs (clozapine, olanzapine, risperidone, quetiapine, or sertindole) on regional brain neurotensin (NT) tissue concentrations, and NT receptor binding were examined. Acute administration of haloperidol, clozapine, olanzapine, and risperidone dose-dependently increased NT tissue concentrations in the nucleus accumbens. Haloperidol, olanzapine, risperidone, and sertindole also increased NT tissue concentrations in the caudate nucleus. NT tissue concentrations in the nucleus accumbens and caudate remained elevated after 14-day administration of haloperidol, olanzapine, sertindole, and risperidone. In contrast, at the doses studied, quetiapine decreased NT tissue concentrations in the nucleus accumbens; clozapine had no effect. Haloperidol significantly increased NT receptor binding in the substantia nigra after 14-day administration. All of the atypical antipsychotic drugs decreased NT receptor binding in the nucleus accumbens and in the substantia nigra. Although these studies do not conclusively support the hypothesis that increased NT neurotransmission is involved in the clinically relevant effects of all antipsychotic drugs, the extant evidence clearly suggests that further study is warranted. Inconsistencies in the data suggest that differential effects of antipsychotic drug administration on subpopulations of NT neurons must be scrutinized further.

Tetanus antibody levels among adolescent girls in developing countries

Neonatal and maternal tetanus infections remain an important cause of death in many countries. Few studies have reported tetanus toxoid antibody levels of adolescent girls. As part of the Expanded Programme on Immunization most girls receive up to 3 injections in early childhood, and many subsequently do not receive booster vaccinations until pregnant. We determined (by ELISA) tetanus antibody seropositivity in adolescent girls from Malawi (in 1996), Nigeria (in 1993) and Pakistan (in 1996), and response to tetanus vaccination in adolescent girls from Pakistan. Geometric mean titres (GMT, IU/mL) were 0.94 in 117 Malawian, 0.32 in 154 Nigerian and 1.08 in 162 Pakistani girls. In Nigeria, 54.7% of adolescents were seronegative, of whom 26.8% had a history of unsafe abortion. In Malawi and Pakistan all girls were seropositive and in Pakistan, following a booster vaccination, titres increased 3-fold, with a lower response in older girls. The results indicated that adequate childhood immunization is likely to provide protective levels through adolescence. Booster vaccination in late childhood/early adolescence should protect the majority of women throughout their reproductive lives. This practice would reduce the risks of girls exposed to infection through unsafe abortions, and may be the best option for countries seeking to improve their vaccination schedule, especially where tetanus vaccine coverage in pregnant women is unacceptably low.