Virtual urgent care is here to stay: driving toward safe, equitable, and sustainable integration within emergency medicine

BACKGROUND

Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine.

METHODS

We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement.

RESULTS

The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada.

CONCLUSION

Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

510 Improving Trauma & Orthopaedic Handover During a Pandemic: Keeping Patients Safe - A Closed Loop QIP

Aim

Lack of communication and incomplete handover leads to errors and patient harm. Staffing challenges caused by Covid-19 highlights the necessity for high-quality handover. Our aim was to assess the quality of T&O weekend ward handover and evaluate the implementation of a formal handover document to improve the process.

Method

Junior doctors completed a survey to measure the efficacy and safety of current handover. A formalised written handover document in line with RCS Safe Handover recommendations was created and included in the doctors’ inductions. Evaluation was after 5 weeks with post-intervention questionnaires and new doctor rotation feedback.

Results

Prior to introduction of the handover document, 78% stated they were unable to formally handover. 77% experienced incomplete or unclear handover when working on the weekend. Lack of a standard handover process was deemed ineffective and unsafe.

All respondents reported more efficient working with the new process. The perceived safety rating significantly increased from 2.33 out of 5 to 4.23 (p<0.0001). The new cohort of junior doctors rated the safety of handover to be 3.54, showing there is still scope for improvement in patient safety.

Conclusions

The use of standardized handover tools had a positive impact, improving the safety and quality of weekend handover. Workload was prioritized appropriately with improved transfer of information between teams. Covid-19 creates numerous challenges for safe clinical care. Working in unfamiliar environments and last-minute rota changes need to be mitigated by robust handover processes.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Cognitive Stimulation for Persons with Dementia: a Systematic Review and Meta-Analysis

OBJECTIVE

We aim to provide an up-to-date systematic review and meta-analysis of the effects of cognitive stimulation (CS) on cognition, depressive symptoms, and quality of life in persons with dementia. Factors affecting the treatment effect were examined.

METHODS

A literature search was performed on databases of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, and Cochrane Library up to 7 March 2019. Only randomised controlled trials investigating the effects of CS in persons with dementia were included. The outcome measures were cognitive function, depressive symptoms, and quality of life.

RESULTS

20 randomised controlled trials with a total of 1251 participants (intervention group: 674; control group: 577) were included for meta-analysis. Most participants had mild to moderate dementia. CS had a significant positive small-to-moderate effect on cognition (Hedges's g = 0.313, p < 0.001). Heterogeneity of CS was low to moderate (Q=30.5854, df=19, p < 0.05, I2 = 37.877%). Inconclusive results were found for depressive symptoms and quality of life.

CONCLUSION

CS has a significant positive effect on cognitive function, but its effect on depressive symptoms and quality of life was inconclusive. Future studies with more robust methodology establishing evidence of its efficacy are required.

Health-related behaviours and mental health in Hong Kong employees

BACKGROUND

Poor physical and mental health in employees can result in a serious loss of productivity. Early detection and management of unhealthy behaviours and mental health symptoms can prevent productivity loss and foster healthy workplaces.

AIMS

To examine health-related behaviours, mental health status and help-seeking patterns in employees, across different industries in Hong Kong.

METHODS

Participants were telephone-interviewed and assessed using the Case-finding and Help Assessment Tool (CHAT) with employee lifestyle risk factors, mental health issues and help-seeking intentions screened across eight industries. Subsequent data analysis involved descriptive statistics and chi-square tests.

RESULTS

There were 1031 participants. Key stressors were work (30%), family (19%), money (14%) and interpersonal issues (5%). Approximately 18, 9 and 9% of participants were smokers, drinkers and gamblers, respectively, and only 51% exercised regularly. Depressive and anxiety symptoms were reported by 24 and 31% of employees, respectively. Issues for which they wanted immediate help were interpersonal abuse (16%), anxiety (15%), anger control (14%) and depression (14%). Employees with higher educational attainment were less likely to smoke, drink and gamble than those with lower attainment. Lifestyle and mental health status were not associated with income. Employees in construction and hotel industries smoked more and those in manufacturing drank more than those in other industries.

CONCLUSIONS

Physical and mental health of Hong Kong employees are concerning. Although employee assistance programmes are common among large companies, initiation of proactive engagement approaches, reaching out to those employees in need and unlikely to seek help for mental health issues, may be useful.

Pathway to mental health recovery: a qualitative and quantitative study on the needs of Chinese psychiatric inpatients

BACKGROUND

Exploration of the information and participation needs of psychiatric inpatients is an important step for the implementation of recovery-oriented mental health service. The objective of this study was to explore the information and participation needs of Chinese psychiatric inpatients in the largest psychiatric hospital in Hong Kong.

METHODS

The study was divided into two parts. In the first part, eight focus groups with patients, patients' relatives and healthcare professionals were held to identify 22 items of information needs and 16 items of participation needs of Chinese psychiatric inpatients. Basing on the items identified in the first part of the study, a questionnaire was developed to survey on the importance of the different information and participation needs in the second part of the study. Participants were asked to rate in rank order their perceived importance of the items in the questionnaire survey.

RESULTS

A hundred and eighty three Chinese psychiatric inpatients completed the questionnaire and the majority of them suffered from schizophrenia (68.3 %). For information needs, the top three needs rated by patients as the most important in descending order were: "Information on the classifications of mental illnesses, signs and symptoms and factors contributing to relapse", "Information on the criteria and arrangements for discharge", and "Information on the importance of psychiatric drug taking and its side effects". For participation needs, the top three needs rated by patients as the most important in descending order were: "Enquiring about personal needs and arrangements", "Keeping in touch with the outside world", and "Learning and practising self-management".

CONCLUSIONS

This study reveals that Chinese psychiatric inpatients are concerned about information on their mental illness and its treatments as well as the criteria for discharge. On the other hand, patients are concerned about their personal needs, their self-management, as well as their keeping in touch with the outside world during their hospitalisation. Moreover, patients with different socio-demographic and clinical characteristics have different information and participation needs. The results of the present study serve as a reference for designing guidelines, strategies, and programmes to meet the information needs and participation needs of psychiatric inpatients in Hong Kong.

A genetic factor associated with low final bone mineral density in children after a long-term glucocorticoids treatment

Treatment with glucocorticoids is associated with lower bone mineral density (BMD). We performed a genome-wide association study to analyze interactive effects between genotypes and cumulative dose of prednisone (PD) over 4.3 years of follow-up period on the final BMD Z-scores in 461 white children from the Childhood Asthma Management Program. No variants met the conventional criteria for genome-wide significance, and thus we looked for evidence of replication. The top 100-ranked single-nucleotide polymorphisms (SNPs) were then carried forward replication in 59 children with acute lymphoblastic leukemia (ALL) exposed to large fixed doses of PD as part of their chemotherapeutic regimen. Among them, rs6461639 (interaction P=1.88 × 10^-5 in the CAMP population) showed a significant association with the final BMD Z-scores in the ALL population (P=0.016). The association of the ALL population was only present after correction for the anti-metabolite treatment arm (high vs low dose). We have identified a novel SNP, rs6461639, showing a significant effect on the final BMD Z-scores in two independent pediatric populations after long-term high-dose PD treatment.

Genetic risk factors for decreased bone mineral accretion in children with asthma receiving multiple oral corticosteroid bursts

BACKGROUND

Long-term intermittent oral corticosteroid (OCS) use in children with asthma leads to significant decreases in bone mineral accretion (BMA).

OBJECTIVE

We aimed to identify genetic factors influencing OCS dose effects on BMA in children with asthma.

METHODS

We first performed a gene-by-OCS interaction genome-wide association study (GWAS) of BMA in 489 white participants in the Childhood Asthma Management Program trial who took short-term oral prednisone bursts when they experienced acute asthma exacerbations. We selected the top-ranked 2000 single nucleotide polymorphisms (SNPs) in the GWAS and determined whether these SNPs also had cis-regulatory effects on dexamethasone-induced gene expression in osteoblasts.

RESULTS

We identified 2 SNPs (rs9896933 and rs2074439) associated with decreased BMA and related to the tubulin γ pathway. The rs9896933 variant met the criteria for genome-wide significance (P = 3.15 × 10(-8) in the GWAS) and is located on the intron of tubulin folding cofactor D (TBCD) gene. The rs2074439 variant (P = 2.74 × 10(-4) in the GWAS) showed strong cis-regulatory effects on dexamethasone-induced tubulin γ gene expression in osteoblasts (P = 8.64 × 10(-4)). Interestingly, we found that BMA worsened with increasing prednisone dose as the number of mutant alleles of the 2 SNPs increased.

CONCLUSIONS

We have identified 2 novel tubulin γ pathway SNPs, rs9896933 and rs2074439, showing independent interactive effects with cumulative corticosteroid dose on BMA in children with asthma receiving multiple OCS bursts.

Expected possible selves and coping skills among young and middle-aged adults with bipolar disorder

OBJECTIVES

This qualitative study explored expected possible selves and coping skills among young and middle-aged adults with bipolar disorder in Hong Kong. Disruptive or positive experiences associated with bipolar disorder can shape the development of the sense of possible selves.

METHODS

Guided by narrative inquiry methodology, 14 Chinese participants (8 women; age range, 22-65 years), recruited from community mental health services and the public, were interviewed.

RESULTS

Young participants (18-40 years) elaborated on their expected possible selves as they related to health, work, and family, whereas middle-aged participants (41-65 years) talked about independent possible selves. The participants used problem-focused, emotion-focused, and cultural coping methods to deal with their bipolar disorder and achieve their expected possible selves. Furthermore, the young participants expressed ambivalence towards self-help strategies to manage high mood episodes.

CONCLUSIONS

This study not only improves our understanding of possible selves among young and middle-aged adults with bipolar disorder, but also provides information for designing self-help interventions. Limitations of the study along with directions for future research are discussed.

What will it take for recovery to flourish in Hong Kong?

The notion of mental health "recovery" is beginning to stimulate important changes in the mental health care provided to persons with serious mental illnesses in Hong Kong. However, the Chinese culture poses many challenges to implementing the types of recovery-oriented practices developed over the last 2 decades in the West. This article considers some of the challenges that policy makers, system leaders, practitioners, family members, and persons with mental illnesses themselves may face in attempting to transform care in Hong Kong. In addition to shifting from an individualistic to a more collectivist culture that emphasises the importance of family involvement, the primarily linear notion of mental stability that currently guides practice may need to be reconsidered in the face of evidence which suggests that recovery is a non-linear path that involves hard work both on the part of the individual as well as the family.

Genetic predictors associated with improvement of asthma symptoms in response to inhaled corticosteroids

BACKGROUND

To date, genome-wide association studies (GWASs) of inhaled corticosteroid (ICS) response in asthmatic patients have focused primarily on lung function and exacerbations.

OBJECTIVE

We hypothesized that GWAS analysis could identify novel genetic markers predicting a symptomatic response to ICSs.

METHODS

We analyzed differences in asthma symptoms in response to ICSs in 124 white children from the Childhood Asthma Management Program (CAMP) trial using scores from diary cards. Of the 440,862 single nucleotide polymorphisms (SNPs) analyzed, the top 100 ranked SNPs were pursued for replication initially in subjects from the pediatric Childhood Asthma Research and Education trials (77 white children) and then in subjects from the adult Asthma Clinical Research Network (110 white adults) and Leukotriene Modifier or Corticosteroid or Corticosteroid-Salmeterol trials (110 white adults).

RESULTS

The lowest P value for GWAS analysis in the CAMP trial was 8.94 × 10(-8) (rs2388639). Of the 60 SNPs available in the Childhood Asthma Research and Education Network trials, rs1558726 (combined P = 1.02 × 10(-5)), rs2388639 (combined P = 8.56 × 10(-9)), and rs10044254 (combined P = 9.16 × 10(-8)) independently replicated. However, these 3 SNPs were not additionally replicated in the adult asthmatic patients of the remaining trials. rs10044254 lies in the intronic region of F-box and leucine-rich repeat protein 7 (FBXL7) and is associated with decreased expression in immortalized B cells derived from CAMP participants.

CONCLUSIONS

We have identified a novel SNP, rs10044254, associated with both decreased expression of FBXL7 and improved symptomatic response to ICSs in 2 independent pediatric cohorts. Our results suggest that there might be a specific genetic mechanism regulating symptomatic response to ICSs in children that does not carry over to adults.

Evaluating possible pharmacokinetic interactions between tobramycin, piperacillin, and a combination of piperacillin and tazobactam in patients with various degrees of renal impairment

A study was performed to further investigate the apparent instability of tobramycin when coadministered with piperacillin/tazobactam in subjects with renal impairment. Twenty-six otherwise healthy volunteers between 23 and 74 years of age were studied. Eight subjects had moderate renal impairment, 10 had mild renal impairment, and 8 had normal renal function. Each subject received single doses of piperacillin/tazobactam and tobramycin alone as well as combined doses in a randomized, three-way crossover design. The subjects with normal renal function also received combined doses of piperacillin and tobramycin. Considerable care was taken to protect against in vitro inactivation of plasma and urine samples after collection. No systematic changes in pharmacokinetic parameters were observed. It is concluded that piperacillin, either alone or with tazobactam, did not change the pharmacokinetics of tobramycin in subjects with renal impairment. The apparent in vivo inactivation of tobramycin in the presence of piperacillin or piperacillin/tazobactam reported by others may be an artifact of ex vivo inactivation.

Intravenous cannula: an instrument and a port in laparoscopic surgery

BACKGROUND

An intravenous cannula was used experimentally as a cheap and scarless alternative to an endoloop to provide retraction and lumen occlusion. It is also a miniport for introduction of ligatures and small catheters.

METHODS

This possibility was explored during standard procedures such as laparoscopic cholecystectomy and laparoscopic appendectomy.

RESULTS

This technique was successfully applied in 89% of laparoscopic cholecystectomies and 86% of laparoscopic appendectomies.

CONCLUSIONS

In many instances a standard port for laparoscopic instruments was unnecessary, despite the fact that the authors did not intentionally work towards port number reduction for laparoscopic procedures.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

The arthritis of inflammatory childhood myositis syndromes

OBJECTIVE

Arthritis has been an associated finding in juvenile dermatomyositis (JDM), but its prevalence, course, and response to therapy has not been well described. We investigated the frequency, course, and clinical and radiographic features in a large cohort of patients with JDM.

METHODS

The charts of 94 patients with idiopathic myositis (1984-99) were reviewed: 80 JDM, 3 juvenile polymyositis (JPM), 5 amyopathic JDM, and 6 overlap myositis syndromes. Compiled data included demographics, clinical features, a detailed description of the arthritis, investigations (radiographs, autoantibodies), course, and response to therapy. All radiographs were independently reviewed by a single radiologist.

RESULTS

Sixty-one percent (95% CI 50-72%) of patients with JDM had arthritis. The arthritis was reported a median 4.5 mo (range -73.6 to 76.6 mo) after the JDM onset. When compared to patients with no arthritis, the occurrence of arthritis was not significantly related to sex, race, positive antinuclear antibody or rheumatoid factor, calcinosis, nodules, vasculitis, or Raynaud's phenomenon. The initial involvement was pauciarticular in 67% and polyarticular in 33%. In the pauci group, asymptomatic knee effusions were the predominant finding (n = 19, 58%), and in 18 patients may have been the result of steroid therapy. Two patients evolved from a pauci onset to a polyarticular course. All responded to therapy (corticosteroids; 47 were taking other medications) with remission of the arthritis within a median of 2.0 mo (range 0.1-64.5 mo). However, the arthritis recurred in 39% as the corticosteroids were tapered. Four patients with JDM eventually required corticosteroid wrist injections, with resolution of the arthritis. The arthritis was nonerosive in all cases. No patient with JPM had arthritis. Three of 5 patients with amyopathic JDM and 4 of 6 with overlap myositis syndrome had a nonerosive polyarthritis.

CONCLUSION

Nonerosive arthritis involving the knees, wrists, elbows, and fingers is a frequent manifestation of JDM and other idiopathic childhood myositis. The arthritis is seen early in the course of JDM and often responds to treatment. However, the arthritis may recur with tapering of corticosteroids despite remission of the JDM. In a significant proportion of JDM cases, arthritis is the major sequela and may warrant further medical therapy or intraarticular corticosteroid injections.

The use of topical lidocaine/prilocaine cream prior to childhood circumcision under local anesthesia

A prospective study was conducted to evaluate the efficacy of prior application of topical eutectic mixture of local anesthetics, EMLA, in alleviating the pain associated with infiltration local anesthetic (LA) for circumcision in children and to assess its impact on the outcome. A total of 173 children aged 3-13 years requiring circumcision were randomly assigned to have EMLA or placebo cream applied over the root of the penis 1 h before subcutaneous ring block. A blinded observer rated the pain response on a 10-point visual scale during needle insertion, injection of local anesthetic and circumcision. Children needing conversion to general anesthesia (GA) were counted as failures. A total of 89 and 82 boys were included in the EMLA group and placebo group, respectively. Significantly lower pain scores were recorded for needle puncture in the former group (P<0.001), whilst pain scores for injection and during circumcision were not statistically different between the two groups (P=0.037 and 0.138, respectively). A total of 88 out of the 89 boys pre-treated with EMLA completed the procedure, whereas seven boys in the placebo group necessitated conversion to GA (P=0.022). The converted cases had higher values for all pain scores and tended to be younger. Therefore, EMLA cream is a useful adjunct to LA for childhood circumcision because it effectively reduces the sharp pain induced by needle puncture. However, careful patient selection is required for a low conversion rate to GA.

Rapid disappearance of zaleplon from breast milk after oral administration to lactating women

Five lactating mothers were administered the therapeutic dose of zaleplon (10 mg) orally in an open-label, single-dose, pharmacokinetic study. Plasma and breast milk were sampled through 8 hours after dose administration for subsequent determinations of zaleplon and its major, though inactive, plasma metabolite 5-oxo-zaleplon. Zaleplon concentrations peaked in plasma and milk approximately 1 hour after dosing and then disappeared rapidly. The mean terminal half-life was slightly greater than 1 hour. Milk concentrations "mirrored" plasma concentrations closely with no discernible delay between peak times. The average milk-to-plasma (M/P) concentration ratio for zaleplon was approximately 0.50 over the time course. 5-oxo-zaleplon was undetectable in all but one milk sample. The maximum exposure of an infant to zaleplon during a feeding at peak milk concentrations was estimated to range from 1.28 micrograms to 1.66 micrograms, corresponding to 0.013% to 0.017% of the maternal dose or 0.320 microgram/kg to 0.415 microgram/kg for a 4 kg infant. The results indicate that zaleplon taken by a nursing mother is transferred through breast milk to her infant in very small quantities that are unlikely to be clinically important.

Myasthenia gravis and polymyositis as manifestations of chronic graft-versus-host-disease

Myasthenia gravis and polymyositis are each a rare manifestation of immune dysregulation in chronic graft-versus-host disease (cGVHD). We report a 4-year-old boy with idiopathic acquired aplastic anemia who developed myasthenia gravis 22 months and polymyositis 69 months after an allogeneic BMT (5/6 matched, MLC-nonreactive). The occurrence of both syndromes in one patient is unique. Autoimmune dysfunction may be associated with the development of cGVHD as demonstrated by the high incidence of prior aplastic anemia in BMT patients presenting with myasthenia gravis and polymyositis. Recognition of these neurologic manifestations is important in the diagnosis and treatment of cGVHD.

Isolated duplications of the cystic duct: case report and implications in laparoscopic cholecystectomy

During laparoscopic cholecystectomy on an elderly patient, we were alarmed to find another "cystic" duct after division of the cystic duct, and the operation was converted to open laparotomy. This is the first documented case in the English literature of duplication of a cystic duct with two ducts joining the common hepatic duct at the same level. This and other anatomic variations are important considerations in the safe performance of laparoscopic cholecystectomy.

Methemoglobinemia associated with prilocaine use in neonatal circumcision

A term, 2500 g infant was circumcised at 2 days of age. The circumcision was uneventful, with no excessive bleeding. Analgesia was provided by prilocaine, 0.5 cc, and subsequently, the neonate developed methemoglobinemia. Alternatives to analgesia with prilocaine are discussed.

Immediate effects of arousal from sleep on cardiac autonomic outflow in the absence of breathing in dogs

To determine the immediate effects of arousal from non-rapid-eye-movement (non-REM) sleep on cardiac sympathetic and parasympathetic activities, six dogs were studied breathing through an endotracheal tube inserted into a chronic tracheostomy. Mean heart rates (HRs) during non-REM sleep were compared with 1) awake periods immediately after spontaneous arousals (ARs) and 2) later periods of stable relaxed wakefulness (RW). During spontaneous breathing, HR increased after AR (mean = 31.0%; P < 0.001) and in RW (mean = 7.6%; P < 0.001). To avoid the confounding influence of changes in breathing pattern, lung volume, and blood gases accompanying AR on HR, further studies were performed during constant mechanical hyperventilation that eliminated spontaneous breathing. In this condition, HR still increased after AR (mean = 29.9%; P < 0.001) and in RW (mean = 5.7%; P < 0.001), suggesting that the HR increases could be mediated by an effect of the state change per se on autonomic activity. This interpretation was confirmed when the HR increases were essentially abolished by combined cardiac sympathetic and parasympathetic block. In contrast, parasympathetic block alone did not prevent the HR increases after AR (mean = 12.2%; P < 0.001) or in RW (mean = 12.3%; P < 0.001), whereas sympathetic block alone almost abolished the HR increases in RW (mean = 3.6%) but did not prevent the HR increases during AR (mean = 30.2%; P < 0.001). The results show that, compared with non-REM sleep, AR is associated with acute cardiac sympathetic activation and parasympathetic withdrawal, whereas stable RW is associated mainly with sympathetic activation. These effects may have clinical relevance to the cardiovascular sequelae of breathing disorders that cause repetitive arousals from sleep.

Increased lipolysis to beta-adrenergic stimulation after dehydroepiandrosterone treatment in rats

Young adult male rats were treated with 4 mg dehydroepiandrosterone (DHEA)/100-g diet for 4 wk or were fed the same purified diet unadulterated (51 carbohydrate:20 fat: 23.5 protein; wt/wt). After 1 wk body weight and fat mass of the DHEA-fed rats were significantly less than the controls. By the end of week 3, fat-free mass of the DHEA rats was less than the controls. Neither food intake nor resting metabolism, measured by indirect calorimetry, was different between groups. Isolated epididymal adipocytes of DHEA rats were significantly smaller and isoproterenol (x 10(7) M) stimulation of glycerol release was 53% greater (P < 0.01) than the controls. Basal rate of glycerol release increased significantly for both groups in response to the adenosine inhibitor adenosine deaminase; there were no significant interaction effects. Inhibition of lipolysis by the adenosine analogue phenylisopropyladenosine was similar between groups. Findings support the hypothesis that DHEA reduces adiposity directly by increased lipolysis, but the mechanism of action does not involve a change in the antilipolytic function of adenosine.

The mechanism of biooxidation of mercury

The mechanism of oxidation of mercury by peroxidase is reported. The reaction is first order both in mercury and in peroxidase Compound I, and involves a one-step two-electron oxidation. The enzyme acts as a recycling chemical oxidant.

Occupational exposure to cyclophosphamide

Several lines of research have demonstrated the risk of occupational exposure of health-care personnel to anticancer drugs. Urine samples from two nurses working in a cancer clinic were analysed for cyclophosphamide (CP) by gas chromatography after they had prepared the drug for treatment. Since the drug might be absorbed through the skin, urine samples from five volunteers were also examined after a solution of CP had been applied topically to the cubital fossa area. Variable quantities of intact CP were identified in samples from the volunteers collected over 24 h, but in most cases the drug was evident only in urine samples given more than 6 h after application. CP was found in several urine samples from the nurses, but the quantities of CP in these samples were not related to the amounts of drug handled. The identity of CP was confirmed by gas-chromatography/mass-spectrometry. CP appeared sooner in the urine samples from the nurses than in those from the volunteers, suggesting a faster route of absorption, perhaps through inhalation of aerosols generated during dissolution of the drug. These findings suggest that the increased levels of mutagenicity observed in urine samples of nurses who worked on oncology wards might have arisen, in part, from metabolites of CP.