Neonatal Survival After Serial Amnioinfusions for Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial

Importance

Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival.

Objective

To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia.

Design, Setting, and Participants

Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies.

Exposure

Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks' gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age.

Main Outcomes and Measures

The primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement.

Results

The trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks' gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks).

Conclusions and Relevance

Serial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden.

Trial Registration

ClinicalTrials.gov Identifier: NCT03101891.

Physiological effects of intraperitoneal versus subcutaneous insulin infusion in patients with diabetes mellitus type 1: A systematic review and meta-analysis

The intraperitoneal route of administration accounts for less than 1% of insulin treatment regimes in patients with diabetes mellitus type 1 (DM1). Despite being used for decades, a systematic review of various physiological effects of this route of insulin administration is lacking. Thus, the aim of this systematic review was to identify the physiological effects of continuous intraperitoneal insulin infusion (CIPII) compared to those of continuous subcutaneous insulin infusion (CSII) in patients with DM1. Four databases (EMBASE, PubMed, Scopus and CENTRAL) were searched beginning from the inception date of each database to 10^th of July 2020, using search terms related to intraperitoneal and subcutaneous insulin administration. Only studies comparing CIPII treatment (≥ 1 month) with CSII treatment were included. Primary outcomes were long-term glycaemic control (after ≥ 3 months of CIPII inferred from glycated haemoglobin (HbA1c) levels) and short-term (≥ 1 day for each intervention) measurements of insulin dynamics in the systematic circulation. Secondary outcomes included all reported parameters other than the primary outcomes. The search identified a total of 2242 records; 39 reports from 32 studies met the eligibility criteria. This meta-analysis focused on the most relevant clinical end points; the mean difference (MD) in HbA1c levels during CIPII was significantly lower than during CSII (MD = -6.7 mmol/mol, [95% CI: -10.3 –-3.1]; in percentage: MD = -0.61%, [95% CI: -0.94 –- 0.28], p = 0.0002), whereas fasting blood glucose levels were similar (MD = 0.20 mmol/L, [95% CI: -0.34–0.74], p = 0.47; in mg/dL: MD = 3.6 mg/dL, [95% CI: -6.1–13.3], p = 0.47). The frequencies of severe hypo- and hyper-glycaemia were reduced. The fasting insulin levels were significantly lower during CIPII than during CSII (MD = 16.70 pmol/L, [95% CI: -23.62 –-9.77], p < 0.0001). Compared to CSII treatment, CIPII treatment improved overall glucose control and reduced fasting insulin levels in patients with DM1.

Probiotics to prevent necrotising enterocolitis in very preterm or very low birth weight infants

BACKGROUND

Intestinal dysbiosis may contribute to the pathogenesis of necrotising enterocolitis (NEC) in very preterm or very low birth weight infants. Dietary supplementation with probiotics to modulate the intestinal microbiome has been proposed as a strategy to reduce the risk of NEC and associated mortality and morbidity.  OBJECTIVES: To determine the effect of supplemental probiotics on the risk of NEC and mortality and morbidity in very preterm or very low birth weight infants.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 2) in the Cochrane Library; MEDLINE Ovid (1946 to 17 Feb 2020), Embase Ovid (1974 to 17 Feb 2020), Maternity & Infant Care Database Ovid (1971 to 17 Feb 2020), the Cumulative Index to Nursing and Allied Health Literature (1982 to 18 Feb 2020). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs comparing probiotic supplementation with placebo or no probiotics in very preterm or very low birth weight infants.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on NEC, all-cause mortality, late-onset infection, and severe neurodevelopmental impairment.

MAIN RESULTS

We included 56 trials in which 10,812 infants participated. Most trials were small (median sample size 149). Lack of clarity on methods to conceal allocation and mask caregivers or investigators were the main potential sources of bias in about half of the trials. Trials varied by the formulation of the probiotics. The most commonly used preparations contained Bifidobacterium spp., Lactobacillus spp., Saccharomyces spp., and Streptococcus spp. alone or in combinations. Meta-analysis showed that probiotics may reduce the risk of NEC: RR 0.54, 95% CI 0.45 to 0.65 (54 trials, 10,604 infants; I² = 17%); RD -0.03, 95% CI -0.04 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) 33, 95% CI 25 to 50. Evidence was assessed as low certainty because of the limitations in trials design, and the presence of funnel plot asymmetry consistent with publication bias. Sensitivity meta-analysis of trials at low risk of bias showed a reduced risk of NEC: RR 0.70, 95% CI 0.55 to 0.89 (16 trials, 4597 infants; I² = 25%); RD -0.02, 95% CI -0.03 to -0.01; NNTB 50, 95% CI 33 to 100. Meta-analyses showed that probiotics probably reduce mortality (RR 0.76, 95% CI 0.65 to 0.89; (51 trials, 10,170 infants; I² = 0%); RD -0.02, 95% CI -0.02 to -0.01; NNTB 50, 95% CI 50 to 100), and late-onset invasive infection (RR 0.89, 95% CI 0.82 to 0.97; (47 trials, 9762 infants; I² = 19%); RD -0.02, 95% CI -0.03 to -0.01; NNTB 50, 95% CI 33 to 100). Evidence was assessed as moderate certainty for both these outcomes because of the limitations in trials design. Sensitivity meta-analyses of 16 trials (4597 infants) at low risk of bias did not show an effect on mortality or infection. Meta-analysis showed that probiotics may have little or no effect on severe neurodevelopmental impairment (RR 1.03, 95% CI 0.84 to 1.26 (five trials, 1518 infants; I² = 0%). The certainty on this evidence is low because of limitations in trials design and serious imprecision of effect estimate. Few data (from seven of the trials) were available for extremely preterm or extremely low birth weight infants. Meta-analyses did not show effects on NEC, death, or infection (low-certainty evidence).

AUTHORS' CONCLUSIONS

Given the low to moderate level of certainty about the effects of probiotic supplements on the risk of NEC and associated morbidity and mortality for very preterm or very low birth weight infants, and particularly for extremely preterm or extremely low birth weight infants, further, large, high-quality trials are needed to provide evidence of sufficient quality and applicability to inform policy and practice.

A phase I dose-escalation study of oxaliplatin delivered via a laparoscopic approach using pressurised intraperitoneal aerosol chemotherapy for advanced peritoneal metastases of gastrointestinal tract cancers

OBJECTIVE

The objectives were to define the maximum tolerated dose (MTD), safety profile and pharmacokinetics (PKs) of intraperitoneal oxaliplatin delivered by pressurised intraperitoneal aerosol chemotherapy (PIPAC) in patients with advanced peritoneal carcinomatosis from gastrointestinal tract cancers.

METHODS

PIPAC was applied every 4-6 weeks, for 5 cycles, in a phase I dose-escalation study using a 3 + 3 design. The first dose level was 90 mg/m² with planned increases of 50 mg/m² per level. Platinum concentration was measured in plasma, tissues and intraperitoneal fluid samples. The trial was registered at ClinicalTrials.gov (NCT03294252).

RESULTS

Ten patients with 33 PIPAC sessions were included. No dose limiting toxicity (DLT) occurred at 90 mg/m² and two at 140 mg/m². The MTD was therefore set at 90 mg/m². Overall treatment included a median number of three PIPAC sessions (range: 1-5) and secondary complete cytoreductive surgery for two patients. Overall safety showed 67 grade I-II and 11 grade III-IV toxicities, usually haematologic, digestive (nausea/vomiting, abdominal pain), and fatigue. Oxaliplatin concentrations were three- to four-fold higher in tissue in contact with aerosol than in muscle without contact. At 140 mg/m², the plasma oxaliplatin concentration was high with Cmax and area under the curve (AUC)_0-48h of 1035 μg/l and 9028 μg h/L, respectively.

CONCLUSIONS

The MTD of oxaliplatin during PIPAC is 90 mg/m². PK data demonstrate a high tumour concentration and a significant systemic absorption.

Intravenous Admixture Preparation Considerations, Part 6: pH Considerations -- Applications

In the formulation of parenteral dosage forms, pH is a critical factor and can be a complicated factor in compounding intravenous admixtures since the additives and the vehicle may have different pH values. This is especially important, as a significant number of parenteral medications require compounding involving dissolution of lyophilized powders; dilution of drug doses for infusion; mixing of dextrose, amino acids, vitamins, and electrolytes for parenteral nutrition; etc. Compounding intravenous admixtures is common practice, but each admixture may present a different set of problems to consider, especially as it relates to pH.

Systematic review of patient reported outcomes (PROs) and quality of life measures after pressurized intraperitoneal aerosol chemotherapy (PIPAC)

Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) constitutes a recently described surgical technique to administer chemotherapy directly to the peritoneum, under pressure, for patients with peritoneal metastasis (PM). The purpose of an oncological treatment is to improve survival but without altering the patient's quality of life. The aim of this review was to evaluate patient-reported outcomes (PRO) after PIPAC for patients with PM. This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Between January 1, 2013, and January 1, 2020, studies were selected according to the following criteria: "pressurized intraperitoneal aerosol chemotherapy" OR "PIPAC" AND "patient-reported outcomes" OR "PRO" OR "Quality of life". In this review, 959 PIPAC and five PITAC (Pressurized IntraThoracic Aerosol Chemotherapy) were performed in 425 patients. We highlight the prominent application of generic EORTC QLQ-C30 followed by SF-36 in this review. The PROs according to the EORTC-QLQ-C30 global health score and based on symptom and function scores were stable across most studies. Moreover, PIPAC has improved the PRO of altered patients in two studies. Among 425 patients, the mortality rate was 0.7% and adverse events of Common Terminology Criteria of Adverse Events grade 3 and grade 4 were 9.6% and 1.6%, respectively. We synthesised current research on PROs among patients with PM. This review increases our understanding of the PIPAC strategy from the patient perspective. The implementation of PROs can be complex but will be essential in delivering quality care.

Norepinephrine prophylaxis for postspinal anesthesia hypotension in parturient undergoing cesarean section: a randomized, controlled trial

OBJECTIVE

To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section.

METHODS

Patients (n = 97) were randomized to receive a bolus of NE (6 μg) immediately following spinal anesthesia with maintenance NE (0.05 μg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores).

RESULTS

The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups.

CONCLUSION

Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.

Psychiatric symptoms and cognitive dysfunction caused by Epstein–Barr virus-induced encephalitis

Epstein-Barr virus (EBV) encephalitis is rare and shows a wide range of clinical manifestations. We report an immunocompromised patient with EBV encephalitis diagnosed by EBV-specific PCR and antibody testing in the cerebrospinal fluid who presented with psychiatric symptoms and cognitive dysfunction in the absence of any neurological impairments or infectious signs. Clinical recovery and clearance of cerebrospinal fluid EBV DNA appeared following ganciclovir treatment within 6 weeks.

Effect of dose and exposure protocol on the toxicokinetics and first-pass elimination of trichloroethylene and 1,1,1-trichloroethane

Trichloroethylene (TCE) and 1,1,1-trichloroethane (TRI) are frequent contaminants of drinking water and of groundwater at hazardous waste sites. There is relatively little information on the target organ deposition of TRI, despite its ingestion and common occurrence in humans. An important aim of the study was to delineate and contrast the toxicokinetics (TK) and bioavailability (F) of TRI and its well metabolized congener, TCE. Blood profiles were obtained from male Sprague-Dawley rats given aqueous emulsions of 6 or 48 mg TRI/kg and 10 or 50 mg TCE/kg as an oral bolus (po) or by gastric infusion (gi) over 2 h. TCE exhibited nonlinear TK, with a disproportionate increase in AUC and decrease in clearance and F with increase in dose. TRI exhibited linear TK. F did not vary significantly with TRI dose or dosage regimen. F values were substantially higher for TRI than for the respective TCE groups. TRI was distributed widely to tissues of rats gavaged with 6 mg TRI/kg, with accumulation in fat. This experiment yielded tissue uptake and elimination profiles and in vivo tissue:blood partition coefficients (PCs). Finally, additional rats were given 10 mg/kg of TCE and TRI po, ia and iv, so that first-pass hepatic (FP_h) and pulmonary (FP_p) elimination could be measured directly. Total and FP_h elimination of TCE exceeded that of TRI. TRI, with its higher air:blood PC, exhibited the higher FP_p. TCE and TRI, despite several common physical and chemical properties resulting in similar absorption and systemic distribution, displayed dissimilar dosage and dose rate effects on their TK.

Delivery, setting and outcomes of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): a scoping review

BACKGROUND

There has been little detailed systematic consideration of the delivery, setting and outcomes of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT), although individual studies report that it is a safe and effective treatment.

OBJECTIVE

This scoping review aimed to examine what is known about the delivery, settings and outcomes of paediatric OPAT and to identify key knowledge deficits.

DESIGN

A scoping review using Arksey and O'Malley's framework was undertaken.

DATA SOURCES

Keywords were identified and used to search MEDLINE and CINAHL.

STUDY APPRAISAL METHODS

Primary research studies were included if samples comprised children and young people 21 or under, who had received OPAT at home or in a day treatment centre. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies MAIN FINDINGS: From a preliminary pool of 157 articles, 51 papers were selected for full review. 19 studies fitted the inclusion criteria. Factors influencing delivery of OPAT were diverse and included child's condition, home environment, child-related factors, parental compliance, training and monitoring. There is little consensus as to what constitutes success of and adverse events in OPAT.

CONCLUSIONS

Future studies need to clearly define and use success indicators and adverse events in order to provide evidence that paediatric OPAT is safe and effective.

IMPLICATIONS

Consensus outcomes that include child and parent perspectives need to be developed to allow a clearer appreciation of a successful paediatric OPAT service.

The scientific report from the first pressurized intraperitoneal aerosol chemotherapy (PIPAC) procedures performed in the eastern part of Central Europe

Objective To perform a single-centre, detailed analysis of the preparations for the introduction of the first pressurized intraperitoneal aerosol chemotherapy (PIPAC) programme in the eastern part of Central Europe. Methods The study analysed the 14-month preparation period prior to the performance of the first PIPAC procedure with respect to: (i) general preparations; (ii) patient referral and qualification; (iii) the first PIPAC procedure; (iv) the 2 weeks following PIPAC programme establishment; and (v) general problematic issues that arose. Results The length of time needed to prepare our institution for the first PIPAC procedure was extremely long compared with other European Union PIPAC centres: 14 months versus a standard 3-6 months of preparation. The longest amount of time (12 months) was required to prepare the required paperwork. Conclusions A new PIPAC programme was successfully established in the eastern part of Central Europe. The length of time to implement this method was significantly longer because of lengthy bureaucratic processes. These current findings should help new centres, especially in this part of Europe, to establish a PIPAC programme more quickly.

Impacts on health outcomes and on resource utilisation of home-based parenteral chemotherapy administration: a systematic review protocol

INTRODUCTION

Despite the demonstrated feasibility and policies to enable more to receive chemotherapy at home, in a few countries, parenteral chemotherapy administration at home remains currently marginal. Of note, findings of different studies on health outcomes and resources utilisation vary, leading to conflicting results. This protocol outlines a systematic review that seeks to synthesise and critically appraise the current state of evidence on the comparison between home setting and hospital setting for parenteral chemotherapy administration within the same high standards of clinical care.

METHODS AND ANALYSIS

This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols approach. Electronic searches will be conducted on bibliographic databases selected from the earliest available data through 15 November 2017 published in French and English languages. Additional potential papers in the selected studies and grey literature will be also included in the review. The review will include all types of studies exploring patients receiving anticancer drugs for injection at home compared with patients receiving the drugs in a hospital setting, and will assess at least one of the following criteria: patients' health outcomes, patients' or caregivers' satisfaction, resource utilisation with cost savings, and incentives and/or barriers of each admission setting according to patients' and relatives' points of view. Two reviewers will independently screen studies and extract relevant data from the included studies. Methodological quality of studies will be assessed using the 'Quality Assessment Tool for Quantitative Studies' developed by the Effective Public Health Practice Project tool, in addition to the Consolidated Health Economic Evaluation Reporting Standards statement for economic studies.

ETHICS AND DISSEMINATION

As the review is focused on the analysis of secondary data, it does not require ethics approval. The results of the study will be disseminated through articles in peer-reviewed journals and trade publications, as well as presentations at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017068164.

Neutropenia following Perioperative Intraperitoneal Chemotherapy

Introduction

The purpose of this retrospective report was to evaluate clinical features associated with profound neutropenia in patients with peritoneal carcinomatosis who were treated with heated intraoperative intraperitoneal chemotherapy (HIIC) followed by early postoperative intraperitoneal chemotherapy (EPIC). Common clinical denominators for significant neutropenia were analyzed.

Materials and Methods

A retrospective study of all available clinical data of six patients with postoperative neutropenia out of a total of 242 was undertaken. All patients underwent cytoreductive surgery, HIIC with mitomycin C (n = 4) or cisplatin (n = 1) and EPIC with 5-fluorouracil (5-FU) for 4 (n = 1) or 5 (n = 5) days.

Results

All six patients presented with hematologic toxicity of WHO criteria grade 4; four of them died postoperatively. Two of the patients who died, and one who did not die, developed bowel perforations. Five patients had prior chemotherapy with 5-FU; three of them had toxic side effects. All patients were overweight, and three patients were anemic preoperatively. The neutropenia presented with fever, leukopenia and thrombocytopenia on postoperative days 10–15. The leukocyte count courses showed a pattern suggesting the 5-FU as the cause of leukopenia. There was no consistent warning signal for predicting severe neutropenia.

Discussion

Neutropenia following cytoreductive surgery combined with HIIC and EPIC has a high mortality (66%). Patients who are at special risk and should have a dose reduction include patients who had toxicities from prior chemotherapy, who present with obesity and anemia. The groups have an increased risk of developing postoperative profound neutropenia. This condition can result in a prohibitively high mortality and morbidity rate. Therefore, reduced doses of chemotherapy in selected patients are necessary to prevent this condition from developing.

Feasibility of Peritonectomy Associated with Intraperitoneal Hyperthermic Perfusion in Patients with Pseudomyxoma Peritonei

Aims and background

Pseudomyxoma peritonei is a rare disease characterized by a complete redistribution of mucin within the peritoneal cavity. It can be classified into three histologic groups: disseminated peritoneal adenomucinosis, peritoneal mucinous carcinomatosis, and an intermediate group. The aim of the present study was to evaluate the feasibility of cytoreductive surgery requiring peritonectomy procedures associated with intraperitoneal hyperthermic perfusion, a technique that combines hyperthermia and high drug doses administered locally.

Methods

Twenty-seven patients with pseudomyxoma peritonei (19 males and 8 females) were enrolled in a phase II clinical trial. Twenty-two cases underwent cytoreductive surgery plus intraperitoneal hyperthermic perfusion, and 6 received de-bulking surgery only. One patient was operated on twice for disease recurrence. All patients with peritoneal mucinous carcinomatosis presented serous ascites, whereas all but one patient with disseminated peritoneal adenomucinosis or in the intermediate group presented mucinous ascites. Cytoreductive surgery was performed with peritonectomy procedures. The closed abdomen technique was adopted for intraperitoneal hyperthermic perfusion using a preheated poly-saline perfusate containing cisplatin (25 mg/m2/L) plus mitomycin-C (3.3 mg/m2/L) through a heart-lung pump at a mean flow of 600 mL/min for 60 mins from the hyperthermic phase (42.5 °C).

Results

All but one of the patients with disseminated peritoneal adenomucinosis and 2 of the 3 patients in the intermediate group were optimally cytoreduced. Patients with serous ascites (all patients with peritoneal mucinous carcinomatosis and 1 patient with disseminated peritoneal adenomucinosis) were considered ineligible for treatment because of tumor diffusion. The morbidity rate was 22%. There was one case of treatment-related mortality 30 days after treatment.

Conclusions

The following conclusions can be drawn from this phase II clinical trial: 1) patients with pseudomyxoma peritonei originating from undifferentiated mucinous adenocarcinoma (peritoneal mucinous carcinomatosis), with complete distribution into the peritoneal cavity, are not eligible for the cytoreductive surgery plus intraperitoneal hyperthermic perfusion technique; 2) the presence of serous ascites would seem to exclude patients from the treatment; 3) cytoreductive surgery associated with intraperitoneal hyperthermic perfusion is the most suitable approach for patients with disseminated peritoneal adenomucinosis and in the intermediate group.

The Prediction of Shunt Response in Idiopathic Normal-Pressure Hydrocephalus Based on Intracranial Pressure Monitoring and Lumbar Infusion

BACKGROUND

Intracranial pressure (ICP) monitoring and infusion studies have long been used in the preoperative workup of patients with suspected idiopathic normal-pressure hydrocephalus (iNPH). We have analysed the predictive values of different measures derived from both investigations, emphasising the differences between responders and nonresponders.

MATERIALS AND METHODS

ICP monitoring and lumbar infusion studies were routinely performed during a 6-year period. Shunting was proposed when the resistance to cerebrospinal fluid outflow (ROUT) >12 mmHg/ml/min and/or a minimum 15 % of slow waves were detected. The outcome was evaluated 6 months after surgery. Recorded data from ICP monitoring were mean pressure and pulse amplitude, the total percentage of slow waves and the presence of different types of slow waves following the classification proposed by Raftopoulos et al. Recorded data from lumbar infusion studies were mean values of pressure and pulse amplitude during three epochs (basal, early infusion and plateau), ROUT and the pulsatility response to the increase in mean pressure during the infusion. This response was quantified by two pulse amplitude indexes: the pulse amplitude index during the early infusion stage (A1) and the pulse amplitude index during the plateau stage (A2).

RESULTS

Thirty shunted patients were evaluated at the end of the follow-up and 23 (76.7 %) of them improved. Differences in the percentage of slow waves, ROUT and both pulsatility indexes were not statistically significant. The proportion of patients with great symmetrical waves and pulse amplitude during the early infusion stage were higher in responders (p < 0.05). The predictive analysis yielded the highest accuracy, with ROUT and A1 as a logical "OR" combination.

CONCLUSION

The combined use of ICP monitoring and lumbar infusion to forecast the response to shunting in patients with suspected iNPH did not improve the accuracy provided by any of them alone.

A New Optimized Percutaneous Access System for CIPII

In recent years, continuous intraperitoneal insulin infusion (CIPII) has become a favored treatment alternative for patients with subcutaneous insulin resistance, mainly due to its ability of mimicking physiological conditions of insulin absorption. CIPII has been shown to improve glycemic control as well as to reduce hypoglycemic events and to lead to increased patient satisfaction and quality of life (QoL). Among CIPII delivery systems, Diaport stands out due to its low side effects, its demonstrated clinical efficacy and the potential for integration into closed-loop systems.

Physical Stability of 20% Lipid Injectable EmulsionsviaSimulated Syringe Infusion: Effects of GlassvsPlastic Product Packaging

BACKGROUND

The United States Pharmacopeia (USP) has proposed large-globule-size limits to ensure the physical stability of lipid injectable emulsions, expressed as the percent fat >5 microm, or PFAT(5), not exceeding 0.05%. Visibly obvious phase separation as free oil has been shown to occur in some samples if PFAT(5) is >0.4%. We recently found that lipids, newly packaged in plastic (P), exceed the proposed USP limits and seem to produce less stable total nutrient admixtures compared with those made from conventional glass (G), which do meet proposed USP standards. We tested the possible stability differences between 20% lipid injectable emulsions in either P or G in a simulated neonatal syringe infusion study.

METHODS

Eighteen individual syringes were prepared from each 20% lipid injectable emulsion product (n = 36) and attached to a syringe pump set at an infusion rate of 0.5 mL/hour. The starting PFAT(5) levels were measured at time 0 and after 24 hours of infusion, using a laser-based light obscuration technique as described by the USP Chapter <729>. The data were assessed by a 2-way analysis of variance (ANOVA) with Container (G vs P) and Time as the independent variables and PFAT as the dependent variable.

RESULTS

At time 0, the starting PFAT(5) level for lipids packaged in G was 0.006% +/- 0.001% vs 0.162% +/- 0.026% for P, whereas at the end of the infusion they were 0.013% +/- 0.003% and 0.328% +/- 0.046%, respectively. Significant differences were noted overall between groups for Container, Time, and Container-Time interaction (all p < .001). Bonferroni tests showed significant differences in PFAT(5) levels between Containers at time 0 (T-0; p < .001) and T-0 vs T-24 for P-based lipids (p < .001), whereas no such differences were noted for Time for the G-based lipids. Similar results were noted for PFAT(10) levels.

CONCLUSIONS

We confirm that presently available lipid injectable emulsions packaged in newly introduced plastic containers exceed the proposed USP <729> PFAT(5) limits and subsequently become significantly less stable during a simulated syringe-based infusion. Although modest growth (p = NS) in large-diameter fat globules was observed for the glass-based lipids, they remained within proposed USP globule size limits throughout the study. Glass-based lipids seem to be a more stable dosage form and potentially a safer way to deliver lipids via syringe infusion to critically ill neonates.

Successful implementation of outpatient parenteral antimicrobial therapy at a medical respite facility for homeless patients

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) is a safe way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). Often, homeless patients with complex infections, who could otherwise be treated as an outpatient, remain in the hospital for the duration of IV antibiotic treatment. Injection drug use (IDU) is a barrier to OPAT.

OBJECTIVE

To evaluate our experience with administering OPAT to homeless patients at a medical respite facility and determine if patients could complete a successful course of antibiotics.

DESIGN

Using retrospective chart review, demographics, diagnosis, and comorbidities including mental illness, current IDU, and remote IDU (>3 months ago) were recorded. Surgical, microbiologic, and antimicrobial therapy including route (IV or oral), duration of therapy, and adverse events were abstracted.

PARTICIPANTS

Homeless patients >18 years old who received OPAT at medical respite after discharge, no exclusions.

MAIN MEASUREMENTS

Primary outcome was successful completion of OPAT at medical respite. Secondary outcome was successful antimicrobial course completion for a specific diagnosis.

RESULTS

Forty-six (87%) patients successfully completed a defined course of antibiotic therapy. Thirty-four (64%) patients were successfully treated with OPAT at medical respite. Readmission rate was 30%. The average length of OPAT was 22 days. The cost savings to our institution (using $1500/day inpatient cost) was $25,000 per episode of OPAT.

CONCLUSIONS

OPAT can be successful in a supervised medical respite setting for homeless patients with the help of a multidisciplinary team, and can decrease inpatient LOS resulting in cost savings. Journal of Hospital Medicine 2016;11:531-535. © 2016 Society of Hospital Medicine.

Percutaneous Transhepatic Thrombectomy and Pharmacologic Thrombolysis of Mesenteric Venous Thrombosis

Mesenteric venous occlusion is a rare yet highly morbid condition that is traditionally treated with anticoagulation while surgery serves as the last resort. Percutaneous intervention provides an effective option with relatively low mortality and morbidity. We herein describe use of transhepatic percutaneous thrombectomy and pharmacologic thrombolysis in treating two cases of symptomatic mesenteric venous thrombosis. These cases underscore the fact that transhepatic thrombectomy and thrombolysis are a highly effective strategy for treating acute symptomatic mesenteric venous thrombosis. Several percutaneous techniques are also reviewed.

Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer

BACKGROUND

Ovarian cancer tends to be chemosensitive and confine itself to the surface of the peritoneal cavity for much of its natural history. These features have made it an obvious target for intraperitoneal (IP) chemotherapy. Chemotherapy for ovarian cancer is usually given as an intravenous (IV) infusion repeatedly over five to eight cycles. Intraperitoneal chemotherapy is given by infusion of the chemotherapeutic agent directly into the peritoneal cavity. There are biological reasons why this might increase the anticancer effect and reduce some systemic adverse effects in comparison to IV therapy.

OBJECTIVES

To determine if adding a component of the chemotherapy regime into the peritoneal cavity affects overall survival, progression-free survival, quality of life (QOL) and toxicity in the primary treatment of epithelial ovarian cancer.

SEARCH METHODS

We searched the Gynaecological Cancer Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, MEDLINE (1951 to May 2011) and EMBASE (1974 to May 2011). We updated these searches in February 2007, August 2010, May 2011 and September 2015. In addition, we handsearched and cascade searched the major gynaecological oncology journals up to May 2011.

SELECTION CRITERIA

The analysis was restricted to randomised controlled trials (RCTs) assessing women with a new diagnosis of primary epithelial ovarian cancer, of any FIGO stage, following primary cytoreductive surgery. Standard IV chemotherapy was compared with chemotherapy that included a component of IP administration.

DATA COLLECTION AND ANALYSIS

We extracted data on overall survival, disease-free survival, adverse events and QOL and performed meta-analyses of hazard ratios (HR) for time-to-event variables and relative risks (RR) for dichotomous outcomes using RevMan software.

MAIN RESULTS

Nine randomised trials studied 2119 women receiving primary treatment for ovarian cancer. We considered six trials to be of high quality. Women were less likely to die if they received an IP component to chemotherapy (eight studies, 2026 women; HR = 0.81; 95% confidence interval (CI): 0.72 to 0.90). Intraperitoneal component chemotherapy prolonged the disease-free interval (five studies, 1311 women; HR = 0.78; 95% CI: 0.70 to 0.86). There was greater serious toxicity with regard to gastrointestinal effects, pain, fever and infection but less ototoxicity with the IP than the IV route.

AUTHORS' CONCLUSIONS

Intraperitoneal chemotherapy increases overall survival and progression-free survival from advanced ovarian cancer. The results of this meta-analysis provide the most reliable estimates of the relative survival benefits of IP over IV therapy and should be used as part of the decision making process. However, the potential for catheter related complications and toxicity needs to be considered when deciding on the most appropriate treatment for each individual woman. The optimal dose, timing and mechanism of administration cannot be addressed from this meta-analysis. This needs to be addressed in the next phase of clinical trials.

[Outpatient parenteral antibiotic therapy (OPAT)]

Traditionally, parenteral (i. e. intravenous) antimicrobial therapy has been used in inpatients with various bacterial infections. In recent decades there has been growing experience with outpatient parenteral antimicrobial therapy, mainly in the USA and western Europe. This article provides basic information on OPAT, based on available literature and the author´s experience on running OPAT service in the UK.

Peritoneal metastases: challenges for the surgeon

Peritoneal surface malignancies (PSM) include peritoneal metastases from gastrointestinal and gynecological tumor and rare primary peritoneal malignancies. PSM have been historically considered as end-stage metastatic conditions only amenable to palliative options. Only in recent years, better knowledge of their natural history and pattern of disease-progression has evolved into the concept that PSM represent a local-regional disease stage. A novel treatment approach aiming at definitive disease eradication combines aggressive cytoreductive surgery (CRS) and perioperative local-regional chemotherapy, either in the form of hyperthermic intraperitoneal chemotherapy (HIPEC), or normothermic early postoperative chemotherapy. Such a combined treatment approach has reportedly resulted in a survival improvement over historical controls, and it is gaining an increasing acceptance as standard of care for selected patients with PSM. This article reviews the most recent literature data on the surgical and comprehensive management of PSM. Epidemiology and natural history of the different disease entities are briefly discussed. Cytoreductive surgical procedures and intraperitoneal chemotherapy administration techniques are described, focusing on the technical variants adopted in our institution. Indications for combined treatment, and outcomes following CRS/HIPEC, are addressed, including peritoneal metastases from appendiceal tumors (pseudomyxoma peritonei), colorectal cancer, gastric cancer, epithelial ovarian cancer, and rare primary peritoneum based neoplasms, such as diffuse malignant peritoneal mesothelioma, and primary peritoneal (extra-ovarian) serous papillary carcinoma.

Filling a niche market: administering drugs by injection or infusion

There is greater incentive than ever to keep individuals requiring injectable or infusion therapy in the nursing facility-and not transfer them to a hospital-to receive those services. There is a demand for pharmacists with the skills, knowledge, and training to provide these services. To make that possible, pharmacies and pharmacists with the proper equipment, supplies, knowledge, training, and expertise are needed to work closely with physicians and nurses to provide sterile, properly compounded products and ensure that drugs are administered appropriately and in the right doses. These pharmacists also can work with facilities and practitioners to assess, improve, and document quality.

Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease

BACKGROUND

Dehydration is an important cause of death in patients with Ebola virus disease (EVD). Parenteral fluids are often required in patients with fluid requirements in excess of their oral intake. The peripheral intravenous route is the most commonly used method of parenteral access, but inserting and maintaining an intravenous line can be challenging in the context of EVD. Therefore it is important to consider the advantages and disadvantages of different routes for achieving parenteral access (e.g. intravenous, intraosseous, subcutaneous and intraperitoneal).

OBJECTIVES

To compare the reliability, ease of use and speed of insertion of different parenteral access methods.

SEARCH METHODS

We ran the search on 17 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE(R) and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), CINAHL (EBSCOhost), clinicaltrials.gov and screened reference lists.

SELECTION CRITERIA

Randomised controlled trials comparing different parenteral routes for the infusion of fluids or medication.

DATA COLLECTION AND ANALYSIS

Two review authors examined the titles and abstracts of records obtained by searching the electronic databases to determine eligibility. Two review authors extracted data from the included trials and assessed the risk of bias. Outcome measures of interest were success of insertion; time required for insertion; number of insertion attempts; number of dislodgements; time period with functional access; local site reactions; clinicians' perception of ease of administration; needlestick injury to healthcare workers; patients' discomfort; and mortality. For trials involving the administration of fluids we also collected data on the volume of fluid infused, changes in serum electrolytes and markers of renal function. We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach for the following outcomes: success of insertion, time required for insertion, number of dislodgements, volume of fluid infused and needlestick injuries.

MAIN RESULTS

We included 17 trials involving 885 participants. Parenteral access was used to infuse fluids in 11 trials and medications in six trials. None of the trials involved patients with EVD. Intravenous and intraosseous access was compared in four trials; intravenous and subcutaneous access in 11; peripheral intravenous and intraperitoneal access in one; saphenous vein cutdown and intraosseous access in one; and intraperitoneal with subcutaneous access in one. All of the trials assessing the intravenous method involved peripheral intravenous access.We judged few trials to be at low risk of bias for any of the assessed domains.Compared to the intraosseous group, patients in the intravenous group were more likely to experience an insertion failure (risk ratio (RR) 3.89, 95% confidence interval (CI) 2.39 to 6.33; n = 242; GRADE rating: low). We did not pool data for time to insertion but estimates from the trials suggest that inserting intravenous access takes longer (GRADE rating: moderate). Clinicians judged the intravenous route to be easier to insert (RR 0.15, 95% CI 0.04 to 0.61; n = 182). A larger volume of fluids was infused via the intravenous route (GRADE rating: moderate). There was no evidence of a difference between the two routes for any other outcomes, including adverse events.Compared to the subcutaneous group, patients in the intravenous group were more likely to experience an insertion failure (RR 14.79, 95% CI 2.87 to 76.08; n = 238; GRADE rating: moderate) and dislodgement of the device (RR 3.78, 95% CI 1.16 to 12.34; n = 67; GRADE rating: low). Clinicians also judged the intravenous route as being more difficult to insert and patients were more likely to be agitated in the intravenous group. Patients in the intravenous group were more likely to develop a local infection and phlebitis, but were less likely to develop erythema, oedema or swelling than those in the subcutaneous group. A larger volume of fluids was infused into patients via the intravenous route. There was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine if the risk of insertion failure differed between the saphenous vein cutdown (SVC) and intraosseous method (RR 4.00, 95% CI 0.51 to 31.13; GRADE rating: low). Insertion using SVC took longer than the intraosseous method (MD 219.60 seconds, 95% CI 135.44 to 303.76; GRADE rating: moderate). There were no data and therefore there was no evidence of a difference between the two routes for any other outcome.There were insufficient data to reliably determine the relative effects of intraperitoneal or central intravenous access relative to any other parenteral access method.

AUTHORS' CONCLUSIONS

There are several different ways of achieving parenteral access in patients who are unable meet their fluid requirements with oral intake alone. The quality of the evidence, as assessed using the GRADE criteria, is somewhat limited because of the lack of adequately powered trials at low risk of bias. However, we believe that there is sufficient evidence to draw the following conclusions: if peripheral intravenous access can be achieved easily, this allows infusion of larger volumes of fluid than other routes; but if this is not possible, the intraosseous and subcutaneous routes are viable alternatives. The subcutaneous route may be suitable for patients who are not severely dehydrated but in whom ongoing fluid losses cannot be met by oral intake.A film to accompany this review can be viewed here (http://youtu.be/ArVPzkf93ng).

Toxicity of L-DOPA coated iron oxide nanoparticles in intraperitoneal delivery setting - preliminary preclinical study

Iron oxide nanoparticles are promising candidates for theranostics in cancer, that aims to achieve in one-step precise tumor imaging by magnetic resonance, and targeted therapy through surface attached anti-cancer drugs. The aim of this study was to investigate in preclinical setting the biocompatibility of new iron oxide-based nanoparticles that were coated with L-DOPA for improved dispersion in biological media. These nanostructures (NPs) were designed for biomedical applications as contrast agents and/or drug carriers. We investigated the effect exerted in vitro by NPs and L-DOPA on the viability and proliferation of normal mouse L929 fibroblasts. NPs exhibited good biocompatibility against these cells. Moreover, L-DOPA contained in NPs sustained fibroblasts proliferation and/or limited anti-proliferative effects of naked nanoparticles. In the animal study, C57BL/6 mice were injected intraperitoneally with a single dose of NPs (approximately 125 mg/kg body weight). We followed up hematological and histological parameters for one, three and seven days after NPs administration. Results indicated that NPs possibly induced local inflammation and consequent recruitment of peripheral lymphocytes, whilst the decrease of platelet counts may reflect tissue lesions caused by NPs. The histopathological study showed mild to moderate alterations in the hepatocytes, splenic and renal cells, while the brain parenchyma only presented nonspecific congestive changes. Taken altogether, the preclinical study indicated that the new iron oxide nanoparticles coated with L-DOPA were biocompatible against fibroblasts and had a convenient toxicological profile when administered intraperitoneally in a single dose to C57BL/6 mice. Accordingly, the proposed nanostructure is a promising candidate for imaging and treating dispersed peritoneal tumors.

Continuous infusions of meropenem in ambulatory care: clinical efficacy, safety and stability

OBJECTIVES

Concerns regarding the clinical impact of meropenem instability in continuous infusion (CI) devices may contribute to inconsistent uptake of this method of administration across outpatient parenteral antimicrobial therapy (OPAT) services.

METHODS

We retrospectively reviewed the clinical efficacy and safety of CIs of meropenem in two Australian tertiary hospitals and assessed its stability under simulated OPAT conditions including in elastomeric infusion devices containing 1% (2.4 g) or 2% (4.8 g) concentrations at either 'room temperature' or 'cooled' conditions. Infusate aliquots were assayed at different time-points over 24 hours.

RESULTS

Forty-one (82%) of 50 patients had clinical improvement or were cured. Adverse patient outcomes including hemato-, hepato- and nephrotoxicity were infrequent. Cooled infusers with 1% meropenem had a mean 24-hour recovery of 90.3%. Recoveries of 1% and 2% meropenem at room temperature and 2% under cooled conditions were 88%, 83% and 87%, respectively. Patients receiving 1% meropenem are likely to receive >95% of the maximum deliverable dose (MDD) over a 24-hour period whilst patients receiving 2% meropenem should receive 93% and 87% of the MDD under cooled and room temperature conditions, respectively.

CONCLUSIONS

Meropenem infusers are likely to deliver ∼95% MDD and maintain effective plasma concentrations throughout the dosing period. These data reflect our local favourable clinical experience with meropenem CIs.

High pressure does not counterbalance the advantages of open techniques over closed techniques during heated intraperitoneal chemotherapy with oxaliplatin

BACKGROUND

Heated intraperitoneal chemotherapy (HIPEC) treats residual microscopic disease after cytoreductive surgery. In experimental models, the open HIPEC technique has shown a higher and more homogenous concentration of platinum in the peritoneum than achieved using the closed technique. A 25-cm H2O pressure enhances the penetration of oxaliplatin. Because pressure is easier to set up with the closed technique, high pressure may counterbalance the drawbacks of this technique versus open HIPEC, and a higher pressure may induce a higher penetration. Because higher concentration does not mean deeper penetration, a study of tissues beneath the peritoneum is required. Finally, achieving a deeper penetration (and a higher concentration) raises the question of the passage of drugs through the surgical glove and the surgeon's safety.

METHODS

Four groups of pigs underwent HIPEC with oxaliplatin (150 mg/L) for 30 minutes in open isobaric pressure and pressure at 25 cm H2O, and closed pressure at 25 and 40 cm H2O. Systemic absorption and peritoneal mapping of the concentration of platinum were analyzed, as well as in the retroperitoneal tissue and the surgical gloves.

RESULTS

Blood concentrations were higher in open groups. In the parietal surfaces, the concentrations were not different between the isobaric and the closed groups (47.08, 56.39, and 48.57 mg/kg, respectively), but were higher in the open high-pressure group (85.93 mg/kg). In the visceral surfaces, they were lower in the closed groups (3.2 and 3.05 mg/kg) than in the open groups (7.03 and 9.56 mg/kg). Platinum concentrations were similar in the deep retroperitoneal tissue when compared between isobaric and high-pressure procedures. No platin was detected in the internal aspect of the gloves.

CONCLUSION

The use of high pressure during HIPEC does not counterbalance the drawbacks of closed techniques. The tissue concentration of oxaliplatin achieved with the open techniques is higher, even if high pressure is applied during a closed technique. Open 25 cm H2O HIPEC achieved the highest tissue penetration of oxaliplatin, but did not enhance the depth of oxaliplatin penetration. High pressure did not enhance the risk of HIPEC.

Amnioinfusion in very early preterm prelabor rupture of membranes (AMIPROM): pregnancy, neonatal and maternal outcomes in a randomized controlled pilot study

OBJECTIVE

To assess short- and long-term outcomes of pregnant women with very early rupture of membranes randomized to serial amnioinfusion or expectant management, and to collect data to inform a larger, more definitive clinical trial.

METHODS

This was a prospective non-blinded randomized controlled trial with randomization stratified for pregnancies in which the membranes ruptured between 16 + 0 and 19 + 6 weeks' gestation and 20 + 0 and 23 + 6 weeks' gestation to minimize the risk of random imbalance in gestational age distribution between randomized groups. Intention-to-treat analysis was used. The study was conducted in four UK hospital-based fetal medicine units (Liverpool Women's NHS Trust, St Mary's Hospital Manchester, Birmingham Women's NHS Foundation Trust and Wirral University Hospitals Trust). The participants were women with confirmed preterm prelabor rupture of membranes at 16 + 0 to 24 + 0 weeks' gestation. Women with multiple pregnancy, fetal abnormality or obstetric indication for immediate delivery were excluded. Participants were randomly allocated to either serial weekly transabdominal amnioinfusions if the deepest pool of amniotic fluid was < 2 cm or expectant management until 37 weeks' gestation. Short-term maternal, pregnancy and neonatal and long-term outcomes for the child were studied. Long-term respiratory morbidity was assessed using validated respiratory questionnaires at 6, 12 and 18 months of age and infant lung function test at around 12 months of age. Neurodevelopment was assessed using the Bayley Scales of Infant Development, second edition (BSID-II) at corrected age of 2 years.

RESULTS

Fifty-eight women were randomized to the study. Two babies were excluded from the analysis because of termination of pregnancy for lethal anomaly, leaving 56 participants (28 assigned to serial amnioinfusion and 28 to expectant management) recruited between 2002 and 2009. There was no significant difference in perinatal mortality (19/28 vs 19/28; relative risk (RR) 1.0 (95% CI, 0.70-1.43)) and maternal or neonatal morbidity. The overall chance of surviving without long-term respiratory or neurodevelopmental disability was 4/56 (7.1%); 4/28 (14.3%) in the amnioinfusion group and 0/28 in the expectant group (RR 9.0 (95% CI, 0.51-159.70)).

CONCLUSIONS

This pilot study found no major differences in maternal, perinatal or pregnancy outcomes. The study was not designed to show a difference between the groups and the number of survivors was too small to draw any conclusions about long-term outcomes. It does, however, signal that a larger definitive study to evaluate amnioinfusion for improvement in healthy survival is needed. The pilot suggests that, with appropriate funding, such a study is feasible.

Probiotics for prevention of necrotizing enterocolitis in preterm infants

BACKGROUND

Necrotizing enterocolitis (NEC) and nosocomial sepsis are associated with increased morbidity and mortality in preterm infants. Through prevention of bacterial migration across the mucosa, competitive exclusion of pathogenic bacteria, and enhancing the immune responses of the host, prophylactic enteral probiotics (live microbial supplements) may play a role in reducing NEC and the associated morbidity.

OBJECTIVES

To compare the efficacy and safety of prophylactic enteral probiotics administration versus placebo or no treatment in the prevention of severe NEC or sepsis, or both, in preterm infants.

SEARCH METHODS

For this update, searches were made of MEDLINE (1966 to October 2013), EMBASE (1980 to October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 10), and abstracts of annual meetings of the Society for Pediatric Research (1995 to 2013).

SELECTION CRITERIA

Only randomized or quasi-randomized controlled trials that enrolled preterm infants < 37 weeks gestational age or < 2500 g birth weight, or both, were considered. Trials were included if they involved enteral administration of any live microbial supplement (probiotics) and measured at least one prespecified clinical outcome.

DATA COLLECTION AND ANALYSIS

Standard methods of The Cochrane Collaboration and its Neonatal Group were used to assess the methodologic quality of the trials and for data collection and analysis.

MAIN RESULTS

Twenty-four eligible trials were included. Included trials were highly variable with regard to enrolment criteria (that is birth weight and gestational age), baseline risk of NEC in the control groups, timing, dose, formulation of the probiotics, and feeding regimens. In a meta-analysis of trial data, enteral probiotics supplementation significantly reduced the incidence of severe NEC (stage II or more) (typical relative risk (RR) 0.43, 95% confidence interval (CI) 0.33 to 0.56; 20 studies, 5529 infants) and mortality (typical RR 0.65, 95% CI 0.52 to 0.81; 17 studies, 5112 infants). There was no evidence of significant reduction of nosocomial sepsis (typical RR 0.91, 95% CI 0.80 to 1.03; 19 studies, 5338 infants). The included trials reported no systemic infection with the supplemental probiotics organism. Probiotics preparations containing either lactobacillus alone or in combination with bifidobacterium were found to be effective.

AUTHORS' CONCLUSIONS

Enteral supplementation of probiotics prevents severe NEC and all cause mortality in preterm infants. Our updated review of available evidence strongly supports a change in practice. Head to head comparative studies are required to assess the most effective preparations, timing, and length of therapy to be utilized.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a case report

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex procedure used for the treatment of various types of cancer. Specifically, HIPEC has shown success where treatment failure sites (metastases) thrive. A classic example of one such area is the peritoneal surface, which remains a prominent failure site for patients with gynecologic and gastrointestinal cancer. Traditionally, most patients with advanced stages of cancer have undergone palliative procedures as part of their treatment modality or had no surgery at all. With the advent of cytoreductive surgery with HIPEC, patients with peritoneal cancer have shown increased survival rates. Anesthetic complications are common during this procedure with disturbances in hemodynamics, coagulation, and respiratory gas exchange. A knowledge of what to anticipate anesthetically will guide the practitioner to achieve successful management during and after the case. In this case report, a 71-year-old woman was treated for stage Ill peritoneal and ovarian cancer by cytoreductive surgery with HIPEC.

Amnioinfusion for third trimester preterm premature rupture of membranes

BACKGROUND

Preterm premature rupture of membranes (PPROM) is a leading cause of perinatal morbidity and mortality. Amnioinfusion aims to restore amniotic fluid volume by infusing a solution into the uterine cavity.

OBJECTIVES

The objective of this review was to assess the effects of amnioinfusion for PPROM on perinatal and maternal morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 December 2013).

SELECTION CRITERIA

Randomised trials of amnioinfusion compared with no amnioinfusion in women with PPROM.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy.

MAIN RESULTS

We included five trials, of moderate quality, but we only analysed data from four studies (with a total of 241 participants). One trial did not contribute any data to the review.Transcervical amnioinfusion improved fetal umbilical artery pH at delivery (mean difference 0.11; 95% confidence interval (CI) 0.08 to 0.14; one trial, 61 participants) and reduced persistent variable decelerations during labour (risk ratio (RR) 0.52; 95% CI 0.30 to 0.91; one trial, 86 participants).Transabdominal amnioinfusion was associated with a reduction in neonatal death (RR 0.30; 95% CI 0.14 to 0.66; two trials, 94 participants), neonatal sepsis (RR 0.26; 95% CI 0.11 to 0.61; one trial, 60 participants), pulmonary hypoplasia (RR 0.22; 95% CI 0.06 to 0.88; one trial, 34 participants) and puerperal sepsis (RR 0.20; 95% CI 0.05 to 0.84; one trial, 60 participants). Women in the amnioinfusion group were also less likely to deliver within seven days of membrane rupture (RR 0.18; 95% CI 0.05 to 0.70; one trial, 34 participants). These results should be treated with circumspection as the positive findings were mainly due to one trial with unclear allocation concealment.

AUTHORS' CONCLUSIONS

These results are encouraging but are limited by the sparse data and unclear methodological robustness, therefore further evidence is required before amnioinfusion for PPROM can be recommended for routine clinical practice.

[Pathogenesis of visceral functions disorder in diffuse peritonitis]

Clinical and laboratory signs of abdominal sepsis and endotoxicosis were noted in 194 examined patients with diffuse peritonitis. It was stated that pathogenesis of visceral functions mainly expressed as a splanchnic blood circulation disturbance, massive translocation of gut organisms in portal bloodstream and the functional liver insufficiency particularly marked as form of macrophage liver insufficiency. The complex program of liver rehabilitation should be included in standards of treatment of the patients with diffuse peritonitis. It should be based on preventive measures of the enteral detoxication and microbial decontamination of small intestine and at the same time the intraportal transsubilical infusion correcting therapy has to be applied.

[Early enteral infussions in complex treatment of severe combined chest trauma]

On the basis of study and treatment of 98 victims it was stated that the absorption of isotonic glucose electrolytes solutions in the small intestine was saved even increased in case of large hemorrhage in severe polytrauma with chest, abdominal injury and other regions trauma. An application of early enteral infusions allowed reducing of the volume of parenteral introduction solutions and facilitated to a reliable decrease of development frequency of nosocomial pneumonia of attributive lethality.

[Prolonged-release drug formulations for parenteral administration. Part l. Suspensions and oily solutions for injection]

The article presents description of the most important parenteral forms, which release an active substance in sustained manner. Technological and biopharmaceutical information is supplemented with examples of commercial products, currently registered in Poland. Mechanism of drug release from the dosage form and duration of the process, role of other excipients and characteristics of certain medicinal products is presented. The information about suspensions and oily solutions for injection is summarized. Owing to specific chemical modifications and selection of suitable excipients, it was possible to develop these types of medicinal products for some antibiotics, hormones, antipsychotics and cytostatics. These formulations, after subcutaneous or intramuscular injection, release the active substances even for several weeks allowing to reduce the frequency of drug administration and finally help to improve patient's compliance. Here also the modified time course of insulin products achieved by selection of appropriate suspension form or insulin analogue is discussed.

Outpatient parenteral antibiotic therapy: principles and practice

Outpatient parenteral antimicrobial therapy (OPAT) refers to the administration of a parenteral antimicrobial in a non inpatient or ambulatory setting with the explicit aim of facilitating admission avoidance or early discharge. Whilst OPAT has predominantly been the domain of the infection specialist, the internal medicine specialist has a key role in service development and delivery as a component of broader ambulatory care initiatives such as "hospital at home". Main drivers for OPAT are patient welfare, reduction of risk of health care associated infection and cost-effective use of hospital resources. The safe practice of OPAT is dependent on a team approach with careful patient selection and antimicrobial management with programmed and adaptable clinical monitoring and assessment of outcome. Gram-positive infections, including cellulitis, bone and joint infection, bacteraemia and endocarditis are key infections potentially amenable to OPAT whilst resistant Gram-negative infections are of increasing importance. Ceftriaxone, teicoplanin, daptomycin and ertapenem lend themselves well to OPAT due to daily (or less frequent) bolus administration, although any antimicrobial may be administered if the patient is trained to administer and/or an appropriate infusion device is employed. Clinical experience from NHS Greater Glasgow and Clyde is presented to illustrate the key principles of OPAT as practised in the UK. Increasingly complex patients with multiple medical needs, the relative scarcity of inpatient resources and the broader challenge of ambulatory care and "hospital at home" will ensure the internal medicine specialist will have a key role in the future development of OPAT.

[The performance of the microbial barrier of needleless positive pressure closed connectors]

OBJECTIVE

Analyzing the performance of microbial barrier of needleless positive pressure closed connectors.

METHODS

Three kinds of brand needleless positive pressure closed connectors were chosen to do the access of microorganisms test.

RESULTS

Positive results were detected in the three experimental groups.

CONCLUSIONS

So far, lots of the connectors are not qualified strictly on the market, some improvement is required in the structure design and process.

Transabdominal amnioinfusion for improving fetal outcomes after oligohydramnios secondary to preterm prelabour rupture of membranes before 26 weeks

BACKGROUND

Preterm prelabour rupture of membranes (PPROM) before 26 weeks can delay lung development and can cause pulmonary hypoplasia, as a result of oligohydramnios. Restoring the amniotic fluid volume by transabdominal amnioinfusion might prevent abnormal lung development and might have a protective effect for neurological complications, fetal deformities and neonatal sepsis.

OBJECTIVES

To assess the effectiveness of transabdominal amnioinfusion in improving perinatal outcome in women with oligohydramnios secondary to rupture of fetal membranes before 26 weeks.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013).

SELECTION CRITERIA

All randomised controlled trials comparing transabdominal amnioinfusion with no transabdominal amnioinfusion. Cluster- or quasi-randomised trials were not eligible for inclusion. In cases where only an abstract was available, we attempted to find the full articles.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trials for inclusion. No eligible trials were identified.

MAIN RESULTS

There are no included studies.

AUTHORS' CONCLUSIONS

There is currently no evidence to evaluate the use of transabdominal amnioinfusion in women with oligohydramnios secondary to rupture of fetal membranes before 26 weeks for improving perinatal outcome. Further research examining the effects of this intervention is needed. Two randomised controlled trials are ongoing but final data have not yet been published.

Intraperitoneal sub-diaphragmatic instillation of bupivacaine plus morphine for reducing postoperative shoulder pain after gynecologic endoscopy

BACKGROUND

Gynecologic endoscopic surgery is a minimally invasive surgical technique for treatment of various gynecologic diseases. When compared to conventional laparotomy, this procedure has advantages in many aspects such as reduced postoperative pain, short hospital stay, and decreased morbidity associated with laparotomy. However 15 to 30% of the patients experienced moderate or severe postoperative shoulder pain. Methods to minimize postoperative shoulder pain after gynecologic endoscopy are essential to maximize the quality of life of the patients.

OBJECTIVE

To evaluate the benefit of intraperitoneal instillation of bupivacaine plus morphine for reducing postoperative shoulder pain incidence after gynecologic endoscopy.

MATERIAL AND METHOD

A randomized clinical trial was conducted in 158 patients undergoing laparoscopic procedures. The patients were randomly assigned to receive either 0.5% bupivacaine hydrochloride 20 mL mixed with morphine 3 mg (study group) or normal saline (control group) instillation to subdiaphragmatic area before finishing the procedure. Shoulder pain was evaluated at immediate post-operative time, and at 12 and 24 hours from the termination of surgery. The data of requested analgesic drugs after surgery was also recorded.

RESULTS

Baseline characteristics were comparable between the two groups. Diagnosis, laparoscopic procedures, and duration of operation were also comparable. There were comparable proportions of patients reporting shoulder pain at 12 and 24 hours between the study and control group (30.4% and 30.4% at 12 hours, and 11.3% and 21.5% at 24 hours, respectively). Median pain scores at 12 and 24 hours were comparable between the study and control group (3 and 2 at 12 hours, and 4 and 4 at 24 hours, respectively). Requirement of analgesics was slightly greater among control than study group, but without statistical significance (17.7% and 24.1% respectively).

CONCLUSION

Intraperitoneal instillation of bupivacaine plus morphine had no efficiency for reducing postoperative shoulder pain incidence after gynecologic endoscopy.

Glycemic management of diabetes by insulin therapy

Recent technological innovations as insulin analogue formulation, devices for insulin delivery and glucose monitoring have allowed diabetic patients to improve their glycemic control and decrease their level of burden due to diabetes. Intensive insulin therapy via insulin pens, subcutaneous or intraperitoneal insulin infusions using pumps instead of vials and syringes, are associated with improved absorption reproducibility, HbA1c levels, reduced risk of hypo- or hyperglycemia, and increased quality of patient's life. These currently used systems are discussed in this review as well as the future of exogenous insulin therapy: closed loop system, the artificial pancreas, and oral insulin delivery. Glucose homeostasis is directly linked to glycemic regulated by portal insulin administration, thus endogenous insulin therapy might be the most promising treatment to "cure" diabetes. Consequently, pancreas and islet transplantation, and the bioartificial pancreas are described.

An in vitro study to evaluate the utility of the "air test" to infer perineural catheter tip location

Injection of air under ultrasound guidance via a perineural catheter after insertion ("air test") has been described as a means to infer placement accuracy, yet this test has never been rigorously evaluated. We tested the hypothesis that the air test predicts accurate catheter location greater than chance and determined the test's sensitivity, specificity, and positive and negative predictive values using a porcine-bovine model and blinded expert in ultrasound-guided regional anesthesia. The air test improved the expert clinician's assessment of catheter tip position compared to chance, but there was no difference when compared to direct visualization of the catheter without air injection.

Primed infusion with delayed equilibrium of Gd.DTPA for enhanced imaging of small pulmonary metastases

Objectives

To use primed infusions of the magnetic resonance imaging (MRI) contrast agent Gd.DTPA (Magnevist), to achieve an equilibrium between blood and tissue (eqMRI). This may increase tumor Gd concentrations as a novel cancer imaging methodology for the enhancement of small tumor nodules within the low signal-to-noise background of the lung.

Methods

A primed infusion with a delay before equilibrium (eqMRI) of the Gd(III) chelator Gd.DTPA, via the intraperitoneal route, was used to evaluate gadolinium tumor enhancement as a function of a bolus injection, which is applied routinely in the clinic, compared to gadolinium maintained at equilibrium. A double gated (respiration and cardiac) spin-echo sequence at 9.4T was used to evaluate whole lungs pre contrast and then at 15 (representative of bolus enhancement), 25 and 35 minutes (representative of eqMRI). This was carried out in two lung metastasis models representative of high and low tumor cell seeding. Lungs containing discrete tumor nodes where inflation fixed and taken for haematoxylin and eosin staining as well as CD34 staining for correlation to MRI.

Results

We demonstrate that sustained Gd enhancement, afforded by Gd equilibrium, increases the detection of pulmonary metastases compared to bolus enhancement and those tumors which enhance at equilibrium are sub-millimetre in size (<0.7 mm²) with a similar morphology to early bronchoalveolar cell carcinomas.

Conclusion

As Gd-chelates are routinely used in the clinic for detecting tumors by MRI, this methodology is readily transferable to the clinic and advances MRI as a methodology for the detection of small pulmonary tumors.

Efficacy and safety of probiotics in preterm infants

Probiotics are live microbial feed supplements that beneficially affect the recipient by improving intestinal balance. In an updated systematic review, nineteen trials randomizing more than 2800 infants were included. In a meta-analysis of trial data, enteral probiotic supplementation significantly reduced the incidence of severe necrotizing enterocolitis (typical RR 0.35, 95% CI 0.24 to 0.52) and mortality (typical RR 0.55, 95% CI 0.40 to 0.74). There was no evidence of significant reduction of nosocomial sepsis (typical RR 0.89, 95% CI 0.77 to 1.03). The included trials reported no systemic infection with - supplemented probiotics. Recent data in addition to a report by the European Society for Pediatric Gastroenterology (ESPGAN) concluded probiotics could be generally considered safe.

[Utility of target controlled infusion technique for deciding the fentanyl infusion rate for post-cholecystectomy pain management in a patient on anticoagulant therapy]

The fentanyl infusion rate was controlled by employing a target controlled infusion (TCI) technique under anticoagulant therapy for postoperative pain management. A 59-year-old woman with atrial fibrillation and mitral stenosis was scheduled for open cholecystectomy. Heparin was continuously infused for anticoagulant therapy. Sevoflurane and remifentanil were used for induction and maintenance of anesthesia. At completion of the operation, her consciousness was checked and the endotracheal tube was then removed under fentanyl TCI (effect-site concentration: Ce = 2.0 ng x ml(-1)). In this case, the spontaneous breathing rate was stable (10-12 x min(-1)) under fentanyl TCI. She had no complaints of pain(pain at rest: VAS 20 mm). The breathing rate in this case provided indication for postoperative pain management. The TIVAtrainer simulation makes the exchange from TCI infusion to continuous infusion easy. And the spontaneous breathing monitoring is useful for postoperative pain measurement of laparotomy cases.

Transabdominal amnioinfusion for preterm premature rupture of membranes: a systematic review and metaanalysis of randomized and observational studies

OBJECTIVE

The purpose of this study was to review systematically the efficacy of transabdominal amnioinfusion (TA) in early preterm premature rupture of membranes (PPROM).

STUDY DESIGN

We conducted a literature search of EMBASE, MEDLINE, and ClinicalTrials.gov databases and identified studies in which TA was used in cases of proven PPROM and oligohydramnios. Risk of bias was assessed for observational studies and randomized controlled trials. Primary outcomes were latency period and perinatal mortality rates.

RESULTS

Four observational studies (n = 147) and 3 randomized controlled trials (n = 165) were eligible. Pooled latency period was 14.4 (range, 8.2-20.6) and 11.41 (range -3.4 to 26.2) days longer in the TA group in the observational and the randomized controlled trials, respectively. Perinatal mortality rates were reduced among the treatment groups in both the observational studies (odds ratio, 0.12; 95% confidence interval, 0.02-0.61) and the randomized controlled trials (odds ratio, 0.33; 95% confidence interval, 0.10-1.12).

CONCLUSION

Serial TA for early PPROM may improve early PPROM-associated morbidity and mortality rates. Additional adequately powered randomized control trials are needed.

Continuous intestinal infusion of levodopa/carbidopa in advanced Parkinson's disease: efficacy, safety and patient selection

Long-term oral therapy with levodopa is associated with the development of motor fluctuations and dyskinesia in a large percentage of patients with Parkinson's disease (PD). Motor complications are associated with a number of non-motor symptoms and have a negative impact on disability and quality of life. There are three therapeutic options available for the management of patients at this advanced stage: high frequency deep brain stimulation, continuous subcutaneous infusion of apomorphine, and continuous intestinal infusion of levodopa/carbidopa. On the basis of published data and in consideration of the risk-benefit profile of current therapeutic strategies, we here propose an algorithm to help clinicians select the most suitable treatment option for patients with advanced PD.