Severe Dehydration and Acute Renal Failure Associated with External Ventricular Drainage of Cerebrospinal Fluid in Children

We report three paediatric cases of severe dehydration and hyponatraemia with circulatory compromise associated with the use of external ventricular drainage of cerebrospinal fluid. Two of the children had cardiac arrests. All were successfully resuscitated. While there were additional factors that contributed to other fluid losses, and fluid balance data are incomplete, these cases highlight a need for increased vigilance when managing children with external ventricular drains.

Dutch health-related quality of life measure for chronic otitis media

OBJECTIVE

Chronic otitis media (COM) describes a variety of symptoms and physical findings that result from prolonged damage to the middle ear by infection and inflammation. The Health-Related Quality of Life measure for COM (COMQ-12) is a new questionnaire for the assessment of COM that evaluates the overall burden of disease from the patient's perspective. The aim of this study was to develop and appraise the psychometric properties of the Dutch version of the COMQ-12.

MATERIALS AND METHODS

The Dutch version of the COMQ-12 was obtained through translation and back-translation. Fifty adult patients with a history of active COM completed the Dutch version of the COMQ-12. The internal consistency of this questionnaire was evaluated using Cronbach's alpha coefficient.

RESULTS

The average COMQ-12 score was 22.4 (SD 11.9). The internal consistency of the Dutch version of the COMQ-12 was high, with a Cronbach's alpha value of 0.833.

CONCLUSIONS

The Dutch version of the COMQ-12 provides appropriate health-related quality of life outcome measures in patients with a history of COM. This questionnaire is a useful tool to evaluate the overall burden of disease from the patient's perspective.

Distribution and characteristics of sexual health service provision in primary and community care in England

The objective of this paper was to identify and describe enhanced sexual health services (ESHSs) commissioned for testing, diagnosis and management of sexually transmitted infections (STIs) in primary and community care settings in England. ESHSs commissioned by Primary Care Trusts (PCTs) in England were determined by telephone survey. Further information on service provision was collected by a follow-up email survey. By April 2009, 464 ESHSs had been commissioned to offer testing, diagnosis and treatment of STIs. Most providers were enhanced general practices (56%). Two in five PCTs did not offer any ESHSs and five PCTs had neither genitourinary medicine services nor ESHSs. Among 52 ESHSs that responded, screening and partner notification strategies varied. The distribution and characteristics of ESHS provision in England are heterogeneous emphasizing the need to establish clear clinical care pathways between services. Routine reporting and analysis of service activity could help ensure provision meets local needs.

Auditing in middle ear surgery, feasibility of the common otology database

OBJECTIVES

Clinical auditing is a systematic process for improving quality of care. The primary goal is to compare current practice with established standards. A common dataset enables the comparison of results, and takes into account the effect of case mix, surgical techniques and follow-up periods on outcome. The Common Otology Database (COD) is a joint effort of an international group of otologists to standardise reporting on middle ear surgery, including myringoplasty, ossiculoplasty, stapes surgery and cholesteatoma removal. It aims to identify audit data using the internet (http://www.ear-audit.net), provide a storage system for otological data, to create a prospective database allowing statistical analysis with sufficient power and to produce standards for comparative auditing.

MATERIALS AND METHODS

The COD provides two levels of data entry, anonymising surgeon and patient data. Level 1 is designed for general otorhinolaryngologists and trainees, and only records main outcomes. Level 2 is designed for benchmark otologists and includes detailed information about pathologies, risk factors, aim of surgery, surgical findings, procedures, follow-up periods and complications. Level-2 surgeons are required to submit pre-operative data on all patients scheduled for surgery in order to eliminate bias as a result of selective reporting.

RESULTS

The COD began in January 2004 and is continuously including patients. In May 2009, 2,291 cases were entered in the level-2 benchmark database, including 1,218 myringoplasties (53.2%), 576 ossiculoplasties (25.1%), 695 stapes surgeries (30.3%) and 532 cholesteatoma surgeries (23.2%). Currently, 151 surgeons use the database system (levels 1 and 2 combined). Eighteen otologists were invited to contribute to the level 2 database. Eight contributors complied with the validation criteria. Others did not cooperate, citing a lack of resources to support data input, or their health system discouraging follow-up. Some were also reluctant to have their outcome data subjected to external validation.

CONCLUSION

The COD has engaged the otological community to participate in a large-scale audit of current practice. The number of surgical procedures included has attained a level of power that will allow introductory statistical analysis.

Titanium prosthesis with malleus notch: a study of its 'user-friendliness'

'User-friendliness' is an important factor in the choice of ossicular prosthesis. The current titanium prostheses have a flat, open head plate and are designed to sit under the tympanic membrane. Previously, the author had designed titanium prostheses with a malleus notch extension at the head plate. The present study aimed to assess whether these customized prostheses were user-friendly, compared with conventional prostheses. Fourteen surgeons were recruited to examine the user-friendliness of several ossicular prostheses. They performed ossiculoplasties on temporal bones and rated the user-friendliness of the malleus notch prosthesis against that of some of the more popular conventional ossicular prostheses. For malleus-stapes assembly, eight out of 13 surgeons preferred the malleus notch prosthesis to the Düsseldorf and Goldenberg designs. For malleus-footplate assembly, six out of 10 surgeons preferred the malleus notch prosthesis to the Düsseldorf and Richards designs. Most of the surgeons stated that the reconstruction was more stable using the malleus notch prosthesis.

TopCount coupled to ultra-performance liquid chromatography for the profiling of radiolabeled drug metabolites in complex biological samples

The recent commercial availability of small particle packed columns (<2microm) and associated instrumentation capable of withstanding the high pressures of such columns, has lead to an increase in the application of so called ultra-performance liquid chromatography (UPLC). It has recently been shown that the improved efficiency, resolution and peak capacity of these columns, when coupled to mass spectrometry, provides particular benefit for the identification of drug metabolites in complex biological samples. In this work, the ability of TopCount, a microplate scintillation counter, to act as a suitable radiodetection system for ultra-performance liquid chromatography methods is tested. TopCount, has innumerable benefits over more traditional on-line radioactivity flow detection methods, when dealing with the narrow peak widths and small peak volumes associated with the enhanced efficiency of sub-2microm columns. The system is tested for robustness and sensitivity, and then used to undertake successful metabolite profiling of actual samples, and the data compared to traditional HPLC with on-line radioactivity flow detector.

Helicobacter pylori eradication prior to initiation of long-term non-steroidal anti-inflammatory drug therapy in Chinese patients – a cost-effectiveness analysis

BACKGROUND

Recent randomized clinical trials suggested that eradication of Helicobacter pylori prior to initiation of non-steroidal anti-inflammatory drug (NSAID) therapy would reduce the rate of peptic ulcer disease (PUD).

OBJECTIVE

To analyze the cost-effectiveness of H. pylori eradication prior to initiation of long-term NSAID therapy for prevention of NSAID-induced PUD in a cohort of Chinese patients at high risk for PUD.

METHODS

Clinical and economic data of 100 participants from a previously reported clinical trial conducted in Hong Kong were analyzed. Patients with a history of peptic ulcers were randomized to 1-week omeprazole 20 mg, amoxicillin 1 g and clarithromycin 500 mg twice daily (eradication group; n = 51) or 1-week omeprazole 20 mg twice daily (omeprazole group; n = 49) before initiation of diclofenac 100 mg daily for 6 months. The rates of PUD and healthcare utilization for routine follow-up as well as for management of symptomatic PUD of the 2 groups were retrieved from medical records.

RESULTS

The rate of symptomatic ulcers in eradication group and omeprazole group were 3.9% and 18%, respectively. The mean direct medical cost of the eradication group was significantly lower than that of the omeprazole group by 30% (US dollar 797 (95% CI = 685 - 909) versus US dollar 1,128 (95% CI = 879 - 1,377)) (p = 0.018). The results were robust to variation of all the cost items.

CONCLUSIONS

H. pylori eradication prior to initiation of NSAID therapy appeared to reduce the ulcer rate and mean direct medical cost when compared to no eradication for Chinese H. pylori-infected NSAID users at high risk for PUD.

Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review

OBJECTIVE

To determine whether routine biopsy of the lacrimal sac wall at dacryocystorhinostomy (DCR) is indicated.

METHODS

A prospective study and literature review. In 193 consecutive endoscopic DCRs performed on 164 patients (108 females and 56 males) part of the medial wall of the lacrimal sac was sent for histological examination. The mean age of the patients was 64 years with a range of 2.5-89 years. Previous reported series were reviewed.

RESULTS

Of the 193 specimens, 44 (23%) showed normal histology, 146 (76%) showed varying degrees of non-specific chronic inflammation, and three (1.2%) showed specific pathology. Of the three specimens that showed specific pathology two showed sarcoidosis and one showed transitional cell papilloma. The two specimens with sarcoidosis were obtained from one patient who underwent bilateral surgery. In this and the six previous reported series only seven of 1294 specimens (0.5%) showed specific pathology, which was definitely not suspected preoperatively or intraoperatively, and only one of these (0.08%) was found to be malignant (a lymphoma).

CONCLUSIONS

Biopsy of the lacrimal sac wall at DCR is not indicated routinely and is only indicated if there is a reason to suspect pathology other than chronic inflammation preoperatively or intraoperatively.

How we do it: Laser reduction of peri-tubal adenoids in selected patients with otitis media with effusion

. The literature supports the benefit of adenoidectomy in patients with otitis media with effusion (OME). . It is difficult to clear adenoid tissue from around the Eustachian tubes using curettes and this conventional method of adenoidectomy is contra-indicated in patients with cleft palates. . Laser reduction of peri-Eustachian adenoid tissue without myringotomies or grommet insertion was performed in three patients with OME. Two patients had previous adenoidectomies performed with curettes and one patient had a cleft palate. . In all three patients, the OME resolved and all had closure of the air-bone gap that was maintained during long-term follow-up (14 months-4 years). . This technique resolved OME without the need for myringotomies or grommet insertion and should be considered particularly in patients who have peri-tubal recurrence of adenoidal tissue following conventional adenoidectomy or in patients with cleft palate where there is concern with regards to palatal incompetence.

Economic analysis of four triple regimens for the treatment of Helicobacter pylori-related peptic ulcer disease in in-patient and out-patient settings in Hong Kong

BACKGROUND

One-week triple regimens have been shown to be effective for the treatment of Helicobacter pylori-related peptic ulcer disease.

AIM

To conduct an economic analysis of four triple regimens for the treatment of H. pylori-related peptic ulcer disease from the perspective of a public health organization in Hong Kong.

METHODS

Records of 200 patients with H. pylori-related peptic ulcer disease, who had previously participated in a randomized comparison of ranitidine bismuth citrate (RBC) with amoxicillin and clarithromycin (RAC), omeprazole with amoxicillin and clarithromycin (OAC), RBC with metronidazole and tetracycline (RMT), or, colloidal bismuth subcitrate with metronidazole and tetracycline (BMT) in either in-patient or out-patient setting were reviewed.

RESULTS

Fifty patients were excluded because of incomplete documentation or lack of peptic ulcer. In the out-patient group (n=72), the median direct costs of the RAC group (HK $ 5094) were lower those of the BMT (HK $ 5400), RMT (HK $ 5394), or OAC (HK $ 5440) groups, but the difference was significant only between the RAC and BMT groups (P < 0.05). In the in-patient group (n=78), the median direct costs of the RMT group (HK $ 8524) were significantly lower than those of the OAC (HK $ 13 871) and RAC (HK $ 12 092) groups (P < 0.05), but were similar to those of the BMT group (HK $ 8758).

CONCLUSIONS

RAC and RMT are the least costly regimens for out-patient and in-patient treatment, respectively, of H. pylori-related peptic ulcer disease in Hong Kong.

Frontal recess surgery for diving-related frontal pain: case report

We report the case of a professional scuba diver who was unable to dive because he began experiencing severe frontal pain on descent. Following endoscopic surgery to open the frontal recess, the man was able to resume diving unrestricted by pain. We discuss the causes and treatment of this complaint, and we suggest that this might be considered a new indication for surgery in a limited number of cases.

Persistent mydriasis following intravenous atropine in a neonate

A neonate whose mother had recently taken amitriptyline developed fixed dilated pupils after a modest dose of intravenous atropine. Interaction of atropine with neonatal amitriptyline levels is suggested and evidence of neonatal effects from maternal antidepressant use is examined. There were no neurological sequelae, and the neonate's pupils became reactive again after 7 h.

Randomised controlled trial of aminophylline for severe acute asthma

OBJECTIVES

To determine whether children with severe acute asthma treated with large doses of inhaled salbutamol, inhaled ipratropium, and intravenous steroids are conferred any further benefits by the addition of aminophylline given intravenously.

STUDY DESIGN

Randomised, double blind, placebo controlled trial of 163 children admitted to hospital with asthma who were unresponsive to nebulised salbutamol.

RESULTS

The placebo and treatment groups of children were similar at baseline. The 48 children in the aminophylline group had a greater improvement in spirometry at six hours and a higher oxygen saturation in the first 30 hours. Five subjects in the placebo group were intubated and ventilated after enrollment compared with none in the aminophylline group.

CONCLUSIONS

Aminophylline continues to have a place in the management of severe acute asthma in children unresponsive to initial treatment.

Evaluation of an asthma severity score

OBJECTIVE

To evaluate inter-observer agreement and validity of an asthma severity score derived from wheeze, heart rate and accessory muscle use components.

METHODOLOGY

Children with acute asthma were examined independently and simultaneously by two observers, followed by pulse oximetry and spirometry in those over 5 years with repeatable measurements.

RESULTS

Inter-observer agreement was very good (weighted kappa 0.82, 95% confidence interval 0.63 to 1.00), the component with the best agreement being the accessory muscle score (0.76, 0.57 to 0.95). The score correlated significantly with oxygen saturation, heart rate, and forced expiratory volume in 1 s (FEV1). In a multivariate model, FEV1 was best related to accessory muscle use.

CONCLUSIONS

The asthma severity score has very good inter-observer agreement with a moderate relationship to oxygenation and FEV1.

Inferior vena cava pressure as an estimate of central venous pressure

OBJECTIVE

To determine whether pressure in the inferior vena cava (IVC) is similar to central venous pressure.

METHODOLOGY

Prospective measurement of both central venous pressure (CVP) and inferior vena cava pressure (IVCP) in the same child; each child had to have both catheters in situ. Two measurements of each pressure in reverse order (IVCP then CVP, and CVP then IVCP) were done and the mean of each was recorded. Comparison of the pressures was performed using the method of Bland and Altman.

RESULTS

Thirty-nine children had pressures recorded. The CVP ranged from 3 to 17 mmHg. In 22 of 39 measurements IVCP was equal to CVP; in 33 of 39 measurements IVCP was different from CVP by 1 mm or less and in 37 of 39 measurements IVCP was different from CVP by 2 mm or less. The mean difference between IVCP and CVP was +0.33 mmHg, the 95% confidence interval was 2.26 to +2.93 mmHg.

CONCLUSION

Measurement of IVCP is a good approximation to CVP and can be routinely used in clinical care of children who do not have raised intra-abdominal pressure.

[Chemotherapy in biliary tract infections (XXX). Special reference to the concentration of micronomicin in human gallbladder tissues and bile]

In this study, 120 mg of micronomicin (MCR) was given to 15 cases intended for cholecystectomy intramuscularly by a single injection or 5 consecutive injections (in the evening of day -2, morning and evening of day -1, morning of day 0, and 1 hour before operation) or intravenously by 1-hour drip infusion, and levels of MCR in serum, B bile and gallbladder tissues were determined by means of HPLC and bioassay. The serum level of MCR 30 minutes after consecutive injections (8 cases) was 11.86 +/- 1.90 micrograms/ml, significantly higher than that after the single injection, 7.08 +/- 0.93 micrograms/ml. The highest bile level of MCR after consecutive injections was 10.0 micrograms/ml. The average level in 4 detectable cases, 6.33 +/- 2.06 micrograms/ml, came up to 50% of the serum level and was higher than that after the single injection, 3.53 +/- 1.39 micrograms/ml. The gallbladder tissue level of MCR after consecutive injections was 4.5 micrograms/g at the highest and 2.51 +/- 0.73 micrograms/g on the average in 5 detectable cases. This was equivalent to 20% of the serum level and higher than that after the single injection, 1.63 +/- 0.26 micrograms/g. The MIC of MCR could be determined against 8 of 10 strains detected in B bile. Against E. coli and K. pneumoniae, main causal bacteria of bile duct infections, it was as low as 0.39 to 0.78 micrograms/ml. Levels of MCR in bile and gallbladder tissues determined in this study exceeded by far the above MIC. From these results, it can be expected that clinical administration of MCR at 2 doses of 120 mg daily for 3 days or more will give rise to a sufficiently antibacterial effect against Gram-negative bacilli.