Implementation of a tier system for IVIG indications to address IVIG shortage at a tertiary care pediatric medical center

BACKGROUND

Drug shortages are a common issue that healthcare systems face and can result in adverse health outcomes for patients requiring inferior alternate treatment. The United States recently experienced a national drug shortage of intravenous immunoglobulin (IVIG). Several reported strategies to address the IVIG and other drug shortages have been proposed; however, there is a lack of evidence-based methods for protocol development and implementation.

OBJECTIVE

To evaluate the efficacy of introducing a multidisciplinary task force and tier system of indications and to minimize adverse effects during a shortage of IVIG.

METHODS

Faculty members across disciplines with expertise in IVIG use were invited to participate in a task force to address the shortage and ensure adequate supply for emergent indications. A tier system of IVIG indications was established according to the severity of diagnosis, urgency of indication, and quality of supporting evidence. Based on inventory, indications in selected tiers were auto-approved. Orders that could not be automatically approved were escalated for task force review.

RESULTS

Overall, there were 342 distinct requests for IVIG during the study period (August 1, 2019 to December 31, 2019). All Tier 1 indications were approved. Of all requests, only 2.6% (9) of requests were denied, none of which resulted in adverse effects based on retrospective chart review. Seven patients who regularly receive IVIG had possible adverse effects due to dose reduction or spacing of treatment; however, each complication was multifactorial and not attributed to the shortage or tier system implementation alone.

CONCLUSION

Implementation of a multidisciplinary task force and tier system to appropriately triage high-priority indications for limited pharmaceutical agents should be considered in health institutions faced with a drug shortage.

Clinical Impact of a Standardized Risk-Stratified Thromboprophylaxis Protocol for Multisystem Inflammatory Syndrome in Children

OBJECTIVE

To evaluate the clinical impact of an institutional thromboprophylaxis protocol in patients with multisystem inflammatory syndrome in children (MIS-C), who are at increased risk for thromboembolism (TE).

STUDY DESIGN

We conducted a single-center retrospective cohort study of children less than 18 years between March 2020 and December 2021. Eligible patients were confirmed with MIS-C and were managed with a standardized multidisciplinary treatment approach that included a thromboprophylaxis protocol to guide and unify clinical practice. For high-risk patients, prophylactic dose enoxaparin (target anti-Factor Xa 0.1-0.3 U/mL) was added. In high-risk patients with TE risk factors persistent at hospital discharge, thromboprophylaxis was prescribed for an additional 30 days.

RESULTS

Of 135 patients with MIS-C, 124 (92%) required intensive care unit stay and 64 (47%) required a central venous catheter for a median duration of 5 days (IQR, 4-7). Prophylactic dose enoxaparin was initiated in 116 out of 121 patients (96%) deemed high-risk per our protocol at a median of 1 day after admission [IQR, 0-3] achieving target levels at a median of 1 day [IQR, 1-2]. The median initial anti-Factor Xa level was 0.13 u/mL [IQR, 0.05-0.19]. One patient (0.7%) developed symptomatic noncatheter related superficial vein thrombosis requiring therapeutic anticoagulation. Thromboprophylaxis was extended for 30 days after discharge in 108 out of 135 patients (80%). Bleeding events occurred in 5 patients during hospitalization (4.2%). All bleeding events were clinically relevant nonmajor bleeding. There were no deaths.

CONCLUSIONS

Implementation of an institutional standardized thromboprophylaxis protocol in MIS-C was feasible and led to timely initiation of prophylactic anticoagulation and low rates of TEs and bleeding complications.

Medich Giant Platelet Syndrome: An Evolving Qualitative and Quantitative Platelet Disorder

Qualitative platelet disorders remain rare and varied. We describe here 2 additional patients with giant platelets, thrombocytopenia, deficiency in alpha granules and the presence of membranous inclusions within the cytoplasm. Collectively known as Medich syndrome, we further elucidated structural and clinical features of this rare syndrome. Platelets obtained from 2 patients with macro-thrombocytopenia were evaluated by electron microscopy. Structural findings were correlated with clinical characteristics. The defining morphologic feature found in the platelets of these patients is the presence of long, tubular inclusions consisting of several layers of membrane wrapped around a core of cytoplasm. These inclusions may deform the discoid shape of the platelet. In addition, abnormal giant alpha granules are present. Clinically all patients in the current report and review of the literature had mucosal bleeding and were often misdiagnosed as having immune related thrombocytopenia. To date five cases of Medich giant platelet syndrome have been reported. The cases are unified by the ultrastructural findings of abnormal alpha granules and unusual cytoplasmic scrolls. All patients experienced mucosal bleeding, however many clinical, biologic and genetic characteristics of this rare disorder remain to be determined.

Cerebral Sinus Venous Thrombosis in Infants after Surgery for Congenital Heart Disease

OBJECTIVE

To determine the prevalence of and risk factors for cerebral sinus venous thrombosis (CSVT) in neonates undergoing congenital heart disease (CHD) repair.

STUDY DESIGN

Neonates who had CHD repair with cardiopulmonary bypass and postoperative brain magnetic resonance imaging (MRI) between 2013 and 2019 at a single tertiary care center were identified from institutional databases. Demographic, clinical, and surgical data were abstracted from these databases and from the medical record; 278 neonates with CHD had cardiopulmonary bypass, 184 of whom had a postoperative brain MRI.

RESULTS

Eight patients (4.3%) had a CSVT. Transposition of the great arteries with an intact ventricular septum (P < .01) and interrupted aortic arch (P = .02) were associated with an increased risk for CSVT. Other risk factors for CSVT included cross-clamp time (98 [IQR, 77.5-120] minutes vs 67 [IQR, 44-102] minutes; P = .03), units of platelets (3.63 [IQR, 3-4] vs 2.17 [IQR, 1-4]; P < .01) and packed red blood cells (0.81 [IQR, 0.25-1] vs 1.21 [IQR, 1-1]; P = .03) transfused intraoperatively, and time between surgery and MRI (10 [IQR, 7-12.5] days vs 20 [IQR, 12-35] days; P < .01). Five patients (62.5%) were treated with anticoagulation. All patients had complete or partial resolution of their CSVT, regardless of treatment.

CONCLUSIONS

Brain MRI after cardiopulmonary bypass in neonates revealed a low prevalence of CSVT (4.3%). Further studies are needed to establish best practices for surveillance, prevention, and treatment of CSVT in this population.

Missed opportunities for ovarian salvage in children: an 8-year review of surgically managed ovarian lesions at a tertiary pediatric surgery centre

INTRODUCTION

The aetiology and management of ovarian pathology in children differs between antenatal and postnatal lesions. However, all lesions may present acutely due to adnexal torsion. In this setting, opportunities to preserve fertility with ovary-sparing surgery (OSS) may be missed. Some studies suggest that pediatric and adolescent gynaecology (PAG) input in care is associated with OSS.

METHODS

A retrospective cohort study of children undergoing surgery for ovarian pathology at a tertiary pediatric surgery centre over an 8-year period (2011-2018). Patient factors, lesion characteristics and PAG involvement were examined for association with OSS using multivariate logistic regression.

RESULTS

Thirty-five patients with ovarian pathology managed surgically were included. Ten were infants with lesions detected antenatally; all were managed by pediatric surgeons (PS) alone at median age 2 weeks (1 day-25 weeks). Twenty-five patients presented postnatally at median age 11 (0.75-15) years. In total, there were 16 cases of adnexal torsion, each managed primarily by PS. Twelve underwent oophorectomy and six (50%) of these cases had viable ovarian tissue on histology. Furthermore, two infants with large simple cysts were similarly managed by unnecessary oophorectomy based on histology. Overall rate of OSS was 46% and PAG involvement was the only factor associated with ovarian salvage.

CONCLUSION

Differences in surgical management between PAGs and PS may be attributable to the different patient populations they serve. We recommend improving the knowledge of PS trainees in OSS approaches for adnexal torsion and large benign lesions.

542. SARS CoV-2-Associated Multisystem Inflammatory Syndrome of Children (MIS-C) in the Washington DC Metropolitan Region

Background

Background: Multi-system Inflammatory Syndrome of Children (MIS-C) has recently emerged internationally as a serious inflammatory complication of SARS-CoV-2 infection with significant morbidity for the pediatric population.

Methods

This observational retrospective cohort study includes 33 children meeting CDC criteria for MIS-C treated between March 15 and June 17, 2020 at Children’s National Hospital in Washington DC. Clinical and demographic data were extracted from medical records and are summarized.

Results

Of 33 hospitalized MIS-C patients, 42% were critically ill, and 58% were non-critically ill. The median age was 8.9 years (0.7–18.7 years). More males (58 %) than females (43 %) were represented in the MIS-C cohort. The majority (75%) of children had no underlying medical condition. Criteria for incomplete or complete Kawasaki Disease (KD) were present in 39% of patients, while an additional 9% had some features of KD. However the remaining 52% of MIS-C patients presented with other sub-phenotypes including prominent severe abdominal pain and/or nonspecific multiorgan dysfunction. 30% presented with shock requiring volume and/or inotropic support. SARS-CoV-2 antibodies were present in 61% of patients. Virus was detectable by PCR in 36% of patients. At the time of initial evaluation, 39% (13/33) of children had identified cardiac abnormalities including myocardial dysfunction (5/33; 15%), coronary ectasia (4/33; 12%), coronary aneurysm (3/33; 9%), or pericardial effusion 5/33; 15%) either alone or in combination. Cytokine profiling identified elevation of several cytokines in this cohort, including IL-6. Treatment has included intravenous immunoglobulin, aspirin, anakinra and other immunomodulatory therapies, with overall rapid response to therapy. No deaths have occurred.

Conclusion

The emergence of MIS-C late in the surge of SARS-CoV-2 circulation in the Washington DC metropolitan region has added to the already significant burden of hospitalized and critically ill children in our region. A significant percentage of these children present with cardiac dysfunction and abnormalities, whether or not with KD features at presentation. Detailed characterization of immune responses and long term outcome of these patients is a priority.

Disclosures

Andrea Hahn, MD, MS, Johnson and Johnson (Consultant)

Targeted Inhibition of the Epidermal Growth Factor Receptor and Mammalian Target of Rapamycin Signaling Pathways in Olmsted Syndrome

Importance

Olmsted syndrome is a rare and disabling genodermatosis for which no successful treatment is currently available.

Objective

To evaluate the clinical response to the mammalian target of rapamycin (mTOR) inhibitor sirolimus and/or the epidermal growth factor receptor (EGFR) inhibitor erlotinib among patients with Olmsted syndrome.

Design, Setting, and Participants

This case series focused on 4 children with treatment-refractory Olmsted syndrome. These children received treatments (initiated in 2017 and 2018) at the outpatient dermatology clinic at the Children's Hospital of Wisconsin in Milwaukee, Wisconsin; Children's National Hospital in Washington, DC; and Hospital Infantil Pequeno Príncipe, Curitiba in Paraná, Brazil.

Exposures

Immunohistochemical analyses for mTOR and EGFR activation were performed on skin biopsy specimens from 2 patients. Oral sirolimus was administered to these 2 patients at a dosage of 0.8 mg/m2 twice daily, titrated to a goal trough whole-blood concentration of 10 to 15 ng/mL. Erlotinib was administered to all 4 patients at a dosage of 2 mg/kg/d.

Main Outcomes and Measures

Clinical responses were assessed with visual analog scales for pruritus and pain and/or the Children's Dermatology Life Quality Index. Adverse effects were monitored throughout treatment.

Results

Four patients (mean [SD] age, 7 [6] years; 2 boys and 2 girls) were analyzed. Lesional skin immunostaining showed increased phosphorylated ribosomal protein S6 (RPS6) and phosphorylated EGFR staining in the epidermis, indicating enhanced mTOR and EGFR signaling activation. Patients 1 and 2 were initially treated with sirolimus, displaying substantial clinical improvement in erythema and periorificial hyperkeratosis afterward. When switched to erlotinib, these patients showed substantial palmoplantar keratoderma (PPK) improvement. Patients 3 and 4 were treated with erlotinib only and later showed rapid and near complete resolution of PPK and substantial improvement in Children's Dermatology Life Quality Index scores. All 4 patients had sustained improvements in pruritus and pain. No severe adverse effects were reported.

Conclusions and Relevance

This study's findings suggest that the EGFR-mTOR cascade may play a substantial role in the pathophysiological process of Olmsted syndrome and may serve as a major therapeutic target. Oral sirolimus and erlotinib may be a promising, life-altering treatment for pediatric patients with Olmsted syndrome.

Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts

BACKGROUND

Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis.

METHODS

Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors.

RESULTS

Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038).

CONCLUSION

Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.

Contralateral Hypoplastic Venous Draining Sinuses Are Associated with Elevated Intracranial Pressure in Unilateral Cerebral Sinovenous Thrombosis

Variations in cerebral venous development can influence the ability to regulate drainage. In cerebral sinovenous thrombosis, these variations can be associated with elevated intracranial pressure. We present a series of pediatric patients with unilateral cerebral sinovenous thrombosis and investigate whether the contralateral venous sinus size increases the risk of developing elevated intracranial pressure. Patients diagnosed with a unilateral cerebral sinovenous thrombosis were identified by querying our institutional radiology data base. The difference in the occurrence of elevated intracranial pressure in patients with cerebral sinovenous thrombosis with and without hypoplastic venous sinuses was studied. Twelve cases of unilateral cerebral sinovenous thrombosis met the inclusion criteria and had sufficient images. Six patients had hypoplastic contralateral venous sinuses. The presence of hypoplastic contralateral venous sinus in the setting of thrombosis of a dominant sinus was associated with elevation of intracranial pressure (83% versus 0%, P = .015). Patients with cerebral sinovenous thrombosis and contralateral hypoplastic venous sinuses are at higher risk of developing elevated ICP and may benefit from screening with an ophthalmologic examination.

Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection

BACKGROUND

The safety profile of anticoagulants, which are being used with increasing frequency in pediatric populations, is not well studied. Automatic triggers built into electronic health record systems (EHR) have been shown to be an effective way to monitor for and identify medication errors. Anticoagulant-associated adverse events were examined through the use of an anticoagulant trigger panel.

METHODS

In a retrospective, five-year (September 2007-September 2012) observational study, four automated triggers were used to detect anticoagulant-related adverse events: activated partial thromboplastin time (aPTT) > 100 seconds in patients on an unfractionated heparin (UFH) infusion, International Normalized Ratio (INR) > 4, anti-factor Xa (anti-FXa) >1.5U/mL for patients on enoxaparin, and the documented use of protamine.

RESULTS

For the 1,664 triggers evaluated, 12 were associated with the aPTT trigger, only 1 of which was preventable. Receiver operator characteristic curve analysis indicated that increasing the aPTT trigger > 140 seconds would optimize sensitivity and specificity. The INR trigger identified four outpatients with adverse events. No adverse events were associated with the anti-FXa trigger. The protamine trigger identified 12 adverse events and was associated with more severe events. Minimal overlap was found with protamine and aPTT triggers.

CONCLUSION

Laboratory- and medication-based triggers can be effective monitoring tools for anticoagulants. For patients receiving a UFH infusion, an aPTT cutoff value of > 140 seconds is more precise. We also found that protamine use as a trigger adds value to a trigger-based anticoagulant monitoring system. Continued improvement in the logic algorithms associated with the EHR-based trigger tool will allow expanded use of this tool in a clinical manner.

Coagulopathy in newborns with hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia: a retrospective case-control study

Background

Newborns with hypoxic ischemic encephalopathy (HIE) are at risk for coagulopathy due to systemic oxygen deprivation. Additionally, therapeutic hypothermia (TH) slows enzymatic activity of the coagulation cascade, leading to constitutive prolongation of routinely assessed coagulation studies. The level of laboratory abnormality that predicts bleeding is unclear, leading to varying transfusion therapy practices.

Methods

HIE infants treated with TH between 2008–2012 were included in this retrospective study. Initial, minimum (min) and maximum (max) values of International Normalized Ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen (Fib) and platelet (PLT) count (measured twice daily during TH) were collected. Bleeding was defined as clinically significant if associated with 1) decreased hemoglobin (Hb) by 2 g/dL in 24 hours, 2) transfusion of blood products for hemostasis, or 3) involvement of a critical organ system. Laboratory data between the bleeding group (BG) and non-bleeding group (NBG) were compared. Variables that differed significantly between groups were evaluated with Receiver Operating Characteristic Curve (ROC) analyses to determine cut-points to predict bleeding.

Results

Laboratory and bleeding data were collected from a total of 76 HIE infants with a mean (±SD) birthweight of 3.34 ± 0.67 kg and gestational age of 38.6 ± 1.9 wks. BG included 41 infants. Bleeding sites were intracranial (n = 13), gastrointestinal (n = 19), pulmonary (n = 18), hematuria (n = 11) or other (n = 1). There were no differences between BG and NBG in baseline characteristics (p > 0.05). Both groups demonstrated INR and aPTT values beyond the acceptable reference ranges utilized for full tem newborns. BG had higher initial and max INR, initial aPTT, and lower min PLT and min Fib compared to NBG. ROC analyses revealed that platelet count <130 × 10⁹/L, fib level <1.5 g/L, and INR >2 discriminated BG from NBG.

Conclusions

Laboratory evidence of coagulopathy is universal in HIE babies undergoing TH. Transfusion strategies to maintain PLT counts >130 × 10⁹/L, fib level >1.5 g/L, and INR <2 may prevent clinical bleeding in this high risk population.

Analysing urban resilience through alternative stormwater management options: application of the conceptual Spatial Decision Support System model at the neighbourhood scale

Recent changes in cities and their environments, caused by rapid urbanisation and climate change, have increased both flood probability and the severity of flooding. Consequently, there is a need for all cities to adapt to climate and socio-economic changes by developing new strategies for flood risk management. Following a risk paradigm shift from traditional to more integrated approaches, and considering the uncertainties of future urban development, one of the main emerging tasks for city managers becomes the development of resilient cities. However, the meaning of the resilience concept and its operability is still not clear. The goal of this research is to study how urban engineering and design disciplines can improve resilience to floods in urban neighbourhoods. This paper presents the conceptual Spatial Decision Support System (DS3) model which we consider a relevant tool to analyse and then implement resilience into neighbourhood design. Using this model, we analyse and discuss alternative stormwater management options at the neighbourhood scale in two specific areas: Rotterdam and New Orleans. The results obtained demonstrate that the DS3 model confirmed in its framework analysis that stormwater management systems can positively contribute to the improved flood resilience of a neighbourhood.

Antimicrobial screening of some Egyptian plants and active flavones from Lagerstroemia indica leaves

One hundred and twenty four plant extracts were evaluated for their antimicrobial activity against four pathogenic bacteria (Staphylococcus aureus (ATCC 8095), Salmonella enteritides (ATCC 13076), Escherichia coli (ATCC 25922), and Listeria monocytogenes (ATCC 15313)) and Candida albicans yeast (ATCC 10231) using the disk diffusion and broth microdilution methods. Of the plant extracts, fourteen exhibited antimicrobial activity against two or more of the five microorganisms tested. Only the methanol extract of Lagerstroemia indica leaves exhibited antimicrobial activity against all pathogenic bacteria and C. albicans yeast that were tested. Purification of the methanol extract of L. indica leaves using antimicrobial assay-guided isolation yielded one pure active compound. The chemical structure of the isolated active compound was found to be '4-methoxy apigenin-8-C-β-D-glucopyranoside; cytisoside according to detailed spectroscopic analysis of its nuclear magnetic resonance and mass spectrometry data. The compound exhibited antimicrobial activity against C. albicans (minimum lethal concentration (MLC): 32 μg/mL), S. aureus (MLC: 16 μg/mL), S. enteritides (MLC: 16 μg/mL), E. coli (MLC: 16 μg/mL), and L. monocytogenes (MLC: 16 μg/mL). The present study found that the methanol extract of L. indica leaves holds great promise as a potential source of beneficial antimicrobial components for different applications.

Pulmonary embolism in children

Pulmonary embolism (PE) has long been described in children. Nevertheless, most of the algorithms applied to patients within this age range, from diagnosis to therapy, have been adapted from adult protocols. This article reviews the progresses that occurred to PE in children placing them in historical perspective with the key events relevant to PE in adults. A brief summary of the initial reports encountered in the pediatric literature followed by key conclusions drawn from national database reports characterizing its epidemiology in children is highlighted. Additionally, a section with the diagnostic tools pertaining to children is included. Closing remarks encompass commentaries related to therapy and outcomes, reflecting on current knowledge gaps related to PE in children.

Storage of aliquots of apheresis platelets for neonatal use in syringes with and without agitation

BACKGROUND

To facilitate volume control in neonates, platelets (PLTs) are aliquoted and stored for short periods in non-gas-permeable syringes before infusion. Although agitation of PLTs during storage in gas-permeable bags is performed to maintain their quality, the effect of syringe agitation during storage is unknown.

STUDY DESIGN AND METHODS

Double apheresis PLTs (n = 6) were collected and split, providing two identical products. On Days 2 and 4 of storage, aliquots from one bag of each pair were transferred to two syringes and stored for 6 hours on flatbed agitator or were left at 20 to 24 °C without agitation. A series of in vitro tests was performed on Days 0, 2 (Hours 0 and 6), and 4 (Hours 0 and 6). Control samples were obtained from the second matched bag that was stored on the agitator. Data were analyzed by one-way analysis of variance with differences considered significant if the p value was less than 0.05.

RESULTS

Comparable results for several PLT variables were obtained with or without agitation of the syringes. On Day 4 Hour 6, pH values were 7.18 ± 0.12 (agitated syringes) and 7.19 ± 0.1 (nonagitated syringes), and extent of shape change and hypotonic shock response measurements were not significantly different between agitated syringes and nonagitated syringes (23.7 ± 6.4 and 74.3 ± 9.8% vs. 23.3 ± 5.4 and 76.0 ± 7.6%), respectively.

CONCLUSION

Based on in vitro testing, apheresis PLT aliquots can be stored in syringes for at least 6 hours without agitation before transfusions.

Telephone gynaecological follow-up

This study was carried out to evaluate the outcome of telephone follow-up in gynaecological patients. The patients were selected using certain criteria. Telephone appointments were arranged with the patient's consent using the computer appointments system, so that data were available for further evaluation. This paper presents the outcome and results of a satisfaction questionnaire sent to the first 100 patients. Seventy-two per cent of the patients replied, of whom 97% were satisfied. This system had an impact on non-attenders. The patients appreciated being able to talk to their consultant directly. Running a telephone follow-up clinic also meant that the consultant was able to see more new patients in the outpatient clinic.

Endometrial ablation with the Cavaterm thermal balloon

This prospective observational study evaluates the efficacy and safety of thermal Balloon endometrial ablation using the Cavaterm system for the treatment of dysfunctional uterine bleeding. Seventy-seven women with a mean age of 43 years who met the inclusion and exclusion criteria were treated under general anaesthesia. A 9-mm diameter catheter with a silicone balloon at its tip was inserted transcervically into the uterus and was inflated with sterile 1.5% glycine and connected to a control unit that maintained the temperature of the circulating heated fluid at 75 degrees C, monitored the pressure and terminated the treatment after 15 minutes. There were no intra-operative complications and patients tolerated the treatment well. Satisfaction rates were 90% at both 12 and 24 months. At 24 months 10% of patients had heavy periods, 5% normal periods, 39% light periods and 46% amenorrhoea. Cavaterm balloon ablation seems a safe and effective option for women with menorrhagia. The procedure does not require additional training and expertise in operative hysteroscopy and compares favourably with established techniques.

The Use in Probabilistic Design of Probability Curves Generated by Maximizing the Shannon Entropy Function Constrained by Moments

A general algorithm is described for obtaining the maximum entropy distribution constrained by moments in functional form. It is based on Jaynes’ principle. The distribution is proposed as a useful tool in probabilistic design. The maximum entropy distribution is generated for a large number of analytical distributions, and compared with the original. The results appear to confirm that it can represent well most populations when four or five moments are used. The maximum entropy distribution is also compared with the Johnson and Pearson empirical distributions. The results are favorable in the two examples given. The practical convenience of the method in probabilistic design is illustrated by an example in structures.