Effect of the introduction of a lumbar-puncture sticker and teaching manikin on junior staff documentation and performance of paediatric lumbar punctures

BACKGROUND

Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post-lumbar-puncture complications in this age group.

AIMS

To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months.

SETTING

The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia).

PARTICIPANTS

Paediatric emergency staff, including residents, registrars and consultants.

METHODS

Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar-puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA).

RESULTS

Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p<0.01, 95% confidence interval 6 to 8).

CONCLUSIONS

The introduction of a lumbar-puncture proforma and formal teaching sessions using a paediatric manikin led to a marked improvement in the documentation of paediatric lumbar-punctures. Lumbar-punctures can be performed only by accredited medical officers who have achieved competency on the lumbar-puncture teaching manikin.

A pilot study to compare the use of prototypes of multipositional paediatric walking sticks and tripods with conventional sticks and tripods by children with cerebral palsy

BACKGROUND

The researchers (B.H. and B.T.) designed prototypes of a walking stick and a tripod termed Multipositional Paediatric Walking Aids for children with cerebral palsy (CP). The design won the 'Jenx Award for Innovation in Paediatric Physiotherapy'. The object of this study was to ascertain whether the prototypes had any benefit over conventional designs in children with CP.

METHODS

A small case series within-subject comparison design was used. There were four periods, AABA, each 4 weeks in length. Prototypes were used during period B. Eight children with CP between 4 and 11 years were recruited, four used sticks and four used tripods. Following an orthopaedic assessment, each child had assessments at the commencement of the study and every 4 weeks thereafter: (1) Energy used while walking using Physiological Cost Index (PCI). (2) Motor abilities using (a) Gross Motor Function Measure (GMFM-88) and (b) Gross Motor Performance Measure (GMPM). (3) Hand/forearm position recorded on a visual analogue. (4) Parent/child questionnaire.

RESULTS

Physiological Cost Index improved overall when the prototypes were used suggesting the amount of energy used when walking with the prototypes was less than with conventional sticks/tripods. GMFM-88 and GMPM results improved for some but not all children. Results for PCI, GMFM and GMPM were not statistically significant. The hand/forearm position of stick users consistently improved at assessment 4. Questionnaire results indicated that stick users preferred the prototypes.

CONCLUSION

Multipositional sticks/tripods may have benefits over conventional sticks/tripods. Children using sticks rather than tripods preferred the prototypes. The study demonstrates the need to undertake scientifically controlled trials before marketing new equipment.

The advisory process for anticancer drug regulation: a global perspective

PURPOSE

This paper summarizes the role of external advisors in oncology drug development and regulation from a global perspective.

DESIGN

Recently, representatives from the United States Food and Drug Administration, European Medicines Agency, the Japanese Pharmaceuticals and Medical Devices Agency, the Australian Therapeutic Goods Administration and Health Canada held a meeting in conjunction with the American Society of Clinical Oncology meeting. The role of external advisors in oncology drug development and regulation in each of these jurisdictions was presented and discussed.

RESULTS

All regulatory bodies described have experience with two forms of outside expertise: advice from individual experts and advice from a group of experts assembled as an advisory group. Regulatory jurisdictions use individual experts variably. In some regions, individual experts provide advice based on knowledge and experience during the drug development phase or in the planning phase for the submission of a drug registration package. In other regions, these individuals serve as external evaluators with the primary responsibility for the review of a clinical trials package submitted for drug registration. Advisory boards have been formalized in all jurisdictions discussed. Advisory boards have a role in discussing specific applications as well as broad policy issues. A common theme is a composition of a core panel of experts with augmentation by additional expertise as needed for consideration of specific scientific questions. In all jurisdictions, advisory board recommendations are not binding on the regulatory body.

CONCLUSIONS

Global oncology drug development and registration involves the use of experts by regulatory authorities. The types of experts needed, the expert's role and the transparency of the advisory process reflect the individual needs in different regions.

The meaning and experience of being a stroke survivor: an interpretative phenomenological analysis

PURPOSE

To investigate the meaning and experience of being a stroke survivor.

METHOD

Qualitative in-depth semi-structured interviews were conducted with 10 stroke survivors (five face-to-face and five e-mail interviews). The interview data were transcribed verbatim (these were pre-transcribed in e-mail exchange) and analysed using Interpretative Phenomenological Analysis.

RESULTS

Four themes emerged from the analysis: Disrupted embodiment and the loss of self; Invisibility of emotional difficulties; Gender, romance and sexuality; and Social interaction. These themes, respectively, revealed that participants often had difficulties with psychological adaptation to the physically disabling aspects of their stroke; they experienced enduring and disabling emotional difficulties; they had a particular concern for the viability and maintenance of romantic and sexual relationships; and they often became socially withdrawn, resulting in an increased pressure on familial caregivers.

CONCLUSION

The findings of the present work suggest the need for post-stroke counselling regarding romantic and sexual relationships, as well as promoting acceptance of some of the physical disabilities that come with having a stroke and encouraging positive self-regard. There would also appear to be a need to address the issue of social withdrawal and familial relationships, perhaps when health professionals convey information regarding the person's stroke, and in counselling targeted specifically at family caregivers.

Fine needle aspiration cytology in the diagnosis of uncommon types of lymphoma

AIMS

Fine needle aspiration (FNA) cytology is an accepted means of diagnosing and typing common forms of lymphoma, particularly small lymphocytic lymphoma, follicular lymphoma, and large B cell lymphoma. However, its usefulness for diagnosing less common forms of lymphoma is not clearly established and this study was designed to examine this.

METHODS

The study reviewed the FNAs of suspected lymphomas collected over a period of approximately five years.

RESULTS

FNA samples were available for 138 definite lymphomas; most were common forms of B cell lymphoma. However, there was also one Burkitt lymphoma (BL), two Burkitt-like large B cell lymphomas, 15 classic Hodgkin lymphomas (HLs), two nodular lymphocyte predominant Hodgkin lymphomas, four mantle cell lymphomas, two mediastinal (thymic) large B cell lymphomas (MLBCLs), 11 peripheral T cell lymphomas (PTCLs), and five T cell rich large B cell lymphomas (TCRLBCLs).

CONCLUSIONS

FNA diagnosis of BL was possible with immunoflow cytometry (IFC), cell block immunohistochemistry (IHC), and cell block fluorescent in situ hybridisation for c-myc alteration. It was difficult to make a definite diagnosis of HL and MLBCL on FNA alone. Both tend to be sclerotic tumours and FNA tends to yield scanty neoplastic cells. The FNA diagnosis of PTCL depended on cell block IHC; IFC was not usually useful. TCRLBCL did not show light chain restriction on IFC of FNA samples, probably because of frequent reactive B cells in the tumour. Thus, HL, MLBCL, and TCRLBCL are often difficult to diagnose accurately on FNA cytology, even when using IFC and cell block IHC.

Multiphase Flow Metering: Current Trends and Future Developments

Distinguished Author Series articles are general, descriptive representations that summarize the state of the art in an area of technology by describing recent developments for readers who are not specialists in the topics discussed. Written by individuals recognized as experts in the area, these articles provide key references to more definitive work and present specific details only to illustrate the technology. Purpose: to inform the general readership of recent advances in various areas of petroleum engineering.

Abstract

Over the last decade, the development, evaluation, and use of multiphase-flow-metering (MFM) systems have been a major focus for the oil and gas industry worldwide. Many alternative metering systems have been developed, but none can be referred to as generally applicable or universally accurate. Both established and novel technologies suitable to measure the flow rates of gas, oil, and water in three-phase flow are reviewed and assessed within this framework. Technologies already implemented in various commercial meters then are evaluated in terms of operational and economical advantages or shortcomings from an operator's point of view. The lessons learned about the practical reliability, accuracy, and use of available technology are discussed. As operators now realize, use of MFM systems (MFMSs) is essential in exploiting marginal fields. A new approach to flow assurance, deepwater developments, downhole/seabed separation systems, and wet-gas fields is foreseen. The authors suggest where additional research to develop the next generation MFM devices will be focused to meet the as yet unsolved problems.

Brief History

The first commercial MFMSs appeared approximately 10 years ago, as a result of several multiphase metering research projects in the early 1980s. The driving force to develop MFM technology was the forecast decline of production from the major North Sea fields, accompanied by the necessity to tie backfuture smaller discoveries to existing infrastructure. Increasing gas and waterfractions, inherent in a mature producing province, would create more-unstable flow conditions in existing production facilities and require more-flexible multiphase solutions.

In less than a decade, MFM has become accepted in the field and is beginning to be considered as a primary metering solution for new field developments.

MFM Applications

Within the oil and gas industry, it is generally recognized that MFM could lead to great benefits in terms of the following.1,2,3

Layout of Production Facilities.

The use of MFMs reduces the hardware needed for onshore, offshore topside, and offshore subsea applications. Of primary importance is the removal of a dedicated test separator for well-testing applications. Use of MFM (with its smaller footprint) for topside applications minimizes platform space and load requirements for well-testing operations. Finally, costly well-testing lines can be stripped from the production facilities, which may be of vital importance for unmanned locations, deepwater developments, and satellite fields.

Well Testing.

Conventional test separators are expensive and require much time to monitor each well's performance because of the time required to reach stabilized flow conditions. It is particularly important in deepwater developments, because of the exceptional length of the flowlines. In such cases, production from individual wells connected to the same manifold may be monitored by use of a dedicated test line to avoid shutting down all the wells, then testing them one by one (with considerable production loss). However, the expense of a separate flowline may be prohibitive, hence the advantages of MFM installed in the subsea manifold. Test separators have an accuracy between approximately 5 and10% (currently achievable with MFMSs) but require regular intervention by trained personnel and cannot provide continuous well monitoring. Another disadvantage of conventional well testing with conventional separators is that well performance suffers after shutdown cycles related to well testing. Often, wells tested on a regular basis require more-frequent workovers to maintain their production rates.

Use of MFMSs for exploration-well testing4 provides satisfactory flow measurements without separation of the phases. It is claimed that they can be used to monitor the well during its cleanup flow (traditionally, this flow information is lost because the well stream is not directed through the test separator). Added value is represented by improved control of the drawdown applied to the formation, the pressure transient, and shortened flow periods.

Reservoir Management.

MFMSs provide real-time, continuous data to enable operators to characterize field and reservoir performance better and react faster. Changes in gas/oil ratio or water cut can be detected and quantified immediately, where as traditional test separators provide information about only cumulative volumes at discrete points in time.

The assignment by linkage mapping of four genes from human chromosome 22 to bovine chromosome 5 and 17

Polymerase chain reaction oligonucleotides were designed to amplify bovine specific sequences for four genes that are located on human chromosome 22 (HSA22): crystallin beta A4 (CRY B A4), parvalbumin (PVALB), tissue inhibitor of metalloproteinase 3 (TIMP3) and matrix metalloproteinase 11 (MMP11). Single strand conformation analysis of these bovine gene fragments defined polymorphisms within a population of three large half-sib families of three F1 Charolais x Brahman sires and a composite herd comprising an equal proportion of Africander, Brahman, Hereford and Shorthorn breeds (CSIRO pedigree). The DNA marker genotypes were used to define linkage associations to other DNA markers already placed on the CSIRO linkage map. The genes TIMP3 and PVALB were assigned to BTA5 and CRYbetaA4 and MMP11 to BTA17.

What is the natural history of rheumatoid arthritis?

Inflammatory polyarthritis can be a self-limiting disease, develop into rheumatoid arthritis (RA) or differentiate into another form of chronic arthritis. It remains a clinical and scientific challenge to understand the relationship between these phenotypes, determine their aetiologies and predict the course and outcome for individual patients. Even patients labelled as having RA show a wide spectrum of clinical phenotypes. Disease definition is a major problem in studying the aetiology of RA as currently used classification criteria were derived using patients with established disease. RA is thought to result from the combination of genetic susceptibility and exposure to an appropriate environmental trigger. The genetic component is probably oligogenic. The association with HLA has been known for over 25 years. RA is now thought to be associated with a conserved sequence of amino acids in a number of HLA-DRB1 alleles, called the RA shared epitope. However, the shared epitope appears to be associated with RA chronicity and severity more than with susceptibility. Other potential RA susceptibility genes include IL-1, aromatase, corticotropin-releasing hormone and a region on the X chromosome. Hormonal and reproductive factors also influence RA susceptibility and severity. RA is more common in women than men, especially before the menopause. Men may be protected by hormonal factors and require a stronger genetic component to develop disease. Although infectious triggers of RA have long been suspected, no definitive evidence has been obtained. Previous blood transfusion, smoking and obesity are also possible risk factors. Chronicity and remission are important aspects of the natural history of early RA. Although we can identify patients at risk of adverse prognosis with some accuracy, we remain unable to predict remission. Functional disability and radiological damage are the most studied outcomes in RA. Radiological damage often occurs early in the course of RA, but patients may show erosion for the first time several years after symptom onset. Many studies have demonstrated a relationship between HLA and features of severe RA in established patients. This appears to be related to gene dosage.

Time to first occurrence of erosions in inflammatory polyarthritis: results from a prospective community-based study

OBJECTIVE

To examine the time of occurrence of first radiographic erosions in a cohort of patients with inflammatory polyarthritis.

METHODS

Patients were recruited through the Norfolk Arthritis Register, which follows up patients annually. Patients with features of rheumatoid arthritis (other than erosions) sufficient, together with erosions, to meet the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 revised criteria were requested to undergo radiographic examinations of the hands and feet at the first and/or second annual followup visits. All patients were requested to undergo radiographic examinations at the fifth annual followup visit. The most recent erosion-free radiograph was identified for 416 eligible patients, and these data were used to derive the duration of disease since the recalled date of onset of first symptoms. The rate of occurrence of first erosions was then determined (as a cumulative prevalence and as an incidence rate using Poisson regression) from analysis of followup films. Patients were assumed to be free of erosions at symptom onset.

RESULTS

The cumulative prevalence of erosions in patients whose first film was obtained 12-24 months after disease onset was 36%, equivalent to an incidence rate of 24.5/1,000 patient-months. We identified 3 analysis groups of patients who were free of erosions based on films obtained 12-24 months, 24-36 months, and 36-60 months since the recalled date of onset of first symptoms. New erosions were observed in all 3 groups, with cumulative prevalences of 23%, 28%, and 47%, respectively. These were equivalent to first-erosion incidence rates/1,000 patient-months of 5.4 (95% confidence interval [95% CI] 3.8-83), 6.8 (95% CI 4.7-10.0), and 13.0 (95% CI 8.9-19.2), respectively.

CONCLUSION

Many patients with erosive disease first develop their erosions >2 years from disease onset.

Lessons from an international survey of paper cases of 10 real patients from an early arthritis clinic. CRI (Club Rhumatismes et Inflammation) Group

OBJECTIVE

To determine how experts would classify 10 early-arthritis cases (7 atypical) and to study discrepancies in diagnoses relative to ACR criteria for rheumatoid arthritis (RA) or ESSG criteria for spondyloarthropathy (SpA).

METHODS

Ten real cases (5 met ACR criteria for RA, 6 ESSG criteria for SpA, 3 both and 2 neither) followed for 28.5 +/- 4.8 months were sent as paper cases to 20 international and 12 French experts. Each expert selected a diagnosis among 8 possible choices and rated it on a 0-10 confidence scale. For each case, 3 analog scales (0-100 mm) were used to indicate the probability of RA, SpA or undifferentiated arthritis (UA).

RESULTS

Experts often disagreed about diagnoses (up to 5 different diagnoses for a given case, with a mean of 3.9 per case). Similarly, expert opinions on probabilities for RA and SpA differed widely, with great overlap between confidence for RA, SpA and UA. Fulfilment of ACR or ESSG criteria was poorly related to the experts' diagnosis and evaluation of probabilities for RA and SpA. However, UA was a relatively infrequent choice (19%).

CONCLUSIONS

There was no general consensus about the nosology of early RA and SpA. Classification of atypical early arthritis was not resolved by currently available criteria for RA and SpA. This may have implications for therapy in early disease.

Remacemide hydrochloride: a placebo-controlled, one month, double-blind assessment of its safety, tolerability and pharmacokinetics as adjunctive therapy in patients with epilepsy

Forty patients (33 male, 7 female) with refractory epilepsy were randomized to receive ascending weekly doses of adjunctive remacemide hydrochloride in a b.i.d. or q.i.d. regimen, or placebo for up to 1 month. Assessments included routine physical examination and laboratory tests, recording of adverse events and seizure frequency, and neuropsychological tests. Trough plasma concentrations of concomitant AEDs were measured at weekly intervals. Trough plasma concentrations of remacemide and its desglycinyl metabolite were measured before each dose increment, and complete 24-hour profiles were measured at steady state following administration of 600 mg day(-1)and 1200 mg day(-1). A daily dose of 1200 mg was well tolerated in a q.i.d. regimen and up to 800 mg was well tolerated in a b.i.d. regimen. The most common adverse events were dizziness, diplopia, dyspepsia and abdominal pain. On some occasions, these were considered to be related to raised concentrations of concomitant AEDs. No adverse effects were observed on seizure frequency. Neuropsychology tests revealed no significant changes. Remacemide and the desglycinyl metabolite demonstrated dose proportional pharmacokinetics over the dose range tested.

A placebo-controlled, double-blind cross-over trial of adjunctive one month remacemide hydrochloride treatment in patients with refractory epilepsy

The efficacy, safety and pharmacokinetics of adjunctive remacemide hydrochloride, a novel, low-affinity non-competitive NMDA receptor channel blocker, were investigated in 28 adult patients with refractory epilepsy. This was a randomized double-blind placebo-controlled cross-over study with five 4-week periods (baseline, treatment 1, washout, treatment 2, washout). Baseline median seizure frequency was reduced by 33% following adjunctive remacemide hydrochloride 150 mg q.i.d. for 4 weeks compared with placebo (P= 0.041). Seizure frequency was reduced by > or =50% in 30% of patients treated with remacemide hydrochloride compared with 9% on placebo. Mean plasma concentration of concomitant carbamazepine increased by approximately 15% following adjunctive remacemide hydrochloride. There was no correlation between increased plasma carbamazepine and reduced seizure frequency. Remacemide hydrochloride was well tolerated and only three patients withdrew due to adverse events (two remacemide hydrochloride, one placebo). Two patients died unexpectedly from their epilepsy during placebo treatment; both deaths were considered by the investigators to be unrelated to earlier remacemide hydrochloride treatment. This first specific efficacy investigation with adjunctive remacemide hydrochloride demonstrated anticonvulsant effects in patients with refractory epilepsy. More extensive clinical investigation is justified.

A crystallization-induced stereoselective glycosidation reaction in the synthesis of the anticancer drug etoposide

The anticancer drug etoposide, 1, is prepared in 79% overall yield from readily available 4'-demethyl-4-epipodophyllotoxin, 3, and 4, 6-O-ethylidene-2,3-O-dibenzyl-D-glucose, 4, via a crystallization-induced stereoselective glycosidation reaction followed by catalytic hydrogenation.

A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics

OBJECTIVE

To better understand the differences between two iatrogenic injury studies of hospitalized patients in 1992 which used ostensibly similar methods and similar sample sizes, but had quite different findings. The Quality in Australian Health Care Study (QAHCS) reported that 16.6% of admissions were associated with adverse events (AE), whereas the Utah, Colorado Study (UTCOS) reported a rate of 2.9%.

SETTING

Hospitalized patients in Australia and the USA.

DESIGN

Investigators from both studies compared methods and characteristics and identified differences. QAHCS data were then analysed using UTCOS methods.

MAIN OUTCOME MEASURES

Differences between the studies and the comparative AE rates when these had been accounted for.

RESULTS

Both studies used a two-stage chart review process (screening nurse review followed by confirmatory physician review) to detect AEs; five important methodological differences were found: (i) QAHCS nurse reviewers referred records that documented any link to a previous admission, whereas UTCOS imposed age-related time constraints; (ii) QAHCS used a lower confidence threshold for defining medical causation; (iii) QAHCS used two physician reviewers, whereas UTCOS used one; (iv) QAHCS counted all AEs associated with an index admission whereas UTCOS counted only those determining the annual incidence; and (v) QAHCS included some types of events not included in UTCOS. When the QAHCS data were analysed using UTCOS methods, the comparative rates became 10.6% and 3.2%, respectively.

CONCLUSIONS

Five methodological differences accounted for some of the discrepancy between the two studies. Two explanations for the remaining three-fold disparity are that quality of care was worse in Australia and that medical record content and/or reviewer behaviour was different.