Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience

PURPOSE

Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation.

MATERIALS AND METHODS

Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days.

RESULTS

The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses.

CONCLUSION

Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.

Constructed wetlands may lower inorganic nutrient inputs but enhance DOC loadings into a drinking water reservoir in North Wales

The objective of this study was to monitor a newly constructed wetland (CW) in north Wales, UK, to assess whether it contributes to an improvement in water quality (nutrient removal) of a nearby drinking water reservoir. Inflow and outflow of the Free Water Surface (FWS) CW were monitored on a weekly basis and over a period of 6 months. Physicochemical parameters including pH, conductivity and dissolved oxygen (DO) were measured, as well as nutrients and dissolved organic and inorganic carbon (DOC, DIC) concentration. The CW was seen to contribute to water quality improvement; results show that nutrient removal took place within weeks after construction. It was found that 72 % of initial nitrate (N03 (-)), 53 % of initial phosphate (PO4 (3-)) and 35 % of initial biological oxygen demand (BOD) were removed, calculated as a total over the whole sampling period. From our study, it can be concluded that while inorganic nutrients do decline in CWs, the DOC outputs increases. This may suggest that CWs represent a source for DOC. To assess the carbon in- and output a C budget was calculated.

Long-term treatment with oral N-acetylcysteine: affects lung function but not sputum inflammation in cystic fibrosis subjects. A phase II randomized placebo-controlled trial

PURPOSE

To evaluate the effects of oral N-acetylcysteine (NAC), which replenishes systemic glutathione, on decreasing inflammation and improving lung function in CF airways.

METHODS

A multicenter, randomized, double-blind proof of concept study in which 70 CF subjects received NAC or placebo orally thrice daily for 24 weeks.

ENDPOINTS

primary, change in sputum human neutrophil elastase (HNE) activity; secondary, FEV(1) and other clinical lung function measures; and safety, the safety and tolerability of NAC and the potential of NAC to promote pulmonary hypertension in subjects with CF.

RESULTS

Lung function (FEV(1) and FEF(25-75%)) remained stable or increased slightly in the NAC group but decreased in the placebo group (p=0.02 and 0.02). Log(10) HNE activity remained equal between cohorts (difference 0.21, 95% CI -0.07 to 0.48, p=0.14).

CONCLUSIONS

NAC recipients maintained their lung function while placebo recipients declined (24 week FEV1 treatment effect=150 mL, p<0.02). However no effect on HNE activity and other selected biomarkers of neutrophilic inflammation were detected. Further studies on mechanism and clinical outcomes are warranted.

A randomized controlled trial studying efficacy and tolerance of a knee-ankle-foot orthosis used to prevent equinus in children with spastic cerebral palsy

Objective:

To examine whether using a knee-ankle-foot orthosis helps maintain ankle-foot dorsiflexion range of motion over time.

Design:

A multicentre randomized controlled trial.

Setting:

Two hospitals and one rehabilitation centre in the Netherlands and the USA.

Subjects:

Children (4-16 years old) with spastic cerebral palsy who were able to walk.

Intervention:

Use of a knee-ankle-foot orthosis, equipped with an Ultraflex® ankle power unit, for at least 6 hours every other night for one year.

Main measures:

Primary outcome measure: ankle-foot dorsiflexion range of motion. Secondary outcome measures: ankle-foot and knee angle in gait and gross motor function. Wearing time was also measured. Measurements were taken at baseline and at 3, 6, 9 and 12 months.

Results:

28 children (experimental group: n=15, control group: n=13) participated in the study. 11 participants (experimental: n=4, control: n=7) did not complete all five measurements, as they needed additional treatment. No significant difference was found in the decrease of ankle-foot dorsiflexion range of motion between the experimental and control groups (difference: −1.05°, 95% confidence interval: −4.71° – 2.61°). In addition, secondary outcome measures did not show differences between groups. Despite good motivation, knee-ankle-foot orthosis wearing time was limited to a mean±SD of 3.2±1.9 hours per prescribed night due to discomfort.

Conclusions:

Knee-ankle-foot orthosis with dynamic ankle and fixed knee are poorly tolerated and are not beneficial in preventing a reduction in ankle-foot dorsiflexion range of motion in children with spastic cerebral palsy, at least with limited use.

A mass analysis technique using coincidence measurements from the Interstellar Boundary Explorer-Hi (approximately 0.3- approximately 6 keV) detector

NASA's Interstellar Boundary Explorer (IBEX) mission, scheduled to launch in October 2008, will make the first observations of charge exchange energetic neutral atoms (ENAs) produced near the edge of the heliosphere. IBEX will measure these ENAs with two ultra-high sensitivity, single-pixel ENA sensors in the energy range of approximately 0.01- approximately 2 keV (IBEX-Lo) and approximately 0.3- approximately 6 keV (IBEX-Hi), respectively. The primary purpose of IBEX is to measure hydrogen ENAs from the outer heliosphere, but it will also be sensitive to heavier species of ENAs produced anywhere throughout the solar system. For this study, we measured the coincidence response of the IBEX-Hi detector section to H, He, N, and O ions. Based on these results, we have developed an innovative technique in estimating the hydrogen to heavy ion ratio in the signal. This new technique can be applied more widely than the IBEX-Hi detector section, and the basic principle may be useful for other, future space and ground-based measurements.

7. THE CHLAMYDIA PROJECT IMPROVING KNOWLEDGE OF, AND TESTING RATES FOR CHLAMYDIA AMONG YOUNG PEOPLE IN A REMOTE ABORIGINAL SETTING

The Kimberley region has some of the highest rates of Chlamydia infection in Australia. NCHS obtained funding to initiate and establish a Chlamydia Project aimed at increasing screening rates amongst indigenous youth aged 15 to 30 in the Fitzroy Valley. Population for the Valley is approximately 3000, predominately Aboriginal, covering more than 40 remote communities and the town of Fitzroy Crossing. The community has a strong belief in traditional values therefore observation of cultural protocols is paramount, especially when working in the area of sexual health. This can present challenges when setting up a sexual health program that is culturally appropriate, accepted and sustainable. The aim of the project is to encourage young people to attend for STI screening when they are asymptomatic. The project will also endeavour to increase awareness of Chlamydia and other sexual health issues relevant to the age group. Methods used, include setting up screening clinics in town and remote communities, involving young people in making decisions about how the clinics are run, holding Feel Good Nights that promote discussion and information sharing about sexual health, peer education and encouraging young people to participate in resource production. Anecdotally, results so far have shown a greater number of young people are accessing sexual health services and there is an increase in knowledge of Chlamydia and sexual health in general amongst the target population. This project will run until May 2008. This paper will present the progress of the project so far, and some of the highlights and challenges of setting up a sexual health program in a remote community setting.

Amplification of DNA encoding entire type I polyketide synthase domains and linkers from streptomyces species

Polyketides are a group of bioactive compounds from bacteria, plants, and fungi. To increase the availability of analogs for testing, the active sites of polyketide synthases are often substituted with homologous domains having altered substrate specificities. This study reports the design of polymerase chain reaction primers that enables isolation of entire active site domains from type I polyketide synthases with native interdomain linkers. This bypasses the need for further genetic screening to obtain functional units for use in genetic engineering. This is especially important in bioprospecting projects exploring new environments for bioresources.

Serum IgA and IgG functional antibodies and their subclasses to Streptococcus pneumoniae capsular antigen found in two aged-matched cohorts of children with and without otitis media with effusion

The relationship between acute otitis media and otitis media with effusion (OME) is uncertain and the aetiology of OME is multifactorial. Otitis media with effusion may be an inflammatory condition; both bacteria and viral infections could play a part in this inflammation. The four bacteria Streptococcus pneumoniae, Haemophilus influenza, Staphylococcus aureus and Branhamella catarrhalis cause 60% of the infections whereas S. pneumoniae accounts for up to 35%. IgA provides the dominant surface response to polysaccharide and lipopolysaccharide antigens, of which IgA2 is the main subclass. Once the mucosa has been breached, most protection is provided by IgG. IgG2 acts mainly against bacterial capsular antigens. This study looked at two groups of 50 children with and without OME who were aged between 3 and 10 years. The aims were to determine if, firstly, the levels of the serum immunoglobulins were different in the two groups, secondly whether these children made the appropriate antibody response to the capsular antigen to S. pneumoniae (PCP), and finally if there was a delay in the maturity of the IgA response. The total IgG, IgA and all subclass levels were measured using radial immunodiffusion. Levels of functional IgA and IgG were measured using ELISAs (25 patients in each group). The results were analysed with non-parametric tests. The immunoglobulin levels were within the normal levels for both groups. There were very good correlations between the IgG total anti-PCP and the IgG2 anti-PCP (R > 0.9, p = 0.001). There was a good correlation between the levels of both IgG total and IgG2 anti-PCP against IgA total anti-PCP in both groups (R > 0.85, p > 0.01). This confirms a normal antibody response between both groups of patients. The ages of the controls and patients (50 samples) were correlated with increasing titres of circulating functional antibodies (P = 0.001). This is highly suggestive of a normal age-related response. In conclusion, the findings were contradictory to our original hypothesis that there is a subtle difference in surface protection between children with and without OME. We believe that a previous history of recurrent acute otitis media is unrelated to the development of OME after 3 years of age.

Surgical emphysema following nose blowing

A 20-year-old woman developed gross surgical emphysema tracking down to the chest after an episode of nose blowing. Fortunately there were no ocular complications and the patient settled with conservative management. Follow-up showed no recurrence. The case presented illustrates the very rare complication of orbital fracture following nose blowing.

Molecular mechanism and biological functions of c-Jun N-terminal kinase signalling via the c-Jun transcription factor

The regulation of c-Jun transcriptional activity by Jun N-terminal kinase (JNK) has become a paradigm for understanding how mitogen-activated protein (MAP) kinase signalling pathways elicit specific changes in gene transcription through selective phosphorylation of nuclear transcription factors. Selective phosphorylation of c-Jun by JNK is determined by a specific docking motif in c-Jun, the delta region, which enables JNK to associate physically with c-Jun. Analogous MAP kinase docking motifs have subsequently been found in several other transcription factors, indicating that this is a general mechanism for ensuring specificity of signal transduction. Genetic and biochemical studies in mice, flies and cultured cells have provided evidence that signals relayed by JNK through c-Jun regulate a range of cellular processes including cell proliferation, tumourigenesis, apoptosis and embryonic development. Despite these advances, in most cases, the genes or programs of gene expression downstream of JNK and c-Jun, which control these processes, have not been defined. Here, we review the current understanding of the molecular basis and biological consequences of JNK signalling via c-Jun and highlight some of the mechanistic issues, which remain to be resolved.

Acceptance of neonatal genetic screening for hereditary hemochromatosis by informed parents

The aim of this study was to assess attitudes to neonatal genetic screening for hereditary hemochromatosis. A total of 135 consecutive, pregnant women and their partners attending a hospital antenatal clinic in the Australian Capital Territory were given detailed written and verbal information about potential risks and benefits of neonatal genetic screening. Issues such as uncertainty of disease expression, confidentiality, genetic discrimination, and storage of genetic data were addressed. Attitudes were assessed by interview and questionnaire. There was a high level of acceptance for neonatal genetic screening in general (99%) and for hemochromatosis in particular (91.5%). There was no association of prior knowledge of hemochromatosis, family history of hemochromatosis, ethnicity, age, education, or occupation class with nonacceptance. Of the subjects, 39.5% reported feeling "a little anxious" about the prospect of screening their infants, although only 5.4% reported feeling "very anxious." Reasons given for nonacceptance of screening included inability of the child to give informed consent, insufficient evidence that diagnosis of hemochromatosis in childhood is beneficial, risk of discrimination on genetic grounds, lack of agreement between partners, and privacy issues. These data suggest that an Australian neonatal genetic screening program for hemochromatosis is likely to be accepted by this and similar groups of subjects, but there should be an opportunity for parents who object to screening to opt out of any such program.

The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review

AIMS

To examine the effectiveness of brief behavioral interventions adapting the principles and techniques of Motivational Interviewing (MI) to four behavioral domains: substance abuse, smoking, HIV risk and diet/exercise.

DESIGN

We conducted a systematic review of 29 randomized trials of MI interventions. Data on methodological quality were extracted and tabulated. Between-group behavior change effect sizes and confidence intervals were calculated for each study.

FINDINGS

Due to varying intervention time lengths, targeted problem behaviors, settings and interventionists' backgrounds and skill levels, outcomes were not combined meta-analytically. Sixty per cent of the 29 studies yielded at least one significant behavior change effect size. No significant association between length of follow-up time and magnitude of effect sizes was found across studies. There was substantial evidence that MI is an effective substance abuse intervention method when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing entry to and engagement in more intensive substance abuse treatment treatment-as-usual. Data were inadequate to judge the effect of MI in the other domains. Client attribute-treatment interactions were understudied and the sparse and inconsistent findings revealed little about the mechanism by which MI works or for whom it works best.

CONCLUSION

To determine more effectively how well MI works in domains other than substance abuse and for whom it works best in all domains, researchers should study MI with risk behaviors other than substance abuse, while examining both interactions and the theoretical components of MI.

Families with deaf members: American Annals of the Deaf, 1996 to 2000

The authors provide an overview of 21 articles from several countries focusing on families with deaf members published in the literary issues of the American Annals of the Deaf from 1996 to 2000. Four categories were identified: Interaction and Involvement, Support Services, Stress and Coping, and Decision Making. The articles represent a commendable expansion of focus from the mother-child dyad to increased attention to fathers, siblings, extended family members, and significant nonfamily members such as deaf adults. The heterogeneity of families was a striking factor, even within those studies dealing with relatively homogeneous populations. Services appeared to be most effective within middle-class, educated family units, illustrating the need for more comprehensive services sensitive to the needs of families from less affluent backgrounds and with lower levels of education. In general, services to families with deaf children may be characterized as better than in the past but still in need of significant sensitivity and improvement. The presence of a deaf child in a family with hearing parents may cause stress, but parents have the flexibility to respond in a positive and beneficial way, especially when provided adequate information and support. The idea that hearing parents go through a grieving process involving the identification of deafness in their child seems to be an overstatement.

'Even the birds round here cough': stigma, air pollution and health in Teesside

In this paper we explore how the presence of hazardous industry may affect the identity of a place and the people who live there. Drawing on Goffman's seminal work on stigma - together with recent debates on environmental and technological stigma - we extend the concepts of difference and spoiled identity from the individual to place. The paper is based on a qualitative study which explored public perceptions of the risks to health from air pollution in Teesside, a heavily industrialised area in north-east England. We did not set out to study stigma per se in this study, but emergent themes produced by grounded theory analysis highlighted the way in which the presence of technologies, air pollution, poor health and social exclusion may be used as 'discrediting' characteristics, to stigmatise one place, whilst confirming the usualness of another. We demonstrate place stigma as a complex, multiple and re-inforcing concept.

Dietary glycine prevents the development of liver tumors caused by the peroxisome proliferator WY-14,643

Previous studies demonstrated that dietary glycine prevents elevated rates of cell proliferation following treatment with the peroxisome proliferator and liver carcinogen WY-14,643. Since increased cell replication is associated with the development of hepatic cancer caused by peroxisome proliferators, glycine may have anti-cancer properties. Therefore, experiments were designed to test the hypothesis that dietary glycine would inhibit the hepatocarcinogenic effect of WY-14,643. Male F344 rats were fed four different NIH 07-based diets: 5% glycine; 5% valine for nitrogen balance (control); 0.1% WY-14,643 + 5% valine (WY-14,643); 0.1% WY-14,643 + 5% glycine (WY-14,643 + glycine). Food consumption did not differ among the groups, but WY-14,643-fed rats weighed 10-25% less than expected based on previous studies. Serum glycine levels were elevated 4-5-fold by glycine-containing diets; however, the 10-fold increase in peroxisomal enzyme activity caused by WY-14,643 was unaffected by the addition of 5% glycine to the diet. After 22 weeks, livers from rats fed WY-14,643 had a similar incidence and multiplicity of proliferative lesions (foci and adenomas) to those fed WY-14,643 + glycine. Moreover, cell proliferation in the surrounding 'normal' parenchyma (labeling index approximately 4%) and foci (labeling index approximately 50%) did not differ between WY-14,643 and WY-14,643 + glycine-fed rats. However, after 51 weeks of dietary exposure to WY-14,643, glycine prevented formation of small (0-5 mm diameter) tumors by 23% and inhibited the development of medium size (5-10 mm) tumors by 64%. Furthermore, glycine prevented the formation of the largest tumors (>10 mm) by nearly 80%. Thus, glycine did not inhibit early foci formation; however, it significantly decreased their ability to progress to tumors. Moreover, the inhibitory effect of glycine was greater with increasing tumor size. These studies demonstrate that dietary glycine prevents the development of hepatic tumors caused by the peroxisome proliferator WY-14,643 consistent with the idea that it may be an effective chemopreventive agent.