Adoption of obesity prevention policies and practices by Australian primary schools: 2006 to 2013

Despite significant investment in many countries, the extent of schools' adoption of obesity prevention policies and practices has not been widely reported. The aims of this article are to describe Australian schools' adoption of healthy eating and physical activity policies and practices over an 8-year period and to determine if their adoption varies according to schools' size, geographic or socio-economic location. Between 2006 and 2013, a representative randomly selected cohort of primary schools (n = 476) in New South Wales, Australia, participated in four telephone interviews. Repeated measures logistic regression analyses using a Generalised Estimating Equation (GEE) framework were undertaken to assess change over time. The prevalence of all four of the healthy eating practices and one physical activity practice significantly increased, while the prevalence of one physical activity practice significantly decreased. The adoption of practices did not differ by school characteristics. Government investment can equitably enhance school adoption of some obesity prevention policies and practices on a jurisdiction-wide basis. Additional and/or different implementation strategies may be required to facilitate greater adoption of physical activity practices. Ongoing monitoring of school adoption of school policies and practices is needed to ensure the intended benefits of government investment are achieved.

[Survey national professional practice on the use of the laryngeal mask]

BACKGROUND

This survey aimed to describe the current use of laryngeal mask (LM) and to define the difference of use according to a group defined like experts.

METHODS

A self-questionnaire available on Internet was sent by e-mail to French anesthesiologists. Results were compared by a Chi(2) test between anesthesiologists according to their expertise defined by a >750 LM use.

RESULTS

Nine hundred and fifty-three anesthesiologists answered to the survey. Only 19 reported never using LM and 37% of responders were defined as expert. More than half of the MAR used the ideal weight to set the size of the MLA to use. Pressure leak was sought by less than one-third of the MAR. In case of leakage, a mobilization of the ML or the patient's head was performed first. In second intention, nearly a quarter of MAR changed technique for the benefit of oral intubation. Only 50% of responders used LM as a rescue technique in case of difficult intubation and ventilation. Experts had less insertion failure and laryngospasm. Complications and medico-legal suites are few.

CONCLUSIONS

Variability of practice may be explained by low-grade recommendations in the literature. LM insertion in case of difficult intubation/ventilation to provide adequate oxygenation and should be formally reminded to clinicians.

[Epidural analgesia apart from obstetrics: a survey of practice]

OBJECTIVES

To describe the current use of epidural anesthesia (EA) apart from obstetrics, and to explain the reasons of its low utilization.

STUDY DESIGN

Observational study.

METHODS

A survey of practice with a self-questionnaire was sent by e-mail and available on Internet. Answers were compared between groups doing or not an epidural analgesia with exact Fisher tests (P<0.05 statistically significant).

RESULTS

Among the 176 anesthesiologists who answered to the questionnaire, only 21.4% never used epidural analgesia. The main reasons were alternatives therapeutics such as PCA with opioids or TAP block (24/38 vs. 46/140). TAP block was the most common alternative used by more than 50% of anesthesiologists. Loss of competence (4/30 vs. 0/39) was rarely the reason to its low utilization. The low accessibility to specialized postoperative units was recognized in both groups as a limiting factor to do an epidural but not the fear of neurological complications. Those who never perform epidural analgesia were statistically more often physicians between 40 and 50 years (12/38 vs. 19/140). Heparin, aspirin and clopidogrel are no longer contraindications according to anesthesiologists less than 40 years old (50/68 vs. 31/68; 44/68 vs. 31/68; 37/68 vs. 23/68 respectively) but not for older.

CONCLUSIONS

Epidural analgesia is performed more often by younger anesthesiologists. This survey suggests the need of specific postoperative area to allow anesthesiologist to perform and supervise safely this technique. Recommendations of the French society of Anesthesiologists are also poorly applied.

[Why use long-term macrolide therapy in pediatric pulmonology?]

Macrolides are well-known antibiotics exerting antimicrobial as well as anti-inflammatory and immunomodulatory effects. Since the observation of a dramatic improvement in lung disease and survival in patients with diffuse panbronchiolitis, macrolides have been used over the long term in several chronic respiratory diseases. This review describes the results of trials that have evaluated long-term macrolides in the treatment of cystic fibrosis, non-cystic fibrosis bronchiectasis, and asthma, particularly focusing on the impact on children. It also provides new insights on the potential effects of macrolides on diffuse parenchymal lung diseases.

[Bronchopulmonary dysplasia-associated pulmonary arterial hypertension of very preterm infants]

Bronchopulmonary dysplasia (BPD) of very preterm infants is a multifactorial chronic lung disease and its incidence has not decreased despite improvements in neonatal intensive care, including lung protective strategies. Pulmonary hypertension (PH) can complicate the course of BPD. Mortality in infants with BPD-associated PH is thought to be very high, but its incidence is unknown and a standard diagnostic and therapeutic strategy has not been well defined. In this article, we will first describe the current knowledge on the BPD-associated PH and the current treatments available for this pathology. We will then present the HTP-DBP Study, carried out in Paris (France) starting in 2012. The diagnosis of PH is suspected on echocardiographic criteria, but cardiac catheterization is considered the gold standard for diagnosis and evaluation of the severity of PH. Moreover, pulmonary vasoreactivity testing is used to guide the management of patients with PH. The pathogenesis of BPD-associated PH is poorly understood and even less is known about appropriate therapy. Today, optimizing ventilation and reducing the pulmonary vascular tone with specific pulmonary vasodilatator drugs are the main goals in treating HTP-associated DBP. Animal studies and a few clinical studies suggest that medications targeting the nitric oxide (NO) signaling pathway (NO inhalation, oral sildenafil citrate) could be effective treatments for BPD-associated PH, but they have not been approved for this indication. The HTP-DBP study is a French multicenter prospective observational study. The objective is to evaluate the frequency of BPD-associated PH, to describe its physiopathology, its severity (morbidity and mortality), and the effectiveness of current treatments.

Eicosanoid and cytokine levels in plasma of patients during mesenteric infarction

Multible organ failure (MOF) induced by mesenteric infarction is associated with a high mortality rate. This study reports eicosanoid and cytokine levels in the blood of three atherosclerotic patients who ultimately died from MOF induced by mesenteric infarction. High plasma levels of 6- keto-prostaglandin (PG) F_1α (the stable metabolite of PGI₂), interleukin (IL)-6 and IL-8 are observed whereas plasma tumour necrosis factor alpha (TNFα), TxB₂ (the stable metabolite of TxA₂), PGE₂, leukotrienes (LT)B₄ and LTC₄, and whole blood platelet-activating factor levels are not different from values obtained in similarly severe atherosclerotic patients. This short report questioned the clinical involvement of TNFα during such a pathology where a persistent translocation of endotoxin has been observed through the gut endothelial barrier. Activation of phospholipase A₂ is suggested by the increase in the stable metabolite of PGI₂ and might be by itself or through lipidic metabolites, a major systemic stimulus of IL-6 and IL-8 production.

[High fidelity simulation in Anesthesia and Intensive Care: context and opinion of performing centres--a survey by the French College of Anesthesiologists and Intensivists]

OBJECTIVES

High fidelity simulation is rapidly expanding in France. The question of knowing how to accredit this new mode of continuous education and how far it is available for this purpose is pending. The purpose of this survey was to collect how active centres operate and which criteria they would prefer to accredit this form of continuing medical education.

STUDY DESIGN

National survey.

METHODS

A questionnaire was sent to all centres using high fidelity simulation in France (December 2009).

RESULTS

Eighteen of 21 centres answered (86%; all university hospitals). These centres are equipped with adult high fidelity simulation and procedural heads for intubation. Funding is achieved via multiple sources and one third of centres benefit from manufacturers' lending. Centres are mostly located within the university premises (70%). One or more staff practitioners are involved in 78% and the majority of centres are operated by more than three. Nurse anaesthetists are not involved in most centres. Operating procedures are similar and high fidelity simulation is mostly used for in-site resident training. At present, centres are only marginally able to train non-resident senior anaesthesiologists. Sessions extend over one day (72%). The majority of centres is prone to share scenarios (75%) and pedagogic aids (93%). Basic scenarios (e.g., cardiopulmonary resuscitation) are mainstream objectives for 85% of centres.

CONCLUSION

high fidelity simulation is rapidly expending in France but its ability to contribute to continuous medical education is still limited to date.

Can oral vitamin K before elective surgery substitute for preoperative heparin bridging in patients on vitamin K antagonists?

BACKGROUND

After a vitamin K antagonist (VKA) overdose, 1-2 mg of oral vitamin K can lower the International Normalized Ratio (INR) to the therapeutic range.

OBJECTIVE

To establish whether oral vitamin K can substitute for heparin bridging and decrease the INR to < or = 1.5 before elective surgery.

METHODS

Patients on long-term VKAs were randomized either to heparin bridging after the last VKA dose on day -5 before surgery (group H) or to VKA treatment until day -2, followed by 1 mg of oral vitamin K on the day before surgery (group K). Blood clotting variables were assessed on days -5/-2, 1 and 0, and postoperatively. If the target INR was not achieved 2 h before incision, surgery was deferred or performed after injection of prothrombin complex concentrate (PCC).

RESULTS

In 30 of 94 included patients, baseline INR was outside the chosen range (18, INR < 2; 12, INR > 3.5), leaving 34 eligible patients in group H and 30 in group K. The groups were balanced in terms of body mass index, VKA treatment duration and indication, scheduled surgery, preoperative and postoperative hemoglobin, and blood loss. The INR was significantly higher in group K on days -1 and 0 than in group H. An INR < or = 1.5 was not achieved in 20 group K patients (66%). Surgery was postponed or performed after PCC injection in 12 of these 20 patients.

CONCLUSIONS

Oral vitamin K (1 mg) cannot substitute for heparin bridging before surgery. In addition, one-third of patients on VKAs were exposed to a risk of bleeding (overdose) or thrombosis (underdose), thus highlighting the need for new oral anticoagulants.

[Anaphylactic shock to iodinated povidone]

Anaphylaxis during anaesthesia is a rare event which is mainly related to neuromuscular blocking agents. Latex and antibiotics are less frequently incriminated. However, allergy may be triggered by other less frequent and hidden allergen. Among these, povidone is largely used in numerous therapeutics and cosmetics. We report here an exceptional case of grade 3 anaphylactic shock with iodinated povidone administered via a rectal route.

[Labour epidural analgesia for a woman with a factor XI deficiency: an illconsidered risk?]

Inherited bleeding disorders contraindicate epidural analgesia because of the risk of epidural haematoma. However, there is no consensus about a minimal rate of factor XI required for its performance. We report here a case of epidural analgesia in a pregnant woman with a moderate and symptomatic factor XI deficiency, despite this theoretical contraindication. Indeed, the factor XI deficiency results in a haemorrhagic risk which is variable and not easily foreseeable. Nevertheless, no neurological after-effect or excessive bleeding occurred although no specific prophylaxis had been performed.

[Pneumocystis jiroveci pneumonia during prolonged corticosteroid therapy in an immunocompetent infant]

INTRODUCTION

Pneumocystis jiroveci (PJ) infection is rare in infants and is suggestive of primary or secondary immunodeficiency. We report on a case of severe PJ pneumonia in an immunocompetent infant after prolonged corticosteroid treatment.

CASE REPORT

A 5 1/2 month-old girl presented with hypoxemic respiratory distress. Her medical record was remarkable only for a bulky parotid haemangioma, which was treated with prolonged oral corticosteroid therapy. The chest X-ray showed a mixed alveolar-interstitial pattern, and bronchoalveolar lavage revealed the presence of PJ. A favourable outcome was obtained after three weeks of intravenous trimethoprim-sulfamethoxazole treatment.

CONCLUSION

PJ infection should be suspected in infants presenting with progressive respiratory distress associated with a mixed alveolar-interstitial pattern. Its potential seriousness justifies prophylactic therapy during prolonged immunosuppressive treatment (chemotherapy, corticosteroid treatment).

Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad

BACKGROUND

Despite the comprehensive World Health Organization (WHO)/United Nations Children's Fund (UNICEF) measles mortality-reduction strategy and the Measles Initiative, a partnership of international organizations supporting measles mortality reduction in Africa, certain high-burden countries continue to face recurrent epidemics. To our knowledge, few recent studies have documented measles mortality in sub-Saharan Africa. The objective of our study was to investigate measles mortality in three recent epidemics in Niamey (Niger), N'Djamena (Chad), and Adamawa State (Nigeria).

METHODS AND FINDINGS

We conducted three exhaustive household retrospective mortality surveys in one neighbourhood of each of the three affected areas: Boukoki, Niamey, Niger (April 2004, n = 26,795); Moursal, N'Djamena, Chad (June 2005, n = 21,812); and Dong District, Adamawa State, Nigeria (April 2005, n = 16,249), where n is the total surveyed population in each of the respective areas. Study populations included all persons resident for at least 2 wk prior to the study, a duration encompassing the measles incubation period. Heads of households provided information on measles cases, clinical outcomes up to 30 d after rash onset, and health-seeking behaviour during the epidemic. Measles cases and deaths were ascertained using standard WHO surveillance-case definitions. Our main outcome measures were measles attack rates (ARs) and case fatality ratios (CFRs) by age group, and descriptions of measles complications and health-seeking behaviour. Measles ARs were the highest in children under 5 y old (under 5 y): 17.1% in Boukoki, 17.2% in Moursal, and 24.3% in Dong District. CFRs in under 5-y-olds were 4.6%, 4.0%, and 10.8% in Boukoki, Moursal, and Dong District, respectively. In all sites, more than half of measles cases in children aged under 5 y experienced acute respiratory infection and/or diarrhoea in the 30 d following rash onset. Of measles cases, it was reported that 85.7% (979/1,142) of patients visited a health-care facility within 30 d after rash onset in Boukoki, 73.5% (519/706) in Moursal, and 52.8% (603/1,142) in Dong District.

CONCLUSIONS

Children in these countries still face unacceptably high mortality from a completely preventable disease. While the successes of measles mortality-reduction strategies and progress observed in measles control in other countries of the region are laudable and evident, they should not overshadow the need for intensive efforts in countries that have just begun implementation of the WHO/UNICEF comprehensive strategy.

High sensitivity and specificity of the Pastorex® latex agglutination test for Neisseria meningitidis serogroup A during a clinical trial in Niger

There is a great need for a rapid diagnostic test to guide vaccine choice during outbreaks of meningococcal meningitis in resource-poor countries. During a randomised clinical trial conducted during an epidemic of Neisseria meningitidis serogroup A in Niger in 2003, the sensitivity and specificity of the Pastorex latex agglutination test for this serogroup under optimal field conditions were assessed, using culture and/or PCR as the gold standard. Results from 484 samples showed a sensitivity of 88% (95% CI 85-91%) and a specificity of 93% (95% CI 90-95%). Pastorex could be a good alternative to current methods, as it can be performed in a local laboratory with rapid results and is highly specific. Sensitivity can be improved with prior microscopy where feasible. A study specifically to evaluate the Pastorex test under epidemic conditions, using laboratories with limited resources, is recommended.

Perioperative platelet transfusion. Recommendations of the French Health Products Safety Agency (AFSSAPS) 2003

The aim of this paper is to present the recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSaPS; French Safety Agency for Health Products). A panel of experts reviewed and graded the literature on platelet transfusions; recommendations were formulated. Threshold platelet counts (PC) for transfusions in the perioperative context have not been clearly defined and should be determined by the existence of hemorrhagic risk factors. In the case of commonly practiced invasive procedures, the recommendation is to transfuse in order to achieve PC > 50,000 x microL-1. In the absence of platelet dysfunction, regardless of the type of surgery, the standard hemorrhagic risk threshold for surgery is 50,000 x microL-1. It has not been proven that the risk threshold is different according to the type of surgery. For neurosurgery and ophthalmologic surgery involving the posterior segment of the eye, a PC of 100,000 x microL-11 is required. For axial regional anesthesia, a PC of 50,000 x microL-11 is sufficient for spinal anesthesia; a PC of 80,000 x microL-11 has been proposed for epidurals. During massive transfusion, prophylactic platelet infusion cannot be recommended beyond a loss of two blood volumes in less than 24 h (Professional Consensus). As for the therapeutic transfusion of plasma and/or platelets, as much as possible, platelet deficit should be documented with test results (PC and fibrinogen) before transfusing. In the event of bleeding, platelet transfusion may precede plasma infusion. However, although this recommendation has been the subject of several professional consensus agreements, it is not based on any randomized studies. Threshold PC for perioperative transfusions have not been clearly defined and most recommendations are the result of a professional consensus.

Les respirateurs d'anesthésie de nouvelle génération vont-ils modifier notre pratique chez l'enfant ?

Because of specific paediatric respiratory physiology (mainly decreased compliance and functional residual capacity, increased O2 demand and CO2 production), ventilators for paediatric anaesthesia need to be powerful and able to deliver small volumes at a high rate without compression volume loss. The compensation of compliance now available on every anaesthesia machine, compensates for the volume of gas lost by compression in the circuit tubing allowing the tidal volume to reach preset commands, even for bellow in box respirators. Preset tidal volume is then totally delivered to the lung by volume-controlled ventilation because it becomes independent of total pulmonary compliance and fresh gas flow. Increased precision of electronic flowmeters and better air-tightness of circuits allow reducing with precision fresh gas flow to values approaching children's O2 consumption and N2O diffusion. New modes of ventilation are now available on anaesthesia machine. Pressure controlled mode, by increasing and maintaining mean airway pressures, ameliorates intrapulmonary gas distribution and compensates for the gas leak from uncuffed tracheal tubes. Unsteady tidal volume resulting from variation of total compliance, is the main drawback of pressure-controlled ventilation that may be overcome by using the "autoflow" mode (better described as a pressure controlled mode ensuring tidal volume) available with one of the last generation of ventilators. Increased accuracy and security of the mode "pressure assist" might increase the use of spontaneous ventilation in paediatric anaesthesia even for low weight children. However tidal volume remains variable with compliance and depth of anaesthesia, which may require several adjustments of ventilator's settings. The clinical conditions (mainly airway control) of pressure assist use for children less than 10 kg should be elucidated before recommending its use.

Design characteristics that affect speed of information access and clarity of presentation in an electronic neuroanatomy atlas

Functional Neuroanatomy, an interactive electronic neuroanatomical atlas, was designed for first year medical students. Medical students have much to learn in a limited time; therefore a major goal in the atlas design was that it facilitate rapid, accurate information retrieval. To assess this feature, we designed a testing scenario in which students who had never taken a neuroanatomy course were asked to complete two equivalent tests, one using the electronic atlas and one using a comparable hard copy atlas, in a limited period of time. The tests were too long to be completed in the time allotted, so test scores were measures of how quickly correct information could be retrieved from each source. Statistical analysis of the data showed that the tests were of equal difficulty and that accurate information retrieval was significantly faster using the electronic atlas when compared with the hard copy atlas (P < 0.0001). Post-test focus groups (n = 4) allowed us to infer that the following design features contributed to rapid information access: the number of structures in the database was limited to those that are relevant to a practicing physician; all of the program modules were presented in both text and image form on the index screen, which doubled as a site map; pages were layered electronically such that information was hidden until requested, structures available on each page were listed alphabetically and could be accessed by clicking on their name; and an illustrated glossary was provided and equipped with a search engine.