Fetal macrosomia and neonatal hyperinsulinemic hypoglycemia associated with transplacental transfer of sulfonylurea in a mother with KCNJ11-related neonatal diabetes

OBJECTIVE

Sulfonylureas (SUs) are effective at controlling glycemia in permanent neonatal diabetes mellitus (PNDM) caused by KCNJ11 (Kir6.2) mutations.

RESEARCH DESIGN AND METHODS

We report the case of a woman with PNDM who continued high doses of glibenclamide (85 mg/day) during her pregnancy. The baby was born preterm, and presented with macrosomia and severe hyperinsulinemic hypoglycemia requiring high-rate intravenous glucose infusion.

RESULTS

Postnatal genetic testing excluded a KCNJ11 mutation in the baby. Glibenclamide was detected in both the baby's blood and the maternal milk.

CONCLUSIONS

We hypothesize that high doses of glibenclamide in the mother led to transplacental passage of the drug and overstimulation of fetal β-cells, which resulted in severe hyperinsulinemic hypoglycemia in the neonate (who did not carry the mutation) and contributed to fetal macrosomia. We suggest that glibenclamide (and other SUs) should be avoided in mothers with PNDM if the baby does not carry the mutation or if prenatal screening has not been performed, while glibenclamide may be beneficial when the fetus is a PNDM carrier.

Nursing education development in China (1887-1949): influences on contemporary nursing

BACKGROUND

On 8 May 2013, the Chinese Nursing Association joined the International Council of Nurses. It is hoped that by sharing the history of nursing in China, scholars globally can incorporate into current thinking the challenges that Chinese nurses have faced in pursuing educational development and professional acknowledgement.

AIM

To review the history of nurse education in China between 1887 and 1949 and summarize events marking its development; and to provide historical references for considering contemporary nurse education and discipline development in China.

METHODS

Content analysis using bibliometric and historical research methods on available documentation sources. Milestone events were listed and their historical significance analysed.

RESULTS

Nurse education development during this period was affected by three major influences: (1) international nursing collaboration and involvement with Chinese nursing in China and abroad, (2) the determination of leaders to develop nursing as a unique and ethical profession, and (3) the pressure of war and civilian need on the focus of nursing development in China.

CONCLUSION

The development of nurse education in China occurred within an environment of social change, war and international collaboration. Throughout the Modern China period (1887-1949), nursing leadership has guided the growth of nurse education to be responsive to individual and community needs as well as ensuring nurse accountability for conduct and nursing practice. Contemporary Chinese nursing and education owes much to those throughout the Modern China period, who laid the foundations that support the current position and status of nursing.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

The study displays the benefits and challenges of participation in policy and forums that help nurse scholars and practitioners understand the development of nurse education in China.

Urinary C-peptide creatinine ratio detects absolute insulin deficiency in Type 2 diabetes

AIMS

To determine the prevalence and clinical characteristics of absolute insulin deficiency in long-standing Type 2 diabetes, using a strategy based on home urinary C-peptide creatinine ratio measurement.

METHODS

We assessed the urinary C-peptide creatinine ratios, from urine samples taken at home 2 h after the largest meal of the day, in 191 insulin-treated subjects with Type 2 diabetes (diagnosis age ≥45 years, no insulin in the first year). If the initial urinary C-peptide creatinine ratio was ≤0.2 nmol/mmol (representing absolute insulin deficiency), the assessment was repeated. A standardized mixed-meal tolerance test with 90-min stimulated serum C-peptide measurement was performed in nine subjects with a urinary C-peptide creatinine ratio ≤ 0.2 nmol/mmol (and in nine controls with a urinary C-peptide creatinine ratio >0.2 nmol/mmol) to confirm absolute insulin deficiency.

RESULTS

A total of 2.7% of participants had absolute insulin deficiency confirmed by a mixed-meal tolerance test. They were identified initially using urinary C-peptide creatinine ratio: 11/191 subjects (5.8%) had two consistent urinary C-peptide creatinine ratios ≤ 0.2 nmol/mmol; 9 of these 11 subjects completed a mixed-meal tolerance test and had a median stimulated serum C-peptide of 0.18 nmol/l. Five of these 9 had stimulated serum C-peptide <0.2 nmol/l and 9/9 subjects with urinary C-peptide creatinine ratio >0.2 had endogenous insulin secretion confirmed by the mixed-meal tolerance test. Compared with subjects with a urinary C-peptide creatinine ratio >0.2 nmol/mmol, those with confirmed absolute insulin deficiency had a shorter time to insulin treatment (median 2.5 vs. 6 years, P=0.005) and lower BMI (25.1 vs. 29.1 kg/m(2) , P=0.04). Two out of the five patients with absolute insulin deficiency were glutamic acid decarboxylase autoantibody-positive.

CONCLUSIONS

Absolute insulin deficiency may occur in long-standing Type 2 diabetes, and cannot be reliably predicted by clinical features or autoantibodies. Absolute insulin deficiency in Type 2 diabetes may increase the risk of hypoglycaemia and ketoacidosis, as in Type 1 diabetes. Its recognition should help guide treatment, education and management. The urinary C-peptide creatinine ratio is a practical non-invasive method to aid detection of absolute insulin deficiency, with a urinary C-peptide creatinine ratio > 0.2 nmol/mmol being a reliable indicator of retained endogenous insulin secretion.

Pleural fluid nucleic acid testing enhances pneumococcal surveillance in children

BACKGROUND AND OBJECTIVE

National surveillance of invasive pneumococcal disease (IPD) includes serotyping Streptococcus pneumoniae (SP) isolates from sterile site cultures. PCR is more sensitive and can identify more SP serotypes (STs) in culture-negative samples. The aim of this study was to determine whether enhanced surveillance of childhood empyema, using PCR, provides additional serotype information compared with conventional surveillance.

METHODS

Pleural fluid (PF) from children with empyema were cultured and tested by PCR to identify SP, targeting the autolysin gene (lytA). Multiplex PCR-based reverse line blot assay was used to identify SP STs. Corresponding IPD surveillance and serotype data were obtained from the National Notifiable Diseases Surveillance System (NNDSS).

RESULTS

Eighty-nine children with empyema, aged ≤16 years, were recruited between April 2008 and March 2009, inclusive. SP was isolated from 5/84 (5.9%) PF cultures and by PCR in 43/79 (54.4%) PF samples. Serotypes were unidentifiable in 15 samples. The frequency of six serotypes (or serotype pairs) identified in 28 samples, including one with two serotypes, were: ST1, n = 4/29 (13.8%); ST3, n = 9/29 (31.0%); ST19A, n = 12/29 (41.4%); ST7F/7A, n = 1/29 (3.4%); ST9V/9A, n = 1/29 (3.4%); ST22F/22A, n = 2/29 (6.9%). Over the same period, 361 IPD patients, aged 16 years or less, were notified to NNDSS. Among 331 serotypeable NNDSS isolates (71.5% from blood), the frequencies of ST1 and 3 were significantly lower than in PF samples: ST1, n = 8/331 (2.4%; P < 0.05); ST3, n = 13/331 (3.9%; P < 0.0001).

CONCLUSIONS

The use of PCR to identify and serotype SP in culture-negative specimens provides additive information.

Bacterial causes of empyema in children, Australia, 2007-2009

An increase in the incidence of empyema worldwide could be related to invasive pneumococcal disease caused by emergent nonvaccine replacement serotypes. To determine bacterial pathogens and pneumococcal serotypes that cause empyema in children in Australia, we conducted a 2-year study of 174 children with empyema. Blood and pleural fluid samples were cultured, and pleural fluid was tested by PCR. Thirty-two (21.0%) of 152 blood and 53 (33.1%) of 160 pleural fluid cultures were positive for bacteria; Streptococcus pneumoniae was the most common organism identified. PCR identified S. pneumoniae in 74 (51.7%) and other bacteria in 19 (13.1%) of 145 pleural fluid specimens. Of 53 samples in which S. pneumoniae serotypes were identified, 2 (3.8%) had vaccine-related and 51 (96.2%) had nonvaccine serotypes; 19A (n = 20; 36.4%), 3 (n = 18; 32.7%), and 1 (n = 8; 14.5%) were the most common. High proportions of nonvaccine serotypes suggest the need to broaden vaccine coverage.

A bedside assay to detect streptococcus pneumoniae in children with empyema

BACKGROUND

Empyema is a complication of pneumonia, commonly caused by Streptococcus pneumoniae.

AIMS

To validate the utility of an immunochromatographic test for the detection of S. pneumoniae antigen in the pleural fluid of children with empyema.

METHODS

Empyema patients had blood and pleural fluid cultured, and polymerase chain reaction (PCR) to detect the S. pneumoniae autolysin gene, lytA, in pleural fluid. Pleural fluid was tested using the Binax NOW S. pneumoniae antigen detection assay and compared with lytA PCR results and/or culture in blood or pleural fluid.

RESULTS

S. pneumoniae was detected by PCR in pleural fluid of 68 of 137 (49.6%) patients, by culture in 11 of 135 (8.1%) pleural specimens and 16 of 120 (13.3%) blood specimens. Pleural fluid Binax NOW testing from 130 patients demonstrated a sensitivity of 83.8% and specificity of 93.5% (positive predictive value of 93.4% and negative predictive value of 84.1%).

CONCLUSIONS

In pediatric empyema, high predictive values of pleural fluid Binax NOW S. pneumoniae antigen test suggest that this test may help rationalize antibiotic choice in these patients.

An information system to manage the rollout of the antiretroviral treatment programme in the Free State

The Acquired Immune Deficiency Syndrome epidemic, caused by the Human Immunodeficiency Virus, is a global crisis which threatens development gains, economies, and societies. Within sub-Saharan Africa, where the epidemic began the earliest and the HIV prevalence is the highest, African countries have death rates not seen before. In South Africa the epidemic has a devastating impact which creates profound suffering on individuals and their families, and the impact on the socio-economic level is of great concern. The eradication of HIV/AIDS represents one of humanity’s greatest challenges, which requires co-operation and comprehensive collaboration between many different role players. In this endeavour clinical information plays a major role. To combat the effect of the disease, the Free State Department of Health started with the provisioning of antiretroviral therapy in the public health sector. The objective of this paper was to address the challenges they faced in order to develop and implement an information system to manage the rollout of antiretroviral treatment effectively. They started with a paper-based system to collect vital information. It was followed by a palm computer project that was initiated to electronically capture the data collected by the paper-based system. This system was then replaced by a comprehensive Hospital and Clinic Information System which was acquired and customised for the antiretroviral data collection process. Research partners developed a standalone antiretroviral data warehouse for collecting information associated with the monitoring and evaluation of the Free State antiretroviral and HIV/ AIDS treatment programme. The data warehouse successfully produced several management information reports to the antiretroviral management team. A need was identified to design a comprehensive antiretroviral data warehouse that will integrate data from several operational sources which are all associated with HIV/AIDS.

Children in the ACT with asthma--are they taking preventer medication according to guidelines?

AIM

To ascertain whether children with asthma in the Australian Capital Territory were taking preventer medications in accordance with National Asthma Council Australia guidelines.

METHODS

Questionnaires were distributed to all parents who indicated in an ACT wide survey of school entry children in 2005 that their child had asthma (n=435), or experienced asthma symptoms/took asthma medication (n=501), exploring dose, frequency and mode of delivery of preventer their child was currently taking.

RESULTS

Data were available for 256 children (response rate 27%). Of the children with parent reported asthma (n=435) the response rate was 42%. Eighty-three (32%) children were currently taking preventers; complete medication details were provided for 60 children. A total of 32% of children on preventers were taking doses of preventers not in accordance with guidelines, while 80% of children were taking their medications at frequencies, or using delivery devices, not in accordance with guidelines.

DISCUSSION

This study suggests that home medical management of asthma with preventers for children may not be optimal.

A unique case of Hajdu-Cheney syndrome and squamous cell carcinoma of the anus

OBJECTIVE

Hajdu-Cheney syndrome (HCS), first described in 1948 by Hajdu and independently in 1965 by Cheney, is an extremely rare disorder characterized by severe and excessive bone resorption leading to osteoporosis, with a wide range of other systemic complications from connective tissue and bone dysplasia. Currently there are approximately 50 distinct cases reported in the literature. There have been several reports associating polycystic kidneys with HCS and several other connective tissue disorders, suggesting a possibility of a hyperproliferative component to the syndrome. No articles exist in the current literature describing a case of HCS with concurrent carcinoma. Here, we present a case of a 54-year-old nonimmune compromised woman with multiple stigmata of HCS and recently diagnosed anal squamous cell carcinoma.

METHOD

This is a case report of HCS and stage T3N0 squamous cell carcinoma of the anus.

RESULTS

This is the first report of a patient with HCS with malignancy.

CONCLUSIONS

We present a patient with HCS who developed anal squamous cell carcinoma. The mechanism of HCS, which is still unknown, may either make patients more susceptible to carcinoma or may just be a reflection of the normal incidence of anal squamous cell carcinoma given attributable risk factors.

Increasing the uptake of hepatitis C virus testing among injecting drug users in specialist drug treatment and prison settings by using dried blood spots for diagnostic testing: a cluster randomized controlled trial

The objective of this study was to assess whether introducing dried blood spot testing can increase hepatitis C virus (HCV) diagnostic testing. A cluster randomized controlled trial was conducted. Sites were matched into pairs, with one site in each pair randomly allocated to receive the intervention (training and use of dried blood spot). Data were collected from all sites for 6 months before and 6 months after the start of the intervention. The participants were 22 specialist drug clinics and six prisons in England and Wales. The main outcome measure of this study was percentage point difference in individuals tested for HCV (the difference between the percentage of patients tested 6 months after and 6 months before the introduction of dried blood spot tests). Before the trial, 8% of patients at control and intervention sites had been tested for HCV, with 16 sites testing less than 5% of their caseload. The average percentage point difference between intervention and control sites was 14.5% (95% CI 1.3-28%, paired t-test, P = 0.03); with 13 of the 14 pairs contributing to the positive effect of the intervention (Wilcoxon matched-pairs signed-rank-test, P = 0.002). The size of the difference between intervention and control sites varied considerably. The study provides preliminary supporting evidence that dried blood spot testing may increase the uptake of HCV diagnostic testing, by increasing the opportunity for patients to be offered testing. Additional trials with a larger number of sites are justified, ideally in the context of drug and treatment policies that gave clearer priority (and targets) to infection control and testing.

Using the PACE EH model to mobilize communities to address local environmental health issues--a case study in Island County, Washington

The Island County Environmental Health Initiative (ICEHI) is a demonstration project in the use of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) to build capacity in the 10 essential services of environmental health. The PACE EH methodology systematically applies the 10 essential services of environmental health through the completion of 13 tasks derived from a community-based environmental health assessment process. The ICEHI has successfully engaged community members, identified environmental health issues important to the community, and led to the implementation of action plans aimed at reducing environmental health risks through use of community resources. This paper describes the methodology utilized by the ICEHI to address locally important environmental health issues so that other local and state environmental health agencies may replicate the process in their communities.

DEHP, bis(2)-ethylhexyl phthalate, alters gene expression in human cells: possible correlation with initiation of fetal developmental abnormalities

Diethylhexylphthalate (DEHP) is a widely distributed phthalate, to which humans are exposed to due to its variety of commercial and manufacturing uses. As a plasticiser, it is found in a wide number of products, and metabolites of DEHP have been detected in urine samples from a high percentage of the people screened for phthalates. We utilised DNA microarray analysis to evaluate DEHP for gene expression disrupting activity using the human cell line MCF-7, and found that DEHP significantly dysregulated approximately 34% of the 2400 genes spotted on the NEN2400 chip we used. The results suggest that DEHP, a known estrogen agonist and probable androgen antagonist, alters the expression of a number of genes, many of which are critical for fetal development. Down-regulation of two genes, FGD1 and PAFAH1B1, related in that both are essential for fetal brain development, was corroborated using quantitative real time PCR. These studies show DEHP to be a highly effective human gene expression-altering chemical, and that, at appropriate concentrations, it has the possibility of altering fetal central nervous system development, resulting in the birth defects lissencephaly and/or faciodigitogenital dysplasia.