Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care

INTRODUCTION

Computerised physician order entry with clinical decision support system (CPOE+CDSS) is an important tool in attempting to reduce medication errors. The objective of this study was to evaluate the impact of a CPOE+CDSS on (1) the frequency of errors in ordering resuscitation (CPR) medications and (2) the time for printing out the order form, in a paediatric critical care department (PCCD).

METHODS

SETTING

An 18-bed PCCD in a tertiary-care children's hospital.

DESIGN

Prospective cohort study.

MEASURES

Compilation and comparison of number of errors and time to fill in forms before and after implementation of CPOE+CDSS. Time to fill in conventional, simulated and CPOE forms was measured and compared.

RESULTS

There were three reported incidents of errors among 13,124 CPR medications orders during the year preceding implementation of CPOE+CDSS. These represent errors that escaped the triple check by three independent staff members. There were no errors after CPOE+CDSS was implemented (100% error reduction for 46,970 orders). Time to completion of drug forms dropped from 14 min 42 s to 2 min 14s (p < 0.001).

CONCLUSIONS

CPOE+CDSS completely eliminated errors in filling in the forms and significantly reduced time to completing the form.

DNA markers for identifying biotypes B and Q of Bemisia tabaci (Hemiptera: Aleyrodidae) and studying population dynamics

The two most widespread biotypes of Bemisia tabaci (Gennadius) in southern Europe and the Middle East are referred to as the B and Q-type, which are morphologically indistinguishable. In this study various DNA markers have been developed, applied and compared for studying genetic diversity and distribution of the two biotypes. For developing sequence characterized amplified regions (SCAR) and cleaved amplified polymorphic sequences (CAPS) techniques, single random amplified polymorphic DNA (RAPD) fragments of B and Q biotypes, respectively, were used. The CAPS were investigated on the basis of nuclear sodium channel and the mitochondrial cytochrome oxidase I genes (mtCOI) sequences. In general, complete agreement was found between the different markers used. Analysis of field samples collected in Israel for several years, using these markers, indicated that the percentage of the Q biotype tends to increase in field populations as time progresses. This may be attributed to the resistance of the Q biotype to neonicotinoids and pyriproxyfen and the susceptibility of the B biotype to these insecticides.

Expression of Albumin in Nonhepatic Tissues and its Synthesis by the Bovine Mammary Gland

Albumin is a well-characterized product of the liver. In the present study, objectives were to determine if the albumin gene is also expressed in various nonhepatic tissues in the bovine; whether mammary gland epithelial cells synthesize albumin; and how its synthesis is affected by bovine mastitis. Albumin expression was monitored using reverse transcription-polymerase chain reaction. Tissues examined were: liver, mammary gland, tongue, intestine, lymph gland, testicle, ovary, and uterus. All tissues except the ovary expressed the albumin gene, albeit less so than the liver. The highest level of expression (other than liver) was found in the lymph nodes but expression was also found in the mammary gland. Incubation of mammary gland explants with the labeled amino acid L-[(35)S] methionine resulted in formation of labeled immunoprecipitable albumin, newly synthesized in the explant. Immunoprecipitable albumin in the medium verified that newly synthesized albumin was also secreted into the medium. This shows that the gland itself is a source of milk albumin. Albumin mRNA expression was approximately 4 times higher in mammary gland tissue from 6 mastitic cows compared with expression in mammary tissue from 6 healthy glands. Further, secretion of albumin was increased 3.5-fold from explants of mastitic mammary glands compared with secretion from explants of healthy mammary glands. Addition of lipopolysaccharide increased the synthesis and secretion of albumin in mammary gland cells in a dose-dependent manner. Exposure to lipopolysaccharide accelerated albumin synthesis in a time-dependent manner up to 48 h. These results lead us to suggest that the secretion of albumin by the mammary gland is part of the innate nonspecific defense system.

Nasojejunal feeding in hyperemesis gravidarum--a preliminary study

Hyperemesis gravidarum is a severe form of nausea and vomiting during the first trimester of pregnancy. Our objective was to assess the feasibility of nasojejunal feeding in our patients. Eleven pregnant women aged 23-46 years with hyperemesis gravidarum, persisting in spite of an in-hospital treatment of 2-15 days by intravenous fluids and antiemetic drugs and accompanied by weight loss, consented to have a nasojejunal feeding tube inserted endoscopically. Mean in-hospital weight loss prior to tube insertion was 2.2+/-1.1 kg (range 0.9-5.1 kg). A clear reduction in the extent of vomiting was already apparent within the first 48 h after tube insertion, but vomiting ceased completely after a mean of 5+/-4 days (range 1-13 days). Weight gain was recorded in six patients who stayed on tube feeding for more than 4 days. Patients were encouraged to start drinking and eating along tube feeding after 3-4 days. Ceasing vomiting and a concomitant sufficient oral intake of at least 1000 kcal/day resulted in the decision to remove the tube after 4-21 days. In three cases, however, the tube was expelled by recurrent vomiting after 1-4 days, or was blocked as in one case. The tube was not reintroduced and patients did not resume vomiting. There were no complications associated with this feeding approach in this population. Only one patient was readmitted. None of the rest resumed vomiting after tube withdrawal.The above suggests that nasojejunal enteral feeding can be an effective option in hyperemesis gravidarum persisting despite intravenous fluids and antiemetic drugs.

Increased erythrocyte aggregation in ovarian hyperstimulation syndrome: a possible contributing factor in the pathophysiology of this disease

BACKGROUND

Many theories regarding the pathophysiology leading to ovarian hyperstimulation syndrome (OHSS) have been proposed and tested. Increased erythrocyte aggregation is associated with capillary slow flow and tissue hypoxaemia. We performed this study in order to assess the degree of erythrocyte aggregation in the peripheral blood of individuals with OHSS and undergoing controlled ovarian stimulation (COH).

METHODS

Twenty women with severe OHSS, 20 women undergoing COH under IVF protocol, and 20 healthy matched controls were recruited for this prospective study. Blood samples were drawn for determination of erythrocyte aggregation as well as haematological indices. The percentage of slide covered by the cells ('erythrocyte percentage': EP) was determined using a simple slide test and image analysis. Lower EP values correspond to higher degrees of aggregation.

RESULTS

The respective measures of EP were 59.2 +/- 3.0, 42.0 +/- 3.0 and 35.0 +/- 2.4% micro m for the controls, women with COH and OHSS (P < 0.01 between controls and the two stimulation groups).

CONCLUSIONS

The degree of erythrocyte aggregation is enhanced in the peripheral venous blood of patients with both COH and OHSS. This finding, known to cause capillary leak, may contribute to the pathophysiology of the OHSS.

[Preservation of alveolar bone of un-restorable traumatized maxillary incisors for future]

Anterior maxillary implantation is a challenging treatment for both the surgeon and prosthodontist due to high esthetic demands in this area. However, it is the most traumatized and most exposed region to habits. Prompt and appropriate management can significantly improve prognosis of many dentoalveolar injuries, especially in young patients. Unfortunately, many traumatized teeth are overtreated or left untreated, which lead to a much more complicated treatment at the time of permanent restoration at adulthood. The facial cortical plate over the roots of the maxillary teeth is thin and porous. Periapical infections, as well as prolonged and stubborn surgical treatments (repeated root end surgeries) can cause resorption of the labial plate, migrate to a more palatal position, and may later require an augmentation procedure prior to implant placement. The treatment-options of traumatized, anterior maxillary, un-restorable fractured root and ankylosed infraocluded teeth, in relation to preservation of the adjacent alveolar bone for future use of dental implantation will be discussed. The recommended treatment of crown-root fracture of permanent incisor includes removal of the coronal fragment and supragingival restoration of the fractured root. In severe cases in which the fracture line positions deeply under the gingival margin, this treatment may be supplemented by gingivectomy and/or osteotomy, as well as surgical or orthodontic extrusion of the root. In young patients, use of these treatment options as temporary treatment to preserve the facial cortical plate is important. Preservation of alveolar dimension will enable implantation after the completion of growth and development. Dento-alveolar ankylosis accompanied by replacement resorption is a serious complication following severe injury to the periodontal membrane. This complication develops mainly following avulsion and intrusion but also following lateral luxation and root fracture. Replacement resorption develops after severe damage to the periodontal ligament cells that cover the root surface. As a result of this damage, the periodontal ligament is replaced by bone tissue, causing ankylosis between bone and tooth. Following ankylosis, resorption of cementum and root dentin occurs. These processes eventually result in replacement of the entire root by bone. In young children it could arrest the growth of the alveolar process and create an infra-occluded tooth, resulting in a severe bony defect that is difficult to correct. In addition, loss of the maxillary incisor leads to serious esthetic and restorative problems, particularly when the trauma occurs at a young age. Therefore, ankylosed teeth should be treated as soon as diagnosed. Alternative treatments include intentional extraction and immediate replantation of the ankylosed tooth to its socket after embedding the tooth and the socket in Emdogain. This treatment is indicated only when the ankylosis or the replacement resorption is diagnosed at an early stage or has affected only a small area of the root. When the resorption is diagnosed at a later stage, auto transplantation of first lower pre-molar to the anterior region or decoronation of the ankylosed tooth may be considered. Decoronation is a simple and safe surgical procedure for preservation of alveolar bone prior to implant placement. It should be considered as a treatment option for teeth affected by replacement resorption. The alternative treatment of surgical extraction of an ankylosed tooth often leads to considerable bone loss and reduced bone volume in the oro-facial dimension. This may later necessitate an augmentation procedure.

CONCLUSION

Scrupulous diagnosis of teeth and the alveolar bone after a traumatic injury is necessary. Treatment is multidisciplinary, requiring endodontic, surgical, orthodontic, operative and prosthetic compliance. An individual treatment plan for each patient is necessary. General rule do not apply. Periodic check-up is essential.

Clinical and economic benefit of HPV-load testing in follow-up and management of women postcone biopsy for CIN2-3

This study aimed to evaluate the clinical and economic implications of integrating human papilloma virus (HPV) load testing into the follow-up and management protocol of women postconisation for high-grade cervical intraepithelial neoplasia (CIN2-3). We evaluated 130 suitable women: 63 were screened biannually by Pap smears ('conventional approach') and 67 also had HPV-load testing ('HPV approach'). More stringent criteria for undergoing colposcopy or reconisation were observed by the former group compared to the latter. Both approaches were analysed for cost effectiveness. There were 33 out of 67 (49.2%) colposcopic referrals and 24 out of 67 (35.8%) reconisation/hysterectomies with the 'conventional approach' compared to 9 out of 63 (14.2%) and 7 out of 63 (11.1%) with the 'HPV approach'. Cervical intraepithelial neoplasia 2-3 residual disease was detected in 7 out of 67 (10.5%) and 7 out of 63 (11.1%) women. The 'conventional approach' had more negative colposcopic biopsies and more negative reconisation/hysterectomy histologies than the 'HPV approach'. The respective cost per detection of one case of residual disease was US$3573 and US$3485. The 'HPV approach' required fewer colposcopic and reconisation procedures to detect one case of residual CIN2-3. Its higher positive predictive value than that of cytology provided a significant decrease in false positive rates and a reduction of US$88 per detected case.

The tomato dark green mutation is a novel allele of the tomato homolog of the DEETIOLATED1 gene

A comprehensive, multi-generation, allele test, carried out in this study, suggests that the tomato mutations dark-green (dg) and high pigment 2(j) (hp-2(j)) are allelic. The hp-2(j) mutant is caused by a mutation in the tomato homolog of the DEETIOLATED1 (DET1) gene, involved in the signal transduction cascade of light perception and morphogenesis. This suggestion is in agreement with the exaggerated photomorphogenic de-etiolation response of homozygous dg mutants grown under modulated light conditions. Sequence analysis of the DET1 gene was carried out in dg mutants representing two different lines, and revealed a single A-to-T base transversion in the second exon of the DET1 gene in comparison with the normal wild-type sequence. This transversion results in a conserved Asparagine(34)-to-Isoleucine(34) amino-acid substitution, and eliminates a recognition site for the AclI restriction endonuclease, present in the wild-type and in the other currently known tomato mutants at the DET1 locus. This polymorphism was used to develop a PCR-based DNA marker, which enables an early genotypic selection for breeding lycopene-rich tomatoes. Using this marker and sequence analysis we demonstrate that an identical base transversion also exists in dg mutants of the cultivar Manapal, in which the natural dg mutation was originally discovered. A linkage analysis, carried out in a F(2) population, shows a very strong linkage association between the DET1 locus of dg mutant plants and the photomorphogenic response of the seedlings, measured as hypocotyl length (12 < LOD Score < 13, R(2) = 51.1%). The results presented in this study strongly support the hypothesis that the tomato dg mutation is a novel allele of the tomato homolog of the DET1 gene.

Multi-functional T-DNA/Ds tomato lines designed for gene cloning and molecular and physical dissection of the tomato genome

In order to make the tomato genome more accessible for molecular analysis and gene cloning, we have produced 405 individual tomato (Lycopersicon esculentum) lines containing a characterized copy of pJasm13, a multifunctional T-DNA/modified Ds transposon element construct. Both the T-DNA and the Ds element in pJasm13 harbor a set of selectable marker genes to monitor excision and reintegration of Ds and additionally, target sequences for rare cutting restriction enzymes (I-PpoI, SfiI, NotI) and for site-specific recombinases (Cre, FLP, R). Blast analysis of flanking genomic sequences of 174 T-DNA inserts revealed homology to transcribed genes in 69 (40%), of which about half are known or putatively identified as genes and ESTs. The map position of 140 individual inserts was determined on the molecular genetic map of tomato. These inserts are distributed over the 12 chromosomes of tomato, allowing targeted and non-targeted transposon tagging, marking of closely linked genes of interest and induction of chromosomal rearrangements including translocations or creation of saturation-deletions or inversions within defined regions linked to the T-DNA insertion site. The different features of pJasm13 were successfully tested in tomato and Arabidopsis thaliana, thus providing a new tool for molecular/genetic dissection studies, including molecular and physical mapping, mutation analysis and cloning strategies in tomato and potentially, in other plants as well.

Identification of molecular markers associated with leptine in reciprocal backcross families of diploid potato

Solanum phureja clone 1-3 and S. chacoense clone 80-1 have a zero and high leptine content in their foliage, respectively. An F(1) hybrid (CP2) was intermediate for the trait, but self-incompatible. Two reciprocal backcross families, PBCp ( phu 1-3 x CP2) and PBCc (CP2 x phu 1-3), and a family of monoploids derived by anther culture of CP2, were characterized for leptine as the aglycon, acetylleptinidine (ALD), content in leaves by gas chromatography. ALD was present in 43 of 87 genotypes in the PBCp backcross, implying simple genetic control by a dominant gene. However, the ALD levels were low compared to CP2. In the PBCc backcross, only 7 of 42 genotypes expressed ALD at a level generally higher than in PBCp. This ratio was significantly different from the 1:1 segregation observed in the reciprocal backcross and suggests a cytoplasmic influence. ALD levels in the CP2 monoploids ranged from 0 to 8,968 &mgr;g.g(-1) of dry weight (dw) with 18 individuals expressing ALD and five with 0 ALD content. Ten high (mean ALD = 546 &mgr;g.g(-1) of dw) and ten low (mean ALD = 0) individual plants within PBCp and seven high (mean ALD = 3,037 &mgr;g.g(-1) of dw) and eight low (mean ALD = 0) individual plants within PBCc were used for bulk segregant analysis (BSA) using 214 RAPD (randomly amplified polymorphic DNA) primers. Three RAPD primers (OPQ-2, OPT-16 and OPT-20) amplified bands exclusively in bulks containing DNA mixes of high ALD producers in both PBCp and PBCc populations. These results suggest that these markers were associated in coupling to ALD content. ANOVAs for ALD content verified association between the markers and the trait. A CAPS (cleaved amplified polymorphic sequence) marker, GP82A, was also significantly associated with ALD production in both the monoploid and the PBCp populations. None of the RAPD markers was associated to ALD in the monoploids but one was associated in repulsion. The monoploid data indicate the likelihood of a recessive gene(s) that controls leptine production, but the backcross data indicate the action of modifying loci.

Regional 14CO2 offsets in the troposphere: magnitude, mechanisms, and consequences

Radiocarbon dating methods typically assume that there are no significant tropospheric (14)CO(2) gradients within the low- to mid-latitude zone of the Northern Hemisphere. Comparison of tree ring (14)C data from southern Germany and Anatolia supports this assumption in general but also documents episodes of significant short-term regional (14)CO(2) offsets. We suggest that the offset is caused by an enhanced seasonal (14)CO(2) cycle, with seasonally peaked flux of stratospheric (14)C into the troposphere during periods of low solar magnetic activity, coinciding with substantial atmospheric cooling. Short-term episodes of regional (14)CO(2) offsets are important to palaeoclimate studies and to high-resolution archaeological dating.

Morphology and spelling among Hebrew-speaking children: from kindergarten to first grade

This study had two major objectives: (1) to analyse the development of two morphological structures in Hebrew, one inflectional and the other derivational and (2) to examine the mutual contribution of morphological knowledge and learning the written code. In a longitudinal design, 40 children were tested twice, first in kindergarten (mean age: 5; 11) and again in first grade (mean age: 6;5), on two oral tasks--inflecting nouns for possession and deriving denominal adjectives--and one written task of writing a series of noun-adjective pairs. The derivational task was found to be harder than the inflectional task, both on the stem and the suffix level, attributable to its higher semantic opacity. In both oral tests, correct stem production when suffixed was related to the morphophonological level of stem change. Correlations were found between morphological and writing scores. Moreover, children who were more advanced in morphology in kindergarten progressed more in writing vowels from kindergarten to first grade, and those who were more advanced in writing in kindergarten improved more in derivational morphology with grade.