The effect of core asymmetries on the polarization properties of hollow core photonic bandgap fibers

We present the results of numerical simulations of the modal properties of Photonic Band Gap Fibers (PBGFs) in which a structural distortion of the silica ring surrounding the air core is gradually introduced. We demonstrate that surface modes supported within such fibers are very sensitive to structural distortions, and that any asymmetric change in the structure can break their degeneracy resulting in associated changes in the anticrossing behavior of the orthogonally polarized core modes, and the development of polarization dependent transmission properties. Our results provide insight into recent experimental observations of wavelength dependent PDL and birefringence in PBGFs.

A randomized clinical trial of activated charcoal for the routine management of oral drug overdose

BACKGROUND

Activated charcoal (AC) is commonly used for the routine management of oral drug overdose.

AIM

To determine whether the routine use of activated charcoal has an effect on patient outcomes.

DESIGN

Randomized controlled unblinded trial.

METHODS

We recruited all adult patients presenting with an oral overdose at The Canberra Hospital, excluding only transfers, late presenters, those who had ingested drugs not adsorbed by activated charcoal or where administration was contraindicated, and very serious ingestions (at the discretion of the admitting physician). Patients were randomized to either activated charcoal or no decontamination.

RESULTS

The trial recruited 327 patients over 16 months. Of 411 presentations, four refused consent, 27 were protocol violations and 53 were excluded from the trial. Only seven were excluded due to the severity of their ingestion. The most common substances ingested were benzodiazepines, paracetamol and selective serotonin reuptake inhibitor antidepressants. More than 80% of patients presented within 4 h following ingestion. There were no differences between AC and no decontamination in terms of length of stay (AC 6.75 h, IQR 4-14 vs. controls 5.5 h, IQR 3-12; p=0.11) or secondary outcomes including vomiting, mortality and intensive care admission.

DISCUSSION

Routine administration of charcoal following oral overdose did not significantly influence length of stay or other patient outcomes following oral drug overdose. There were few adverse events. This does not exclude a role in patients who present shortly after ingestion of highly lethal drugs.

Investigation of human contacts: a Mycobacterium bovis outbreak among cattle at a California dairy

BACKGROUND

In May 2002, a Mycobacterium bovis outbreak occurred among cattle at a California dairy. We investigated to determine whether persons were infected after working with the cattle or drinking their raw milk.

METHODS

We identified persons with potential contact with infected cattle, including dairy workers, their family members, and slaughterhouse workers. Persons were given a tuberculin skin test (TST), and their occupational and milk-drinking habits were recorded.

RESULTS

Of 88 potential contacts, 78 (90%) were given a TST; 33 (43%) had positive TST results, of whom 32 were Mexican-born (RR 15.8, 95%CI 2.3-108.8). No persons had active tuberculosis. Eighteen (72%) dairy workers, 11 (27%) family members, and four (33%) slaughterhouse workers had positive TST results. After adjusting for Mexican-birth and age, dairy workers were no more likely to have positive TST results than others (adjusted RR 1.2, 95%CI 0.6-2.1). Forty-one (62%) dairy staff and their family members drank raw milk from the dairy; 21 (51%) had positive TST results and were Mexican-born. All 13 US-born raw milk drinkers had negative TST results.

CONCLUSION

A high prevalence of positive TST results was documented among workers at the affected dairy, although results were not independently associated with contact with infected cattle or milk products. Further assessment of California dairy workers should be considered.

Cyclooxygenase-2 protein levels are independent of epidermal growth factor receptor expression or activation in operable non-small cell lung cancer

Both cyclooxygenase (COX)-2 and epidermal growth factor receptor (EGFR) are thought to play important roles in the pathogenesis of non-small cell lung cancer (NSCLC). A number of in vitro studies have postulated a link between EGFR activation and subsequent COX-2 upregulation. The relationship between these factors has not been established in patients with NSCLC. COX-2 and EGFR expression were studied in 172 NSCLC specimens using standard immunohistochemical techniques. Western blotting was used to determine COX-2 and EGFR levels in five NSCLC cell lines. The effect of treatment with EGF on COX-2 expression in A549 cells was assessed.

RESULTS

Both EGFR and COX-2 are overexpressed in NSCLC. The predominant pattern of COX-2 and EGFR staining was cytoplasmic. Membranous EGFR staining was seen in 23.3% of cases. There was no relationship between COX-2 and EGFR expression and survival or any clinicopathological features. No correlation was seen between EGFR expression and COX-2 expression in the immunohistochemical series or in the cell lines. Treatment with EGF did not upregulate COX-2 levels in A549 cells, either in serum free or serum-supplemented conditions.

CONCLUSIONS

Although COX-2 and EGFR are over-expressed in NSCLC neither was of prognostic significance in this series of cases. There is no correlation between these two factors in either tumour samples or cell lines. Although these factors show no correlation in NSCLC, they remain potential, though independent targets for treatment.

Bismuth glass holey fibers with high nonlinearity

We report on the progress of bismuth oxide glass holey fibers for nonlinear device applications. The use of micron-scale core diameters has resulted in a very high nonlinearity of 1100 W-1 km-1 at 1550 nm. The nonlinear performance of the fibers is evaluated in terms of a newly introduced figure-of-merit for nonlinear device applications. Anomalous dispersion at 1550 nm has been predicted and experimentally confirmed by soliton self-frequency shifting. In addition, we demonstrate the fusion-splicing of a bismuth holey fiber to silica fibers, which has resulted in reduced coupling loss and robust single mode guiding at 1550 nm.

Evidence for differential modulation of conditioned aversion and fear-conditioned analgesia by CB1 receptors

Fear-conditioned analgesia is an important survival response mediated by substrates controlling nociception and aversion. Cannabinoid(1) (CB(1)) receptors play an important role in nociception and aversion. However, their role in fear-conditioned analgesia has not been investigated. This study investigated the effects of systemic administration of the CB(1) receptor antagonist, SR141716A (1 mg/kg, i.p.), on fear-conditioned analgesia and conditioned aversion in rats. Twenty-four hours after receiving footshock, rats exhibited reduced formalin-evoked nociceptive behaviour, increased freezing and increased defecation when tested in the footshock apparatus, compared with non-footshocked formalin-injected rats. SR141716A attenuated fear-conditioned analgesia, freezing and defecation. Importantly, SR141716A had no effect on formalin-evoked nociceptive behaviour over an equivalent time period in rats not receiving footshock. SR141716A had no effect on contextually induced freezing during the first half of the test trial in rats receiving intra-plantar injection of saline. Administration of SR1417176A did, however, attenuate short-term extinction of contextually induced freezing and ultrasound emission in rats receiving intra-plantar saline, compared with vehicle-treated saline controls. These data suggest an important role for the CB(1) receptor in mediating fear-conditioned analgesia and provide evidence for differential modulation of conditioned aversive behaviour by CB(1) receptors during tonic, persistent pain.

High gain efficiency amplifier based on an erbium doped aluminosilicate holey fiber

We demonstrate an optical amplifier based on an erbium doped holey fiber (EDHF) with a small core. Owing to the high NA, which is readily achievable using holey fiber technology, and the tight physical confinement of the erbium ions, we show that it is possible to achieve an internal gain efficiency of >8.5dB/mW using an aluminosilicate based glass within the core. The dependence of the gain and noise figure performance with respect to fiber length and wavelength are experimentally characterized.

Emergency surgery in patients in extremis from blunt torso injury: heroic surgery or futile care?

BACKGROUND

Trauma strikes unexpectedly, frequently in the young and fit. When trauma victims arrive in the emergency room all possible steps, including surgery, are often undertaken in an attempt to achieve a successful outcome. However, for patients presenting in extremis, with cardiac arrest or exsanguinating blunt chest injury, the results of resuscitation and emergency surgery are extremely poor.

PATIENTS AND SETTING

Eight patients in extremis with a mean injury severity score of 36, presented to the resuscitation room of Queens Medical Centre during 2001. On arrival all were in extremis or cardiac arrest after significant blunt injury to the torso, and during resuscitation had a brief loss of cardiac output. They underwent emergency surgery to control haemorrhage and correct injuries in an attempt to preserve life. Seven patients died within hours of their initial presentation either in theatre or the intensive care unit and one patient survived.

CONCLUSIONS

Futile care in the management of severely injured patients is a controversial concept although the literature defines four concepts of futility within surgery. At present, while there remains even the remotest possibility of survival, there remains a strong incentive to act and reports of isolated survivors from studies of trauma patients in extremis or cardiac arrest continue to emerge. This may be seen as justification for either an aggressive surgical approach or an indication that surgery is futile. In an emerging culture of guidelines regarding effectiveness of treatment, is this an area in which such guidelines can or should be applied?

Polarization mode dispersion reduction in spun large mode area silica holey fibres

We report the fabrication of the first spun holey optical fibre. Our experiments show that the complex air/glass transverse structure can be retained when the preform is spun during the fibre drawing process. Measurements of differential group delay (DGD) confirm that significant reductions in polarization mode dispersion (PMD) can be readily achieved using this approach.

Adiponectin receptors gene expression and insulin sensitivity in non-diabetic Mexican Americans with or without a family history of Type 2 diabetes

AIMS/HYPOTHESIS

The recent discovery of two adiponectin receptors (AdipoR1 and AdipoR2) will improve our understanding of the molecular mechanisms underlying the insulin-sensitising effect of adiponectin. The aim of this study was to determine for the first time whether skeletal muscle AdipoR1 and/or AdipoR2 gene expression levels are associated with insulin resistance.

METHODS

Using RT-PCR and northern analysis we measured AdipoR1 and AdipoR2 gene expression in skeletal muscle from healthy Mexican Americans with normal glucose tolerance who had (n=8) or did not have (n=10) a family history of Type 2 diabetes.

RESULTS

Gene expression profiling indicated that the AdipoR1 and AdipoR2 isoforms are highly expressed in human skeletal muscle, unlike in mice where AdipoR2 expression was highest in the liver, and AdipoR1 was highest in skeletal muscle. In the study subjects, the expression levels of AdipoR1 (p=0.004) and AdipoR2 (p=0.04), as well as plasma adiponectin concentration (p=0.03) were lower in people with a family history of Type 2 diabetes than in those with no family history of the disease. Importantly, the expression levels of both receptors correlated positively with insulin sensitivity (r=0.64, p=0.004 and r=0.47, p=0.048 respectively).

CONCLUSIONS/INTERPRETATION

Collectively, these data indicate that both isoforms of the adiponectin receptor play a role in the insulin-sensitising effect of adiponectin.

Prospective comparison of methods of closure of the coronal flap after craniofacial surgery in children

The coronal flap in children may be closed with clips or sutures. The results of closure with clips in patients treated during 1 year at the paediatric craniofacial unit, Liverpool, UK, were audited. Eight of 43 required a further general anaesthetic for removal of clips. A prospective audit the following year of patients whose wounds were closed with a rapidly-absorbed polyglactin suture (Vicryl rapide) showed that 3 out of 39 required re-suture of the wound in theatre (two following trauma from falls). There was one infection in each group. Neither of these patients required formal debridement of the wound in theatre. Rapidly-absorbed polyglactin is a safe alternative to clips for wound closure after craniofacial surgery in children and the morbidity is less because fewer patients have to return to theatre than closure with surgical clips.

Highly nonlinear and anomalously dispersive lead silicate glass holey fibers

In this paper we present significant progress on the fabrication of small-core lead-silicate holey fibers. The glass used in this work is SF57, a commercially available, highly nonlinear Schott glass. We report the fabrication of small core SF57 fibers with a loss as low as 2.6 dB/m at 1550 nm, and the fabrication of fibers with a nonlinear coefficient as high as 640 W-1km-1. We demonstrate the generation of Raman solitons at ~1550 nm in a short length of such a fiber which highlights the fact that the group velocity dispersion can be anomalous at these wavelengths despite the large normal material dispersion of the glass around 1550nm.

Physical therapy in spasticity

Physiotherapists are part of the rehabilitation team involved in the management of adult spasticity. Physical therapy is one part of the armoury in the fight against this disabling symptom of the upper motor neurone syndrome. Identifying the physiological changes brought about by physical therapy or physiotherapy, is difficult. As with many interventions in rehabilitation, this area is poorly studied and, until recently, there was little or no evidence for its effectiveness. The aim of this presentation is to identify key components of a physiotherapy approach and outline specific techniques. The key components considered are: education of the patient and their carers; the 'intervention cycle' - involving accurate assessment, careful measurement, intervention and evaluation; accurate goal setting and a staged stepwise approach over prolonged periods. The specific techniques used include treatments targeted at: muscle length changes, muscle strengthening and functional performance. Broadly these techniques can be divided into biomechanical, cognitive and neurophysiological, each being interdependent on the others. Physiotherapy combined with the other available treatments should meet the challenge arising from adult spasticity.

Soliton transmission and supercontinuum generation in holey fiber, using a diode pumped Ytterbium fiber source

We report linear dispersion compensation, soliton pulse formation, soliton compression, and ultra-broad supercontinuum generation in a holey fiber with anomalous dispersion at wavelengths above 800nm. The holey fiber was seeded with ultrashort pulses from a diode pumped, Ytterbium (Yb)-doped fiber source operating at 1.06 microm. The results highlight the compatibility of the rapidly developing holey fiber technology with short pulse Yb-doped fiber lasers for wide application.

Effect of urate on nitric oxide microcirculatory response in the rat tail to body heating

OBJECTIVE

The objective of this study was to determine if nitric oxide (NO)-mediated cutaneous vasodilation depends on urate concentrations.

METHODS

Capillary blood cell velocities (BCV) in the tail capillary vessels of anesthetized, heat-stressed Sprague-Dawley rats were measured by the videomicroscopy method, and the femoral mean arterial pressure (MAP) was recorded on a Grass polygraph. The effects of urate or urate and NO production on the above parameters were determined by using specific inhibitors of these compounds, for example, allopurinol (All) or All or N-nitro-L-arginine (NNA), respectively. Urate concentrations were determined by an enzymatic, colorimetric method, and total nitrite levels were measured fluorometrically.

RESULTS

During heat stress, All or All and NNA significantly decreased plasma urate or urate and total nitrite concentrations, respectively, and the response of vascular conductance (estimated as a ratio of BCV to MAP). Urate administration, after All and NNA pretreatment, restored plasma urate and total nitrite concentrations and increased BCV/MAP.

CONCLUSIONS

Urate at physiological concentration helps to maintain vascular conductance of cutaneous capillaries in the rat tail during body heating. The effect of urate on vascular conductance may be mediated by NO.

Selective renal embolisation for renovascular hypertension?

An 11 year old girl developed hypertensive encephalopathy and renal failure from reflux nephropathy. Resection of her shrunken left kidney did not control her hypertension. Two selective arterial embolisations of the scarred right lower pole produced only transient benefit, but a heminephrectomy gave good control. Embolisation may delay definitive treatment.

Nitrate reduction in the periplasm of gram-negative bacteria

In contrast to the bacterial assimilatory and membrane-associated, respiratory nitrate reductases that have been studied for many years, it is only recently that periplasmic nitrate reductases have attracted growing interest. Recent research has shown that these soluble proteins are widely distributed, but vary greatly between species. All of those so far studied include four essential components: the periplasmic molybdoprotein, NapA, which is associated with a small, di-haem cytochrome, NapB; a putative quinol oxidase, NapC; and a possible pathway-specific chaperone, NapD. At least five other components have been found in different species. Other variations between species include the location of the nap genes on chromosomal or extrachromosomal DNA, and the environmental factors that regulate their expression. Despite the relatively small number of bacteria so far screened, striking correlations are beginning to emerge between the organization of the nap genes, the physiology of the host, the conditions under which the nap genes are expressed, and even the fate of nitrite, the product of Nap activity. Evidence is emerging that Nap fulfills a novel role in nitrate scavenging by some pathogenic bacteria.

Cladding pumped Ytterbium-doped fiber laser with holey inner and outer cladding

We have fabricated an ytterbium doped all-glass double-clad large mode area holey fiber. A highly efficient cladding pumped single transverse mode holey fiber laser has been demonstrated, allowing continuous-wave output powers in excess of 1W with efficiencies of more than 80%. Furthermore both Q-switched and mode-locked operation of the laser have been demonstrated.

Safety evaluation of a glutaraldehyde modified tyrosine adsorbed housedust mite extract containing monophosphoryl lipid A (MPL) adjuvant: a new allergy vaccine for dust mite allergy

A new allergy vaccine is currently under clinical evaluation for the prevention or relief of symptoms caused by specific housedust mites. It consists of a 50:50 mixture of the mite Dermatophagoides pteronyssinus and D. farinae protein derived from aqueous extracts of the mites which is chemically modified by glutaraldehyde and adsorbed onto L-tyrosine with addition of the immunostimulatory adjuvant, monophosphoryl lipid A (MPL) "Polymite". A specific preclinical safety testing strategy was developed to support clinical use and comprised single and repeat dose toxicity, reproduction toxicity and local tolerance studies. Dose levels of up to 0.5ml for the mouse and up to 1ml for both the rat and the rabbit were used. Overall, the product was shown to produce no toxicological findings of significance at levels greatly in excess to those proposed for clinical use. A not unexpected, but relatively minor, immunostimulatory effect was seen following repeated dosing (once weekly for 13 weeks) at 1ml per rat; the Polymite formulation also resulted in injection site reaction which can largely be attributed to the presence of tyrosine. No reproduction toxicity was found.

Towards a biological staging model for operable non-small cell lung cancer

Non-small cell lung cancer is the most common cause of cancer-related death in North America and Europe. Despite improvements in the diagnosis and treatment of the disease the prognosis remains poor, the overall 5-year survival being 4-14%. An increased understanding of the molecular biology of the disease may identify novel targets for drug development. We evaluated epidermal growth factor receptor (EGFR), HER-2/neu, matrix metalloproteinase (MMP)-2, MMP-9, p53 and bcl-2 expression and microvessel density (MVD) in patients who underwent surgery with curative intent in our department between 1991 and 1996. Co-expression of EGFR/MMP-9, MVD and bcl-2 were found to be independent prognostic variables, which allowed prediction of patient outcome independent of surgical stage. Other prognostic factors identified in our series were gender, surgical stage, platelet count, extent of necrosis, the hypoxia marker carbonic anhydrase-9 and beta-catenin. In collaboration with groups in Oxford and Greece, we were also able to establish the angiogenic growth factors vascular endothelial growth factor and platelet-derived endothelial growth factor as prognostic variables. The inter-relationships between these factors are currently being examined in an expanded patient series. Through this work we hope to be able to construct an integrated biological prognostic model which can be tested in prospective studies. This work has identified several potential targets for novel therapeutic agents currently in development.

Dialysis in non-renal organ (liver) transplantation

The renal management of acute hepatic failure and liver transplantation requires an understanding of the features of liver failure and the causes of liver graft dysfunction. The management of any underlying pathology in addition to supportive care is fundamental to successful management and a return to independent renal function. These issues are discussed particularly in relationship to a case history involving a patient presenting with acute fulminant liver failure secondary to a paracetamol overdose who was successfully treated by liver transplantation and continuous veno-venous haemodiafiltration. The liver can be successfully transplanted but acute renal failure is a severe complication post-transplantation. Its appearance can be predicted in patients with pre-transplant renal dysfunction, severe graft dysfunction, or both. It may be avoided through careful selection of transplant recipients and correct timing of transplantation. Prevention of renal failure, appropriate patient selection for transplantation and timely procurement of a donor organ are vital for best use of limited donor resources. Treatment success depends on patient and donor selection, skilled surgeons, careful post-operative care, and successful immunosuppression.

Optimizing erythropoietin therapy in hemodialysis patients

The European Best Practice Guidelines for the management of anemia in patients with chronic renal failure recommend the percentage of hypochromic red blood cells (%HRCs) as the best measure of iron use by erythropoietic tissues. They suggest that "sufficient iron should be administered to attain: serum ferritin 100 ng/mL, HRCs <10%. In practice, to achieve these minimum criteria will mean aiming for optimal levels of serum ferritin 200-500 ng/mL, HRCs <2.5%." We increased prospectively the delivered dose of iron supplements to a large (n = 228) unselected hemodialysis cohort with a sustained (24-month) hemoglobin (Hb) outcome meeting the UK Renal Association minimum standard of 85%, greater than or equal to 10.0 g/dL. This was managed through a computer-aided decision support system for erythropoietin (EPO) and intravenous iron sucrose therapy. Hb outcome was maintained with medians between 11.3 and 11.8 g/dL. Median red blood cell hypochromia (%HRCs) decreased from 8% (interquartile range [IQR], 3 to 15) to 4% (IQR, 2 to 8; P < 0.001, U-Mann Whitney test). Serum ferritin level increased from a median of 188 (IQR, 115 to 256) to 480 ng/mL (IQR, 397 to 595; P < 0.001, U-Mann Whitney test). Median EPO dose decreased from 136 (IQR, 83 to 216) to 72 IU/kg/wk (IQR, 33 to 134), which strongly correlated with median %HRCs through the range less than 10% (Spearman's correlation, 0.73; P < 0.01). These data suggest that EPO responsiveness continues to improve toward the normal range for %HRCs (<2.5%) and aspiring to values much less than 10% is cost-effective. The ferritin outcome required to achieve these lower values for %HRC outcome is greater than the current recommended range, although in steady state, the mean iron treatment dose is similar to that in previous studies (ie, approximately 60 mg/wk).

Renal diagnosis without renal biopsy. Nephritis and sensorineural deafness

Two examples of hereditary nephropathy within the context of clinical syndromes are described. Emphasis is put on the ability to make a renal diagnosis without renal biopsy and the benefits of screening relatives once a diagnosis is achieved. A variant of Alport's syndrome with associated macrothrombocytic thrombocytopenia, known as Epstein's syndrome, is reported. In addition siblings with Alström's syndrome characterized by pigmentary retinal degeneration (causing blindness in early childhood), progressive sensorineural hearing loss, and progressive renal failure are reported. Both cases had previously presented for non-renal pathology in advance of the onset of symptomatic renal failure and may have benefited from appropriate screening.

Training for the role of triage in Australasia

OBJECTIVE

To characterize the prerequisite experience and training undertaken by nurses for the role of triage in emergency departments in Australasia.

METHODS

Postal survey of charge nurses/unit nurse managers of all Australasian emergency departments accredited for specialist emergency physician training by the Australasian College for Emergency Medicine.

RESULTS

The response rate was 89%. The most common duration of prerequisite experience was 12-18 months. Most programmes use a combination of educational activities, with self-directed learning packages, lectures and mentored experience being the most common. Three hospitals reported no preparation for triage.

CONCLUSION

In Australasia, there is wide variability in required training and experience before triage duties are performed. Strategies to set suggested minimum standards in these areas and to make training activities more accessible are recommended.

Radiation risk estimates in the beginning of the 21st century

In the early years of the 21st century, results from a number of epidemiologic studies of populations with specific ionizing radiation exposures will become available. These include populations with accidental exposures in the former Soviet Union and elsewhere and populations with occupational exposures from routine operations of nuclear power plants. The strengths and limitations of these studies are reviewed together with the radiation protection questions they may answer. Many of these studies will provide specific information to complement the atomic-bomb survivor studies, particularly the effects of dose-rate and exposure protraction, modifiers of radiation risks (both environmental and host factors), and different types of radiation. These studies will therefore be important as a test of the adequacy of the current scientific bases for the radiation protection of workers and the general public. An example is thyroid cancer risk in young children following the Chernobyl accident, which has brought attention to a very high sensitivity of very young children that was difficult to assess on the basis of atomic-bomb data alone. Radiation protection will also benefit from formal comparisons and combined analyses of data from populations with different exposure patterns and exposures. Finally, future epidemiological studies will be most valuable if they are well focused, designed specifically to answer outstanding radiation protection questions. An integrated approach based on epidemiology and mechanistic studies, in which epidemiologic studies are designed to test specific mechanistic hypotheses and realistic mechanistic models are used for the analysis of epidemiological data, will probably be the most fruitful for radiation protection.

Optimal frequency of changing intravenous administration sets: is it safe to prolong use beyond 72 hours?

OBJECTIVE

To determine the safety and cost-effectiveness of replacing the intravenous (IV) tubing sets in hospitalized patients at 4- to 7-day intervals instead of every 72 hours.

DESIGN

Prospective, randomized study of infusion-related contamination associated with changing IV tubing sets within 3 days versus within 4 to 7 days of placement.

SETTING

A tertiary university cancer center.

PATIENTS AND METHODS

Cancer patients requiring IV infusion therapy were randomized to have the IV tubing sets replaced within 3 days (280 patients) or within 4 to 7 days of placement (232 patients). Demographic, microbiological, and infusion-related data were collected for all participants. The main outcome measures were infusion- or catheter-related contamination or colonization of IV tubing, determined by quantitative cultures of the infusate, and infusion- or catheter-related bloodstream infection (BSI), determined by quantitative culture of the infusate in association with blood cultures in febrile patients.

RESULTS

The two groups were comparable in terms of patient and catheter characteristics and the agents given through the IV tubing. Intent-to-treat analysis demonstrated a higher level of tubing colonization in the 4- to 7-day group versus the 3-day group (median, 145 vs 50 colony-forming units; P=.02). In addition, there were three episodes of possible infusion-related BSIs, all of which occurred in the 4- to 7-day group (P=.09). However, when the 84 patients who received total parenteral nutrition, blood transfusions, or interleukin-2 through the IV tubing were excluded, the two groups had a comparable rate of colonization (0.4% vs 0.5%), with no catheter- or infusion-related BSIs in either group.

CONCLUSION

In patients at low risk for infection from infusion- or catheter-related infection who are not receiving total parenteral nutrition, blood transfusions, or interleukin-2, delaying the replacement of IV tubing up to 7 days may be safe, as well as cost-effective

Intravenous iron for CAPD populations: proactive or reactive strategies?

BACKGROUND

The European best practice guideline [Nephrol Dial Transplant 1999; 14 (Suppl 5)] (5A) for the management of anaemia suggests that > 85% of the CAPD population should have a haemoglobin level of > 11.0 g/dl.

METHODS

We developed and implemented an outpatient-based protocol for intravenous iron sucrose (IV Fe) and erythropoietin (Epo) in CAPD patients showing iron deficiency despite oral iron therapy. We managed a total of 103 patients over 13 months of study. All CAPD patients were included, regardless of co-morbidity. Treatment developed in two phases: in phase 1 (reactive) (months 1-8), patients with markers of iron deficiency (ferritin < 100 ng/ml or ferritin 100-500 and percentage hypochromic red cells (%HRC) > or =5) were converted from oral iron to IV Fe (300 mg) and reviewed after 4-8 weeks according to haemoglobin (Hb). In phase 2 (proactive) (months 9-13), the criteria for iron therapy were extended: ferritin < 150 ng/ml or ferritin 150-500 and %HRC > or = 2. Patients then received IV Fe (200 mg) and were reviewed after 4 weeks according to Hb.

RESULTS

The median haemoglobin increased from 11.0 (Inter quartile range, IQR, 10.1-12.6) g/dl to 11.7 (11.0-12.7) g/dl (P = 0.06). The proportion of patients with absolute iron deficiency (ferritin < 100 ng/ml) decreased from 24 to 2%. The percentage of hypochromic red cells (%HRC) decreased from 4 (2-7) to 1 (1-4) (P < 0.01).

CONCLUSIONS

An integrated Epo and IV Fe policy increased the number of patients reaching the European guideline from 50 to 75% with no increase in the population median Epo requirements (42 (IQR, 25-95) IU/kg/week vs 45 (27-101) (P = NS)). This study demonstrates the benefit of early (proactive) intervention in achieving population compliance within current guidelines for renal anaemia.