Genetic variants associated with sleep disorders

OBJECTIVE

The diagnostic boundaries of sleep disorders are under considerable debate. The main sleep disorders are partly heritable; therefore, defining heritable pathophysiologic mechanisms could delineate diagnoses and suggest treatment. We collected clinical data and DNA from consenting patients scheduled to undergo clinical polysomnograms, to expand our understanding of the polymorphisms associated with the phenotypes of particular sleep disorders.

METHODS

Patients at least 21 years of age were recruited to contribute research questionnaires, and to provide access to their medical records, saliva for deoxyribonucleic acid (DNA), and polysomnographic data. From these complex data, 38 partly overlapping phenotypes were derived indicating complaints, subjective and objective sleep timing, and polysomnographic disturbances. A custom chip was used to genotype 768 single-nucleotide polymorphisms (SNPs). Additional assays derived ancestry-informative markers (eg, 751 participants of European ancestry). Linear regressions controlling for age, gender, and ancestry were used to assess the associations of each phenotype with each of the SNPs, highlighting those with Bonferroni-corrected significance.

RESULTS

In peroxisome proliferator-activated receptor gamma, coactivator 1 beta (PPARGC1B), rs6888451 was associated with several markers of obstructive sleep apnea. In aryl hydrocarbon receptor nuclear translocator-like (ARNTL), rs10766071 was associated with decreased polysomnographic sleep duration. The association of rs3923809 in BTBD9 with periodic limb movements in sleep was confirmed. SNPs in casein kinase 1 delta (CSNK1D rs11552085), cryptochrome 1 (CRY1 rs4964515), and retinoic acid receptor-related orphan receptor A (RORA rs11071547) were less persuasively associated with sleep latency and time of falling asleep.

CONCLUSIONS

SNPs associated with several sleep phenotypes were suggested, but due to risks of false discovery, independent replications are needed before the importance of these associations can be assessed, followed by investigation of molecular mechanisms.

The role of rotational mobility and power on throwing velocity

Sound rotational power and mobility are an integral component in functional performances, such as throwing and striking. The purpose of this study was to examine the role of rotational power and mobility on cricket ball-throwing velocity. Eleven professional cricketers and 10 under-19 club-level cricketers performed the chop and lift, seated and standing cricket ball throw, seated and standing side medicine ball throw, and seated active thoracic rotation range of motion (ROM) and hip rotation ROM on one occasion. Participants were divided into 2 groups (fast and slow) based on their standing cricket ball-throwing velocity. The seated and standing cricket ball throw on the dominant side was significantly different (p < 0.00) between fast and slow throwers (11.03 and 10.7 km·h(-1), respectively). Muscular performance measures, such as bilateral thoracic rotation ROM, hip external rotation ROM on the dominant side, and force and work required in the chop, were significantly different (p ≤ 0.05) between fast and slow throwers. Faster throwers in this study displayed greater force (18.4%) and work (31.2%) outputs in the chop compared with the slower throwers; however, slower throwers showed significantly greater ROM in the thoracic (13.4-16.8%) and hip regions (11.8%). It was concluded that greater ROM at proximal segments, such as hips and thoracic, may not increase throwing velocity in cricket as reduced ROM at proximal segments can be useful in transferring the momentum from the lower extremity in an explosive task such as throwing.

Intranasal fentanyl for the management of acute pain in children

BACKGROUND

Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula.

OBJECTIVES

We identified and evaluated all randomized controlled trials (RCTs) and quasi-randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of "rescue analgesia," patient/parental satisfaction and patient mortality.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014).

SELECTION CRITERIA

We included RCTs comparing INF versus any other pharmacological/non-pharmacological intervention for the treatment of children in acute pain (aged < 18 years).

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a "bad taste" and vomiting with INF. Overall the risk of bias in all studies was considered low.

AUTHORS' CONCLUSIONS

INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non-inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a "medical" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a "medical" cause.

Poor Efficacy of Haemodiafiltration to Treat Dabigatran-Associated Coagulopathy

Dabigatran is a novel oral direct thrombin inhibitor, licensed for stroke prevention in atrial fibrillation and the primary prevention of venous thromboembolism in patients who have undergone hip or knee replacement. It has been shown to cause a lower rate of major life-threatening haemorrhage compared to warfarin, although the incidence of gastrointestinal bleeding is higher. When bleeds do occur, however, there is no immediate reversal agent available. In several case reports, haemodialysis has been successfully used to treat life-threatening bleeding associated with dabigatran. We present a case of a patient receiving dabigatran who suffered a severe gastrointestinal bleed where haemodiafiltration did not provide rapid normalisation of clotting parameters as previously reported.

Methods of recording theatre activity across publicly funded hospitals in Ireland

BACKGROUND

A review of theatre activity in all Health Service Executive (HSE) hospitals in Cork and Kerry in 2008 required a manual extraction of theatre activity data from largely paper-based log books. A key data management recommendation suggested that "a standardised computerised theatre log book system be developed in all hospitals in the region". HSE (2010) Reconfiguration of health services for Cork and Kerry—theatre utilisation review. ISBN 978-1-906218-54-6.

MATERIALS AND METHODS

In 2010, a computerised minimum dataset project group conducted a telephone survey of theatre managers nationally to determine the methods of recording theatre activity across publicly funded hospital theatres in Ireland.

RESULTS

Sixty-one percent of acute hospitals nationally did not have a computerised theatre register. Of those who did, 15 % had a fully electronic system, 13 % had a dual paper-based and electronic system and 7 % had a single surgical specialty system. The HSE South region was significantly deprived of an electronic operating system in comparison to other HSE regions. While the total number of fully computerised hospital theatres remained small,they still dealt with the greater number of hospital discharges nationally.

CONCLUSIONS

The roll-out of the productive operating theatre programme is facilitating the implementation of operating room management systems on a phased basis nationally. This will greatly facilitate audit, research,patient care and theatre efficiencies.

A review of cricket Fielding requirements

Cricket is played in three formats at elite level: Test, One Day and Twenty20. Fielding is an important component of cricket, as all players are obliged to field. However, there is a paucity of literature on fielding compared with that on batting and bowling. We review the available literature in terms of technical, mental, physiological and physical factors important to fielding, to identify knowledge gaps and better understand the performance requirements of fielding in cricket.

A review of cricket Fielding requirements

Cricket is played in three formats at elite level: Test, One Day and Twenty20. Fielding is an important component of cricket, as all players are obliged to field. However, there is a paucity of literature on fielding compared with that on batting and bowling. We review the available literature in terms of technical, mental, physiological and physical factors important to fielding, to identify knowledge gaps and better understand the performance requirements of fielding in cricket.

A review of a paediatric emergency department vaccination programme for patients at risk of allergy/anaphylaxis

AIM

We sought to review the clinical outcomes of patients referred to our emergency department (ED) vaccination service for children with a history of allergy or anaphylaxis or in whom there was a concern of a significant adverse reaction.

METHODS

This was a prospective observational cohort study set in an urban tertiary Paediatric ED. All attendances for any childhood vaccination for a 5-year period (from January 1, 2006 to December 31, 2010) were included. Our primary outcome measure was any adverse reaction as a result of the vaccine administered.

RESULTS

A total of 446 vaccines were administered during the study period in 374 patients. Of these vaccinations, 310 (69.5%) were Measles, Mumps, Rubella (MMR). The majority of patients (348, 93%) were referred from the community. Suspected egg allergy was the reason for the majority of referrals for MMR (261/310 (84.2%)). Only six patients (1.3%) experienced an immediate reaction to a vaccination. All reactions were minor.

CONCLUSION

This is one of the largest studies looking at childhood vaccinations performed in a hospital setting for children who are 'at risk' of allergy, anaphylaxis or hypersensitivity. A significant number of referrals were unwarranted and the majority could have been safely managed in the community.

Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial

Background

Asthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß₂-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department.

Methods/design

This is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patients will be randomized to either oral dexamethasone 0.3 mg/kg stat or prednisolone 1 mg/kg/day for three days. The primary outcome measure is the comparison between the Pediatric Respiratory Assessment Measure (PRAM) across both groups on Day 4. The PRAM score, a validated, responsive and reliable tool to determine asthma severity in children aged 2 to 16 years, will be performed by a clinician blinded to treatment allocation. Secondary outcomes include relapse, hospital admission and requirement for further steroid therapy. Data will be analyzed on an intention-to-treat and a per protocol basis. With a sample size of 232 subjects (105 in each group with an estimated 10% loss to follow-up), we will be able to reject the null hypothesis - that the population means of the experimental and control groups are equal with a probability (power) of 0.9. The Type I error probability associated with this test (of the null hypothesis) is 0.05.

Discussion

This clinical trial may provide evidence that a shorter steroid course using dexamethasone can be used in the treatment of acute pediatric asthma, thus eliminating the issue of compliance to treatment.

Registration

ISRCTN26944158 and EudraCT Number 2010-022001-18

Measurement of the proton-air cross section at √s=57 TeV with the Pierre Auger Observatory

We report a measurement of the proton-air cross section for particle production at the center-of-mass energy per nucleon of 57 TeV. This is derived from the distribution of the depths of shower maxima observed with the Pierre Auger Observatory: systematic uncertainties are studied in detail. Analyzing the tail of the distribution of the shower maxima, a proton-air cross section of [505±22(stat)(-36)(+28)(syst)] mb is found.

Long-term oestradiol treatment enhances hippocampal synaptic plasticity that is dependent on muscarinic acetylcholine receptors in ovariectomised female rats

Short-term oestradiol treatment modulates hippocampus-dependent memory and synaptic plasticity in the hippocampus. Long-term oestradiol treatment can also enhance hippocampus- dependent memory, although the effects of long-term oestradiol treatment on synaptic plasticity are unknown. We investigated the effects of long-term oestradiol treatment on synaptic plasticity at the Schaeffer Collateral/CA1 synapse in 8-month-old female rats. In addition, we determined the role of endogenous activation of muscarinic acetylcholine receptors (mAChRs) in synaptic transmission and plasticity using scopolamine (1 μm), an antagonist of mAChRs. Hippocampus slices from ovariectomised rats that were treated with oestradiol-containing capsules for 5 months were compared with slices from ovariectomised rats that received cholesterol-containing capsules. Unexpectedly, scopolamine application significantly increased the baseline field excitatory postsynaptic potentials (fEPSP) and decreased paired pulse facilitation (PPF) in slices from cholesterol-treated rats. Baseline fEPSPs and PPF were not significantly modulated in slices from oestradiol-treated rats by scopolamine. Slices from oestradiol-treated rats showed enhanced long-term potentiation relative to slices from cholesterol-treated rats. Scopolamine significantly reduced the magnitude of plasticity in slices from oestradiol-treated rats. Taken together, these results suggest that mAChRs have a significant effect on baseline synaptic transmission through a decrease in the probability of glutamate release in slices from cholesterol-treated rats. Long-term oestradiol treatment blocks this effect and enhances theta-burst stimulation-induced synaptic plasticity in the middle-aged female rat, and this effect is mediated by activation of mAChRs.