State-of-the-art chronic thromboembolic pulmonary hypertension diagnosis and management

Chronic thromboembolic pulmonary hypertension (CTEPH) is a debilitating disease caused by chronic obstruction of pulmonary artery branches following episodes of pulmonary embolism and incomplete thrombus resolution. The prognosis of patients with CTEPH is poor unless an early diagnosis is made and treatment is initiated. Chest radiography and echocardiography are used in the initial assessment of suspected pulmonary hypertension. A diagnosis of CTEPH may be confirmed by the presence of a mismatched wedge-shaped perfusion deficit during ventilation/perfusion scintigraphy or characteristic findings during multi-slice computed tomography (CT) angiography, including a mosaic perfusion pattern, dilatation of proximal pulmonary arteries and right heart chambers, and the presence of vascular stenosis or obstruction. Prior to possible surgery, pulmonary angiography remains the definitive diagnostic technique, indicating the site and accessibility of the obstruction. However, many centres utilise CT and magnetic resonance imaging following recent advances in these noninvasive techniques. Haemodynamic evaluation via right heart catheterisation is also mandatory, as pulmonary vascular resistance is the most important determinant of both prognosis and the risk associated with pulmonary endarterectomy surgery. Accurate CTEPH diagnosis and characterisation of its extent and distribution are imperative to allow the prompt initiation of treatment, particularly surgical pulmonary endarterectomy in eligible patients.

Evidence for a smooth onset of deformation in the neutron-rich Kr isotopes

The neutron-rich nuclei 94,96Kr were studied via projectile Coulomb excitation at the REX-ISOLDE facility at CERN. Level energies of the first excited 2(+) states and their absolute E2 transition strengths to the ground state are determined and discussed in the context of the E(2(1)(+)) and B(E2;2(1)(+)→0(1)(+)) systematics of the krypton chain. Contrary to previously published results no sudden onset of deformation is observed. This experimental result is supported by a new proton-neutron interacting boson model calculation based on the constrained Hartree-Fock-Bogoliubov approach using the microscopic Gogny-D1M energy density functional.

Botox A injection for pain after laparoscopic ventral hernia: a case report

INTRODUCTION

Laparoscopic ventral hernia repair has many advantages over open techniques: adequate visualization of the entire abdominal wall, ease of placement of preperitoneal mesh with adequate overlap, and cosmesis. Intense and activity limiting pain is often one inferior aspect of this repair. We report the case of a patient who was intolerant of narcotic pain medicine with activity limiting pain. A novel technique for postoperative pain control was instituted utilizing Botox A (Allergan Inc., Irvine, CA, USA).

METHODS

Botox A was diluted to 2 units per mL and three injection sites were chosen on each side of the abdominal wall. All three muscle bellies (external oblique, internal oblique, and transversus) were identified by ultrasound and 8 mL was injected in each. This resulted in three muscle layers at six sites for a total of 18 injections. A total of 300 units of Botox A were utilized.

RESULTS

Pain scores improved from 10/10 to 2/10 and were durable at 3-month follow up.

CONCLUSION

Botox A provided significant pain control for this patient after laparoscopic ventral hernia repair. Continued prospective study to define long-term outcomes, cost savings, and appropriate timing of injections is underway.

How do ward pharmacists spend their time?: An activity sampling study

A regular clinical pharmacy service to wards is well established in Britain, yet there has been little practice research in this area. In this study, we established how pharmacists distribute their time between different activities on all the wards. All 28 pharmacists in two London hospitals were observed. The observer recorded their activities at one minute intervals and categorised the activity. Thirty-three hours and five minutes of observations were made. The pharmacists visited a total of 55 wards, and checked 982 drug charts.

The major activities were prescription monitoring, which accounted for 31 per cent ± 2 per cent, of the time (mean of pooled data ± 95 per cent confidence intervals), travel to wards 21 per cent ± 2 per cent, stock control 12 per cent ± 1 per cent, transcription 8 per cent ± 1 per cent and clinical monitoring (such as checking giving sets) 7 per cent ± 1 per cent.

The proportion of time spent on each activity was very similar between the two sites, except for the category “transcription”, which took 11 per cent ± 2 per cent of the time in one hospital, where all discharge prescriptions were transcribed onto ward pharmacy sheets (allowing processing in the pharmacy without the need for drug charts to leave the ward), and 3 per cent ± 1 per cent at the other site, in which they were not transcribed.

These results demonstrate that, when on the ward, pharmacists spend the majority of their time in a clinical role. The methodology is simple to use and appears reproducible. This work, if repeated locally, could be used to highlight areas of inefficiency, and could be used to test and predict the impact of other methods of delivery of clinical pharmacy.

Costing inpatient drug treatment

The aim of this study was to examine costs of charted drugs by using three data capture techniques. Data were manually extracted retrospectively from drug charts for a stratified sample of 200 inpatient stays at each of two London hospitals — a teaching hospital (St George's) and a district general hospital (Kingston). Specialties where costing was not feasible were excluded. These were: intensive care, oncology, dermatology and paediatrics. Three costs were calculated: nonstock drugs administered (the capability of traditional pharmacy computer systems), drugs prescribed (the data captured by a basic computerised prescribing system) and drugs administered (the data captured by a drug administration recording system). Pharmaceuticals not prescribed on the drug chart, such as anaesthetics, contrast media and disinfectants, were not included.

At St George's 2,739 and at Kingston 2,843 prescription entries were recorded, amounting to costs of £2,940 and £2,327, respectively, for drugs administered. A range of £0.01 to £171 per patient (median £4.67) at St George's and £0.00 to £122.66 (median £2.88) at Kingston demonstrates a skewed distribution, with most patients incurring low costs. Non-stock drugs accounted for 21 per cent of the cost of drugs administered at St George's and 15 per cent at Kingston. Twenty-four patients incurred costs above £50, their non-stock drugs being a mean of 21 per cent of their total costs. The cost of drugs administered at both hospitals was found to be 95 per cent of the cost of drugs prescribed.

Computerised prescribing and drug administration recording systems would significantly improve cost allocation. However, it is unlikely that the expense could be justified on the basis of the low value of drugs received by most patients.

The role of dispersed nocardioform filaments in activated sludge foaming

Activated sludge foaming caused by filamentous microorganisms is a major wastewater treatment plant operating problem. This paper presents the results of an investigation of the role of dispersed nocardioforms in activated sludge foaming. Dispersed nocardioforms had a greater propensity for foaming than floc-bound nocardioforms. The mode of effluent withdrawal from an aeration basin plays a major role in determining the relative proportion of dispersed and floc-bound nocardioforms in the activated sludge. Reactors with "trapping" features (sub-surface mixed liquor withdrawal) had significantly higher dispersed nocardioform populations than reactors with "non-trapping" features (surface mixed liquor withdrawal). High dispersed nocardioform filament concentrations were correlated with a high propensity for foaming. Cationic polymer and polyaluminum chloride reduced foaming by flocculating dispersed nocardioforms, thereby converting them to floc-bound nocardioforms. Low non-ionic surfactant concentrations changed the relative proportions of dispersed and floc-bound nocardioforms by deflocculating floc-bound filaments and converting them to the dispersed growth form. This could act as a trigger for initiating the rapid-onset nocardioform foaming events observed at activated sludge plants.

Impact of joint theater trauma system initiatives on battlefield injury outcomes

INTRODUCTION

The US military forces developed and implemented the Joint Theater Trauma System (JTTS) and Joint Theater Trauma Registry (JTTR) using US civilian trauma system models with the intent of improving outcomes after battlefield injury.

METHODS

The purpose of this analysis was to elaborate the impact of the JTTS. To quantify these achievements, the JTTR captured mechanism, acute physiology, diagnostic, therapeutic, and outcome data on 23,250 injured patients admitted to deployed US military treatment facilities from July 2003 through July 2008 for analysis. Comparative analysis to civilian trauma systems was done using the National Trauma Data Bank (NTDB).

RESULTS

In contrast to civilian trauma systems with an 11.1% rate of penetrating injury, 68.3% of battlefield wounds were by penetrating mechanism. In the analyzed cohort, 23.3% of all patients had an Injury Severe Score (ISS) > or = 16, which is similar to the civilian rate of 22.4%. In the military injury population, 66% of injuries were combat-related. In addition, in the military injury group, 21.8% had metabolic evidence of shock with a base deficit > or = 5, 29.8% of patients required blood transfusion, and 6.4% of the total population of combat casualties required massive transfusion (>10 U red blood cells/24 hours). With this complex and severely injured population of battlefield injuries, the JTTS elements were used to recognize and remedy more than 60 trauma system issues requiring leadership and advocacy, education, research, and alterations in clinical care. Of particular importance to the trauma system was the implementation and tracking of performance improvement indicators and the dissemination of 27 evidence-based clinical practice guidelines (CPGs). In particular, the damage control resuscitation guideline was associated with a decrease in mortality in the massively transfused from 32% pre-CPG to 21% post-CPG. As evidence of the effectiveness of the JTTS, a mortality rate of 5.2% after battlefield hospital admission is comparable to a case fatality rate of 4.3% reported in an age-matched cohort from the NTDB.

CONCLUSIONS

JTTS initiatives contributed to improved survival after battlefield injury. The JTTS has set the standard of trauma care for the modern battlefield using contemporary systems-based methodologies.

Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms

Some patients with colonic diverticula suffer recurrent abdominal pain and exhibit visceral hypersensitivity, though the mechanism is unclear. Prior diverticulitis increases the risk of being symptomatic while experimental colitis in animals increases expression of neuropeptides within the enteric nervous system (ENS) which may mediate visceral hypersensitivity. Our aim was to determine the expression of neuropeptides within the ENS in diverticulitis (study 1) and in patients with symptomatic disease (study 2). Study 1 - Nerves in colonic resection specimens with either acute diverticulitis (AD, n = 16) or chronic diverticulitis (CD, n = 16) were assessed for neuropeptide expression recording % area staining with protein gene product (PGP9.5), substance P (SP), neuropeptide K (NPK), pituitary adenylate cyclase activating polypeptide (PACAP), vasoactive intestinal polypeptide (VIP) and galanin. Study 2 - Seventeen symptomatic and 15 asymptomatic patients with colonic diverticula underwent flexible sigmoidoscopy and multiple peridiverticular mucosal biopsies. Study 1- Neural tissue, as assessed by PGP staining was increased to a similar degree in circular muscle in both AD and CD. The CD specimens showed significant increases in the immunoreactivity of SP, NPK and galanin in both mucosal and circular muscle layer compared with controls. Study 2 - Mucosal histology was normal and PGP9.5 staining was similar between groups however patients with symptomatic diverticular disease demonstrated significantly higher levels of SP, NPK, VIP, PACAP and galanin within the mucosal plexus. Patients with symptomatic diverticular disease exhibit increased neuropeptides in mucosal biopsies which may reflect resolved prior inflammation, as it parallels the changes seen in acute and chronic diverticulitis.

Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women

BACKGROUND

The human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine was immunogenic, generally well tolerated, and effective against HPV-16 or HPV-18 infections, and associated precancerous lesions in an event-triggered interim analysis of the phase III randomised, double-blind, controlled PApilloma TRIal against Cancer In young Adults (PATRICIA). We now assess the vaccine efficacy in the final event-driven analysis.

METHODS

Women (15-25 years) were vaccinated at months 0, 1, and 6. Analyses were done in the according-to-protocol cohort for efficacy (ATP-E; vaccine, n=8093; control, n=8069), total vaccinated cohort (TVC, included all women receiving at least one vaccine dose, regardless of their baseline HPV status; represents the general population, including those who are sexually active; vaccine, n=9319; control, n=9325), and TVC-naive (no evidence of oncogenic HPV infection at baseline; represents women before sexual debut; vaccine, n=5822; control, n=5819). The primary endpoint was to assess vaccine efficacy against cervical intraepithelial neoplasia 2+ (CIN2+) that was associated with HPV-16 or HPV-18 in women who were seronegative at baseline, and DNA negative at baseline and month 6 for the corresponding type (ATP-E). This trial is registered with ClinicalTrials.gov, number NCT00122681.

FINDINGS

Mean follow-up was 34.9 months (SD 6.4) after the third dose. Vaccine efficacy against CIN2+ associated with HPV-16/18 was 92.9% (96.1% CI 79.9-98.3) in the primary analysis and 98.1% (88.4-100) in an analysis in which probable causality to HPV type was assigned in lesions infected with multiple oncogenic types (ATP-E cohort). Vaccine efficacy against CIN2+ irrespective of HPV DNA in lesions was 30.4% (16.4-42.1) in the TVC and 70.2% (54.7-80.9) in the TVC-naive. Corresponding values against CIN3+ were 33.4% (9.1-51.5) in the TVC and 87.0% (54.9-97.7) in the TVC-naive. Vaccine efficacy against CIN2+ associated with 12 non-vaccine oncogenic types was 54.0% (34.0-68.4; ATP-E). Individual cross-protection against CIN2+ associated with HPV-31, HPV-33, and HPV-45 was seen in the TVC.

INTERPRETATION

The HPV-16/18 AS04-adjuvanted vaccine showed high efficacy against CIN2+ associated with HPV-16/18 and non-vaccine oncogenic HPV types and substantial overall effect in cohorts that are relevant to universal mass vaccination and catch-up programmes.

FUNDING

GlaxoSmithKline Biologicals.