Improvement in intraoperative fresh frozen plasma transfusion practice--impact of medical audits and provider education

OBJECTIVE

To determine the practice of anaesthesiologists in our institution for intraoperative transfusion of Fresh Frozen Plasma (FFP) and to see whether provider education can reduce the incidence of inappropriate FFP transfusion.

MATERIAL AND METHODS

A retrospective audit was done for 6 months in all patients who received intraoperative FFP transfusion. The result were compared with recommendations by the British Committee for Standards in Haematology. These results were presented in the departmental meeting and guidelines were circulated. Another prospective audit was conducted for six months to see whether there was any effect of provider education on the intraoperative transfusion practice.

RESULTS

The first audit showed that 14.6% of the transfusion were definitely indicated, 40.2% were conditionally indicated whereas there was no justification in 45.1%. The subsequent audit showed a significant reduction (23.3%) in the unjustified transfusions of FFP whereas conditional use was significantly increased (69.1%), showing an overall improvement in the intraoperative transfusion practice.

CONCLUSION

Further education and a monitoring system to ensure adherence to the recommended guidelines is required to improve transfusion practice.

Predictors of tobacco and alcohol consumption and their relevance to oral cancer control amongst people from minority ethnic communities in the South Thames health region, England

The purpose of this study was to examine the determinants of the health behaviour of ethnic groups in relation to alcohol and tobacco use. A cross-sectional questionnaire survey was carried out using network sampling amongst community groups in the South Thames region of the United Kingdom. Self-classified ethnic groups were identified: Black-African; Black-Caribbean; Indian; Pakistani; Bangladeshi and Chinese/Vietnamese. A total of 1113 people were recruited in the study. In all of the ethnic groups, men were more likely than women to smoke tobacco. Chewing of pan and tobacco was common in the South Asian communities and alcohol consumption was high among the Black-Caribbean group. Those factors were predicted by education, employment, gender and being born in the UK. It is important to examine the determinants of such risk behaviours in order to aid appropriate targeting of health promotion interventions, particularly those related to cancer control.

Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study

BACKGROUND

The current study was designed to examine whether a combination of three nutrients, consisting of beta-hydroxy-beta-methylbutyrate (HMB), a metabolite of leucine, L-glutamine (Gln) and L-arginine (Arg), each of which has been previously shown to slow muscle proteolysis, could synergistically alter the course of muscle wasting in patients with established acquired immunodeficiency syndrome (AIDS).

METHODS

Sixty-eight human immunodeficiency virus (HIV)-infected patients with a documented weight loss of at least 5% in the previous 3 months were recruited from the HIV clinic at Nassau County Medical Center. The subjects were randomly assigned in a double-blind fashion to receive either placebo containing maltodextrin or the nutrient mixture (HMB/Arg/Gln) containing 3 g HMB, 14 g L-glutamine, and 14 g L-arginine given in two divided doses daily for 8 weeks. Body weights (BW) were recorded weekly and lean body mass (LBM) and fat mass (FM) were measured by air displacement plethysmography and by a single computerized tomography (CT) slice through the thigh at 0, 4, and 8 weeks.

RESULTS

Forty-three subjects completed the 8-week protocol, (placebo, n = 21; HMB/Arg/Gln, n = 22). At 8 weeks, the subjects consuming the HMB/Arg/Gln mixture gained 3.0 +/- 0.5 kg of BW while those supplemented with the placebo gained 0.37 +/- 0.84 kg (p = .009). The BW gain in the HMB/Arg/Gln-treated subjects was predominantly LBM (2.55 +/- 0.75 kg) compared with the placebo-supplemented subjects who lost lean mass (-0.70 +/- 0.69 kg, p = .003). No significant change in FM gain was observed (0.43 +/- 0.83 kg for the group receiving HMB/Arg/Gln and 1.07 +/- 0.64 kg for the group receiving the placebo, p > .20). Similar percentage changes in muscle mass and fat mass were observed with CT scans. Immune status was also improved as evident by an increase in CD3 and CD8 cells and a decrease in the HIV viral load with HMB/Arg/Gln supplementation.

CONCLUSIONS

The data indicate that the HMB/Arg/Gln mixture can markedly alter the course of lean tissue loss in patients with AIDS-associated wasting.

Diaphragmatic rupture: A complication of violent cough

The cough is a complex physiologic response designed to protect airways from unwanted secretions and foreign materials. Violent and paroxysmal coughs are associated with many complications. In this article, we will discuss a patient who sustained diaphragmatic rupture as a result of violent coughing. The possible mechanisms of this rare complication are explained.

Dental caries and treatment experience of adults from minority ethnic communities living in the South Thames Region, UK

OBJECTIVE

To describe the dental caries and treatment experience of groups of adults from minority ethnic communities living in the South Thames Region of England.

DESIGN

Cross-sectional clinical study.

SETTINGS

Community, religious and educational centres for adults from minority ethnic communities.

PARTICIPANTS

Snowball sample of 928 adults from 44 ethnic groups including: Black Caribbean (141), Black African (134); Pakistani (123); Indian (190); Bangladeshi (78); Chinese/Vietnamese (143) and 119 from other groups.

RESULTS

More participants were dentate or had 18 or more sound and untreated teeth than adults living in the same area (Todd and Lader, 1991). Duration of residence in the United Kingdom predicted caries or treatment experience in the sample as a whole and in Chinese/Vietnamese people. Increased DMFT was predicted by age and by history of visiting a UK dentist in the sample as a whole and in the Black African group.

CONCLUSIONS

Effect of duration of UK residence on presence and extent of caries suggests that oral health may be better among adults from these ethnic minority groups than among the general population. However, the differences can also be attributed to sampling bias and old comparison data. Better sampling strategies are required for research of this type.

Comparison of thiopentone sodium and propofol for electro convulsive therapy (ECT)

OBJECTIVE

For safe conduct of electro convulsive therapy (ECT), general anaesthesia is administered to the patients. In this study we compared thiopentone sodium and propofol as induction agents for ECT.

PATIENTS AND METHODS

Twenty five patients each undergoing at least 2 sessions of ECT at the psychiatry department were included in the study. Each patient either received thiopentone or propofol for induction of sleep in a randomized manner. Drugs were evaluated regarding their effects on ECT induced haemodynamic changes (Blood pressure, Heart rate), seizure duration related to the procedure and recovery from sleep. Any side effects during the procedure and recovery were also noted.

RESULTS

Propofol offered a superior haemodynamic stability during the procedure and a quick recovery from sleep.

CONCLUSION

Propofol was found to be a better induction agent for ECT compared to thiopentone sodium.

Effect of cricoid pressure on the incidence of nausea and vomiting in the immediate postoperative period

This study aimed to evaluate whether the application of cricoid pressure at the time of induction of anaesthesia was associated with a lesser incidence of postoperative nausea or vomiting in the immediate postoperative period compared with a group in which no cricoid pressure was applied, in patients undergoing day care gynaecological laparoscopy. One hundred ASA I and II females were randomly allocated to receive cricoid pressure at the time of induction. The peri-operative anaesthetic technique was standardised. The incidence of postoperative nausea and vomiting in the group who received cricoid pressure was 16% in the recovery room compared with 26% in the no cricoid group. When the period was extended to the first 6 h post anaesthesia the incidence was 30% in the cricoid and 44% in the no cricoid group. This difference did not achieve statistical significance in either period (p > 0.05). The results suggest that application of cricoid pressure at the time of induction does not significantly alter the incidence of postoperative nausea and vomiting in the first 6 h of recovery from anaesthesia.

Cultural barriers to successful communication during orthodontic care

OBJECTIVE

To determine to what extent barriers related to culture and language, and how inappropriate expectations might impede orthodontic care, among Pakistani Muslims when compared to white Caucasians from similar socio-economic backgrounds in Bradford, UK.

DESIGN

Semi-structured interviews.

SETTING

Dentists were interviewed in the clinic. Parents and children were interviewed separately in the waiting room or in adjacent rooms depending on availability.

PARTICIPANTS

Four dentists working in the Community and Hospital Dental Services, 30 children and 10 parents of white and Pakistani origin.

RESULTS

Among the white Caucasian groups, three-way communication involving parents, children and dentist enhanced understanding, supported orthodontic treatment and reinforced the need for good home care. Among Pakistani families communication was primarily two-way, involving the dentist and the child. Parents and families had limited understanding of the process and were unable to offer a comparable level of support that would benefit their children most. This can place additional burdens on the Pakistani child patient and requires a very positive approach from the dental team.

CONCLUSIONS

There is a clear need for chairside support, through patient advocates or interpreters, as well as the provision of appropriate educational material to match parents' educational needs on behalf of their children.

Paget's disease of the bone

Full text is available as a scanned copy of the original print version.

Inclusion of entire pancreas in the composite liver and intestinal graft in pediatric intestinal transplantation

An entire pancreatico-duodenal complex was included in the liver and intestinal graft in eight children who received small-size grafts. This method showed several advantages compared to the traditional approach. They included reducing time for graft preparation by eliminating donor pancreas resection, no necessity of biliary reconstruction and leaving natural tissue support for blood vessels. The method was not associated with an increased risk of complications such as pancreatitis or rejection. It should be considered in pediatric liver and intestinal transplant recipients who require small-size grafts.

Genomic organization and promoter activity of glucosidase I gene

Glucosidase I initiates the processing of asparagine (N-) linked glycoproteins by removing the distal alpha1,2-linked glucosyl residue of the tetradecasaccharide Glc(3)Man(9)GlcNAc(2). The gene encoding this enzyme was isolated and its structural organization and promoter activity determined. The major transcript for glucosidase I on northern blot appeared to be 3.1 kb; Southern blotting and DNA sequencing indicated the size of the gene to be 6.8 kb, comprising four exons separated by three introns. The first exon encodes the cytoplasmic tail and transmembrane domain; the fourth encodes the putative catalytic domain of the enzyme. Exon-intron junctions are flanked by consensus splice donor and acceptor sequences. Transcription initiation sites were mapped by primer extension, ribonuclease protection assay and RT-PCR analysis. Primer extension results showed multiple initiation sites at -150, -156, and -272 bp relative to the translation initiation codon ATG. Sequence analysis of 5' flanking region showed no canonical TATA box, a high GC content, Sp1 and ETF binding sites (typical of a housekeeping gene promoter). Also noteworthy, the promoter region contains several generic STAT factor binding sites, one nearly perfect, and two half GR binding elements. Other cis- acting elements recognized by transcription factors such as AP-2, NF-kappaB, estrogen receptor, and progesterone receptor (PR) were also present in the putative promoter region. To determine the promoter activity, a construct encompassing the region between -2114 to -5 bp of the putative promoter was ligated to the chloramphenicol acetyltransferase (CAT) reporter plasmid and transiently transfected into COS 7 cells. CAT assay results clearly show transcriptional activity of the promoter.

Comparative anthelmintic activity of strategic sustained low-level administration of albendazole in feed pellets compared to single doses of closantel and tetramisole against natural ovine parasitic gastroenteritis

The strategic use of single therapeutic doses of closantel, tetramisole or sustained low-level administration of albendazole in feed pellets in controlling naturally acquired parasitic gastroenteritis in sheep was investigated on a farm in semi-arid Rajasthan, India. A total of 303 5- to 6-month-old sheep were divided into three groups. Two groups were dosed with single therapeutic doses of closantel and tetramisole and the third group was given a low-level medication with albendazole through feed pellets for 30 days. Faecal egg counts revealed significantly lower counts (p<0.001) in the group treated with closantel compared to the other two groups. The faecal egg counts in the group receiving sustained low-level albendazole rose after withdrawal of the medication but remained significantly lower than those in the group treated with tetramisole up to 7 weeks after treatment (p<0.05). On the other hand, in the group treated with tetramisole, the mean faecal egg count rose from 3 weeks after treatment and remained continuously higher than those in any other group up to 12 weeks after treatment. The closantel-treated group gained more body weight but the first six-monthly greasy fleece yield was greater in the group treated with medicated pellets. During the first 3 months of the experiment, three animals in the group treated with tetramisole died of parasitic gastroenteritis. Following sustained low-level administration of albendazole in feed pellets, the plasma disposition curve of both the sulphoxide and sulphone metabolites reached its plateau level by day 5 and remained almost constant thereafter. The comparative cost-effectiveness of the three treatment regimes during the first 3 months of treatment was best for the group treated with closantel followed by the group treated with medicated feed pellets.

Influence of diet type and pretreatment fasting on the disposition kinetics of albendazole in sheep

The influence of the quality and quantity of diets on the disposition kinetics of albendazole were studied in sheep in two different experiments. The plasma concentration profiles of albendazole sulphoxide and albendazole sulphone were measured following intraruminal administration of albendazole at 5.0 mg/ kg body weight in weaner sheep offered three different diets: 100% green Sorghum spp., 100% dry mature Cenchrus ciliaris hay and a 50:50 mix of these two diets. The peak plasma concentrations and the availability of the albendazole metabolites, as measured by the area under the concentration time curve, were significantly higher (p < 0.01) in the animals offered exclusively dry fodder compared to other diets. Changing the diet from dry to green fodder resulted in a significantly lower systemic availability of the drug metabolites. It is suggested that a decreased transit time of the digesta in the bowel on the green diet, with its high water content, limited the systemic availability of the drug by reducing the time available for gastrointestinal absorption. An experiment on the influence of different levels of pretreatment fasting on the pharmacokinetics of albendazole revealed significantly higher (p < 0.05) plasma concentrations of the anthelmintically active sulphoxide metabolite from 12 h onwards following administration of the drug in animals subjected to 24 h of pretreatment fasting compared to other groups with pretreatment fasting of 8, 12 or 18 h. The area under the concentration time curve and the minimum residence time of the drug metabolites were significantly greater (p < 0.05) in animals that had been fasted for 24 h. It is suggested that fasting induces a decrease in the flow of digesta through the gastrointestinal tract of ruminants and prolongs the duration of dissolution of the drug, resulting in enhancement of the absorption of albendazole and of the systemic availability of its metabolites.

Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients

BACKGROUND

Some critically ill patients have difficulty in mobilizing their respiratory secretions. These patients can develop pulmonary atelectasis that may result in hypoxemia. There are some data to show that atelectasis may be prevented by turning a patient from side to side utilizing special beds.

STUDY OBJECTIVES

To determine the role of kinetic therapy (KT) combined with mechanical percussion (P) in the resolution of established atelectasis of the lungs and hypoxemia in critically ill, hospitalized patients. (KT was defined as rotation of a patient along the longitudinal axis of > or = 40 degrees to each side continuously.)

DESIGN

Prospective and randomized study (2:1 test to control group).

PATIENTS

Twenty-four patients with respiratory failure, either mechanically ventilated or spontaneously breathing, who demonstrated segmental, lobar, or unilateral entire lung atelectasis were studied.

SETTING

Medical ICU and adult respiratory ward in a county hospital in New York.

INTERVENTIONS

Seventeen patients were treated with KT combined with mechanical P using a KT system (Triadyne Kinetic Therapy System; KCI; San Antonio, TX). Seven patients received manual repositioning and manual P every 2 h. Both groups received similar conventional therapy with inhaled bronchodilators and suctioning.

RESULTS

Partial or complete resolution of atelectasis was seen in 14 of 17 patients (82.3%) in the test group as compared with 1 of 7 patient (14.3%) in the control group. The median duration to resolution of atelectasis was 4 days in the test group. Bronchoscopy was performed in 3 of 7 patients in the control group, but in none of the patients in the test group. A cost of $720 was incurred per patient for utilizing the specialty beds for a mean duration of 4 days. An improvement in oxygenation index occurred in the test group (change in baseline PaO2/fraction of inspired oxygen from 207.4+/-106.7 mm Hg to 318+/-100.7 mm Hg) at the end of therapy, while the control group showed a reduction over a similar duration of time (181.3+/-96.3 mm Hg to 112+/-21.2 mm Hg).

CONCLUSIONS

KT and mechanical P therapy resulted in significantly greater partial or complete resolution of atelectasis as compared with conventional therapy. There was a generalized trend toward statistical significance in the improvement of oxygenation and a reduced need for bronchoscopy in the group receiving KT and P therapy.

Further studies on anthelmintic resistance in sheep at an organised farm in arid region of Rajasthan

Faecal egg count reduction test (FECRT) and in vitro egg hatch assay (EHA) was performed on Indian Karakul (3/4 crosses of Karakul with Malpura, Marwari and Sonadi) transported from arid region campus, Bikaner, where resistance was reported in 1996. FECRT revealed that fenbendazole and levamisole were 100% effective in reducing the egg counts. LC50 value on EHA was 0.074 +/- 0.015 microg thiabendazole ml(-1). The faecal culture examination revealed the presence of Haemonchus contortus only. It was concluded that H. contortus was fully susceptible to both benzimidazole and levamisole.

Role of bronchoscopy in AIDS

The differential diagnosis of pulmonary disorders in the HIV-infected individual is broad. Clinical features and chest radiographs may point towards a diagnosis but cannot reliably establish one. It is important to know the conditions in which bronchoscopy, BAL, and TBB are likely to be diagnostic, just as it is to know when other invasive or noninvasive procedures may be more useful. Finally, the incidence of transmission of infections such as tuberculosis during bronchoscopy and cross-contamination of patients with an improperly sterilized bronchoscope, cannot be overemphasized.

Beta-endorphin-like immunoreactivity in the forebrain and pituitary of the teleost Clarias batrachus (Linn.)

The organization of beta-endorphin-like immunoreactivity in the olfactory system, forebrain, and pituitary of the teleost Clarias batrachus was investigated. Immunoreactivity was prominently seen in the sensory neurons and basal cells in the olfactory epithelium and in some cells in the periphery and center (granule cells) of the olfactory bulb. Immunoreactive fibers in the olfactory nerve enter the olfactory nerve layer of the olfactory bulb and branch profusely to form tufts organized as spherical neuropils in the glomerular layer. While fascicles of immunoreactive fibers were seen in the medial olfactory tracts, the lateral olfactory tracts showed individual immunoreactive fibers. Immunoreactive fibers in the medial olfactory tract extend into the telencephalon and form terminal fields in discrete telencephalic and preoptic areas; some immunoreactive fibers decussate in the anterior commissure, while others pass into the thalamus. While neurons of the nucleus lateralis tuberis revealed weak immunoreactivity, densely staining somata were seen at discrete sites along the wall of the third ventricle. Although a large population of immunoreactive cells was seen in the pars intermedia of the pituitary gland, few were seen in the rostral pars distalis and proximal pars distalis; immunoreactive fibers were seen throughout the pituitary gland.

Prevalence of macrovascular complications in diabetics of WAH, District Rawalpindi

OBJECTIVE

To determine the prevalence of macrovascular complications in diabetic subjects with relation to age duration of diabetes and metabolic control.

SETTING

Primary care centres of WAH, District Rawalpindi cross sectional population based study.

METHODS

A total of 805 known diabetics (380 males and 425 females) were studied. Relevant history, detailed physician examination and ECG were done to assess the presence of ischaemic heart disease, stroke and diabetic foot complications. Their diabetic control was assessed by estimation of their plasma glucose and glycosylated haemoglobin.

RESULTS

The prevalence of macrovascular complications was as follows: Ischaemic heart disease 19.8% (female 4.7%, males 7.8%), cerebrovascular disease 6.2% (females 4.7%, males 22.1%) and diabetic foot complications 2.1%. The macrovascular complications increased with age, duration of diabetes and were more prevalent in uncontrolled diabetics having glycosylated haemoglobin > 8.6%.

CONCLUSION

Prevalence of macrovascular complication in our population is higher as compared to the West probably due to better management and diabetic care in those countries.

Patients view of the anaesthetist in a developing country

OBJECTIVE

The objective of this study was to assess patients regarding their knowledge and perception of the anaesthetists' role in patient care in a developing country.

SETTING

The audit was conducted at the Aga Khan University Hospital, Karachi.

METHODS

Two hundred surgical and 102 medical out-patients were included in the audit prospectively who filled a detailed questionnaire.

RESULTS

Fifty-six percent of the patients knew that anaesthetists were medically qualified but only 20% and 27% had an idea about their role in the intraoperative and immediate postoperative period. 14.6% were aware of the anaesthetists role outside the operating room. No difference was observed between the two groups of patients except that a higher percentage of surgical patients were interested in having more information regarding anaesthesia and wanted to choose their anaesthetist if the need arose. Gender difference was observed in answer to two questions only. A higher percentage of males know the role of anaesthetist in the recovery room whereas a greater number of females who had surgery before remembered their anaesthetist postoperatively.

CONCLUSION

The results of this audit show a poor perception of the anaesthetists role both inside and outside the operating room. Although public knowledge surveys have been carried out in developed countries there is a pressing need to repeat these in developing countries since the image as perceived by public may have a direct bearing on the recruitment of young doctors into an already shortage specialty in these less affluent countries.

Comparative disposition kinetics of albendazole in sheep following oral and intraruminal administration

The pharmacokinetics of albendazole was studied in sheep following single oral and intraruminal administration at nematocidal dose rates. The disposition curves of its metabolites indicated increased uptake of the drug in sheep following intraruminal as compared to oral dosing (p < 0.05). The increased bioavailability of benzimidazole anthelmintics given by the intraruminal route could be exploited for optimizing the use of anthelmintic for sustained parasite control in small ruminants.

Staphylococcus capitis causing aortic valve endocarditis

Coagulase-negative staphylococci have been implicated in certain human infections but are generally considered to be contaminants. Although their clinical significance has been questioned, rare species of coagulase-negative staphylococci such as Staphylococcus capitis and Staphylococcus ludgunensis have recently emerged which cause endocarditis with high morbidity and mortality rates. We report a case of severe aortic valve endocarditis with conduction delays due to S. capitis infection which was treated successfully with antibiotics.

Truncated N-terminal fragments of huntingtin with expanded glutamine repeats form nuclear and cytoplasmic aggregates in cell culture

Huntington's disease (HD) is a progressive neurodegenerative disorder caused by an expanding CAG repeat coding for polyglutamine in the huntingtin protein. Recent data have suggested the possibility that an N-terminal fragment of huntingtin may aggregate in neurons of patients with HD, both in the cytoplasm, forming dystrophic neurites, and in the nucleus, forming intranuclear neuronal inclusion bodies. An animal model of HD using the short N-terminal fragment of huntingtin has also been found to have intranuclear inclusions and this same fragment can aggregate in vitro . We have now developed a cell culture model demonstrating that N-terminal fragments of huntingtin with expanded glutamine repeats aggregate both in the cytoplasm and in the nucleus. Neuroblastoma cells transiently transfected with full-length huntingtin constructs with either a normal or expanded repeat had diffuse cytoplasmic localization of the protein. In contrast, cells transfected with truncated N-terminal fragments showed aggregation only if the glutamine repeat was expanded. The aggregates were often ubiquitinated. The shorter truncated product appeared to form more aggregates in the nucleus. Cells transfected with the expanded repeat construct but not the normal repeat construct showed enhanced toxicity to the apoptosis-inducing agent staurosporine. These data indicate that N-terminal truncated fragments of huntingtin with expanded glutamine repeats can aggregate in cells in culture and that this aggregation can be toxic to cells. This model will be useful for future experiments to test mechanisms of aggregation and toxicity and potentially for testing experimental therapeutic interventions.

FMRFamide-like immunoreactivity in the olfactory system responds to morphine treatment in the teleost Clarias batrachus: involvement of opiate receptors

In view of the close relationship between the FMRF-related peptides and the central opiate-sensitive system, we investigated the effects of morphine, alone and in combination with naloxone, on the FMRFamide-like immunoreactivity in the olfactory system of the teleost, Clarias batrachus. In the olfactory system of normal and untreated fish, FMRFamide-like immunoreactivity was confined to the ganglion cells and fibers of the terminal nerve; the cells in the olfactory epithelium per se or the olfactory nerve were not immunoreactive. Intensely immunoreactive cells appeared in the olfactory epithelium following 2 h of intracranial morphine administration. FMRFamide-like immunoreactivity also appeared in the olfactory nerve fibers as they ran caudally and arborized in the glomerular layer of the bulb. However, immunoreactivity in the ganglion cells of the terminal nerve and the ensuing fibers was abolished, suggesting the transport/release of the immunoreactive material. Pretreatment with naloxone, a potent opiate receptor antagonist, reversed the effects of morphine, suggesting the involvement of opiate receptors in the regulation of the ganglion cells of the terminal nerve. The results provide initial immunocytochemical evidence in favor of a relationship between the opiates and FMRFamide-containing systems within the framework of the olfactory system.