Glucose control in the intensive care unit: how it is done

Hyperglycaemia occurs in the majority of critically-ill patients, partly because patients are hypercatabolic and consequently have increased glucose levels and partly because of insulin resistance. Hyperglycaemia is associated with increased mortality in critical illness. In 2001 it was shown that mortality and other complications of critical illness can be decreased by adopting 'tight' glycaemic control (4.1-6.4 mmol/l). The critical care world adopted tight glycaemic control enthusiastically, until it became apparent that profound life-threatening hypoglycaemia could result. Most clinicians, currently, have adopted regimens aiming to control glucose between 4 and 8 mmol/l. Practising this regimen safely requires attention to detail. Patients must be provided with energy as well as insulin; preferably via the enteral route, but parenterally if necessary. Insulin is administered according to a relatively simple scale that is adjustable by nursing staff according to patients' glucose results. Frequent glucose measurement is essential to success, along with using visual charting that makes sudden changes in blood glucose levels obvious. There are several 'champions' of safe implementation of glucose control in the intensive care unit at the Royal Liverpool University Hospital who are educators and who feed results back to staff regularly. Further studies will clarify the ultimate role of tight glycaemic control, but it can be done safely with meticulous attention to detail.

Antibiotic and infection tracking in Minnesota long-term care facilities

OBJECTIVES

To describe current systems used to track infections, antibiotic use, and antibiotic-resistant infections in Minnesota long-term care facilities (LTCFs).

DESIGN

Self-administered multiple-choice survey assessing the methods, frequency, content, and dissemination of information used to track infections and antibiotic use.

SETTING

Licensed Minnesota LTCFs providing skilled nursing care to geriatric residents as of June 2005.

PARTICIPANTS

Surveys addressed to the director of nursing at 393 eligible LTCFs.

MEASUREMENTS

Responses to survey questions, assessed by percentage of all responders. Of the 345 surveys returned, the majority had a system to track infections (94.1%), antibiotics prescribed (80.6%), and antibiotic-resistant infections (86.2%). Most facilities used only a nonelectronic format to track antibiotic use (73.4%) and antibiotic-resistant infections (72.4%). Respondents collected information on antibiotic susceptibility results from cultures of blood (49.0%), urine (53.0%), sputum (50.0%), or wounds (50.0%). One third of attending clinicians were routinely informed of trends in facility antibiotic use. In 42% of facilities, less than 5 hours per month of paid time for an infection control practitioner was provided. Two-thirds of responders (64.2%) described their systems as not or somewhat effective at optimizing appropriate antibiotic use in their facilities.

CONCLUSION

Most facilities in Minnesota have a system in place to track infections, antibiotic use, and antibiotic resistance. These systems may not collect or disseminate information effectively enough to identify or address the development of antibiotic resistance. Paid infection control practitioner time is limited.

Portable digital assistants (PDAs) in dentistry: part II--pilot study of PDA use in the dental clinic

AIM

To describe a simple technical evaluation of the access, security issues and uses of wireless networked PDAs in a dental clinic and report a pilot study investigating students' educational use of PDAs to access a Virtual Learning Environment (VLE) in a dental clinic.

OBJECTIVES

To undertake a technical evaluation of wireless networking to PDAs focusing on security issues, robustness of the system and accessibility particularly to educational resources. To evaluate the impact of using a PDA on undergraduate students in the dental clinic and at home.

DESIGN

Part II describes the technical and educational evaluation of PDAs used by one group of 12 undergraduate fourth year students in the Primary Dental Care clinic. A cross over trial of six students with PDAs and six without was carried out during one semester of 12 weeks.

METHODS

Technical issues such as secure internet access using wireless connectivity were addressed. An assessment of the general and educational use and the students' attitudes towards using PDAs was undertaken using online questionnaires and focus group discussions.

RESULTS

Over 90% of participants wanted PDAs as part of their dental kit. The potential of PDA use in dental training was demonstrated by a good to excellent response by over 75% of participants to having access to online support materials, particularly videos, being able to make notes for individual study and to keep a diary of their commitments to teaching sessions. Recreational use included a 100% good to excellent response to playing games and keeping a diary.

CONCLUSION

The PDA proved to be a convenient and versatile mode of access to online education. Technical solutions enabled a substantial proportion of the functionality of WebCT (Web Course Tools) to be accessed by the students in a clinical environment. Both novice and experienced users were able to appreciate the use of the PDA and the less able considered that their ICT skills had improved. However, further research is needed to determine how students use a range of new technologies in their undergraduate programmes. The Dental Institute plans to recommend that all students will use this device in the future throughout their five-year curriculum, and the scoping of the implications of this recommendation is underway.

Portable Digital Assistants (PDAs) in dentistry: Part I

AIM

To provide a basic understanding of the features of a portable digital assistant (PDA) and how it may be useful for the general dental practitioner.

OBJECTIVES

To outline the various types, functions and applications of a PDA and suggest its use for the dental professional now and in the future. To enable appreciation of the technology and educational evaluation carried out in the pilot study reported in Part II.

DESIGN

Part I is a descriptive account of the use and function of the PDA in dentistry and its potential for the future.

METHOD

A review of the literature was carried out drawing on evidence from general healthcare and assessments of portable computing aids evaluated in a dentally related setting. RESULTS Choosing a PDA for use in dental practice is complex but should be based on the user's needs mapped to key features, size and cost of the device.

CONCLUSION

No ideal customisable mobile digital solution currently exists but evidence from general healthcare use suggests that there are valuable features that can aid the general dental practitioners such as personal management and point of source assistance.

Views of BRCA gene mutation carriers on preimplantation genetic diagnosis as a reproductive option for hereditary breast and ovarian cancer

BACKGROUND

In May 2006, the UK Human Fertilization and Embryology Authority (HFEA) approved use of preimplantation genetic diagnosis (PGD) for lower penetrance, late onset cancer susceptibility syndromes such as hereditary breast and ovarian cancer (HBOC). This is the first report on views of BRCA gene mutation carriers on use of PGD for HBOC.

METHODS

Between December 2005 and February 2006, a postal survey of BRCA mutation carriers attending a Familial Cancer Clinic was undertaken.

RESULTS

Of 102 women sent questionnaires, 52 (51%) responded. Thirty-nine (75%) felt it was acceptable to offer PGD for HBOC. Fifteen (37.5%) of 40 who had completed their families would personally have considered PGD if it had been available. Only one of seven (14%) contemplating a future pregnancy would consider PGD. Eighteen (35%) wrote extensively about their concerns including increasing availability of effective treatment and good quality of life.

CONCLUSIONS

The majority of BRCA gene mutation carriers are supportive of offering PGD to others, thus endorsing the HFEA decision. However, most women would not consider it personally. Concerns raised highlight the need for regular HFEA reviews of the licensing criteria, as HBOC may cease to be a "serious life threatening illness" in the future.

Treatment of patients with atopic dermatitis using wet-wrap dressings with diluted steroids and/or emollients. An expert panel's opinion and review of the literature

BACKGROUND

The use of dampened bandages to reduce inflamed eczema (synonyme dermatitis) is an old remedy. In order to evaluate the current indications for so-called wet-wrap treatment (WWT) for atopic dermatitis (AD), and to compare the different currently recognized methods, a group of experts critically reviewed their own expertise on WWT in respect to the existing literature on the subject.

RESULTS

WWT is well tolerated in eczema due to the cooling effect on the skin and the rapid improvement in skin inflammation. It has been shown to be an extremely effective treatment for acute erythrodermic dermatitis, therapy-resistant AD and intolerable pruritus. Advantages of WWT include rapid response to therapy, reduction in itch and sleep disturbance, and potential for reduction in usage of topical corticosteroids (TCS). However, disadvantages include high cost, the necessity for special training in usage, potential for increased TCS absorption, increased cutaneous infections and folliculitis, and poor tolerability. Precautions to reduce the risks of long-term treatment should include education, monitoring of weight and height and, if necessary, serum cortisol levels. In adolescents the risk of striae from TCS absorption around puberty is high, and WWT with TCS in this age group should be used as a short-term therapy only and with extreme caution. To reduce risks, dilutions of steroids may be used ranging from 5 to 10%. In the maintenance phase this treatment can be rotated with the use of emollients only. Low potency TCS should be used on the face (with a mask).

CONCLUSION

WWT using diluted steroids is a relatively safe addition to the therapeutic treatment options for children and adults with severe and/or refractory AD. Explanation and education is extremely important in the treatment of AD and WWT should only be employed by practitioners trained in its use. Specialized nursing care is essential, especially when using WWT for prolonged periods.

Peripherally inserted central catheters and upper extremity deep vein thrombosis

The purpose of the study was to determine the incidence and risk factors for venous thrombosis in patients with a peripherally inserted central catheter (PICC). A retrospective study of all upper extremity venous duplex scans was carried out in the Vascular Medicine department from year 2000 to 2002 inclusive. A chart review of positive scans was undertaken to identify possible thrombotic risk factors. Of 317 upper extremity venous duplex scans carried out, 115, or 32%, were positive for upper extremity deep vein thrombosis. Three main risk factors were identified - presence of a central line, malignancy and administration of chemotherapy. PICC were the most common central line present. Symptomatic thrombosis occurred in 7% of PICC inserted for chemotherapy compared with 1% of PICC inserted for other reasons. Ten per cent of the patients receiving chemotherapy through a PICC developed a thrombosis. The post-thrombotic syndrome was infrequent following upper extremity deep vein thrombosis. Patients receiving chemotherapy through a PICC are at increased risk of thrombosis. There may be a role for prophylactic low-dose anticoagulation in these high-risk patients.

Comparison of the efficacy of an existing versus a locally developed metabolic fingerprint database to identify non-point sources of faecal contamination in a coastal lake

A comparison of the efficacy of an existing large metabolic fingerprint database of enterococci and Escherichia coli with a locally developed database was undertaken to identify the sources of faecal contamination in a coastal lake, in southeast Qld., Australia. The local database comprised of 776 enterococci and 780 E. coli isolates from six host groups. In all, 189 enterococci and 245 E. coli biochemical phenotypes (BPTs) were found, of which 118 and 137 BPTs were unique (UQ) to host groups. The existing database comprised of 295 enterococci UQ-BPTs and 273 E. coli UQ-BPTs from 10 host groups. The representativeness and the stability of the existing database were assessed by comparing with isolates that were external to the database. In all, 197 enterococci BPTs and 179 E. coli BPTs were found in water samples. The existing database was able to identify 62.4% of enterococci BPTs and 64.8% of E. coli BPTs as human and animal sources. The results indicated that a representative database developed from a catchment can be used to predict the sources of faecal contamination in another catchment with similar landuse features within the same geographical area. However, the representativeness and the stability of the database should be evaluated prior to its application in such investigation.

Patterns of food allergen-specific cytokine production by T lymphocytes of children with multiple allergies

BACKGROUND

The contribution of different T cell subsets to the overall measured cytokine response to food allergens is largely unexplored.

METHOD

The patterns of cytokine production of peripheral blood-derived T cells after allergen stimulation were studied in 22 children with multiple food allergies and in 20 non-allergic children as controls, using flow cytometry.

RESULTS

Proportions of T cells of food-sensitized children spontaneously secreting IFN-gamma and IL-10 (without antigen stimulation) were lower than non-atopic children and adult controls (P<or=0.001). The proportions of IL-4-producing cells in vitro were significantly increased (P<or=0.04) and IFN-gamma-producing cells were significantly reduced (P<or=0.05) in sensitized children after incubation with and without dendritic cell presentation of peanut extract, beta-lactoglobulin and ovalbumin. The reverse pattern was found in non-sensitized children and adult controls. IL-4 secretion in allergic children to sensitizing allergens was mainly restricted to the CD4(+) CD45 RO(+) population while in non-atopic controls both CD4(+) and CD8(+) CD45 RO(+) cells produced mostly IFN-gamma. Food-specific IgE values did not correspond with cytokine responses but IL-4 production and IFN-gamma reduction relative to normal children were closely associated with total IgE levels.

CONCLUSION

Food-allergic children's IL-4 cytokine response to their relevant allergens is predominantly from a memory population of CD4(+) CD45 RO(+) cells, whereas IL-4 and IFN-gamma secretion of non-allergic controls was predominantly from mixed CD4(+) and CD8(+) CD45 RO(+) populations.

Is the E133K allele of VG5Q associated with Klippel-Trenaunay and other overgrowth syndromes?

BACKGROUND

It has been reported that the activating mutation, E133K, in the angiogenic factor VG5Q (formally named AGGF1) causes Klippel-Trenaunay Syndrome (KTS), a rare vascular disease associated with asymmetric overgrowth. This proposal followed from the observation that five out of 130 KTS patients were constitutionally heterozygous for VG5Q, E133K.

OBJECTIVE

To explore the possibility that VG5Q, and specifically E133K, is implicated in other mosaic overgrowth syndromes.

RESULTS

24 patients were analysed for this sequence change. One patient was constitutionally heterozygous for E133K. Analysis of both parents revealed that the patient's mother, who was healthy, also carried E133K. An analysis of 275 healthy controls showed that 3.3% (9/275) of the population were carriers of E133K.

CONCLUSIONS

The findings bring into question the assertion that VG5Q, E133K is a mutation and that it causes KTS.

Bone mineralization in children with epidermolysis bullosa

BACKGROUND

Various factors may have deleterious effects on bone health in patients with epidermolysis bullosa (EB).

OBJECTIVES

In a retrospective notes review, to assess bone mineralization in children with EB and to identify the relative contributions of nutrition, activity and disease severity to low bone mass.

METHODS

Thirty-nine children with EB [32 recessive dystrophic EB (RDEB), four Dowling-Meara EB simplex (DMEBS) and three junctional EB (JEB)] had lumbar spine bone mass measured using dual X-ray absorptiometry (GE Lunar Prodigy; GE Healthcare, Chalfont St Giles, U.K.). Seventy-six healthy children were also studied. Weight and height were recorded and mobility was rated.

RESULTS

Children with RDEB and JEB, but not those with DMEBS, had lower bone mineral density SD scores than controls; differences remained after adjusting for the smaller body size of the patients. Bone mass was best predicted by mobility rating.

CONCLUSIONS

Children with RDEB and JEB have low bone mass after adjusting for their smaller size, which may put them at risk for fragility fractures. Low bone mass was best predicted by the level of mobility, raising the hypothesis that improving activity or bone loading may be a potential preventive intervention in these children. However, as low bone mass may be multifactorial in these children, more detailed investigation of potential aetiological factors is required before interventions are planned.