Prognostic usefulness of white blood cell count on admission and one-year outcome in patients with non-ST-segment elevation acute chest pain

Little is known about the prognostic value of leukocyte count on admission for patients with chest pain. In total, 1,461 patients who presented to the emergency department with non-ST-segment elevation chest pain were studied by clinical history, electrocardiography, serial troponin I determination, and leukocyte count on admission. End points were 1-year mortality and major events (mortality or infarction). Overall patient distribution by quartiles of leukocyte count showed increased mortality (6%, 7%, 6%, and 17%, p = 0.0001) and major events (13%, 13%, 15%, and 24%, p = 0.0001) in the fourth quartile. After adjustment for other risk factors, the fourth quartile cut-off value (>10,000 cells/ml) predicted mortality (hazard ratio 2.0, 95% confidence interval 1.4 to 2.8, p = 0.0001) but not major events (p = 0.07). When analysis was performed to assess troponin status, in the subgroup with increased troponin (n = 634, 16% mortality), a leukocyte count >10,000 cells/ml was related to mortality (hazard ratio 2.2, 95% confidence interval 1.5 to 3.4, p = 0.0001). However, in the subgroup with normal troponin levels (n = 827, 4.2% mortality), there were no differences in mortality between patients with or without a leukocyte count >10,000 cells/ml (4.4% vs 4.2%, p = 0.8), with survival curves showing a tight overlap (p = 0.9). Further, in the subgroup with normal troponin levels, leukocyte count was not significantly different between patients with or without ST depression (7,969 +/- 2,171 vs 8,108 +/- 2,356 cells/ml, p = 0.6) and was not associated with mortality in patients with ST depression (p = 0.7). In conclusion, leukocyte count on admission is predictive of mortality in patients with chest pain and non-ST-segment elevation myocardial infarction. However, in the absence of myocardial necrosis, leukocyte count lacks prognostic value.

Factors affecting recurrence in patients with Crohn's disease under nutritional therapy

PURPOSE

This retrospective study was designed to determine risk factors for recurrence of Crohn's disease under enteral nutrition.

METHODS

The clinical course of 145 patients with Crohn's disease, who were primarily induced into remission by total parenteral nutrition, was reviewed. The patients were classified into two groups: enteral nutrition group (n = 98; >/=1,200 kcal/day of enteral nutrition), or nonenteral nutrition group (n = 47;<1,200 kcal/day of enteral nutrition) according to the amount of their daily elemental or polymeric diet. Contributions of enteral nutrition and other clinical variables to the recurrence were analyzed retrospectively. A Crohn's disease activity index of >150 plus an increase in Crohn's disease activity index of >70 from the baseline value was defined as recurrence.

RESULTS

Forty-two patients in the enteral nutrition group and 29 patients in the nonenteral nutrition group recurred during periods ranging from 3 to 159 months. The cumulative rate of recurrence was significantly higher in the nonenteral nutrition group than in the enteral nutrition group (P = 0.047). Among the Crohn's disease patients in the enteral nutrition group, penetrating type (relative risk, 3.89; 95 percent confidence interval, 1.58-9.62), colonic involvement (relative risk, 3.10; 95 percent confidence interval, 1.39-6.9), and previous history of surgery (relative risk, 2.48; 95 percent confidence interval, 1.16-5.33) were factors that significantly affected recurrence. In contrast, penetrating type was the only possible factor associated with recurrence in the nonenteral nutrition group (relative risk, 2.75; 95 percent confidence interval, 0.96-7.81).

CONCLUSIONS

Among patients with Crohn's disease under maintenance enteral nutrition, the risk of recurrence differs according to the disease type and the site of involvement. The maintenance treatment by enteral nutrition alone seems insufficient for patients with penetrating type or with colonic involvement.

Eosinophilic disorders: molecular pathogenesis, new classification, and modern therapy

Before the 1990s, lack of evidence for a reactive cause of hypereosinophilia or chronic eosinophilic leukemia (e.g. presence of a clonal cytogenetic abnormality or increased blood or bone marrow blasts) resulted in diagnosticians characterizing such nebulous cases as 'idiopathic hypereosinophilic syndrome (HES)'. However, over the last decade, significant advances in our understanding of the molecular pathophysiology of eosinophilic disorders have shifted an increasing proportion of cases from this idiopathic HES 'pool' to genetically defined eosinophilic diseases with recurrent molecular abnormalities. The majority of these genetic lesions result in constitutively activated fusion tyrosine kinases, the phenotypic consequence of which is an eosinophilia-associated myeloid disorder. Most notable among these is the recent discovery of the cryptic FIP1L1-PDGFRA gene fusion in karyotypically normal patients with systemic mast cell disease with eosinophilia or idiopathic HES, redefining these diseases as clonal eosinophilias. Rearrangements involving PDGFRA and PDGFRB in eosinophilic chronic myeloproliferative disorders, and of fibroblast growth factor receptor 1 (FGFR1) in the 8p11 stem cell myeloproliferative syndrome constitute additional examples of specific genetic alterations linked to clonal eosinophilia. The identification of populations of aberrant T-lymphocytes secreting eosinophilopoietic cytokines such as interleukin-5 establish a pathophysiologic basis for cases of lymphocyte-mediated hypereosinophilia. This recent revival in understanding the biologic basis of eosinophilic disorders has permitted more genetic specificity in the classification of these diseases, and has translated into successful therapeutic approaches with targeted agents such as imatinib mesylate and recombinant anti-IL-5 antibody.

Children exposed to environmental smoking have a higher antibiotic consumption

In order to investigate what factors influence antibiotic prescribing, a questionnaire answered by 8700 parents to 4-year-old children in Malmö between 1999 and 2004 was analyzed. 51.3% of the 4-year-old children had been treated with antibiotics. Exposure to environmental smoking, attending day care centers, employment of parents and parents born in Sweden was found to be statistically significant risk factor for antibiotic prescribing. The association between environmental smoking and antibiotic treatment found in this study could be used in information campaigns which might not only lead to a decreased antibiotic prescribing among the children, but also future positive health effects for their parents.

Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy

BACKGROUND

Propofol-mediated sedation for endoscopy is popular because of its rapid onset and recovery profile.

AIM

To examine procedure-specific occurrence and risk factors for cardiopulmonary events during propofol-mediated upper endoscopy (EGD) and colonoscopy.

DESIGN

A cohort study using the Clinical Outcomes Research Initiative database was used to determine the frequency of cardiopulmonary events. Clinical Outcomes Research Initiative consisted of 69 practice sites comprising 593 US endoscopists. Multivariate logistic regression analysis used variables, such as age, ASA classification and propofol administration by monitored anaesthesia care or gastroenterologist-administered propofol to determine the risk of cardiopulmonary events.

RESULTS

The overall cardiopulmonary event rate for 5928 EGDs and 11 683 colonoscopies was 11.7/1000 cases. For colonoscopy, ascending ASA classification was associated with an increased risk. Monitored anaesthesia care was associated with a decreased adjusted relative risk (0.5, 95% CI: 0.36-0.72). ASA I and II patients receiving monitored anaesthesia care for EGD exhibited a significantly lower relative risk (ARR 0.29, 95% CI: 0.14-0.64). For subjects with ASA class III or greater, there was no difference in the risk between monitored anaesthesia care and gastroenterologist-administered propofol.

CONCLUSIONS

There are procedure-specific risk factors for cardiopulmonary events during propofol-mediated EGD and colonoscopy. These should be taken into account during future prospective comparative trials.

Progesterone supplementation to prevent recurrent miscarriage and to reduce implantation failure in assisted reproduction cycles

Implantation failure has been questioned for many cases of recurrent miscarriage and unsuccessful assisted reproduction. The exact cause of implantation failure is not known, but luteal phase defect is encountered in many of these cases. Consequently, women with recurrent miscarriages have been treated with progesterone supplementation with various degrees of success, and a recent meta-analysis has shown trends for improved live birth rates in those women. Progesterone probably acts as an immunological suppressant blocking T-helper (Th)1 activity and inducing release of Th2 cytokines. Numerous studies have confirmed that ovarian stimulation used in assisted reproduction is associated with luteal phase insufficiency, even when gonadotrophin-releasing hormone antagonists are used. In those patients, advanced endometrial histological maturity and a decrease in the concentration of cytoplasmic progesterone receptors are observed. Progesterone supplementation results in a trend towards improved ongoing and clinical pregnancy rates, except in patients treated with human menopausal gonadotrophin-only regimens, in whom ongoing pregnancy rates increase significantly. More randomized controlled trials are needed to increase the power of the currently available meta-analyses to further evaluate progesterone supplementation in both conditions.

Nonpharmacological, somatic treatments of depression: electroconvulsive therapy and novel brain stimulation modalities

Until recently, a review of nonpharmacological, somatic treatments of psychiatric disorders would have included only electroconvulsive therapy (ECT). This situation is now changing very substantially. Although ECT remains the only modality in widespread clinical use, several new techniques are under investigation. Their principal indication in the psychiatric context is the treatment of major depression, but other applications are also being studied. All the novel treatments involve brain stimulation, which is achieved by different technological methods. The treatment closest to the threshold of clinical acceptability is transcranial magnetic stimulation (TMS). Although TMS is safe and relatively easy to administer, its efficacy has still to be definitively established. Other modalities, at various stages of research development, include magnetic seizure therapy (MST), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). We briefly review the development and technical aspects of these treatments, their potential role in the treatment of major depression, adverse effects, and putative mechanism of action. As the only one of these treatment modalities that is in widespread clinical use, more extended consideration is given to ECT Although more than half a century has elapsed since ECT was first introduced, it remains the most effective treatment for major depression, with efficacy in patients refractory to antidepressant drugs and an acceptable safety profile. Although they hold considerable promise, the novel brain stimulation techniques reviewed here will be need to be further developed before they achieve clinical acceptability.

Characterization of Bouveret's syndrome: a comprehensive review of 128 cases

AIM

The aim of the study was to characterize the clinical presentation, evaluation, and therapy of Bouveret's syndrome, by comprehensively reviewing all the identified previously reported cases, to facilitate early diagnosis and thereby to improve the prognosis.

METHODS

Relevant articles were identified by MEDLINE computerized searches, by consultation with all available reference books, and by review of the first author's teaching files. A new case in which the diagnosis of Bouveret's syndrome was missed at esophagogastroduodenoscopy (EGD)--despite endoscopic findings of gastric outlet obstruction caused by a hard, nonfleshy, and convex pyloric mass--prompted this review.

RESULTS

Review of 128 reported cases identified syndromic characteristics. Patients on average were 74.1 +/- 11.1 (SD) yr old. The female-to-male sex ratio was 1.86. Prominent symptoms were nausea and vomiting in 87%, abdominal pain in 71%, hematemesis in 15%, recent weight loss in 14%, and anorexia in 13% of patients. Prominent signs were abdominal tenderness in 44%, signs of dehydration in 31%, and abdominal distention in 26% of patients. Endoscopy revealed gastroduodenal obstruction in nearly all cases, but identified the obstructing stone in only 69%. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.

CONCLUSIONS

The following endoscopic findings are suggestive of Bouveret's syndrome: a dilated stomach containing old digested food from gastrointestinal obstruction together with a hard and nonfleshy mass at the obstruction. These endoscopic findings, in the setting of the currently reported characteristic epidemiologic and clinical findings, should strongly suggest this syndrome. Abdominal ultrasound or computerized tomography is recommended to confirm and extend the endoscopic diagnosis.

Pluripotent stem cells and their niches

The ability of stem cells to self-renew and to replace mature cells is fundamental to ontogeny and tissue regeneration. Stem cells of the adult organism can be categorized as mono-, bi-, or multipotent, based on the number of mature cell types to which they can give rise. In contrast, pluripotent stem cells of the early embryo have the ability to form every cell type of the adult body. Permanent lines of pluripotent stem cells have been derived from preimplantation embryos (embryonic stem cells), fetal primordial germ cells (embryonic germ cells), and malignant teratocarcinomas (embryonal carcinoma cells). Cultured pluripotent stem cells can easily be manipulated genetically, and they can be matured into adult-type stem cells and terminally differentiated cell types in vitro, thereby, providing powerful model systems for the study of mammalian embryogenesis and disease processes. In addition, human embryonic stem cell lines hold great promise for the development of novel regenerative therapies. To fully utilize the potential of these cells, we must first understand the mechanisms that control pluripotent stem cell fate and function. In recent decades, the microenvironment or niche has emerged as particularly critical for stem cell regulation. In this article, we review how pluripotent stem cell signal transduction mechanisms and transcription factor circuitries integrate information provided by the microenvironment. In addition, we consider the potential existence and location of adult pluripotent stem cell niches, based on the notion that a revealing feature indicating the presence of stem cells in a given tissue is the occurrence of tumors whose characteristics reflect the normal developmental potential of the cognate stem cells.

Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial

BACKGROUND AND AIMS

Bispectral (BIS) monitoring provides an objective, non-invasive measure of the level of consciousness in sedated patients. BIS has been shown to lag behind the level of sedation during induction and emergence of sedation with propofol. In this study, we sought to determine whether BIS is a useful adjunctive maneuver to registered nurse-administered propofol sedation (NAPS) as measured by reductions in recovery time and doses of propofol administered.

METHODS

A randomized controlled trial of 102 outpatients presenting for colonoscopy was performed. BIS values were recorded continuously in all subjects. Patients were randomized to receive NAPS with BIS visible to nurse and endoscopist versus BIS invisible to nurse and endoscopist. In phase 1 (47 patients), the nurse and endoscopist team were instructed to consider BIS (when visible) as only adjunctive information with regard to titrating sedation. In phase 2 (55 patients), the nurse endoscopist team was instructed to use BIS as the primary endpoint for titration of sedation, and to target BIS to greater than 60 (60-70 is deep sedation).

RESULTS

In phase 1, the mean (SD) BIS value from scope-in (SI) to scope-out (SO) for BIS was 59.3 (9.9) and was not different from controls at 59.9 (10.1; p= 0.82). The mean (SD) propofol dose (mg/min) was 15.8 (5.6) and 17.2 (6.2) for BIS and controls, respectively (p= 0.45). The mean (SD) recovery time with BIS visible in phase 1 was 20.6 min (5.5) versus 19.2 min (4.5) in controls (p= 0.34). In phase 2, the mean (SD) BIS from SI to SO in those randomized to have BIS visible was 64.1 (5.4) versus 63.1 (8.5) in controls (p= 0.58). The mean (SD) dose of propofol (mg/min) was 16.1 (11.2) and 16.4 (12.3) for BIS and control groups, respectively (p= 0.92). The mean (SD) recovery time in phase 2 with BIS visible was 18.7 (3.5) versus 20.1 (5.6) in controls (p= 0.27).

CONCLUSIONS

BIS did not lead to reductions in mean propofol dose or recovery time when used as an adjunct to NAPS for colonoscopy, or when used as the primary target for sedation. No clinically important role for BIS monitoring as an adjunct to NAPS has yet been established.

Nonsurgical treatment of abdominal or pelvic abscess in consecutive patients with Crohn's disease

BACKGROUND

There is little agreement about the efficacy of nonsurgical treatment for abscess associated with Crohn's disease. Furthermore, there is no study on characteristics of abscess or patient that nonsurgical treatment could be worth trying as initial treatment.

AIMS

To evaluate the outcome of nonsurgical treatment in Crohn's disease-related abscess and identify factor leading to failure of nonsurgical treatment of this complication.

PATIENTS

Twenty-four patients, who consecutively admitted for Crohn's disease-related abscess to our institution during a 7-year period, underwent nonsurgical treatment as initial therapy.

METHODS

Outcome data such as recurrence and intractability, and clinical features were retrospectively analysed. Univariate analysis with patient-related factors and abscess-related factors was performed for risk factor identification.

RESULTS

Median follow-up period was 47.5 months. Of the eligible patients, 19 patients were treated medically and 5 patients underwent percutaneous catheter drainage with medical treatment. Overall success rate of nonsurgical treatment in our centre was 66.7%. The cumulative recurrence rate at 7 months was 12.5%. All recurrences occurred within 7 months from complete resolution on follow-up imaging. Univariate analysis showed that the significant factors which lead to failure of nonsurgical treatment were presence of associated fistula and concurrent steroid use (P=0.019 and P=0.019, respectively).

CONCLUSION

Nonsurgical treatment can be considered as initial treatment modality for the Crohn's disease-related abscess without concurrent steroid therapy or relevant fistula.

Crohn's disease activity index and Vienna classification--is it worthwhile to calculate before surgery?

BACKGROUND

Crohn's disease (CD) patients with increased disease activity may reveal an increased risk for perioperative complications. The "Crohn's disease activity index" (CDAI) and the "Vienna classification" (VC) were developed for standardized disease activity estimations. The significance of these scores to predict extent, type and early outcome of surgery in CD patients was analyzed.

METHODS

In 179 surgically treated CD patients, the CDAI and VC were assessed from a prospective database. Relations of the scores with CD risk factors, type, number, location and complications of surgery were analyzed.

RESULTS

VC behavior and location subtypes were associated with distinct types of surgery (i.e. "strictureplasty" in "stricturing disease", "colon surgery" in "colon involvement"), but not with surgery type and extent or outcome. Surgery extent (i.e. with 5 vs. 3 "surgical sites" 425 +/- 25 vs. 223.3 +/- 25) and complications (357.1 +/- 36.9 (with) vs. 244.4 +/- 13 (without)) were associated with elevated CDAI levels; however, nicotine abuse remained the only significant risk factor for perioperative complications after multiple logistic regression.

CONCLUSION

The significance of VC or CDAI for predicting the extent of surgery or complications is limited. None of the tested variables except preoperative nicotine abuse influenced the likelihood for perioperative complications.

True malignant histiocytosis with trisomy 9 following primary mediastinal germ cell tumor

A 24-year-old Japanese man was admitted due to bloody phlegm in May 2002. A diagnosis of mediastinal germ cell tumor, mixed type involving seminoma, immature teratoma and embryonal carcinoma, was made by transthoracic needle biopsy. Three months later, his complete blood counts revealed pancytopenia with high fever. Examination of bone marrow revealed increased atypical large histiocytes (5.6%) with hemophagocytosis, and thus, hemophagocytic syndrome related to germ cell tumor was diagnosed. In addition, chromosomal analysis of the bone marrow cells revealed a 47, XY, +9 genotype. Chemotherapies for germ cell tumor and hemophagocytic syndrome were performed without any improvement, and he died of diffuse alveolar damage. Autopsy revealed diffuse infiltration of immature histiocytes with hemophagocytosis in the liver, spleen and bone marrow. The atypical histiocytes were positive for CD68 and lysozyme and negative for lymphoid markers, and the diagnosis of true malignant histiocytosis associated with mediastinal germ cell tumor was made. The rare chromosomal abnormality of trisomy 9, a marker for benzene-related leukemia, was seen in the present case without apparent benzene exposure.

Accessing adult smokers in the pediatric setting: What do parents think?

The anticipation of negative parental reaction is cited by pediatricians as a common barrier to intervening with parents who smoke. In an effort to clarify perceived versus actual parent reaction, the present study investigated the reactions of a diverse parent sample toward pediatricians addressing parental smoking in the outpatient setting. This study represents a descriptive cross-sectional in-person survey of 906 parents interviewed exiting four geographically diverse pediatric practices. Only 3% of the sample felt their smoking status was not the pediatrician's business, 89% stated they believe it is an important part of a pediatrician's job to ask about their smoking status, and 8% stated it wouldn't matter if the pediatrician asked. Demographic characteristics were associated with a positive attitude about being asked. Compared with nonsmokers, fewer smokers had positive attitudes (81% vs. 91%, p = .0002); and more highly educated parents were more strongly positive about being asked (91% vs. 83%, p = .006). Among 187 smokers, 177 (95%) would appreciate or feel okay about the physician's concern if advised to quit and 57% reported wanting some kind of smoking cessation help from the pediatrician's office. In a heterogeneous sample of parents, strong support exists for pediatricians addressing parental smoking at pediatric office visits. This finding is encouraging for pediatricians who are concerned about negative parental reaction.

A dose escalating, placebo controlled, double blind, single dose and multidose, safety and tolerability study of fontolizumab, a humanised anti-interferon gamma antibody, in patients with moderate to severe Crohn's disease

INTRODUCTION

This study was designed to evaluate the safety of fontolizumab, a humanised anti-interferon gamma antibody, in patients with moderate to severe Crohn's disease (CD).

PATIENTS AND METHODS

Forty five patients with a CD activity index (CDAI) of 250-450 were randomised in a double blind, placebo controlled, dose escalating fashion to receive single doses of fontolizumab (0.1, 1.0, and 4.0 mg/kg) or placebo. By day 29, patients with clinical response were re-randomised to receive three additional doses of one half their initial fontolizumab dose or placebo at four weekly intervals. Primary objectives were safety and tolerability. Secondary outcomes included assessments of immunogenicity, clinical activity, and potential pharmacodynamic surrogates.

RESULTS

Treatment was generally well tolerated. There were slightly more reports of chills, flu-like syndrome, asthenia, nausea, and vomiting in the 1.0 mg and 4.0 mg/kg fontolizumab cohorts. Two serious adverse events rated as worsening of CD occurred under fontolizumab. Antibodies to fontolizumab were confirmed in one patient. No differences in clinical activity parameters were noted between any of the active treatment groups and placebo, with the placebo group having a particularly favourable outcome (60% response and 40% remission). By day 29, a more enhanced decrease in median Crohn's disease endoscopic index of severity (p = 0.02) and serum C reactive protein (p<0.001) was observed in the 4.0 mg/kg (n = 14) fontolizumab cohort compared with placebo (n = 10). Pharmacodynamic effects were observed by immunohistochemistry.

CONCLUSIONS

Fontolizumab was well tolerated with minimal immunogenicity at doses of up to 4.0 mg/kg in patients with CD. A biological activity of fontolizumab is suggested.

Environmental tobacco smoke exposure in school children: parent report and urine cotinine measures

BACKGROUND

Environmental tobacco smoke (ETS) in the home continues to be a major health risk for children around the world. Measuring ETS is a central feature of clinical and epidemiological studies, with children's exposure often assessed through parental estimates. The authors examined the relationship between parent-reported estimates of children's exposure to ETS and children's urinary cotinine levels and evaluated the ETS exposure and its effect on respiratory health in children.

METHODS

A total of 188 school children were included in the study. Parents were asked to complete a questionnaire about their smoking habits, their children's respiratory morbidity status and housing conditions. Urinary cotinine levels were measured in children.

RESULTS

According to the responses, 72.3% of the children came from households with smokers, and 34.6% had daily exposure to ETS. When urine cotinine levels of >10 ng/mL were used as the yardstick of exposure, 76% of the children were identified as ETS exposed. No relation was detected between the symptoms of respiratory tract diseases and ETS exposure. To determine the amount of ETS exposure, the contribution of parental reports was low.

CONCLUSION

To evaluate the level of ETS exposure of children, the parents' reports were not reliable. The addition of a biological measure results in a more informative estimate of ETS exposure in children.

Phenotype at diagnosis predicts recurrence rates in Crohn's disease

BACKGROUND

In Crohn's disease (CD), studies associating phenotype at diagnosis and subsequent disease activity are important for patient counselling and health care planning.

AIMS

To calculate disease recurrence rates and to correlate these with phenotypic traits at diagnosis.

METHODS

A prospectively assembled uniformly diagnosed European population based inception cohort of CD patients was classified according to the Vienna classification for disease phenotype at diagnosis. Surgical and non-surgical recurrence rates throughout a 10 year follow up period were calculated. Multivariate analysis was performed to classify risk factors present at diagnosis for recurrent disease.

RESULTS

A total of 358 were classified for phenotype at diagnosis, of whom 262 (73.2%) had a first recurrence and 113 patients (31.6%) a first surgical recurrence during the first 10 years after diagnosis. Patients with upper gastrointestinal disease at diagnosis had an excess risk of recurrence (hazard ratio 1.54 (95% confidence interval (CI) 1.13-2.10)) whereas age >/=40 years at diagnosis was protective (hazard ratio 0.82 (95% CI 0.70-0.97)). Colonic disease was a protective characteristic for resective surgery (hazard ratio 0.38 (95% CI 0.21-0.69)). More frequent resective surgical recurrences were reported from Copenhagen (hazard ratio 3.23 (95% CI 1.32-7.89)).

CONCLUSIONS

A mild course of disease in terms of disease recurrence was observed in this European cohort. Phenotype at diagnosis had predictive value for disease recurrence with upper gastrointestinal disease being the most important positive predictor. A phenotypic North-South gradient in CD may be present, illustrated by higher surgery risks in some of the Northern European centres.

Review article: moderate sedation for endoscopy: sedation regimens for non-anaesthesiologists

BACKGROUND

Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands with or without light tactile stimulation. Moderate sedation is typically accepted in the anaesthesia community as an appropriate target for sedation by non-anaesthesiologists.

AIM

To describe drug regimens that can be successfully and safely targeted to moderate sedation for endoscopy by non-anaesthesiologists.

RESULTS

Moderate sedation can be achieved using narcotics and benzodiazepines. There is interest in some countries in propofol for endoscopy, which is often viewed as an agent for deep sedation. Indeed, propofol cannot be targeted to moderate sedation for endoscopy as a single agent because of coughing during upper endoscopy and pain withdrawal responses during colonoscopy. Pre-treatment with low doses of narcotic and/or benzodiazepine blocks these effects, allowing propofol to be targeted to moderate sedation. Fospropofol, a prodrug of propofol in clinical development, can also be targeted to moderate sedation if co-administered with narcotic.

CONCLUSION

Moderate sedation provides a safety margin when compared with deep sedation and general anaesthesia. Development of protocols that target agents such as propofol to moderate sedation will expand the sedation agents available to non-anaesthesiologists and help ensure that this expansion occurs safely.

In utero and postnatal maternal smoking and asthma in adolescence

BACKGROUND

Asthma in early childhood has been associated with maternal smoking during pregnancy and parental smoking soon after birth. However, less is known about these exposures and the development of asthma symptoms in adolescence.

METHODS

Data were taken from the Mater University Study of Pregnancy, a large birth cohort study of mothers and children enrolled in Brisbane, Australia, beginning in 1981. Smoking was assessed at 2 stages during pregnancy and at the 6-month and 5-year follow-up visits. Asthma was assessed from maternal reports that were provided when the child was age 14 years. We conducted multivariable multinomial logistic regression analyses to assess the effect of maternal smoking on asthma symptoms.

RESULTS

There was a strong sex interaction such that girls whose mothers had smoked heavily (20 or more cigarettes per day) in pregnancy and at the 6-month follow up had increased odds of experiencing asthma symptoms at age 14 (odds ratio = 1.96; 95% confidence interval = 1.25-3.08). The contribution of heavy smoking during pregnancy appeared to be stronger than heavy smoking after the birth. No similar associations were seen for boys.

CONCLUSION

Female adolescents whose mothers smoked heavily during the fetal period and the early months of life have increased risk of asthma symptoms in adolescence. In utero exposure to heavy smoking was found to have a stronger effect than postnatal environmental tobacco exposure.

Measuring exposure to environmental tobacco smoke (ETS): a developing country's perspective

AIMS

To assess exposure to ETS among nonsmokers in the community and examine the relation between various subjective and objective measures of exposure to ETS in a developing country's setting.

METHODS

An interviewer-administered population-based survey of adults 18-65 years residing in Aleppo, Syria. From a total number of 2038 participants, a sub-sample of 419 nonsmokers (27.2% men, 72.8% women, mean age 34 years) underwent subjective and objective assessment of exposure to ETS (saliva cotinine, breath CO, self-reported measures of exposure combined into ETS exposure scale).

RESULTS

Overall, 97.6% of adults nonsmokers assessed in this study, 72.9% of whom were women, have detectable saliva cotinine levels (mean +/- SD 1.7 +/- 1.5 ng/ml). Correlation between self-reported exposure measures and saliva cotinine was moderate with the strongest observed for number of cigarette smokers in the house, average number of cigarettes smoked daily in the house, house policy regarding smoking, and total ETS score (r 0.3-0.4). These same variables were among the best predictors of saliva cotinine according to stepwise linear regression analysis, but their individual relevance differed between men and women reflecting underlying differences in gender-based behavior-mobility patterns. Generally, subjective measures could explain 22% of the variability in cotinine levels in men and 19% in women.

CONCLUSIONS

Exposure to ETS is universal among adult nonsmokers in Syria. Saliva cotinine correlated moderately with self-reported measures, whereby selected subjective measures can be as informative as composite scores incorporating multiple measures. Even in this environment of omnipresence of smoking, household restrictions seem to offer protection against ETS exposure.

Tobacco and its trendy alternatives: implications for pediatric nurses

Although acute and critical care pediatric nurses may not rank tobacco prevention and cessation among their top patient-care priorities, the importance of providing health education, especially during vulnerable moments, cannot be overlooked. This article provides an overview of trendy tobacco alternatives, such as bidis, clove cigarettes, hookah pipes, and smokeless tobacco, that entice youth. The significant health consequences of these tobacco products and the implications for pediatric acute and critical care nursing practice are also discussed.

The effects of exposure to environmental tobacco smoke on pulmonary function in children undergoing anesthesia for minor surgery

BACKGROUND

The objectives of this study were to assess whether children exposed to environmental tobacco smoke (ETS) present for surgery with poorer pulmonary function, and experience a more pronounced deterioration in pulmonary function following anesthesia and surgery, than non-ETS-exposed children.

METHODS

Fifty-four children aged 5-15 years with a history of ETS exposure from one or both parents and 54 children with no such ETS history were included in the study. All participants were presenting for ambulatory surgery and were judged to conform to American Society of Anesthesiology class I or II. Spirometry was performed preoperatively, postoperatively in the recovery ward when the child met criteria for discharge (Aldrete score 8), and before discharge from the day ward.

RESULTS

The ETS-exposed group had a significantly lower mean preoperative peak expiratory flow rate (PEFR) (9.5 points lower percent predicted, 95% confidence interval -18.1 to -1.0, P = 0.03). Although not statistically significant, they also had lower percent predicted baseline mean values of the other spirometric variables that were measured (forced expiratory volume in 1 s -4.5%, P = 0.07; forced vital capacity -4.1%, P = 0.10; forced expiratory flow between 25% and 75%-3.6%, P = 0.44). Pulmonary function tests (PFTs) performed in recovery were between 8% and 14% worse than preoperative values, but the results were similar in the two groups of children. PFTs performed before hospital discharge demonstrated an near-complete recovery to baseline values. Again the pattern was similar in exposed and nonexposed children.

CONCLUSIONS

Environmental tobacco smoke exposure is associated with lower preoperative PEFR values, but does not impact on recovery from anesthesia for healthy children undergoing ambulatory anesthesia.

The value of myenteric plexitis to predict early postoperative Crohn's disease recurrence

BACKGROUND & AIMS

Early ileocolonoscopy allows detection of recurrence after surgically induced remission of Crohn's disease (CD). Unequivocal histologic markers predicting recurrence have not been identified. We assessed the predictive value of neural lesions for early endoscopic CD recurrence and long-term reintervention risk.

METHODS

Ileocolonic resection specimens from 59 patients with CD and 21 control patients were histologically scored for typical inflammatory bowel disease lesions, neural hypertrophy, and presence and severity of inflamed ganglia and nerve bundles. Endoscopic recurrence was determined at 3 months in all patients and at 1 year in 32 patients as part of 2 prospective clinical trials.

RESULTS

Myenteric plexitis of the proximal resection margin was present in 32 patients with CD (54%) in absence of surrounding inflammation. Patients with this feature had a higher endoscopic recurrence (Rutgeerts score >/=2) at 3 months (75% vs 41%; odds ratio, 4.36; 95% confidence interval, 1.44-13.23; P = .008) and at 1 year (93% vs 59%; odds ratio, 9.80; 95% confidence interval, 1.04-92.70; P = .041) and had a trend toward an earlier reintervention (mean, 7.00 vs 5.30 years; P = .174). The severity of myenteric plexitis in the proximal resection margin correlated with the severity of endoscopic recurrence at 3 months (r = 0.334, P = .010) and 1 year (r = 0.560, P = .001). Myenteric plexitis was the only consistent predictor of endoscopic recurrence.

CONCLUSIONS

The presence of myenteric plexitis in proximal margins of ileocolonic resection specimens is predictive of early endoscopic CD recurrence.

Respiratory infections in schoolchildren: co-morbidity and risk factors

AIMS

To assess co-morbidity and risk factors for otitis media, tonsillopharyngitis, and lower respiratory infections in school children.

METHODS

Logistic regression analysis of co-morbidity and risk factors for airway infections in a population based sample of 10 year old children living in Oslo, Norway.

MAIN OUTCOME MEASURES

otitis media, tonsillopharyngitis, and lower respiratory infections in past 12 months.

RESULTS

Airway infections in 10 year old children were common, and significant co-morbidity was found between the various airway infections. Home dampness was a risk factor for all infections, adjusted odds ratios ranging from 1.2 (95% CI 1.0 to 1.5) to 1.4 (95% CI 1.1 to 1.6) for otitis media and tonsillopharyngitis respectively. Atopic disease was a constitutional risk factor, particularly strong for lower airway infections (adjusted odds ratio 2.4, 95% CI 1.8 to 3.1). African or Asian ethnicities were associated with the airway infections, adjusted odds ratios ranging from 1.2 (95% CI 0.9 to 1.7) to 1.7 (95% CI 1.2 to 2.3).

CONCLUSIONS

Respiratory tract infections were common in 10 year old children. There was substantial co-morbidity between upper and lower airway infections. Environmental and constitutional factors were identified and positively associated with the infections. Results support the hypothesis of 1957 that the whole respiratory tract is one unit.

Oocyte and embryo donation 2006: reviewing two decades of innovation and controversy

For over 21 years, oocyte and embryo donation have been used to treat infertility caused by a variety of conditions affecting the ovary. Many disorders, including premature ovarian failure, advanced reproductive age, unexplained recurrent implantation failure and inherited conditions, are amenable to gamete donation, with high pregnancy rates and good obstetrical outcomes observed in recipients. Protocols for the medical screening of recipients and donors, as well as infectious disease and genetic testing, have become relatively uniform and well accepted. Established guidelines allow synchronization of the menstrual cycles of both women to ensure that embryos are transferred to a receptive endometrium. The high demand for donor services has led to escalating costs and long waiting lists. American programmes bid against each other to secure the participation of young women often motivated as much by financial reward as altruism. In the United States, where the majority of oocyte donation is practised, more than 100,000 treatment cycles have occurred. However, to date no meaningful longitudinal studies detailing the long term effects of treatment on donors, recipients, children born, or families created have been published. Throughout its history, oocyte and embryo donation has proven to be both efficacious and clinically innovative, yet remains highly controversial.

Risk factors for initial surgery in pediatric patients with Crohn's disease

BACKGROUND & AIMS

The cumulative incidence of surgery ranges from 40%-70% at 10 years from the time of diagnosis of Crohn's disease in adults. We retrospectively determined the cumulative incidence of and risk factors for surgery (intestinal resection) in pediatric patients with Crohn's disease.

METHODS

Uniform data from 989 consecutive Crohn's disease patients (age 0-17 years at diagnosis), collected from 6 different pediatric centers between January 2000 and November 2003 and stored in the Pediatric IBD Consortium Registry, were analyzed.

RESULTS

Median follow-up time was 2.8 years (range, 1 day to 16.7 years). One hundred twenty-eight patients underwent surgery. Kaplan-Meier survival estimates of the cumulative incidence of surgery were 17% at 5 years and 28% at 10 years from the diagnosis of inflammatory bowel disease. Univariate Cox proportional hazards models showed leukocytosis (2.85 [hazard ratio]; P = .02), hypoalbuminemia (3.41; P = .05), and anti-Saccharomyces cerevisiae antibody (ASCA) positivity (3.43; P = .05) were associated with increased risk for surgery. Multivariate Cox models showed female gender (1.49; P = .03), initial diagnosis of ulcerative colitis (3.63; P < .0001), poor growth at presentation (2.16; P = .007), and abscess (1.90; P = .009), fistula (2.30; P = .0005), or stricture (3.41; P < .0001) development were associated with increased risk for surgery. Age 3-5 years (0.26; P = .01) or 6-12 years (0.62; P = .01) at diagnosis, fever at presentation (0.50; P = .03), and treatment with infliximab (0.36; P = .0005) or 5-aminosalicylic acid (0.44; P < .0001) were associated with decreased risk for surgery.

CONCLUSIONS

Risk stratification during the course of Crohn's disease in pediatric patients will help to guide therapy that may improve the natural history of disease and decrease the need for surgery.

Asthma symptoms in early childhood--what happens then?

AIM

To study the outcome in early adulthood for children with early asthma symptoms and to analyse the factors associated with current asthma.

METHODS

In a prospective study, we have re-investigated 89/101 children who were hospitalized before the age of two years due to wheezing. The children were investigated using a questionnaire and allergy and bronchial hyper-responsiveness tests at the age of 17-20 years and compared with age-matched controls.

RESULTS

In the cohort, 43% had had asthma symptoms in the preceding 12 months compared with 15% in the control group. The strongest risk factors for asthma were current allergy, bronchial hyper-responsiveness and female gender. Female gender and passive smoking in infancy were independent infantile risk factors. In addition to female gender, two pathways led to current asthma: an allergic pathway from family atopy via the development of allergy and another pathway from early passive smoking via hyper-responsiveness and active smoking.

CONCLUSION

In children with early wheezing disorder, current allergy, bronchial hyper-responsiveness and female gender were the strongest risk factors for asthma in early adulthood, while female gender and passive smoking in infancy were independent infantile risk factors. The effects of early passive smoking persist longer than previously reported.

Predictors of support for environmental tobacco smoke bans in state government

BACKGROUND

Environmental tobacco smoke (ETS) is a major threat to public health, associated with a number of serious diseases, and a leading cause of death. Previous research demonstrates that enactment of government policies mandating clean indoor air is effective in creating more smoke-free public places and decreasing the incidence of smoking. Both researchers and community activists have an interest in understanding the factors that predict support for the regulation of ETS.

METHODS

This study examined predictors of support for regulating ETS by surveying 684 city and county public officials in Colorado who were interviewed by phone and mail (response rate 61%).

RESULTS

Thirty-five percent of public officials reported that it is a "serious" or "very serious" problem that nonsmokers breathe in other people's cigarette smoke, 21% were "neutral," and 42% said that it was "not serious" or "not serious at all." Results indicated that support for policies to control ETS and promote clean indoor air is significantly more prevalent among public officials who: (1) believe that tobacco use is a serious problem in their community, (2) believe that breathing environmental tobacco smoke is a serious problem for nonsmokers, (3) believe that city and county government should get involved with people's decisions about smoking, (4) support smoking-cessation programs for public employees, and (5) have smoked less than 100 cigarettes during their lifetime.

CONCLUSIONS

Both the harms of ETS and legislation to create smoke-free environments remain controversial among local officials. Smoke-free advocates should support officials who believe that ETS is a problem and persuade officials on the harms of ETS and the need for government intervention.

Association of parental and children behaviors with the health status of preschool children

BACKGROUND

Parental and children behaviors can be associated with health promotion and illness prevention in preschool children.

METHODS

We interviewed mothers of 804 out of 1000 households with children aged 3 to 5 years randomly sampled in Tokyo, in 1997. Child health status was categorized as: "good", that is, good general health with no sick days; "poor", that is, fair to poor with frequent sick days; or "moderate". RESULTS.: Good health status was associated with playing outside (OR=1.19, 95% CI: 1.03, 1.37) and family income (OR=1.38-1.78, depending on family income). Mothers of children with poor health were less likely to have good health behavior themselves (OR=0.76, 95% CI: 0.64, 0.90) and were more often sick (OR=1.55, 95% CI: 1.24, 1.94).

CONCLUSION

Outdoor playing, good health practice of the mother and high income are associated with a better health status of urban preschool children.

[Predictive value of chest pain score for the diagnosis of acute coronary syndromes]

BACKGROUND AND OBJECTIVE

We analyzed the diagnostic utility of a chest pain score in patients evaluated for chest pain of possible coronary origin.

PATIENTS AND METHOD

We studied 1,068 consecutive patients coming to the emergency room with acute chest pain of possible coronary origin without ST-segment elevation, using a chest pain unit protocol. Chest pain was quantified by validated score (0-20 points). The diagnostic value of the chest pain score was analyzed for the diagnosis of acute myocardial infarction (AMI), unstable angina (UA) and acute coronary syndrome (ACS; AMI or UA).

RESULTS

The diagnosis of ACS was established in 651 patients (61%), AMI in 439 (41%) and UA in 212 (20%). In the multivariate analysis a chest pain score > or = 10 was an independent predictor of ACS (odds ratio [OR] = 2.9; 95% confidence interval [CI] 2.1-4; p = 0.0001), along with an age older than 70 years (OR = 2.6; 95% CI,1.8-3.7; p = 0.0001), male gender (OR = 2; 95% CI, 1.4-2.8; p = 0.0001); insulin-dependent diabetes (OR = 2.3; 95% CI, 1.2-4.6; p = 0.016); previous myocardial infarction (OR = 1.6; 95% CI, 1.1-2.4; p = 0.022), ST depression (OR = 9.3; 95% CI, 5.2-16.7; p = 0.0001) and T wave inversion (OR = 2.5; 95% CI, 1.4-4.3; p = 0.0001). The chest pain score was associated with the diagnosis of both AMI (OR = 1.4; 95% CI, 1.1-1.9; p < 0.02) and UA (OR = 2.8; 95% CI, 1.8-4.2; p < 0.0001).

CONCLUSIONS

The chest pain score allows independent information for the early diagnosis of patients coming to the emergency department with acute chest pain of possible coronary origin.

A comparison of virus-associated and multi-trigger wheeze in school children

To examine differences between virus-associated wheeze and wheeze associated with other triggers (multi-trigger wheeze) in elementary school children, we performed a cross-sectional school-based questionnaire study of 5,998 children mainly 7 to 12 years of age, with outliers 6 and 13 years of age. Using parent-completed questionnaires, we identified 522 children who wheezed only during upper respiratory tract infections (virus-associated wheeze), 1,186 children who wheezed on other occasions (multi-trigger wheeze), and 4,290 children with no wheeze. In comparison with children who had multi-trigger wheeze, children with virus-associated wheeze were more likely to be male, to be younger, and to have less frequent wheezy episodes. They were less likely to have night cough, shortness of breath or chest tightness, to have a personal or parental history of atopic disorders, to have a diagnosis of asthma, or to be receiving asthma treatment. Both types of wheeze were associated with social deprivation, a relationship that persisted after controlling for family smoking. Virus-associated wheeze is a common but diminishing problem in this age group, and the differences between virus-associated wheeze and multi-trigger wheeze already noted in pre-school children persist in this older age group.

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

Usefulness of early exercise testing and clinical risk score for prognostic evaluation in chest pain units without preexisting evidence of myocardial ischemia

We investigated whether the result of early exercise testing yields prognostic information in addition to that afforded by a clinical risk score in patients who present with chest pain in the emergency department. The study group consisted of 340 patients without preexisting evidence of myocardial ischemia. A clinical risk score was calculated. Primary (mortality or myocardial infarction) and secondary (mortality, myocardial infarction, or rehospitalization due to unstable angina) end points at 1 year were defined. Patients with a positive exercise test result underwent invasive management. Frequencies of primary (7.4% vs 2.1%, p = 0.06) and secondary (9.3% vs 2.8%, p = 0.04) end points and risk score (1.6 +/- 1.0 vs 1.0 +/- 0.9 points, p = 0.0001) were higher in patients with a positive exercise test result. However, in multivariate analysis, clinical risk score was the only independent predictor for the primary (hazard ratio 2.0, 95% confidence interval 1.2 to 3.2, p = 0.004) and secondary (hazard ratio 1.9, 95% confidence interval 1.2 to 2.9, p = 0.003) end points. In conclusion, if a policy of invasive management is implemented for patients with positive exercise test results, the clinical risk score constitutes the main prognostic predictor of 1-year outcome.

Midwives’ attitudes to counselling women about their smoking behaviour during pregnancy and postpartum

OBJECTIVE

to investigate the attitudes of midwives to counselling women about their smoking behaviour during pregnancy and postpartum.

DESIGN

survey using postal questionnaires.

SETTING

the entire federal state of Mecklenburg-West-Pomerania in Germany.

PARTICIPANTS

189 midwives constituting 77% of all midwives working in that State.

FINDINGS

midwives reported that they assessed smoking behaviour regularly (77%), addressed the consequences of smoking (70%) and advised women to quit. Among the midwives, 81% saw low chances of success and parents' expectations as the biggest barriers to counselling. Midwives reported that about 28% of women quit following their advice.

KEY CONCLUSIONS

smoking and exposure to environmental tobacco smoke are seen as prominent health threats that midwives reported they addressed routinely, including giving advice to stop smoking.

IMPLICATIONS FOR PRACTICE

midwives should be supported in learning effective intervention strategies to further strengthen their work. They are a target population to deliver brief smoking interventions.

Risk factors regarding the need for a second operation in patients with Crohn's disease

BACKGROUND/AIMS

The majority of Crohn's disease patients undergo surgery. However, the factors that predict post-operative recurrence remain controversial. The aim of the present study was to shed light on the potential predictors of such recurrence.

METHODS

86 patients who underwent operative procedures for Crohn's disease were retrospectively studied. Recurrence was defined as the need for a second operation. Life table and multivariate analysis were performed to find the predictors of recurrence.

RESULTS

In 26/86 (30%) of the patients, post-operative recurrence was diagnosed within a mean of 42 months of the follow-up. Logistic regression analysis revealed that smoking (OR 3.69, 95% CI 2.06-11.52) and perforating disease (OR 4.09, 95% CI 1.31-12.65) were associated with a risk of recurrence. However, survival analysis showed that only perforating disease was associated with an early post-operative recurrence (log-rank test, p < 0.001). Neither resected surgical specimen characteristics, nor the duration and the location of the disease were found to predict the need for a second operation.

CONCLUSION

The risk for Crohn's disease patients who undergo surgery is related to the presence of perforating disease and smoking, which predict the need for a second operation. The former is associated with an even earlier recurrence.

Maternal education, lone parenthood, material hardship, maternal smoking, and longstanding respiratory problems in childhood: testing a hierarchical conceptual framework

BACKGROUND

Maternal smoking and low socioeconomic status are known to be associated with each other and with longstanding respiratory problems in childhood but their interrelation has received little attention. In this paper, the interrelations is studied using a conceptual hierarchical framework among children aged 0-11 years in a representative sample of British households with children.

METHOD

With data from the family and children study, this paper tested a conceptual hierarchical framework, in which maternal education acting through lone parenthood would influence material hardship and all three would have effects on maternal smoking increasing the risk of children's longstanding respiratory problems.

RESULTS

Among children 0-2, maternal education and material hardship had indirect effects on respiratory problems mediated through more proximal variables. After adjustment for maternal education, the effect of lone parenthood was partially mediated through material hardship and maternal smoking. Adjustment for socioeconomic status variables attentuated but did not eliminate the effect of maternal smoking (odds ratio=2.04, 95% confidence interval=1.30, 3.20). Among children 3-11, the effect of maternal education was partially mediated through proximal variables. Lone parenthood and material hardship had indirect effects only. Adjustment for confounding eliminated the effect of maternal smoking (odds ratio=1.06, 95% confidence interval=0.88, 1.26).

CONCLUSIONS

Reducing childhood longstanding respiratory problems will require attention to background socioeconomic status factors in addition to maternal smoking.

Sedation for procedures in children: a guide for the non-anaesthetist

The aim of this review is to provide a succinct guide to sedation of children for procedures. Uncooperative children are notoriously hard to sedate and the choice of appropriate technique depends upon the intended procedure. It is too easy to exceed safe dose limits and cause airway obstruction or respiratory depression. ‘Sedationists’ must remember that safety is paramount; they must receive training and work within protocols. Published guidelines are available.

Gene by environment interactions and the development of asthma and allergy

Asthma is the most common chronic disease during childhood in modern societies. Prevalence rates differ between countries, but on an average, 10-20% of the children in Western Europe and the US are affected. While the true cause of the disease is not yet known, it is common perception that genetic alterations and environmental factors act together in the development of atopic diseases such as asthma, allergic rhinitis and atopic eczema. Numerous studies have reported an association between environmental tobacco smoke (ETS) exposure and respiratory diseases: maternal smoking during pregnancy and early childhood is associated with impaired lung growth and diminished lung function, and in asthmatic children parental smoking increases symptoms and the frequency of asthma attacks. Recent studies have shown that the capability of ETS to induce asthma and asthma symptoms may be modified by genetics. Linkage studies, which took smoking and passive smoking status of study subjects into account, came to different results than those studies based on unstratified samples. These analyses indicated that some chromosomal regions (e.g. 5q) might harbor genes that exert their effects predominantly in combination with ETS exposure. Some of the genes modifying the effect of ETS and air pollution on the body may have been identified. When these detoxification enzymes are genetically defect or missing the capability of the lung to metabolize hazardous substances is dramatically diminished. As a consequence, pulmonary inflammation may occur and the barrier function of the lung may be compromised allowing allergens to penetrate and asthma to start. Knowledge of these interactions may be the key in understanding the complex nature of the disease. It may allow for prediction and an earlier diagnosis of the disease as well as better and more efficient prevention. In the long run, it may contribute significantly to the development of new and better-tailored drugs for one of the major diseases of the 21st century.

Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer

AIM: To evaluate the contrast-enhanced endosonography as a method of differentiating inflammation from pancreatic carcinoma based on perfusion characteristics of microvessels.

METHODS: In 86 patients with suspected chronic pancreatitis (age: 62 ± 12 years; sex: f/m 38/48), pancreatic lesions were examined by conventional endoscopic B-mode, power Doppler ultrasound and contrast-enhanced power mode (Hitachi EUB 525, SonoVue^®, 2.4 mL, Bracco) using the following criteria for malignant lesions: no detectable vascularisation using conventional power Doppler scanning, irregular appearance of arterial vessels over a short distance using SonoVue^® contrast-enhanced technique and no detectable venous vessels inside the lesion. A malignant lesion was assumed if all criteria were detectable [gold standard endoscopic ultrasound (EUS)-guided fine needle aspiration cytology, operation]. The criteria of chronic pancreatitis without neoplasia were defined as no detectable vascularisation before injection of SonoVue^®, regular appearance of vessels over a distance of at least 20 mm after injection of SonoVue^® and detection of arterial and venous vessels.

RESULTS: The sensitivity and specificity of conventional EUS were 73.2% and 83.3% respectively for pancreatic cancer. The sensitivity of contrast-enhanced EUS increased to 91.1% in 51 of 56 patients with malignant pancreatic lesion and the specificity increased to 93.3% in 28 of 30 patients with chronic inflammatory pancreatic disease.

CONCLUSION: Contrast-enhanced endoscopic ultrasound improves the differentiation between chronic pancreatitis and pancreatic carcinoma.

What can the clinician do to improve implantation?

Implantation is a complicated process that requires the orchestration of a series of events involving both the embryo and the endometrium. Even with the transfer of high quality embryos, implantation rates remain relatively low. The growing tendency towards transferring fewer embryos provides further incentives to improve implantation rates. In this article, the various clinical strategies employed to increase the chance of implantation are reviewed. Embryo transfer technique is a critical step in assisted reproductive technology cycles. Recent studies have shown significant improvements in clinical pregnancy rates resulting from careful embryo transfer technique, appropriate catheter type and placing for embryo transfer. Increasingly, adjuvant pharmaceutical therapies are also being applied with the aim of improving embryo implantation. However, the evidence for their efficacy and safety is limited. Recent evidence suggests that adoption of milder ovarian stimulation regimens may provide a more effective clinical approach to improving implantation, since beneficial effects have been shown for both endometrial receptivity and embryo quality.

Midazolam (dormicum®): Clinical practice guidelines

Introduction. Three benzodiazepines are available for IV injection and are commonly used in anesthesia practice: diazepam, lorazepam, and midazolam. The last is the most frequently used in anaesthesia practice. Benzodiazepines induce amnesia and sedation secondary to potentiation of the inhibitory neurotransmitter gamma amino-butyric acid (GABA). Although sleep inducing doses of midazolam (0,2-0,4 mg/kg) may produce unconsciousness in one to three minutes it is commonly used for sedation and to ensure amnesia and premedication. The effects of midazolam on the cardiovascular system are minimal. Mild decreases in blood pressure and heart rate are indicative of its sedative effect. There have been reports of respiratory depression with diazepam, however this response is dose dependent and can be marked if concomitant doses of narcotics are used. Because of its potential for depressing respiration, especially if given with narcotics, the respiratory response of these patients needs to be monitored. Intravenous midazolam should be titrated to effect and the benzodiazepine antagonist flumazenil should be immediately available. .

Early consumption of human milk oligosaccharides is inversely related to subsequent risk of respiratory and enteric disease in infants

A pilot study tested the relationship between human milk oligosaccharide consumption, oligosaccharide content of feces, and subsequent disease in breastfed infants. Forty-nine (49) mother-infant pairs provided milk and fecal samples 2 weeks postpartum; infant health was assessed through 2, 6, 12, and 24 weeks. LNF-II (lacto-N-fucopentaose II), a major human milk oligosaccharide, was measured to represent levels of total oligosaccharides consumed in milk and remaining in feces. LNF-II levels in milk at 2 weeks postpartum were associated with fewer infant respiratory problems by 6 weeks (p = 0.010), as were LNF-II levels in infant feces (p = 0.003). LNF-II levels in milk at 2 weeks were also associated with fewer respiratory problems by 12 weeks (p = 0.038), and fewer enteric problems by 6 weeks (p = 0.004) and 12 weeks (p = 0.045). Thus, consumption of human milk oligosaccharides through breastfeeding, represented by LNF-II, was associated with less reported respiratory and gastrointestinal illness in infants.

Pharmacokinetic and Pharmacodynamic Characteristics of??Medications Used for Moderate Sedation

The ability to deliver safe and effective moderate sedation is crucial to the ability to perform invasive procedures. Sedative drugs should have a quick onset of action, provide rapid and clear-headed recovery, and be easy to administer and monitor. A number of drugs have been demonstrated to provide effective sedation for outpatient procedures but since each agent has its own limitations, a thorough knowledge of the available drugs is required to choose the appropriate drug, dose and/or combination regimen for individual patients. Midazolam, propofol, ketamine and sevoflurane are the most frequently used agents, and all have a quick onset of action and rapid recovery. The primary drawback of midazolam is the potential for accumulation of the drug, which can result in prolonged sedation and a hangover effect. The anaesthetics propofol and sevoflurane have recently been used for sedation in procedures of short duration. Although effective, these agents require monitored anaesthesia care. Ketamine is an effective agent, particularly in children, but there is concern regarding emergence reactions. AQUAVAN injection (fospropofol disodium), a phosphorylated prodrug of propofol, is an investigational agent possessing a unique and distinct pharmacokinetic and pharmacodynamic profile. Compared with propofol emulsion, AQUAVAN is associated with a slightly longer time to peak effect and a more prolonged pharmacodynamic effect. Advances in the delivery of sedation, including the development of new sedative agents, have the potential to further improve the provision of moderate sedation for a variety of invasive procedures.

Accounting for risk and responsibility associated with smoking among mothers of children with respiratory illness

Contemporary public health discourses construct individuals as rational, responsible and knowledgeable, and thus promote a self-controlled prudent response to risk. In the context of evidence emphasising risks to children's health associated with passive smoking, mothers of children with respiratory illness may knowingly place their children at increased risk should they continue to smoke in their presence. Drawing on an analysis of depth qualitative interview accounts with mothers who smoke and whose young child was recently admitted to hospital with respiratory illness, this study describes mothers' constructions of risk and responsibility associated with their smoking. Three forms of accounting style were identified: 'stories of acceptability'; 'denial of agency'; and 'reflections of guilt'. 'Stories of acceptability' either positioned the risk of passive smoking as contained and controlled to an acceptable level, or disputed the level of risk that passive smoke posed. 'Denial of agency' drew on discourses of addiction and shared responsibility to exonerate the mother of responsibility or blame. 'Reflections of guilt' were presented when contradictions arose within accounts, particularly in relation to discussions of agency and rationality in decision-making. The study illustrates how constructions of moral responsibility, especially in relation to being a 'good mother', framed mothers' accounts of smoking in the face of risk. The study concludes that far greater consideration be given to the way in which mothers rationalise their smoking to others if paediatric doctors are to foster risk reduction practices associated with passive smoking more effectively.