Filling gaps in notification data: a model-based approach applied to travel related campylobacteriosis cases in New Zealand

Background

Data containing notified cases of disease are often compromised by incomplete or partial information related to individual cases. In an effort to enhance the value of information from enteric disease notifications in New Zealand, this study explored the use of Bayesian and Multiple Imputation (MI) models to fill risk factor data gaps. As a test case, overseas travel as a risk factor for infection with campylobacteriosis has been examined.

Methods

Two methods, namely Bayesian Specification (BAS) and Multiple Imputation (MI), were compared regarding predictive performance for various levels of artificially induced missingness of overseas travel status in campylobacteriosis notification data. Predictive performance of the models was assessed through the Brier Score, the Area Under the ROC Curve and the Percent Bias of regression coefficients. Finally, the best model was selected and applied to predict missing overseas travel status of campylobacteriosis notifications.

Results

While no difference was observed in the predictive performance of the BAS and MI methods at a lower rate of missingness (<10 %), but the BAS approach performed better than MI at a higher rate of missingness (50 %, 65 %, 80 %). The estimated proportion (95 % Credibility Intervals) of travel related cases was greatest in highly urban District Health Boards (DHBs) in Counties Manukau, Auckland and Waitemata, at 0.37 (0.12, 0.57), 0.33 (0.13, 0.55) and 0.28 (0.10, 0.49), whereas the lowest proportion was estimated for more rural West Coast, Northland and Tairawhiti DHBs at 0.02 (0.01, 0.05), 0.03 (0.01, 0.08) and 0.04 (0.01, 0.06), respectively. The national rate of travel related campylobacteriosis cases was estimated at 0.16 (0.02, 0.48).

Conclusion

The use of BAS offers a flexible approach to data augmentation particularly when the missing rate is very high and when the Missing At Random (MAR) assumption holds. High rates of travel associated cases in urban regions of New Zealand predicted by this approach are plausible given the high rate of travel in these regions, including destinations with higher risk of infection. The added advantage of using a Bayesian approach is that the model’s prediction can be improved whenever new information becomes available.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1784-8) contains supplementary material, which is available to authorized users.

Haploidentical related-donor hematopoietic cell transplantation in children using megadoses of CliniMACs-selected CD34(+) cells and a fixed CD3(+) dose

We conducted a prospective phase II trial utilizing the CliniMACs system to perform CD34(+)-cell selection of PBSCs from haploidentical donors to evaluate engraftment and hematoimmunological reconstitution. In total, 21 children with hematological malignancies or nonmalignant conditions underwent conditioning with 1200 cGy TBI, thiotepa, fludarabine and Thymoglobulin. Patients received megadoses of CD34(+) cells (median: 22 × 10(6)/kg) with a fixed dose of 3 × 10(4)/kg CD3(+) cells/kg, and engraftment occurred in 90% with prompt recovery of neutrophils and platelets. Grade II acute GVHD (aGVHD) was seen in 32% (95% confidence interval (CI), 15-54%) of evaluable patients, there was no grade III-IV aGVHD, and chronic extensive GVHD was seen in 35% (95% CI, 17-59%) of patients. The estimated 2-year EFS was 62% (95% CI, 48-83%) with a median survivor follow-up of 49 months (range: 18-119 months). Patients with nonmalignant diseases had an estimated 2-year EFS of 100% (95% CI, 56-100%) and patients with malignancies in remission had an estimated 2-year EFS of 56% (95% CI, 22-89%). Megadose CD34(+) cells with a fixed CD3(+) cell dose from haploidentical related donors resulted in good outcomes for pediatric patients with nonmalignant diseases and those with malignant diseases transplanted in remission.

The differences in sleep profile changes under continuous positive airway pressure (CPAP) therapy between non-obese, obese and severely obese sleep apnea patients

Sleep disturbances in obstructive sleep apnea are caused mainly by repetitive apneas and hypopneas. An alternative factor contributing to disordered sleep may be the obesity, which is frequently associated with sleep apnea. The sleep disturbing effect of obesity was found previously in obese nonapneic subjects. The aim of this study was to evaluate the effect of obesity on sleep quality in sleep apnea patients in particular in patients under continuous positive airway pressure (CPAP) with successfully normalized respiration. We reviewed the archive data of 18 non-obese, 18 obese and 17 severely obese age and gender matched sleep apnea patients treated with CPAP. The polysomnographic parameters from the diagnostic night, from the second night under CPAP and from the follow up night (after three months of CPAP use) were compared. Before CPAP the apnea hypopnea index was worse in obese and in severely obese group and it normalised under CPAP in all groups. The severely obese group showed more light sleep and less REM sleep before CPAP and inversely - less light and more REM sleep in the second night under CPAP than the non-obese group. In the follow up, there was no differences in sleep profile between groups. This study indicates obesity does not affect the sleep independently of respiratory disorders. Before therapy it is associated with more severe sleep apnea and indirectly with worse sleep quality.

Implementation of a teleradiology system to improve after-hours radiology services in kaiser permanente southern california

Kaiser Permanente Southern California (KPSC) has implemented a teleradiology service to provide after-hours radiology services to its 11 medical centers from 7:00 pm to 7:00 am each day of the week. Features of the service include a Web application that is used to manage the workflow associated with teleradiology exams and to provide reports of the teleradiologists' findings to referring clinicians. Currently, two teleradiologists who can be located at any KPSC facility (varies from day to day) are used to provide preliminary interpretations of CT, MRI and ultrasound exams. However, the service is scalable and could be easily reconfigured to accommodate additional teleradiologists if needed. The service also includes a quality monitoring system that tracks significant discrepancies between the teleradiologist's findings and the subsequent final report of a medical center's staff radiologist. Clinicians who utilize the teleradiology service have been highly satisfied with the responsiveness of the service-median time between performance of an exam and availability of a wet read is 19 minutes.

Off-label use of rituximab in a tertiary Queensland hospital

BACKGROUND

Rituximab is a monoclonal antibody directed against CD20, a pan B lymphocyte marker. It is approved in Australia for treatment of CD20-positive B cell non-Hodgkin lymphoma and rheumatoid arthritis. There is increasing off-label use of rituximab in conditions where B cells and autoantibodies play a role in the pathophysiology. Rituximab is not only expensive, but its safety in unregistered indications is uncertain.

METHODS

We performed a retrospective review of the off-label use of rituximab approved by the High Cost Drug Subcommittee at the Princess Alexandra Hospital between 2005 and 2008. Cases of post transplant lymphoproliferative disorder were excluded.

RESULTS

A total of 28 patients received rituximab for a variety of off-label indications. There were no reported cases of serious infusion reactions or other notable adverse events. The most favourable outcomes were seen in myasthenia gravis, shrinking lung syndrome, thrombotic thrombocytopenic purpura, prevention and treatment of renal transplant rejection and lupus nephritis. No benefit was observed in cases of focal segmental glomerulosclerosis (primary or post-transplant recurrence) and post-transplant recurrence of haemolytic uremic syndrome. There was limited benefit in cryoglobulinaemic vasculitis. The cost of off-label use was in excess of $210,000.

CONCLUSION

In the absence of formal clinical trials, decisions regarding off-label use of rituximab are difficult. Our cases contribute to the published literature and should help provide clinicians with greater insights into which conditions are likely to respond. As can be seen in our series, rituximab benefits people with certain conditions; longevity and cost-effectiveness are currently unknown.

Clinical and immunologic outcomes following haplocompatible donor lymphocyte infusions

We retrospectively analyzed the characteristics of 16 consecutive pediatric patients who received one or more G-CSF-mobilized donor lymphocyte infusions (DLI) following a T-cell-depleted haplocompatible hematopoietic SCT (HSCT) to enhance immune recovery and/or treat an infection. The median time from HSCT to administration of first DLI was 12 weeks and the median dose of DLI administered was 3 x 10(4)/kg (range, 2.5-6 x 10(4)/kg). The incidence of Grade I-II acute GVHD was 19% (95% confidence interval (CI), 6-44%), and there were no cases of Grade III-IV acute GVHD. Chronic GVHD developed in 13% (95% CI, 2-37%) of patients. In surviving patients who did not undergo a second stem cell infusion, T-cell numbers and function increased to a protective level in a median of 3 months (range, 2-12.5 months) following the first DLI administration. In patients given DLI for treatment of an infection, 75% (95% CI, 46-92%) cleared their infection after a median of 9 weeks (range, 1-27 weeks). In patients with CMV infection, the development of CMV-specific T cells was observed following DLI. The 1-year overall survival following haplocompatible DLI was 71% (95% CI, 59-83%), with a median follow-up of 16 months from the first DLI.

The influence of obesity on sleep quality in male sleep apnea patients before and during therapy

Evidence exists that obesity, even in the absence of sleep related respiratory disorders, affects sleep negatively. In this study we examined the influence of obesity on sleep quality of male sleep apnea patients before and after breathing normalization with continuous positive airway pressure (CPAP). We compared the polysomnography from the diagnostic night, second night with CPAP, and a control night (three months later) in 13 non-obese, 13 obese, and 12 severely obese male obstructive sleep apnea patients. In the diagnostic polysomnography, obese and severely obese subjects showed increases in apnea-hypopnea index (AHI) and NREM-1 sleep, and decreases in min SaO(2), REM sleep, and partially slow wave sleep (SWS), when compared with the non-obese group. In the second night under CPAP, normalization of the AHI and a rebound of REM and SWS occurred, which was more pronounced in severely obese than in the non-obese and obese group. The polysomnography recorded three months thereafter revealed no differences in sleep stages between the groups. We conclude that after the long-term CPAP therapy, no effect of obesity on sleep quality is apparent.

Assessing dental students' competence: best practice recommendations in the performance assessment literature and investigation of current practices in predoctoral dental education

In this article, the Task Force on Student Outcomes Assessment of the American Dental Education Association's Commission on Change and Innovation in Dental Education describes the current status of student outcomes assessment in U.S. dental education. This review is divided into six sections. The first summarizes the literature on assessment of dental students' performance. Section two discusses catalysts, with a focus on problem-based learning, for development of new assessment methods, while the third section presents several resources and guides that can be used to inform selection of assessment techniques for various domains of competence. The fourth section describes the methodology and results of a 2008 survey of current assessment practices in U.S. dental schools. In the fifth section, findings from this survey are discussed within the context of competency-based education, the educational model for the predoctoral curriculum endorsed by the American Dental Education Association and prescribed by the Commission on Dental Accreditation. The article concludes with a summary of assessments recommended as optimal strategies to measure three components of professional competence based on the triangulation model. The survey of assessment practices in predoctoral education was completed by 931 course directors, representing 45 percent of course directors nationwide, from fifty-three of the fifty-six U.S. dental schools. Survey findings indicate that five traditional mainstays of student performance evaluation-multiple-choice testing, lab practicals, daily grades, clinical competency exams, and procedural requirements-still comprise the primary assessment tools in dental education. The survey revealed that a group of newer assessment techniques, although frequently identified as best practices in the literature and commonly used in other areas of health professions education, are rarely employed in predoctoral dental education.

Die Pest im Grindelwaldtal 1669 – was lehrt uns die Geschichte einer Krankheit?

«Am Mittag war das Fieber auf seinem Höhepunkt. Ein, wie aus den Eingeweiden kommender Husten schüttelte den Körper des Kranken, der erst jetzt Blut zu spucken begann. Die Lymphknoten waren nicht mehr weiter angeschwollen. Sie waren immer noch da, hart wie in die Gelenkhöhlen geschraubte Muttern (A. Camus: Die Pest).

[Chronic disease management]

Chronic disease management by primary care physician is one of the outstanding challenges in family medicine. Regular checking of possible interactions between different diagnoses and treatments is of great opportunity. Optimal communication and cooperation between doctors in hospital and primary care is a continuous commitment.

Gibt es triviale (banale) Fieberzustände in der hausärztlichen Praxis?

Information, was Fieber im praktischen Alltag bedeutet. Erarbeiten einer rationalen und rationellen Abklärung zwischen «watchful waiting» und diagnostischem Übereifer (abwarten oder abklären, Priorität von Anamnese und klinischer Untersuchung). Vor- und Nachteile einer Fiebersenkung, Pandemieproblem, was nie vergessen?

Reduced intensity conditioning using intravenous busulfan, fludarabine and rabbit ATG for children with nonmalignant disorders and CML

The major problems with busulfan/cyclophosphamide (Bu/Cy)-containing conditioning regimens are acute toxicities and graft failure. To decrease acute toxicities, we have prospectively evaluated a reduced intensity conditioning (RIC) regimen using targeted dosing of i.v. busulfan, fludarabine, and rabbit ATG (Bu/Flu/rATG) in children with diagnoses that historically would have been conditioned with Bu/Cy regimens. Nineteen pediatric patients were enrolled in the study. The donors included HLA-matched and one antigen-mismatched unrelated volunteers (n = 11), unrelated cord blood (n = 1), and related donors (n = 7). Four patients developed graft failure, which occurred between 1 and 8.5 months post transplant. All four of them underwent a second transplantation and 3/4 are alive without evidence of disease. The mean follow-up of living patients is 29.5 +/- s.d. 11 months. Despite excellent 2-year post-transplant overall survival (89 +/- s.d.7%) and event-free survival (74 +/- s.d.10%), the study was closed prematurely due to high graft failure rate (21%). Receiving a transplant from a mismatched unrelated donor was identified as a risk factor for graft failure. The Bu/Flu/rATG RIC regimen was very well tolerated, resulted in excellent overall survival, and provided sustained engraftment in patients undergoing transplant from matched sibling and unrelated donors. However, it did not provide sustained engraftment in the majority of children with nonmalignancies undergoing mismatched unrelated donor transplants.

[Problems concerning the general practitioner and emergencies--what should I not forget?]

BME and vocational training, legal, insurance, financial and social problems. Standards and guidelines, publicity, emergency equipment, emergencies in GP's office and at home, patient information, problems of elderly patient, ethical aspects. Some "key messages".

Safety and efficacy of allogeneic PBSC collection in normal pediatric donors: The Pediatric Blood and Marrow Transplant Consortium Experience (PBMTC) 1996–2003

The use of peripheral blood stem cells (PBSC) for allogeneic transplants in adults has greatly increased. This trend is reflected in pediatrics, where healthy children increasingly are donating PBSC or donor lymphocyte infusion (DLI) via apheresis for use by ill siblings. There is a potential concern that the risks of PBSC collection may differ for pediatric donors. However, no large studies have assessed safety issues in this population. To address this need, we reviewed 218 (213 PBSC, five DLI) collections in 201 normal pediatric donors (8 months to 17 years, median 11.8 years) at 22 institutions in the Pediatric Blood and Marrow Transplant Consortium. Donors received a median of 4 days of growth factor, and mean collection yield was 9.1 x 10(6) CD34+ cells/kg recipient weight. Younger age, days of apheresis, and male gender predicted increased yield of CD34+ cells/kg donor weight. Growth factor-induced pain was mild and reported in less than 15% of patients. Most donors <20 kg (23/25, 92%) required PRBC priming of the apheresis machine. This experience with over 200 collections demonstrates that PBSC collection is safe in normal pediatric donors and desired CD34 cell yields are easily achieved. Younger children utilize more medical resources and children <20 kg usually require a single blood product exposure.

Falsche Perlen... Imperative Tagesschläfrigkeit – ein Erlebnisbericht

Ausgehend vom persönlichen Erleben einer Narkolepsie, insbesondere von imperativer Tagesschläfrigkeit und Kataplexien, wird dieses zweifellos zu selten beachtete und oft verdrängte Krankheitsbild beschrieben. Die ökonomische (Vermeiden von Arbeitsunfähigkeit) und ethische (Straßenverkehr!) Dimension der Krankheit ist sehr groß.

Immune reconstitution, infectious complications and post transplant supportive care measures after autologous blood and marrow transplantation in children

We retrospectively analyzed data on T- and B-cell reconstitution and infectious complications in 58 children undergoing ABMT, in order to evaluate post-transplant supportive care measures used during the study period. Normalization of T-cell number and lymphocyte proliferative responses to phytohemagglutinin (PHA) and alloantigen (MLC) occurred in two-thirds of children by 6 months post transplant. Normal IgM levels developed in 75% of children by 6 months post transplant. A total of 34 children (59%) developed 39 episodes of infection between neutrophil engraftment and 1 year post transplant. The most common infections included bacteremia, varicella-zoster virus infection and pneumonia, which represented 46, 23 and 9% of infections, respectively. All patients with bacteremia had a central venous catheter in place at the time of infection. Most infections (77%) developed by 6 months post transplant. In this small patient cohort, time to normalization of tests of T- and B-cell function was not significantly different between patients with and without infection. Earlier removal of an indwelling central venous catheter may decrease the risk of bacteremia post transplant. Post-transplant supportive care measures may be discontinued at 6 months post ABMT in most children, as the risk of infection decreases after that time.

Treatment of acute embolic occlusions of the subclavian and axillary arteries using a rotational thrombectomy device

Acute embolic or local thrombotic ischaemia of the upper limbs can be treated by embolectomy or by endovascular techniques. We report here on the endovascular thrombectomy of acute embolic occlusions of subclavian and axillary arteries in two patients using a rotational thrombectomy device and give an overview about the actual literature. Two female patients, each with a history of multivessel coronary disease and intermittent atrial fibrillation, complained of sudden onset of pain at rest and paleness of the left and right arm, respectively. Duplex ultrasound showed a localized embolic occlusion of the left subclavian artery and the bifurcation of the brachial artery in the first patient and a localized embolic occlusion of the distal right subclavian and axillary artery in the second patient. In the first patient, the left subclavian artery was reopened using a 8F-Rotarex device via the femoral access, while the bifurcation of the brachial artery was reopened by local thrombolysis using 25 mg rt-PA because of the insufficient length of the thrombectomy device of 80 cm. In the second patient, the right subclavian and axillary arteries were reopened using a 6F-Rotarex device. Follow-up examinations before discharge and after 6 months showed normalized perfusion of the arms of both patients.

[Long-term results after recanalization of acute and subacute thrombotic occlusions of the infra-aortic arteries and bypass-grafts using a rotational thrombectomy device]

BACKGROUND

Evaluation of the acute and long-term results after recanalization of thrombotic occlusions of infra-aortic native arteries, stented arteries and bypass-grafts using a rotational thrombectomy device (8F Straub-Rotarex TM).

MATERIALS AND METHODS

From July 2000 to February 2002, in 98 patients (64 % male, mean age 66 +/- 9 (range 47 to 90) years, mean duration of occlusion 31 +/- 33 (range 0 to 140) days, mean occlusion length 21 +/- 11 [range 2 to 40] cm) 100 vessel recanalizations were performed. 42 % of the interventions were performed during the first 14 days after the onset of the symptoms (acute occlusions). These patients were classified according to the after the TASC protocol modified SVS/ISCVS-classification: Class I: n = 22 (52 %); class lla: n = 13 (32 %); class llb: n = 6 (14 %); class III: n = 1 (2 %). Subacute and chronic occlusions were classified according to Rutherford (58 %): Stage 1: n = 5 (9 %); stage 2 and 3: n = 39 (68 %); stage 4: n = 6 (10 %); stage 5: n = 8 (13 %).

RESULTS

Primary success rate was 96 % (ipsilateral interventions 99 %, cross-over 40 %). The restenosis rate after a mean follow-up of 13 +/- 4 months was 33 % for native arteries (group 1), 74 % for instent-recanalizations (group 2) and 86 % for bypass-graft occlusions (group 3). 3 % severe complications occurred: two amputations below the knee after unsuccessful recanalizations of a native artery and a bypass-graft, respectively. One death because of multiorgan failure in patient who was already in cardiac shock before the successful intervention. Further 16 complications could be solved periinterventionally. The ancle-brachial index was significantly improved during follow-up (from 0.37 +/- 0.19 to 0.82 +/- 0.22 before discharge, 0.70 +/- 0.21 after 12 months, p < 0.001).

CONCLUSION

The Straub-Rotarex TM device is useful in the treatment of acute and subacute thrombotic occlusions of infra-aortic arterial and bypass-graft occlusions, with promising long-term results in native vessels but unchanged high restenosis of stented arteries and bypass-grafts.

[Normal values for the internal thoracic artery by Doppler ultrasound and modification of the Doppler curve after bypass to the left anterior descending artery]

AIM

In coronary heart disease, the surgical therapy of choice is the construction of an artenal bypass of the left anterior descending artery (LAD) using the internal thoracic artery 8ITA). We define age dependent normal values for the ITA such as diameter of the lumen (LD), peak systolic (Vs) and diastolic (Vd) flow velocity and the ratio of these two values (SDR) measured by duplex ultrasound. Furthermore, the modification and pathological changes of the Doppler curve after minimal invasive bypass of the LAD (MIDCAB) are described.

MATERIAL AND METHODS

96 people, age 18 - 87 years, subdivided into 6 age groups were examined by duplex to define the normal values of the ITA, and 55 patients (mean age 63 +/- 10 years, 48 men, 7 women) were evaluated after MIDCAB-surgery to describe the postoperative modification of the Doppler curve. The examinations were performed using a 4 - 7 MHz linear ultrasound transducer in the right and left 1. or 2. intercostal space parasternally.

RESULTS

In all 96 people, the ITA was detectable on both sides presenting a typical bi- or triphasic Doppler flow profile. A linear age dependent increase in the LD of 1.95 +/- 0.15 mm (right ITA) and 1.93 +/- 0.27 mm (left ITA) respectively to 2.65 +/- 0.48 mm and 2.55 +/- 0.43 mm was found. No significant side difference was found for Vs and Vd, nor were there any age dependent differences for Vs. The SDR showed an age dependent linear increase on the right side from 3.5 +/- 1.1 to 6.1 +/- 2.2, p < 0.0012, and on the left from 3.9 +/- 1.2 to 6.7 +/- 1.7, p < 0.0001. Postoperatively, the Doppler spectrum was modified into a mono- or biphasic Doppler curve with a reduced Vs and an increased Vd resulting in a significantly decreased SDR on the left side compared with the right side (1.3 +/- 0.8 vs. 5.4 +/- 2.0, p < 0.00001). Three patients with angiographically proven graft failure had an SDR of 2.6 - 5.2 (mean 3.8), as opposed to a value of < 2.0 in case of a patent bypass. An SDR > 2.0 has a sensitivity of 100 % and a specificity of 97 % in the detection of a haemodynamically relevant (>70 %) ITA-graft-stenosis.

CONCLUSIONS

With rising age, there is an increase in the LD of the ITA and the peripheral resistance, expressed as SDR. After MIDCAB surgery the former triphasic Doppler flow curve changes into a mono- or biphasic curve corresponding to the coronary blood flow. An SDR >2.0 is a strong indicator of bypass failure.

Veno-occlusive disease of the liver in children with solid tumors undergoing autologous hematopoietic progenitor cell transplantation: a high incidence in patients with neuroblastoma

We retrospectively analyzed the incidence and risk factors for veno-occlusive disease (VOD) in 83 consecutive children with solid tumors, who underwent autologous blood or bone marrow (BM) transplantation at UCSF between 1992 and 2000. Forty-one patients were diagnosed with neuroblastoma and 42 had another solid tumor (Ewing's sarcoma, soft tissue sarcomas, germ cell tumors, etc). Patients with neuroblastoma were more likely than patients with other solid tumors (ST) to be < or =7 years of age, to have a decreased serum albumin level, and to have received abdominal radiation and surgery prior to transplant. Patients with neuroblastoma received a different conditioning regimen and a purged stem cell product. Twenty patients (24%) developed VOD. VOD was self-limited in 15 (75%) patients and severe in five (25%) patients. Univariate analysis identified the following risk factors for VOD: diagnosis of neuroblastoma (odds ratio 6.1, P < 0.01), abdominal radiation (odds ratio 4.1, P < 0.01), abdominal surgery (odds ratio 4.1, P < 0.01), and age < or =7 years of age (odds ratio 3.3, P = 0.02). Disease status at transplant, intensity of previous chemotherapy, conditioning regimen, progenitor cell source, ALT, AST, albumin level, renal function prior to transplant, or use of amphotericin, growth-factor or heparin during transplant, did not affect the incidence of VOD. On multivariate analysis, only the diagnosis of neuroblastoma remained significant (odds ratio 7.8, P = 0.03). Larger studies of patients with neuroblastoma are necessary in order to confirm our findings and better define the risk factors for VOD development in neuroblastoma patients.

[First experiences with a 6F-sheath compatible self-expanding nitinol stent]

BACKGROUND

To evaluate the efficacy, safety and limitation of a new 6F-compatible nitinol stent (Dynalink(TM).

MATERIAL AND METHODS

We treated 50 patients (17 women, 33 men, mean age 72 +/- 8 years) by implanting 80 Dynalink(TM)-stents into 75 vessels during a 6-month period. Target lesions were: iliac artery: 25, femoral artery: 31, popliteal artery: 16, femoro-popliteal bypass: 5, subclavian vein: 3. Preinterventional Rutherford classifications: Class 1 : 3 legs (5 %), class 2 : 27 legs (51 %), class 3 : 16 legs (31 %), class 4 : 2 legs (4 %), class 5 : 5 legs (9 %). 40 % stents each were implanted ipsilateral, 60 % cross-over.

RESULTS

All interventions were successful regardless of a sometimes anatomically difficult access to the lesion. The device was characterised by a high flexibility and radial force and the stent did not shorten.

COMPLICATIONS

One distal stent dislocation during placement occurred, no puncture site complication. The mean diameter stenosis was reduced from 91 +/- 10 % (75 - 100 %) to 4 +/- 8 % (0 - 30 %). The ankle-brachial index was improved from 0.46 +/- 0.22 to 0.75 +/- 0.23 (p < 0.001). Post-interventional Rutherford classifications: Class 0 : 43 legs (81 %), class 1 : 5 legs (4,5 %), class 5 : 5 legs (4,5 %).

CONCLUSIONS

The new 6F-sheath compatible nitinol stent is characterised by a good flexibility, radial force, and a lack of shortening. By the reduction of the diameter of the device to 6F, the potential risk of a local bleeding complication may be reduced and 6F sealing devices will be usable. Disadvantages are the 0.018 inch guide-wire lumen and the limited stent sizes.

Bone marrow transplantation for T-B- severe combined immunodeficiency disease in Athabascan-speaking native Americans

A distinct form of autosomal recessive T-B- severe combined immunodeficiency disease occurs with a high frequency among Athabascan-speaking Native Americans (SCIDA), including Navajo and Apache Indians from the southwestern US and Dene Indians from the Canadian Northwest Territories. The SCIDA gene has been linked to markers on chromosome 10p although its identity and role in the pathogenesis of this disease are unknown. We report our experience in treating 18 Navajo and Dene children with SCIDA between 1984 and 1999; 16 underwent bone marrow transplants (BMT). All children were symptomatic within 2 months of birth, had the T-B- NK(+)SCID phenotype and 67% presented with oral and/or genital ulcers. Three children had evidence of maternal engraftment prior to transplant. Two children died shortly after diagnosis. Three children required more than one BMT and 12 are alive with T cell reconstitution at a median follow-up of 7 years. Three children developed normal B cell immunity, two of whom received ablative conditioning therapy with either radiation or busulfan. Three of the four children who died received therapy with either radiation or busulfan and two of eight long-term survivors who were also recipients of cytotoxic chemotherapy have failed to develop secondary teeth. These results demonstrate the efficacy of BMT in treating infants with this distinct form of SCID, although B cell reconstitution remains a problem even with HLA-matched donors. Without conditioning, T cell engraftment is likely when closely HLA-matched donors are used. With T cell depletion of haplocompatible marrow, conditioning with immunosuppressive therapy may be necessary; however, children with SCIDA who were treated with intensive immunosuppressive and myeloablative therapy had a poor outcome.

Comparison of angiotensin II receptor antagonists

Nonpeptide orally active angiotensin II type 1 (AT1) receptor antagonists are the most specific means presently available to block the renin-angiotensin enzymatic cascade. Six of these drugs have already been licensed in Europe and in the United States for the treatment of high blood pressure, and additional candidates are in the pipeline. The World Health Organisation has also recently endorsed their use for this condition. Inasmuch as AT1 receptor antagonists have proven themselves the equals of angiotensin converting enzyme inhibitors with respect to antihypertensive efficacy, but demonstrated better safety profiles, this class of drugs may be considered to be a qualitative improvement in the treatment of essential hypertension. Interestingly, the six agents now on the market diverge considerably with respect to their pharmacokinetic and pharmacodynamic properties, although it is not certain whether such differences are clinically relevant. A considerable number of large, multicentre trials are in progress to ascertain the possible longer-term organoprotective effects of these substances on cardiovascular morbidity and mortality. Because of their noteworthy safety record to date, and simple once-a-day dosage regimen, AT1 receptor antagonists have the potential to improve compliance in patients with chronic hypertension.

[The Straub-Rotarex thrombectomy system: initial experiences]

BACKGROUND

To evaluate the efficacy, safety and limitations of a new rotational thrombectomy device (Straub-Rotarex) in clinical practice.

MATERIAL AND METHODS

The Straub-Rotarex catheter is a new, wire-guided rotational thrombectomy device for the treatment of acute and subacute occlusions of the femoro-popliteal arteries. Over a 6-month period, 28 patients (64% male, mean age 69 +/- 9.5, 51-91 years) with 31 legs, mean duration of occlusion 4.4 +/- 4 (0-20) weeks, mean occlusion length 22 +/- 11 (5-40) cm were treated with the device, 5 of them in a cross-over technique. Target lesions: Aortic-femoral bypass, common iliac artery, external iliac artery, common femoral artery: 1 each, superficial femoral artery: 23, popliteal artery: 17. Initial stage of claudication: IIa: 6%, IIb: 72%, III: 16%, IV: 6%.

RESULTS

Primary success rate: 90% (ipsilateral: 100%, cross-over: 40%). Stage of claudication after intervention: I: 85%, IIa: 7%, III: 4%, IV 4%, one amputation. 3-months follow-up: stage I: 86% (n = 24), IIa: 14% (n = 4), one femoro-popliteal bypass. Restenosis rate 18%. 6-months follow-up: stage I: 56% (n = 9), IIa: 31% (n = 5), IIb: 13% (n = 2). Restenosis rate 56%.

COMPLICATIONS

32% (5 perforations, three cases of embolism after PTA, one wire-induced dissection, one retroperitoneal bleeding coming from the puncture site).

CONCLUSIONS

The new device is a useful tool for the treatment of (sub)acute long-distance occlusions of the SFA and popliteal artery and in-stent restenosis as well in antegrade technique. Main complications are perforations. Cross-over interventions can only be done in special cases.

Evaluation of an insulin zinc suspension for control of naturally occurring diabetes mellitus in dogs

OBJECTIVE

To evaluate duration of action of an insulin zinc suspension (Caninsulin, Intervet) in spontaneously occurring cases of canine diabetes mellitus and suitability of its use as a once daily administered insulin for treatment of this disease.

DESIGN

Eight client-owned canine diabetics were included in a prospective pilot study. All dogs had been treated with Caninsulin for a minimum of 2 months and were considered on clinical grounds to be adequately stabilised.

PROCEDURE

Dogs were hospitalised for 24 h and blood collected every 2 h via indwelling venous catheters for blood glucose determination.

RESULTS

Once daily Caninsulin administration failed to maintain glycaemic control for greater than 13 h in five of eight dogs, but acceptable blood glucose concentrations were maintained for 22 h and greater than 24 h in two others. One dog became distressed during hospitalisation and the blood glucose curve did not show an identifiable response to the insulin.

CONCLUSION

Most diabetic dogs may require twice daily administration of Caninsulin for satisfactory glycaemic control, but once daily administration may be adequate in some animals. More comprehensive investigation into duration of activity of Caninsulin is warranted.

Transient hypoparathyroidism following successful treatment of hypercalcaemia of malignancy in a dog

A 4-year-old, entire female, English Cocker Spaniel was presented for treatment of lymphosarcoma and secondary hypercalcaemia. After induction chemotherapy the dog became severely hypocalcaemic and showed signs of weakness, muscle fasciculation and facial pruritus. Hormone analysis confirmed inadequate production of parathyroid hormone. Although hypocalcaemia has been previously reported as a component of tumour lysis syndrome, it has not been associated with transient parathyroid hormone deficiency.

Disseminated Mycobacterium avium infection in a dog with chronic diarrhoea

A 3-year-old Maltese-cross dog presented with a 4-month history of chronic diarrhoea and inappetence. Poorly regenerative anaemia, leukocytosis and hypoproteinaemia were evident on several occasions. Biopsies of stomach, duodenum and colon revealed marked infiltration of mucosae by macrophages containing many acid-fast bacilli. Similar organisms were numerous in a faecal smear. Melaena, hematochezia and severe abdominal pain developed and were unresponsive to therapy. Following euthanasia and necropsy, histiocytic cells containing acid-fast bacilli were found throughout the gastrointestinal tract, mesenteric and peripheral lymph nodes, spleen, liver, kidney and lungs. The organism was identified as Mycobacterium avium by bacterial culture and polymerase chain reaction testing.

HLA-A*2416: a new allele of the HLA-A19 lineage

We here report on a new HLA-A19 allele (A*2416) found in a German kidney recipient. Serological class I typing revealed HLA-A11,19 without clear definition of the A19 split antigen. As with serology, polymerase chain reaction (PCR)-based typing also revealed inconclusive results. We therefore sequenced the gene from the 5' flanking region through the 3'-end of exon 4 of this allele after haplotype-specific PCR amplification. The sequence analysis revealed a new HLA-A allele which is identical to A*3101 with the exception of the 3' half of exon 2 which is identical to the common A9 alleles. The phylogenetic analysis constructed with the nearest-neighbor algorithm and based on exons 1-4 or introns 1-3 clearly indicated, that A*2416 belongs unequivocally to the A19 lineage.

Autoimmune hemolytic anemia in patients with SCID after T cell-depleted BM and PBSC transplantation

We report a high incidence (19.5%) of autoimmune hemolytic anemia (AIHA) in 41 patients with SCID who underwent a T cell-depleted haploidentical transplant. Other than infections, AIHA was the most common post-transplant complication in this patient cohort. Clinical characteristics and treatment of eight patients who developed AIHA at a median of 8 months after the first T cell-depleted transplant are presented. All patients had warm-reacting autoantibodies, and two of eight had concurrent cold and warm autoantibodies. Clinical course was most severe in two patients who had cold and warm autoantibodies. Five patients received specific therapy for AIHA. Successful taper off immunosuppressive therapy for AIHA coincided with T cell reconstitution. Delayed reconstitution of T cell immunity, due to T cell depletion, immunosuppressive conditioning and CsA, as well as paucity of regulatory T cells, are the likely explanations for the occurrence of AIHA in our patient cohort. Screening of the population at risk may prevent morbidity and mortality from AIHA.

Pressure-limited ventilation of infants with low-compliance lungs: the efficacy of an adult circle system versus two free-standing intensive care unit ventilator systems using an in vitro model

We compared the efficacy of a Drager Narkomed GS (North American Drager, Telford, PA) equipped with an adult circle system with two free-standing infant ventilator systems (Servo 300; Siemens Medical Systems, Danvers, MA and Babylog 8000; North American Drager) to deliver minute ventilation (VE) using pressure-limited ventilation to a test lung set to low compliance. To simulate a wide variety of potential patterns of ventilation, VE was measured at peak inspiratory pressures (PIP) of 20, 30, 40, and 50 cm H2O and at respiratory rates (RR) of 20, 30, 40, and 50 breaths/min. Each measurement was made three times; the average was used for data analysis using the multiple regression technique. Delivered V(E) was positively correlated with both PIP (P = 0.001) and RR (P = 0.001). Only minimal differences in VE were observed between the circle and the two free-standing systems. At lower RR and PIP, the Babylog 8000 system delivered slightly higher VE than the circle system, whereas at higher RR and PIP, the Babylog 8000 delivered slightly lower VE than the circle system; these differences in VE were not statistically significant (P = 0.45). The Servo 300 delivered slightly higher VE than the circle system in all test conditions, but these differences were not statistically significant (P = 0.09). None of the differences in delivered VE between the Servo 300 and the circle system are of clinical importance.

IMPLICATIONS

Our laboratory investigation suggests that pressure-limited ventilation delivered by a standard adult circle system compares favorably with that of freestanding infant ventilators used in pressure-limited mode. Changing from an adult circle system to a free-standing pressure-limited ventilator may not substantially improve ventilation of a low-compliance infant lung; the efficacy of such a practice should be investigated.

A multi-institutional retrospective study of intracranial ependymoma in children: identification of risk factors

PURPOSE

The goal of this multi-institutional retrospective study of children with intracranial ependymoma was to identify risk factors associated with unfavorable overall survival (OS) and event-free survival (EFS).

PATIENTS AND METHODS

Clinical data, including demographics, tumor location, spread, histology, details of surgery, radiation treatment, and chemotherapy were collected. Clinical characteristics and univariate and multivariate analyses of risk factors for OS and EFS are presented.

RESULTS

Eleven U.S. institutions contributed 83 patients treated from 1987 to 1991. The OS at 5 and 7 years was 57% and 46%, and EFS at 5 and 7 years was 42% and 33%. Patients 3 years of age or younger differed from the older group by more common infratentorial location, less common gross total resection (GTR), and postoperative use of chemotherapy rather than radiation. This younger group of patients had worse survival (P < 0.01) than the older age group. Other than young age, less than GTR and World Health Organization (WHO) II grade 3 histology were significant adverse risk factors for EFS in univariate and multivariate analyses. OS shared the same adverse risk factors except for histology in multivariate analysis, which was only of borderline significance (P = 0.05). Progression at the original tumor location, present in 89% of patients, was the major pattern of tumor recurrence. Adjuvant chemotherapy in the group older than 3 years or craniospinal radiation in M0 patients did not significantly change EFS.

CONCLUSIONS

Adverse outcome in childhood intracranial ependymoma is related to age (3 years or younger), histology (grade 3), and degree of surgical resection (less than GTR). New approaches, particularly for local tumor control in younger patients, are needed to improve survival.

An adult system versus a Bain system: comparative ability to deliver minute ventilation to an infant lung model with pressure-limited ventilation

We compared the efficacy of an adult circle system versus a Bain system to deliver minute ventilation (V(E)) to an infant test lung model using pressure-limited ventilation. To simulate a wide variety of potential infant clinical states, V(E) was measured with two compliances: at peak inspiratory pressures (PIP) of 20, 30, 40, and 50 cm H2O and at respiratory rates (RR) of 20, 30, 40, and 50 breaths/min. Each measurement was made three times, and their average was used for analysis. Data were analyzed using the multiple regression technique. In both normal and low-compliance lung models, V(E) was nearly identical between adult circle and Bain systems (P = 0.67 for normal compliance model, P = 0.89 for low-compliance model). V(E) positively correlated with RR (P < 0.001), PIP (P < 0.001), and lung compliance (P < 0.001). Very high PIP or RR were required to deliver V(E) to the low-compliance lung model. The adult circle system is equivalent to the Bain system in its ability to ventilate an infant test lung over a wide range of RR, PIP, and two compliances during pressure-limited ventilation. V(E) is dependent of PIP, RR, and lung compliance. With low-compliance lungs, both systems require a high PIP. We conclude that both anesthetic systems deliver ventilation over a wide range of respiratory variables during pressure-limited ventilation in infants.

IMPLICATIONS

We obtained results from this infant test lung study that indicate that either an adult circle breathing system or the Bain system can reliably deliver ventilation over a wide range of respiratory variables during pressure-limited ventilation in infants.