Liver Impairment and Elevated Aminotransferase Levels Predict Severe Dengue in Vietnamese Children

BACKGROUND

The degree of liver impairment in children with dengue infection varies from mild to severe injury. Aminotransferase levels may be useful in predicting severe dengue. This study aimed to evaluate the degree of liver impairment and determine whether elevated aminotransferases could be used to discriminate between non-severe and severe dengue in Vietnamese children.

METHODS

This was a prospective cohort study of pediatric patients with confirmed dengue infection who were admitted to Can Tho Children's Hospital, Vietnam. The receiver operating characteristic (ROC) curve was used to discriminate the power of Aspartate transaminase (AST) or Alanine transaminase (ALT) to predict severe dengue.

RESULTS

Two hundred and thirty confirmed dengue patients were enrolled, including 70% (161) patients with non-severe dengue and 30% (69) with severe dengue. This study indicates that 73.9% of patients had abnormal AST (＞40 U/L), and 34.8% of patients had abnormal ALT (＞40 U/L). The incidence of dengue patients with hepatitis (AST or ALT ≥ 4×ULN) and severe hepatitis (AST or ALT ≥ 10×ULN) were 18.7% and 17.0%, respectively. At a cut-off point of 120 U/L, AST's AUROC, sensitivity, and specificity were 0.93 (95% CI: 0.90-0.96), 82.5%, and 87.3%, respectively. At a cut-off point of 80 U/L, ALT's AUROC, sensitivity, and specificity were 0.89 (95% CI: 0.84-0,93), 87.5%, and 85.2%, respectively, for predicting severe dengue.

CONCLUSION

Elevated aminotransferase levels were associated with severe dengue, and AST/ALT were good markers for predicting severe dengue in Vietnamese children.

Therapeutic intervention for internalized stigma of severe mental illness: A systematic review and meta-analysis

OBJECTIVE

Internalized stigma can lead to pervasive negative effects among people with severe mental illness (SMI). Although prevalence of internalized stigma is high, there is a dearth of interventions and meanwhile a lack of evidence as to their effectiveness. This study aims at unraveling the existence of different therapeutic interventions and the effectiveness internalized stigma reduction in people with SMI via a systematic review and meta-analysis.

METHODS

Five electronic databases were searched. Studies were included if they (1) involved community or hospital based interventions on internalized stigma, (2) included participants who were given a diagnosis of SMI>50%, and (3) were empirical and quantitative in nature.

RESULTS

Fourteen articles were selected for extensive review and five for meta-analysis. Nine studies showed significant decrease in internalized stigma and two showed sustainable effects. Meta-analysis showed that there was a small to moderate significant effect in therapeutic interventions (SMD=-0.43; p=0.003). Among the intervention elements, four studies suggested a favorable effect of psychoeducation. Meta-analysis showed that there was small to moderate significant effect (SMD=-0.40; p=0.001).

CONCLUSION

Most internalized stigma reduction programs appear to be effective. This systematic review cannot make any recommendation on which intervention is more effective although psychoeducation seems most promising. More Randomized Controlled Trials (RCT) on particular intervention components using standard outcome measures are recommended in future studies.

[Electrocardiogram change of workers after disengaging occupational noise exposure]

OBJECTIVE

To examine electrocardiogram (ECG) change of workers after leaving occupational noise exposure.

METHODS

In the first phase of the Guangzhou Biobank Cohort Study, 10413 Guangzhou residents aged 50 years or more received a face-to face interview including noise exposure history, a full medical check-up and laboratory tests in 2003 - 4. ECG examination was carried out using 12-lead MAC-CS ECG machine made in HP Ltd, Shanghai, China. ECG of every subject was independently diagnosed by two doctors who had obtained ECG diagnosis qualification.

RESULTS

(1) Among 10413 subjects, 70% were female, and more than half were aged 60-69 years. The mean age and education level in males were higher than those in females. (2) 2119 subjects (21.0%) were previously exposed to noise and were retired now. (3) The prevalence of ECG abnormality was respectively 82.4% and 79.1% in females and males. Rate of ECG abnormality increased with age in both females and males (P = 0.000), and was lower in females with higher education level (P = 0.000). There was not significant difference in ECG abnormality between workers previously exposed or unexposed to noise in both females and males (P > 0.05). 4 Comparing workers previously exposed to those unexposed to noise in both females and males, after adjusting for age, educational level and smoking status, the rates of arrhythmia, axes deviation, atria and ventricle hypertrophy, ST-T change and coronary artery syndrome were not significantly different (P > 0.05).

CONCLUSION

Our study showed that the prevalence of ECG abnormality was not significantly increased in workers previously exposed to noise and had left exposure now compared to those never exposed to noise. Because our study was cross section and occupational history was obtained from a questionnaire but was not confirmed by the companies, further study is needed.

Building better team charters: an example from reengineering the preoperative system

This article illustrates a six-step chartering method using a successful project at the West Los Angeles VA Medical Center. The annual savings generated from this project were estimated at $13 million.

Effectiveness of a prospective physician self-audit transfusion-monitoring system

BACKGROUND

The purpose of this study was to search for a more effective transfusion-monitoring system than the existing system of retrospective peer review.

STUDY DESIGN AND METHODS

This research used a study-control, preintervention and postintervention design, to evaluate the effectiveness of a prospective physician self-audit transfusion-monitoring system that functioned without the direct involvement of transfusion service physicians. This research also evaluated the effectiveness of issuing to physicians a memo with transfusion guidelines. Three process indicators were used to assess physician behavior at various stages of the blood-ordering process: 1) the number of crossmatches ordered per admission, 2) the transfusion-to-crossmatch ratio, and 3) the number of blood units returned to the laboratory after physician self-auditing. The study used two outcome indicators to reflect overall blood utilization: 1) the percentage of patients who received red cell transfusions and 2) the number of blood units transfused per recipient each month.

RESULTS

The prospective physician self-audit system implemented at the study hospital did not reverse physician transfusion decisions, and the process of issuing to physicians a memo with transfusion guidelines at the control hospital failed to reduce blood usage. However, a transient reduction in blood utilization was observed at the study hospital.

CONCLUSION

The reduction was hypothesized to be due to a Hawthorne effect, in which observed behavior is affected by the subject's awareness of the research study.

Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization?

OBJECTIVE

This research used a study-control group design and examined data collected from five hospitals to evaluate the effectiveness of retrospective peer-review systems on reducing utilization of red blood cells (RBCs).

DESIGN

The effects of retrospective peer-review systems were studied in three parts: (1) trends of RBC utilization were compared by the slopes of linear regression lines that assessed the effect of time on RBC utilization among four study hospitals and one control hospital, (2) diagnosis-specific RBC utilization was compared between the control hospital and one matched study hospital, and (3) the effect of the retrospective review system of one study hospital was assessed by linear regression using data accumulated 1 year before and 2 years after implementation of the program.

RESULTS

Three study hospitals showed no significant changes in RBC utilization during the 10-month study period. One study hospital and the control hospital demonstrated trends of reduced RBC use with negative slopes of regression lines; however, there was no difference in the degree of the two slopes, and the diagnosis-specific RBC utilization was not lower at the study hospital than at the control hospital. Furthermore, implementation of the retrospective peer-review system at one study hospital demonstrated no effect on RBC utilization.

CONCLUSIONS

We conclude that the retrospective peer-review systems implemented at these four hospitals had no effect on reducing red blood cell utilization.

The problem of coping as a reason for psychiatric consultation

To examine those patients referred to psychiatry for the "problem of coping," a structured clinical databased management system--MICRO-CARES--was employed to identify the frequency, demographic characteristics, psychiatric diagnoses, psychosocial interventions, use of psychopharmacology, number of follow-up visits, and discharge placement of these referrals. Consultations totaling 1,157 from July 1, 1988 through January 1, 1990 were divided into two groups and compared: "Not coping" (N = 456, 28.5%) and "others" (N = 701, 61%). Those with a "problem in coping" more often had no Axis I diagnosis (p = 0.001), or were described as adjustment disorders (p = 0.0001). Fewer recommendations were made for those with a coping problem, although lag time (admission date to request for consultation), number of follow-ups, and discharge placement were not significantly different between the two groups. Stepwise logistic regression analyses revealed that the aged had lesser risk for being referred with a coping problem; those who were white, had their own income, experienced greater stress prior to hospitalization (Axis IV), and had higher functioning during the last year (Axis V) were at greater risk.

Production of a positive direct antiglobulin test due to suramin

Drugs and chemicals containing multiple reactive carbonyl groups have been postulated to produce nonimmunologic positive direct antiglobulin tests (DATs) both in vitro and in vivo. Suramin sodium, a reverse transcriptase inhibitor that was under investigation as a potential treatment for human immunodeficiency virus infection, has six reactive carbonyl groups. Because of suramin's chemical structure, it was hypothesized that the drug might cause a positive DAT in vitro and possibly in vivo. Suramin was found to produce a positive DAT in vitro at concentrations of 2100 mg/L or greater but did not cause a positive DAT in five patients with acquired immunodeficiency syndrome who were treated with suramin, probably because the serum levels of suramin were too low in these patients (peak therapeutic blood levels ranged from 171 to 443 mg/L).

An explanation for nonimmunologic adsorption of proteins onto red blood cells: Schiff's base reactions

During a phase I evaluation of diglycoaldehyde (INOX), an intravenous chemotherapeutic agent used to treat children with malignancies, all of eight patients tested developed a positive direct antiglobulin test (DAT) in vivo. The DAT became positive within one to seven days after the first administration of the drug and remained positive for up to 12 days following the last dose. The indirect antiglobulin tests were negative. None of the patients showed clinical or laboratory evidence of hemolysis at the time the DAT became positive or during follow-up. Eluates made from the red cells of two of the eight patients were both negative by indirect antihuman globulin testing. In vitro studies with INOX and glutaraldehyde, both dialdehyde compounds, showed nonimmunologic adsorption of protein onto red cells, probably by the condensation of aldehyde groups of these compounds to form Schiff's bases with amino acids of serum proteins and red cell membrane proteins. This reaction provides an explanation for the globulin detected on the red cells of patients treated with INOX.

Thimerosal-dependent agglutination complicating the serologic evaluation for unexpected antibodies

Thimerosal (merthiolate) is a preservative present in several low-ionic-strength blood bank reagents. Thimerosal-dependent panagglutinins were found in the serum of a hospitalized patient during serologic testing for unexpected red cell antibodies. The agglutinins behaved like a mixture of IgG and IgM and reacted with all red cells tested. Once the true nature of the serum panagglutinins was determined, blood bank reagents free of thimerosol were used, and no further serologic problems were encountered. Agglutination of this type should be considered whenever sera appear to contain panagglutinins and thimerosal is present in the test system.