Influence of Evidence-Based Design Strategies on Nurse Wellness

OBJECTIVES

The purpose of this study was to understand how specific evidence-based design strategies are related to aspects of nurse wellness.

BACKGROUND

Addressing burnout among the healthcare workforce is a system-level imperative. Nurses face continuous and dynamic physical and emotional demands in their role. Greater insight into the role of the physical environment can support efforts to promote nurse wellness.

METHODS

This exploratory qualitative study was conducted at new Parkland Hospital in Dallas, TX. We conducted five focus groups with nursing staff in July 2018. These sessions covered five topics related to nursing work in the facility which had been redesigned nearly 3 years earlier: (1) professional and social communication, (2) workflow and efficiency, (3) nurses' tasks and documentation, (4) ability to care for patients, and (5) nurses' overall health. We conducted a thematic analysis and first identified different aspects of wellness discussed by participants. Then, we examined how nurses related different design elements to different aspects of their wellness.

RESULTS

Participants included 63 nurses and nurse managers. They related environmental factors including facility size, break rooms, and decentralized workstations to social, emotional/spiritual, physical, intellectual, and occupational aspects of wellness.

CONCLUSIONS

It is critical to inform and integrate nurses at all levels into planning, design, and activation of new healthcare environments in order to ensure the well-being of nurses and, therefore, their ability to effectively support patients.

A Review of the Effectiveness of Audio-Only Telemedicine for Chronic Disease Management

Background: The clinical effectiveness of audio-only telemedicine has not been fully quantified. The pandemic afforded a unique situation to retrospectively observe clinical outcomes of care for three disease cohorts within three care models, including audio-only telemedicine. Methods: Patients were classified into three care models: audio-only telemedicine, in-person, and hybrid. Each model was compared with an aggregate group before the onset of the pandemic and within each group during the pandemic. Each disease cohort was evaluated in cross-sectional and paired analyses. Results: Patients (n = 52,720) were grouped within one of three care models. A majority (n = 48,335) of patients qualified for the "pre" group comparison. The audio-only telemedicine care model showed similar control of renal disease, hypertension control, and diabetes management than in-person and hybrid care models. Conclusions: Audio-only telemedicine appears to be noninferior to in-person or hybrid models for chronic disease management for the diseases studied. In all instances, it had similar control compared with the in-person care model. We acknowledge the limitations of this study, including convenience sampling and a limited observation timeframe. Audio-only telemedicine should be considered a viable care model modality that can be integrated into options for patient care. Further study and investment are warranted, as it provides efficacy and convenience to health systems (Clinical Registration Number # 32449).

From Fable to Reality at Parkland Hospital: The Impact of Evidence-Based Design Strategies on Patient Safety, Healing, and Satisfaction in an Adult Inpatient Environment

OBJECTIVE

This research aimed to evaluate the quantitative effects of new hospital design on adult inpatient outcomes.

BACKGROUND

Tenets of evidence-based healthcare design, notably single-patient acuity-adaptable and same-handed rooms, decentralized nursing stations, onstage offstage layout, and access to nature were expected to promote patient healing and increase patient satisfaction, while decreasing adverse events.

METHODS

Patient healing was operationalized through length of stay (LOS) and patient safety through three adverse events: falls, hospital-acquired infections (HAI), and medication-related events. Standard patient surveys captured patient satisfaction. Patient records from 2013 through 2017 allowed for equivalent time periods surrounding the move to the new hospital in August 2015. Stratified by hospital division where significant, pre/post comparisons utilized proportional hazards or logistic regression models as appropriate; interrupted time series analyses afforded longitudinal interpretations.

RESULTS

Observed higher postmove LOS was due to previously increasing trends, not increases after the move. In surgical and trauma units, a constant increase in falls was unaffected by the move. Medication events decreased consistently over time; medication events with harm dropped significantly after the move. No change in HAI was found. Significant improvement on most relevant patient satisfaction items occurred after the move. Call button response decreased immediately after the move but subsequently improved.

CONCLUSION

Results did not clearly indicate a net change in adult inpatient outcomes of healing and safety due to the hospital design. There was evidence that the new hospital improved patient satisfaction outcomes related to the environment, including comfort, noise, temperature, and aesthetics.

Eurados review of retrospective dosimetry techniques for internal exposures to ionising radiation and their applications

This work presents an overview of the applications of retrospective dosimetry techniques in case of incorporation of radionuclides. The fact that internal exposures are characterized by a spatially inhomogeneous irradiation of the body, which is potentially prolonged over large periods and variable over time, is particularly problematic for biological and electron paramagnetic resonance (EPR) dosimetry methods when compared with external exposures. The paper gives initially specific information about internal dosimetry methods, the most common cytogenetic techniques used in biological dosimetry and EPR dosimetry applied to tooth enamel. Based on real-case scenarios, dose estimates obtained from bioassay data as well as with biological and/or EPR dosimetry are compared and critically discussed. In most of the scenarios presented, concomitant external exposures were responsible for the greater portion of the received dose. As no assay is available which can discriminate between radiation of different types and different LETs on the basis of the type of damage induced, it is not possible to infer from these studies specific conclusions valid for incorporated radionuclides alone. The biological dosimetry assays and EPR techniques proved to be most applicable in cases when the radionuclides are almost homogeneously distributed in the body. No compelling evidence was obtained in other cases of extremely inhomogeneous distribution. Retrospective dosimetry needs to be optimized and further developed in order to be able to deal with real exposure cases, where a mixture of both external and internal exposures will be encountered most of the times.

Single-family room neonatal intensive care unit design: do patient outcomes actually change?

OBJECTIVE

This study examined outcomes in a single-family room neonatal intensive care unit (NICU) compared to an open bay within a public safety net hospital.

STUDY DESIGN

We included 9995 NICU encounters over 5 years pre and post move for a predominantly low SES population. Outcomes were length of stay (LOS), growth, time to first oral feeding, and incidence of sepsis. Analysis included regression models, interrupted time series, and growth models.

RESULTS

LOS decreased over time in preterm infants both pre and post move, but increased post move for term/post-term infants (p < 0.001). First oral feeding decreased over time in both periods. A higher incidence of sepsis was found in the post period for term/post-term infants (p = 0.01).

CONCLUSION

Our analysis appropriately accounted for time trends. Few differences were observed. Changes in LOS for term/post-term infants should be further explored as well as the impact of NICU care patterns.

Deer keds on wild ungulates in northern Italy, with a taxonomic key for the identification of Lipoptena spp. of Europe

Deer keds (Lipoptena spp.) are blood-sucking ectoparasites of domestic and wild animals, and also accidentally of humans. In Europe, five Lipoptena spp. have been recorded, although the lack of specific taxonomic keys has often led to mistaken identification or to missing data. The present study aimed to develop an identification key of the European species and also to identify Lipoptena spp. found on wild ungulates in northern Italy. In total, 390 hippoboscids were collected from Rupicapra rupicapra, Capreolus capreolus, Cervus elaphus and Ovis aries musimon in an Alpine area of Italy. After morphological identification, 140 specimens were subjected to phylogenetic analysis based on mitochondrial (CO1) and nuclear (CAD) gene sequences. Despite the expected presence of slight morphological variations, all specimens examined were identified both microscopically and molecularly as Lipoptena cervi (100% identity for both CO1 and CAD genes). The massive increase in wild ungulate populations can favour the possibility of detecting other species of Lipoptena. The identification keys proposed in the present study may help with monitoring the presence of Lipoptena species, particularly in European countries where this ectoparasite is neglected and for which various data (from diffusion to control methods) are still missing.

From Competition to Collaboration: How a Multi-Firm Research Coalition Is Realizing Rigorous Facility Evaluation at Parkland Hospital

This case study presents the process of developing a multi-entity Research Coalition to evaluate the new Parkland Hospital. The field of evidence-based design has made progress in systematically investigating relationships between healthcare facility design and a range of human outcomes. Yet healthcare facility evaluation is not typically included in the scope of building contracts. Lack of clear responsibility for evaluation and limited funding have been long-term barriers that the industry has yet to overcome. Firms engaged in design research at Parkland Hospital agreed with hospital representatives to collaborate on an integrated facility evaluation. Each participating entity contributed resources toward the effort. To formalize shared goals and priorities, the group developed a Research Coalition Charter. Goals included streamlining evaluation efforts to minimize burden on the hospital, leveraging multiple expertise areas to vet research aims and approaches, contributing knowledge to inform healthcare design, and innovating a model for multi-firm collaboration. The Coalition also developed guidelines for sharing data and disseminating research findings. To date, the Research Coalition has achieved key milestones including institutional review board exemption, data use and research collaboration agreements, and data collection. The research aims encompass patient and staff outcomes hypothesized to improve in the new facility. Both primary and secondary data are being analyzed to test the hypotheses. Publications of findings are forthcoming. Collaborative research among competitors may be a viable approach to realizing evaluation that is critical to learning for healthcare facility decision makers and design practitioners.

P11.39 Chloroquine as an anti-glioblastoma therapeutic: repurposing of an old drug

BACKGROUND

Glioblastoma (GBM) is the most common and aggressive type of primary brain tumour in adults. These tumours depict anarchic proliferation and brain infiltration as well as radio- and chemoresistant profiles. The complete surgical resection is unachievable and responses to standard therapy are transitory. Recurrence is thus inevitable and patient prognosis is generally less than 15 months. Transforming growth factor-beta (TGF-β) holds a substantial role in supporting the GBM phenotype. We showed that TGF-β 1 expression levels correlate with overall and progression-free survival in newly diagnosed GBM patient. We also observed that chloroquine (CQ) can reduce the production of TGF-β together with proliferation, invasion, radioresistance and radio-induced invasion in vitro. Unfortunately, little is known regarding the ability of CQ to penetrate the blood-brain barrier (BBB). Therefore, our objective is to determine whether intravenous (IV) or intra-arterial (IA) infusions of CQ and hydroxychloroquine (HCQ), a pharmacological analog of CQ, can yield therapeutic brain concentrations.

MATERIAL AND METHODS

To assess BBB penetration, the brain, plasma and cerebrospinal fluid (CSF) concentrations of CQ/HCQ were measured by LCMS/MS at different timepoints post-IV or post-IA infusions with 20 mg/kg of CQ/HCQ in tumour-free Wistar rat. For the survival studies, We implanted 10’000 F98 murin glioblastoma cells in the right putamen of Fischer rats. Ten days post-implantation, IA and IV infusion were accomplished through cannulations of the external right carotid and tail vein respectively.

RESULTS

With IV injections, CQ/HCQ brain concentrations 15 minutes post-injection reached 15.76 mg/g (0.18 µM) and 1.67 mg/g (0.078 µM) respectively. However, following IA infusions, we observed a 1.74 and 20.9 fold increase (20 mg/kg HCQ) as well as 7.1 and 84.7-fold-increase (20 mg/kg CQ) in contra- and ipsilateral brain concentrations respectively. Although brain concentrations gradually decreased over time post-IA infusions, the ipsilateral hemisphere CQ concentration was still 82.81 mg/g (34.52 µM) after 6 hours. Whereas plasma concentrations were very similar following IV and IA infusions, both molecules barely accumulated in the CSF and only when using IA infusions. The median survival of the control group (IA phosphate-buffered saline) and the group treated with 20 mg/kg CQ IV were 23.5 days and 24.5 days respectively. However, rats injected with 20 mg/kg CQ IA had a median survival of 28.5 days.

CONCLUSION

These results suggest that IA CQ could be used to abrogate the GBM phenotype. As TGF-β is associated with resistance to both radio- and chemotherapy, we plan to characterize the combination of IA infusions of CQ in combination with radiation or chemotherapy (carboplatin).

Reducing Hospitalizations: Institution of Outpatient Infusional EPOCH-Based Chemotherapy at a Safety Net Hospital

PURPOSE:

EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) -based chemotherapy is traditionally administered inpatient because of its complex 96-hour protocol and number of involved medications. These routine admissions are costly, disruptive, and isolating to patients. Here, we describe our experience transitioning from inpatient to outpatient ambulatory EPOCH-based chemotherapy in a safety-net hospital, associated cost savings, and patient perceptions.

METHODS AND MATERIALS:

Guidelines for chemotherapy administration and educational materials were developed by a multidisciplinary team of physicians, nurses, and pharmacists. Data were collected via chart review and costs via the finance department. Patient satisfaction with chemotherapy at home compared with hospitalization was measured on a Likert-type scale via direct-to-patient survey.

RESULTS:

From January 30, 2017, through January 30, 2018, 87 cycles of EPOCH-based chemotherapy were administered to 23 patients. Sixty-one ambulatory cycles (70%) were administered to 18 patients. Of 26 cycles administered in the hospital, 18 (69%) were the first cycle of treatment. Rates of inappropriate prophylactic antimicrobial prescription and laboratory testing were lower in the outpatient setting. Eight of nine patients surveyed preferred home chemotherapy to inpatient chemotherapy. Per-cycle drug costs were 57.6% lower in outpatients as a result of differences in the acquisition cost in the outpatient setting. In total, the transition to ambulatory EPOCH-based chemotherapy yielded 1-year savings of $502,030 and an estimated 336 days of avoided hospital confinement.

CONCLUSION:

Multiday ambulatory EPOCH-based regimens were successfully and safely administered in our safety-net hospital. Outpatient therapy was associated with significant savings through avoided hospitalizations and reductions in drug acquisition cost and improved patient satisfaction.

BIODOSIMETRY AND BIODOSIMETRY NETWORKS FOR MANAGING RADIATION EMERGENCY

Biological dosimetry enables individual dose reconstruction in the case of unclear or inconsistent radiation exposure situations, especially when a direct measurement of ionizing radiation is not or is no longer possible. To be prepared for large-scale radiological incidents, networking between well-trained laboratories has been identified as a useful approach for provision of the fast and trustworthy dose assessments needed in such circumstances. To this end, various biodosimetry laboratories worldwide have joined forces and set up regional and/or nationwide networks either on a formal or informal basis. Many of these laboratories are also a part of global networks such as those organized by World Health Organization, International Atomic Energy Agency or Global Health Security Initiative. In the present report, biodosimetry networks from different parts of the world are presented, and the partners, activities and cooperation actions are detailed. Moreover, guidance for situational application of tools used for individual dosimetry is given.

Wolverines (Gulo gulo luscus) on the Rocky Mountain slopes: natural heterogeneity and landscape alteration as predictors of distribution

A species’ occurrence can be influenced by natural and anthropogenic factors; disentangling these is a precursor to understanding the mechanisms of distribution. Anthropogenic factors may be especially important at contracting range edges. We test this premise for wolverines (Gulo gulo luscus L., 1758) at the edge of their Rocky Mountain range in Alberta, Canada, a mosaic of natural heterogeneity and extensive landscape development. As wolverines have a suspected negative response to human activity, we hypothesized their occurrence on the Rockies’ slopes is predicted by a combination of natural and anthropogenic features. We surveyed wolverines at 120 sites along a natural and anthropogenic gradient using hair trapping and noninvasive genetic tagging. We used abundance estimation, generalized linear, and hierarchical models to determine whether abundance and occurrence was best predicted by natural land cover, topography, footprint, or a combination. Wolverines were more abundant in rugged areas protected from anthropogenic development. Wolverines were less likely to occur at sites with oil and gas exploration, forest harvest, or burned areas, even after accounting for the effect of topography. The relative paucity of wolverines in human-impacted portions of this range edge suggests that effective conservation requires managing landscape development, and research on the proximal mechanisms behind this relationship.

Identification of peanuts and tree nuts: are allergists smarter than their patients?

BACKGROUND

It has been reported that peanut- or tree nut-allergic individuals and their guardians are poorly capable of differentiating various tree nuts and peanuts. No information exists on the ability of allergists to differentiate peanuts and tree nuts.

OBJECTIVE

To measure the ability of allergists and other specialists within the allergy and immunology field to identify various types of tree nuts and peanuts.

METHODS

A nut box with a clear cover was constructed and contained various tree nuts and peanuts in shelled and unshelled forms. Attendees at the 2012 national meeting of the American Academy of Allergy, Asthma, and Immunology were offered participation by viewing the nut box and filling in their responses to a questionnaire. A similar procedure was conducted in the Food Allergy Center at Children's Medical Center (Dallas, TX) for guardians of children with and without peanut or tree nut allergies.

RESULTS

Allergists were better able to identify and differentiate tree nuts and peanuts than guardians of peanut- or tree nut-allergic children, guardians of children without food allergies, and allergy and immunology fellows in training.

CONCLUSION

It is important for allergists to educate peanut- and tree nut-allergic individuals and their guardians on the proper avoidance of peanuts and tree nuts. This includes education in the ability to identify peanuts and tree nuts. In addition, allergy and immunology fellows in training may benefit from education in proper peanut and tree nut identification.

Interlaboratory comparison of dicentric chromosome assay using electronically transmitted images

The bottleneck in data acquisition during biological dosimetry based on a dicentric assay is the need to score dicentrics in a large number of lymphocytes. One way to increase the capacity of a given laboratory is to use the ability of skilled operators from other laboratories. This can be done using image analysis systems and distributing images all around the world. Two exercises were conducted to test the efficiency of such an approach involving 10 laboratories. During the first exercise (E1), the participant laboratories analysed the same images derived from cells exposed to 0.5 and 3 Gy; 100 images were sent to all participants for both doses. Whatever the dose, only about half of the cells were complete with well-spread metaphases suitable for analysis. A coefficient of variation (CV) on the standard deviation of ∼15 % was obtained for both doses. The trueness was better for 3 Gy (0.6 %) than for 0.5 Gy (37.8 %). The number of estimated doses classified as satisfactory according to the z-score was 3 at 0.5 Gy and 8 at 3 Gy for 10 dose estimations. In the second exercise, an emergency situation was tested, each laboratory was required to score a different set of 50 images in 2 d extracted from 500 downloaded images derived from cells exposed to 0.5 Gy. Then the remaining 450 images had to be scored within a week. Using 50 different images, the CV on the estimated doses (79.2 %) was not as good as in E1, probably associated to a lower number of cells analysed (50 vs. 100) or from the fact that laboratories analysed a different set of images. The trueness for the dose was better after scoring 500 cells (22.5 %) than after 50 cells (26.8 %). For the 10 dose estimations, the number of doses classified as satisfactory according to the z-score was 9, for both 50 and 500 cells. Overall, the results obtained support the feasibility of networking using electronically transmitted images. However, before its implementation some issues should be elucidated, such as the number and resolution of the images to be sent, and the harmonisation of the scoring criteria. Additionally, a global website able to be used for the different regional networks, like Share Points, will be desirable to facilitate worldwide communication.

Adverse reactions during drug challenges: a single US institution's experience

BACKGROUND

Drug challenge is a useful tool when diagnostic testing lacks predictive value for a questionable history of drug allergy. Placebo-controlled drug challenge studies demonstrate that a significant number of patients report purely subjective symptoms to placebo.

OBJECTIVE

To evaluate the safety and rate of adverse effects when performing drug challenges and to identify predictive factors for occurrences of subjective symptoms during drug challenges.

METHODS

We performed a 6-year, retrospective medical record review of patients who underwent drug challenges by members of the Allergy and Immunology Division after consultation deemed drug challenges to be appropriate. Statistical analysis was performed to compare the proportion of patients with subjective symptoms based on certain factors, including sex, age, number of listed drug allergies, interval from historical drug reaction to the drug challenge, and types of historical reaction.

RESULTS

A total of 114 patients underwent 123 drug challenges. Only 1 patient was deemed to have a true positive drug challenge result. Twenty patients reported subjective symptoms during graded challenge, all of which were not deemed a positive challenge. There was a significantly higher proportion of patients who reported subjective symptoms in females, those with a higher number of listed drug allergies, and those whose historical reactions were primarily subjective in nature.

CONCLUSION

Drug challenges are safe procedures in appropriately selected patients. A number of patients report subjective symptoms during drug challenges. Identifying patients at high risk for subjective symptoms may assist in determining whether placebo-controlled drug challenges should be performed.

Effect of lymphocytes culture variations on the mitotic index and on the dicentric yield following gamma radiation exposure

Fundamentals of biological dosimetry are described in the International Atomic Energy Agency manual, but all over the world each laboratory is using its own protocol. To test the influence of protocol variations, some blood samples were exposed to 0.5 Gy of gamma radiation and mitotic index and dicentric rates were measured under different experimental conditions. The effect of seven parameters [bromodeoxyuridin (BrdU), phytohaemagglutinin and colcemid concentrations, blood and medium volumes, culture duration and incubation temperature] was tested using a Placket and Burman experimental design. The analysis reveals that the mitotic index was influenced by the concentration of BrdU, medium and blood volumes, the culture duration and the temperature. However, none of the factors has a significant impact on the yield of dicentrics. The dicentric assay is robust against reagent variations within the range tested. These results could be used by relevant laboratories as elements of their procedures robustness in any event requiring such demonstration.

Potential for liver and kidney donation after circulatory death in infants and children

OBJECTIVE

To determine the potential effect of organ donation after circulatory death (DCD) on the number of kidney and liver donors in a PICU.

PATIENTS AND METHODS

All deaths in the PICU of an academic, tertiary care children's hospital from May 1996 to April 2007 were retrospectively reviewed. Patient demographics, premortem physiology, and end-of-life circumstances were recorded and compared with basic criteria for potential organ donation. A sensitivity analysis was performed to examine the effect of more strict physiologic and time criteria as well as 3 different rates of consent for donation.

RESULTS

There were 1389 deaths during 11 years; 634 children (46%) underwent withdrawal of life support, of whom 518 had complete data and were analyzed. There were 131 children (25% of those withdrawn, 9% of all deaths) who met basic physiologic and time criteria for organ donation (80 kidney; 107 liver). Consideration of consent rates in sensitivity analysis resulted in an estimated 24 to 85 organ donors, an increase of 28% to 99% over the 86 actual brain-dead donors during the same time period. Assuming historical rates of organ recovery, these DCD donors might have produced 30 to 88 additional kidneys and 8 to 56 additional livers, an increase of 21% to 60% in kidney donation and 13% to 80% in livers above the number of organs recovered from brain-dead donors.

CONCLUSIONS

Although relatively few children may have been eligible for DCD, they might have increased the number of organ donors from our institution, depending greatly on consent rates. DCD merits additional discussion and exploration.

Health-related quality of life in children and adolescents with sickle cell disease

OBJECTIVE

To assess health-related quality of life (HRQOL) in children and adolescents with sickle cell disease (SCD).

DESIGN, SETTING, AND PARTICIPANTS

The PedsQL 4.0 Generic Scales, a multidimensional self-report instrument that has been shown to be valid and reliable for use in children and adolescents with chronic illness, consists of 23 items that assess physical, emotional, social, and school functioning. Questionnaires were administered to 124 children and adolescents (ages 8 to 18 years, child self-report) with SCD (100 sickle cell anemia, 24 sickle β zero thalassemia) and their parents (parent-proxy report). Summary scores for children's and parents' ratings of overall HRQOL and psychosocial health and subscale scores for physical, emotional, social, and school functioning were compared with published data for healthy children. Both summary and subscale scores for children with SCD also were compared with those of their parents.

RESULTS

Children with SCD and their parents rated overall HRQOL and all subdomains of HRQOL lower than did healthy children and their parents (P < .001). Children with SCD rated their own HRQOL significantly better than their parents did for overall HRQOL and all subdomains (P < .001) except emotional functioning (P = .06).

CONCLUSIONS

Children with SCD and their parents perceived overall HRQOL and all HRQOL subdomains to be lower than scores reported in healthy children. Therefore, successful therapeutic efforts to improve HRQOL could represent important advances in the health of children with SCD.

Effects of different dietary omega-6/3 polyunsaturated fatty acids ratios on infarct size and the limbic system after myocardial infarction

Changes in dietary omega-6/3 polyunsaturated fatty acids (PUFA) ratios affect anti- and proinflammatory equilibrium. As reperfused myocardial infarction (MI) is an inflammatory pathology that alters the cell integrity of the myocardium but also of other tissues, such as the hippocampus and amygdala, attenuation of the inflammation could be helpful in maintaining cell integrity after MI. Therefore, we hypothesized that a decrease in the dietary omega-6/3 PUFA ratio, without altering the diet content in total fat, proteins, or carbohydrates, will result in a reduction of infarct size and a diminution of postreperfusion apoptosis observed in the amygdala and hippocampus. Male Sprague–Dawley rats were fed 1 of 3 diets containing different omega-6/3 PUFA ratios for 2 weeks (5:1; 1:1; 1:5). Then, myocardial ischemia was induced by left anterior descending coronary artery occlusion for 40 min, followed by reperfusion. Cardioprotective mechanisms were studied in the myocardium at 15 min of reperfusion, along with myocardial infarct size after 24 h of reperfusion. Apoptosis was evaluated in the hippocampus and the amygdala. We found that infarct size was significantly reduced by 32% in groups 1:5 and 1:1 vs. group 5:1. Akt activity was higher in groups 1:5 and 1:1 compared with group 5:1. Caspase-3 enzymatic activity doubled in area CA1 and the dentate gyrus (DG) in group 5:1 compared with groups 1:1 and 1:5. In addition, caspase-8 enzymatic activity was increased in the DG at 24 h, and caspase-9 was enhanced in CA1 at 24 h in group 5:1 vs. groups 1:1 and 1:5. These results demonstrate that the increase in the dietary omega-3 PUFA, at the expense of omega-6 PUFA, reduces infarct size and helps to inhibit apoptosis in the limbic system after MI.

Biological dosimetry intercomparison exercise: an evaluation of triage and routine mode results by robust methods

Well-defined protocols and quality management standards are indispensable for biological dosimetry laboratories. Participation in periodic proficiency testing by interlaboratory comparisons is also required. This harmonization is essential if a cooperative network is used to respond to a mass casualty event. Here we present an international intercomparison based on dicentric chromosome analysis for dose assessment performed in the framework of the IAEA Regional Latin American RLA/9/054 Project. The exercise involved 14 laboratories, 8 from Latin America and 6 from Europe. The performance of each laboratory and the reproducibility of the exercise were evaluated using robust methods described in ISO standards. The study was based on the analysis of slides from samples irradiated with 0.75 (DI) and 2.5 Gy (DII). Laboratories were required to score the frequency of dicentrics and convert them to estimated doses, using their own dose-effect curves, after the analysis of 50 or 100 cells (triage mode) and after conventional scoring of 500 cells or 100 dicentrics. In the conntional scoring, at both doses, all reported frequencies were considered as satisfactory, and two reported doses were considered as questionable. The analysis of the data dispersion among the dicentric frequencies and among doses indicated a better reproducibility for estimated doses (15.6% for DI and 8.8% for DII) than for frequencies (24.4% for DI and 11.4% for DII), expressed by the coefficient of variation. In the two triage modes, although robust analysis classified some reported frequencies or doses as unsatisfactory or questionable, all estimated doses were in agreement with the accepted error of ±0.5 Gy. However, at the DI dose and for 50 scored cells, 5 out of the 14 reported confidence intervals that included zero dose and could be interpreted as false negatives. This improved with 100 cells, where only one confidence interval included zero dose. At the DII dose, all estimations fell within ±0.5 Gy of the reference dose interval. The results obtained in this triage exercise indicated that it is better to report doses than frequencies. Overall, in both triage and conventional scoring modes, the laboratory performances were satisfactory for mutual cooperation purposes. These data reinforce the view that collaborative networking in the case of a mass casualty event can be successful.

Cytogenetic assessment of heterogeneous radiation doses in cancer patients treated with fractionated radiotherapy

The purpose of this study was to evaluate the in vivo dose-response relation of chromosome aberration formation and distribution in a context of localised and fractionated radiotherapy. Cytogenetic analysis was applied to eight patients, all treated for the same tumour localisation; the same localisation was used to prevent the variability usually observed between patients treated with radiotherapy and to allow the corresponding roles of the size of irradiation field and of the dose rate to be studied. The yield of dicentrics, centric rings and fragments was measured in blood samples taken before treatment, during the course of radiotherapy and up to 6 months after. After the first fraction of radiotherapy, we observed that the whole-body dose estimated from the yield of dicentrics and rings was higher (0.35+/-0.2 Gy) than the calculated equivalent whole-body dose (0.07+/-0.04 Gy). By contrast, the partial-body dose derived from the Qdr (quotient of dicentrics and rings) model was estimated to be 2.2+/-0.3 Gy, which agreed quite well with the dose delivered to the tumour (2.1+/-0.1 Gy). We also found a correlation between the yield of induced chromosome aberrations and the target field size (p = 0.014). U-value analysis showed that the distribution of dicentrics and rings was overdispersed, despite the fractionation of the exposure, and a positive correlation between the U-value and the dose rate was observed (p = 0.017). Overall, these results suggest that the proportion of undamaged lymphocytes could increase with the dose rate.

Echocardiographic predictors of symptomatic patent ductus arteriosus in extremely-low-birth-weight preterm neonates

OBJECTIVE

Identify echocardiographic parameters at <or=4 day postnatal that predict the subsequent need for closure of a clinically significant patent ductus arteriosus (sPDA) in extremely-low-birth-weight neonates (ELBW).

STUDY DESIGN

Serial echocardiograms obtained in 115 ELBW at <or=10 day postnatal were examined to estimate PDA size using the PDA:left pulmonary artery (LPA) diameter ratio: >or=1 indicated a large PDA, <1 but >or=0.5 moderate, and <0.5 small. Sensitivity, specificity, and positive predictive values (PPV) were determined for ELBW <27 weeks and >or=27 weeks gestational age.

RESULT

Neonates with moderate to large PDA at <or=4 day had 15-times greater likelihood of requiring treatment for sPDA than those with a small PDA (95% confidence interval (CI): 5.6-41). Sensitivity, specificity and PPV of the PDA:LPA at <27 weeks was 80, 86 and 92%, respectively.

CONCLUSION

A moderate to large PDA determined from the PDA:LPA ratio at <or=4 day postnatal identifies neonates <27 week gestation who subsequently require closure of a PDA.

A randomised clinical trial comparing minimally invasive surgery to conventional approach for endoprosthesis in elderly patients with hip fractures

BACKGROUND

In recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied in a randomised fashion.

METHODS

This study is a prospective clinically randomised trial whose primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for endoprosthesis in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. 25 patients in the mini-incision surgery (MIS) group and 31 patients in the standard incision group (STD) were available for analysis. The following validated disease-specific outcome instruments were used: the Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life were assessed by the components of the Harris Hip Score (HHS) and SF-36. Radiographic outcomes were also evaluated as well as the rates of all reported complications and adverse events during the 2 years follow-up.

RESULTS

There was no significant difference for operative time, blood losses, 72 h postoperative haemoglobin as well as the need for transfusion therapy between the two groups. Also, there was no difference between the groups for postoperative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using LEM and TUG did not demonstrate any statistically significant difference between mini- and standard incision. However, the HHS and the physical function component of the SF-36 were statistically better at 2 years in favour of the standard incision group.

CONCLUSION

Based on the results of the present study, we cannot recommend the use of a minimally invasive approach over a standard approach in the implantation of a cemented endoprosthesis.

Comparative study of kala-azar vector control measures in eastern Nepal

This study was conducted to explore the most effective vector control tool among indoor residual spraying (IRS), long lasting insecticidal nets (LLINs) and ecological vector management (EVM) as a part of the regional visceral leishmaniasis elimination initiative. Alpha-cypermethrin as IRS, PermaNet as LLINs and plastering the inner walls of houses with lime as EVM were the interventions. One baseline and three follow-up entomological surveys were carried out in all arms using CDC miniature light traps (LT) and mouth aspirators. Comparisons were made between intervention arms and control arms with pre-intervention and post-intervention vector densities. Light traps were found more efficient in the collection of Phlebotomus argentipes in comparison with aspiration. Vector densities were significantly low in both IRS arm (p=0.009 in LT and p<0.001 in aspirator collections) and LLIN arm (p=0.019 in LT and p=0.023 in aspirator collections) in comparison with control arm. However, in EVM arm, there was no significant difference in P. argentipes sand fly density in comparison with control arm (p=0.785) in LT collections in follow-up surveys. Hence, IRS was found most effective control measure to decrease vector density. LLINs were also found effective and can be considered as a promising alternative vector control tool in VL elimination initiative.

Molecular phylogenetic assessment of host range in five Dermanyssus species

Given that 14 out of the 25 currently described species of Dermanyssus Dugès, 1834, are morphologically very close to each another, misidentifications may occur and are suspected in at least some records. One of these 14 species is the red fowl mite, D. gallinae (De Geer, 1778), a blood parasite of wild birds, but also a pest in the poultry industry. Using molecular phylogenetic tools we aimed to answer two questions concerning host specificity and synanthropicity: (1) is D. gallinae the only species infesting European layer farms?, and (2) can populations of D. gallinae move from wild to domestic birds and vice versa? Mitochondrial cytochrome oxidase I gene sequences were obtained from 73 Dermanyssus populations collected from nests of wild European birds and from poultry farms and these were analyzed using maximum parsimony and Bayesian inference. Mapping of the observed host range on the obtained topology and correlation with behavioural observations revealed that (1) host range is strongly dependent on some ecological parameters (e.g. nest hygiene, exposure to pesticides and predators), that (2) out of five species under test, synanthropic populations were found only in lineages of D. gallinae, and that (3) at least some haplotypes found in wild birds were very close to those found in association with domestic birds.

Subcutaneous omacetaxine mepesuccinate in chronic myeloid leukemia (CML) patients resistant or intolerant to two or more tyrosine kinase inhibitors (TKIs): Data from an ongoing phase II trial

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Background: Omacetaxine (OM), a first-in-class cetaxine, shows clinical activity against Ph+ CML with a mechanism of action independent to tyrosine kinase inhibition. Patients (Pts) who have failed multiple TKIs may benefit from an alternative therapy for CML. Methods: Pts include adult CML following resistance or intolerance to at least 2 TKIs. T315I+ Pts are enrolled in a separate trial. Pts receive OM induction at 1.25 mg/m2 subcutaneous (SC) BID for 14 days every 28 days followed by maintenance at 1.25 mg/m2 SC BID for 7 days every 28 days (maintenance after at least one induction cycle and achievement of hematologic response). Results: 60 pts (30 chronic phase [CP], 14 accelerated phase [AP], and 16 blast phase [BP] have been enrolled with 51% having failed at least 3 prior TKIs. Median age: 58 yrs; 50% male. Median disease duration: 74 months. At baseline, 38.5% of pts had Bcr-Abl mutations including 9.6% with compound mutations. The most frequently observed mutations were F317L (11.5%) and V299L (5.8%). OM is well tolerated with transient myelosuppression as the primary toxicity. Grade 3/4 non-hematologic events are rare with pyrexia occurring in 4.3% of patients. Efficacy data are available for 30 Pts: Conclusions: Omacetaxine in multi-TKI resistant or intolerant CML is well tolerated and has achieved hematologic and cytogenetic responses in these heavily pre-treated Pts.

[Table: see text]

[Table: see text]

Differential recruitment of dendritic cells and monocytes to respiratory mucosal sites in children with influenza virus or respiratory syncytial virus infection

BACKGROUND

Influenza virus and respiratory syncytial virus (RSV) are among the most common viruses causing infections of the lower respiratory tract in young children. Although there are important differences in the immunopathogenesis of these 2 viral pathogens, little is known about how they affect antigen-presenting cells in children with acute infections.

METHODS

To characterize the immune cells that are mobilized to the respiratory tract by influenza virus and RSV, we analyzed nasal wash and blood samples obtained from children hospitalized with acute respiratory infections.

RESULTS

Influenza virus and RSV mobilize immune cells, including myeloid dendritic cells (mDCs) and plasmacytoid dendritic cells (pDCs), to the nasal mucosa. Patients with influenza virus infection had greater numbers of mDCs, pDCs, and monocytes in nasal wash samples than did patients with RSV infection. The frequencies of respiratory tract and blood T cell subsets were not affected by infection with influenza virus or RSV. Monocyte chemoattractant protein-1 concentrations in nasal wash samples were significantly increased in patients with influenza virus infection but not in those with RSV infection. RANTES (regulated on activation, normally T cell expressed and secreted) concentrations were increased only in the blood of patients with influenza virus infection.

CONCLUSIONS

Infection with influenza virus or RSV mobilizes antigen-presenting cells to the respiratory tract. The differences in antigen-presenting cell numbers and cytokine concentrations suggest that there are distinctive, early immune responses to these 2 viruses.

Delimiting species boundaries within Dermanyssus Dugès, 1834 (Acari:Dermanyssidae) using a total evidence approach

The genus Dermanyssus is currently composed of 24 hematophagous mite species and includes the Poultry Red Mite, Dermanyssus gallinae, a serious pest in poultry houses. Morphologically, Dermanyssus species fall into two groups corresponding to Moss'gallinae-group and to hirsutus-group+Microdermanyssus. Species of the gallinae-group exhibit high levels of morphological variability, and are nearly impossible to distinguish. Species of the second group display consistent characters and host associations and are easily distinguishable. Species of the gallinae-group tend to be the major problems in poultry houses and it is unknown whether D. gallinae is the only pest, or if there are numerous cryptic species present in the system. Twenty species of Dermanyssus were tested phylogenetically based on 46 morphological characters. A subset of species, mainly of the gallinae-group, represented each by several populations, was sequenced for two mitochondrial and one nuclear gene regions. This allowed testing their specific status and their interrelationships based and on morphological and molecular characters. The molecular data was analysed separately and in combination with morphological characters. As expected, morphology did a poor job resolving relationships. Molecular data proved more informative. The resulting phylogenetic hypotheses brought some information about interrelationships among species of the gallinae-group showing a split into two main clades. The invasion of human managed environments seems to occur only in taxa within one of the two clades. The host spectrum seems to get enlarged in more derived taxa in the same clade. A delineation of six species within the gallinae-group is provided. Additionally, a key for morphological identification of these species is provided. D. gallinae appears to be the only pest in poultry houses, but is composed of several different and more or less strongly isolated lineages. A new species found from the black swift is described.

Effect of low-dose naloxone infusion on fentanyl requirements in critically ill children

OBJECTIVE

Sedating critically ill patients often involves prolonged opioid infusions causing opioid tolerance. Naloxone has been hypothesized to limit opioid tolerance by decreasing adenylate cyclase/cyclic adenosine monophosphate activation. The study purpose was to investigate the effect of low-dose naloxone on the maximum cumulative daily fentanyl dose in critically ill children.

METHODS

We conducted a double-blinded, randomized, placebo-control trial from December 2002 through July 2004 in a university PICU. We enrolled 82 children age 1 day to 18 years requiring mechanical ventilation and fentanyl infusions anticipated to last for >4 days were eligible for enrollment. Those receiving additional oral analgesia or sedation, having a history of drug dependence or withdrawal, or having significant neurologic, renal, or hepatic disease were excluded. In addition to fentanyl infusions, patients received low-dose naloxone or placebo infusions. Medications were adjusted using the Modified Motor Activity Assessment Scale. Withdrawal was monitored using the Modified Narcotic Withdrawal Scale. Intervention was a low-dose naloxone infusion (0.25 microg/kg per hour) and the main outcome variable was the maximum cumulative daily fentanyl dose (micrograms per kilogram per day).

RESULTS

There was no difference in the maximum cumulative daily fentanyl dose between patients treated with naloxone (N = 37) or those receiving placebo (N = 35). Adjustment for the starting fentanyl dose also failed to reveal group differences. Total fentanyl dose received throughout the study in the naloxone group (360 microg/kg) versus placebo (223 microg/kg) was not statistically different. Placebo patients trended toward fewer rescue midazolam boluses (10.7 vs 17.8), lower total midazolam dose (11.6 mg/kg vs 23.9 mg/kg), and fewer rescue fentanyl boluses (18.5 vs 23.9).

CONCLUSIONS

We conclude that administration of low-dose naloxone (0.25 microg/kg per hour) does not decrease fentanyl requirements in critically ill, mechanically ventilated children.