Overactive Pattern Separation Memory Associated with Negative Emotionality in Adults Diagnosed with Autism Spectrum Disorder

Bowler et al. (Journal of Autism and Developmental Disorders 44(9):2355-2362. doi:10.1007/s10803-014-2105-y, 2014) have suggested that a specific memory impairment in autism spectrum disorders (ASD) arises from hippocampal failure to consolidate multiple related pieces of information. Twenty-four adults diagnosed with ASD and matched healthy controls completed a pattern separation memory task that is known to critically depend on hippocampal involvement. They additionally completed questionnaires regarding anxiety, depression, and behavioral motivation. Specific deficits in pattern separation were significantly correlated with negative emotionality; the best predictor of memory deficit was from a measure of achievement motivation that has also been associated with hyperactivity and impulsivity. In the context of impaired emotion regulation in ASD, there is a need for integrated cognitive, affective, and neural systems approaches to build targeted interventions.

Drug approval processes in Australian Paediatric Hospitals

OBJECTIVE

To describe and evaluate the decision-making processes for drug approval in Australian paediatric hospitals.

DESIGN

Multicentre descriptive study involving face-to-face interviews of drug and therapeutics committee chairs and secretaries, review of committee documents and drug submissions for all Australian paediatric hospital drug and therapeutics committees over a 1-year period.

SETTING

All eight paediatric hospitals in Australia.

PARTICIPANTS

Eight committee chairs and seven secretaries or delegates.

MAIN OUTCOME MEASURES

Total drug expenditure, number of formulary submissions, individual-patient use approvals and approval rates for each hospital from 1 July 2006 to 30 June 2007, stratified by therapeutic class. Qualitative description of the approval processes.

RESULTS

Total drug expenditure varied from $A1.7 million (US$1.5 million) to $A11.1 million (US$9.8 million) per hospital. The number of formulary submissions also varied, from 7 to 21, but approval rate was high (76%-100%) and not significantly different among hospitals (p=0.17). Several committees approved identical submissions for five drugs. The number of individual-patient use applications varied considerably, ranging from 10 to 456 per hospital. Where estimable, individual-patient use approval was 76%-100% and variable (p=0.03). Quality of evidence relating to safety and efficacy of drugs being considered was regarded as the most important factors influencing decision making, with the cost less important. Most committees had poor infrastructural support for approval processes. No committee formally included a pharmaco-economic evaluation.

CONCLUSIONS

Most drug submissions in tertiary paediatric hospitals are approved; however, workload, drug expenditure and individual-patient use schemes vary considerably. Duplication of effort occurs, and few committees are resourced sufficiently given their terms of reference.

Anxiety is more common in children with asthma

OBJECTIVE

There are a variety of reasons why there may be an association between asthma and anxiety in children. Research into the relation between asthma and anxiety has been limited by the sole use of parent-reported or self-reported asthma symptoms to define asthma status. The objective of this study was to determine if children with physician-defined asthma are more likely to suffer anxiety than children without asthma.

DESIGN

A population-based, cross-sectional assessment, of self-reported anxiety symptoms.

SETTING AND PARTICIPANTS

Children aged 5-13 years from Barwon region of Victoria, Australia. Asthma status was determined by review with a paediatrician. Controls were a sample of children without asthma symptoms (matched for age, gender and school).

OUTCOME MEASURE

The Spence Children's Anxiety Scale (SCAS) written questionnaire. The authors compared the mean SCAS score, and the proportion of children with an SCAS score in the clinical range, between the groups.

RESULTS

Questionnaires were issued to 205 children with asthma (158 returned, response rate 77%), and 410 controls (319 returned, response rate 78%). The SCAS scores were higher in asthmatics than controls (p<0.001); and were more likely to be in the clinical range (OR=2.5, 95% CI 1.1 to 5.8, p=0.036). There was no evidence that these associations could be explained by known confounding factors.

CONCLUSIONS

Children with asthma are substantially more likely to suffer anxiety than children without asthma. Future studies are required to determine the sequence of events that leads to this comorbidity, and to test strategies to prevent and treat anxiety among children with asthma.

Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial

OBJECTIVE

To evaluate the efficacy of a short course of parent initiated oral prednisolone for acute asthma in children of school age.

DESIGN

Double blind, randomised, placebo controlled, crossover trial in which episodes of asthma, rather than participants, were randomised to treatment.

SETTING

The Barwon region of Victoria, Australia.

PARTICIPANTS

Children aged 5-12 years with a history of recurrent episodes of acute asthma.

INTERVENTION

A short course of parent initiated treatment with prednisolone (1 mg/kg a day) or placebo.

MAIN OUTCOME MEASURES

The primary outcome measure was the mean daytime symptom score over seven days. Secondary outcome measures were mean night time symptom score over seven days, use of health resources, and school absenteeism.

RESULTS

230 children were enrolled in the study. Over a three year period, 131 (57%) of the participants contributed a total of 308 episodes of asthma that required parent initiated treatment: 155 episodes were treated with parent initiated prednisolone and 153 with placebo. The mean daytime symptom score was 15% lower in episodes treated with prednisolone than in those treated with placebo (geometric mean ratio 0.85, 95% CI 0.74 to 0.98; P=0.023). Treatment with prednisolone was also associated with a 16% reduction in the night time symptom score (geometric mean ratio 0.84, 95% CI 0.70 to 1.00; P=0.050), a reduced risk of health resource use (odds ratio 0.54, 95% CI 0.34 to 0.86; P=0.010), and reduced school absenteeism (mean difference -0.4 days, 95% CI -0.8 to 0.0 days; P=0.045).

CONCLUSION

A short course of oral prednisolone initiated by parents when their child experiences an episode of acute asthma may reduce asthma symptoms, health resource use, and school absenteeism. However, the modest benefits of this strategy must be balanced against potential side effects of repeated short courses of an oral corticosteroid.

TRIAL REGISTRATION

ISRCTN 26232583.

Radiological investigations following urinary tract infection: changes in Australian practice

OBJECTIVE

To examine practice changes in the conduct of radiological investigations in Australia following urinary tract infection (UTI).

DESIGN

Observational study using data from the national Medicare database over the 15-year period July 1993 to June 2008 for four investigations: renal ultrasound (renal US), micturating cystourethrography (MCU), intravenous pyelography (IVP) and nuclear medicine isotope scanning of the renal tract (NM). Rates per 100,000 children in the age groups 0-4 years and 5-14 years were calculated for each test.

SETTING

Australian medical practice, including private and public medical settings.

RESULTS

The rates of performance of renal US remained fairly constant throughout the study period in both age groups, while those for MCU, IVP and NM showed a strong falling trend over time for each test in both age groups. For the more invasive tests (MCU, IVP and NM) the total number performed per annum fell from 11,169 (costing 2,032,621 dollars) to 3361 (costing 689,742 dollars) in the last 10 years.

CONCLUSION

There have been very marked practice changes over the last 10-15 years. This trend followed the publication of scientific evidence which has raised doubts about the benefit of performing these investigations.

Pelvic organ prolapse: a review of the current literature

Pelvic organ prolapse has afflicted women since the beginning of mankind. Even though we have been faced with this problem for so many centuries, we still have not found a way to overcome gravity and prevent prolapse. We continue to make efforts to manage prolapse, modifying our techniques based on burgeoning research. This knowledge helps us to avoid repetitive complications from surgery and to improve techniques to prevent recurrent prolapse. In addition, we are constantly adapting our methods depending on available technology. With an aging population, the demand for physicians and surgeons trained in management of pelvic organ prolapse will increase. The rapidly evolving literature on pelvic organ prolapse makes a comprehensive review difficult. However, based on the current literature, randomized controlled trials are needed to compare new prolapse repair techniques to traditional techniques. Physicians specializing in surgical management of pelvic organ prolapse will need to work together to complete quality clinical trials. The primary focus of this review will be on the recent research concerning the epidemiology, etiology, presenting symptoms, and diagnosis of pelvic organ prolapse. We will also discuss the different types of prolapse by compartments of the vagina in which they occur and how each of these types of prolapse can be managed. Finally, we will review recent literature evaluating surgical repairs using transvaginal mesh kits.

Parent-initiated oral corticosteroid therapy for intermittent wheezing illnesses in children

BACKGROUND

Intermittent wheezing illnesses, which include viral associated wheeze and asthma, are amongst the most common reasons for children to present urgently to a doctor. Whether parents should commence oral corticosteroids (OCS) for an episode of acute wheeze in their child without waiting for a medical review is an important question, as the potential benefits of early oral corticosteroid intervention have to be weighed against the potential adverse effects of treatment.

OBJECTIVES

The objectives were to assess the benefits and harmful effects of parent-initiated OCS, in the management of intermittent wheezing illnesses in children, based on the results of randomised clinical trials.

SEARCH STRATEGY

The Cochrane Airways Group Specialised Register, The Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, LILACS, Web of Science and Dissertation Abstracts were combined (all searched November 2005). Manufacturers and researchers in the field were also contacted.

SELECTION CRITERIA

Only randomised clinical trials studying patients aged between one and eighteen years old, with an intermittent wheezing illness (asthma, viral wheeze, preschool viral wheeze) were included. Interventions encompassed OCS at any dose or duration versus placebo or other drug combination. The trials could be unpublished or published and no language limitations were applied.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. The statistical package (RevMan 4.2) provided by the Cochrane Collaboration was used.

MAIN RESULTS

From 572 original citations, a total of 2 randomised clinical trials (303 randomised participants) were included. The quality of the included trials was high; however, marked clinical heterogeneity precluded a meta-analysis. The two trials did not find evidence that parent-initiated OCS are associated with a benefit in terms of hospital admissions, unscheduled medical reviews, symptoms scores, bronchodilator use, parent and patient impressions, physician assessment, or days lost from work or school. Adverse outcomes were inadequately documented.

AUTHORS' CONCLUSIONS

Limited current evidence is available and it is inconclusive regarding the benefit from parent-initiated OCS in the treatment of intermittent wheezing illnesses in children. Widespread use of this strategy cannot be recommended until the benefits and harms can be clarified further.

ER+ PR- breast cancer defines a unique subtype of breast cancer that is driven by growth factor signaling and may be more likely to respond to EGFR targeted therapies

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Background: Hormonal based therapy has long been the mainstay for treatment of ER+ breast cancer. ER+ PR- disease is now known to exhibit different clinical behavior compared to ER+PR+ disease. Recent data indicate that ER+PR- disease is characterized by a lower response rate to estrogen deprivation, has a worse prognosis compared to ER+ PR+ disease, and may be dependent on other signaling pathways. To evaluate the role of the EGFR tyrosine kinase inhibitor gefitnib in the treatment of breast cancer, we conducted a pre-surgical study in women with operable disease. Methods: Frozen core biopsies were obtained at baseline. Patients then received a short-term exposure to gefitinib (at least 2 weeks) prior to definitive surgery when a frozen tumor specimen was obtained. Tissue integrity and composition was verified by H and E and RNA was isolated for microarray analysis. 59 women were enrolled in the study of which 43 were evaluable for molecular analysis. Baseline microarrays were performed on the initial biopsies to classify the ‘subtype‘ of breast cancer (e.g. basal, luminal, HER2 amplified). To analyze the genetic changes that occur in breast cancer tissue with exposure to gefitinib, a direct comparison of the baseline sample and post-treatment tumor was performed. In addition, ER and PR status were determined by immunohistochemistry and compared to the microarray findings. Changes in Ki67 and a set of cell cycle genes were used to define ‘molecular response” to gefitinib. Of the 43 samples evaluated by microarray, 11 patients were categorized as exhibiting molecular growth inhibition, 10 patients as molecular growth proliferation, and 22 did not have a significant change in Ki67 and the cell cycle gene set to assign a response. When grouped by subtype, ER+PR- and HER2 amplified tumors define a subgroup more likely to show molecular growth inhibition with gefitinib. Conversely, ER+PR+ tumors were more likely to show molecular growth proliferation. Conclusions: These results support the hypothesis that ER+PR- breast cancer is growth factor dependent and constitutes a unique subgroup of ER+ patients which may be more likely to benefit from EGFR inhibition.

[Table: see text]

Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children's hospitals

AIMS

To compare prevalence, reasons, motivations, initiation, perceived helpfulness, and communication of complementary and alternative medicine (CAM) use between two tertiary children's hospitals.

METHODOLOGY

A study, using a face-to-face questionnaire, of 500 children attending the University Hospital of Wales, Cardiff, UK was compared to an identical study of 503 children attending the Royal Children's Hospital, Melbourne, Australia.

RESULTS

One year CAM use in Cardiff was lower than Melbourne (41% v 51%; OR = 0.67, 95% CI 0.52-0.85), reflected in non-medicinal use (OR = 0.41, 95% CI 0.29-0.58) and general paediatric outpatients (OR = 0.38, 95% CI 0.21-0.67). Compared to Melbourne, factors associated with lower CAM use in Cardiff included families born locally (father: OR = 0.58, 95% CI 0.44-0.77) or non-tertiary educated parents (mother: OR = 0.54, 95% CI 0.38-0.77). Cardiff participants used less vitamin C (OR = 0.31, 95% CI 0.18-0.51) and herbs (OR = 0.49, 95% CI 0.34-0.71), attended less chiropractors (OR = 0.25, 95% CI 0.06-0.37) and naturopaths (OR = 0.08, 95% CI 0.02-0.33), but saw more reflexologists (OR = 3.33, 95% CI 1.08-10.29). In Cardiff, CAM was more popular for relaxation (OR = 1.92, 95% CI 1.03-3.57) but less for colds/coughs (OR = 0.4, 95% CI 0.27-0.73). Most CAM was self-initiated (by parent) in Cardiff and Melbourne (74% v 70%), but Cardiff CAM users perceived it less helpful (OR = 0.46, 95% CI 0.31-0.68). Non-disclosure of CAM use was high in Cardiff and Melbourne (66% v 63%); likewise few doctors/nurses documented recent medicinal CAM use in inpatient notes (0/21 v 2/22).

CONCLUSIONS

The differences in CAM use may reflect variation in sociocultural factors influencing reasons, motivations, attitudes, and availability. The regional variation in use and poor communication highlights the importance of local policy development.

Are we managing primary upper limb deep venous thrombosis aggressively enough in the district?

AIM

The objective of this retrospective study was to analyse risk factors, management and outcome of primary upper limb deep venous thrombosis (ULDVT, Paget von Schroetter syndrome) in 4 district hospitals.

METHODS

The study group audited between May 1995 and January 2004 comprised of 24 patients with primary ULDVTs (8 male, 16 female; age range 21-80 years, mean 46 years).

RESULTS

Common risk factors included smoking (n=8, 33.3%) and hormonal therapy for women (n=4, 25%). Diagnosis was established by duplex ultrasound alone in 13 patients (54.2%), by venogram alone in 9 patients (37.5%) and by both investigations in 2 patients (8.3%). A thrombophilia screen was performed in 19 patients (79.2%) of which 5 patients (20.8%) were identified with a hypercoagulable state. Twenty-three patients were anticoagulated (95.8%). One patient (4.2%) was initially thrombolysed and subsequently anticoagulated. Overall symptoms resolved or improved in 14 patients (58.3%), symptoms persisted in 8 patients (33.3%) and in 2 patients (8.3%) the outcome was not documented. Only one patient was further evaluated and identified as having thoracic outlet compression. Most patients were managed by physicians (n=19 versus surgeons n=5).

CONCLUSIONS

This study reveals that most patients with primary ULDVT are treated with anticoagulation alone probably based on protocols for lower limb deep vein thromboses which results in an unacceptable high number of patients (33.3%) with persisting disability. Therefore, we suggest a more proactive approach in such patients with evaluation for thoracic outlet compression.

Development and use of a portable paediatric resuscitation card

OBJECTIVES

Inaccuracy and delay in decision making in paediatric resuscitation has been previously demonstrated and may result in preventable death. We assessed several domains of paediatric resuscitation knowledge amongst a sample of tertiary hospital paediatric doctors, developed a portable aide-memoire reference card containing reference normal values, including an algorithm for recognition and management of the seriously ill/arrested child, and assessed the ability of medical staff to use this card to obtain accurate information.

METHODS

A convenience sample of 46 members of the Royal Children's Hospital medical staff completed a questionnaire. Knowledge deficits identified were used to create a 9 x 6 cm, name tag sized, laminated card providing physiological parameters and information required for paediatric resuscitation. The card was then distributed to all medical staff. A sample of 18 doctors completed an identical questionnaire 4 months after introduction of the card. Pre- and post-card results were analysed across a range of knowledge domains.

RESULTS

Basic calculations were incorrect in over 40% of all pre-card responses. Seniority did not predict more correct answers. The post-card group obtained significantly more correct answers than the pre-card group.

CONCLUSION

Medical staff wore, and were able to use the card to provide the correct values for paediatric resuscitation parameters. The use of a card significantly improved knowledge of the correct values for resuscitation data. This project has resulted in the card being issued to all medical and nursing staff and is now accessible via the Royal Children's Hospital internet at http://perseus.rch.unimelb.edu.au/genmed/resuscardontheweb.htm

Implementation of evidence based guidelines for paediatric asthma management in a teaching hospital

AIMS

To evaluate a systematic approach to the development and implementation of evidence based asthma management guidelines.

METHODS

Comparative study of children (2-18 years) with acute asthma; a control cohort (cohort 1) was recruited before implementation of the guidelines and two cohorts were recruited after implementation (cohorts 2 and 3).

RESULTS

There was no difference in the proportion of patients who reattended in the six months following initial presentation for cohort 1 (21.5%), cohort 2 (27.8%), or cohort 3 (25.4%) and no difference in readmission rates (11.4%, 11.3%, 11.0% respectively). There was no difference in measures of asthma morbidity between the cohorts at 3 and 6 months across three domains: interval symptoms, exercise limitation, and bronchodilator use. Of those who did not have a management plan before presentation, one was provided to 46.9% of cohort 1, 74.8% of cohort 2, and 81.1% of cohort 3. There was no difference comparing cohort 2 or cohort 3 with cohort 1 regarding quality of life for either the subjects or their parents.

CONCLUSIONS

Implementation of our evidence based guidelines was associated with the improved provision of asthma management plans, but there was no effect on reattendance or readmission to hospital, asthma morbidity, or quality of life. Future efforts to improve asthma management should target specific components of asthma care.

Use of complementary and alternative medicine in children: too important to ignore

There is evidence that complementary and alternative medicine (CAM) is commonly being used for Australian children, however, at the same time, many doctors have little interest or understanding of the topic. Just as with mainstream treatments, CAM therapies have significant potential for adverse effects and drug interactions. Some of these are potentially serious. The use of CAM therapies in children is not an occasional fringe activity, and evidence suggests its usage will increase further. Whatever one's own views on the role of CAM in childrens health care, the topic is important and it should not be ignored.

Multisite, double-blind, placebo-controlled trial of porcine secretin in autism

OBJECTIVE

To examine the efficacy of intravenous porcine secretin for the treatment of autistic disorder.

METHOD

Randomized, double-blind, placebo-controlled, crossover design. Fifty-six subjects with autistic disorder received either a secretin or placebo infusion at baseline and the other substance at week 4. Subjects were given the Autism Diagnostic Observation Schedule (ADOS) and other pertinent developmental measures at baseline and at weeks 4 and 8 to assess drug effects.

RESULTS

For the primary efficacy analysis, change of ADOS social-communication total score from week 0 to week 4, no statistically significant difference was obtained between placebo (-0.8 +/- 2.9) and secretin groups (-0.6 +/- 1.4; t54 = 0.346, p < .73). The other measures showed no treatment effect for secretin compared with placebo.

CONCLUSION

There was no evidence for efficacy of secretin in this randomized, placebo-controlled, double-blind trial.

Successful implementation of spacer treatment guideline for acute asthma

AIMS

To develop and implement an evidence based guideline for the treatment of acute asthma using a metered dose inhaler and spacer combination.

METHODS

Defined strategies were used for the development and implementation of a guideline, assessed by a prospective, descriptive, study using notes review, and patient, nursing, and medical staff telephone contact. The setting was a tertiary referral hospital in Victoria, Australia with 25 000 yearly admissions, and asthma accounting for about 7% of total. The first 200 children and families to use the guideline after its introduction were evaluated.

RESULTS

A total of 191 (95.5%) children were treated according to the guideline. Six (3.0%) children were given nebulisers appropriately based on severity; five (2.5%) were given nebulisers at parental or child choice; and four (2.0 %) who did not have severe asthma, received nebulised treatment inappropriately.

CONCLUSIONS

Successful implementation of a new evidence based guideline can be achieved using specific strategies for promoting the application of research findings in the clinical arena.

Updating asthma management: the process of change

A strategic approach to changing clinical practice that is managed by a multidisciplinary team is an effective way of implementing new treatment methods or approaches to patient care. The Royal Children's Hospital, Melbourne, Australia, a tertiary pediatric hospital, instituted new Asthma Delivery Device Guidelines in recognition of current evidence that described the benefits of treating acute pediatric asthma with pressurized metered dose inhalers and spacer devices. The working group that coordinated the project attributes the successful change in practice to a multifaceted, multidisciplinary approach, a significant planning stage, initial and ongoing intensive staff and patient/parent education, and accessibility of information.

Surfactant and surfactant inhibitors in meconium aspiration syndrome

Surfactant indices and inhibitors were measured in lung lavage fluid from 8 infants with meconium aspiration syndrome (MAS) who were receiving mechanical ventilation and 11 healthy control subjects. Surfactant phospholipid and surfactant protein A content in MAS was not different from that of control subjects, but concentrations of total protein, albumin, and membrane-derived phospholipid were elevated. All infants with MAS had hemorrhagic pulmonary edema. These findings reinforce the notion of MAS as a toxic pneumonitis with epithelial disruption and proteinaceous exudation.

Validity of markers of dilution in small volume lung lavage

Definitive analysis of solute concentrations in lung lavage fluid involves the use of a marker of dilution to correct for variable recovery of epithelial lining fluid (ELF), but the question of the most appropriate dilutional marker remains unresolved. In lavage fluid collected from infants with lung disease and healthy control subjects, we examined ELF concentration of protein, albumin, sphingomyelin (SM), and IgA secretory component (SC), and critically appraised the relative validity of SC and urea as dilutional markers in the context of lung infection and lung injury. Protein, albumin, and SM were found not to be valid dilutional markers, as their ELF concentration varied significantly between the diseased, recovering, and normal lung. Differences in concentration were noted in both tracheal aspirate samples (TA, 4 x 0.5 ml) and nonbronchoscopic bronchoalveolar lavage fluid (NB-BAL, 3 x 1 ml/kg), but were not uniform (e.g., TA-disease versus control: albumin 2.8 versus 0.68 mg/ml, SM 45 versus 16 microgram/ml, both p < 0.05; NB-BAL-disease versus recovery: protein 8.1 versus 4.8 mg/ml, albumin 2.9 versus 1. 4 mg/ml, both p < 0.05). Overall, SC concentrations in ELF were not different between the diseased and normal lung, but in the NB-BAL samples, significantly higher SC concentration was noted in viral bronchiolitis and pneumonia than in noninfective lung diseases. No clear evidence of additional influx of urea into lavage fluid in association with epithelial disruption was found in the diseased lung. Comparative analysis of SC and urea revealed no difference in TA samples, but in NB-BAL specimens, urea best standardized the lavage concentration of surfactant indices to correspond to the degree of lung dysfunction as indicated by oxygenation index. We conclude that SC and urea, but not protein, albumin, or SM, are valid dilutional markers with which to estimate ELF recovery during small volume lung lavage. Urea appears a more appropriate choice in return fluid derived from the distal tracheobronchial tree, and SC should not be used in the context of lung infection.

Measures for decreasing inpatient stay in childhood asthma

Traditionally, studies of asthma have concentrated on interventions that were mainly pharmaceutical and outcomes that were usually based on pulmonary function testing. More recently, there has been increasing emphasis on organisational procedures that can enhance the delivery of effective care, and outcomes based more on the clinical than the physiological. Minimum length of stay is targeted as one outcome of benefit for patients and their families. The methods of decreasing hospital stay for asthmatic children which have been proposed and studied are reviewed.

Comparison of two methods of diagnostic lung lavage in ventilated infants with lung disease

The methods of nonbronchoscopic lung lavage used for collection of samples of epithelial lining fluid (ELF) in intubated patients are poorly standardized and incompletely validated. In infants with lung disease requiring ventilatory support, we evaluated two techniques of small volume saline lavage for the collection of a specimen suitable for pulmonary surfactant analysis. We aimed to compare apparent origin of the return fluid obtained by each method, equivalence and agreement of the estimates of measured pulmonary surfactant concentration, and the relative strength of association between surfactant indices and lung dysfunction. Fifty-three contemporaneous paired samples of lung lavage fluid suitable for surfactant analysis were collected from 31 infants using tracheal aspirate (TA, 4 x 0.5 ml saline), and then nonbronchoscopic bronchoalveolar lavage (NB-BAL, 3 x 1 ml/kg). Return fluid from TA had higher mean ELF concentration of total protein and IgA secretory component (SC), and a lower surfactant protein A (SP-A) concentration than NB-BAL, indicating that the TA lavage was sampling ELF more proximally in the tracheobronchial tree (protein: TA 7.7 versus NB-BAL 4.7 mg/ml; SC: 21 versus 1.8 microgram/ml; SP-A: 9.8 versus 19 microgram/ml; all p < 0.01). Mean concentration of surfactant indices in ELF differed only for SP-A, but for all indices, paired values showed poor agreement on Bland-Altman analysis, highlighting the potential imprecision associated with small volume lung lavage. TA return fluid yielded estimates of surfactant indices which were at least equivalent to NB-BAL in prediction of the severity of lung dysfunction. We conclude that NB-BAL return fluid has more distal origin, but analysis of TA fluid may have equal validity in the estimation of indices of pulmonary surfactant. The results of individual estimates of ELF constituents in a single sample of lavage fluid should be interpreted with caution, even when standardized sampling techniques are employed.

Spontaneous arterial thrombosis in children

Spontaneous peripheral artery thrombosis in children is rare. We present 2 cases, in both of which the diagnosis was delayed. Acute arterial insufficiency should be considered in children who have clinical symptoms of leg pain, pallor, and reduced pulses. Angiography is the gold standard to confirm or exclude the diagnosis.

Randomised controlled trial of aminophylline for severe acute asthma

OBJECTIVES

To determine whether children with severe acute asthma treated with large doses of inhaled salbutamol, inhaled ipratropium, and intravenous steroids are conferred any further benefits by the addition of aminophylline given intravenously.

STUDY DESIGN

Randomised, double blind, placebo controlled trial of 163 children admitted to hospital with asthma who were unresponsive to nebulised salbutamol.

RESULTS

The placebo and treatment groups of children were similar at baseline. The 48 children in the aminophylline group had a greater improvement in spirometry at six hours and a higher oxygen saturation in the first 30 hours. Five subjects in the placebo group were intubated and ventilated after enrollment compared with none in the aminophylline group.

CONCLUSIONS

Aminophylline continues to have a place in the management of severe acute asthma in children unresponsive to initial treatment.

Pulmonary surfactant concentration during transition from high frequency oscillation to conventional mechanical ventilation

OBJECTIVE

To test the hypothesis that conventional mechanical ventilation (CV) provides a greater stimulus to secretion of pulmonary surfactant than high frequency oscillatory ventilation (HFO).

METHODOLOGY

Sequential examination of surfactant indices in lung lavage fluid in a group of six infants with severe lung disease (group 1), ventilated with HFO and then converted back to CV as their lung disease recovered. A similar group of 10 infants (group 2) ventilated conventionally throughout the course of their illness were studied for comparison. In groups 1 and 2, two sequential tracheal aspirate samples were taken, the first once lung disease was noted to be improving, and the second 48-72 h later. Group 1 infants had converted from HFO to CV during this time.

RESULTS

A marked increase in concentration of total surfactant phospholipid (PL) and disaturated phosphatidylcholine (DSPC) was seen in group 1 after transition from HFO to CV; the magnitude of this increase was significantly greater than that sequentially observed in group II (total PL: 9.4-fold increase in group 1 vs 1.8-fold in group 2, P = 0.006; DSPC: group 1 6.4-fold increase vs. group 2 1.7-fold, P = 0.02).

CONCLUSION

These findings suggest that intermittent lung inflation during CV produces more secretion of surfactant phospholipid than continuous alveolar distension on HFO, and raise the possibility that conservation and additional maturation of surfactant elements may occur when the injured lung is ventilated with HFO.

Early markers of major adverse events in children after cardiac operations

OBJECTIVES

The purpose of this study was to determine the physiologic variables that predict major adverse events in children in the intensive care unit after cardiac operations.

METHODS

A cohort observational study was conducted. At the time of admission to the intensive care unit and 4, 8, 12, and 24 hours later the following variables were recorded: mean arterial pressure, heart rate, cardiac index, oxygen delivery, mixed venous oxygen saturation, base deficit, blood lactate, gastric intramucosal pH, carbon dioxide difference (the difference between arterial carbon dioxide tension and gastric intraluminal carbon dioxide tension), and toe-core temperature gradient. Major adverse events were prospectively identified as cardiac arrest, need for emergency chest opening, development of multiple organ failure, and death.

RESULTS

Ninety children were included in the study; 12 had major adverse events and there were 4 deaths. Blood lactate level, mean arterial pressure, and duration of cardiopulmonary bypass were the only significant, independent predictors of major adverse events when measured at the time of admission to the intensive care unit. The odds ratio (95% confidence intervals) for major adverse events if a lactate level was greater than 4.5 mmol/L was 5.1 (1.2 to 21.1), for admission hypotension 2.3 (0.5 to 9.8), and for a cardiopulmonary bypass time greater than 150 minutes 13.7 (3.3 to 57.2). Four hours after admission lactate and carbon dioxide difference, and 8 hours after admission lactate and base deficit, were independently significant predictors. The odds ratios for major adverse events if the blood lactate level was greater than 4 mmol/L at 4 and 8 hours were 8.3 (1.8 to 38.4) and 9.3 (1.9 to 44.3), respectively. At no time in the first 24 hours were cardiac output, oxygen delivery, mixed venous oxygen saturation, toe-core temperature gradient, or heart rate significant predictors of major adverse events.

CONCLUSIONS

In the context of our current treatment strategies, the duration of cardiopulmonary bypass and blood lactate level, measured in the early postoperative period, were the best predictors of impending major adverse events.

Altered activation of the L-arginine nitric oxide pathway during and after cardiopulmonary bypass

The serum concentrations of nitrogen oxides, the stable metabolites of nitric oxide, were measured in 61 children during and after cardiopulmonary bypass (CPB) for surgery of congenital heart disease. Overall, there was a small reduction in serum nitrogen oxide concentrations during CPB, from a median of 27.5 (interquartile range 16.6-55.7) to 26.4 (15.3-40.6) mumol/l, followed by an increase in the following 24 h to 33.1 (21.3-46.7) mumol/l. The largest postoperative increases in nitrogen oxides occurred in children who developed renal impairment, or were treated with nitrovasodilators. There was no relationship between changes in serum nitrogen oxides intraoperatively and early changes in pulmonary vascular resistance, and a weak positive relationship between changes in serum nitrogen oxides and early postoperative changes in cardiac index (r2 = 0.09, p = 0.04). We found no evidence for increased activation of the L-arginine nitric oxide pathway during CPB; and the reduction in nitric oxide metabolites that occurred during CPB were of doubtful significance to pulmonary or systemic haemodynamic changes in the postoperative period.

Effect of recombinant alpha-interferon on pharmacokinetics, biodistribution, toxicity, and efficacy of 131I-labeled monoclonal antibody CC49 in breast cancer: a phase II trial

Preclinical studies have demonstrated that recombinant IFN-alpha (rIFN-alpha) can enhance the tumor associated glycoprotein 72 (TAG-72) on tumors. To determine whether rIFN-alpha could enhance TAG-72 expression in vivo in patients, 15 women with breast cancer were randomized to receive daily injections of rIFN-alpha (3 x 10(6) units/m2 for 14 days) beginning on day 1 (group 1 = 7 patients) or on day 6 (group 2 = 8 patients). On day 3, all patients received a 10-20-mCi tracer dose of 131I-CC49, a high-affinity murine monoclonal antibody reactive against TAG-72, followed by a therapy dose of 60-75 mCi/m2 of 131I-CC49 on day 6. Whole body and single-photon emission computed tomography scans along with whole blood pharmacokinetics were performed following tracer and treatment phases. Hematological toxicity was considerable; reversible grade 3-4 neutropenia and thrombocytopenia was observed in 12 of 15 patients. Twelve of 14 patients tested developed human antimouse antibodies 3-6 weeks after treatment. For group 1 patients, whole blood residence time increased significantly between that predicted from the tracer doses and therapy doses (42.6 +/- 4.7 versus 51.5 +/- 4.8 h, respectively; P < 0.01). The calculated radiation absorbed dose to red marrow from therapy compared to tracer activity was also significantly higher for this group (1.25 +/- 0.35 versus 1. 07 +/- 0.26 cGy/mCi; P < 0.05). Treatment with rIFN-alpha was found to enhance TAG-72 expression in tumors from patients receiving rIFN-alpha (group 1) by 46 +/- 19% (P < 0.05) compared to only 1.3 +/- 0.95% in patients not initially receiving IFN (group 2). The uptake of CC49 in tumors was also significantly increased in rIFN-alpha-treated patients. One partial and two minor tumor responses were seen. In summary, rIFN-alpha treatment altered the pharmacokinetics and tumor uptake of 131I-CC49 in patients at the expense of increased toxicity.

Reduction in length of hospital stay for acute childhood asthma associated with the introduction of casemix funding

OBJECTIVE

To examine changes to hospital admission rates, length of stay (LOS), bed use, and unplanned readmission rates for children with acute exacerbations of asthma following the change of the Victorian health care system to casemix funding.

SETTING

Large university-affiliated children's hospital in Melbourne, Victoria.

DESIGN

Prospective collection of data from July 1989 to June 1996 for all children admitted with acute asthma (n = 11939).

RESULTS

The number of admissions for acute asthma showed a rising trend before the introduction of casemix funding in July 1993, and subsequently fell. There was a significant fall in mean LOS (64.5 to 39 hours; -40%; P = 0.001), and hence in bed-hours occupied for asthma (115370 to 61116; -47%; P = 0.001). There were no increases in unplanned readmission rates for asthma within the next seven or 14 days.

CONCLUSION

LOS and bed use for acute asthma at our hospital have been significantly reduced since the introduction of casemix funding, although this study does not prove a causal relationship. There was no increase in readmission rates, and thus no suggestion of any adverse effects as a result of reducing LOS. The 47% reduction in bed-hours should lead to large reductions in cost to the hospital.

Surfactant composition in infants and young children with cystic fibrosis

We tested the hypothesis that the composition of bronchial surfactant is normal in infants with cystic fibrosis (CF) in the absence of active lung disease but that it is altered by lower respiratory tract infection and inflammation. We examined the total phospholipid (PL), disaturated phospholipid (DSP), surfactant protein-A (SP-A), surfactant protein B (SP-B), and surface activity in bronchoalveolar lavage fluid from 27 subjects with CF whose mean age was 22.7 (SD 14.5) mo. Six infants with stridor served as non-CF controls. Twelve of the subjects with CF (CF-I group) had evidence of active pulmonary infection or inflammation which was absent in the remaining 15 subjects (CF-NI group). We found no differences in the surfactant composition or activity between controls and the CF-NI group. In contrast, the DSP/PL ratio was lower in the CF-I subjects than in both the CF-NI subjects (p = 0.05) and controls (p < 0.01) suggesting a disturbance of surfactant function. SP-A concentrations were higher in the CF-I group compared to the other two groups (p < 0.05). These results suggest that the bronchial surfactant of infants with CF is altered following lower airway infection and inflammation and is not a primary abnormality associated with this disorder.

Predictors of mortality and multiple organ failure in children with sepsis

OBJECTIVES

To assess the markers of perfusion which best discriminate survivors from non-survivors of childhood sepsis and to compare the information derived from gastric tonometry with conventionally measured haemodynamic and laboratory parameters.

DESIGN

Prospective clinical study of children with sepsis syndrome or septic shock.

SETTING

Paediatric intensive care unit in a tertiary referral centre.

PATIENTS

31 children with sepsis syndrome or septic shock.

INTERVENTIONS

A tonometer was passed into the stomach via the orogastric route.

MEASUREMENTS AND MAIN RESULTS

The following data were recorded at admission, 12, 24 and 48 h: heart rate, mean arterial pressure, arterial pH, base deficit, arterial lactate, gastric intramucosal pH (pHi) and DCO2 (intramucosal carbon dioxide tension minus arterial partial pressure of carbon dioxide). The principal outcome measure was. The secondary outcome measure was the number of organ systems failing at 48 h after admission. There were 10 deaths and 21 survivors. No variable discriminated survival from death at presentation. Blood lactate level was the earliest discriminator of survival. Using univariate logistic regression, lactate discriminated survivors from those who died at 12 and 24 h after admission, but not at 48 h (p = 0.049, 0.044 and 0.062, respectively). The area under the receiver operating characteristic (ROC) curve for lactate was 0.81, 0.88 and 0.89 at 12, 24 and 48 h, respectively. At 12 h after admission, a blood lactate level > 3 mmol/l had a positive predictive value for death of 56% and a lactate level of 3 mmol/l or less had a positive predictive value for survival of 84%. At 24 h a lactate level > 3 mmol/l had a positive predictive value for death of 71% and a level of 3 mmol/l or less had a positive predictive value for survival of 86%. No other variable identified non-survivors from survivors at 12 h. Gastric tonometry could only be done on 19 of the 31 children, of whom 8 died and 11 survived. In these 19 children, DCO2 measured at 24 h, but not at 12 or 48 h, distinguished those who died from those who survived (p = 0.045 and p = 0.20, respectively). The area under the ROC curve for DCO2 measured at 24 h as a predictor of survival was 0.71. Neither the absolute value of pHi nor the trend of change in pHi at any time in the first 48 h identified survivors in this series. The mean arterial pressure distinguished survivors from non-survivors at 24 and 48 h (area under ROC curve = 0.80 and 0.78, respectively). The base deficit and heart rate did not identify non-survivors from survivors at any time in the first 48 h.

CONCLUSIONS

Blood lactate level was the earliest predictor of outcome in children with sepsis. In this group of patients, gastric tonometry added little to the clinical information that could be derived more simply by other means.

Activation of the L-arginine nitric oxide pathway in severe sepsis

AIMS

To determine in children with sepsis syndrome and septic shock the time course of nitric oxide metabolites: nitrate and nitrite (nitrogen oxides). To determine whether serum concentrations of nitrogen oxides distinguished those children who died from sepsis from those who survived; those who required prolonged inotropic support compared with those who did not; and whether there was any relationship of the levels of nitrogen oxides to markers of tissue perfusion.

METHODS

Nitrogen oxides were measured in 30 children with sepsis syndrome or septic shock at admission, 12, 24, and 48 hours. A non-septic control group had serum nitrogen oxides measured at admission. Markers of haemodynamics and tissue perfusion measured were mean arterial pressure, blood lactate, base deficit, gastric intramucosal pH, and deltaCO2 (DCO2: the difference between arterial and gastric intraluminal carbon dioxide tensions). Inotrope doses, number of organ systems failing at 48 hours, and outcome as survival were recorded.

RESULTS

Children with sepsis had increased nitrogen oxide concentrations at presentation compared with a group of non-septic controls. Children with organ failure at 48 hours had higher serum nitrogen oxide concentrations than those with sepsis uncomplicated by organ failure at 48 hours. There was no difference in nitrogen oxide when patients were subgrouped according to the receipt of inotropes at 48 hours, and no association with markers of tissue perfusion, or survival.

CONCLUSIONS

While this study shows that nitric oxide production is increased in sepsis in children, there was a limited relationship with clinically important markers of illness severity and no relationship to survival.