«The Application of the New Law of Adoption and the Psychological Preparation of Prospective Stepparents»

Introduction

The new adoption law, which was introduced in Greece in 2018, brought radical changes in adoption.

Objectives

This presentation aimed to investigate the emotions of the prospective stepparents, based on the changes which were effectuated by the new law of adoption.

Methods

This survey was conducted through mixed methodology. Quantitative research was addressed to investigate the emotions of the to prospective stepparents. Qualitative research was addressed to social workers and its goal was to depict their opinion about the new law and the prospective stepparents’ expressed emotions.

Results

The findings of the survey have demonstrated that the stepparents had a variety of emotions that changed throughout the adoption process. The dominant feelings of parents at the first visit with the social worker were stress and anxiety. However, at the end of the training process, these feelings were replaced by confidence and impatience. This emotional rotation of prospective stepparents was confirmed in the social workers’ interviews. In addition, social workers interviews highlighted the importance of the amendment of the old law of adoption’s process.

Conclusions

To sum up, this research has shown the importance of the new law and therefore the significance of its right application from all children’s placements in Greece. Nevertheless, it seems that due to the recent application of the new law, many placements have not yet complied with it and therefore there is urgent need for reinforcement of its application, according to the guidelines of the European Union that demanded gradual deinstitutionalization using the alternative types of child care.

Disclosure

No significant relationships.

Thrombosis with Thrombocytopenia Syndrome (TTS) following AstraZeneca ChAdOx1 nCoV-19 (AZD1222) COVID-19 vaccination - A risk-benefit analysis for people < 60 years in Australia

The AstraZeneca ChAdOx1 nCoV-19 (AZD1222) vaccine is associated with Thrombosis with Thrombocytopenia Syndrome (TTS) in 3/100,000 vaccinations with high fatality rates reported in many countries. We conducted a risk-benefit analysis for Australians aged 18-59 years, comparing the risk of vaccination versus infection, and rate of TTS to other vaccines which prompted policy change following rare adverse events - rotavirus, smallpox and oral polio vaccines. COVID-19 deaths over 12 months range from 0 to 417 in current and future worst case scenarios. In the past 15 months 20 COVID-19 deaths occurred in people < 60 years compared to 890 deaths over 60 years. The estimated possible number of TTS cases is 347, with vaccine-related deaths ranging from 17 to 153if 80% of adults 18-59 years are vaccinated. The reported rate of TTS is in the same range as rare but serious adverse events associated with other vaccines that have been subject to policy change. In Australia, the potential risks of the AZD1222 vaccine in younger adults, who are at low risk of dying from COVID-19, may outweigh the benefits.

Serum Prolactin Level of Subfertile Women

Subfertility is a major reproductive health problem all over the world as well as Bangladesh, and the problem is increasing day by day. This study was done to estimate the serum prolactin concentration in primary and secondary subfertile women. Laboratory investigation included serum prolactin level, as well as LH, FSH, TSH blood glucose (2 hours after 75 gm glucose load) of 50 women who attended infertility unit, Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2009 and February 2010. In most cases, common age group 26-30 years (52%), primary subfertility (74%), duration of marriage >5 years (60%), trying to conceive duration ≤5 years (54%), BMI >25 kg/m² (60%), menstrual cycle regular (58%), history of abortion absent (90%), and history of menstrual regulation absent (94%). Common investigation findings was normal serum follicle stimulating hormone (FSH) 1.0-10.0 mIU/ml in 82%, normal serum luteinizing hormone (LH) 1.0-10.0 mIU/ml in 50%, normal serum prolactin 1.9-25.0 ng/ml in 36%, normal serum thyroid stimulating hormone (TSH) 0.4-4.0 μIU/ml in 56%, and normal blood glucose level (2 hours after breakfast) (<7.8 mmol/) in 66% women. Ultrasonographic finding of lower abdomen was normal in 14% women. Common finding of semen analysis husbands of the study women was normozoospermia in 88% cases. Serum prolactin concentration may have role to play in subfertility of women.

Comparative efficacy of subcutaneous versus oral methotrexate in active rheumatoid arthritis

This prospective study was conducted in rheumatology clinic under the department of medicine of Bangabandhu Sheikh Mujib Medical University from December 2004 to December 2005 to asses the efficacy, safety and compliance of subcutaneous methotrexate (MTX) in active rheumatoid arthritis (RA) patients. A total of 92 active rheumatoid arthritis patients according to American College of Rheumatology (ACR) criteria were recruited for the trial for six months. Among them 46 cases belonged to injectable MTX group and 46 cases belonged to oral MTX group. Mean±SD age of patients was 45.54±12.42 vs. 44.63±13.99 years in subcutaneous group and oral group respectively. In the subcutaneous group 41 were female and 5 male; in the oral group 34 were female and 12 male. Mean duration of the disease was 49.74 months in subcutaneous group and 49 months in oral group. RA test was positive in 35 cases in both groups whereas Rose Waaler test was positive in 19 patients in subcutaneous group and 14 patients in oral group. At 24 week, response rate of ACR 20 was significantly higher in subcutaneous MTX than oral MTX group (93% vs. 80%, p=0.02). Similarly ACR 50 response was significantly higher in subcutaneous MTX than in oral group (89% vs. 72%, p=0.03). ACR 70 response was not significantly higher in SCMTX group then oral group (11% vs. 9 %, p=0.72). Adverse effects were relatively less in subcutaneous MTX and most common side effects were nausea (37% vs. 63%), vomiting (11% vs. 30%), dyspepsia (29% vs. 48%), dizziness (4l% vs. 52%) and alopecia (72% vs. 85%). The results of the study demonstrated that subcutaneous MTX was significantly more effective than oral MTX at the same dosage in active Rheumatoid arthritis patients with no increase in side effects.

Calcineurin inhibitor sparing with mycophenolate mofetil in liver transplantion: a systematic review of randomized controlled trials

Liver transplant recipients are at high risk of developing acute and chronic renal failure. Moreover, introduction of the model for end-stage liver disease (MELD) score for primary allocation of liver grafts favors patients with pretransplant kidney dysfunction, which in turn have a higher risk of posttransplant renal failure. Calcineurin inhibitors (CNI) further increase the risk of renal failure and therefore sparing CNI with the use of mycophenolate mofetil (MMF) may improve renal function. MMF may either be used de novo in the immediate posttransplant period in combination with low-dose CNI (scenario 1) or patients that receive immunosuppression based on CNI may be converted to MMF in combination with minimization or elimination of CNI (scenario 2). Although many retrospective cohort studies and nonrandomized trials have implicated efficacy of this approach the evidence from randomized controlled studies has not been summarized. In the current review we report the results of a systematic review and meta-analysis of randomized controlled trials.

Coronary angiographic profile in bangladeshi patients with metabolic syndrome and ischemic heart disease

The metabolic syndrome, which is characterized by a constellation of fasting hyperglycemia, hypertriglyceridemia, low HDL cholesterol, hypertension, and/or abdominal obesity, is a risk factor for the development of coronary artery disease (CAD) and cardiovascular events. We evaluated interrelationships between angiographic CAD and the metabolic syndrome, in 478 patients who were referred for coronary angiography to evaluate suspected myocardial ischemia in the department of cardiology of BSMMU between June 2007 and May 2008. We applied the criteria for the metabolic syndrome proposed by ATP III guideline. Study populations were divided into two groups on the basis of presence or absence of metabolic syndrome. Age was similar in both groups. Body mass index (BMI) was higher (26.22 ± 1.94 vs. 22.07 ± 1.55) in metabolic syndrome group (p ≤ 0.0001). All parameters, waist circumference (103.16 ± 10.21 vs. 91.45 ± 7.61) cm, blood pressure both systolic (141.34 ± 21.49 vs. 127.94 ± 13.01) and diastolic (86.8 5 ± 8.42 vs. 79.28 ± 7.77) mm of Hg, serum triglyceride (248.32 ± 77.88 vs. 128.35 ± 19.00)mg/dl, fasting blood glucose (125.40 ± 22.86 vs. 95.65 ± 10.63)mg/dl were significantly higher in metabolic syndrome group (p value=0.0001), whereas HDL (33.10 ± 6.55 vs. 39.30 ± 6.17)mg/dl was lower (p value = 0.0001). More subjects in metabolic syndrome were having type B (55.60% vs. 31.00%) and type C (9.50% vs. 2.70%) lesion as compared to non-metabolic syndrome group. Involvement of left main artery was more (4.80% vs. 0.90%) in metabolic syndrome group. Metabolic syndrome has primary predictive ability for CAD. A metabolic profile should form part of the risk assessment in all patients with coronary disease, not just those who are obese.

Outcome of metformin treatment in polycystic ovary syndrome

The polycystic ovary syndrome (PCOS) is a clinical diagnosis. During one year period, 50 women suffering from PCOS were treated with either 850 mg/twice daily or 500 mg/thrice daily along with clomiphene citrate and/or letrozole, with advice for exercise and dietary therapy. Diagnosis of the PCOS patients was made by the presence of two out of the following three criteria: (a) oligo and/or anovulation, (b) hyperandrogenism (clinical and/or biochemical), and (c) polycystic ovaries, with the exclusion of other aetiologies. The mean±SD age of our patients was 26.74±3.85 years, BMI 26.64±2.64 kg/m2, pulse 80.56±4.61 b/min, systolic blood pressure 113.80±4.40 mmHg and diastolic blood pressure 76.10±4.77 mmHg, duration of marriage 6.19±3.20 years, and parity was 43(86%) nulliparous and 7(14%) primiparous. Oligomenorrhoea was present in 100%, hypomenorrhoea in 38%, secondary amenorrhoea in 28% and acne in 70% women. Results showed that 92% women followed advice on exercise and dietary therapy, in maximum number of women progesterone level was 31.40 nmol/L (66%), weight loss was 2 kg (44%), menstrual cycle regular (90%) and pregnancy test negative (90%). Only in 5 cases (10%) pregnancy test was positive.

Acute supraglottitis in adults

OBJECTIVES

Adult supraglottitis is a potentially life-threatening airway infection. We reviewed the management and outcome of supraglottitis in 169 adults admitted to Liverpool Hospital between 1999 and 2009.

METHODS

A retrospective review was conducted of all admissions with supraglottitis in patients at least 18 years of age. The diagnosis was confirmed by fiberoptic nasolaryngoscopy or direct laryngoscopy under general anesthesia. The main outcome measure was the need for intubation or tracheotomy. Univariate analysis was performed to determine factors that led to a worse outcome.

RESULTS

There were 80 men and 89 women in the cohort, with a median age of 51 years. Of these, 140 patients were admitted to the intensive care unit for a mean duration of 2 days. The common symptoms and signs at presentation were odynophagia and dysphagia (94%), dysphonia (65%), and stridor (33%). Endotracheal intubation was performed in 16 patients, and an awake tracheotomy was required in 4 patients. Dexamethasone acetate was used in 103 patients. Thirty-five patients had diabetes mellitus as a comorbidity. The presence of diabetes was predictive of the need for intubation or tracheotomy (p < 0.05), and the use of steroids was predictive of an intensive care unit stay of 24 hours or less (p < 0.05).

CONCLUSIONS

Fiberoptic laryngoscopy is the gold standard for diagnosis of supraglottitis, and close airway monitoring is crucial. Conservative management of the airway is a viable option, but the presence of diabetes makes airway intervention more likely. The use of steroids aids in symptom alleviation and hastens resolution of airway swelling, with no negative sequelae.

Chronic abdominal wall sinus and recurrent abscesses caused by a foreign body after laparotomy

The prolonged failure of a wound to heal due to the existence of a foreign body can result in chronic sinuses and fistulae and is a situation that should be avoided through thorough assessment of the wound in the first instance.

Desensitization of the platelet aggregation response to ADP: differential down-regulation of the P2Y1 and P2cyc receptors

Platelets activated by ADP become refractory to restimulation, but the mechanism of this process is not well understood. A normal platelet response to ADP requires coactivation of the P2Y(1) receptor responsible for shape change and the P2cyc receptor, responsible for completion and amplification of the response. The aim of the present study was to characterize the desensitization of platelets to ADP and to determine whether or not these two receptors are desensitized simultaneously through identical pathways when platelets become refractory to ADP. It was found that full inhibition of platelet aggregation in response to restimulation by ADP required the presence of ADP in the medium or use of a high concentration (1 mM) of its non-hydrolysable analogue ADPbetaS. Platelets incubated for 1 h at 37 degrees C with 1 mM ADPbetaS and resuspended in Tyrode's buffer containing apyrase displayed a stable refractory state characterized by the inability to aggregate or change shape in response to ADP. ADPbetaS treated platelets loaded with fura-2/AM showed complete blockade of the calcium signal in response to ADP, whereas the capacity of ADP to inhibit PGE1 stimulated cAMP accumulation in these platelets was only diminished. Consequently, serotonin was able to promote ADP induced aggregation through activation of the Gq coupled 5HT(2A) receptor while adrenaline had no such effect. These results suggested that the refractory state of ADPbetaS treated platelets was entirely due to desensitization of the P2Y(1) receptor, the P2cyc receptor remaining functional. Binding studies were performed to determine whether the P2Y(1) and/or P2cyc binding sites were modified in refractory platelets. Using selective P2Y(1) and P2cyc antagonists (A3P5P and AR-C66096 respectively), we could demonstrate that the decrease in [33P]2MeSADP binding sites on refractory platelets corresponded to disappearance of the P2Y(1) sites with no change in the number of P2cyc sites, suggesting internalization of the P2Y(1) receptor. This was confirmed by flow cytometric analysis of Jurkat cells expressing an epitope-tagged P2Y(1) receptor, where ADPbetaS treatment resulted in complete loss of the receptor from the cell surface. We conclude that the P2Y(1) and P2cyc receptors are differently regulated during platelet activation.

Late referral of end-stage renal failure

We studied all new patients accepted for renal replacement therapy (RRT) in one unit from 1/1/96 to 31/12/97 (n = 198), to establish time from nephrology referral to RRT, evidence of renal disease prior to referral and the adequacy of renal management prior to referral. Sixty four (32.3%, late referral group) required RRT within 12 weeks of referral. Fifty-nine (29.8%) had recognizable signs of chronic renal failure > 26 weeks prior to referral. Patients starting RRT soon after referral were hospitalized for significantly longer on starting RRT (RRT within 12 weeks of referral, median hospitalization 25.0 days (n = 64); RRT > 12 weeks after referral, median 9.7 days (n = 126), (p < 0.001)). Observed survival at 1 year was 68.3% overall, with 1-year survival of the late referral and early referral groups being 60.5% and 72.5%, respectively (p = NS). Hypertension was found in 159 patients (80.3%): 46 (28.9%) were started on antihypertensive medication following referral, while a further 28 (17.6%) were started on additional antihypertensives. Of the diabetic population (n = 78), only 26 (33.3%) were on an angiotensin-converting-enzyme inhibitor (ACEI) at referral. Many patients are referred late for dialysis despite early signs of renal failure, and the pre-referral management of many of the patients, as evidenced by the treatment of hypertension and use of ACEI in diabetics, is less than optimal.

Salicylate poisoning

Salicylate poisoning continues to be an important cause of drug related mortality. The zero order kinetics of salicylates at high doses is responsible in part for cases of iatrogenic poisoning. Serum levels tend to correlate with severity of poisoning in acute overdose cases only. Clinical manifestations include involvement of nervous system, hepatic and pulmonary systems along with metabolic disturbances. Measures at enhancing elimination and reducing absorption, while providing supportive care form the basis of management.

Post-anaesthetic pulmonary oedema following upper airway obstruction

Twelve cases of post-anaesthetic pulmonary oedema (PO) secondary to upper airway obstruction (UAO) are reported. All were adult male patients undergoing uneventful elective surgical procedure under general anaesthesia. Post-anaesthetic laryngospasm was the single most important factor for the upper airway obstruction (UAO) in 5 (41.6%) patients. PO secondary to partial UAO in drowsy patients was observed in 4 (33.3%) patients. UAO due to foreign body was responsible for PO in two patients. A combination of negative intrathoracic pressure, hypoxia and associated hyperadrenergic state were the most likely causes of PO in these patients with UAO. Early recognition, maintenance of patent airway and adequate oxygenation via face mask or endotracheal tube with mechanical ventilation resolved the syndrome within 6-36 hours in all of these patients. Invasive haemodynamic monitoring or aggressive drug therapy were not applied in any of the patients. A heightened awareness among anaesthesiologists of the varied causes of post-anaesthetic UAO leading to PO may help reduce the occurrence and facilitate early management of the potential complications.

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team

OBJECTIVE

To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency.

DESIGN

Retrospective review with cost-effectiveness analysis.

SETTING

A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program.

PATIENTS

All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation.

INTERVENTION

A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service.

MEASUREMENTS AND MAIN RESULTS

The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation.

CONCLUSION

We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.