Use of Polyurethane-Covered Stents for Exclusion of Pulmonary Arteriovenous Malformations

PURPOSE

To evaluate the safety, technical success and short-term effectiveness of polyurethane-covered stent (PK Papyrus, BioTronik, Berlin) in the treatment of pulmonary arteriovenous malformations (PAVMs) that are not amenable to embolotherapy.

MATERIALS AND METHODS

In this IRB-approved, retrospective study, data from patients who received polyurethane-covered stents for exclusion of PAVMs were analyzed. The study included 5 patients (all women) with a median age of 40 years (range 25-60). Patients presented with hypoxemia, TIAs, and/or epistaxis; 4 were confirmed to have HHT. All had multiple PAVMs diagnosed on chest CT and underwent embolization with other devices in addition to the polyurethane-covered stent. The indication for stent placement in all cases was a short and/or tortuous feeding artery. Safety was assessed by immediate or short-term complications, e.g., migration, stent thrombosis, and fracture. Technical success was defined as the ability to accurately place the stent at the intended location. Effectiveness was defined as successful exclusion of PAVM with no perfusion across the AVM.

RESULTS

Technical success of stent placement was 100%. AVM exclusion rate was 80% after single stent deployment; in the case of incomplete exclusion, success was achieved using an overlapping stent to completely cover a second feeding artery. During the median follow-up period of 5 months (range 2-10), all stents remained patent, and AVMs were excluded without other complications.

CONCLUSION

Exclusion of PAVMs with polyurethane-covered stents is technically feasible, safe, and shows short-term effectiveness for PAVMs with a short/tortuous feeding artery when traditional embolization techniques are not possible.

Improvement of pulmonary sarcoidosis following sleeve gastrectomy

Pulmonary sarcoidosis is unlikely to resolve if it persists for greater than five years. A growing body of literature supports the involvement of the microbiome in sarcoidosis and a role for sex hormones in pulmonary fibrosis. Additionally, obesity is a risk factor for the development of sarcoidosis. Bariatric surgery is an effective treatment for obesity and can lead to microbial and endocrine changes. Here, we report the clinical improvement of longstanding pulmonary sarcoidosis following sleeve gastrectomy.

Topical paromomycin for New World cutaneous leishmaniasis

Background

Paromomycin-based topical treatments were shown to be effective in curing cutaneous leishmaniasis (CL) lesions caused by Leishmania major in Tunisia. Cure rates of an index lesion were approximately 80%. As a follow on, we conducted a similar Phase 3 trial in Panama to demonstrate the efficacy of these treatments against New World species. The primary objective was to determine if a combination topical cream (paromomycin-gentamicin) resulted in statistically superior final clinical cure rates of an index lesion compared to a paromomycin alone topical cream for the treatment of CL, primarily caused by Leishmania panamensis.

Methods

We conducted a randomized, double blind, Phase 3 trial of topical creams for the treatment of CL caused by Leishmania spp. Three hundred ninety nine patients with one to ten CL lesions were treated by topical application once daily for 20 days. The primary efficacy endpoint was percentage of subjects with clinical cure of an index lesion confirmed to contain Leishmania with no relapse.

Results

The clinical cure of the index lesion for paromomycin-gentamicin was 79% (95% CI; 72 to 84) and for paromomycin alone was 78% (95% CI; 74 to 87) (p = 0.84). The most common adverse events considered related to study cream application were mild to moderate dermatitis, pain, and pruritus.

Conclusions

Superiority of paromomycin-gentamicin was not demonstrated. However, the approximately 80% cure rates for both topical creams were similar to those demonstrated in Tunisia and previously reported with parenteral antimonials.

Leishmaniasis, a neglected parasitic infection transmitted by the bite of a female sand fly, is endemic in 98 countries or territories with approximately 0.7 to 1.2 million cutaneous leishmaniasis (CL) cases occurring each year. In Panama, most of the CL cases are caused by L. panamensis and, the first line of treatment is pentavalent antimony, given parenterally for 20 days. These systemic regimen is associated with toxicities that can limit the patient from receiving a full course of treatment. Alternative therapies are needed particularly for patients with mild disease, no mucosal involvement, no immunosuppression, and for patients living in areas with scarce infrastructure. Therefore, less toxic, non-parenteral new therapies against CL are urgently needed. We conducted a comparative clinical study that evaluated Paromomycin topical creams (Paromomycin alone versus Paromomycin+Gentamicin) for the treatment of cutaneous leishmaniasis (n = 399) in three sites of country. Our study demonstrated the efficacy of these preparations against New World leishmanial species (mostly L. panamensis) with a cure rate close to 80%.

Our trial supports Paromomycin as a viable alternative treatment for CL caused for the New World Leishmania species.

Topical paromomycin with or without gentamicin for cutaneous leishmaniasis

BACKGROUND

There is a need for a simple and efficacious treatment for cutaneous leishmaniasis with an acceptable side-effect profile.

METHODS

We conducted a randomized, vehicle-controlled phase 3 trial of topical treatments containing 15% paromomycin, with and without 0.5% gentamicin, for cutaneous leishmaniasis caused by Leishmania major in Tunisia. We randomly assigned 375 patients with one to five ulcerative lesions from cutaneous leishmaniasis to receive a cream containing 15% paromomycin-0.5% gentamicin (called WR 279,396), 15% paromomycin alone, or vehicle control (with the same base as the other two creams but containing neither paromomycin nor gentamicin). Each lesion was treated once daily for 20 days. The primary end point was the cure of the index lesion. Cure was defined as at least 50% reduction in the size of the index lesion by 42 days, complete reepithelialization by 98 days, and absence of relapse by the end of the trial (168 days). Any withdrawal from the trial was considered a treatment failure.

RESULTS

The rate of cure of the index lesion was 81% (95% confidence interval [CI], 73 to 87) for paromomycin-gentamicin, 82% (95% CI, 74 to 87) for paromomycin alone, and 58% (95% CI, 50 to 67) for vehicle control (P<0.001 for each treatment group vs. the vehicle-control group). Cure of the index lesion was accompanied by cure of all other lesions except in five patients, one in each of the paromomycin groups and three in the vehicle-control group. Mild-to-moderate application-site reactions were more frequent in the paromomycin groups than in the vehicle-control group.

CONCLUSIONS

This trial provides evidence of the efficacy of paromomycin-gentamicin and paromomycin alone for ulcerative L. major disease. (Funded by the Department of the Army; ClinicalTrials.gov number, NCT00606580.).

PEG-based hydrogels with tunable degradation characteristics to control delivery of marrow stromal cells for tendon overuse injuries

Marrow stromal cells (MSCs) have been suggested as a means to improve healing in tendon overuse injuries (tendinopathy), but optimal delivery methods for these cells have yet to be determined. In this study novel degradable hydrogels based on oligo(poly(ethylene glycol) fumarate) (OPF) and acrylated poly(ethylene glycol)-dithiothreitol (Ac PEG-DTT) with tunable degradation times ranging from a few days to >1 month were synthesized as MSC carriers for tendon overuse injuries. The addition of higher amounts of OPF or higher dithiothreitol (DTT) concentrations resulted in enhanced fold swelling and degradation. Three formulations, including non-degrading, slower degrading (degraded in ∼10 days) and faster degrading (degraded in ∼5 days) hydrogels were selected for studies with MSCs in tendon tissue explants that had been treated with collagenase as a reproducible model of tendinopathy. Quantitative analysis of the resulting histology images indicated that cell delivery from the hydrogels was dependent on the degradation rate, with cells present in the tissue only after hydrogel dissolution. In addition, significantly more cells were found in the tendon after 14 days with the fast degrading (53±19) vs. slow degrading (20±6) hydrogels. Based on these results, OPF/Ac PEG-DTT hydrogels provide a versatile biomaterial platform to control cell delivery and thus better identify dosing regimens required for MSC-based therapies for tendinopathy.

Maternal domestic violence screening in an office-based pediatric practice

BACKGROUND

Maternal domestic violence (MDV) screening by pediatricians is not well-studied. Objectives. To determine the practicality and dynamics of routine MDV screening in a private pediatric office and to determine the rate of MDV in Upper Cape Cod, Massachusetts.

SETTING

A 3-pediatrician, private pediatric office in Falmouth, Massachusetts.

PARTICIPANTS

Mothers of children aged 1 month to 10 years scheduled to undergo a well-child visit between February 7 and July 7, 2000.

INTERVENTION

Completion of an 11-item questionnaire related to violence.

RESULTS

Seven hundred sixty-six families were scheduled for well visits. Five hundred ninety-two eligible mothers presented to the office. Five hundred fifty-three completed questionnaires were returned (71.2%). The rate of MDV was 2.5% in current relationships (95% confidence interval [CI]: 1.4-4.3), 14.7% in past relationships (95% CI: 11.9-18.0), and 16.5% overall (95% CI: 13.5-19.9). Increased incidence of MDV was associated with the following variables: 1) harm to a child (odds ratio [OR]: 57.3, 95% CI: 7.3-1232.4), 2) being in a relationship other than a first marriage (OR: 4.6, 95% CI: 2.7-7.8), 3) having been previously asked about MDV (OR: 3.5, 95% CI: 2.1-6.1), 4) having 4 or more children (OR: 3.1, 95% CI: 1.6-6.1), 5) Women, Infants, and Children's program eligibility (OR: 3.0, 95% CI: 1.8-5.0), 6) having public insurance (ie, Medicaid or Children's Medical Security Plan) (OR: 2.2, 95% CI: 1.3-3.7), 7) a history of failure to present for a scheduled well-child visit (no-show; OR: 2.0, 95% CI: 1.0-4.2) and 8) anonymous questionnaire completion (OR: 1.7, 95% CI: 1.0-2.9). Thirty-two and one-half percent (32/91, 95% CI: 25.6-46.0) of mothers with a history of MDV recall having previously been asked about this by a health professional, compared with 16.9% overall (93/551, 95% CI: 13.9-20.3). Eighty-two and eight tenths (82.8) percent (457/552, 95% CI: 79.3-85.8) of mothers favored pediatricians asking about MDV.

DISCUSSION

This information was gathered within the context of normal work hours in a busy office. No additional staff were required. Hence, routine MDV screening appears feasible. The results suggest that a documented history of child abuse in a family makes it very likely that the mother has also been abused. However, child abuse among abused mothers is probably underreported. Furthermore, because most mothers favor domestic violence screening, concerns about lack of acceptance of maternal screening at pediatric visits seem to be unfounded. Screening may actually increase satisfaction with care. In addition, families who do not show up for appointments are at higher risk. Therefore, screening only at well visits will miss an important group.

CONCLUSIONS

Maternal domestic violence screening at well-child visits is practical in a private pediatric office setting. Current rates of screening are low; however, most mothers favor such screening. Furthermore, MDV screening should also be offered on a catch-up basis for those who miss well-child visits, as is currently recommended for immunizations.

Felbamate urolithiasis

PURPOSE

To report a case of felbamate (FBM) urolithiasis.

METHODS

Urographic imaging [sonography, abdominal computed tomography (CT), intravenous pyelogram, voiding cystourethrogram] and urologic procedures (cystoscopy with lithotripsy, ureteral stent) to define and capture the stones. Stone identification was by infrared spectroscopy and gas chromatography/mass spectrometry.

RESULTS

A 15-year-old boy had painful hematuria, bilateral ureteral obstruction, and urinary retention. Kidney, bladder, and ureteral stones were found, and ureteral stent placement was required to relieve obstruction. The stone material was identified as FBM by chemical analysis. Stone formation ceased with discontinuation of FBM.

CONCLUSIONS

FBM urolithiasis can occur, and possible contributory factors include high felbamate dosage, drug polypharmacy, and risk factors for forming stones of other types. FBM urolithiasis may be heralded by crystalluria.

Decision-making for a successful bowel continence program

Bowel continence is one of the most difficult challenges for patients with spina bifida. Incontinence acts as a social stigma for children and a barrier for adults seeking employment. We present an algorithm for stepwise decision-making in construction of personalized continence programs for greater likelihood of success. The protocol contains 13 assessment points including; stool consistency, frequency and amount; mobility; level of paraplegia: diet; medication; anal/rectal canal tone; prior programs attempted; family routines; age; accessibility; and learning issues. Based on outcomes of these assessments, an individualized bowel program is constructed. The algorithm helps the practitioner and patient decide on components and indicators of a successful continence program. The recommended program might include timed toileting, suppository, continence enema, and ACE procedure, or a combination. Evaluation and patient education address adequate fluid/fiber, appropriate toileting equipment, and use of stool softeners/laxatives. Descriptions are available. Key elements in monitoring a continuing plan for continence include: the degree of constipation and its etiology; changing age; family availability for assistance until interdependence is optimal; wheelchair accessibility of the toilet; and ability to transfer to and from the toilet. Use of the algorithm allows for careful decision-making based on information from the patient and family. This has led to greater success in bowel continence in children with spina bifida.

Initial experience with intravenous pentobarbital sedation for children undergoing MRI at a tertiary care pediatric hospital: the learning curve

OBJECTIVE

Our purpose is to describe the initial experience with intravenous pentobarbital sedation in children undergoing MRI at a tertiary pediatric hospital to identify errors associated with inexperience.

SUBJECTS AND METHODS

The study included the first 100 children sedated with intravenous pentobarbital prior to magnetic resonance examination at a tertiary pediatric hospital. The protocol included a maximum dose of 6 mg/kg administered in three divided doses with the total dose not to exceed 200 mg. Flow sheets documenting vital signs, administered drug doses, and adverse reactions were maintained contemporaneous to sedation.

RESULTS

Sedation was successful in 92 children. Of the eight children who failed sedation, three were at least 12 years old and three weighed more than 50 kg. chi2 tests identified significantly greater failure rates in children older than 11 years or weight greater than 50 kg. Two children had prolonged sedation after the maximum suggested dose was exceeded.

CONCLUSIONS

The success rate was good, but could have been improved by restricting the use of pentobarbital to children less than 12 years of age and weighing less than 50 kg. Radiologists inexperienced with intravenous sedation should strictly observe the maximum suggested dose of pentobarbital to prevent prolonged sedation.

Autologous TMJ disk replacement

Several techniques have been advocated for replacement of displaced or diseased temporomandibular joint disks. Techniques are reviewed and the author's experience in managing this complex problem is presented.

Sedation of difficult-to-sedate children undergoing MR imaging: value of thioridazine as an adjunct to chloral hydrate

OBJECTIVE

The purpose of this prospective study was to evaluate the safety and efficacy of thioridazine as an adjunct to chloral hydrate sedation when children undergoing MR imaging are difficult to sedate.

SUBJECTS AND METHODS

All 87 children in the study either could not be sedated with chloral hydrate alone or were mentally retarded. Thioridazine (2-4 mg/kg) was administered orally 2 hr before and chloral hydrate (50-100 mg/kg) was administered orally 30 min before the 104 MR examinations. All children were monitored by continuous pulse oximetry. All images were individually evaluated by pediatric radiologists and were graded acceptable if they contained only minimal motion artifact or no motion artifact. Studies were considered successful only when 95% or more of the images were acceptable.

RESULTS

MR imaging was successful in 93 (89%) of 104 examinations. The success rate for children entered into the study because of prior failure of chloral hydrate sedation was not significantly different from the success rate for children with mental retardation. A tendency for increasing failure rate with age was not significant. No serious complications occurred during the study. The most common adverse reaction, transient reduced oxygen saturation, was seen in five children. Other adverse effects encountered were vomiting in four children, hyperactivity in two children, transient tachycardia in one child, and prolonged sedation in one child. No child required hospitalization because of an adverse reaction to sedation.

CONCLUSION

The study indicates that thioridazine is a safe and effective adjunct to chloral hydrate when a child undergoing MR imaging is difficult to sedate.

High-dose chloral hydrate sedation for children undergoing MR imaging: safety and efficacy in relation to age

OBJECTIVE

Sedation is frequently essential for successful MR imaging, and chloral hydrate is the most commonly used drug for this purpose in infants and children. Our experience with these patients suggested that this sedative is less effective in older children, even when administered in high doses. However, no prospective study comparing the efficacy of chloral hydrate sedation for children of different ages undergoing MR imaging has been reported. Accordingly, we performed a study to evaluate the effectiveness and safety of chloral hydrate sedation in children of various ages.

SUBJECTS AND METHODS

The study included 300 infants and children, 1 month to 11 years old (mean, 3 years), who were given oral chloral hydrate, 100 mg/kg, for sedation before MR imaging. The maximum total dose administered was 2.5 g, which limited the study to children who weighed 25 kg or less. Sedation was considered successful when MR studies were completed and at least 95% of the images had little or no motion artifact.

RESULTS

Sedation was successful in 273 (91%) of 300 children. It was unsuccessful in nine of the 203 children who were 48 months old or younger (96% success rate) and in 18 of the 97 children who were more than 48 months old (81% success rate). A single-tailed t-test showed that the children in whom sedation was unsuccessful were significantly older than those in whom it was successful to the .0005 level of significance. The failure rate increased steadily for children more than 48 months old. Several failures may also have resulted from lengthy examination times. Adverse reactions to chloral hydrate sedation included hyperactivity (6%), vomiting (4%), and mild respiratory depression (4%). No adverse reaction was severe enough to require hospitalization.

CONCLUSION

The higher failure rate for chloral hydrate sedation in children more than 48 months old suggests that the patient's age is an important limitation to the usefulness of chloral hydrate sedation for children undergoing MR imaging. However, the low rate of adverse reactions makes chloral hydrate a safe drug for sedation of children undergoing MR imaging.

Regulation of the tension of human chorionic vasculature by histamine and prostaglandin F2 alpha

The calcium dependence of potassium chloride-, prostaglandin F2 alpha (PGF2 alpha)-, and histamine-induced contractions of human chorionic vasculature segments was investigated. In physiologic buffer that contained 1.5 mM calcium chloride, 60 mM potassium chloride induced a rapid and sustained contraction of the vasculature. Potassium chloride-induced contractions were completely inhibited by the calcium channel blockers diltiazem and nifedipine or by excluding Ca2+ from the medium. Histamine (100 microM) induced a rapid increase in vascular tension in physiologic buffer which rapidly faded or desensitized after maximal tension was obtained. The maximal contractile responses to histamine were reduced approximately 50% by diltiazem and nifedipine in physiologic buffer or by suspension in calcium-free medium (OCaPB). Pretreatment of vessels with 20 mM caffeine in OCaPB completely abolished histamine-dependent contractile responses. Prostaglandin F2 alpha (100 nM)-induced increases in vascular tension developed slowly but remained maximal for at least 40 minutes. Contractile responses to PGF2 alpha were reduced 50% to 65% by diltiazem and nifedipine in physiologic buffer or by suspension in OCaPB. Caffeine pretreatment failed to alter the contractile response to PGF2 alpha in OCaPB. The differences in responsiveness of potassium chloride, histamine, and PGF2 alpha under the various conditions used suggest that these agents act by different mechanisms to elicit contractions in chorionic vessels. The potential roles of PGF2 alpha, histamine, and calcium channel blockers in modulating the fetoplacental circulation is discussed.

Enhancing interdepartmental relations

In summary, it is important that the hospital manager have a positive attitude; recognize that not all projects will gain approval and that competition with others for scarce resources is a reality. A well throughout plan, anticipating questions, objections, and including affected departments, is a necessary first step to enhancing the manager's image. Being a polished orator is not essential, but being organized is. Most important, a progressive, "can-do" attitude is always respected by others.

PharmaTrend as a management tool: evaluation of the program

A critical evaluation of PharmaTrend, a personal computer-based program for the analysis of pharmacy workload and productivity, is presented. The use of PharmaTrend is facilitated by a number of support features. A tutorial program instructs first-time and infrequent users on how to negotiate PharmaTrend's data-entry screens. The manual is well written and organized, and a toll-free number is available should more technical questions arise. However, some of PharmaTrend's definitions are confusing, as is the program's method of capturing workload data on the preparation of intravenous solutions. Some of the data currently maintained in pharmacies will need considerable modification before they can be used as PharmaTrend entries. A few minor changes would transform PharmaTrend from a good to an exceptional program. In addition to clearer definitions, an option allowing the user to edit the definitions shown on the screen is needed. A line should be added to the data-entry screen to remind the user that F1 is the help key. Reporting would be facilitated if deadlines were changed to reflect standard quarters. PharmaTrend is advantageous for the analysis of departmental operations because it provides regional and national standards for comparison. It can also help justify proposals and defend existing services and staffing. The monthly and quarterly reports generated with PharmaTrend are useful in analyzing pharmacy operations, and the user can modify work-load times on the basis of local circumstances. These difficulties notwithstanding, the current cost of PharmaTrend appears to be a bargain. Although some aspects of PharmaTrend need refinement, its basic features make it a valuable management tool.

A case of Dipylidium caninum in Baton Rouge, Louisiana

The relevant literature concerning human dipylidiasis has been reviewed with specific reference to the association of children and their pet dog and cats. A specific case is recounted which is considered to be typical of the condition as encountered by pediatricians and general practitioners.

Supportive personnel training program based at a technical college

A supportive personnel training program based at a technical college is described. During the nine-month curriculum, the students spend time in the classroom and in a laboratory on the college campus. Part of the program is taught by the college faculty, providing the students with courses on basic chemistry, anatomy and physiology, medical vocabulary, typing, and math fundamentals. The other part of the curriculum is taught by pharmacists, including courses on hospital pharmacy, pharmacology, and pharmacy mathematics. The students' first experiences with unit-dose and i.v.-admixture programs are in an artificial laboratory under controlled conditions. Later in the program, the students rotate through each of the participating hospitals for thorough on-the-job training. By combining the resources of a local technical college and the area hospitals, a uniform program of training supportive personnel has been implemented that produces enough technical support for all the participating hospital pharmacies.

Readability--its applicability to education of patients by pharmacy

The applicability of readability to the development of pharmacy educational materials is reviewed. The importance of reading skills must be recognized in all areas of education, including pharmacy patient education. If people are to perform certain tasks, they must understand the instructions for those tasks. To be understandable, the instructions must be written on the reading level of the people who will be following the instructions. Readability has been defined as those characteristics of reading materials, involving certain mental processes, that make for ease or difficulty of comprehension of the reading material. It is the task of the reader to use as few or as many of these mental processes as necessary to grasp the intended meaning of the material. It has been estimated that the average reading level of the American public is approximately 7th to 8th grade. However, many adults do not have sufficient reading skills to comprehend fully material written on these levels. Therefore, pharmacy educational material should be written on the reading level of the patient population it serves. Several readability formulas have been developed to evaluate the various characteristics of reading material that lead to reading comprehension. Among the ones recommended for use with pharmacy educational materials are the Fry Readability Graph and the Gunning Fog Index.

Pharmacy involvement in a multidisciplinary diabetic teaching program

The following article describes a method of developing a workable diabetic teaching program within a hospital setting. Emphasis is placed on involving other health professionals with expertise in their respective areas. Development of behavioral and learning objectives along with learning activities and methods of evaluation are discussed. The purposes of this program are: 1) to reduce the overlap in educational instructions given to patients with diabetes, and 2) to remove the problem of an unorganized patient education effort by placing such patients into a structured learning situation in which they feel comfortable and which is conducive to learning. This program has proved successful and provides a viable means of involving staff pharmacists with patients. It has taken a minimal amount of time and did not necessitate an increase in our staff.

Clinical usefulness of polymorphonuclear leukocyte vacuolization in predicting septicemia in febrile children

Vacuolization of the polymorphonuclear leukocyte (PMN) has generally been regarded as an indication of bacterial infection and has been particularly useful in diagnosing septicemia. In an effort to predict septicemia, peripheral blood smears from 69 febrile children were examined and systematically scored for severity of vacuolization. Thirteen children had remarkable vacuolization compared to the others. These 13 included only five children with bacterial illnesses and only one of the seven children with septicemia. Our finding that PMN vacuolization was neither diagnostic of septicemia nor predictive of bacterial infection suggests that the specificity of the link between vacuoles and bacteremia needs to be reassessed.

Perceptual correlates of the rod-and-frame test: a critical response

One of the recent research reports that has proffered a bifactorial explanation of field independence-dependence is critiqued for its use of factor analysis. A more traditional and conservative use of the statistic supports the original definition and suggests mirror-tracing speed as an additional assessment tool.

A CASE OF OBSTRUCTION OF THE STOMACH BY AN IMPACTED MASS OF HAIR

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