Codesigning consumer engagement strategies with ethnic minority consumers in Australian cancer services: the CanEngage Project protocol

INTRODUCTION

Consumer engagement is central to high-quality cancer service delivery and is a recognised strategy to minimise healthcare-associated harm. Strategies developed to enhance consumer engagement specifically in relation to preventing healthcare harm include questioning health professionals, raising concerns about possible mistakes or risks in care and encouraging patients and caregivers to report suspected errors. Patients from ethnic minority backgrounds are particularly vulnerable to unsafe care, but current engagement strategies have not been developed specifically for (and with) this population. Using an adapted approach to experience-based codesign (EBCD) to support the target population, the aim of the project is to codesign consumer engagement interventions to increase consumer engagement and safety in New South Wales and Victorian cancer inpatient, outpatient and day procedure services.

METHODS AND ANALYSIS

A mixed-method project will be undertaken at six study sites. Our EBCD approach includes a preparatory phase in which we will provide training and support to the codesign participants, in addition to recruiting and training consumer cofacilitators for the codesign workshops. The project will follow the EBCD process of gathering and synthesising observational data from each cancer service, with interview data from consumers and staff. With the resulting in-depth understanding of the safety threats commonly experienced by ethnic minority consumers in each site, we will work through feedback events and codesign groups with consumers and staff to determine how they can be more involved with their care to minimise the potential for patient harm. Consumer engagement interventions will be coproduced in each of the six participating services that are tailored to the ethnic minority populations served.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Western Sydney Local Health District Human Research Ethics Committee. The project will provide strategies for ethnic minority consumers to engage with cancer services to minimise healthcare-associated harm that may be applied to diverse healthcare settings.

Effects of tetracycline on entomopathogenic nematodes and their bacterial symbionts

Among the new contaminants relevant for environment, one of the most significant roles is played by pharmaceuticals like antibiotic products for either human or veterinary use. Their presence could cause serious damage to bacteria and microfauna, like nematodes. Within the widely investigated nematodes, very little is known about the interaction between antibiotics and entomopathogenic nematodes (EPN). EPNs have been used for biological control of crops, due to their ability to penetrate arthropod pests and kill their hosts thanks to a complex symbiotic mechanism with specific gram-negative bacteria. Tetracycline is an antibiotic used in human and veterinary medicine, both for therapeutic purposes and for the growth of livestock. Since its action against gram-negative bacteria is documented, we verified in this study the survival, growth and pathogenicity of two species of EPNs, Steinernema vulcanicum and S. feltiae. All tests were performed with tetracycline in 1% ethanol solution and up to 300 mg/L. Apparently, this incubation did not harm the vitality of EPNs. Both S. vulcanicum as S. feltiae recovered their vitality and entomopathogenic ability after 48 h. Moreover, the latter EPN species did not grow nor reproduce in the hemolymph of the Greater Wax Moth, Galleria mellonella, and their endosymbionts did not grow on MacConkey Agar. Our results suggest that the first EPN species has always retained all its abilities and that endosymbionts have acquired resistance to tetracycline, while experiments with the second EPN species provided some contrasting results in time that will require further investigations.

Cardiovascular risk assessment in multiple myeloma patients undergoing carfilzomib therapy: a new risk prediction model for cardiovascular adverse events

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular adverse events (CVAEs) are closely related to Carfilzomib (CFZ) therapy in multiple myeloma (MM), but validated management protocols are lacking. Moreover, the incidence, nature and risk factors for each type of CVAEs are incompletely characterized.

Purpose

To assess if the European Myeloma Network Guidelines (EMN) protocol is effective on cardiovascular risk assessment before CFZ starting. A prediction model for estimating the probability of CVAEs was developed and validated. Major and hypertensive-related CVAEs were investigated.

Methods

A perspective study on 116 MM patients scheduled for CFZ therapy was conducted from 2015 to 2020. Before CFZ starting, a baseline evaluation, according to the EMN protocol, was performed; during the follow-up, the incidence of CVAEs was detected. The potential risk factors for CVAEs were identified and a risk score was developed.

Results

The rate of all-grade CVAEs was 44.8% (24.1% CTCAE≥3): 14.7% experienced major CVEAs (41.2% arrhythmias, 23.5% acute ischemic cardiopathy as most represented) and 30.2% hypertensive-related CVAEs. At baseline, five independent predictors for all-CVAEs were identified: office systolic blood pressure (p = 0.003), 24-hours blood pressure variability (p = 0.004), left ventricular mass (p = 0.015), pulse wave velocity (p = 0.002) and global longitudinal strain (p = 0.033). The resulting CVAEs risk score allows to define the low- and high-risk groups, obtaining a sensibility of 94% in predicting CVAEs (AUC 0.76).

Conclusions

The comprehensive evaluation of EMN Guidelines is effective in CVAEs prediction. The use of CVAEs risk score will identify the higher risk patients, targeting appropriate follow-ups and organizing effective risk mitigation strategies.

Instrumental determinants with CVAEs Parameters No CVAEs N = 64 [N (%)] CVAEs N = 52[N (%)] P value LV mass/BSA 85.30 ± 19.72 95.14 ± 21.75 0.013 LV hypertrophy [> = 95 g/m2 F > = 115 g/m2 M] 8 (12.7) 16 (30.8) 0.018 LV dilation 5 (9.3) 4 (8.9) 0.949 LV EF % 63.03 ± 6.56 61.96 ± 7.13 0.414 GLS % -22.37 ± 2.56 -21.3 ± 2.46 0.029 LV Diastolic dysfunction 1 (1.6) 0(0) 0.362 PWV 7.41 ± 1.63 8.55 ± 1.855 0.002 PWV ³ 8.75 m/s 10 (17.5) 24 (54.2) 0.000 SBP Systolic Blood Pressure; ABPM Ambulatory Blood Pressure Monitoring; BPV Blood Pressure Variability; BSA Body Surface Area; SD Standard Deviation; EF Ejection Fraction; GLS Global Longitudinal Strain; LV Left Ventricle; PWV Pulse Wave Velocity Abstract Figure. CVAEs risk score

Duchenne muscular dystrophy: preliminary experience with sacubitril-valsartan in patients with asymptomatic left ventricular dysfunction

OBJECTIVE

Duchenne muscular dystrophy (DMD) is an inherited X-linked recessive neuromuscular disease caused by mutations of the dystrophin gene, leading to early and progressive muscle deterioration and dilated cardiomyopathy. The aim of this investigation was to assess whether treatment with sacubitril/valsartan (S/V) is well tolerated and may have beneficial effects in DMD patients with left ventricle (LV) dysfunction.

PATIENTS AND METHODS

We administered S/V to 3 DMD patients (19-29 yeard old) with LV ejection fraction <35% at echocardiography but no symptoms of heart failure. All patients were on optimal medical therapy. S/V was initiated at a very low dose of 12/13 mg/die, after withdrawal of angiotensin-converting enzyme inhibitor therapy, and slowly titrated to the dose of 49/51 mg twice daily or the maximally tolerated dose. Clinical and echocardiographic follow-up was performed after 3, 6 and 12 months.

RESULTS

At baseline, the LV ejection fraction was 32±1%. A significant improvement of LV ejection fraction was observed at 3 months (44.0±6.0%; p<0.05), which was maintained at 6 (45.7±5.0%) and 12 (43.3±3.2%) months (p<0.05 for both). No relevant side effects were reported throughout the period of the study.

CONCLUSIONS

Our preliminary data suggest that, in DMD patients with reduced LV ejection fraction, S/V is safe and may improve LV function.

The safety of health care for ethnic minority patients: a systematic review

INTRODUCTION

Evidence to date indicates that patients from ethnic minority backgrounds may experience disparity in the quality and safety of health care they receive due to a range of socio-cultural factors. Although heightened risk of patient safety events is of key concern, there is a dearth of evidence regarding the nature and rate of patient safety events occurring amongst ethnic minority consumers, which is critical for the development of relevant intervention approaches to enhance the safety of their care.

OBJECTIVES

To establish how ethnic minority populations are conceptualised in the international literature, and the implications of this in shaping of our findings; the evidence of patient safety events arising among ethnic minority healthcare consumers internationally; and the individual, service and system factors that contribute to unsafe care.

METHOD

A systematic review of five databases (MEDLINE, PUBMED, PsycINFO, EMBASE and CINAHL) were undertaken using subject headings (MeSH) and keywords to identify studies relevant to our objectives. Inclusion criteria were applied independently by two researchers. A narrative synthesis was undertaken due to heterogeneity of the study designs of included studies followed by a study appraisal process.

RESULTS

Forty-five studies were included in this review. Findings indicate that: (1) those from ethnic minority backgrounds were conceptualised variably; (2) people from ethnic minority backgrounds had higher rates of hospital acquired infections, complications, adverse drug events and dosing errors when compared to the wider population; and (3) factors including language proficiency, beliefs about illness and treatment, formal and informal interpreter use, consumer engagement, and interactions with health professionals contributed to increased risk of safety events amongst these populations.

CONCLUSION

Ethnic minority consumers may experience inequity in the safety of care and be at higher risk of patient safety events. Health services and systems must consider the individual, inter- and intra-ethnic variations in the nature of safety events to understand the where and how to invest resource to enhance equity in the safety of care.

REVIEW REGISTRATION

This systematic review is registered with Research Registry: reviewregistry761.

What is the role of cultural competence in ethnic minority consumer engagement? An analysis in community healthcare

BACKGROUND

Effective patient engagement has been associated with high quality health care. There is a dearth of evidence around effective engagement with consumers from ethnic minority backgrounds; specifically in relation to the role of cultural competence amongst healthcare professionals in effective engagement with consumers from ethnic minority backgrounds. To address this knowledge gap, we analysed the role of cultural competence in the consumer engagement approaches taken by community healthcare professionals working with consumers from ethnic minority backgrounds.

METHODS

Semi-structured individual interviews were conducted with 21 healthcare professionals employed across four community healthcare and affiliated services in four local government areas in Australia.

RESULTS

Adopting patient-centric approaches (that seek to understand and be responsive to the patient as an individual) featured as an underpinning theme that transcended other emerging themes. Recognition of diversity within communities and individuals in those communities, all with their own story, was described as pivotal to effective engagement. This was encapsulated in the theme of Cultural standpoints and personal context that contained four further themes of: (1) Build foundations of trust and respect; (2) Diversify communication channels; (3) Generate system, service and community partnerships; (4) Take the time.

CONCLUSION

Our findings indicate that cultural competence and effective consumer engagement are closely linked in ethnic minority populations. Embedding cultural competence as a health system, service and professional capability is therefore critical to ensure equitable healthcare quality for consumers from all ethnic backgrounds.

Beyond translation: Engaging with culturally and linguistically diverse consumers

Background

In the context of an effective consumer engagement framework, there is potential for health‐care delivery to be safer. Consumers from culturally and linguistically diverse (CALD) backgrounds may experience several barriers when trying to engage about their health care, and they are not acknowledged sufficiently in contemporary strategies to facilitate patient engagement.

Methods

Four focus group discussions were facilitated by bilingual fieldworkers in Arabic, Mandarin, Turkish and Dari in a district of Sydney, Australia that has a high proportion of CALD consumers. Each group included 5‐7 health‐care consumers who, using a topic guide, discussed their experiences of barriers and facilitators when engaging with health‐care services in Australia. Thematic analysis was undertaken to identify, analyse and report patterns in the data.

Results

In all, 24 consumers participated. Six inter‐related themes emerged: navigating the health system; seeking meaningful interpretation; understanding and managing expectations; respectful professional care; accessing services; and feeling unsafe.

Conclusions

The incorporation of strategies such as professional interpreters and migrant health workers may go some way to addressing the needs of culturally or linguistically diverse consumers and facilitate communication, but do not sufficiently address the range of barriers to consumer engagement identified in this work. Understanding consumer experience in the context of the complex factors that may be associated with poor engagement and poor outcomes such as health literacy, cultural, educational and linguistic background, and health‐care setting or condition, may contribute to better understanding about how to deliver quality health care to these patients.

Patient-centered communication, patient satisfaction, and retention in care in assisted reproductive technology visits

PURPOSE

To explore the association between patient-centered communication, patients' satisfaction, and retention in care in assisted reproductive technology (ART) visits.

METHODS

ART visits at eight Italian clinics were videotaped and coded using the Roter Interaction Analysis System, which includes a Patient-Centered Index (PCI), a summary "patient-centered communication" ratio. After the visit, patients completed a satisfaction questionnaire (SATQ). After 3 months, patients were asked about their retention in care. Spearman correlations and Mann-Whitney tests were used to test associations between the study variables; the open-ended item of SATQ was analyzed through content analysis.

RESULTS

Eighty-five visits were videotaped (involving 28 gynecologists and 160 patients). PCI score (μ = 0.51 ± 0.28) revealed a more disease-oriented communication during the visit. Patients reported high levels of satisfaction with the visit and identified in the information provision or in the doctor's humanity or kindness the main reasons of satisfaction. At the follow-up, the majority of the couples declared to have followed the clinicians' recommendations and to have remained related to the ART center. No associations were found among the study variables, except for a lower male satisfaction among couples who declared to have changed ART clinic.

CONCLUSIONS

Contrary to what was expected, the style of physician-patient communication was not found to be associated with patient satisfaction and retention in care. However, patients were highly satisfied and engaged. The actual meaning of a communication that is "patient-centered" in the ART context might be wider, including the couples' need for information, as suggested by qualitative findings.

Doctor-couple communication during assisted reproductive technology visits

STUDY QUESTION

What are the characteristics of doctor-couple communication content during actual ART visits?

SUMMARY ANSWER

Physicians were mainly focused on providing biomedical information, while communication content from couples had a 2-fold focus on providing biomedical information and on positive talk.

WHAT IS KNOWN ALREADY

Communication aspects in ART seem crucial for clinical decision-making, retention in care and critical conversations with couples due to low treatment success rates. However, no studies have been carried out on the actual interaction between the doctor and the couple in this context.

STUDY DESIGN, SIZE, DURATION

This observational study involved 28 clinicians and 160 patients referred to eight Italian ART clinics during a one-year recruitment period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

ART visits at eight Italian clinics were videotaped. The visits were coded using the Roter Interaction Analysis System (RIAS), particularly focusing on RIAS composite categories, verbal dominance and patient-centeredness score.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 85 visits were eligible for analysis (62% acceptance rate), involving 28 clinicians and 160 patients (including 75 couples). The average visit duration was 37 ± 17.7 min. The mean verbal dominance was 1.9 ± 0.86 (range: 0.72-5.74). Physicians mainly focused on providing biomedical information. Communication content from couples had a 2-fold focus on providing biomedical information and on positive talk. The mean of patient centeredness index (PCI) was 0.51 (SD = 0.28; range 0.08-1.77); visits in which the doctor was a woman or the treatment indication was for heterologous fertilization showed higher PCI scores. Overall, females accounted for 67% of all patient talk. Taking this imbalance into account as expected frequencies for each composite category, males reported significantly more utterances in almost all of the socioemotional categories.

LIMITATIONS, REASONS FOR CAUTION

These results are preliminary and observational and only regard Italy. Communication during visits may have been biased since the professionals who agreed to participate showed an interest in communication issues. Another limitation is a possible Hawthorne effect due to the fact that participants were aware of being videotaped.

WIDER IMPLICATIONS OF THE FINDINGS

Our study showed that ART physicians mainly adopted an informative model of communication and a more disease-oriented approach. Findings revealed the complexity of communication content during ART consultations, given its triadic characteristic in which the third party is also a patient; clinicians should be aware of this complex aspect and of the specific male and female perspectives to be taken into account. The results could be useful for training ART professionals.

STUDY FUNDING/COMPETING INTEREST(S)

This study was possible thanks to an unconditional grant from Ferring Spa to the Department of Health Sciences, University of Milan. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

In silico analysis of the anti-hypertensive drugs impact on myocardial oxygen balance

Hypertension is a very common pathology, and its clinical treatment largely relies on different drugs. Some of these drugs exhibit specific protective functions in addition to those resulting from blood pressure reduction. In this work, we study the impact of commonly used anti-hypertensive drugs (RAAS, [Formula: see text] and calcium channel blockers) on myocardial oxygen supply-consumption balance, which plays a crucial role in type 2 myocardial infarction. To this aim, 42 wash-out hypertensive patients were selected, a number of measured data were used to set a validated multi-scale cardiovascular model to subject-specific conditions, and the administration of different drugs was suitably simulated. Our results ascribe the well-known major cardioprotective efficiency of [Formula: see text] blockers compared to other drugs to a positive change of myocardial oxygen balance due to the concomitant: (1) reduction in aortic systolic, diastolic and pulse pressures, (2) decrease in left ventricular work, diastolic cavity pressure and oxygen consumption, (3) increase in coronary flow and (4) ejection efficiency improvement. RAAS blockers share several positive outcomes with [Formula: see text] blockers, although to a reduced extent. In contrast, calcium channel blockers seem to induce some potentially negative effects on the myocardial oxygen balance.

THE EURADOS-KIT TRAINING COURSE ON MONTE CARLO METHODS FOR THE CALIBRATION OF BODY COUNTERS

Monte Carlo (MC) methods are numerical simulation techniques that can be used to extend the scope of calibrations performed in in vivo monitoring laboratories. These methods allow calibrations to be carried out for a much wider range of body shapes and sizes than would be feasible using physical phantoms. Unfortunately, nowadays, this powerful technique is still used mainly in research institutions only. In 2013, EURADOS and the in vivo monitoring laboratory of Karlsruhe Institute of Technology (KIT) organized a 3-d training course to disseminate knowledge on the application of MC methods for in vivo monitoring. It was intended as a hands-on course centered around an exercise which guided the participants step by step through the calibration process using a simplified version of KIT's equipment. Only introductory lectures on in vivo monitoring and voxel models were given. The course was based on MC codes of the MCNP family, widespread in the community. The strong involvement of the participants and the working atmosphere in the classroom as well as the formal evaluation of the course showed that the approach chosen was appropriate. Participants liked the hands-on approach and the extensive course materials on the exercise.

Le metastasi spinali in età pediatrica

Il rachide e il suo contenuto costituiscono in età pediatrica sede infrequente di localizzazione metastatica di neoplasie primitive del Sistema Nervoso Centrale o di altri organi. La classificazione delle metastasi spinali si basa attualmente sulla loro localizzazione in rapporto ai diversi compartimenti interessati: si distinguono pertanto metastasi extradurali, intradurali-extramidollari e intramidollari. A partire dal 1989, anno di introduzione della RM nel nostro Istituto, 123 bambini affetti da neoplasie primitive del Sistema Nervoso Centrale o di altri organi sono stati sottoposti a esame RM per la valutazione del rachide e del suo contenuto; in 13 di essi sono state riscontrate localizzazioni secondarie a tale livello. Si è messo in luce il comportamento neuroradiologico relativamente aspecifico delle metastasi stesse, che pone problemi talvolta complessi nella diagnosi differenziale sia con le neoplasie primitive che con processi patologici non neoplastici.

Si ribadisce come la RM costituisca oggi la metodica elettiva per la ricerca e lo studio delle metastasi spinali, da eseguire anche all'esordio, anche se, a tutt'oggi, un ruolo di primo piano spetta ancora a indagini complementari, quali la citologia liquorale.

A pilot of an intervention delivered to Chinese- and Spanish-speaking carers of people with dementia in Australia

There are limited language- and culture-specific support programs for carers of people with dementia living in Australia. A group intervention for use with Chinese and Spanish speakers in the United States was adapted to the Australian context, and a pilot study was undertaken with these 2 communities. The intervention is based on a cognitive behavioral therapy approach and was delivered by bilingual health professionals. The adapted material comprised 7 sessions, spanning 2 hours in duration. All 22 participants completed the Depression Anxiety and Stress Scale-Short form (DASS-21) pre- and postintervention. A significant decrease in depression, anxiety, and stress was observed among Spanish speakers; a significant decrease in depression and anxiety was present among the Chinese speakers. The implications are considered in the context of Australia's changing aged care service system.

Qualitative research on dementia in ethnically diverse communities: fieldwork challenges and opportunities

Australia, like other ethnically diverse societies, needs to provide culturally appropriate health care to all its citizens. One way of facilitating this is to ensure that health services research adequately reflects the circumstances and needs of culturally and linguistically diverse (CALD) communities within the population. This article discusses the fieldwork phase of a qualitative research project on dementia caregiving in 4 CALD communities in south west Sydney, Australia. Rather than focusing on the study results-which have been published elsewhere-this article presents and discusses crucial fieldwork issues that arose in the conduct of the project, particularly regarding participant recruitment and facilitation of focus groups. In being transparent about some of the difficulties encountered and how these were managed, we offer suggestions for other researchers wanting to include CALD communities in a meaningful way in their research projects.

Simulation of phoswich detectors using MCNPX and EGSNRC

The in vivo monitoring Lab at KIT uses two phoswich detectors for routine lung counting. A simplified model of one of them has been implemented in the two Monte Carlo codes EGSnrc and MCNPX. The active part of the detector consists of a crystal of NaI(Tl) and one of CsI(Tl): the energy deposited in both the crystals have been studied to consider the effect of the anticoincidence logic, present in the read-out electronics of the detectors and not yet studied with Monte Carlo simulations. Only the NaI(Tl) crystal has then been used to study the escape peaks at several energies, which are more prominent at low energies. The results from the two codes have been compared. The comparison of the codes predictions for the escape peaks has been then extended using the model of a germanium detector.

Erroneously low continuous ScvO2 reading due to red blood cells transfusion

Hemoglobin oxygen saturation in superior vena cava (ScvO(2)) is used as a parameter to guide hemodynamic management in shock patients and it can be continuously read through a central venous catheter equipped with a fiberoptic spectrophotometric probe (Edwards PreSep catheter) connected to a specific monitor (Edwards Vigileo). We report of an episode of erroneous ScvO(2) reading by this technology in a patient with septic shock who was receiving an erythrocytes transfusion through the PreSep catheter main lumen. We think this artifact should be known by intensivists since it can lead to ScvO(2) misinterpretation and subsequent erroneous therapeutic decisions.

[The incidence of dental caries during childhood. A clinical and epidemiologic study in Matera (Southern Italy)]

AIM

The aim of the present study is to obtain comprehensive epidemiological data of the incidence of oral and dental health conditions in an Italian homogeneous population of schoolchildren.

MATERIALS AND METHODS

The study has been performed on schoolchildren born, living and attending the primary school in Matera, Basilicata, Southern Italy. Such data have been compared with the alimentary habits of the participants to the study, as well as with the social-economic family situations and with the social-environmental data.

RESULTS

The data show a marked difference in the habits of oral hygiene, and in the health status of the oral structures also, based on both the sex and the environment of life.

CONCLUSIONS

Such differences in the prevalence of caries among various urban areas and the behavioural habits related to sex and age ratios may be very useful findings for future regional prevention programs.

Antenatal post-hemorrhagic ventriculomegaly: a prospective follow-up study

OBJECTIVE

The aim of this study was to evaluate the presence and the severity of neurological and cognitive impairment at 2 years of age in 16 infants (9 term born, 7 preterm of mean gestation 33.6 weeks) with cerebral ventriculomegaly of antenatal onset associated with intraventricular haemorrhage.

METHODS

Ventricular dilatation, with or without associated lesions, was, with one exception, not identified on the antenatal routine scan at approximately 22 weeks but was obvious on the scans performed between weeks 27 and 33. In 8 of the 16 cases there were signs of parenchymal involvement or of abnormalities of the corpus callosum or cerebellum. In all patients the diagnosis of antenatal IVH was confirmed by early neonatal imaging. Outcome was measured using the Hammersmith infant neurological examination and the Griffiths developmental scales at 2 years.

RESULTS AND CONCLUSIONS

At 2 years, 8 infants had normal motor outcome and 8 had cerebral palsy. The presence and severity of cerebral palsy or neurodevelopmental delay was not always related to the magnitude or symmetry of the ventricular dilatation per se. The presence of associated lesions was a negative prognostic marker. The early development of epilepsy was also associated with an abnormal outcome.

Neurological examination at 6 to 9 months in infants with cystic periventricular leukomalacia

The Hammersmith Infant Neurological Examination was performed in 24 infants with cystic periventricular leukomalacia whose gestational age ranged between 26-38 weeks. The infants were examined between 6 and 9.5 months corrected age. The aim of the study was to establish the different patterns of neurological abnormality as well as the optimality scores that predict the severity of motor sequelae at 2 years. Increased neck and trunk extensor tone, and a posture of flexed arms and extended legs between 6 and 9 months were always associated with the inability to sit unsupported at 2 years, whilst truncal hypotonia and extended arms and legs were associated with unsupported sitting but not walking. Optimality scores between 41 and 60 were generally associated with sitting but not walking at 2 years whilst scores below 40 were always associated with the inability to sit independently at 2 years. All infants who did not develop cerebral palsy at 2 years had scores > 60. Our results suggest that the pattern of findings on neurological examination performed between 6 and 9 months as well as the calculated optimality score helps to predict motor impairment in infants with PVL.

[Nutritional problems in the surgical patients with head and neck tumours. Literature review and personal experience]

During the last years the importance of the correct nutritional assessment as a part of the therapeutic process of the human pathologies has a greatly increased relevance. Still more in oncology, such relationship among nutritional assessment and good result of the therapeutic treatment have a fundamental importance. Among the neoplastic diseases those of the head and the neck result to be particularly aggressive, both for their nature and for the particular anatomical organization of such body areas, and the affected patients also need a precise evaluation of the nutritional assessment to obtain an optimal therapeutic result. On the basis of such premises and to their own clinical experience, the authors describe the main nutritional problems of the patients with tumours of the head and the neck and the possible therapeutic solutions.

[Drug/food interactions: an actual therapeutic outcome]

The biological effects of specific interactions occurring between drugs and foods may greatly vary, determining severe side effects in some people. A lot of factors may influence such interactions, i.e. age, sex, dietary composition, and so. In addition, further interaction may be determined by cigarette smoking, alcohol abuse and coffee consumption. Older people, as well as children, chronic ill and malnourished people seems to be most commonly affected by side effects due to food/drugs interaction. The aim of this review is to give a synopsis of the drug/food interactions most commonly occurring in clinical practice.

Direct DNA analysis in a new Italian carrier of Hb-Belfast: beta 15 (A12) Trp-->Arg

A young woman aged 21 was found to be a new carrier of Hb-Belfast: beta 15 (A 12) Trp-->Arg, and the characteristics of her hemoglobinopathy were not different from those of the four cases so far described: mild hemolysis with molecular instability of the abnormal Hb, red cells inclusion bodies, and slight alterations of some functional parameters of whole blood. On this occasion, direct DNA analysis indicated the genomic nucleotide replacement of the disease: TGG-AGG. This was inherited by the mother, originating from Bari (Apulia).

Molecular characterization of a rare hemoglobin variant: Hb-Hinsdale: beta139(H17)ASN-->Lys

The authors describe the characteristics of a rare hemoglobin mutant found in a young female. She carries the aminoacid replacement of Hb-Hinsdale:beta139(H17)ASN-->Lys, which was identified at molecular level. This case, clinically and hematologically symptomless, is identical, but genetically independent, to the cases first described in an American family.

Inter-method differences and commutability of control materials for HbA2 measurement

The intermethod variability of control materials and patient blood samples for the measurement of hemoglobin A2 (HbA2) were compared. A set of 54 blood samples and 10 control materials were analyzed in duplicate by HPLC and microcolumn methods. For each set of methods the distances of the materials from the regression line of patient blood results (expressed as normalized residuals) were calculated. Four out of ten controls had normalized residuals exceeding three standard deviations from the regression line. Moreover, total Hb and Hb derivatives analysis proved that only a minority of the controls could be considered similar to patients' blood samples. Intermethod calibration performed "a posteriori" by the two best performing control materials improved intermethod variability among all the five tested methods. We conclude that the use of high resolution HPLC methods together with appropriate commutable control materials allows for better harmonization of results in the field of diagnosis of hemoglobin disorders in research and clinical practice.

Subjects positive for hepatitis C virus RNA with normal aminotransferase levels, a "trompe l'oeil" clinical picture?

BACKGROUND

Quite often subjects affected by chronic hepatitis C virus infection have no clinical signs of liver disease and serum aminotransferase values never go beyond the upper limit of normal. Yet these subjects, defined "asymptomatic HCV carriers", often have active viral replication and various degrees of histological damage.

AIMS

To verify, in a population of antibody to hepatitis C virus carriers, if normal serum aminotransferase values in hepatitis C virus-RNA positive differed considerably from those in hepatitis C virus-RNA negative subjects.

SUBJECTS/METHODS

We followed 24 anti-hepatitis C virus-positive subjects (15 hepatitis C virus-RNA positive and 9 negative) by measuring alanine and aspartate aminotransferase levels at 3-month intervals for a median of 40 months (range 6-77).

RESULTS

Determinations resulted repeatedly and rigorously within the normal range in all participants. Alanine aminotransferase values were higher in hepatitis C virus-RNA positives than in negatives (mean +/- SD: 0.609+/-0.172 vs 0.434+/-0.153 times the upper limit of normal; p<O.001). Aspartate aminotransferase values in both groups reflected the same consistent difference (mean +/- SD: 0.652+/-0.170 vs 0.528+/-0.151 times the upper limit of normal, p<0.001).

CONCLUSIONS

Our findings demonstrate that biochemical activity exists in asymptomatic hepatitis C virus-RNA-positive carriers, but it is so slight that serum aminotransferase levels do not go beyond the upper limit of normal. With the prevailing range of normality, serum aminotransferase determination is a helpful but not reliable marker of disease activity in chronic hepatitis C virus infection. The normal range for aminotransferases needs to be redefined in order to set up a more accurate diagnostic profile of subjects with chronic hepatitis C virus infection.

Infusion of an antialpha4 integrin antibody is associated with less neoadventitial formation after balloon injury of porcine coronary arteries

BACKGROUND

The alpha4beta1 (or very late antigen-4 [VLA-4]) integrin is thought to play a role in inflammatory processes, mediating mononuclear leukocyte infiltration. The adventitial response to balloon injury is an important determinant of neointimal formation and arterial remodelling.

OBJECTIVES

To determine whether the monoclonal antibody hHP1/2 directed against the human alpha4-integrin subunit decreases neoadventitial formation and subsequent luminal narrowing following balloon injury.

DESIGN

Randomized, double-blind, placebo controlled study.

SETTING

Tertiary care, Canadian university hospital vascular biology laboratory.

ANIMALS AND METHODS

In 16 pigs, two coronary arteries were injured with an oversized balloon, while a third coronary artery was designated as an uninjured control vessel. One hour before balloon injury, 5 mg/kg of hHP1/2 was administered to eight animals, while another eight animals received an infusion of a saline placebo. Animals were killed three and 14 days following balloon injury.

MAIN RESULTS

Administration of hHP1/2 resulted in an immediate decrease in circulating monocyte and lymphocyte counts. These parameters returned to normal within three days. There was a decrease in neoadventitial formation 14 days after arterial injury in pigs treated with hHP1/2 compared with controls (2.26+/-0.77 versus 3.42+/-1.01 mm, respectively, P=0.04). There was a loss of lumen area between days 3 (4.33+/-1.09 mm2) and 14 (3.09+/-0.38 mm2, P=0.02) after balloon injury in pigs treated with saline, but not in the pigs treated with hHP1/2.

CONCLUSIONS

Administration of an antibody to the alpha4-integrin subunit is associated with less neoadventitial formation and less lumenal narrowing after balloon injury. This novel therapy may play an important role in modulating arterial remodelling and thereby may reduce restenosis following percutaneous coronary interventions in humans.

Minimal flow and half-closed system ventilation in lung surgery

BACKGROUND

This study aimed at determining the applicability of minimal flow anaesthesia in lung surgery.

METHODS

The standards anaesthesiological technique was modified to perform minimal flow half-closed system ventilation. For procedures on left lung orobronchial intubation was performed by a White no. 41 and no. 39 orotracheal tube, respectively in male and in female patients, in order to achieve a perfect tight of bronchial cuff and prevent gas loss from the circuit, because of the greater calibre of the right stem bronchus. The metal double lumen connector was replaced by a plastic tube that is clamped to exclude the lung from ventilation, whenever necessary. Fibrin glue was systematically applied on the bronchial stump or resected lung tissue before restoring ventilation.

RESULTS

No significant changes were recorded in heart rate, arterial systolic and diastolic pressure, end-expiratoy CO2 concentration, oxygen saturation, airways maximum and minimum pressure.

CONCLUSIONS

Minimal flow half-closed system ventilation can be easily performed also in pulmonary surgery provided that gas loss from the circuit is 50 ml/min by means of specific technical adjustments.

[Evaluation of continuous measurement of cardiac output with thermodilution in critical patients]

BACKGROUND

A new pulmonary artery catheter and monitor for continuous cardiac output measurement (CCO), based on thermodilution principle, has been recently developed. Aim of our study was to evaluate the new system by comparing data obtained with the CCO with the standard bolus thermodilution method (TD).

METHODS

Nineteen patients admitted in a medical intensive care unit were studied. In each patient 6 daily measurements of cardiac output (CO) were recorded using both the CCO and the TD. The parallel monitoring was continued for 48 h; 12 pair determinations were obtained in each patient with a total of 228.

RESULTS

Total CO ranged from 2.6 L/min to 10.6 L/min. The regression coefficient was 0.94. The bias of all measurements was 0.03 (SD: +1.22-1.16). The mean relative error was 1.52% +/- 29.9. Modifications in temperature or variations in heart rate did not change the agreement between the two techniques.

CONCLUSIONS

Our results confirm that CCO, although does not have all the characteristics of an ideal monitoring system, can be considered extremely useful and safe.

[Monitoring cardiac output: esophageal doppler vs thermodilution]

OBJECTIVE

Evaluation of continuous cardiac output monitoring based on the esophageal Doppler in the critically ill.

DESIGN

Prospective clinical investigation.

SETTING

An intensive care unit of an University hospital.

PATIENTS

Ten critically ill patients who needed pulmonary artery catheterization.

MEASUREMENTS

Cardiac output was monitored continuously by a transesophageal Doppler device, consisting of an esophageal probe and a bedside microprocessor that calculated cardiac output using a new algorithm. Standard bolus thermodilution technique (10 ml of saline solution) was used to compare the continuous Doppler cardiac output measurement with the intermittent bolus measurement.

MAIN RESULTS

A total of 50 pairs of intermittent (bolus) cardiac output and continuous (Doppler) cardiac output measurements were obtained from the 10 patients. The mean value of CO measured with TD was 5.81 +/- 0.83, while using esophageal Doppler was 5.84 +/- 0.81. The correlation coefficient of the two methods was r = 0.93. The Bland and Altman showed 95% of agreement limits as +0.52 and -0.64 L/min.

CONCLUSIONS

Continuous monitoring of cardiac output using esophageal Doppler has proven to be safe, accurate, and precise when compared with the standard intermittent bolus thermodilution technique. The continuous monitoring technique improves our armamentarium for more intensive monitoring of the critically ill patients.

Multicenter trial comparing tramadol and morphine for pain after abdominal surgery

Seventy patients (40 male, 30 female), mean (SD) age 60.8 +/- 13.7 years were treated with parenteral morphine (10 mg/1 ml ampul) or tramadol (100 mg/2 ml ampul) to verify their analgesic effects in pain following abdominal surgery. The multicenter trial followed an open, controlled experimental design between patients, randomized within the centers. The drugs were given by intramuscular injection, as requested by patients, starting in the postoperative period when pain was more than 70 mm, assessed on a visual analog scale. Patients were allowed up to six ampuls of tramadol or morphine in the 24-h trial but in the first 4 h, if they asked for supplementary analgesic, only diclofenac (75 mg in a 3-ml ampul) was allowed. Both test drugs gave rapid and constant pain relief. After the first dose, pain intensity was reduced 36.2% with tramadol, and 51% with morphine; the pain-free interval was similar for both treatments. The quality of sleep and the number of hours of sleep the night after surgery were similar for both groups. Tramadol was tolerated better, giving rise to no untoward reactions; with morphine there was one case of mild respiratory depression. In abdominal surgery, therefore, tramadol given by intramuscular injection has postoperative analgesic activity similar to morphine, but is better tolerated.

A new fast-moving variant causing erythrocytosis and mild hemolysis: Hb Gàmbara [beta 82(EF6)Lys-->Glu]

Hb Gàmbara is a new hemoglobin variant with abnormal beta chains that has been found in three out of four members of a family of Lombardy origin (Gàmbara, Brescia, Northern Italy). The affected subjects led a normal life, but they had modest erythrocytosis and mild (compensated) hemolysis with slight splenomegaly. Their abnormal hemoglobin was about 52% of the total hemoglobin, and was shown to be stable by the isopropanol test. Whole blood P50 of the proband was 19.3 Torr, Bohr effect was decreased (-0.25), as well as the molar ratio between the 2,3-diphosphoglycerate level and total hemoglobin of erythrocytes (0.68). The purified abnormal hemoglobin was characterized by an altered oxygen affinity, low n-factor, chloride, and 2,3-diphosphoglycerate effects. The Bohr effect was about 40% of the normal control. The abnormal hemoglobin moved faster than Hb A at alkaline electrophoresis, and split into two fractions, probably due to the formation of hybrid tetramers (alpha 2 beta A beta X). The reversed phase high performance liquid chromatogram from the tryptic digest of the aminoethylated abnormal beta chain subunits indicated the presence of an extra peptide, beta T-9, 10, replacing the individual peptides beta T-9 and beta T-10. Finally, the proband's DNA, drawn from a suitable segment of the beta structural gene (exon 2), revealed a nucleotide sequence carrying the heterozygous mutation AAG-->GAG at codon 82. This led to a Lys-->Glu substitution at position 82(EF6) of the beta chain.

Long-term adrenalectomy can decrease or increase hippocampal dentate gyrus volumes

Male and female Long-Evans adult rats were adrenalectomized and sacrificed 6 weeks later to determine whether dentate gyrus damage would differ in females and males. A subset of adrenalectomized rats of both sexes had significantly reduced dentate gyrus volumes compared to the same sex SHAM operated rats. The remainder of the male and female adrenalectomized rats which did not have clear dentate gyrus damage had significantly larger dentate gyrus volumes compared to the same sex SHAM rats. The dentate gyrus volumes of all adrenalectomized rats were significantly correlated with two indices of residual hormonal levels (Na+/K+ ratios and body weight gain 6 weeks after surgery), indicating that endogenous corticosterone levels may be a determining factor in the response of the dentate gyrus to adrenalectomy. These dentate gyrus volumetric changes could not be attributed to tissue shrinkage as there were no changes in CA3 volumes in any of the groups. These results suggest that long-term adrenalectomy can result in either increased or decreased dentate gyrus volumes and that the adrenal steroid levels of each individual adrenalectomized rat may be the factor determining the direction of the dentate gyrus volumetric response.

Evaluation of brain perfusion with high resolution single photon emission tomography in the diagnosis of brain death

Nuclear Medicine studies performed with tomographic acquisition and tracers such as Technetium-99m hexamethyl-propyleneamine oxime (99mTc-HMPAO) are able to assess cerebral blood flow. A case is reported of a patient with a large intracranial tumor, of possible pituitary origin, with a clinical and electroencephalographic suspicion of brain death. The patient had endocrinous-metabolic impairments for a history of impotence, since 18 months, and diabetes insipidus with a urine output of 350 ml/hr in the first 24 hours from the clinical suspicion of brain death. Due to the endocrinous-metabolic impairments, according to Italian law, it was necessary to confirm the diagnosis of brain death by performing a study able to assess cerebral blood flow. A single Photon Emission Tomography (SPET) scan was performed after the intravenous administration of 99mTc-HMPAO using a high resolution, brain dedicated device. No tracer uptake was evident in cerebral, cerebellar and brain stem structures. The cerebral blood flow study by SPET confirmed the diagnosis of brain death and made the organ transplant possible in a short period of time. High resolution SPET studies are useful to confirm the diagnosis of brain death when there are factors that can influence clinical and electroencephalographic signs, reducing time to authorise the organ explant.

[Results of early external ventricular diversion in posthemorrhagic ventricular dilatation in the newborn]

OBJECTIVE AND DESIGN

The authors report the outcome of early treatment with long-term external ventricular drainage (EVD) of progressive post-hemorrhagic ventricular dilatation (PPHVD), following peri-intraventricular hemorrhage (PIVH) in a population of preterm newborns.

SETTING

Neonatal Intensive Care Unit (NICU) of a Children's Hospital.

PATIENTS

Twenty-one preterms of 29.6 +/- 2.4 weeks of gestational age, weighing at birth 1443 +/- 445 g, mechanically ventilated, submitted to early EVD because of PPHVD following PIVH of III (n 11) e IV (n 10) grade.

METHODS

PPHVD was diagnosed on the basis of US and TC findings. An external liquoral drainage suitable, for its technical characteristics, to be maintained for a long period of time and peculiar anesthesiologic, intra and postoperative treatments were utilized.

RESULTS

EVD was placed at 21 +/- 5.8 days of life and maintained for 40 +/- 16 days. In all cases reduction of ventricular size was observed. One case (5%) developed liquoral infection and recovered with antibiotic therapy. No obstruction or dislocation of the ventricular catheter occurred. During EVD 3 patients (14%) died because of respiratory complications. After the normalization of cerebrospinal fluid (CSF), a "permeability test" was performed to assess the canalization of the liquoral system. Seven patients (33.5%) underwent ventriculo-peritoneal shunt (VPS) and 11 (52.5%) became shunt-free.

CONCLUSIONS

Our results indicate that long-term use of EVD has a low risk of complications, avoids the need for transcutaneous tips and allows monitoring of CSF characteristics. Furthermore EVD protects the brain from liquoral hypertension, while waiting for a possible recurrence of natural CSF circulation, and is associated with a low number of definitive VPS.

Mucopolysaccharidosis: thickening of dura mater at the craniocervical junction and other CT/MRI findings

Cranial CT and/or MRI imaging of 8 patients with mucopolysaccharidosis (MPS) was retrospectively evaluated. Two patients had MPS IH, 1 had MPS IS, 1 had MPS IVA and 4 had MPS IV. CT and MRI showed thickening of dura mater at the cranio-cervical junction, causing narrowing of the subarachnoid space, in all the patients examined. Spinal cord compression was detected in 4 patients. Other findings were: white matter alterations, mild to severe hydrocephalus, skull dysplasia and odontoid dysplasia. White matter alterations were evident as large areas and as multiple dispersed spots of prolonged T1 and T2 value. Reduced gray/white matter contrast was demonstrated on T2-weighted MRI images. It is important to examine the cranio-cervical junction carefully for thickening of dura mater in all patients with mucopolysaccharidosis examined by CT or MRI, because of the generally progressive clinical course of MPS. In patients with symptomatic cord compression, surgical intervention should be considered.

[Mucopolysaccharidoses: evaluation of the cranium by computed tomography and magnetic resonance]

Cranial CT and/or MRI examinations were performed in 8 patients affected with mucopolysaccharidosis. Two patients were affected with mucopolysaccharidosis IH,1 had mucopolysaccharidosis IS, 1 had mucopolysaccharidosis IV A and 4 presented mucopolysaccharidosis VI. CT and MRI showed white matter changes consisting of symmetric and diffuse hypodense areas on CT, large areas and multiple spots of prolonged T1 and T2 value on MRI. Reduced gray/white matter contrast was demonstrated on T2-weighted sequences. Furthermore, CT and MRI showed thickening of the dura mater at the cranio-cervical junction, which caused subarachnoid space narrowing in all patients. Spinal cord compression was detected in 4 patients. Additional findings were mild to severe hydrocephalus, skull dysplasia and odontoid dysplasia. Owing to the progressive clinical course of all mucopolysaccharidosis, the authors stress the importance of a careful study of the cranio-cervical junction in all the patients with mucopolysaccharidosis examined by CT or MRI in order to demonstrate essential thickening of the dura mater. In the patients with symptomatic cord compression, surgery should be considered.