Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse?

BACKGROUND

Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care.

METHODS

We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race.

RESULTS

Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons).

CONCLUSIONS

Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.

The WHO quality of life assessment instrument (WHOQOL-Bref): the importance of its items for cross-cultural research

One of the fundamental issues in the area of assessment of quality of life is to determine what is important to the individuals' quality of life. This is even more crucial when the instrument is for use in diverse cultural settings. This paper reports on the importance ratings on WHOQOL-Bref items obtained as a part of WHOQOL pilot field trial on 4804 respondents from 15 centres from 14 developed and developing countries using 12 languages. All items were rated as moderately or more important, but this was expected because the items were selected by extensive qualitative research for their salience across the centres. Significant differences on mean importance ratings were found between centres, but rank orders of item for their importance showed highly significant correlations between centres. This was especially true for items in the top and the bottom thirds of the item list arranged by overall importance. Most items were rated as more important by women compared to men and by younger compared to older persons. The results are discussed for their relevance in cross-cultural research on quality of life assessment.

Students with disabilities: a national survey of participation in school activities

INTRODUCTION

The policies of integration and full inclusion in school activities have been enacted to promote the independence and social participation of students with disabilities. This study examined the nature and extent of participation in schools by students with disabilities in the context of the physical, social and psychological features of the school environment.

METHOD

A national survey was completed by 1180 teachers of students with disabilities in the US describing student participation in school activities encompassing involvement in social activities, sports, academic and artistic/creative endeavours.

RESULTS/CONCLUSIONS

Multivariate analysis revealed that school life in elementary, middle and high school could be defined by six distinct factors describing individual and group roles. Structural equation modelling yielded a second order latent variable that captured the complex and multi-dimensional aspect of participation, accounting for availability, eligibility, student characteristics/status, and student choice within a larger framework of participation.

Sleep in the laboratory and sleep at home: comparisons of older insomniacs and normal sleepers

Many laboratory polysomnographic (LPSG) studies have shown only modest sleep differences between insomniacs and matched, noncomplaining normal controls. However, the extent to which LPSG methodology affects the outcome of such comparisons has yet to be tested. In the current investigation, 32 (16 females, 16 males) older (age > or = 60 years) insomniacs and an age-matched and gender-matched sample of 32 noncomplaining normal sleepers underwent three consecutive nights of LPSG monitoring and another three consecutive nights of PSG monitoring in their homes (HPSG). By random assignment, one-half of the subjects in each group underwent LPSG first, whereas the remaining subjects underwent HPSG first. Each PSG recording was blindly scored using conventional scoring criteria, and resulting measures of total sleep period, total sleep time, sleep efficiency percent, stage 1 time, slow-wave sleep time, and rapid eye movement latency were used to compare the two subject groups within each PSG recording site (i.e. lab and home). Statistical analyses showed the normals sleepers and insomniacs evidenced similar pronounced first night effects (FNEs) when undergoing LPSG. However, neither mean values of the selected sleep parameters nor measures reflecting their night-to-night variability differentiated the insomniacs from the normal sleepers when such measures were derived from LPSG. In contrast, FNEs were generally absent for both subject groups when they underwent HPSG. Moreover, the insomniacs displayed significantly greater variability in several of their sleep measures during HPSG than did the normal sleepers. Overall, results suggest FNEs are a concern mainly when using LPSG, and HPSG may be more sensitive than LPSG for documenting sleep differences between normal sleepers and insomniacs. Additional studies are needed to determine if the findings reported herein are similar for young and middle-aged adults.

The Caltrac accelerometer as a physical activity monitor for school-age children

The performance of the Caltrac accelerometer was studied in elementary school-age children under field and laboratory conditions. In Study 1, 35 children (20 boys, 15 girls, mean age = 10.8 yr) wore the accelerometer and a heart rate (HR) monitor for 2 d. Caltrac activity counts per hour were compared to the mean "activity HR", which was calculated by subtracting the mean of the five lowest HRs of the day from each recorded HR. Pearson r's between accelerometer and activity HR were 0.54 (P less than 0.001) on day 1 and 0.42 (P less than 0.02) on day 2. Inter-instrument reliability in the field was r = 0.96. Both accelerometer and HR data were significantly correlated with physical activity recalls of the same day. In Study 2, 15 children walked/ran for 10 min at 3, 4, and 5 mph on a horizontal treadmill while wearing two accelerometers. Oxygen uptake was directly measured each minute. Reliability of the Caltracs in the laboratory was 0.89. Activity count correlated r = 0.82 (SEE = 23%) with net calorie cost per kg of body weight. Net caloric expenditure per kg of weight was 0.101 kcal.kg-1.d-1 per Caltrac activity count. These data support the use of the Caltrac accelerometer as a physical activity measure for school-age children, and the objective data tended to corroborate the children's short-term activity recalls.

Lower electrical membrane potential and altered pHi homeostasis in multidrug-resistant (MDR) cells: further characterization of a series of MDR cell lines expressing different levels of P-glycoprotein

Recently [Roepe, P.D. (1992) Biochemistry 31, 12555-12564], increased steady-state levels of chemotherapeutic drug efflux from multidrug-resistant (MDR) myeloma cells were correlated with intracellular alkalinization. To better understand elevated pHi in MDR cells, Na(+)- and Cl-dependent recovery of pHi upon intracellular acid or alkaline shock has been examined for this same series of MDR cell lines. In agreement with another recent report [Boscoboinik, D., Gupta, R.S., & Epand, R.M. (1990) Br. J. Cancer 61, 568-572], we find that the rate of Na(+)-induced alkalinization after an intracellular acid shock is increased in the MDR cells, relative to the drug-sensitive parent. Interestingly, we also now find that mRNA encoding the human Na+/H+ exchanger (NHE) is overexpressed in these MDR cells, but the level of overexpression does not correlate with the relative drug resistance or steady-state pHi. It is also found that the efficiency of Cl(-)dependent reacidification of pHi, after an intracellular alkaline shock is reduced in the MDR cells. This effect appears to correlate with the relative expression of MDR protein, but not the relative expression of Cl-/HCO3- exchanger (AE), which we now find is also altered in the series of cells. Since elevated pHi will increase delta pH across the plasma membrane, we have also measured the electrical potential for these cells using three different methods. Most interestingly, the magnitude of the plasma membrane electrical potential (delta psi) decreases concomitant with increased expression of the MDR protein. Energy provided by increased delta pH compensates for the lowered delta psi, such that the total electrochemical membrane potential (delta mu H+) remains similar among the cells in this series (delta mu H+ = delta psi - Z delta pH). These data, along with other recent experiments that associated an increased Cl- conductance with the expression of MDR protein [Valverde, M., Diaz, M., Sepúlveda, F.V., Gill, D.R., Hyde, S.C., & Higgins, C.F. (1992) Nature 355, 830-833], are consistent with a model for MDR protein-mediated multidrug resistance that does not entail direct active transport of lipophilic drugs by the MDR protein.

Inadvertent ketamine overdose in children: clinical manifestations and outcome

STUDY OBJECTIVE

We sought to characterize the clinical manifestations, outcome, and etiology of inadvertent ketamine overdose in the emergency department.

METHODS

We investigated cases of inadvertent ketamine overdose in children seen in the ED solicited through electronic mail subscription lists or reported to the Institute for Safe Medication Practices. The clinical manifestations, outcome, and reported cause for each case are described.

RESULTS

We identified 9 cases of inadvertent ketamine overdose in children treated in the ED. Patients received either 5(n=3), 10(n=5), or 100(n=1) times the intended dose, either by the intramuscular (n=5) or intravenous (n=4) route. All 9 experienced prolonged sedation (3 to 24 hours). Four experienced brief respiratory depression shortly after administration, and assisted ventilation was performed in 2. Two children without respiratory difficulty or hypoxemia were intubated by their physicians as a precaution. In 5 children, the dosing error was not discovered until late in the sedation, often when the child was not waking at the expected time. No adverse outcomes were noted, and all children were normal neurologically on discharge and longer-term follow-up if available.

CONCLUSION

No adverse outcomes were noted in 9 healthy children treated in the ED who inadvertently received 5 to 100 times the intended dose of ketamine. Toxicity manifested as prolonged sedation in all 9 and brief respiratory depression in 4. The margin of safety in ketamine overdose may be wide, although less common and more serious outcomes cannot be excluded by this small, self-reported sample.

Lack of Borrelia burgdorferi DNA in synovial samples from patients with antibiotic treatment-resistant Lyme arthritis

OBJECTIVE

To determine whether Borrelia burgdorferi DNA may be detected in synovial tissue from patients with Lyme arthritis who have persistent synovial inflammation after antibiotic treatment.

METHODS

Synovial specimens obtained at synovectomy from 26 patients with antibiotic treatment-resistant Lyme arthritis and from 10 control subjects were tested for B burgdorferi DNA using 3 primer-probe sets that target genes encoding outer surface proteins A or B or a flagellar protein (P41) of the spirochete.

RESULTS

The 26 patients with Lyme arthritis, who had received antibiotic therapy for a mean total duration of 8 weeks prior to synovectomy, and the 10 control subjects each had negative polymerase chain reaction (PCR) results in synovial samples. When the samples were spiked with approximately 1-10 B burgdorferi, all but 1 had positive PCR results, suggesting that spirochetal DNA could have been detected in most of the unspiked samples if it had been present.

CONCLUSION

These results indicate that synovial inflammation may persist in some patients with Lyme arthritis after the apparent eradication of the spirochete from the joint with antibiotic therapy.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Urinary and hematologic indexes of hypohydration

As part of a large-scale field feeding system test we were able to collect and study hundreds of aliquots of overnight urine samples obtained immediately prior to a fasting blood sample on days 1, 20, and 44 of the field test. The large number of experimental samples (greater than 650) and concomitant collection of blood and urine aliquots along with data on body weights gave us the opportunity to assess and quantitate the sensitivity of commonly used criteria of hypohydration. Urine aliquots for all test days were initially categorized by specific gravity (SG) greater than or equal to 1.03 (n = 124) or less than 1.03 (n = 540). Creatinine levels were elevated (P less than 0.001) in the concentrated urine samples, but a decreased trend in sodium-to-potassium ratios in these samples failed to achieve statistical significance (P greater than 0.05). However, when individuals with high SG urine were subclassified by a criterion of weight loss greater than 3% from original body weight, then creatinine concentrations were elevated (P = 0.05), whereas sodium-to-potassium ratios were decreased (P = 0.05) when subjects also with high SG but weight loss less than 3% were compared. Because of the moderate altitude (2,000 m) of the field site and the time of sojourn (44 days), there occurred a slight, but significant (P less than 0.001), erythropoietic response. Hematocrit and serum osmolality were not significantly different when examined by the criteria of high or low SG urine and weight loss greater than or less than 3% original body weight.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of suckling interval on milk production of sows

The objective of this study was to determine whether sow milk yield per gland could be increased by reducing the interval between suckles (suckling interval). Eighteen sows were allocated at their first farrowing to three treatments comprising litter sizes of 6 or 12 piglets or a cross-suckling treatment that was imposed to increase suckling frequency. The cross-suckled treatment comprised two groups of six piglets each. Each suckling group was allowed to suckle the sow during 30-min intervals each day between d 6 and d 28 of lactation. The suckling interval was shorter (P < .05) for cross-suckled sows than for sows suckling single litters of 6 or 12 piglets during early lactation (d 10 to 14) and late lactation (d 24 to 28). Average piglet growth rate between birth and 28 d of age was greatest (P < .05) for piglets in the single litters of six and lowest for piglets in the cross-suckled treatments. Single litters of 12 piglets had the highest (P < .05) litter growth rates, followed by the cross-suckled litters and then the single litters of six piglets. The concentration of lactose and fat in milk from sows remained relatively stable, although milk from the cross-suckled sows contained more protein in early lactation (P < .05). Milk yield of sows was not significantly increased (P > .05) by the cross-suckle treatment, although during early lactation, milk yield tended to be greater from sows in the cross-suckle treatment than from sows suckling single litters of six (8,920 g/d vs 7,819 g/d, P < .1). The concentration of DNA and total RNA and the RNA:DNA ratio in mammary glands was unaffected by treatment (P > .05). Sows with single litters of 12 piglets had the greatest total DNA in their udders (P < .05). However, individual gland weights were heavier (P < .05) in cross-suckled sows than in sows with single litters of 6 or 12 piglets. Increased suckling frequency seemed to play a role in increased mammary gland weight and milk production during lactation.

Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions

OBJECTIVE

To evaluate the nature, frequency, and predictors of adverse events during the use of propofol by pediatric hospitalists.

STUDY DESIGN

We reviewed 1649 charts of patients sedated with propofol by pediatric hospitalists at St Louis Children's Hospital between January 2005 and September 2009.

RESULTS

Hospitalists were able to complete 1633 of the 1649 sedations reviewed (99%). Major complications included 2 patients with aspiration and 1 patient intubated to complete the study. We observed a 74% reduction in the number of patients with respiratory events and airway interventions from 2005 to 2009. Predictors of respiratory events were history of snoring (OR, 2.40; 95% CI, 1.52-3.80), American Society of Anesthesiologists (ASA) physical status classification of ASA 3 (OR, 2.30; 95% CI, 1.22-4.33), age >12 years (OR, 4.01; 95% CI, 2.02-7.98), premedication with midazolam (OR, 1.85; 95% CI, 1.15-2.98), and use of adjuvant glycopyrrolate (OR, 4.70; 95% CI, 2.35-9.40). All except ASA 3 status were also predictors for airway intervention. There was a decline in the prevalence of all of these predictors over the study years (P < .05) except for use of glycopyrrolate.

CONCLUSION

Our pediatric hospitalists implemented a successful propofol sedation program that realized a 74% reduction in respiratory events and airway interventions between 2005 and 2009. Decreased prevalence of the predictors of adverse events that we identified likely contributed to this reduction.

The use of high-dose epinephrine for patients with out-of-hospital cardiopulmonary arrest refractory to prehospital interventions

OBJECTIVE

To determine if high-dose epinephrine (HDE) used during out-of-hospital cardiopulmonary arrest refractory to prehospital interventions improves return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcomes.

METHODS

A multicenter randomized controlled trial was conducted between May 1991 and October 1996 to compare the effectiveness of HDE versus standard-dose epinephrine (SDE) in patients having out-of-hospital cardiopulmonary arrest refractory to prehospital resuscitation efforts. Cardiopulmonary arrest was classified as "medical" or "traumatic." Two hundred thirty patients were enrolled in 7 pediatric emergency departments. Ages ranged from newborn to 22 years. Seventeen patients met exclusion criteria. Patients were assigned to receive HDE (0.1 mg/kg for the initial dose and 0.2 mg/kg for subsequent doses) or SDE (0.01 mg/kg). The main end points evaluated were return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcome.

RESULTS

One hundred twenty-seven patients received HDE (32 trauma patients), and 86 patients received SDE (27 trauma patients). Among medical patients, 24 (25%) of 95 experienced return of spontaneous circulation in the HDE group as compared with 9 (15%) of 59 in the SDE group (P = 0.14, chi2 = 2.17, relative risk = 1.66 [0.83-3.31]). Sixteen (17%) of 95 HDE patients and 5 (8%) of 59 SDE patients survived at least 24 hours (P = 0.14, chi2 = 2.16, relative risk = 1.99 [0.77-5.14]). Nine survivors to discharge received HDE, and 2 received SDE (P = 0.21, Fisher exact test, relative risk = 2.75 [0.61-12.28]). There were no long-term survivors among the trauma patients. Eight of 11 long-term survivors had severe neurological outcomes defined by the Glasgow Outcome Scale (2/2 SDE, 6/9 HDE; P = 0.51, Fisher exact test).

CONCLUSION

HDE does not improve or diminish return of spontaneous circulation, 24-hour survival, long-term survival, or neurological outcome compared with SDE in out-of-hospital cardiopulmonary arrest.

A randomized study of mitomycin augmentation in combined phacoemulsification and trabeculectomy

PURPOSE

The purpose of the study is to determine whether the intraoperative application of subconjunctival mitomycin C (MMC), during combined phacoemulsification and trabeculectomy, is an effective means of improving filtration, defined as overall lower intraocular pressure (IOP) and less antiglaucoma medication use.

METHODS

Twenty-nine patients with a visually significant cataract and glaucoma were randomized, in a double-masked fashion, to receive intraoperative MMC (0.5 mg/ml) or placebo.

RESULTS

Follow-up ranged from 6 to 30 months (mean, 20 months). Postoperative visual acuity at 1 year was 20/40 or better in 14 of 15 eyes operated on in the placebo group and 13 of 14 eyes operated on in the MMC group. Intraocular pressure at 8 months averaged 15.2 +/- 1.5 mmHg in the placebo-treated eyes versus 12.3 +/- 1.6 mmHg in the MMC-treated eyes. At 12 months, IOPs averaged 16.2 +/- 1.5 mmHg in the placebo-treated eyes versus 12.6 +/- 1.0 mmHg in the MMC-treated eyes. On average, the MMC group had postoperative IOP levels 3.0 mmHg lower than did the placebo group (P = 0.04) throughout the study. In the placebo group, laser suture lysis was required in a greater number of patients (80% versus 43%) and to a greater extent (mean = 2.0 versus 0.7 suture lysed) (P < 0.05). At 12 months, 5 of the 15 patients in the placebo group required an average of 1.8 medications for IOP control, whereas 0 of the 14 patients in the MMC group needed IOP-lowering medications. A late endophthalmitis developed through an intact bleb in one patient in the MMC group; otherwise, complications were minimal in each group.

CONCLUSION

These results suggest that intraoperative MMC application, during combined phacoemulsification and trabeculectomy surgery, does improve early filtration as shown by overall lower IOPs and less antiglaucoma medication use.

Effect of succinylcholine on the intraocular contents of open globes

The use of succinylcholine in patients with suspected or proven open globes is considered dangerous by some for fear of extruding the intra-ocular contents as a consequence of the co-contraction of the extraocular muscles it produces. To test this hypothesis, the authors devised an anterior and a posterior trauma model in the cat eye. Thirty events were studied using the anterior trauma model and eight with the posterior model. The only observable effect of succinylcholine administration was forward displacement of the lens and iris. No intraocular content was lost in any event. The authors believe this study supports the argument that, when indicated, succinylcholine may be considered in open globes.

Femur fractures in chest-injured patients: is reaming contraindicated?

OBJECTIVE

To determine if reamed femoral intramedullary nailing increases the pulmonary complications seen in chest-injured patients.

DESIGN

Retrospective review of prospectively collected trauma database data from January 1991 to October 1994.

SETTING

Methodist Hospital, Indianapolis, Indiana, Level I Trauma Center.

PATIENTS

Group I: Chest-injured patients [chest Abbreviated Injury Score (AIS) > or = 2] without femur or tibia fractures. Group II: Chest-injured patients (chest AIS > or = 2) with femoral reamed intramedullary fixation. Group III: Chest-injured patients (chest AIS > or = 2) with femoral shaft fixation using nonreamed fixation (rush rods, plating, or external fixation). Group IV: Non-chest-injured patients (chest AIS < 2) with femoral reamed intramedullary fixation. MAIN OUTCOME MEASUREMENT/HYPOTHESIS: Reamed femoral intramedullary nailing does not alter pulmonary outcomes, even in chest-injured patients.

RESULTS

Groups I and II had a very similar incidence of adult respiratory distress syndrome (ARDS), pneumonia, and number of ventilator days. Group III had a significantly higher incidence of ARDS and number of ventilator days than did Group I or II. Group III did not have a chest AIS score significantly different than Groups I and II. Group II had significantly higher ARDS and more ventilator days than did Group IV when only analyzing raw data. When injury severity was adjusted, there were no significant differences in pulmonary outcomes.

CONCLUSION

Reamed intramedullary femoral fixation did not increase pulmonary morbidity in chest-injured patients.

Development of fatigue symptoms during simulated driving

Why do people sometimes allow themselves to be overcome by fatigue? Ancient human survival may have depended on ignoring fatigue. Its modern occurrence in the absence of strain may further render us insensitive to its warning value. To test whether deliberate monitoring of certain symptoms may help drivers and other workers realize when they need to rest to avoid hazard, the development of fatigue while driving a simulator was objectively measured in terms of how many persons quit driving as a function of time. Some subjects asked to stop after 90 minutes; others lasted 240 minutes. Grouping data from an adapted Pearson [(1957) Journal of Applied Psychology, 44, 186-191] fatigue checklist revealed a curious phenomenon. No matter how long subjects drove before wanting to quit, they still developed much the same subjective level of fatigue at the end. This suggests that people do not differ greatly in how much fatigue they can tolerate but rather how quickly they reach a certain critical level of fatigue. Averaging fatigue scores backwards from the time subjects quit produced a function similar to the quitting function. Similar treatment of the other data revealed certain clusters of symptoms whose development also paralleled the development of fatigue.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

Additional dietary zinc for weaning piglets is associated with elevated concentrations of serum IGF-I

Two experiments were performed in order to study how weaning and post-weaning dietary zinc level affect serum IGF-I. Further, whether the growth-enhancing effect of 2500 ppm of dietary zinc (Zn2500) and/or 175 ppm of dietary copper (Cu175) in post-weaning diets is associated with elevated serum IGF-I levels in piglets was studied. Experiment 1 included 54 piglets (six litters of nine piglets). One piglet from every litter was assigned to a control group (blood sampled 1 day before weaning). At weaning the remaining eight piglets from every litter were allocated randomly to four dietary treatments with increasing zinc inclusions (Zn100, Zn250, Zn1000, Zn2500). In exp. 2, 48 piglets (six litters of eight piglets) were allocated to four dietary treatments (Zn100, Zn100Cu175, Zn2500, Zn2500Cu175). All piglets in exp. 1 were blood sampled at -1, 1-2, 5-6 or 14-15 days after weaning and in exp. 2 blood samples were taken from all pigs 5-7 days after weaning. Feed intake was recorded per pen (two piglets) and weight gain was recorded for every piglet. Just after weaning feed intake was very low, piglets lost weight and serum IGF-I decreased in exp. 1. However, the piglets fed 2500 ppm of zinc reached pre-weaning levels of serum IGF-I at 14-15 days post-weaning, whereas piglets receiving lower zinc levels showed no changes in serum IGF-I. In exp. 2, additional dietary zinc in weaning diets for piglets was found to be associated with increased feed intake, improved growth rate and increased serum IGF-I. High levels of dietary copper did not affect any of these measurements. Zinc-induced rise in serum IGF-I was partly due to increased feed intake. After correcting for differences in feed intake, zinc significantly increased serum IGF-I. However, to completely separate effects of feed intake from effects of zinc status, pair-feeding should be considered in future studies.

Development of a pediatric hospitalist sedation service: training and implementation

OBJECTIVE

There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital.

METHODS

In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC.

RESULTS

This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers.

CONCLUSIONS

A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists.

Prenatal diagnosis and dysmorphic findings in mosaic trisomy 16

We report two cases of mosaic trisomy 16 diagnosed by amniocentesis, with dysmorphic findings in both cases evident upon delivery. Following elective termination, case 1 demonstrated a trisomy 16 cell line in fetal skin (4 per cent) and placental tissue (64 per cent). Molecular studies on the disomic cell line indicated that both chromosome 16s were maternal in origin, suggesting loss of the paternal chromosome 16 from a trisomic zygote (uniparental heterodisomy). At birth, case 2 demonstrated only disomic cells in skin and blood, with trisomy 16 present in 4 per cent of cells from the amnion. Molecular studies confirmed both maternal and paternal contributions of the chromosome 16s. We analysed DNA from one previously reported case of mosaic trisomy 16 (Williams et al., 1992) and failed to find signs of uniparental disomy in this child with congenital heart defects. These cases had distinctive but different dysmorphic features. We suggest that trisomy 16 embryos may revert to disomy during the course of pregnancy, allowing for longer survival with various abnormalities in growth and morphogenesis. The clinical significance of prenatally detected mosaic trisomy 16 may not be completely defined by additional cytogenetic, molecular, and ultrasound studies.

Serosal zinc attenuate serotonin and vasoactive intestinal peptide induced secretion in piglet small intestinal epithelium in vitro

This study addressed the mechanisms by which dietary zinc affects diarrhoea and aimed to study possible interactions between zinc status and the presence of zinc in vitro on secretagogue-induced secretion from piglet intestinal epithelium in Ussing chambers. In addition, it was studied from which side of the epithelium zinc would perform an effect and if copper caused similar effects. Twenty-four piglets (28 days of age) were weaned and fed diets containing 100 or 2500 mg zinc/kg (as ZnO) for 5 or 6 days (12 piglets per group). Intestinal epithelium underwent the following 5 treatments: zinc at the mucosal side (M(Zn)), zinc at the serosal side (S(Zn)), zinc at both sides (MS(Zn)), copper at both sides (MS(Cu)) or water at both sides (control). Provoked secretion in terms of short circuit responses to serotonin (5-HT) and vasoactive intestinal peptide (VIP) were measured. Zinc at the serosal or both sides of the epithelium reduced the 5-HT induced secretion (P<0.001); however, due to interactions (P=0.05) the effect of zinc in vitro was only present in the ZnO(100) group. The secretion caused by VIP was not affected by the diet (P=0.33), but zinc at the serosal side or both sides reduced the response to VIP (P<0.001). Copper reduced the 5-HT and VIP induced secretion to a larger extent than zinc. However, copper also disturbed intestinal barrier function as demonstrated by increased transepithelial conductance and increased short circuit current, which was unaffected by zinc. In conclusion, zinc at the serosal side of piglet small intestinal epithelium attenuated 5-HT and VIP induced secretion in vitro. These in vitro studies indicate that in vivo there will be no positive acute effect of increasing luminal Zn concentration on secretagogue-induced chloride secretion and that zinc status at the serosal side of the epithelium has to be increased to reduce secretagogue-induced chloride secretion and thereby diarrhoea.

Morphological and biochemical responses of Bacillus subtilis to selenite stress

When introduced into a chemically defined minimal medium supplemented with 1 mM sodium selenite (79 ppm Se(o)), Bacillus subtilis was found to undergo a series of morphological and biochemical adaptations. The morphological changes included the formation of "round bodies" associated with the detoxification of selenite to elemental selenium. Round bodies observed transiently were not apparent during balanced growth of cells adapted previously to selenite-containing medium. Under balanced growth conditions, cell structures similar to "round bodies", could be produced by treating cells with lysozyme. The selenite-induced structural alterations in cells were accompanied by an increase in the content of thioredoxin and the associated enzyme, NADP-thioredoxin reductase. The results suggest that the biovalence transformation of high levels of selenite may involve a dithiol system.