Accidental Chlorine Gas Exposure in a Pediatric Patient: A Case Report

Introduction

Chlorine gas is a known irritant of the respiratory tract, which may cause damage to various systems depending on time of exposure and concentration of the gas. Current treatments are mainly supportive. While no definitive studies have been completed to date, it has been noted that treatment with a sodium bicarbonate solution via nebulizer may lead to improved outcomes for patients dealing with chlorine gas exposure.

Case Report

We present a case of a nine-year-old child arriving at the emergency department after exposure to chlorine gas. Complete recovery from his symptoms occurred rapidly with the administration of nebulized sodium bicarbonate.

Discussion

Inhaled chlorine gas acts as a mucous membrane irritant, with symptoms usually beginning within minutes of exposure. Inhaled nebulized sodium bicarbonate has been suggested as a therapy for chlorine exposure. Although its mechanism of action is not well understood, it is thought that inhaled sodium bicarbonate neutralizes the hydrochloric acid formed when the chlorine gas reacts with the water in the lungs.

Conclusion

Nebulized sodium bicarbonate solution at a low concentration appeared to rapidly and effectively reverse the symptoms due to chlorine gas inhalation in a young child.

Bug off! Severe toxicity following inhalational exposure to N, N-diethyl-meta-toluamide (DEET)

N, N-diethyl-meta-toluamide (DEET) is an insect repellent currently used by millions of people since 1956. DEET has an excellent safety profile and has remarkable protection against mosquitoes, ticks and various other arthropods. Toxicity is unusual, and is generally associated with incorrect, or overuse of the product. We report a patient with severe toxicity following inhalational exposure to a "bug bomb". containing 98% DEET.

BET 2: Usefulness of IV lidocaine in the treatment of renal colic

A shortcut review was carried out to establish whether intravenous lidocaine is effective in the management of renal colic. Two studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these studies are tabulated. The clinical bottom line is that intravenous lidocaine may be of some benefit in renal colic. However, there are other maybe more effective drugs available.

Patient selection for prostate focal therapy in the era of active surveillance: an International Delphi Consensus Project

BACKGROUND

Whole-gland extirpation or irradiation is considered the gold standard for curative oncological treatment for localized prostate cancer, but is often associated with sexual and urinary impairment that adversely affects quality of life. This has led to increased interest in developing therapies with effective cancer control but less morbidity. We aimed to provide details of physician consensus on patient selection for prostate focal therapy (FT) in the era of contemporary prostate cancer management.

METHODS

We undertook a four-stage Delphi consensus project among a panel of 47 international experts in prostate FT. Data on three main domains (role of biopsy/imaging, disease and patient factors) were collected in three iterative rounds of online questionnaires and feedback. Consensus was defined as agreement in ⩾80% of physicians. Finally, an in-person meeting was attended by a core group of 16 experts to review the data and formulate the consensus statement.

RESULTS

Consensus was obtained in 16 of 18 subdomains. Multiparametric magnetic resonance imaging (mpMRI) is a standard imaging tool for patient selection for FT. In the presence of an mpMRI-suspicious lesion, histological confirmation is necessary prior to FT. In addition, systematic biopsy remains necessary to assess mpMRI-negative areas. However, adequate criteria for systematic biopsy remains indeterminate. FT can be recommended in D'Amico low-/intermediate-risk cancer including Gleason 4+3. Gleason 3+4 cancer, where localized, discrete and of favorable size represents the ideal case for FT. Tumor foci <1.5 ml on mpMRI or <20% of the prostate are suitable for FT, or up to 3 ml or 25% if localized to one hemi-gland. Gleason 3+3 at one core 1mm is acceptable in the untreated area. Preservation of sexual function is an important goal, but lack of erectile function should not exclude a patient from FT.

CONCLUSIONS

This consensus provides a contemporary insight into expert opinion of patient selection for FT of clinically localized prostate cancer.

Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project

PURPOSE

To reach standardized terminology in focal therapy (FT) for prostate cancer (PCa).

METHODS

A four-stage modified Delphi consensus project was undertaken among a panel of international experts in the field of FT for PCa. Data on terminology in FT was collected from the panel by three rounds of online questionnaires. During a face-to-face meeting on June 21, 2015, attended by 38 experts, all data from the online rounds were reviewed and recommendations for definitions were formulated.

RESULTS

Consensus was attained on 23 of 27 topics; Targeted FT was defined as a lesion-based treatment strategy, treating all identified significant cancer foci; FT was generically defined as an anatomy-based (zonal) treatment strategy. Treatment failure due to the ablative energy inadequately destroying treated tissue is defined as ablation failure. In targeting failure the energy is not adequately applied to the tumor spatially and selection failure occurs when a patient was wrongfully selected for FT. No definition of biochemical recurrence can be recommended based on the current data. Important definitions for outcome measures are potency (minimum IIEF-5 score of 21), incontinence (new need for pads or leakage) and deterioration in urinary function (increase in IPSS >5 points). No agreement on the best quality of life tool was established, but UCLA-EPIC and EORTC-QLQ-30 were most commonly supported by the experts. A complete overview of statements is presented in the text.

CONCLUSION

Focal therapy is an emerging field of PCa therapeutics. Standardization of definitions helps to create comparable research results and facilitate clear communication in clinical practice.

RETRACTED: The Virtual Cutting Edge: Adolescent Self-injury and YouTube

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief and Authors. We wish to retract the abstract "The Virtual Cutting Edge: Adolescent Self-injury and YouTube," published in the October 2015 issue of Annals. The abstract excessively borrowed from the text and methodology of a previous study published elsewhere.¹ All authors recognize the seriousness of this issue and apologize to the editors and readers of Annals. Jeffrey S. Jones, MD Chad Garthe, MD Lindsey Ouellette, MS Jason Seamon, DO Department of Emergency Medicine MSU College of Human Medicine Grand Rapids, MI 1. Lewis SP, Heath NL, St. Denis JM, et al. The scope of nonsuicidal self-injury on YouTube. Pediatrics. 2011;1127:e552-e557.

Assessment of risk factors for post-rewarming "rebound hyperthermia" in cardiac arrest patients undergoing therapeutic hypothermia

INTRODUCTION

The outcomes associated with therapeutic hypothermia (TH) after cardiac arrest, while overwhelmingly positive, may be associated with adverse events. The incidence of post-rewarming rebound hyperthermia (RH) has been relatively unstudied and may worsen survival and neurologic outcome. The purpose of this study was to determine the incidence and risk factors associated with RH as well as its relationship to mortality, neurologic morbidity, and hospital length of stay (LOS).

METHODS

A retrospective, observational study was performed of adult patients who underwent therapeutic hypothermia after an out-of-hospital cardiac arrest. Data describing 17 potential risk factors for RH were collected. The primary outcome was the incidence of RH while the secondary outcomes were mortality, discharge neurologic status, and LOS.

RESULTS

141 patients were included. All 17 risk factors for RH were analyzed and no potential risk factors were found to be significant at a univariate level. 40.4% of patients without RH experienced any cause of death during the initial hospitalization compared to 64.3% patients who experienced RH (OR: 2.66; 95% CI: 1.26-5.61; p=0.011). The presence of RH is not associated with an increase in LOS (10.67 days vs. 9.45 days; absolute risk increase=-1.21 days, 95% CI: -1.84 to 4.27; p=0.434). RH is associated with increased neurologic morbidity (p=0.011).

CONCLUSIONS

While no potential risk factors for RH were identified, RH is a marker for increased mortality and worsened neurologic morbidity in cardiac arrest patients who have underwent TH.

Pain distribution and predictors of widespread pain in the immediate aftermath of motor vehicle collision

BACKGROUND

Musculoskeletal pain is common after motor vehicle collision (MVC). The study objective was to evaluate distribution of pain and predictors of widespread musculoskeletal pain in the early aftermath (within 48 h) of collision.

METHODS

European American adults aged 18-65 years presenting to the emergency department (ED) after collision who were discharged to home after evaluation were eligible. Evaluation included an assessment of reported pre-collision psychological characteristics, crash characteristics, current pain severity and location, and current psychological symptoms. Adjusted risk ratios were estimated using generalized linear models.

RESULTS

Among 890 participants included in the study, 589/890 (66%) had pain in three or more regions, and 192/890 (22%) had widespread musculoskeletal pain (pain in seven or more regions). In adjusted analyses, the presence of widespread pain was strongly associated with depressive and somatic symptoms prior to collision, pain catastrophizing, and acute psychological symptoms, and was not associated with most collision characteristics (road speed limit, extent of vehicle damage, collision type, driver vs. passenger, airbag deployment). The reported number of body regions that struck an object during the collision was associated with both reported pre-collision depressive symptoms and with widespread pain.

CONCLUSION

More than one in five individuals presenting to the ED in the hours after MVC have widespread pain. Widespread pain is strongly associated with patient characteristics known to be modulated by supraspinal mechanisms, suggesting that stress-induced hyperalgesia may influence acute widespread pain after collision.

Molecular area effects in Cepaea

Enzyme polymorphisms in the land snail Cepaea nemoralis in the central Pyrenees show concordant geographic patterns of strong differentiation that are not correlated with the distributions of characters of shell color and banding or with the major pattern of variation in climate and vegetation type. Three regions of relative genetic uniformity separated by steep clines in allele frequencies are designated as "molecular area effects." A model of allopatric differentiation of populations in temporary geographic isolation during the last period of Pleistocene glaciation, followed by invasion of the Pyrenees and hybridization in secondary contact, is proposed to account for the present-day pattern of genetic differentiation. The genetic structure of the Pyrenean populations of C. nemoralis is not interpretable in terms of stasipatric or parapatric models of speciation.

Can residents perform transrectal ultrasound-guided prostate biopsy with patient comfort comparable to biopsy performed by attending staff urologists?

Transrectal ultrasound (TRUS)-guided prostate biopsy is a critical diagnostic tool in urology. Residents require adequate training but resident education could have a deleterious effect on patient comfort and morbidity. We compared pain associated with prostate biopsy when performed by staff versus resident urologists in order to determine the impact of resident training. Male patients scheduled to undergo prostate biopsy were assigned to either a staff urologist or a resident as the primary surgeon. All residents were directly assisted by the staff surgeon. The patients were given a visual analogue scale (VAS; 0-100 mm) and were asked to assess the pain associated with each component of prostate biopsy, including probe insertion, anesthetic injection and the biopsies themselves. The mean VAS scores for probe insertion, anesthetic injection and biopsies were 31.0, 30.4 and 30.1, respectively, for patients in the staff cohort and 37.1, 28.9 and 33.6, respectively, for those in the resident cohort. There was a statistically significant difference between staff and resident VAS scores, marked by a higher odds of greater pain with ultrasound probe placement (odds ratio (OR)=1.48, P=0.012) and the biopsies themselves (OR=1.52, P=0.01) in the resident cohort. TRUS biopsy can be performed by adequately trained and supervised resident urologists of all levels, but there is the potential for increased patient pain, particularly with ultrasonic probe insertion and obtaining core biopsies. However, the absolute magnitude of the differences in pain scores between residents and staff was small and may not be clinically meaningful. Such data indicate that urological resident training can be accomplished without compromising patient care and comfort.

Evaluation of the prostate-specific antigen/solvent interaction analysis (PSA/SIA) assay for prostate cancer (CaP) diagnosis

5053

Background: We describe the clinical performance of a novel protein structural assay for prostate cancer (CaP) diagnosis. The assay uses Solvent Interaction Analysis (SIA) to accurately detect changes in PSA isoform composition that differentiate benign and malignant disease, independent of total serum PSA (tPSA). Methods: From January 2007 to September 2008, men already undergoing biopsy for accepted clinical criteria at 3 sites [University Hospitals Case Medical Center (Cleveland); Cleveland Clinic (Cleveland); and Veterans Administration Hospital (Boston)] were enrolled in an IRB approved study. Prior to standard transrectal ultrasound (TRUS) guided biopsy, patients received a digital rectal examination with systematic prostate massage followed by collection of voided urine for use in PSA/SIA. The assay determined the relative distribution of the entire heterogeneous PSA isoform population between two coexisting aqueous phases for diagnostic purposes. Results: 222 men were enrolled in the trial. Biopsy results were classified as case (malignant, n = 100) or control (benign, n = 122). Receiver operating characteristic performance results demonstrated AUC of = 0.88 for PSA/SIA and 0.58 for tPSA. At a cut-off value of the composite structural index K = 1.73, PSA/SIA displayed sensitivity = 100%, specificity = 80%, PPV = 83%, and NPV = 100%. For the same patients at tPSA cut-off level of 4 ng/ml, the sensitivity = 82%, specificity = 27%, PPV = 54%, and NPV = 87%. Conclusions: PSA/SIA uniquely exploits the inherent structural heterogeneity in PSA resulting in superior diagnostic performance over conventional biopsy selection criteria. We hypothesize that the high specificity of PSA/SIA is actually underestimated by standard prostate biopsy sampling error. Future trials will assess the utility of the assay in the surveillance of CaP patients after definitive local therapy and other applications in the diagnosis and management of CaP.

[Table: see text]

Incidence of prostate cancer in male breast cancer patients: a risk factor for prostate cancer screening

Synchronous or metachronous occurrences of both prostate cancer and male breast cancer are rarely reported, but provide insight into their hormonal and genetic biology. We sought to determine the incidence of prostate cancer in male breast cancer patients at our institution, and to examine estrogen receptor (ER), progesterone receptor (PR) and HER-2/neu receptor (HR) status in these patients. A retrospective review was conducted of male breast cancer patients from 1990 to 2006. Histopathologic characteristics and hormone receptor expression was obtained. In 69 patients with male breast cancer, 12 (17%) also had a diagnosis of prostate cancer. Nine had ER-positive status and three were unreported. PR status was positive in 5, whereas 3 had PR-negative status. HR status was positive in 1, whereas 5 had HR-negative status. Male breast cancer patients in this cohort have an incidence of prostate cancer higher than would be predicted in the general population; this risk factor has implications for careful prostate cancer screening.

Parasagittal biopsies are more important as part of an initial biopsy strategy than as part of a repeat biopsy strategy: observations from a unique population

Comparing the yield of parasagittal biopsies during initial saturation biopsy to the yield during repeat saturation biopsy for detection of prostate cancer. Office-based saturation biopsy (24 cores) with periprostatic lidocaine block was performed in 139 consecutive men who had never previously undergone prostate biopsy. Indication for biopsy was elevated prostate-specific antigen >2.5 ng/dl. Biopsy specimens were obtained and marked by location for histological examination. Subanalysis of patients from this unique study was performed to compare the location of saturation biopsy cancer detection in these patients to a cohort of 100 patients who had previously undergone biopsy with nonmalignant findings. In the initial biopsy group, cancer was detected in 62/139 patients (44.6%). Breakdown of cancer location demonstrated unique parasagittal cancers in 9/62 patients (14.5%). Laterally base cancer was found exclusively in 22/62 patients (35.5%). For the repeat biopsy population, cancer was found in 25 patients (25%); no patients (0%) had exclusive parasagittal cancer. To our knowledge, this is the first study to demonstrate a difference in the location of positive cores between initial and repeat biopsy status. The exclusive parasagittal cancer detection rate decreases significantly in the repeat biopsy population when using the same biopsy method. Our findings support including traditional template parasagittal sampling of the prostate on first-time biopsy in addition to lateral cores typical of extended field biopsies for a total of 10-12 cores. However, parasagittal sampling adds negligible additional information in repeat biopsy; thus we recommend obtaining primarily laterally based cores for repeat biopsy.

Number of Repetitions to Maximum in Hop Tests in Patients with Anterior Cruciate Ligament Injury

The unilateral horizontal, triple cross-over and vertical hops are commonly used as outcome measures after knee injury but there is little knowledge of the number of repetitions needed to reach maximum performance. Seventy subjects who had either an anterior cruciate ligament deficient or reconstructed knee participated in this study. Unilateral vertical, horizontal, and triple cross-over hop testing was applied to each leg until two consecutive decrements in performance occurred. The number of repetitions to reach maximum during these tests were calculated. Fifteen repetitions of the horizontal and vertical hops, and 10 repetitions of the triple-crossover hop enable distances to be achieved that are acceptably close to maximal levels in these knee-injured patients. In order to increase the likelihood of finding a patient's maximum hop performance after knee injury, more repetitions are suggested than has been reported in the literature.

Frequency of nursing, physician and hospital interventions in women at risk for preterm delivery

OBJECTIVE

To determine the frequency of nursing intervention, physician treatment and hospital evaluation for women receiving outpatient management services for preterm labor.

METHODS

Outpatient services included: patient education; daily and as-needed nursing assessment of monitored uterine activity (MUA) and patient symptoms; treatment compliance; and physician notification for values exceeding established limits. We analyzed service data from women with singleton gestations at 20.0-34.9 weeks.

RESULTS

Overall, 307 249 days of data from 10 660 women were reviewed, and 634 983 hours of MUA was assessed. On 53 665 (17.5%) of monitored days, patients exhibited increased MUA and/or symptoms of preterm labor with nursing intervention and reassessment. Physician notification/intervention was required 7316 (13.6%) times, and hospital admission was needed for 3163 (43.2%) of these patients. In the hospital 1400 (44.3%) patients received tocolysis. The mean ( +/- standard deviation) length of hospital stay was 3.2 +/- 7.2 days, and 428 (13.5%) of women remained hospitalized until delivery, with 324 (10.2%) delivering within 48 h.

CONCLUSION

In this population of women receiving outpatient preterm-labor management services, 95.1% of excessive MUA or patient-reported symptoms of preterm labor were managed on an outpatient basis. Outpatient management allowed for appropriate identification and triage of women requiring hospital admission.

Bupivacaine provides rapid, effective periprostatic anaesthesia for transrectal prostate biopsy

OBJECTIVE

To examine the effectiveness of the longer acting agent bupivacaine in providing periprostatic anaesthesia during transrectal ultrasonography (TRUS)-guided biopsy, as the periprostatic injection of lidocaine has been shown to significantly alleviate the pain of this procedure.

PATIENTS AND METHODS

Seventy-five patients were randomized to receive a periprostatic injection with either bupivacaine, a lidocaine/bupivacaine (1/1) combination, or no local anaesthesia. Immediately before biopsy 5 mL of the anaesthetic was injected under TRUS guidance into the periprostatic nerves bilaterally. After taking a 10-core biopsy the patients were given a visual analogue scale (VAS; 0-10) to assess their pain during the procedure.

RESULTS

The mean VAS scores were 2.04 in the bupivacaine group and 4.46 in the control (no local anaesthetic) group (P < 0.001).

CONCLUSIONS

Bupivicaine provides significant, immediate periprostatic anaesthesia for TRUS biopsy.

Periprostatic local anesthesia eliminates pain of office-based transrectal prostate biopsy

Up to 96% of patient who undergo prostate biopsy report pain. We performed periprostatic local anesthesia injection in an effort to improve patient acceptance of prostate biopsy. Sixty patients were randomized to receive either local injection of lidocaine in the periprostatic nerves or no anesthetic. Lidocaine was injected through a 7-inch spinal needle placed through a transrectal ultrasound biopsy guide. Ten-core biopsies were immediately performed. Following biopsy, all patients gave a Visual Analog Scale (VAS) assessment of their pain experienced during biopsy.A majority of patients reported Visual Analog Scale (VAS) scores in the moderate (28.6%) or severe (28.6%) ranges unless local anesthesia was given. Only one of 27 patients (3.7%) receiving local anesthetic reported moderate pain, and none reported severe pain. Mean VAS pain scores were 1.4 in the anesthetic group and 4.5 in the control group (P<0.0001). No difficulty was encountered from scarring in the five patients who underwent nerve spring radical retropubic prostatectomy following local anesthetic injection. Periprostatic injection of local anesthetic essentially eliminates pain from prostate biopsy. Nerve-sparing radical retropubic prostatectomy is not more difficult as a result.

The pleura in health and disease

The normal structure and function of the pleura are discussed here in addition to how physiological abnormalities and various pathological processes can upset the finely balanced situation between the visceral and parietal pleural surfaces, leading to effusion formation, and/or adhesions. The various inflammatory and reactive processes that affect the pleura, together with primary and secondary tumor formations are described. Particular emphasis is placed on those conditions of the pleura that are associated with asbestos exposure because this group of diseases will increase over the next few decades due to the large number of workers who have been exposed to asbestos. They will therefore be of increasing importance to the clinician, radiologist, and pathologist in future years.

Insulin-like growth factor I measurement on filter paper blood spots

The measurement of insulin-like growth factor I (IGF-I) from extracted whole dried blood spots on filter paper is a simple method allowing sample collection to be carried out by the patient at home. One drop of blood is applied to a filter card, air dried and posted to the laboratory. The IGF-I is dissociated from its binding protein by an acidification and neutralization procedure, and IGF-I is then measured by an enzyme-linked immunosorbent assay. Results from the analysis of IGF-I using blood spots on filter paper compared favourably with those from conventional methods, thus showing it to be an ideal and cost-effective technique for the measurement of IGF-I in both adults and children.

Control of bias in randomized controlled trials published in prosthodontic journals

STATEMENT OF PROBLEM

Randomized controlled trials (RCTs) have become the gold standard for evaluating the effectiveness of treatment interventions. If not properly controlled, bias in the design of trial methodology can affect the validity of the study results.

PURPOSE

The purpose of this investigation was to assess the methodological quality of RCTs published in 3 prosthodontic journals over a 10-year period.

MATERIAL AND METHODS

Issues of The International Journal of Prosthodontics, The Journal of Prosthetic Dentistry, and The Journal of Prosthodontics published between 1988 and 1997 were searched manually to identify RCTs. Specific inclusion and exclusion criteria were established to identify articles about studies that qualified as RCTs. Two independent reviewers evaluated all qualified RCTs on the basis of how potential sources of bias in the trial methodology were controlled. Three areas-control of bias at entry, control of bias in assessment of outcome, and control of bias after entry-were evaluated with a scheme developed through the Cochrane Collaboration. A score of 1 or 0 was assigned for each of the 3 potential sources of bias, with the maximum quality score for an RCT being 3 (good bias control) and the minimum 0 (poor control). Frequencies were calculated for each dimension of trial methodology and overall quality scores of the RCTs.

RESULTS

Sixty-two RCTs were identified from 3631 articles screened. The method of randomization was explicit in only 47% of the RCTs. Forty percent of RCTs incorporated blinding in the assessment of outcome, and 76% accounted for all subjects at the end of the study. Overall quality scores revealed that only 16% of RCTs attempted to control bias in all 3 areas examined. Forty percent were deficient in 1 area, 34% were deficient in 2 areas, and 10% were deficient in all areas examined.

CONCLUSION

The quality of RCTs published in prosthodontic journals may be improved by minimizing potential sources of bias and adequately reporting trial methodology.

Immunization recall: effectiveness and barriers to success in an urban teaching clinic

OBJECTIVE

To examine effectiveness of immunization recall in an urban pediatric teaching clinic and to identify barriers to recall effectiveness.

DESIGN

Randomized, controlled trial. Children aged 5 to 17 months who were not up to date (UTD) with recommended immunizations were identified and assigned to intervention (n = 294) or control groups (n = 309). The intervention consisted of a mailed postcard and up to 4 telephone calls. Two months after intervention, UTD status, visit, and probable missed opportunity rates were assessed.

RESULTS

Of the intervention group, 30% could not be reached. In 12-month-old children in the intervention group compared with those in the control group, there was a trend toward higher UTD rates (51% vs 39%, P =.07) and a higher proportion of UTD children receiving immunizations as opposed to getting more complete documentation (25% vs 10%, P =.005). Similar differences between intervention and control children were not seen in the 7-month and 19-month age categories. More children in the intervention group had a health maintenance visit (17% vs 11%, P =.03). Of children in the intervention group who were seen when not UTD, 17 of 24 (71%) of those seen for an illness visit and 5 of 24 (21%) of those seen for health maintenance probably had missed opportunities to be immunized.

CONCLUSIONS

Recall efforts were partially successful but were undermined by inability to reach the clinic population, poor documentation of immunizations, and missed opportunities.

Treatment of hepatitis C virus and HIV coinfection: the road less traveled

The use of HAART for HIV infection has significantly reduced morbidity and mortality secondary to AIDS-related opportunistic infections. In hepatitis C virus (HCV)-HIV-coinfected patients, progression to AIDS, cirrhosis, and liver failure from HCV infection has become an important issue. Liver disease caused by chronic HCV infection has become the second leading cause of death in some HIV-infected populations. HIV infection is not a contraindication to HCV infection therapy. Several clinical studies have borne out that HCV infection can be safely and successfully treated in HIV-HCV-coinfected patients. These patients should be evaluated and offered anti-HCV treatment as clinically indicated.

Role of iron in estrogen-induced cancer

Redox cycling of catecholestrogen metabolites between quinone and catechol forms is a mechanism of generating potentially mutagenic oxygen radicals in estrogen-induced carcinogenesis. Consistent with this concept, multiple forms of oxygen radical-generated DNA damage are induced by estrogen in cell-free systems, in cells in culture and in rodents prone to estrogen-induced cancer. Metal ions, specifically iron, are necessary for the production of hydroxy radicals. Iron has not received much attention in discussions of estrogen-induced carcinogenesis and human hormone-associated cancer, and is the focus of this review. An elevated dietary iron intake enhances the incidence of carcinogen-induced mammary cancer in rats and estrogen-induced kidney tumors in Syrian hamsters. Estrogen administration increases iron accumulation in hamsters and facilitates iron uptake by cells in culture. In humans, elevated body iron storage has been shown to increase the risk of several cancers including breast cancer. A role of iron in hormone-associated cancer in humans offers attractive routes for cancer prevention by regulating metal ion metabolism and interfering with iron accumulation in tissues.

Effect of thimerosal recommendations on hospitals' neonatal hepatitis B vaccination policies

We describe neonatal hepatitis B virus (HBV) vaccine policies in Colorado before and after thimerosal recommendations, plans for use of thimerosal-free HBV vaccine, and nurses' awareness of high-risk criteria for HBV vaccination. The results suggest that fewer neonates are receiving HBV vaccine at birth hospitals.

Barriers to enrollment in a state child health insurance program

OBJECTIVE

To identify barriers to enrollment into Colorado's Child Health Insurance Plan (CHP+) for non-Hispanic (NH), Hispanic (H), and uninsured families.

DESIGN

Telephone survey of 1) random samples of families who requested an application but did not complete it (N = 273 NH, N = 159 H) and 2) families with uninsured children identified by random-digit-dial statewide surveys (N = 165).

RESULTS

Major reasons for not enrolling included 1) got other insurance (NH 16.5%; H 27.2% P <.01), 2) thought household income was too high to qualify (NH 21.0%; H 11.9% P =.01), and 3) paperwork (NH 13.4%; H 14.7%, P = NS). Of those who thought their income was too high (N = 76, 17.6%), 58.5% appeared eligible based on reported income. Of uninsured families, only 41.7% had heard of CHP+. Of those who had never applied, major remediable reasons included not knowing enough about the program (20.9%) and thinking household income was too high (9.3%).

CONCLUSIONS

Effective marketing and education to increase awareness of CHP+ and ensure understanding of eligibility are critical to the success of the program.

Transcatheter coil closure of a right pulmonary artery to left atrial fistula in an ill neonate

Although rare, a congenital direct fistula connection between the proximal right pulmonary artery and the left atrium can present as cyanosis in the newborn. We report the first case in which catheter-based coil closure of such a fistula in a neonate resulted in rapid clinical improvement, obviating the need for surgical repair.

An unusual case of impalement injury to the urinary bladder

Isolated impalement injury to the urinary bladder is a rare occurrence. We present a case in which the delay in the diagnosis reveals the potential pitfalls in the management of such injuries.

Antenatal dexamethasone and the growth hormone-insulin-like growth factor axis

Dexamethasone administration has marked effects on the growth hormone-insulin-like growth factor axis (GH-IGF) in animal and human studies. During pregnancy in the rat, it is associated with fetal growth restriction due to inhibition of IGF bioactivity. In the human only repeated dosages have been associated with fetal growth restriction. The aim of this study is to test the hypothesis that antenatal dexamethasone administration to pregnant women is associated with reduced activity of the GH-IGF axis. To achieve this blood samples were taken from 12 pregnant women pre- and at 24 h and 48 h after dexamethasone administration. In these samples GH, IGF-I, IGF bioactivity and IGF binding protein (IGFBP)-3 protease activity were measured. In view of the interaction between insulin and the GH-IGF axis, glucose and insulin concentrations were also measured. There were no significant differences between the concentrations of GH, IGF-I, IGF bioactivity and IGFBP-3 protease activity before and after dexamethasone. The concentrations of glucose and insulin were significantly higher at 24 h, but not 48 h post-dexamethasone. It is concluded that a single antenatal course of dexamethasone does not alter the GH-IGF-I axis in pregnant women at the time points studied.

Assessment of MEDLINE search strategies for randomized controlled trials in prosthodontics

PURPOSE

The purpose of this study was to evaluate the sensitivity, specificity, and precision of MEDLINE search strategies for detecting randomized controlled trials (RCTs) in prosthodontics.

MATERIALS AND METHODS

A list of RCTs was obtained by hand-searching the International Journal of Prosthodontics, Journal of Prosthetic Dentistry, and Journal of Prosthodontics published between 1988 and 1997. RCTs identified served as the "gold standard" with which different MEDLINE search strategies were compared. Subject headings, keywords, MEDLINE checktags, publication types, and combinations thereof were used, and their results were compared with the "gold standard".

RESULTS

Sensitivity ranged from 9% to 67%, specificity was at least 96% for all searches, and precision ranged from 22% to 59%. The most productive searches were by publication type clinical trial and publication type randomized controlled trial. Combining search terms did not improve sensitivity for detecting RCTs published in prosthodontic journals (p > .10).

CONCLUSION

These findings support the need for more detailed reporting of trial methodologies to facilitate accurate indexing of prosthodontic articles in MEDLINE.

Dysregulation of the insulin/IGF binding protein-1 axis in transgenic mice is associated with hyperinsulinemia and glucose intolerance

The insulin/IGF binding protein-1 (IGFBP-1) axis is important in coordinating insulin- and IGF-mediated regulation of glucose metabolism and glycemia. Dysregulation of the axis may play a role in the pathophysiology of disorders of insulin deficiency and resistance. We have investigated this hypothesis by generating transgenic mice that overexpress hIGFBP-1. To study the axis in its true physiological context, we used a human (h) IGFBP-1 cosmid clone so that transgene expression is responsive to normal hormonal stimuli. hIGFBP-1 mRNA is expressed in a tissue-specific fashion, and measurement of serum protein levels by specific immunoassay indicates normal physiological regulation in response to fasting/feeding and appropriate post-translational modification as indicated by the detection of phosphorylated and nonphosphorylated isoforms of the protein. The hypoglycemic response to exogenous IGF-I is attenuated in transgenic mice. Transgenic mice exhibit an enhanced insulin secretory response to a glucose challenge, although basal and stimulated blood glucose levels are similar to controls. There is a sexual dimorphism in phenotypic expression: male transgenic mice had higher stimulated glucose and insulin levels than did females. Transgenic mice exhibit fasting hyperglycemia and hyperinsulinemia and glucose intolerance in later life, indicating an age-related decline in glucocompetence. These findings demonstrate the importance of the normal inverse relationship between serum insulin and IGFBP-1 levels in glucoregulation and that sustained dysregulation of the insulin/IGF-I/IGFBP-1 axis is associated with impaired glucose tolerance and abnormalities of insulin action.

Use of recombinatory PCR to insert subtle genetic markers into Moloney murine leukemia virus-based retroviral vectors

As tools to examine template switches and recombination events during the process of reverse transcription, two nearly identical Moloney murine leukemia virus-based (MoMLV) retroviral vectors were constructed using the technique of recombinatory polymerase chain reaction (PCR). The experimental vectors designed for this study were based on the well-characterized LN series vectors. The protein coding regions normally present in the retroviral genome have been replaced by the coding regions for two drug resistance markers, neomycin phosphotransferase (Neo) and hygromycin phosphotransferase (Hyg). With only one functional drug resistance gene in each vector, the individual vectors as well as recombination events between them can be followed by phenotypic selection. Utilization of recombinatory PCR allowed the insertion of very subtle nucleotide changes resulting in a series of restriction site polymorphisms in the two retroviral vectors. The ability to create these subtle mutations in specific locations of these retroviral vectors allowed the utilization of naturally occurring areas of variability in the vectors and avoid regions important for replication.

Paternal hamsters mechanically assist the delivery, consume amniotic fluid and placenta, remove fetal membranes, and provide parental care during the birth process

We report the first description of a male mammal behaviorally participating in the birth of his young. Djungarian hamsters, Phodopus campbelli, are naturally biparental and males contribute to pup survival and growth through direct paternal care and indirect effects on maternal physiology. Males of the closely related Siberian hamster, P. sungorus, have only seasonal opportunities to interact with pups and neither contribute to pup survival and growth nor provide extensive paternal care under laboratory conditions. Male P. campbelli undergo a series of hormonal changes prior to the birth of their first litter which are not shared with P. sungorus males and may "prime" males to express paternal behavior. We hypothesized that P. campbelli males would behave paternally on first contact with pups during the birth process, whereas P. sungorus males would not. In addition to showing paternal behavior toward neonates, male P. campbelli licked amniotic fluid before the birth, mechanically assisted the delivery, opened an airway by clearing the nostrils (so that pups flushed red with oxygenation), licked and sniffed pups in the moments and minutes after birth to clean the pups of membranes, and ate the placenta. None of these behaviors were observed in P. sungorus. We anticipate that P. campbelli will not be the only species with highly developed paternal behavioral repertoires during the birth.

Nasogastric feeding enhances nutritional status in paediatric liver disease but does not alter circulating levels of IGF-I and IGF binding proteins

OBJECTIVE

Complications of childhood cirrhosis include abnormal growth and malnutrition, associated with abnormalities in circulating IGFs and IGFBPs. Controlled studies suggest that intensive enteral feeding enhances nutritional status. The aim was to ascertain whether nasogastric feeding improves nutritional status in clinical practice and to assess the effect of feeding on serum IGF-I and IGFBPs.

PATIENTS

Thirty-three children (median age 0.6 years) with biliary atresia and failure to thrive who were treated with nasogastric feeding.

MEASUREMENTS

Height, weight and triceps skin fold thickness were measured prior to feeding and regularly for 1 year or until feeding was stopped. Serum IGF-I and IGFBPs were measured by immunoassay at the same intervals.

RESULTS

The median duration of feeding was 3.7 months. Twenty-two stopped feeding after liver transplantation, while 10 stopped electively and 1 boy died. Before feeding, the children were losing weight and height centile. Triceps skin fold thickness, weight and height SD scores improved with feeding. Baseline serum IGF-I and IGFBP-3 were low, while IGFBP-1 and IGFBP-2 were raised. IGF-I and IGFBP-1 did not change with feeding. IGFBP-2 fell and reached a nadir by 3 months, while IGFBP-3 rose temporarily for 4-6 weeks.

CONCLUSIONS

Nasogastric feeding improves body composition in paediatric liver disease but circulating IGF-I and IGFBPs remain abnormal and do not play a major role in mediating these changes. This does not exclude a paracrine or autocrine effect of IGF-I.

Developing a register for randomized controlled trials in prosthodontics: results of a search from prosthodontic journals published in the United States

STATEMENT OF PROBLEM

Treatment decisions are often made despite absence of evidence from well-conducted clinical trials. Conclusions about treatment efficacy derived from nonexperimental approaches often overestimate treatment effect. Randomized controlled trials (RCTs) provide the most reliable basis for evaluating effectiveness of treatment interventions.

PURPOSE

This study attempted to identify and catalog RCTs in prosthodontic journals published in the United States as an initial step in creating a register of clinical trials that would be a resource in setting up systemic overviews of prosthodontic literature.

METHODS

The International Journal of Prosthodontics, The Journal of Prosthetic Dentistry, and The Journal of Prosthodontics published between 1988 and 1997 were searched manually to identify clinical trials. Clinical trials had to meet the following criteria for inclusion in the register: the trial must involve human subjects, must include at least 2 treatment groups, and treatment group allocation must be randomized.

RESULTS

A total of 3,631 articles in 196 journal issues were screened. Sixty-two articles (1.7%) met the minimum criteria for inclusion in the RCT register.

CONCLUSION

Given the lack of randomized controlled trials in prosthodontic journals, a concerted effort by the organized prosthodontic community should be made to screen national and international journals and contribute to the development of a register of randomized controlled trials relevant to prosthodontics.