Surgical sensation during caesarean section: a qualitative analysis

BACKGROUND

Caesarean section (CS) is a major abdominal surgery performed usually on a young and healthy population under neuraxial anesthesia with little to no sedation. This creates a distinct surgical experience whereby patients are aware of the surgical process, physical sensations, and their environment. This study aimed to provide an in-depth descriptive assessment of subjective surgical experience during CS under regional anaesthesia. We expected the information gained would enhance our current understanding and better alleviate patient anxiety through informed counselling.

METHODS

This qualitative descriptive study was conducted at a Canadian academic centre. Twenty patients participated in semi-structured interviews within a week of CS, using an interview guide developed for this study. Patient medical records were reviewed to collect demographic and surgical information. Thematic analysis was conducted using an inductive approach to determine common themes.

RESULTS

Nine themes were identified. Five themes were identified in the category of surgical sensation and four themes were identified in the category of peri-operative education.

CONCLUSIONS

Patients commonly experienced pressure and movement sensations at varying intensity, and most did not experience pain. Environmental factors, including sounds and distraction by the newborn, affected perception of surgical sensation. Patients wish to receive pre-operative counselling regarding potential surgical sensations, as well as ongoing communication from their anaesthesiologist. These results can be used to guide informed discussions with patients and direct further investigation in this area.

Active video games and weight management in overweight children and adolescents-systematic review and meta-analysis

BACKGROUND

The prevalence of childhood obesity has been increasing for several decades. Active video games (AVG) may be an effective intervention to help manage this rising health crisis. The aim of this review is to evaluate whether AVG are effective at reducing weight or improving body composition in overweight youths.

METHOD

Medline, Embase, SportDiscus, ASSIA, CINAHL Plus, CENTRAL, CDSR and PsychINFO databases were searched for studies assessing quantitative or qualitative impact of AVG in overweight adolescents published in English. Three authors screened the results using inclusion/exclusion criteria.

RESULTS

A total of 12 studies met the inclusion criteria; 11 reported a significant decrease in at least one weight outcome. Results from seven randomized controlled trials were pooled by meta-analysis, which compared with controls subjects in AVG groups demonstrated greater body mass index (BMI) Z-score reduction (mean difference: -0.09 (-0.12, -0.05) I2 = 34%, P < 0.0001). The mean weight reduction (-2.66 Kg (-5.67, +0.35) I2 = 0%, P = 0.08) and BMI (-2.29 (-4.81, +0.22) I2 = 49%, P = 0.07) were greater in AVG groups but results did not reach statistical significance.

CONCLUSIONS

BMI Z-score was significantly reduced in the AVG group and the majority of included studies reported significant results in at least one weight outcome, suggesting AVG can be used to reduce weight or improve body composition in overweight youths. Further studies investigating the long-term sustainability of this change in body composition are needed.

Examining the association between socio-demographic factors, catheter use and antibiotic prescribing in Northern Ireland primary care: a cross-sectional multilevel analysis

Inappropriate use of antibiotics is among the key drivers of antimicrobial resistance (AMR). Antibiotic use in Northern Ireland (NI) is the highest in the UK and approximately 80% is prescribed in primary care. Little information however exists about the patient and prescriber factors driving this. We described the trend in NI primary care total antibiotic prescribing 2010–2019 and conducted a cross-sectional study using a random sample of individuals registered with an NI GP on 1st January 2019. We used multilevel logistic regression to examine how sociodemographic factors and urinary catheter use was associated with the likelihood of being prescribed an antibiotic during 2019, adjusting for clustering at GP practice and GP federation levels. Finite mixture modelling (FMM) was conducted to determine the association between the aforementioned risk factors and quantity of antibiotic prescribed (defined daily doses). The association between age and antibiotic prescription differed by gender. Compared to males 41–50 years, adjusted odds of prescription were higher for males aged 0–10, 11–20 and 51 + years, and females of any age. Catheter use was strongly associated with antibiotic prescription (aOR = 6.82, 95% CI 2.50–18.64). Socioeconomic deprivation and urban/rural settlement were not associated in the multilevel logistic analysis. GP practices and federations accounted for 1.24% and 0.12% of the variation in antibiotic prescribing respectively. FMM showed associations between larger quantities of antibiotics and being older, male and having a catheter. This work described the profile of individuals most likely to receive an antibiotic prescription in NI primary care and identified GP practice as a source of variation; suggesting an opportunity for reduction from effective interventions targeted at both individuals and general practices.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

The epidemiology and management of candidemia in Northern Ireland during 2002-2011, including a 12-month enhanced case review

In Northern Ireland there are concerns about candidaemia, with rates higher than those reported in England and Wales. Our aim was to explore the epidemiology of candidaemia during a 10 year period and the clinical management upon suspicion of cases during a one year enhanced investigation in Northern Ireland.Candidaemia reports to the Public Health Agency were validated during 2002-2011 and used to examine incidence and antifungal sensitivity trends (during 2007-2011). A clinical proforma was used to collate information for all patients with candidaemia in 2011.The majority (96%) of isolates were captured through voluntary laboratory reporting. There was a year-on-year increase in candidaemia from 2002-2011, from 80 to 131 episodes (incidence rate ratio 1.09 95% CI 1.05-1.13). Rates were highest in males under 1 year and over 75 years. 83/98 (85%) of case notes were available from candidaemia patients during 2011. The most prevalent risk factors were patients on total parenteral nutrition (26 people, 31.3%), surgery in the two months prior to the candidaemia (25 people, 30.1%), significant steroid use in the previous 3 months (24 people, 28.9%) and active neoplastic disease (23 people, 27.7%),This study confirmed an increase in candidaemia rates over time, with the observed incidence in 2011 higher than England and Wales. We identified areas for improvement around the clinical management of candidaemia. We recommend raising the awareness of guidelines for fundoscopy, echocardiography and central venous catheter removal.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Health status in Europe: comparison of 24 urban areas to the corresponding 10 countries (EURO-URHIS 2)

Background

: In Europe, over 70% of the population live in urban areas (UAs). Most international comparative health research is done using national level data, as reliable and comparable urban data are often unavailable or difficult to access. This study aims to investigate whether population health is different in UAs compared with their corresponding countries. : Routinely available health-related data were collected by the EURO-URHIS 2 project, for 10 European countries and for 24 UAs within those countries. National and UA level data for 11 health indicators were compared through the calculation of relative difference, and geographical patterns within Europe were investigated using the Mann Whitney U test. Linear regression modelling was used to adjust for population density, gross domestic product and urbanicity. : In general, the urban population in Eastern Europe is less healthy than the Western European urban population. However, people in Eastern Europe have significantly better broad health outcomes in UAs as compared with the corresponding country as a whole, whereas people in Western Europe have generally worse broader health outcomes in UAs. : For most European countries and UAs that were investigated, the national level health status data does not correspond with the health status at UA level. In order to identify health problems in UAs and to provide information for local health policy, health monitoring and international benchmarking should also be conducted at the local level.

Outbreak of invasive pneumococcal disease at a Belfast shipyard in men exposed to welding fumes, Northern Ireland, April-May 2015: preliminary report

We report an outbreak of four confirmed cases of invasive pneumococcal disease (IPD) in individuals occupationally exposed to welding fumes, at a Belfast shipyard (Northern Ireland). All cases were hospitalised. A high-risk sub-group of 679 workers has been targeted for antibiotic prophylaxis and pneumococcal vaccination. Physicians and public health institutions outside Northern Ireland should be alert to individuals presenting with pneumonia or IPD and recent links to the shipyard, to facilitate early assessment and treatment.

Morbidity and mortality associated with Clostridium difficile ribotype 078: a case-case study

The morbidity and mortality associated with Clostridium difficile ribotype 078 were examined by comparison with other known outbreak strains. A healthcare interaction within eight weeks of a positive specimen significantly increased the likelihood of ribotype 078 compared with ribotype 027. Individuals with ribotype 078 also tended to come from community sources, have a hospital stay post specimen similar to ribotype 027 and a lower 30-day mortality, but these differences were not statistically significant. This study generates several hypotheses and a methodological platform to explore this unique profile.

The development and performance of a rapid-access neurovascular (TIA) assessment clinic in a rural hospital setting

INTRODUCTION

Following the withdrawal of acute medical services from rural Angus, a rapid-access Neurovascular (TIA) Clinic was established at Stracathro Hospital in December 2003. Referral protocols were agreed with Angus Primary Care. We measured the performance of this clinic over its first two years against national standards outlined by Quality Improvement Scotland (2005).

METHODS

In a retrospective study between 1st December 2003 and 30th November 2005, patient demographics, waiting times, investigation results, diagnoses, and secondary prevention issues were analysed. Challenges presented by a rural setting were also examined,

RESULTS

By November 2005, from a total of 355 patients, 79% were seen within 7 days and 98% within 14 days of clinic referral. Pre-clinic bloods were increasingly done in general practice. All patients had CT head and carotid NIVA scans performed on the day of clinic attendance. A high positive diagnostic yield from CT scanning was obtained in the first year of the clinic, and a significant proportion of patients had new secondary drug prevention treatment recommended. Organisational and transport difficulties were addressed and overcome.

DISCUSSION

Developing a rapid-access neurovascular clinic in a rural setting is achievable, and waiting times approaching national standard targets are possible. A TIA clinic can identify rapidly those with cerebrovascular disease, allowing commencement of appropriate secondary prevention therapy.

Pre-training to improve workshop performance in supervisor skills: an exploratory study of Latino agricultural workers

Employees with limited education may be excluded from advanced training due to assumptions that they might not learn rapidly. However, preparatory training may be able to overcome missing experience in education. The purpose of this study was to test the hypothesis that computer-based training (CBT) in supervisor skills of Latino agricultural workers would improve subsequent performance in a workshop designed to teach supervisor skills. Ten men born and educated in Mexico participated in the study; all spoke Spanish, the language of the training. Five participants (mean 6.4 years of education) completed supervisor skills CBT, and five participants (mean 8.2 years of education) completed hazard communication (HazCom) CBT as a control condition. Following the CBT, all participants completed a two-day face-to-face workshop on supervisory skills conducted by an experienced behavior management consultant. Although the groups did not differ in their knowledge scores on a multiple-choice test before the face-to-face workshop, after the workshop the HazCom group had a mean test score of 51.2% (SD = 8.7) while the supervisor group had a higher mean test score of 65.2% (SD = 14.3). The difference was marginally significant by a t-test (p = 0.052), and the effect size was large (d = 1.16). The results suggest that computer-based training in supervisor skills can be effective in preparing participants with limited education to learn supervisor skills from a face-to-face workshop. This result suggests that limited educational attainment is not a barrier to learning the complex knowledge required to supervise employees, that pre-training may improve learning in a workshop format, and that training may be presented effectively in a computer-based format to employees with limited education.

An audit of the use of isolation facilities in a UK National Health Service trust

To aid the ongoing battle against hospital-acquired infection in the UK, all acute National Health Service (NHS) trusts should have audit data about how dedicated isolation beds within the trust are being used. In a previously published audit, we demonstrated that one-third of patients admitted to a dedicated isolation room in Tayside were not thought to be an infection risk by experienced healthcare staff. Since this audit, Tayside's isolation facilities have moved from a small peripheral 'fever' hospital to a large central teaching hospital site. At the time of this move, and using the above audit data, we designed and implemented a guideline for general practitioners and hospital doctors regarding the admission of patients to an isolation bed. The aim of this study was to compare the use of isolation beds before and after the move to the new facilities, which we anticipated would increase the demand for isolation. The results show that by all three criteria used, the utilization of isolation beds has deteriorated following the move, mainly due to the increased admission of general medical 'boarders' and low-risk infection patients. At a time when hospital-acquired infections are increasing, NHS trusts should ensure that dedicated isolation beds are used appropriately.

Series of laryngomalacia, tracheomalacia, and bronchomalacia disorders and their associations with other conditions in children

Laryngomalacia, bronchomalacia, and tracheomalacia are commonly seen in pediatric respiratory medicine, yet their patterns and associations with other conditions are not well-understood. We prospectively video-recorded bronchoscopic data and clinical information from referred patients over a 10-year period and defined aspects of interrelationships and associations. Two hundred and ninety-nine cases of malacia disorders (34%) were observed in 885 bronchoscopic procedures. Cough, wheeze, stridor, and radiological changes were the most common symptoms and signs. The lesions were most often found in males (2:1) and on the left side (1.6:1). Concomitant malacia lesions ranged from 24% for laryngotracheobronchomalacia to 47% for tracheobronchomalacia. The lesions were found in association with other disorders such as congenital heart disorders (13.7%), tracheo-esophageal fistula (9.6%), and various syndromes (8%). Even though the understanding of these disorders is in its infancy, pediatricians should maintain a level of awareness for malacia lesions and consider the possibility of multiple lesions being present, even when one symptom predominates or occurs alone.

Preclinical antitumor activity and pharmacodynamic studies with the farnesyl protein transferase inhibitor R115777 in human breast cancer

Antitumor and pharmacodynamic studies were performed in MCF-7 human breast cancer cells and companion xenografts with the farnesyl protein transferase inhibitor, R115777, presently undergoing Phase II clinical trials, including in breast cancer. R115777 inhibited growth of MCF-7 cells in vitro with an IC(50) of 0.31 +/- 0.25 microM. Exposure of MCF-7 cells to increasing concentrations of R115777 for 24 h resulted in the inhibition of protein farnesylation, as indicated by the appearance of prelamin A at concentrations >1 microM. After continuous exposure to 2 microM R115777, prelamin A levels peaked at 2 h post drug exposure and remained high for up to 72 h. R115777 administered p.o. twice daily for 10 consecutive days to mice bearing established s.c. MCF-7 xenografts induced tumor inhibition at a dose of 25 mg/kg [percentage of treated versus control (% T/C) = 63% at day 21]. Greater inhibition was observed at doses of 50 mg/kg (% T/C at day 21 = 38%) or 100 mg/kg (% T/C at day 21 = 43%). The antitumor effect appeared to be mainly cytostatic with little evidence of tumor shrinkage to less than the starting volume. Tumor response correlated with an increase in the appearance of prelamin A, but no changes in the prenylation of lamin B, heat shock protein 40, or N-Ras were detectable. In addition, significant increases in apoptotic index and p21(WAF1/CIP1) expression were observed, concomitant with a decrease in proliferation as measured by Ki-67 staining. An increase in prelamin A was also observed in peripheral blood lymphocytes in a breast cancer patient who responded to R115777. These data show that R115777 possesses preclinical antitumor activity against human breast cancer and that the appearance of prelamin A may provide a sensitive and convenient pharmacodynamic marker of inhibition of prenylation and/or response.

The addition of fentanyl does not alter the extent of spread of intrathecal isobaric bupivacaine in clinical practice

PURPOSE

Fentanyl is commonly added to intrathecal local anesthetic solutions. In vitro data has shown fentanyl to render isobaric local anesthetics hypobaric, and alter the spread in artificial cerebrospinal fluid. This study examined whether the addition of fentanyl to isobaric bupivacaine with morphine leads to a clinically important alteration in the extent of spread of anesthesia.

METHODS

Forty-four ASA I-III patients undergoing lower limb orthopedic procedures completed this double-blind, placebo-controlled trial. Patients were randomized into one of two groups, receiving intrathecal bupivacaine 15 mg and preservative-free morphine 200 microg without (Control group), or with the addition of fentanyl 0.02 mg (Fentanyl group). Patients were maintained at a slight head-up tilt. Variables studied over three hours included sensory level to cold and pinprick, motor blockade (Bromage scale), and circulatory data.

RESULTS

No differences existed between the Fentanyl and Control groups with respect to highest level of block for cold: T4 (T2-T5) vs T3.5 (T3-T8) respectively (median, 95% confidence interval) or pinprick: T4 (T3-T6) vs T4.5 (T3-T8). Similarly, there was no difference in the time taken to reach maximum block height to cold (20 +/- 9 vs 23 +/- 13 min, mean +/- SD) or pinprick (20 +/- 9 vs 24 +/- 13 min).

CONCLUSION

The addition of fentanyl 0.02 mg to 0.5% bupivacaine with morphine does not affect the maximal block height or time to maximal block in clinical practice.

Ozone predictions in Atlanta, Georgia: analysis of the 1999 ozone season

Ozone prediction has become an important activity in many U.S. ozone nonattainment areas. In this study, we describe the ozone prediction program in the Atlanta metropolitan area and analyze the performance of this program during the 1999 ozone-forecasting season. From May to September, a team of 10 air quality regulators, meteorologists, and atmospheric scientists made a daily prediction of the next-day maximum 8-hr average ozone concentration. The daily forecast was made aided by two linear regression models, a 3-dimensional air quality model, and the no-skill ozone persistence model. The team's performance is compared with the numerical models using several numerical indicators. Our analysis indicated that (1) the team correctly predicted next-day peak ozone concentrations 84% of the time, (2) the two linear regression models had a better performance than a 3-dimensional air quality model, (3) persistence was a strong predictor of ozone concentrations with a performance of 78%, and (4) about half of the team's wrong predictions could be prevented with improved meteorological predictions.

Absorption of alkalized intravesical lidocaine in normal and inflamed bladders: a simple method for improving bladder anesthesia

PURPOSE

Pharmacokinetic studies have shown that intravesical lidocaine is not sufficiently absorbed by human bladders to achieve significant serum levels and it only provides a superficial local anesthetic effect. We investigated the pharmacokinetics of alkalized intravesical lidocaine in healthy volunteers and patients with interstitial cystitis to determine a safe dose of buffered lidocaine, the effect of interstitial cystitis on lidocaine uptake and the acute local anesthetic effect on bladder pain in interstitial cystitis.

MATERIALS AND METHODS

An initial dose finding study was done in 12 healthy volunteers using 4, 5 and 6 mg./kg. 5% lidocaine buffered with 8.4% sodium bicarbonate. Serial lidocaine levels were measured for 3 hours. Serum measurement was repeated in 12 patients with interstitial cystitis using 5 mg/kg. 5% lidocaine with sodium bicarbonate daily for 2 days. Patients rated pain before and during treatment.

RESULTS

Healthy volunteers and patients with interstitial cystitis had similar lidocaine absorption profiles with a peak of 1.06 microg/ml. (range 0.66 to 1.71) and 1.3 (range 0.2 to 2.0) at about 30 minutes. Mean pain score in the interstitial cystitis group decreased from a baseline of 6.0 to 1.8 on day 1 and 0.6 on day 2. There were complaints of urethral discomfort after voiding the buffered lidocaine in each group.

CONCLUSIONS

Alkalization provides safe and predictable lidocaine absorption into the bladder, as indicated by therapeutic systemic levels in healthy and inflamed bladders. Furthermore, the decrease in acute pain scores in the interstitial cystitis group indicated a concentration of local anesthetic within the bladder wall that was sufficient to block the sensory neurons within the submucosal plexus.

Linezolid for the treatment of community-acquired pneumonia in hospitalized children. Linezolid Pediatric Pneumonia Study Group

OBJECTIVE

To determine the safety, tolerance, pharmacokinetics and efficacy of linezolid, a new oxazolidinone antibiotic in the treatment of community-acquired pneumonia in hospitalized children.

DESIGN

A Phase II, open label multicenter study of intravenous linezolid followed by oral linezolid suspension, both at a dose of 10 mg/kg every 12 h. Efficacy was assessed at 7 to 14 days after the last dose of linezolid.

PATIENTS

Children 12 months to 17 years old with community-acquired pneumonia admitted to the hospital of 14 participating centers.

RESULTS

From July 21, 1998, through May 14, 1999, 79 children were enrolled and 78 received linezolid. Sixty-six children completed treatment and follow-up and were evaluable for clinical outcome. The median age of the evaluable patients was 3 years (range, 1 to 12 years); 47 were 2 to 6 years old. Pathogens were isolated from blood or pleural fluid cultures in 8 children: Streptococcus pneumoniae, 6 (2 penicillin-resistant); Group A Streptococcus, 1; methicillin-resistant Staphylococcus aureus, 1. Chest tubes were placed in 9 patients. The mean total duration of intravenous and oral administration was 12.2 +/- 6.2 days (range, 6 to 41 days). The mean peak and trough plasma concentrations of linezolid were 9.5 +/- 4.8 and 0.8 +/- 1.2 microg/ml, respectively. At the follow-up visit 7 to 14 days after the last dose of linezolid, 61 patients (92.4%) were considered cured including all the patients with proven pneumococcal pneumonia, one failed (methicillin-resistant Staphylococcus aureus) and 4 were considered indeterminate. The most common adverse effects in the intent to treat group were diarrhea (10.3%), neutropenia (6.4%) and elevation in alanine aminotransferase (6.4%).

CONCLUSIONS

Linezolid was well-tolerated and could be considered an alternative to vancomycin for treating serious infections caused by antibiotic-resistant Gram-positive cocci in children pending results of additional studies.

Serum titanium level for diagnosis of a failed, metal-backed patellar component

A case is presented in which an elevated serum titanium level was used to make the diagnosis of a failed metal-backed patellar component. The preoperative serum titanium level was 536.8 ppb, which was 98 times higher than the patient's previous level (taken 1 year earlier, when he was asymptomatic) and 2 orders of magnitude higher than the expected level with a well-functioning implant of this type. Revision surgery confirmed that the polyethylene portion of the patellar component had worn through, leaving the titanium portion of the patellar implant to articulate with the femoral component. Wear-through was not evident on preoperative radiographs or clinical examination. As knowledge about the expected ranges for serum metal ion levels after total joint arthroplasty continues to increase, the diagnostic utility of serum metal ion testing in the evaluation of joint arthroplasty function will continue to improve.

Infantile hypertrophic pyloric stenosis after pertussis prophylaxis with erythromcyin: a case review and cohort study

BACKGROUND

In February, 1999, a local US health department identified a cluster of pertussis cases among neonates born at a community hospital and recommended oral erythromycin for post-exposure prophylaxis for about 200 neonates born at that hospital between Feb 1 and Feb 24, 1999. We investigated a cluster of seven cases of infantile hypertrophic pyloric stenosis (IHPS) that occurred the following month among the neonates who had received erythromycin.

METHODS

We obtained a masked, independent review of the IHPS ultrasonography diagnoses, calculated the monthly IHPS incidence, and compared index and historical (1998-99) IHPS cases with respect to several characteristics including erythromycin exposure. We used a retrospective cohort of infants born in January and February, 1999, to investigate further erythromycin exposure and development of IHPS.

FINDINGS

An independent review confirmed the ultrasonographic diagnoses of all seven index IHPS cases. All index cases versus none of the historical IHPS cases had been given erythromycin for pertussis prophylaxis. The IHPS rate for infants born in the hospital in February, 1999, was 32.3 per 1000 liveborn infants, representing nearly a seven-fold increase over 1997-98 (relative risk 6.8 [95% CI 3.0-15.7]). Among infants born in January and February, 1999, erythromycin was associated with IHPS (absolute risk 4.5%, relative risk infinity [1.7-infinity]).

INTERPRETATION

Neonates receiving oral erythromycin may have an increased risk of IHPS. The risks and benefits of erythromycin for neonatal pertussis prophylaxis should be re-evaluated, and caution should be used in defining risk groups for prophylaxis.

Molecular analysis of the klarsicht gene and its role in nuclear migration within differentiating cells of the Drosophila eye

BACKGROUND

The temporally regulated, cell-type-specific transport of organelles has great biological significance, yet little is known about the regulation of organelle transport during development. The Drosophila gene klarsicht is required for temporally regulated lipid droplet transport in developing embryos and for the stereotypical nuclear migrations in differentiating cells of the developing eye. Klarsicht is thought to coordinate the function of several molecular motors bound to a single lipid droplet or to facilitate the attachment of dynein to the cargo, but it is not known whether Klarsicht affects motors directly or indirectly.

RESULTS

Here, we have cloned the klarsicht gene and shown that it encodes a unique large protein. Drosophila klarsicht null mutants were viable, with obvious defects only in adult eye morphology. Epitope-tagged Klarsicht expressed in the eye from a transgene was perinuclear. In flies carrying transgenes that express markers for microtubule plus and minus ends, microtubules in differentiating cells of the eye were oriented with their plus ends apical and their minus ends at the nucleus.

CONCLUSIONS

Drosophila klarsicht null mutants were viable and fertile, demonstrating that klarsicht is essential only for specific motor protein functions. Perinuclear localization of Klarsicht protein indicates that Klarsicht has a direct mechanical role in nuclear migration. Taken together with the finding that the minus ends of the microtubules are associated with the photoreceptor nuclei, the observation that Klarsicht is largely perinuclear supports the idea that Klarsicht associates with dynein, consistent with a model in which Klarsicht assists dynein in 'reeling in' the nucleus.

Carriage of multidrug-resistant Streptococcus pneumoniae and impact of chemoprophylaxis during an outbreak of meningitis at a day care center

Three cases of meningitis due to multidrug-resistant serotype 14 Streptococcus pneumoniae occurred at a day care center (DCC) over 5 days. Cultures of nasopharyngeal samples were done at the index DCC, 2 comparison DCCs, and a pediatrics practice. Isolates were serotyped and subtyped by pulsed-field gel electrophoresis (PFGE) with SmaI. Pneumococcal carriage rates ranged from 44%-65% at the 3 DCCs and 29% in the pediatrics practice. Carriage of multidrug-resistant serotype 14 S. pneumoniae was noted in 13%-19% of children at the 3 DCCs. An outbreak strain was identified by PFGE at the index DCC and 1 other DCC; a closely related strain was found in the third DCC. Carriage of the outbreak strain was associated with being age 0-24 months, antibiotic use, upper respiratory tract infections, and otitis media. DCC contacts of the ill children were offered chemoprophylaxis with rifampin and clindamycin, which produced a profound but transient decrease in carriage. No additional cases occurred.

Efficacy of finasteride is maintained in patients with benign prostatic hyperplasia treated for 5 years. The North American Finasteride Study Group

OBJECTIVES

The purpose of this open-label study extension was to assess the long-term safety and efficacy of finasteride in the treatment of men with benign prostatic hyperplasia (BPH).

METHODS

A Phase III North American BPH trial originally enrolled 895 men, 297 of whom were randomized to receive finasteride 5 mg. An enlarged prostate gland by digital rectal examination, symptoms of urinary obstruction, and a maximal urinary flow rate of less than 15 mL/s were required for entry. Patients who completed the initial 12-month, double-blind, placebo-controlled study were invited to participate in an open-label extension for 4 additional years.

RESULTS

Of the 297 patients initially randomized to receive finasteride 5 mg, 259 completed 12 months in the double-blind period and 186 completed 48 months of open-label therapy. Prostate volume reached a nadir of -24.6% at month 24, and the effect was maintained through month 60. Compared with baseline values, month 60 prostate volume was decreased by 22.7% (P<0.001), the quasi-American Urological Association symptom score was decreased by 4.3 points, and maximal urinary flow was increased by 2.3 mL/s (P<0.001) on average. Finasteride was well tolerated, with no significant increase in the prevalence of sexual adverse events over time.

CONCLUSIONS

Patients treated with finasteride 5 mg maintained an initial decrease in prostate volume and improvement in symptom score and maximal urinary flow rate over 5 years.

Metal release and excretion from cementless titanium alloy total knee replacements

Concentrations of titanium, aluminum, and vanadium were measured in the serum and urine of patients with titanium alloy cementless primary total knee arthroplasty components. Patients were categorized in one of five groups. In Group 1, the patellar and tibial articulating surfaces were made of carbon fiber reinforced ultrahigh molecular weight polyethylene. In Group 2, the patellar and tibial surfaces were made of ultrahigh molecular weight polyethylene. In Group 3, the femoral titanium alloy articulating surface was nitrogen ion implanted with ultrahigh molecular weight polyethylene patellar and tibial articulating surfaces. Patients in Group 4 had failed patellar components, and Group 5 was comprised of age and gender matched control subjects without implants. Serum concentrations of titanium were approximately 50 times greater in patients with failed patellar components (Group 4) and approximately 10 times greater in patients with carbon fiber reinforced polyethylene bearing surfaces (Group 1) when compared with Groups 2 and 3 and the control subjects (Group 5). For aluminum and vanadium, no detectable differences were observed among any of the groups. In addition, analysis of 24-hour urine samples showed no significant differences in titanium, aluminum, or vanadium concentrations among any of the groups. Elevated serum titanium levels may serve as a marker of patellar component failure or accelerated femoral component wear in total knee replacements with titanium alloy bearings. The toxicologic ramifications of these findings are unknown.

Treatment with finasteride preserves usefulness of prostate-specific antigen in the detection of prostate cancer: results of a randomized, double-blind, placebo-controlled clinical trial. PLESS Study Group. Proscar Long-term Efficacy and Safety Study

OBJECTIVES

To evaluate prostate cancer detection and prostate-specific antigen (PSA) among men with benign prostatic hyperplasia treated with finasteride.

METHODS

Three thousand forty men 45 to 78 years of age with PSA less than 10 ng/mL and no history of prostate cancer were randomized in a double-blind, placebo-controlled trial to finasteride (n = 1524) or placebo (n = 1516) for up to 4 years. A prerandomization biopsy negative for prostate cancer was obtained in 98% of patients with a screening PSA of 4.0 ng/mL or more, and an end-of-study biopsy was requested of all such patients without a recent second negative biopsy or a prostate cancer diagnosis.

RESULTS

Overall, 644 patients (21%) underwent biopsy and 201 (6.6%) underwent transurethral resection of the prostate. Prostate cancer was diagnosed in 4.7% of men on finasteride and 5.1% on placebo (P = 0.7). Elevated PSA prompted diagnosis in 35% of cases on finasteride and 34% on placebo. The area under the receiver operating characteristic curve for last PSA was 0.84 on finasteride and 0.79 on placebo (P = 0.07). Use of an upper limit of normal for last PSA of 2.0 ng/mL for finasteride and 4.0 ng/mL for placebo yielded similar sensitivity (66% versus 70%, P = 0.6), higher specificity (82% versus 74%, P < 0.0001), and a higher likelihood ratio (3.6 versus 2.7, P < 0.05) for finasteride than for placebo.

CONCLUSIONS

In men treated with finasteride, multiplying PSA by 2 and using normal ranges for untreated men preserves the usefulness of PSA for prostate cancer detection.

Electrostimulation: addiction treatment for the coming millennium

At a period of fundamental review of the health care system, it is timely to re-assess one of medicine's most intractable problems--the treatment of addictions. The apparently insoluble dilemmas posed by the acute and chronic withdrawal syndromes underlie universally high drop-out and relapse rates. In a decade of HIV and AIDS infection, poly-substance addiction, potent street drugs, and ossified treatment strategies, it is urgent that policy formulators investigate seriously a flexible system of non-pharmacological transcranial electrostimulation treatment, based on its record of rapid, safe, and cost-effective detoxification in several countries, as one innovative contribution to the challenges presented by addiction in the 1990s. This is a brief report of the introduction of NeuroElectric Therapy (NET) into Germany, describing the responses of the first 22 cases. The daily progress of a heroin addict and a methadone addict are detailed: both were treated as outpatients for 8 hours daily, for 7 and 10 days respectively.

The relationship between mitochondrial state, ATP hydrolysis, [Mg2+]i and [Ca2+]i studied in isolated rat cardiomyocytes

1. As ATP has a higher affinity for Mg2+ than ADP, the cytosolic magnesium concentration rises upon ATP hydrolysis. We have therefore used the Mg(2+)-sensitive fluorescent indicator Magnesium Green (MgG) to provide an index of changing ATP concentration in single rat cardiomyocytes in response to altered mitochondrial state. 2. In response to FCCP, [Mg2+]i rose towards a plateau coincident with the progression to rigor, which signals ATP depletion. Contamination of the MgG signal by changes in intracellular free Ca2+ concentration (the KD of MgG for Ca2+ is 4.7 microM) was excluded by simultaneous measurement of [Ca2+]i and [Mg2+]i in cells dual loaded with fura-2 and MgG. The response to FCCP was independent of external Mg2+, confirming an intracellular source for the rise in [Mg2+]i. 3. Simultaneous measurements of mitochondrial NAD(P)H autofluorescence and mitochondrial potential (delta psi m; .-1 fluorescence) and of autofluorescence and MgG allowed closer study of the relationship between [Mg2+]i and mitochondrial state. Oligomycin abolished the FCCP-induced rise in [Mg2+]i without altering the change in autofluorescence. Thus, the rise in [Mg2+]i in response to FCCP is consistent with the release of intracellular Mg2+ following ATP hydrolysis by the mitochondrial F1F0-ATPase. 4. The rise in [Mg2+]i was correlated with cell-attached recordings of ATP-sensitive K+ channel (KATP) activity. In response to FCCP, an increase in KATP channel activity was seen only as [Mg2+]i reached a plateau. In response to blockade of mitochondrial respiration and glycolysis with cyanide (CN-) and 2-deoxyglucose (DOG), [Mg2+]i rose more slowly but again KATP channel opening increased only when [Mg2+]i reached a plateau and the cells shortened. 5. Oligomycin decreased the rate of rise of [Mg2+]i delayed the onset of rigor and increased the rate of mitochondrial depolarization in response to CN-_DOG. Thus, with blockade of mitochondrial respiration delta psi m is maintained by the mitochondrial F1F0-ATPase at the expense of ATP reserves. 6. In response to CN-_DOG, the initial rise in [Mg2+]i was accompanied by a small rise in [Ca2+]i. After [Mg2+]i reached a plateau and rigor developed, [Ca2+]i rose progressively. On reperfusion, in hypercontracted cells, [Ca2+]i recovered before [Mg2+]i and [ca2+]i oscillations were sustained while [Mg2+]i decreased. Thus on reperfusion, full recovery of [ATP]i is slow, but the activation of contractile elements and the restoration of [Ca2+]i does not require the re-establishment of millimolar concentrations of ATP.

Internal carotid artery gunshot wounds

OBJECTIVE

To review a series of patients who sustained internal carotid artery (ICA) gunshot wounds.

DESIGN, MATERIALS, AND METHODS

We retrospectively studied the demographics and clinical presentation, angiographic findings, methods of treatment, and outcome of 38 consecutive patients who had ICA injury identified by angiography.

RESULTS

Thirty-four of 38 patients were symptomatic with neck hematomas (32 patients), active hemorrhage (12 patients), and/or neurologic deficit (10 patients). Angiography showed active bleeding in 22 patients and occlusion in 16 patients. Twelve patients were treated operatively by ligation (seven patients), repair (four patients), or intracranial/extracranial bypass (one patient). Twenty-six patients were managed nonoperatively either by angioplasty (one patient), embolotherapy (17 patients), or observation alone (eight patients). Percutaneous balloon catheters were also used in three patients for vascular control of the ICA before operative repair or as a method of assessing intracranial collateral circulation. The mortality of 18.4% was largely related to strokes.

CONCLUSIONS

Penetration of the ICA is a very severe injury with a high mortality. The major cause of death in this series was related to neurologic damage associated with carotid injury and shock. However, neurologic deficit among the survivors was uncommon and often resulted from emboli. Interventional radiology can play an important role in the management of these wounds and often obviates the need for operative exploration.