Need For Medical Intervention Research Articles

Induction Of In Vivo Oligoclonal T Cell Expansion and Specific In Vitro T Cell Responses Following K562/GM-CSF Vaccination Of MDS Patients

BackgroundMyelodysplatic syndromes (MDS) are a heterogeneous group of clonal hematopoietic stem cell malignancies, characterized by the ineffective hematopoiesis, and risk of progression to acute myeloid leukemia. Allogeneic stem cell transplant (SCT) remains the only potentially curative therapy, but toxicities limit its application in older adults. Vaccination strategies have been developed to modulate the immune system, ideally with less toxicity. We present results from a pilot study of single agent K562/GM-CSF whole cell vaccination in MDS patients (pts). MethodsPoor-risk or transfusion-dependent MDS pts (n=5) were enrolled and received K562/GM-CSF whole cell vaccine (1 X 108 cells) every 3 weeks for 4 cycles followed by a booster vaccination 8 weeks later. Eligible pts could receive supportive care only for the 2 months preceding study entry, have no history of SCT, and not be on immunosuppressants. Blood, bone marrow, and skin biopsies were taken prior to vaccination, day 4 following first vaccine, and at 4 weeks after the booster vaccination. Diversity of the T cell compartment was assessed in the blood, marrow and skin using the TCRExpress Quantitative Analysis Kit (Biomed Immunotech, Tampa FL). Fragment length analysis was performed by the DNA Analysis Facility. In vitro stimulation studies for proliferation and cytokine production were performed using peripheral blood monocytes (PBMCs) for the pt with the best clinical response (>4 years). Proliferation of banked PBMCs, collected prior to every vaccination and stimulated with the vaccine, was assessed using 3H-Thymidine. The cytokines generated were measured using a multiplexed bead based immunoassay (Human 17-plex bioplex pro-panel) (Biorad, Hercules CA). ResultsAll pts tolerated the vaccinations well with localized skin reactions being common. Clinically, 2 pts normalized their blood counts and became transfusion independent following the immunotherapy. One responding pt (CMML) remained stable without need for medical intervention for 4 yrs and only recently showed progression. T cell spectratyping indicated oligocolonal populations of T cells in post-vaccination skin, blood and marrow samples. T cells infiltrating the skin were tracked to the marrow. Interestingly, the best clinical responder demonstrated the most restricted skewed repertoire with a significant number of oligoclonal T cells tracking from skin to marrow (n=5). The marrow also had infiltrates of oligoclonal T cells not detected in the post-vaccination skin. Further, this skewed repertoire was absent when the pt relapsed. Proliferation assays measuring this pt's T cell cytokine production in response to the vaccine cells in vitro, showed increased levels of IL-2, IL-13 and IL-5 that were suppressed or not produced by the time of the 4th vaccination. Inversely, IL-6, IL-10, IL-17, IL-1beta, MIP-1beta and TNF alpha levels increased throughout. The expected proliferative “boost” was seen with the initiation of the booster vaccine series at the time of progression, and co-culture of the pt's lymphocytes with the vaccine cells suppressed the ability of the vaccine cells to produce GM-CSF in vitro. The ability to suppress GM-CSF production decreased during therapy and the pt's lymphocytes had no effect on GM-CSF production by the vaccine at the end of the immunotherapy. ConclusionsAll pts showed T cell skewing by spectratyping analysis, suggesting that each had a change in T cell proliferation patterns in response to the vaccine. One pt had a significant clinical response and the most specific T cell response by spectratyping to the original vaccine, followed by the absence of these cells in the marrow at the time of progression. This suggests that an immune response may have stabilized his disease and progression was associated with loss of this T cell population. Proliferation studies suggest that the lymphocytes recognized the vaccine. Lastly, GM-CSF levels produced by the vaccine were decreased during the vaccination cycles suggesting that the pt's lymphocytes and/or tumor had a suppressive effect on the vaccine cells. It is unclear if the GM-CSF suppression was essential, detrimental, or unrelated to the pt's clinical response. Further study of the T cells patterns in these pts may elucidate details of the immune response that are integral to clinical responses. Disclosures:No relevant conflicts of interest to declare.

Recurrent miscarriage

Recurrent miscarriage is defined as three or more consecutive pregnancy losses prior to the 24th week of gestation. The condition affects 1% of couples attempting to conceive and in the majority of cases no cause is identified. It can be an anxious and worrying time for those involved, and our role as GPs is made up of reassurance, support and tertiary referral where necessary. Fortunately, many couples proceed to having a successful pregnancy without the need for medical intervention. This article aims to discuss the aetiology, investigation and subsequent evidence-based management of recurrent pregnancy loss.

Criteria for fairly allocating scarce health-care resources to genetic tests: which matter most?

The use of genetic tests is expanding rapidly. Given limited health-care budgets throughout Europe and few national coverage decisions specifically for genetic tests, decisions about allocating scarce resources to genetic tests are frequently ad hoc and left to lower-level decision makers. This study assesses substantive ethical and economic criteria to prioritize genetic services in a reasonable and fair manner. Principles for allocating health-care resources can be classified into four categories: need-based allocation; maximizing total benefits; treating people equally; and promoting and rewarding social usefulness. In the face of scarcity, the degree of an individual's need for medical intervention is an important criterion. Also, different economic concepts of efficiency are of relevance in the theory and practice of prioritizing genetic tests. Equity concerns are most likely to be relevant in terms of avoiding undesirable inequities, which may also set boundaries to the use of efficiency as a prioritization criterion. The aim of promoting and rewarding social usefulness is unlikely to be relevant to the question of what priority a genetic test should have in clinical practice. Further work is needed to select an appropriate set of criteria; operationalize them; and assign weights before some kind of standardized priority information can be added to information sources for genetic services. Besides the substantive criteria, formal considerations like those pointed out in the framework of accountability for reasonableness need to be considered in decision making.

Transcutaneous carbon dioxide levels and oxygen saturation following caesarean section performed under spinal anaesthesia with intrathecal opioids

BackgroundIntrathecal opioids can be associated with respiratory depression which may have serious consequences. We describe the use of a non-invasive monitor (TOSCA) to measure transcutaneous carbon dioxide levels and percentage of haemoglobin oxygen saturation in post-caesarean section patients in two hospitals which used different intrathecal opioids. MethodsEighty-nine women undergoing caesarean section were monitored postoperatively until 08.00h on the first postoperative day. In addition to hyperbaric bupivacaine, patients from Hospital 1 received intrathecal diamorphine 300μg: those from Hospital 2 received intrathecal fentanyl 15μg and postoperative intramuscular morphine 10mg and were given morphine patient-controlled analgesia. Data from TOSCA were analysed the following day. Respiratory depression was defined as oxygen saturations <90% or transcutaneous carbon dioxide levels >7kPa for >2min or the need for medical intervention for clinical respiratory depression. ResultsSustained hypercapnia was recorded in 8/45 (17.8%) patients from Hospital 1 and 3/44 (6.8%) from Hospital 2. Sustained oxygen saturations <90% were recorded in one patient from Hospital 2 and none from Hospital 1. The overall incidence of respiratory depression was 17.8% in Hospital 1 and 9.1% in Hospital 2. The median duration of hypercapnia was 9min [IQR 5.8–12.4] in Hospital 1 and 11.5min [IQR 7–32.8] in Hospital 2. No patient required medical intervention. ConclusionsThe incidence of opioid-induced respiratory depression detected by TOSCA is higher than previously reported by other monitoring methods. TOSCA may have a role in detecting subclinical respiratory depression in the obstetric population. Further studies with a control population are needed.

A Review of Comparison of Complications of Vaginal Hysterectomy with and without Concomitant Surgery for SUI: A 5 Years’ Experience at a Tertiary Care Hospital of Pakistan

Objective. The study was performed to review the complications of surgery for POP with or without surgery for SUI. This included the need for second procedure two years after the primary surgery. Study Design. We conducted a retrospective cross-sectional comparative study at the Aga Khan University, Karachi, Pakistan. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) was used to identify women who underwent vaginal hysterectomy with anterior/posterior repair alone and those with concomitant tension-free vaginal tape surgery for urodynamic stress incontinence. Results. The 28 cases of VH/repair combined with TVT were compared for complications with 430 cases of VH with repair alone. The basic characteristics like age, BMI, and degree of prolapse showed no statistical difference among two groups. The main comorbidities in both groups were hypertension, diabetes, and bronchial asthma. We observed no significant differences in intraoperative and postoperative complications except for cuff abscess, need for medical intervention, and readmission following discharge from hospital, which were higher in cases with vaginal hysterectomy with concomitant TVT. Conclusions. Vaginal hysterectomy is an efficient treatment for uterovaginal prolapse with a swift recovery, short length of hospital stay, and rare serious complications. The addition of surgery for USI does not appear to increase the morbidity.

Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice

A study analyzing closed professional liability claims against nurse practitioners over a 5-year period was completed by CNA and Nurses Service Organization (NSO). Of 200 closed claims, the average total incurred payment per claim was $285 645. The study identifies current liability patterns and trends and provides risk-control recommendations to enhance patient safety and minimize liability exposure. Study results indicate that while the number of nurse practitioner claims have been relatively stable over the past 5 years (2007-2011), the number of claims resulting in very severe indemnity payment have increased 19% since 2009. The data also show that many claims develop from a failure involving core competencies, such as treatment and care management, and medication prescribing. Allegations related to failure to diagnose and delay in making a correct diagnosis were found most frequently. The claims demonstrate that nurse practitioners are responsible for obtaining and documenting the results of appropriate tests, consultations, and overall need for medical intervention to meet the patient's medical needs.

A comparison study of two lower urinary tract symptoms screening tools in clinical practice: The B-SAQ and OAB-V8 questionnaires

Lower urinary tract symptoms (LUTS) have a detrimental effect on quality-of-life (QoL). However, sufferers are often reluctant to seek help. Screening for LUTS will identify patients with bothersome symptoms who may benefit from treatment and allow patients to self-assess their symptoms and the need for medical intervention, potentially saving costly medical time and reducing long-term morbidity. The aim of this study was to compare the value of two validated questionnaires: the Bladder Control Self Assessment Questionnaire (B-SAQ) and the Overactive Bladder Awareness Tool (OAB-V8) as screening questionnaires in clinical practice. A total of 223 women were recruited prospectively from three centres. Participants completed both questionnaires in the waiting area prior to assessment by a clinician, who completed a symptom evaluation sheet. Data were analysed using receiver operating characteristic curves. Both the B-SAQ and the OAB-V8 performed well in detecting symptoms of OAB and mixed urinary symptoms. The B-SAQ performed better in detecting symptoms of stress incontinence than the OAB-V8. The opportunity to screen for haematuria should never be missed and this is an important omission from the OAB-V8.

The Quality Metric Prolonged Length of Stay Misses Clinically Important Adverse Events

The National Quality Forum endorses prolonged length of stay of more than 14 days (PLOS) as a quality metric for lobectomy for lung cancer. Because PLOS rates are lower than complication rates, we hypothesized that PLOS misses a significant proportion of clinically important events. A retrospective study was performed on patients undergoing lobectomy (2000 to 2009). The severity of adverse events was based on the National Cancer Institute common terminology criteria for adverse events (grade 2 or higher indicates symptoms or need for medical intervention; grade 5 indicates death). Among 2,667 patients, 163 (6%) experienced PLOS and 773 (29%) experienced an adverse event. Although the frequency of adverse events was higher among the PLOS group (99% [161 of 163] versus 24% [612 of 2504]), 79% (612 of 773) of adverse events occurred in the non-PLOS group. Whereas PLOS was associated with more severe events, 89% of those in the non-PLOS group experienced a grade 2 or higher event. Likewise, although PLOS was associated with the lowest 5-year survival rate (31%), patients in the non-PLOS group who had an adverse event had significantly lower survival rates than patients in the non-PLOS group who did not have any adverse events (55% versus 68%, p<0.001; adjusted hazard ratio 1.3 [95% confidence interval: 1.1 to 1.6]). The PLOS missed a high proportion of adverse events defined by the need for ongoing inpatient therapy and an association with poor long-term survival. These findings have implications for efficient and fair performance assessment in the setting of a quality improvement program.

Perioperative Lung Protective Strategies

Perioperative Lung Protective Strategies

Maternal social capital and birth outcomes in the mother–child cohort in Crete, Greece (Rhea study)

This cohort study aimed to estimate the effect of individual maternal social capital during pregnancy on birth outcomes in the context of the Mother–child cohort (Rhea study), in Crete – Greece. Women were recruited from four prenatal clinics in Heraklion – Crete for one year beginning in February 2007. 610 women completed the self-administered Social Capital Questionnaire at about the 24th week of gestation. The scale assessed total maternal social capital and four social capital subscales: Participation in the Community, Feelings of Safety, Value of Life and Social Agency, and Tolerance of Diversity. Potential confounders included characteristics that have an established or potential association with the maternal social capital, and the birth outcomes (preterm birth, small weight for the gestational age, fetal weight growth restriction, weight, length and head circumference). The results of logistic and linear regression models indicated that there was an increase in the risk of preterm birth for every unit increase in maternal participation (range 12–48), and especially in the risk of medically indicated preterm birth. Although the findings suggest that participation is associated with an increased probability for preterm birth, we cannot know whether this is a protective or damaging social capital effect. Women who participate more in their communities may have enhanced access to information and/or resources, easier access to health care and support when they face maternal and fetal conditions that trigger the need for medical intervention. On the other hand, women may be more exposed to social and/or environmental stressors. Future research needs to distinguish between different types of participation and different components of social capital to better understand their associations with birth outcomes.

Normal Interstitial Flow is Critical for Developmental Lymphangiogenesis in the Zebrafish

The lymphatic system plays a critical role in the body's fluid and protein homeostasis, immune regulation, and dietary fat absorption. One of the major pathologies of the lymphatic system is primary lymphedema, which occurs in approximately 0.6% of live births and is caused by missing or impaired lymphatic vessels. Although there is a great need for medical intervention into diseases of the lymphatic system, very little is known about its development or how it maintains integrity over time. Recent studies have suggested that biophysical components, such as local extracellular fluid flow, may be important factors during initiation of lymphangiogenesis. We hypothesize that interstitial fluid flow functions as an important morphoregulator during developmental lymphangiogenesis. In the present study we use pharmacological agents and a mutant fish line to modulate interstitial flow. Our data confirm that a sufficient increase or decrease in interstitial flow can profoundly affect lymphatic patterning and may result in a lymphedema-like phenotype. Proper interstitial flow appears to be necessary during LEC migration for proper lymphatic development. These results support the contention that interstitial flow is an important morphoregulator of developmental lymphangiogenesis.

Air Travel Can Be Safe and Well Tolerated in Patients with Clinically Stable Pulmonary Hypertension

Our aim was to determine what proportion of patients with pulmonary hypertension (PH) has undertaken air travel contrary to the general medical advice and to characterize these patients according to disease severity and medical treatment. In cooperation with Pulmonale Hypertonie e.V., the German patient organization, a questionnaire was distributed. In total, 430 of 720 questionnaires were returned completed. Of the 179 patients who travelled at least once by air, the distribution of New York Heart Association functional classes I/ II/ III/ IV was 2/ 77/ 74/ 8, respectively; 83 patients were receiving monotherapy; 58 patients were receiving a combination of two or more therapies; 57 patients were on long-term ambulatory oxygen treatment; and 29 patients used supplemental oxygen while travelling. Overall, 20 adverse events were reported, mostly of mild to moderate severity (i.e., peripheral edema, dyspnea), with need of medical intervention in only 7 cases. The 251 patients who did not travel by air were, on average, in more advanced stages of disease and/or clinically unstable. In conclusion, a majority of patients (159 out of 179) did not experience any complications during or directly after the flight even though no special precautions were taken. Thus we conclude that for patients with PH in a stable clinical condition, air travel can be safe and well tolerated.

Evaluation of the Severity and Pattern of Epistaxis In Children with a Mucocutaneous Bleeding Disorder and In Healthy Children Using a Standardized Questionnaire

AbstractAbstract 713Epistaxis is a common symptom in children with mucocutaneous bleeding disorders such as von Willebrand disease (VWD) or a platelet function disorder (PFD), but also occurs in healthy children. Determining the features of epistaxis that suggest underlying hemostatic defects would help distinguish which children with epistaxis should undergo laboratory testing to screen for an inherited bleeding disorder. This is particularly significant in young children who may not yet have been exposed to a hemostatic challenge. However, there is no standardized approach to determine which children presenting with epistaxis should undergo testing. The aim of this study was to describe the severity and pattern of epistaxis in children with VWD or a PFD vs. healthy children using the PBQ, a standardized, validated Pediatric Bleeding Questionnaire (Bowman et al, J Thromb Haemost 2009:7;1418). PBQ epistaxis scores were assigned depending on clinical severity of the most severe episode (0: no epistaxis or trivial, ≤5/yr; 1: >5/yr or >10 min duration; 2: consultation with a healthcare professional; 3: packing, cauterization or antifibrinolytics; 4: blood transfusion, replacement therapy or desmopressin); scores of ≥2 were considered clinically significant. Epistaxis scores and features (frequency, duration, onset (spontaneous or not), site (uni- or bilateral), presence of seasonal correlation, whether cessation required medical intervention) were retrospectively reviewed in 107 questionnaires administered to patients/parents of patients with a known diagnosis of VWD (type 1, n=60 [definite, with abnormal laboratory results at least twice + a significant bleeding history, n=37; possible, with abnormal laboratory results at least once ± a significant bleeding history, n=23]; type 2, n=8; type 3, n=16) or a PFD (Glanzmann thrombasthenia, dense granule disorder, MYH9-related disorder, Noonan syndrome, Ehlers-Danlos syndrome, unspecified; n=23) and in 163 questionnaires administered to healthy children (Bowman et al, J Thromb Haemost 2009:7;1418; Biss et al, J Thromb Haemost 2010:8;950; Biss et al, J Thromb Haemost 2010:8;1416). Epistaxis was present in 66/107 patients (62%) (definite type 1 VWD: 62%; possible type 1 VWD: 48%; type 2 VWD: 38%; type 3 VWD: 75%; PFD: 74%) with a median age of 12 yrs (range: 0.6–18.3 yrs), and in 56/163 healthy children (34%), with a median age of 11.5 yrs (range: 1.5–17.0 yrs). 59% of the 66 patients with epistaxis were males, as were 50% of the 56 controls with epistaxis. The mean PBQ epistaxis score in these 66 patients with VWD or a PFD was greater, 2.1 (range: 0–4), than in the 56 controls, 0.4 (range: 0–2) (P<0.0001). The mean PBQ epistaxis score in patients varied according to underlying diagnosis and was greater in those with type 3 VWD (3.1) than in the patients with definite type 1 VWD (2.2), possible type 1 VWD (0.8), type 2 VWD (2.0) or a PFD (2.1) (P<0.05). There was no effect of age or gender on PBQ epistaxis scores within patient and control groups. 38/66 patients (58%) had a clinically significant score compared to only 5/56 (9%) of controls (P<0.0001). Epistaxis frequency (>5 episodes/yr) was greater in patients than controls, 44/66 (67%) vs. 11/56 (20%) (P<0.0001). More patients (41/66; 62%) had epistaxis lasting >10 min compared with controls (5/56; 9%) (P<0.0001). Most patients and controls reported spontaneous onset of epistaxis − 57/66 (86%) and 44/56 (79%), respectively (P=0.2316). However, a greater number of patients bled from both nostrils (51/66; 77%) than controls (15/56; 27%) (P<0.0001). Seasonal correlation of epistaxis occurred less frequently in the patient group; 14/66 patients (21%) had epistaxis only during 1 or 2 specified seasons of the year while 24/56 controls (43%) had seasonal correlation of epistaxis (P=0.0219). More patients (38/66; 58%) required medical intervention for cessation of epistaxis than controls (5/56; 9%) (P<0.0001). In conclusion, the standardized PBQ is useful in the assessment of epistaxis pattern and severity in children with a mucocutaneous bleeding disorder – VWD or a PFD. The severity score is significantly greater in patients vs. controls. Features of epistaxis suggestive of an underlying bleeding disorder include: epistaxis frequency >5 episodes/yr; duration >10 min; epistaxis occurring from both nostrils; lack of seasonal correlation; and need for medical intervention for cessation. Disclosures:No relevant conflicts of interest to declare.

Does Allocation of Low Risk Parturient Women to a Separate Maternity Unit Decrease the Risk of Emergency Cesarean Section?

In response to escalating rates of cesarean section, the Norwegian Parliament in 2001 decreed that maternity units should be organized into separate units to differentiate between low and high risk deliveries. This action was based on the assumption that low risk patients were being subjected to unnecessary and possibly harmful interventions when treated together with high risk patients. Moreover, it was suggested that the calmer environment for low risk women and less need for medical interventions would achieve a better outcome for mother and child. Accordingly, a number of obstetrical departments were reorganized by physical separation of perceived high and low risk patients. However, the benefit of separate maternity units for low risk patients is questionable. A Cochrane review reported that births in home-like settings appeared to have only a marginally lower rate of cesarean births. No studies have examined the effect of separating low and high risk pregnancies on frequency of cesarean deliveries. This hospital-based registry study investigated whether assignment of women with low risk births to special maternity units reduced emergency cesarean section rates compared with giving birth in a unit with mixed cases. The patient population was comprised of women with intended vaginal delivery during 2001-2003 at 2 urban university hospitals in Norway. There were a total of 11,686 low and high risk deliveries. Data were obtained from standardized prenatal and perinatal health charts. The primary study outcome measure was the risk of emergency cesarean section. The risk of emergency cesarean section was higher in the low risk maternity unit compared with a maternity unit with both high and low risk women; the adjusted odds ratio was 1.4, with a 95% confidence interval of 1.2 to 1.6. These findings provide no support for the separation of maternity wards into high and low risk units. Lower rates of emergency cesarean section among the mixed cases may be due to the better maternity care of low risk women by personnel who are trained to manage high risk pregnancies.

RAPID INTERNAL DOSE MAGNITUDE ESTIMATION IN EMERGENCY SITUATIONS USING ANNUAL LIMITS ON INTAKE (ALI) COMPARISONS

It is crucial to integrate health physics into the medical management of radiation illness or injury. The key to early medical management is not necessarily radiation dose calculation and assignment, but radiation dose magnitude estimation. The magnitude of the dose can be used to predict potential biological consequences and the corresponding need for medical intervention. It is, therefore, imperative that physicians and health physicists have the necessary tools to help guide this decision making process. All internal radiation doses should be assigned using proper dosimetry techniques, but the formal internal dosimetry process often takes time that may delay treatment, thus reducing the efficacy of some medical countermeasures. Magnitudes of inhalation or ingestion intakes or intakes associated with contaminated wounds can be estimated by applying simple rules of thumb to sample results or direct measurements and comparing the outcome to known limits for a projection of dose magnitude. Although a United States regulatory unit, the annual limit on intake (ALI) is based on committed dose, and can therefore be used as a comparison point. For example, internal dose magnitudes associated with contaminated wounds can be estimated by comparing a direct wound measurement taken soon after the injury to the product of the ingestion ALI and the associated f1 value (the fractional uptake from the small intestine to the blood). International Commission on Radiation Protection Publication 96, as well as other resources, recommends treatment based on ALI determination. Often, treatment decisions have to be made with limited information. However, one can still perform dose magnitude estimations in order to help effectively guide the need for medical treatment by properly assessing the situation and appropriately applying basic rules of thumb.

Risk Factors for Organ Dysfunction and Failure in Patients with Acute Traumatic Cervical Spinal Cord Injury

Traumatic injuries to the cervical spine cause significant disability. Much of the morbidity and mortality that occurs in patients afflicted with cervical spinal cord injury (SCI) occurs early after injury due to primary neurologic dysfunction, systemic inflammation, concomitant injuries, treatments to prevent and ameliorate secondary insults, and prolonged immobilization. This study was undertaken to determine the incidence of organ dysfunction and failure using validated measures: the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA). We also sought to determine if certain patient or injury characteristics were associated with the development of organ dysfunction and failure. All patients who sustained isolated blunt cervical SCIs admitted to the R Adams Cowley Shock Trauma Center over a 15-month period were identified. American Spinal Injury Association (ASIA) motor scores, ASIA impairment scale (AIS) scores, and level of injury were recorded. Admission, first daily, worst daily, and aggregate MOD and SOFA scores were assigned for each of six organ systems. A P < 0.05 was considered significant for all statistical tests. Of 1,028 patients admitted with blunt spine injuries between January, 2007 and March, 2008, 40 patients were identified with an isolated cervical SCI that required an ICU length of stay (LOS) >24 h. Organ failure of at least one organ system occurred in 75% of patients as calculated by MOD score and 85% of patients calculated using SOFA criteria. Multiple organ failure was found in 55% by MOD and 62.5% by SOFA scores. The most frequent system to fail was the cardiovascular system by aggregate MODS (84%), while the respiratory system was the most frequently failed system by aggregate SOFA criteria (70%). There was a strong inverse correlation between ASIA motor score and aggregate MODS and SOFA scores (r = -0.56, P = 0.0002 and r = -0.51, P = 0.0009). AIS was also found to be inversely correlated with the development of organ failure (r = -0.47, P = 0.002 and r = -0.45, P = 0.004) while anatomic level of injury was found to correlate poorly with the incidence of organ failure (r = -0.11, P = 0.5 and r = -0.10, P = 0.5). Only ASIA motor score was significantly associated with sum aggregate organ dysfunction scores when controlling for age and injury severity score (parameter estimate = -0.082, P = 0.0005 for MODS and parameter estimate = -0.057, P = 0.006 for SOFA). This study is the first to describe the incidence of organ dysfunction and failure in patients with isolated acute traumatic cervical SCI using validated organ system dysfunction scores. Respiratory, cardiovascular, neurologic, renal, hepatic, and hematologic dysfunction occurred commonly both on admission and over the ICU stay. Respiratory, cardiovascular, and neurologic failure were frequently found, while renal, hepatic, and hematologic failures were uncommon. Multiple organ failure occurred in the majority of patients. ASIA motor score and AIS were found to strongly correlate with the development of organ dysfunction and failure. Level of injury should be used with caution when describing the risk of complications and the need for medical interventions.

Utilização da insulina glargina em crianças menores de oito anos de idade

To evaluate prospectively the efficacy and safety of insulin glargine use for the metabolic control of type 1 diabetes mellitus (T1DM) children younger than eight years old. Nineteen boys and 11 girls with T1DM were included. Before initiating insulin glargine, all children received intensive NPH and aspart insulins for three months. Afterwards, they were assisted for 12 more months for glargine treatment. All patients performed self blood glucose monitoring before and two hours after meals and in early morning (3:00 AM). Primary endpoints: metabolic control using A1C levels; frequency of mild hypoglycemia (capillary glycemia < 60 mg/dL); and frequency of severe hypoglycemia (loss or alteration of consciousness, seizures or need for medical intervention). Mean A1C at the study entry was 8.68% and after 12 months of glargine, was 8.64% (p = 0.82). Frequency of mild hypoglycemia at 3.00 AM was 1.43/3 months during the NPH period and 0.28/3 months during the glargine period (p < 0.007). Frequency of severe hypoglycemia was 0.56/3 months during the NPH period and 0.008/3 months during the glargine period (p < 0.002). The treatment of T1DM children with insulin glargine was considered as efficacious as with NPH. However, a better safety profile, disclosed by the lower incidence of nocturnal and severe hypoglycemia episodes, was observed for insulin glargine.

Optimal Management of Nasal Congestion Caused by Allergic Rhinitis in Children

Nasal congestion is such a frequent and multifactorial occurrence in young children that parents and medical caregivers often overlook the need for medical intervention. However, children with congestion can suffer quality-of-life detriments resulting from sleep disturbance, learning impairment, and fatigue. Congestion also impairs the normal nasal breathing that is physiologically important for the efficient cleaning and conditioning of inspired air. Further, the most common cause of congestion, allergic rhinitis, is considered a potential risk factor for asthma. Published guidelines on the treatment of allergic rhinitis agree that management strategies in children should follow the same principles as in adults, while recognizing the need for dosage adjustments and being aware of unique safety issues. Intranasal corticosteroids, with robust effects in reducing congestion and good tolerability, remain a treatment of choice. Despite lingering concerns about the potential for growth suppression with these drugs, clinical evidence suggests a very low risk at prescribed dosages, especially with compounds that have a low systemic bioavailability. Oral antihistamines are commonly cited as first-line options for allergic rhinitis, although their effect on nasal congestion is relatively modest. First-generation antihistamines should not be administered to children because of their sedative properties, which can worsen learning problems associated with allergic rhinitis. Second-generation oral antihistamines are preferred, although this class is not completely devoid of adverse effects. Other treatments, such as a nasal antihistamine, decongestants, and immunotherapy, present varying levels of safety and tolerability issues in children.

Forced expiratory volume in one second: not just a lung function test but a marker of premature death from all causes

The clinical utility of spirometric screening of asymptomatic smokers for early signs of air flow limitation has recently come under review. The current authors propose that reduced forced expiratory volume in one second (FEV(1)) is more than a measure of airflow limitation, but a marker of premature death with broad utility in assessing baseline risk of chronic obstructive pulmonary disease (COPD), lung cancer, coronary artery disease and stroke, collectively accounting for 70-80% of premature death in smokers. Reduced FEV(1) identifies undiagnosed COPD, has comparable utility to that of serum cholesterol in assessing cardiovascular risk and defines those smokers at greatest risk of lung cancer. As such, reduced FEV(1) should be considered a marker that identifies smokers at greatest need of medical intervention. Smoking cessation has been shown to attenuate FEV(1) decline and, if achieved before the age of 45-50 yrs, may not only preserve FEV(1) within normal values but substantially reduce cardiorespiratory complications of smoking. Recent findings suggest inhaled drugs (bronchodilators and corticosteroids), and possibly statins, may be effective in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease. The current authors propose that spirometry has broad utility in identifying smokers who are at greatest risk of cardiorespiratory complications and greatest benefit from targeted preventive strategies, such as smoking cessation, prioritised screening and effective pharmacotherapy.

ORIGINAL RESEARCH—COUPLES' SEXUAL DYSFUNCTIONS: Prostate Cancer Patients and Their Partners: Differences in Satisfaction Indices and Psychological Variables

Prostate cancer is the most common type of cancer found in American men. Patient adjustment to prostate cancer is not limited to attempts to restore sexual function, a process that can pose significant challenges to couples following most surgical and nonsurgical treatments. Patients often struggle with depression and other relational stressors. Partners also undergo psychosocial, relational, sexual, and quality-of-life changes and their responses to these changes may relate to patient adjustment. To evaluate to what extent partners' psychosocial and relational adjustment relates to prostate cancer patient adjustment. Partner and patient general and sexual depression; patient relationship satisfaction, quality of sexual communication, sexual satisfaction, and life satisfaction. A total of 77 patients and 57 partners responded to a mail survey that included demographic information, the Beck Depression Inventory, Life Satisfaction Index, Index of Sexual Satisfaction, Relationship Assessment Scale, Dyadic Sexual Communication Scale, Sexuality Scale, and Client Satisfaction Questionnaire. Patients and their partners differed in their sexual self-esteem, sexual depression, sexual preoccupation, and life satisfaction. Both had greater levels of depression, poorer quality of sexual communication, and more sexual dissatisfaction than the general population. Partners' level of general depression and depression concerning their sex lives were significant predictors of patients' relationship satisfaction, perceived quality of communication about the sexual relationship, and sexual satisfaction after controlling for patients' general and sexual depression. Partners often serve as primary caregivers, thus partner adjustment can be critical to the health of the patient and to his primary relationship. Results suggest the importance of including partners' adjustment in assessing patient adjustment post-treatment. We suggest that physicians working with these patients partner with mental health professionals who can help couples address the challenges they encounter and extend the continuity of care when the need for medical intervention has passed.