Specific Indications For Use Research Articles

The use of cuffed tracheal tubes for paediatric tracheal intubation, a survey of specialist practice in the United Kingdom

For more than 50 yr, uncuffed tracheal tubes have been the gold standard for intubation in children under the age of 8 yr. However, recently there has been interest in the use of cuffed tubes in paediatric practice. This survey aimed to benchmark UK practice with regard to tracheal intubation within specialist paediatric centres, exploring current cuffed tracheal tube use in children. A questionnaire was e-mailed to the paediatric intensive care unit and anaesthetic department clinical leads in all UK specialist paediatric hospitals with a paediatric intensive care unit (n = 30). Information was requested on the use of tracheal tubes across all paediatric age groups, as well as the reasons for non-use and the incidence of complications attributed to cuffed tubes. A total of 20 paediatric intensive care unit and 15 anaesthetic questionnaires were returned, equating to a response rate of 67% and 50%, respectively. Only 5% of the paediatric intensive care unit and 7% of the anaesthetic respondents routinely use a cuffed tube in children under the age of 8 yr. The commonest reason cited in both groups for non-cuff use was that there is minimal benefit to be gained over using an uncuffed tracheal tube. The most frequent specific indication for use of a cuffed tube was a reduced lung compliance (60% respondents both groups). In all, 45% of the paediatric intensive care unit respondents and 100% of the anaesthetists reported that they did not routinely monitor the intracuff pressure when using a cuffed tube. The incidence of observed complications attributed to the use of cuffed tubes was far higher amongst paediatric intensive care unit consultants (65% vs. 7% anaesthetists); however, the majority in both groups stated that such complications were no more common than when using an uncuffed tube (60% paediatric intensive care unit and 53% anaesthetists). Cuffed tracheal tubes are rarely routinely used in children, particularly in the under 8 yr age group, in specialist paediatric centres in the UK. When used, it is predominantly for a specific indication, and the monitoring of intracuff pressure is not routine. Current expert consensus is that complications are equally as common when using a cuffed as an uncuffed tube.

The in vitro anticoagulant effects of Danaparoid, Fondaparinux, and Lepirudin in children compared to adults

Introduction Major physiological differences in the coagulation system of children compared to that of adults are well documented. We have previously investigated the age-related differences in response to Unfractionated Heparin (UFH). However, the impact of developmental haemostasis on more recent anticoagulant drugs is unknown. A number of these drugs are approved for use in specific indications in adults and none are approved for use in children. This study aimed to determine whether age-related differences in effect and impact on monitoring tests exist in vitro for danaparoid, fondaparinux and lepirudin. Materials and Methods Plasma samples were obtained from healthy children and pooled into age-specific pools, in order to obtain sufficient quantity of plasma required for the analysis of the three drugs. Each age-specific pool was spiked with different concentrations of danaparoid, fondaparinux and lepirudin and response was measured using standard techniques. All experiments were repeated using three separate plasma pools. The effect of each drug in children's plasma was compared to the effect in the respective adult plasma pool. Results Age-related differences in effect on thrombin potential and monitoring tests were observed only with the drug lepirudin. Specifically, APTT for children up to 5 years of age was increased compared to adults; all children had lower ECT results compared to adults; children up to 10 years of age had increased inhibition of ETP as compared to adults. Conclusions This study confirms age-related differences in response to anticoagulants with predominant anti-IIa effect and highlights the need for further research into this area.

Pediatric traumatic brain injury: not just little adults

This review will update the reader on the most significant recent findings with regards to both the clinical research and basic science of pediatric traumatic brain injury. The developing brain is not simply a smaller version of the mature brain. Studies have uncovered important distinctions of the younger brain after traumatic brain injury, including an increased propensity for apoptosis, age-dependent parameters for cerebral blood flow and metabolism, development-specific biomarkers, increased likelihood of early posttraumatic seizures, differential sensitivity to commonly used neuroactive medications and altered neuroplasticity during recovery from injury. Specifically, there is strong preclinical evidence for increased neuronal apoptosis in the developing brain being triggered by anesthetics and anticonvulsants, making it paramount that future studies more clearly delineate preferred agents and specific indications for use, incorporating long-term functional outcomes as well as short-term benefits. In addition, the young brain may actually benefit from therapeutic interventions that have been less effective following adult traumatic brain injury, such as decompressive craniectomy and hypothermia. An increasing body of evidence demonstrates the importance of establishing age-dependent guidelines for physiological monitoring, pharmacological intervention, management of intracranial pressure and facilitating recovery of function.

Use of specific indicators to detect warfarin-related adverse events

The use of specific indicators, or "triggers," to identify adverse drug events (ADEs) associated with warfarin therapy is described. Automated triggers provided by laboratory and pharmacy data were used to identify potential ADEs associated with warfarin therapy among patients treated in the emergency room or admitted to six community hospitals between July 2002 and December 2003. The triggers consisted of an International Normalized Ratio (INR) of greater than 3.0 and pharmacy orders for vitamin K. Pharmacists reviewed the triggers monthly for clinical determination of ADEs during preintervention and postintervention periods. Interventions consisted of staff education and real-time adjustments in therapy. A 39% overall reduction in ADEs occurred between the preintervention and postintervention periods. Harmful ADEs declined by 70%. INRs of greater than 3.0 and vitamin K administration appeared to be reliable indicators of warfarin-associated ADEs, and detection with these indicators appeared to reduce ADEs when combined with appropriate interventions.

Bilevel noninvasive positive pressure ventilation for acute respiratory failure: Survey of Ontario practice*

To determine physicians' stated practices regarding the use of bilevel noninvasive ventilation (NIV) for acute respiratory failure and the predictors of practice variation. Cross-sectional postal survey. Province of Ontario, Canada. Attending physicians and residents in four specialties at 15 teaching hospitals. We used literature searches and focus groups to design questions related to NIV utilization with respect to frequency, location of and indications for use, awareness of supporting literature, and perceived efficacy. We assessed the survey's clinical sensibility and reliability. We used regression analyses to evaluate practice variation among hospitals and specialties and to determine predictors of more frequent NIV use, initiation of and continued use in nonmonitored settings, and use for specific indications. Three hundred eighty-five (48%) of 808 physicians responded; 242 used NIV. The two most common indications for NIV use were chronic obstructive pulmonary disease and congestive heart failure. NIV guidelines, protocols, or policies were available in 12 of 15 hospitals. We found variation in NIV utilization among specialties but not hospitals. Specialty (critical care and respirology versus internal and emergency medicine), fewer years of postgraduate experience, and a greater number of noninvasive ventilators were predictors of more frequent NIV use (all p < or = .001). Only 6% of respondents reported initiation of use and continued use most frequently in nonmonitored settings, which increased with the number of noninvasive ventilators (p = .02). Physician characteristics such as awareness of the literature were predictive of NIV use for exacerbations of chronic obstructive pulmonary disease, whereas perceived NIV efficacy was predictive of use for many indications, including congestive heart failure. Self-reported practice variation for bilevel NIV exists among specialties but not hospitals and differs with respect to frequency, location of use, and use for specific indications. Some factors associated with variation in NIV use may be suitable targets for utilization improvement interventions.

LASERS FOR USE IN DENTISTRY

Lasers were first developed in the 1960s, and research into their applications in dentistry began soon thereafter. Early lasers were continuous wave devices with noncontact delivery that were found to be too hot for practical dental use. Of these early devices, CO2 lasers were developed further and had limited use for soft tissue excision, primarily by oral surgeons. In the early 1980s, short-pulsed, fiber-optic contact delivery laser technology was developed. Neodymium:yttrium-aluminum-garnet (Nd:YAG), erbium:YAG (Er:YAG), and erbium-chromium:yttrium-scandium-gallium-garnet. Currently, there are 20 specific indications for use of a variety of dental lasers. These applications have been reviewed for safety and effectiveness following the US Food and Drug Administration (FDA) 51 0 (k) clearance for market mechanism. Specific laser devices are cleared for a number of soft tissue applications, including intraoral soft tissue surgery (ablating, incising, excising, coagulating), sulcular debridement, treatment of aphthous ulcers and herpetic lesions, removal of coronal pulp and pulpotomy (adjuncts to root canal procedures), and coagulation of extraction sites. Hard tissue applications include caries removal, cavity preparation, selective caries removal in enamel, enamel roughening, tooth preparation to obtain access to the root canal, root canal cleaning, and root canal preparation, including enlargement, apicoectomy, bone cutting, shaving, contouring, and resection. Miscellaneous uses of lasers include curing of composite materials, removal of composite filling materials (not amalgam), and softening gutta percha. Lasers also are used as an aid in diagnosis of dental caries, illumination of caries detection and endodontic orifice location, and blood flow measurements. Clearly, no one device can accomplish all of these practical dental uses. Generally, a specific laser device is maximized for diagnosis or for use in soft or hard tissues. It is common to find lasers that are good for use in soft tissues with some hard tissue applications, and other lasers that are good for hard tissue with some soft tissue applications. Research is ongoing in the areas of caries prevention using lasers to change the structure of enamel. Research also is progressing in the area of optical coherence tomography for the nondestructive imaging of enamel and dentin to determine lesion progression over time. Exciting developments are occurring in the area of laser use in periodontal therapy for the removal and coagulation of the sulcular soft tissues and in the future for the selective removal of calculus on the tooth surface. There has been continued growth in this new and maturing field in dentistry. The profession can review the substantial scientific evidence available in the field, including at least two texts, and a large amount of information is available through organized dentistry. The standard for practitioners who use lasers is successful completion of a recognized standard proficiency course according to a defined and accepted curriculum. This Critical Appraisal focuses on the most used dental laser applications and the clinical trials conducted to support their safe and effective use.

Applications of contact lens devices in the management of corneal disease.

Contact lens devices have a variety of therapeutic applications in the management of corneal diseases. A wide range of devices is available, some with very specific indications for use, including scleral lenses, silicone elastomer, collagen shields, large diameter corneal lenses, and silicone hydrogels. The traditional hydrogel contact lens is the most frequently used device and is indicated in at least 80% of cases. Common indications for use are relief of pain, promotion of corneal healing, mechanical protection and support, and control of corneal hydration, often a combination of effects being achieved. Visual improvement may be achieved but this is not the primary role of such devices.

Indocyanine green angiography in chorioretinal diseases: indications and interpretation: An evidence-based update

Topic/purpose To assess the clinical usefulness and relevance of indocyanine green angiography (ICG) in the investigation of chorioretinal disorders and assess specifically in what conditions it may add useful information to that obtained using standard fluorescein angiography. Clinical relevance Many publications on ICG have appeared in recent years touting its use in ophthalmology. These publications have led to increasing use of this technique and to its application in numerous retinal diseases in which the fluorescein angiographic findings have been thoroughly described. Methods/literature reviewed During this systematic literature review, we identified and reviewed a total of 376 articles, from among which we selected 92 that we considered most relevant to our purpose of evaluating published evidence as to the efficacy of ICG. We excluded many articles with weak study designs and those that simply duplicated previously published information. Our literature search used PubMed and was confined to articles in English or that included an English abstract. Results Our systematic review suggests that ICG has relatively few specific indications for use as justified by previously published peer-reviewed studies. In keeping with the requirements for this Journal’s evidence-based articles, we have divided our clinical recommendations for the use of ICG into three categories: (A) strongly recommended and supported by strong evidence; (B) recommended with moderately strong supporting evidence; (C) not recommended at present because supported only by anecdotal or group consensus evidence. A. We highly recommended ICG for (1) identification of polypoidal choroidal vasculopathy, (2) occult choroidal neovascularization, (3) neovascularization associated with pigment epithelial detachments, and (4) recurrent choroidal neovascular membranes. These are all conditions in which ICG contributes to the identification of lesions that may be treatable. B. We recommend ICG with some enthusiasm for identifying feeder vessels in age-related macular degeneration, choroidal neovascular membranes, chronic central serous retinopathy, multiple evanescent white dot syndrome, vasculitis, acute multifocal placoid pigment epitheliopathy, Vogt-Koyanagi-Harada syndrome, macular lesions associated with angioid streaks, and birdshot retinopathy. In all these conditions, ICG may help establish a diagnosis and provide some useful guidance for therapy. C. At present, we do not recommend ICG for scleritis and posterior scleritis, drusen differentiation, Behçet’s disease, or sarcoidosis, because it has not been demonstrated to add useful clinical information. Conclusions ICG, although now a well established technique, has clear advantage over fluorescein angiography in relatively few chorioretinal disorders. It has, however, contributed to the understanding of pathologic processes in many ocular diseases. As yet, no published randomized controlled clinical trials show any benefit to the use of ICG in the management of any specific ocular disease.

Advances in airway management for outpatients

As outpatient anaesthesia increases in volume so does research, especially in ways to reduce morbidity from relatively minor complications such as sore throat and hoarseness, as well as aiming to reduce costs and length of hospital stay. The past year has produced many studies in which newer airway devices have been compared with the laryngeal mask airway and this review evaluates them all. The relatively recent introduction of the ProSeal laryngeal mask airway shows promise when insertion of a gastric tube is preferred in patients breathing spontaneously, whilst the intubating laryngeal mask airway has demonstrated its usefulness in those situations where the patient prefers to be anaesthetized but intubation may be difficult following classic laryngoscopy. The cuffed oropharyngeal airway and combitube probably only have a place in emergency airway management rather than elective anaesthesia. Despite the introduction of new airway devices, some of which have specific indications for use, the classic laryngeal mask airway remains the 'gold standard' with which newer devices are compared. Whilst some of these new devices show promise in the outpatient setting, further research is required before their universal acceptance.

Tyrosine kinase inhibitors: a clinical perspective.

Cancer treatment has so far been restricted to cytotoxic and hormonal agents. These have been of limited value in their efficacy and their toxicity profile. A new era of targeted therapies is rapidly evolving. A key target being actively pursued is the receptor tyrosine kinase. Several compounds that inhibit this target are in preclinical and clinical development. These compounds broadly fall into two categories: monoclonal antibodies and small-molecule inhibitors. The common targets are epidermal growth factor receptor, Bcr-Abl tyrosine kinase, vascular endothelial growth factor, fibroblast growth factor receptor, and platelet-derived growth factor. Two of these compounds, trastuzumab and imatinib mesylate, have been approved by the US Food and Drug Administration for use in specific indications. Other uses are being tested, such as imatinib for gastrointestinal stromal tumor. These compounds will alter cancer care as adjuncts to currently available treatment options.

Effect of resin matrix on degree of conversion and fracture toughness of dental composites

Current composites are made with dimethacrylate monomers and silane-treated silica microfillers, either alone or with silane treated glass fillers The main reasons for clinical failure of dental composites are secondary caries, wear and fracture. Most of practitioner want to get a composite which is more tougher under occlusal stress, less polymerization contraction, and better handling properties in application clinically. The aim of this study was to investigate the influence of resin matrix with various flows on the physical proper-ties such as fracture toughness and degree of conversion of the experimental resins. It was hypothesized that flexible or tough resin composites can be designed by judicious choice of monomer composition Various flow resin matrices containing Bis-GMA, UDMA, and TEG-DMA were made by altering the pro-portion of the monomers. After the unfilled resins were light-cured for different light intensity, the fracture toughness(K) was measured according to ASTM standard using the single edge notched geometry, and degree of conversion(DC) was measured by FTIR. And experimental composites were formulated with variations in the proportion of silanated quartz and strontium glass fillers as 60, 75, and 77wt%. Also, the physical properties of composites with various filer contents were evaluated as same manner. All resulting data were compared by ANOVA/Tukeys test at 0.05 level. The results were as follows; 1. The degree of conversion of high flow resin containing less Bis-GMA was higher than that of low flow unfilled resin 2. While the degree of conversion of unfilled resin was increased according to light intensity for polymerization, there was no significant increase with moderate and high light intensity. Also, the fracture toughness was not increased by high light intensity. 3. The fracture toughness was high in the low flow unfilled resin containing higher contents of Bis-GMA. 4. There was a significant increase for fracture toughness and a tendency for degree of conversion to be reduced when the content of fillers was increased. 5. In the experimental composites, the flow of resin matrix did not affected on the fracture toughness, even, which was decreased as increase of viscosity. These results showed that the physical properties of a dental composite could be attributed to the flow of resin matrix with relative content of monomers. Specific combination of resin monomers should be designed to fulfil the needs of specific indication for use.

Efficacy, pharmacology, and adverse effects of antiepileptic drugs

This article discusses the factors involved in the appropriate selection of anticonvulsant medications. The clinical use of commonly used traditional antiepileptic drugs and the newly marketed antiepileptic drugs is discussed. This includes the specific indications for use, adverse effects, and dosing of each drug. Drug interactions, mechanisms of action, and pharmacological properties of each drug is also reviewed.

Newer drugs in pediatric anesthesia.

Recent developments in pharmacology have offered new and broader options to the anesthesiologist caring for pediatric patients. Many new drugs do not have specific indications for use in the pediatric population, but clinical studies have examined the utility and cost-effectiveness of some of these agents. Information is presented on drugs used for premedication, induction, and maintenance of anesthesia. The clinical pharmacology of several new nondepolarizing muscle relaxants, and the recent controversy with regard to the use of succinylcholine also are presented. New drugs used in topical and regional anesthesia as well as options for anti-emetic therapy are discussed.

Antibacterial Chemotherapeutants for Finfish Aquaculture: A Synopsis of Laboratory and Field Efficacy and Safety Studies

This review summarizes the extensive and disparate world literature pertaining to antibacterial chemotherapeutants which may be of use in finfish aquaculture. Currently, the veterinarian or fish health professional in the USA has only two legal antibacterials available, Terramycin for Fish® and Romet-30®, each with limited and specific indications for use including treatable fish species and pathogens. If an indicated bacterial pathogen is not sensitive to these chemotherapeutants, the producer has limited treatment options. Extralabel usage of these or other antibacterials is not permitted via the feed (currently the only practical route for treating large populations of fish) without specific U.S. Food and Drug Administration approval, including the Investigational New Animal Drug (INAD) process or an emergency INAD exemption. Research to develop and approve new antibacterials to treat commercial aquaculture species has identified specific fluoroquinolones (enrofloxacin, sarafloxacin), macrolides (erythromycin), penicillin derivatives (amoxicillin), and chloramphenicol-like (flofenicol) antibacterials as the best candidates for current registration efforts in the USA.

Issues in gynecologic radiation oncology

Radiation therapy has a number of established roles in the curative, adjuvant, and palliative management of gynecologic malignancies. Specific indications for use of radiation therapy, concepts of integration of radiation therapy with other modalities, and techniques of radiation therapy, however, continue to evolve. Rather than discuss the use of radiation therapy in specific diseases, this paper reviews recent studies dealing with current issues in gynecologic radiation oncology.

Innovative designs and practices for acute systemic toxicity studies.

Over a four year period our laboratory has conducted 124 acute systemic toxicity studies (64 oral, 39 dermal, and 21 inhalation), altering study and program designs with the objectives of maximizing information while minimizing animal usage. By employing dose selection strategies, probes, lethality limits instead of LD50's, staggered sequential dosing, and by conducting studies in batteries, animal usage was reduced by 48% below the average number currently quoted as necessary for an LD50 study. Simultaneously, use of a neurobehavioral screen, adjunct studies and a flexible study design have led to a significant upgrading in the information generated by these studies. Additionally, the use of a decision tree approach for selecting tissues for histopathology was developed. The use of specific indicators (such as organ weights) for selecting organs for microscopic examination was also evaluated. Our efforts demonstrate that significantly more information can be generated by studies utilizing fewer animals than is now common practice.

Effect of drugs on the gastrointestinal tract.

Topics discussed by the panel include specific indications for use of vitamins, choice of the best sedative and the best antacid for routine use9 beneficial effect of anticholinergics, medical versus surgical treatment of hiatus hernia, management of mild cirrhosis, criteria for resumption of activity following hepatitis, treatment of pancreatitis, precautions and technic of needle biopsy of the liver, measures to relieve constipation, preparation of the intestine for surgery, complications of the use of mineral oil, operative management of patients receiving steroids, indications for steroids in gastrointestinal disorders, and drugs to use in the terminal stage of cancer.