Three-day Course Research Articles

Case Report: A 72 Years Old Man with Isaacs’ Syndrome: A Rare Entity with Different Outcomes

Neuromyotonia is a neuromuscular hyperexitability disorder characterized by muscle stiffness caused by continuous muscle fiber activity. It is an immune mediated disorder with elevated antibody level against presynaptic, voltage gated potassium channels, either as isolation or as a paraneoplastic process. Symptoms usually include muscle twitching during rest (myokymia), cramps, peudomyotonia (delayed relaxation), increased sweating, and sometimes motor weakness. In this case report, we present a seventy-two years old man who presented with pain in both thighs for one month. It gradually became worse to involve feet and chest. His brain CT scan showed features of brain atrophy. EMG showed fasciculation along neuromyotonic discharges with characteristic wave in frequency and amplitude typical of Isaacs’ syndrome. Potassium channel antibodies were very high. Diagnosis of Isaacs’ syndrome was made. He was followed up for two months with treatment by three-day course of methyl prednisolone followed by oral steroid and methotrexate with much improvement. This is the first case of Isaacs’ syndrome in Kurdistan.

New Oral Anticoagulants for the Management of Heparin Induced Thrombocytopenia: A Focused Literature Review.

Drugs currently in use for the management of heparin-induced thrombocytopenia (HIT) have their limitations. Several new oral anticoagulants (NOACs) such as dabigatran, rivaroxaban and apixaban may offer attractive therapy options for HIT. Although the clinical data are sparse on this topic, we have summarized the available clinical data, discussed pertinent in-vitro studies and provided the rational and advantages of using NOACs in patients with suspected or confirmed HIT. We have also reviewed the safety and efficacy of these NOACs in patients with HIT based on published literature. We reviewed all suspected or confirmed HIT cases treated with NOACs and indexed in English language in MEDLINE and EMBASE by July 2015. The bibliography of each relevant article was searched for additional reports. In-vitro studies and other pertinent literature were briefly discussed. A total of 36 HIT patients were treated with the following NOACs: rivaroxaban (50%), dabigatran (36%) and apixaban (14%). Sixty-one percent of patients received argatroban bolus before NOACs and 3% received rivaroxaban after a lack of response with three-day course of fondaparinux. Three percent (n=1) received rivaroxaban after the patient responded to intravenous immunoglobulin for 2 days, following a lack of response to fondaparinux and bilvalirudin. In another 3% (n=1), prophylactic dose of rivaroxaban was used for 21 days and then changed to dabigatran because of persistent thrombocytopenia. All cases responded with early signs of clinical improvement and increase in platelet counts. A follow-up after a median 47 days (range 4- 450) reported no bleeding or thrombotic complications. In this review, all patients with HIT treated with NOACs responded without any bleeding or thrombotic complication. Although the argatroban bolus might have contributed to a response in some patients, response to NOAC alone in other patients and in-vitro studies provide a proof of principle that NOACs can be effective in the management of HIT. Additionally, properties such as rapid onset of action, oral administration, ease of use and a lack of need for monitoring make these drugs attractive options for HIT. However, given several limitations of prior reports, further confirmation of the results are desirable.

Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults.

Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, current national guidelines for the treatment of hospital-acquired pneumonia (HAP) are several years old and the diagnosis of pneumonia in mechanically ventilated patients (VAP) has been subject to considerable recent attention. The optimal duration of antibiotic therapy for HAP in the critically ill is uncertain. To assess the effectiveness of short versus prolonged-course antibiotics for HAP in critically ill adults, including patients with VAP. We searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June 2015), MEDLINE in-process and other non-indexed citations (5 June 2015), EMBASE (2010 to June 2015), LILACS (1982 to June 2015) and Web of Science (1955 to June 2015). We considered all randomised controlled trials (RCTs) comparing a fixed 'short' duration of antibiotic therapy with a 'prolonged' course for HAP (including patients with VAP) in critically ill adults. Two review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information. We identified six relevant studies involving 1088 participants. This included two new studies published after the date of our previous review (2011). There was substantial variation in participants, in the diagnostic criteria used to define an episode of pneumonia, in the interventions and in the reported outcomes. We found no evidence relating to patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, overall a short seven- or eight-day course of antibiotics compared with a prolonged 10- to 15-day course increased 28-day antibiotic-free days (two studies; N = 431; mean difference (MD) 4.02 days; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (one study; N = 110; odds ratio (OR) 0.44; 95% CI 0.21 to 0.95), without adversely affecting mortality and other recurrence outcomes. However, for cases of VAP specifically due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (two studies, N = 176; OR 2.18; 95% CI 1.14 to 4.16), though mortality outcomes were not significantly different. One study found that a three-day course of antibiotic therapy for patients with suspected HAP but a low Clinical Pulmonary Infection Score (CPIS) was associated with a significantly lower risk of superinfection or emergence of antimicrobial resistance, compared with standard (prolonged) course therapy. On the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.

Introducing basic principles of medication safety: Development of a three-day continuing education course for health care professionals

ObjectiveTo develop innovative educational approaches for introducing medication safety principles for health care professionals as a three-day interdisciplinary course. Educational activityThe data for developing the educational activity were collected at a workshop at the 2009 International Life-Long Learning in Pharmacy Conference. A total of 19 higher education and adult learning experts in pharmacy brainstormed four syllabi using teaching and assessment methods. Qualitative content analysis was used to develop a combined syllabus. All four syllabi involved constructive, problem-based learning with personal learning objectives and reflection, and methods for facilitating interactive learning and learning at the workplace. This focused on understanding a systems approach in managing medication safety. The phases of learning covered pre- and post-course learning and learning during the course. One month’s period between training days was suggested. ConclusionsOur work suggests that constructive problem-based learning linked to learners’ practice through assignments is the key in a continuing education course on medication safety for health care professionals. A significant amount of learning occurs outside the training days through assignments.

Assessing Improvement in Diagnostic Knee Arthroscopic Skill During the AAOS Fundamentals of Knee and Shoulder Arthroscopy Course for Orthopaedic Residents

Objectives:The purpose of the AAOS Fundamentals of Knee and Shoulder Arthroscopy Course for Orthopaedic Residents is to provide an opportunity for orthopaedic trainees to practice and improve basic arthroscopic surgical skills. During the course, residents spend the majority of their time in the Orthopaedic Learning Center laboratory performing basic arthroscopic procedures on cadaveric specimens under the direction of an expert faculty. Residents are also exposed to various didactic lectures during this intensive three-day course. Historically, feedback from the course has been extremely positive from both resident participants and faculty, however no attempt has previously been made to more objectively determine the degree to which improvement in resident skill has occurred. The purpose of this study is to determine whether participation in the AAOS Fundamentals of Arthroscopic Surgery Course for Residents led to improved diagnostic knee arthroscopy performance. We hypothesized that scores on post course assessments of knee arthroscopy skills and confidence would be higher in comparison to scores on the same assessments prior to the course.Methods:46 orthopaedic surgical residents enrolled in the AAOS Fundamentals of Arthroscopic Surgery Course volunteered to participate in the study. Participants were asked to perform a diagnostic knee arthroscopy on a cadaveric knee specimen both before and immediately after the conclusion of the knee portion of the course. Diagnostic knee arthroscopy performance was assessed using the Arthroscopic Surgical Skill Evaluation Tool (ASSET). Residents were also assessed before and after the course using the TolTech virtual reality simulator which enables the objective assessment of several measures that correlate with arthroscopic proficiency. Confidence, before and after the course, for several arthroscopic procedures was also assessed via a self-reported questionnaire.Results:Following the course, residents demonstrated a 9.2% improvement in mean ASSET score (p=0.001). ASSET score improved most (13.2%) for those with less than 20 arthroscopic cases (p=0.007). On the TolTech virtual reality simulator, mean scores demonstrated significant improvements for multiple measures of proficiency including: Time, which improved 18% (p=.01), Arthroscope path distance, which improved 13% (p=.02), Probe path distance, which improved 16% (p=.05), Smoothness, which improved 10% (p=.001), and excessive probe pressure, which improved 440% (p=.02). Overall completeness improved 1.8%, but this was not significant (p=0.11). Confidence in performing arthroscopic partial menisectomy improved 13% (p=.002) and confidence in performing ACL reconstruction improved 9% (p=.01).(Table 1).Conclusion:It was feasible to assess several outcomes related to resident proficiency and confidence within the structure of the AAOS Fundamentals of Arthroscopic Surgery Course. Resident participation in the course resulted in modest improvements for many of the outcomes measured demonstrating the value of this and similar courses. This data will be critically evaluated to determine curricular changes in an effort to maximize course benefit for future participants.

Chelation for autism spectrum disorder (ASD).

It has been suggested that the severity of autism spectrum disorder (ASD) symptoms is positively correlated with the level of circulating or stored toxic metals, and that excretion of these heavy metals, brought about by the use of pharmaceutical chelating agents, results in improved symptoms. To assess the potential benefits and adverse effects of pharmaceutical chelating agents (referred to as chelation therapy throughout this review) for autism spectrum disorder (ASD) symptoms. We searched the following databases on 6 November 2014: CENTRAL, Ovid MEDLINE, Ovid MEDLINE In-Process, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and 15 other databases, including three trials registers. In addition we checked references lists and contacted experts. All randomised controlled trials of pharmaceutical chelating agents compared with placebo in individuals with ASD. Two review authors independently selected studies, assessed them for risk of bias and extracted relevant data. We did not conduct a meta-analysis, as only one study was included. We excluded nine studies because they were non-randomised trials or were withdrawn before enrolment. We included one study, which was conducted in two phases. During the first phase of the study, 77 children with ASD were randomly assigned to receive seven days of glutathione lotion or placebo lotion, followed by three days of oral dimercaptosuccinic acid (DMSA). Forty-nine children who were found to be high excreters of heavy metals during phase one continued on to phase two to receive three days of oral DMSA or placebo followed by 11 days off, with the cycle repeated up to six times. The second phase thus assessed the effectiveness of multiple doses of oral DMSA compared with placebo in children who were high excreters of heavy metals and who received a three-day course of oral DMSA. Overall, no evidence suggests that multiple rounds of oral DMSA had an effect on ASD symptoms. This review included data from only one study, which had methodological limitations. As such, no clinical trial evidence was found to suggest that pharmaceutical chelation is an effective intervention for ASD. Given prior reports of serious adverse events, such as hypocalcaemia, renal impairment and reported death, the risks of using chelation for ASD currently outweigh proven benefits. Before further trials are conducted, evidence that supports a causal link between heavy metals and autism and methods that ensure the safety of participants are needed.

Targeting the cell stress response of Plasmodium falciparum to overcome artemisinin resistance.

Successful control of falciparum malaria depends greatly on treatment with artemisinin combination therapies. Thus, reports that resistance to artemisinins (ARTs) has emerged, and that the prevalence of this resistance is increasing, are alarming. ART resistance has recently been linked to mutations in the K13 propeller protein. We undertook a detailed kinetic analysis of the drug responses of K13 wild-type and mutant isolates of Plasmodium falciparum sourced from a region in Cambodia (Pailin). We demonstrate that ART treatment induces growth retardation and an accumulation of ubiquitinated proteins, indicative of a cellular stress response that engages the ubiquitin/proteasome system. We show that resistant parasites exhibit lower levels of ubiquitinated proteins and delayed onset of cell death, indicating an enhanced cell stress response. We found that the stress response can be targeted by inhibiting the proteasome. Accordingly, clinically used proteasome inhibitors strongly synergize ART activity against both sensitive and resistant parasites, including isogenic lines expressing mutant or wild-type K13. Synergy is also observed against Plasmodium berghei in vivo. We developed a detailed model of parasite responses that enables us to infer, for the first time, in vivo parasite clearance profiles from in vitro assessments of ART sensitivity. We provide evidence that the clinical marker of resistance (delayed parasite clearance) is an indirect measure of drug efficacy because of the persistence of unviable parasites with unchanged morphology in the circulation, and we suggest alternative approaches for the direct measurement of viability. Our model predicts that extending current three-day ART treatment courses to four days, or splitting the doses, will efficiently clear resistant parasite infections. This work provides a rationale for improving the detection of ART resistance in the field and for treatment strategies that can be employed in areas with ART resistance.

Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study.

BackgroundPediatric adenotonsillectomy (A&T) is associated with prolonged pain and functional limitation. Celecoxib is an effective analgesic in adult surgery patients; however, its analgesic efficacy on pain and functional recovery in pediatric A&T patients is unknown.MethodsDuring 2009-2012, children (age 2-18 yr) scheduled for elective A&T were enrolled in a single-centre double-blind randomized controlled trial. Study participants received either oral placebo or celecoxib 6 mg·kg−1 preoperatively, followed by 3 mg·kg−1 twice daily for five doses. The primary outcome was the mean “worst 24-hr pain” scores during postoperative days (PODs) 0-2 on a 100-mm visual analogue scale (VAS). Secondary outcomes for PODs 0-7 included co-analgesic consumption, adverse events, and functional recovery. The impact of the CYP2C9*3 allele – associated with reduced celecoxib hepatic metabolism – on recovery was considered.ResultsOf the 282 children enrolled, 195 (celecoxib = 101, placebo = 94) were included in the primary outcome analysis. While on treatment, children receiving celecoxib experienced a modest reduction in the average pain experienced over PODs 0-2 (7 mm on a VAS; 95% confidence interval [CI]: 0.3 to 14; P = 0.04) and a “clinically significant” reduction (≥ 10 mm on a VAS; P ≤ 0.01) on PODs 0 and 1. During PODs 0-2, the mean acetaminophen consumption was lower in the celecoxib group vs the placebo group (78 mg·kg−1; 95% CI: 68 to 89 vs 97 mg·kg−1; 95% CI: 85 to 109, respectively; P = 0.03). No differences in adverse events, functional recovery, or satisfaction were observed by POD 7. The CYP2C9*3 allele was associated with less pain and improved functional recovery.ConclusionsA three-day course of oral celecoxib reduces early pain and co-analgesic consumption; however, an increase in dose, dose frequency, and duration of dose may be required for sustained pain relief in the pediatric setting. The CYP2C9*3 allele may influence recovery. This trial was registered at: ClinicalTrials.gov: NCT00849966.Electronic supplementary materialThe online version of this article (doi:10.1007/s12630-015-0376-1) contains supplementary material, which is available to authorized users.

Showcasing Chemical Engineering Principles through the Production of Biodiesel from Spent Coffee Grounds

Chemical engineering is rarely encountered before higher-level education in the U.S. or in Europe, leaving prospective students unaware of what an applied chemistry or chemical engineering degree entails. In this lab experiment, we report the implementation of a three-day course to showcase chemical engineering principles for 16–17 year olds studying chemistry and mathematics at high school level. The course focused on simple mass and energy balances and reaction engineering and aided the students in making an informed decision toward what to study at university. In addition, we introduced sustainability and renewable energy concepts in a laboratory environment.

A nine-month-old girl with respiratory failure and rhomboencephalitis.

CASE PRESENTATION A nine-month-old girl from northern Manitoba presented in September 2014, with a three-day history of vesicular rash on the soles of her feet. She was diagnosed with hand, foot and mouth disease, and discharged from the local nursing station. Over the next 24 h, she developed cough and fever that led to progressive vomiting, diarrhea and increased work of breathing, causing significant oxygen requirements, which led her to be transferred to a tertiary care centre. On admission, she required intubation and fluid resuscitation for respiratory failure and hypotension. On physical examination, she was afebrile. On respiratory examination, there were diffuse crackles and coarse breath sounds bilaterally. Cardiac and abdominal examinations were normal. The only remaining rash consisted of vesicular lesions on an erythematous base on the sole of the right foot. Laboratory tests revealed a white blood cell count of 4.3×109/L, including an absolute neutrophil count of 1.7×109/L. The rest of the complete blood cell count, liver enzyme levels, renal function and electrolytes were normal. Blood and endotracheal tube aspirate cultures, obtained before vancomycin and ceftriaxone were administered, were negative. Urine analysis revealed no leukocytes or nitrites; however, urine culture was positive for pansusceptible Escherichia coli (2×106 CFU/L). Cerebrospinal fluid obtained one day after admission, when her hemodynamic status improved, revealed a total white blood cell count of 28×106 cells/L, including 66% lymphocytes, 8% neutrophils, 26% monocytes, glucose 5 mmol/L, protein 0.21 g/L and a few red blood cells observed on microscopy. Bacterial cultures and polymerase chain reaction (PCR) for enterovirus and herpes simplex virus were negative. Stool sent for electron microscopy was negative, but stool for viral culture was pending. Chest x-ray revealed a right middlelobe infiltration. A nasopharyngeal aspirate and bronchoalveolar lavage sent for respiratory virus panel PCR, which included adenovirus, human coronavirus OC43, 229E and NL63, repiratory syncytial virus A and B, influenza A and B, parainfluenza 1, 2, 3 and 4, enterovirus, rhinovirus A, B and C, bocavirus 1 and 2, and human metapneumovirus, were both negative. Acid-fast bacilli smear and culture, bacterial culture and fungal culture from the bronchoalveolar lavage were negative. The patient became unable to move her upper extremities on day 2 of admission. Magnetic resonance imaging of the head and spine was performed on the same day, and revealed restricted diffusion at the dorsal brain stem and patchy areas of prolonged signal intensity involving the cranial-cervical junction, cervical and, to a lesser extent, the thoracic and lumbar spinal cord, suggestive of transverse myelitis with rhomboencephalitis. An autoimmune-mediated process was suspected due to the absence of detection of infectious agents. A three-day course of pulse methylprednisolone led to no improvement. The patient developed increased ventilator requirements, including high frequency jet ventilation on days 6 to 11 of admission. The patient slowly recovered with supportive care over the next five days. She was extubated on day 14 of admission and discharged on day 37, with residual impaired mobility of her right arm. She was seen two months after discharge with improved, but ongoing, difficulty lifting her right arm to her face, and was unable to lift her right arm above her shoulder. She is followed by physiotherapy, occupational therapy and pediatric neurology.

Teaching experimental design.

Awareness of poor design and published concerns over study quality stimulated the development of courses on experimental design intended to improve matters. This article describes some of the thinking behind these courses and how the topics can be presented in a variety of formats. The premises are that education in experimental design should be undertaken with an awareness of educational principles, of how adults learn, and of the particular topics in the subject that need emphasis. For those using laboratory animals, it should include ethical considerations, particularly severity issues, and accommodate learners not confident with mathematics. Basic principles, explanation of fully randomized, randomized block, and factorial designs, and discussion of how to size an experiment form the minimum set of topics. A problem-solving approach can help develop the skills of deciding what are correct experimental units and suitable controls in different experimental scenarios, identifying when an experiment has not been properly randomized or blinded, and selecting the most efficient design for particular experimental situations. Content, pace, and presentation should suit the audience and time available, and variety both within a presentation and in ways of interacting with those being taught is likely to be effective. Details are given of a three-day course based on these ideas, which has been rated informative, educational, and enjoyable, and can form a postgraduate module. It has oral presentations reinforced by group exercises and discussions based on realistic problems, and computer exercises which include some analysis. Other case studies consider a half-day format and a module for animal technicians.

Impact of a training course on the quality of malaria diagnosis by microscopy in Angola.

BackgroundIn Angola, malaria is an endemic disease having a major impact on the economy. The WHO recommends testing for all suspected malaria cases, to avoid the presumptive treatment of this disease. In malaria endemic regions laboratory technicians must be very comfortable with microscopy, the golden standard for malaria diagnosis, to avoid the incorrect diagnosis. The improper use of medication promotes drug resistance and undesirable side effects. The present study aims to assess the impact of a three-day refresher course on the knowledge of technicians, quality of blood smears preparation and accuracy of microscopy malaria diagnosis, using qPCR as reference method.MethodsThis study was implemented in laboratories from three hospitals in different provinces of Angola: Bengo, Benguela and Luanda. In each laboratory samples were collected before and after the training course (slide with thin and thick blood smears, a dried blood spot and a form). The impact of the intervention was evaluated through a written test, the quality of slide preparation and the performance of microscopy.ResultsIt was found a significant increase on the written test median score, from 52.5% to 65.0%. A total of 973 slides were analysed to evaluate the quality of thick and thin blood smears. Considering all laboratories there was a significant increase in quality of thick and thin blood smears. To determine the performance of microscopy using qPCR as the reference method we used 1,028 samples. Benguela presented the highest values for specificity, 92.9% and 98.8% pre and post-course, respectively and for sensitivity the best pre-course was Benguela (75.9%) and post-course Luanda (75.0%). However, no significant increase in sensitivity and specificity after the training course was registered in any laboratory analysed.DiscussionThe findings of this study support the need of continuous refresher training for microscopists and other laboratory staff. The laboratories should have a quality control programme to supervise the diagnosis and also to assess the periodicity of new training. However, other variables needed to be considered to have a correct malaria diagnosis, such as adequate equipment and reagents for staining and visualization, good working conditions, motivated and qualified personnel.

P05.07 * A LOWER-DOSE CISPLATIN-ETOPOSIDE REGIMEN FOR CHILDREN WITH HYPOTHALAMIC/CHIASMATIC TUMOR AND DIENCEPHALIC CACHEXIA

Diencephalic Syndrome (DS) is a rare but potentially lethal condition, which may complicate the clinical course of infants with hypothalamic/chiasmatic tumors, usually low-grade gliomas, either pilocytic (WHO-grade I) or pilomyxoid (WHO-grade II) astrocytomas. The mean survival of DS patients who do not receive any treatment after diagnosis, is usually less than 12 months. Yet, effective therapy is hampered by the tumor location preventing its complete resection, and by significant neurocognitive and endocrinological sequelae associated with potentially curative radiotherapy. The aim of our study was to induce an objective tumor response and to obtain a rapid weight recovery, using ten three-day courses of reduced dose cisplatin-etoposide. Between 2004 and 2009, 8 pediatric patients with DS due to a hypothalamic tumor and a median age at diagnosis of 6.5 months (range: 4-60 months) received 10 monthly courses of cisplatin (25 mg/m2/d on days 1 to 3) and etoposide (100 mg/m2/d on days 1 to 3). All patients had a rapid weight recovery and a tumor response in 6 (75%;partial response in four and minimal response in two), while the remaining two had a stable disease at completion of treatment. Mean time to weight recovery was 6 months (range, 5 - 7 months) for pilomyxoid astrocytoma patients, and 3.3 months (range, 3 - 4 months) for those with pilocytic astrocytoma. DS patients who received nutritional support (enteral or parenteral nutrition) had a mean time of weight recovery of 5 months (range: 3 - 7 months), while children who were able to assume high energy diet by oral route had a mean time of weight recovery of 8.66 months (range 3 - 19 months). After a follow-up time ranging from 22 to 89 months (median, 38 months), all patients are alive. In conclusion, a chemotherapy program with ten three-day courses of reduced dose cisplatin-etoposide, according to a LGG type schedule, seems appropriate and effective in far most cases of DS, with lower ototoxicity and myelosuppression compared with other LGG regimens.

Safer obstetric anesthesia through education and mentorship: a model for knowledge translation in Rwanda.

High rates of maternal mortality remain a widespread problem in the developing world. Skilled anesthesia providers are required for the safe conduct of Cesarean delivery and resuscitation during obstetrical crises. Few anesthesia providers in low-resource settings have access to continuing education. In Rwanda, anesthesia technicians with only three years of post-secondary training must manage complex maternal emergencies in geographically isolated areas. The purpose of this special article is to describe implementation of the SAFE (Safer Anesthesia From Education) Obstetric Anesthesia course in Rwanda, a three-day refresher course designed to improve obstetrical anesthesia knowledge and skills for practitioners in low-resource areas. In addition, we describe how the course facilitated the knowledge-to-action (KTA) cycle whereby a series of steps are followed to promote the uptake of new knowledge into clinical practice. The KTA cycle requires locally relevant teaching interventions and continuation of knowledge post intervention. In Rwanda, this meant carefully considering educational needs, revising curricula to suit the local context, employing active experiential learning during the SAFE Obstetric Anesthesia course, encouraging supportive relationships with peers and mentors, and using participant action plans for change, post-course logbooks, and follow-up interviews with participants six months after the course. During those interviews, participants reported improvements in clinical practice and greater confidence in coordinating team activities. Anesthesia safety remains challenged by resource limitations and resistance to change by health care providers who did not attend the course. Future teaching interventions will address the need for team training.

Preliminary investigation of the contribution of CYP2A6, CYP2B6, and UGT1A9 polymorphisms on artesunate-mefloquine treatment response in Burmese patients with Plasmodium falciparum malaria.

CYP2A6, CYP2B6, and UGT1A9 genetic polymorphisms and treatment response after a three-day course of artesunate-mefloquine was investigated in 71 Burmese patients with uncomplicated Plasmodium falciparum malaria. Results provide evidence for the possible link between CYP2A6 and CYP2B6 polymorphisms and plasma concentrations of artesunate/dihydroartemisinin and treatment response. In one patient who had the CYP2A6*1A/*4C genotype (decreased enzyme activity), plasma concentration of artesunate at one hour appeared to be higher, and the concentration of dihydroartemisinin was lower than for those carrying other genotypes (415 versus 320 ng/mL). The proportion of patients with adequate clinical and parasitologic response who had the CYP2B6*9/*9 genotype (mutant genotype) was significantly lower compared with those with late parasitologic failure (14.0% versus 19.0%). Confirmation through a larger study in various malaria-endemic areas is required before a definite conclusion on the role of genetic polymorphisms of these drug-metabolizing enzymes on treatment response after artesunate-based combination therapy can be made.

A three-day course can increase knowledge and interest in disaster medicine for medical students

The incidence of disasters increases and the need for physicians with an interest in disaster medicine is essential. As an early introduction of disaster medicine, medical students from Denmark, members of the Students' Society for Anesthesiology and Traumatology, participated on a three-day course, Trauma Days 2013, with full-scale simulations. The students underwent debriefings and questionnaires were handed out. 94% of the students increased their interest in disaster medicine.

Antibiotic therapy versus no antibiotic therapy for children aged two to 59 months with WHO-defined non-severe pneumonia and wheeze.

Worldwide, pneumonia is the leading cause of death among children under five years of age and accounts for approximately two million deaths annually. The World Health Organization (WHO) has developed case management guidelines based on simple clinical signs to help clinicians decide on the appropriate pneumonia treatment. Children and infants who exhibit fast breathing (50 breaths per minute or more in infants two months to 12 months of age and 40 or more in children 12 months to five years of age) and cough are presumed to have non-severe pneumonia and the WHO recommends antibiotics. Implementation of these guidelines to identify and manage pneumonia at the community level has been shown to reduce acute respiratory infection (ARI)-related mortality by 36%, although apprehension exists regarding these results due to the questionable quality of evidence. As WHO guidelines do not make a distinction between viral and bacterial pneumonia, these children continue to receive antibiotics because of the concern that it may not be safe to do otherwise. Therefore, it is essential to explore the role of antibiotics in children with WHO-defined non-severe pneumonia and wheeze and to develop effective guidelines for initial antibiotic treatment. To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged two to 59 months with WHO-defined non-severe pneumonia and wheeze. We searched CENTRAL (2014, Issue 1), MEDLINE (1946 to March week 3, 2014), EMBASE (January 2010 to March 2014), CINAHL (1981 to March 2014), LILACS (1982 to March 2014), Networked Digital Library of Theses and Dissertations (23 July 2013) and Web of Science (1985 to March 2014). Randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children aged two to 59 months with non-severe pneumonia and wheeze. We considered studies that defined non-severe pneumonia as cough or difficulty in breathing with a respiratory rate above the WHO-defined age-specific values (respiratory rate of 50 breaths per minute or more for children aged two to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months) and wheeze for inclusion. We have excluded non-RCTs (quasi-RCTs). Two review authors independently assessed the search results and extracted data. We did not identify any study that completely fulfilled our inclusion criteria. There is a clear need for RCTs to address this question in representative populations. We do not currently have evidence to support or challenge the continued use of antibiotics for the treatment of non-severe pneumonia, as suggested by WHO guidelines.

Biodegradable Antibiotic Delivery Systems in the treatment chronic osteomyelitis

An 82-year-old woman was referred to the orthopedic department with a three-month history of low-grade fever. She had a known past history of type 2 diabetes. She had been unwell for last 5-days, complaining of feeling hot and 'shivery' with general aches, particularly in her right shoulder. The staff in the residential home where she lived had called the general practitioner who had prescribed a three-day course of trimethoprim for a suspected urinary tract infection. On examination, she was pyrexia with a temperature of 39.5°C. She was drowsy but reusable. Pulse was 125 beats per minute and regular. Blood pressure was 90/55 mmHg. Heart sounds were normal with no added sounds or murmurs. The chest was clear. Her abdomen was soft and non-tender with no palpable masses or organs. The skin overlying the right shoulder was warm to touch and erythematous. She was unable to tolerate any passive movement of the joint. A plain x ray of her shoulder shows lucent defects in the head of the humerus with loss of the normally well-corticated surface. This is consistent with osteomyelitis. Two of 2-blood cultures and numerous operative cultures grew MRSA. His subsequent treatment consisted of intravenous vancomycin, achieving plasma drug levels approximating 24 μg/mL. This treatment was extended for 8 weeks, given the clinical concern for possible osteomyelitis in an area. Treatment was complicated by significant a decline in hearing. Biodegradable drug delivery systems provide a method for local delivery of drugs in deeper tissues, obviating parenteral or enteral usage; in some situations, a significant advantage is that much higher doses and/or strengths of the drug can be delivered locally than can be tolerated if the drug is delivered systemically. In this case report, we discussed the use of Biodegradable Antibiotic Delivery Systems in treatment chronic osteomyelitis.

Effect of hyperbaric oxygenation on metabolism of glutamine in the liver

The effect of three-day course of hyperbaric oxygenation (HBO; 3 atm, 50 min, 1 session per day) on glutamine metabolism in the liver has been investigated in 72 adult albino rats. The content of ammonia, glutamate, glutamine, activity of glutamine synthetase (GS), phosphate-dependent glutaminase (PDG), and glutamate dehydrogenase (GDH) were studied in left (LLL) and median (MLL) lobes of the liver. The course of HBO had an inhibitory effect on all the enzymes studied. Inhibitory effect of hyperoxia on GDH activity persisted up to day 11 after the course of HBO in both lobes of the liver, while decreased glutamate normalized in both lobes. Reduced glutamine concentration normalized to day 4, and the concentration of ammonia and remained elevated for 11 days after the end of hyperoxic exposure. Inhibitory effect of hyperoxia on GS activity in LLL and MLL disappeared on day 4 and day 11 day after the end of the HBO course. PDG activity reduced by HBO in both lobes normalized to the day 4 day after oxygenation; however, on day 11 it selectively decreased in LLL, where simultaneous stimulation of GS activity was also observed. The results demonstrate different sensitivity of liver GS, PDG and GDH of normal rats to the inhibitory effect of HBO. Different dynamics of GS and PDG activity in LLL and MLL of oxygenated rats suggests functional heterogeneity of the glutamine cycle in hepatocytes of liver lobes after HBO.

Education of clinical nurses in nursing documentation in accordance with the VIPS-model.

The purpose of this study is to describe some effects on the clinical nursing documentation after registered nurses (RN) had participated in a three-day course in nursing documentation in accordance with the VIPS-model. Between November 1993 and December 1996, 4594 registered nurses participated in the course. In order to evaluate the effects of the course two questionnaires were sent out to 900 participants, one concerning the degree of development in their nursing documentation and another concerning what they perceived as inhibitors and facilitators to the development of nursing documentation. The result will be presented at the conference.