Characterization of Plasmid-Mediated Quinolone Resistance Determinants in High-Level Quinolone-Resistant Enterobacteriaceae Isolates from the Community: First Report of qnrD Gene in Algeria

Microbial Drug Resistance , Vol. 0, No. 0.


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Chronic kola nut consumption and its effect on uric acid level and lipid profile.

2016-04-26T11-58-18Z
Source: Journal of Molecular Pathophysiology
chinwe Ewenighi, Uchechukwu Dimkpa, Linus Onoh, Gladys Onoh, Uchechukwu Ezeugwu, Joy Dibia.
Background: Kolanut, a caffeine rich nut is widely consumed in West African cultures as food, drug and beverages. Little is known about the health implications of kola nut consumption in humans. Aim: The present study therefore aimed at assessing the effects of chronic consumption of kola nut on uric acid and lipid profiles in humans. Method: Thirty chronic kola nut consumers with mean age of 55 ± 9.15 yrs and their age-matched non-kola nut consuming controls with mean age of 57.50 ± 7.85 yrs were recruited from Uburu in Ohozara L.G.A of Ebonyi State, Nigeria. Blood samples were collected for the measurements of uric acid and lipid profile. Assays were done by enzymatic colorimetric methods. Result: The chronic kola nut consumers had significantly (p


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Editorial board members

Publication date: March 2016
Source:Gene Expression Patterns, Volume 20, Issue 2





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What level of ballistics protection do EMS providers need?

Body armor continues to be a heated topic of discussion in light of the daily threats responders' face

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Why a normal ECG has five visible waveforms

Each portion of a heartbeat produces a different deflection on the ECG. These deflections are recorded as a series of positive and negative waves. On a normal ECG, there are typically up to five visible waveforms: P wave, Q wave, R wave, S wave, T wave.

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Can your EMS director pass the physical ability test?

Wake County EMS Director Jose Cabanas completing the EMS Physical Ability Test.

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How labeling a patient's problem 'impaired consciousness' keeps me objective

Alcoholism affects people from all walks of life. There is no escape from its clutches for those afflicted with the disease. The rich, the poor and everybody in between has their share of alcoholic persons.

Responding to calls to treat intoxicated persons is frustrating, time consuming and has the potential to be the undoing of any well-meaning EMT or paramedic.

Remembering that a 911 call for an intoxicated person is the same thing as a call for a person with an impaired consciousness helped me keep things in perspective, and not judge the people entrusted to my care. When I learned to stop hearing the "intoxicated person" message from dispatch and replaced to words I heard to "impaired consciousness" my frustration diminished greatly.

Ultimately, people suffering from alcoholism deserve the same level of professionalism as everybody else.

Not so healthy
Fleas flutter around the sleeping man, land on his face, his hands, bite him, then fly off.

"Rubin!" I said, crouching down.

He was sixty, looked seventy, wrinkled, tired and just about done.

Sixty years. That's longer than most street people last. They don't have longevity.

Tonight, Rubin is inside, lying on a flea-infested air mattress at one of the state's largest homeless shelters. He considers the place his home. It's where he lays his head at the end of long days spent wandering the streets of Providence. They let him stay here, tucked away in the corner of the day room, along with anywhere from ten to 100 other homeless folks.

At six or seven in the morning, they are all shown the door, left to their own devices for the day. For some, that means looking for work. For most, it means looking for a high: booze, heroin, crack, pills; whatever works. Rubin depends on vodka in little half pints.

"I'm sleeping," Rubin said. "Leave me alone."

"They're kicking you out."

"Why""

"Because you are intoxicated."

He's nearly always intoxicated.

I watch as he closes his eyes and falls back asleep. The fleas return to his face. I brush them off, he swipes at my hand, thinking I'm a giant flea. He misses.

I pull a sleeping bag over his face and leave him where he lies.

The girl at the desk apologizes for calling us, but also lets us know that she's not going to be responsible for him if he gets sick. Or seizes. Or dies.

I tell her to call us back if he wakes up and walk back to the truck.

Rubin returns to his dreams.

Wealthy
At the end of the road, fifty yards from the river on the front steps of a well-maintained home, sits a 60-year-old woman. Her brother stands close by, apologetic and concerned.

"We tried to get her to go, but she won't budge."

The woman stayed seated, defiant. She knew what little control was hers was about to be taken away, and she had no intention of giving it up willingly.

A little dog scurried over. I knelt and scratched behind his ears as the intoxicated woman looked on.

"She's been drinking for 10 days. Says she wants to drink herself to death. My sister is inside getting some things."

I looked her in the eye while petting her dog.

"We're taking you to the hospital."

"Bullshit," she slurred.

One of the firefighters who was on scene before us chimed in.

"We can do this the easy way or the hard way, it's up to you."

I never was a fan of the strong-arm tactic.

"In five minutes we are going to be at the ER. I know you don't want to go but I am required by law to intervene if family members present a strong case that you may harm yourself. And, you are intoxicated, so I can't leave you here."

She tried to rationalize, claim her freedom was being compromised, get up and run, be a rock and simply not cooperate.

Years ago, I would have called police and let the firefighters help me wrestle her and tie her to the stretcher and drag her away from her home. Today, I let go of the dog, took hold of her arm, had my partner take the other and lifted her to her feet. We walked to the stretcher, put her on it and fastened the seat belts. The struggle lasted about 20 seconds.

Then the crying began. She cried all the way to the hospital, taking a break now and then to glare at me, but her resolve was broken, along with her spirit. She did make one desperate lunge for the rear door, but before the seat belt was undone I had her back down.

As I walked out the door of the ER, the woman's sister who had accompanied us in the back of the rescue stopped me. She took my hand and looked me in the eye.

"I want to thank you for being so kind."

She held the gaze for a moment, her eyes filled up and she turned and walked away.

I quickly wiped my own eyes and got back in the truck.

Alcoholism is a crafty, evil disease.

A little too wise
Monday she was drunk at home, a concerned friend called 911 to have strangers check on her well-being. I guess it is easier to call the fire department when a friend is in need than getting up and doing something yourself.

We found her inside her apartment, empty beer cans littering the floor, highly intoxicated. There is no law against being drunk at home, but our patient clearly needed some help.

After a small brawl, we talked her into going to the hospital for detox, hopefully eventual rehab.

Wednesday she was home again, drunk. This time she called 911 for a ride to the hospital because she wanted to go to detox. Apparently, rehab wasn't in the cards on Monday.

Saturday we got a call for an intoxicated person at an address on Broad Street. Our friend, drunk again, this time at an acquaintance's place. He was tired of her, wanted us to get rid of his problem guest.

By now I thought we had become friends with the woman. It's a short trip to the emergency room, but a bond quickly forms between patient and caregiver, especially a frequent customer.

Monday we got a call for a person down in the bushes. I saw a hand rise from some hedges in front of one of the high-rise buildings where the elderly and disabled residents of Providence reside. Walking closer, I saw my newest old friend, drunk again, unable to extricate herself from where she fell.

She fought for a while, learned quickly that a 60-year-old former prostitute is no match for five firefighters sent to help her. "I have a knife," she said, enraged now that we had her out of her nest.

You would think that after all of these years I would learn never to let my guard down. Because familiarity sets in by no means diminishes the potential threat on every call.

To the patients we are sent to treat, we are no more than a blur, a momentary diversion from their otherwise dreary existence. Once we part ways we are forgotten, the next person who enters their lives more important than the last.

She ripped open the front of her coat and brandished a 12-inch butcher's knife. Her eyes were wild, full of hate.

Before she had a chance to hurt herself, or us, we disarmed her, put her on the stretcher and took her to the hospital. There was no real malice once the knife was out of her hands, but for one moment, when she was capable of murder, she could have altered a lot of lives.

These three 60-year-old people have one thing in common. They call it alcoholism.

For me to remain objective, I call it impaired consciousness.

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Why a normal ECG has five visible waveforms

Each portion of a heartbeat produces a different deflection on the ECG. These deflections are recorded as a series of positive and negative waves. On a normal ECG, there are typically up to five visible waveforms: P wave, Q wave, R wave, S wave, T wave.

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Can your EMS director pass the physical ability test?

Wake County EMS Director Jose Cabanas completing the EMS Physical Ability Test.

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TN A-EMT - Greater Memphis EMS

Greater Memphis EMS is currently looking to fill several full and part time AEMT positions. Competitive pay and fexible scheduling.

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Why a normal ECG has five visible waveforms

Each portion of a heartbeat produces a different deflection on the ECG. These deflections are recorded as a series of positive and negative waves. On a normal ECG, there are typically up to five visible waveforms: P wave, Q wave, R wave, S wave, T wave.

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Can your EMS director pass the physical ability test?

Wake County EMS Director Jose Cabanas completing the EMS Physical Ability Test.

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Why a normal ECG has five visible waveforms

Each portion of a heartbeat produces a different deflection on the ECG. These deflections are recorded as a series of positive and negative waves. On a normal ECG, there are typically up to five visible waveforms: P wave, Q wave, R wave, S wave, T wave.

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Can your EMS director pass the physical ability test?

Wake County EMS Director Jose Cabanas completing the EMS Physical Ability Test.

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NAAC Launches New Interactive Educational Website

Mechanicsburg, PA - NAAC®, the nation's leading source for education and certification programs in ambulance billing and compliance, announces the launch of its all new website at http://ift.tt/1pBKzyG. NAAC- The National Academy of Ambulance Compliance™- was formed in 2008 to provide education and certification programs to ambulance billing and compliance professionals. Since ...

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Lack of mutation–histopathology correlation in a patient with Proteus syndrome

Proteus syndrome (PS) is characterized by progressive, disproportionate, segmental overgrowth, and tumor susceptibility caused by a somatic mosaic AKT1 activating mutation. Each individual has unique manifestations making this disorder extremely heterogeneous. We correlated three variables in 38 tissue samples from a patient who died with PS: the gross affection status, the microscopic affection status, and the mutation level. The AKT1 mutation was measured using a PCR-based RFLP assay. Thirteen samples were grossly normal; six had detectable mutation (2–29%) although four of these six were histopathologically normal. Of the seven grossly normal samples that had no mutation, only four were histologically normal. The mutation level in the grossly abnormal samples was 3–35% and all but the right and left kidneys, skull, and left knee bone, with mutation levels of 19%, 15%, 26%, and 17%, respectively, had abnormal histopathology. The highest mutation level was in a toe bone sample whereas the lowest levels were in the soft tissue surrounding that toe, and an omental fat nodule. We also show here that PS overgrowth can be caused by cellular proliferation or by extracellular matrix expansion. Additionally, papillary thyroid carcinoma was identified, a tumor not previously associated with PS. We conclude that gross pathology and histopathology correlate poorly with mutation levels in PS, that overgrowth can be mediated by cellular proliferation or extracellular matrix expansion, and that papillary thyroid carcinoma is part of the tumor susceptibility of PS. New methods need to be developed to facilitate genotype–phenotype correlation in mosaic disorders. © 2016 Wiley Periodicals, Inc.

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Three cases of Troyer syndrome in two families of Filipino descent

Troyer syndrome is a complex hereditary spastic paraplegia (HSP) due to a mutation in SPG20 first reported in the Old Amish population. A genetic mutation in SPG20 is responsible for a loss of function of the protein spartin in this disease. Since its initial report, this syndrome has also been reported in Turkish and Omani families. Here we report the case of three patients of Filipino descent with Troyer syndrome. Whole exome sequencing (WES) identified a homozygous mutation c.364_365delAT which predicts p.Met122Valfs*2 in SPG20. This is the same mutation identified in affected patients from the Omani and Turkish families, and is the first report of this syndrome in the Filipino population. Although Troyer syndrome has characteristic phenotypic manifestations it is likely underdiagnosed due to its rarity and we expect that WES will lead to identifying this disease in other individuals. © 2016 Wiley Periodicals, Inc.

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Analysis of TFGBR1*6A variant in individuals evaluated for Marfan syndrome

Marfan syndrome (MFS) and Loeys–Dietz syndrome (LDS) are genetic disorders that affect connective tissue as a result of dysregulated TGF-β signaling. MFS is most frequently caused by mutations in FBN1 whereas Loeys–Dietz syndrome results from mutations in TGFBR1 or TGFBR2. There is substantial inter- and intra-familial phenotypic variability among these disorders, suggesting the presence of genetic modifiers. Previously, a polymorphism in the TGFβR1 protein termed the TFGBR1*6A allele was found to be overrepresented in patients with MFS and was identified as a low penetrance allele with suggestion as a possible modifier. To further investigate the importance of this variant, a retrospective review of genetic and phenotypic findings was conducted for 335 patients evaluated for suspicion of MFS or related disorders. In patients with a diagnosis of MFS, the presence of the TFGBR1*6A allele was not associated with phenotypic differences. Similarly, careful phenotyping of patients who carried the TFGBR1*6A allele but did not have MFS did not identify an altered frequency of specific connective tissue features. In this small cohort, the results did not reach significance to identify the TFGBR1*6A allele as a major modifier for aortic dilation, ectopia lentis, or systemic features associated with MFS or other connective tissue disorders. © 2016 Wiley Periodicals, Inc.

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The role of objective facial analysis using FDNA in making diagnoses following whole exome analysis. Report of two patients with mutations in the BAF complex genes

The genetic basis of numerous intellectual disability (ID) syndromes has recently been identified by applying exome analysis on a research or clinical basis. There is significant clinical overlap of biologically related syndromes, as exemplified by Nicolaides–Baraitser (NCBRS) and Coffin–Siris (CSS) syndrome. Both result from mutations affecting the BAF (mSWI/SNF) complex and belong to the growing category of BAFopathies. In addition to the notable clinical overlap between these BAFopathies, heterogeneity exists for patients clinically diagnosed with one of these conditions. We report two teenagers with ID whose molecular diagnosis of a SMARC2A or ARID1B mutation, respectively, was established through clinical exome analysis. Interestingly, using only the information provided in a single clinically obtained facial photograph from each patient, the facial dysmorphology analysis detected similarities to facial patterns associated with NCBRS as the first suggestion for both individuals, followed by CSS as the second highest ranked in the individual with the ARID1B mutation. Had this information been available to the laboratory performing the exome analysis, it could have been utilized during the variant analysis and reporting process, in conjunction with the written summary provided with each test requisition. While the available massive parallel sequencing technology, variant calling and variant interpretation are constantly evolving, clinical information remains critical for this diagnostic process. When trio analysis is not feasible, additional diagnostic tools may become particularly valuable. Facial dysmorphology analysis data may supplement the clinical phenotype summary and provide data independent of the clinician's personal experience and bias. © 2016 Wiley Periodicals, Inc.

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State EMS directors discuss hot topics in rural EMS

SAN ANTONIO — Four state EMS directors shared the stage at the National Rural EMS Conference to discuss some of the more unique and pressing issues that rural EMS agencies are facing in the United States.

• Jay Bradshaw, retired Director of Maine EMS
• Joe Schmider, Texas State EMS Director
• Andy Gienapp, Manager of the Wyoming Office of Emergency Medical Services
• Tom Nehring, Director of the North Dakota Division of Emergency Medical Services and Trauma

The Recognition of EMS Personnel Licensure Interstate CompAct is model legislation written by the National Association of State EMS Officials that would allow EMTs and paramedics to have one license that is recognized by all states that have signed the compact. REPLICA would support providers that practice across state lines, a situation many urban providers never need to consider, but one that would help some rural communities gain access to a wider array of providers. 

When asked what advice they would give to rural EMS leaders the panel recognized that individuals running these agencies are balancing more than their fair share; often working full-time, being there for their family, all while managing their respective organizations. They recognized that rural EMS was created to fill a gap in care, and that this gap has only continued to grow, leading to a greater reliance on rural EMS with a shrinking level of support. 

When someone in the audience asked about lowering educational standards to allow for a greater number of applicants, the panel shut down that logic immediately. Nehring recognized that this was a tempting solution to current problems, but reiterated that for EMS to move forward as a profession, "going backwards would be a big mistake." The panelists also made sure to advocate for increased educational opportunities for leaders on the non-clinical components of running an EMS organization. 

After the panel Nehring and Gienapp reiterated that rural EMS has the capacity to bring lessons learned to the national conversation, and that the experiences of rural agencies could serve as learning opportunities for their urban counterparts. They also shone a light on the increasing number of hospital closures in rural areas, something of an underutilized window of opportunity for rural EMS leaders. 

Memorable quotes on rural EMS
"It's about funding, it's about workforce, and it's about leadership that doesn't know how to get the first two."
 – Andy Gienapp

"Stop trying to be an island within ourselves … it's a community approach."
 – Joe Schmider

"The more complex EMS becomes, the more competent leadership has to become."
 –Jack Stout, attributed

Key takeaways
Here are three key takeaways from the panel discussion:

• Rural EMS faces many barriers to success that their urban counterparts never need to consider, but they also exist in environments that have less of an issue with bureaucracy and red tape.
• Legislative changes such as REPLICA can be a big step forward for the industry.
• Solutions must be found that allow for the industry to remain solvent, without lowering any educational or hiring standards.

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Macrodactyly in tuberous sclerosis complex: Case report and review of the literature

Macrodactyly in the context of tuberous sclerosis complex (TSC) is a known but rare manifestation. We report the case of a boy diagnosed with TSC at 2 years and 4 months of age, presenting with bilateral macrodactyly of the first three fingers of both hands, with underlying radiographic changes, in whom molecular analysis identified a frameshift mutation on the TSC1 gene (encoding hamartin), leading to a premature stop codon. We reviewed the literature for reported cases of TSC patients with the same manifestation. In four of 14 patients, including ours, macrodactyly caused some type of joint limitation or flexion deformity, thus contradicting the established idea that this is a finding without clinical significance. Our patient is, to our knowledge, the first reported to have clear bilateral involvement. We briefly discuss the underlying mechanism for this phenomenon, which has yet to be fully elucidated, although somatic mosaicism for loss of heterozygosity at TSC loci is a plausible explanation. © 2016 Wiley Periodicals, Inc.

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Why a bully-free EMS workplace is 'just correct'

The news that a female firefighter, who died by suicide, had also received numerous sexist and harassing comments in social media should give us pause for concern. At this point in the investigation, it's very unclear whether there was a causal relationship between the death of Nicole Mittendorff and the messages; time will tell.

However, there have been other recent, well-publicized suicide deaths that may have been triggered by such bullying behavior. One of the most recent is the death of Evan Ziemniak. He was bullied at school and his parents are speaking out to prevent other tragic deaths.

The vast majority of public safety providers genuinely care about each other and their communities. We work alongside folks who don't look like us, but feel the same passion for the work we do. The desire to serve the community crosses all boundaries: race, sex, gender identity, religious beliefs, sexual orientation and socioeconomic status.

Nevertheless, it's perturbing and disturbing that in 2016 bullies continue to roam EMS and fire stations across this nation. It's even more alarming that bullying behavior can be so ingrained in a department's culture that mid- and senior management allow it to flourish through benign neglect.

A major role of leadership is to provide a safe workplace, including one that is free from harassment. Common sense, not federal law should be the driver of creating strong, fair policies that guide workplace behavior, rewarding those that promote teamwork and just culture, and punishing acts that can harm not just one individual, but a whole class of employees and the entire department.

Staff is also not absolved from being responsible to each other. We sit through hours of mandated training, reading the same bulletins year after year. But until it becomes an organizational norm that personal bias has no role in workplace behavior, we'll continue to numb a lot of brain cells just going through the routine.

As for the accusations that all of this harassment-free stuff is just "political correctness," it's not. Just call it "correct." This is stuff that parents should have told their children and school teachers should tell their students, long before they ever get to the workplace.

Personal bias is fine. You are entitled to your opinion. But we don't live in caves by ourselves.

Our lives today are tightly connected, both online as in person. Things that are said out of ignorance and meanness get amplified and take on greater meaning in an always-on world. It becomes very difficult to understand what impact such behavior will have on individuals, groups of people or entire departments.

But there is an impact. We can make sure it's a positive one, through good words and deeds, not disparaging ones.

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Molecular and clinical analyses with neuropsychological assessment of a case of del(10)(q26.2qter) without intellectual disability: Genomic and transcriptomic combined approach and review of the literature

Terminal deletion of the long arm of the chromosome 10 is a rare but well known abnormality, with a large phenotypic variability. Very few data are available about subtelomeric deletion 10q26 patients without intellectual disability. Herein, we report the case of a young adult with a classical 10q26.2qter deletion. She exhibited mainly short stature at birth and in childhood/adulthood without intellectual disability or behavioral problems. After clinical and neuropsychological assessments, we performed genomic array and transcriptomic analysis and compared our results to the data available in the literature. The patient presents a 6.525 Mb heterozygous 10q26.2qter deletion, encompassed 48 genes. Among those genes, DOCK1, C10orf90, and CALY previously described as potential candidate genes for intellectual disability, were partially or completed deleted. Interestingly, they were not deregulated as demonstrated by transcriptomic analysis. This allowed us to suggest that the mechanism involved in the deletion 10qter phenotype is much more complex that only the haploinsufficiency of DOCK1 or other genes encompassed in the deletion. Genomic and transcriptomic combined approach has to be considered to understand this pathogenesis. © 2016 Wiley Periodicals, Inc.

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State EMS directors discuss hot topics in rural EMS

SAN ANTONIO — Four state EMS directors shared the stage at the National Rural EMS Conference to discuss some of the more unique and pressing issues that rural EMS agencies are facing in the United States.

• Jay Bradshaw, retired Director of Maine EMS
• Joe Schmider, Texas State EMS Director
• Andy Gienapp, Manager of the Wyoming Office of Emergency Medical Services
• Tom Nehring, Director of the North Dakota Division of Emergency Medical Services and Trauma

The Recognition of EMS Personnel Licensure Interstate CompAct is model legislation written by the National Association of State EMS Officials that would allow EMTs and paramedics to have one license that is recognized by all states that have signed the compact. REPLICA would support providers that practice across state lines, a situation many urban providers never need to consider, but one that would help some rural communities gain access to a wider array of providers.

When asked what advice they would give to rural EMS leaders the panel recognized that individuals running these agencies are balancing more than their fair share; often working full-time, being there for their family, all while managing their respective organizations. They recognized that rural EMS was created to fill a gap in care, and that this gap has only continued to grow, leading to a greater reliance on rural EMS with a shrinking level of support.

When someone in the audience asked about lowering educational standards to allow for a greater number of applicants, the panel shut down that logic immediately. Nehring recognized that this was a tempting solution to current problems, but reiterated that for EMS to move forward as a profession, "going backwards would be a big mistake." The panelists also made sure to advocate for increased educational opportunities for leaders on the non-clinical components of running an EMS organization.

After the panel Nehring and Gienapp reiterated that rural EMS has the capacity to bring lessons learned to the national conversation, and that the experiences of rural agencies could serve as learning opportunities for their urban counterparts. They also shone a light on the increasing number of hospital closures in rural areas, something of an underutilized window of opportunity for rural EMS leaders.

Memorable quotes on rural EMS
"It's about funding, it's about workforce, and it's about leadership that doesn't know how to get the first two."
– Andy Gienapp

"Stop trying to be an island within ourselves … it's a community approach."
– Joe Schmider

"The more complex EMS becomes, the more competent leadership has to become."
–Jack Stout, attributed

Key takeaways
Here are three key takeaways from the panel discussion:

• Rural EMS faces many barriers to success that their urban counterparts never need to consider, but they also exist in environments that have less of an issue with bureaucracy and red tape.
• Legislative changes such as REPLICA can be a big step forward for the industry.
• Solutions must be found that allow for the industry to remain solvent, without lowering any educational or hiring standards.

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Ambulance contracts begin to measure what matters

By Jay Fitch, PhD

EMS systems often evolve slowly in the absence of a crisis. One needs only to look at the contracting and RFP processes utilized by many communities to see that the contracting processes for ambulance services have become stagnant. Without a scandal, bankruptcy or other red flag drawing scrutiny to the system, these agreements with ambulance services use antiquated provisions and often measure the wrong things.

Communities frequently rely on data and measures that are easy to find and calculate, rather than those that can be most effective in assessing performance and making improvements. Many communities focus almost exclusively on response time, subsidy amounts and the user fees charged by the contracted ambulance service.

Developing ways to effectively measure clinical performance and customer satisfaction is far more difficult. But with more communities focused on resident needs and the rise of patient-centered health care, building these metrics into ambulance contracts and budget cycles is critical to achieving the best outcomes for patients and the community.

Measuring what matters is key to that effort. In addition to baseline response time and service costs, RFPs must meaningfully delineate the expectations for clinical outcomes and improving the patient experience. To be minimally qualified to participate in a sophisticated procurement process, an organization needs to demonstrate its capabilities and experience measuring impacts on each of these dimensions.

Community leaders are beginning to appreciate that what they emphasize in the RFP shapes the expectations and performance of its provider. For example, clinical management in the call center is essential to begin making evidence-based decisions for safe and effective deployment and dispatch of resources.

In those systems where the response to every 911 call is "hot," leaders are not considering the risk versus the benefit. Any ambulance RFP that does not require utilization of an accredited emergency medical dispatch criteria quite simply is putting patients, caregivers and citizens at risk and should constitute culpable community negligence.

Because outcome data is often difficult for EMS agencies to access — and the EMS impact on patient outcomes is not always easy to determine — many of the clinical metrics being used in today's contracts focus on clinical skills and procedure success rates rather than patient outcomes. Process measures, such as intubation and intravenous access success rates and correct recognition of strokes and STEMIs, are a good start and can help an agency assess its own training efforts.

While the evidence base is growing, it still isn't always clear which processes are tied to good outcomes, although we're starting to achieve more clarity. At the same time, though, even our measurement of processes is limited.

The Cornerstone Survey, which last year asked more than 500 agencies about data collection and analysis, revealed that while most systems measure cardiac arrest return of circulation and STEMI and stroke recognition, only 53 percent track door-to-balloon time and only 47 percent track cardiac arrest survival to discharge [1].

In contrast, ambulance service contracts of the future will objectively report an expanded series of clinical process measures and ultimately will require linking those measures to actual outcomes as software tools facilitate improved data sharing — a few include these measures already. There is significant work that needs to be done to facilitate cost-effective data exchanges in a more integrated system of care. That said, several EMS software vendors have already created initiatives to meet this need.

The patient experience
Hallmarks of good system design and RFP processes were best articulated by the American Ambulance Association nearly a decade ago in its guide for contracting for ambulance service [2].

The five hallmarks are:

1. Holding the service accountable.
2. Objective and independent oversight.
3. Accounting for all system costs.
4. Requiring system features that ensure economic efficiency.
5. Ensuring long-term high-performance service through measurement.

Since the contracting guide was published, the health care community has widely adopted the Institute for Healthcare Improvement's Triple Aim, placing an increased emphasis on the patient experience in addition to heath outcomes and costs. As they continue to advocate for value-based purchasing, federal agencies may well use an EMS agency's patient satisfaction scores when determining reimbursement levels, as they do in the hospital setting by utilizing the Hospital Consumer Assessment of Healthcare Providers and Systems.

The HCAHPS survey is a very structured process, typically administered by a third party. Yet while nearly six of 10 agencies reported in the Cornerstone Survey that they are attempting to track patient satisfaction, only 18 percent are measuring it through a third party.

EMS agencies can expect that future professionally managed RFPs will likely require the independent measurement of patient satisfaction. This will be a significant factor used to differentiate the agency's performance under the contract.

While the state of performance measurement in EMS continues to evolve, traditional measures to report performance used in professionally managed RFP processes are clearly moving beyond response time to include increasingly sophisticated measures of clinical metrics and patient satisfaction. That trend will continue, and future ambulance RFPs and contracts will require more integration with local healthcare systems in order to truly measure what matters.

About the author
Jay Fitch is the founding partner at Fitch & Associates, which has managed procurements successfully in major U.S. cities and smaller communities. Contact Jay directly at jfitch@emprize.net.

References
1. Fitch, J. & Fuentes, G. (2016). The State of Data Use in EMS. Download the Cornerstone survey.

2. American Ambulance Association (2008). EMS Structured for Quality: Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service.

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Prevent Laundry Packet Poisoning

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Prevent Laundry Packet Poisoning

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Prevent Laundry Packet Poisoning

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Prevent Laundry Packet Poisoning

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Evaluation of sleep habits in children with obesity

2016-04-26T06-47-38Z
Source: Journal of Contemporary Medicine
Samet Özer, Hasan Bozkurt, Ergün Sönmezgöz, Resul Yılmaz, Osman Demir.
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Clinico laboratory determinants of outcome among babies with perinatal asphyxia in Osogbo, Southwestern Nigeria

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Olusegun J. Adebami, Victor I. Joel-Medewase, Gabriel A. Oyedeji.
Background: Many clinical, pathological, biochemical and metabolic changes occur as a result of perinatal asphyxia. These changes affect many organ and systems like central nervous system, cardiovascular system, pulmonary, renal, adrenal, gastrointestinal tract, skin and haemopoetic systems. The aim of the study was to identify various clinical and biochemical determinants of outcome in perinatal asphyxia so as to institute proactive the management of such babies. Methods: All newborn infants with birth asphyxia over 5 year period (2009-2013) were retrospectively studied. The data studied included place of birth, gestational age, Apgar score, mode of resuscitation, details of complete physical examination especially as regard each of the system. Results of investigations like haematocrit, serum electrolytes and urea, blood glucose done in the first 24 hours of life and also other investigations like lumbar puncture, full blood count, cultures were noted. The outcome studied was survival and death of the babies. Results: One thousand, six hundred and seven babies were admitted into special care babys unit over the 5 year period, between 2009 and 2013. Nine hundred and seventy nine (60.9%) of them were males while 628 (39.1%) were females, M:F ratio was 1.6:1. Of the 1607 babies, 563 (35.0%) were asphyxiated. Of 1607 admitted during the period of study, 304 (18.9%) died while 128 (22.7%) of 563 babies with perinatal asphyxia died. Therefore, perinatal asphyxia accounted for 42.1% of the total mortality. 22 (7.8%) of the 280 babies who suffered moderate asphyxia compared with 106 (37.9%) of 283 babies who suffered severe asphyxia died. (χ2 = 72.4, p=0.000). Many of the asphyxiated babies had multisystemic adverse features. Significantly more babies who were out born, low birth weight, macrosomic and hypothermic than otherwise died. Also more babies with cyanosis, respiratory distress, apnoea, abdominal distension, feed intolerance, oliguria/anuria, bleeding disorder, abnormal muscle tone, seizures, bulging frontannel, and coma died, p ≥ 0.001. Also, mean haematocrit, plasma potassium and urea was significantly lower while plasma sodium was significantly higher among the babies who survived (p ≥0.001). Conclusions: Our findings have highlighted the major role of asphyxia in neonatal mortality and multisystemic morbidities or complications which contributed to death. It is therefore, likely that efforts at preventing perinatal asphyxia will be more rewarding. Such efforts include free and compulsory antenatal care, training of more skilled labour attendants and women empowerment.


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Determinants of nutritional anaemia in children less than five years age

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Sandip Ray, Jagdish Chandra, Jayashree Bhattacharjee, Sunita Sharma, Anuja Agarwala.
Background: According to WHO, highest prevalence of anemia is found in pre-school aged children. The objective of this study was to determine demographic, socio-economic & nutritional factors for nutritional anemia in children


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A comparison of pRIFLE and AKIN criteria for acute kidney injury in pediatric intensive care unit patients

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Srinivasa S., Reshmavathi V., Srividya G. S..
Background: ADQI group proposed the Risk, Injury, Failure, Loss of Kidney Function, and End-stage Kidney Disease (RIFLE) criteria for defining AKI. RIFLE criteria were later modified for paediatric patients and termed as Paediatric Risk, Injury, Failure, Loss, End Stage Renal Disease (pRIFLE). The Acute Kidney Injury Network (AKIN) group proposed modification to this system. While there are studies comparing RIFLE and AKIN criteria, they are limited to adult population. This study aims to compare between the pRIFLE and AKIN criteria in critically ill children admitted to Pediatric intensive care unit (PICU). Methods: All children admitted to PICU during December 2013 to May 2015 were included in the study. Serum creatinine was estimated on alternate days till death or discharge. The performance of pRIFLE and AKIN criteria for diagnosis and classification of AKI and its association with mortality was compared. Results: AKI occurred in 178 (26.1%) PICU patients through pRIFLE, risk in 108(15.9%), injury in 51 (7.5%) and failure in 19 (2.8%), while by AKIN criteria, AKI occurred in 248 (36.5%) patients, with 93 (37.5%) in Stage 1, 88(35.5%) in Stage 2 and 67(27 %) in Stage 3. Mortality rates were 13 (27.65%), 7 (14.89%), 12 (25.53%) and 15 (31.91%) for patients without AKI and at stages of Risk, Injury and Failure, respectively according to pRIFLE criteria. While for AKIN criteria, mortality rates were 7 (14.89%), 14 (29.78%), 15 (31.91%) and 11 (23.4%) for patients without AKI and at stages 1, 2 and 3 respectively. For pRIFLE criteria odds ratio (OR) for mortality was 0.92, 5.22 and 73.71 for Risk, Injury and Failure stage respectively. Results for AKIN criteria were, OR of 2.98, 3.60 and 3.15 for stage 1, 2 and 3 respectively. Conclusions: A higher incidence of AKI was diagnosed by AKIN criteria in comparison to pRIFLE criteria. Patients diagnosed with AKI had higher mortality. Both criteria had good association with mortality.


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Knowledge and attitude towards oral rehydration therapy among mothers of under-five children of South Rajasthan, India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Hemant Jain, Subhash Bamnawat.
Background: Diarrhoea is the major cause of morbidity and mortality among children less than 5 year of age. Adequate rehydration therapy is most important aspect of management. Home based Oral Rehydration Therapy (ORT) prevents morbidity and mortality. In this study our objective was to assess the awareness, knowledge and practice of mothers of under-five children regarding ORT and home management of diarrhoea. Methods: A cross-sectional study was carried out at tertiary care centre of south Rajasthan. A questionnaire was provided to all the mothers of under-five children. Results: A total of 235 mothers were enrolled. 65% mothers have awareness regarding diarrhoea prevention. 80% of mothers were aware of Oral Rehydration Solution (ORS) and 72.7% knew how to prepare and administer ORS. Also, majority of mothers 78% were aware about home available fluids for rehydration. Knowledge of danger sign of severe dehydration was poor. Mothers educated only till class eight were almost twice less likely to know about ORS preparation as compared to better educated mothers (70%vs 30%). No association was found between lack of knowledge regarding home available fluids with younger age. Conclusions: Majority of mothers were aware regarding ORS and home available fluids. Knowledge of danger signs related to severe dehydration was low. Lack of education predisposed to ignorance regarding ORS preparation. Health education will be required to prevent diarrhoea morbidity and mortility.


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Effect of dengue fever on serum aminotransferases in children

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Rohit Khandelwal, Leeni Mehta Khandelwal, Susheela C..
Background: Dengue infection is associated with liver dysfunction, which tends to become severe with severe dengue. In the acute phase of the disease, an increase occurs in aminotransferases, the levels of which subsequently decrease as the liver function recovers. Significant rise of liver enzymes helps in recognition of severe forms of dengue infection. Methods: The study was conducted in the Department of Pediatrics of Vydehi Institute of Medical Sciences and Research Center, Bangalore from January 2015 to June 2015. 50 patients of 1-14 years age group, who presented with fever of recent duration and serologically positive for dengue, were included in the study. Results: 38% (19) were females and 62% (31) were males. NS1 was positive in 48% (24) and IgM was positive in 52% (26) of patients. IgG was negative in all the patients. AST was raised in 36% (18) of patients, ALT was raised in 34% (17) patients and ALP raised in 42% (21) patients. AST (Mean ± SD 53.84±43.32) was raised more than ALT (Mean ± SD 48.76±41.11) Conclusions: Liver enzymes were mildly elevated in patients with dengue fever in the initial stage of illness. AST was elevated more than ALT.


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Clinical profile and outcome of poisoning in pediatric age group at a tertiary care teaching hospital, Mandya, Karnataka, India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Sridhar PV, Sandeep M., Thammanna PS.
Background: Poisoning causes considerable morbidity and mortality worldwide. Most of the poisoning in children is accidental and most cases are preventable. The profile and outcome of poisoned patients vary from place to place. Objective was to study the profile and outcome of poisoning in Pediatric age group. Methods: A 2 year retrospective study of Pediatric poisoning cases at Mandya Institute of Medical Sciences, Mandya from August 2013 to July 2015 was conducted; data was collected in predesigned proforma and analyzed. Results: Poisoning patients constituted 5.667% of all Pediatric admission, Male: Female ratio was 1.24: 1, 157 (62.06%) were from rural area, 139 (54.94%) of children were of the age 1- 4 years. Most of poisoning happened in home environment (n= 216, 85.38%), majority were accidental poisoning (n= 217, 85.77%), kerosene (n= 89, 35.18%) was the most common compound responsible for poisoning, followed by drugs (n= 38, 15.02%). 142 (56.13%) children were discharged within 24 hours of admission, overall survival rate noted in the study is 98.81% (n= 250). Conclusions: Incidence of poisoning in Pediatric age has remained same. Kerosene, drugs and pesticides continue to be leading causes of poisoning. Child under the age of


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Nutritional status of adolescent school children in a semi-urban area based on anthropometry

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Vinoth Selvaraj, Shanthi Sangareddi, Lakshmi Velmurugan, Umakanthan Muniyappan, Fatima Shirly Anitha.
Background: Adolescent nutrition is generally given less importance when compared to the under-five nutrition in developing countries like India. Studies throwing light on the nutritional status of adolescent children are needed. Aims and objectives of the study were to know the prevalence of obesity, overweight, thinness, severe thinness and stunting in adolescent schoolchildren based on anthropometry and its association with various factors. Methods: A cross sectional study was done in six schools in a semi urban area of Southern part of India during November 2012-November 2013.Obesity,overweight,thinness, severe thinness and stunting were determined in the children of the age group of 9-17 years based on WHO Z scores. A predesigned questionnaire and clinical examination were used to find out the factors associated with malnutrition and their implications. Results: Out of the 2100 children studied, the prevalence of obesity was 6%; overweight 10.9%, thinness 13%; severe thinness 5% and stunting 19.8%. Mothers education, occupation and socioeconomic status have significant associations with both over nutrition and under nutrition. Skipping breakfast is associated with thinness. Conclusions: Even though obesity and overweight are increasing in recent times; under nutrition is still prevalent in adolescent school children. Routine school health visits, improving female literacy, dietary modifications, imparting health as well as physical education are the need of the hour to avoid malnutrition in adolescent school children.


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Outpatient management of severe acute malnutrition among children under five years old, in Yemen: a retrospective cohort study

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Salem Muftah.
Background: severe acute malnutrition is one of the major health problems in Yemen. The aim of this study is to determine the efficacy of national guidelines of C-MAM on management of severe acute malnutrition among under five years old children in Yemen. Methods: Retrospective cohort study, conducted during the period from 5 October 2011 to 5 October 2013. Study procedures involved assessing clinical records of 303 children aged 6-59 months. The outcomes were recovery, death, default and transfer from programme. Results: a total of 303 children (6-59 months old) suffered from SAM were underwent treatment in the C-MAM programme. Recovered 31 (10.2%), died 10 (3.3%), transferred 19 (6.3%), defaulted 243 (80.2%) and median stay of children in programme were 40 days. In children who defaulted from the programme, a Chi-square test for independence indicated significant association to children aged less than 24 months (Chi(2); 4.441, df;1, and p = 0.025). There were no significant associations between defaulted children and gender, residents and distances to OTP service. Logistic regression identified four significant contributing factors to high defaulter rate: new admission in the programme (OR 6.904; 95%CI: 1.089-43.788), MUAC entrance criteria less than 115 (OR 0.247; 95%CI: 0.115-0.533), z-sore less than -3SD (OR 9.236; 95% CI: 4.940-16.475) and length of stay in the programme more than 42 days (OR 6.353; 95% CI: 3.623 11.022). Conclusions: Low recovery and high defaulter rates of children with SAM were identified as a major determinant of a performance indicator values in these communities.


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Pulse oximetry as a simple diagnostic test for persistent pulmonary hypertension of newborn in limited resource settings

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
G. Fatima Shirly Anitha, S. Lakshmi, C. Danny Darlington.
Background: Persistent Pulmonary Hypertension of newborn (PPHN), results from the disruption in the normal perinatal fetal- neonatal circulatory transition. The condition remains a difficult neonatal emergency to manage which is mainly attributed to the delay in diagnosis and stabilisation. Although the management of PPHN involves advanced diagnostic and therapeutic interventions, our study highlights that PPHN can be diagnosed even in limited resource settings, with simple bedside evaluation of pre-ductal and post-ductal saturation (Spo2) difference. Methods: A retrospective study of neonates with PPHN, admitted in NICU, of a government hospital in a limited resource setting, over a period of 6 months. Results: Out of the 592 neonates admitted during the 6 months period in NICU, PPHN was diagnosed in 26 neonates (4.4%).The incidence was higher for male (57.7%),term gestation (84.6%), and appropriate for gestational age- AGA (88.5%). Meconium aspiration (53.8%) followed by perinatal asphyxia- clear liquor (30.8%) were the most common underlying etiology for PPHN in our study. Around 61.5% were diagnosed with PPHN based on pulse oximetry alone before the first dose of sildenafil, which was confirmed by ECHO later in 75% of the cases. PPHN improved in 92.3% of the study population (24/26 cases), out of which 62.5% were diagnosed based on pulse oximetry alone before intervention. Conclusions: Our study emphasises that even in peripheral health centres with limited resources, PPHN can be diagnosed by pulse oximetry (pre and post ductal Spo2 difference of >10%) along with clinical assessment. Such critically ill neonates can be initiated on pulmonary vasodilators like sildenafil and stabilised at the earliest that is crucial before referral to a tertiary care centre.


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Clinical profile and outcome of dengue fever and dengue haemorrhagic fever in pediatric age group

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Jasashree Choudhury, Debaprasad Mohanty, Sidharth Sraban Routray.
Background: Dengue infection, an arthropod-borne viral hemorrhagic fever, continues to be a major challenge to public health, especially in South-East Asia. We have done an observational study of dengue and dengue hemorrhagic fever in which we have studied the clinical pattern of dengue presentation. Methods: This study was conducted in the CICU and PICU of SCB medical college, Cuttack, Odisha, India. 100 patients, serologically dengue positive were included in this study. Hematological and other clinical parameters were evaluated. Statistical analysis was done after estimating p-value. Results: Fever, vomiting, abdominal pain, hepatomegaly, bleeding diathesis and hypotension were common clinical symptoms. Serological tests, hematocrit, platelet counts, liver enzymes and abdominal ultrasonography and fluid therapy were useful in management of all cases. Conclusions: Patients presented with variable symptoms both in dengue fever and dengue hemorrhagic fever in pediatric age group.


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Chronic juvenile recurrent parotitis: a retrospective study in a tertiary care hospital in South India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Manoj Joshi, Dilip Phansalkar, Zile Singh.
Background: Chronic juvenile recurrent parotitis is a rare disease with unknown etiology. This study was aimed to analyze clinico-social parameters of chronic juvenile recurrent parotitis in children. Methods: Case records of nine children with recurrent parotid swellings and radiological diagnosis of chronic juvenile recurrent parotitis were reviewed from September 2012 to March 2015. These were assessed for parameters like gender, age, laterality, number of recurrences, symptoms of presentation, associated conditions, radiology reports, treatment done, outcome and follow up. Results were analyzed by using percentage. Results: Male to female ratio was 2:1. Mean age of presentation was 6.33 years. Five cases (62.5%) were left sided, three cases (33.3%) were right sided and one case had bilateral parotid involvement. Pain and swelling were present in all nine patients. Fever and whitish discharge from duct were present in seven and two patients respectively. Numbers of recurrences were in range of one to 12 times per year. Six (66.7%) children had associated active viral respiratory tract infection during or just before the attack. Sonography was diagnostic in all cases. Sialography showed punctate sialectasis. Two patients developed suppuration in their second recurrence and underwent drainage. Mean follow up period was 7.1 months (1- 24 months).Seven patients were asymptomatic till last follow up. Two patients had recurrence while on oral antibiotic treatment. Conclusions: In chronic juvenile parotitis morbid recurrences are common after variable interval and even while on treatment. Acute viral infections contribute to exacerbation of symptoms. Sonography is useful in diagnosis. It may rarely suppurate and need drainage. However a larger prospective study is needed to establish these findings.


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Estimation of small intestinal bacterial overgrowth in children patients with different gastrointestinal symptoms

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Dong Xi, Roger Kim, Yatian Zhang, Fernanda Kupferman, Radha Nathan.
Background: Small intestinal bacterial overgrowth (SIBO) is a condition presenting with increased bacterial colonization. Lactulose breath test (LBT) is widely used for the diagnosis of SIBO. However the clinical symptom most likely to have positive LBT is still unknown. The objective of the study was to analyze the correlation between different gastrointestinal (GI) symptoms and positive LBT, and identify the symptom with highest positive LBT rate. Methods: Retrospective study was performed in pediatric patients who underwent LBT from 2011 to 2014. Patients presented with one or multiple GI symptoms. LBT was performed and considered to be positive if hydrogen level was increased by 20ppm. The percentage of positive LBT in all the patients and patients with individual GI symptom was calculated. The symptom with highest positive LBT rate was identified. Results: Totally 48 patients were tested. 34 patients (71%) were found to have positive LBT and 14 patients (29%) were negative. LBT was found to be positive in 85% of patients with failure to thrive, higher than other GI symptoms. Failure to thrive was identified to have highest positive LBT rate and less likely to be associated with multiple manifestations in patient with SIBO. Conclusions: Our study showed strong correlation between positive LBT and failure to thrive, and less association of failure to thrive with multiple symptoms in SIBO. LBT should be considered in patients with failure to thrive and no other etiologies.


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Hyponatremia in lower respiratory tract infections

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Chaitra K. M., Mohan Kumar N., Saipraneeth Reddy G..
Background: Hyponatremia is the most common electrolyte abnormality seen in PICU. The main Objective is to characterize the relationship between hyponatremia within 2 hours of admission to the intensive care unit, in the setting of lower respiratory tract infections, and to investigate whether there is a link between hyponatremia and the severity and outcome of LRTI. Methods: This was a prospective medical chart review of all children admitted to the PICU with a diagnosis of lower respiratory tract infections such as pneumonia, bronchiolitis, wheezing, empyema. Between Jan 1, 2015, and june 30, 2015. Severity of Hyponatremia was defined as mild= serum sodium concentration 131-135 mmol/L, moderate = 126-130 mmol/L, and severe HNa = less than 125 mmol/L (the normal values for serum sodium at our institution are 135-145 mmol/L). Results: The present study showed that hyponatremia was a frequent finding in children with bronchopneumonia 28 (46.7%). Lobar pneumonia which was next common respiratory infection in our study had hyponatremia in 6 cases (50%) In our study it was found that all cases with empyema had hyponatremia (100%). Bronchiolitis and wheeze associated LRTI relatively had less incidence of hyponatremia in our study. on the whole, it was found that among all hyponatremia cases in lower respiratory tract infection, mild hyponatremia was common (70.7%), followed by moderate and only 3 cases were having severe hyponatremia. Conclusions: Our study suggests that all cases of empyema develop hyponatremia is a new association derived. Patients with lobar segmental pneumonia and bronchopneumonia are at higher risk of developing moderate or severe Hyponatremia. Thus the appropriate fluid therapy must be carefully arranged in children with lower respiratory tract infection.


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A study of clinical profile and outcome of intra ventricular hemorrhage in neonates admitted to neonatal intensive care unit of a tertiary care hospital, Eluru, Andhra Pradesh, India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Majeti Srinivasa Rao, Manas Ranjan Sahoo, Arigela Vasundhara, Swetha K., Sudarsini P..
Background: The human hemostatic system is dynamic and is profoundly influenced by age. Although considered immature in the new-born, it is a physiological system which results in few problems for the healthy term neonate, but may contribute to morbidity in the sick and preterm infants when additional acquired abnormalities may be present. The objectives were, the study has been conducted to evaluate the clinical presentation, etiological risk factors of Intraventricular haemorrhage (IVH) and to correlate the birth weight, gestational age, sex, mode of delivery, perinatal factors with the incidence of IVH and to study the immediate outcome. Methods: This is a prospective study which included neonates admitted in the Neonatal intensive care unit (NICU) of Department of Paediatrics, Alluri Sita Rama Raju Medical College, Eluru, Andhra Pradesh, India during the period of March 2013 and September 2014. We enrolled 135 newborns in the study and blood investigations and transcranial USG was done in all. Results: Incidence of IVH in new-borns admitted in NICU at Alluri Sita Rama Raju Medical College was 13.3% (18 out of 135 babies), whereas incidence of IVH in preterm babies was 26.9% (17 out of 63 babies) and incidence of IVH in term babies was 1.3% (1 out of 72 babies). 94.4% of the new-borns with IVH had prolonged prothrombin time (p


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Association of obstructive sleep apnea on surgically treated cleft anomalies

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Madhava Kamath K., Prijo Philip, Vikram Shetty, Rajesh Venkataram, Giridhar B. H..
Background: Palatoplasty is frequently employed to correct the many anatomical and physiological effects of cleft disorders in children, including Obstructive Sleep Apnea (OSA). It is as yet unclear, whether Sleep Disordered Breathing (SDB) and OSA are encountered post palatoplasty. This study attempts to analyze the occurrence, if any, of the same. Methods: The study is a retrospective analysis, involving patients who had undergone palatoplasty. Patients were subjected to overnight Polysomnography (PSG), and data pertaining to Apnea Hypopnea Index (AHI), Desaturation Index (DI) and Periodic Limb Movements (PLMS) were recorded. Results: Of the 21 patients evaluated for post palatoplasty OSA, eleven patients were found to have mild OSA (52.3%), and four patients had moderate OSA (19.04%). Of the patients with mild OSA, five patients had complaints of postoperative snoring (45.4%). Conclusions: A sizeable risk of post palatoplasty OSA does exist, and the incidence of postoperative OSA may be higher than previously noted. However, further studies are warranted, in this regard.


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A study on knowledge, attitude and practice of sexually transmitted diseases and HIV in adolescent population in Wardha, Maharashtra, India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Manish A. Jain, Shuchi M. Jain, Shubhangi Patil, Akash Bang.
Background: Adolescent sexuality leads to adolescent pregnancy, unsafe abortion, Reproductive Tract Infections, Sexually transmitted infections and HIV. Over 35% of all reported HIV/AIDS infections in India occur amongst young people 15-24 years age. To study knowledge, attitude and practice regarding this sensitive problem among adolescents, which can help young people, overcome from sexual related problems. Methods: Systematic random sampling was used to select participants from the schools. 375 students were selected for the study. A predesigned, pre-tested, self-administered multiple response questionnaires was provided to the students. Results: Regarding knowledge about STDs, 73.9% had heard about HIV and 11.5% about syphilis Genital discharge as a symptom of STD was known to 171 (45.6%) students, genital ulcer was known to 67 (17.9%) students while dysuria was known to 23.2% of students. Nearly 50% of students had knowledge about routes of transmission of HIV. However majority of student had misconceptions regarding transmission of HIV. Males had better knowledge as compared to females regarding vertical and transfusion related transmission.15% accepted that they have used condom in which the proportion of males was higher. The attitude of students about having multiple sexual partners was very casual. Significant proportions (39%) of students also feel that sexual intercourse make them popular. Conclusions: There was an evident gap between knowledge and practices especially with respect to the sexual practices of youth which needs to be bridged.


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Prevalence of obesity and its risk factors in school going adolescents of urban Bangalore, India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Vedavathy S., Ganesh Kamath, Sangamesh.
Background: Obesity, one of the most widespread and major problems affecting children and adolescents is of global nutritional concern. In last two decades, the prevalence of obesity has doubled in children and tripled in adolescents in United States of America. There is not enough data on the prevalence of obesity in adolescents in urban Bangalore. Hence the present study aims to fulfil this urgent requirement. Aims & objectives of the study were to study the prevalence of obesity and its risk factors in school going adolescents of urban Bangalore. Methods: Observational study conducted in adolescents between the ages 11 to 19 years from the schools around Indira Gandhi Institute of Child Health, Bangalore. Results: The maximum number of adolescents in the present study belonged to the 14 years age group. Majority of the adolescents studied had a birth weight of 2.5 to 3.5 kg. 6.7% of the total adolescents had history of sleep disturbance. There was family history of hypertension in 19.4%, diabetes mellitus in 8.7%, obesity in 9.9% and cardiovascular diseases in 1.1% of the adolescents. The prevalence of obesity was 5.9%. Conclusions: The overall prevalence of obesity is 5.9%, 4.2% girls and 6.9% boys are obese. Obese children were more likely to belong to higher socioeconomic strata; more obese children had mixed diet. Family histories of hypertension, obesity and diabetes mellitus were significant risk factors. Sleep disturbance was associated with obesity.


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A study on incidence of congenital anomalies in newborns and their association with maternal factors: a prospective study

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Rekha Thaddanee, Hemant S. Patel, Nilesh Thakor.
Background: Congenital malformation represents defects in morphogenesis during early fetal life. Congenital anomalies account for 815% of perinatal deaths and 13-16% of neonatal deaths in India. The objective was to study incidence of clinically detectable congenital malformations in newborns delivered at a tertiary hospital and their association with maternal factors. Methods: The present study is a prospective study of all the newborns delivered at Obstetrics and Gynecology Department, GMERS Medical College, Dharpur-Patan, Gujarat, India for a period of three years from 1st January 2013 to 31st December 2015. Total 2760 consecutive births including both live born babies and still born babies were examined after taking verbal and written consent of their mothers for a visible structural anomalies to determine the overall incidence of congenital malformations and their association with maternal factors. Data were statistically analyzed using SPSS software (trial version). Results: A total of 2760 babies were born out of which 38 were twins. Total numbers of malformed babies were 34, so total point incidence of congenital anomalies turned out to be 1.23%. Out of total 2722 mothers 1815 (66.7%) were in the age group of 21-35 years and out of them 30 (1.70%) malformed babies were born. 167 (6.13%) mothers had consanguineous marriage and out of them 5 (2.99%) had malformed babies. 9 (0.33%) mothers had previous malformed child and out of them 3 mothers gave birth of 3 (33.33%) malformed babies. 397 (14.58%) mothers had history of previous abortion and out of them 10 (2.51%) had malformed babies. 151 (5.54%) mothers had severe anemia and out of them 09 (5.90%) had malformed babies. Conclusions: From present study it has been concluded that congenital anomalies in newborns were significantly associated with maternal factors like maternal age, consanguinity, previous child with malformation, history of previous abortion and severe anemia.


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Reevaluation of baseline Widal titres in children: a cross-sectional survey of 250 children (1-15 years) in and around Davangere, Karnataka, India

2016-04-26T05-24-29Z
Source: International Journal of Contemporary Pediatrics
Ramesh H., Nagesh B. P., Sandeep Karanam, Sankeerth Yellinedi, Suresh Babu P. S..
Background: Typhoid fever is a serious health problem in developing countries including India. Isolation of S. typhi by culture is the gold standard for diagnosis, but the positive cases are very less, time consuming and expensive, so the best alternative is Widal test. Widal test can be used as a diagnostic tool if we know the baseline titres in a particular community. Objective: To re-evaluate the baseline Widal titres in apparently healthy children in and around Davangere, and to find the significance of 1:160 titres in Widal test. Methods: Cross sectional study was done on 250 children. Tube agglutination test was done on 112 healthy and 138 children with minor nontyphoidal illness. Titres were studied in relation to age, sex, nutritional status and healthy children to minor nontyphoidal illness. Results: Out of 112 healthy children, 52.7% had titres less than 1: 20, 25% had 1:20, 18.8% had 1:40 and 3.6% had a titre level of 1:80 for O antigen of S. typhi. 63% children had a titre of less than 1: 20, 21.4% had 1:20, 8% for 1:40 and 7.1% had a titre of 1:80 for H antigen of S. typhi. For H antigen of S. paratyphi A the titres for less than 1:20 were 83%, 8% cases had a titre of 1:20 and 4.5% cases had titre levels of 1:40 and 1:80. No children had a titre value of ≥1:160 for both S. typhi and paratyphi A in the healthy children group. Conclusions: The baseline titres of healthy children in all the age groups and both sex is ≤ 1:80 for O and H antigen of S. typhi and H antigen of S. paratyphi A.


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Intestinal failure following necrotizing enterocolitis: A clinical approach

Early Human Development

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Combination of preoperative platelet/lymphocyte and neutrophil/lymphocyte rates and tumor-related factors to predict lymph node metastasis in patients with gastric cancer

European Journal of Gastroenterology & Hepatology

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Success of extracorporeal shock wave lithotripsy in chronic calcific pancreatitis management: a meta-analysis and systematic review

Pancreas

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Treatment of Helicobacter pylori infection

Journal of Gastroenterology and Hepatology

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Application of FLEEOX preoperative chemotherapy via intra-arterial and intravenous administration in treatment of unresectable locally advanced gastric cancer

Journal of Gastrointestinal Surgery

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Gastrointestinal and liver issues in heart failure

Circulation

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The prevalence of irritable bowel syndrome-type symptoms in paediatric inflammatory bowel disease, and the relationship with biochemical markers of disease activity

Alimentary Pharmacology and Therapeutics

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Serum levels of hepatitis B surface antigen and DNA can predict inactive carriers with low risk of disease progression

Hepatology

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Establishment and characterization of new cell lines of anaplastic pancreatic cancer, which is a rare malignancy: OCUP-A1 and OCUP-A2

BMC Cancer

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Urine uric acid excretion is associated with nonalcoholic fatty liver disease in patients with type 2 diabetes

Journal of Diabetes and its Complications

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Pouchitis is a common complication in patients with familial adenomatous polyposis following ileal pouch-anal anastomosis

Clinical Gastroenterology and Hepatology

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Management of refractory typical GERD symptoms

Nature Reviews Gastroenterology and Hepatology

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Prognostic significance of 2-Deoxy-2-[18F]-Fluoro-D-Glucose PET/CT in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiotherapy before surgery: a nonparametric approach

Medicine

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Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based cohort study

Clinical Gastroenterology and Hepatology

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Obesity Prevention Practices and Policies in Child Care Settings Enrolled and Not Enrolled in the Child and Adult Care Food Program

Abstract

Objectives The United States Department of Agriculture's Child and Adult Care Food Program (CACFP) provides meals and snacks to low-income children in child care. This study compared nutrition and physical activity practices and policies as well as the overall nutrition and physical activity environments in a sample of CACFP and non-CACFP child care settings. Methods A random stratified sample of 350 child care settings in a large Midwestern city and its suburbs, was mailed a survey on obesity prevention practices and policies concerning menu offerings, feeding practices, nutrition and physical activity education, activity levels, training, and screen time. Completed surveys were obtained from 229 of 309 eligible child care settings (74.1 % response rate). Chi square tests were used to compare practices and policies in CACFP and non-CACFP sites. Poisson and negative binomial regression were used to examine associations between CACFP and total number of practices and policies. Results Sixty-nine percent of child care settings reported CACFP participation. A significantly higher proportion of CACFP sites reported offering whole grain foods daily and that providers always eat the same foods that are offered to the children. CACFP sites had 1.1 times as many supportive nutrition practices as non-CACFP sites. CACFP participation was not associated with written policies or physical activity practices. Conclusions for Practice There is room for improvement across nutrition and physical activity practices and policies. In addition to food reimbursement, CACFP participation may help promote child care environments that support healthy nutrition; however, additional training and education outreach activities may be needed.

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Aluminum and Phthalates in Calcium Gluconate; Contribution from Glass and Plastic Packaging.

Introduction: Aluminum contamination of parenteral nutrition solutions has been documented for three decades. It can result in elevated blood, bone, and whole body aluminumlevels associated with neurotoxicity, reduced bone mass and mineral content, and perhaps hepatotoxicity. The primary aluminumsource among parenteral nutrition components is glass-packaged calcium gluconate, in which aluminum concentration the past three decades has averaged~ 4000 [mu]g/L, compared to

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Savary Dilation is Safe and Effective Treatment for Esophageal Narrowing Related to Pediatric Eosinophilic Esophagitis.

Objectives: Data on management of esophageal narrowing related toeosinophilic esophagitis (EoE) in children is scanty. We aim to assess the safety and effectiveness of esophageal dilation in pediatric EoE from the largest case series to date. Methods: Children diagnosed withEoE during 2004 - 2015 were reviewed for the presence of esophageal narrowing. Esophageal narrowing was categorized as short segment narrow caliber, long segment narrow caliber, and single short stricture. The characteristics of the narrowed esophagus, therapeutic approach, clinical outcome and complications were reviewed. Results: Of the 50EoE cases diagnosed during the study period, 11 cases (9 males; median age 9 years, range 4-12) were identified with esophageal narrowing (22%). Six had short segment narrow caliber esophagus and 5 had long segment narrow caliber esophagus (median length of the narrowing was 4 cm, range 3-20 cm). Three cases with narrow caliber esophagus also had esophageal stricture 2-3 cm below the upper esophageal sphincter. Nineteen dilation sessions were performed in 10 cases using Savary dilator. Esophageal size improved from median 7 mm to median 13.4 mm. Good response was obtained in all cases. Following the dilation procedure, longitudinal esophageal mucosal tear occurred in all cases without esophageal perforation or chest pain. Conclusions: Esophageal dilation using Savary dilator is safe and highly effective in the management of esophageal narrowing related toEoE in children. Dilation alone does not improve the inflammatory process, and hence a combination with dietary or medical intervention is required. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://ift.tt/OBJ4xP (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Pediatric Irritable Bowel Syndrome Patient and Parental Characteristics Differ By Care Management Type.

Objectives: This study evaluate whether certain patient or parental characteristics are associated with gastroenterology (GI) referral vs primary pediatrics care for pediatric irritable bowel syndrome (IBS). Methods: A retrospective clinical trial sample of patients meeting pediatric Rome III IBS criteria was assembled from a single metropolitan healthcare system. Baseline socioeconomic status and clinical symptom measures were gathered. Various instruments measured participant and parental psychosocial traits. Study outcomes were stratified by GI referral vs primary pediatrics care. Two separate analyses of (1) socioeconomic status measures and GI clinical symptoms and (2) psychosocial measures identified key factors by univariate and multiple logistic regression analyses. For each analysis, identified factors were placed in unadjusted and adjusted multivariate logistic regression models to assess their impact in predicting GI referral. Results: Of the 239 participants, 152 were referred to pediatric GI, and 87 were managed in primary pediatrics care. Of the socioeconomic status and clinical symptom factors, child self-assessment of abdominal pain duration and lower percentage of people living in poverty were the strongest predictors of GI referral. Among the psychosocial measures, parental assessment of their child's functional disability was the sole predictor of GI referral. In multivariate logistic regression models, all selected factors continued to predict GI referral in each model. Conclusions: Socioeconomic environment, clinical symptoms, and functional disability are associated with GI referral. Future interventions designed to ameliorate the effect of these identified factors could reduce unnecessary specialty consultations and healthcare overutilization for IBS. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Long-term Follow-up of Children Treated With Peginterferon and Ribavirin for Hepatitis C Virus Infection.

Objectives: To describe the 5-year follow-up of children who received peginterferon and ribavirin in a global, open-label study. Methods: A 5-year follow-up study of 107 children and adolescents aged 3-17 years with chronic hepatitis C virus infection who received peginterferon and ribavirin for 24 or 48 weeks. No drugs were administered during follow-up. Results: Ninety-four patients were enrolled in the long-term follow-up portion of the study; the median duration of follow-up was 287 weeks (range, 73-339). Of 63 patients with sustained virologic response who were enrolled, 54 completed 5 years of follow-up; none had relapse in the 5-year follow-up period. Significant decreases in height z scores were observed during treatment. The impact of treatment on height z score was larger in patients treated for 48 weeks compared with those treated for 24 weeks (mean change from baseline to the end of treatment was -0.13 (p

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Controlled Substance Reconciliation Accuracy Improvement Using Near Real-Time Drug Transaction Capture from Automated Dispensing Cabinets.

BACKGROUND: Accurate accounting of controlled drug transactions by inpatient hospital pharmacies is a requirement in the United States under the Controlled Substances Act. At many hospitals, manual distribution of controlled substances from pharmacies is being replaced by automated dispensing cabinets (ADCs) at the point of care. Despite the promise of improved accountability, a high prevalence (15%) of controlled substance discrepancies between ADC records and anesthesia information management systems (AIMS) has been published, with a similar incidence (15.8%; 95% confidence interval [CI], 15.3% to 16.2%) noted at our institution. Most reconciliation errors are clerical. In this study, we describe a method to capture drug transactions in near real-time from our ADCs, compare them with documentation in our AIMS, and evaluate subsequent improvement in reconciliation accuracy. METHODS: ADC-controlled substance transactions are transmitted to a hospital interface server, parsed, reformatted, and sent to a software script written in Perl. The script extracts the data and writes them to a SQL Server database. Concurrently, controlled drug totals for each patient having care are documented in the AIMS and compared with the balance of the ADC transactions (i.e., vending, transferring, wasting, and returning drug). Every minute, a reconciliation report is available to anesthesia providers over the hospital Intranet from AIMS workstations. The report lists all patients, the current provider, the balance of ADC transactions, the totals from the AIMS, the difference, and whether the case is still ongoing or had concluded. Accuracy and latency of the ADC transaction capture process were assessed via simulation and by comparison with pharmacy database records, maintained by the vendor on a central server located remotely from the hospital network. For assessment of reconciliation accuracy over time, data were collected from our AIMS from January 2012 to June 2013 (Baseline), July 2013 to April 2014 (Next Day Reports), and May 2014 to September 2015 (Near Real-Time Reports) and reconciled against pharmacy records from the central pharmacy database maintained by the vendor. Control chart (batch means) methods were used between successive epochs to determine if improvement had taken place. RESULTS: During simulation, 100% of 10,000 messages, transmitted at a rate of 1295 per minute, were accurately captured and inserted into the database. Latency (transmission time to local database insertion time) was 46.3 +/- 0.44 milliseconds (SEM). During acceptance testing, only 1 of 1384 transactions analyzed had a difference between the near real-time process and what was in the central database; this was for a "John Doe" patient whose name had been changed subsequent to data capture. Once a transaction was entered at the ADC workstation, 84.9% (n = 18 bins; 95% CI, 78.4% to 91.3%) of these transactions were available in the database on the AIMS server within 2 minutes. Within 5 minutes, 98.2% (n = 18 bins; 95% CI, 97.2% to 99.3%) were available. Among 145,642 transactions present in the central pharmacy database, only 24 were missing from the local database table (mean = 0.018%; 95% CI, 0.002% to 0.034%). Implementation of near real-time reporting improved the controlled substance reconciliation error rate compared to the previous Next Day Reports epoch, from 8.8% to 5.2% (difference = -3.6%; 95% CI, -4.3% to -2.8%; P

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Correlation between Aeroallergen Levels and New Diagnosis of Eosinophilic Esophagitis in NYC.

Objective: The relationship between food allergies & eosinophilic esophagitis (EoE) is well established. Aeroallergens may also contribute to the development of EoE, however there are limited data to support or refute this hypothesis. The objectives of this pilot study were to determine i) whether there is a seasonal variation in the onset of symptoms and/or diagnosis of EoE, and ii) whether these variations correlate with a specific pollen concentration within New York City (NYC). Methods: We performed a retrospective chart review to identify all pediatric patients at New York Presbyterian Weill Cornell Medical Center diagnosed with EoE between 2002 and 2012. Sixty-six patients were identified and 28 were excluded. Cases were classified by both date of initial symptoms as well as date of histologic diagnosis. Pollen counts from a certified NYC counting station and the percent of EoE cases were collated monthly and seasonally and compared. Results: There was a seasonal variation in onset of symptoms as well as diagnosis of EoE, with the highest number of patients reporting onset of symptoms of EoE in July-September, and those being diagnosed with EoE in October-December. There was a seasonal correlation between peak levels of grass pollen and peak onset of EoE symptoms, which were both highest in July-September. The diagnosis of EoE peaked one season later. Conclusions: The study findings suggest that there is a correlation between specific aeroallergens and both the onset of symptoms as well as time of diagnosis of patients with EoE. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Response Patterns to the Electric Stimulation of Epidural Catheters in Pregnant Women: A Randomized Controlled Trial of Uniport Versus Multiport Catheters.

BACKGROUND: The transcatheter electric stimulation test (Tsui test) can be performed at the bedside to confirm the correct placement of a wire-reinforced epidural catheter within the epidural space. The most commonly observed motor response with a uniport epidural catheter placed in the lumbar area is the unilateral contraction of the lower limbs. Wire-reinforced multiport catheters have recently been introduced into clinical practice; however, the characteristics of the Tsui test with such catheters are unknown. We designed a randomized controlled trial to test the hypothesis that the incidence of a bilateral response to the Tsui test would be higher with a multiport catheter, with all other characteristics of the test remaining unchanged. METHODS: We recruited laboring women requesting epidural analgesia. The epidural catheter placement was performed in a standard fashion, assisted by ultrasound, aiming at the L3-L4 interspace. Patients were randomly allocated for the placement of either a 19-G uniport or a 19-G multiport wire-reinforced catheter. The Tsui test (frequency 2 Hz; pulse width 0.2 millisecond) was performed immediately after securing the catheter (baseline) and at 5 minutes after a test dose with 3 mL lidocaine 2%. The current output was increased from zero until motor activity was detected up to a maximum of 20 mA. Subsequently, an initial loading dose of 10 mL bupivacaine 0.125% and 50 [mu]g fentanyl was administered. The sensory block level to ice was assessed bilaterally at 20 minutes after injection of the loading dose. The primary outcome was the motor response pattern to the electric stimulation of the epidural catheter, either unilateral or bilateral; secondary outcomes included minimal current intensity needed to elicit a motor response at baseline and 5 minutes after the test dose, sensory block level and incidence of symmetrical sensory block at 20 minutes after injection of the loading dose, pain scores before the test dose and at 20 minutes after the loading dose, and need for catheter replacement within 2 hours of completion of the loading dose. RESULTS: Sixty-three women were assessed for eligibility and 46 were randomly allocated equally to each group. Three patients were excluded, resulting in 21 subjects in the multiport group and 22 subjects in the uniport group. Patient characteristics in both groups were similar. The incidence of unilateral motor response to the Tsui test was 95.2% (20/21) and 95.5% (21/22) in the multiport and uniport groups, respectively (rate difference 0.22%; 95% confidence interval, for the difference -29.2 to 29.2%; P = 0.99). The minimal current intensity (mean +/- SD) required to produce a motor response at baseline was 5.4 +/- 3.5 mA and 5.4 +/- 4.1 mA in the multiport and uniport groups, respectively (P = 0.98). The sensory block levels to ice on the left and right, as well as pain scores at 20 minutes, were similar in both groups. No epidural catheters were resited. CONCLUSIONS: The Tsui test produced a high percentage of unilateral motor response in women with both uniport and multiport wire-embedded catheters. A larger study is necessary to confirm that there is no clinically significant difference in the motor response patterns between the 2 catheter types. (C) 2016 International Anesthesia Research Society

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Costs Associated with Anesthesia-Related Adverse Events During Labor and Delivery in New York State, 2010.

BACKGROUND: The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery. METHODS: Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia. RESULTS: There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively. CONCLUSIONS: ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage. (C) 2016 International Anesthesia Research Society

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Comparison of Changes in Tensile Strength in 3 Different Flexible Epidural Catheters Under Various Conditions.

BACKGROUND: Rarely, epidural catheters may fracture upon removal or insertion. Understanding some of the mechanical properties of epidural catheters, such as their tensile strength and how external factors (including temperature) can influence their strength, will aid physicians in making decisions if faced with an entrapped catheter. In the present study, we evaluated the impact in tensile strength when catheters are exposed to 37 +/- 1[degrees]C, after the removal of the inner metal coil and after the injection of sterile saline through the catheter. METHODS: We analyzed the tensile strength of a total of 120 catheters (19-gauge) from 3 different brands and materials. The reinforced epidural catheters were affixed to opposing, specially designed tensile test fixtures and then installed in an Applied Test System tensile test apparatus. We evaluated the strength of 10 catheters from different brands and materials for each of the following variables: at room temperature (control group), after the removal of the inner wire present in all the flexible catheters tested, injection of normal saline, and at 37 +/- 1[degrees]C. RESULTS: When compared with their control groups, the Arrow catheter (2.85 kg) was shown to be superior to B-Braun (2.17 kg; P

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One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury.

BACKGROUND: To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol. METHODS: This observational cohort included 3224 patients >=60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 [mu]g/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation. RESULTS: Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P

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Applying Latent Class Analysis to Risk Stratification for Perioperative Mortality in Patients Undergoing Intraabdominal General Surgery.

BACKGROUND: Perioperative risk stratification is often performed using individual risk factors without consideration of the syndemic of these risk factors. We used latent class analysis (LCA) to identify the classes of comorbidities and risk factors associated with perioperative mortality in patients presenting for intraabdominal general surgery. METHODS: The 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program was used to obtain a cohort of patients undergoing intraabdominal general surgery. Risk factors and comorbidities were entered into LCA models to identify the latent classes, and individuals were assigned to a class based on the highest posterior probability of class membership. Relative risk regression was used to determine the associations between the latent classes and 30-day mortality, with adjustments for procedure. RESULTS: A 9-class model was fit using LCA on 466,177 observations. After combining classes with similar adjusted mortality risks, 5 risk classes were obtained. Compared with the class with average mortality risk (class 4), the risk ratios (95% confidence interval) ranged from 0.020 (0.014-0.027) in the lowest risk class (class 1) to 6.75 (6.46-7.02) in the highest risk class. After adjusting for procedure and ASA physical status, the latent classes remained significantly associated with 30-day mortality. The addition of the risk class variable to a model containing ASA physical status and surgical procedure demonstrated a significant increase in the area under the receiver operator characteristic curve (0.892 vs 0.915; P

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