Pediatric pain management education in medical students: impact of a web-based module

Abstract Objective: Reports from the Institute of Medicine and American Medical Association's Pain and Palliative Medicine Specialty Section Council emphasize the need for pain management education in medical schools, yet training in pediatric pain management (PPM) is limited. In this pilot program, we evaluated the effectiveness of a web-based PPM module on knowledge, confidence, attitudes, and self-reported skills in medical students. Methods: Third- and fourth-year medical students (n=291) completed the module and a knowledge test. Of these students, 53 completed a pre- and postsurvey of confidence, attitudes, and self-reported skills and module evaluation. Results: For the 291 students, knowledge scores increased significantly by 21.8 points (95% confidence interval [CI]=19.7-23.8; p<0.001). The majority of scores on the survey items significantly increased postmodule, including: increase in confidence in assessing pain in pediatric patients (6% to 25%; p=0.004), increase in responses of "strongly disagree" or "disagree" to the belief that opioids will delay diagnosis (62% to 85%; p=0.005), and increase in responses of "frequently" or "very frequently" to "how often do you use behavioral instruments to assess pain severity?" (35% to 57%; p=0.008). The majority reported they intend to make changes in behavior or practice (71%), and would recommend the module to fellow students (88%). Conclusion: This pilot program supports the effectiveness of a web-based module in improving knowledge, confidence, attitudes, and self-reported skills in PPM. Evaluation responses indicate high-quality content. Further evaluation for sustained impact is warranted.     

Nomograms of total renal volume,urinary bladder volume and bladder wall thickness index in 3,376 children with a normal urinary tract

Background We have previously shown that urinary bladder volume index (BVI = length × width × depth of bladder) and bladder volume wall thickness index (BVWI = BVI at full bladder/average bladder wall thickness) are useful indicators of bladder dysfunction in children with enuresis and urinary tract infection. These indices show a good correlation with urodynamic studies. We have expanded the study to include normal paediatric subjects with a wide age range. We illustrate a simple sonography protocol with nomograms of different parameters, which provide useful references for functional assessment in children with urological abnormalities. Objective To construct nomograms of total renal volume, maximum BVI and BVWI based on a Chinese paediatric population with age range from newborn to adolescence. Materials and methods Sonography was performed in consecutive children with normal urinary tracts on imaging, using a standardized protocol. Data were collected for construction of nomograms for different parameters. Results Nomograms of total renal volume, BVI and BVWI were constructed based on 3,376 consecutive paediatric subjects. All parameters consistently increased with age. Conclusion Nomograms of total renal volume, BVI and BVWI could provide useful references for studying bladder dysfunction in children using noninvasive dynamic sonography.     

Concurrent repletion of iron and zinc reduces intestinal oxidative damage in iron- and zinc-deficient rats

AIM： To understand the interactions between iron and zinc during absorption in iron- and zinc-deficient rats, and their consequences on intestinal oxidant-antioxidant balance. METHODS： Twenty-four weanling Wistar-Kyoto rats fed an iron- and zinc-deficient diet （〈 6.5 mg Fe and 4.0 mg Zn/kg diet） for 4 wk were randomly divided into three groups （n = 8, each） and orally gavaged with 4 mg iron, 3.3 mg zinc, or 4 mg iron ＋ 3.3 mg zinc for 2 wk. At the last day of repletion, 3 h before the animals were sacrificed, they received either 37 mBq of SSFe or ^65Zn, to study their localization in the intestine, using microautoradiography. Hemoglobin, iron and zinc content in plasma and liver were measured as indicators of iron and zinc status. Duodenal sections were used for immunochemical staining of ferritin and metallothionein. Duodenal homogenates （mitochondrial and cytosolic fractions）, were used to assess aconitase activity, oxidative stress, functional integrity and the response of antioxidant enzymes. RESULTS： Concurrent repletion of iron- and zinc-deficient rats showed reduced localization of these minerals compared to rats that were teated with iron or zinc alone; these data provide evidence for antagonistic interactions. This resulted in reduced formation of lipid and protein oxidation products and better functional integrity of the intestinal mucosa. Further, combined repletion lowered iron-associated aconitase activity and ferritin expression, but significantly elevated metallothionein and glutathione levels in the intestinal mucosa. The mechanism of interactions during combined supplementation and its subsequent effects appeared to be due to through modulation of cytosolic aconitase, which in turn influenced the labile iron pool and metallothionein levels, and hence reduced intestinal oxidative damage.CONCLUSION： Concurrent administration of iron and zinc corrects iron and zinc deficiency, and also reduces the intestinal oxidative damage associated with iron supplementation.     

Early transposition of the sartorius muscle for exposed patent infrainguinal bypass grafts

The traditional approach for patent and exposed and infected infrainguinal bypass grafts in the groin has included wide operative debridement and secondary or delayed primary closure. However, this has been associated with significant risk of further contamination and length of stay. The authors reviewed their experience using the wide debridement, sartorius muscle flap transposition, and primary wound closure as an alternative. During the past 5 years, they have had 50 patients with major wound necrosis or infection in the groin or thigh with the graft or native artery being exposed after debridement. This group included 28 men; 74% of the patients had hypertension, 58% had diabetes, and 20% had renal failure. The grafts were split evenly between native vein and prosthetic material. After wide debridement, closure was performed by the vascular surgeon using the sartorius muscle flap. Postoperatively, there was an 8% major amputation rate and a 12% mortality rate in the first 30 days. One patient developed a pseudoaneurysm 5 weeks after placement of the flap. This patient underwent removal of the infected polytetrafluoroethylene graft with ligation of the common femoral artery. None of the procedures have resulted in further systemic or graft sepsis. None have resulted in arterial or graft blowout. Follow-up was for an average of 18 months. Closure of groin and thigh wounds with exposed bypass graft or native artery can be safely performed with the sartorius muscle flap with excellent results. The length of stay of these patients compared to historical controls is acceptable. Furthermore, the chance of infection of the native artery or bypass may be reduced. Familiarity with this simple technique can be a valuable tool for the vascular surgeon.     

Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis

PURPOSE: Although large published series have described their experience with the management of failed or failing prosthetic arteriovenous grafts for hemodialysis, there are scant data regarding failing arteriovenous fistulae (AVFs). To analyze the management of nonfunctioning or nonmaturing AVFs, we reviewed our experience with salvage procedures for these AVFs. MATERIALS AND METHODS: Of the 474 AVFs placed at our institution in 380 patients between June 1997 and March 2001, 75 revisions were performed in 46 patients (49 AVFs). Ages of these patients ranged from 29 to 94 years (mean, 68 +/- 1.4 years). Diabetic patients comprised 51%, and hypertensive patients comprised 75%. Twenty patients underwent 26 vein patch angioplasties, and 17 patients underwent 24 balloon angioplasties. Four patients required four vein interpositions, and 12 patients underwent 12 revisions of the fistula to a more proximal level. Extended salvage procedures consisted of four turn-downs to the basilic vein for proximal cephalic vein thrombosis or stenosis and five extension bypasses to the axillary or jugular vein for subclavian vein thrombosis. RESULTS: Follow-up ranged from 1 to 31 months (mean, 10 months). The patients who underwent open revisions tended to need fewer subsequent procedures. However, primary patency of the vein patch angioplasty was not significantly better as compared with balloon angioplasty (P = .8) by life table analysis. Patency after revision of a radial cephalic fistula and brachial cephalic fistula were not statistically different. One interposition failed during the follow-up, and one revision to a more proximal level thrombosed during the follow-up. Two of the turn-down procedures had thrombosed at 2 and 11 months. The remaining two turn-down procedures have remained functional at 1 and 24 months. One of the extensions thrombosed at 8 months whereas the other four have remained functional at 1, 6, and 8 months. CONCLUSIONS: Despite the limited follow-up data, this review suggests that simple and extended salvage procedures may allow maturation and add to the life span of AVFs for hemodialysis. In addition, these data suggest an advantage for open techniques as compared with percutaneous techniques but only in terms of requiring fewer subsequent procedures.     

Double-chambered right ventricle: Magnetic resonance imaging findings

Primary double-chambered right ventricle is an uncommon congenital anomaly that presents with right ventricular outflow tract obstruction in childhood or adolescence. A search of the literature revealed only a few documented case reports with MRI findings. We present a case with mixed lesions, and with anomalous muscle bundles located both in the middle portion of the right ventricular sinus and at the subinfundibular level.     

Combination of pan-histone deacetylase inhibitor and autophagy inhibitor exerts superior efficacy against triple-negative human breast cancer cells

Histone deacetylase (HDAC) inhibitors (HDI) induce endoplasmic reticulum (ER) stress and apoptosis, while promoting autophagy, which promotes cancer cell survival when apoptosis is compromised. Here, we determined the in vitro and in vivo activity of the combination of the pan-HDI panobinostat and the autophagy inhibitor chloroquine against human estrogen/progesterone receptor and HER2 (triple)-negative breast cancer (TNBC) cells. Treatment of MB-231 and SUM159PT cells with panobinostat disrupted the hsp90/histone deacetylase 6/HSF1/p97 complex, resulting in the upregulation of hsp. This was accompanied by the induction of enhanced autophagic flux as evidenced by increased expression of LC3B-II and the degradation of the autophagic substrate p62. Treatment with panobinostat also induced the accumulation and colocalization of p62 with LC3B-II in cytosolic foci as evidenced by immunofluorescent confocal microscopy. Inhibition of panobinostat-induced autophagic flux by chloroquine markedly induced the accumulation of polyubiquitylated proteins and p62, caused synergistic cell death of MB-231 and SUM159PT cells, and inhibited mammosphere formation in MB-231 cells, compared with treatment with each agent alone. Finally, in mouse mammary fat pad xenografts of MB-231 cells, a tumor size-dependent induction of heat shock response, ER stress and autophagy were observed. Cotreatment with panobinostat and chloroquine resulted in reduced tumor burden and increased the survival of MB-231 breast cancer xenografts. Collectively, our findings show that cotreatment with an autophagy inhibitor and pan-HDI, for example, chloroquine and panobinostat results in accumulation of toxic polyubiquitylated proteins, exerts superior inhibitory effects on TNBC cell growth, and increases the survival of TNBC xenografts.