EPSTEIN-BARR VIRUS PCR CORRELATED WITH VIRAL HISTOLOGY AND SEROLOGY IN PEDIATRIC LIVER TRANSPLANT PATIENTS

Epstein-Barr virus (EBV)-associated illnesses in posttransplant patients are difficult to diagnose. Attempts to aid in the diagnosis of such illnesses using the polymerase chain reaction (PCR) analysis for EBV have met with variable success due to the potential exquisite sensitivity of the assay. We have designed a relatively insensitive EBV PCR assay and compared the results with objective evidence of EBV activity including serologic response and in situ hybridization for the EBV genome. Eighty-five specimens from 65 patients were analyzed by the EBV PCR using DNA from whole blood. EBV serologic evaluation was done on 53 of the samples and in situ hybridization for EBV (EBER-1 mRNA) on 46 paired liver biopsies. Of 85 samples, 25 (29 ) were positive for EBV using the PCR assay. Intensity of amplification was graded 0.5-1 (weak) to 3 (strong). Using these criteria, 19 EBV PCR-positive samples were graded 0.5-1 , 5 were graded 2 , and 1 was graded 3 . Of the moderate to strongly positive samples (2 or 3 ), five of six had two or more EBER-1-positive cells in the liver biopsies. Of the remaining 40 liver biopsies with either negative or weak positive PCR results, 3 had only single cells positive for EBER-1; the remainder were negative. In addition, PCR-positive results correlated with increasing EBV anti-early antigen antibody (P.005) and viral capsid antigen IgG immunoglobulin G VCA (P.05) EBV-positive results using the PCR assay correlated with objective evidence for increased EBV burden in children after liver transplantation. These preliminary data suggest that this PCR test may be useful to help guide immunosuppressive therapy in the posttransplant patient. Further evaluation using larger numbers of patients will be necessary to confirm this.     

Haemodynamic responses and population pharmacokinetics of midazolam following administration to ventilated, preterm neonates

Objective: To evaluate the effects of intravenous midazolam on haemodynamic variables and cerebral blood flow velocity (CBFV) and to determine the pharmacokinetics using a population approach in very low birthweight (VLBW) ventilated infants.
Methodology: Physiological variables were measured at predetermined times in 10 infants with birthweight ≤1500 g following a bolus dose of intravenous midazolam (0.1 mg/kg). Heart rate, mean arterial blood pressure (MAP) and transcutaneous CO₂ (TcPCO₂) were recorded and CBFV was assessed by Doppler ultrasound. Midazolam concentrations were also measured and pharmacokinetic parameters determined using a population modelling package.
Results: No change in heart rate occurred during the study period, while the MAP decreased by 3 mmHg 5 min after midazolam administration compared to baseline values. A non-significant fall in TcPCO₂ was seen at 20 min. Mean CBFV decreased from the baseline by 12% at 5 min, then returning to predose values. Midazolam concentrations were in the range shown to be effective in sedation of paediatric intensive care infants with the elimination being delayed in comparison to older children.
Conclusions: As only minor cerebral and haemodynamic effects were found with the use of midazolam in stable ventilated preterm infants, it appears to be a safe, short-term sedative agent.     

Perinatal outcome following conservative management of mid-trimester pre-labour rupture of the membranes

To assess perinatal outcome and the effect of antenatal steroid use following conservative management of 86 consecutive singleton pregnancies complicated by pre-labour rupture of membranes (ROM) in the mid-trimester (13–26 weeks; mean 22.8 weeks).

Methodology:

Review of obstetric and neonatal case notes between 1 January 1990 and 31 December 1993.

Results:

The duration of ruptured membranes (latent period) ranged from 1.25 to 105 days (mean 23.8 days; median 14 days) and was inversely related to gestational age at ROM. There was clinical evidence of chorioamnionitis in 39.5% with placental histological changes consistent with chorioamnionitis in 76.6%. All infants were delivered before 33 weeks gestation (mean 26 weeks). Overall, the mortality rate was 43.0% but 62.5% in infants with ROM before 24 completed weeks gestation. Adverse outcome (defined as death, severe intraventricular haemorrhage (IVH) or periventricular leucomalacia (PVL)) occurred in 46.5% and was significantly related to both gestation at delivery and gestation at ROM. In the group ( n = 40) with ROM before 24 weeks gestation, adverse outcome occurred in 65% and was inversely related to gestation at ROM independent of gestation at delivery. Antenatal steroid administration resulted in less adverse outcome independent of gestation at delivery (OR 0.31; 95% CI (0.09–0.98; P = 0.046)).

Conclusion:

From the neonatal perspective conservative management is justified for pregnancies with ROM at or after 24 weeks gestation; in this group the use of antenatal steroids prior to delivery may improve perinatal outcome. A poor outcome is associated with ROM that occurs before 24 weeks gestation.     

Intracranial hypertension in Africans with cerebral malaria

The causes of death and neurological sequelae in African children with cerebral malaria are obscure. Intracranial pressure (ICP) was monitored and cerebral perfusion pressure (CPP) calculated in 23 Kenyan children with cerebral malaria. Four children had severe intracranial hypertension (ICP > 40 mm Hg, CPP < 40 mm Hg): two died, one with an ICP of 158 mm Hg and signs of transtentorial herniation, the other one with an ICP of 42 mm Hg and cardiorespiratory arrest. The other two survived with severe neurological sequelae. Nine had intermediate intracranial hypertension (ICP > 20 mm Hg, CPP < 50 mm Hg) and 10 had mild intracranial hypertension (maximum ICP 10-20 mm Hg); all survived without severe sequelae. Mannitol controlled the ICP in children with intermediate intracranial hypertension, but it did not prevent the development of intractable intracranial hypertension in children with severe intracranial hypertension. Intracranial hypertension is a feature of Kenyan children with cerebral malaria and severe intracranial hypertension is associated with a poor outcome.     

Mortality and diabetes from a population based register in Yorkshire 1978-93

OBJECTIVE: To investigate mortality of children diagnosed with insulin dependent diabetes mellitus (IDDM) and to identify common factors before death. DESIGN: Follow up of a population based cohort of children diagnosed with IDDM to ascertain deaths. SETTING: Children were diagnosed in Yorkshire but followed up throughout the United Kingdom. SUBJECTS: From the Yorkshire Children's Diabetes Register details of 1854 children aged 0-16 years (1978-93) were submitted to the NHS Central Register. MAIN OUTCOME MEASURE: Notification and causes of death. RESULTS: 98.3% of cases were traced and 26 deaths identified. Follow up ranged from 1-18 years (median 9.3 years), providing 17,350 person-years of IDDM. Fifteen deaths (58%) were attributed to diabetes or its complications; 11 (42%) were unrelated and included one suicide. For mortality from all causes, the standardised mortality ratio (SMR) of 247 (95% confidence interval (CI) 163 to 362) was significantly increased for those under 34 years. The largest number of deaths (n = 10) occurred in the 15-19 year age range, with an SMR of 442 (95% CI 209 to 802). Case note examination showed a clear tendency towards poor diabetic control, and worries over control were expressed before death by health care professionals. CONCLUSIONS: Despite advances in treatment, IDDM still carries an increased mortality for young people, particularly in the "transition" age range.     

Factors influencing the willingness of community service organisation staff to provide smoking cessation support: a qualitative study

Objective : This study aimed to explore factors influencing community service organisation (CSO) staff members’ willingness to provide tobacco cessation support to clients experiencing disadvantage. Methods : Face‐to‐face semi‐structured interviews were conducted with 29 staff members from seven services in the alcohol and other drugs, homelessness, and mental health sectors in Western Australia. Results : The primary barriers to providing cessation support were believing that addressing smoking was not a priority relative to other issues, being a current smoker, and the lack of a formal tobacco cessation program within the organisation. Factors that appeared to be most influential in enabling the delivery of cessation support were organisational processes requiring staff to routinely ask clients about tobacco use, confidence to provide support, and being a past smoker. Conclusions : The introduction of organisational procedures that include routine cessation care should be of high priority in CSOs to help reduce smoking rates among clients. Staff may also benefit from receiving training in the provision of cessation support and education about the importance and feasibility of addressing smoking concurrently with other issues. Implications for public health : The results may inform future efforts to increase the delivery of cessation care to groups of people experiencing disadvantage and comorbidity.     

Raising Awareness for Lung Cancer Prevention and Healthy Lifestyles in Female Scholars from a Low-Income Area in Bogota,Colombia: Evaluation of a National Framework

This study aims to determine the effects of an educational intervention, based on the Colombian guidelines for educational communication in the framework of cancer control, for raising lung cancer prevention-related awareness, and improving healthy lifestyles in female scholars from a low-income area in Bogota, Colombia. Uncontrolled trial conducted in 243 female scholars (mean age 14 years ± 1.5 SD). Two 90 min educational sessions were carried out in March 2015 according to the Colombian guidelines for educational communication in the framework of cancer control. Posters and other educational materials were created by scholars after the intervention. All participants completed a self-reported questionnaire—The Cancer Awareness Measure—at pre and post-intervention, as well as 1, 3, and 6 months after the intervention. Smoking prevalence (8.2% at baseline) was reduced by 3.7% at 6 months follow-up (p < 0.005). The scholars exhibited low to moderate awareness of both warning signs and risk factors for lung cancer at baseline. These variables showed statistically significant improvements at 6 months follow-up (p < 0.005). Similar improvements were also found for physical activity, high-fat diet, and fruits and vegetable intake. This evaluation of the Colombian guidelines for educational communication in the framework of cancer control raised awareness towards lung cancer prevention, reduced smoking, and improved other healthy-lifestyle-related factors in a group of female scholars from a low-income area in Bogota, Colombia. Further randomized controlled studies are needed.     

Implant radiography and radiology

The practitioner placing dental implants has many options with respect to pre-implant radiographic assessment of the jaws. The advantages and disadvantages of the imaging modalities currently available for pre-implant imaging are discussed in some detail. Intra-oral and extra-oral radiographs are generally low dose but the information provided is limited as the images are not three-dimensional. Tomography is three-dimensional, but the image quality is highly variable. Computed tomography (CT) has been the gold standard for many years as the information provided is three-dimensional and generally very accurate. However, CT examinations are expensive and deliver a relatively high radiation dose to the patient. The latest imaging modality introduced is cone beam volumetric tomography (CBVT) and this technology is very promising with regard to pre-implant imaging. CBVT generally delivers a lower dose to the patient than CT and provides reasonably sharp images with three-dimensional information. A comparison between CT and CBVT is provided. Magnetic resonance imaging is showing some promise, but the examinations are not readily available, generally expensive and bone is not well imaged. Magnetic resonance imaging is excellent for demonstrating soft tissues and therefore may be of great use in identifying the inferior dental nerve and vessels. All of the above technology is of little value if the information required is not obtained and so information is also provided on imaging of some of the vital structures. Of particular interest is the inferior dental canal, incisive canals of the mandible, genial foramina and canals, maxillary sinus and the incisive canal and foramen of the maxilla.