Indications and outcomes of adenoidectomy in infancy

Adenoid hypertrophy is one of the most common causes of pediatric obstructive sleep apnea. Although adenoidectomy is the only effective treatment for adenoid hypertrophy, it is rarely performed in infants less than 1 year old. This study reports on the successful use of adenoidectomy in 24 infants less than 1 year old with a triad of upper airway obstruction symptoms, findings of obstructing adenoids, and obstructive sleep apnea (but no other anomalies). This is a retrospective case series reviewing each infant's clinical data, including presenting symptoms (with special emphasis on apnea episodes), physical examination findings, and results of other investigations such as polysomnography, endoscopy, pH-metry, and echocardiography. With careful preoperative and postoperative monitoring, the 24 infants underwent adenoidectomy without complications. After the procedure, all showed marked improvement with complete disappearance of symptoms of upper airway obstruction, failure to thrive, and gastroesophageal reflux disease. Adenoidectomy was found to be sufficient and curative for such infants.     

Fetal inherited thrombophilias influence the severity of preeclampsia, IUGR and placental abruption

OBJECTIVE: To determine whether common inherited thrombophilias in the fetus influence the severity of severe preeclampsia, IUGR and placental abruption. DESIGN: A case-control study among patients with complicated pregnancies. Cases were defined as fetuses with thrombophilia. Setting: A university hospital with 3700 deliveries per year. POPULATION: Seventy cases with severe preeclampsia, IUGR or placental abruption. METHODS: Mothers and neonates were tested for mutation of factor V Leiden, prothrombin gene and methylenetetrahydrofolate reductase. Main outcome measures: Gestational age at delivery, birth weight and early neonatal complications. RESULTS: Gestational age at delivery and birth weight were significantly lower in fetuses with factor V Leiden or prothrombin gene mutation compared to control fetuses. CONCLUSIONS: Fetal factor V Leiden mutation and prothrombin gene mutation may influence the course of severe preeclampsia, IUGR and placental abruption. These thrombophilic changes may cause an earlier appearance or lead to a late pregnancy complication of a greater severity.     

Evaluation of techniques for treating the bleeding wound

BACKGROUND: Despite the fact that the urgent control of active bleeding from external body surfaces demands a basic procedure, it is puzzling that this topic has received little if any attention in modern medical research. Elastic adhesive dressing (ELAD) has been proposed for dressing the bleeding wound. METHODS AND MATERIALS: Three techniques were compared over a simulated wound in a human model. Pressures generated between the chosen dressing surface and the underlying mock wound's cutaneous surface, time consumption, convenience, satisfaction and pain were tested for each technique. RESULTS: Sixty-eight experiments were performed over nine separate anatomical sites. Average pressures for field dressing, ELAD and manual compression were 33, 88 and 180 mmHg, respectively; these differences in pressure were statistically significant. Manual pressure was equally inconvenient for both patient and caregiver. The more proximal and wider anatomical regions were more difficult and time consuming to compress. The caregivers graded ELAD the highest level of convenience and general satisfaction. CONCLUSIONS: Field bandage testing reflected its inadequacy in controlling bleeding from most body regions. The results suggest that ELAD may be the hands-free technique of choice. We hope that this article will stimulate further research and elicit evidence on precisely which technique is most suitable for various anatomical location.     

Bone strength in multiple sclerosis: cortical midtibial speed-of-sound assessment

It has been previously suggested that multiple sclerosis (MS) patients are at increased risk for osteoporosis due to reduced mobility, decreased exposure to sunlight and recurrent steroid treatment. In order to systematically evaluate bone strength we assessed 256 MS patients (171 females, 75 males) through quantitative ultrasound measurement of cortical bone. Tibial speed of sound (SOS, m/sec) was measured at midpoint of the tibial shaft using a Soundscan 2000 (Myriad Ultrasound Systems, Rehovot, Israel) and results were compared to age- and gender-matched population norms. T-score distribution in male MS patients was similar to normal population. In contrast, for female MS patients T-score distribution was significantly different from population norms, reflected by increased SOS in 30.4% (T-score intervals 1-2 and >2 above normal values; P=0.001), compared with 7.4% in controls. These findings held true for both female patients younger and older than 45 years of age. Increased neurological disability and specifically motor involvement were more frequent in female patients with increased SOS (P<0.05). Bone strength was preserved in MS patients. In a subgroup of female patients increased SOS was conceivably related to spasticity.     

Intravenous immunoglobulin treatment following the first demyelinating event suggestive of multiple sclerosis: a randomized, double-blind, placebo-controlled trial

BACKGROUND: Intravenous immunoglobulin (IVIg) has been reported to reduce disease activity in patients with relapsing-remitting multiple sclerosis. We assessed the effect of IVIg treatment in patients after the first neurological event suggestive of demyelinative disease and evaluated the occurrence of a second attack and dissemination in time demonstrated by brain magnetic resonance imaging within the first year from onset. METHODS: We conducted a randomized, placebo-controlled, double-blind study in 91 eligible patients enrolled within the first 6 weeks of neurological symptoms. Patients were randomly assigned to receive IVIg treatment (2-g/kg loading dose) or placebo, with boosters (0.4 g/kg) given once every 6 weeks for 1 year. Neurological and clinical assessments were done every 3 months, and brain magnetic resonance imaging was performed at baseline and the end of the study. RESULTS: The cumulative probability of developing clinically definite multiple sclerosis was significantly lower in the IVIg treatment group compared with the placebo group (rate ratio, 0.36 [95% confidence interval, 0.15-0.88]; P = .03). Patients in the IVIg treatment group had a significant reduction in the volume and number of T2-weighted lesions and in the volume of gadolinium-enhancing lesions as compared with the placebo group (P = .01, P = .01, and P = .03, respectively). Treatment was well tolerated, compliance was high, and incidence of adverse effects did not differ significantly between groups. CONCLUSIONS: Intravenous immunoglobulin treatment for the first year from onset of the first neurological event suggestive of demyelinative disease significantly lowers the incidence of a second attack and reduces disease activity as measured by brain magnetic resonance imaging.     

Monitoring indirect presentation of alloantigens by utilizing the autologous processing machinery of dendritic cells in-vitro

BACKGROUND: Judicious individualization of immunosuppression protocols requires the ability to monitor the recipients' specific immune response towards the allograft. While several indirect presentation studies have been reported, currently there are no consistently reliable means to assess the state of transplant acceptance. A potential explanation might be the lack of established kinetics for in-vitro indirect presentation assays. METHODS: Dendritic cell (DCs) were used as self-specific "processing machinery" for the generation of allogeneic peptide repertoire tailored by the individual's capacity to process antigens via the indirect pathway. The kinetics of antigen processing and presentation of newly acquired antigens was then assessed to define the following: (1) Optimal time to introduce apoptotic-allogeneic cells to DCs; (2) optimal time for processing before induction of DC maturation; and (3) optimal time for stimulation of autologous T cells by the pulsed DCs. RESULTS: Altering kinetic parameters associated with time allotted for antigen processing; antigen presentation and DCs maturation, showed substantial variations in the level of T cell activation, as was documented by mixed lymphocyte reaction (MLR)-like proliferation assays. Further experiments using allogeneic cellular extracts showed similar variations in T cell stimulation by monitoring T cell precursor frequencies and interferon (IFN)-gamma secretion ELISPOT assays. Using the appropriate kinetic parameters, we have also shown difference in T-cell-subsets (CD4, CD8) precursor frequencies and cytokine secretion in response to different antigenic sources. CONCLUSIONS: The ability to construct an in-vitro, recipient-tailored, donor-specific, indirect presentation assay is dependent on essential kinetic parameters associated with antigen processing and presentation, as described in this report. Moreover, the use of this approach may circumvent the need for identifying specific immunogenic peptides for cancer-related or other vaccine-development studies.     

From caring to managing and beyond: an examination of the head nurse's role

AIM: The aim of this study was to depict the essence of what head nurses do, and how they perform their managerial role. METHODS: To achieve this, the work behaviour of 48 head nurses was examined by a semi-structured observation technique for 6 hours each. RESULTS: Results demonstrated that head nurses spent a large proportion of their time in clinical practice, followed by co-ordinating care, operating the unit's functions, and leading staff. Personnel management and quality improvement occupied only a marginal share of head nurses' time. CONCLUSIONS: These results implied that head nurses exhibited a management style orientated to maintenance rather than to re-creation, focusing more on the 'doing' and the 'here and now' aspects of the job than on leading, planning, and proactive problem solving.     

Replacing the Amsler grid: a new method for monitoring patients with age-related macular degeneration

PURPOSE: To investigate a method that uses hyperacuity, the Macular Computerized Psychophysical Test (MCPT), to evaluate the central macular visual field in patients with age-related macular degeneration (AMD). DESIGN: Prospective case-control study of a diagnostic test. PARTICIPANTS AND CONTROLS: One hundred eight eyes of 108 Patients with AMD and 51 eyes of 51 age-matched patients with no retinal disease. Patients with AMD included 32 (30%) patients with choroidal neovascularization (CNV), 23 (21%) with geographic atrophy (GA), 35 (32%) with AMD with high-risk characteristics (HRC), and 18 (17%) with early AMD with non-HRC. TESTING: Each subject underwent the MCPT, in which a virtual line composed of dots (white dots on a black background, maximal contrast) is flashed across different macular loci to a perifoveal radius of 7 degrees. Patients' responses were recorded and automatically analyzed using a specific algorithm developed before the onset of the study. All patients also underwent a supervised Amsler grid examination on the encounter before or after the MCPT in random order. MAIN OUTCOME MEASURES: Distortion, scotoma, or blurring perceived by the patient after a swift change of fixation was considered positive on the MCPT. Any perception of distortion, scotoma, or blurring was considered positive on the Amsler grid. RESULTS: Of the 32 patients with CNV, 30 (94%) were found positive on the MCPT and 11 (34%) were found positive on the Amsler grid. Of the 23 GA patients, 21 (91%) were found positive on the MCPT and 7 (30%) were found positive on the Amsler grid. Of the 35 HRC patients, 28 (80%) were found positive on the MCPT and 3 (9%) were found positive on the Amsler grid, and of the 18 early AMD with non-HRC patients, 8 (44%) were found positive on the MCPT and 3 (17%) were found positive on the Amsler grid. Of the 51 controls, 3 (6%) were positive on the MCPT and 1 (2%) was positive on the Amsler grid. CONCLUSIONS: The MCPT was superior to the Amsler grid in detecting AMD-related lesions in this cohort. Studies are underway to determine whether the MCPT is feasible for home monitoring to provide early detection of progression to CNV.