Impact of a designated hepatology nurse on the clinical course and quality of life of patients treated with rebetron therapy for chronic hepatitis C.

A two- to three-fold increase in mortality from hepatitis C is predicted in the next 10-20 years as the largest cohort of patients age. More qualified providers are needed to care for this population. The objective of this study was to assess the impact of a hepatology nurse practitioner as compared to care by a physician on the quality of life and treatment outcomes of patients with chronic hepatitis C. Seventy-five patients with chronic hepatitis C were assigned to either a nurse practitioner or physician and asked to complete a SF-36 Health Survey quarterly to measure their perceived quality of life.Two-sided t-tests comparing the quality of life scores in the physician and nurse practitioner groups at weeks 1, 12, and 24 were calculated using SPSS version 12.0 (Chicago, IL). Although marginal differences between physicians and nurse practitioners were noted for physical function at week 1, bodily pain at week 12, and role physical at week 24 by the patients, no statistically significant differences were observed overall in the quality of life scores reported by the patients according to healthcare provider. The treatment outcome data for the nurse practitioner groups showed 12/25 (48%) of patients with genotype 1 achieved a sustained virologic response as did 13/22 (59%) of patients with genotype 2 or 3. In the physician groups, 11/27 (41%) of patients with genotype 1 achieved a sustained virologic response as did 14/23 (61%) of patients with genotype 2 or 3. These results suggest nurse practitioners can provide effective care to the chronic hepatitis C population.     

A study of confidential unit exclusion

The effectiveness of the confidential unit exclusion (CUE) procedure recommended by the Food and Drug Administration has been questioned by the blood banking community. The purpose of this study was to determine whether donors were informing the blood center correctly regarding the disposition (transfuse or do not transfuse) of their donated blood. A letter explaining the confidential study and requesting permission to send the participant a questionnaire noting his or her self-exclusion choice was mailed to 230 donors who had chosen transfuse and 276 donors who had chosen do not transfuse. After consent was obtained, participants were sent a second packet and asked to indicate whether they had chosen correctly and, if not, to identify reasons for that incorrect choice. A seven-word terminology quiz made up of words from the CUE form was also enclosed. All participants who had chosen transfuse indicated that this was the correct choice. Approximately 50 percent of those who had chosen do not transfuse indicated that this was an incorrect choice; the most common reason was that "I was not paying attention." The most frequently misunderstood term was "confidential." Donors who chose do not transfuse had a significantly higher rate of error on the terminology quiz (p less than 0.01) than did those who chose transfuse.     

Does limited placement of bioresorbable membrane of modified sodium hyaluronate and carboxymethylcellulose (Seprafilm®) have possible short-term beneficial impact?

PURPOSE: The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm®) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity. METHODS: All patients who had Seprafilm® placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm®. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fisher's exact test was used to compare gender distribution, nature of diagnosis (inflammatoryvs. noninflammatory), and urgency of surgery (electivevs. emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Student'st-test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan-Meier product limit method and log-rank test. RESULTS: Two hundred fifty-nine patients in whom Seprafilm® was placed were compared with a well-matched control cohort of 179 patients. The two groups did not differ in gender or age. One-half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm® group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm® group and 12 intestinal obstructions in 11 patients in the control group at a follow-up period of 65 months in the Seprafilm® group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm® group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm® group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm®. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm® (3.4 percent) and control (1.1 percent) groups. CONCLUSION: During short-term follow-up in this nonprospective, nonrandomized study, limited placement of Seprafilm® did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long-term, prospective, randomized trial is underway to elucidate these issues.Supported by an educational grant from Genzyme Surgical Products, Inc.Presented at the Association of Coloproctology of Great Britain and Ireland, Southport, UK, July 10 to 12, 1999.     

Toxicology today: what you need to know now

Clinicians are frequently confronted with toxicological emergencies and challenged with the task of correctly identifying the possible agents involved and providing appropriate treatments. In this review article, we describe the epidemiology of overdoses, provide a practical approach to the recognition and diagnosis of classic toxidromes, and discuss the initial management strategies that should be considered in all overdoses. In addition, we evaluate some of the most common agents involved in poisonings and present their respective treatments. Recognition of toxidromes with knowledge of indications for antidotes and their limitations for treating overdoses is crucial for the acute care of poisoned patients.     

Virtual blood banking in Hong Kong

OBJECTIVE. To review our experience in virtual blood banking for intra-operative transfusion in Hong Kong. DESIGN. Retrospective study. SETTING. Three major acute hospitals and a specialised centre for joint replacement surgery with installation of an Operating Theatre Blood Transaction System. PATIENTS. Patients undergoing surgery under anaesthesia and requiring intra-operative transfusion for the period from the implementation of the system in individual institutes (Queen Elizabeth Hospital: June 1997; Princess Margaret Hospital: May 2001; Queen Mary Hospital: October 2009; and Hong Kong Buddhist Hospital: December 2010) till September 2011. RESULTS. Under the system, 58 923 units of red cells were released intra-operatively for 18 264 patients (11% of the total number of blood units issued by the blood banks in these institutes during the study period). About 1% of them (613 units) entailed unmatched red cells given to 183 patients for emergency transfusions during surgery. The mean time required for the issue of the first unit of red cells was less than 1 minute. A total of 1231 units of red cells were returned unused after being released. Among them, 95 units were deemed unfit for re-issue because they had left the temperature-monitored blood storage refrigerators in the operating theatres for more than 30 minutes. There was no delay in transfusion or postponement of surgery due to problems or downtime of the Operating Theatre Blood Transaction System. CONCLUSION. Our experience has shown that our virtual blood banking system was efficient and effective, and helped ensure that the right patient received the right amount of the right blood at the right time. The system can be implemented either locally in the same hospital with a central blood bank, or in a more remote and networked site without a nearby supporting blood bank.     

Cannabinoids attenuate cancer pain and proliferation in a mouse model

We investigated the effects of cannabinoid receptor agonists on (1) oral cancer cell viability in vitro and (2) oral cancer pain and tumor growth in a mouse cancer model. We utilized immunohistochemistry and Western blot to show that human oral cancer cells express CBr1 and CBr2. When treated with WIN55,212-2 (non-selective), ACEA (CBr1-selective) or AM1241 (CBr2-selective) agonists in vitro, oral cancer cell proliferation was significantly attenuated in a dose-dependent manner. In vivo, systemic administration (0.013 M) of WIN55,212-2, ACEA, or AM1241 significantly attenuated cancer-induced mechanical allodynia. Tumor growth was also significantly attenuated with systemic AM1241 administration. Our findings suggest a direct role for cannabinoid mechanisms in oral cancer pain and proliferation. The systemic administration of cannabinoid receptor agonists may have important therapeutic implications wherein cannabinoid receptor agonists may reduce morbidity and mortality of oral cancer.     

Cefpodoxime 10 μg disc screening test for detection of Neisseria gonorrhoeae with mosaic PBP2 and decreased susceptibility to extended-spectrum cephalosporins for public health purposes

Antimicrobial resistance (AMR) in Neisseria gonorrhoeae remains a global public health problem. Susceptibility to first-line treatment extended-spectrum cephalosporins (ESCs) is decreasing worldwide resulting in therapeutic failures with oral ESCs. This study describes a cefpodoxime 10 μg disc test for screening for gonococci containing a penA mosaic allele encoding a mosaic penicillin-binding protein 2 (PBP2) and decreased ESC susceptibility. Selected clinical gonococcal isolates (n = 315), containing a high proportion of gonococci with decreased ESC susceptibility and high geographical, temporal and genetic diversity, were examined using agar dilution (n = 149; cefpodoxime and ceftriaxone) and Etest (n = 315; cefixime), and disc diffusion using a commercially available cefpodoxime 10 μg disc (n = 315). penA sequencing was performed on all isolates. The 2008 WHO gonococcal reference strains (n = 8) were included as quality controls. Using a ≤11 mm annular radius of growth inhibition as the breakpoint for the cefpodoxime 10 μg disc, all 78, with exception of one isolate (13 mm), mosaic PBP2-containing isolates, which also displayed decreased susceptibility to oral ESCs, were identified. In addition, 85 non-mosaic PBP2-containing isolates (44% of which contained a PBP2 A501 alteration) had annular radii ≤11 mm and raised minimal inhibitory concentrations to the ESCs. Screening for detection of mosaic PBP2-containing gonococci and decreased ESC susceptibility, most pronounced to oral ESCs, using a commercially available cefpodoxime 10 μg disc was rapid, inexpensive and sensitive. This test can be used in AMR surveillance programmes for public health purposes especially in less-resourced settings. Further studies to refine this disc testing-based approach are in progress.