Heterotopic heart transplantation and native heart ventricular arrhythmias

Heterotopic heart transplantation has been said to be contraindicated in patients with serious native heart arrhythmias that produce hemodynamic instability. Placement of heterotopic allografts, however, can theoretically act as a biological biventricular assist device to provide hemodynamic support during these unstable rhythms. Further, this operation might beneficially alter the hemodynamic milieu of heart failure such that the arrhythmias are ameliorated. Described is our experience with 4 patients with heart failure receiving heterotopic cardiac allografts, documenting changes in native heart arrhythmia that occurred. These cases demonstrate that heterotopic grafts can adequately sustain hemodynamics during malignant native heart dysrhythmia. We believe native heart ventricular arrhythmias are not a contraindication to heterotopic heart transplantation.     

A phenomenon: left-biassed asymmetrical eye-opening in artificially reared rat pups

From 4 or 5 postnatal days, rat pups were either reared by their mothers (MR) or artificially reared (AR) without their mothers by infusion of 'milk' through a gastric cannula. In AR, but not MR, pups the left eye was more likely to open first than the right eye (P less than 0.001). The left-biassed eye-opening of AR pups may be a manifestation of stress-induced lateralisation of their brains.     

Imaging of neonatal pulmonary sequestration including Doppler ultrasound

Seven cases of neonatal pulmonary sequestration are reviewed which illustrate the varied clinical presentations and radiological findings. In four patients, real time ultrasound scanning was used to image the chest and the features are described. In three cases, the systemic supplying artery was demonstrated by duplex Doppler scanning and further invasive investigations were avoided; after a chest radiograph, this should be the examination of choice in the investigation of a neonate with a possible pulmonary sequestration.     

Translational development of splice-modifying antisense oligomers

Introduction: Antisense nucleic acid analogues can interact with pre-mRNA motifs and influence exon or splice site selection and thereby alter gene expression. Design of antisense molecules to target specific motifs can result in either exon exclusion or exon inclusion during splicing. Novel drugs exploiting the antisense concept are targeting rare, life-limiting diseases; however, the potential exists to treat a wide range of conditions by antisense-mediated splice intervention.

Areas covered: In this review, the authors discuss the clinical translation of novel molecular therapeutics to address the fatal neuromuscular disorders Duchenne muscular dystrophy and spinal muscular atrophy. The review also highlights difficulties posed by issues pertaining to restricted participant numbers, variable phenotype and disease progression, and the identification and validation of study endpoints.

Expert opinion: Translation of novel therapeutics for Duchenne muscular dystrophy and spinal muscular atrophy has been greatly advanced by multidisciplinary research, academic-industry partnerships and in particular, the engagement and support of the patient community. Sponsors, supporters and regulators are cooperating to deliver new drugs and identify and define meaningful outcome measures. Non-conventional and adaptive trial design could be particularly suited to clinical evaluation of novel therapeutics and strategies to treat serious, rare diseases that may be problematic to study using more conventional clinical trial structures.     

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis

Background

Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure.

Methods

As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure.

Results

Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001).

Conclusions

The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

     

Critical Care Management of Peritonitis in a Low-Resource Setting

Background

Management of critically ill patients is challenging in a low-resource setting. In Rwanda, peritonitis is a common surgical condition where patients often present late, with advanced disease. We aim to describe critical care management of patients with peritonitis in Rwanda.

Methods

Data were collected at a tertiary referral hospital in Rwanda on patients undergoing operation for peritonitis over a 6-month period. Data included epidemiology, hospital course and outcomes. Patients requiring admission to the intensive care unit (ICU) were compared with those not requiring ICU admission using Chi-square and Wilcoxon rank-sum test.

Results

Over a 6-month period, 280 patients were operated for peritonitis. Of these, 46 (16.4%) were admitted to the ICU. The most common diagnoses were intestinal obstruction (N?=?17, 37.0%) and typhoid intestinal perforation (N?=?6, 13.0%). Thirty-nine (89%) patients had sepsis. The median American Society of Anesthesiologist score was 3 (range 2–4), and the median Surgical Apgar Score was 4 (range 0–6). Twenty-four (52.2%) patients required vasopressors, with dopamine and adrenaline being the only vasopressors available. Patients admitted to the ICU, compared with non-critically ill patients, were more likely to have major complications (80.4 vs. 14%, p?<?0.001), unplanned reoperation (28 vs. 10%, p?<?0.001) and death (72 vs. 8%, p?<?0.001).

Conclusion

Patients with peritonitis admitted to the ICU commonly presented with features of sepsis. Due to limited resources in this setting, interventions are primarily supportive with intravenous fluids, intravenous antibiotics, ventilator support and vasopressors. Morbidity and mortality remain high in this patient population.

     

Rh33 in two of three German siblings with D+ C+ c+ E− e+ red cells

The proposita in a German family of three siblings has D+ C+ c+ E- e+ f+ Rh: -17,19,33,34 red cells with weak C, e, f, Rh19, and Rh34 and stronger-than-usual Rh33 expression. One sibling has D+ C+ c+ E- e+ f+ Rh:17,19,33,34 red cells with weak f and ordinary-strength Rh33, and the other sibling has D+ C+ c+ E- e+ f+ Rh:17,19,-33,34 red cells. In the absence of any further family members, the proposita's unusual phenotype suggests that she has an RoHar haplotype and a "new" Rh haplotype, provisionally named R1Lisa, that encodes Rh33, normal-strength D, weak C, weak or nondemonstrable e, Rh19, and Rh34, but not Rh17. Her Rh:33 sibling may have R1 and RoHar and her Rh:-33 sibling R1 and r haplotypes.     

Developing an integrated nursing team approach

Nursing Standard recently published a literature search that explored different models of integrated nursing and more traditional models of community nursing in primary care (Baileff 2000). Models of change for implementing integrated nursing were also examined. This article aims to explore the development of an integrated nursing team in a healthcare centre in Northampton.