Fungus-infected fluid collections in thorax or abdomen: effectiveness of percutaneous catheter drainage

PURPOSE: To retrospectively evaluate the effectiveness of percutaneous catheter drainage in the treatment of fungus-infected fluid collections in the thorax or abdomen and to identify any factor that may be predictive of a poor clinical outcome. MATERIALS AND METHODS: Approval for this study was obtained from the hospital ethics subcommittee on human studies. Because the study was retrospective, patient informed consent was not required. This study was compliant with the Health Insurance Portability and Accountability Act. Retrospective analysis was performed of cases of fungus-infected fluid collections in the thorax or abdomen treated by using percutaneous catheter drainage in 60 patients (36 male and 24 female patients; mean age, 57 years; range, 2 months to 91 years) during 5 years. The patient medical records were reviewed to identify recognized factors for predisposition to fungal infection. The details of percutaneous catheter drainage and microbiologic findings were recorded. The technical success (ability of catheters placed to drain collections treated) and the clinical success (ability of patients to recover fully without surgery) of percutaneous catheter drainage were determined. A multifactor logistic regression analysis was performed to identify any clinical or microbiologic factor predictive of a poor clinical outcome. RESULTS: Seventy-three fungus-infected fluid collections were drained in 60 patients. The collections originated from the pleura (n = 6), mediastinum (n = 2), liver (n = 3), pancreas (n = 5), obstructed biliary or urinary tract (n = 9), gallbladder (n = 1), and abdominopelvic area (n = 47). The technical success rate for catheter drainage was 79% (41 of 52 patients); the clinical success rate, 57% (34 of 60 patients). Twenty (33%) patients died from all causes during hospital admission. Multifactor logistic regression analysis was used to identify predictors of a poor clinical outcome; complexity of collection, history of malignancy, and admission to intensive care unit were significant (P < .03) and independent predictors. CONCLUSION: Despite a moderately high technical success rate with percutaneous catheter drainage of fungus-infected fluid collections, clinical success rate was much lower. Both imaging appearance (complexity of collection) and clinical factors (history of malignancy, admission to intensive care unit) influenced prognosis.     

Sterically Stabilized Phospholipid Mixed Micelles: In Vitro Evaluation as a Novel Carrier for Water-Insoluble Drugs

Purpose. Sterically stabilized phospholipid micelles (SSMs) composed of poly(ethylene glycol-2000)-grafted distearoyl phosphatidylethanolamine (PEG(2000)-DSPE) are new and promising lipid-based carriers for water-insoluble drugs. This study investigates and compares sterically stabilized mixed micelles (SSMM), composed of (PEG(2000)-DSPE) plus egg-phosphatidylcholine, with SSM as a novel delivery system for improved solubilization of water-insoluble drugs using paclitaxel as a model. Methods. Paclitaxel was solubilized in SSM (P-SSM) and SSMM (P-SSMM) by coprecipitation and rehydration with isotonic 0.01M HEPES buffer, pH 7.4. After separation of excess drug by centrifugation, mean particle size and morphology of particles in the supernatant were determined by quasi-elastic light scattering and transmission electron microscopy. The solubilization potentials of SSMM and SSM for paclitaxel were determined by reverse phase high pressure liquid chromatography (RP-HPLC). Cytotoxic activity of paclitaxel in SSMM, SSM, and dimethyl sulfoxide (10% DMSO) was determined against human breast cancer cells (MCF-7). Results. Mean hydrodynamic diameter of P-SSMM and P-SSM were 13.1 ± 1.1 nm and 15 ± 1 nm (n = 3), respectively. SSMM solubilized 1.5 times more paclitaxel than SSM for the same total lipid concentration. Solubilized paclitaxel amount increased linearly with an increase in lipid concentration. A therapeutically relevant lipid concentration (15 mM) of SSMM solubilized 1321 ± 48g/ml of paclitaxel. Paclitaxel in the absence of sufficient SSM aggregated to form lipid-coated crystals. P-SSMM, P-SSM, and paclitaxel in DMSO had comparable cytotoxic activities against MCF-7 cells. Conclusions. SSMM showed increased solubilization potential compared with SSM while retaining all of its own advantages. Therefore, it can be used as an improved lipid-based carrier for water-insoluble drugs.     

A Novel Formulation of VIP in Sterically Stabilized Micelles Amplifies Vasodilation In Vivo

Purpose. To determine whether human vasoactive intestinal peptide (VlP)-poly(ethylene glycol) (PEG)-grafted distearoyl-phosphatidyleth-anolamine (DSPE) micelles elicit potent and stable vasodilation in vivo. Methods. PEG-DSPE micelles were prepared by co-precipitation. VIP was loaded into micelles by incubation at room temperature. Vasoactivity of VIP in SSM was determined by monitoring changes in diameter of resistance arterioles in the in situ hamster cheek pouch using intravital microscopy. Results. VIP easily undergoes self-assembly into small PEG-DSPE micelles (mean [±SEM] size, 18 ± 1 nm) in a time-dependent fashion. This generates a potent vasoactive matrix at nanomole concentrations of VIP as manifested by ~3-fold potentiation and prolongation of vasodilation relative to that evoked by aqueous VIP alone (p < 0.05). This response is specific and mediated by the L-arginine/nitric oxide (NO) biosynthetic pathway. Micellar VIP dispersion remains vasoactive for at least 14 days after preparation and storage at 4°C. Conclusions. A novel, self-associated, small and stable PEG-DSPE micellar formulation of VIP amplifies vasodilation in the in situ peripheral microcirculation in a specific fashion by elaborating NO. An optimized formulation could be considered for certain cardiovascular disorders associated with L-arginine/NO biosynthetic pathway dysfunction.     

Assessment of health-related quality of life among hypertensive patients: a cross-sectional study from Palestine

Aim

The ability to identify indicators of poor health-related quality of life (HRQoL) is crucial for both improving clinical care and determining targets of intervention for the prevention and treatment of disease. The main objectives of this study were to assess the HRQoL profile of the hypertensive population from Palestine, and to determine the socio-demographic and clinical characteristics associated with poor HRQoL.

Subject and methods

A cross sectional study was conducted, adopting the EuroQoL-5 Dimensions scale (EQ-5D-5 L) for the assessment of HRQoL. Hypertensive patients attending outpatients’ clinics at Al-Makhfyah primary health care clinic and from Alwatani Hospital, Nablus, Palestine were approached for study.

Results

Four hundred and ten hypertensive patients were enrolled in the study. Of these, 213 patients (52 %) were female. The average age of the study population was 58.38?±?10.65 years. HRQoL was good, with a mean EQ-5D-5 L index value and EQ visual analogue scale (EQ-VAS) score of 0.80?±?0.16 and 74.1?±?15.6 respectively. There was a significant positive correlation (r?=?0.56; p?<?0.001) between the EQ-5D-5 L index values and the reported EQ-VAS scores. A significant difference in EQ-5D-5 L index values was found among participants when grouped according to age, occupation, marital status, income, educational level, duration of disease, total number of chronic diseases, and total number of medications (Kruskal–Wallis test; p-value?<?0.05), as well as gender and therapy type (Mann–Whitney test, p-value?<?0.05).

Conclusions

This study highlighted that specific socio-demographic and disease-related characteristics of hypertensive patients as well as treatment factors were strongly associated with HRQoL. The study findings could be helpful in clinical practice, mainly in the early treatment of hypertensive patients, at a point where improving HRQoL is still possible.     

Nickel: An Overview of Uptake,Essentiality and Toxicity in Plants

Nickel even though recognized as a trace element, its metabolism is very decisive for certain enzyme activities, maintaining proper cellular redox state and various other biochemical, physiological and growth responses. Study of the aspects related with uptake, transport and distributive localization of Ni is very important in various cellular metabolic processes particularly under increased nitrogen metabolism. This review article, in core, encompasses the dual behavior of Ni in plants emphasizing its systemic partitioning, essentiality and ill effects. However, the core mechanism of molecules involved and the successive physiological conditions required starting from the soil absorption, neutralization and toxicity generated is still elusive, and varies among the plants.     

A successful chronic care program in Al Ain-United Arab Emirates

Background

The cost effective provision of quality care for chronic diseases is a major challenge for health care systems. We describe a project to improve the care of patients with the highly prevalent disorders of diabetes and hypertension, conducted in one of the major cities of the United Arab Emirates.

Settings and Methods

The project, using the principles of quality assurance cycles, was conducted in 4 stages. The assessment stage consisted of a community survey and an audit of the health care system, with particular emphasis on chronic disease care. The information gleaned from this stage provided feedback to the staff of participating health centers. In the second stage, deficiencies in health care were identified and interventions were developed for improvements, including topics for continuing professional development. In the third stage, these strategies were piloted in a single health centre for one year and the outcomes evaluated. In the still ongoing fourth stage, the project was rolled out to all the health centers in the area, with continuing evaluation. The intervention consisted of changes to establish a structured care model based on the predicted needs of this group of patients utilizing dedicated chronic disease clinics inside the existing primary health care system. These clinics incorporated decision-making tools, including evidence-based guidelines, patient education and ongoing professional education.

Results

The intervention was successfully implemented in all the health centers. The health care quality indicators that showed the greatest improvement were the documentation of patient history (e.g. smoking status and physical activity); improvement in recording physical signs (e.g. body mass index (BMI)); and an improvement in the requesting of appropriate investigations, such as HbA1c and microalbuminurea. There was also improvement in those parameters reflecting outcomes of care, which included HbA1c, blood pressure and lipid profiles. Indicators related to lifestyle changes, such as smoking cessation and BMI, failed to improve.

Conclusion

Chronic disease care is a joint commitment by health care providers and patients. This combined approach proved successful in most areas of the project, but the area of patient self management requires further improvement.     

Evaluation of a Mindfulness-Based Intervention Program to Decrease Blood Pressure in Low-Income African-American Older Adults

Hypertension affects a large proportion of urban African-American older adults. While there have been great strides in drug development, many older adults do not have access to such medicines or do not take them. Mindfulness-based stress reduction (MBSR) has been shown to decrease blood pressure in some populations. This has not been tested in low-income, urban African-American older adults. Therefore, the primary purpose of this pilot study was to test the feasibility and acceptability of a mindfulness-based program for low income, minority older adults provided in residence. The secondary purpose was to learn if the mindfulness-based program produced differences in blood pressure between the intervention and control groups. Participants were at least 62 years old and residents of a low-income senior residence. All participants were African-American, and one was male. Twenty participants were randomized to the mindfulness-based intervention or a social support control group of the same duration and dose. Blood pressure was measured with the Omron automatic blood pressure machine at baseline and at the end of the 8-week intervention. A multivariate regression analysis was performed on the difference in scores between baseline and post-intervention blood pressure measurements, controlling for age, education, smoking status, and anti-hypertensive medication use. Effect sizes were calculated to quantify the magnitude of the relationship between participation in the mindfulness-based intervention and the outcome variable, blood pressure. Attendance remained >80% in all 8 weeks of both the intervention and the control groups. The average systolic blood pressure decreased for both groups post-intervention. Individuals in the intervention group exhibited a 21.92-mmHg lower systolic blood pressure compared to the social support control group post-intervention and this value was statistically significant (p = 0.020). The average diastolic blood pressure decreased in the intervention group post-intervention, but increased in the social support group. Individuals in the intervention group exhibited a 16.70-mmHg lower diastolic blood pressure compared to the social support group post-intervention, and this value was statistically significant (p = 0.003). Older adults are at a time in life when a reflective, stationary intervention, delivered in residence, could be an appealing mechanism to improve blood pressure. Given our preliminary results, larger trials in this hypertensive study population are warranted.     

Caring for Tube‐Fed Children

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral‐motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech‐language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent‐child interaction is an important part of the assessment and treatment of the tube‐fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube‐fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.     

Testing a predictive regression model for response in adult acute myeloid leukemia comparing two induction regimens of the E.O.R.T.C. -AML-5 and AML-6 trial

Pretreatment characteristics of 295 adults with acute myeloid leukemia who were treated in a large cooperative group of the E.O.R.T.C. between 1976 and 1982 (AML-5) have been evaluated to assess their value as prognostic indicators. Logistic regression methods were applied to derive a model for prediction of achievement of CR. The model was tested prospectively in an independent group of 274 subsequent patients treated with a different but similar induction regimen (AML-6), who were matched in all eligibility criteria. The concordance between the observed percentage of response in the AML-6 trial population and the expected response given by the model built on the AML-5 study was very close for the good response subgroups (WBC less than 50,000/mm3 and age less than 60 yrs), while the discrepancies in the poor prognostic groups were considerable. Furthermore, our study shows that the prognostic value of factors may shift as treatment strategies change and that caution is necessary in applying conclusions from a preceding trial to a current patient population.