Creutzfeldt--Jakob Disease in Recipients of Human Growth Hormone in the United Kingdom: A Clinical and Radiographic Study

In the past 3 years there have been five further cases, in additionto one case reported in 1985, of Creutzfeldt-Jakob disease inrecipients of human growth hormone in the United Kingdom. Theclinical findings of two of these cases are described, demonstratinga typical presentation with a predominantly cerebellar syndromeat onset which is not commonly a presenting feature of sporadicCreutzfeldt-Jakob disease. In one case a ^99mTc hexamethylpropylenaminesingle photon emission tomographic scan showed marked impairmentof tracer uptake in the basal ganglia and cerebral cortex ata time when the clinical picture was predominantly cerebellar.This technique may be useful in early diagnosis. In the othercase post mortem examination of the brain showed prominent amyloiddeposition in the cerebellum, which has not been described previouslyin pituitary-hormone related Creutzfeldt-Jakob disease. Thepreviously published cases of growth hormone-related Creutzfeldt-Jakobdisease are reviewed and reasons for the particular clinicalpattern seen are discussed.     

Nationwide survey of home transfusion practices

BACKGROUND: Limited information exists on home transfusion practices. STUDY DESIGN AND METHODS: In 1995, a survey requesting data for 1994 was sent to 1273 American Association of Blood Banks (AABB) institutional members and 113 non-AABB home health care agencies that provide out-of-hospital transfusions. RESULTS: Of 943 respondents, 102 provide blood to a home transfusion program, 37 provide blood and run a home transfusion program, and 13 run a home transfusion program only, for a total of 152 (16%) with some involvement in home blood transfusions. Most of the 50 respondents with a home transfusion program are licensed by their state and accredited by the Joint Commission on Accreditation of Healthcare Organizations. All respondents have written policies for home transfusion, and 90 percent require a signed informed-consent document before initiating transfusions in the home. Most have policies requiring that there be a second adult and a telephone in the home, that the home be deemed safe for transfusion, that the patient's physician be readily available, and that the patient have had prior transfusions. The most common component issued by the blood providers was red cells, followed by platelets. White cell-reduced components were always provided by 36 percent of respondents. The most common patient diagnosis was cancer. Home transfusions were provided primarily by registered nurses. Only 14 percent of respondents indicated that the medical director of the blood bank is responsible for approving a patient for home transfusion. A posttransfusion visit is performed by 46 percent of respondents. CONCLUSION: Although most facilities have policies for the administration of home transfusions, there remains marked heterogeneity among blood providers and transfusionists regarding home transfusion practices.     

Juvenile myasthenia gravis

Juvenile myasthenia gravis shares a similar pathophysiologic origin with adult myasthenia gravis, but there are important differences, mostly relating to epidemiology, presentation, and therapeutic decision making. Gender ratios and the proportion of seropositive patients differ in the pre‐ and postpubertal age groups. The diagnostic evaluation is similar to that in adults, although special techniques are sometimes necessary to perform single‐fiber electromyography in younger patients. Therapeutic decisions in affected children and adolescents are complicated by the greater long‐term consequences of using steroids, and thus other interventions, such as intravenous immunoglobulin (IVIg) and plasmapheresis, may play a greater therapeutic role in this population than in adults. Steroid‐sparing agents may contribute to the management of refractory cases, but they should be used with caution due to the risk of malignancy. Muscle Nerve, 2008     

Is Patients’ Preferred Involvement in Health Decisions Related to Outcomes for Patients with HIV?

BACKGROUND Previous studies suggest that patients who are more involved in their medical care have better outcomes. OBJECTIVES We sought to compare health care processes and outcomes for patients with HIV based on their preferred level of involvement in health decisions. DESIGN Cross-sectional analysis of audio computer-assisted interviews with patients at an urban HIV clinic. PATIENTS One thousand and twenty-seven patients awaiting an appointment with their primary care provider. MEASURES Patients were asked how they preferred to be involved in decisions (doctor makes most or all decisions, doctor and patient share decisions, patient makes all decisions). We also asked patients to rate the quality of communication with their HIV provider, and their self-reported receipt of and adherence to HAART. RESULTS Overall, 23% patients preferred that their doctor make all or most decisions, 63% preferred to share decisions with their doctor, and 13% preferred to make all final decisions alone. Compared to patients who prefer to share decisions with their HIV provider, patients who prefer that their provider make all/most decisions were significantly less likely to adhere to HAART (OR [odds ratio] 0.57, 95% CI 0.38–0.86) and patients who preferred to make decisions alone were significantly less likely to receive HAART or to have undetectable HIV RNA in unadjusted analyses (OR 0.52, 95% CI 0.31–0.87 for receipt of HAART; OR 0.64, 95% CI 0.44–0.95 for undetectable HIV RNA). After controlling for potentially confounding patient characteristics and differences in patient ratings of communication quality, patients who preferred that their provider make all/most decisions remained significantly less likely to adhere to HAART (OR 0.58, 95% CI 0.38–0.89); however, the associations with receipt of HAART and undetectable HIV RNA were no longer significant (OR 0.60, 95% CI 0.34–1.05 for receipt of HAART; OR 0.80, 95% C.I 0.53–1.20 for undetectable HIV RNA). CONCLUSIONS Although previous research suggests that more patient involvement in health care decisions is better, this benefit may be reduced when the patient wants to make decisions alone. Future research should explore the extent to which this preference is modifiable so as to improve outcomes.     

.VO2 kinetics during supramaximal exercise: relationship with oxygen deficit and 800-m running performance

The aim of this study was to compare .VO2 kinetics of highly- versus recreationally-trained subjects during a constant velocity test of supramaximal intensity. Eighteen trained male subjects were recruited to one of two groups: highly trained (HT, n = 8, .VO(2max) = 70.1 +/- 6.5 ml . min (-1) . kg (-1)) and recreationally trained (RT, n = 10, .VO(2max) = 63.2 +/- 6.4 ml . min (-1) . kg (-1)). All subjects performed an incremental test to exhaustion for the determination of .VO(2max) and peak treadmill velocity (PTV), two constant velocity tests at 110 % of PTV to determine .VO2 kinetics and oxygen deficit (O(2)def), and a 800-m time trial to determine running performance (mean velocity over the distance, V (800 m)). We found significant differences between HT and RT for the on-transient of the .VO2 response (tau, 24.7 +/- 3.3 and 30.9 +/- 7.0 s, respectively), the amplitude of the .VO2 response (60.0 +/- 5.0 and 53.5 +/- 5.7 ml . min (-1) . kg (-1), respectively) and V (800 m) (6.27 +/- 2.1 and 5.45 +/- 0.38 m . s (-1), respectively). O(2)def (24.6 +/- 2.7 and 27.7 +/- 7.8 ml . kg (-1), respectively) and the gain of the .VO2 response (193 +/- 14 and 194 +/- 13 ml . kg (-1) . m (-1), respectively) were similar between groups. tau was associated with O(2)def (r = 0.90, p < 0.05), but not with V (800 m) (r = 0.30, p > 0.05). It was concluded that HT subjects exhibited faster on-kinetics and higher amplitude than their RT counterparts. The higher amplitude was not thought to reflect any difference in underlying physiological mechanisms. The faster tau, whose exact mechanisms remain to be elucidated, may have practical implications for coaches.     

Internal fixation in compound type III fractures presenting after golden period

Objective:

Patients often reach the hospital late after passage of golden hours (initial 6 hours) after sustaining high-velocity injuries. The decision of internal fixation in Gustilo''s Type IIIA and IIIB fractures becomes a formidable challenge in patients reaching late. The purpose of the present study was to find out if internal fixation could be safely undertaken in these patients.

Materials and Methods:

Sixty-three patients, having 70 compound fractures (46 Type IIIA and 24 IIIB), which were internally fixed after 6h but within 24h after injury, were included in the present analysis. Follow-up ranged from 18 to 48 months with mean of 28 months.

Result:

Overall infection rate noted was (n = 11) 15.71% (8.7% in IIIA, and 29.16% in IIIB). The difference in deep infection rate between Type IIIA and Type IIIB was found to be statistically significant (P value < 0.01). Nonunion was seen in five fractures. Functional evaluation using Katenjian''s criteria, showed 62.85% (44 fractures of 70) good to excellent results.

Conclusion:

Satisfactory results may be obtained in Gustilo''s Type IIIA and IIIB fractures even if fixed after the golden period, provided strict protocol such as aggressive debridement, prophylactic antibiotic coverage, early soft tissue reconstruction and timely bone grafting is followed. The primary coverage of the wound is discouraged.     

Serological studies of piperacillin antibodies

BACKGROUND: Penicillin‐induced immune hemolytic anemia (IHA) is associated with immunoglobulin G antipenicillin detected by testing penicillin‐coated red blood cells (RBCs). Antibodies to piperacillin, a semisynthetic penicillin, would be expected to react similarly; however, antipiperacillin can be detected by testing in the presence of the drug. Piperacillin is commonly used in combination with tazobactam, which causes nonimmunologic protein adsorption onto RBCs. In six cases of piperacillin‐induced IHA, reactivity with piperacillin‐coated RBCs was not similar to reactivity of antipenicillin with penicillin‐coated RBCs. STUDY DESIGN AND METHODS: Antipiperacillin was tested against piperacillin‐coated RBCs prepared using different pH buffers. Plasma from blood donors and sera/plasma from patients were tested with piperacillin‐coated, penicillin‐coated, and uncoated RBCs. Hapten inhibition studies were performed using different concentrations of piperacillin. Donors' plasma were tested in the presence of piperacillin; sera from patients with IHA were tested in the presence of tazobactam. RESULTS: Piperacillin required high pH for binding to RBCs. Agglutination of piperacillin‐coated RBCs was observed in 91 percent of donors' and 49 percent of patients' plasma and was inhibited by piperacillin. In contrast to patients with IHA due to piperacillin, donors' plasma tested in the presence of piperacillin did not react. Tazobactam antibodies were not detected. CONCLUSION: A high percentage of donors' and patients' plasma contain an antibody to piperacillin or a chemically related structure detected by testing with piperacillin‐coated RBCs. A diagnosis of piperacillin‐induced IHA should not be made solely on the reactivity of a patient's plasma/serum with piperacillin‐ or piperacillin/tazobactam‐coated RBCs; testing in the presence of piperacillin is more reliable.     

Schools for health, education and development: a call for action

In 2007, the World Health Organization, together with UnitedNations and international organization as well as experts, metto draw upon existing evidence and practical experience fromregions, countries and individual schools in promoting healththrough schools. The goal of the meeting was to identify currentand emerging global factors affecting schools, and to help themrespond more effectively to health, education and developmentopportunities. At the meeting, a Statement was developed describingeffective approaches and strategies that can be adopted by schoolsto promote health, education and development. Five key challengeswere identified. These described the need to continue buildingevidence and capturing practical experience in school health;the importance of improving implementation processes to ensureoptimal transfer of evidence into practice; the need to alleviatingsocial and economic disadvantage in access to and successfulcompletion of school education; the opportunity to harness mediainfluences for positive benefit, and the continuing challengeto improve partnerships among different sectors and organizations.The participants also identified a range of actions needed torespond to these challenges, highlighting the need for actionby local school communities, governments and international organizationsto invest in quality education, and to increase participationof children and young people in school education. This paperdescribes the rationale for and process of the meeting and thedevelopment of the Statement and outlines some of the most immediateefforts made to implement the actions identified in the Statement.It also suggests further joint actions required for the implementationof the Statement.     

Sleep/wake cycles in the dark: sleep recorded by polysomnography in 26 totally blind subjects compared to controls.

OBJECTIVES: To evaluate subjective sleep difficulties and nocturnal sleep with polysomnography in 26 completely blind subjects, living in normal social environments and to compare the findings with those of matched controls.METHODS: Twenty-six blind individuals with no light perception and free-running melatonin rhythms, as assessed by measurements of urinary and salivary 6-sulfatoxymelatonin, were polygraphically monitored. Actigraphy and Braille sleep logs were obtained from the individuals for 14 days. Their sleep was compared to that of matched controls.RESULTS: Blind individuals were 'free-running' despite normal and regular social interaction. Each had ordinary working conditions and/or a family life with seeing spouse and children. Actigraphy obtained on 14 successive days showed the presence of small amount of daytime 'sleep' - 24.7+/-25.1 min per day. Total sleep time, sleep latency, sleep efficiency, and total REM sleep were significantly lower than in matched controls. Working blind subjects had a slightly higher total sleep time than those retired and unemployed. Congenital blindness, acquired blindness, presence of bilateral prosthetic eyes or presence of normal human eyes did not produce different nocturnal sleep and 'free-running' pattern results.CONCLUSIONS: Reduced total sleep time and other sleep abnormalities were associated with the complaint of daytime sleepiness and poor sleep in blind subjects. The abnormalities of sleep, which may be related to the free-running condition, present an additional challenge for these subjects, who are already severely impaired by their complete lack of vision.