Chemoprophylaxis for pulmonary aspergillosis during intensive chemotherapy

Three children who developed pulmonary aspergillosis while being treated for leukaemia or non-Hodgkin's lymphoma. Each child continued with intensive myelosuppressive chemotherapy regimens during the infection and each was successfully treated with antifungal prophylaxis based on itraconazole by mouth. Amphotericin B was also given during periods of severe neutropenia. No reactivation of the fungal infection was seen.     

Documentation of do-not-resuscitate orders in an Irish hospital

Background Some studies have suggested that do-not-resuscitate (DNR) decisions are often documented poorly in European countries. Aim To examine the use and documentation of DNR orders in a large Irish teaching hospital. Methods Resuscitation status of all inpatients on a single day was determined using interviews with nursing staff and examination of the nursing and medical case notes. Results Seventeen (3.5%) of 485 patients were identified as not for resuscitation. There was written confirmation of the DNR order in the nursing notes for 14 (82%) and in the medical notes for 15 (88%) patients; in two cases, it was reported that doctors were reluctant to write down the agreed decision. Documentation of DNR orders was by consultant (7), registrar (7) and intern (1). Discussion with patient (2), family (10) or both (1) was recorded in 14 cases. Conclusion The majority of DNR orders were clearly documented by senior doctors and had been discussed with the patient or with the relatives. A number of problems were identified that might be avoided by development of guidelines regarding use and documentation of DNR orders.     

患者安全与医疗系统的持续改进

20世纪90年代以来,患者安全的问题受到世界各国的重视,国际上几个探讨医疗错误的大规模流行病学研究所,特别是1999年美国医学研究所发表了著名的报告--"错误凡人皆有:构建一个更安全的卫生系统,"揭露了在目前的医疗环境中存在的相当程度的医疗错误与风险.本文概述了全球面临患者安全问题的挑战;应对患者安全挑战的国内外动态;以及安全医疗环境的建立应该妥善处理个人责任与管理系统原因的关系,摈弃苛责个人的文化而以系统改善为导向的思考;最后就促进医疗质量和患者安全的持续改进提出了建议.     

Ultrasound contrast agent Levovist® in colour Doppler sonography of hepatocellular carcinoma in Chinese patients

In a phase IIIb clinical trial of the ultrasound contrast agent Levovist® (Schering AG, Berlin, Germany), the role of Levovist® in the management of patients with clinically suspected hepatocellular carcinoma (HCC) was evaluated and its efficacy was assessed. The assessment included the duration of diagnostically usable Doppler signal enhancement, and safety and tolerance of intravenous administration. All patients with clinically suspected hepatocellular carcinoma were referred for Doppler sonographic examination over a 5-month period and lesions with absent or suboptimal Doppler signals were included in the trial. A total of 300 mg/mL in concentration (8.5 mL) of Levovist® was administered through a peripheral vein while Doppler signal intensity in the lesion, based on a visual score, was recorded. Blood pressure and pulse were recorded before and after injection. Thirty-eight patients were examined, of which 29 were included in the trial. The lesions were subsequently proven histologically to be 19 HCC, one cholangiocarcinoma, two regeneration nodules and one colonic metastasis. For six patients in whom histological proof was not available, the diagnosis of HCC was suggested based on markedly elevated serum alpha-fetoprotein levels. All but one (96%) of the 25 HCC demonstrated increased Doppler signal after Levovist®. There were no Doppler signals before and after Levovist® injection in three non-HCC lesions (two regeneration nodules and one colonic metastasis). Two patients (6.9%) suffered minor adverse reactions of nausea and vomiting. The results show that Levovist® is safe and is able to improve lesion characterization and increase diagnostic confidence of hepatocellular carcinoma by enhancing tumour vascularization Doppler signal intensity.     

Cardiac transplantation for Kawasaki disease

OBJECTIVE: Severe cardiac sequelae from Kawasaki disease include coronary ischemia and have been treated with a variety of coronary artery bypass procedures. There is only one published report of a child who underwent cardiac transplantation for severe Kawasaki disease-related cardiac complications. The purpose of this study was to gather the worldwide experience with cardiac transplantation for Kawasaki disease. METHODS: Data were obtained from the United Network for Organ Sharing Registry, the European transplant experience, and a phone survey of many Kawasaki disease investigators. Diagnostic and surgical reports as well as clinical records were reviewed. Results. We identified 13 Kawasaki disease patients who underwent cardiac transplantation and obtained data on 10. In these 10 patients, the timing of transplantation was within 6 months after diagnosis of Kawasaki disease (4 patients), 1 to 5 years after diagnosis (3 patients), and 9 to 12 years after diagnosis (3 patients). Indications for transplantation included severe myocardial dysfunction, severe ventricular arrhythmias including cardiac arrest, and severe distal multivessel occlusive coronary artery disease. Nine of the 10 patients remain alive and healthy, with up to 6 years' posttransplant follow-up. One patient died 10 months posttransplant after severe refractory rejection. In addition, 1 patient required retransplantation at 4 years for severe rejection. CONCLUSIONS: Cardiac transplantation for severe ischemic heart disease as a sequela of Kawasaki disease is feasible and can benefit the small subgroup of patients who are not candidates for revascularization because of distal coronary stenosis or aneurysms and/or those with severe irreversible myocardial dysfunction.     

Bloodspot cortisol in mild asthma: the effect of inhaled corticosteroids

Bloodspot cortisol, where finger pricked blood is applied to blotting paper, is suitable for repeated measurements in the home environment. The use of bloodspot cortisol measurements in children with asthma and the effect of inhaled corticosteroids on daytime cortisol concentrations were assessed. Twenty children with mild asthma were randomised to receive double blind either placebo or beclomethasone dipropionate 200 micrograms twice daily. Blood was taken by finger prick at home on waking, and treatment administered. Blood was then taken one hour after treatment, at lunchtime, and in the evening. The area under the curve (AUC) for the four time points was calculated as a composite index of daytime cortisol. Mean (SEM) bloodspot cortisols fell progressively over the day from 199.2 (15.6) nmol/l to 58.4 (8.9) nmol/l. Cortisol in the group treated with beclomethasone dipropionate was lower at all time points, but was significant only after treatment (mean (SEM) 120.9 (14.3) v 177.5 (21.0) nmol/l) and at lunchtime (mean (SEM) 82.7 (12.4) v 128.9 (12.6) nmol/l). AUC for the beclomethasone dipropionate treated group was also significantly decreased (mean (SEM) 317 (31.4) v 446 (29.7)). Beclomethasone dipropionate at a dose of 400 micrograms/day significantly suppresses the daytime cortisol profile.     

Emerin deletions occurring on both Xq28 inversion backgrounds

Emery-Dreifuss muscular dystrophy (EMD) is an X-linked disorder characterized by contractures, progressive weakness and cardiomyopathy. EMD is caused by mutations in the 2 kb emerin gene that is located within human Xq28. Emerin is immediately distal to the 26 kb filamin gene, and flanking the filamin-emerin region are two large inverted repeats. This entire region previously has been found to be inverted in approximately 20% of X chromosomes, presumably mediated by the inverted repeats. Only one complete emerin deletion has been reported previously. It was found to be due to a complex rearrangement involving the inverted repeats which partially duplicated filamin. We report here two additional EMD patients who have large deletions of 20 and 34 kb, respectively. Unlike the previously reported deletion, these deletions appear to be simple deletions, with each breakpoint junction showing only 2 bp of overlap, suggesting an end-joining mechanism. However, the two deletions were found on each of the two inverted backgrounds. The 20 kb deletion includes the entire emerin gene and extends well into most of the distal inverted repeat. In contrast, the 34 kb deletion occurs on the inverted X chromosome and extends centromeric, well beyond the proximal inverted repeat. In addition, at least three nearby putative genes detected by previous sequence analysis are deleted among these patients but without obvious deviation from a typical EMD phenotype. Similarly to the previously reported deletion, filamin remains intact in these two deletions. All three deletions involve distinct breakpoints within the 4.7 kb filamin-emerin intergenic region, suggesting that loss of filamin is a lethal event. Thus, the close proximity of filamin to emerin may place constraints upon potential emerin deletions and probably accounts for the rarity of complete emerin deletions in EMD patients.      

Bovine β-1actoglobulin in human milk from atopic and non-atopic mothers. Relationship to maternal intake of homogenized and unhomogenized milk

Human milk samples (n = 300) were collected during a 3-week period from 10 healthy mothers and from 10 atopic mothers, all with healthy, solely breast-fed infants. The milk samples were analysed by an enzyme-linked immunosorbent assay (ELISA) for the content of bovine beta-lactoglobulin (BLG). In a cross-over design the atopic and non-atopic mothers alternated their intake of milk between homogenized and unhomogenized milk each week. On day 7, in each week, consecutive milk samples were taken before and 4, 8, 12 and 24 hr after a single ingestion of 500 ml of homogenized or unhomogenized milk. Detectable amounts of BLG (0.9-150 micrograms/l, median value 4.2 micrograms/l) were measured in 19/20 of the mothers (95%), in 9 of 10 atopic mothers and in all 10 of 10 non-atopic mothers. No correlation was found between the type of milk preparation (homogenized or unhomogenized) and the presence of BLG or the level of BLG in human milk. A great intra-individual and inter-individual variation of BLG level was found, and no relationship was observed between BLG levels and atopic status of the mothers. The interval between ingestion of 500 ml of milk and the maximal concentration of BLG on milk-free diet varied between 4 and 24 hr, median value 8 hr. The presence of BLG in human milk is a common finding in both atopic and non-atopic mothers.