Cholestasis in neonatal intensive care unit: incidence, aetiology and management

Aim:  Prevalence, aetiology, management and outcome of cholestasis were evaluated in infants admitted to neonatal intensive care unit (NICU).
Methods:  Medical records of all infants admitted to two Italian level III NICUs from January 2005 to August 2007 were retrospectively reviewed. The role of ursodeoxycholic acid (UDCA) therapy was also investigated.
Results:  Twenty-seven of 1289 enrolled infants developed cholestasis. In 25 infants, cholestasis had a multifactorial basis, while in two, no aetiology was found. UDCA did not significantly affect clinical and biochemical course of cholestasis. During a period of 12 months, eight cholestatic infants died, one underwent liver transplantation and 18 fully recovered.
Conclusion:  Infants admitted in NICU have a rate of cholestasis higher than that reported in the general population of live births; in most cases, cholestasis is associated to multiple risk factors and shows a favourable outcome. UDCA does not seem to affect clinical course of cholestasis in this setting.     

Documentation and Billing for Services Provided by Midwives Teaching Obstetrics and Gynecology Residents and Medical Students

Certified nurse‐midwives are teaching obstetrics and gynecology residents and medical students in major academic institutions across the United States. In these instances, the ability to appropriately document services rendered to support a billable service is paramount. This article explains the difference in requirements for mid‐wives' documentation when working with residents compared with documentation required of an attending obstetrician‐gynecologist. It also reviews the teaching physician guidelines developed by the Centers for Medicare and Medicaid Services (CMS) as well as current evaluation and management documentation requirements. Several examples of documentation are provided, as are suggestions for enhancement and simplification of the guidelines to include midwives. An important point to remember is that the CMS rules do not prohibit a certified nurse‐midwife from teaching a resident.     

A Colorectal Cancer Screening Program in an Underserved, Ethnically Diverse Population in Chicago, IL

The purpose of this project was to describe the structure and outcomes of a colorectal cancer screening program at CommunityHealth, the largest free health clinic in Illinois. We conducted a retrospective observational study using administrative clinical data from 2006 to 2011. A total of 4,026 patients were eligible for colorectal cancer screening of which 2,418 (60.0 %) completed fecal occult blood testing (FOBT). Subsequently, 1,657 patients had negative FOBT results and 1,365 patients underwent on-site flexible sigmoidoscopy. Over 90 % of patients had never had a prior screening examination. A majority of patients were female (61.7 %) and self-identified as Mexican (37.5 %) or Polish (28.2 %). A total of 203 biopsies were performed resulting in the detection of 69 adenomas (5.0 %) and 1 adenocarcinoma (0.1 %). A comprehensive colorectal cancer screening program was successfully implemented in a large community health center serving a population of diverse racial and ethnic backgrounds without prior access to screening. This program could serve as model for colorectal cancer screening in diverse, low resource communities.     

Metabolic Syndrome and Mammographic Density in Premenopausal Chilean Women

Background: Metabolic syndrome (MetS) has been previously associated with an increased risk of breast cancer in postmenopausal women. Mammographic density (MD) is a marker of breast cancer risk. There is little evidence of an association between MetS and MD in premenopausal women. Methods: Through a cross-sectional study, we evaluated 364 premenopausal Chilean women in which we measured anthropometric, blood pressure, and metabolic markers. MetS and its components were defined according to the National Cholesterol Education Program Adult Treatment Plan III criteria. We estimated MD by absolute dense volume (ADV, cm³), nondense volume (NDV, cm³), and percentage of dense volume (PDV, %). The relationship between MetS and MD was assessed by linear regression models. Results: After adjusting for sociodemographic and gyneco-obstetrics variables, nonsignificant association was found between MetS and ADV (log β = 0.10; 95%CI: ?0.01, 0.21). However, abdominal obesity, high triglycerides, and number of components of MetS were directly related to higher ADV (P < 0.05). Conclusion: Our results showed no association between MetS and ADV; nevertheless, abdominal obesity and triglycerides were related to higher ADV. If MD could be modifiable through nutritional factors, it would open new perspectives for the prevention of breast cancer through obesity prevention strategies at population level.     

Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts

Objective: To assess interruptions in chest compressions associated with advanced airway placement during cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrest (OHCA) victims. Methods: The method used was observational analysis of prospectively collected clinical and defibrillator data from 339 adult OHCA victims, excluding victims with <5 minutes of CPR. Interruptions in CPR, summarized by chest compression fraction (CCF), longest pause, and the number of pauses greater than 10 seconds, were compared between patients receiving bag valve mask (BVM), supraglottic airway (SGA), endotracheal intubation (ETI) via direct laryngoscopy (DL), and ETI via video laryngoscopy (VL). Secondary outcomes included first pass success and the effect of multiple airway attempts on CPR interruptions. Results: During the study period, paramedics managed 23 cases with BVM, 43 cases with SGA, 148 with DL, and 125 with VL. There were no statistically significant differences between the airway groups with regard to longest compression pause (BVM 18 sec [IQR 11–33], SGA 29 sec [IQR 15–65], DL 26 sec [IQR 12–59], VL 22 sec [IQR 14–41]), median number of pauses greater than 10 seconds (BVM 2 [IQR 1–3], SGA 2 [IQR 1–3], DL 2 [IQR 1–4], VL 2 [IQR 1–3]), or CCF (0.92 for all groups). However, each additional attempt following failed initial DL was associated with an increase in the risk of additional chest compression pauses (relative risk 1.29, 95% confidence interval 1.02–1.64). Such an association was not observed with additional attempts using VL or SGA. First pass success was highest with SGA (77%), followed by between DL (68%) and VL (67%); these differences were not statistically significant. Conclusions: While summary measures of chest compression delivery did not differ significantly between airway classes in this observational study, repeated attempts following failed initial DL during cardiopulmonary resuscitation were associated with an increase in the number of pauses in chest compression delivery observed     

Anaphylactic shock depends on endothelial Gq/G11

Anaphylactic shock is a severe allergic reaction involving multiple organs including the bronchial and cardiovascular system. Most anaphylactic mediators, like platelet-activating factor (PAF), histamine, and others, act through G protein–coupled receptors, which are linked to the heterotrimeric G proteins G_q/G₁₁, G₁₂/G₁₃, and G_i. The role of downstream signaling pathways activated by anaphylactic mediators in defined organs during anaphylactic reactions is largely unknown. Using genetic mouse models that allow for the conditional abrogation of G_q/G₁₁- and G₁₂/G₁₃-mediated signaling pathways by inducible Cre/loxP-mediated mutagenesis in endothelial cells (ECs), we show that G_q/G₁₁-mediated signaling in ECs is required for the opening of the endothelial barrier and the stimulation of nitric oxide formation by various inflammatory mediators as well as by local anaphylaxis. The systemic effects of anaphylactic mediators like histamine and PAF, but not of bacterial lipopolysaccharide (LPS), are blunted in mice with endothelial Gα_q/Gα₁₁ deficiency. Mice with endothelium-specific Gα_q/Gα₁₁ deficiency, but not with Gα₁₂/Gα₁₃ deficiency, are protected against the fatal consequences of passive and active systemic anaphylaxis. This identifies endothelial G_q/G₁₁-mediated signaling as a critical mediator of fatal systemic anaphylaxis and, hence, as a potential new target to prevent or treat anaphylactic reactions.