Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough

BACKGROUND: Impaired cough secondary to weakness from neuromuscular disease (NMD) can cause serious respiratory complications, including atelectasis, pneumonia, small airway obstruction, and acidosis. The mechanical in-exsufflator (MI-E) delivers a positive-pressure insufflation followed by an expulsive exsufflation, thereby simulating a normal cough. Use of the MI-E in adults with impaired cough results in improved cough flows and enhanced airway clearance. However, only limited reports of MI-E use in children exist. OBJECTIVE: To determine the safety, tolerance, and effectiveness of the MI-E in a pediatric population. METHOD: Retrospective medical record review. PARTICIPANTS: Sixty-two patients (34 male patients) observed in a pediatric pulmonary program with NMD and impaired cough in whom MI-E therapy was initiated. Median age at initiation of MI-E use was 11.3 years (range, 3 months to 28.6 years). Diagnoses included the following: Duchenne muscular dystrophy (17 patients); spinal muscular atrophy, types I and II (21 patients); myopathy (12 patients); other nonspecific NMD (12 patients). Mechanical ventilation via tracheostomy was used in 29 patients, and 25 patients used noninvasive ventilation. RESULTS: The median duration of use was 13.4 months (range, 0.5 to 45.5 months). One infant died before using MI-E at home. Five patients chose not to continue MI-E therapy. Complications were reported in two patients, but ultimately they used the MI-E device. Chronic atelectasis resolved in four patients after beginning MI-E therapy, and five patients experienced a reduction in the frequency of pneumonias. CONCLUSION: In 90% of our study population, the use of an MI-E was safe, well-tolerated, and effective in preventing pulmonary complications.     

Bladder perforation during laparoscopic donor nephrectomy

We present two cases of bladder perforation during laparoscopic donor nephrectomy at our institution. Neither of the surgeries was otherwise complicated, and the diagnoses were made post-operatively. The kidneys were extracted through a Pfannenstiel incision and used blunt dissection to penetrate the peritoneum. Both patients had previous tubal ligations, adhesions from which may have increased the chance of injury. We believe that this is a previously unreported complication that merits attention. Care should be taken with the peritoneal incision and dissection as the bladder may be susceptible to injury.     

Probiotics in neonatology

Probiotics are micro-organisms that confer health benefits on the host. Postulated mechanisms include: increasing resistance of the mucosal barrier to migration of bacteria and their toxins by strengthening intestinal cell junctions, modification of host response to microbial products, augmentation of immunoglobulin A mucosal responses, enhancement of enteral nutrition to inhibit the growth of pathogens; production of antimicrobial proteins; and competitive exclusion of potential pathogens. Published meta-analyses and systematic reviews report the effects of probiotics on important clinical outcomes in neonates. This paper will review the evidence for probiotic supplementation in neonatology, with a focus on preterm infants.     

Spatial Dimensions of Child Social Exclusion Risk in Australia: Widening the Scope

Despite great concern about child well-being, and an increasing recognition of the need to monitor how well children are doing, small area measures of child disadvantage are a very recent development in understanding child well-being both within Australia and internationally. This paper describes the further development of Australia??s only small area index of child social exclusion risk. Drawing on the latest conceptual and methodological developments in child indicator research, the authors have identified additional domains and variables to best measure child social exclusion at a small area level. Incorporating new data, the paper then goes on to discuss the use of principal components analysis and equal weighting to transform the individual indicators into domain scores, and then the domain scores into a single composite index.     

Rural inpatient telepharmacy consultation demonstration for after-hours medication review

Abstract Objective: Medication errors contribute to a significant number of fatal and nonfatal adverse medical events each year. Many actions, from both a policy and innovation standpoint, have been taken to reduce medication errors in the inpatient setting; yet, these actions often target larger urban hospitals. Rural hospitals face many more challenges in implementing these changes due to fewer resources and lower patient volumes. Our article discusses the implementation and results of a telepharmacy demonstration implemented between the University of California Davis Health System and six rural hospitals. Materials and Methods: A retrospective chart review obtained baseline medication errors for comparison with the prospective review of medication orders through telepharmacy. Medication orders from rural hospitals were transmitted via fax to the University of California Davis Pharmacy for after-hours review. If a medication required after-hours removal from the pharmacy, it was requested that video verification by a telepharmacist be used to verify that the correct medication was removed from the pharmacy. Results: Baseline findings from the retrospective chart review indicated that 30.0% of patients had one or more medication errors and that these errors occurred in 7.2% of the medication orders. None of these errors were found to have resulted in harm to the patients. During the telepharmacy demonstration, 2,378 medication orders were screened from 504 independent order review requests. In total, 58 (19.2%) patients had one or more medication errors. The errors from the telepharmacy demonstration represented potential errors that were identified through telepharmacy medication review. Conclusions: Telepharmacy represents a potential alternative to around-the-clock on-site pharmacist medication review for rural hospitals.     

Development and characterization of a multiplex bead-based immunoassay to quantify pneumococcal capsular polysaccharide-specific antibodies

Enzyme-linked immunosorbent assay (ELISA), the traditional antibody quantification technique, has several limitations, especially when used to evaluate multivalent and/or infant vaccines. We have developed a multiplex bead-based antibody quantification assay (MBIA) to measure antibody response to multiple pneumococcal (Pn) serotypes (St) in a single assay. MBIA was compared with the WHO ELISA using a WHO panel of 12 international calibration sera for 7 Pn Sts. An agreement of 75 to 92% was obtained for all 7 Sts. MBIA exhibited good robustness, with the assay variability at ≤16%. A major contributor to MBIA variability was the cell wall polysaccharide (CWPs) content in Pn St-specific capsular Ps. This necessitated careful CWPs (20 μg/ml) preadsorption of sera. MBIA is specific, robust, and reproducible and offers high throughput. The use of MBIA will greatly reduce the cost and time required to evaluate the immune response to multiple Pn Sts and could help promote the licensure of future Pn and other multivalent vaccines.     

Uncoupling response inhibition

The ability to prevent unwanted movement is fundamental to human behavior. When healthy adults must prevent a subset of prepared actions, execution of the remaining response is markedly delayed. We hypothesized that the delay may be sensitive to the degree of similarity between the prevented and continued actions. Fifteen healthy participants performed an anticipatory response inhibition task that required bilateral index finger extension or thumb abduction with homogeneous digit pairings, or a heterogeneous pairing of a combination of the two movements. We expected that the uncoupling of responses required for selective movement prevention would be more difficult with homogeneous (same digit, homologous muscles) than heterogeneous pairings (different digits, nonhomologous muscles). Measures of response times (and asynchrony between digits) during action execution, stopping performance, and electromyography from EIP (index finger extension) and APB (thumb abduction) were analyzed. As expected, selective trials produced a delay in the remaining movement compared with execution trials. Successful performance in the selective condition occurred via suppression of the entire prepared response and subsequent selective reinitiation of the remaining component. Importantly, the delayed reinitiation of motor output was sensitive to the degree of similarity between responses, occurring later but at a faster rate with homogeneous digits. There were persistent aftereffects from the selective condition on the motor system, which indicated greater levels of inhibition and a higher gain were necessary to successfully perform selective trials with homogeneous pairings. Overall, the results support a model of inhibition of a unitary response and selective reinitiation, rather than selective inhibition.     

Muscle power and function two years after unicompartmental knee replacement

Unicompartmental knee replacement (UKR) is a commonly performed procedure, suitable for one in four patients requiring knee replacement for end-stage osteoarthritis. Recovery and return of function is quicker than with total knee replacement (TKR), but little information is known about the recovery of muscle power. We prospectively studied a cohort of forty four patients undergoing medial UKR to document their functional recovery and leg extensor power. Muscle power was measured using a Leg Extensor Power rig preoperatively and at 1 and 2 years after surgery. Function was self reported using the Oxford Knee Score (OKS) and Tegner Activity Scale (TAS). At 1 year all patients had made significant improvements on all functional measures, with a mean gain in OKS of 15.9 and TAS of 0.84. There were also significant increases in leg extensor power (LEP) of both legs. The mean change in LEP of the operated leg at 1 year was 0.50 W/kg and the non-operated leg was 0.10 W/kg. Between 1 and 2 years there were very slight improvements in strength in both legs, but these were not significant. Compared with healthy age matched normative values, the UKR LEP values at 2 years after surgery were decreased. The recovery of strength and function following UKR had stabilised by 1 year and during the following year further improvements were minimal.