Quality Improvement Study on New Endotracheal Tube Securing Device (Neobar) in Neonates

Objectives

To examine the rate of unplanned extubation (UE) after the introduction of NeoBar (endotracheal tube stabilization device) compared to the previous tapping method and to analyze the factors associated with UE in the neonatal intensive care unit (NICU).

Methods

A quality improvement study was conducted in a tertiary NICU between October 2011 and December 2013. In October 2012, after many educational sessions NeoBar was introduced as a tool for securing endotracheal tube. The UE rate was compared one year before and one year after the introduction of NeoBar. The UE rate was reported as UE per 100 intubation days. Statistical process control charts were used for understanding the special cause variation. The authors used Standards for Quality Improvement Reporting Excellence (SQUIRE) method of reporting for this project.

Results

The UE rate decreased from 1.47 per 100 intubation days to 1.17 per 100 intubation days following the introduction of NeoBar (p=0.91). The UE rate was consistently below/at the mean, showing a stable change following the introduction of NeoBar, despite no statistically significant difference in UE rate. The common factors associated with UE were retaping/adjustment of endotracheal tube, infant agitation and performance of other procedures in both time periods.

Conclusions

Use of NeoBar as endotracheal tube securing device was associated with similar UE rates compared to taping method. Large prospective studies are required to assess whether NeoBar reduces the UE rate.

     

Multi-quadrant biopsy technique improves diagnostic ability in large heterogeneous renal masses. Abel EJ,Heckman JE,Hinshaw L,Best S,Lubner M,Jarrard DF,Downs TM,Nakada SY,Lee FT Jr,Huang W,Ziemlewicz T.J Urol. 2015 Oct;194(4):886-91. [Epub 2015 Mar 30]. doi: 10.1016/j.juro.2015.03.106.

Purpose

Percutaneous biopsy obtained from a single location is prone to sampling error in large heterogeneous renal masses, leading to nondiagnostic results or failure to detect poor prognostic features. We evaluated the accuracy of percutaneous biopsy for large renal masses using a modified multi-quadrant technique vs. a standard biopsy technique.

Mediastinal lymph node metastases from bronchogenic carcinoma: detection with MR imaging and CT

Magnetic resonance (MR) imaging and computed tomography (CT) were compared in a prospective study of 48 patients for the detection of metastatic mediastinal lymphadenopathy from bronchogenic carcinoma. The images were interpreted by three experienced radiologists using a five-point rating scale, enabling receiver operating characteristic (ROC) analysis. Imaging results were evaluated against "truth" data based on analysis of surgical specimens from mediastinoscopy and thoracotomy. All MR images were cardiac gated to reduce cardiac motion artifacts in the mediastinum. MR and CT both performed well, as indicated by similar areas under the ROC curves of 0.779 +/- 0.039 for MR imaging and 0.781 +/- 0.038 for CT scanning. No strong correlation between nodal size and metastatic involvement could be found for either MR or CT results. As long as nodal size remains the sole criterion in the detection of metastatic mediastinal lymphadenopathy, MR imaging is unlikely to enable better interpretations than CT scanning.     

To disrupt and displace: placing domestic violence on the public health agenda

In 1996, in Geneva, the World Health Assembly declared the violence as a major and growing public health problem. Others have gone further in describing (sexual) violence against women as a weapon of terror. In the local community of Hamilton, Ontario Canada (population approximately 500,000), domestic violence represents 25% of the workload of the local police service. The literature has shown that violence in general, and domestic violence in particular, presents tremendous social and health impacts for individuals and communities. In this local community, however, an evaluation of a recently piloted cutting edge domestic violence response system highlights how difficult it is to place domestic violence on the policy and/or public health agendas. Qualitative interviews with 23 key stakeholders were undertaken to assess their views on the success of the program. While overall findings indicate that the success of this brief (11 month) pilot project was limited, important insights emerged around responding to the domestic violence issue, at the community level.     

Investigation into the Ability of SNP Chipsets and Microsatellites to Detect Association with a Disease Locus

We wished to investigate the ability of different SNP chipsets to detect association with a disease and to investigate the linkage disequilibrium (LD) relationships between microsatellites and nearby SNPs in order to assess their potential usefulness to detect association.
SNP genotypes were obtained from HapMap and microsatellite genotypes from CEPH. 5000 SNPs were simulated as disease genes which increased penetrance from 0.01 to 0.02 in a sample of 400 cases and 400 controls. The power of flanking SNPs to detect association was tested using sets of 1, 2, 3 or 4 markers analysed with haplotype analysis or logistic regression and using either all HapMap markers or those from the Affymetrix 500K, Illumina 300K or Illumina 550K chipsets. Additionally, LD relationships between 10 microsatellites and SNPs within 2Mb of each other were studied.
The power for one of the markers to detect association at p = 0.001 was around 0.4. Power was slightly better for logistic regression than haplotype analysis and for two-marker as opposed to single marker analysis but analysing with larger numbers markers had little benefit. The Illumina 550K marker set was better able to detect association than the other two and was almost as powerful as using all HapMap markers. Microsatellites had detectable LD with only a small number of nearby SNPs and the pattern of LD was very variable.
Available chipsets have quite good ability to detect association although obviously results will be critically dependent on the nature of the genetic effect on risk, sample size and the actual LD relationships of the susceptibility polymorphisms involved. Microsatellites seem ill-suited for systematic studies to detect association.     

Posttransfusion purpura following bone marrow transplantation

BACKGROUND : Thrombocytopenia is a major cause of morbidity and hospital expense following bone marrow transplantation. Platelet transfusions in these patients are frequently complicated by the recipient's development of antibodies to HLA class I antigens. When these patients become refractory to the transfusion of HLA-matched platelets, the recipient's platelet antigen phenotype must be determined, to ensure that donor platelets will be phenotypically compatible. Cases of alloimmunization to HPA-1a and HPA-1b resulting in refractoriness to transfused platelets and the subsequent development of a posttransfusion purpura-like syndrome are reported. CASE REPORTS: In the first case, a 43-year-old woman with Stage IV infiltrating ductal breast cancer presented to the hospital for a transplant of autologous peripheral blood stem cells. After the transplant, her platelet count remained less than 10 × 10⁹ per L, despite daily platelet transfusions, including HLA-matched platelets. Fourteen days following the transplant, her serum was found to contain anti-HPA-1a. Initially, the patient was refractory to the transfusion of HPA-1a-negative platelets, but after treatment with intravenous immunoglobulin, she had transient increases in posttransfusion platelet counts. She was also treated with a staphylococcal protein A immunoadsorption column and has not had any such subsequent refractoriness. Her genotype has been found, by use of allele-specific oligonucleotide hybridization with white cell DNA, to be HPA-1b/1b. The second case involved a 32-year-old woman with chronic myelogenous leukemia who received an unrelated-donor marrow transplant. Three years later, her CML recurred, and she was treated with interferon-alpha. Four months afterward, she experienced interferon-alpha-induced thrombocytopenia and the interferon therapy was discontinued. She received 12 platelet transfusions in 20 days, but none was effective. Antibodies specific for HLA antigens and HPA-1b were detected, and three HLA-matched, HPA-1b-negative apheresis platelet components were given, but without effect. Two days after treatment with methylprednisolone (1 g intravenously) and prednisone (2 mg/kg/day orally), her platelet count was 26 × 10⁹ per L, and after 8 more days, it was 102 × 10⁹ per L, without further transfusions. She was found to be homozygous for HPA-1a (HPA-1a/1a). CONCLUSION : Anti-HPA- 1a and anti-HPA-1b can cause refractoriness to platelet transfusions in bone marrow transplant patients. Testing for platelet-specific antibodies should be considered in all patients who are refractory to HLA-matched platelets.     

Congestive heart failure

Causes of congestive heart failure include hypertension, coronary artery disease, alcohol abuse and valvular heart disease. Two-dimensional echocardiography with Doppler examination is excellent for identifying valvular heart disease. While noninvasive screening for coronary artery disease may seem cost-effective, the consequences of a missed diagnosis are such that coronary angiography should be strongly considered if there is any suggestion of ischemic heart disease. Medical management primarily consists of vasodilators, diuretics and inotropic agents. Vasodilator therapy may prolong the patient's life. Digoxin and diuretics improve symptoms and hemodynamic abnormalities. With advanced heart failure, adequate control of fluid retention and dyspnea may require diuretic doses associated with azotemia, and systolic blood pressure may have to be maintained at less than 100 mm Hg in spite of postural hypotension.     

Chloramphenicol-dependent antibody: a case report

BACKGROUND: Chloramphenicol-dependent antibodies are a rare cause of interference in pretransfusion serologic testing. Their presence can be confirmed by the testing of red cells in both the presence and absence of chloramphenicol. CASE REPORT: A 29-year-old, group A, Rh-positive man with no history of chloramphenicol exposure was found to have a chloramphenicol-dependent panagglutinin in his serum. The antibody was IgM with a titer of 8. It showed no blood group specificity when tested with common and rare red cell phenotypes, and it failed to react with platelets and granulocytes. Confirmation attempts using a chloramphenicol sodium succinate solution as the cell-suspending medium led to negative results. The antibody reacted serologically only in the presence of chloramphenicol, which arises from the succinate derivative by the action of blood esterases. CONCLUSION: This case is an additional example of a chloramphenicol-dependent antibody. It demonstrates how the laboratory investigation of drug-related phenomena is dependent on testing the drug from that reacts in vivo.