Systemic candidiasis and pneumonia in preterm infants

Twenty-two preterm infants with systemic candidiasis are reported, of which seven cases were presumed to be antenatally acquired and 15 postnatally acquired. All except one were of very low birthweight. Fifteen infants had positive cultures of blood, cerebrospinal fluid or urine and seven had candida pneumonia only. Clinical features included general instability, respiratory deterioration and a necrotizing enterocolitis-like presentation. The incidence of leukocytosis, shift to the left, eosinophilia and thrombocytopenia were not different from those with bacterial infection. The diagnosis was made after death in two infants. In the remaining 20 infants, treatment was initiated between 5 and 97 days of age, with a median delay of 4 days after the first positive cultures were taken. Complications of amphotericin and 5-flucytosine therapy which developed in five infants resolved on cessation of treatment. The mortality rate was 18% and impairment rate among the 17 very low birthweight survivors was 18%. A high index of suspicion is required for systemic candidiasis, especially in infants of less than 1000 g birthweight. If recognized early, effective and safe antifungal therapy is possible with favourable short- and long-term outcome.     

The cost of family-oriented communication before air medical interfacility transport

INTRODUCTION: Family-oriented communication with parents by transport teams eases the stress associated with transferring children to tertiary care. This study was conducted to determine the duration of family-oriented visits and whether the visit contributed significant cost to the mission. METHOD: Data collection was prospective and double-blind; questions were incorporated into another study. Subjects were infants or children requiring assisted ventilation and air transport to tertiary care. Time from completion of stabilization to departure and reasons for any delay were recorded. Cost of contact time longer than 20 minutes (total acceptable time for family visit and transfer to vehicle) was calculated at paramedic overtime at $0.82/minute and aircraft wait time at $200/hour if incurred. RESULTS: Forty-six patients were enrolled. In 16 cases (35%), time between completing stabilization and hospital departure exceeded 20 minutes, with "family visit" listed as the explanation. Nine of these visits incurred overtime, and two incurred aircraft wait costs. Total costs for providing communication visits more than 10 minutes long were $607 or approximately $13 per patient. CONCLUSION: The costs for visit time longer than 10 minutes are small compared with the documented benefits of family-oriented communication. However, transport personnel must be mindful of the potential to incur additional cost through overtime, aircraft wait time, or pilot replacement.     

Continuous EEG monitoring in comatose intensive care patients

Introduction: It is unclear whether patients or subpopulations of patients might benefit from EEG monitoring. Methods: We conducted a prospective trial of continuous electroencephalogram monitoring (CEEG; 48 hours). Results: Eleven of 55 (20%) patients who underwent CEEG monitoring recorded seizures. Of patients with acute structural brain lesions (ASBLs), 10 of 31 (32%) patients experiences recorded seizures, whereas only 24 (4%) patients with metabolic encephalopathies experienced recorded seizures (p<0.01). Six patients with ASBLs (11%) and one patient with metabolic encephalopathy (4%) had spikes/interictal epileptiform discharges (p=0.087). Conclusion: Our study suggests that CEEG monitoring may be more valuable for detection of seizures in patients with ASBLs than in patients with metabolic encephalopathies.     

Prolonged deficits after focal inhibitory seizures

Introduction: Seizures are most commonly associated with positive phenomena such as tonic, clonic or myoclonic movements, automatisms, paresthesias and hallucinations. Negative phenomena, however, are not an uncommon manifestation of seizure activity. Examples of negative seizure phenomena include speech arrest, aphasia, amaurosis, amnesia, numbness, deafness, neglect and atonic seizures. Less commonly described in the literature are focal inhibitory motor seizures. Methods and Results: Two patients presenting with rapidly progressive, prolonged hemiparesis, sensory neglect and hemi-visual field obscuration are described. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain did not reveal progression of known structural lesions or new lesions. The superficial cortex of the hemisphere contralateral to the hemiparesis and sensory neglect enhanced diffusely with gadolinium on T1-weighted MRI images. Electroencephalography demonstrated periodic lateralized epileptiform discharges (PLEDs) in one patient and lateralized suppression and slowing in the other patient. Single photon emission computed tomography (SPECT) revealed hyperperfusion in the hemisphere contralateral to the hemiparesis and sensory neglect. The changes seen on MRI and SPECT resolved with resolution of the symptoms. Conclusion: Taken together with the clinical history, the results from these investigations suggest focal inhibitory seizure as the underlying etiology. A review of the literature and investigations helpful in making this difficult diagnosis are provided.     

Cost-Effectiveness of Interferon Beta-1a, Interferon Beta-1b, and Glatiramer Acetate in Newly Diagnosed Non-primary Progressive Multiple Sclerosis

OBJECTIVE: To perform a cost-effectiveness analysis of three immunomodulatory treatments for newly diagnosed nonprimary progressive MS: interferon beta-1a, interferon beta-1b, and glatiramer acetate. METHODS: We developed a state-transition model to estimate the health effects and costs associated with interferon beta-1a, interferon beta-1b, glatiramer acetate, and no treatment for hypothetical cohorts of men and women with non-primary progressive MS. We used the Expanded Disability Status Scale as the measure of disability and included both relapses and disease progression in the model. We evaluated treatment strategies assuming a 10-year treatment duration using the societal perspective. We elicited preferences for disability and treatment states using standard-gamble questions and modeled the disutility associated with treatment administration and side effects explicitly. Main outcome measures were net gains in quality-adjusted life expectancy and incremental cost-effectiveness ratios in dollars per quality-adjusted life year (QALY) gained. RESULTS: For treatment duration of 10 years for newly diagnosed non-primary progressive MS, interferon beta-1a yielded the largest gain in quality-adjusted life expectancy with an incremental cost-effectiveness ratio of $2,200,000/QALY for women and $1,800,000/QALY for men, compared with no treatment. For a 5-year treatment duration, a "no treatment" strategy yielded more quality-adjusted life years than any of the treatment strategies. Cost-effectiveness ratios were similar for all three immunomodulatory treatments evaluated. CONCLUSIONS: Cost-effectiveness results for all three immunomodulatory treatments for MS were unfavorable in the simulated study population under a wide range of assumptions. For treatment duration less than or equal to 5 years, expected benefits of treatment may not outweigh disutility associated with side effects and treatment discomfort.     

A critique of ancillary tests for brain death

The acceptance of brain death by society has allowed for the discontinuation of “life support” and the transplantation of organs. The standard clinical criteria for brain death, when rigorously applied, ensure that the brainstem is destroyed. Because more rostral structures are more vulnerable than the brainstem, these are almost invariably devastated when brainstem function is irreversibly lost as a result of whole brain insults. Then, clinical criteria for “brainstem death” ensure that “whole-brain death” is present. However, if the brainstem is selectively damaged or if brainstem function cannot be adequately assessed clinically, ancillary tests are needed to confirm whole-brain death with certainty. Ancillary tests are also required in very young children. In addition, some societies require their use as a matter of principle. Only tests of whole-brain perfusion adequately serve these purposes.     

Treatment of Facial Telangiectasia With Variable-Pulse High-Fluence Pulsed-Dye Laser: Comparison of Efficacy with Fluences Immediately Above and Below the Purpura Threshold

BACKGROUND. : Pulsed-dye laser treatment has been shown to be highly effective for the treatment of facial telangiectasia. Posttreatment purpura after such treatment has limited patient acceptance of the procedure. OBJECTIVE. : To determine whether purpura-free treatment with recently introduced variable-pulsed pulsed-dye lasers can effectively reduce facial telangiectasia. METHODS. : This was a prospective, randomized, controlled, nonblinded trial. Eleven patients received variable-pulse pulsed-dye laser treatment with and without induction of purpura. Telangiectasia were graded on a "telangiectasia density scale," on which a 1 signified extremely fine, sparsely distributed telangiectasia, and 5 referred to thick, ropelike telangiectasia covering the affected area. For each subject, two areas on either side of the facial midline with equivalent telangiectasia density ratings were randomized to the purpura and purpura-free treatment groups, respectively. All treatments used a 7-mm spot size and a 10-ms pulse duration. The fluence associated with the purpura threshold for each patient was determined in test areas. Purpura-free treatment entailed a fluence 1.0 J/cm2 less than the purpura threshold, and purpura-level treatment entailed a fluence 0.5 J/cm2 greater than the threshold. RESULTS. : Six weeks after a single purpura-free treatment, mean telangiectasia ratings were reduced from 2.7 to 2.4. Purpura-level treatments resulted in a decrease to 1.4 from the same baseline. Thicker, denser telangiectasia appeared to benefit more from purpura-level treatment (a mean telangiectasia density scale reduction of 1.7) than finer, sparser telangiectasia (a mean reduction of 0.8). In 81% of cases, both investigators and patients rated the side treated with purpura as undergoing a greater reduction in telangiectasia density. CONCLUSION. : Although facial telangiectasia do improve after a single purpura-free treatment with the variable-pulse pulsed-dye laser, they improve more after purpura is induced. Purpura-free and purpura-level treatments may be close to equivalent for treating fine telangiectasia, but purpura-level treatments have a distinct advantage for treating thicker telangiectasia. Significantly, the variable-pulse pulsed-dye laser offers patients the option of effective treatment of some telangiectasia without bruising.