Hospital response to chemical terrorism: personal protective equipment, training, and operations planning

BACKGROUND: Hospitals distant from the immediate site of an incident involving a hazardous materials (HAZMATs) release which could include chemical warfare agents, must develop emergency response plans (ERPs) to protect healthcare professionals if they receive potentially contaminated victims. The ERP must address OSHA, EPA, and JCAHO requirements. METHODS: The VHA convened groups to develop a hazard and exposure assessment, identify actions for compliance with existing regulatory standards, and review site and operational planning issues. Exposure modeling results were used to derive relationships between operational parameters (time and distance from sites/sources) and potential exposure for healthcare workers. RESULTS: According to exposure modeling, level C personal protective equipment is adequate to protect hospital staff distant from the chemical release site. Decontamination runoff and contaminated clothing should also be controlled to limit exposure. CONCLUSIONS: Development and coordination of ERPs must include the local emergency planning committee, with clear assignment of tasks, locations, and training in order to prevent exposures to healthcare workers.     

Fallopian tube carcinoma presenting with a brain metastasis

BACKGROUND: Fallopian tube carcinoma is a rare gynecologic cancer. An extensive literature search reveals no previous case report of fallopian tube carcinoma presenting with a brain metastasis. CASE: A 63-year-old woman presented with 3 weeks of progressive left-sided weakness. CT scan of the brain revealed a solitary lesion in the right parietal lobe. The patient underwent a complete resection, followed by whole-brain radiation therapy. Pathologic review demonstrated adenocarcinoma with follicular structures. A directed workup revealed a large right adnexal mass. She underwent resection of a large fallopian tube carcinoma with normal ovaries. She recovered from surgery and is receiving combination chemotherapy. CONCLUSION: This is the first case report of a fallopian tube carcinoma presenting as a brain metastasis.     

Phenotypes of patients with mild to moderate obstructive sleep apnoea as confirmed by cluster analysis

Background and objective: Patients with OSA manifest different patterns of disease. However, this heterogeneity is more evident in patients with mild‐moderate OSA than in those with severe disease and a high total AHI. We hypothesized that mild‐moderate OSA can be categorized into discreet disease phenotypes, and the aim of this study was to comprehensively describe the pattern of OSA phenotypes through the use of cluster analysis techniques. Methods: The data for 1184 consecutive patients, collected over 24 months, was analysed. Patients with a total AHI of 5–30/h were categorized according to the sleep stage and position in which they were predominantly affected. This categorization was compared with one in which patients were grouped using a K‐means clustering technique with log linear modelling and cross‐tabulation. Results: Patients with mild‐moderate OSA can be categorized according to polysomnographic parameters. This clinical categorization was validated by comparison with a categorization in which patients were grouped by unsupervised K‐means cluster analysis. The clinical groups identified were: (i) rapid eye movement (REM) predominant OSA, 44.6%; (ii) non‐REM predominant OSA, 18.9%; (iii) supine predominant OSA, 61.9%; and (iv) intermittent OSA, 12.4%. Patients categorized as having both REM and supine predominant OSA showed characteristics of both the REM predominant and supine predominant OSA groups. Conclusions: Patients with mild‐moderate OSA show different polysomnographic phenotypes. This approach to categorization more appropriately reflects disease heterogeneity and the likely multiple pathophysiological processes involved in OSA.     

Echocardiographic screening for congenital heart disease: a randomized study

OBJECTIVES: To assess the effectiveness and potential cost of an echocardiographic screening program for congenital heart disease (CHD). PATIENTS AND METHODS: Between 01/11/94 and 28/02/98 there were 9697 deliveries in The Royal Maternity Hospital Belfast. Mothers were randomized before delivery. 4875 infants were allocated to the scan group, while 4822 were assigned to clinical assessment alone. High-risk infants were considered separately. Cases of CHD detected before hospital discharge were documented. The annual cost of screening was estimated and the time to accurate diagnosis in each group was assessed. RESULTS: During the study 124 scan allocated infants and 50 controls were identified as having significant CHD before hospital discharge. With a minimum of 3 years follow-up there were 27 additional late diagnoses in controls and 1 in scanned infants. During a single year of the study the mean time to complete diagnosis was 2 days for scanned cases and 110 in controls. The projected cost of screening for all infants was 22 Pounds/infant for the first year. CONCLUSIONS: Adding echocardiography to clinical examination greatly enhances early detection of CHD. Although screening is expensive, once established it may reduce the cost of unnecessary outpatient referrals.     

The place of premedication in pediatric practice

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro–con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.     

Successful treatment of severe subcutaneous insulin resistance with inhaled insulin therapy

van Alfen‐van der Velden AAEM, Noordam C, de Galan BE, Hoorweg‐Nijman JJG, Voorhoeve PG, Westerlaken C. Successful treatment of severe subcutaneous insulin resistance with inhaled insulin therapy. The potential of inhaled insulin therapy for severe resistance to subcutaneous insulin was tested in a 7‐yr old boy with type 1 diabetes mellitus. The efficiency of 1 mg inhaled insulin (Exubera^®) was examined by a 4‐h euglycemic clamp study. During the clamp, the glucose infusion rate started to increase 25 min after inhalation and peaked 120 min after inhalation. Subsequently, a trial of inhaled insulin monotherapy was initiated consisting of pre‐meal inhalations and one inhalation during the night. Since glycemic control remained fair (HbA1c ～8.5%), this therapy was continued. Over the ensuing 18 months, mild keto‐acidosis occurred twice during gastro‐enteritis. Inhaled insulin was well tolerated and pulmonary function did not deteriorate. We conclude that severe resistance to subcutaneous insulin does not preclude sufficient absorption of insulin delivered by pulmonary.