THE USE OF PHARMACEUTICALS FOR DIALYSIS PATIENTS. HOW WELL DO WE KNOW OUR PATIENTS' ALLERGIES?

Medication allergies are potentially important but usually poorly documented in patient medical records. Allergy awareness by clinical staff may be low in the haemodialysis population despite their regular attendance for treatment sessions. A cross‐sectional study of 25 patients in a satellite unit was performed. All known allergies were not documented in 36% of patients despite the patients being known to the renal service for more than five years. 81% of allergies were medication allergies. The rest were due to topical agents. 57% (affecting 8 patients) of the medication allergies related to antibiotics (especially penicillin). Four patients had multiple antibiotic allergies. The nature and severity of these allergies was not well documented. This study demonstrates that despite being under long‐term care there remains incomplete information, which is vital for optimal safe practice. Without such information, the potential for adverse events and anaphylaxis is significant in a population that is exposed to numerous pharmaceutical agents and are frequently prescribed antibiotics. Medication histories should be comprehensively re‐evaluated regularly and prescribing should not occur unless the allergy box is completed.     

Dynamics of Pseudomonas aeruginosa genome evolution

One of the hallmarks of the Gram-negative bacterium Pseudomonas aeruginosa is its ability to thrive in diverse environments that includes humans with a variety of debilitating diseases or immune deficiencies. Here we report the complete sequence and comparative analysis of the genomes of two representative P. aeruginosa strains isolated from cystic fibrosis (CF) patients whose genetic disorder predisposes them to infections by this pathogen. The comparison of the genomes of the two CF strains with those of other P. aeruginosa presents a picture of a mosaic genome, consisting of a conserved core component, interrupted in each strain by combinations of specific blocks of genes. These strain-specific segments of the genome are found in limited chromosomal locations, referred to as regions of genomic plasticity. The ability of P. aeruginosa to shape its genomic composition to favor survival in the widest range of environmental reservoirs, with corresponding enhancement of its metabolic capacity is supported by the identification of a genomic island in one of the sequenced CF isolates, encoding enzymes capable of degrading terpenoids produced by trees. This work suggests that niche adaptation is a major evolutionary force influencing the composition of bacterial genomes. Unlike genome reduction seen in host-adapted bacterial pathogens, the genetic capacity of P. aeruginosa is determined by the ability of individual strains to acquire or discard genomic segments, giving rise to strains with customized genomic repertoires. Consequently, this organism can survive in a wide range of environmental reservoirs that can serve as sources of the infecting organisms.     

Prevention and treatment of vitamin D and calcium deficiency in children and adolescents: Indian Academy of Pediatrics (IAP) guidelines

Justification

Vitamin D deficiency (VDD) is being increasingly reported from India from all age-groups. Reports suggest that VDD affects all age groups, from neonates to adolescents. Further, habitually low calcium intakes are also reported in Indian children. Given the multiple guidelines, peculiarities of Indian circumstances, changing lifestyles, and lack of fortification, the Indian Academy of Pediatrics (IAP) felt the need for a Practice Guideline for Pediatricians for the prevention and treatment of vitamin D and calcium deficiency in children and adolescents.

Process

The ‘Guideline for Vitamin D and Calcium in Children’ committee was formed by the IAP in September 2016. A consultative committee meeting was held in November 2016 in Mumbai. Evidence from Indian and international studies and other previous published recommendations, which were pertinent to the Indian circumstances, were collated for the preparation of these guidelines.

Objectives

To present a practice guideline for pediatricians for the prevention and treatment of deficiency of vitamin D and calcium in the Indian context.

Recommendations

For the prevention of rickets in premature infants, 400 IU of vitamin D and 150-220 mg/kg of calcium, and in neonates, 400 IU of vitamin D and 200 mg of calcium are recommended daily. For prevention of rickets and hypocalcemia in infants (after neonatal period) upto 1 year of age, and from 1-18 years, 400 IU and 600 IU vitamin D/day and 250-500 mg/day and 600-800 mg/day of calcium, respectively, are recommended. For treatment of rickets in premature neonates, infants upto 1 year and from 1-18 years, 1000 IU, 2000 IU and 3000-6000 IU of vitamin D daily, respectively, and elemental calcium of 70-80 mg/kg/day in premature neonates and 500-800 mg daily for all children over that age are recommended. Larger doses of vitamin D may be given from 3 months to 18 years of age as 60,000 IU/week for 6 weeks.

     

Improved esophageal patency when inserting the ProSeal™ laryngeal mask airway with an Eschmann™ tracheal tube introducer

Purpose

We hypothesized that a more accurate alignment of the tip of the drain tube with the upper esophageal opening would be achieved in adult patients, as confirmed by fibreoptic bronchoscopy, by placing the ProSeal? laryngeal mask airway (PLMA) by means of guiding it over an Eschmann? tracheal tube introducer, commonly know as a gum elastic bougie (GEB), that was previously inserted into the esophagus, rather than by placing the PLMA with a curved metal introducer (IT).

Methods

Seventy-five adult elective surgery patients, whose airway management involved a PLMA, were randomly allocated to either the GEB- or IT-guided techniques. After inserting the PLMA, alignment of the tip of the drain tube relative to the esophageal opening was verified by a fibrescope introduced through the drain tube. Placing the fibrescope through the PLMA identified the glottic structures. The primary endpoint indicating the proper alignment of the tip of the drain tube of the PLMA with the upper esophageal opening was the ability to pass the fibrescope into the esophagus through the drain tube by a distance >35 cm without obstruction and the ability to simultaneously visualize the esophageal mucosa.

Results

The overall success rates of PLMA insertion were similar in the GEB and IT groups. However, the mean airway insertion times were longer with the GEB than with the IT-PLMA. The GEB group achieved proper alignment of the drain tube and the upper esophageal opening more frequently than the IT group (97% confidence interval (CI₉₅) 91.5–100% vs 81% CI₉₅ 68.5–93.5% of subjects, respectively; P = 0.027). When the GEB was used to place the PLMA, the patients’ vocal cords were visualized more frequently than when the IT technique was used (100% vs 73% CI₉₅ 58.9–87.1% of subjects, respectively; P = 0.003).

Conclusion

Fibreoptic bronchoscopy confirmed that GEB is superior to the IT technique in ensuring precise alignment of the tip of the drain tube of the PLMA with the upper esophageal opening. Accurate positioning may better preserve gastroesophageal drainage function of the PLMA.     

Minimal change disease complicated by contrast-induced nephropathy

We present a clinical case with histopathological findings of an adult presentation of nephrotic syndrome complicated by acute kidney injury (AKI) following a CT contrast study. A 45-year old female with no significant past medical history was admitted following a 1 week history of peripheral oedema. She developed AKI following CT abdomen and pelvis with contrast, before being transferred to the renal team and being diagnosed with nephrotic syndrome. Histopathological assessment of a renal biopsy displayed evidence of both acute tubular injury and minimal change disease (MCD). To the author's knowledge, this is the first documented case of MCD complicated by contrast-induced nephropathy, with evidence of both pathologies on electron microscopy. Clinically, such cases emphasise the need for awareness of susceptibility to AKI in patients with MCD.     

Multi-gene testing in neurological disorders showed an improved diagnostic yield: data from over 1000 Indian patients

Journal of Neurology - Neurological disorders are clinically heterogeneous group of disorders and are major causes of disability and death. Several of these disorders are caused due to genetic...     

Cardiac and Noncardiac Determinants of Exercise Capacity in CKD

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