Update on the management of neuromuscular block: focus on sugammadex

Steroidal neuromuscular blocking agents (NMBAs), such as rocuronium, are widely used in clinical anesthesia and emergency medicine to facilitate endotracheal intubation and artificial ventilation and to allow surgical access to body cavities. Reversal of neuromuscular blockade is important for the acceleration of patient recovery and prevention of postoperative residual neuromuscular blockade and reduces the incidence of severe morbidity and mortality associated with anesthesia management. Sugammadex is the first selective relaxant binding agent (SRBA) and has been designed to reverse the steroidal neuromuscular blocking drug rocuronium. Encapsulation of the rocuronium molecule by sugammadex results in a rapid decrease in free rocuronium in the plasma and subsequently at the nicotinic receptor at the motor endplate. After encapsulation, rocuronium is not available to bind to the nicotinic receptor in the neuromuscular junction. This promotes the liberation of acetylcholine receptors, and muscle activity reappears. This new concept of reversal of neuromuscular block induced by rocuronium (or vecuronium) led to impressive results in animal and phase 1 and 2 studies. Sugammadex is currently in phase 3 clinical studies and may be commercially available by 2008.     

Adverse learning strategy: the Adelaide Diagnostic Learning Inventory and its subscale replicability in a medical student population

The Adelaide Diagnostic Learning Inventory (ADLIMS) is a measure of learning styles and learning pathologies that was designed to investigate the impact of traditional approaches to learning versus problem-based learning and to identify students whose approach to learning tasks predicted poor academic performance. In this study, some important psychometric properties of the ADLIMS were examined, including its factor structure. In this study, factor replicability across samples was argued to provide a more robust and psychologically meaningful factor solution than that which can be obtained using traditional mathematical criteria. The results of the factor analysis did not confirm the presence of the four factor solution earlier reported for the ADLIMS, but did identify three clear factors that had very high replicability. An inspection of the items comprising these three factors showed that factor 1 tapped subjective distress related to poor study habits, lack of motivation to study, and distraction from social activities. Factor 2 tapped distress arising from high achievement expectations that were hampered by superficial or disorganized study habits that did not enable the student to grasp the relationships between concepts and ideas. Factor 3 tapped positive feelings and a sense of satisfaction associated with a problem-based approach to the learning of new study material. Although the internal reliability of the ADLIMS subscales met the requirements of a measure to be used in general research such as in the investigation of correlates among groups of medical students, they did not meet the higher requirements of a measure to be used to identify or predict individuals with pathological learning styles.     

Incompatibility of contrast agents with intravascular medications. Work in progress

In vitro and in vivo precipitation of iodinated contrast agents when ioxaglate and papaverine are given together has been reported. To verify these reports and to investigate other medications not previously tested, the authors analyzed mixtures of contrast agents and medications in vitro with a light spectrophotometer and observed them for visible precipitates for up to 120 minutes. Previously reported incompatibilities between ionic or low-osmolality contrast media and medications were verified, and several new incompatibilities were discovered. No incompatibilities were found when the drugs tested were mixed with the new nonionic contrast media.     

Public-private partnership in water supply and sanitation in Sub-Saharan Africa

Purely public water supply systems are characterized by highcosts, insufficient supplies and chronic deficits that are coveredby central government transfers. The private water supply programmein Abidjan has not met its coverage targets either, but thesystem has remained financially solvent and fostered a rapidgrowth in capacity through the informal sector. The materialreviewed here and the experience of developing country watersystems in general support several conclusions. (1) Water vendingis common in developing countries, which suggests that chargingfor water is not culturally unacceptable. Demand for wastewaterservices is low, but surcharges could be imposed on water usageto cover some sanitation costs. (2) Incentives are criticalto sound management of water supply and sanitation services.They are typically part of the structure of private firms, butare rare in publicly run systems. (3) The private sector's rolein the provision of water supply and sanitation can be extensive.Regulation of private activity and quality control by publicauthorities is essential to maintain competition and ensureproper and fair operation. (4) Public efforts to supply watercan be supplemented by a government-regulated, parallel systemto increase the amount of water available. Normally these systemsinvolve trucked water, but private sales outlets with pipe infrastructureshould be encouraged where feasible. (5) Even where the publicsector decides to control and operate the water supply and sanitationsystem, some partnership with the private sector is possiblethrough contracting out specific tasks such as billing, metering,maintenance of various components or tracking water losses.Finally, the supply of water is an ideal activity for a public-privatepartnership. Both sectors have comparative advantages that arebest applied in conjunction with the other.