Variation in pediatric aerosol delivery: importance of facemask.

We have quantified in vitro the influence of the facemask on the amount of drug delivered (e.g., inhaled mass) by jet nebulizer and pressurized metered dose inhaler (pMDI) valved holding chamber (VHC) combinations (non-detergent-coated and detergent-coated). Pediatric breathing patterns were used with a breathing simulator, which was connected to a face onto which each device was positioned. An inhaled mass filter interposed between the simulator and the face captured the aerosolized drug. Budesonide inhalation suspension (0.25 mg) was used with the jet nebulizers and fluticasone propionate (220 microg) pMDI with the VHCs. Maximal drug delivery was measured using constant flow through each device. Breathing pattern effects were assessed for sealed devices (no leaks) and with facemasks (possible leaks at the facemask). Inhaled mass from both nebulizers and pMDI VHCs was affected by breathing pattern, but compared to nebulizers the pMDI VHCs were significantly more variable and sensitive to several factors. The influence of VHC conditioning combined with effects of breathing pattern resulted in the inhaled mass ranging from 0.7 +/- 0.5 to 53.3 +/- 6.2%. Nebulizers were less variable (9.6 +/- 0.7 to 24.3 +/- 3.1%). Detergent coating of VHC markedly increased the inhaled mass and reproducibility of drug delivery (27.2 +/- 1.4 to 53.3 +/- 6.2%) for pMDI VHC combinations, but these effects were lost in the presence of facemasks. Using pediatric patterns of breathing, nebulizer/facemask combinations delivered 4.1 +/- 0.8 to 19.3 +/- 2.3% of the label dose while pMDI and detergent-coated VHC delivered 4.0 +/- 1.6 to 28.6 +/- 2.5%. Facemask seal is a key factor in drug delivery. Leaks around the facemask reduce drug delivery and for pMDI VHCs can negate effects of detergent coating.     

Analyzing the Patient's First Name in the Search for Identity

A first name captures indispensable information about its bearer, including aspects of the individual's inner world and approach to the environment, the aspirations and attributions of the name-givers for the individual, and the transferences and countertransferences involving the feelings that a first name evokes. A name is therefore a code waiting to be deciphered that, when explored, can reveal its significance to its bearer. A name can impart multiple meanings; the process of interpreting a name is akin to peeling an onion layered in infinite sequences. This article proposes that an examination of the analysand's first name can be a useful clinical tool in psychoanalytic therapy. An exploration into the origin and meaning of a patient's first name through detailed inquiry and association can serve as a rich source of insight regarding relationships between name and self-identity, and can quickly expand the analytic process.     

Poor Short Term Outcome with a Metal-On-Metal Total Hip Arthroplasty

Metal-on-metal (MoM) bearings for total hip arthroplasty (THA) have come under scrutiny with reports of high failure rates. Clinical outcome studies with several commercially available MoM THA bearings remain unreported. We evaluated 78 consecutive MoM THAs from a single manufacturer in 68 patients. Sixty-six received cobalt–chrome (CoCr) monoblock and 12 received modular titanium acetabular cups with internal CoCr liners. Femoral components were titanium with modular necks. At average 2.1 years postoperatively, 12 THAs (15.4%) demonstrated aseptic failure (10 revisions, 2 revision recommended). All revised hips demonstrated capsular necrosis with positive histology reaction for aseptic lymphocytic vasculitis-associated lesions/adverse local tissue reactions. Prosthetic instability following revision surgery was relatively common. Female gender was a strong risk factor for failure, though smaller cups were not. Both monoblock and modular components fared poorly. Corrosion was frequently observed around the proximal and distal end of the modular femoral necks.     

Benzodiazepine receptors in chick retina: development and cellular localization

Benzodiazepine receptors are present in high concentration in the chick retina. Their pharmacological properties are similar to those of the benzodiazepine receptors present in the brain. The retina receptors appear prior to, as well as during, the period of synaptogenesis. In the newborn chick retina the receptors are localized in the inner synaptic layer, probably on or close to synaptic connections.     

Effects of chlordiazepoxide on single-unit activity in the septal region of the freely moving rat: aversive vs. non-aversive contexts

Evidence suggests that stimuli that have the property of inhibiting fear in a Pavlovian fear conditioning paradigm increase cellular activity in the lateral septum, a result consistent with the idea that the lateral septum is actively involved in the inhibition of fear. The experiments reported here were designed to determine if an anxiolytic drug with fear-inhibiting properties would also increase neuronal activity in the lateral septum in a manner that might relate to its mechanism of action as an anxiolytic. An experiment was performed to compare the effects of the benzodiazepine anxiolytic chlordiazepoxide (CDP) upon single-unit activity in the septal region of the rat brain during Pavlovian aversive conditioning with the effects of CDP in a non-aversive context. During Pavlovian conditioning there was a decrease in unit activity in the more lateral regions of the septum, the dorsolateral and ventrolateral nuclei, when a stimulus signaling footshock (CS+) was presented. This conditioned suppression of unit activity was blocked by an intraperitoneal injection of CDP. Additionally, CDP increased baseline unit activity in these regions in the absence of conditioned stimuli. In the more medial regions of the septum, the intermediate lateral septum, we observed few consistent changes either to the conditioned stimuli or to the drug. In a non-aversive context CDP had either no effect at low to moderate doses, or a suppressant effect at a higher dose. The results support a fear-relief hypothesis of lateral septal functioning and suggest the lateral septum as a possible site for the anxiolytic action of benzodiazepines.     

Safe use of cellular telephones in hospitals: fundamental principles and case studies

Many industries and individuals have embraced cellular telephones. They provide mobile, synchronous communication, which could hypothetically increase the efficiency and safety of inpatient healthcare. However, reports of early analog cellular telephones interfering with critical life-support machines had led many hospitals to strictly prohibit cellular telephones. A literature search revealed that individual hospitals now are allowing cellular telephone use with various policies to prevent electromagnetic interference with medical devices. The fundamental principles underlying electromagnetic interference are immunity, frequency, modulation technology, distance, and power Electromagnetic interference risk mitigation methods based on these principles have been successfully implemented. In one case study, a minimum distance between cellular telephones and medical devices is maintained, with restrictions in critical areas. In another case study, cellular telephone coverage is augmented to automatically control the power of the cellular telephone. While no uniform safety standard yet exists, cellular telephones can be safely used in hospitals when their use is managed carefully.     

Hypertension in hypophosphatemic rickets—role of secondary hyperparathyroidism

Hypertension has been anecdotally reported in children with familial hypophosphatemic rickets (XLH). To better identify and characterize the clinical and laboratory features of hypertensive XLH children, we reviewed the medical records of 41 XLH children, all treated with phosphate and vitamin D analogues. Eight children, who were originally normotensive, developed hypertension during the 2nd decade of life. At diagnosis of hypertension all had persistent secondary/tertiary hyperparathyroidism (HPTD), defined as high serum parathyroid hormone (PTH) for 12 months or longer. Seven had nephrocalcinosis (NC). Analysis of data showed that of 11 children with HPTD, 8 developed hypertension compared with 0 among 30 without HPTD (P<0.001). Of 40 children studied, 18 had NC that was significantly associated with both HPTD (P<0.01) and hypertension (P<0.025). At diagnosis of hypertension, serum calcium was elevated in 2. Plasma renin activity was high in 3 of 4 patients in whom it was measured. Doppler ultrasonography or renal scan was normal in the 5 children studied. Early echocardiography showed left ventricular hypertrophy in only 2 of 5 children studied. In 3 patients who underwent parathyroidectomy, hypertension persisted and 1 progressed to renal failure. Serum creatinine remained normal in all others. Successful treatment of hypertension consisted of beta-adrenergic blockers, angiotensin converting enzyme inhibitors, and Ca channel blockers as monotherapy or in combination. We conclude that hypertension in treated XLH children is closely associated with HPTD. Emphasis should therefore be placed on prevention of the development of HPTD as a complication of XLH treatment, and close monitoring for hypertension in those who do develop HPTD.