Hypnosis and Sedation for Anxious Children Undergoing Dental Treatment: A Retrospective Practice-Based Longitudinal Study.

To assess whether the treatment of children with oral midazolam and pediatric hypnosis techniques can improve the compliance in consecutive sessions, a retrospective longitudinal practice-based observational study was designed and carried out. A total of 311 children between 3 and 12 years of age were treated under hypnosis and sedation with midazolam (0.40 mg/kg body weight). Treatments were performed in one to a maximum of three sessions. A total of 183 children received one, 103 received two and 25 children received three treatment sessions. The behavior of the children during the sessions was examined by means of the Venham score. The self-evaluation of the children was based on the Wong−Baker Scale. Child behavior using midazolam and hypnosis techniques showed little difference and good compliance between the sessions. Venham scores did not increase significantly regarding total treatment from the first (0.99 ± 1.41) to the second (1.17 ± 1.39) and to the third session (1.27 ± 1.20) (p > 0.05). However, considering the highest Venham scores that occurred in each case, the behavior of the children worsened significantly (p < 0.01) during the three treatment sessions, from 1.37 ± 1.31 (first) to 1.87 ± 1.74 (second) to 2.32 ± 1.33 (third). In 6.11% of the children, treatment was discontinued in the first session (n = 19), 0.96% in the second (n = 3) and 0% in the third. Treatment with low-dose midazolam, combined with hypnosis techniques, showed to be an effective option for dental treatment in children. Within the limitations of the current study, and with consideration of highest possible compliance, no more than two treatment sessions for pediatric dental treatment should be performed.

Acute Congestive Heart Failure in a Young Woman.

We describe the case of an adult First Nations woman employed as a daycare worker who presented with clinical symptoms, signs, and imaging suggestive of acute heart failure. In our report, we discuss the likely diagnosis of acute rheumatic fever. Novel teaching points: The incidence of rheumatic fever in Canada is likely underestimated, and it is important to consider the diagnosis of acute rheumatic fever in individuals presenting with acute heart failure. More research is needed in Canada to further identify groups most at risk for developing this disease.

Nous exposons le cas d'une femme adulte d'origine autochtone travaillant dans une garderie dont les symptômes et signes cliniques ainsi que les résultats aux examens d'imagerie évoquaient une insuffisance cardiaque aiguë. Nous expliquons pourquoi nous avons plutôt envisagé un diagnostic de rhumatisme articulaire aigu. Nouveaux points d'enseignement : l'incidence des cas de rhumatisme articulaire aigu au Canada est vraisemblablement sous-estimée, et il importe d'envisager ce diagnostic chez les personnes présentant des signes évocateurs d'une insuffisance cardiaque aiguë. D'autres recherches s'imposent au Canada afin de mieux cerner les groupes les plus susceptibles de présenter une telle affection.

Outcome with lenalidomide plus dexamethasone followed by early autologous stem cell transplantation in patients with newly diagnosed multiple myeloma on the ECOG-ACRIN E4A03 randomized clinical trial: long-term follow-up.

In Eastern Cooperative Oncology Group-ACRIN E4A03, on completion of four cycles of therapy, newly diagnosed multiple myeloma patients had the option of proceeding to autologous peripheral blood stem cell transplant (ASCT) or continuing on their assigned therapy lenalidomide plus low-dose dexamethasone (Ld) or lenalidomide plus high-dose dexamethasone (LD). This landmark analysis compared the outcome of 431 patients surviving their first four cycles of therapy pursuing early ASCT to those continuing on their assigned therapy. Survival distributions were estimated using the Kaplan-Meier method and compared with log-rank test. Ninety patients (21%) opted for early ASCT. The 1-, 2-, 3-, 4- and 5-year survival probability estimates were higher for early ASCT versus no early ASCT at 99, 93, 91, 85 and 80% versus 94, 84, 75, 65 and 57%, respectively. The median overall survival (OS) in the early versus no early ASCT group was not reached (NR) versus 5.78 years. In patients <65 years of age, median OS in the early versus no early ASCT groups was NR in both, hazard ratio 0.79, 95% confidence interval: (0.50, 0.25). In patients ⩾65 years of age, median OS in the early versus no early ASCT was NR versus 5.11 years. ASCT dropped out of statistical significance (P=0.080). Patients opting for ASCT after induction Ld/LD had a higher survival probability and improvement in OS regardless of dexamethasone dose density.

Oral antibiotic prophylaxis of early infection in multiple myeloma: a URCC/ECOG randomized phase III study.

Multiple myeloma (MM) is a malignancy of clonal plasma cells, resulting in an increased production of ineffective immunoglobulins with suppression of non-involved immunoglobulins. Patients with MM are at increased risk of infectious complications, particularly streptococcal and staphylococcal infections. This study evaluated the impact of prophylactic antibiotics on the incidence of serious bacterial infections (SBIs) during the first 2 months of treatment in patients with newly diagnosed MM. Patients with MM receiving initial chemotherapy were randomized on a 1:1:1 basis to daily ciprofloxacin (C; 500 mg twice daily), trimethoprim-sulfamethoxazole (T; DS twice daily) or observation (O) and evaluated for SBI (Eastern Cooperative Oncology Group ≥grade 3) for the first 2 months of treatment. From July 1998 to January 2008, 212 MM patients were randomized to C (n=69), T (n=76) or O (n=67). The incidence of SBI was comparable among groups: C=12.5%, T=6.8% and O=15.9%; P=0.218. Further, any infection during the first 2 months was also comparable (20% vs 23% vs 22%, respectively, P=0.954). We demonstrate that prophylactic antibiotics did not decrease the incidence of SBI (≥grade 3) within the first 2 months of treatment. We conclude that routine use of prophylactic antibiotics should not be mandated for patients receiving induction chemotherapy.

Primary therapy with single agent bortezomib as induction, maintenance and re-induction in patients with high-risk myeloma: results of the ECOG E2A02 trial.

Single agent bortezomib results in response rates of 51% in patients with newly diagnosed multiple myeloma and is touted to be especially effective in high-risk disease. We are the first to prospectively explore single agent bortezomib as primary therapy (induction, maintenance and re-induction) without consolidative autologous stem cell transplant in a cohort selected to have high-risk multiple myeloma. Patients received eight cycles of induction, followed by maintenance bortezomib every other week, indefinitely. Patients relapsing on maintenance had the full induction schedule resumed. On an intention-to-treat basis, the response rate (>or=partial response) was 48%. Among seven patients who progressed on maintenance bortezomib and received re-induction, two responded to the treatment. With a median follow-up of 48.2 months, 1- and 2-year overall survival probabilities were 88% (95% confidence interval (CI) 79-98%) and 76% (95% CI 60-86%), respectively. Median progression-free survival was 7.9 months (95% CI 5.8-12.0). Twenty-three and thirty-four patients had >or=grade 3 hematological and non-hematological toxicity, respectively, with treatment-emergent neuropathy in 7% with motor grade 1-2, 56% with sensory grade 1-2 and 2% with grade 3, and in 14% with neuropathic pain grade 1-2 and 2% with grade 3. In high-risk patients, upfront bortezomib results in response rates that are comparable to those reported for unselected cohorts, but single agent bortezomib is not sufficient as primary therapy.

Young children's Oral Health-Related Quality of Life and dental fear after treatment under general anaesthesia: a randomized controlled trial.

During the past decade the research interest in Oral Health-Related Quality of Life (OHRQoL) has been prospering. This study was performed to test (using a randomized controlled trial design) the hypothesis that young children's OHRQoL improves after oral rehabilitation under general anaesthesia (GA). A further aim of this study was to explore whether dental fear also changes. One-hundred and four children (54 boys; mean age 4.08 yr, standard deviation = 1.09), who had been referred to a specialized clinic in paediatric dentistry, were randomly assigned, based on a Solomon four-group design, to two treatment (GA) and two control conditions. The Early Childhood Oral Health Impact Scale (ECOHIS) and the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) were used to assess OHRQoL and dental fear, respectively, before and after the rehabilitation procedures. A 2 x 2 analysis of variance revealed that the total ECOHIS score after GA was more positive in the GA group than in the control group. There was no effect found of the pre-test and there was also no interaction between the pre-test and treatment. In the total CFSS-DS scores no effects were found. The results of this study showed that the child's OHRQoL improved after treatment under GA. Furthermore, children need guidance in reducing dental fear after treatment under GA.

Expedited transfer for primary percutaneous coronary intervention: a program evaluation.

BACKGROUND: A shorter time from symptom onset to reperfusion is associated with improved outcomes for patients with ST-segment elevation myocardial infarction (MI). Primary percutaneous coronary intervention is a favourable method of reperfusion if performed effectively and expeditiously. We sought to evaluate the impact of an expedited pre-hospital diagnosis and transfer pathway developed by a multidisciplinary team on the door-to-balloon time in a large urban community. METHODS: We included all patients with ST-segment elevation MI who presented within 12 hours after symptom onset and who sought medical attention through Emergency Medical Services within the boundaries of the city of Calgary in the 16 months following the introduction of the pathway in June 2004. The primary aim was to determine the proportion of patients who received percutaneous coronary intervention within the recommended door-to-balloon time of 90 minutes. RESULTS: The 358 patients (268 men) in the study cohort had a mean age of 63.2 (standard deviation 12.7) years; 140 (39.1%) had an anterior MI; and 23 (6.4%) had cardiogenic shock. The introduction of the pathway resulted in a median door-to-balloon time of 62 (interquartile range 45-84) minutes. A door-to-balloon time within 60 minutes and within the currently recommended 90 minutes was achieved in 48.9% and 78.8% of the patients respectively. The in-hospital and 30-day mortality rates were both 3.1%. INTERPRETATION: In a community with multiple regional hospitals and a single facility for percutaneous coronary intervention, the implementation of a multidisciplinary pre-hospital diagnosis and transfer pathway was feasible and resulted in most patients in the study cohort receiving primary percutaneous coronary intervention within the recommended door-to-balloon time of 90 minutes.

High rates of HIV in surgical patients in Soweto, South Africa: impact on resource utilisation and recommendations for HIV testing.

Interactions between HIV and surgical diseases are relatively poorly described in high HIV prevalence settings. We report HIV prevalence and its associations in a prospective study of adults admitted to surgical units in Soweto, South Africa. Voluntary counselling and testing (VCT) for HIV was offered to surgical inpatients. Research nurses interviewed participants at enrolment and doctors reviewed records after discharge. In HIV-infected participants, CD4 counts and viral loads were ascertained. Of 1000 participants, 537 consented to VCT, of whom 176 (32.8%, 95% CI 28.8-36.9%) tested HIV positive. A history of tuberculosis (adjusted odds ratio (AOR) 3.0, 95% CI 1.5-6.2) or sexually transmitted infection (AOR 2.7, 95% CI 1.8-4.2) was associated with HIV infection. Diagnoses of cutaneous abscesses (OR 3.4, 95% CI 1.4-8.1) and anorectal sepsis (OR 3.1, 95% CI 1.1-9.0) were associated with HIV and indicated advanced disease. There were no differences in rates of operative procedures, wound sepsis, investigations or length of stay by HIV status. Hospital-acquired pneumonia was more common in HIV-infected participants (P=0.028). In conclusion, in this high HIV prevalence setting, resource utilisation is similar between HIV-infected and uninfected patients in surgical wards where high rates of HIV in young adults support routine HIV testing. WHO clinical staging of HIV should include anal sepsis as an indicator of advanced HIV disease.

Prognostic factors for hyperdiploid-myeloma: effects of chromosome 13 deletions and IgH translocations.

Chromosomal hyperdiploidy is the defining genetic signature in 40-50% of myeloma (MM) patients. We characterize hyperdiploid-MM (H-MM) in terms of its clinical and prognostic features in a cohort of 220 H-MM patients entered into clinical trials. Hyperdiploid-myeloma is associated with male sex, kappa immunoglobulin subtype, symptomatic bone disease and better survival compared to nonhyperdiploid-MM (median overall survival 48 vs 35 months, log-rank P = 0.023), despite similar response to treatment. Among 108 H-MM cases with FISH studies for common genetic abnormalities, survival is negatively affected by the existence of immunoglobulin heavy chain (IgH) translocations, especially those involving unknown partners, while the presence of chromosome 13 deletion by FISH did not significantly affect survival (median overall survival 50 vs 47 months, log-rank P = 0.47). Hyperdiploid-myeloma is therefore a unique genetic subtype of MM associated with improved outcome with distinct clinical features. The existence of IgH translocations but not chromosome 13 deletion by FISH negatively impacts survival and may allow further risk stratification of this population of MM patients.

Nicotine dependence and likelihood of quitting smoking.

This study examined the hypothesis that high nicotine dependent smokers would have more difficulty with initial cessation of smoking than low dependent smokers as measured by the Fagerstrom Tolerance Questionnaire (FTQ). Two replications of a nicotine-fading smoking program were conducted at different worksites. Significantly less heavily dependent smokers quit smoking during treatment. The correlation between the FTQ and smoking rate at posttreatment remained even when the pretreatment rate of smoking was partialled out. It was concluded that the concept of nicotine dependence should be re-examined especially in the context of improving the quit rates of behavioral programs at the worksite.

Psychosocial stress and coping in smokers who relapse or quit.

Relapse remains a major problem in successful smoking cessation. This study evaluated selected responses and coping skills in male and female quitters and relapsers in four situational contexts: general social competence, smoking-specific "high-risk-for-relapse" situations, social anxiety, and relaxation. Results showed that quitters coped better than relapsers with intrapersonal (e.g., negative mood) smoking-specific situations. Quitters had lower heart rates than relapsers during relaxation and intrapersonal situations and had lower anxiety scores at the end of the procedures. Women showed more stress and less confidence in their ability to cope than did men. Groups did not differ in responses to the general social competence and social anxiety procedures. Results are discussed in the context of the importance of considering individual differences in responses and in coping skills for treatment and relapse prevention for smokers.

Age-related changes in inducible mouse liver enzymes: ornithine decarboxylase and tyrosine aminotransferase.

The time required to induce two inducible hepatic enzymes, ornithine decarboxylase (ODC) and tyrosine aminotransferase (TAT), by growth hormone and dexamethasone, respectively, increases with age. Specific activity at the peak of induction is the same for all ages. On the other hand, for basal TAT the specific activity per unit of TAT antigen was found to decrease considerably with age. The half-life of ODC was determined after cycloheximide administration. The apparent half-life at the peak of ODC induction increases from 15 minutes in 3-4-month-old mice to 30 minutes in 24-month-old animals. Loss of efficiency in the protein degradation system is implicated in this phenomenon as no apparent differences could be observed in the susceptibility of ODC and TAT from young or old mice to chymotrypsin. ODC and TAT are activated by temperatures of up to 37 degrees C and 50 degrees C, respectively. ODC is inactivated at 50 degrees C while TAT is inactivated at 76 degrees C. "Young" ODC and TAT are more readily activated or inactivated by heating than the "old" enzymes.