Development of a PICU in Nepal: the experience of the first year.

OBJECTIVE: Analysis of hospitalization data can help elucidate the pattern of morbidity and mortality in any given area. Little data exist on critically ill children admitted to hospitals in the resource-limited nation of Nepal. We sought to characterize the profile, management, and mortality of children admitted to one PICU. DESIGN: Retrospective analysis. SETTING: A newly established PICU in Nepal. PATIENTS: All patients between the ages of 0 to 16 years admitted to the PICU from July 2009 to July 2010. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: In 12 months, 126 children were admitted to the PICU including 43% female patients. Sixty-three percent were under 5 years. Twenty-nine percent came from tertiary care hospitals and 38% from rural areas outside Kathmandu. Only 18% were transported by ambulance. Median distance travelled to be admitted was 30 km (interquartile range, 10-193). Highest number of admissions were in spring (40%) followed by summer (25%). Almost half were admitted for shock (45%), particularly septic shock (30%). The second commonest reason for admission was neurologic etiologies (15%). Neonatal admissions were also significant (19%). Mortality was 26% and was significantly associated with septic shock (p < 0.01), mechanical ventilation (p < 0.01), and multiple organ dysfunction (< 0.05). Almost one third of patients required mechanical ventilation; median duration was 4 days (interquartile range, 2-8). Mean length of stay in the hospital was 6.2 days (± 5.3) and median 4 (interquartile range, 2.5-9.0). Median Pediatric Risk of Mortality II score for nonsurvivors was 12 (interquartile range, 7-21), and median Pediatric Index of Mortality II for nonsurvivors was 10 (interquartile range, 3-32). CONCLUSIONS: Within a short time of opening, the PICU has been seeing significant numbers of critically ill children. Despite adverse conditions and limited resources, survival of 75% is similar to many units in developing nations. Sepsis was the most common reason for PICU admission and mortality.

Effect of normal saline and half normal saline on serum electrolytes during recovery phase of diabetic ketoacidosis.

OBJECTIVE: This study aims to describe the effect of 0.9% saline (NS) versus 0.45% saline (half NS) when used during recovery phase of diabetic ketoacidosis (DKA) in children. METHODS: A retrospective analysis of all children (1-18 years old) with DKA admitted in the pediatric intensive care unit (PICU) from 2005 to 2009 was undertaken. The primary end point was effect on serum electrolytes and acidosis. RESULTS: Compared to 47 patients who received only NS (group A) throughout the recovery period and 33 patients who received NS but were switched to half NS (group B) at some point during recovery, 41 who received only half NS (group C) had a significant decrease in corrected serum sodium (P < .01). Hyperchloremia leading to nonanion gap acidosis was significantly greater in NS groups A and B than in half NS group C (P < .01). This led to increased duration of insulin infusion and length of stay in the PICU in the NS groups. CONCLUSIONS: Hyperchloremia resulting in nonanion gap acidosis can occur and may prolong the duration of insulin infusion and length of PICU stay in patients receiving NS as post-bolus rehydration fluid. Alternatively, the use of half NS may result in a decrease in serum-corrected sodium. Providers need to be vigilant toward this while using higher or lower sodium chloride when managing children with DKA. Larger trials are required to study the clinical significance of the results of this study.

Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus: a pilot study.

OBJECTIVES: Although noninvasive positive pressure ventilation is increasingly used for respiratory distress, there is not much data supporting its use in children with status asthmaticus. The objective of this study was to determine safety, tolerability, and efficacy of early initiation of noninvasive positive pressure ventilation in addition to standard of care in the management of children admitted with status asthmaticus. STUDY DESIGN: A prospective, randomized, controlled, clinical trial. PATIENTS: Twenty patients (1-18 yrs old) admitted to the pediatric intensive care unit with status asthmaticus. METHODS AND MAIN RESULTS: Children were randomized to receive either noninvasive positive pressure ventilation plus standard of care (noninvasive positive pressure ventilation group) or standard of care alone (standard group). Improvement in clinical asthma score was significantly greater in noninvasive positive pressure ventilation group compared to standard group at 2 hrs, 4-8 hrs, 12-16 hrs, and 24 hrs after initiation of interventions (p < .01). A significant decrease in respiratory rate at ≥ 24 hrs oxygen requirement after 2 hrs was noted in noninvasive positive pressure ventilation group as compared to standard group (p = .01 and p = .03, respectively). Although statistically not significant, fewer children in the noninvasive positive pressure ventilation group required adjunct therapy compared to standard group (11% vs. 50%; p = .07). There were no major adverse events related to noninvasive positive pressure ventilation. Nine out of ten patients tolerated noninvasive positive pressure ventilation through the duration of the study; noninvasive positive pressure ventilation had to be discontinued in one patient because of persistent cough. CONCLUSIONS: Early initiation of noninvasive positive pressure ventilation, along with short acting ß-agonists and systemic steroids, can be safe, well-tolerated, and effective in the management of children with status asthmaticus.

"Real-world" effectiveness of reactive telephone counseling for smoking cessation: a randomized controlled trial.

BACKGROUND: Reactive telephone helplines for smoking cessation (where all calls to counselors are smoker initiated) are increasingly used in the United States. However, limited data from randomized controlled trials are available on their effectiveness. The study objective was to evaluate the real-world effectiveness of reactive telephone counseling for smoking cessation using a randomized controlled trial study design. METHODS: The study was implemented during a period from 2003 to 2006 to evaluate a reactive telephone helpline run by the American Lung Association chapter of Illinois-Iowa. The 990 new callers, all adult current smokers who called the helpline, were randomized on their first call into one of the two following groups: a control group that received only mailed self-help literature (n = 496); and a study group that received supplemental live reactive telephone counseling (n = 494). Telephone follow-up was completed at 1, 3, 6, and 12 months after study enrollment by interviewers blinded to group assignment. Seven-day point prevalence rates of self-reported abstinence at follow-up evaluations were compared between the two groups using an intent-to-treat design. RESULTS: The two groups did not differ significantly in baseline demographics and smoking-related behavior. The abstinence rates (ranging between 0.09 and 0.15) were not significantly different between the two groups at 1-, 3-, 6-, and 12-month follow-up evaluations. Post hoc subgroup analysis showed that black callers had lower abstinence rates at the 3- and 12-month follow-up evaluations as compared with white callers. CONCLUSION: Supplemental live, reactive telephone counseling does not provide greater success in smoking cessation than self-help educational materials alone.

Sex- and race-related differences among smokers using a national helpline are not explained by socioeconomic status.

The bases for sex- and race-related differences in smoking behavior are not well understood. Studying the difference in smoking behavior among population segments may allow for effective utilization of resources towards quitting and help understand the cause of existing smoking-related disparities. Our objective was to evaluate whether sex- and race-related differences in smoking behavior were explained by socioeconomic status (SES), using a population of smokers that called a national reactive telephone helpline. This cross-sectional study evaluated 990 new callers to a helpline. Information on demographics and smoking behavior was collected by a telephone interview. Statistical techniques included t test, Chi square and regression analyses. Women and black smokers had lower SES than men and white smokers, respectively. Women smokers had lower rates of tobacco exposure and were more likely to be tempted to smoke by environmental cues. Blacks also had lower rates of tobacco exposure and reported a higher confidence in their ability to quit. Both men and black smokers were less likely to have used other methods of quitting before calling the helpline. These differences persisted after adjusting for SES. This study demonstrates that sex- and race-related differences in smoking among helpline callers are not explained by SES.

Characteristics of smokers calling a national reactive telephone helpline.

PURPOSE: Although reactive telephone helplines for quitting smoking are increasingly popular in the United States, the characteristics of callers using this resource have not been adequately studied. The objective of this study was to describe the characteristics of the current smokers calling a national reactive telephone helpline (i.e., study population). DESIGN AND SETTING: In this cross-sectional study, information was obtained from eligible participants telephonically. SUBJECTS: The study included 890 adult current smokers who were new callers to a national reactive helpline. MEASURES: The information collected included selected demographic and smoking-related characteristics. ANALYSIS: The proportions of the above characteristics were analyzed. RESULTS: There was a significant overepresentation of blacks, non-Hispanics, women, and urban residents, as well as poorer, older, less educated, and heavier smokers in the study population (p < .01 for all comparisons). CONCLUSIONS: Reactive telephone helplines may be preferentially used by population segments who are disadvantaged or smoke heavily and thus are in greatest need for assistance. These helplines may therefore fill a much-needed niche in the marketplace of smoking cessation strategies.

Vitamin E succinate suppresses prostate tumor growth by inducing apoptosis.

Prostate cancer is a major cause of cancer death and morbidity in western countries. However, because of its intrinsic nature of chemoresistance, there is only limited systemic therapy available for the patients. Vitamin E (VE) has been under intensive study as a chemopreventive agent for various types of cancers. Preclinical studies suggest that vitamin E succinate (VES) is the most effective antitumor analogue of VE, yet there are scarce studies of VES in prostate cancer. In this study, we investigated the effects of VES on a panel of prostate cancer cells, and a xenograft model of prostate cancer. Our results indicate that VES significantly inhibited proliferation and induced apoptosis of prostate cancer cell lines in a dose and time dependent manner. The results of microarray analysis followed by real-time RT-PCR and inhibitor analyses indicated that the VES-induced apoptosis is mediated by caspase-4 in prostate tumor cells. In our animal model of prostate cancer in SCID mouse, daily injection of VES significantly suppressed tumor growth as well as lung metastases. These results suggest a potential therapeutic utility of VES for patients with prostate cancer.