How should children with West syndrome be efficiently and accurately investigated? Results from the National Infantile Spasms Consortium.

OBJECTIVE: To prospectively evaluate the etiology of new-onset infantile spasms and evaluate the yield of genetic and metabolic investigations in those without obvious cause after initial clinical evaluation and magnetic resonance imaging (MRI). METHODS: Twenty-one U.S. pediatric epilepsy centers prospectively enrolled infants with newly diagnosed West syndrome in a central database. Etiology and investigations performed within 3 months of diagnosis were documented. RESULTS: From June 2012 to June 2014, a total of 251 infants were enrolled (53% male). A cause was identified in 161 (64.4%) of 250 cases (genetic,14.4%; genetic-structural, 10.0%; structural-congenital, 10.8%; structural-acquired, 22.4%; metabolic, 4.8%; and infectious, 2.0%). An obvious cause was found after initial clinical assessment (history and physical examination) and/or MRI in 138 of 161, whereas further genetic and metabolic studies were revealing in another 23 cases. Of 112 subjects without an obvious cause after initial evaluation and MRI, 81 (72.3%) had undergone genetic testing, which showed a causal abnormality in 23.5% and a variant of unknown significance in 14.8%. Although metabolic studies were done in the majority (serum, 79.5%; urine, 69.6%; and cerebrospinal fluid [CSF], 38.4%), these revealed an etiology in only five cases (4.5%). No correlation was found between type of health insurance (public vs. private) and either genetic or metabolic testing. SIGNIFICANCE: Clinical evaluation and MRI provide a specific diagnosis in 55% of children presenting with West syndrome. We propose that a cost-effective workup for those without obvious cause after initial clinical evaluation and MRI includes an array comparative genomic hybridization (aCGH) followed by an epilepsy gene panel if the microarray is not definitive, serum lactate, serum amino acids, and urine organic acids.

If I were a band-aid, where would I be? Researching the use and location of supplies on two patient units.

OBJECTIVE: The purpose of this study was to gain insight into the use and storage of supplies in the neonatal intensive care and women's health units of Parkland Hospital in Dallas, Texas. BACKGROUND: Construction of a new Parkland Hospital is underway, with completion of the 862-bed, 2.5-million square feet hospital in 2014. Leaders from the hospital and representatives from one of its major vendors collaborated on a research study to evaluate the hospital's current supply management system and develop criteria to create an improved system to be implemented at the new hospital. METHOD: Approach includes qualitative and quantitative methods, that is, written survey, researcher observations, focus groups, and evaluation of hospital supply reports. RESULTS: Approaching the ideal location of supplies can be best approached by defining a nurse's activity at the point of care. Determining an optimal supply management system must be approached by understanding the "what" of caregivers' activities and then determining the "where" of the supplies that support those activities. CONCLUSIONS: An ideal supply management system locates supplies as close as possible to the point of use, is organized by activity, and is standardized within and across units.

Do new vessel sealing devices and harmonic ace increase ureteric injury in total laparoscopic hysterectomy?

OBJECTIVES: To compare the risk of ureteric injury in total laparoscopic hysterectomy (TLH) using new vessel sealing devices (VSDs) and harmonic scalpel with simple scissors, bipolar and suturing. This was an evaluation of 1209 cases, carried out from May 1999 to April 2010. DESIGN AND SETTING: A retrospective comparative study was carried out at a tertiary gynecological endoscopic unit. MATERIALS AND METHODS: Out of 1209 patients, who had hysterectomies for various indications, TLH was done in 892 patients, 273 had vaginal hysterectomy and 44 had abdominal hysterectomy. We evaluated the incidence of ureteric injury in these cases. RESULTS: There was no mortality. In the group of vaginal and abdominal hysterectomy, there were no ureteric injuries. In the TLH group, we had 390 cases with simple scissors, bipolar and suturing with no ureteric injury. In 502 cases, new VSDs, e.g., plasma kinetic gyrus, Martin Maxim with Robi grasper, with or without harmonic 5 mm scalpel/ace were used. There were five ureteric injuries, all on the right side (one double ureter): first case was with Martin Maxim and Robi grasper, two with plasma kinetic gyrus 10 mm trissector, one with harmonic scalpel and the last one with scissors. We evaluated the reasons for such ureteric injuries, with experienced laparoscopic surgeons and the best possible set up. There were seven conversions to open surgery out of 892 cases of TLH, more due to poor case selection.

A Comparative Evaluation of Suburethral and Transobturator Sling in 209 Cases with Stress Urinary Incontinence in 8 years.

AIMS AND OBJECTIVES: To evaluate the outcome of suburethral and transobturator sling in treatment of female stress urinary incontinence in 209 cases from 2002 to 2010. The criteria evaluated were success, failure, complications, operating time, ease of the procedure, availability and cost effectivity of the sling. DESIGN AND SETTING: A retrospective comparative study was carried out at a tertiary referral centre for female urinary incontinence. MATERIAL AND METHODS: A total of 209 patients (females from 27 to 79 years of age) with proven stress urinary incontinence were treated by suburethral transvaginal tape (TVT) type of slings in 101 cases and transobturator Monarc type of sling in 108 cases at the National Institute of Endoscopic Surgery and Urinary Incontinence Center, Mumbai, India, from March 2002 to June 2010. The maximum follow up was for 8 years. RESULTS: The TVT type of slings had higher complication rate like needle entering the bladder, retention of urine necessitating to cut the tape in the center and had a success rate of 94.5% compared to Monarc/Trivedi obturator tape (TrOT) type of sling with outside-in technique, which had a negligible complication (less than 1%), pain in groin or leg movement that reduced in 6 weeks and a success rate of 95%. Specially, the Indian design Trivedi's stress urinary incontinence tape (TSUIT) and TrOT with reusable needles, the cost was only 15-20% of the international brands.