The need for Paediatric Emergency Laparotomy Audit (PELA) in the UK.

INTRODUCTION: The National Emergency Laparotomy Audit (NELA) has raised serious concerns about the processes of care and outcomes in adult emergency laparotomies in the UK. To date, no comparable data have been published for children. The aim of this study was to investigate the need for a similar audit in children. METHODS: Data were collected retrospectively following NELA guidelines. Results were analysed using QuickCalcs (GraphPad Software, La Jolla, CA, US). RESULTS: The study period spanned 7.5 years. A total of 161 patients were identified for inclusion in the audit. The median patient age was 2.8 years. Half (49%) of the cohort were deemed ASA (American Society of Anesthesiologists) grade ≥2. A history of previous abdominal surgery was noted in 37% of the patients. The median time from admission to operation was 15 hours. Over a third (39%) of the operations were performed out of hours. The most common indications for surgery comprised adhesive bowel obstruction (37%), intussusception (27%) and volvulus (9%).The median length of hospital stay was 8 days with the median postoperative stay being 6 days (NELA data 10.6 days). Half (51%) of the cases required intensive care following surgery. The 30-day mortality rate was 3.1%. The overall mortality rate was 4.3% (NELA data 16%). Patient care was led by a consultant surgeon in 100% of cases (NELA data 89%). CONCLUSIONS: This is the first study in children that provides baseline data about the standards of care and outcomes from a single centre paediatric emergency laparotomy audit. A larger study using data from multiple centres would be of great benefit.

Platelets loaded with liposome-encapsulated thrombin have increased coagulability.

Essentials Platelet transfusions can have limited efficacy during hemorrhage associated with coagulopathy. Thrombin can be shielded by encapsulation into nanoliposomes and delivered to platelets ex vivo. Loading platelets with liposomal thrombin improved several aspects of platelet coagulability. Platelets loaded with liposomal thrombin can overcome some coagulopathic deficiencies in vitro. SUMMARY: Background Platelets are integral to clot formation and are often transfused to stop or prevent bleeding. However, transfusions of platelets are not always effective, particularly in the most severe cases of hemorrhage. Nanoparticle systems have been developed to mimic platelets but inherently lack important aspects of platelet function, which limits their potential effectiveness. Objectives Increasing the natural coagulability of transfusable platelets could increase their efficacy during treatment of severe hemorrhage. Thrombin is a potent platelet agonist that currently cannot be used intravenously because of the risk of thrombosis. We hypothesized that delivery of thrombin to ex vivo platelets via liposomal encapsulation would enable transfusable platelets to become more coagulable in response to platelet agonists. Methods Thrombin was encapsulated into nanoliposomes and delivered to platelets ex vivo. Platelet coagulability was measured by monitoring platelet activation, clot contraction, clot time and clot stability in several in vitro assays. These parameters were also measured under conditions where coagulation is compromised, including during acidosis, antiplatelet drugs, hemophilia A and trauma-induced coagulopathy. Results Liposomal thrombin was endocytosed and used by platelets ex vivo but was not secreted upon activation. These modified platelets became more sensitive and responsive to agonists and improved clotting time even under conditions that normally cause platelet dysfunction or have impaired coagulation. Conclusions Several aspects of platelet function were enhanced by ex vivo delivery of liposomal thrombin.

C-reactive protein as a predictor of outcome after discharge from the intensive care: a prospective observational study.

BACKGROUND: Recent studies have found plasma C-reactive protein (CRP) to be a predictor of outcome after discharge from the intensive care unit (ICU). To assess the generalizability of this finding, we assessed the value of CRP on the day of ICU discharge as a predictor of unplanned ICU readmission and unexpected death within 2 weeks. Plasma albumin and white cell count at discharge were also considered as markers associated with ongoing inflammation. METHODS: This was a single-centre observational study involving a medical-surgical ICU in a university teaching hospital. Data were prospectively collected from 1487 admissions involving 1401 patients over a 12 month period. Patients' admission details and APACHE II score were collected in addition to plasma CRP, white cell count, and albumin values from the day of discharge from ICU. We assessed the difference in these variables between patients who were readmitted, who died unexpectedly, and those who did not. RESULTS: We found that 9.9% of patients discharged were either readmitted (7.0%) or died unexpectedly (2.9%). Patients who were readmitted had a lower plasma albumin concentration [20 (16, 24) vs 22 (19, 27), P<0.001] and a higher admission APACHE II score [median (inter-quartile range, IQR) 16.5 (13, 21) vs 15 (12, 18), P=0.02]. Patients who died unexpectedly on the ward were older [mean (sd): 76 (12) vs 59 (19), P<0.001] and had a higher APACHE II score [21 (17.25, 26) vs 15 (12, 18), P<0.001]. There was not a statistically significant difference in CRP concentration between patients who either required ICU readmissions or died unexpectedly on the ward and those who did not. CONCLUSIONS: In a mixed medical-surgical intensive care, plasma CRP measured at the day of discharge from intensive care is not a predictor of readmissions or deaths.

Philosopher, pediatrician, pathologist? John Locke's thoughts on Rhicketts and a missed case of Ebstein's anomaly.

John Locke (1632-1704) is primarily remembered for his highly influential philosophical works regarded as the engine of the Enlightenment. It is less well known that Locke also was a highly regarded and influential physician. In 1666, Locke performed a postmortem examination of an 18-month-old child who had physical signs of rickets. Locke, a medical student at this time, attributed rickets as the cause of death. However, Locke described and recognized severe cardiac abnormality and speculated that right-to-left interatrial shunting was part of rickets. Locke's clearly described clinical history and postmortem findings are more consistent with a congenital cardiac malformation, an Ebstein's anomaly, in addition to the rickets. Locke did not consider this case as other than rickets. His opinion was not challenged when the case report was re-presented in the past half century. This article forces a reevaluation of the 17th-century understanding of infant cardiovascular physiology and pathology: Locke clearly gives one of the earliest descriptions of right-to-left shunting through the patent foramen ovale. It is unfortunate that Locke apparently did not discuss his postmortem findings with his contemporary Richard Lower (1631-1691), whose celebrated masterpiece on the heart, Tractatus de Corde, was published in 1669.

Recurrent cerebral fever in the seventeenth and twenty first centuries.

The development of modern neuroscience away from the concepts of Hippocrates and Galen can be traced to the writings of some 17th century clinicians, especially Thomas Willis. His exceptional skills in observation and description allow a window into the experiences of our medical forebears. His approach to the management of infection-related coma in a child is amenable to modern interpretation and comparison with modern management because of the clarity of his clinical descriptions. Modern clinicians may benefit from this historical perspective into influences on the origins of neuroscience. The different outcome for a child presenting in the 17th and 21st century encourage grateful reflection on our current privileged position.

Continuing decline in acute asthma episodes in the community.

BACKGROUND: Acute asthma episodes prompting consultation with general practitioners in the sentinel practices of the Weekly Returns Service (WRS) of the Royal College of General Practitioners increased through the 1980s and early 1990s, reaching a peak in 1993. AIMS AND METHODS: To report on trends in the incidence of asthma episodes in children reported to the WRS over the period 1980-2002. RESULTS: Data confirm the steady upward trend from 1980 to 1993. The downward trend since 1993 was consistent in both male and female preschool and school age children, in all regions of the country simultaneously, and during all seasons until 1999 since when it has stabilised. No causative factor has been identified and no temporal association found between factors previously postulated as causing the increase in acute asthma. The decline in acute asthma episodes in children is consistent with observed declines in all other respiratory infections in this community.

A case of pituitary adenoma: Thomas Willis revisited.

Thomas Willis (1621-1675) was the founder of modern clinical neuroscience. His habit of taking detailed histories with acute clinical observation often accompanied by post mortem studies has left a body of work which still provokes thought and debate. While we were considering a case of pituitary tumour described by Willis, a similar case presented coincidentally at our hospital. The two cases are compared and contrasted.

Cholesterol lowering benefits of soy and linseed enriched foods.

Foods such as breads and breakfast cereals enriched with a combination of soy protein (soy grits and/or soy flour) and whole linseed are gaining popularity. Regular consumption of either whole grains or soy protein can lower risk factors for coronary heart disease. Furthermore, linseed is a rich source of the omega-3 fatty acid. alpha-linolenic acid (LNA), with purported cardiovascular benefits. The aim of this study was to determine the effect of daily consumption of soy and linseed containing foods and Canola (as an added source of LNA) on plasma lipid concentrations in 20 mildly hypercholesterolaemic postmenopausal women. Fasted blood samples were taken initially and after 3 and 8 weeks to assay plasma lipids and both plasma and erythrocyte membrane fatty acids. Urinary isoflavones were also measured. Data from 18 subjects were used for analysis. Plasma total, low-density lipoprotein (LDL) and non-high-density lipoprotein (HDL) cholesterol concentrations fell significantly (10, 12.5 and 12%, respectively) within 3 weeks. Although attenuated, there were still significant reductions in total and non-HDL cholesterol (5 and 6.5%, respectively) after 8 weeks of intervention. These reductions were associated with increases in urinary isoflavone excretion. This pilot study indicates that regular inclusion of foods containing soy and linseed in the diet may improve plasma lipids in subjects with hypercholesterolaemia.

Declining incidence of episodes of asthma: a study of trends in new episodes presenting to general practitioners in the period 1989-98.

BACKGROUND: A study was undertaken to determine trends in the incidence of new episodes of asthma presented to general practitioners participating in the Weekly Returns Service of the Royal College of General Practitioners, comprising 92 practices with a registered population of approximately 680 000 persons well distributed throughout England and Wales. These practices monitor the morbidity presented at every consultation, distinguishing between new episodes of illness and ongoing consultations. METHODS: Age specific weekly rates of new episodes of asthma (and of acute bronchitis) presenting to the general practitioners over the years 1989-98 were examined in four week blocks and analysed by multiple regression, separating secular from seasonal trends. RESULTS: Quadratic trends in episodes of asthma were evident in each of the age groups with peaks in 1993/4. Corresponding analyses for acute bronchitis disclosed similar trends generally peaking in the winter of 1993/4. Mean weekly incidence data (all ages combined) decreased in all quarters since 1993. Regional analysis (North/Central/South) showed similar decreases. CONCLUSIONS: There has been a gradual decrease in the incidence of asthma episodes and of acute bronchitis presenting to general practitioners since 1993. The trend of an increase before 1993 followed by a decrease cannot be explained by changes in the patterns of health care usage or diagnostic preference of doctors.

Comparison of the seasonal patterns of asthma identified in general practitioner episodes, hospital admissions, and deaths.

BACKGROUND: Seasonal variations in asthma are widely recognised. This study was undertaken to investigate the relative differences in seasonal patterns by age as they impact on episodes of care in general practice, hospital admissions, and deaths. METHODS: General practice episode data from the Weekly Returns Service of the Royal College of General Practitioners, hospital admissions for asthma in England, and deaths registered as due to asthma in England and Wales over the years 1990-7 were examined. Age specific weekly rates of new episodes of asthma presenting to general practitioners, numbers of hospital admissions and deaths were analysed by the multiplicative decomposition method to separate secular from seasonal trends. The seasonal indices thereby obtained were plotted as three week moving averages. RESULTS: In children aged 0-4 and 5-14 years general practice episodes and admissions to hospital were strikingly congruent in timing and in magnitude, except in September when particularly high rates of admission (absolute and relative to general practice episodes) occurred. In the 15-44 age group there were marked mid summer peaks of general practice episodes and deaths but admissions to hospital were at about the annual average; in September/October there were peaks of episodes and admissions whereas deaths peaked in November. In the 45-64 age group a peak in general practice episodes of asthma was evident in mid summer when admissions were about average and deaths were at a minimum; all three measures tended to increase gradually with the approach of winter. Finally, in those age over 65 years, general practice episodes of asthma, admissions to hospital, and deaths followed similar 'U' shaped patterns with substantial peaks in mid winter. CONCLUSIONS: The seasonal pattern of asthma evolves with age. There are important differences in the seasonal pattern of general practice episodes, admissions to hospital, and deaths. Individual seasonal histories are important for the management of asthma. The combined analysis of these three data sets provides a new perspective on the epidemiology of asthma.

The Foundation for Interfaith Research and Ministry, Houston, Texas.

The Foundation for Interfaith Research and Ministry (FIRM) promotes, sponsors, and conducts interfaith and interdisciplinary programs of scholarship, research, education, and service.

Prediction of grief and HIV/AIDS-related burnout in volunteers.

Burnout in volunteer workers in the HIV/AIDS area results in the loss of dedicated personnel, consequently straining the HIV/AIDS care delivery system. By assessing the predictors of burnout and grief this study describes the role of grief in HIV/AIDS volunteer burnout. Voluntary and anonymous questionnaires were sent to members of the Foundation for Interfaith Research and Ministry (FIRM), a multi-religious organization formed to provide volunteer work in HIV/AIDS care facilities around Houston, Texas. In 174 valid responses, grief was measured against work characteristics, burnout, rewards, stressors, and the general health questionnaire (GHQ). No significant relationship was found between grief and burnout; however, burnout in volunteers may be different from that in health care professionals for the following reasons: (1) volunteers choose to work in the HIV/AIDS area; (2) they have control over the time they spend volunteering; (3) volunteers are internally motivated to work in the HIV/AIDS area; and (4) if the volunteers do not enjoy the work, they can terminate their involvement with minimal cost. The best univariate predictors of grief are time spent as a volunteer and volunteer hours per week, where those who spend the most hours volunteering experience less grief The Reward/Stress measures most significantly associated with grief include empathy/self-knowing reward, emotional support reward, and emotional overload stress. The strongest predictors of grief in the regression analysis, which account for 21% of the variance, were time as a volunteer, emotional support, emotional overload, GHQ-somatic symptoms, and GHQ social dysfunction. The data suggest that in order to reduce grief special attention should be paid te allowing volunteers freely to express problems with emotional overload and workload adjustments, and providing clear emotional support as a reward.

The relationship between recognition, rewards and burnout in AIDS caring.

The positive psychological and sociological dimensions of AIDS care provision may produce important information to assist burnout prevention. While most studies on stress and burnout in AIDS health care have focused on the negative and difficult aspects of this work, few have considered the notion that the rewards of care-giving may buffer against stress or counterbalance experiences that may otherwise lead to burnout. A study of HIV/AIDS volunteers examined the relationship between stressors, rewards and burnout, using the HIV Volunteer Inventory and the Maslach Burnout Inventory. Correlation data indicates that a lack of a sense of personal accomplishment is a contributor to frequency of burnout. Over a fifth of the variance of burnout frequency can be accounted for by both stress and reward factors. Qualitative interview data also support the importance of rewards. Rewards in the form of gratitude from clients and recognition and support from management positively influenced the organizational climate. This study points to the need to find ways to increase the recognition and rewards experienced by carers. The potential benefits include reduced attrition and burnout and enhanced quality of life in the work setting.

Scanning tunnelling microscopy and dynamic contact angle studies of the effects of partial denaturation on immunoassay solid phase antibody.

A range of partial denaturation antibody pre-treatments that affect immunoassay performance have been evaluated. Monoclonal anti-ferritin antibody was either partially denatured by heat, urea or pH pre-treatment or left untreated and then passively adsorbed to polystyrene microtiter wells. The adsorption characteristics and functionality of the different surfaces produced have been evaluated by dynamic contact angle (DCA) analysis and scanning tunnelling microscopy (STM) imaging respectively. The DCA data show that the effect of partial denaturation is to change the wetting characteristics of the antibody surfaces, while, in addition, STM imaging reveals marked effects seen in the aggregation properties of the denatured antibodies.

A scanning tunnelling microscopy comparison of passive antibody adsorption and biotinylated antibody linkage to streptavidin on microtiter wells.

An antiferritin antibody was either, (a) passively adsorbed to microwells or (b) biotinylated and immobilised to streptavidin coated microwells. Scanning tunnelling microscope (STM) imaging of these well surfaces coated with a platinum (95%) carbon (5%) coating (Pt/C) conductive layer showed a randomly oriented array of antibodies for passive adsorption whereas for biotin-streptavidin immobilisation there was a more uniform and even distribution of antibodies on the well surface. On further incubation with ferritin STM imaging showed that for passive adsorption approximately 5% of the surface was functional, while for the biotinylated antibody it was greater than 60%. The images presented in this paper show graphically the loss of functionality that occurs using passive adsorption and, conversely, the preservation of antibody functionality using the biotin-streptavidin linkage for antibody immobilisation. These results correlate well with the work of others in the field.