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PubMed1998

Errors by paediatric residents in calculating drug doses.

BACKGROUND: Errors in calculating drug doses in infants and small children can cause morbidity and mortality, especially with agents exhibiting a narrow therapeutic window. A previous study from this institution has detected potential life threatening errors in calculations performed by trainees while writing prescriptions. OBJECTIVES: To verify whether the true incidence of trainees' errors in prescribing can be explained by impaired calculation skills in written tests. SETTING: A tertiary paediatric hospital; educational rounds for core paediatric residents. METHODS: Two anonymous written tests, which included calculations of doses similar to those performed at the paediatric bedside; one was conducted in 1993 and one in 1995. RESULTS: Thirty four paediatric residents participated in 1993 and 30 in 1995. A substantial number of trainees in both years committed at least one error. In general, there was no correlation between the length of training (0 to 4 years) and likelihood of making a mistake. Three trainees in 1993 and four in 1995 committed 10-fold errors. These seven residents committed significantly more errors than the rest of the group in each of the tests separately. All seven were in their first two years of training, and six were in their first year of residency. CONCLUSIONS: A substantial proportion of paediatric trainees make mistakes while calculating drug doses under optimal test conditions. Some trainees commit 10-fold errors, which may be life threatening. The results of these anonymous tests suggest that testing of calculations skills should be mandatory, and appropriate remedial steps should follow to prevent paediatric patients receiving wrong drug dosages.

Clinical Competence↗
PubMed1995

Screening for drugs of abuse. I: Opiates, amphetamines and cocaine.

(1) In order to provide an efficient and reliable service for drugs of abuse screening in urine, the laboratory should analyse 20-30 samples per week, and the staff should include a scientist with special expertise in the subject. (2) Turnaround times should be between 2-3 days of sample collection. To achieve this aim it may be necessary to make special arrangements for the delivery of samples to the laboratory. Results should preferably be transmitted by electronic mail or facsimile with the necessary precautions for security and confidentiality: hardcopy reports may also be required. (3) Good communications between the requesting clinician and the laboratory are essential. An advisory service should be provided by the laboratory and clinicians should be encouraged to discuss requests and results with laboratory staff. It is important that the laboratory inform doctors of the range of substances detected and the sensitivity and specificity of laboratory assays. (4) Assays should be performed according to the manufacturer's protocols, or by modified methods that have been rigorously validated. Quality control samples should be included in each analytical run and participation in an external quality assessment scheme, e.g. UKNEQAS, is essential to provide independent confirmation and confidence that results compare with those from other laboratories. Other requirements include adequate training and supervision of staff, and careful recording of samples and results. (5) Drugs to be tested will depend on the drug 'scene' in the area but should include those drugs regularly prescribed for maintenance therapy (e.g. methadone, dihydrocodeine, benzodiazepines), and drugs frequently misused (e.g. heroin, buprenorphine, amphetamines, cocaine). (6) Positive results obtained by preliminary screening methods e.g. EMIT, should be confirmed by another analytical technique, e.g. TLC, GC or GC-MS. If there are potentially serious or legal implications, and in employment and preemployment testing, confirmation of positive results is mandatory. In some cases, e.g. checking for methadone or benzodiazepine compliance, it may be considered unnecessary to confirm positive results although possible spiking of samples cannot be excluded without checking for the presence of metabolites by a chromatographic procedure.

Amphetamines↗
PubMed2005

Compliance and toxicity of adjuvant CMF in elderly breast cancer patients: a single-center experience.

BACKGROUND: Few data are available on compliance and safety of adjuvant chemotherapy when indicated in elderly breast cancer patients; CMF (cyclophosphamide, methotrexate, fluorouracil) can be reasonably considered the most widely accepted standard of treatment. METHODS: We retrospectively reviewed compliance and safety of adjuvant CMF in patients older than 60. The treatment was indicated if patients had no severe comorbidity, a high-risk of recurrence, and were younger than 75. Toxicity was coded by NCI-CTC. Toxicity and compliance were compared between two age subgroups (< 65, > or = 65) by Fisher exact test and exact Wilcoxon rank-sum test. RESULTS: From March 1991 to March 2002, 180 patients were identified, 100 older than 60 and younger than 65, and 80 aged 65 or older. Febrile neutropenia was more frequent among older patients (p = 0.05). Leukopenia, neutropenia, nausea, cardiac toxicity and thrombophlebitis tended to be more frequent or severe among elderlies, while mucositis tended to be more evident among younger patients, all not significantly. Almost one half (47%) of the older patients receiving concomitant radiotherapy experienced grade 3-4 haematological toxicity. Compliance was similar in the two groups, with 6 cycles administered in 86% and 79%, day-8 chemotherapy omitted at least once in 36% and 39%, dose reduction in 27% and 38%, prolonged treatment duration (> or = 29 weeks) in 10% and 11% and need of G-CSF in 9% and 18%, among younger and older patients, respectively. CONCLUSION: Our data show that, in a highly selected population of patients 65 or more years old, CMF is as feasible as in patients older than 60 and younger than 65, but with a relevant burden of toxicity. We suggest that prospective trials in elderly patients testing less toxic treatment schemes are mandatory before indicating adjuvant chemotherapy to all elderly patients with significant risk of breast cancer recurrence.

Aged↗
PubMedDate not supplied

[Heterogeneous distribution of the prevalence of anti-Trypanosoma cruzi antibodies among blood donors in the State of Puebla, Mexico].

OBJECTIVE: To determine the seroprevalence and associated factors, of antibodies against Trypanosoma cruzi (T. cruzi Ab) among blood donors living in rural and suburban areas and risk regions. MATERIAL AND METHODS: A cross-sectional study was conducted from January to December 2003, in 2489 blood donors of seven regions of Puebla, who were evaluated for mandatory viral and T. cruzi serological tests using validated procedures. RESULTS: The seroprevalence for T. cruzi Ab was 1.24% (31/2489), similar to hepatitis C (HVC) (1.5%) and higher than human immunodeficiency virus (HIV) (0.4%) and hepatitis B (HVB) (0.3%). The highest seroprevalences were observed in the regions of Tehuacan-Sierra Negra and Mixteca, up to 2.6%, while in Sierra nororiental and Angelopolis no positive blood donors were identified. A positive association was observed between seropositivity and being older than forty years and being born and raised in Tehuacan-Sierra Negra and Mixteca. CONCLUSIONS: T. cruzi seroprevalence distribution is heterogeneous, from 0% to 2.6%, with higher seroprevalences in the regions of Tehuacan-Sierra Negra and Mixteca.

Adolescent↗
PubMed2001

Traceability in cattle and small ruminants in Canada.

Traceback systems for cattle and small ruminants are of international concern after the outbreaks of bovine spongiform encephalopathy in the European Union and foot and mouth disease in the United Kingdom and South America. Implementation of a national or international identification system depends on meeting a balance between cost, reliability/durability, ease of use, data transfer speed, protection from fraud, avoidance of entry into the food chain and animal welfare issues. As of 1 January 2001, Canada has instituted a national identification programme for cattle, which will have annual operating and administrative costs of Can$0.20 per head, excluding ear tags. The system will provide herd of origin traceback and individual animal identification by ear tags for all beef cattle. A number of identification technologies are available that would have advantages over visual tags, but these are currently too costly without government support (electronic identification, deoxyribonucleic acid [DNA] fingerprinting), too slow (DNA fingerprinting) or have not been tested sufficiently (retinal imaging) to warrant mandatory inclusion in a national traceback/identification system.

Animal Husbandry↗
PubMed1992

Ethical aspects of genetic screening.

Public and professional concern associated with the idea of genetic screening has generated numerous publications on the ethics of genetic screening (e.g. 1-4). Concerns revolve around inadequate consultation before screening is carried out, the unearthing of worrying risks, the use of genetic information in ways that could be disadvantageous to the person involved, stigma, and a phenomenon known as the 'technological imperative', which means that simply because a technology is available there is a tendency to use it. Most reports agree that, in practice, the main ethical problems are likely to involve screening for risk of common diseases of adult life, because of the possible impact on a person's healthy self-image, implications for health and life insurance, and the possibility of commercial exploitation of people who know themselves to be vulnerable. In this paper I do not propose to address these issues directly. I have been invited to discuss this subject as a clinician involved with genetic screening, counselling and prenatal diagnosis for the haemoglobin disorders, the most common serious human recessively inherited diseases. Since we are scientists, any recommendations we make should be based on experience: my aim is to show that experience is often surprising, and that it is often possible to meet public concerns by taking quite simple practical steps.

Ethics, Medical↗
PubMed1999

Applications of forensic identity testing in the clinical laboratory.

DNA analysis is becoming routine in the clinical laboratory for the diagnosis of human diseases using various tissue sources. Most clinical specimens are followed by tracking forms that include patient demographic data, accession number, and date and time of collection. As part of a thorough quality assurance program, proper documentation of test requisitions and tracking forms is mandatory. Despite these efforts, specimen mislabeling or other mix-ups can, and do, occur. We demonstrate the utility of the PM + DQA1 typing kit and STR analysis using the Visible Genetics automated DNA sequencing system in the proper identification of such clinical specimens as urine, blood, and paraffin-embedded tissues. In each case, sufficient DNA was extracted from these specimen types using a nonorganic extraction protocol for typing purposes. We conclude that DNA typing methods are feasible for distinguishing clinical laboratory specimens of questionable identity and compliment existing quality assurance techniques.

Blotting, Southern↗
PubMed1999

[History of the elimination of bovine tuberculosis in the Czech Republic].

In 1968 in the Czech republic the programme of elimination of tuberculosis in cattle caused by germs of Mycobacterium bovis was successfully completed. The project proper was started in 1959 by examination of the whole population of cattle with tuberculin tests. The situation which was revealed was disastrous: the prevalence in cattle was on average 21.03% whereby it reached 32.26% in milking cows, i.e. every third cow had TB, as was also confirmed in slaughterhouses. Hundreds of cases in humans caused by M. bovis were notified. The annual economic losses were more than a billion crowns. The health campaign was based on the method "test and slaughter" and on the replacement of heavily infected herds by TB free ones. It was necessary to replace 1,360,000 heads of TB cattle. This called for the solution of many complicated methodical, legislative, organizational, economic and social problems. Mandatory pasteurization of milk was introduced. Tuberculin tests of the whole cattle population (on average twice a year) supplemented by epizootological, laboratory and postmortem examinations led to the detection of all foci. The final results are up to the present time reflected in the substantially better production capacity of the cattle, TB free milk and a marked decline of M. bovis in humans.

Animals↗
PubMed1999

Differentiated thyroid cancer: lobectomy and radioiodine, a treatment suitable for all cases?

When treating differentiated carcinoma of the thyroid, lobectomy is the minimum surgical requirement, but there is a strong case for ablation of the whole gland. Controversy centres on the management of the contralateral lobe, which may be ablated by total thyroidectomy, by near total thyroidectomy and ablation of thyroid fragments by 131I, or by 131I alone. Operative morbidity is increased after total thyroidectomy compared with lobectomy. However, radioactive 131I ablation of the contralateral lobe is associated with a longer period of hospitalization than if radioactive 131I is given to ablate residual fragments of thyroid tissue after total thyroidectomy. The use of lobectomy may lead to a higher incidence of patients requiring more than one administration of 131I. The evidence available indicates that radioactive 131I ablation of the contralateral lobe is a safe procedure unless tumour deposits within this lobe are large enough to be visualized on an ultrasound scan, when total thyroidectomy becomes mandatory. Clinical trials are necessary to test this hypothesis.

Combined Modality Therapy↗
PubMedDate not supplied

[Snoring and obstructive sleep apnea].

Snoring and obstructive sleep apnea are similar disorders in etiology, with differences in clinical presentation and treatment. 5-20% of young and 40-50% of older population are affected by either of these disorders. Etiology of snoring should be sought in the anatomic irregularities of commencing portions of the upper respiratory and gastrointestinal tracts, obesity, alcohol abuse, use of some medications as well as in the sleep architecture disturbance. Treatment success depends on correctly established diagnosis and precise localisation of anatomic irregularity implicated in snoring. A wide array of diagnostic tests exist some of which are mandatory while the others are used on a case-by-case basis. Treatment is either conservative or surgical. The success rate is 30-90% depending on the type and the management of disorder. An algorithm for diagnosis and treatment of snoring and obstructive sleep apnea is shown at the end of the paper.

Humans↗
PubMed2001

New oral agents for erectile dysfunction: what is changing in our practice?

Erectile dysfunction (ED) is a highly prevalent disorder affecting an estimated 152 million men worldwide and is associated with a variety of behavioral risk factors, such as cigarette smoking and excessive alcohol consumption, as well as numerous age-related medical conditions, notably type-2 diabetes mellitus and cardiovascular disease. A rational step-wise approach which includes comprehensive medical and sexual history, a focused physical examination and essential laboratory tests such as fasting glucose, lipid profile and testosterone assay is to be preferred. Current diagnostic work-up does not recommend any of the specialized tests which were previously considered mandatory-i. e. penile pharmacotesting, Duplex ultrasound and nocturnal penile tumescence. Hormonal replacement therapy is appropriate only in the hypogonadal male with ED. Prior to direct intervention, the physician should consider altering modifiable risk factors or causes, although frequently insufficient to reverse ED completely. When indicated, oral therapy with new molecules (phosphodiesterase inhibitors or apomorphine) is the first-line treatment for the majority of patients because of potential benefits and lack of invasiveness.

Administration, Oral↗
PubMed2002

[Fabry's disease (alpha-galactosidase-A deficiency): physiopathology, clinical signs, and genetic aspects].

Fabry disease (FD, OMIM 301500) is an X-linked inherited disorder of metabolism due to mutations in the gene encoding alpha-galactosidase A, a lysosomal enzyme. The enzymatic defect leads to the accumulation of neutral glycosphingolipids throughout the body, particularly within endothelial cells. Resulting narrowing and tortuosity of small blood vessels lead to tissue ischaemia and infarction. Inability to prevent the progression of glycosphingolipid deposition causes significant morbidity (acroparesthesia, angiokeratoma, autonomic dysfunction, cardiomyopathy and deafness), and mortality from early onset strokes, heart attack and renal failure in adulthood. Demonstration of alpha-galactosidase A deficiency in leukocytes or plasma is the definitive method for the diagnosis of affected hemizygous males. Most heterozygotes present with a cardiac, renal or neurological symptomatology, although to a lesser extent than what is observed in hemizygotes. Due to random X-chromosomal inactivation, enzymatic detection of carriers is often inconclusive. Molecular testing of possible carriers is therefore mandatory for accurate genetic counselling. The GLA gene has been cloned and more than 200 mutations have been identified. Medical management is symptomatic and consists of partial pain relief with analgesic drugs (gabapentin, carbamazepine), whereas renal transplantation or dialysis is available for patients experiencing end-stage renal failure. However, the ability to produce high doses of alpha-galactosidase A in vitro has opened the way to clinical studies and enzyme replacement therapy has recently been validated as a therapeutic agent for FD patients in clinical trials. Long term safety and efficacy of replacement therapy are currently being investigated.

Amino Acid Substitution↗
PubMed1992

The epidemiology of HIV infection and AIDS in east and central Harlem, NY.

This report describes the AIDS epidemic in East and Central Harlem, among the hardest-hit communities in the nation. Information was obtained from two New York State mandatory reporting programs: anonymous HIV antibody testing of newborns, and physician and hospital reports of AIDS cases to city and county public health departments. One of 30 babies born in East Harlem and one of 46 newborns in Central Harlem are seropositive. The cumulative rate of reported AIDS cases in these communities is 10-15 times the national rate, and together, the communities reported 1.3% of all AIDS cases in the nation, although they have only 0.1% of the nation's population; 2.2% of all childhood AIDS cases have been reported from East and Central Harlem. Women, minorities, and injection drug users comprise a higher proportion of the cases than in the city, the state, and the nation. The consequences of the epidemic in these communities are enormous, including profound stresses on community institutions and exacerbation of the resurgence of tuberculosis.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

[Clozapine and resistant schizophrenia].

Clozapine is an atypical antipsychotic drug, with distinguishing features from neuroleptics which are believed to exert their therapeutic effect by blocking dopamine receptors in the limbic system. Clozapine is both chemically and pharmacologically distinct from neuroleptics such as chlorpromazine and haloperidol. This tricyclic dibenzodiazepine derivative is moderately active on the dopaminergic pathways, blocking D1 and D2 receptors to the same extent; and chronic treatment with clozapine does not lead to a compensatory increase in the number of striatal D2 receptors in rats. Pharmacological studies showed that clozapine produces psychomotor inhibition but without catalepsy and other typical effects of dopamine receptor blockade. The drug also has adrenergic (alpha 1), histamine (H1), and serotonin (5-HT2) blocking activity and is a potent muscarinic antagonist. The efficacy and side-effect profile of clozapine are unique. Treatment-resistant patients are much more likely to respond to clozapine than to haloperidol or chlorpromazine. In double-blind trials, clozapine has improved both positive and negative psychotic symptoms in schizophrenic patients who were refractory to conventional neuroleptics. Extrapyramidal side-effects are exceptional during therapy and tardive dyskinesia never demonstrated in relationship to clozapine. There is an increased risk of agranulocytosis with clozapine use estimated to be up to 20 cases of agranulocytosis per thousand patients treated during one year. Accordingly, a careful patient selection and regular blood monitoring are mandatory over the treatment period (blood testing to be performed weekly and immediately at the first sign of infection). Generally, this agranulocytosis is reversible with early detection and prompt drug discontinuation.

Antipsychotic Agents↗
PubMed1989

[Social acceptability of screening for HIV seropositivity in pregnant women. An inquiry in the Paris region].

Current debate about screening strategies for HIV during pregnancy is not limited to clinical and epidemiologic arguments; ethical and social concerns about the risk of stigmatization against HIV carriers are also taken into account. Therefore, data on public perception of AIDS and attitudes toward preventive measures against the disease can be of interest. In December 1987, a survey was carried out, through personal interview, in a representative sample (900 individuals selected by the quota method) of the 10.5 million inhabitants 18 years of age and over, in the Paris region. 9.8% of the women declared having been tested for HIV, at least once, during 1987, and 20% of these tests were part of prenatal care. Mandatory screening for HIV among pregnant women is supported by 78.6% of the respondents while only 64% support screening during premarital examinations and a minority (37.8%) is in favour of mandatory screening for the whole population. 48.5% of respondents share the misperception that transmission from mother to fetus always happens, and 70% think that women who are HIV carriers should renounce pregnancy: willingness to support mandatory screening for pregnant women is significantly higher among individuals who share these two beliefs.

Adult↗
PubMed1984

Flavobacterium meningosepticum.

lavobacterium meningosepticum is an opportunistic pathogen of low virulence found in the hospital environment in water-containing equipment. Of primary importance is its role in outbreaks of neonatal meningitis which tends to be severe with a high mortality rate and serious sequelae. Changing all equipment concerned with humidifying or administering gases every 24 hours can help prevent these outbreaks in neonatal nurseries. Treatment is difficult because of the resistance of F. meningosepticum to most antimicrobial agents used to treat meningitis. Sensitivity tests, using a MIC method, are mandatory for infections caused by F. meningosepticum and, pending these results, vancomycin, given intravenously and, if necessary, intrathecally, appears to be the drug of choice for initial therapy.

Adult↗
PubMed1995

Hereditary medullary thyroid carcinoma.

The most well-known form of familial thyroid cancer is hereditary medullary thyroid carcinoma (MTC). This neoplasm is often associated with pheochromocytoma and hyperparathyroidism, a combination known as the multiple endocrine neoplasia syndrome type 2A (MEN 2A). The rare association of MTC and pheochromocytoma with multiple mucosal neuromas is called multiple endocrine neoplasia syndrome type 2B (MEN 2B). Of those who present with clinical signs and symptoms, almost half die of the disease and others may suffer significant morbidity. By contrast, early diagnosis by screening of family members allows for treatment with thyroidectomy and/or adrenalectomy, which are often curative. Measurement of serum calcitonin before and after stimulation with pentagastrin and/or calcium is mandatory for the diagnosis of MTC. Testing of first-degree relatives of patients with MTC should be started by the age of 3 to 5 years. In families with the MEN 2B syndrome, screening should be started during the first year after birth and include a search for the characteristic phenotype. The mapping of the MEN 2A gene to the centromeric region of chromosome 10 has provided an alternative approach to the diagnosis of MEN 2A gene carriers. Genetic screening using linked markers can now be done with an accuracy of 95% in informative families. Surgery is the treatment of choice for cases of MEN 2, but the extent of surgical resection of the involved endocrine organs is still a subject of debate.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗