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After prolonged parenteral nutrition a 12 month old infant died with pulmonary hypertension and granulomatous pulmonary arteritis. A review of necropsy findings in 41 infants who had been fed parenterally showed that two of these also had pulmonary artery granulomata, while none of 32 control patients who died from sudden infant death syndrome had similar findings. Particulate contaminants have been implicated in the pathogenesis of such lesions and these were quantified in amino acid/dextrose solutions and fat emulsions using automated particle counting and optical microscope counting respectively. Parenteral feed infusions compounded for a 3000 g infant according to standard nutritional regimens were found to include approximately 37,000 particles between 2 and 100 microns in size in one day's feed, of which 80% were derived from the fat emulsion. In-line end filtration of intravenous infusions may reduce the risk of particle associated complications. A suitable particle filter is required for use with lipid. [ABSTRACT FROM AUTHOR]

Background: The Black Country (BC) is an area of the United Kingdom covering Dudley, Sandwell, Walsall, and Wolverhampton. The area is ethnically, culturally and religiously diverse. One-fifth of the total population is in the lowest socioeconomic quintile, with an uneven distribution of wealth. The area manifests unmet needs and as perceived underserved community groups. Objectives and Methods: To better understand the situation and inform future provision, listening events were organised across the BC to engage with local underserved communities. A mixed-methods design was employed, using collaborative workshops. The workshops enabled stakeholders to explore priorities, perceived barriers and solutions to mental health services' access within the BC. Results: Sixty participants verbally consented and signed in to attend the three workshops. There were nine groups that provided 247 statements on the topic, yielding a total of 12 codes and six themes (priorities). The top identified priorities were inappropriate periodisation of accessible funded healthcare needs (n = 42, 18.03%), barriers to appropriate healthcare (n = 49, 21.03%) and limited resources for training, health promotion, preventative care and support networks (n = 62, 26.61%). Conclusions: Addressing the identified priorities will require location and community-specific solutions to establish those communities' trust and engagement. Cultural stigma should not be viewed as the only barrier to access healthcare but should be considered in combination with the population's reluctance to reach out to healthcare services due to loss of trust between community groups and lack of co-design of culturally and religiously appropriate services for the community.

Background: Diabetic ketoacidosis (DKA) is a life-threatening condition among diabetic patients characterized by metabolic anion gap (AG) acidosis of arterial pH <7.30, glucose >250 mg/dL, and positive ketones. The triggers for DKA can be infection, surgery, and, in reported cases, intraparenchymal hemorrhage (IPH). In rare cases of DKA, despite being in active ketoacidosis, glucose levels may be within normal or accepted range. Such a condition is called euglycemic DKA. It has been recently recognized in association with the use of sodium glucose co-transporter-2 (SGLT-2) inhibitors in the treatment of type 2 diabetes., Case Description: An 83-year-old male taking an SGLT-2 inhibitor (empagliflozin) for type 2 diabetes presented with an IPH. His laboratory studies revealed an elevated AG acidosis, an elevated beta hydroxybutyrate, and serum glucose levels within the acceptable range. Urine studies revealed elevated ketones and glucose. The diagnosis of euglycemic DKA was made, and the patient was treated with insulin and glucose infusions., Conclusion: Like hyperglycemic ketoacidosis, euglycemic DKA requires prompt recognition and immediate aggressive medical therapy, but the diagnosis can be challenging, and the treatment using insulin in the setting of a normal glucose can be counterintuitive. Euglycemic DKA can often be missed in the setting of blood glucose not being elevated. Prompt recognition and treatment are critical for successful management., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Aim: This survey was conducted to determine the type and frequency of antibiotics (AB) use for the prevention of infections in dental third molar (M3) extraction and implantation procedures (DIP) among UK dentists and the opinions underpinning their practice., Methods and Design: Systematic reviews of the evidence were undertaken alongside this survey of practicing dentists in the United Kingdom to identify the opinions and practices of those undertaking the procedures.With ethical approval, a survey was designed for online delivery and was sent to every dental practitioner in the UK with a publicly available email address or social media contact. The opening page provided the project information sheet and proceeding to complete and submit the questionnaire was considered consent to participate. The online survey was circulated to 900 identified addresses and a total of 145 responses were received. Responses were collated in Microsoft® Excel™ and analyzed using IBM® SPSS™ plus thematic analysis of free text responses., Results: There were 42% of participants (n=61) who discouraged AB prophylactic use in M3 extractions in people with no systemic conditions and who also preferred postoperative AB use when required. Where, 57.9% of respondents (n=84) supported the short-term use of ABs (5-7 days) for M3 extraction and 53% (n=77) in DIP placement in patients with no relevant medical history. As an ad hoc finding, dentists reported on the negative impact of heavy smoking and oral parafunctional behavior on DIP success., Conclusion: The use of antibiotics and broad spectrum antibiotics remains higher than current guidelines would recommend. Further research is required to clarify the specific risks arising from underlying medical conditions to further clarify where prophylaxis is required.

This systematic review compared the efficacy and tolerance of oral antipsychotics (APDs) used in the treatment of schizophrenia following the PRISMA-P© statement ( n = 21). The primary outcomes of interest were clinical response measured with symptoms' improvement, tolerance to side effects and discontinuation reasons. There was better individual patients' response to aripiprazole vs. ziprasidone and quetiapine ((CDSS p = 0.04), BPRS p = 0.02, YMRS p = 0.001) and ziprasidone vs. quetiapine (CGI p = 0.02, CDSS p = 0.02). Aripiprazole was more tolerated than risperidone, ziprasidone and quetiapine ( p < 0.05). Quetiapine was more tolerated than aripiprazole, ziprasidone and risperidone ( p < 0.05). Ziprasidone was more tolerated than quetiapine haloperidol and olanzapine ( p < 0.05). Risperidone was more tolerated than olanzapine ( p = 0.03) and haloperidol was more tolerated than olanzapine and quetiapine ( p < 0.05). Olanzapine caused less discontinuation than quetiapine; quetiapine caused less discontinuation than ziprasidone, aripiprazole and haloperidol; ziprasidone caused less discontinuation than quetiapine, aripiprazole and haloperidol; aripiprazole caused less discontinuation than quetiapine, ziprasidone and olanzapine and olanzapine caused less discontinuation than ziprasidone and haloperidol ( p < 0.05). It was concluded that individual patient clinical response, tolerance to side effects and life-threatening side effects remain the most reliable basis for selecting and continuing the use of APD.

The aim of this survey of psychiatrists from the UK and India was to compare their opinions on antipsychotic medication choice and their experiences of such medications' effectiveness and tolerability in patients who were newly diagnosed with acute schizophrenia. Following ethical approval, a cross-sectional online survey of psychiatrists from the UK and India was conducted. Ninety-five responses were received from each country. The most selected first-line APDs in both countries were olanzapine (47.5%), risperidone (42.8%) and aripiprazole (25.3%). A total of 60% of psychiatrists from India (60%) and 48% from the UK (48%) selected 'medication efficacy' as the main factor in their choice. Reassessment and consideration to switch most often took place within 4-6 weeks (53.7%) and 3-6 months (11.6%). The major reasons for switching antipsychotic medications were poor clinical efficacy (69%) and lack of tolerability (45%). Nonadherence was the most common reason for relapse (90% of UK psychiatrists and 70% of Indian psychiatrists), followed by illicit drug use (27.6%). The most commonly reported side effects that led to nonadherence were weight gain (10.8%), drowsiness (10.4%), erectile dysfunction and movement disorders (equally 8.7%). It was concluded that olanzapine, risperidone and aripiprazole are the most commonly selected as the initial treatment choice by psychiatrists from India and the UK. They are perceived as widely effective and well tolerated.

Background: A limited number of studies have explored patients' experience with home parenteral (injectable) therapy (HPT) in the UK., Aim: To explore the immediate-, short-, and long-term experience of patients with self-management of any home parenteral therapy with the intention for developing a guideline for service development in the United Kingdom., Methods and Design: An interview-based study of patients receiving HPT. Invitations were posted to all patients on the hospital HPT register. The sessions were conducted by telephone for all consenting patients. The interviews were recorded, transcribed, and analysed thematically. Participants completed the 'Health Education Impact Questionnaire' (heiQ) before and after the education session., Results: Of the 640 patients invited to participate in the study, 45 (7%) patients completed the interviews and the education session. An interview analysis revealed that the patients' experiences of HPT were generally positive, but the levels of training and support received showed wide individual variations. The patients had experienced periods of doubt and uncertainty, where they would have appreciated quick access to professional advice to alleviate their concerns. There was a reliable positive change (10.5-18.4%) from before and after the education sessions in six out of the eight domains on the heiQ questionnaire (health-directed behaviour, self-monitoring and insight, constructive attitudes and approaches, skill and technique acquisition, social integration and support, and emotional distress) and moderate change in two domains (5.3% in positive and negative engagement in life, and 2.6% in health services navigation)., Conclusion: Self-administered parenteral therapy at home is a valuable option, but training and preparation standards should be optimised across hospitals and the wider NHS.

Objective: Interstitial lung disease (ILD) is relatively common in patients with lung cancer with an incidence of 7.5%. Historically pre-existing ILD was a contraindication to radical radiotherapy owing to increased radiation pneumonitis rates, worsened fibrosis and poorer survival compared with non-ILD cohorts. Herein, the clinical and radiological toxicity outcomes of a contemporaneous cohort are described., Methods: Patients with ILD treated with radical radiotherapy for lung cancer at a regional cancer centre were collected prospectively. Radiotherapy planning, tumour characteristics, and pre- and post-treatment functional and radiological parameters were recorded. Cross-sectional images were independently assessed by two Consultant Thoracic Radiologists., Results: Twenty-seven patients with co-existing ILD received radical radiotherapy from February 2009 to April 2019, with predominance of usual interstitial pneumonia subtype (52%). According to ILD-GAP scores, most patients were Stage I. After radiotherapy, localised (41%) or extensive (41%) progressive interstitial changes were noted for most patients yet dyspnoea scores ( n = 15 available) and spirometry ( n = 10 available) were stable. One-third of patients with ILD went on to receive long-term oxygen therapy, which was significantly more than the non-ILD cohort. Median survival trended towards being worse compared with non-ILD cases (17.8 vs 24.0 months, p = 0.834)., Conclusion: Radiological progression of ILD and reduced survival were observed post-radiotherapy in this small cohort receiving lung cancer radiotherapy, although a matched functional decline was frequently absent. Although there is an excess of early deaths, long-term disease control is achievable., Advances in Knowledge: For selected patients with ILD, long-term lung cancer control without severely impacting respiratory function may be possible with radical radiotherapy, albeit with a slightly higher risk of death., (© 2023 The Authors. Published by the British Institute of Radiology.)

Background and Objectives : This project was developed from anecdotal evidence of varied practices around antibiotic prescribing in dental procedures. The aim of the study was to ascertain if there is evidence to support whether antibiotic (AB) use can effectively reduce postoperative infections after dental implant placements (DIPs). Materials and Methods : Following PRISMA-P© methodology, a systematic review of randomised controlled clinical trials was designed and registered on the PROSPERO© database. Searches were performed using PubMed ® , Science Direct ® and the Cochrane© Database, plus the bibliographies of studies identified. The efficacy of prophylactic antibiotics, independent of the regimen used, versus a placebo, control or no therapy based on implant failure due to infection was the primary measured outcome. Secondary outcomes were other post-surgical complications due to infection and AB adverse events. Results : Twelve RCTs were identified and analysed. Antibiotic use was reported to be statistically significant in preventing infection ( p < 001). The prevention of complications was not statistically significant ( p = 0.96), and the NNT was >5 (14 and 2523 respectively), which indicates that the intervention was not sufficiently effective to justify its use. The occurrence of side effects was not statistically significant ( p = 0.63). NNH was 528 indicating that possible harm caused by the use of ABs is very small and does not negate the AB use when indicated. Conclusion : The routine use of prophylactic antibiotics to prevent infection in dental implant placement was found to be not sufficiently effective to justify routine use. Clear clinical assessment pathways, such as those used for medical conditions, based on the patients' age, dental risk factors, such as oral health and bone health, physical risk factors, such as chronic or long-term conditions and modifiable health determinants, such as smoking, are required to prevent the unnecessary use of antibiotics.

Background and Objectives : Anecdotal evidence suggested variation in practices for antibiotic prescribing around dental procedures including route of administration of antibiotics, timing of the course prescribed (before, after or both), length of course prescribed, narrow vs. broad spectrum agents prescribed, use of single or combination of antibiotics, and the use of loading doses. This review aims to investigate this disparity of practices and the absence of global and local recent consensus on the most appropriate antibiotic interventions around invasive dental procedures. Material and methods : Following PRISMA-P © methodology, a systematic review of randomised controlled clinical trials was designed, reviewed, and entered on the PROSPERO © website prior to commencement. Ethics approval was gained from the University of Wolverhampton Committee. Searches were performed using PubMed © , Science Direct™, and the Cochrane Database, plus the bibliographies of studies identified. They investigated studies examining the efficacy and safety of any antibiotic regimen tested, independent of regimen used, versus a placebo, control, or no therapy, on outcomes in post third molar extraction. Results : The primary outcome of interest was postoperative infection and secondary outcomes were other post-surgical related complications of infectious nature and antibiotic adverse events. Sixteen RCTs were identified that met the selection criteria. Antibiotic use was reported to be safe, causing few adverse events. Meta-analysis of infection events showed antibiotics reduced the risk of an infection by 69%, but routine use for prophylaxis in uncomplicated procedures was not supported, and their role in patients with comorbidities or impaired immunity remains controversial. The effect on the incidence of dry socket showed no difference based upon regimen used. No significant benefit was found with respect to reduction of intraoral inflammation, wound dehiscence, haematoma, and lymphadenopathy. Conclusion : The effect on postoperative pain reduction was inconclusive. Routine use of antibiotics around M3 extraction procedures is not supported, but their use in the presence of co-morbidities and or immunosuppression remains controversial to be confirmed by future studies.

Irregularities of vitamin levels are being increasingly identified associated with skin conditions, and systemic and topical therapies have shown promising improvements. There have been some remarkable improvements achieved, but large variations in outcomes suggest that these conditions are not simply related to a single deficiency or solved by providing a single supplement. Cyanocobalamin, pyridoxine (B6) and riboflavin (B2) supplementation were linked with exacerbating existing acne. There were also reports of allergic reactions to parenteral cobalamin including acne, rosacea, allergic site reactions or anaphylaxis with cobalamin injections. This was also reported in patients who had allergic contact dermatitis to cobalt, where cobalamin therapy resulted in cutaneous manifestations such as chronic vesicular hand dermatitis, cheilitis and stomatitis. The use of niacinamide in acne vulgaris as an alternative to clindamycin or adjunct is also notable, as well as its application for hyperpigmentation. Vitamin B3 also has promise in chemoprevention in particular nonmelanoma skin cancer prophylaxis. Folic acid has a developing role in psoriasis. The data for vitiligo remains inconclusive. Assessment for potential vitamin deficiency, particularly B vitamins, should form part of the normal work-up for a wide range of skin conditions., Competing Interests: Conflict of interest: The authors declare no potential conflict of interest., (©Copyright: the Author(s).)

Zinc is a trace nutrient essential for the normal growth and development of human body. The main aim was to evaluate the significant association between measured zinc status in relation to different skin disorders and their severity. PubMed®, Google® Scholar™ and Cochrane© Reviews databases were searched for studies from January 2017 to June 2021, using the terms; zinc serum levels, zinc plasma levels and different dermatosis in the review, only human studies in English language were reviewed and the studies designs were controlled, cross sectional, observational and analytic types. A total of forty-eight research studies were included in this review. All studies have evaluated serum zinc in skin diseases including psoriasis, atopic dermatitis, pityriasis alba, androgenetic alopecia areata, telogen effluvium, vitiligo, melasma, acne, seborrheic dermatitis and hidradenitis suppuritiva. It was found that 33 studies had validated statistically significant differences in serum zinc levels between patients and controls. There is a predominance of low serum zinc levels in all the dermatoses reviewed. The clinical significance of this finding highlights the possible value, and need to investigate, the use of Zinc supplementation as an adjuvant therapy in the management of chronic inflammatory and autoimmune skin diseases proven to manifest altered zinc levels., Competing Interests: Conflict of interest: The authors declare no conflict of interest., (©Copyright: the Author(s).)

Aim: This review aimed to explain novel coronavirus (COVID-19) infection impact on cardiovascular system and patients management in community and primary care settings., Method: Literature search and review limited to 2020 of published papers identified dealing with Coronavirus and cardiovascular disease., Results: Coronavirus is a large family of positive-sense, enveloped, single-stranded RNA viruses that belong to the Nidovirales order. Covid-19 refers to infection with the SARS-CoV-2 variant. Myocardial injury has a considerable association with mortality outcomes for COVID-19 infection. The prognosis of patients with underlying cardiovascular diseases, who had not sustained myocardial injury was relatively favourable. Inflammation may also be a potential mechanism for myocardial injury. So far, current evidence suggests statistically significant associations between cardiac injury and mortality in patients with COVID-19. Whether this is mediated by destruction of angiotensin converting enzyme 2 in heart cells or by other mechanisms, is being investigated., Conclusion: In patients with underlying cardiovascular diseases, aggressive treatment for COVID-19 should be considered and clinicians should be aware of the significantly increased risk of serious infection and worse prognosis in this patient group. New evidence and studies are continually emerging and will confirm or refute our current understanding about COVID-19 impact. Primary care practitioners are urged to continue to monitor the evolving evidence to appropriately manage their patients who are at risk of, or currently diagnosed with cardiovascular conditions.

Cardiac computerized tomography (CT) has evolved from a research tool to an important diagnostic investigation in cardiology, and is now recommended in European, US, and UK guidelines. This review is designed to give the reader an overview of the current state of cardiac CT. The role of cardiac CT is multifaceted, and includes risk stratification, disease detection, coronary plaque quantification, defining congenital heart disease, planning for structural intervention, and, more recently, assessment of ischemia. This paper addresses basic principles as well as newer evidence.

Background: Construct failure is an uncommon but well-recognized complication following anterior cervical corpectomy and fusion (ACCF). In order to screen for these complications, many centers routinely image patients at outpatient visits following surgery. There remains, however, little data on the utility of such imaging., Methods: The electronic medical record of all patients undergoing anterior cervical corpectomy and fusion at Dartmouth-Hitchcock Medical Center between 2004 and 2009 were reviewed. All patients had routine cervical spine radiographs performed perioperatively. Follow-up visits up to two years postoperatively were analyzed. , Results: Sixty-five patients (mean age 52.2) underwent surgery during the time period. Eighteen patients were female. Forty patients had surgery performed for spondylosis, 20 for trauma, three for tumor, and two for infection. Forty-three patients underwent one-level corpectomy, 20 underwent two-level corpectomy, and two underwent three-level corpectomy, using an allograft, autograft, or both. Sixty-two of the fusions were instrumented using a plate and 13 had posterior augmentation. Fifty-seven patients had follow-up with imaging at four to 12 weeks following surgery, 54 with plain radiographs, two with CT scans, and one with an MRI scan. Unexpected findings were noted in six cases. One of those patients, found to have asymptomatic recurrent kyphosis following a two-level corpectomy, had repeat surgery because of those findings. Only one further patient was found to have abnormal imaging up to two years, and this patient required no further intervention., Conclusions: Routine imaging after ACCF can demonstrate asymptomatic occurrences of clinically significant instrument failure. In 43 consecutive single-level ACCF however, routine imaging did not change management, even when an abnormality was discovered. This may suggest a limited role for routine imaging after ACCF in longer constructs involving multiple levels.

Background: To date, the majority of studies on hyponatremia focussed on hyponatremia at admission, and came from developed countries. This study aimed to identify the prevalence of hyponatremia during hospitalization in patients hospitalized for HF and its association with in-hospital mortality., Methods: This was an observational study using retrospective data from patients' records between 2010-2013. It focused on those patients carrying an ICD-10 code of 150.0(Congestive Heart Failure) as their primary diagnosis. Hyponatremia during hospitalization was defined as serum sodium level lower than 135 mEq/L obtained from a blood chemistry measurement on the next days after admission. Patients' characteristics were examined and the association between hyponatremia during hospitalization and in-hospital mortality was analyzed., Results: Among 464 patients hospitalized for HF, hyponatremia during hospitalization was observed in 22 % of patients with 44 % of this group had normal serum sodium level on admission. Hyponatremia during hospitalization was associated with lower blood pressure on admission, both systolic and diastolic, peripheral oedema, ascites and fatigue. Patients having history of hospitalization for cardiac diseases and renal failure were higher in patients developing hyponatremia during hospitalization. In this group, amiodarone, heparin, insulin and antibiotics were administered more frequently. Factors potentially increase the risk of hyponatremia during hospitalization include history of fatigue (OR = 3.23, 95 % CI 1.79-5.82), presence of ascites (4.14, 1.84-9.31), and administration of heparin (3.85, 1.78-8.31) and antibiotics (3.08, 1.71-5.53). Length of hospital stay was significantly longer in patients with hyponatremia during hospitalization and in-hospital mortality was also higher compared to non-hyponatremic patients, 7.7 % and 29.1 %, respectively., Conclusion: This study found that the prevalence of hyponatremia during hospitalization in patients hospitalized for HF was almost the same as hyponatremia on admission and administration of heparin and antibiotics can potentially worsen hyponatremia during hospitalization. In this study population, hyponatremia during hospitalization was found to be associated with in-hospital mortality.

Aims: To determine the symptomatic and prognostic differences resulting from a novel diagnostic pathway based on cardiac computerized tomography (CT) compared with the traditional exercise stress electrocardiography test (EST) in stable chest pain patients., Methods and Results: A prospective randomized controlled trial compared selected patient outcomes in EST and cardiac CT coronary angiography groups. Five hundred patients with troponin-negative stable chest pain and without known coronary artery disease were recruited. Patients completed the Seattle Angina Questionnaires (SAQ) at baseline, 3, and 12 months to assess angina symptoms. Patients were also followed for management strategies and clinical events. Over the year 12 patients withdrew, resulting in 245 in the EST cohort and 243 in the CT cohort. There was no significant difference in baseline demographics. The CT arm had a statistical difference in angina stability and quality-of-life domains of the SAQ at 3 and12 months, suggesting less angina compared with the EST arm. In the CT arm, there was more significant disease identified and more revascularizations. Significantly, more inconclusive results were seen in the EST arm with a higher number of additional investigations ordered. There was also a longer mean time to management. There were no differences in major adverse cardiac events between the cohorts. At 1 year in the EST arm, there were more Accident and Emergency (A&E) attendances and cardiac admission., Conclusion: Cardiac CT as an index investigation for stable chest pain improved angina symptoms and resulted in fewer investigations and re-hospitalizations compared with EST., Clinical Trial Registration: http://www.controlled-trials.com/ISRCTN52480460., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Background: Review of recent journal articles and various relevant current textbooks provides strong evidence to show that anticholinergic burden is a material issue in frail and at-risk patients. This study assesses the anticholinergic burden in a group of patients in residential care facilities and then applies a theoretical intervention model. It is based on a scoring system known as the Anticholinergic Cognitive Burden (ACB) scale, and attempts to reduce the anticholinergic burden while maintaining therapeutic benefits., Methods: A database of 691 patients was analyzed for each individual's ACB based on the scale of scoring produced by groups of experts in the area. A theoretical intervention was then conducted using relevant, evidence-based practice guidelines for clinical therapeutics in Australia. The intervention had the aim of reducing the total ACB without affecting the apparent intended effectiveness of the prescribed therapy., Results: Of the 35% (n = 242) patients who score at least 1 point on the ACB, a reduction is achievable in 59% of the cases. In particular, the reduction from a clinically significant score of 3 or above to 2 or below for 49 of those patients is possible in 85% of the cases. Overall, this represents a reduction from 7.10% to 1.01% for the entire population. It is also found that of the 246,960 counts of items dispensed (both prescription and non-prescription) for these patients, 47,334 (or 19.2%) of these were of agents on the ACB scale., Conclusions: The study found that it appears to be possible that the total ACB of a group of 691 patients can be significantly reduced.

Postural orthostatic tachycardia syndrome (POTS) has been recognized since at least 1940. A review of the literature identifies differences in the definition for this condition and wide variations in treatment and outcomes. This syndrome appears to describe a group of conditions with differing pathophysiology, which requires treatment tailored to the true underlying disorder. Patients need to be fully evaluated to guide treatment. Further research is required to effectively classify the range of underlying pathophysiology that can produce this syndrome and to guide optimal management.

Introduction: Little research has been conducted analysing the organisational risks that compound and trigger dispensing and medication errors. This pilot study appraises the attitudes to and behaviours related to the dispensing errors of pharmacists practising in diverse venues and roles in inland Australia., Methods: Twelve pharmacists working in the Riverina (Wiradjuri country) participated in a structured interview consisting of a brief survey and open-ended questions. The interviews were audio-recorded for transcription, then analysed by the interviewer for emerging themes. In this pilot study, the attitudes and actions of pharmacists in response to dispensing errors were explored to determine the nature of organisational strategies implemented to detect and recover 'slips, lapses and mistakes'. The rationale behind investigating attitudes and actions stems from the theory of planned behaviour., Results: While many common themes emerged, the attitudes of each pharmacist were unique. The strategies implemented to prevent errors were venue-specific and purpose-designed to the training level of the staff and physical environment. A diverse mix of attitudes was represented by the sample, with no correlation between worksite, sex, age or role identified. Trends may emerge because, in regard to dispensing errors, subjective norms and perceived behavioural control play a greater role in forming the intention to act, rather than personal attitudes. The majority of examples given by participants was discussion of recorded errors and near misses, which included changes to procedures implemented to prevent the same error occurring. This culture of continuous quality improvement was the overarching common theme. Other common themes were the role of technology in the supply of medicines, privacy implications when drawing staff from a rural or regional centre, workload concerns with regard to management responsibility and the impact of the way error management was demonstrated during the formative early years of practice. Distraction from dispensing, through management roles in pharmacies with moderate prescription volumes, was a common contributor to errors., Conclusion: A culture of continuous quality improvement exists amongst pharmacists in Inland Australia, which would benefit from improved dialogue about the impact of organisational risks on the rate of dispensing errors. The safety culture, and behaviour modelling experienced during the internship program has a profound impact on the perceived behavioural control of young pharmacists. This year instils mores, which may be the result of independent survival in remote and regional settings, rather than compliance with professional practice standards. While many of the pressures and demands of minimising errors are common across the profession; unique, venue specific strategies are commonly implemented in the cycle of continuous quality improvement in regional and remote settings.

Background: The male-specific region of the mouse Y chromosome long arm (MSYq) is comprised largely of repeated DNA, including multiple copies of the spermatid-expressed Ssty gene family. Large deletions of MSYq are associated with sperm head defects for which Ssty deficiency has been presumed to be responsible., Results: In a search for further candidate genes associated with these defects we analyzed changes in the testis transcriptome resulting from MSYq deletions, using testis cDNA microarrays. This approach, aided by accumulating mouse MSYq sequence information, identified transcripts derived from two further spermatid-expressed multicopy MSYq gene families; like Ssty, each of these new MSYq gene families has multicopy relatives on the X chromosome. The Sly family encodes a protein with homology to the chromatin-associated proteins XLR and XMR that are encoded by the X chromosomal relatives. The second MSYq gene family was identified because the transcripts hybridized to a microarrayed X chromosome-encoded testis cDNA. The X loci ('Astx') encoding this cDNA had 92-94% sequence identity to over 100 putative Y loci ('Asty') across exons and introns; only low level Asty transcription was detected. More strongly transcribed recombinant loci were identified that included Asty exons 2-4 preceded by Ssty1 exons 1, 2 and part of exon 3. Transcription from the Ssty1 promotor generated spermatid-specific transcripts that, in addition to the variable inclusion of Ssty1 and Asty exons, included additional exons because of the serendipitous presence of splice sites further downstream., Conclusion: We identified further MSYq-encoded transcripts expressed in spermatids and deriving from multicopy Y genes, deficiency of which may underlie the defects in sperm development associated with MSYq deletions.

Nucleus pulposus herniations are far less common in the thoracic spine than at the cervical and lumbar regions. Traditionally, diagnosis of thoracic disc herniations has been challenging because the signs and symptoms are often subtle early in their course. As a result, delays in diagnoses are common. Because they are uncommon as well as difficult to diagnosis, the neurosurgical community has sparse data on which to base good clinical decision making for the treatment of these herniations. In this review the authors seek to place the phenomenon of thoracic disc disease into the context of its pathophysiology. After a careful evaluation of the available clinical, pathological, and basic science data, a case is made that the cause of nucleus pulposus herniations in the thoracic spine is similar to those occurring in the lumbar and cervical regions. The lower incidence of herniations is ascribed primarily to the reduced allowable flexion at the thoracic level compared with the lumbar and cervical levels. To a lesser extent, the contribution of the ribs to weight-bearing may also play a role. Further review of clinical data suggests that thoracic disc herniations, like herniated cervical and lumbar discs, may be asymptomatic and may respond to conservative therapy. Similarly, good surgery-related results have been reported for herniated thoracic discs, despite the more challenging nature of the surgical procedure. The authors conclude that treatment strategies for thoracic disc herniations may logically and appropriately follow those commonly used for the cervical and lumbar levels.

BACKGROUND: In order to determine the type and incidence of pulmonary complications associated with the placement of narrow-bore enteral feeding tubes we conducted a prospective, descriptive study in the multidisciplinary intensive care unit (ICU) of a university hospital. All patients that had narrow-bore enteral feeding tubes inserted over a 2-year period (1993-1995) were included. The study required no clinical interventions. RESULTS: Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram. CONCLUSIONS: Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.

A microcomputer program has been designed to provide comprehensive assistance to the clinician in prescribing parenteral nutrition in children of all ages. It is implemented on a fully portable, independent machine that can be taken to the bedside anywhere in the hospital. The user is guided through a standardised prescribing process based on a well tried protocol and taking into account the patient's age, clinical condition, concurrent parenteral infusions, laboratory findings, and enteral intake. A printout is produced for insertion into the patient's clinical record, giving all concerned in the care of the child a clear, legible record of when, how, and by whom the prescription was calculated. The user can review and amend the proposed prescription before printing, giving ultimate control to the prescriber, not the computer. The system saves time by performing accurately the necessary calculations, and provides financial savings by reducing wastage of parenteral nutrition during the re-introduction of enteral feeding.

A nitrogen source based on egg protein (Vamin 9 glucose) and an alternative with an amino acid profile more similar to breast milk (Vaminolact), were compared in 14 parenterally fed infants. Subjects were randomly allocated to receive one or other amino acid solution, but were otherwise given identical diets. At the start of the study the two groups did not differ significantly in postconceptual age, postnatal age, or weight. Over a six day study period on a stable intake of intravenous nutrients there was no significant difference in growth or nitrogen retention between the two groups. Plasma amino acid profiles in those receiving Vamin 9 glucose, however, were frequently abnormal. Notably, mean concentrations of potentially neurotoxic phenylalanine and tyrosine were significantly higher (140% and 420%, respectively) in patients fed Vamin 9 compared with those given Vaminolact. An amino acid solution based on the composition of breast milk protein therefore brings plasma amino acid profiles during parenteral nutrition closer to those found in breast fed infants, and reduces in particular, the risks of hyperphenylalaninaemia and hypertyrosinaemia.

Immediate and delayed skin reactions to antigens derived from Ascaris suum, Necator americanus, and Toxocara canis are described in three subjects and related to eosinophil counts and serum IgE levels. One, who had laboratory contact with ascarides but no known infection, gave positive immediate reactions to all three antigens. Another, following repeated experimental infection with necator, gave positive immediate reactions to all three antigens and a delayed reaction to necator alone. The third, following a single recent infection with necator, gave no immediate or delayed reaction.

Two sisters had primary biliary disease and associated autoimmune thyroiditis with high titres of mitochondrial and other autoantibodies. Their deceased mother possibly suffered from similar disorders. In the same family two brothers had multiple autoimmune reactions, including mitochondrial antibodies, but liver function tests gave normal results. Ten other close relatives were investigated. Australia antigen was not found in the proband or her relatives.