A hospital is not the best place to get a good night
It appears that sugar really may help the medicine go down – studies suggest a few drops can comfort babies who are having their jabs. The Cochrane team reviewed 14 studies involving more than 1,500 infants going for routine childhood immunisations or a heel-prick blood test.
Babies given a sugary solution to suck as they were about to be injected cried far less than those given water. While sugar may pacify, it is unclear if it also relieves pain.
Experts say more research is needed to explore this.
A small study published a couple of years ago in The Lancet medical journal looked at the responses of 44 infants given either sugar or water as they had a heel-prick blood test. The sugar did not appear to make a difference to pain – all babies similarly grimaced and had comparable electrical activity measured with EEG readings in areas of the brain that process pain.
The lead researcher in the Cochrane review, Dr Manal Kassab of the Jordan University of Science and Technology in Irib, Jordan, said: ‘Giving babies something sweet to taste before injections may stop them from crying for as long.
‘Although we can’t confidently say that sugary solutions reduce needle pain, these results do look promising.’
Dr David Elliman of the Royal College of Paediatrics and Child Health said sugar solution was not used routinely in practice.
‘Generally, doctors recommend that the mother holds the baby and comforts it while they have their immunisation. If she is breastfeeding still, she might want to breastfeed her baby at the same time.
‘With older children we try to distract them. If you do the usual holding and comforting, I’m not sure how much sucrose would add.
‘What we do know is that using a shorter needle tends to be more painful, even though this might seem counterintuitive. That’s because the injections need to go into the muscle.’
By the time a child has reached its second birthday it should have had around 10 different injections to protect against various infectious diseases, including measles, mumps and rubella.
BBC
In one of the largest observational studies of its kind, researchers report that a combination of chemotherapy and radiation followed by surgery in patients with stage 3 non-small cell lung cancer improves survival.
Patients who had chemoradiation therapy followed by surgery had twice the five-year survival rate of those who had only chemoradiation, says Dr. Matthew Koshy, a radiation oncologist at the University of Illinois Hospital & Health Sciences System and lead author of the study.
The study looked at various treatment strategies in an effort to identify the best option for overall survival. The researchers used the National Cancer Database to identify 11,242 adult patients ages 19 and older who were treated for stage 3 non-small cell lung cancer between 1998 and 2004.
Treatment strategies used against this form of lung cancer include chemoradiation therapy; chemoradiation followed by surgery; and surgery followed by chemoradiation.
‘The role of chemoradiation therapy followed by surgery is somewhat controversial, because previous clinical studies have not shown a clear survival benefit,’ said Koshy, who noted that the practice of using chemotherapy and radiation to reduce the extent of cancer prior to surgery was begun in an effort to improve poor survival rates in this group of patients.
Dr. Matthew Koshy, radiation oncologist, University of Illinois Hospital & Health Sciences System
The new study found that five-year overall survival was 34 percent for patients who received chemoradiation therapy followed by surgery to remove a lobe of the lung, 20 percent for patients who had the surgery followed by the adjuvant therapy, and 13 percent for patients who received chemoradiation therapy but no surgery.
The researchers say that additional prospective studies are needed to confirm the benefit of chemoradiation prior to surgery and define the standard of care for patients with stage 3 non-small cell lung cancer.
‘The main message to patients,’ Koshy said, ‘is to seek care from a multidisciplinary group of physicians that includes a thoracic surgeon, medical oncologist and radiation oncologist who can work together to determine the most appropriate initial treatment strategy.’ The University of Illinois Hospital & Health Sciences System
Very low birth weight infants, those weighing less than 3.25 pounds, account for half of infant deaths in the United States each year, yet a new study released documents that these critically ill infants do not receive optimal nursing care, which can lead to hospital-acquired infections that double their death rate and may result in long-term developmental issues affecting the quality of their lives as adults.
These vulnerable infants are the highest risk pediatric patients in hospitals and account for half of all infant deaths in the country each year. These hospital-acquired infections afflicted 13.9 percent of these frail infants in 2009, the last year reported in the study.
The lead authors, based at the University of Medicine and Dentistry of New Jersey- School of Public Health and the University of Pennsylvania School of Nursing, studied very low birth weight infants cared for in 67 Neonatal Intensive Care Units (NICU).
‘One-third of NICU infants were understaffed, according to current guidelines. Understaffing varies further across acuity levels with the greatest fraction of understaffed infants (92 percent) requiring the most complex critical care, translating into a needed 25% increase in the numbers of nurses,’ wrote co-principal investigators Jeannette A. Rogowski, PhD, the University Professor in Health Economics at the UMDNJ-School of Public Health and Eileen T. Lake, PHD, RN, FAAN, associate director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
The researchers noted that infection caused four to seven days of longer hospitalisation with associated increased costs, notably to Medicaid. ‘Under recent changes in Medicaid policy, hospitals will no longer be reimbursed for the costs associated with these infections,’ said Lake. ‘Sadly, because Medicaid is the largest payer for premature newborns, the additional costs may lead hospitals to further cut the nursing staff, leading to a cycle of infection and mortality that could impact even more of these fragile infants.’
‘These are the first data that demonstrate the extent of adherence to national staffing guidelines and the shortfall is dramatic,’ said Rogowski. ‘Fewer nursing hours could lead to less time devoted to cleaning and maintaining intravenous catheters used to deliver medications thus leading to the higher rates of infection.’ University of Pennsylvania School of Nursing
Despite receiving blood thinners and other clot prevention treatment, some patients still develop potentially lethal blood clots in the first month after their operations anyway, especially if they developed a surgical-site infection while in the hospital, according to results of a study at Johns Hopkins.
The research found that patients who experience a surgical-site infection after their abdominal surgery are four times more likely than infection-free patients to develop a deep-vein thrombosis (DVT) in the legs, or its more deadly cousin, a pulmonary embolism (PE) in the lungs. While only 4 percent of patients developed a DVT, 92 percent of those who did had received prophylaxis that previous research has shown is the best practice for prevention.
‘We need heightened awareness about the potential for venous thromboembolism (VTE) in patients with surgical-site infections,’ says study leader Susan L. Gearhart, M.D., an associate professor of surgery at the Johns Hopkins University School of Medicine. ‘We need to think beyond the prophylaxis we are already giving these patients. We need to think smarter.’
Nearly all surgical patients at The Johns Hopkins Hospital are routinely given proven treatments to prevent VTEs, usually the regular administration of low-dose blood thinners and the use of compression devices to keep blood flowing in the legs. Typically the treatments cease when people are discharged from the hospital.
Gearhart notes that much work in hospitals has gone into ensuring compliance with prophylaxis measures, including automated checklists to remind health care workers of their importance. VTEs are considered a form of preventable harm, and the Centers for Medicare & Medicaid Services may penalise hospitals where patients develop clots after some orthopedic procedures. But this new study shows that even when hospitals comply with prevention guidelines, VTEs can still occur.
For their study, Gearhart and her colleagues reviewed the records of 615 adults who underwent colorectal surgery at The Johns Hopkins Hospital between July 2009 and July 2011. Twenty-five (4.1 percent) developed VTE. Among patients who experienced a VTE, 92 percent had been given risk-appropriate VTE prophylaxis.
What was even more interesting to Gearhart, she says, was that 14 of the 25 patients with VTE (56 percent) also developed postoperative infections compared with 168 patients (28.5 percent) without VTE. The infectious complications in nine of the 14 patients (64.3 percent) occurred prior to or on the same day as the VTE. She says she had never before seen a link between infections and VTE in surgical patients.
One theory for the apparent link is that an increase of inflammatory protein molecules that accompanies an infection affects the functioning of platelets in the blood, which could increase the risk of thrombosis. Platelets are the sticky cells that facilitate clot formation in the blood.
Gearhart says it may be time to conduct more intense monitoring of colorectal surgery patients who develop surgical-site infections, and consider frequent screening for clots in those with infections. Such screening can be done with ultrasound equipment. She also suggests such patients be kept on blood thinners for 30 days after surgery regardless of when they are discharged.
Johns Hopkins Medicine
Immobile patients are in constant danger of developing pressure ulcers on the skin. Empa, Schoeller Medical and the Swiss Paraplegic Centre have worked together to develop a special sheet that is gentle on the skin and helps to make patients more comfortable.
The skin is the most versatile of our organs: It protects the body from environmental effects, contributes to the body
Nanodiamonds bound to the chemotherapy drug epirubicin are enclosed within a lipid membrane and coupled to antibodies specific to hard-to-treat tumors.
Recently, doctors have begun to categorise breast cancers into four main groups according to the genetic makeup of the cancer cells. Which category a cancer falls into generally determines the best method of treatment.
But cancers in one of the four groups
A team of researchers from Johns Hopkins Children
Blind mice can see again, after Oxford University researchers transplanted developing cells into their eyes and found they could re-form the entire light-sensitive layer of the retina.
The researchers say the approach has relevance for treating patients with retinitis pigmentosa, a condition in which the light-sensing cells in the retina gradually die leading to progressive blindness.
The study was led by Professor Robert MacLaren in the Nuffield Department of Clinical Neurosciences at the University of Oxford, together with Dr Mandeep Singh, an eye surgeon from the National University Hospital of Singapore who is currently undertaking PhD studies in Oxford
The researchers worked with mice that are blind due to complete loss of the light-sensing photoreceptor cells in their retinas. This is the most relevant mouse model for treating patients who are blind from retinitis pigmentosa.
After two weeks, the researchers showed the cells transplanted into the eye had re-formed a full light-detecting layer on the retina and the mice could see.
The cells used were mouse ‘precursor’ cells that are on an initial path towards developing into retinal cells.
A pupil constriction test showed that, of the 12 mice that received the cell transplant, 10 showed improved pupil constriction in response to light. This shows that the retinas of the mice were sensing the light once more, and this was being transmitted down the optic nerve to the brain.
Dr Singh says: ‘We found that if enough cells are transplanted together, they not only become light sensing but they also regenerate the connections required for meaningful vision.’
Dr Mandeep Singh Professor MacLaren explains: ‘Stem cells have been trialled in patients to replace the pigmented lining of the retina, but this new research shows that the light-sensing layer might also be replaced in a similar way. The light-sensing cells have a highly complex structure and we observed that they can resume function as a layer and restore connections after transplantation into the completely blind retina.’
In looking forward towards potential cell treatments for blindness in humans, Professor MacLaren explains that they would like to use induced pluripotent stem cells, or iPS cells. These are stem cells that have been generated from the patient
Researchers at the University of Virginia (UVA) Health System recommend radiosurgery for treating unruptured arteriovenous malformations (AVMs), because the procedure has a reasonable benefit-to-risk profile. They base this recommendation on an evaluation of clinical and radiographic outcomes in 444 patients treated with radiosurgery for unruptured AVMs at their institution.
Arteriovenous malformations are vascular anomalies in which arteries feed directly into veins, bypassing the capillary system, which provides nutrients to tissues, clears waste products, and decreases the pressure of blood as it moves from arteries to veins. Usually congenital, AVMs occur in approximately 1 in 100,000 persons and present equally in both sexes. Most people with AVMs in the brain live full lives with no knowledge of ever having the anomaly; sometimes the lesions are identified during workup for another disorder. Other patients experience symptoms such as headaches, seizures, and neurological deficits. Patients who do experience symptoms often do so by the time they are in their thirties. Occasionally, AVMs rupture due to increased blood pressure and damage to the walls of the vessels involved. Past medical studies show the annual risk of AVM haemorrhage to be 2 to 4 percent.
In the present study, the UVA researchers reviewed a database of 1204 cases of AVMs that were treated by radiosurgery with a Gamma Knife between 1989 and 2009. The researchers focused on 444 patients whose AVMs were unruptured at the time of radiosurgery and who participated in follow-up for at least 2 years (less if there was early proof that radiosurgery had obliterated the AVM). The patients’ mean age was 36.9 years; 11% of patients were younger than 18 years at the time of radiosurgery. The patient cohort was evenly split between the sexes. The authors report that the mean size of the AVM nidus was 4.2 cubic centimetres (approximately 2 centimetres in diameter). Nearly 14 percent of the AVMs were located deep within the brain. Twelve percent of patients presented with neurological deficits, 28 percent with headaches, and 47 percent with seizures.
The median dose of radiation directed to the edge of the AVM during radiosurgery was 20 Gray and the median maximum dose was 40 Gray. Sixty-four patients underwent radiosurgery as a repeat procedure. Univariate and multivariate Cox regression analyses were performed to identify the effects of various factors on AVM obliteration and determine risk factors associated with radiosurgery.
The researchers state that 62 percent of unruptured AVMs in this patient cohort were obliterated by radiosurgery. Their analyses showed that a higher prescribed radiation dose, a single draining vein, radiation-induced changes apparent on neuroimages, a lower Spetzler-Martin AVM grade, and no earlier embolisation procedure performed to treat the AVM were statistically significant positive predictors of AVM obliteration. Following radiosurgery, the annual haemorrhage rate was 1.6 percent, which is equivalent to or may be slightly better than the 2 to 4 percent estimated for unruptured AVMs left untreated. Once an AVM has been obliterated, however, there is no longer a risk of haemorrhage.
In comparison with the patients’ pre-radiosurgery neurological symptoms, 7 percent of patients showed improvement, 7 percent were worse, and 86 percent were unchanged. The authors state, ‘the risks associated with stereotactic radiosurgery were temporary; those risks that were permanent were typically not debilitating for the patient.’ Statistical analysis showed that worsening of clinical conditions was significantly more common in patients who experienced haemorrhage after radiosurgery.
Patients generally present with unruptured AVMs when they are young. Without treatment, they must face many years at risk for haemorrhage, which can cause neurological impairment and even death. The authors believe that treatment of an AVM is indicated for these younger patients as well as for patients with large AVMs and those with worse radiosurgery-based AVM scores. Treatment of an AVM with the Gamma Knife appears warranted in most patients, even if the AVM has not previously ruptured. These researchers recommend radiosurgery as the means of treatment because of its ‘reasonable chance of obliteration of unruptured AVMs with relatively low rates of clinical and radiological complications.’
When asked for the take-home message of the study, the senior author, Dr. Jason Sheehan, said, ‘The essence of this study is that unruptured AVMs can rupture, and rupture has significant morbidity or even mortality. Gamma Knife radiosurgery yielded obliteration in the majority of unruptured AVMs. Obliterated AVMs do not rupture. The overall surgical risks of Gamma Knife radiosurgery in unruptured AVMs seem lower than those in the natural history of an AVM if left untreated, even if the AVM has not previously ruptured.’
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