Use of ultrasound guidance improves central venous catheter insertion success rates among junior residents.

OBJECTIVES: The purpose of this study was to determine whether junior residents had higher rates of first cannulation and overall success at central venous catheter insertions with the use of ultrasound (US) guidance compared to the landmark technique. METHODS: We conducted a secondary analysis of data from a prospective randomized controlled study of junior residents from January 2007 through September 2008, which assessed the impact of simulation training on central venous catheter insertion success rates. Blinded independent raters observed in-hospital central venous catheter insertions using a procedural checklist. Success at first cannulation and successful insertion were the primary outcomes. Secondary outcomes included rates of technical errors and mechanical complications. RESULTS: Independent raters observed 480 central venous catheter insertions by 115 residents. Successful first cannulation occurred in 27% of landmark compared to 49% of dynamic US-guided (P < .01), and 50% of static US-guided (P = .01) cannulations. Insertion success occurred for 55% of landmark compared to 80% of dynamic US-guided (P < .01) and 80% of static US-guided (P < .01) cannulations. Dynamic US guidance was associated with increased odds of first cannulation success compared to the landmark technique (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.37-3.67) and successful insertion (OR, 3.80; 95% CI, 2.34-6.19). Static US guidance was associated with increased odds of first cannulation success compared to the landmark technique (OR, 2.59; 95% CI, 1.25-5.39) and successful insertion (OR, 3.48; 95% CI, 1.54-7.87). The results were independent of central venous catheter insertion training, patient comorbidities, and resident specialties. There was no difference related to mechanical complications between the procedures. CONCLUSIONS: Dynamic and static US guidance during central venous catheter insertion was associated with improved in-hospital first cannulation rates and overall success rates of insertions by junior residents.

Reactivation of a silenced H19 gene in human rhabdomyosarcoma by demethylation of DNA but not by histone hyperacetylation.

BACKGROUND: The active copy of the imprinted gene H19 is turned off by inappropriate methylation in several pediatric tumors including Wilms' Tumour and embryonal rhabdomyosarcoma. H19 controls in cis the linked Insulin-like Growth Factor 2 (IGF2) gene, encoding an important growth factor. Recent work has suggested that methylation of a gene may lead to deacetylation of its associated histones and that silenced genes can be reactivated by increasing histone acetylation levels. RESULTS: Treatment of a rhabdomyosarcoma cell line which has a silent, methylated H19 gene with histone deacetylase (HDAC) inhibitors under conditions which gave maximal hyperacetylation of histone 4, both globally and at the H19 gene itself could not reactivate H19 or affect the active Insulin-like Growth Factor 2 (IGF2) gene, but caused clear up-regulation of the Tissue-type Plasminogen Activator (TPA) gene, a non-imprinted gene known to respond to changes in histone acetylation. In contrast, mild treatment of the cells with the methylation inhibitor 5-AzaC-2'-deoxycytidine (AzaC) on its own was able to reactivate H19. Combining AzaC treatment with HDAC inhibitors gave a reduced rather than enhanced reactivation. These findings were confirmed in mouse primary liver and kidney explants which maintain normal imprinting, where we also found that the silent Igf2 gene could not be reactivated by HDAC inhibitors. CONCLUSION: These results suggest that DNA methylation rather than histone acetylation is the primary determinant of silencing of H19 in rhabdomyosarcoma.

Acute myocardial infarction in sub-Saharan Africa: the need for data.

BACKGROUND: Trends in the prevalence of acute myocardial infarction in sub-Saharan Africa have not been well described, despite growing recognition of the increasing burden of cardiovascular disease in low- and middle-income countries. The aim of this systematic review was to describe the prevalence of acute myocardial infarction in sub-Saharan Africa. METHODS: We searched PubMed, EMBASE, Global Health Archive, CINAHL, and Web of Science, and conducted reference and citation analyses. Inclusion criteria were: observational studies, studies that reported incidence or prevalence of acute myocardial infarction, studies conducted in sub-Saharan Africa, and studies that defined acute myocardial infarction by EKG changes or elevation of cardiac biomarkers. Studies conducted prior to 1992 were excluded. Two independent reviewers analyzed titles and abstracts, full-texts, and references and citations. These reviewers also performed quality assessment and data extraction. Quality assessment was conducted with a validated scale for observational studies. FINDINGS: Of 2292 records retrieved, seven studies met all inclusion criteria. These studies included a total of 92,378 participants from highly heterogeneous study populations in five different countries. Methodological quality assessment demonstrated scores ranging from 3 to 7 points (on an 8-point scale). Prevalence of acute myocardial infarction ranged from 0.1 to 10.4% among the included studies. INTERPRETATION: There is insufficient population-based data describing the prevalence of acute myocardial infarction in sub-Saharan Africa. Well-designed registries and surveillance studies that capture the broad and diverse population with acute myocardial infarction in sub-Saharan Africa using common diagnostic criteria are critical in order to guide prevention and treatment strategies. REGISTRATION: Registered in International Prospective Register of Systematic Reviews (PROSPERO) Database #CRD42012003161.

Positive outcome after intentional overdose of dabigatran.

INTRODUCTION: Dabigatran (Pradaxa™), an orally active direct thrombin inhibitor, was approved by the United States Food and Drug Administration for the prevention of stroke in patients with atrial fibrillation in October 2010. Life-threatening consequences from dabigatran therapy include hemorrhage and bleeding complications, but they typically occur after renal impairment. We describe the first case report of intentional, acute overdose with dabigatran. CASE REPORT: A 57-year-old woman with a medical history of depression and atrial fibrillation presented to the emergency department after ingesting 11.25 g of dabigatran in a suicide attempt. Despite an ecchymosis indicative of prior trauma, there was no evidence of acute bleeding. After receiving gastric lavage and activated charcoal therapy in the emergency department, she was admitted to the ICU. On presentation, dabigatran blood levels measured 970 ng/mL and thrombin clot times measured above the testable limits (>120 s) until 52 h post-arrival. The remainder of her clinical course was uncomplicated, and the patient was transferred to an inpatient psychiatric unit for depression follow-up. DISCUSSION: This case shows the clinical course of a patient with an acute, massive dabigatran overdose with no significant clinical consequences. Currently, there is no ideal method to monitor anticoagulation levels; there is no pharmacologic reversal method, and hemodialysis is an undesirable treatment option.

Under reporting of road traffic injuries in the district of Kandy, Sri Lanka.

OBJECTIVES: To conduct a community survey to estimate the degree to which road traffic injuries (RTIs) are under reported and to compare the characteristics of RTI reported to the police to those not reported. DESIGN: A cross-sectional population-based study. SETTING: Kandy district, Sri Lanka. PARTICIPANTS: RTIs and deaths during the preceding 12 months were identified through a community-based cross-sectional survey with a sample size of 3080 households. A stratified multistage cluster sampling with population proportion to size was used. 'Events reported' to the police were cross checked against events in the police records of the given or adjacent police stations, and either were 'Events found' or 'Not found'. 'Under reported' included those 'Not reported' and those reported but 'Not found' in the police dataset. RESULTS: Information about 11 724 persons were obtained from 3080 households, identifying 149 persons who suffered an RTI. Of these, 57% were 'Events reported', and of these 43.6% (n=65) were 'Events found' in police records (95% CI, 36.0 to 51.6). There were 42 events 'Not reported' to police while an additional 7 were 'Not found' in the police records of the given police station. Although they were claimed to have been reported to the police, 33% (95% CI 25.8 to 40.7) were 'Under reported'. There were significant differences in age (p=0.02), family income (p<0.001), road user type (p=0.001), injury severity (p<0.001) and injury category (p=0.01) between 'Events found' in the police records and 'Under reported' events. CONCLUSIONS: In the Kandy district, 33% of RTIs were 'under reported'. These findings could be used as evidence for policy planning to prevent RTIs, and highlights the need for a nation-wide community-based survey to determine the true rates of RTI for a better understanding of the reasons for under reporting.

Evidence-based community consultation for traumatic brain injury.

OBJECTIVES: The objective was to determine if geospatial techniques can be used to inform targeted community consultation (CC) and public disclosure (PD) for a clinical trial requiring emergency exception from informed consent (EFIC). METHODS: Data from January 2007 to December 2009 were extracted from a Level I trauma center's trauma database using the National Trauma Registry of the American College of Surgeon (NTRACS). Injury details, demographics, geographic codes, and clinical data necessary to match core elements of the clinical trial inclusion criteria (Glasgow Coma Scale [GCS] 3-12 and blunt head injury) were collected on all patients. Patients' home zip codes were geocoded to compare with population density and clustering analysis. RESULTS: Over a 2-year period, 179 patients presented with moderate to severe traumatic brain injury (TBI). Mapping the rate and frequency of TBI patients presenting to the trauma center delineated at-risk populations for moderate to severe head injury. Four zip codes had higher incidences of TBI than the rest, with one zip code having a very high rate of 80 per 100,000 population. CONCLUSIONS: Geospatial techniques and hospital data records can be used to characterize potential subjects and delineate a high-risk population to inform directed CC and public disclosure strategies.

Characteristic of victims of family violence seeking care at health centers in Maputo, Mozambique.

BACKGROUND: Family violence (FV) is a common, yet often invisible, cause of violence. To date, most literature on risk factors for family, interpersonal and sexual violence is from high-income countries and might not apply to Mozambique. AIMS: To determine the individual risk factors for FV in a cohort of patients seeking care for injuries at three health centers in Maputo, Mozambique. SETTING AND DESIGN: A prospective multi-center study of patients presenting to the emergency department for injuries from violence inflicted by a direct family member in Maputo, Mozambique, was carried out. MATERIALS AND METHODS: Patients who agreed to participate and signed the informed consent were verbally administered a pilot-tested blank-item questionnaire to ascertain demographic information, perpetrator of the violence, historical information regarding prior abuse, and information on who accompanied the victim and where they received their initial evaluation. De-identified data were entered into SPSS 13.0 (SPSS, version 13.0) and analyzed for frequencies. RESULTS: During the 8-week study period, 1206 assault victims presented for care, of whom 216 disclosed the relationship of the assailant, including 92 being victims of FV (42.6%). The majority of FV victims were women (63.0%) of age group 15-34 years (76.1%) and were less educated (84%) compared to national averages. Of the patients who reported assault on a single occasion, most were single (58.8%), while patients with multiple assaults were mostly married (63.2%). Most commonly, the spouse was the aggressor (50%) and a relative accompanied the victim seeking care (54.3%). Women most commonly sought police intervention prior to care (63.2%) in comparison to men (35.3%). CONCLUSION: In Mozambique, FV affects all ages, sexes and cultures, but victims seeking care for FV were more commonly women who were less educated and poorer.

Treatment, Services and Follow-up for Victims of Family Violence in Health Clinics in Maputo, Mozambique.

BACKGROUND: Family violence (FV) is a global health problem that not only impacts the victim, but the family unit, local community and society at large. OBJECTIVE: To quantitatively and qualitatively evaluate the treatment and follow up provided to victims of violence amongst immediate and extended family units who presented to three health centers in Mozambique for care following violence. METHODS: We conducted a verbally-administered survey to self-disclosed victims of FV who presented to one of three health units, each at a different level of service, in Mozambique for treatment of their injuries. Data were entered into SPSS (SPSS, version 13.0) and analyzed for frequencies. Qualitative short answer data were transcribed during the interview, coded and analyzed prior to translation by the principal investigator. RESULTS: One thousand two hundred and six assault victims presented for care during the eight-week study period, of which 216 disclosed the relationship of the assailant, including 92 who were victims of FV. Almost all patients (90%) waited less than one hour to be seen, with most patients (67%) waiting less than 30 minutes. Most patients did not require laboratory or radiographic diagnostics at the primary (70%) and secondary (93%) health facilities, while 44% of patients received a radiograph at the tertiary care center. Among all three hospitals, only 10% were transferred to a higher level of care, 14% were not given any form of follow up or referral information, while 13% required a specialist evaluation. No victims were referred for psychological follow-up or support. Qualitative data revealed that some patients did not disclose violence as the etiology, because they believed the physician was unable to address or treat the violence-related issues and/or had limited time to discuss. CONCLUSION: Healthcare services for treating the physical injuries of victims of FV were timely and rarely required advanced levels of medical care, but there were no psychological services or follow-up referrals for violence victims. The healthcare environment at all three surveyed health centers in Mozambique does not encourage disclosure or self-report of FV. Policies and strategies need to be implemented to encourage patient disclosure of FV and provide more health system-initiated victim resources.