Chronic Gestational Inflammation: Transfer of Maternal Adaptation over Two Generations of Progeny.

Changes in the in utero environment result in generational transfer of maladapted physiology in the context of conditions such as stress, obesity, and anxiety. Given the significant contribution of noncommunicable diseases-which are characterised by chronic inflammation-to population mortality, the potential for chronic maternal inflammation mediating foetal programming is a growing concern. The extent of generational transfer in terms of immune functionality and leukocyte glucocorticoid sensitivity was investigated over two generations of offspring (F1 and F2) in a model of chronic LPS-induced maternal inflammation in C57/BL/6 mice. Maternal inflammation resulted in glucocorticoid hypersensitivity (increased glucocorticoid receptor expression levels) in the majority of leukocyte subpopulations in both F1 and F2 offspring. Furthermore, splenocytes stimulated with LPS in vitro exhibited exacerbated inflammatory cytokine responses, which were even more prominent in F2 than F1; this effect could be ascribed to NLRP3 inflammasome hyperactivity in F1 but not F2. Current data illustrates that parental chronic inflammation may mediate the inflammatory profile in offspring, potentially propagating a maladapted proinflammatory phenotype in subsequent generations.

Clinical usefulness of polymorphonuclear leukocyte vacuolization in predicting septicemia in febrile children.

Vacuolization of the polymorphonuclear leukocyte (PMN) has generally been regarded as an indication of bacterial infection and has been particularly useful in diagnosing septicemia. In an effort to predict septicemia, peripheral blood smears from 69 febrile children were examined and systematically scored for severity of vacuolization. Thirteen children had remarkable vacuolization compared to the others. These 13 included only five children with bacterial illnesses and only one of the seven children with septicemia. Our finding that PMN vacuolization was neither diagnostic of septicemia nor predictive of bacterial infection suggests that the specificity of the link between vacuoles and bacteremia needs to be reassessed.

Decision-making for a successful bowel continence program.

Bowel continence is one of the most difficult challenges for patients with spina bifida. Incontinence acts as a social stigma for children and a barrier for adults seeking employment. We present an algorithm for stepwise decision-making in construction of personalized continence programs for greater likelihood of success. The protocol contains 13 assessment points including; stool consistency, frequency and amount; mobility; level of paraplegia: diet; medication; anal/rectal canal tone; prior programs attempted; family routines; age; accessibility; and learning issues. Based on outcomes of these assessments, an individualized bowel program is constructed. The algorithm helps the practitioner and patient decide on components and indicators of a successful continence program. The recommended program might include timed toileting, suppository, continence enema, and ACE procedure, or a combination. Evaluation and patient education address adequate fluid/fiber, appropriate toileting equipment, and use of stool softeners/laxatives. Descriptions are available. Key elements in monitoring a continuing plan for continence include: the degree of constipation and its etiology; changing age; family availability for assistance until interdependence is optimal; wheelchair accessibility of the toilet; and ability to transfer to and from the toilet. Use of the algorithm allows for careful decision-making based on information from the patient and family. This has led to greater success in bowel continence in children with spina bifida.

Autologous TMJ disk replacement.

Several techniques have been advocated for replacement of displaced or diseased temporomandibular joint disks. Techniques are reviewed and the author's experience in managing this complex problem is presented.

Regulation of the tension of human chorionic vasculature by histamine and prostaglandin F2 alpha.

The calcium dependence of potassium chloride-, prostaglandin F2 alpha (PGF2 alpha)-, and histamine-induced contractions of human chorionic vasculature segments was investigated. In physiologic buffer that contained 1.5 mM calcium chloride, 60 mM potassium chloride induced a rapid and sustained contraction of the vasculature. Potassium chloride-induced contractions were completely inhibited by the calcium channel blockers diltiazem and nifedipine or by excluding Ca2+ from the medium. Histamine (100 microM) induced a rapid increase in vascular tension in physiologic buffer which rapidly faded or desensitized after maximal tension was obtained. The maximal contractile responses to histamine were reduced approximately 50% by diltiazem and nifedipine in physiologic buffer or by suspension in calcium-free medium (OCaPB). Pretreatment of vessels with 20 mM caffeine in OCaPB completely abolished histamine-dependent contractile responses. Prostaglandin F2 alpha (100 nM)-induced increases in vascular tension developed slowly but remained maximal for at least 40 minutes. Contractile responses to PGF2 alpha were reduced 50% to 65% by diltiazem and nifedipine in physiologic buffer or by suspension in OCaPB. Caffeine pretreatment failed to alter the contractile response to PGF2 alpha in OCaPB. The differences in responsiveness of potassium chloride, histamine, and PGF2 alpha under the various conditions used suggest that these agents act by different mechanisms to elicit contractions in chorionic vessels. The potential roles of PGF2 alpha, histamine, and calcium channel blockers in modulating the fetoplacental circulation is discussed.

Pharmacy involvement in a multidisciplinary diabetic teaching program.

The following article describes a method of developing a workable diabetic teaching program within a hospital setting. Emphasis is placed on involving other health professionals with expertise in their respective areas. Development of behavioral and learning objectives along with learning activities and methods of evaluation are discussed. The purposes of this program are: 1) to reduce the overlap in educational instructions given to patients with diabetes, and 2) to remove the problem of an unorganized patient education effort by placing such patients into a structured learning situation in which they feel comfortable and which is conducive to learning. This program has proved successful and provides a viable means of involving staff pharmacists with patients. It has taken a minimal amount of time and did not necessitate an increase in our staff.

Readability--its applicability to education of patients by pharmacy.

The applicability of readability to the development of pharmacy educational materials is reviewed. The importance of reading skills must be recognized in all areas of education, including pharmacy patient education. If people are to perform certain tasks, they must understand the instructions for those tasks. To be understandable, the instructions must be written on the reading level of the people who will be following the instructions. Readability has been defined as those characteristics of reading materials, involving certain mental processes, that make for ease or difficulty of comprehension of the reading material. It is the task of the reader to use as few or as many of these mental processes as necessary to grasp the intended meaning of the material. It has been estimated that the average reading level of the American public is approximately 7th to 8th grade. However, many adults do not have sufficient reading skills to comprehend fully material written on these levels. Therefore, pharmacy educational material should be written on the reading level of the patient population it serves. Several readability formulas have been developed to evaluate the various characteristics of reading material that lead to reading comprehension. Among the ones recommended for use with pharmacy educational materials are the Fry Readability Graph and the Gunning Fog Index.

Enhancing interdepartmental relations.

In summary, it is important that the hospital manager have a positive attitude; recognize that not all projects will gain approval and that competition with others for scarce resources is a reality. A well throughout plan, anticipating questions, objections, and including affected departments, is a necessary first step to enhancing the manager's image. Being a polished orator is not essential, but being organized is. Most important, a progressive, "can-do" attitude is always respected by others.

PharmaTrend as a management tool: evaluation of the program.

A critical evaluation of PharmaTrend, a personal computer-based program for the analysis of pharmacy workload and productivity, is presented. The use of PharmaTrend is facilitated by a number of support features. A tutorial program instructs first-time and infrequent users on how to negotiate PharmaTrend's data-entry screens. The manual is well written and organized, and a toll-free number is available should more technical questions arise. However, some of PharmaTrend's definitions are confusing, as is the program's method of capturing workload data on the preparation of intravenous solutions. Some of the data currently maintained in pharmacies will need considerable modification before they can be used as PharmaTrend entries. A few minor changes would transform PharmaTrend from a good to an exceptional program. In addition to clearer definitions, an option allowing the user to edit the definitions shown on the screen is needed. A line should be added to the data-entry screen to remind the user that F1 is the help key. Reporting would be facilitated if deadlines were changed to reflect standard quarters. PharmaTrend is advantageous for the analysis of departmental operations because it provides regional and national standards for comparison. It can also help justify proposals and defend existing services and staffing. The monthly and quarterly reports generated with PharmaTrend are useful in analyzing pharmacy operations, and the user can modify work-load times on the basis of local circumstances. These difficulties notwithstanding, the current cost of PharmaTrend appears to be a bargain. Although some aspects of PharmaTrend need refinement, its basic features make it a valuable management tool.

Initial experience with intravenous pentobarbital sedation for children undergoing MRI at a tertiary care pediatric hospital: the learning curve.

OBJECTIVE: Our purpose is to describe the initial experience with intravenous pentobarbital sedation in children undergoing MRI at a tertiary pediatric hospital to identify errors associated with inexperience. SUBJECTS AND METHODS: The study included the first 100 children sedated with intravenous pentobarbital prior to magnetic resonance examination at a tertiary pediatric hospital. The protocol included a maximum dose of 6 mg/kg administered in three divided doses with the total dose not to exceed 200 mg. Flow sheets documenting vital signs, administered drug doses, and adverse reactions were maintained contemporaneous to sedation. RESULTS: Sedation was successful in 92 children. Of the eight children who failed sedation, three were at least 12 years old and three weighed more than 50 kg. chi2 tests identified significantly greater failure rates in children older than 11 years or weight greater than 50 kg. Two children had prolonged sedation after the maximum suggested dose was exceeded. CONCLUSIONS: The success rate was good, but could have been improved by restricting the use of pentobarbital to children less than 12 years of age and weighing less than 50 kg. Radiologists inexperienced with intravenous sedation should strictly observe the maximum suggested dose of pentobarbital to prevent prolonged sedation.

Supportive personnel training program based at a technical college.

A supportive personnel training program based at a technical college is described. During the nine-month curriculum, the students spend time in the classroom and in a laboratory on the college campus. Part of the program is taught by the college faculty, providing the students with courses on basic chemistry, anatomy and physiology, medical vocabulary, typing, and math fundamentals. The other part of the curriculum is taught by pharmacists, including courses on hospital pharmacy, pharmacology, and pharmacy mathematics. The students' first experiences with unit-dose and i.v.-admixture programs are in an artificial laboratory under controlled conditions. Later in the program, the students rotate through each of the participating hospitals for thorough on-the-job training. By combining the resources of a local technical college and the area hospitals, a uniform program of training supportive personnel has been implemented that produces enough technical support for all the participating hospital pharmacies.

Maternal domestic violence screening in an office-based pediatric practice.

BACKGROUND: Maternal domestic violence (MDV) screening by pediatricians is not well-studied. Objectives. To determine the practicality and dynamics of routine MDV screening in a private pediatric office and to determine the rate of MDV in Upper Cape Cod, Massachusetts. SETTING: A 3-pediatrician, private pediatric office in Falmouth, Massachusetts. PARTICIPANTS: Mothers of children aged 1 month to 10 years scheduled to undergo a well-child visit between February 7 and July 7, 2000. INTERVENTION: Completion of an 11-item questionnaire related to violence. RESULTS: Seven hundred sixty-six families were scheduled for well visits. Five hundred ninety-two eligible mothers presented to the office. Five hundred fifty-three completed questionnaires were returned (71.2%). The rate of MDV was 2.5% in current relationships (95% confidence interval [CI]: 1.4-4.3), 14.7% in past relationships (95% CI: 11.9-18.0), and 16.5% overall (95% CI: 13.5-19.9). Increased incidence of MDV was associated with the following variables: 1) harm to a child (odds ratio [OR]: 57.3, 95% CI: 7.3-1232.4), 2) being in a relationship other than a first marriage (OR: 4.6, 95% CI: 2.7-7.8), 3) having been previously asked about MDV (OR: 3.5, 95% CI: 2.1-6.1), 4) having 4 or more children (OR: 3.1, 95% CI: 1.6-6.1), 5) Women, Infants, and Children's program eligibility (OR: 3.0, 95% CI: 1.8-5.0), 6) having public insurance (ie, Medicaid or Children's Medical Security Plan) (OR: 2.2, 95% CI: 1.3-3.7), 7) a history of failure to present for a scheduled well-child visit (no-show; OR: 2.0, 95% CI: 1.0-4.2) and 8) anonymous questionnaire completion (OR: 1.7, 95% CI: 1.0-2.9). Thirty-two and one-half percent (32/91, 95% CI: 25.6-46.0) of mothers with a history of MDV recall having previously been asked about this by a health professional, compared with 16.9% overall (93/551, 95% CI: 13.9-20.3). Eighty-two and eight tenths (82.8) percent (457/552, 95% CI: 79.3-85.8) of mothers favored pediatricians asking about MDV. DISCUSSION: This information was gathered within the context of normal work hours in a busy office. No additional staff were required. Hence, routine MDV screening appears feasible. The results suggest that a documented history of child abuse in a family makes it very likely that the mother has also been abused. However, child abuse among abused mothers is probably underreported. Furthermore, because most mothers favor domestic violence screening, concerns about lack of acceptance of maternal screening at pediatric visits seem to be unfounded. Screening may actually increase satisfaction with care. In addition, families who do not show up for appointments are at higher risk. Therefore, screening only at well visits will miss an important group. CONCLUSIONS: Maternal domestic violence screening at well-child visits is practical in a private pediatric office setting. Current rates of screening are low; however, most mothers favor such screening. Furthermore, MDV screening should also be offered on a catch-up basis for those who miss well-child visits, as is currently recommended for immunizations.