Mitigating Pediatric Inpatient Aggression: A Quality Improvement Initiative.

BACKGROUND: Patient aggression in the health care workplace has increased significantly, and the impact of workplace violence can be profound, including psychological trauma and lost productivity. We suspect these safety events are often unreported, leading to missed opportunities to design interventions to reduce harm. The primary aim of the interdisciplinary quality improvement team was to increase staff reporting of safety events utilizing our event reporting system related to the care of verbally and/or physically aggressive pediatric patients by 10% over a 12-month period. METHODS: An interdisciplinary quality improvement team addressed existing gaps in the care of pediatric inpatients with escalating behavior. Interventions included a survey of staff knowledge, use of the care guideline for management, updates to the electronic medical record, patient aggression screening tool, an electronic order set, and an online education module. The primary outcome measure was the number of reported staff safety events related to the care of aggressive patients. Compliance with the use of the pediatric aggression risk screening tool was tracked as a process measure. RESULTS: The reporting of safety events related to the care of aggressive patients increased from just <1.0 events per 1000 patient days to 3.0 with special cause variation observed on a statistical process control chart. The compliance with the use of the pediatric aggression risk screening tool improved during the time of the project, nearing 90%. CONCLUSIONS: A variety of interventions aimed to address pediatric inpatient aggression can improve the reporting of events related to workplace violence and foster a culture of employee safety.

Long-term clinical and positron emission tomography outcome of fetal striatal transplantation in Huntington's disease.

Two patients with moderate Huntington's disease (HD) received bilateral fetal striatal allografts. One patient demonstrated, for the first time, increased striatal D2 receptor binding, evident with 11C-raclopride positron emission tomography, and prolonged clinical improvement over 5 years, suggesting long term survival and efficacy of the graft. The other patient did not improve clinically or radiologically. Our results indicate that striatal transplantation in HD may be beneficial but further studies are needed to confirm this.

A multicentre longitudinal observational study of changes in self reported health status in people with Parkinson's disease left untreated at diagnosis.

BACKGROUND: The issue of when to start treatment in Parkinson's disease (PD) remains controversial. Some favour treatment at diagnosis while others opt for a "wait and watch" policy. The effect of the latter policy on the self reported health status of people with PD is unknown. AIMS: To record self reported health status through longitudinal use of a validated PD specific questionnaire (PDQ-39) in untreated PD patients in multiple centres in the UK. To compare patients who were left untreated with those who were offered treatment during follow-up. METHODS: A multicentre, prospective, "real life" observational audit based study addressing patient reported outcomes in relation to self reported health status and other sociodemographic details. RESULTS: 198 untreated PD were assessed over a mean period of 18 months. During two follow-up assessments, the self reported health status scores in all eight domains of the PDQ-39 and the overall PDQ-39 summary index worsened significantly (p<0.01) in patients left untreated. In a comparative group in whom treatment was initiated at or soon after diagnosis, there was a trend towards improvement in self reported health status scores after treatment was started. CONCLUSIONS: This study addresses for the first time self reported health status, an indicator of health related quality of life, in untreated PD. The findings may strengthen the call for re-evaluation of the policy to delay treatment in newly diagnosed patients with PD.

New developments in medical specialty training.

Medical specialty training is changing which will result in shorter, more focused training programmes. Senior house officer posts will disappear from August 2007, and be replaced by training posts and trust grade doctors. Eventually specialist registrars in higher specialty training will join with these new training posts to create run-through training. Curricula development and delivery with quality assurance is now the responsibility of a new training board--the Postgraduate Medical Education and Training Board (PMETB). There is an opportunity to create a new specialty of acute medicine to help meet the crisis of care for acutely ill patients in our hospitals.

MAIT cells are licensed through granzyme exchange to kill bacterially sensitized targets.

Mucosal-associated invariant T (MAIT) cells are an innate-like T-cell population restricted by the non-polymorphic, major histocompatibility complex class I-related protein 1, MR1. MAIT cells are activated by a broad range of bacteria through detection of riboflavin metabolites bound by MR1, but their direct cytolytic capacity upon recognition of cognate target cells remains unclear. We show that resting human MAIT cells are uniquely characterized by a lack of granzyme (Gr) B and low perforin expression, key granule proteins required for efficient cytotoxic activity, but high levels of expression of GrA and GrK. Bacterial activation of MAIT cells rapidly induced GrB and perforin, licensing these cells to kill their cognate target cells. Using a novel flow cytometry-based killing assay, we show that licensed MAIT cells, but not ex vivo MAIT cells from the same donors, can efficiently kill Escherichia coli-exposed B-cell lines in an MR1- and degranulation-dependent manner. Finally, we show that MAIT cells are highly proliferative in response to antigenic and cytokine stimulation, maintaining high expression of GrB, perforin, and GrA, but reduced expression of GrK following antigenic proliferation. The tightly regulated cytolytic capacity of MAIT cells may have an important role in the control of intracellular bacterial infections, such as Mycobacterium tuberculosis.

Oculogyric crises and parkinsonism. A case of recent onset.

Oculogyric crisis in association with postencephalitic parkinsonism has been reported only following encephalitis lethargica (Economo's disease). Generally, it has been assumed that this phenomenon would fade away with the demise of these postencephalitic patients. Therefore, we report a case of recent onset of persistent oculogyric crisis with parkinsonism in a 35-year-old man following an apparent attack of encephalitis in 1972.

A case of sporadic juvenile Parkinson's disease.

Juvenile Parkinson's disease is rare. Virtually all reported cases are either associated with a family history or additional neurologic findings. We report a sporadic case of classic Parkinson's disease, without other abnormal neurologic signs and age at onset of 15 years.

Implantation of human fetal ventral mesencephalon to the right caudate nucleus in advanced Parkinson's disease.

Disaggregated ventral mesencephalic tissue from single aborted human fetuses of 11 to 18 weeks' gestation was implanted stereotaxically into a consistent striatal site in 12 patients with advanced Parkinson's disease. All were receiving optimum levodopa therapy and were examined preoperatively and at 3,6,9, and 12 months postoperatively. Immunosuppression was not used. There were significant sustained improvements at 12 months in three patients; motor fluctuations were absent in two. There were modest group improvements up to 6 months, with increased quality of "on" and "off" phases, quantity of on times, and specific improvements in contralateral upper limb bradykinesia. Preoperative levodopa requirements were reduced to a mean of 64% at 6 months and 61% at 12 months. Deterioration below baseline ratings occurred in three of nine patients who had consistent follow-up to 12 months. Grafting of midgestational human fetal tissue can lead to improvement in Parkinson's disease. Individual disease severity may be critical, and further trials are needed to identify host factors influencing outcome.

Bilateral deficit is larger for step than for ramp isometric contractions.

The force produced by a muscle group during a maximum effort bilateral task has been reported to be less than that produced during a maximum effort unilateral task. It was hypothesized that if decreased activation of primarily fast motor units is responsible for this bilateral deficit, 1) the bilateral deficit would be larger in step than in ramp isometric contractions and 2) the rate of torque generation in step contractions would be slower in bilateral than in unilateral tasks. Twelve healthy male subjects performed unilateral and bilateral isometric knee joint extension tasks in which maximum torque was generated under ramp and step conditions. The maximum torques produced in the bilateral tasks were 17.0 and 24.6% less than those produced in the unilateral tasks during the ramp and step conditions, respectively (both P < 0.001). The bilateral torque deficit for the step condition was significantly greater than that for the ramp condition (P = 0.012). The rate of torque generation in the step condition was 19.7% slower in the bilateral than in the unilateral task (P = 0.010). Thus the results from these torque measurements support the notion that decreased activation of primarily fast motor units may be responsible for the bilateral deficit.

Brain implants in man do not break down the blood-brain barrier to dopamine and domperidone.

We have evaluated the blood-brain barrier (BBB) in 8 Parkinsonian patients before and after stereotactic implantation of foetal mesencephalon (STIM) and one patient with an adrenal medullary implant. Parenteral administration of dopamine did not reverse Parkinsonism pre-operatively or at 5 days, 1, 2, 3, 4 months and 1 year post-operatively. Apomorphine and domperidone reversed Parkinsonism and produced dyskinesia in all patients pre- and post-operatively. We conclude that the BBB remains intact to dopamine following implantation.

Limb contractures in levodopa-responsive parkinsonism: a clinical and investigational study of seven new cases.

We describe six patients with classical levodopa-responsive Parkinson's disease (PD) and one case of levodopa-responsive familial juvenile dystonia-parkinsonism with fixed contractures of the hands, feet or legs. In most patients contractures became established over a short period (2 months-2 years) but a considerable time after onset of parkinsonism (mean 13 years). Mean disease duration was 17 years, and all patients had severe levodopa-induced dyskinesias, either biphasic or peak dose, in the affected limb prior to onset of the contracture. Nerve conduction studies excluded peripheral ulnar nerve lesions in all patients with one exception, who was found to have a mild bilateral ulnar entrapment neuropathy. Transcranial magnetic stimulation performed in five of the seven patients showed shorter mean central motor conduction time in the affected than in the unaffected limb. Results of magnetic resonance imaging of the brain performed in a subgroup of patients were normal, with no evidence to suggest multiple system atrophy, cerebral infarction or focal abnormalities of the basal ganglia. We conclude that hand and feet contractures are not necessarily restricted to parkinson plus syndromes and may complicate otherwise typical PD in the absence of a structural or peripheral nervous cause. Striatal dopaminergic deficiency, particularly long-standing, may have a role in the pathogenesis of limb contractures in PD.

Visual evoked cortical responses and electroretinograms following implantation of human fetal mesencephalon to the right caudate nucleus in Parkinson's disease.

Pattern electroretinograms and visual evoked cortical responses following flash and checkerboard pattern reversal stimulation were performed in 7 patients with advanced Parkinson's disease before and after implantation of human fetal ventral mesencephalon to the head of the right caudate nucleus. Six to nine months following surgery there was bilateral enhancement of flash-evoked response amplitudes. Electroretinogram measurements were unchanged. Individual increases in amplitude and decreases in latency were seen following pattern stimulation which were not statistically significant. A relationship between change in dyskinesia, and change in checkerboard pattern stimulation amplitude at 2.4 cycles per degree suggests that amplitude effects at this stimulus frequency are mediated via altered dopaminergic receptor status in the grafted hemisphere. This may be relevant to the mechanisms leading to generalised clinical improvements following this grafting technique.

The survival of malignant hypertension in blacks, whites and Asians in Britain.

Life table analysis was used to compare survival rates in 168 whites, 39 blacks and 26 Asians with malignant phase hypertension. Amongst men, survival until death or the requirement of chronic renal dialysis was significantly worse in blacks, who initially presented with higher blood pressures and more renal impairment. There were no differences in survival in women in the three ethnic groups. Malignant hypertension remains common in Britain and still carries a poor prognosis.

Cerebellar astrocytomas in elderly patients with very long preoperative histories: report of three cases.

Three patients, ages 69, 67, and 74 years, respectively, underwent surgical removal of cystic cerebellar astrocytomas. All three had past histories pointing to the existence of a cerebellar lesion for many decades prior to surgery: Patient 1 had had nystagmus on lateral gaze on the side of the tumor since early childhood; Patient 2 had had sensorineural hearing loss on the side of her neoplasm for 38 years preceding the operation; and Patient 3 was diagnosed as having a brain tumor 51 years before the operation. (He has been blind because of pressure hydrocephalus for half a century, but otherwise managed to live a productive farming and family life until he sustained a head injury in a car accident, which forced him to undergo removal of his cerebellar tumor.) The neoplasms in all three instances were found by histological examination to be low-grade astrocytomas. These cases indicate that low-grade cerebellar astrocytomas, which are well known for their characteristically long postoperative courses, may at times manifest a slow growth potential with an exceptionally long preoperative course.

Cholinergic and dopaminergic mechanisms in Parkinson's disease after long-term L-DOPA administration.

A study of parkinsonian patients suffering from ON-OFF phenomena, who had been on long-term treatment with L-DOPA, to the parenteral administration of apomorphine and physostigmine is reported. All patients, whether of the end-dose failure type or of the randomly occurring variety, when given apomorphine in an OFF phase, showed prompt reversal to an ON phase. Physostigmine given during an ON phase produced the opposite effect with induction of parkinsonian symptoms. These findings are interpreted as indicating that the dopaminergic receptors are available for stimulation during the OFF phase but are not receiving sufficient neurotransmitter, that is, dopamine, to stimulate their activity. The response to physostigmine is indicative of a return of cholinergic supersensitivity after long-term L-DOPA administration, the mechanisms by which this may occur are discussed. Based on these findings, therapeutic strategies are suggested that may overcome this major limitation of the use of L-DOPA in the treatment of parkinsonism.

Does type II diabetes predispose to retinal vein occlusion?

Retinal vein occlusion (RVO) not infrequently occurs in diabetic patients. Although the aetiology is unclear, it could relate to the other microvascular complications of diabetes. In the non-diabetic, both the central (CRVO) and branch (BRVO) forms are commonly associated with hypertension and hyperlipidaemia. We have therefore studied fifty type II diabetic patients with RVO compared to a carefully matched diabetic control group (n = 50) to elucidate underlying medical conditions and hence the aetiology of RVO in diabetic patients. The two groups were well matched. Diabetics with RVO showed a strikingly high prevalence of hypertension compared to the controls (72% versus 32%: p < 0.001) and a trend to increased hyperlipidaemia (54% versus 36%). Diabetic microvascular complications were more common in the control group (diabetic retinopathy and proteinuria). No significant differences were observed in mean HbA1 or weight, but current smoking habits and blood pressure levels were increased in the diabetics with RVO. 80% of diabetic patients with the BRVO form, were hypertensive. We conclude that the main underlying medical conditions for RVO in diabetics are hypertension and hyperlipidaemia, and these may be important in the aetiology as in the non-diabetic. RVO is more common in type II rather than type I diabetes, and does not associate with the presence of diabetic microvascular complications. Clinical assessment for hypertension and hyperlipidaemia is therefore important in diabetic patients with RVO, especially if recurrence of the condition and further visual loss is to be prevented.