Virus variant-specific clinical performance of SARS coronavirus two rapid antigen tests in point-of-care use, from November 2020 to January 2022.

OBJECTIVES: Antigen rapid diagnostic tests (RDTs) for SARS coronavirus 2 (SARS-CoV-2) are quick, widely available, and inexpensive. Consequently, RDTs have been established as an alternative and additional diagnostic strategy to quantitative reverse transcription polymerase chain reaction (RT-qPCR). However, reliable clinical and large-scale performance data specific to a SARS-CoV-2 virus variant of concern (VOC) are limited, especially for the Omicron VOC. The aim of this study was to compare RDT performance among different VOCs. METHODS: This single-centre prospective performance assessment compared RDTs from three manufacturers (NADAL, Panbio, MEDsan) with RT-qPCR including deduced standardized viral load from oropharyngeal swabs for detection of SARS-CoV-2 in a clinical point-of-care setting from November 2020 to January 2022. RESULTS: Among 35 479 RDT/RT-qPCR tandems taken from 26 940 individuals, 164 of the 426 SARS-CoV-2 positive samples tested true positive with an RDT corresponding to an RDT sensitivity of 38.50% (95% CI, 34.00-43.20%), with an overall specificity of 99.67% (95% CI, 99.60-99.72%). RDT sensitivity depended on viral load, with decreasing sensitivity accompanied by descending viral load. VOC-dependent sensitivity assessment showed a sensitivity of 42.86% (95% CI, 32.82-53.52%) for the wild-type SARS-CoV-2, 43.42% (95% CI, 32.86-54.61%) for the Alpha VOC, 37.67% (95% CI, 30.22-45.75%) for the Delta VOC, and 33.67% (95% CI, 25.09-43.49%) for the Omicron VOC. Sensitivity in samples with high viral loads of ≥106 SARS-CoV-2 RNA copies per mL was significantly lower in the Omicron VOC (50.00%; 95% CI, 36.12-63.88%) than in the wild-type SARS-CoV-2 (79.31%; 95% CI, 61.61-90.15%; p 0.015). DISCUSSION: RDT sensitivity for detection of the Omicron VOC is reduced in individuals infected with a high viral load, which curtails the effectiveness of RDTs. This aspect furthert: limits the use of RDTs, although RDTs are still an irreplaceable diagnostic tool for rapid, economic point-of-care and extensive SARS-CoV-2 screening.

[Postpartum hemorrhage : Interdisciplinary consideration in the context of patient blood management]. / Postpartale Hämorrhagie : Interdisziplinäre Betrachtung im Kontext des Patient Blood Management.

Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.

[Patient blood management in the preparation for birth, obstetrics and postpartum period]. / Patient Blood Management in der Geburtsvorbereitung, Geburtshilfe und postpartalen Phase.

The implementation of patient blood management (PBM) is increasingly becoming standard in operative medicine. Recently, interest has also been shown for the vulnerable collective of pregnant women and neonates. As the information regarding anesthesiological procedures for pregnant women and the peripartum period including an informed consent process should be carried out long before childbirth, this provides a good possibility in this connection to incorporate PBM. An anesthesiological risk estimation as well as the diagnostic workup and treatment of potential anemia should be carried out during the pregnancy. Furthermore, loss of blood in anticipation of bleeding complications should be reduced by interdisciplinary preventive measures and an individually coordinated postpartum care should be organized. This results in an early diagnosis of anemia or iron deficiency with subsequent treatment also postpartum, analogous to the prepartum period.

Influence of Gender and Self-Perceived Competence on Psychological Well-Being in Adolescent and Young Adult Cancer Survivors.

Elucidating factors associated with mental health and well-being among adolescent and young adult cancer survivors (AYAs) is increasingly important as this population continues to grow. Adolescence and young adulthood are critical times for developing self-perceived competencies (SPCs), which may be shaped by the cancer experience and may have different consequences based on the person's gender. We assessed whether gender moderated the association between perceived competencies and mental health in 61 AYAs (51% males; 11-20 years old; diagnosed between 0.33 and 17.33 years old). Gender moderated the association of SPC in close friendship, job, and scholastic domains with depression, anxiety, and optimism.

Clinical performance evaluation of SARS-CoV-2 rapid antigen testing in point of care usage in comparison to RT-qPCR.

BACKGROUND: Antigen rapid diagnostic tests (RDT) for SARS-CoV-2 are fast, broadly available, and inexpensive. Despite this, reliable clinical performance data from large field studies is sparse. METHODS: In a prospective performance evaluation study, RDT from three manufacturers (NADAL®, Panbio™, MEDsan®, conducted on different samples) were compared to quantitative reverse transcription polymerase chain reaction (RT-qPCR) in 5 068 oropharyngeal swabs for detection of SARS-CoV-2 in a hospital setting. Viral load was derived from standardised RT-qPCR Cycle threshold (Ct) values. The data collection period ranged from November 12, 2020 to February 28, 2021. FINDINGS: The sensitivity of RDT compared to RT-qPCR was 42·57% (95% CI 33·38%-52·31%). The specificity was 99·68% (95% CI 99·48%-99·80%). Sensitivity declined with decreasing viral load from 100% in samples with a deduced viral load of ≥108 SARS-CoV-2 RNA copies per ml to 8·82% in samples with a viral load lower than 104 SARS-CoV-2 RNA copies per ml. No significant differences in sensitivity or specificity could be observed between samples with and without spike protein variant B.1.1.7. The NPV in the study cohort was 98·84%; the PPV in persons with typical COVID-19 symptoms was 97·37%, and 28·57% in persons without or with atypical symptoms. INTERPRETATION: RDT are a reliable method to diagnose SARS-CoV-2 infection in persons with high viral load. RDT are a valuable addition to RT-qPCR testing, as they reliably detect infectious persons with high viral loads before RT-qPCR results are available. FUNDING: German Federal Ministry for Education and Science (BMBF), Free State of Bavaria.

Anti-inflammatory effects of the new generation synthetic surfactant CHF5633 on Ureaplasma-induced cytokine responses in human monocytes.

BACKGROUND: Synthetic surfactants represent a promising alternative to animal-derived preparations in the treatment of neonatal respiratory distress syndrome. The synthetic surfactant CHF5633 has proven biophysical effectiveness and, moreover, demonstrated anti-inflammatory effects in LPS-stimulated monocytes. With ureaplasmas being relevant pathogens in preterm lung inflammation, the present study addressed immunomodulatory features on Ureaplasma-induced monocyte cytokine responses. METHODS: Ureaplasma parvum-stimulated monocytes were exposed to CHF5633. TNF-α, IL-1ß, IL-8, IL-10, TLR2 and TLR4 expression were analyzed using qPCR and flow cytometry. RESULTS: CHF5633 did not induce pro-inflammation, and did not aggravate Ureaplasma-induced pro-inflammatory cytokine responses. It suppressed U. parvum-induced intracellular TNF-α (p < 0.05) and IL-1ß (p < 0.05) in neonatal monocytes and inhibited Ureaplasma-induced TNF-α mRNA (p < 0.05), TNF-α protein (p < 0.001), and IL-1ß (p = 0.05) in adult monocytes. Ureaplasma-modulated IL-8, IL-10, TLR2 and TLR4 were unaffected. CONCLUSION: CHF5633 does neither act pro-apoptotic nor pro-inflammatory in native and Ureaplasma-infected monocytes. Suppression of Ureaplasma-induced TNF-α and IL-1ß underlines anti-inflammatory features of CHF5633.

The new generation synthetic reconstituted surfactant CHF5633 suppresses LPS-induced cytokine responses in human neonatal monocytes.

BACKGROUND: New generation synthetic surfactants represent a promising alternative in the treatment of respiratory distress syndrome in preterm infants. CHF5633, a new generation reconstituted agent, has demonstrated biophysical effectiveness in vitro and in vivo. In accordance to several well-known surfactant preparations, we recently demonstrated anti-inflammatory effects on LPS-induced cytokine responses in human adult monocytes. The present study addressed pro- and anti-inflammatory effects of CHF5633 in human cord blood monocytes. METHODS: Purified neonatal CD14(+) cells, either native or simultaneously stimulated with E. coli LPS, were exposed to CHF5633. TNF-α, IL-1ß, IL-8 and IL-10 as well as TLR2 and TLR4 expression were analyzed by means of real-time quantitative PCR and flow cytometry. RESULTS: CHF5633 did not induce pro-inflammation in native human neonatal monocytes and did not aggravate LPS-induced cytokine responses. Exposure to CHF5633 led to a significant decrease in LPS-induced intracellular TNF-α protein expression, and significantly suppressed LPS-induced mRNA and intracellular protein expression of IL-1ß. CHF5633 incubation did not affect cell viability, indicating that the suppressive activity was not due to toxic effects on neonatal monocytes. LPS-induced IL-8, IL-10, TLR2 and TLR4 expression were unaffected. CONCLUSION: Our data confirm that CHF5633 does not exert unintended pro-apoptotic and pro-inflammatory effects in human neonatal monocytes. CHF5633 rather suppressed LPS-induced TNF-α and IL-1ß cytokine responses. Our data add to previous work and may indicate anti-inflammatory features of CHF5633 on LPS-induced monocyte cytokine responses.

Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods.

BACKGROUND: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs. METHODS: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected. RESULTS: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders. CONCLUSIONS: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Autologous Breast Reconstruction in Women Older Than 65 Years Versus Women Younger Than 65 Years: A Multi-Center Analysis.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson χ² and analysis of variance tests were used. Given the number of analyses, a more conservative α of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

Impact of caring for a child with cancer on single parents compared with parents from two-parent families.

BACKGROUND: It is currently unknown how the intensive and often prolonged treatment of childhood cancer impacts on the lives of single parents. Our aims were to determine whether single parents differ from parents from two-parent families in terms of caregiver demand (the time and effort involved in caregiving), and health-related quality of life (HRQL). PROCEDURES: Forty single parents and 275 parents from two-parent families were recruited between November 2004 and February 2007 from five pediatric oncology centers in Canada. Parents were asked to complete a questionnaire booklet composed of items and scales to measure caregiver demand and HRQL (SF-36). The booklet also measured the following constructs: background and context factors, child factors, caregiving strain, intrapsychic factors, and coping factors. RESULTS: Single parents did not differ from parents from two-parent families in caregiving demand and physical and psychosocial HRQL. Compared with Canadian population norms for the SF-36, both groups reported clinically important differences (i.e., worse health) in psychosocial HRQL (effect size ≥ -2.00), while scores for physical HRQL were within one standard deviation of population norms. CONCLUSION: Our findings suggest that the impact of caregiving on single parents, in terms of caregiving demand and HRQL is similar to that of parents from two-parent families.

Perfectionistic self-presentation in children and adolescents: development and validation of the Perfectionistic Self-Presentation Scale--Junior Form.

Research on adults indicates that perfectionistic self-presentation, the interpersonal expression of one's perfection, is associated with a variety of psychopathological outcomes independent of trait perfectionism and Big Five traits. The current article reports on the development and evidence for the validity of the subtest score interpretations of an 18-item self-report measure of perfectionistic self-presentation for children and adolescents. Analyses conducted on data from two clinical samples and one nonclinical sample of children and adolescents found that the Perfectionistic Self-Presentation Scale--Junior Form (PSPS-Jr) reflected a multidimensional model of perfectionistic self-presentation with three subscales: Perfectionistic Self Promotion, Nondisplay of Imperfection, and Nondisclosure of Imperfection. The subscale scores were found to demonstrate internal consistency, and there was good evidence supporting the validity of the interpretation of subscale scores based on this new measure. The subscales were associated with maladaptive outcomes, but were not influenced unduly by biases that included social desirability and differential item functioning by gender. Overall, the PSPS-Jr appears to be a useful measure of the expression of perfection among youths and an important tool in attempting to understand the nature and the consequences of perfectionistic self-presentation in children and adolescents.

Poly(ADP-ribosyl)ation polymerases: mechanism and new target of anticancer therapy.

Poly(ADP-ribose)polymerase (PARP) is a ubiquitously present nuclear enzyme that is not only involved in many important cellular pathways but also contributes to chromosomal structure and genomic stability. The development of highly selective and potent PARP inhibitors has become of increasing clinical interest because of their promising efficacy in patients with breast or ovarian cancer. Furthermore, recent Phase I and Phase II trials have demonstrated that PARP inhibitors have low toxicity rates. In particular patients with either deficiency or dysfunction of BRCA, which is involved in DNA double strand break repair, appear to benefit from PARP inhibition. This article summarizes the present knowledge regarding the physiological function of PARP and ([poly]ADP-ribose) PAR, the functional product of PARP, the development of PARP inhibitors, the recent clinical data of PARP inhibitors in cancer treatment and the selection of patients who may benefit from PARP inhibition.

Prenatal effects of selective serotonin reuptake inhibitor antidepressants, serotonin transporter promoter genotype (SLC6A4), and maternal mood on child behavior at 3 years of age.

OBJECTIVES: To investigate whether prenatal selective serotonin reuptake inhibitor (SSRI) antidepressant exposure affects behavior in 3-year-olds of antenatally anxious or depressed mothers and whether risk was moderated by the serotonin transporter promoter (SLC6A4) genotype. DESIGN: Prospective longitudinal cohort design. SETTING: Vancouver. PARTICIPANTS: Mothers and their 3-year-old children (n = 33 SSRI exposed and n = 42 nonexposed). Main Exposures Prenatal exposure to SSRI antidepressants and prenatal and postnatal maternal mood disturbances. MAIN OUTCOME MEASURES: Parent report of child behavior (Child Behavior Checklist, ages 1.5-5 years) and the child SLC6A4 genotype. The covariates used were maternal mood during the third trimester, 3 months postpartum, and at the 3-year follow-up study and the child's 5-minute Apgar score. RESULTS: Prenatal exposure to both maternal depressed mood and SSRI antidepressants were associated with increased internalizing behaviors during early childhood, whereas current maternal mood increased risk for externalizing behaviors. Increased child anxiety and depression symptoms were predicted by higher third-trimester maternal anxiety only in children with 2 short S alleles. In contrast, increased aggression and externalizing behaviors were predicted by third-trimester maternal anxiety only in children with 2 copies of the L allele. CONCLUSIONS: Exposure to prenatal SSRIs and maternal mood had distinct effects on child behavior at 3 years of age, reflected in an increased level of internalizing behaviors. The impact of antenatal maternal anxiety on child mood was moderated by the child SLC6A4 genotype. Despite SSRI treatment for prenatal maternal mood disturbances, childhood behavior at 3 years of age remained at risk.

Neonatal S100B protein levels after prenatal exposure to selective serotonin reuptake inhibitors.

OBJECTIVE: This study investigated neonatal S100B levels as a biomarker of prenatal selective serotonin reuptake inhibitor (SSRI) exposure. METHODS: Maternal (delivery; N = 53) and neonatal (cord; N = 52) serum S100B levels were compared between prenatally SSRI-exposed (maternal, N = 36; neonatal, N = 37; duration: 230 +/- 71 days) and nonexposed (maternal, N = 17; neonatal, N = 15) groups. Measures of maternal depression and anxiety symptoms were assessed during the third trimester (33-36 weeks), and neonatal outcomes, including Apgar scores, birth weight, gestational age at birth, and symptoms of poor neonatal adaptation, were recorded. RESULTS: S100B levels were significantly lower in prenatally SSRI-exposed neonates than in nonexposed neonates, controlling for gestational age and third-trimester maternal mood (P = .036). In contrast, SSRI-exposed mothers had significantly higher maternal serum S100B levels, compared with nonexposed mothers (P = .014), even controlling for maternal mood in the third trimester. S100B levels were not associated with maternal or neonatal drug levels, duration of prenatal exposure, demographic variables, or risk for poor neonatal adaptation. CONCLUSIONS: Prenatal SSRI exposure was associated with decreased neonatal serum S100B levels, controlling for prenatal maternal mood. Neonatal S100B levels did not reflect neonatal behavioral outcomes and were not related to pharmacologic indices. These findings are consistent with prenatal alcohol and cocaine exposures, which also alter central serotonin levels.

Factors affecting the delivery of family-centered care in pediatric oncology.

BACKGROUND: The provision of family-centered care (FCC) emphasizes a partnership between parents and health-care providers so that families are involved in every aspect of services for their child. Our study examines factors related to parental perception of the family-centeredness of pediatric oncology services. PROCEDURE: This Canadian multi-institutional cross-sectional study included children with cancer receiving active treatment. One parent from each family provided information about the child, parent/family demographics, diagnosis, and treatment. FCC was measured with the MPOC-20, a valid and reliable tool in the pediatric oncology setting that consists of two subscales: "Family-Centered Service" and "Providing General Information." Logistic multiple regression analyses were used to identify factors that were associated with lower ratings of FCC for each subscale. RESULTS: Completed questionnaires were received back from 411 parents, giving an overall response rate of 80%. Worse perceived prognosis and worse parental psychosocial health were associated with less favorable ratings for both MPOC-20 subscales. In addition, parents who were not married or living common-law scored lower ratings for the Family-Centered Services subscale, whereas scores for the Provision of General Information subscale differed depending on the treatment facility at which the child received care. CONCLUSIONS: Our study identified child/parent factors and health-care delivery factors associated with FCC provided in the pediatric oncology setting. These results could be used as the starting point for future research looking at optimization of the FCC process.

Hypothalamic-pituitary-adrenal (HPA) axis function in 3-month old infants with prenatal selective serotonin reuptake inhibitor (SSRI) antidepressant exposure.

BACKGROUND: Prenatal exposure to stress and selective serotonin reuptake inhibitors (SSRIs) alter hypothalamic-pituitary-adrenal (HPA) stress reactivity in offspring, however, the effects of combined exposure to HPA activity in human infants is unknown. OBJECTIVE: To examine HPA basal levels and stress responsiveness in 3-month olds with prenatal exposure to SSRIs. METHODS: Salivary cortisol levels in infants of SSRI treated mothers (n=31, mean exposure 230.2+/-72.2 days) were compared with non-SSRI exposed (n=45) infants in response to a challenge (infant-controlled habituation task) and under basal conditions in the late afternoon/early evening. Mode of feeding, to account for possible postnatal drug exposure via breast milk, as well as measures of pre and postnatal maternal mood, were included as covariates. RESULTS: Lower post-stress cortisol levels were observed in non-SSRI exposed/non-breastfed infants compared with non-SSRI exposed infants who were breastfed at 3 months of age. Stress reactivity patterns among SSRI exposed infants did not differ with mode of feeding. The cortisol reactivity slope (CRS) was significantly lower among non-SSRI exposed non-breastfed infants compared with non-SSRI exposed breastfed infants. Early evening basal cortisol levels were lower in SSRI exposed infants than in non-SSRI exposed infants, controlling for maternal mood and mode of feeding. Postnatal SSRI exposure (infant SSRI drug levels) via breast milk was not associated with stress or basal cortisol levels. Total cortisol, reflected by the AUC measure, did not differ significantly between exposure groups. CONCLUSIONS: Prenatal SSRI exposure altered HPA stress response patterns and reduced early evening basal cortisol levels. Stress challenge HPA response differences only became apparent when the moderating effect of method of feeding was accounted for. These findings suggest an early "programming" effect of antenatal maternal mood, prenatal SSRI exposure and postnatal maternal care giving on the HPA system.

Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses.

BACKGROUND: In animal models, variations in early maternal care are associated with differences in hypothalamic-pituitary-adrenal(HPA) stress response in the offspring, mediated via changes in the epigenetic regulation of glucocorticoid receptor (GR) gene (Nr3c1) expression. OBJECTIVE: To study this in humans, relationships between prenatal exposure to maternal mood and the methylation status of a CpG-rich region in the promoter and exon 1F of the human GR gene (NR3C1) in newborns and HPA stress reactivity at age three months were examined. RESULTS: Prenatal exposure to increased third trimester maternal depressed/anxious mood was associated with increased methylation of NR3C1 at a predicted NGFI-A binding site. Increased NR3C1 methylation at this site was also associated with increased salivary cortisol stress responses at 3 months, controlling for prenatal SRI exposure, postnatal age and pre and postnatal maternal mood. METHODS: The methylation status of a CpG-rich region of the NR3C1 gene, including exon 1F, in genomic DNA from cord blood mononuclear cells was quantified by bisulfite pyrosequencing in infants of depressed mothers treated with a serotonin reuptake inhibitor antidepressant (SRI) (n = 33), infants of depressed nontreated mothers (n = 13) and infants of non depressed/non treated mothers (n = 36). To study the functional implications of the newborn methylation status of NR3C1 in newborns, HPA function was assessed at three months using salivary cortisol obtained before and following a non noxious stressor and at a late afternoon basal time. CONCLUSIONS: Methylation status of the human NR3C1 gene in newborns is sensitive to prenatal maternal mood and may offer a potential epigenetic process that links antenatal maternal mood and altered HPA stress reactivity during infancy.

Fluid management in burn patients: results from a European survey-more questions than answers.

Many strategies were proposed for fluid management in burn patients with different composition containing saline solution, colloids, or plasma. The actual clinical use of volume replacement regimen in burn patients in Europe was analysed by an international survey. A total of 187 questionnaires consisting of 20 multiple-choice questions were sent to 187 burn units listed by the European Burn Association. The response rate was 43%. The answers came from a total of 20 European countries. Volume replacement is mostly exclusively with crystalloids (always: 58%; often: 28%). The majority still use fixed formulae: 12% always use the traditional Baxter formula, in 50% modifications of this formula are used. The most often used colloid is albumin (always: 17%, often: 38%), followed by HES (always: 4%, often: 34%). Gelatins, dextrans, and hypertonic saline are used only very rarely. Fresh frozen plasma (FFP) is given in 12% of the units as the colloid of choice. Albumin was named most often to be able to improve patients' outcome (64%), followed by HES (53%), and the exclusive use of crystalloids (45%). Central venous pressure (CVP) is most often used to monitor volume therapy (35%), followed by the PiCCO-system (23%), and mixed-venous saturation (ScVO2; 10%). It is concluded that the kind of volume therapy differs widely among European burn units. This survey supported that no generally accepted volume replacement strategy in burn patients exists. New results, e.g. importance of goal-directed therapy or data concerning use of albumin in the critically ill, have not yet influenced strategies of volume replacement in the burn patient.

Services for children and youth with chronic health conditions: views of pediatricians in British Columbia.

Canadian research on health services for children and youth with chronic health conditions (CHC) is limited. In a postal survey, pediatricians in British Columbia rated the quality and safety of health care services for children with chronic medical conditions (Ch-Med) lower (mean rating +/- SD on a seven-point scale: 4.86 +/- 1.02 ) than services for children with acute conditions/injuries (5.97 +/- 1.01), and lowest for children with chronic developmental, behavioral and mental health conditions (Ch-DBM; 3.06 +/- 1.17). To improve health care services for CHC, respondents especially favoured improving access to community-based services and resources and to medical specialists and specialized facilities, and the implementation of alternative models of care. Respondents indicated that physician care of children with CHC could be enhanced by extending the physician's role, better integrating medical with other aspects of care and adopting more flexible payment mechanisms. Findings suggest the need for enhancement and innovation in medical services for children with CHC, especially Ch-DBM, but also that solutions need to take account of CHC subcategory, geographic factors and differences in practitioner readiness to embrace change.