bluuebunny/crossref_metadata_2025 huggingface dataset:
Dietary energy sources affect insulin sensitivity and β‐cell responsiveness of trained Arabian geldings during endurance exercise
Authors: Treiber K. H. , Hess T. M. , Kronfeld D. S. , Boston R. C. , Geor R. , Harris P. A.
Published: November 2005

Adaptation to diets which replace carbohydrates with fat as an energy source have been shown to avoid insulin resistance and improve metabolic regulation during exercise. This study compared the effects of diet and moderate‐intensity exercise on glucose and insulin concentrations in 12 trained Arabian geldings. Six Arabians were adapted for 8 weeks to a feed high in sugar and starch (SS) and six were adapted to a feed rich in fat and fibre (FF). All horses were exercise‐trained prior to and throughout feed adaptation. Horses were sampled between 0900 and 1000 h at rest and during moderate‐intensity exercise on a treadmill at 57% of their lactate threshold following 25 min of warm‐up. Plasma was analysed for glucose and insulin. Basal proxies for insulin sensitivity (LRIB = log[100/basal insulin]) and pancreatic β‐cell response to circulating glucose (MIRG = log[(100·basal insulin)/(basal glucose – 50 mg/dL)]) were calculated. Basal insulin tended to be lower in FF adapted horses (p = 0.068) and was lower during exercise as compared to rest in FF horses (p = 0.013) but not SS horses (p = 0.44). Plasma glucose concentration was lower in FF horses (p < 0.001) and increased during exercise for SS adapted horses (p = 0.015) but not FF horses (p = 0.38). Insulin sensitivity as determined by LRIB was higher during exercise (p = 0.019) for all 12 horses while β‐cell response as determined by MIRG was lower (p = 0.006). Arabians adapted to the FF diet also had higher LRIB (p = 0.047) but diet had no affect on MIRG (p = 0.20). Exercise tended to increase (p = 0.11) LRIB more in FF horses (34%) than SS horses (11%). These differences indicate that horses adapted to high carbohydrate diets have lower insulin sensitivity and impaired metabolic regulation involving insulin signalling. These effects are avoided in horses adapted to the FF feed, with potential benefits to their health and endurance exercise performance.
Effects of glucose polymer with and without potassium and different diets on glycogen repletion after a treadmill exercise test in endurance horses
Authors: Hess T. M. , Kronfeld D. S. , Treiber K. H. , Souza‐Freire M. , Geor R. J.
Published: November 2005

Glycogen repletion involves absorption of glucose and its uptake into the muscle cells through GLUT‐4 transporters. In the muscle and adipose tissue GLUT–4 transporters facilitates the glucose transport in the presence of insulin and K+. Potassium supply has been shown to stimulate insulin secretion. This study tested the effects of a glucose polymer added with electrolytes containing potassium (GP+K) compared to a glucose polymer with electrolytes without potassium (GP‐K) on glycogen repletion. Also it compared the effect of different diet adaptations on glycogen repletion. Six horses were fed a diet rich in sugar and starch (SS), and six horses a diet rich in fat and fibre (FF) for 6 months before the test. In a crossover designed study, 12 trained Arabian or Arabian cross horses were submitted to a glycogen depleting exercise test on the treadmill. After exercise stopped six horses were supplied with GP‐K and six other horses supplied with GP+K, at a dose of 5 g/kg BW, and a rate of 1 g/kg BW/hour through naso‐gastric gavage. Muscle biopsies were taken before, just after they stopped exercise, and 16 h after they had been supplied with glycogen replacing formulas, and analysed for muscle glycogen. Blood was taken before, after 3 h of exercise, after the stepwise exercise test, at 0, 1 and 4 h after exercise stopped and analysed for plasma glucose, insulin and [K+]. Muscle glycogen decreased from 516.41 ± 12.92 glucosyl units/kg dry weight muscle to 408.74 ± 12.92 glucosyl units/kg dry weight muscle (79%). Sixteen hours after the repletion protocol horses recovered their muscle glycogen to 458.53 ± 12.91 glucosyl units/kg dry weight muscle (89%). Plasma glucose had a glucose polymer by sampling effect (p = 0.013) and a feed by sampling effect (p = 0.022). Plasma glucose was higher in SS fed horses at 1 and 4 h after exercise. Plasma glucose was lower in GP+K supplied horses 4 h after exercise. Plasma insulin had a trend (p = 0.070) for a glucose polymer effect. No differences were found in muscle glycogen between the two GP treatments. Although the present results demonstrate that intensive nasogastric supplementation with glucose polymer can result in glycogen repletion approaching that following i.v. administration, the addition of potassium conferred no advantage.
Pre‐laminitic metabolic syndrome in genetically predisposed ponies involves compensated insulin resistance
Authors: Treiber K. H. , Kronfeld D. S. , Hess T. M. , Byrd B. M. , Splan R. K.
Published: November 2005

Metabolic syndromes associated with insulin resistance are found in approximately 25% of apparently healthy Americans and are risk factors for type 2 diabetes or coronary heart disease. We sought to quantitatively describe a comparable metabolic syndrome in apparently healthy ponies previously diagnosed with pasture laminitis (PL, n = 54), compared to those without previous indications of laminitis (NL, n = 116). Laminitis histories were obtained on 170 Dartmoor and Welsh ponies in one inbred herd maintained on grass‐clover pasture. Pedigree analysis has revealed a dominant mode of inheritance for PL, with nutrition playing a key role in its expression. In March 2004 the ponies were gathered, weighed, scored for body condition, and sampled for blood between 0800 and 1000 h. Body condition scores were higher (p = 0.001) in the PL group (6.4 ± 0.1) than the NL (5.8 ± 0.1). Plasma analysis revealed higher (p < 0.001) concentrations of insulin (22 ± 2 and 11 ± 1 μIU/ml in PN and NL respectively) and triglycerides (99 ± 11 and 52 ± 4 mg/dl), lower (p < 0.001) cortisol (5.3 ± 0.3 and 6.8 ± 0.2 μg/dl), and no differences for glucose or non‐esterified fatty acids. Statistically validated proxies based on insulin and glucose indicated insulin sensitivity in the lowest reference quintile of apparently healthy horses and pancreatic β‐cell response in the highest reference quintile, the combination of results indicating compensated insulin resistance. The data allow the tentative proposal of a diagnostic definition of a pre‐laminitic metabolic syndrome (PLMS) with four criteria: Insulin sensitivity (log 100/[insulin]), 0.68 units or lower; Pancreatic β‐cell response (log[100(insulin)/(glucose ‐50)]), 1.52 units or higher: Serum triglycerides, 73 mg/dl or higher; Body condition score, 6 or higher. The tentative cut‐offs are based on the total predictive power of each criteria, with each having a predictive power of 70% or higher. This PMLS in healthy ponies is analogous to the pre‐diabetic metabolic syndrome in apparently healthy people, and is the first such set of risk factors to be supported by data in horses. By the end of May 2004, 13 clinical cases of laminitis developed in the PL group, none in the NL group (p < 0.0001). These prospective results demonstrate the predictive value of the PLMS and encourage its further development as a means to identify ponies in special need of nutritional management to avoid laminitis.
Laminitic metabolic profile in genetically predisposed ponies involves exaggerated compensated insulin resistance
Authors: Hess T. M. , Kronfeld D. S. , Treiber K. H. , Byrd B. M. , Staniar W. B. , Splan R. K.
Published: November 2005

Twenty years ago Jeffcott and associates proposed a clinical syndrome of laminitis and hyperlipaemia that involved adrenal stress and insulin resistance in ponies predisposed to insulin resistance by a thrifty gene. Our primary purpose was to quantitatively determine a metabolic profile for this clinical syndrome. An inbred herd of 170 ponies had no clinical cases of laminitis in March, 2004, but 13 active cases developed at the end of May and were studied on day 1 or 2 of initial diagnosis. This was based on hesitant gait, posture, hoof temperature and bouncing digital pulse. All 13 cases of clinical laminitis (CL) developed in a group of 54 ponies that had previously been positive for laminitis (PL), while no cases developed (p < 0.0001) in the remaining 116 ponies that had never exhibited laminitis (NL). This result established the predictive value of a pre‐laminitic metabolic syndrome in apparently healthy ponies, which is a phenotypic representation of a genotype characterized as dominance with partial suppression that may be amenable to nutritional intervention. The advent of clinical laminitis occurred at the same time as an 83% increase (p = 0.039) of starch in the pasture, which was attributable to a rich growth of clover. Ponies were gathered, weighed, scored for body condition, and sampled for blood between 08:00 and 10:00 hours. Body condition scores were higher (p = 0.002) in the CL and PL groups (6.5 ± 0.1) than the NL (6.1 ± 0.1). Plasma analysis revealed higher (p < 0.001) concentrations of insulin in the affected group (92 ± 2, 32 ± 6 and 15 ± 2 μIU/ml in CL, PL and NL respectively) and triglycerides (58 ± 6, 44 ± 4, and 44 ± 4 mg/dl), but no differences were found for glucose, non‐esterified fatty acids, and cortisol. Plasma insulin and glucose concentrations were applied as proxies that indicate low insulin sensitivity and extremely high pancreatic β‐cell response, together indicating a transition state between compensated and uncompensated insulin resistance in the CL group that might be regarded as exaggerated compensation. For comparison, in two cases of subacute laminitis studies on the 8th day of the disease, insulin resistance was uncompensated. The effectiveness of the extreme pancreatic response in the prodromal stage is also indicated by the lack of hyperglycaemia and only mild elevation of serum triglycerides. Absence of hypercortisolaemia suggests that affected ponies were not undergoing adrenal stress. Collectively these results indicate a changing role of insulin resistance in laminitis: a compensated predisposing factor in healthy but genetically predisposed ponies, then a pathogenetic component as a transient exaggerated compensation during the advent of laminitis, and finally uncompensated insulin resistance later in the course of the disease.
Paediatric trauma
Authors: Holland AJA
Published: November 2005

Abstract:  Trauma remains the most common cause of death in childhood after the first year of life. It accounts for considerable morbidity that may extend into adult life at great cost to the community. Despite the scale of the disease, paediatric trauma and injury prevention research attract little funding. International data indicate that children in Australia and New Zealand would benefit from improved injury prevention strategies and the introduction of a more formalized paediatric trauma system. Such a system would need to take account of Australasian geographical and population distribution characteristics, which mandate local provision of expert and immediate care in rural areas. There would appear to be economic and clinical arguments for the introduction of an ambulance trauma bypass system for stable but severely injured children in metropolitan areas with a paediatric trauma centre.
Who's got what? A benchmarking exercise for tertiary neonatal units
Authors: Kuschel CA , Roy RN
Published: November 2005

Objectives: To determine the current facilities available in level‐3 neonatal units (NNU) in Australia and New Zealand to assist with establishment of standards for new NNU design.

Background: Many current NNU in Australia and New Zealand are planning new or redesigning existing facilities. There are no adequate local standards for NNU design available which reflect changing neonatal practices.

Methods: All level‐3 neonatal units belonging to the Australia and New Zealand Neonatal Network (ANZNN) were invited to respond to a survey on NNU facilities. Questions were based around obtaining information on whether the NNU were planning to build or redesign the space and clinical facilities available in their existing facilities and what support and family spaces were provided.

Results: Twenty‐six (six in New Zealand and 20 in Australia) of the 29 tertiary NNU in the ANZNN responded the survey. The oldest facility was built in 1960, with the most recent NNU being commissioned in 2003. Of the 26 responders, 18 indicated that they were planning to rebuild or renovate, with 13 anticipating completion within 6 years. The median floor area for existing level‐3 cots was 11.1 m2 (range 5.5–18.0 m2) and 5.8 m2 (range 2.3–15.6 m2) for level‐2 cots, respectively. Most units responded that storage space was insufficient (median 1.5 m2 per cot, range 0.4–3.3 m2 per cot). Most units had facilities for parents including a family lounge and parent overnight rooms, although 16 units indicated that they needed more overnight rooming in facilities. Noise levels in level‐3 areas were described as being ‘generally’ or ‘mostly noisy’ in 14 of 25 responses, but noise levels in level‐2 areas were less in the majority of responses. Privacy was cited as an issue for 80% of responding NNU with comments directed at either the layout or space constraints interfering with confidentiality or interactions with families.

Conclusions: The majority of NNU have inadequate space and environmental control. The lack of space particularly impacts on infection control aspects, parental privacy and participation and staff satisfaction. Level‐2 areas, where parent participation in the care of infants is often greater, should receive as much attention as higher technology level‐3 areas. Furthermore, work should be undertaken to develop appropriate local recommendations for NNU design which are acknowledged by local government agencies and professional bodies and take into account the changes in neonatal care practices, integration of family in the care of infants and the needs of the staff.
Childhood sleep‐disordered breathing and its implications for cardiac and vascular diseases
Authors: Ng DK , Chan C , Chow AS , Chow P , Kwok K
Published: November 2005

Objective: To systematically evaluate the recent literature regarding the relationship between childhood sleep‐disordered breathing (SDB)/obstructive sleep apnoea (OSA) and cardiovascular diseases in children.

Methods: The literature about SDB/OSA and blood pressure, sympathetic activation, arterial distensibility, ventricular hypertrophy and insulin resistance were studied. Meta‐analysis of risk of hypertension and high apnoea–hyponoea index were performed to calculate the combined odds ratio and it is equal to 2.93 (95% CI = 1.18–7.29).

Results: The results suggest a significant association between SDB/OSA and hypertension. However, the data are not adequate to draw firm conclusion although evidences were emerging to suggest that SDB/OSA affects blood pressure in either directions in children. Limited evidences also suggest that SDB/OSA is associated with increased sympathetic activation, decreased arterial distensibility and ventricular hypertrophy.

Conclusions: There is now increasing but not adequate evidence that childhood SDB/OSA is associated with detectable cardiovascular abnormalities.
Retrospective review of the management of simple febrile convulsions at a tertiary paediatric institution
Authors: Dunlop S , Taitz J
Published: November 2005

Objectives: To review the medical records of children presenting to a tertiary paediatric emergency department (ED) with febrile convulsions over a 3‐year period in order to assess quality of clinical practice.

Methods: The medical records of all children presenting to our ED with a discharge diagnosis of ‘simple febrile convulsion’ during the years 2001–03 were reviewed. Data was extracted based on the parameters of clinical presentation, diagnosis and management.

Results: A total of 288 patients were identified. The patients were separated into two groups – those that were discharged from the ED and those that were admitted to the hospital. Two hundred and sixty (84%) of the children were discharged from the ED. A further 28 (15%) patients were admitted to the ward. Of the children discharged from the ED, 78% had not been seen by a medical professional in the previous 24 h, 82% were diagnosed with a viral illness and clinical examination was normal in 88% of cases. A total of 36 out of 527 (6.8%) investigations performed on this group were abnormal. Most children (85%) had no clinical indication to necessitate investigation. Almost all (91%) were treated with antipyretics. The number of inappropriate investigations was directly linked to the inexperience of the treating medical officer. Of the 28 patients admitted to the hospital, 61% were diagnosed with a viral illness. A total of 15 out of 137 (10.9%) investigations were abnormal. Sixty‐one per cent of patients were admitted for less than 24 h, a further third of children for 48 h. Twenty of the 28 children had no parental education documented. None were readmitted with a simple febrile convulsion during the same illness.

Conclusions: Although many children who present to the hospital with simple febrile convulsions are managed appropriately, a large number are overinvestigated and overtreated, based on the clinical experience of the treating doctor. In these cases, medical record documentation can be improved. A clinical guideline based on our local fever guideline is suggested.
Paediatric home ventilatory support: The Auckland experience
Authors: Edwards EA , Hsiao K , Nixon GM
Published: November 2005

Objectives: To examine the trend over time, describe the disease categories treated, intervention success and outcomes of the children treated at home with continuous positive airway pressure (CPAP), non‐invasive ventilation (NIV) and ventilation via tracheostomy (invasive ventilatory support, IVS) by the Respiratory Service at the Starship Children's Hospital in Auckland.

Methods: A retrospective review was undertaken of the Respiratory Service records from November 1991 to February 2004.

Results: Home CPAP, NIV or IVS was initiated in 160 children (89 boys, median age 6 years) in the study period. Sixty‐nine (46 boys) remain on support and are still actively managed by the Starship Respiratory Service, of whom 46% live outside the Greater Auckland Region. Despite 42% of children being less than 5 years of age at initiation of therapy, institution of support failed in only 11%. The majority received treatment by non‐invasive mask interface (68% (n = 108) CPAP, 29% (n = 47) NIV), with only 3% (n = 5) supported via tracheostomy. The numbers and complexity of support rose over the 12 years. Respiratory support was discontinued in 57% of cases, after a median of 12.5 months (range 3–52 months); in two‐thirds, support was no longer required due to an improvement in the medical condition. The most common indication for support in current patients is respiratory parenchymal or airway disease followed by neuromuscular disease. Obesity is not a common indication.

Conclusion: This review documents the increasing trend in children receiving respiratory support at home. Future planning and resources are needed to address this growing need.
Feasibility and safety of early transfer of premature infants from incubators to cots: A pilot study
Authors: West CR , Williams M , Weston PJ
Published: November 2005

Objectives: To document whether medically stable infants can be transferred safely from incubators to unheated, open cots at 1500 g.

Methods: Four cohorts were recruited in a stepwise observational trial of transfer from incubators to unheated, open cots. We aimed to transfer the first 15 infants into cots on reaching a weight of 1800 g, the second at 1700 g, the third at 1600 g and the fourth at 1500 g. Nursery temperatures were set at 25°C. The primary outcome measure was failure of transfer defined as the inability to maintain body temperatures in a cot despite additional coverings, with two consecutive axillary temperatures below 36.6°C 1 h apart. Secondary aims were to determine temperature stability, growth, medical complications and time to discharge for these infants. Weight and corrected gestation at discharge were recorded.

Results: A total of 61 infants were recruited and transferred into cots. Cohorts were similar in gestation and sex. Infants recruited to the 1500 g cohort had higher birthweights than the other cohorts. There was no difference in the rate of infants failing transfer into cots between cohorts. Rate of weight gain before and after transfer and the number of high and low temperatures per infant after transfer was not different between cohorts. There were no differences between cohorts for discharge weight or corrected gestation.

Conclusions: The results of this pilot study indicate the potential to transfer very low birthweight infants to an open unheated cot at a bodyweight of 1500 g. This study provides information for the design of future randomized controlled trials that are required to confirm the findings of this study before routine adoption of this intervention into clinical practice.
Vitamin A and E deficiency and lung disease in infants with cystic fibrosis
Authors: Bines JE , Truby HD , Armstrong DS , Carzino R , Grimwood K
Published: November 2005

Objectives: Vitamin A and E deficiency is common in cystic fibrosis (CF). These vitamins have immunomodulating properties and we determined whether decreased serum vitamin A and E levels in young infants are associated with early CF lung disease and lower airway inflammation.

Methods: A post‐hoc analysis was undertaken on previous data collected prospectively in 39 newly diagnosed infants identified by a newborn CF screening programme. Assessment of CF genotype, nutrition, pancreatic status, serum retinol and α‐tocopherol levels was performed at diagnosis. Pulmonary status was determined clinically, by Brasfield chest radiographic scores and analysis of bacterial counts and inflammatory indices in bronchial lavage (BL) fluid. These assessments were repeated 12 months later.

Results: At diagnosis, 20 out of 39 (51%) CF infants had low serum retinol (mean (SD) 0.7 (0.3) μmol/L) and 9/38 (24%) had low α‐tocopherol (mean (SD) 13.4 (8.4) μmol/L) levels. Dietary energy intake was related to serum retinol concentrations at diagnosis (r2 = 0.27; P = 0.001). At 1 year, serum retinol and α‐tocopherol levels had normalized following vitamin A and E supplementation. Respiratory symptoms, radiographic scores and BL inflammatory indices systematically deteriorated during infancy, reaching significance for free neutrophil elastase activity (9 out of 29 vs 21 out of 33; P = 0.01) and IL‐8 levels (79 vs 416; P = 0.046) in BL fluid. No association was seen between serum vitamin levels at diagnosis and airway inflammatory indices at either diagnosis or 12 months later.

Conclusion: We found in this CF birth cohort no evidence to implicate vitamin A or E deficiency in the development of lung disease or airway inflammation during infancy.
Interpretation of recent sudden infant death syndrome rates in Western Australia
Authors: Freemantle CJ , Read AW , De Klerk NH , Charles AK , McAullay D , Stanley FJ
Published: November 2005

Abstract:  The diagnosis of sudden infant death syndrome (SIDS) has undergone several changes in definition since first being recognised as a cause of death. Linked total population data from Western Australia enable investigations to determine changes in classifications of mortality for the infants of Aboriginal and non‐Aboriginal mothers (Aboriginal and Torres Strait Islander people are referred to throughout this report as ‘Aboriginal’). Data for recent years show a shift away from a classification of ‘SIDS’ towards a classification of ‘unascertainable’, particularly for Aboriginal infants. This has implications for the accurate translation of data into policy and practice.
Mycoplasma pneumoniae infections in Australian children
Authors: Othman N , Isaacs D , Kesson A
Published: November 2005

Objectives: To describe the epidemiology, clinical features and outcome of Mycoplasma pneumoniae infection in children presenting to a tertiary children's hospital.

Methods: Sixty‐three month retrospective review of serologically diagnosed M. pneumoniae infections.

Results: There were 76 children, 42 boys and 34 girls, mean age 6.3 ± 3.5 years. The age group most commonly affected was 5–9 years, followed by children 1–5 years. More than half of the patients had failed to respond to antibiotics before referral. The commonest presentation was with cough and fever. Coryza, diarrhoea, vomiting, tachypnoea and recession were significantly more common in children less than 5 years than in children 5–15 years. Hospitalized patients were more likely than non‐hospitalized patients to have respiratory distress with recession and wheeze. Radiographic findings were non‐specific. Thrombocytosis was found in 29 (41.4%) of 70 children studied.

Conclusion: The clinical features of M. pneumoniae infection were different in children less than 5 years than in children aged 5–9 years. The presence of thrombocytosis in 40% of the cases has not previously been reported in children.
Obligation of clinicians to treat unwilling children and young people: An ethical discussion
Authors: Zutlevics TL , Henning PH
Published: November 2005

Abstract:  The refusal of a child or young person to comply with a clinician's recommendations for treatment creates a challenging ethical problem. We describe an approach that seeks to balance the clinician's duty of care to their patient with the need to respect and indeed foster the developing sense of autonomy in young people. Central to this approach is a theory in which the standard of competence required of a patient is flexible and commensurate with the level of medical risk inherent in the decision. High‐risk situations require an exacting standard for the determination of competence whereas a lower standard may be accepted where risk is relatively minor. The argument also allows that levels of competence may fluctuate as a result of illness itself and be influenced by social and cultural factors to which a child is perhaps particularly prone. The obligations of treating clinicians in these circumstances are complex but we believe that a moral framework can be offered that clinicians will find useful in the treatment of unwilling children.
Occult carotid pseudoaneurysm following streptococcal throat infection
Authors: Mordekar SR , Bradley PJ , Whitehouse WP , Goddard AJP
Published: November 2005

Abstract:  Pseudoaneurysm of the internal carotid artery (PAICA) is a rare complication of neck space infection. An 8‐year‐old girl presented with odynophagia (painful swallowing), trismus and left peritonsillar swelling. Abscess was suspected, but aspiration was dry. The PAICA was diagnosed on computed tomography. The aneurysm and involved left internal carotid artery were occluded endovascularly. She has made an uneventful recovery.
Severe colonic diverticulitis in an adolescent with Williams syndrome
Authors: Deshpande AV , Oliver M , Yin M , Goh TH , Hutson JM
Published: November 2005

Abstract:  Williams Syndrome (WS) is a condition with multisystemic involvement caused by a genetic deletion in chromosome 7. Colonic diverticulosis has been described in adults with WS; however, it has not previously been reported in adolescents with WS. We report an adolescent boy with WS who developed complicated colonic diverticulitis and briefly review the possible aetiology of diverticular disease.
Clostridium difficile associated severe enterocolitis: A feature of Hirschsprung's disease in a neonate presenting late
Authors: Parsons SJ , Fenton E , Dargaville P
Published: November 2005

Abstract:  We report a case of Hirschsprung's disease presenting late in the newborn period with severe enterocolitis and Clostridium difficile toxin detectable in the stool. Enterocolitis associated with Hirschsprung's disease is a potentially fatal complication that may occur at presentation or later in the life of an affected child. Its association with toxin‐producing Clostridium difficile growth in the bowel may be under recognized, especially in newborns.
Rectal atresia
Authors: Kisra M , Alkadi H , Zerhoni H , Ettayebi F , Benhammou M
Published: November 2005

Abstract:  Rectal atresia is a rare condition, with a reported incidence of 1–2% of all anorectal anomalies. The extensive list of ingenious operative procedures used for the correction of this malformation is testimony to the great difficulty faced in treating this anomaly. Posterior sagittal anorectoplasty using end‐to‐end anastomosis is a safe, technically well known that achieves this goal.
Management of attention deficit hyperactivity disorder: A parental perspective
Authors: Concannon PE , Tang YP
Published: November 2005

Objectives: There are few studies exploring parental perceptions of the diagnosis and overall treatment of their children with attention deficit hyperactivity disorder (ADHD). This community‐based study was conducted to consider this important aspect of care.

Methods: A total of 7 226 (65%) parents responded to a community survey of 11 184 children aged 10–12 years living in northern Sydney in 2000, out of which 278 children with ADHD were identified. Their parents completed an anonymous questionnaire covering their perceptions relating to diagnosis, treatment and overall management.

Results: Only 66% of parents recalled the use of questionnaires or rating scales. There were 82% of children who had trialed medication and 66% of these were still taking it. Behavioural intervention had occurred in 42% of the children. Non‐conventional treatments, most commonly elimination diet and/or fatty acid supplementation, had been used in 71% of the children. These were considered helpful in one‐third of cases.

A total of 55% of parents reported being either satisfied or very satisfied with their child's care. Parents were more likely to report satisfaction when their children were on medication and when reviews were held at least 6 monthly. Lack of educational support and teachers' understanding of ADHD were identified as ongoing issues.

Conclusion: Parental responses suggested that adherence to recommended diagnostic guidelines was inadequate. Behavioural intervention was underutilized despite its documented positive role. Non‐conventional therapies were widely used and considered helpful in one‐third of the children who used them.

Use of stimulant medication and frequent reviews were more likely to be associated with overall management satisfaction.
Recurrent parotitis of childhood
Authors: Leerdam CM , Martin HCO , Isaacs D
Published: November 2005

Background: Recurrent parotitis (RP) of childhood is a rare condition of unknown aetiology, probably immunologically mediated.

Objective: To review the clinical presentation, diagnosis and management of RP of childhood.

Methods: Retrospective study from 1983 to 2004 of children diagnosed with RP of childhood at a tertiary children's hospital.

Results: We identified 53 children, 37 (70%) male and 16 (30%) female. The age of onset was biphasic, with peaks at 2–5 years of age and at 10 years. The commonest symptoms were swelling (100%), pain (92.5%) and fever (41.5%). Symptoms usually lasted 2–7 days with a median of 3 days. The mean frequency was 8 episodes per year. The diagnosis was often delayed, >1 year in 70% of patients, maximum 8 years. The most common diagnoses, before the definitive diagnosis of RP, were mumps (21%), ‘infection’ (15%) and stones (11%). Sialogram (57%) and/or ultrasound (41%) showed sialectasis in 81% of patients. Over half the patients (54%) were given antibiotics at least once to treat the parotitis.

Two children had hypogammablobulinaemia, one child had human immunodeficiency virus infection, and one child had Sjogren's syndrome. Two children had high titre antinuclear antibodies.

Conclusions: Recurrent parotitis had a biphasic age distribution. The major clinical features that distinguish it from other causes of parotid swelling are the lack of pus and recurrent episodes. A clinical diagnosis can often be confirmed by ultrasound. Antibiotics do not have a role in treatment. Affected children should be screened for Sjogren's syndrome and immune deficiency.
Potential distribution of the Asian disease vector Culex gelidus Theobald (Diptera: Culicidae) in Australia and New Zealand: a prediction based on climate suitability
Authors: Williams Craig R , Ritchie Scott A , Whelan Peter I
Published: November 2005

Abstract  Culex gelidus has a wide distribution throughout Asia, where it is a vector of Japanese encephalitis. It was first detected in Australia in 1999, with archived material revealing an introduction sometime prior to 1994. It is currently widely distributed throughout northern and particularly north‐eastern Australia. Using climate matching software (CLIMEX Version 1.1) and the known distribution of Cx. gelidus throughout Asia, a predicted distribution for Australasia based on current climate was developed. A potentially wide distribution throughout coastal Australia, particularly in tropical and subtropical areas, was revealed. Few inland locations were suitable, except in tropical areas of the Northern Territory and Queensland. The predicted distribution presented here is concordant with most recent collection records of Cx. gelidus in Australasia. However, there are a small number of exceptions which highlight some of the limitations of this approach for predicting mosquito distributions. The presence of Cx. gelidus in a large artificial swamp in Alice Springs is one such example. The predicted Cx. gelidus distribution incorporates highly populated areas, in which people may experience an increased risk of mosquito‐borne viral encephalitis should this mosquito spread throughout its entire predicted range.
Percutaneous closure of patent foramen ovale
Authors: Bijl J. M. , Ruygrok P. N. , Hornung T. S. , Wilson N. J. , West T.
Published: November 2005

Abstract

Aim: To review the safety and efficacy of percutaneous closure of patent foramen ovale (PFO) in symptomatic patients without the use of general anaesthesia or echocardiographic guidance.

Method: All patients accepted for percutaneous PFO closure by our service from August 2002 to August 2004 were included. Patient demographics and clinical information were obtained from clinical records and by telephone interview. Follow‐up outcomes recorded were recurrence of systemic thromboembolism, residual shunt, and change in pattern of migraines.

Results: Forty consecutive adult patients, of whom 19 (48%) had an atrial septal aneurysm (ASA), underwent PFO closure using the Amplatzer occluder device with fluoroscopic guidance alone. Their mean age was 45 ± 10 years (range 23–63 years) and 24 (60%) were male. The indications for closure were ischaemic stroke (n = 26), transient ischaemic attack (TIA) (n = 8), both stroke and TIA (n = 2), refractory hypoxia (n = 2), platypnoea‐orthodeoxia (n = 1) and severe migraine with seizures (n = 1). Twenty patients suffered a single neurological event and 16 suffered >1 event, including six with only radiographic evidence of >1 event. Mean procedure time was 17.7 ± 9.6 min and fluoroscopy time was 6.7 ± 7.3 min. Implanted device sizes were 18 mm (n = 1), 25 mm (n = 37) and 35 mm (n = 2). In 33 patients, the procedure was performed as a day‐case. No complications were encountered. No further neurological events occurred in 39 patients at a mean follow‐up time of 11 ± 7 months (3–25 months) nor was a significant shunt detected in the 34 who underwent follow‐up echocardiography.

Conclusions: Percutaneous closure of PFO with or without ASA, under local anaesthesia and without echocardiographic guidance, is a safe and effective procedure which can be performed as a day‐case. This has now become our standard clinical practice. (Intern Med J 2005; 35: 706–710)
Symptomatic hypocalcaemia and renal impairment associated with bisphosphonate treatment in patients with multiple myeloma
Authors: Henley D. , Kaye J. , Walsh J. , Cull G.
Published: November 2005

Abstract

We report three cases of severe hypocalcaemia associated with i.v. bisphosphonate treatment in patients with multiple myeloma. All patients had symptomatic hypocalcaemia, including a tonic‐clonic seizure and tachyarrhythmia in one case. Two cases were associated with the development of acute renal failure, whereas the third patient had pre‐existing renal impairment. We recommend that bisphosphonates be used with caution in patients with myeloma and renal impairment, that vitamin D deficiency be corrected prior to treatment (to reduce the risk of hypocalcaemia) and that serum calcium and renal function be monitored during treatment. (Intern Med J 2005; 35: 726–728)
Printed patient education interventions to facilitate shared management of chronic disease: a literature review
Authors: Harris M. , Smith B. , Veale A.
Published: November 2005

Abstract

Background: Printed materials for patient self‐education are a comparatively low cost, flexible and potentially useful aid for dealing with the growing burden of chronic disease in our society. A comprehensive review of existing trials is required.

Aims:  We conducted a comprehensive review which aimed to (i) evaluate the evidence for effectiveness of print‐only interventions in increasing patient participation in chronic disease management and (ii) identify disease or intervention characteristics associated with success.

Methods:  Medline, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL were searched for the period 1992 to January 2005 for reports of controlled trials of printed patient materials in chronic disease. The quality of both studies and interventions was assessed.

Results:  Seven studies were found. They focussed on inflammatory bowel disease, arthritis, asthma and diabetes. Few studies named primary outcomes, continued beyond 6 months or included process evaluations. Few reports gave the behaviour‐change rationale of the intervention. Few interventions were reported as having been designed using testing and improvement, psychosocial theory, checks of patient understanding or other patient input. A variety of outcomes was measured. Statistically significant change was found for few. Knowledge improved in three studies, adherence improved in two and quality of life declined in one.

Conclusions:  We found that printed interventions as currently designed appear to produce, at best, modest benefits. The design of interventions, studies and study reports all need improvement before decisions can be made about effectiveness and characteristics associated with success. (Intern Med J 2005; 35: 711–715)
Severe community‐acquired pneumonia: an Australian perspective
Authors: Wilson P. A. , Ferguson J.
Published: November 2005

Abstract

Background:  Severe community‐acquired pneumonia (CAP) is a common disease with a relatively high mortality. The initial treatment is empirical, based on a broad range of potential pathogens. There are minimal published data describing microbiological causes of pneumonia in Australia.

Aims:  To describe the aetiology and characteristics of severe CAP in patients requiring intensive care unit (ICU) admission, to identify factors predicting mortality and to audit current practices of investigation and antibiotic management of these patients from an Australian perspective.

Methods:  A retrospective analysis of patient case notes was performed for 96 consecutive patients admitted to two ICU with severe CAP. Data recorded included patient demographics, comorbidities, antimicrobial treatment, investigations and outcome (mortality, length of stay).

Results:  Overall, mortality was 32%. A microbiological diagnosis was made in 46% of patients. The most frequent causative organisms were Streptococcus pneumoniae (13 cases), influenza A (9), Haemophilus influenzae (5) and Staphylococcus aureus (4); aerobic Gram‐negative bacilli collectively accounted for five cases. Blood cultures were positive in 20% of patients. Seventy patients (73%) required mechanical ventilation and 61 patients (63%) required inotropic support. Laboratory abnormalities including acute renal failure, metabolic acidosis and coagulopathy were frequent. Factors associated with mortality on multivariate analysis were age, antibiotic administration prior to hospital presentation, delay in hospital antibiotic administration of more than 4 h, and presence of multilobar or bilateral consolidation on chest X‐ray.

Conclusions:  Severe CAP requiring ICU admission was associated with a mortality rate of 32%, despite appropriate antimicrobial therapy including a beta‐lactam and a macrolide antibiotic in most cases. Causative organisms identified were similar to those found in previous studies. High rates of viral causes (28% of identified pathogens) were noted. Low rates of legionellosis and other atypical causes were found, most probably due to a lack of systematic testing for these agents. (Intern Med J 2005; 35: 000–000)
Doubling daily inhaled corticosteroid dose is ineffective in mild to moderately severe attacks of asthma in adults
Authors: Rice‐McDonald G. , Bowler S. , Staines G. , Mitchell C.
Published: November 2005

Abstract

Background:  Asthma guidelines recommend increasing or doubling inhaled corticosteroid (ICS) dose to treat mild and moderate exacerbations of asthma in adults.

Aim:  To: (i) compare the effectiveness of doubling existing daily ICS dose (fluticasone) with maintaining usual ICS dose and usual daily ICS dose accompanied by oral steroids (OS) (dexamethasone) during mild and moderately severe exacerbations of asthma in adults; (ii) examine determinants of success and failure; and (iii) compare side‐effect profiles.

Methods:  A randomized, double‐blind, placebo‐controlled (double‐dummy), triple crossover trial. Participants acted as their own control. Outcome measures included treatment success/failure, peak expiratory flow (PEF) after 7 days therapy or at treatment failure, and side‐effects.

Results:  From 22 participants (nine males and 13 females), 18 pairs of data were available for maintaining usual ICS versus doubling ICS and doubling ICS versus OS, and 19 for maintaining usual ICS versus OS. Median (fifth–95th percentile) age was 46.5 (32–64) years and forced expiratory volume in one second (FEV1) 73% (29–97%) predicted. The outcome after doubling ICS was not superior to maintaining usual ICS, with 11 (61%) failures in both arms (P = 0.66). OS, with only 5 (26%) failures, was superior to maintaining usual ICS with 12 (63%) failures (P = 0.04), and to doubling ICS with 5 (28%) versus 11 (61%) failures (P = 0.07). Median PEF (as percentage of run‐in best) at end‐points were 90.5% (57.1–177.1) for OS, 78.3% (39.5–103.1) for maintaining usual ICS and 77.9 (27.7–110.3) for doubling ICS. Neither gender nor PEF at exacerbation were predictive of failure. Although doubling ICS was not an effective therapy overall, ICS dose at exacerbation were predictive of success in the doubling ICS arm (P = 0.04). Treatment failures when doubling daily ICS dose were more common if achieved fluticasone dose was less than 2000 µg (three of 11, 73%) compared to 2000 µg or greater (eight of eight, 37.5%). Increasing age and the presence of an upper respiratory tract infection (URTI) were predictive of failure with OS. Side‐effects were more commonly reported with OS (52.6%) than doubling ICS (42.1%) or maintaining usual ICS (19.1%) with the most common being mood changes (36.8%), sleep disturbance (31.6%) and changes in appetite (26.3%).

Conclusions:  Doubling daily ICS dose per se is not effective for the treatment of mild to moderately severe exacerbations of asthma in adults. Success may depend on achieved ICS dose. Oral steroids are effective, but side‐effects are common. A review of current guidelines may be warranted. (Intern Med J 2005; 35: 693–698)
Warfarin induction at 5 mg daily is safe with a low risk of anticoagulant overdose: results of an audit of patients with deep vein thrombosis commencing warfarin
Authors: Harper P. , Monahan K. , Baker B.
Published: November 2005

Abstract

Background:  Conventionally warfarin therapy is initiated using a loading dose given over several days. Daily international normalised ratio (INR) monitoring is recommended to prevent overdose; however, with a large proportion of patients with deep vein thrombosis now receiving treatment out of hospital daily blood tests are inconvenient. We introduced a low‐dose protocol for starting anticoagulant therapy that only required INR testing on days 4 and 6 and audited the results to assess safety and efficacy.

Methods: Two‐hundred and forty‐eight patients with confirmed deep vein thrombosis were started on warfarin therapy at 5 mg daily for 3 days. INR measurements were taken at day 4 and day 6.

Results:  Of these patients, 21% had an INR within the therapeutic range on day 4 and 52% had a therapeutic INR on day 6. The risk of overdose was small with only one case with an INR above 4.0 on day 4 and nine cases on day 6. There were no reported cases of bleeding.

Conclusion: The low‐dose protocol with infrequent testing is safe and convenient for outpatient management. However, our results suggest that patients on this protocol take between 6–10 days to achieve a stable INR. (Intern Med J 2005; 35: 717–720)
Attention deficit disorder: not just for children
Authors: Clarke S. , Heussler H. , Kohn M. R.
Published: November 2005

Abstract

Attention deficit/hyperactivity disorder (ADHD) has long been described in children who demonstrate developmentally inappropriate symptoms of inattention, impulsivity and motor restlessness. In adults, symptoms are known to persist and the validity of adult ADHD as an entity is now recognized. There is an associated high proportion of other serious psychiatric comorbidities, especially substance abuse, mood and anxiety disorders. Advances have been made into the aetiology and management of ADHD. Many of these focus on the dopamine and noradrenaline pathways. (Intern Med J 2005; 35: 721–725)
Effect of copper and zinc supplementation on peripheral leukocytes in neutropenia due to copper deficiency
Authors: Kikuchi Motoo , Inagaki Toshiaki , Hanaki Hidekazu
Published: November 2005

Background:  Recent quantitative and qualitative studies in animals suggest that copper deficiency causes immunological impairment and a decrease in leukocytes. We investigated the effect of copper supplementation in remedying these effects of its deficiency and whether zinc, a trace element that is significant to the immune status modifies such effects.

Methods:  In the present investigation, the effects of copper supplementation on circulating lymphocyte levels of 18 patients (aged 61–98 years, mean 85 years) with severe copper deficiency, elicited by a long‐term low copper diet, were examined in comparison with six age and sex‐matched healthy elderly subjects. Every day for 28 days, 2 mg of copper sulfate was added to the diets of 12 of the copper‐deficient subjects. The remaining copper‐deficient subjects received 2 mg of copper sulfate daily in their diets and were also given 17.3 mg of zinc sulfate every day by intravenous infusion, both supplements were also given for 28 days. Two‐color flow‐cytometry was conducted and the blastogenesis of circulating lymphocytes was examined.

Results:  Copper supplementation increased the number of circulating CD2+, CD4+, CD20+ cells without affecting numbers of NK‐type CD8+ T cells (CD11b+ and CD57+ lymphocytes). The percentage of monocytes to total leukocytes decreased after copper supplementation. Zinc supplementation, however, did not augment these effects and did not increase the total number of CD57+ cells. The ratio of pokeweed mitogen reactivity to concanavalin‐A reactivity was diminished by copper supplementation but not additional zinc. There was no change in the immunological colloid reaction in the zinc sulfate turbidity test.

Conclusion:  Our results suggest that copper depletion has a deleterious effect on the immune system, with a decrease in circulating lymphocytes numbers. Monocytes seemed to be more resistant to copper deficiency than neutrophils, and to play a significant role in lymphocyte activation. Despite this, however, it seems unlikely that there is any synergy between copper supplementation and zinc supplementation.