Adverse drug reactions in hospitalized children in Germany are decreasing: results of a nine year cohort-based comparison

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Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analgesia in a UK paediatric hospital

Background Administering nurse/patient controlled analgesia (N/PCA) to children requires complex dose calculations and multiple manipulations to prepare morphine solutions in 50 mL syringes for administration by continuous infusion with additional boluses. Objective To investigate current practice and accuracy during preparation of morphine N/PCA infusions in hospital theatres and wards at a UK children's hospital. Methods Direct observation of infusion preparation methods and morphine concentration quantification using UV-Vis spectrophotometry. The British Pharmacopoeia specification for morphine sulphate injection drug content (±7.5 %) was used as a reference limit. Results Preparation of 153 morphine infusions for 128 paediatric patients was observed. Differences in preparation method were identified, with selection of inappropriate syringe size noted. Lack of appreciation of the existence of a volume overage (i.e. volume in excess of the nominal volume) in morphine ampoules was identified. Final volume of the infusion was greater than the target (50 mL) in 33.3 % of preparations. Of 78 infusions analysed, 61.5 % had a morphine concentration outside 92.5-107.5 % of label strength. Ten infusions deviated by more than 20 %, with one by 100 %. Conclusions Variation in morphine infusion preparation method was identified. Lack of appreciation of the volume overage in ampoules, volumetric accuracy of different syringe sizes and ability to perform large dilutions of small volumes were sources of inaccuracy in infusion concentration, resulting in patients receiving morphine doses higher or lower than prescribed

Standardised concentrations of morphine infusions for nurse/patient-controlled analgesia use in children

BACKGROUND: Standardizing concentrations of intravenous infusions enables pre-preparation and is effective in improving patient safety by avoiding large deviations from the prescribed concentration that can occur when infusions are made individually in wards and theatres. The use of pre-prepared morphine standardized concentration infusions for paediatric nurse/patient-controlled analgesia (N/PCA) has not been previously investigated. We aimed to establish, implement and evaluate standardized concentrations of morphine in pre-filled syringes (PFS) for use in paediatric N/PCA. METHODS: Concentrations of morphine in PFS for N/PCA were identified that accommodated dosage variation across a 1-50 kg weight range. The use of infusions in PFS was implemented and evaluated using mixed methods involved direct observation of healthcare professionals (HCPs), focus groups and failure mode and effects analysis, a HCP survey and medication incident reports analysis. RESULTS: Standardized concentrations, 3 mg, 10 mg and 50 mg morphine in 50 mL sodium chloride 0.9%, delivered prescribed continuous and bolus doses using programmable smart pumps with variable infusion rates. During the implementation, 175 morphine pre-prepared infusions were administered to 157 children (9.4 ± 5.1 years) in theatres and wards. Time taken to set up a N/PCA was 3.7 ± 1.7 min, a reduction of one third compared with the previous system. The number of incidents associated with N/PCA infusions was reduced by 41.2%, and preparation errors were eliminated. HCPs reported using morphine PFS was an easier and safer system. CONCLUSION: A system using pre-prepared standardized concentrations of morphine for paediatric N/PCA was implemented successfully and sustainably

GAPPS (Grading and Assessment of Pharmacokinetic-Pharmacodynamic Studies) a critical appraisal system for antimicrobial PKPD studies - development and application in pediatric antibiotic studies

Introduction: There are limited data on optimal dosing of antibiotics in different age groups for neonates and children. Clinicians usually consult pediatric formularies or online databases for dose selection, but these have variable recommendations, are usually based on expert opinion and are not graded based on the existing pharmacokinetic-pharmacodynamic (PKPD) studies. We describe here a potential new tool that could be used to grade the strength of evidence emanating from PKPD studies. Areas covered: A scoring system was developed (GAPPS tool) to quantify the strength of each PK assessment and rate the studies quality in already published articles. GAPPS was evaluated by applying it to pediatric PKPD studies of antibiotics from the 2019 Essential Medicines List for children (EMLC), identified through a search of PubMed. Expert opinion: Evidence for most antibiotic dose selection decisions was generally weak, coming from individual PK studies and lacked PKPD modeling and simulations. However, the quality of evidence appears to have improved over the last two decades. Incorporating a formal grading system, such as GAPPS, into formulary development will provide a transparent tool to support decision-making in clinical practice and guideline development, and guide PKPD authors on study designs most likely to influence guidelines

Deviation from Tri-Bimaximal Mixing and Large Reactor Mixing Angle

Recent observations for a non-zero $\theta_{13}$ have come from various experiments. We study a model of lepton mixing with a 2-3 flavor symmetry to accommodate the sizable $\theta_{13}$ measurement. In this work, we derive deviations from the tri-bimaximal (TBM) pattern arising from breaking the flavor symmetry in the neutrino sector, while the charged leptons contribution has been discussed in a previous work. Contributions from both sectors towards accommodating the non-zero $\theta_{13}$ measurement are presented.Comment: 25 pages, 12 figures. arXiv admin note: text overlap with arXiv:1109.232

SU(3) Gauge Family Symmetry and Prediction for the Lepton-Flavor Mixing and Neutrino Masses with Maximal Spontaneous CP Violation

A model for the lepton-flavor mixing and CP violation is proposed based on the SU$_F$(3) gauge family symmetry and the Majorana feature of neutrinos. A consistent prediction for the lepton-flavor mixing and masses is shown to be resulted from the appropriate vacuum structure of SU$_F$(3) gauge symmetry breaking. By choosing the SU$_F$(3) gauge fixing condition to possess a residual $Z_2$ symmetry and requiring the vacuum structure of spontaneous symmetry breaking to have approximate global U(1) family symmetries, we obtain naturally the tri-bimaximal mixing matrix and largely degenerate neutrino masses in the neutrino sector and the small mixing matrix in the charged-lepton sector. With a simple ansatz that all the smallness due to the approximate global U(1) family symmetries is characterized by a single Wolfenstein parameter $\lambda \simeq 0.22$, and the charged-lepton mixing matrix has a similar hierarchy structure as the CKM quark mixing matrix, we arrive at a consistent prediction for the MNSP lepton-flavor mixing with a maximal spontaneous CP violation: $\delta =\pi/2$, $\sin^2\theta_{13} \simeq 1/2\lambda^2 \simeq 0.024$ ($\sin^22\theta_{13} \simeq 0.094$), $\sin^2\theta_{12} \simeq 1/3{3}(1 - 2\lambda^3) \simeq 0.326$ and $\sin^2\theta_{23} \simeq 1/2(1 - \lambda^2) \simeq 0.48$, which agree well with the current experimental data. The CP-violating Jarlskog-invariant is obtained to be $J_{CP} \simeq 1/6\lambda(1-\lambda^2/2-\lambda^3)\sin\delta \simeq 0.035$, which is detectable in next generation neutrino experiment. The largely degenerate neutrino masses with the normal hierarchy and inverse hierarchy are discussed and found be at the order $m_{\nu_i} \simeq O(\lambda^2) \simeq 0.04\sim 0.06$ eV with a total mass $\sum m_{\nu} \sim 0.15$ eV, which is testable in future precision astrophysics and cosmology.Comment: 14 pages, it is explicitly shown that the smallness for both the charged-lepton mixing and neutrino masses with the standard seesaw mechanism can naturally be explained by the approximate global U(1) family symmetries of vacuum structure in the SU(3) gauge family model, references added, published version in PL

“There's very little that you can do other than refer them to the doctor if you think they've got postnatal depression”: Scoping the potential for perinatal mental health care by community pharmacists: Community pharmacists and perinatal mental health

Background: Twenty percent of women in the UK develop perinatal mental health (PMH) problems, which have widespread effects on maternal and child health. Community pharmacists are ideally placed to identify PMH problems and refer to other trained healthcare professionals. Objective: This study explored community pharmacists’ attitudes, current counselling practices, and barriers to providing mental health advice to perinatal women. Methods: A qualitative focus group study was performed virtually with community pharmacists (n = 11), working in urban settings across London. A topic guide was used to cover current counselling practice, barriers to and confidence in counselling women, and thoughts on potential pharmacist-led perinatal mental health services. The focus groups were recorded, transcribed, and analysed using thematic analysis. Results: Three themes were identified: Doing Mental Health Care; Willing, but Unable; and Introspection and reflection, which were related through a central organising concept of ‘Perinatal mental health care as a new frontier for community pharmacy’. It was found that while community pharmacists provide mental health advice to perinatal women and their partners, they lacked confidence, which was related to a lack of knowledge and inadequate training opportunities. Organisational barriers were identified including a lack of a formal referral pathway to existing mental health services and other trained healthcare professionals. Perceptions of opportunities and recommendations for service improvement and change were also garnered. Conclusion: This study demonstrates community pharmacists have a potential role within community mental healthcare in identification of PMH problems and providing appropriate advice and support. Upskilling community pharmacists in mental health should be considered to increase knowledge and confidence while formal referral pathways to other trained healthcare professionals and existing services should be established and made available to pharmacists

Comparison of two novel MRAS strategies for identifying parameters in permanent magnet synchronous motors

Two Model Reference Adaptive System (MRAS) estimators are developed for identifying the parameters of permanent magnet synchronous motors (PMSM) based on Lyapunov stability theorem and Popov stability criterion, respectively. The proposed estimators only need online detection of currents, voltages and rotor rotation speed, and are effective in the estimation of stator resistance, inductance and rotor flux-linkage simultaneously. Their performances are compared and verified through simulations and experiments. It shows that the two estimators are simple and have good robustness against parameter variation and are accurate in parameter tracking. However, the estimator based on Popov stability criterion, which can overcome the parameter variation in a practical system, is superior in terms of response speed and convergence speed since there are both proportional and integral units in the estimator in contrast to only one integral unit in the estimator based on Lyapunov stability theorem. In addition, there is no need of the expert experience which is required in designing a Lyapunov function

Left atrial voltage, circulating biomarkers of fibrosis, and atrial fibrillation ablation. A prospective cohort study.

Aims To test the ability of four circulating biomarkers of fibrosis, and of low left atrial voltage, to predict recurrence of atrial fibrillation after catheter ablation. Background Circulating biomarkers potentially may be used to improve patient selection for atrial fibrillation ablation. Low voltage areas in the left atrium predict arrhythmia recurrence when mapped in sinus rhythm. This study tested type III procollagen N terminal peptide (PIIINP), galectin-3 (gal-3), fibroblast growth factor 23 (FGF-23), and type I collagen C terminal telopeptide (ICTP), and whether low voltage areas in the left atrium predicted atrial fibrillation recurrence, irrespective of the rhythm during mapping. Methods 92 atrial fibrillation ablation patients were studied. Biomarker levels in peripheral and intra-cardiac blood were measured with enzyme-linked immunosorbent assay. Low voltage (<0.5mV) was expressed as a proportion of the mapped left atrial surface area. Follow-up was one year. The primary endpoint was recurrence of arrhythmia. The secondary endpoint was a composite of recurrence despite two procedures, or after one procedure if no second procedure was undertaken. Results The biomarkers were not predictive of either endpoint. After multivariate Cox regression analysis, high proportion of low voltage area in the left atrium was found to predict the primary endpoint in sinus rhythm mapping (hazard ratio 4.323, 95% confidence interval 1.337–13.982, p = 0.014) and atrial fibrillation mapping (hazard ratio 5.195, 95% confidence interval 1.032–26.141, p = 0.046). This effect was also apparent for the secondary endpoint. Conclusion The studied biomarkers do not predict arrhythmia recurrence after catheter ablation. Left atrial voltage is an independent predictor of recurrence, whether the left atrium is mapped in atrial fibrillation or sinus rhythm

Effect of a single acupuncture treatment on surgical wound healing in dogs: a randomized, single blinded, controlled pilot study

<p>Abstract</p> <p>Background</p> <p>The aim of the study was to investigate the effect of acupuncture on wound healing after soft tissue or orthopaedic surgery in dogs.</p> <p>Methods</p> <p>29 dogs were submitted to soft tissue and/or orthopaedic surgeries. Five dogs had two surgical wounds each, so there were totally 34 wounds in the study. All owners received instructions for post operative care as well as antibiotic and pain treatment. The dogs were randomly assigned to treatment or control groups. Treated dogs received one dry needle acupuncture treatment right after surgery and the control group received no such treatment. A veterinary surgeon that was blinded to the treatment, evaluated the wounds at three and seven days after surgery in regard to oedema (scale 0-3), scabs (yes/no), exudate (yes/no), hematoma (yes/no), dermatitis (yes/no), and aspect of the wound (dry/humid).</p> <p>Results</p> <p>There was no significant difference between the treatment and control groups in the variables evaluated three and seven days after surgery. However, oedema reduced significantly in the group treated with acupuncture at seven days compared to three days after surgery, possibly due the fact that there was more oedema in the treatment group at day three (although this difference was nor significant between groups).</p> <p>Conclusions</p> <p>The use of a single acupuncture treatment right after surgery in dogs did not appear to have any beneficial effects in surgical wound healing.</p