Management of acromegaly in Latin America: expert panel recommendations

Although there are international guidelines orienting physicians on how to manage patients with acromegaly, such guidelines should be adapted for use in distinct regions of the world. A panel of neuroendocrinologists convened in Mexico City in August of 2007 to discuss specific considerations in Latin America. Of major discussion was the laboratory evaluation of acromegaly, which requires the use of appropriate tests and the adoption of local institutional standards. As a general rule to ensure diagnosis, the patient`s GH level during an oral glucose tolerance test and IGF-1 level should be evaluated. Furthermore, to guide treatment decisions, both GH and IGF-1 assessments are required. The treatment of patients with acromegaly in Latin America is influenced by local issues of cost, availability and expertise of pituitary neurosurgeons, which should dictate therapeutic choices. Such treatment has undergone profound changes because of the introduction of effective medical interventions that may be used after surgical debulking or as first-line medical therapy in selected cases. Surgical resection remains the mainstay of therapy for small pituitary adenomas (microadenomas), potentially resectable macroadenomas and invasive adenomas causing visual defects. Radiotherapy may be indicated in selected cases when no disease control is achieved despite optimal surgical debulking and medical therapy, when there is no access to somatostatin analogues, or when local issues of cost preclude other therapies. Since not all the diagnostic tools and treatment options are available in all Latin American countries, physicians need to adapt their clinical management decisions to the available local resources and therapeutic options.

Management of Common Bile Duct Stones in Cirrhotic Patients with Coagulopathy: A Comparison of Supra-Papillary Puncture and Standard Cannulation Technique

Bleeding is not uncommon following endoscopic sphincterotomy. Supra-papillary puncture (SPP) might be safer than standard cannulation (SC) techniques in patients with coagulopathy. The aim of the study was to compare the safety and effectiveness of SPP and SC. This was a prospective case control intervention study. Decompensated cirrhotic patients with coagulopathy and choledocolithiasis underwent SC and SPP methods for biliary access. One hundred five patients (56 [53.3%] men, mean [SD] age 56 [15.8]) underwent ERCP. SC and SPP were performed in 63 and 42 patients, respectively. Biliary access was achieved in 56/63 (89%) and 40/42 (95%) of patients undergoing SC and SPP, respectively (P = 0.13; 95% CI [-0.16; 0.03]). Complications occurred in 10/63 (15.8%) patients undergoing SC and 5/42 (11.9%) SPP (P = 0.28; 95% CI [-0.17, 0.16]). Five (7.9%) and two (3.2%) episodes of post-sphincterotomy bleeding was seen in the SC and SPP groups, respectively (P = 0.36; 95% CI [-0.16, 0.05]). In contrast, three (4.8%) episodes of pancreatitis were seen in the SC and none in the SPP group (P = 0.05; 95% CI [0.001; 0.004]). A cost-effectiveness analysis demonstrated that SPP is an acceptable alternative at an ICER of US$ 5,974.92 per additional successful procedure. SPP is a safe and effective technique for the management of common bile duct stones in decompensated cirrhotic patients. Conditional to the willingness-to-pay and to the local ERCP-related costs, SPP is also a cost-effective alternative to the SC methods. SPP is associated with a lower rate of complications but larger studies to validate these findings are necessary.

Current management practices for acromegaly: an international survey

To determine whether peer-reviewed consensus statements have changed clinical practice, we surveyed acromegaly care in specialist centers across the globe, and determined the degree of adherence to published consensus guidelines on acromegaly management. Sixty-five acromegaly experts who participated in the 7th Acromegaly Consensus Workshop in March 2009 responded. Results indicated that the most common referring sources for acromegaly patients were other endocrinologists (in 26% of centers), neurosurgeons (25%) and primary care physicians (21%). In sixty-nine percent of patients, biochemical diagnoses were made by evaluating results of a combination of growth hormone (GH) nadir/basal GH and elevated insulin like growth factor-I (IGF-I) levels. In both Europe and the USA, neurosurgery was the treatment of choice for GH-secreting microadenomas and for macroadenomas with compromised visual function. The most widely used criteria for neurosurgical outcome assessment were combined measurements of IGF-I and GH levels after oral glucose tolerance test (OGTT) 3 months after surgery. Ninety-eight percent of respondents stated that primary treatment with somatostatin receptor ligands (SRLs) was indicated at least sometime during the management of acromegaly patients. In nearly all centers (96%), the use of pegvisomant monotherapy was restricted to patients who had failed to achieve biochemical control with SRL therapy. The observation that most centers followed consensus statement recommendations encourages the future utility of these workshops aimed to create uniform management standards for acromegaly.

Improved case management and continued government investment are needed for malaria eradication in Henan Province, China

A two-year study of malaria control began in Henan Province following cuts in government malaria spending in 1993. Cost data were collected from all government levels and on treatment-seeking (diagnosis, treatment) from 12,325 suspected malaria cases in two endemic counties. The cost burden was found to fall mainly on patients, but using government infrastructure. Good stewardship requires continuing government investment, to at least current levels, along with improved case management. In mainland China, vivax malaria is a significant factor in poverty and economic underdevelopment.

Replantation of an avulsed maxillary primary central incisor and management of dilaceration as a sequel on the permanent successor

This case report outlines the sequel and possible management of a permanent tooth traumatized through the predecessor, a maxillary right primary central incisor that was avulsed and replanted by a dentist 1 h after the trauma in a 3-year-old girl. Three years later, discoloration and fistula were present, so the primary tooth was extracted. The patient did not come to the scheduled follow-ups to perform a clinical and radiographic control of the succeeding permanent incisor, and only returned when she was 10 years old. At that moment, the impaction and dilaceration of the maxillary right permanent central incisor were observed through radiographic examination. The dilacerated permanent tooth was then surgically removed, and an esthetic fixed appliance was constructed with the crown of the extracted tooth. Positive psychological influence of the treatment on this patient was also observed.

Differential inclusions and robust control theory

Uncontrolled systems (x) over dot is an element of Ax, where A is a non-empty compact set of matrices, and controlled systems (x) over dot is an element of Ax + Bu are considered. Higher-order systems 0 is an element of Px - Du, where and are sets of differential polynomials, are also studied. It is shown that, under natural conditions commonly occurring in robust control theory, with some mild additional restrictions, asymptotic stability of differential inclusions is guaranteed. The main results are variants of small-gain theorems and the principal technique used is the Krasnosel'skii-Pokrovskii principle of absence of bounded solutions.

Comparison of oral versus sublingual piroxicam during postoperative pain management after lower third molar extraction

In this study, 53 patients received piroxicam, administered orally or sublingually, after undergoing removal of symmetrically positioned lower third molars, during two separate appointments. This study used a randomized, blind, cross-over protocol. Objective and subjective parameters were recorded for comparison of postoperative results for 7 days after surgery. Patients treated with oral or sublingual piroxicam reported low postoperative pain scores. The patients who received piroxicam orally took a similar average amount of analgesic rescue medication compared with patients who received piroxicam sublingually (p > 0.05). Patients exhibited similar values for mouth opening measured just before surgery and immediately following suture removal 7 days later (p > 0.05), and showed no significant differences between routes of piroxicam administration for swelling control during the second or seventh postoperative days (p > 0.05). In summary, pain, trismus and swelling after lower third molar extraction, independent of surgical difficulty, could be controlled by piroxicam 20 mg administered orally or sublingually and no significant differences were observed between the route of delivery used in this study.

The structure of middle management remuneration packages: An application to Australian mine managers

This paper investigates the composition of remuneration packages for middle managers and relates the structure of remuneration contracts to firm-specific attributes. A statutorily defined position in a single industry is studied as an example of middle management. This allows us to control for differences in task complexity across managers and industry-induced factors that could determine differences in remuneration contracts. Higher-risk firms are expected to pay their mine managers a greater proportion of variable salaries and market and/or accounting-based compensation than low-risk firms. Results indicate that high-risk firms pay a higher proportion of variable salaries and more compensation based on market and/or accounting performance.

Improving pain management by nurses: A pilot peer intervention program

Significant pain continues to be reported by many hospitalized patients despite the numerous and varied educational programs developed and implemented to improve pain management. A theoretically based Peer Intervention Program was designed from a predictive model to address nurses' beliefs, attitudes, subjective norms, self-efficacy, perceived control and intentions in the management of pain with p.r.n. (as required) narcotic analgesia. The pilot study of this program utilized a quasi-experimental pre-post test design with a patient intervention, nurse and patient intervention and control conditions consisting of 24, 18 and 19 nurses, respectively. One week after the intervention, significant differences were found between the nurse and patient condition and the two other conditions in beliefs, self-efficacy, perceived control, positive trend in attitudes, subjective norms and intentions. The most positive aspects of the program were supportive interactive discussions with peers and an awareness and understanding of beliefs and attitudes and their roles in behavior.

Evaluation of liquid Bacillus thuringiensis var. israelensis products for control of Australian Aedes arbovirus vectors

Laboratory bioassay studies were conducted in southeast Queensland, Australia,: on the efficacy of Teknar (R), VectoBac (R) 12AS, and Cybate (R) (active ingredient: 1,200 international toxic units Bacillus thuringiensis var, israelensis [Bti]) against 3rd instars of the arbovirus vectors Aedes aegypti. Ae. notoscriptus, Ae. vigilax, and Ae. camptorhynchus. Probit analyses were then used to determine LD,, (median lethal dose), LD95, and lethal dose ratios (LDR). Aedes aegypti and Ae. notoscriptus, both container-habitat species, tolerated the highest Bti concentrations compared with saltmarsh Ae. vigilax and Ae. camptorhynchus. For example, the LDR for Ae. vigilax versus Ae. notoscriptus exposed to Cybate was 0.14 (95% confidence limit [CL] 0.03-0.61). Similarly, the Cybate LDR for Ae. camptorhynchus versus Ae. notoscriptus was 0.22 (95% CL 0.07-0.70). Teknar produced similar results with an LDR of 0.21 (95% CL 0.04-1.10) for Aedes vigilax versus Aedes notoscriptus. Differences in product efficacy were found when tested against the 2 container-breeding species. Cybate was less effective than Teknar with LDRs of 1.55 (95% CL 0.65-3.67) and 1.87 (95% CL 0.68-5.15) for Aedes aegypti and Ae. notoscriptus, respectively. The significant differences in susceptibility between mosquito species and varying efficacy between products highlight the importance of evaluating concentration-response data prior to contracting with distributors of mosquito control products. This information is crucial to resistance management strategies.

A field trial of the effect of improved piglet management on smallholder sow productivity in the Philippines

We conducted a randomised, controlled field trial during 1998/1999 to evaluate the hypothesis that improved piglet management would improve the reproductive performance of smallholder sows. Simple changes were introduced into the treatment herds including the construction of a heated piglet-separation pen, vitamin injections, creep feeding and early weaning. The control herds were unchanged. Data were collected from all sows in each enrolled herd over two farrowings. We enrolled 176 sows, including 170 (96 treatment and 74 control) sows that remained throughout the study period. Significant differences in the reproductive performance of treatment and control sows were recorded for interfarrowing interval (median 176 versus 220 days), average number liveborn over 2 litters (11 versus 12), and average preweaning mortality over 2 litters (0 versus 37%). Based on a discount rate of 17%, the benefit-cost ratio of the treatment was 11.1 and 12.1 over 3 and 5 years, respectively. (C) 2001 Elsevier Science B.V. All rights reserved.

A risk-based system to penalize and reward line management for occupational safety and health performance

Penalizing line management for the occurrence of lost time injuries has in some cases had unintended negative consequences. These are discussed. An alternative system is suggested that penalizes line management for accidents where the combination of the probability of recurrence and the maximum reasonable consequences such a recurrence may have exceeds an agreed limit. A reward is given for prompt effective control of the risk to below the agreed risk limit. The reward is smaller than the penalty. High-risk accidents require independent investigation by a safety officer using analytical techniques. Two case examples are given to illustrate the system. Continuous safety improvement is driven by a planned reduction in the agreed risk limit over time and reward for proactive risk assessment and control.