Objectives To determine the importance of sodium content versus administration rate of intravenous fluids in the development of hyponatremia in postoperative children. Study design In this ...prospective, randomized, nonblinded study, 124 children admitted for surgery received 0.9% (NS) or 0.45% (N/2) saline solution at 100% or 50% maintenance rates. Plasma electrolytes, osmolality, and ADH at induction of anesthesia were compared with values 8 hours (T8 ), and 24 hours (T24 ; n = 67) after surgery. Blood glucose and ketones were measured every 4 hours. Electrolytes and osmolality were measured in urine samples. Results Plasma sodium concentrations fell in both N/2 groups at T8 (100%: −1.5 ± 2.3mmol/L 50%: −1.9 ± 2.0mmol/L; P < .01) with hyponatremia more common than in the NS groups at T8 (30% vs 10%; P = .02) but not T24 . Median plasma antidiuretic hormone concentrations increased 2- to 4-fold during surgery ( P ≤ .001) and only reattained levels at induction of anesthesia by T24 in the N/2 100% group. On multiple linear regression analysis, fluid type, not rate determined risk of hyponatremia ( P < .04). Two children on 100% developed SIADH (1NS). Fourteen (23%; 7NS) on 50% maintenance were assessed as dehydrated. Dextrose content was increased in 18 for hypoglycemia or ketosis. Conclusions The risk of hyponatremia was decreased by isotonic saline solution but not fluid restriction.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Context: Hyperinsulinism and its associated metabolic abnormalities, including diabetes mellitus (DM), have been reported in long-term survivors of childhood cancer, mainly after bone marrow ...transplant (BMT); however, the predisposing factors are unclear, and early markers have not been identified.
Methods: The prevalence of overweight/obesity, abdominal adiposity and hyperinsulinemia (HI), impaired glucose tolerance (IGT), or DM was examined prospectively in 248 survivors of childhood cancer (36 prepubertal, 88 pubertal, and 124 adult subjects; 67 BMT) at a median of 12.9 yr (2.3–33.6) after diagnosis and compared with healthy controls. Potential risk factors for the development of HI, IGT, or DM were sought.
Results: Overweight/obesity was not increased when comparing subjects with controls; however, the prevalence of abdominal adiposity in prepubertal and pubertal subjects was roughly doubled (P ≤ 0.04). Fasting insulin concentrations were higher in prepubertal and pubertal subjects compared with their controls (P < 0.001) and were similar in adult and pubertal subjects. HI, IGT, or DM was detected in 39 of 212 (18%) pubertal or adult subjects (23 BMT). Ten of 88 (11%) pubertal and 14 of 124 (11%) adult subjects had IGT/DM (vs. 0 and 4.9% controls, respectively; P < 0.001). Total body irradiation, untreated hypogonadism, and abdominal adiposity emerged as independent risk factors for the development of HI, IGT, or DM in multivariate regression analysis.
Conclusions: The risk factors identified suggest the need for reconsideration of BMT protocols and regular screening of survivors. The increased prevalence of abdominal adiposity among prepubertal subjects, none of whom had developed HI/IGT/DM, suggests that a waist to height ratio greater than 0.5 has potential as a clinical screening tool.
Patients have unprecedented online access to their medical records. More than 6 million Americans can now read their doctors' notes via patient portals, and continued rapid growth is likely. Sharing ...notes with patients may yield important health benefits, including increased patient empowerment and improved medication adherence. Seeing written information, including notes, helps patients remember the plan of care, reinforces patients' positive behaviors, and strengthens the patient-doctor alliance. In an effort to ease the transition to what they believe will be a widespread and ultimately beneficial practice, Klein et al draw on over 5 years of their clinical experience and conversations with clinicians around the country to offer suggestions for creating notes that can work for all concerned.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes ...with their clinicians, an intervention called OurNotes.
This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention.
Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements.
Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits.
OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
McNab and colleagues1 and Eldridge and Ledoux5 in their accompanying Comment advocate use of a more balanced solution than 0·9% sodium chloride because of the theoretical risk of hyperchloraemic ...metabolic acidosis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
In the absence of international standards, widely differing attitudes and laws, medical and social cultures strongly influence whether and how patients may access their medical records in various ...settings of care. Reviewing records, including the notes clinicians write, can help shape how people participate in their own care. Aided at times by new technologies, individual patients and care partners are repurposing existing tools and designing innovative, often ‘low-tech’ ways to collect, sort and interpret their own health information. To illustrate diverse approaches that individuals may take, six individuals from six nations offer anecdotes demonstrating how they are learning to collect, assess and benefit from their personal health information.
Summary
Background
It is unclear whether the rate of vitamin D deficiency in paediatric cancer survivors is higher than in the background population, and whether this is of pathological significance.
...Patients and Methods
25OHD was measured in a previously studied group of 208 survivors (n = 108 paediatric 5–17 years, n = 99 adults 18–39 years) and compared with paediatric (5–17 years; n = 132) and adult controls (25–35 years; n = 1393 from the AusDiab cohort) adjusted for age and gender. Relationships with treatment factors (irradiation, bone marrow transplantation and intensity of treatment) along with overweight/obesity (defined by BMI), abdominal adiposity (waist:height ratio >0·5) and hyperinsulinism or abnormal glucose tolerance (HI/aGT) were sought.
Results
25OHD concentrations were similar in paediatric survivors compared with controls (64·3 ± 21·6 nmol/l vs 66·3 ± 22·8 nmol/l), with no effect of age or gender. Adjusted for gender, rates of 25OHD deficiency (<50 nmol/l) were higher in adult survivors compared with AusDiab controls (42·4% vs 20·8%; P < 0·001). Apart from time since diagnosis (P = 0·03), no relationship with treatment factors was detected. In multivariate regression analysis, abdominal adiposity (P = 0·001), but not overweight/obesity by BMI status nor HI/aGT, was associated with significantly lower 25OHD concentrations.
Conclusions
Adult survivors are at increased risk of abnormalities in vitamin D compared to the background population, probably reflecting longer time since diagnosis. Like others, we have not identified any contributory treatment‐related factors. Vitamin D deficiency does not appear to be associated with the development of abnormal glucose tolerance in this population.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
The aim of this study was to determine if once daily insulin detemir reverses decline in weight and lung function in patients with cystic fibrosis (CF). 12 patients with early insulin deficiency and ...six with CF related diabetes (aged 7.2–18.1 years) were treated for a median of 0.8 years. Changes in weight and lung function following treatment were compared to pretreatment changes. Before treatment, the change in weight SD score (ΔWtSDS), percentage of predicted forced expiratory volume in 1 s (Δ%FEV1) and percentage of predicted forced vital capacity (Δ%FVC) declined in the whole study population (−0.45±0.38, −7.9±12.8%, −5.8±14.3%) and in the subgroup with early insulin deficiency (−0.41±0.43, −9.8±9.3%, −6.8±10.3%). Following treatment with insulin ΔWtSDS, Δ%FEV1 and Δ%FVC significantly improved in the whole study population (+0.18±0.29 SDS, p=0.0001; +3.7±10.6%, p=0.007; +5.2±12.7%, p=0.013) and in patients with early insulin deficiency (+0.22±0.31 SDS, p=0.003; +5.3±11.5%, p=0.004; +5.8±13.4%, p=0.024). Randomised controlled trials are now needed.
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