Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma

OBJECTIVE

To evaluate systemic versus epidural opioid administration for analgesia in patients sustaining thoracic trauma.

SUMMARY BACKGROUND DATA

The authors have previously shown that epidural analgesia significantly reduces the pain associated with significant chest wall injury. Recent studies report that epidural analgesia is associated with a lower catecholamine and cytokine response in patients undergoing elective thoracotomy compared with patient-controlled analgesia (PCA). This study compares the effect of epidural analgesia and PCA on pain relief, pulmonary function, cathechol release, and immune response in patients sustaining significant thoracic trauma.

METHODS

Patients (ages 18 to 60 years) sustaining thoracic injury were prospectively randomized to receive epidural analgesia or PCA during an 18-month period. Levels of serum interleukin (IL)-1beta, IL-2, IL-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) were measured every 12 hours for 3 days by enzyme-linked immunosorbent assay. Urinary catecholamine levels were measured every 24 hours. Independent observers assessed pulmonary function using standard techniques and analgesia using a verbal rating score.

RESULTS

Twenty-four patients of the 34 enrolled completed the study. Age, injury severity score, thoracic abbreviated injury score, and length of hospital stay did not differ between the two groups. There was no significant difference in plasma levels of IL-1beta, IL-2, IL-6, or TNF-alpha or urinary catecholamines between the two groups at any time point. Epidural analgesia was associated with significantly reduced plasma levels of IL-8 at days 2 and 3, verbal rating score of pain on days 1 and 3, and maximal inspiratory force and tidal volume on day 3 versus PCA.

CONCLUSIONS

Epidural analgesia significantly reduced pain with chest wall excursion compared with PCA. The route of analgesia did not affect the catecholamine response. However, serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury, were significantly reduced in patients receiving epidural analgesia on days 2 and 3. This may have important clinical implications because lower levels of IL-8 may reduce infectious or inflammatory complications in the trauma patient. Also, tidal volume and maximal inspiratory force were improved with epidural analgesia by day 3. These results demonstrate that epidural analgesia is superior to PCA in providing analgesia, improving pulmonary function, and modifying the immune response in patients with severe chest injury.

Discovery of self: exploring, interconnecting and integrating self (concept) and nursing

Self concept of individual nurses is still largely unexplored in nursing. While the role of self-knowledge and self-actualisation are recognised as integral to nursing practice, little has been done to examine their relationships to self concept and nursing practice. The aim of this research study was to explore the role and significance that self concept plays in women nurses' experience of their beginning practice. The exploration examined factors which contribute to and impact on self concept within a nursing practice environment. Self concept relates to how an individual experiences oneself and is integrally linked to one's interactions and relationships with others. This two phase research was situated in critical and feminist theory using reflective journalling (phase one) and story telling/narrative (phase two) as the research methods. This paper discusses the three major themes which arose in phase one of the research. Those were: exploring experiences; interconnecting personal and professional worlds; and, integrating self 'into' nursing. The paper also explores inter-subjectivity in terms of the contribution this concept makes to our understanding of research findings.

Primitive human hematopoietic progenitor cells express receptors for granulocyte-macrophage colony-stimulating factor

Most cytokines act only synergistically in assays of primitive progenitor cell proliferation, and effects have usually been observed first after prolonged cell culture. Studies reporting that primitive progenitors lack receptors for a number of cytokines, including granulocyte-macrophage colony stimulating factor (GM-CSF), could indicate that several "synergistic" cytokines primarily affect cells that have differentiated in vitro. Here, however, we show that freshly isolated primitive progenitor cells (CD34hi CD38-) express receptors for GM-CSF at levels 20%-30% of granulo-monocytic progenitors. Although GM-CSF had minimal effects on the survival or proliferation of primitive progenitors when added alone, the cytokine enhanced stem cell factor (SCF) induced cell cycle entry in the first generation. The effect was not observed when cells were incubated sequentially with SCF and GM-CSF. The results suggest that the synergistic effects of GM-CSF are mediated directly on primitive progenitor cells and that the cytokine may be useful to enhance cell cycle entry of hematopoietic stem cells.

Shaping the future of Medicare

This article suggests that further major changes in Medicare at this time are unwarranted. The enactment of the Balanced Budget Act (BBA) has eliminated the need for quick action to assure solvency of the Part A Trust Fund, which is projected to be in balance for at least ten years. It will take time to implement and assess the effects of the BBA. The uncertainties of future trends in the health sector and Medicare suggest a go-slow approach. Future reforms to finance health care as the baby boom generation retires should be guided by the goals of continuing to assure health and economic security to elderly and disabled beneficiaries, with particular attention to the financial burdens on lower-income beneficiaries and those with serious illnesses or chronic conditions. Employers are cutting back on retiree health coverage, and the appropriate contribution of employers will need to be addressed. The BBA included major provisions to expand Medicare managed care choices. Special attention will need to be given to how well these innovations work, their cost impact on Medicare, the extent to which beneficiaries are able to make informed choices, and whether risk selection among plans and between traditional Medicare and plans can be adequately addressed. Most of the savings of BBA came from tighter payment rates to managed care plans and fee-for-service providers; it is unclear whether these will lead to rates well below the private sector or whether further savings can be achieved by extending these changes beyond 2002.

Systemic sclerosis prevalence and mortality in Sydney 1974-88

BACKGROUND

Systemic sclerosis prevalence and mortality estimates have demonstrated wide variability. The sole Australian study published to date demonstrated high prevalence rates when compared to overseas estimates. The prevalence and mortality findings reported in this paper derive from a larger study which addressed the distribution and determinants of systemic sclerosis within Sydney.

AIMS

To determine systemic sclerosis prevalence and mortality rates within Sydney over 15 years, 1974-88.

METHODS

Cases were ascertained from multiple sources including death certificates, hospitals, physicians, vascular surgeons' and dermatologists' private practices, a systemic sclerosis self-help group and private medical laboratories.

RESULTS

Overall, 715 cases were identified. Females comprised 77% (95% CI: 74-80) of cases. Disease of the limited subtype accounted for 79% (95% CI: 76-82) of all systemic sclerosis, being relatively more frequent in living than deceased cases, and in females than males. Crude prevalence estimates appeared to rise between 1975 (4.52/100,000 95% CI:3.75-5.29/100,000) and 1988 (8.62/100,000 95% CI:7.64-9.60/100,000) as did estimates of diffuse disease. However, diffuse disease prevalence, when expressed as a proportion of total disease prevalence, showed no significant temporal change. Although crude mortality rates also showed apparent temporal increases (0.24/100,000 in 1975 to 0.80/100,000 in 1988) standardised mortality rates showed less convincing trends (0.41/100,000 in 1976 and 0.40/100,000 in 1988). Death certificate-derived mortality rates provided relatively large underestimates of total mortality. However, these underestimates were relatively constant over time.

CONCLUSIONS

This study has demonstrated systemic sclerosis prevalence and mortality rates comparable to overseas estimates, consistently higher prevalence and mortality rates in females than males, proportionally higher rates of diffuse disease in males than females and in deceased cases than living cases, a diffuse: limited disease ratio apparently stable over time, apparently increasing temporal prevalence and mortality rates and, by implication, rising incidence rates. The observed temporal rise in diffuse disease prevalence and the absence of a convincing fall in diffuse disease mortality suggests a rising temporal incidence rate of diffuse disease. Standardised mortality rates demonstrated less consistent trends than did crude mortality rates and failed to demonstrate convincing declines in mortality subsequent to the introduction of ACE inhibitors for management of systemic sclerosis renal disease. Death certificate-derived systemic sclerosis mortality rates considerably and consistently underestimated systemic sclerosis-all cause mortality.

A mouse model for evaluation of prophylaxis and therapy of Ebola hemorrhagic fever

The Zaire subtype of Ebola virus (EBO-Z) is lethal for newborn mice, but adult mice are resistant to the virus, which prevents their use as an animal model of lethal Ebola infection. We serially passed EBO-Z virus in progressively older suckling mice, eventually obtaining a plaque-purified virus that was lethal for mature, immunocompetent BALB/c and C57BL/6 inbred and ICR (CD-1) outbred mice. Pathologic changes in the liver and spleen of infected mice resembled those in EBO-Z-infected primates. Virus titers in these tissues reached 10(9) pfu/g. The LD50 of mouse-adapted EBO-Z virus inoculated into the peritoneal cavity was approximately 1 virion. Mice were resistant to large doses of the same virus inoculated subcutaneously, intradermally, or intramuscularly. Mice injected peripherally with mouse-adapted or intraperitoneally with non-adapted EBO-Z virus resisted subsequent challenge with mouse-adapted virus.

Familial risk estimation in systemic sclerosis

BACKGROUND

Familial systemic sclerosis has been rarely reported. Assumptions have therefore been made implying no familial disease aggregation. This study critically challenges the assumption using a methodical population-based epidemiological approach to quantify the prevalence and characteristics of familial systemic sclerosis.

METHODS

In this retrospective cohort study the systemic sclerosis prevalence in first degree family members was compared between 715 systemic sclerosis patients (710 families) and 371 randomly ascertained age and gender group-matched general practice controls (371 families). These data, obtained by telephone questionnaire (living patients) or medical records review (deceased patients and untraceable patients of unknown living status), were validated, where necessary, and expressed in terms of relative risk, absolute risk and population point prevalence.

RESULTS

Systemic sclerosis affecting first degree members was validated in ten of 710 families. Reporting of systemic disease in another four more distant family members, and the co-occurrence of systemic and localised disease in three families was also documented. Observed and expected disease subtype concordance was 80% (44-97%) and 68% respectively and the female predominance among familial cases was similar to that for non-familial disease. The risk of disease in a subsequent first degree relative was compared to the risk in an initial first degree family member. Its estimated magnitude was wide (11-158). However, use of population prevalence data to determine the expected number of systemic sclerosis patients in the negative cohorts' families suggests the higher estimate is more realistic. Despite the high magnitude, the absolute disease risk in first degree family members remained low--approximating 1%. The population prevalence of familial systemic sclerosis approximated 1.4/million.

CONCLUSIONS

This study substantially increases the otherwise small list of documented instances of familial systemic sclerosis. More importantly, it quantifies the risk for the first time, ranking it as the disease's most powerful determinant identified to date.

CASS Registry long term surgical survival. Coronary Artery Surgery Study

OBJECTIVES

To show the effect of clinical, angio and demographic traits on late survival of Coronary Artery Surgery Study (CASS) patients following coronary artery bypass grafting (CABG) and introduce Hazard Function analysis to CASS survival data.

METHODS

Patients were reached by mail survey with 94% response. By National Death Index, vital status was obtained in 99.7% (n = 8221) with a mean follow up of 15 years. Cox proportional hazard and Blackstone Hazard Function regressions were used to assess effects of preoperative traits.

RESULTS

Ninety percent of patients were alive at 5, 74% at 10 and 56% at 15 years. Of those age 65 and age 75 at operation, 74% and 59% were living at 10 years and 54% and 33% at 15 years (now age 90), survival exceeding the matched U.S. population. Hazard Function falls rapidly after CABG to 9 to 12 months, then rises, doubling by 15 years. Young patients, below age 35, had lower late survival. The time-segmented Cox model (divided at time suggested by the Hazard Function) identified traits showing predictive power early, throughout and late. Female sex, small body surface, ischemic symptoms and emergency status affected survival early. Heavier weight, infarct(s), diuretics, diabetes, smoking, left main and LAD stenosis and use of vein grafts only increased hazard late only.

CONCLUSIONS

There are still lessons from the CASS database. CABG in the elderly is supported by the survival pattern of our patients age 75 at operation. Time-segmented Cox analysis and Hazard Function analysis separate baseline variables into those that predict early mortality and those that predict long survival.

Changes in respiratory mechanics after tracheostomy

OBJECTIVE

To determine the effects of tracheostomy on respiratory mechanics and work of breathing (WOB).

DESIGN

A before-and-after trial of 20 patients undergoing tracheostomy for repeated extubation failure.

SETTING

Surgical intensive care unit at a university teaching hospital and a level I trauma center.

PATIENTS

A consecutive sample of 20 patients who met extubation criteria (Pa(O2), >55 mm Hg; pH >7.30; and respiratory rate, <30/min on room air continuous positive airway pressure after 20 minutes) but failed extubation on 2 occasions were eligible for the study.

INTERVENTIONS

Respiratory mechanics, lung volumes, and WOB were measured before and after tracheostomy.

MAIN OUTCOME MEASURES

Patients in whom extubation fails often progress to unassisted ventilation after tracheostomy. The study hypothesis was that tracheostomy would result in improved pulmonary function through changes in respiratory mechanics.

RESULTS

Data are given as means +/- SDs. After tracheostomy, WOB per liter of ventilation (0.97+/-0.32 vs. 0.81+/-0.46 J/L; P<.09), WOB per minute (8.9+/-2.9 vs. 6.6+/-1.4 J/min; P<.04), and airway resistance (9.4+/-4.1 vs. 6.3+/-4.5 cm H20/L per second; P<.07) were reduced compared with breathing via an endotracheal tube. These findings, however, do not fully explain the ability of patients to be liberated from mechanical ventilation after tracheostomy. In 4 patients who were extubated before tracheostomy, WOB was significantly greater during extubation than when breathing through an endotracheal or tracheostomy tube (1.2+/-0.19 vs. 0.81+/-0.24 vs. 0.77+/-0.22 J/L).

CONCLUSIONS

We believe that the rigid nature of the tracheostomy tube represents reduced imposed WOB compared with the longer, thermoliable endotracheal tube. The clinical significance of this effect is small, although as respiratory rate increases, the effects are magnified. In patients in whom extubation failed, WOB may be elevated because of incomplete control of the upper airway. Future studies should evaluate the cause of increased WOB after extubation.

Primary care and psychiatry: anticipating an interfaith marriage

The emergence of a managed-care--driven health delivery system in the United States has had a major impact on both primary care physicians and psychiatrists. Since a significant portion of psychiatric disorders present in primary care settings and a significant number of patients with emotional disorders receive their care from primary care physicians, the convergence of the two fields of medicine seems likely. Surveys document that both the diagnosis and the treatment of emotional disorders are inadequate in primary care. The authors review possible approaches to rectifying this situation and show that the attachment of the psychiatrist to the primary care team offers many advantages to the provision of clinical services, the education of a diverse group of trainees, and the collaboration of two categories of physician not typically seen as working closely together. The authors also describe an outpatient county medical clinic in which the concept of "attachment-liaison" of the psychiatrist to the primary care setting is tested on a daily basis. The authors (a psychiatrist and an internist), who met in this setting, detail their initial expectations and the observed outcomes of having a psychiatrist join the clinic team. The various tasks of the psychiatrist in this primary care setting are enumerated, along with several typical case presentations.

An activity in rat tissues that modifies nitrotyrosine-containing proteins

Homogenates from rat spleen and lung could modify nitrotyrosine-containing BSA. With incubation, nitrotyrosine-containing BSA lost its epitope to a monoclonal antibody that selectively recognized nitrotyrosine-containing proteins. In the presence of protease inhibitors, the loss of the nitrotyrosine epitope occurred without protein degradation and hydrolysis. This activity was found in supernatant but not particulate fractions of spleen homogenates. The factor was heat labile, was sensitive to trypsin treatment, and was retained after passage through a membrane with a 10-kDa retention. The activity was time- and protein-concentration dependent. The activity increased about 2-fold in spleen extracts with endotoxin (bacterial lipopolysaccharide) treatment of animals, suggesting that the activity is inducible or regulatable. Other nitrotyrosine-containing proteins also served as substrates, while free nitrotyrosine and some endogenous nitrotyrosine-containing proteins in tissue extracts were poor substrates. Although the product and possible cofactors for this reaction have not yet been identified, this activity may be a "nitrotyrosine denitrase" that reverses protein nitration and, thus, decreases peroxynitrite toxicity. This activity was not observed in homogenates from rat liver or kidney, suggesting that there may also be some tissue specificity for the apparent denitrase activity.

An emancipatory impulse: a feminist postmodern integrated turning point in nursing research

This article critiques the current debates regarding feminism, postmodernism, and feminist/postmodernism within nursing research. The critique classified the debates into three identifiable constructs: dissatisfaction, fragmentation, and integration. The authors propose a solution from the integration debate as an emancipatory "workable" turning point for nursing research. The solution is situated within feminism and draws on the epistemological constructs of both modernism and postmodernism. Nursing research is framed within the proposed ontological links that characterize the integrated solution.

A mouse model for evaluation of prophylaxis and therapy of Ebola hemorrhagic fever

The Zaire subtype of Ebola virus (EBO-Z) is lethal for newborn mice, but adult mice are resistant to the virus, which prevents their use as an animal model of lethal Ebola infection. We serially passed EBO-Z virus in progressively older suckling mice, eventually obtaining a plaque-purified virus that was lethal for mature, immunocompetent BALB/c and C57BL/6 inbred and ICR (CD-1) outbred mice. Pathologic changes in the liver and spleen of infected mice resembled those in EBO-Z-infected primates. Virus titers in these tissues reached 10(9) pfu/g. The LD50 of mouse-adapted EBO-Z virus inoculated into the peritoneal cavity was approximately 1 virion. Mice were resistant to large doses of the same virus inoculated subcutaneously, intradermally, or intramuscularly. Mice injected peripherally with mouse-adapted or intraperitoneally with non-adapted EBO-Z virus resisted subsequent challenge with mouse-adapted virus.

Mutational analysis of exoribonuclease I from Saccharomyces cerevisiae

Exoribonuclease I from yeast is a 175 kDa protein that is responsible for the majority of cytoplasmic mRNA degradation. Alignment of the Xrn1p sequence with homologs from yeast as well as from higher eukaryotes suggests that the protein is composed of several domains: two acidic N-terminal domains which likely contain the exonuclease, a basic middle domainand a basic C-terminal domain. Deletion analysisdemonstrated that the C-terminus is dispensable for most in vivo and in vitro functions but confers a dominant negative growth inhibition when expressed at high levels. This growth inhibition is not due to the exonuclease function of the protein. To identify specific residues responsible for in vivo function, a screen was carried out for non-complementing missense mutations. Fourteen single point mutations were identified that altered highly conserved amino acids within the first N-terminal domain of Xrn1p. All of the mutations reduced exonuclease activity measured in vivo and in vitro using affinity-purified proteins. The mutants fell into two phenotypic classes, those that reduced or abolished exonuclease activity without qualitatively changing the products of RNA degradation and those that gave rise to novel degradation intermediates on certain RNAs.

Dignified dying as a nursing outcome

The goal for humanistic end-of-life care is to maintain quality of life and personal dignity. The nursing outcome called "dignified dying" is defined as maintaining personal control and comfort with the approaching end of life and lists indicators for measuring this. These criteria enable nurses to measure the effectiveness of their nursing interventions, monitor patient progress over time, and summarize research data. This article describes the development of this outcome and illustrates its use with a case study.