Alveolar capillary dysplasia. Report of a case of prolonged life without extracorporeal membrane oxygenation (ECMO) and review of the literature

We describe an unusual infant with the diagnosis of alveolar capillary dysplasia who had a relatively prolonged life without extracorporeal membrane oxygenation (ECMO). We have used this case as a springboard for a thorough review of the literature. This was a full-term female infant who presented with a picture of persistent pulmonary hypertension of the newborn. She was treated as such, with various ventilatory modes, alkalinizing agents, surfactant therapy, tolazoline, prostacyclin and nitric oxide. Because of the prolonged clinical course the possibility of alveolar capillary dysplasia was raised. The parents refused ECMO. Despite all efforts she progressively deteriorated and died at 22 days of age. Macro- and microscopic examination of the lung at autopsy were diagnostic of alveolar capillary dysplasia. A detailed review of 39 cases published in the literature with comments regarding incidence, etiology, pathophysiology, clinical picture, diagnosis and treatment is presented.

A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England

BACKGROUND

The incidence of acute pancreatitis shows regional variations in the UK.

AIMS

To document the incidence and presentation of acute pancreatitis in hospitals in Wessex, and to audit the process and outcome of management of patients against the UK guidelines.

METHODS

A prospective survey was carried out of all patients with acute pancreatitis in a one year period, in eight geographically adjacent acute hospitals in the Wessex region.

RESULTS

186 patients with acute pancreatitis were identified, an incidence of 152 per million in the adult population. Aetiology was: gallstones 33%, alcohol 20%, idiopathic 32%, other 15%. There were 60 severe cases with 17 deaths. Age and APACHE-II score had significant relations to outcome, but delay to admission, serum amylase level, aetiology, and sex did not. The mortality rate (9.1%) was within the audit standard of 10%. Some management goals were not met: in mild cases, only one third of patients with gallstone pancreatitis had definitive treatment within four weeks. In severe cases, there was poor use of objective severity stratification (19%), low admission rates to a high dependency unit or intensive care unit (67%), and only 33% of patients had computed tomography. Only seven of 17 patients with severe gallstone pancreatitis had an urgent endoscopic retrograde cholangiopancreatography.

CONCLUSIONS

The incidence of clinically diagnosed acute pancreatitis in England continues to rise. Current management of acute pancreatitis is suboptimal when compared with evidence based UK guidelines but the mortality rate was within the guideline standard.

Postoperative bladder distention: measurement with bladder ultrasonography

Bladder distention is a common postoperative occurrence. A process improvement project was conducted at a Midwestern Veteran Affairs Medical Center to determine whether a new method for detecting bladder distention, bladder ultrasonography, was more effective than manual palpation in the perianesthesia setting. Data were collected on 494 men over a 9-month period using bladder ultrasonography. Of those patients, 19.4% had postoperative bladder distention with greater than 400 mL of urine. This compared with 1.4% of patients who had bladder distention detected during the previous year using manual palpation. Data from the project supported the use of bladder ultrasonography as being more effective than manual palpation in the assessment of postoperative bladder distention in the PACU.

Capturing the paradigm shift in HIV treatment: changing attitudes in the choice of combination antiretroviral drugs by high HIV caseload Australian GPs (1996-1997)

The use of combination antiretroviral therapy for HIV infection is a rapidly changing field. To assess the impact of recent studies on prescribing patterns, two surveys of 21 high HIV caseload Australian GPs were undertaken in June 1996 and June 1997 to plot changes in the choice of combination antiviral therapy. Of the 17 GPs who responded to the survey in each year, the number of HIV-infected patients seen at their practices were estimated to be 5,061 in 1996 and 5,912 in 1997. In 1996, 40% of their patients were estimated to be on antiretroviral therapy compared to 60% in 1997 (p < 0.05). In 1996, most GPs preferred using dual combination therapy (59%); whereas in 1997, triple combination therapy was preferred (82%). Between 1996 and 1997, there was a significant change by high caseload Australian GPs in the choice of antiretroviral drugs with many combinations being preferred prior to presentation of efficacy data for those combinations, or recommendation through national guidelines.

Genetic studies of the human melanocortin-1 receptor

Genetic approaches have suggested a critical role for the melanocortin-1 receptor in the control of pigmentation. We showed that this gene is unusually polymorphic in European populations and that, of the many variants, three in particular appear to be associated with red hair or fair skin. Family studies suggest these are inherited as an autosomal recessive trait (or at least approximate to this in many families). To date all individuals with two of these three changes (homozygote or compound heterozygote) have red hair. Early functional studies are in keeping with defective signalling through MC1R. An interested and perhaps unexpected question relates to the evolutionary factors that have given rise to such variants. Two models can be proposed, that are based on multiple alleles with minor changes in function or genetic hitch-hicking.

Analysis of the sequence of dioscorea Alata bacilliform virus: comparison to others members of the badnavirus group

The complete nucleotide sequence of the genome of Dioscorea alata bacilliform virus (DaBV) has been determined from cloned fragments. Features of the genome confirm DaBV to be a pararetrovirus of the genus Badnavirus which is more similar to other mealy-bug transmitted badnaviruses, in particular to cacao swollen shoot virus, than to rice tungro bacilliform virus. Sequence variability between cloned fragments suggests that the genetic variability of the virus may be quite high (up to 11% nucleotide sequence variation for some small regions of the genome) although the overall variability detected was 4.2% at the nucleotide level.

What is the cost of admitting patients with transient ischaemic attacks to hospital?

Financial constraints at our institution prompted us to evaluate the management of patients referred to the Acute Stroke Service because of transient ischaemic attack (TIA). We analysed age, gender, length of stay, hospital costs, discharge disposition and stroke recurrence for all cases of TIA admitted to the Acute Stroke Service between January 1, 1994, and December 31, 1996. During this time, 110 cases of TIA were admitted. All had a CT head scan, 60% had carotid Doppler ultrasound, and 30% had transthoracic echocardiography. No patients admitted with TIA died, and 92% were discharged home. The average annual cost of in-patient management of TIA was 328,000 Canadian dollars, of which 95% were accounted for by the cost of the hospital bed alone. If hospitalisation of patients with TIA could be reduced, significant cost-savings could be realised.

Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group

BACKGROUND

Ethylene glycol poisoning causes metabolic acidosis and renal failure and may cause death. The standard treatment is inhibition of alcohol dehydrogenase with ethanol, given in intoxicating doses, and adjunctive hemodialysis. We studied the efficacy of fomepizole, a new inhibitor of alcohol dehydrogenase, in the treatment of ethylene glycol poisoning.

METHODS

We administered intravenous fomepizole to 19 patients with ethylene glycol poisoning (plasma ethylene glycol concentration, > or =20 mg per deciliter [3.2 mmol per liter]). Patients who met specific criteria also underwent hemodialysis. Treatment was continued until plasma ethylene glycol concentrations were less than 20 mg per deciliter. Acid-base status, renal function, the kinetics of fomepizole, and ethylene glycol metabolism were assessed at predetermined intervals.

RESULTS

Fifteen of the patients initially had acidosis (mean serum bicarbonate concentration, 12.9 mmol per liter). Acid-base status tended to normalize within hours after the initiation of treatment with fomepizole. One patient with extreme acidosis died. In nine patients, renal function decreased during therapy; at enrollment, all nine had high serum creatinine concentrations and markedly elevated plasma glycolate concentrations (> or =97.7 mg per deciliter [12.9 mmol per liter]). None of the 10 patients with normal serum creatinine concentrations at enrollment had renal injury during treatment; all 10 had plasma glycolate concentrations at or below 76.8 mg per deciliter (10.1 mmol per liter). Renal injury was independent of the initial plasma ethylene glycol concentration. The plasma concentration of glycolate and the urinary excretion of oxalate, the major metabolites of ethylene glycol, uniformly fell after the initiation of fomepizole therapy. Few adverse effects were attributable to fomepizole.

CONCLUSIONS

In patients with ethylene glycol poisoning, fomepizole administered early in the course of intoxication prevents renal injury by inhibiting the formation of toxic metabolites.

Ultrashort laser pulse bioeffects and safety

Recent studies of retinal damage due to ultrashort laser pulses have shown that less energy is required for retinal damage for pulses shorter than 1 ns than that for longer pulses. It has also been shown that more energy is required for near-infrared (NIR) wavelengths than in the visible because the light focuses behind the retina, requiring more energy to produce a damaging fluence on the retina. We review the progress made in determining the trends in retinal damage from laser pulses of 1 ns to 100 fs in the visible and NIR wavelength regimes. We have determined the most likely damage mechanism(s) operative in this pulse width regime.

Impact of HIV type 1 subtype variation on viral RNA quantitation

We evaluated the performance of three HIV-1 RNA quantitation methods (Amplicor HIV-1 MONITOR-1.0, NASBA, and Quantiplex HIV RNA 2.0 [branched DNA (bDNA)]) using plasma specimens (N = 60) from individuals from Asia and Africa infected with one of three HIV-1 subtypes (A, Thai B [B'] or E; N = 20 each). Our results demonstrate that of the 20 subtype A specimens, 19 were quantifiable by the bDNA assay compared with 15 by the MONITOR-1.0 and 13 by NASBA. Of those quantifiable, the mean log10 difference was 0.93 between bDNA and MONITOR-1.0 and 0.46 between bDNA and NASBA. For subtype B' specimens, the correlation among methods was better with only 2 specimens missed by NASBA and 3 by the bDNA assay. However the missed specimens had viral burden near the lower limit (1000 copies/ml) for these assays. For the 20 subtype E specimens, MONITOR-1.0 and NASBA quantified RNA in 17 and 14 specimens, respectively, as compared with 19 specimens quantified by the bDNA assay. The correlation among different assays, especially between bDNA/NASBA and MONITOR-1.0/NASBA, was poor, although the mean log10 difference for subtype E specimens was 0.4 between bDNA and MONITOR-1.0 and only 0.08 between bDNA and NASBA. The addition of a new primer set, designed for non-B HIV-1 subtypes, to the existing MONITOR assay (MONITOR-1.0+) resulted in RNA detection in all 60 specimens and significantly improved the efficiency of quantitation for subtypes A and E. Our data indicate that HIV-1 subtype variation can have a major influence on viral load quantitation by different methods. Periodic evaluation and modification of these quantitative methods may be necessary to ensure reliable quantification of divergent viruses.

Alkylfurans: effects of alkyl side-chain length on insecticidal activity

The insecticidal activity of five alkylfurans against the generalist insect herbivore beet armyworm, Spodoptera exigua, was examined. Two naturally occurring compounds, the avocadofurans 2-(pentadecyl)furan (1) and 2-(heptadecyl)furan (2), previously isolated from specialized avocado idioblast oil cells, and three homologues, 2-(tetradecyl)furan (3), 2-(hexadecyl)furan (4), and 2-(octadecyl)furan (5), were synthesized. Bioassays of alkylfurans 1-5 using a 9-day diet-incorporation initiated with neonates showed that all alkylfurans tested significantly increased S. exigua larval mortality and reduced larval weights, with maximal biological activity detected among the naturally occurring alkylfurans 1 and 2.

Oklahoma physician needs

State policy makers, healthcare professionals, and advocates have been asking various iterations of the question, Do we have too many or too few physicians? In order to address this question, a relative-needs analysis was conducted for the state of Oklahoma. Six projection-needs studies were used for comparison with Oklahoma's supply of practicing physicians. This analysis found that Oklahoma did not have a surplus of primary care physicians. While the national average for primary care physicians per 100,000 was 79, Oklahoma's ratio was 68. This analysis also compares not only the number of physicians in Oklahoma per 100,000 population, it also discusses the proportion of primary care physicians in the physician workforce. Primary care physicians were found to be neither oversupplied nor undersupplied in Oklahoma. Oklahoma was found to be closer to national planning model goals than most states in the United States. Because this study combines both allopathic and osteopathic physicians and includes only those physicians in active practice, it is unique in comparison to many other studies concerning physician workforce needs.

Processing capacity defined by relational complexity: implications for comparative, developmental, and cognitive psychology

Working memory limits are best defined in terms of the complexity of the relations that can be processed in parallel. Complexity is defined as the number of related dimensions or sources of variation. A binary relation has one argument and one source of variation; its argument can be instantiated in only one way at a time. A binary relation has two arguments, two sources of variation, and two instantiations, and so on. Dimensionality is related to the number of chunks, because both attributes on dimensions and chunks are independent units of information of arbitrary size. Studies of working memory limits suggest that there is a soft limit corresponding to the parallel processing of one quaternary relation. More complex concepts are processed by "segmentation" or "conceptual chunking." In segmentation, tasks are broken into components that do not exceed processing capacity and can be processed serially. In conceptual chunking, representations are "collapsed" to reduce their dimensionality and hence their processing load, but at the cost of making some relational information inaccessible. Neural net models of relational representations show that relations with more arguments have a higher computational cost that coincides with experimental findings on higher processing loads in humans. Relational complexity is related to processing load in reasoning and sentence comprehension and can distinguish between the capacities of higher species. The complexity of relations processed by children increases with age. Implications for neural net models and theories of cognition and cognitive development are discussed.

An investigation into the effects of nicotine gum on short-term memory

Using a between-subjects 2x2x2 factorial design, 60 smokers and 60 non-smokers (equal number of males and females) performed a short-term memory task requiring delayed free recall of a visually presented supraspan word list. Using a double-blind procedure, half the subjects chewed nicotine gum and the other half chewed placebo gum prior to performing the memory task. Results support previous research findings which show that nicotine significantly improves short-term memory. Sex differences were also investigated, but findings showed no significant differences between male and female subjects. Methodological considerations are discussed and directions for future research are suggested.

In whose best interest? The impact of changing public policy on relatives caring for children with incarcerated parents

Changes in criminal justice policy have resulted in the incarceration of an unprecedented number of parents. Consequently, more children than ever before are living with grandparents and other relatives while their parents are imprisoned. Historically, child welfare and criminal justice policy have been treated as distinct and unrelated areas of policy. This article discusses the interdependence of criminal justice policy, welfare reform legislation, and kinship foster care, and the impact of this interdependence on children whose parents are in jail or in prison.

Prevalence of diabetes mellitus in elderly people in Canada: report from the Canadian Study of Health and Aging

AIMS

to estimate the age-specific prevalence of diabetes mellitus in elderly people in Canada, and to examine the effect of method of ascertainment on the estimation of prevalence.

METHOD

three measures of diabetes were used in a secondary analysis of the Canadian Study of Health and Aging--a 1991 nation-wide cross-sectional study of the prevalence of dementia in a sample of 10,263 elderly subjects (aged 65-106 years).

RESULTS

of community-dwelling subjects, 10.3% reported diabetes. Supplementing this information with clinical reports and random plasma glucose measurements increased the prevalence to 12.0% in the community, 17.5% in institutions and 12.4% overall.

CONCLUSION

diabetes is common in elderly people, although the prevalence falls in the very elderly. The method of ascertainment influences estimation of prevalence.

Pediatricians' pet peeves about mental health referrals

This chapter has described a number of problems encountered by pediatricians when referring their patients for mental health services; these are related to access to care, quality of providers and service, attitudes of patients and providers, and lack of adequate communication. We have discussed some of the reasons for these difficulties, provided information that may assist pediatricians in making referrals to appropriate mental health providers, and offered suggestions to facilitate the referral process. We have highlighted the utility of developing and maintaining a relationship with mental health referral sources, and noted a number of advantages of including mental health providers in pediatric practices.

Genomic structure and domain organisation of the human Bak gene

The Bcl-2 homologue, Bak, is a potent inducer of apoptosis. FISH data presented here located the gene to 6p21.3. Mapping was consistent with its location centromeric of the HSET locus and approximately 400kb from the MHC. The construction of a contig of genomic clones across the locus facilitated the sequencing of a PAC containing the gene. Comparison of the gene structure to functional and physical domains revealed a good agreement between the physical structure and the intron-exon organisation. The position of a single intron was conserved in comparison to other members of the Bcl-2 family, namely Bax, CED-9, Bcl-X and Bcl-2, but all other introns were displaced, consistent with a divergent phylogeny.

Prospective randomized controlled trial comparing Lichtenstein with modified Bassini repair of inguinal hernia

We present a prospective randomized study of 80 patients with inguinal hernia who underwent either a modified Bassini repair (n = 38) or a Lichtenstein mesh repair (n = 42). Treatment groups were matched for age, side of hernia, type of hernia and ASA grade. There was no difference in the time taken to perform the two operations: the mean time taken to perform Lichtenstein repair was 26.8 min (range 12 to 49), Bassini repair taking a mean of 27.5 min (range 9 to 51), P = 0.76. There was, however, a difference between the operating times with respect to the type of hernia present, direct hernias being the fastest to repair. Pain scores were assessed by a visual analogue scale, and there was significantly less pain in the Lichtenstein group, P = 0.028. Despite this, there was no difference between the analgesic requirements of the two groups, P = 0.073. In order to assess rehabilitation, lengths of time not working and not driving were assessed. There was no difference in either measurement, P = 0.335 and 0.467 respectively. Patients were followed up a mean of 7 weeks post-operatively (range 1 to 13 weeks). There was no significant difference between the two procedures with regard to post-operative urinary complications, wound infection or other complications. All measurements except the time taken to perform the operation were independent of the surgeon involved. The accuracy of the clinical diagnosis was also assessed, and found to be moderate, with 63% of diagnoses being correct.

The psychosocial and physiological experiences of patients with an implantable cardioverter defibrillator

This article describes the relationships between anxiety, self-efficacy, as well as the psychosocial and physiological experiences of patients with an internal cardioverter defibrillator (ICD). Although survival rates with ICDs are impressive, patients experience psychological and physiological responses to their lifesaving devices. Thirty-nine patients completed questionnaires during outpatient clinic visits. Patients' anxiety levels were correlated with fears about ICD malfunction, fear of death, fear of being shocked, loss of control, trouble related to sleeping, inability to concentrate, overprotective family members, and depression. Patients with physical symptoms had higher anxiety levels than those without physical symptoms. There was not a significant relationship between anxiety and discomfort associated with discharge, the number of discharges, or ejection fractions. Low self-efficacy was significantly related to fears about ICD malfunction as well as patients' inability to work, engage in hobbies, and drive a car. Patients with low self-efficacy had more physical symptoms and lower ejection fractions. There were no significant relationships between self-efficacy and frequency of ICD discharge or patients' discomfort during ICD discharge.