Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery

We have studied prospectively the effect of 10 cm H2O of PEEP on the incidence of venous air embolism and on the cardiovascular response to change from the supine to the seated position in a large neurosurgical population. Patients were allocated randomly to receive either PEEP (10 cm H2O, n = 45) or conventional (control, n = 44) ventilation. Cardiovascular and respiratory variables were measured in the supine and sitting positions, and monitoring included precordial Doppler probe, pulmonary artery pressure and expiratory carbon dioxide concentration. Venous air embolism was assumed if changes in precordial Doppler sounds occurred, end-tidal carbon dioxide concentration decreased or air could be retrieved from a central venous multi-orifice catheter. The incidence of venous air embolism (26%) did not differ between patients undergoing conventional ventilation and those undergoing ventilation with 10 cm H2O of PEEP. Venous air embolism was always detected first by alterations in Doppler sounds. Cardiac output was significantly higher in patients undergoing conventional ventilation than in those undergoing ventilation with PEEP in the supine but not in the sitting position. Furthermore, pulmonary vascular resistance increased significantly only in the upright position in those undergoing ventilation with PEEP. The pulmonary artery wedge pressure to central venous pressure gradient did not attain negative values with PEEP or with upright positioning. We conclude that the use of PEEP during neurosurgical procedures performed in the sitting position should be abandoned as it does not decrease the incidence of venous air embolism but is associated with significant adverse cardiovascular effects.

Economic burden of environmental tobacco smoke on Hong Kong families: scale and impact

STUDY OBJECTIVE

To examine the financial cost of doctor consultations for cough, phlegm, and wheeze in children living in a home where family members smoke compared with those not exposed to environmental tobacco smoke. To model these costs to provide the Territory of Hong Kong with estimates of potentially avoidable health care resource use.

DESIGN

Cross sectional questionnaire survey.

SUBJECTS AND SETTING

All children (10,615) in classes primary 3 to 6 (aged 8-13 years) attending 27 schools in two districts of Hong Kong in 1992 and their parents.

MEASUREMENTS AND MAIN RESULTS

Doctor consultations during the previous three months for symptoms of either cough, phlegm or wheeze were higher in younger children, ranging from 22.9% in 8 year olds to 8.4% in those aged 12 or over. For those children living in homes with one, or more than one, smoker category (there were four categories of smokers: father, mother, siblings, others), the adjusted odds ratios (95% confidence intervals) for a doctor consultation for any of these symptoms were 1.15 (1.01, 1.31) and 1.38 (1.14, 1.67) respectively. Using US$15 as the minimum cost incurred per consultation, the expected direct cost per annum per child of doctor consultations was 14% higher for children living in a one smoker category home and 25% for two or more compared with exposure to no smokers in the home. Using these values on a territory wide basis, the annual avoidable direct cost associated with exposure to tobacco smoke in children from birth to 12 years of age ranged from US$338,042 to US$991,591.

CONCLUSIONS

Exposure to environmental tobacco smoke not only provides a respiratory health risk for children but also an avoidable excess cost to the family's financial resources and health service providers.

From laboratory to clinic: a large scale study of distortion product otoacoustic emissions in ears with normal hearing and ears with hearing loss

OBJECTIVES

1) To describe distortion product otoacoustic emission (DPOAE) measurements in large groups of subjects with normal hearing and with hearing loss, and to use these data to provide comprehensive descriptions of DPOAE test performance. 2) To describe the effects of primary frequency and audiometric threshold on the extent to which DPOAE measurements accurately identify auditory status. 3) To develop an approach that describes the probability that any measured response is coming from either a normal or an impaired ear. 4) To develop an approach for representing DPOAE data clinically. 5) To explore the relation between magnitude of hearing loss and DPOAE measurements.

DESIGN

DPOAE measurements were made in 1267 ears of 806 subjects, using stimulus conditions that previously had been demonstrated to result in the greatest separation between normal and impaired ears (i.e., primary levels of 65/55 dB SPL for f1/f2; Stover et al., 1996). Subjects were recruited from local clinical populations and through local advertisements. All data were analyzed using clinical decision theory, including relative operating characteristic (ROC) curves and estimates of areas under these curves (Az). In addition, cumulative distributions were constructed of response properties from both normal and hearing-impaired ears. These cumulative distributions were used to select specific probabilities that measured responses were coming from either the normal or impaired distributions, and to develop an approach for describing clinical DPOAE data.

RESULTS

For no conditions were the distributions of DPOAE responses from normal and impaired ears completely separated, meaning that optimal criterion values would still result in errors in identification of auditory status. Test performance, defined by Az, was best for mid and high frequencies and poorest for lower frequencies and for the highest frequency tested (8000 Hz). Performance was best when normal hearing was defined as audiometric thresholds between 20 and 30 dB HL, with poorer performance for more stringent or lax audiometric criteria.

CONCLUSIONS

Within the limits related to the effects of primary frequency and audiometric criterion, it appears that DPOAE measurements can be used to accurately identify auditory status. An approach is described, using the present data set, that allows one to assign to any measured DPOAE value (DPOAE amplitudes, DPOAE/noise) the probability that the response is coming either from the distribution of normal or impaired responses. In addition, DPOAE/noise systematically decreases as hearing loss increases over the range of hearing losses from 0 to about 40 to 60 dB HL (depending on frequency), thus potentially enabling one to differentiate hearing losses over this range. For hearing losses greater than 50 to 60 dB HL, ears do not produce measurable DPOAEs and thus, no predictive relationship exists.

The influence of antithrombin III (AT III) substitution to supranormal activities on systemic procoagulant turnover in patients with end-stage chronic liver disease

OBJECTIVE

Since antithrombin III (AT III) substitution to normal activities could not be shown to have major beneficial effects in patients with end-stage chronic liver disease in a variety of clinical settings, we tested the hypothesis that substitution to supranormal activities decreases systemic procoagulant turnover better in this patient group.

DESIGN

Controlled prospective clinical study.

SETTING

Operating rooms at a University Hospital.

PATIENTS

Twenty-four patients with histologically verified liver cirrhosis consecutively scheduled for liver transplantation.

INTERVENTIONS

Nineteen patients were given an antithrombin III concentrate to achieve either 100% (n = 10) or 175% (n = 9) AT III activity. Control patients (n = 5) received saline 0.9% instead.

MEASUREMENTS AND RESULTS

Molecular markers of coagulation activation, platelet count and aggregability, and global coagulation variables were measured prior to AT III infusion and 60 min thereafter. In both AT III-treated groups thrombin-antithrombin III-complex increased significantly (p < 0.005), whereas prothrombin fragment F1 + 2, soluble fibrin and D-dimer concentrations, as well as other variables, did not show major changes.

CONCLUSIONS

Despite thrombin inhibition by AT III in patients with end-stage chronic liver disease, systemic procoagulant turnover was not significantly decreased 60 min after AT III application even to supranormal activities. Replenishment of the inhibitory antithrombin III pool, decreased in chronic liver disease, should not be expected to slow down the baseline consumptive component of the haemostatic disorder in this patient group.

[The dromedary: ancestry, history of domestication and medical treatment in early historic times]

Research on camel bones from archaeological excavations in North Africa and the Near East contradict the current opinion in textbooks that the dromedary and the Bactrian camel are domesticated forms derived from a single species, the two-humped wild camel (C. ferus). The probable ancestor of the domestic one-humped camel is Thomas' camel (C. thomasi). The wild dromedary was probably domesticated on the Arabian peninsula, perhaps as early as the 4th millennium BC. From the 2nd millennium BC onward there is evidence for the use of the one-humped camel for riding and transport purposes. Camel-keeping also implied the therapy of diseased animals, the main source of information about their treatment being medieval arabic texts dealing with veterinary medicine. An expert of such an early 13th century text is presented and discussed. From this it can be seen that the medieval camel treatment fits the principles of the so-called humoral theory, a medical concept which at that time already existed for more than 1500 years.

Genetic and functional analysis of neuronatin in mice with maternal or paternal duplication of distal Chr 2

Functional differences between parental genomes are due to differential expression of parental alleles of imprinted genes. Neuronatin (Nnat) is a recently identified paternally expressed imprinted gene that is initially expressed in the rhombomeres and pituitary gland and later more widely in the central and peripheral nervous system mainly in postmitotic and differentiating neuroepithelial cells. Nnat maps to distal chromosome (Chr) 2, which contains an imprinting region that causes morphological abnormalities and early neonatal lethality. More detailed mapping analysis of Nnat showed that it is located between the T26H and T2Wa translocation breakpoints which is, surprisingly, proximal to the reported imprinting region between the T2Wa and T28H translocation breakpoints, suggesting that there may be two distinct imprinting regions on distal chromosome 2. To investigate the potential role of Nnat, we compared normal embryos with those which were PatDp.dist2.T26H (paternal duplication/maternal deficiency of chromosome 2 distal to the translocation breakpoint T26H) and MatDp.dist2.T26H. Expression of Nnat was detected in the PatDp.dist2.T26H embryos, where both copies of Nnat are paternally inherited, and normal embryos but no expression was detected in the MatDp.dist2.T26H embryos with the two maternally inherited copies. The differential expression of Nnat was supported by DNA methylation analysis with the paternally inherited alleles being unmethylated and the maternal alleles fully methylated. Although experimental embryos appeared grossly similar phenotypically in the structures where expression of Nnat was detected, differences in folding of the cerebellum were observed in neonates, and other more subtle developmental or behavioral effects due to gain or loss of Nnat cannot be ruled out.

Behavioral and functional analysis of mouse phenotype: SHIRPA, a proposed protocol for comprehensive phenotype assessment

For an understanding of the aberrant biology seen in mouse mutations and identification of more subtle phenotype variation, there is a need for a full clinical and pathological characterization of the animals. Although there has been some use of sophisticated techniques, the majority of behavioral and functional analyses in mice have been qualitative rather than quantitative in nature. There is, however, no comprehensive routine screening and testing protocol designed to identify and characterize phenotype variation or disorders associated with the mouse genome. We have developed the SHIRPA procedure to characterize the phenotype of mice in three stages. The primary screen utilizes standard methods to provide a behavioral and functional profile by observational assessment. The secondary screen involves a comprehensive behavioral assessment battery and pathological analysis. These protocols provide the framework for a general phenotype assessment that is suitable for a wide range of applications, including the characterization of spontaneous and induced mutants, the analysis of transgenic and gene-targeted phenotypes, and the definition of variation between strains. The tertiary screening stage described is tailored to the assessment of existing or potential models of neurological disease, as well as the assessment of phenotypic variability that may be the result of unknown genetic influences. SHIRPA utilizes standardized protocols for behavioral and functional assessment that provide a sensitive measure for quantifying phenotype expression in the mouse. These paradigms can be refined to test the function of specific neural pathways, which will, in turn, contribute to a greater understanding of neurological disorders.

Interaction between haematocrit and pulmonary blood volume on pulmonary vascular flow resistance and pressure flow relationships

OBJECTIVE

Pulmonary vascular flow resistance depends on blood viscosity, mainly due to haematocrit, and on vessel dimensions determining blood volume in this highly compliant vascular bed. We, therefore, evaluated the interaction between haematocrit, blood flow, and transpulmonary vascular pressure gradient under conditions of controlled pulmonary blood volume.

DESIGN

Experimental study in isolated zone-III rabbit lungs perfused with autologous blood.

SETTING

Laboratory for experimental studies.

INTERVENTIONS

Stepwise and independent variation of flow (50, 100, and 200 ml/min), pulmonary blood volume (increments of 2.5 ml and 5 ml imposed by changes of left atrial pressure), and haematocrit (0-50%) varied by haemodilution (Krebs-Henseleit/albumin) or haemoconcentration (centrifugation).

MEASUREMENTS

Pulmonary arterial, left atrial, and airway pressures as well as reservoir volume (reflecting reciprocal changes of lung blood volume) and lung weight.

RESULTS

Haemodilution from the normal haematocrit (32%) to 10% at constant pulmonary blood volume and flow decreased flow resistance only slightly, whereas haemoconcentration (50%) increased flow resistance up to 130%. At the same time increments of in pulmonary blood volume of 2.5 and 5 ml (approx. 15 and 30% of normal pulmonary blood volume) at constant haematocrit significantly shifted downwards pressure-flow relationships for all investigated haematocrits (0-50%).

CONCLUSIONS

Because of the multiple interrelationships between haematocrit, blood flow and pulmonary blood volume, haematocrit effects on pulmonary flow resistance and pressure-flow relationships in the pulmonary vasculature should be studied at controlled blood volume. While haemodilution only has minor effects, haemoconcentration changes pressure-flow relationships markedly. Pulmonary blood volume has a major impact on slope and position of pressure-flow relationships for all haematocrits investigated.

The effect of delayed analysis or freeze-thawing on the measurement of natural anticoagulants, resistance to activated protein C and markers of activation of the haemostatic system

We provide a centralised thrombophilia screening service with sample transfer by courier or first class mail, a practice common to many centres. Sample quality is of prime importance, thus we have assessed the effect of delayed sample handling upon the haemostatic variables within our thrombophilia profile. This comprises screening for familial natural anticoagulant deficiency and APC resistance (1-4), and acquired lupus anticoagulant (5,6). The effect upon hypercoagulable markers were also assessed to facilitate evaluation of these in prospective clinical studies (7).

Vaginal Ureaplasma urealyticum colonization: influence on pregnancy outcome and neonatal morbidity

The effects of Ureaplasma urealyticum colonization on pregnancy and neonatal outcome was prospectively studied in women with impending term or preterm delivery. One hundred and seventy women colonized with U. urealyticum as the only pathogenic microorganism and 83 women with negative cultures were enrolled for study. Compared to the controls, U. urealyticum colonization was associated with a significantly increased rate of amnionitis (2% vs 35%; p < 0.001), chorioamnionitis (0% vs 10%; p < 0.05), premature rupture of membranes (12% vs 35%; p < 0.001) and preterm delivery (10% vs 41%; p < 0.001). The rate of vertical transmission ranged from 38% in term infants to 95% in very low birth weight infants. U. urealyticum colonization at birth was associated with an increased risk for the development of respiratory distress syndrome (9% vs 51%), intraventricular hemorrhage (1% vs 7%) and bronchopulmonary dysplasia (4% vs 17%) in very low birth weight infants (< 1500 g). It is concluded that maternal U. urealyticum colonization is associated with amnionitis, chorioamnionitis and preterm delivery, and that tracheal colonization with U. urealyticum increases the risk for respiratory and neurological complications in very low birth weight infants.

Tumor suppressor activity of neural cell adhesion molecule in colon carcinoma

BACKGROUND AND AIMS

Neural Cell Adhesion Molecule (NCAM) is a well-characterized member of the immunoglobin superfamily. The structure of NCAM is similar to the tumor suppressor Deleted in Colon Carcinoma (DCC). NCAM has been found in some epithelial tissues and plays a role in tumorigenesis of some cancers. The purpose of the present study was to determine if NCAM is present in normal human colon. Once its presence was established, its function as a tumor suppressor was investigated.

METHODS

Colon tumors and normal proximal margins were processed for reverse transcription-polymerase chain reaction (RT-PCR) of the NCAM-180 message. Immunohistochemistry of the tissue was performed to determine the distribution of NCAM.

RESULTS

RT-PCR analysis demonstrated the presence of the NCAM-180 kD isoform in normal colonic epithelia. Immunohistochemistry showed NCAM on the basolateral surface of colonic epithelial cells of the villous tips. Tumors from 15 patients followed up for 4 years were studied. All seven tumors expressing NCAM-180 were from patients having a benign clinical course. Seven of eight tumors that lacked NCAM-180 were associated with aggressive clinical behaviors (presenting with obstruction, perforation or metastatic disease, or patient death within 18 months of presentation). The sole exception was in a villous adenoma excised from a patient who has had multiply recurrent polyps on follow-up.

CONCLUSION

We conclude that like DCC, NCAM is an important colonic adhesion molecule that functions as a tumor suppressor.

Swelling and damage of glial cells by lactacidosis and glutamate: effect of alpha-trinositol

The therapeutical efficacy of alpha-trinositol (D-myo-inositol-1,2,6-trisphosphate), an isomer of the intracellular messenger IP3, was analyzed on cytotoxic swelling and damage of glial cells in vitro from lactacidosis or glutamate. C6 glioma cells suspended in a physiological medium were either exposed to pH 5.0 by administration of lactic acid, or to 1 mM glutamate. Cell swelling and viability were quantified by flow cytometry. Lactacidosis of pH 5.0 led to an increase in cell volume to 139.7 +/- 1.3% within 20 min whereas alpha-trinositol was reducing the swelling response by approximately 25% (P < 0.01). In addition, at pH 5.0 the fraction of viable cells was lowered from 94.3 +/- 0.2% (control) to only 53.8 +/- 3.1% after 60 min. Alpha-trinositol was found to protect also cell viability; at 60 min of lactacidosis 70.2 +/- 1.6% of the cells still were viable (P < 0.01). The addition of glutamate (1 mM) to the cell suspension led to a steady increase in cell size, reaching 110% of control at 120 min, irrespectively of whether alpha-trinositol was added or not.

Hemofiltration increases IL-6 clearance in early systemic inflammatory response syndrome but does not alter IL-6 and TNF alpha plasma concentrations

OBJECTIVE

To test the hypothesis that continuous hemofiltration increases interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF alpha) clearances and results in decreased cytokine plasma concentrations independent of renal function in patients with early SIRS.

DESIGN

Prospective, controlled, randomized study.

SETTING

Intensive care units at a university hospital.

PATIENTS

28 consecutive patients who fulfilled the criteria of the systemic inflammatory response syndrome (SIRS).

INTERVENTIONS

Patients with SIRS were randomly assigned to either a hemofiltration or a control group irrespective of renal function. In patients of the hemofiltration group an isovolemic hemofiltration was initiated directly after the diagnosis of SIRS and maintained for at least 48 h.

MEASUREMENTS AND RESULTS

A significant (p < 0.001) increase in total IL-6 clearance (hemofiltrate + urine), but not in TNF alpha clearance, was observed with hemofiltration. However, the plasma concentrations of both cytokines remained unchanged. Hemodynamic variables did not change significantly.

CONCLUSIONS

Continuous hemofiltration increases IL-6 plasma clearance but not TNF alpha clearance. However, hemofiltration failed to decrease plasma concentrations of TNF alpha and IL-6 and, therefore, cannot be used effectively for cytokine elimination in SIRS. Accordingly, beneficial effects occasionally reported with hemofiltration are unlikely to be expected due to elimination of IL-6 or TNF alpha.

Renin-1 is essential for normal renal juxtaglomerular cell granulation and macula densa morphology

The secretion of renin from granules stored in renal juxtaglomerular cells plays a key role in blood pressure homeostasis. The synthesis and release of renin and the extent of granulation is regulated by several mechanisms including signaling from the macula densa, neuronal input, and blood pressure. Through the use of a gene-targeting vector containing homology arms generated using the polymerase chain reaction, we have inactivated the Ren-1(d) gene, one of two mouse genes encoding renin, and report that lack of renin-1(d) results in altered morphology of the macula densa of the kidney distal tubule and complete absence of juxtaglomerular cell granulation. Furthermore, Ren-1(d-/-) mice exhibit sexually dimorphic hypotension. The altered growth morphology of the macula densa in Ren-1(d)-null mice should provide a tool for the investigation of the JG cell-macula densa signaling. Furthermore, the current data indicate that expression of the Ren-1(d) gene is a prerequisite for the formation of storage granules, even though the related protein renin-2 is present in these mice, suggesting that renin-1(d) and renin-2 are secreted by distinct pathways in vivo.

The association between body mass and health care expenditures

With several studies estimating the health care costs attributable to obesity-related medical conditions, the economic consequences of being overweight are beginning to come into focus. The present study complements this growing body of literature by directly estimating health care costs across a broad range of body mass index values. Data were obtained from the 1987 National Medical Expenditure Survey (NMES) public use data tapes and retrospective analyses conducted on NMES Household Survey data only. The analyses included a total of 16,217 individuals between the ages of 18 and 65. Four classes of health care utilization and expenditures were derived using the NMES data: (1) use of any health care service and total health care expenditures, (2) use of inpatient services and inpatient expenditures, (3) use of outpatient services and outpatient expenditures, and (4) use of prescription medication and medication expenditures. Estimates based on our findings suggested strong relationships between body mass and the likelihood of using health care services and between body mass and average annual health care expenditures for both men and women. Increased body mass was associated with increased expenditures. However, this association was greater among males than among females and did not hold for individuals in the lowest body mass category. Ideal body mass was associated with 6.3% to 36.1% lower annual health care expenditures among females and 3.6% to 18.2% lower health care expenditures among males. The results of this set of analyses suggest that health care expenditures increase as weight deviates from the ideal-that is, health care expenditures among both underweight and overweight individuals in the United States were increased in relation to ideal weight. Separate analyses including weight-related diseases such as diabetes and hypertension indicated that body mass increased health care expenditures largely by increasing the risk for these costly chronic medical conditions.

A transcript map encompassing the multiple endocrine neoplasia type-1 (MEN1) locus on chromosome 11q13

A transcription map of a 1200-kb region encompassing the MEN1 locus was constructed by direct cDNA selection and mapping ESTs. A total of 29 genes were mapped. Ten transcripts were identified by cDNA selection of a focused 300-kb genomic region telomeric to the MEN1 consensus region. Since many of the sequences cloned by cDNA selection also identified ESTs from the region, 19 additional RH-mapped ESTs were mapped to the entire contig region by PCR amplification of genomic clones. Nine known genes, 2 putative human homologues to mouse genes, and 18 novel transcripts map to the region. Transcripts that map to the MEN1 interval PYGM-D11S449 include SGC35223, IB1256, AA147620, ZFM1, FAU, and CAPN1. The latter 3 known genes have already been excluded as candidate MEN1 genes. The 2 putative human homologues of mouse genes Ltbp2 and Spa-1 may be candidate tumor suppressor genes, but they map telomeric to D11S449. Although both of these genes map outside the MEN1 consensus region they may play a role in sporadic endocrine tumors independent of the MEN1 gene or in other tumors, such as breast cancer, that have loss of heterozygosity within this region.