Perspectives of residential contractors on nail gun safety

Perspectives on nail gun safety were sought from residential contractors as part of an injury surveillance and prevention effort (2005-2008). Anonymous surveys inquired about tool use, training, injury risk, and awareness of the 2003 American National Standards Institute (ANSI) standard calling for shipment of pneumatic nail guns used in wood framing with sequential actuation. Despite some awareness of inexperience, lack of training, speed and tool design in injury causation, 55 percent consistently reported injuries resulted from worker carelessness. Contractors reported safety experiences of their employees were considerably better than those of other residential contractors. After five years, only 16 percent reported any awareness of the voluntary standard. These findings raise questions as to what gains can realistically be expected from passage of voluntary standards such as the one described here. Given that the epidemiology of acute injuries from pneumatic nail guns is now well-described, the safer sequential trigger should be required to protect workers.

A simple, noninvasive test for the diagnosis of liver fibrosis in patients with hepatitis C recurrence after liver transplantation

Recurrent hepatitis C is a common cause of graft loss in patients undergoing liver transplantation, and serial protocol liver biopsies have been used to identify patients at risk of graft loss from rapid fibrosis progression. The aim of this study was to derive a simple noninvasive index to predict fibrosis in patients with recurrent hepatitis C post-transplant. A retrospective study was performed assessing serial liver biopsies for post-transplant chronic hepatitis C infection. One hundred eighty-five patients were included in the analysis; median age 53 years (interquartile range 48-59) and 140 (76%) were male. Liver histology showed 53 (29%) had Ishak fibrosis stages F0/F1, 31 (17%) had F2, 29 (16%) had F3, 19 (10%) had F4 and 53 (29%) had F5/F6. The London Transplant Centres' (LTC) score was derived combining aspartate aminotransferase (AST IU/L), time from liver transplant (TFLT months), international normalized ratio and platelets. Diagnostic accuracy of the LTC score was assessed using area under receiver-operating characteristic (ROC) curves. The area under the ROC curve for moderate fibrosis (F >or= 2) was 0.78 (95% CI, 0.70-0.86; P < 0.0001), for advanced fibrosis (F4-6) was 0.80 (95% CI, 0.72-0.87; P < 0.0001) and for cirrhosis was 0.80 (95% CI, 0.72-0.88; P < 0.0001). An optimal cut-off value of 6.3 distinguished patients with no or mild fibrosis (F <or= 1) odds ratio 10.8 (95% CI, 5.1-22.9); P < 0.0001), sensitivity 88%, specificity 60%, negative predictive value 67% and positive predictive value 84%. The LTC score can identify patients with Hepatitis C virus recurrence following liver transplant with a low risk of significant fibrosis, thus avoiding the need for protocol biopsy.

Do steatosis and steatohepatitis impact on sustained virological response (SVR) rates in patients receiving pegylated interferon and ribavirin for chronic hepatitis C infection?

The impact of steatosis on treatment response in chronic hepatitis C infection is controversial. The aim of this study was to determine whether steatosis +/- steatohepatitis on pre-treatment liver biopsy influenced sustained virological response (HCV RNA negative 6 months after completing therapy) in patients with chronic hepatitis C infection treated with pegylated interferon-alpha and ribavirin. One hundred and seventy-nine patients, median age 46 years (interquartile range 40-52), treated between 2001 and 2005. Histological evidence of steatosis was present in 93 patients (52%) and steatohepatitis in 33 patients (18%), 31 patients (17.3%) were cirrhotic. There were 106 (59%) responders, who were similar to non-responders in respect to gender, age, and pre-treatment ALT. On univariate analysis, infection with genotype 2 or 3 was associated with sustained virological response (odds ratio 6.5 (95% CI, 3.3-12.5); P < 0.0001), whereas cirrhosis and patient weight were associated with a reduced response (odds ratios 0.23 (95% CI, 0.11-0.48); P < 0.0001, and 0.97 (95% CI, 0.95-0.99); P < 0.01, respectively); steatohepatitis but not steatosis impacted on the likelihood of achieving sustained virological response (odds ratio 0.37 (95% CI, 0.17-0.77); P = 0.009, and P = 0.18, respectively). Multivariate analysis revealed that infection with genotype 1 or 4 (odds ratio 0.09 (95% CI, 0.03-0.32); P < 0.001) and pre-treatment weight (odds ratio 0.94 (95% CI, 0.90-0.98); P = 0.002) were the only variables associated independently with sustained virological response. In chronic hepatitis C infection, although steatosis was associated with steatohepatitis, neither was shown to affect sustained virological response, which was influenced by genotype, patient weight and the presence of cirrhosis.

Evaluation and comparison of guidelines for the management of people with type 2 diabetes from eight European countries

METHODS

The most recent nationally recognised guidelines for type 2 diabetes from eight European countries (Belgium, England/Wales, France, Germany, Ireland, Italy, the Netherlands and Sweden) were compared. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used for quality assessment. Details of recommendations for key process and outcome indicators were also extracted. Appraisal and data extraction were conducted independently by two researchers.

RESULTS

AGREE domain scores varied between guidelines, including a range of 31-95% for rigour of development. The highest mean domain scores were for Scope and Purpose (81%) and Clarity and Presentation (85%); the lowest was for Stakeholder Involvement (49%). Specific recommendations, including targets relating to intermediate outcomes, were broadly similar. However, at detailed level, there were variations, particularly in terms of the level of information provided, for example, only two countries' guidelines provided cut-off points in relation to risk associated with waist circumference.

IMPLICATIONS

Our findings suggest that there are some areas of good practice relating to guideline development where more attention is needed. Despite a substantial degree of consensus for specified targets, observed differences at detailed level suggest a lack of consistency in relation to some aspects of the information provided to clinicians across Europe.

Advanced life support resuscitation protocols

The use of standardized protocols during resuscitation attempts should enable resuscitation team members to work effectively together. The current Resuscitation Council (UK) guidelines (Handley, 2006) are based on the recommendations that came from an international consensus on resuscitation science conference held in 2005. These guidelines are revised and updated regularly to take account of improvements in knowledge and treatments.

Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis

The rate and mode of early failure in 463 Birmingham hip resurfacings in a two-centre, multisurgeon series were examined. Of the 463 patients two have died and three were lost to follow-up. The mean radiological and clinical follow-up was for 43 months (6 to 90).

We have revised 13 resurfacings (2.8%) including seven for pain, three for fracture, two for dislocation and another for sepsis. Of these, nine had macroscopic and histological evidence of metallosis. The survival at five years was 95.8% (95% confidence interval (CI) 94.1 to 96.8) for revision for all causes and 96.9% (95% CI 95.5 to 98.3) for metallosis.

The rate of metallosis related revision was 3.1% at five years. Risk factors for metallosis were female gender, a small femoral component, a high abduction angle and obesity. We do not advocate the use of the Birmingham Hip resurfacing procedure in patients with these risk factors.

CT and MRI of hip arthroplasty

Plain films are the initial imaging method of choice for evaluation of hip arthroplasty. Recent advances in technology and imaging techniques have largely overcome the problems of beam hardening in computed tomography (CT) and magnetic susceptibility artefact in magnetic resonance imaging (MRI). CT and MRI have now become useful imaging techniques in the assessment of hip arthroplasty.

Traumatic pulmonary pseudocysts

We describe a case of a 19-year-old man who developed traumatic pulmonary pseudocysts after a rollover road traffic crash. These were associated with significant pulmonary haemorrhage requiring a period of mechanical ventilation, but resolved without specific intervention. Review of the literature confirms that this rare complication of blunt chest trauma occurs usually in young adults and, although normally benign, can be associated with life-threatening haemoptysis and secondary infection.

Post resuscitation care: what are the therapeutic alternatives and what do we know?

A large proportion of deaths in the Western World are caused by ischaemic heart disease. Among these patients a majority die outside hospital due to sudden cardiac death. The prognosis among these patients is in general, poor. However, a significant proportion are admitted to a hospital ward alive. The proportion of patients who survive the hospital phase of an out of hospital cardiac arrest varies considerably. Several treatment strategies are applicable during the post resuscitation care phase, but the level of evidence is weak for most of them. Four treatments are recommended for selected patients based on relatively good clinical evidence: therapeutic hypothermia, beta-blockers, coronary artery bypass grafting, and an implantable cardioverter defibrillator. The patient's cerebral function might influence implementation of the latter two alternatives. There is some evidence for revascularisation treatment in patients with suspected myocardial infarction. On pathophysiological grounds, an early coronary angiogram is a reasonable alternative. Further randomised clinical trials of other post resuscitation therapies are essential.

Macular pigment levels following successful macular hole surgery

AIM

Macular pigment (MP) is composed of two hydroxycarotenoids contained within the photoreceptors and the axons of the central neurosensory retina, with peak concentrations in the Henle layer. A full thickness macular hole (FTMH) is characterised by absence of all retinal layers in an area centred at the former centre of the fovea. The authors report the results of a study designed to investigate MP levels in patients following successful FTMH surgery, using Raman spectroscopy, and to correlate these findings with functional and topographic outcomes.

METHODS

The following details were recorded for 12 eyes of 12 patients following successful closure of a FTMH: best corrected visual acuity; macula threshold test, fixation, fundus photography, and macular pigment levels using Raman spectroscopy. High resolution imaging of the retina using optical coherence tomography (OCT) was performed in nine of the 12 study eyes.

RESULTS

Mean (SD) best corrected visual acuity was 0.6 (0.4) and improved significantly from preoperative levels. On macula threshold testing of the operated eye, a central scotoma was detectable in one eye only (8.3%). MP levels were demonstrable in 10 of the 12 study eyes following successful FTMH surgery. MP levels were higher in three study eyes, and lower in seven study eyes, when compared with the fellow eye. Of the three pairs of eyes where MP levels were greater in the study eye, macular pathology was present in two fellow eyes.

CONCLUSIONS

The presence of MP was confirmed in the neurosensory retina of an anatomically closed FTMH in 10 of 12 study eyes, although the levels were lower than the fellow normal macula in nine of 10 cases. This suggests a good degree of physiological recovery of photoreceptors and their axons following successful FTMH surgery.

Clinician-led surgical site infection surveillance of orthopaedic procedures: a UK multi-centre pilot study

The UK Department of Health established the Healthcare-associated Infection (HAI) Surveillance Steering Group in 2000 to develop a strategy for implementing a national programme for HAI surveillance in National Health Service trusts. A subgroup of this committee examined the surveillance of surgical site infections following orthopaedic surgery. This group oversaw a pilot scheme that was set up in 12 hospitals around the UK to explore the feasibility of implementing a system of surveillance that engaged clinical staff in its operation, provided a process for continuous data collection and could be maintained as part of routine hospital operation over time. A minimum data set was established by the subgroup, and Centers for Disease Control and Prevention (CDC) definitions of infection were used. By March 2003, the surveillance had been undertaken continuously in 11 sites for one to two years, depending on the date of implementation. Only one hospital had ceased data collection. The information was collected mainly by clinical staff, with support and co-ordination usually provided by infection control teams. Data on more than 5400 procedures were available for analysis for four core procedures: arthroplasty of the hip and knee; hemi-arthroplasty of the hip; and internal fixation of trochanteric fractures of the femur. The data set permitted the calculation of risk-adjusted rates, allowing comparisons between hospitals and within a hospital over time. The methodology enhanced clinical ownership of the surveillance process, re-inforced infection control as the responsibility of all staff, and provided timely feedback and local data analysis. The use of CDC definitions permitted international comparisons of the data.

A novel index for predicting intraocular pressure reduction following cataract surgery

AIM

The results of a study designed to investigate the predictive value of preoperative anterior chamber depth (ACD) and intraocular pressure (IOP) are reported. The relation between these factors and their effect on the reduction in IOP following phacoemulsification cataract surgery was also studied.

METHODS

The ACD and IOP were prospectively measured in 103 non-glaucomatous eyes of 103 patients who underwent uneventful phacoemulsification and posterior chamber intraocular lens (PCIOL) implantation. Other data which were recorded included best corrected visual acuity, axial length, lens thickness, and severity of lens opacity.

RESULTS

The ACD increased by a mean (SD) of 1.10 (0.44) mm (p<0.00001) and this increase was significantly and inversely related to preoperative ACD (r(2) = 68%; p<0.01). IOP dropped by a mean of 2.55 (1.78) mm Hg following cataract surgery (p<0.0001), and this reduction was significantly and positively related to preoperative IOP (r(2) = 56%; p<0.01), and significantly and inversely related to preoperative ACD (r(2) = 21%; p<0.01). A novel ratio, the pressure to depth (PD) ratio (preoperative IOP/preoperative ACD), was found to be significantly and positively related to the surgically induced reduction in IOP (r(2) = 73%; p<0.01), and IOP was reduced by > or =4 mm Hg in all patients with a PD ratio >7.

CONCLUSION

The reduction in IOP following cataract surgery was found to be positively related to preoperative IOP, and inversely related to preoperative ACD. Furthermore, these results indicate that a novel index, the PD ratio, is strongly predictive for IOP reduction following cataract extraction, and may prove useful in surgical decision making.

Observations and warning signs prior to cardiac arrest. Should a medical emergency team intervene earlier?

BACKGROUND

The Medical Emergency Team (MET) has evolved in some hospitals as a means of delivering effective treatment early enough to prevent cardiac arrests. Our aim was to analyze the effectiveness of observation practice to detect abnormalities in vital signs prior to cardiac arrest and to determine the need for a MET system in Finnish hospitals.

METHODS

The charts of patients who suffered cardiac arrest during 18 months in four hospitals were reviewed. The vital signs, symptoms and interventions during 8 h prior to arrest were recorded and analyzed against trigger criteria of the MET.

RESULTS

During the study period, 110 patients suffered cardiac arrest in hospitals, and 56 (51%) of the arrests occurred on the wards. Of those patients, 30 (54%) had an abnormal vital sign fulfilling the MET criteria, documented on average 3.8 h prior to the arrest. During this period, 13 patients did not receive any intervention (e.g. supplemental oxygen or medication), eight received intervention within 1 h and nine received intervention after more than 1 h. Response to the first intervention was not attained in any patient; nevertheless re-interventions took place in one patient only.

CONCLUSION

Significant physiological deterioration seems to be common in the hours before a cardiac arrest on the wards of Finnish hospitals, suggesting that implementation of a MET-system may be worthwhile. However, the practice of vital sign observation by the nursing staff should be improved before maximal benefit of a MET can be achieved.

Predicting sudden death in patients with mild to moderate chronic heart failure

OBJECTIVES

To explore the relation between non-invasive measures of cardiac function and sudden cardiac death, as well as the development and utility of an index integrating these variables to identify patients at increased risk of this mode of death.

DESIGN

UK-HEART (United Kingdom-heart failure evaluation and assessment of risk trial) was a prospective study conducted between December 1993 and April 2000. The study was specifically designed to identify non-invasive markers of death and mode of death among patients with chronic heart failure.

SETTING

8 UK general hospitals.

MAIN OUTCOME MEASURES

Death and mode of death.

RESULTS

553 patients aged a mean (SD) of 63 (10) years, in New York Heart Association functional class 2.3 (0.02), recruited prospectively. After 2365 patient-years' follow up, 201 patients had died (67 suddenly). Predictors of sudden death were greater cardiothoracic ratio, QRS dispersion, QT dispersion corrected for rate (QTc) across leads V1-V6 on the 12 lead ECG, and the presence of non-sustained ventricular tachycardia. The hazard ratio and 95% confidence intervals (CI) of sudden death for a 10% increase in cardiothoracic ratio was 1.43 (95% CI 1.20 to 1.71), for a 10% increase in QRS dispersion 1.11 (95% CI 1.04 to 1.19), for the presence of non-sustained ventricular tachycardia 2.03 (95% CI 1.27 to 3.25), and for a 10% increase in QTc dispersion across leads V1-V6 1.03 (95% CI 1.00 to 1.07) (all p < 0.04). An index derived from these four factors performed well in identifying patients specifically at increased risk of sudden death.

CONCLUSIONS

Results show that an index derived from three widely available non-invasive investigations has the potential to identify ambulant patients with chronic heart failure at increased risk of sudden death. This predictive tool could be used to target more sophisticated investigations or interventions aimed at preventing sudden death.

Quantification of EGFP expression on Molt-4 T cells using calibration standards

BACKGROUND

Enhanced green fluorescent protein (EGFP) is used extensively to assess gene expression on cells; however, quantification of this expression by flow cytometry has been limited by the unavailability of calibration standards. Thus, we characterized the response of an experimental set of EGFP calibration standards to environmental changes and then quantitate the expression of EGFP, in molecules of equivalent soluble fluorochrome (MESF) units, of a transfected Molt-4 T cell line by flow cytometry.

METHODS

Characterization of the EGFP standards: EGFP standards were equilibrated in suspension solutions having a pH range of 5.0-9.0, temperatures of 37-80 degrees C, and osmolalities of 100-600 mOsm/kg. Quantification of EGFP on cells: For transfections, Molt-4 T cells were incubated with two different concentrations (0.2 microg and 0.4 microg) of pEGFP-N2 vector and the EGFP expression was quantified after 48 h by flow cytometry using the EGFP standards and by the cytofluor technique using a standard curve of known EGFP solutions.

RESULTS

The fluorescence intensity of the EGFP standards increased from pH 5.0 to 9.0 and remained relatively constant from 37 degrees C to 65 degrees C, and from 100 to 600 mOsm/kg. After transfection, the expression of the populations with high and low EGFP expression averaged 8,098 +/- 584 MESF and 3,808 +/- 375 MESF respectively. No significant differences were observed after comparing the MESF values obtained by flow cytometry and the values obtained by Cytofluor technique (high: 8,791 +/- 492 MESF; low: 4,082 +/- 398 MESF).

CONCLUSIONS

Our data demonstrate the feasibility of using calibration standards to quantify EGFP expression on cells. Our results emphasize the importance of monitoring the effects of environmental changes in the fluorescence intensity of both standards and samples when quantifying the expression of EGFP on living cells.

Effect of high levels of intense sweetener intake in insulin dependent diabetics on the ratio of dietary sugar to fat: a case–control study

OBJECTIVE

To examine the influence of intense sweetener consumption on nutrient intakes in insulin dependent diabetics compared to controls.

DESIGN

Case-control food consumption survey.

SETTING

Dietary data were collected from individuals in Ireland between 1998 and 1999.

SUBJECTS

Diabetics were recruited through diabetic outpatient departments of St. James's Hospital Dublin. Controls were friends of the patients or staff/students of Trinity College and University College Dublin. Of the 171 diabetics contacted, 122 agreed to participate (70% response rate) and 119 completed the study.

INTERVENTIONS

In all, 3-day food diaries were used to collect the food consumption data.

MAIN OUTCOME MEASURES

Fat--sugar seesaw, intense sweetness.

RESULTS

Patients had significantly higher % energy from starch, lower % energy from sugars and a high intake of fibre compared to controls. In both groups, there was an inverse relationship between % energy from fat and % en from sugar, with the diabetics at the lower level of sugar intake. A score of intense sweetness intakes was computed and across tertiles of this score, there were no significant effects on macronutrient intakes.

CONCLUSION

The fat-sugar seesaw present in the diabetic group was at a lower level compared to the control group. A high intake of intense sweeteners does not have a detrimental effect on macronutrient and micronutrient intakes.

Open source clustering software

SUMMARY

We have implemented k-means clustering, hierarchical clustering and self-organizing maps in a single multipurpose open-source library of C routines, callable from other C and C++ programs. Using this library, we have created an improved version of Michael Eisen's well-known Cluster program for Windows, Mac OS X and Linux/Unix. In addition, we generated a Python and a Perl interface to the C Clustering Library, thereby combining the flexibility of a scripting language with the speed of C.

AVAILABILITY

The C Clustering Library and the corresponding Python C extension module Pycluster were released under the Python License, while the Perl module Algorithm::Cluster was released under the Artistic License. The GUI code Cluster 3.0 for Windows, Macintosh and Linux/Unix, as well as the corresponding command-line program, were released under the same license as the original Cluster code. The complete source code is available at http://bonsai.ims.u-tokyo.ac.jp/mdehoon/software/cluster. Alternatively, Algorithm::Cluster can be downloaded from CPAN, while Pycluster is also available as part of the Biopython distribution.

Effect of remifentanil infusion rate on stress response to the pre-bypass phase of paediatric cardiac surgery

BACKGROUND

Opioids are used routinely to eliminate the stress response in the pre-bypass phase of paediatric cardiac surgery. Remifentanil is a unique opioid allowing a rapidly titratable effect. No data are available regarding a suitable remifentanil dose regimen for obtunding stress and cardiovascular responses to such surgery.

METHODS

We recruited 49 infants and children under 5 yr old who were randomized to receive one of four remifentanil infusion rates (0.25, 1.0, 2.5, or 5.0 micro g kg(-1) min(-1)). Blood samples were obtained at induction, pre-surgery, 5 min after opening the chest, and immediately pre-bypass. Whole blood glucose was measured at all time points while cortisol and neuropeptide Y (NPY) were measured in the first and last samples. Heart rate and arterial pressure were also recorded.

RESULTS

There was a significant increase in whole blood glucose 5 min after opening the chest and pre-bypass (P=0.009, P=0.002) in patients receiving remifentanil 0.25 micro g kg(-1) min(-1), but not in those receiving higher doses. Increased remifentanil dosage was associated with reduced plasma cortisol during surgery (P<0.001). Baseline NPY showed considerable variation and there was no association between pre-bypass NPY and remifentanil dose. There was a significantly higher heart rate at the pre-bypass stage of surgery in the remifentanil 0.25 micro g kg(-1) min(-1) group compared with higher doses (P=0.0006). Four out of five neonates with complex cardiac conditions showed severe bradycardia associated with remifentanil.

CONCLUSIONS

In infants and children under 5 yr, remifentanil infusions of 1.0 micro g kg(-1) min(-1) and greater can suppress the glucose increase and tachycardia associated with the pre-bypass phase of cardiac surgery, while 0.25 micro g kg(-1) min(-1) does not. Remifentanil should be used with caution in neonates with complex congenital heart disease.

A comparative study of amino acid consumption by rat islet cells and the clonal beta-cell line BRIN-BD11 - the functional significance of L-alanine

Evidence has been published that L -alanine may, under appropriate conditions, promote insulin secretion in normal rodent islets and various beta cell lines. Previous results utilising the clonal beta-cell line BRIN-BD11, demonstrated that alanine dramatically elevated insulin release by a mechanism requiring oxidative metabolism. We demonstrate in this paper that addition ofL -alanine had an insulinotropic effect in dispersed primary islet cells. Addition of D -glucose increasedL -alanine consumption in both BRIN-BD11 cells and primary islet cells.L -glutamine consumption in the BRIN-BD11 cell line and primary rat islets was also determined. The consumption rate was in line with that previously reported for cells of the immune system and other glutamine-utilising cells or tIssues. However,L -alanine consumption was at least an order of magnitude higher thanL -glutamine consumption. The metabolism ofL -alanine in the beta-cell may result in stimulation of insulin secretion via generation of metabolic stimulus secretion coupling factors such asL -glutamate.

Nail gun injuries in residential carpentry: lessons from active injury surveillance

OBJECTIVE

To describe circumstances surrounding injuries involving nail guns among carpenters, calculate injury rates, identify high risk groups and preventive measures.

METHODS

and setting: Active injury surveillance was used to identify causes of injury among a large cohort of union residential and drywall carpenters. Injured carpenters were interviewed by experienced journeymen; enumeration of workers and hourworked were provided by the union. The combined data allowed definition of a cohort of carpenters, their hours worked, detailed information on the circumstances surrounding injuries, and identification of preventive measures from the perspectives of the injured worker and an experienced investigator.

RESULTS

Nail guns were involved in 14% of injuries investigated. Ninety percent of these injuries were the result of the carpenter being struck, most commonly by a nail puncturing a hand or fingers. The injury rate among apprentices was 3.7 per 200 000 hours worked (95% confidence interval (CI) 2.7 to 4.9) compared with a rate of 1.2 among journeymen (95% CI 0.80 to 1.7). While not always the sole contributing factor, a sequential trigger would have likely prevented 65% of the injuries from tools with contact trip triggers.

CONCLUSIONS

Training, engineering, and policy changes in the workplace and manufacturing arena are all appropriate targets for prevention of these injuries. Use of sequential triggers would likely decrease acute injury rates markedly. Over 70% of injuries among residential carpenters were associated with through nailing tasks (such as nailing studs or blocks, trusses or joists) or toe nailing (angled, corner nailing) as opposed to flat nailing used for sheathing activities; this provides some indication that contact trip tools could be used solely for flat nailing.

Evidence for a sustained increase in clonal beta-cell basal intracellular Ca2+ levels after incubation in the presence of newly diagnosed Type-1 diabetic patient sera. Possible role in serum-induced inhibition of insulin secretion

We have previously reported that newly diagnosed Type-1 diabetic patient sera potently suppressed insulin secretion from a clonal rat pancreatic beta-cell line (BRIN BD11) but did not alter cell viability. Here, we report that apoptosis in BRIN BD11 cells incubated in various sera types (fetal calf serum (FCS), normal human serum and Type-1 diabetic patient) was virtually undetectable. Although low levels of necrosis were detected, these were not significantly different between cells incubated in sera from different sources. ATP levels were reduced by approximately 30% while nitrite production increased twofold from BRIN BD11 cells incubated for 24 h in the presence of Type-1 diabetic patient sera compared with normal human sera. Additionally, ATP levels were reduced by approximately 40% and DNA fragmentation increased by more than 20-fold in BRIN BD11 cells incubated in FCS in the presence of a pro-inflammatory cytokine cocktail (interleukin-1beta, tumour necrosis factor-alpha and interferon-gamma), compared with cells incubated in the absence of cytokines. Nitric oxide production from BRIN BD11 cells was markedly increased (up to 10-fold) irrespective of sera type when the cytokine cocktail was included in the incubation medium. Type-1 diabetic patient sera significantly (P<0.001) raised basal levels of intracellular free Ca(2+ )concentration ([Ca(2+)](i)) in BRIN BD11 cells after a 24-h incubation. The alteration in [Ca(2+)](i) concentration was complement dependent, as removal of the early complement components C1q and C3 resulted in a significant reduction (P<0.01) of sera-induced [Ca(2+)](i )changes. We propose that the mechanism of Type-1 diabetic patient sera-induced inhibition of insulin secretion from clonal beta-cells may involve complement-stimulated elevation of [Ca(2+)](i) which attenuates the nutrient-induced insulin secretory process possibly by desensitizing the cell to further changes in Ca(2+).

Airway management in the emergency department

Airway management in the emergency department and the role of anaesthetists and emergency physicians is reviewed. The training for emergency physicians in the advanced airway skills of rapid sequence induction and tracheal intubation is discussed.

Double-blind, placebo-controlled analgesic study of ibuprofen or rofecoxib in combination with paracetamol for tonsillectomy in children

BACKGROUND

The analgesics used for paediatric tonsillectomy may be associated with side-effects such as sedation, respiratory depression and vomiting (opioids) or increased bleeding [non-steroidal anti-inflammatory drugs (NSAIDs)]. In our institution, we employ a combination of paracetamol, NSAID and opioid, although there is no published evidence of analgesic benefit from adding NSAIDs to paracetamol in children.

METHODS

This randomized, double-blinded clinical study examined the analgesic effectiveness of combining paracetamol (20 mg kg(-1)) with rofecoxib (0.625 mg kg(-1)), ibuprofen (5 mg kg(-1)) or placebo as premedication for (adeno)tonsillectomy (n=98) in children aged 3-15 yr. Intravenous fentanyl 1-2 microg kg(-1) was given intraoperatively. Regular oral paracetamol (15 mg kg(-1), 4 hourly) was given after operation and could be supplemented on request from the child with oral ibuprofen 5 mg kg(-1) or oral codeine 1 mg kg(-1). The primary outcome variable was need for early supplementary analgesia (within 2 h after surgery).

RESULTS

The addition of ibuprofen to paracetamol reduced the need for early analgesia from 72% to 38% of children (difference 34%; 95% confidence interval 4-64%). The addition of rofecoxib to paracetamol did not significantly alter the need for early analgesia (68 vs 72%). Pain scores were higher in those children who required early analgesia. There were no differences between the groups in operative blood loss or complications, total 24-h analgesic consumption, pain scores at 4 and 8 h, vomiting or antiemetic use.

CONCLUSION

This study provides evidence to support the combination of ibuprofen (but not rofecoxib) with paracetamol for perioperative analgesia in children.