Interface gateways: defining the solutions

In summary, an interface gateway is able to quickly create and support relationships. In the healthcare environment of the 1990s, organization executives will be faced with an exponential increase in the number of provider, payor and employer alliances, affiliations and acquisitions. One of the recurring requirements in this scenario is the need to share information. Most of the data standards in existence today do not address the vast interface requirements of these organizations. However, the capabilities, flexibility and capacity of interface gateways can allow these relationships to be created and supported in a fraction of the time that conventional methods require.

A lymphocyte colony assay for culture of sheep lymphocytes

A procedure for culturing sheep peripheral blood lymphocytes in soft agar was standardized. The variables that were evaluated included the type of T lymphocyte mitogens, mitogen doses, cell number, distribution of the cells in the culture vessel and the duration of the culture. Both concanavalin A (CON A) and phytohemagglutinin A (PHA) stimulated the formation of lymphocyte colonies. However, CON A consistently produced more and larger colonies. The doses of CON A and PHA which yielded the maximum number of colonies were 35 and 61 micrograms/ml, respectively. The optimum number of cells per well as 1.36 x 10(6). Adherence of the cells to the floor of the culture vessel was required for the colonies to form. The maximum number of colonies was attained between day 5 and day 6 of culture. The lymphocyte colony assay may be a useful adjunct to other immunologic assays for studying cell-mediated immunity of sheep.

Lymphocyte colony formation by aleukemic sheep infected with bovine leukemia virus

The objective of this study was to investigate the effects of bovine leukemia virus (BLV) infection in sheep. A prospective study of the serologic, hematologic, and histologic changes of sheep infected with BLV was conducted. Antibodies to BLV were detectable in the sheep 3 weeks after exposure to blood from an infected cow and persisted during a 120 week examination period, whereas all control sheep remained seronegative. There were no statistically significant differences between the leucocyte counts, lymphocyte counts, and lymphocyte percentages of the infected and control sheep during the first 120 weeks of this study. However, one sheep did develop a leukopenia and lymphopenia 95 weeks after it became infected and died of histologically-confirmed lymphosarcoma 10 days later. A lymphocyte colony assay was used to study the effects of BLV infection on colony formation by sheep lymphocytes in vitro. There was no significant difference in the number of lymphocyte colonies formed by BLV infected and control sheep. Nor was there a significant difference in the number of colonies formed by lymphocytes from the BLV infected sheep, when the autologous sheep serum was replaced with either pooled serum from the infected sheep or with pooled serum from the control sheep. BLV infection in aleukemic sheep does not appear to have an adverse affect on colony formation by lymphocytes in vitro.

Cavitary coccidioidomycosis with fungus ball formation. Diagnosis by fiberoptic bronchoscopy with coexistence of hyphae and spherules

Pulmonary cavitary coccidioidomycosis with fungus ball formation was observed in two individuals with hemoptysis. The first patient had no overt compromise; the second was an insulin-dependent diabetic. In both, fiberoptic bronchoscopy was performed and cultures yielded Coccidioides immitis. The coexistence of spherules and hyphae of C immitis was seen histologically on bronchoscopic biopsy specimen of one cavitary lesion. Specific antifungal therapy and surgical excision were withheld and each patient has done well. This report provides for the first time nonsurgical confirmation that C immitis can produce an intracavitary fungus ball.

A nation's response to attack: Israelis' depressive reactions to the Gulf War

We examined Israelis' reactions to the Gulf War and SCUD missile attacks. Four national samples of Israelis (n = 3,204) were interviewed as to depressive mood on four occasions--prior to the Gulf Crisis, as the war approached, during the SCUD missile attacks, and after cessation of hostilities. There was an expected increase in depressive mood during the period of SCUD missile attacks and a quick return to base-line levels following the hostilities. Less educated and older individuals reported higher base-line levels of depressive mood and were at higher risk for clinical depression. Women and men did not differ in depressive mood before or after the SCUD missile attacks. However, women experienced a marked increase in depressive mood when the SCUD missile attacks occurred.

Pacing system analyzers: different systems--different results

When a pacemaker is implanted, several electrophysiological parameters are measured using pacing system analyzers (PSA). Different PSAs may use different filter settings and measuring techniques when compared to the implanted pacemaker. In order to determine if there were significant differences in measurements obtained with different PSAs, we obtained measurements in a group of 99 patients with three different PSAs and a manual method. The results show that with each of the three different PSAs tested, different amplitudes of intracardiac electrograms are obtained and that they are usually higher than those obtained by manual measurement of recorded electrograms. Despite significant differences, however, all methods correlate well with each other. Following common practice of pacemaker programming, the use of a PSA for the implantation of a pacemaker that uses different sensing technique does not lead to clinical complications.

Cell-to-cell communication in a differentiating ovine lens culture system

PURPOSE

This study was performed to determine whether the junctions between both the epithelial and the differentiating fiber-like cells of ovine lens cultures, like gap junctions in other tissues, exhibit cell-to-cell communication that is inhibited by n-octanol, and to determine whether lens connexins and the fiber cell membrane proteins MP20 and MP26 are expressed by these ovine lens cell cultures.

METHODS

Cells were injected with Lucifer yellow CH to measure cell-to-cell communication. Antibodies to connexin-related lens membrane protein MP70, connexin 43 (Cx43), and connexin 46 (Cx46) and to membrane proteins MP20 and MP26 were used to immunofluorescently label lens cultures and probe Western blots of membranes isolated from lens cultures.

RESULTS

Both epithelial cells and differentiating clear cells exhibited cell-to-cell transfer of Lucifer yellow that was inhibited by n-octanol. Although a Cx43 antibody immunofluorescently labeled small plaques between the epithelial cells, an MP70 antibody labeled large plaques as well as small punctate areas of the differentiating fiber-like cells. It is interesting that Cx43 and MP70 were frequently present in the same plaques at cell interfaces between epithelial cells as well as some of the larger plaques on the differentiating fiber-like cells. Cx46 and MP70 antibodies labeled the same plaques in membranes of differentiating fiber-like cells and late-stage epithelial cells. The electrophoretic mobility of all three connexin proteins was modified after treatment with alkaline phosphatase. Immunohistochemical staining of these differentiating regions and Western immunoblotting of purified membranes derived from differentiated cultures also showed the presence of MP20 and MP26.

CONCLUSIONS

The different cell types in the ovine lens culture exhibit gap junction-mediated cell-to-cell communication that is likely effected by one or more of the connexin proteins.

Advancing clinical excellence: competency-based patient care

A competency-based patient care program was developed to measure current levels in staff nurses. Use of evaluative tools designed on site has resulted in: 1) Development of a credentialing and privileging process which meets JCAHO requirements; 2) Planning of an educational calendar based on identified needs; 3) Strengthening the foundations of the nursing career ladder; 4) Overall team building which integrates nurses with other healthcare professionals; and 5) Improved patient care.

Model for trauma outcomes management in patients with multiple trauma

Critically injured patients with chest trauma generally sustain severe life-threatening injuries. Post-operative care tends to be complex, and all aspects of care from pre-hospital through rehabilitation must be coordinated and communicated to maximize patient outcomes. The Trauma Outcomes Management Model allows clinicians to assess, track, and analyze the relationship among interventions, outcomes, and the cost of care for each phase of the trauma care continuum. This article presents the design and utilization of trauma outcome guides in the Emergency and Critical Care departments.

Factors affecting the range of movement of total knee arthroplasty

We have investigated those factors which influence the range of movement after total knee arthroplasty, including sex, age, preoperative diagnosis and preoperative flexion deformity and flexion range. We also compared cemented and cementless tibial fixation, the influence of collateral ligament and lateral parapatellar releases and of replacement of the patella, and of the period of postoperative immobilisation. We reviewed 516 Johnson-Elloy (Accord) knee arthroplasties performed between 1982 and 1989, with a minimum follow-up of 12 months. The most important factors in the range of flexion achieved after arthroplasty are the diagnosis and the preoperative range of flexion. In patients with osteoarthritis there was a mean loss of flexion; in rheumatoid arthritis there was a mean gain. In both groups, the stiffer knees gained motion and the more mobile knees lost it. Post-operative range of motion was not influenced significantly by cement fixation, collateral ligament or patellar retinacular releases, prolonged immobilisation or patellar replacement.

Antihelicase action of DNA-binding anticancer agents: relationship to guanosine-cytidine intercalator binding

DNA-binding antibiotics such as intercalators, narrow groove binders, and other substances modify duplex DNA, making it an altered substrate for DNA helicases. The intercalators daunorubicin, actinomycin D, echinomycin, and elsamicin, the narrow groove binders distamycin and mithramycin, and the plant toxin teniposide, each representing a different chemical class, block SV40 large T antigen DNA helicase action with IC50 values ranging from 4 x 10(-8) to 2 x 10(-6) M. A partially purified human HeLa cell DNA helicase is also potently blocked by daunorubicin, distamycin, and teniposide. Because eukaryotic cells contain helicases of varying abundance, specificity, and type, this site of action for DNA-binding antibiotics may help explain antibiotic potency and specificity for DNA or RNA inhibition. The antihelicase effect of the antibiotic-double-stranded DNA complex may be central to the anticancer activities of these substances. An additional interesting correlation is the antihelicase action of DNA-intercalating antibiotics and their DNA-binding preference for G-C base pair sites. The G-C base pair binding preference of the intercalating antibiotics may result from evolutionary selection because of the higher G-C binding stability, compared with A-T binding stability. The combination of the higher base pair stability at G-C regions and increased duplex DNA stability induced by intercalating antibiotic yields a total additive stability of the intercalator-G-C base pair complex that resists helicase action.

Transoral-transpharyngeal approach to the upper cervical vertebrae

The classical operative approaches to the cervical spine include the posterior one and the anterior exposure along the sternomastoid muscle. However, neither of these are helpful in exposing the upper cervical vertebrae, especially the odontoid process, atlas, and axis. We have used the transoral-transpharyngeal exposure for lesions of the odontoid process and upper (first to third) cervical vertebrae in six patients. The pathologic processes included rheumatoid disease and fracture of the cervical vertebrae, suspected tumor with compression of the spinal cord, basilar invagination, and compression of the medulla. In all six patients, the exposure was excellent, and postoperative morbidity was minimal. Tracheostomy was performed routinely in all these patients. In five patients, vertebral stabilization was performed as a secondary procedure a few days after the initial anterior decompressive surgery. The transoral-transpharyngeal approach appears to be relatively easy. It is associated with minimal complications and provides excellent exposure of the odontoid and upper cervical vertebrae for a microneurosurgical approach. Modifications of this approach include incision of the soft palate, excision of a portion of the hard palate, and, occasionally, transmandibular median labio-mandibulo-glossotomy (Trotter's) approach. Although the technique was described initially approximately 35 years ago, this neglected anatomic approach will facilitate cooperative efforts between head and neck surgeons and neurosurgeons.

Cutaneous metastasis of neuroendocrine carcinoma of uterine origin

We report a case of a 33-year-old woman who presented with the rapid development of multiple dermal and subcutaneous nodules on the chest, back, abdomen, axilla, neck, and scalp. These nodules were firm, tender, and non-ulcerated and measured from 0.2 to 1.2 cm in diameter. A punch biopsy of one of the subcutaneous nodules in the scalp showed a poorly differentiated carcinoma in the reticular dermis with light microscopic, immunohistochemical, and ultrastructural features supporting neuroendocrine differentiation. The past medical history was significant for a recent total abdominal hysterectomy for carcinoma of the cervix at another hospital, originally characterized as a poorly differentiated adenocarcinoma of the cervix and lower uterine segment. Review of the microscopic slides of the uterine neoplasm revealed features suggesting a more appropriate classification as a primary neuroendocrine carcinoma; this was subsequently confirmed by immunophenotyping and ultrastructural evaluation. This is the first reported case of a uterine neuroendocrine carcinoma metastasizing exclusively to the skin. It further illustrates the important contribution of dermatopathology to the understanding of a systemic pathologic process.

Accessory molecules involved in antigen-mediated cytolysis and lymphokine production by cytotoxic T lymphocyte subsets. I. Identification of functions for the T cell surface molecules Ly-6C and Thy-1

The murine T cell surface molecules Ly-6C and Thy-1 are genetically and structurally distinct, yet they share two interesting properties: both are attached to the plasma membrane through a glycophosphatidylinositol linkage, and some mAb reactive with these molecules can activate T cells. Although mAb for Ly-6C and Thy-1 appear to mimic the function of physiologic ligands, direct evidence for the existence of these putative ligands has not been presented. In this report, we describe CTL clones that use Ly-6C and Thy-1 as accessory molecules for activation of cytolysis and the production of IFN-gamma based on inhibition of these functions with mAb. These studies were facilitated by the derivation of a nonactivating hamster IgM mAb specific for Ly-6C. CTL clones that use Ly-6C and Thy-1 as accessory molecules include a subpopulation of the previously described CD8+ alloreactive CTL that are not inhibited by mAb reactive with CD8, a CD8+ TCR-alpha/beta+ T cell clone specific for HSV glycoprotein D, and a CD4-CD8- TCR-gamma/delta+ T cell clone specific for HSV glycoprotein I. The role of Ly-6C and Thy-1 in target cell recognition is to some degree tissue-specific with respect to the APC/target cell. A mAb specific for Ly-6C appears to inhibit activation by prevention of adhesion between the effector cells and the target cells. This is the most direct evidence to date of a functional ligand for Ly-6C.

Accessory molecules involved in antigen-mediated cytolysis and lymphokine production by cytotoxic T lymphocyte subsets. I. Identification of functions for the T cell surface molecules Ly-6C and Thy-1

The murine T cell surface molecules Ly-6C and Thy-1 are genetically and structurally distinct, yet they share two interesting properties: both are attached to the plasma membrane through a glycophosphatidylinositol linkage, and some mAb reactive with these molecules can activate T cells. Although mAb for Ly-6C and Thy-1 appear to mimic the function of physiologic ligands, direct evidence for the existence of these putative ligands has not been presented. In this report, we describe CTL clones that use Ly-6C and Thy-1 as accessory molecules for activation of cytolysis and the production of IFN-gamma based on inhibition of these functions with mAb. These studies were facilitated by the derivation of a nonactivating hamster IgM mAb specific for Ly-6C. CTL clones that use Ly-6C and Thy-1 as accessory molecules include a subpopulation of the previously described CD8+ alloreactive CTL that are not inhibited by mAb reactive with CD8, a CD8+ TCR-alpha/beta+ T cell clone specific for HSV glycoprotein D, and a CD4-CD8- TCR-gamma/delta+ T cell clone specific for HSV glycoprotein I. The role of Ly-6C and Thy-1 in target cell recognition is to some degree tissue-specific with respect to the APC/target cell. A mAb specific for Ly-6C appears to inhibit activation by prevention of adhesion between the effector cells and the target cells. This is the most direct evidence to date of a functional ligand for Ly-6C.

Eosinophilic pleocytosis in coccidioidal meningitis: frequency and significance

PURPOSE

Coccidioidal meningitis (CM) is a major source of morbidity and mortality in endemic regions. The diagnosis of CM is a clinical challenge. Eosinophilic pleocytosis (EP) is an uncommon finding and present in a relatively limited number of conditions. In order to determine the frequency and the prognostic significance of EP in CM, we conducted the present study.

PATIENTS AND METHODS

Retrospective chart review of all patients diagnosed as having CM between 1986 and 1991 at Kern Medical Center. All patients had clinical and cerebrospinal fluid (CSF) findings confirmatory of CM.

RESULTS

Nineteen patients (70%) in the study group had EP, and of these, 8 patients (30%) met the criteria for eosinophilic meningitis (greater than or equal to 10 eosinophils/mm3). No correlation was found between EP and age, sex, race, results of complement fixation test for coccidioidal antigen in CSF or serum, peripheral eosinophilia, or outcome.

CONCLUSION

The presence of EP is a frequent observation in CM. Although we did not demonstrate any prognostic correlation with EP, this finding is of major diagnostic significance and its presence should bring attention to the diagnosis of CM.

Caffeine enhanced measurement of mutagenesis by low levels of gamma-irradiation in human lymphocytes

The well-known action of caffeine in synergizing mutagenesis (including chromosome aberrations) of agents like ionizing radiation by inhibition of cellular repair processes has been incorporated into a rapid procedure for detection of mutagenicity with high sensitivity. Effects of 5-10 rads of gamma-irradiation, which approximate the human lifetime dose accumulation from background radiation, can be detected in a two-day procedure using an immortalized human WBC culture. Chromosomally visible lesions are scored on cells incubated for 2 h after irradiation in the presence and absence of 1.0 mg/ml of caffeine. An eightfold amplification of scorable lesions is achieved over the action of radiation alone. This approach provides a closer approximation to absolute mutagenicity unmitigated by repair processes, which can vary in different situations. It is proposed that mutagenesis testing of this kind, using caffeine or other repair-inhibitory agents, be employed to identify mutagens in their effective concentrations to which human populations may be exposed; to detect agents such as caffeine that may synergize mutagenic actions and pose epidemiologic threats; and to discover effective anti-mutagens. Information derived from the use of such procedures may help prevent cancer and newly acquired genetic disease.

Tolerability of prophylactic Lariam regimens

Three hundred and fifty-nine US Marines participated in a randomized double-blind clinical trial to assess tolerance of two prophylactic mefloquine regimens [250 mg salt weekly (n = 157) or 250 mg daily for 3 days followed by 250 mg weekly (n = 46)] compared with 300 mg weekly chloroquine (n = 156) over a 12-week period. The study participants were seen daily for four days, then weekly for 11 weeks. On each visit, the subject answered two computerized questionnaires (a review of body systems and an evaluation of mood states), participated in a physician interview, and was administered medications under supervision. A random sample of each group was assigned to either pharmacokinetic sampling or two wear a wrist watch size computerized sleep monitor (actigraph). The frequencies of intercurrent illness and other concomitant medications were tabulated. End study mefloquine plasma levels were obtained on all study participants. The results obtained showed no compromise in function due to dizziness or incoordination in the mefloquine groups. Overall, both weekly mefloquine and loading dose mefloquine were well tolerated. Sleep disturbance and increased dream activity were detected in the mefloquine groups. Depressive feelings were noted in two to three times more individuals in the mefloquine groups than in the chloroquine group early in the course of the study, and resolved in the majority of subjects as tolerance developed. Steady state mefloquine plasma levels were attained rapidly with the loading dose regimen in four days versus seven weeks with weekly mefloquine.(ABSTRACT TRUNCATED AT 250 WORDS)

Radioactive waste management at a large university and medical research complex

A radioactive waste management program was developed for a large university and medical research complex to contain costs and to reduce the impact of the Low-Level Radioactive Waste Policy Act. The program takes advantage of decay-in-storage, incineration, special packaging techniques, and increased training and awareness. A series of metrics are presented to evaluate the effectiveness of the radioactive waste management program. Through the use of this program the amount of waste disposed of at commercial burial sites decreased from 98% to 1.61% of the waste generated. At the same time the volume of waste generated per laboratory declined by almost 45%, from 0.35 m3 (12.31 ft3) to 0.19 m3 (6.80 ft3).

Erythropoietin with oral iron in peritoneal and hemodialysis patients. A comparison in an inner city population

Studies on the comparative efficacy of erythropoietin (rHuEPO) in chronic hemodialysis (HD) and peritoneal dialysis (PD) patients are scarce. The authors compared the use of rHuEPO in 74 stable patients on hemodialysis with 24 on chronic peritoneal dialysis. All patients were on oral iron supplements. In PD patients, hematocrits were 23.1 and 30.1%, rHuEPO dose 80.9 and 89.0 U/kg/wk, whereas in HD patients, hematocrits were 21.2 and 27.5 and rHuEPO dose was 140.2 and 165.0 U/kg/wk at initiation and 6 months, respectively. Serum iron and transferrin saturations were unchanged in peritoneal, but decreased in hemodialysis patients on rHuEPO therapy. These findings suggest that rHuEPO is more effective in peritoneal dialysis patients than in hemodialysis patients receiving oral iron. The improved efficacy of rHuEPO in peritoneal dialysis may be due to decreased blood loss, subcutaneous administration, or better removal of inhibitors of erythropoiesis. Peritoneal dialysis may be more cost effective and desirable than hemodialysis for rHuEPO dependent or resistant patients.

What does it all mean?

Now that the concerns, issues, ideas and constraints have been discussed, how does all of this come together? There are three basic questions we should ask.• Can we improve natural resource management through monitoring?• Will those that make the decisions listen?• Will they use the generated data in their decision?I am going to relate to you what has happened in California over the last fifteen years. I believe it will point out that the answer to the three questions are a resounding yes, with some qualifications and some bumpy roads along the way.

Is air medical scene response for illness appropriate?

The purpose of this study was to determine the appropriateness of air medical scene response for illness. The study consisted of a retrospective chart review of a two-helicopter urban air medical transport program with a transport volume of 1,700 flights annually. During the study period, January 1988 through March 1990, 68 patients were transported by helicopter from scene of illness to a tertiary care facility. In cases in which patients could be managed appropriately locally, air transport was deemed unnecessary. Of the 68 patients with illness, 40 were males and 28 were females; the average age was 39.2 years (from a range of 0 to 93). The average transport time was 46.3 minutes. Dispatch diagnoses were cardiac arrest (20), seizure (14), myocardial infarction (8), overdose (6), stroke (5), labor (4), respiratory distress (3) and miscellaneous (8). The discharge (final) diagnosis was different from dispatch diagnoses in 10 patients (14.7%). Fifty-four patients (79.4%) required no tertiary care, and 30 of them were discharged from the emergency department or were pronounced dead there or at the scene. The results of the study indicate air medical response to scene of illness did not appear justified in this study. Transport should be local, by ground, with subsequent tertiary care being arranged as needed. Further prospective study is warranted.

Marginal gap width of a new refractory porcelain system

This study was conducted to determine whether matching the physical properties of refractory die material to porcelain could increase the marginal accuracy of porcelain inlays. Restorations made with a matched Fortune refractory porcelain system were compared with restorations made with unmatched Vita porcelain and Polyvest refractory material. Thirty addition-silicone impressions were made of a master mesioocclusodistal inlay preparation. Fifteen refractory dies were made for each of the refractory materials. The dies were prepared and the porcelain applied according to the manufacturer's specifications. Three measurements of marginal gap were recorded adjacent to premarked points on each proximal box by use of a Unitron microscope with micrometer adjustment. The mean marginal gap was 51.24 +/- 20.84 microns for the matched material and 100.43 +/- 17.30 microns for the unmatched material. A Student's t-test was performed, which showed a significantly greater mean gap for the unmatched system compared with the matched system (t[28] = 7.03, p < 0.005). The results indicate that a matched refractory porcelain system can produce restorations with significantly improved marginal accuracy.