Aggressive out-of-hospital treatment regimen for severe closed head injury in patients undergoing air medical transport

The impact of aggressive out-of-hospital management on disposition for 1286 patients with closed head injuries in ground advanced life support (ALS) and helicopter services was evaluated over 60 months in San Diego County. The case group included 196 air medical patients with a scene Glascow coma scale (GCS) < 9 who were treated according to a standard head injury protocol. The frequency matched control group included 1090 ground ALS patients receiving airway management with hyperventilation but neither induction agents nor mannitol. The trauma registry provided admission and discharge dates, neurosurgical interventions, and disposition. Patient age, scene GCS, head and neck abbreviated injury scale (HNAIS), and injury severity score (ISS) served to stratify study groups. Case-control distribution of mortality was compared with the two-tailed Mantel-Haenszel weighted odds ratio (OR) and chisquared test; significance at P < or = 0.05. The case group displayed an 11% decreased mortality (P < 0.01), remaining significant after adjusting for age (P = 0.05) and scene GCS (P = 0.06). The case group displayed 10% (P < 0.01) greater survivor discharges to rehabilitation and 6% (P < 0.05) fewer discharges to extended care facilities. This study's data indicate a strong possibility for improved patient morbidity and mortality in severe closed head injuries treated with an aggressive treatment protocol and rapid air medical transport.

Effects of glibenclamide on blood pressure and cardiovascular responsiveness in non-insulin dependent diabetes mellitus

OBJECTIVE

To compare the effects of chronic glibenclamide therapy and placebo on blood pressure and cardiovascular responsiveness in patients with non-insulin-dependent diabetes.

DESIGN AND METHODS

Fourteen patients with non-insulin-dependent diabetes mellitus, seven of whom were receiving angiotensin converting enzyme inhibitor therapy, received glibenclamide or placebo for 1 month in a double-blind, randomized crossover study. At the end of each treatment period patients attended for studies of forearm vascular responsiveness to intra-brachial arterial infusions of angiotensin II, acetylcholine, sodium nitroprusside and noradrenaline, responses of blood pressure to intravenous infusions of noradrenaline and angiotensin II and 24 h ambulatory blood pressure monitoring.

RESULTS

Administration of glibenclamide produced significantly better glycaemic control than placebo (fasting blood glucose level 8.5 +/- 2.4 versus 13.5 +/- 4.5 mmol/l, P < 0.001) and plasma insulin levels were significantly higher during glibenclamide treatment than they were with placebo (12.9 +/- 4.4 versus 9.2 +/- 4.1 mU/l, P < 0.05). Body weights at the ends of the glibenclamide treatment and placebo phases were similar (92.1 +/- 14.3 versus 91.1 +/- 14.3 kg, P = 0.085). Night-time systolic blood pressures were significantly higher during glibenclamide treatment than they were with placebo (128 +/- 17 versus 118 +/- 10 mmHg, P < 0.05) due to there being a smaller day-night difference in systolic blood pressure during glibenclamide treatment that appeared to occur mainly in patients receiving angiotensin converting enzyme inhibitors. Responses of diastolic blood pressure to intravenous infusion of angiotensin II and forearm vascular responses to intra-brachial arterial infusion of angiotensin II were significantly greater during glibenclamide treatment than they were with placebo (P < 0.05). However, the enhancement of forearm vascular responses during glibenclamide treatment appeared to be restricted to patients receiving angiotensin converting enzyme inhibitors. Responses of blood pressure to intravenous infusion of noradrenaline and forearm vascular responses to infusions of noradrenaline, acetylcholine and nitroprusside did not differ between glibenclamide treatment and placebo; neither did basal forearm vascular resistance.

CONCLUSIONS

Glibenclamide therapy is associated with greater responses of blood pressure and forearm vascular responses to infusion of angiotensin and higher nocturnal blood pressures. This effect appears to be influenced by concomitant angiotensin converting enzyme inhibition.

Low dose oestrogen prophylaxis for recurrent urinary tract infections in elderly women

OBJECTIVE

To assess the efficacy of oral oestriol in the prevention of recurrent urinary tract infections in elderly women.

DESIGN

Double-blind, randomised, parallel group, placebo controlled trial

SETTING

Urogynaecology Unit at King's College Hospital with some women recruited from the geriatric units of St. Pancras Hospital and Dulwich Hospital, London (UK).

PARTICIPANTS

Seventy-two postmenopausal women older than 60 years of age (mean 73.2 years) suffering from recurrent urinary tract infections.

INTERVENTION

Oral oestriol (3 mg per day) or placebo for six months. MAIN: outcome measures Urinary tract infection rates.

RESULTS

The study was difficult to conduct because of its design and the age of the participants. Oral oestriol (3 mg per day) was not shown to be superior to placebo in the prevention of recurrent urinary tract infections, but both oestriol and placebo improved urinary symptoms during the trial.

CONCLUSION

The power of the study might have been too low to detect a significant difference between the groups, or oral oestriol (3 mg per day) may have been either the wrong dose or the wrong route of administration for this indication.

Lipoproteins and cardiovascular reactivity

The observation that relatively short periods of cholesterol lowering therapy can reduce the incidence of coronary artery disease events has prompted interest in the short term effects of lipoproteins on cardiovascular responsiveness. Numerous studies in animals and humans have demonstrated that oxidized LDL-cholesterol can impair endothelial dependent vasodilation in coronary arteries and peripheral resistance vessels. Reduction of plasma LDL-cholesterol levels in hypercholesterolaemic patients improves nitric oxide mediated vasodilator responses in the coronary and peripheral circulation. LDL-cholesterol also potentiates responses to vasoconstrictors such as noradrenaline and endothelin-1 in the absence of endothelium, possibly by enhancing calcium influx into vascular smooth muscle cells. Pharmacological reduction of plasma LDL-cholesterol levels has been shown to reduce blood pressure responses to intravenous infusions of pressor hormones and to stress. However, the relative contribution of changes in endothelial dependent vasodilation and vasoconstrictor or inotropic responses remains to be established. Short term changes in LDL-cholesterol produce changes in cardiovascular responsiveness that may influence the development of ischaemic events.

A complex arrangement of genes at a starch branching enzyme I locus in the D-genome donor of wheat

Genomic DNA fragments from Triticum tauschii (D-genome donor to wheat) carrying starch branching enzyme I (SBE I) type genes have been characterized. One fragment contains one complete gene and two partial genes in 16 kb of DNA. One of the partial genes is oriented in the opposite strand to the other two. The gene that is complete was sequenced. Its structure corresponds closely to that of rice in that exons 3-8 are retained at similar sizes and spacings. A cDNA closely corresponding to the complete gene was isolated and characterized; it codes for a putative protein that represents a novel type of SBE I, as it is shorter at the 3' end than the forms reported so far in other plants. A second genomic fragment contains a different SBE I gene. There appear to be approximately 10 copies of SBE I type genes in wheat (approximately 5 in T. tauschii) and most of them have been assigned to group 7 chromosomes. In situ hybridization indicates that a major locus for the genes is located at the distal end of the short arm of chromosome 7D.

Characterization of dynamic 3-D PET imaging for functional brain mapping

Methods for optimizing the acquisition, reconstruction and analysis of positron emission tomography (PET) images for functional brain mapping have been investigated. The scatter fraction and noise-equivalent count rate characteristics were measured for the ECAT 951/31R PET scanner operating in septa-extended two-dimensional (2-D) and septa-retracted three-dimensional (3-D) modes. The 3-D mode is shown to provide higher signal-to-noise images than the 2-D mode at specific activities less than 30 kBq/ml. To enable increased temporal resolution in dynamic 3-D PET activation studies, a parallel version of the 3-D reconstruction algorithm was developed. Implementation of the reprojection algorithm on an 88 processor 1860 supercomputer resulted in a more than tenfold increase in reconstruction speed compared to a single 1860 processor system. An investigation of the optimal duration for imaging brain activations was undertaken in 12 normal subjects using repeated H2(15)O slow infusions and a visually presented lexical decision task. The significance of change in regional cerebral blood flow (CBF) was determined using statistical parametric maps for images acquired during stimulation, immediately after stimulation, and commencing 1 min after cessation of the stimulus. Regions of CBF change were detected in all three images. Dynamic 3-D, or four-dimensional (4-D), PET activation scanning is shown to be practical and likely to further improve the sensitivity of PET for detection of subtle regional CBF changes in functional brain mapping research.

GAX collagen in the treatment of urinary incontinence in elderly women: a two year follow up

OBJECTIVE

To determine the efficacy of GAX collagen in the treatment of elderly women with genuine stress incontinence.

DESIGN

A single centre prospective study.

SETTING

A London teaching hospital.

PARTICIPANTS

Thirty-four women older than 60 years of age with genuine stress incontinence diagnosed on videocystourethrography.

INTERVENTIONS

Up to three paraurethral injections of GAX collagen.

MAIN OUTCOME MEASURES

Subjective and pad test assessments performed pre-operatively, after one month, one year and two years after the first injection of collagen. Videocystourethrography and urethral pressure profilometry were carried out pre-operatively, after three months and one year.

RESULTS

There was a reduction in urinary leakage as measured on pad testing. After two years 77% of the surviving 26 women were symptomatically cured. Objectively after two years 48% of the women were cured and 9% were improved over their initial pre-treatment level of incontinence. The cure rate was the same whether or not the women had undergone previous vaginal surgery. The maximum urethral closure pressure was not increased with treatment indicating that collagen injections do not act by producing obstruction, but this should be interpreted with caution due to the small sample size.

CONCLUSION

GAX collagen is an effective method of treating urinary incontinence in the elderly and especially women who have undergone previous continence procedures. The technique is easy to perform and particularly suitable in those who are frail, but if failure occurs after two years consideration needs to be given to its cost effectiveness.

Self-measurement of blood pressure: issues related to the training of patients. Canadian Coalition for High Blood Pressure Prevention and Control

For effective self-measurement of blood pressure, patients need to be able to obtain accurate and reproducible measurements. Criteria for measuring blood pressure have been well developed in research studies, and through the use of standardized training programs it has been established that nonmedically trained individuals can obtain valid measurements. These recommendations for blood pressure measurement were adapted to the self-measurement situation. Either manual sphygmomanometers or automated electronic devices can be used effectively. Although automated devices may be easier to use, the health care practitioner should ensure that any such device has been demonstrated to be accurate and reliable before its adoption. There are no reported programs available for training individuals in the use of self-measurement. A check-list has been developed for use by health care practitioners. It is estimated that proper training will usually take more than 20 mins. Since many health care practitioners do not use the recommended blood pressure measurement technique, there is also a need to develop programs to 'train the trainers'. Finally, individuals undertaking regular self-measurement should have their technique and the calibration of their instruments checked at regular intervals (six to 12 months).

Self-measurement of blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control

OBJECTIVE

To provide health care professionals with guidelines on the use of blood pressure self-measurement.

METHODS

Recommendations were devised after consideration of expert reviews and guidelines, personal files, international standards documents, personal communication with investigators and the results of a MEDLINE search (1966-94) using the term 'blood pressure determination'.

BENEFITS, HARMS, COSTS

Self-measurement of blood pressure can be used to detect white coat hypertension, monitor changes in blood pressure closely, more rapidly achieve desired blood pressure goals, increase adherence to antihypertensive therapy and improve patient self-reliance. However, self-measured blood pressure readings may be misleading because there is insufficient normative, prognostic and outcome data and because some patients may not take accurate measurements. The use of self-measurement of blood pressure has a relatively small direct cost and may result in an overall reduction in treatment costs.

RECOMMENDATIONS

Self-measured blood pressure readings can be a valuable supplement to clinic (or office) blood pressure readings. However, self-measurement is appropriate neither for patients who are physically or mentally incapable of accurate assessment and interpretation of readings nor for those who do not want to participate. Patients who self-monitor blood pressure require careful training in blood pressure measurement and instruction on the recording and interpretation of blood pressure readings. Advice to patients using monitoring equipment must take into account the needs and abilities of the patient. Although only a few electronic devices for the self-measurement of blood pressure have met recommended performance standards, their use may be more appropriate for some patients and the training requirements fewer than if manual devices are used.

VALIDATION

The guidelines of several expert groups were examined in the preparation of these recommendations. The recommendations were presented at the World Conference on Hypertension Control in 1995 and were reviewed by the parent societies of the Canadian Coalition for High Blood Pressure Prevention and Control.

Guidelines for measurement of blood pressure, follow-up, and lifestyle counselling. Canadian Coalition for High Blood Pressure Prevention and Control

As part of the Coalition's mandate to promote the prevention and control of high blood pressure in Canada, an interdisciplinary Workgroup was established to review and update the existing standards (1987) for blood pressure measurement and referral guidelines. The intent was to prepare a scientifically based document which contained practical guidelines for the measurement of blood pressure and criteria for follow-up, and one which promoted the concept of cardiovascular health in the assessment and interpretation of blood pressure readings. These guidelines were primarily developed to assist primary health care providers and/or clinicians to assess, monitor, counsel, refer, and develop treatment plans for adults-at-risk for high blood pressure or those with the confirmed diagnosis of hypertension. Readers are referred to The Canadian Hypertension Society Consensus Conference series (Canadian Medical Association Journal 1993) for specific guidelines on the evaluation, diagnosis, and treatment of hypertension. The document is divided into three sections: 1. Measurement of blood pressure 2. Criteria for follow-up 3. Guidelines for lifestyle counselling Each section cites the references used in developing the guidelines and where relevant, identifies other resources which can be used in clinical practice.

A novel technique for measuring bladder wall thickness in women using transvaginal ultrasound

A new technique of measuring bladder wall thickness using transvaginal ultrasound is described. Measurement of the bladder wall using ultrasound was found to have a good intra- and interobserver reproducibility. Measurements of the bladder wall thickness were altered if more than 50 ml of fluid was within the bladder. Forty-five women with urinary symptoms were recruited from the urodynamic clinic; those with urodynamically diagnosed detrusor instability were found to have significantly thicker bladder walls than women with urodynamically diagnosed genuine stress incontinence. Application of this technique may be useful in the diagnosis of detrusor instability.

Father involvement in infant care: two longitudinal studies

Data collected from two samples of fathers in separate longitudinal studies were compared. One sample consisted of 53 first-time fathers and the other of 69 multiple-time fathers. A post-test only time-series design was used for both studies, and both employed the same procedures and instruments. The studies examined role enactment of fathers with different child-caring experiences using role-theory concepts. Fathers' normative expectations, personal expectations, and personal learning about parenting were tested to determine if they were predictive of paternal role performance. The findings seem to indicate that the culture of fatherhood has changed more rapidly than the conduct of fatherhood.

Drainage of subretinal fluid with the argon laser

We performed 115 scleral-buckling procedures for primary rhegmatogenous retinal detachments in which the argon endolaser drained subretinal fluid. The laser was set at 0.80 to 1.25 W and 0.5 second; the endolaser probe was held adjacent to, but not touching, the choroid. The procedure was successful in 112 of 115 (97.0%) patients. When inadequate drainage occurred, the use of the penetrating diathermy tip was successful. The only major complications were subretinal hemorrhages that had migrated posterior to the buckle in two patients (1.70%), retinal perforation in one patient (0.87%), and retinal incarceration in one patient (0.87%). Laser drainage caused a slow, controlled drainage of subretinal fluid.