Failure of retrograde cerebral perfusion to attenuate metabolic changes associated with hypothermic circulatory arrest

OBJECTIVES

Although retrograde cerebral perfusion has become a popular adjunctive technique and may improve cerebral ischemic tolerance during hypothermic circulatory arrest, direct cerebral metabolic benefit has yet to be demonstrated in human subjects. We investigated the post-arrest metabolic phenomena with and without retrograde cerebral perfusion in patients.

METHODS

In a prospective randomized trial, 42 patients undergoing aortic surgery requiring hypothermic circulatory arrest were allocated to receive hypothermic circulatory arrest alone (n = 21) or hypothermic circulatory arrest with additional retrograde cerebral perfusion (n = 21). Circulatory arrest was commenced at 15 degrees C, and retrograde perfusion was instituted through the superior vena cava at a maximum jugular bulb pressure of 25 mm Hg. Transcranial, paired, repeated samples of the arterial and jugular bulb blood were analyzed for oxygen and glucose. Velocity in the right middle cerebral artery was also measured simultaneously.

RESULTS

There were 3 (7.1%) deaths and 3 (7.1%) episodes of neurologic deficit. Mean bypass and circulatory arrest duration (in minutes) were similar between groups (P =.4 and.14). The mean retrograde perfusion duration was 23 minutes. Post-arrest nasopharyngeal temperature was similar (15.3 degrees C vs. 15.3 degrees C). Retrograde perfusion did not affect post-arrest oxygen extraction, glucose extraction, or jugular bulb Po(2). There was no immediate lactate release immediately after hypothermic circulatory arrest.

CONCLUSIONS

Retrograde cerebral perfusion did not influence immediate post-arrest nasopharyngeal temperature or cerebral metabolic recovery. The low jugular bulb Po(2) suggests equivalent ischemia. These findings cast doubt on the effectiveness of retrograde cerebral perfusion as a metabolic adjunct to hypothermic circulatory arrest.

Surface immunolocalisation of HPr in the equine pathogen Streptococcus equi

We have investigated the surface localisation of the phosphotransferase system protein HPr in the equine pathogen Streptococcus equi subsp. equi using immunogold localisation and transmission electron microscopy. Like the LppC acid phosphatase lipoprotein, a reference surface antigen, the S. equi HPR could be clearly detected on the surfaces of intact cells. This study is consistent with previous reports that some streptococcal HPr is cell surface associated and suggests that the extracytoplasmic mobilisation and transfer of phosphate groups by streptococci warrant further investigation.

Outcome of patients with a performance status of 2 in Eastern Cooperative Oncology Group Study E1594: a Phase II trial in patients with metastatic nonsmall cell lung carcinoma

BACKGROUND

Eastern Cooperative Oncology Group (ECOG) Study E1594 compared paclitaxel and cisplatin with three newer chemotherapy doublets in the treatment of patients with advanced nonsmall cell lung carcinoma (NSCLC). The accrual of patients with an ECOG performance status (PS) of 2 was discontinued due to a perceived rate of unacceptable toxicity.

METHODS

Patients were stratified by PS and randomized to one of the following treatments: 1) paclitaxel (135 mg/m2) over 24 hours with cisplatin (75 mg/m2) on a 21-day cycle; 2) cisplatin (100 mg/m2) with gemcitabine (1 g/m2) on Days 1, 8, and 15 on a 28-day cycle; 3) cisplatin (75 mg/m2) with docetaxel (75 mg/m2) on a 21-day cycle; and 4) paclitaxel (225 mg/m2) over 3 hours with carboplatin (area under the curve, 6). All tests of statistical significance were two-sided.

RESULTS

Sixty-eight patients with an ECOG PS of 2 were enrolled, and 64 patients were evaluable for toxicity and response. Fifty-six percent of 64 evaluable patients were male, and 81% had Stage IV disease. Grade 3-4 hematologic toxicities occurred in > 50% of the patients in each treatment group. Nonhematologic Grade 3-4 toxicities occurred significantly less often in the paclitaxel and carboplatin arm (P = 0.0032). The overall rate of toxicity did not differ significantly from the rate of toxicity in the PS-0 or PS-1 cohorts. There were 5 deaths (7.35%) among 68 patients with a PS of 2 during therapy; however, only 2 of those deaths were attributed to therapy. The overall response rate for the 64 evaluable patients was 14%. The overall median survival of all 68 patients with a PS of 2, as determined by an intent-to-treat analysis, was 4.1 months.

CONCLUSIONS

Patients with advanced NSCLC and a PS of 2 experienced a large number of adverse reactions and overall poor survival. A comparison with patients with a PS of 0-1 suggests that these events and the shorter survival were related to disease process rather than treatment. Alternative strategies need to be explored with therapy specifically tailored for this group of patients.

Deletions of chromosome 13 in multiple myeloma identified by interphase FISH usually denote large deletions of the q arm or monosomy

Deletions of the long arm of chromosome 13 (13q-) are observed in patients with multiple myeloma (MM), are rarely observed in the monoclonal gammopathy of undetermined significance (MGUS) and have been associated with a worsened prognosis in MM. However, no minimally deleted region in the 13q arm has been defined at 13q, and consequently no tumor suppressor genes have yet been identified that are important for disease pathogenesis. We attempted to characterize these chromosome 13q deletions at the molecular cytogenetic level. We studied 351 newly diagnosed patients, entered into the E9486/E9487 clinical study of the Eastern Cooperative Oncology Group. Fluorescent in situ hybridization (FISH) combined with immune fluorescent detection (cIg-FISH) of clonal plasma cells (PC) and cytomorphology were used to analyze interphase, bone marrow (BM) cell, cytospin slides. We simultaneously used DNA probes for the following locus specific probes (LSI); LSI 13 (Rb) and D13S319, which hybridize to 13q14. We subsequently studied distal deletions using the D13S25 probe (13q14.3) and a subtelomeric probe (13qSTP) for the 13q-arm (D13S327) in 40 cases with documented LSI 13 (Rb)/D13S319 deletion and 40 without deletion of these loci. Of 325 evaluable patients, we found 13q deletions in 176 (54%) using LSI 13 (Rb) and D13S319 probes. Of 40 patients with LSI 13 (Rb)/D13S319 deletions, 34 (85%) had coexistent deletion of both D13S25/13qSTP. These results indicate that chromosome 13 deletions in MM involve loss of most if not all of the 13q arm perhaps even indicating monosomy. In six cases the 13qSTP signal was conserved, but D13S25 was lost indicating large interstitial deletions involving 13q14. In 39 of the 40 cases without LSI 13 (Rb)/D13S319 deletions, the normal pattern of two pairs of signals was observed for D13S25/13qSTP. Deletions involving 13q14 are very common in MM as detected by cIg-FISH. These deletions appear to predominantly involve loss of large segments of the 13q arm or monosomy 13, and only occasionally represent an interstitial deletion.

Comparison of selective and non-selective enrichment media in the detection of Listeria monocytogenes from meat containing Listeria innocua

AIMS

This study investigated whether the higher incidence of recovery from meat of Listeria innocua compared with L. monocytogenes could be due to the laboratory media used, leading to an artificially lower detection of the pathogenic species, L. monocytogenes.

METHODS AND RESULTS

Minced beef was inoculated with L. monocytogenes, L. innocua, or a mixture of these species, and stored at 0 or 10 degrees C under vacuum or aerobic conditions for up to 28 days. Listeria were recovered from the minced beef using selective (University of Vermont Medium, UVM) and non-selective (Buffered Peptone Water, BPW) enrichment broths after 0, 14, and 28 days of storage. In general, there were no significant differences (P < 0.05) between the numbers of L. monocytogenes recovered from minced beef samples after 24 h enrichment in BPW and the numbers recovered using UVM. In addition, the presence of L. innocua in meat samples containing L. monocytogenes did not significantly (P < 0.05) affect the numbers of L. monocytogenes recovered using either enrichment broth. In most cases there were no significant differences (P < 0.05) between the numbers of L. innocua recovered from minced beef samples after 24 h enrichment in BPW compared with numbers recovered using UVM.

CONCLUSION

Listeria innocua was found to have no significant competitive advantage over L. monocytogenes in selective or non-selective enrichment media.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results suggest that, in some instances, the use of a selective enrichment broth offers no advantage over a non-selective enrichment broth for the recovery of Listeria species from minced beef.

Thermal resistance of wild-type and antibiotic-resistant Listeria monocytogenes in meat and potato substrates

AIMS

This study aimed to elucidate the relationship, if any, between the acquisition/possession of antibiotic resistance in strains of Listeria monocytogenes and the resistance of such strains to heat stress.

METHODS AND RESULTS

D-values calculated using a linear survival model were used to compare the heat resistance of two wild-type (WT) and two antibiotic (streptomycin)-resistant (AR) mutant strains of L. monocytogenes measured in minced beef and potato substrates at 55 degrees C, with and without prior heat shock at 48 degrees C. In both minced beef and potato, no significant differences (P < 0.05) between D-values of AR and WT strains were noted. Heat shock did not significantly increase D-values of WT or AR strains in minced beef, while in potato slices, D-values in almost all cases were significantly higher in samples which had received heat-shock treatment. In minced beef, the use of a non-selective/overlay recovery medium did not result in higher D-values for any strains, while in potato, significantly higher (P < 0.05) D-values were obtained in most cases.

CONCLUSION

The presence or absence of antibiotic resistance genes did not modulate the heat resistance of the strains examined in this study.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study demonstrated that heat shock, and the type of media used to determine bacterial numbers during heat processing, can significantly affect the D-values obtained.

Paclitaxel and concurrent radiation for locally advanced pancreatic cancer

PURPOSE

To determine the activity and toxicity of paclitaxel and concurrent radiation for pancreatic cancer.

METHODS AND MATERIALS

Forty-four patients with locally unresectable pancreatic cancer were studied. Patients received paclitaxel, 50 mg/m(2) by 3 h i.v. (IV) infusion, weekly, on Days 1, 8, 15, 22 and 29. Radiation was administered concurrently to a total dose of 50.4 Gy, in 1.80 Gy fractions, for 28 treatments.

RESULTS

Nausea and vomiting were the most common toxicities, Grade 3 in five patients (12%). Two patients (5%) had Grade 4 hypersensitivity reactions to their first dose of paclitaxel. Of 42 evaluable patients, the overall response rate was 26%. The median survival was 8 months, and the 1-year survival was 30%.

CONCLUSION

Concurrent paclitaxel and radiation demonstrate local-regional activity in pancreatic cancer. Future investigations combining paclitaxel with other local-regional and systemic treatments are warranted.

Preservation of exercise capacity and lack of peripheral changes in asymptomatic patients with severely impaired left ventricular function

AIMS

To establish the extent, if any, of peripheral changes in asymptomatic patients with severe left ventricular dysfunction. METHODS ANS RESULTS: Nine asymptomatic and nine symptomatic patients with left ventricular ejection fraction, <25%, matched for age and left ventricular ejection fraction (asymptomatic vs symptomatic, age: 52+/-1.5 vs 55.9+/-2.5 years [Mean+/-SEM], left ventricular ejection fraction: 16+/-2 vs 19+/-2%P=0.23 and 0.48, respectively) were studied and compared with 26 age-matched normal controls. We assessed exercise capacity, leg blood flow (occlusion plethysmography), respiratory muscle strength, quadriceps maximal isometric strength, fatigue and CT cross-sectional muscle area at mid thigh. Fatigue was expressed as the percentage reduction in maximal strength following a 20 min fatiguing protocol. There was a graded increase in peak oxygen consumption comparing symptomatic, asymptomatic and control groups (16.6+/-1.3 vs 27.1+/-1.6 vs 32.8+/-1.3 ml x min(-1) x kg(-1)respectively, ANOVA P<0.0001). Between the three groups there was significant variation in muscle strength (P<0.0001), endurance (P=0.0002) and cross-sectional area (P=0.0003) and in peak blood flow (P=0.027) and respiratory muscle strength (P<0.05). When asymptomatic patients and controls were compared no significant differences existed.

CONCLUSIONS

Patients with severe left ventricular dysfunction may have near normal exercise capacity and no peripheral changes. Exercise capacity may depend less upon left ventricular function than on the presence or absence of peripheral factors.

An investigation of a new activated clotting time "MAX-ACT" in patients undergoing extracorporeal circulation

Activated clotting time (ACT) is a test used in the operating room for monitoring heparin effect. However, ACT does not correlate with heparin levels because of its lack of specificity for heparin and its variability during hypothermia and hemodilution on cardiopulmonary bypass (CPB). A modified ACT using maximal activation of Factor XII, MAX-ACT (Actalyke MAX-ACT; Array Medical, Somerville, NJ), may be less variable and more closely related to heparin levels. We compared MAX-ACT with ACT in 27 patients undergoing CPB. We measured ACT, MAX-ACT, temperature, and hematocrit at six time points: baseline; postheparin; on CPB 30, 60, and 90 min; and postprotamine. Additionally, we assessed anti-Factor Xa heparin activity and antithrombin III activity at four of these six time points. With institution of CPB and hemodilution, MAX-ACT and ACT did not change significantly but had a tendency to increase, whereas concomitant heparin levels decreased (P = 0.065). Neither test correlated with heparin levels. ACT and MAX-ACT did not differ during normothermia but did during hypothermia, and ACT was significantly longer than MAX-ACT (P = 0.009). At the postheparin time point, ACT-heparin sensitivity (defined as [ACT postheparin - ACT baseline]/[heparin concentration postheparin - heparin concentration baseline]) was greater than MAX-ACT-heparin sensitivity (analogous calculation for MAX-ACT; 520 [266 - 9366] s. U(-1). mL(-1) vs 468 [203 - 8833] s. U(-1). mL(-1); P = 0.022).

IMPLICATIONS

MAX-ACT (a new activated clotting time [ACT] test) uses more maximal clotting activation in vitro and, although it is less susceptible to increase because of hypothermia and hemodilution than ACT, lack of correlation with heparin levels remains a persistent limitation.

A 9-year, single-institution, retrospective review of death rate and prognostic factors in adult respiratory distress syndrome

OBJECTIVE

To evaluate, at a single institution, the adult respiratory distress syndrome (ARDS) death rate in critically ill ventilated surgical/trauma patients and to identify the factors predicting death in these patients.

SUMMARY BACKGROUND DATA

The prognostic features affecting mortality at the onset of ARDS have not been clearly defined. Defining rare characteristics would be valuable because it would allow for better stratification of patients in clinical trials and more appropriate utilization of constrained resources in ICU environments.

METHODS

A retrospective analysis of 980 ventilated surgical and trauma intensive care unit patients from January 1990 to December 1998 was performed at Rhode Island Hospital. One hundred eleven adult intensive care unit patients with ARDS were identified using the criteria of Lung Injury Score more than 2.50 and the definition from the American-European Consensus Conference. Slightly more than half were trauma patients, 57% were men, and the median age was 59 years. The overall death rate was 52%. Patients were segregated by admission date to the intensive care unit (before or after January 1, 1995). Severity of illness was measured by the Revised Trauma Score for trauma patients and the Acute Physiology and Chronic Health Evaluation III for surgical patients. The Multiple Organ Dysfunction Score was determined on the day of onset of ARDS for all patients. Other recorded variables were age, sex, intensive care unit length of stay, length and mode of ventilation, presence or absence of tracheostomy, ventilation variables of peak and mean airway pressures, lung injury scores, elective versus emergency surgery, and presence or absence of pneumonia.

RESULTS

There was a significant decrease in the ARDS death rate from the period 1990 to 1994 to the period 1995 to 1998. The major reason for the decline was a reduction in the posttraumatic ARDS death rate. Lung-protective ventilation strategies were used more frequently in the second period than in the first, and the death rate was significantly decreased in trauma patients in the second period when lung-protective ventilation modes were used. Predictors of death at the onset of ARDS were advanced age, Multiple Organ Dysfunction Score of 8 or more, and Lung Injury Score of 2.76 or more.

CONCLUSION

In this single-institution series, the death rate from ARDS declined from 1990 to 1998, primarily in posttraumatic patients, and the decrease is related to the use of lung-protective ventilation strategies. Based on this patient population, the authors developed a statistical model to evaluate important prognostic indicators (advanced age, organ system and pulmonary dysfunction measurements) at the onset of ARDS.

Identification of methionine-processed HPr in the equine pathogen Streptococcus equi

Using preparative electrophoresis, a low molecular weight protein has been partially purified from a cell extract of the equine pathogen Streptococcus equi susp. equi. N-terminal sequence analysis and Western blotting revealed the protein to be HPr, a central component of the phosphoenolpyruvate:sugar phosphotransferase system (PTS). Interestingly, the only form of the HPr protein detected in S. equi was one with the amino-terminal methionine removed, a modification that has previously been associated with surface localization of streptococcal HPr proteins.

Characterization of acid phosphatase activities in the equine pathogen Streptococcus equi

Acid phosphatases hydrolyse phosphomonoesters at acidic pH in a variety of physiological contexts. The recently defined class C family of acid phosphatases includes the 32 kDa LppC lipoprotein of Streptococcus equisimilis. To define further the distribution of acid phosphatases in the genus Streptococcus we have examined the equine pathogens Streptococcus equi subsp. equi and Streptococcus equi subsp. zooepidemicus. Whole cell assays indicated that these organisms possess two acid phosphatases with activity optima at pH 5.0 and pH 6.0-6.5 and that only the former of these was, like LppC, resistant to EDTA. Western blotting with a polyclonal anti-LppC antiserum revealed the presence of a cross-reactive 32 kDa protein in both organisms. The cross-reactive protein in S. equi was shown to be a surface accessible lipoprotein as its processing was inhibited by the antibiotic globomycin and it was released from whole cells by treatment with trypsin. The presence of DNA sequences homologous to the S. equisimilis lppC gene were confirmed by PCR. These data strongly suggest that Streptococcus equi subsp. equi and Streptococcus equi subsp. zooepidemicus produce a lipoprotein acid phosphatase homologous to LppC of S. equisimilis.

Different response of patients with idiopathic and ischaemic dilated cardiomyopathy to exercise training

We looked at the benefits and complications of a home-based exercise programme in patients with ischaemic and idiopathic dilated cardiomyopathy. Twenty-four patients with left ventricular end-diastolic dimension >6.5 cm and fractional shortening <25% entered a cross-over trial of 8 weeks training versus 8 weeks rest. Echocardiography, electrocardiogram and cardiopulmonary exercise testing were performed at baseline, after training and after detraining. Training resulted in a higher peak oxygen consumption (26.5 versus 21.3 ml/kg/min, P=0.004), a higher peak heart rate (161 versus 152 bpm, P=0.02) and improved well-being. Patients with idiopathic dilated cardiomyopathy showed a significant increase in exercise time (879 versus 828 s, P=0.03) and peak oxygen consumption (31.3 versus 24.3 ml/kg/min, P=0.02) and a decrease in left ventricular end-diastolic dimension (6.4 versus 6.9 cm, P=0.01) and end-systolic dimension (5.3 versus 5.8 cm, P=0.04) in contrast to those with coronary artery disease, who developed a reduction in septal excursion and shortening rate following training. Complications of training were more common in those patients with ischaemic cardiomyopathy, greater left ventricular dimensions, poorer exercise tolerance and greater ventilation drive at baseline, and included fluid retention and exercise-induced ventricular tachycardia. We found that this group of patients with a dilated, poorly functioning left ventricle can safely derive benefit from a home-based exercise programme, particularly those of idiopathic origin, but they should be closely monitored for the development of complications.

The effect of salbutamol on skeletal muscle in chronic heart failure

We performed a randomised placebo-controlled trial to investigate the effects of the anabolic drug salbutamol on skeletal muscle and exercise capacity in chronic heart failure. Twelve patients received salbutamol slow-release 8 mg twice daily or placebo for 3 weeks. We assessed the effect of treatment on exercise capacity, quadriceps muscle bulk, maximal isometric strength and fatigue, respiratory muscle strength, spirometry and 24-h ECG (electrocardiogram). There was no significant change in the muscle indices, exercise time or peak oxygen consumption. The frequency of ventricular arrhythmias and spirometric measurements were also unchanged. Maximal expiratory mouth pressure, measured at total lung capacity and functional residual capacity, increased significantly (+29.7+/-10.6 vs. -0. 5+/-7.5 cm H(2)O [mean+/-S.E.M., change over 3 weeks treatment salbutamol vs. placebo] and +31.2+/-5.4 vs. +0.2+/-4.0 cm H(2)O both P<0.05). Maximal inspiratory pressures showed a trend towards increasing with treatment when measured from either lung volume (-22. 8+/-9.5 vs. -6.2+/-3.6 cm H(2)O, P=0.14 and -21.5+/-7.5 vs. -3.5+/-3. 4 cm H(2)O, P=0.054). Treatment with 3 weeks of salbutamol increases respiratory muscle strength in chronic heart failure but does not improve quadriceps abnormalities or exercise capacity. Salbutamol is unlikely to have a role in treating the muscle abnormalities in chronic heart failure.

The relationship between hide cleanliness and bacterial numbers on beef carcasses at a commercial abattoir

Cattle were visually inspected in the lairage of a commercial abattoir and assigned to a category ranging from 1 (very clean) to 5 (very dirty) depending on the observed cleanliness of the hide. Animals from categories 2, 3 and 5 were slaughtered and total viable counts (TVCs) enumerated at five sites (hock, brisket, cranial back, bung and inside round) on the subsequent carcasses. The TVCs at the hock were significantly higher on category 5 than on category 2 carcasses (P < 0.05). Similarly, TVCs at the brisket were significantly higher on categories 3 and 5 than on category 2 carcasses (P < 0.05). There were no differences in counts among the categories at any of the other sites. The TVCs averaged over the five carcass sites were higher for category 5 than for category 2 carcasses (P < 0.05). The TVCs at the brisket were significantly higher than all other sites (P < 0.01). In general, carcasses from category 2 animals slaughtered in a batch with dirtier animals (categories 3 and 5) did not have higher TVCs than carcasses of category 2 animals slaughtered at the beginning of the day in the absence of dirtier animals. The introduction of improved hygienic practices during the dehiding of category 4 animals resulted in reduced TVCs at the brisket (P < 0.001).

Thermal inactivation of Listeria monocytogenes and Yersinia enterocolitica in minced beef under laboratory conditions and in sous-vide prepared minced and solid beef cooked in a commercial retort

D-values were obtained for Listeria monocytogenes and Yersinia enterocolitica at 50, 55 and 60 degrees C in vacuum-packed minced beef samples heated in a laboratory water-bath. The experiment was repeated using vacutainers, which allowed heating of the beef to the desired temperature before inoculation. D-values of between 0.15 and 36.1 min were obtained for L. monocytogenes. Pre-heating the beef samples significantly affected (P < 0.05) the D60 value only. D-values for Y. enterocolitica ranged from 0.55 to 21.2 min and all the D-values were significantly different (P < 0.05) after pre-heating. In general, the D-values obtained for core inoculated solid beef samples were significantly higher (P < 0.05) than those generated in minced beef when heated in a Barriquand Steriflow commercial retort.

Anticoagulation for cardiac surgery in patients receiving preoperative heparin: use of the high-dose thrombin time

Patients receiving heparin infusions have an attenuated activated clotting time (ACT) response to heparin given for cardiopulmonary bypass (CPB). We compared patients receiving preoperative heparin (Group H) to those not receiving heparin (REF group) with respect to ACT, high-dose thrombin time (HiTT), and markers of thrombin generation during CPB. Sixty-five consecutive patients (33 Group H, 32 REF group) undergoing elective CPB were evaluated. ACT and HiTT were measured at multiple time points. Plasma levels of thrombin-antithrombin III complex and fibrin monomer were determined at baseline, during CPB, and after protamine administration. Transfusion requirements and postoperative blood loss were measured and compared. ACT values after heparinization increased less in Group H and were significantly lower than those in the REF group (P < 0.01). HiTT values did not differ significantly between the two groups. Blood loss and transfusion requirements were not significantly different between the two groups. Plasma levels of thrombin-antithrombin III complexes and fibrin monomer also did not differ between groups at any time, despite a lower ACT in Group H after heparinization and during CPB. Our data suggest that thrombin formation and activity are not enhanced in patients receiving heparin therapy, despite a diminished ACT response to heparin. The utility of ACT and the threshold values indicative of adequate anticoagulation for CPB are relatively undefined in patients receiving preoperative heparin. HiTT should be investigated as a safe and accurate monitor of anticoagulation for CPB in patients receiving preoperative heparin therapy.

IMPLICATIONS

The diminished activated clotting time response to heparin, in patients receiving preoperative heparin therapy, poses difficulties when attempting to provide adequate anticoagulation for cardiopulmonary bypass. Current data suggest that heparin resistance is not observed when high-dose thrombin time is used to monitor anticoagulation and that a lower activated clotting time value in these patients may be safe.

Quality management in Irish health care

This paper reports on the findings from a quantitative research study of quality management in the Irish health-care sector. The study findings suggest that quality management is what hospitals require to become more cost-effective and efficient. The research also shows that the culture of health-care institutions must change to one where employees experience pride in their work and where all are involved and committed to continuous quality improvement. It is recommended that a shift is required from the traditional management structures to a more participative approach. Furthermore, all managers whether from a clinical or an administration background must understand one another's role in the organisation. Finally, for quality to succeed in the health-care sector, strong committed leadership is required to overcome tensions in quality implementation.

β -amyloid precursor protein positive axonal bulbs may form in non-head-injured patients

Since the early 1980s axonal bulbs staining positively for beta-amyloid precursor protein (betaAPP) have been used as a marker of diffuse axonal injury (DAI), bulb formation been attributed to shearing forces generated during rotational acceleration/deceleration head injury. This study draws attention to the observation that they may form in the absence of a head injury and, thus, axonal injury cannot be assumed to result from mechanical injury alone. Out of 20 cases with no history of head injury studied, which only showed evidence of neuronal hypoxic change, 11 (55%) showed variable positive staining for betaAPP in a similar anatomical distribution to that previously described for DAI. The role of hypoxia in the formation of axonal bulbs, as well as the possible role of betaAPP as an acute phase protein, are discussed. These observations further clarify the pattern and relationship between neuronal and axonal staining observed following a brain insult and emphasize the possible role of betaAPP as a neuroprotective protein.

Fathers and child neglect

OBJECTIVE

To examine the association between father involvement and child neglect.

DESIGN

Cohort study.

SETTING

Participants were recruited from an inner-city pediatric primary care clinic and a clinic for children at risk for human immunodeficiency virus infection in a teaching hospital.

PARTICIPANTS

Mothers and fathers or father figures, and 244 five-year olds participating in a longitudinal study.

MAIN OUTCOME MEASURES

Child neglect measured via home observation, a videotaped mother-child interaction, and child protective services reports.

RESULTS

A father or father figure was identified for 72% of the children. Rates of neglect ranged between 11% and 30%. Father absence alone was not associated with neglect. However, in families with an identified and interviewed father, a longer duration of involvement (P<.01), a greater sense of parenting efficacy (P<.01), more involvement with household tasks (P<.05), and less involvement with child care (P<.05) were associated with less neglect. The overall model explained 26.5% of the variance in neglect.

CONCLUSIONS

There is substantial involvement of fathers in a subset of this high-risk sample, although more than a quarter of the children lacked a father or father figure. The mere presence of a father did not significantly influence the neglect of the children; rather, the nature of his involvement did. Fathers who felt more effective as parents were less likely to have neglected their children. A greater sense of efficacy may reflect parenting skills and be important in enhancing the contribution of fathers to their children's well-being. Pediatric health care providers can play a valuable role in enhancing the involvement and skills of fathers.