Therapeutic efficacy of pooled buffy-coat platelet components prepared and stored with a platelet additive solution

Despite the introduction of platelet additive solutions for the preparation of pooled platelet components, only a few studies of limited scope have evaluated the clinical efficacy of platelets stored in these solutions. The current report presents an analysis of data to evaluate the response to the transfusion of pooled buffy-coat components suspended in storage solution with reduced (35%) plasma content in comparison with 100% plasma products. During the euroSPRITE clinical trial of platelet components treated with a pathogen inactivation process, control treatment group platelet components were prepared in 100% allogeneic donor plasma (plasma control) or in platelet additive solution (T-Sol) mixed with plasma (T-Sol control). Control group thrombocytopenic patients received either plasma control or T-Sol control platelet components. One-hour and 24-h platelet count increments (CIs) and corrected count increments (CCIs) were analysed for these two types of preparation. In addition, haemostatic assessments were conducted for each transfusion. One-hour and 24-h mean platelet CIs and post-transfusion haemostatic scores were not significantly different for patients receiving platelet components suspended in 100% plasma and T-Sol plasma mixtures. Pooled buffy-coat platelet components prepared in reduced plasma content mixtures provided therapeutic platelet CIs with effective haemostasis.

A case-based evaluation of SRD5A1, SRD5A2, AR, and ADRA1A as candidate genes for severity of BPH

In men with a clinical diagnosis of benign prostatic hyperplasia (BPH), polytomous logistic regression analysis was conducted to evaluate associations between two silent polymorphisms in SRD5A1 (codon positions 30 and 116), two polymorphisms in SRD5A2 (Val89Leu substitution and C to T transition in intron 1), a trinucleotide (CAG)n repeat in androgen receptor (AR), and an Arg492Cys substitution in ADRA1A and clinical parameters that characterize severity of BPH. Candidate gene selection was based on two mechanistic pathways targeted by pharmacotherapy for BPH: (1) androgen metabolic loci contributing to prostate growth (static obstruction); and (2) factors affecting smooth muscle tone (dynamic obstruction). Polymorphisms in SRD5A2 were not associated with severity of BPH; however, SRD5A1 polymorphisms were associated with severity of BPH. The process(es) in which these silent single-nucleotide polymorphisms (SNPs) influence BPH phenotypes is unknown and additional studies will be needed to assess whether these SNPs have direct functional consequences. The characterization of additional molecular factors that contribute to static and dynamic obstruction may help predict response to pharmacotherapy and serve to identify novel drug targets for the clinical management of BPH.

Consistent cytotoxic-T-lymphocyte targeting of immunodominant regions in human immunodeficiency virus across multiple ethnicities

Although there is increasing evidence that virus-specific cytotoxic-T-lymphocyte (CTL) responses play an important role in the control of human immunodeficiency virus (HIV) replication in vivo, only scarce CTL data are available for the ethnic populations currently most affected by the epidemic. In this study, we examined the CD8(+)-T-cell responses in African-American, Caucasian, Hispanic, and Caribbean populations in which clade B virus dominates and analyzed the potential factors influencing immune recognition. Total HIV-specific CD8(+)-T-cell responses were determined by enzyme-linked immunospot assays in 150 HIV-infected individuals by using a clade B consensus sequence peptide set spanning all HIV proteins. A total of 88% of the 410 tested peptides were recognized, and Nef- and Gag-specific responses dominated the total response for each ethnicity in terms of both breadth and magnitude. Three dominantly targeted regions within these proteins that were recognized by >90% of individuals in each ethnicity were identified. Overall, the total breadth and magnitude of CD8(+)-T-cell responses correlated with individuals' CD4 counts but not with viral loads. The frequency of recognition for each peptide was highly correlated with the relative conservation of the peptide sequence, the presence of predicted immunoproteasomal cleavage sites within the C-terminal half of the peptide, and a reduced frequency of amino acids that impair binding of optimal epitopes to the restricting class I molecules. The present study thus identifies factors that contribute to the immunogenicity of these highly targeted and relatively conserved sequences in HIV that may represent promising vaccine candidates for ethnically heterogeneous populations.

Translating the Short-Form Headache Impact Test (HIT-6) in 27 countries: methodological and conceptual issues

The process of translating the Short-Form Headache Impact Test (HIT-6) in 27 countries and the comparability of the content of the translations is discussed. HIT-6 translations were developed using a standard forward-backward translation process, including a cognitive debriefing step and international harmonization of the translations. Prior to translating the HIT-6, modifications were made to the English-language source form, to improve translation equivalence. In general, the HIT-6 was not difficult to translate. The most difficult items included colloquial expressions such as 'fed up' and words whose intended meaning changed in translation such as 'school' or 'lie down.' Subjects generally found the HIT-6 translations to be clear and relevant. The translation process resulted in questionnaires that are both culturally appropriate and comparable in content.

Symptoms and anal sphincter morphology following primary repair of third-degree tears

Background

Approximately 0·6–9 per cent of vaginal deliveries are complicated by third-degree tears. The precise impact of such injuries on future pelvic floor function remains unknown. The aim of this study was to define the extent of structural and physiological damage to the anal sphincter and to investigate anorectal function in women who sustained third-degree tears during vaginal delivery.

Methods

Fifty-six women who sustained a third-degree tear were investigated prospectively. All patients had a primary repair of the anal sphincter complex, and were assessed by anorectal physiology and endoanal ultrasonography at a mean of 3·6 months. Symptoms were assessed by direct personal interview and also by a self-completed questionnaire.

Results

Forty-four patients had a persistent anal sphincter defect on ultrasonography. The mean resting and squeeze anal canal pressures were significantly lower in patients with a combined defect than in those in whom the repair was intact (P = 0·036 and P = 0·005 respectively). At direct interview three patients volunteered current symptoms of faecal and/or urinary incontinence whereas 32 reported bothersome symptoms on the questionnaire (P < 0·001).

Conclusion

The anatomical and physiological damage sustained during third-degree tears appears to be much greater than is generally appreciated. Primary repair does not provide lasting integrity. A self-administered questionnaire appears to be more accurate in defining the symptomatology.

Preliminary evaluation of an injectable anal sphincter bulking agent (Durasphere) in the management of faecal incontinence

BACKGROUND

It has been previously shown that 'bulking' of internal anal sphincter defects may provide an effective method to treat patients with faecal incontinence, but the benefit wears off with time.

AIM

To assess the efficacy of a larger molecule, bulking agent (Durasphere) over the short- and long-term in patients with an internal anal sphincter defect refractory to conservative management.

PATIENTS

Eighteen patients (nine male, nine female) with a mean age of 60 years were recruited. All patients had persistent faecal leakage/soiling.

METHODS

Durasphere was injected in the submucosal plane to restore anal canal symmetry. All patients had anorectal physiology, endoanal ultrasound, continence grading, patient satisfaction and quality of life scores assessed at 1, 3, 6 and 12 months.

RESULTS

The mean follow-up is 28.5 months. Changes from baseline were not statistically significant up to 6 months. At 12 months there was significant improvement in the continence grading (P=0.003), patient satisfaction (P=0.053) and all quality of life subscales: lifestyle (P=0.004), coping (P=0.011), depression (P=0.024) and embarrassment (P=0.059). Anorectal physiological parameters apart from the maximum tolerable rectal volume at 12 months (P=0.036) showed no significant improvement.

CONCLUSIONS

Anal sphincter bulking with Durasphere is safe and effective in the short term as well as the longer term. More importantly, there is no evidence of attenuation of effect over time.

IMBA Expert: internal dosimetry made simple

In 1997, a collaboration between British Nuclear Fuels plc (BNFL), Westlakes Research Institute and NRPB started, with the aim of producing IMBA (Integrated Modules for Bioassay Analysis), a suite of software modules that implement the new ICRP models for estimation of intakes and doses. This was partly in response to new UK regulations, and partly due to the requirement for a unified approach in estimating intakes and doses from bioassay measurements within the UK. Over the past 5 years, the IMBA modules have been developed further, have gone through extensive quality assurance, and are now used for routine dose assessment by approved dosimetry services throughout the UK. More recently, interest in the IMBA methodology has been shown by the United States Department of Energy (USDOE), and in 2001 an ambitious project to develop a software package (IMBA Expert USDOE Edition) which would meet the requirements of all of the major USDOE sites began. Interest in IMBA Expert is now being expressed in many other countries. The aim of this paper is to outline the origin and evolution of the IMBA modules (the past); to describe the full capabilities of the current IMBA Expert system (the present) and to indicate possible future directions in terms of capabilities and availability (the future).

Search for R-parity violating supersymmetry in two-muon and four-jet topologies

We present results of a search for R-parity-violating decay of the neutralino chi;01, taken as the lightest supersymmetric particle, to a muon and two jets. The decay proceeds through a lepton-number violating coupling lambda(')(2jk) (j=1,2; k=1,2,3), with R-parity conservation in all other production and decay processes. In the absence of candidate events from 77.5+/-3.9 pb(-1) of data collected by the D0 experiment at the Fermilab Tevatron in pp collisions at sqrt[s]=1.8 TeV, and with an expected background of 0.18+/-0.03+/-0.02 events, we set limits on squark and gluino masses within the framework of the minimal low-energy supergravity-supersymmetry model.

Evaluation of the Digene Hybrid Capture II Assay with the Rapid Capture System for detection of Chlamydia trachomatis and Neisseria gonorrhoeae

Screening for chlamydial and gonococcal infection has been strongly recommended for all sexually active women under the age of 26. Advances in the ability to detect infection by nucleic acid detection techniques have improved access to screening methods in routine clinical practices. To meet the increasing demand for testing, a high-throughput system is desirable. We evaluated the performance of the Hybrid Capture 2 CT/GC (HC2) assay with the Digene Rapid Capture System (HC2-RCS). The results of HC2-RCS for endocervical samples from 330 women were compared to those of culture and the COBAS Amplicor PCR. For detection of chlamydial infection, HC2-RCS had a sensitivity and a specificity similar to those of PCR (P > 0.5) and an improved sensitivity compared to that of culture (P = 0.007). For identification of gonococcal infections, all assays performed similarly (P > 0.5). The performance of HC2-RCS was also compared to that of the manual HC2 format (HC2-M) with these samples and with 911 endocervical samples collected previously. The performance of HC2-RCS was equivalent to that of HC2-M; the overall concordance rates for the detection of chlamydia and gonorrhea were 99.7% (kappa = 0.97) and 99.8% (kappa = 0.97), respectively. When the HC2 assay was performed with a semiautomated system application designed for high throughput, it demonstrated high sensitivity and a high specificity for detection of both Chlamydia trachomatis and Neisseria gonorrhoeae.

Re-sequencing of multiple single nucleotide polymorphisms by liquid chromatography-electrospray ionization mass spectrometry

Allelic discrimination of single nucleotide polymorphisms (SNPs) and, particularly, determination of the phase of multiple variations are of utmost importance in genetics. The physicochemical separation of alleles by completely denaturing ion-pair reversed-phase high-performance liquid chromatography and their on-line sequence determination by electrospray ionization mass spectrometry is demonstrated. Simultaneous genotyping of two and three simple sequence polymorphisms contained within 73-114 bp was accomplished with low femtomolar amounts of unpurified amplicons from polymerase chain reaction. Determination of allelic composition is enabled by the high accuracy (better than 0.019%) of intact mass measurements or by comparative sequencing using gas-phase fragmentation and tandem mass spectrometry in combination with fully automated, computer-aided data interpretation.

Search for leptoquark pairs decaying into nunu+jets in pp collisions at square root[s] = 1.8 TeV

We present the results of a search for leptoquark (LQ) pairs in (85.2+/-3.7) pb(-1) of pp* collider data collected by the D0 experiment at the Fermilab Tevatron. We observe no evidence for leptoquark production and set a limit on sigma(pp*-->LQLQ-->nunu+jets) as a function of the mass of the leptoquark (m(LQ)). Assuming the decay LQ-->nuq, we exclude scalar leptoquarks for m(LQ) < 98 GeV/c(2), and vector leptoquarks for m(LQ) < 200 GeV/c(2) and coupling which produces the minimum cross section, at a 95% confidence level.

Search for the scalar top quark in pp collisions at square root[s] = 1.8 TeV

We have performed a search for scalar top quark (stop) pair production in the inclusive electron-muon-missing transverse energy final state, using a sample of pp events corresponding to 108.3 pb(-1) of data collected with the D0 detector at Fermilab. The search is done in the framework of the minimal supersymmetric standard model assuming that the sneutrino is the lightest supersymmetric particle. For the dominant decays of the lightest stop, t-->b chi+1 and t-->blnu, no evidence for signal is found. We derive cross-section limits as a function of stop ( t ), chargino ( chi+1), and sneutrino ( nu) masses.

Direct search for charged higgs bosons in decays of top quarks

We present a search for charged Higgs bosons in decays of pair-produced top quarks in pp collisions at sqrt[s] = 1.8 TeV recorded by the D0 detector at the Fermilab Tevatron collider. With no evidence for signal, we exclude most regions of the ( M(H+/-),tan(beta)) parameter space where the decay t--> H(+)b has a branching fraction >0.36 and B(H+/--->tau(nu)(tau)) is large.

The intersection of socioeconomic variables, oral health, and systemic disease: all health care is cultural

In the last decade, there has been an increase in the proportion of the American population that lacks health insurance. Additionally, long-term disparities in health access and status for populations of color have continued to exist without major change. A review of the literature in periodontia shows a statistical relationship between the risk of periodontal disease and a range of sociodemographic characteristics (race, income, social class). However, the factors giving rise to this increased risk or how to reduce it are unclear. Cultural competence, an elaboration of biopsychosocial theory, hypothesizes a relationship between the culture of a group and its risk of disease and the kind and quality of services obtained. Four areas of a culturally competent approach are cited as a minimum base of standards for providing services to people of color.

Ratio of isolated photon cross sections in pp macro collisions at square root of s = 630 and 1800 GeV

The inclusive cross section for production of isolated photons has been measured in pp macro collisions at square root of s = 630 GeV with the D0 detector at the Fermilab Tevatron Collider. The photons span a transverse energy (E(T)) range from 7-49 GeV and have pseudorapidity absolute value of eta < 2.5. This measurement is combined with the previous D0 result at square root of s = 1800 GeV to form a ratio of the cross sections. Comparison of next-to-leading-order QCD with the measured cross section at 630 GeV and the ratio of cross sections show satisfactory agreement in most of the E(T) range.

Search for new physics using QUAERO: a general interface to D0 event data

We describe QUAERO, a method that (i) enables the automatic optimization of searches for physics beyond the standard model, and (ii) provides a mechanism for making high energy collider data generally available. We apply QUAERO to searches for standard model WW, ZZ, and t t macro production, to searches for these objects produced through a new heavy resonance, and to the first direct search for W'-->WZ. Through this interface, we make three data sets collected by the D0 experiment at square root of [s] = 1.8 TeV publicly available.

Quantity and rigor of qualitative research in four pastoral counseling journals

Examines the quantity (N = 26) and rigor of qualitative research in The Journal of Pastoral Care, Pastoral Sciences, Journal of Religion and Health, and Pastoral Psychology for 1993-1997. Defines qualitative research using the work of Douglas Sprenkle and Sidney Moon. Uses the eleven criteria developed by Nicholas Mays and Catherine Pope in British Medical Journal for judging rigor. Finds low quantity and mixed quality and discusses implications.

Design of clinical trials to evaluate the efficacy of platelet transfusion: the euroSPRITE trial for components treated with Helinx technology

Methods of collection, preparation, and transfusion of platelet components have evolved markedly since the introduction of modern platelet transfusion therapy three decades ago. Despite these improvements, few randomized, prospective, controlled studies have been conducted to evaluate the effects of these innovations on the outcome of platelet transfusion--prevention and treatment of bleeding due to thrombocytopenia. The majority of studies have used posttransfusion platelet count increments (CIs) as the primary outcome variable rather than bleeding assessments. In general, these studies have only examined average values for platelet CIs or adjusted ratio measures such as corrected count increment (CCI). Because platelet transfusions are given repeatedly over variable periods of time, this type of analysis has not provided information about the effects of multiple platelet transfusions or about specific product or patient-related covariates that may impact the outcome. Longitudinal regression analysis of platelet CIs offers the potential to provide more information than simple average values of ratio measures. The euroSPRITE trial, a European, multicenter, phase III study undertaken to assess the clinical efficacy and safety of platelets prepared with Helinx technology (Cerus Corp, Concord, CA), used longitudinal regression analysis to characterize more fully the response to platelet transfusions with products prepared with this new pathogen inactivation technology. In contrast to previous studies, the euroSPRITE study examined peritransfusion hemostasis and global indices of hemostasis to correlate the effect of platelet CI with prevention and treatment of bleeding during a period of platelet transfusion support.

Racial and ethnic differences in drug treatment entry of injection drug users in Massachusetts

This article examines patterns of drug treatment entry among 28,000 adult injection drug users (IDUs), with special attention to racial and ethnic differences. The data analyzed originates from a statewide drug-treatment database covering four years. Through the use of logistic regression analysis, the study identified significant population differences between those who used detoxification only, those who used residential treatment and those who used methadone maintenance. Latino IDUs were approximately a third less likely than Caucasian IDUs to enter residential treatment and African American IDUs were half as likely as Caucasian IDUs to enter methadone maintenance treatment. This article discusses specific programmatic and research implications including the need to determine whether differential entry rates are due to access, client awareness, cultural, referral or other factors.

Multiinstitutional experience with the management of superior mesenteric artery injuries

BACKGROUND

Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America.

DESIGN

We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality.

RESULTS

There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure.

CONCLUSION

SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Dual control modes: combining volume and pressure breaths

New modes of ventilator operation are often introduced without rhyme or reason. The dual control modes are, however, a response of the manufacturers to clinician desire to provide constant minute volume/tidal volume while operating in the pressure support or pressure control mode. Dual control modes allow the ventilator to control pressure or volume. The ventilator cannot control pressure and volume at the same time, so it is an either/or phenomenon. Dual control modes can operate "within a breath" or on a "breath to breath" basis. Dual control within a breath refers to a technique whereby the ventilator switches from pressure to volume control in the middle of a breath. In the technique of dual control breath to breath, all breaths are pressure control breaths, but the level of pressure varies from breath to breath in an effort to maintain a constant tidal volume.

Search for heavy particles decaying into electron-positron pairs in pp collisions

We present results of searches for technirho (rho(T)), techniomega (omega(T)), and Z' particles, using the decay channels rho(T),omega(T),Z'-->e(+)e(-). The search is based on 124.8 pb(-1) of data collected by the D0 detector at the Fermilab Tevatron during 1992-1996. In the absence of a signal, we set 95% C.L. upper limits on the cross sections for the processes pp-->rho(T),omega(T),Z'-->e(+)e(-) as a function of the mass of the decaying particle. For certain model parameters, we exclude the existence of degenerate rho(T) and omega(T) states with masses below about 200 GeV. We exclude a Z' with mass below 670 GeV, assuming that it has the same couplings to fermions as the Z boson.

Gaps in health coverage among working-age Americans and the consequences

This paper examines health coverage and access to care among working-age adults using the Kaiser/Commonwealth 1997 National Survey of Health Insurance. One in three (52 million) working-age adults were either uninsured at the time of the survey or had a recent gap in their health coverage in the past two years. Having even a temporary gap in health coverage made a significant difference in access to care. Compared to the elderly, who are continuously covered by Medicare, working-age adults have greater problems paying their medical bills and gaining access to care and are less satisfied with their health insurance coverage.

Cancer-related fatigue: prevalence of proposed diagnostic criteria in a United States sample of cancer survivors

PURPOSE

To evaluate the proposed cancer-related fatigue (CRF) diagnostic criteria in a sample of cancer survivors. More accurate prevalence estimates of CRF may result in improved diagnosis and management of one of the most common symptoms associated with cancer and its treatment.

METHODS

Three hundred seventy-nine individuals who had been treated with chemotherapy, either alone or in combination with radiation therapy, were surveyed. Patients were asked background questions about their current condition, their medical history, and the frequency of fatigue during their chemotherapy. Additionally, patients who reported experiencing fatigue at least a few days each month during treatment were asked a series of questions about the impact of fatigue on their daily functioning.

RESULTS

One hundred forty-one (37%) individuals reported at least 2 weeks of fatigue in the previous month. Of the respondents who had received their last treatment more than 5 years ago, 33% still reported at least a 2-week period of fatigue in the month before the interview. Evaluation of the proposed criteria revealed that 17% of respondents met at least two criteria for CRF.

CONCLUSION

The prevalence of diagnosable CRF in the individuals in this sample, most of whom had completed treatment more than 1 year ago, was 17%-lower than expected based on previous reports that have used less-strict criteria. In a sizable number of people, CRF persists well beyond active treatment and should be a focus of intervention. Although they will require replication in other samples and clinical validation, these formal diagnostic criteria can be a step toward common language and a better understanding of the severity range and persistence of CRF.

Oxygen-induced seizures and inhibition of human glutamate decarboxylase and porcine cysteine sulfinic acid decarboxylase by oxygen and nitric oxide

The recombinant forms of the two human isozymes of glutamate decarboxylase, GAD65 and GAD67, are potently and reversibly inhibited by molecular oxygen (Ki = 0.46 and 0.29 mM, respectively). Inhibition of the vesicle-associated glutamate decarboxylase (GAD65) by molecular oxygen is likely to result in incomplete filling of synaptic vesicles with gamma-aminobutyric acid (GABA) and may be a contributing factor in the genesis of oxygen-induced seizures. Under anaerobic conditions, nitric oxide inhibits both GAD65 and GAD67 with comparable potency to molecular oxygen (Ki = 0.5 mM). Two forms of porcine cysteine sulfinic acid decarboxylase (CSADI and CSADII) are also sensitive to inhibition by molecular oxygen (Ki = 0.30 and 0.22 mM, respectively) and nitric oxide (Ki = 0.3 and 0.2 mM, respectively). Similar inhibition of glutamate decarboxylase and cysteine sulfinic acid decarboxylase by two different radical-containing compounds (O2 and NO) is consistent with the notion that these reactions proceed via radical mechanisms.

Assessment of mortality rates for congenital heart defects and surgeons' performance

BACKGROUND

In the absence of reliable national data, we have collected results of all operations for congenital heart defects from five departments to assess mortality rates and compare them among surgeons and departments.

METHODS

Data relating to all operations (2,718) carried out at the five centers during a period from April 1, 1997 through March 31, 1999. Clearly defined criteria were agreed for the classification of patients into various subgroups.

RESULTS

The overall hospital mortality was 4.4% (95% confidence intervals 3.7%-5.3%). Mortality for open-operations was 12.6% in neonates, 5.1% in infants, and 3.5% in children. Mortality rates were 1.1% for coarctation, 0.4% ventricular septal defect, 4.1% atrioventricular septal defect, 2.9% Fallot, 0.9% switch, and 15.6% truncus arteriosus. Although individual surgeons' mortality rates ranged from 1.8% to 7.5%, none of the 12 surgeons' data were above 95% confidence intervals. For individual surgeons, the change in mortality rates between the 2 years ranged between -3.3% and +3.8%.

CONCLUSIONS

With 2 years' data available, estimates of mortality rates are more precise as reflected by tighter confidence intervals. There were relatively small data sets for individual hospitals and surgeons, which made statistical evaluation difficult. For setting standards, data from more departments for a longer period will be required. Statistical methods alone cannot be used as a sole arbiter of what is considered acceptable performance.

Narrative accounts of tracking the rural domestic violence survivors' journey: a feminist approach

This research represents the first stage of a project to determine the level of use and effectiveness of informal support networks utilised by Australian rural women. We used a feminist narrative approach with semistructured interviews and a convenience sample of 26 rural women. Only 9 out of 12 women's stories are presented. We found that poverty and geographical, social, and emotional isolation resulted in the privatisation of abuse. Women were triggered to leave the family home when their children, friends, or family became victims of the abuse. They planned their escape by telephone with support of friends and family. Although they used these informal supports, the participants paradoxically expected a high level of expertise in domestic violence knowledge and skills. We recommend an integrated multilevel model of support for rural women in violent intimate relationships and their informal supporters.

Epistemology at work: the ontological relationship between feminist methods, intersubjectivity and nursing research--a research exemplar

This article explores the importance of strong epistemological and ontological links in nursing research by examining the design and process of a recent research project. The research topic concerns the relationship between self-concept and nursing practice. In this article, the authors demonstrate that commitment to a methodologically consistent process and the necessary associated epistemological and ontological positions provides a depth and structure to nursing research. It is the authors' belief that such consistency within research acts to strengthen the research process, and consequently strengthens nursing's research base and knowledge.

Clinical skin temperature measurement to predict incipient pressure ulcers

OBJECTIVE

To evaluate temperature differences between areas of erythema and surrounding healthy tissue to determine whether clinical temperature measurement of sites at risk for pressure ulcer development could be used to indicate tissue damage. To validate the temperature portion of the National Pressure Ulcer Advisory Panel's new Stage I pressure ulcer definition.

DESIGN

Repeated measures design.

SETTING

Acute rehabilitation hospital.

SUBJECTS

65 outpatients and inpatients presenting with pressure-induced erythema at areas at risk for pressure ulcer development. The subjects were primarily non-ambulatory and exhibited a range of skin pigmentation and disabilities, including spinal injury, multiple sclerosis, and lower-limb amputations.

MAIN RESULTS

The temperature and appearance of 80 pairs of erythematic and control sites were documented. Sites were considered to have equal temperatures if the difference was within plus or minus 1.0 degree F. Fifteen percent (n = 12) of the erythematic sites were the same temperature as the surrounding tissue, 23% (n = 18) of the erythematic sites were cooler than the control sites, and 63% (n = 50) were warmer.

CONCLUSION

Both increased and decreased temperature differences can be used to indicate reactive hyperemia or a Stage I pressure ulcer, but a tissue integrity problem may still exist despite the absence of a temperature difference.

Physicians' views on quality of care: a five-country comparison

Interest is resurging in the problems relating to the quality of patient care. This paper provides a comparative perspective on this issue from a five-country physician survey conducted in Australia, Canada, New Zealand, the United Kingdom, and the United States in 2000. Physicians in all five countries reported a recent decline in quality of care and concerns with how hospitals address medical errors. Physicians in four countries expressed serious concerns about shortages of medical specialists and inadequate facilities. U.S. physicians reported problems caused by patients' inability to pay for prescription drugs and medical care. Asked about efforts to improve quality of care in the future, physicians indicated support for electronic medical records, electronic prescribing, and initiatives to reduce medical errors.

Quasi-model-independent search for new high p(T) physics at D0

We apply a quasi-model-independent strategy ("Sleuth") to search for new high p(T) physics in approximately 100 pb(-1) of pp collisions at square root of (s) = 1.8 TeV collected by the D0 experiment during 1992-1996 at the Fermilab Tevatron. We systematically analyze many exclusive final states and demonstrate sensitivity to a variety of models predicting new phenomena at the electroweak scale. No evidence of new high p(T) physics is observed.

Prone positioning and inhaled nitric oxide: synergistic therapies for acute respiratory distress syndrome

BACKGROUND

Inhaled nitric oxide (INO) and prone positioning have both been advocated as methods to improve oxygenation in patients with acute respiratory distress syndrome (ARDS). This study was designed to evaluate the relative contributions of INO and prone positioning alone and in combination on gas exchange in trauma patients with ARDS.

METHODS

Sixteen patients meeting the consensus definition of ARDS were studied. Patients received mechanical ventilation in the supine position, mechanical ventilation plus INO at 1 part per million in the supine position, mechanical ventilation in the PP, and mechanical ventilation in the prone positioning plus INO at 1 part per million. A stabilization period of 1 hour was allowed at each condition. After stabilization,hemodynamic and gas exchange variables were measured.

RESULTS

INO and prone positioning both increased PaO2/FIO2 compared with ventilation in the supine position. PaO2/FIO2 increased by 14% during use of INO, and 10 of 16 patients (62%) responded to INO in the supine position. PaO2/FIO2 increased by 33%, and 14 of 16 patients (87.5%) responded to the prone position. The combination of INO and prone positioning resulted in an improvement in PaO2/FIO2 in 15 of 16 patients(94%), with a mean increase in PaO2/FIO2 of 59%. Pulmonary vascular resistance was reduced during use of INO, with a greater reduction in pulmonary vascular resistance seen with INO plus prone positioning (175 +/- 36 dynes x s/cm5 vs. 134 +/- 28 dynes x s/cm5) compared with INO in the supine position (164 +/- 48 dynes x s/cm5 vs.138 +/- 44 dynes x s/cm5). There were no significant hemodynamic effects of INO or prone positioning and no complications were seen during this relative short duration of study.

CONCLUSIONS

INO and prone positioning can contribute to improved oxygenation in patients with ARDS. The two therapies in combination are synergistic and may be important adjuncts to mechanical ventilation in the ARDS patient with refractory hypoxemia.

Ratio of jet cross sections at square root of s = 630 GeV and 1800 GeV

The D0 Collaboration has measured the inclusive jet cross section in barpp collisions at square root of s = 630 GeV. The results for pseudorapidities (eta)<0.5 are combined with our previous results at square root of s = 1800 GeV to form a ratio of cross sections with smaller uncertainties than either individual measurement. Next-to-leading-order QCD predictions show excellent agreement with the measurement at 630 GeV; agreement is also satisfactory for the ratio. Specifically, despite a 10% to 15% difference in the absolute magnitude, the dependence of the ratio on jet transverse momentum is very similar for data and theory.

Ratios of multijet Cross Sections in p p collisions at radical(s) = 1.8 TeV

We report on a study of the ratio of inclusive three-jet to inclusive two-jet production cross sections as a function of total transverse energy in p&pmacr; collisions at a center-of-mass energy sqrt[s] = 1.8 TeV, using data collected with the D0 detector during the 1992-1993 run of the Fermilab Tevatron Collider. The measurements are used to deduce preferred renormalization scales in perturbative O(alpha(3)(s)) QCD calculations in modeling soft-jet emission.

Universal coverage in the United States: lessons from experience of the 20th century

Both the rising numbers of uninsured Americans and the recent presidential election have put the issue of universal health insurance coverage back on the national agenda. Lack of health insurance is a major barrier to care for 44 million Americans, and lack of high-quality, comprehensive insurance is a barrier to millions more. Universal coverage is one of the best ways to ensure that all Americans have equitable access to quality care, and it also contributes to the financial stability of health care providers, especially those in the urban safety net. A wide variety of ideas to expand health care coverage were proposed, and in some cases enacted, during the last century. At the beginning of the 21st century, the American health care system is made up of varied elements, ranging from employer-sponsored health insurance for the majority of working-age adults to the public Medicare program for the elderly. While this patchwork system leaves many Americans without health insurance, it also creates many different ways to expand coverage, including various options in both the private and public sectors. By understanding how the current health care system developed, how the various proposals for universal health coverage gained and lost political and public support, and the pros and cons of the various alternatives available to expand coverage, we create a solid base from which to solve the problem of the uninsured in the 21st century.

Inclusive jet production in pp(macro) collisions

We report a new measurement of the pseudorapidity (eta) and transverse-energy ( E(T)) dependence of the inclusive jet production cross section in pp(macro) collisions at square root of s = 1.8 TeV using 95 pb(-1) of data collected with the D0 detector at the Fermilab Tevatron. The differential cross section d(2)sigma/(dE(T)d eta) is presented up to eta = 3, significantly extending previous measurements. The results are in good overall agreement with next-to-leading order predictions from QCD and indicate a preference for certain parton distribution functions.

Search for large extra dimensions in dielectron and diphoton production

We report a search for effects of large extra spatial dimensions in pp collisions at a center-of-mass energy of 1.8 TeV with the D0 detector, using events containing a pair of electrons or photons. The data are in good agreement with the expected background and do not exhibit evidence for large extra dimensions. We set the most restrictive lower limits to date, at the 95% C.L. on the effective Planck scale between 1.0 and 1.4 TeV for several formalisms and numbers of extra dimensions.

Long term modulation of the HPA axis by the hippocampus. Behavioral, biochemical and immunological endpoints in rats exposed to chronic mild stress

Mature rats were given lesions of the hippocampus (HIPPO), subiculum (SUBIC) or fimbria-fornix (FIFO) and then received the mild chronic stressors of food deprivation and isolation housing for ten months prior to testing. Group differences in circadian activity were investigated along with locomotion elicited by amphetamine (AMP 1.0-2.0 mg/kg i.p.) alone, and following the corticosterone (CORT) synthesis inhibitor, metyrapone (MET 10.0-25.0 mg/kg i.p.). Basal levels of plasma CORT, (ng/ml), plasma glucose (GLUC, mmol/l), thymic and splenic wet weights were subsequently determined along with complete blood counts (CBC). In comparison to age matched, unoperated controls, selective SUBIC lesions altered the circadian periodicity of locomotion, while rats with FIFO lesions were spontaneously hyperactive. Both HIPPO and FIFO animals showed significantly higher levels of amphetamine-induced locomotion. In all groups metyrapone significantly enhanced locomotion elicited by amphetamine, probably due to a pharmacokinetic interaction between these drugs. In comparison to controls, animals in the HIPPO group showed significant reductions in plasma glucose levels, decreased thymic wet weights and reductions in lymphocyte numbers, indicating lesion-related immuno-suppression. These findings highlight a functional difference among the effects of these specific hippocampal lesions on neural regulation of the HPA axis, under conditions of chronic mild stress, suggesting that the modulatory influence of the hippocampus on the stress axis is dependent on the neuroanatomical location and total extent of cell loss within this structure. They further suggest that the heightened response to amphetamine occurs independently of any lesion-induced changes in modulation of the HPA axis.

The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury

BACKGROUND

Routine turning of critically ill patients is a standard of care. In recent years, specialized beds that provide automated turning have been introduced. These beds have been reported to improve lung function, reduce hospital-acquired pneumonia, and facilitate secretion removal. This trial was designed to measure the physiological effects of routine turning and respiratory therapy in comparison with continuous lateral rotation (CLR).

METHODS

The study was a prospective, quasi-experimental, random assignment, trial with patients serving as their own controls. Paralyzed, sedated patients with acute respiratory distress syndrome were eligible for study. Patients were randomized to receive four turning and secretion management regimens in random sequence for 6 h each over a period of 24 h: (1) routine turning every 2 h from the left to right lateral position; (2) routine turning every 2 h from the left to right lateral position including a 15-min period of manual percussion and postural drainage (P&PD); (3) CLR with a specialized bed that turned patients from left to right lateral position, pausing at each position for 2 min; and (4) CLR with a specialized bed that turned patients from left to right lateral position pausing at each position for 2 min, and a 15-min period of percussion provided by the pneumatic cushions of the bed every 2 h.

RESULTS

Nineteen patients were entered into the study. There were no statistically significant differences in the measured cardiorespiratory variables. There was a tendency for the ratio of partial pressure of arterial oxygen to fractional inspired oxygen concentration (PaO2/FIO2) to increase (174 +/- 31 versus 188 +/- 36; P = 0.068) and for the ratio of deadspace to tidal volume (Vd/Vt) to decrease (0.62 +/- 0.18 versus 0.59 +/- 0.18; P = 0.19) during periods of CLR, but these differences did not achieve statistical significance. There were statistically significant increases in sputum volume during the periods of CLR. The addition of P&PD did not increase sputum volume for the group as a whole. However, in the four patients producing more than 40 ml of sputum per day, P&PD increased sputum volume significantly. The number of patient turns increased from one every 2 h to one every 10 min during CLR.

CONCLUSION

The acute effects of CLR are undoubtedly different in other patient populations (spinal cord injury and unilateral lung injury). The link between acute physiological changes and improved outcomes associated with CLR remain to be determined.

Condom effectiveness in reducing heterosexual HIV transmission

BACKGROUND

The amount of protection that condoms provide for HIV and other sexually transmitted diseases is unknown. Cohort studies of sexually active HIV serodiscordant couples with follow-up of the seronegative partner, provide a situation in which a seronegative partner has known exposure to the disease and disease incidence can be estimated. When some individuals use condoms and some do not, namely some individuals use condoms 100% of the time and some never use (0%) condoms, condom effectiveness can be estimated by comparing the two incidence rates. Condom effectiveness is the proportionate reduction in disease due to the use of condoms.

OBJECTIVES

The objective of this review is to estimate condom effectiveness in reducing heterosexual transmission of HIV.

SEARCH STRATEGY

Studies were located using electronic databases (AIDSLINE, CINAHL, Embase, and MEDLINE) and handsearched reference lists.

SELECTION CRITERIA

For inclusion, studies had to have: (1) data concerning sexually active HIV serodiscordant heterosexual couples, (2) a longitudinal study design, (3) HIV status determined by serology, and (4) contain condom usage information on a cohort of always (100%) or never (0%) condom users.

DATA COLLECTION AND ANALYSIS

Studies identified through the above search strategy that met the inclusion criteria were reviewed for inclusion in the analysis. Sample sizes, number of seroconversions, and the person-years of disease-free exposure time were recorded for each cohort. If available, the direction of transmission in the cohort (male-to-female, female-to-male), date of study enrollment, source of infection in the index case, and the presence of STDs was recorded. Duplicate reports on the same cohort and studies with incomplete or nonsepecific information were excluded. HIV incidence was estimated from the cohorts of "always" users and for the cohorts of "never" users. Effectiveness was estimated from these two incidence estimates.

MAIN RESULTS

Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of "always" users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.:.56, 2.04] per 100 person-years. There were 10 cohorts of "never" users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%.

REVIEWER'S CONCLUSIONS

This review indicates that consistent use of condoms results in 80% reduction in HIV incidence. Consistent use is defined as using a condom for all acts of penetrative vaginal intercourse. Because the studies used in this review did not report on the "correctness" of use, namely whether condoms were used correctly and perfectly for each and every act of intercourse, effectiveness and not efficacy is estimated. Also, this estimate refers in general to the male condom and not specifically to the latex condom, since studies also tended not to specify the type of condom that was used. Thus, condom effectiveness is similar to, although lower than, that for contraception.