Severe hypothermia with cardiac arrest: complete neurologic recovery in a 4-year-old child

A 4-year-old girl was lost for 17 hours in a snowstorm. Upon discovery, her core temperature was 72 degrees F (22 degrees C). While undergoing endotracheal intubation in the emergency department, she experienced sudden ventricular fibrillation and cardiac arrest. Closed chest cardiopulmonary resuscitation (CPR) was instituted, and standard rewarming measures were begun. Despite this, neither core temperature, nor the patient's arrhythmia, changed. An infraumbilical "mini-laparotomy" incision was made, with placement of a large silicone peritoneal dialysis catheter into the abdomen. This was then connected to a rapid infuser device, with the delivery of 1L of warmed, normal saline every 90 seconds. The core temperature reached 29 degrees C in 15 minutes, and a palpable pulse was detected. Lavage was continued until core temperature reached 34 degrees C, at which time transport to the pediatric intensive care unit was arranged. She was extubated the next day and discharged home, on the fourth hospital day, with apparent complete neurologic recovery. This is the first report of the successful use of rapid high-volume peritoneal lavage for the treatment of accidental severe hypothermia in a pediatric patient.

Altered immune response in adult women exposed to diethylstilbestrol in utero

OBJECTIVE

Between 1940 and 1970, 1.5 million female fetuses were exposed to diethylstilbestrol in utero. Numerous deleterious effects on reproductive anatomic and physiologic characteristics have been documented in these women. However, the effects of this exposure on nonreproductive systems, which may have lifelong consequences as this cohort of women progresses beyond the childbearing years, have received little attention. On the basis of an earlier preliminary observation of altered immune reponse, we hypothesized that diethylstilbestrol-exposed women may show abnormalities in T-cell-mediated immune response.

STUDY DESIGN

Thirteen women exposed to diethylstilbestrol in utero were compared with 13 age- and menstrual cycle phase-matched control subjects with respect to the in vitro T-cell response to the mitogens phytohemagglutinin, concanavalin A, and interleukin 2.

RESULTS

As compared with controls, tritiated thymidine incorporation by T cells harvested from diethylstilbestrol-exposed women was increased 3-fold over a range of concentrations in response to concanavalin A (P <.001), increased by 50% over a range of concentrations in response to phytohemagglutinin (P <.001), and increased 2-fold in response to the endogenous mitogen interleukin 2 (P <.05).

CONCLUSIONS

In vitro evidence suggests that women exposed to diethylstilbestrol have alterations in T-cell-mediated immunity. These changes require further attention with regard to their characterization, their role in the pathogenesis of cancer and autoimmunity, and their presence in normal women exposed to diethylstilbestrol in utero.

Relative risk of high grade squamous intraepithelial lesion associated with prior abnormal Pap smears

OBJECTIVE

Pap smear frequency remains controversial, especially for women with consecutive negative smears. We undertook the current study to ascertain the association of high grade squamous intraepithelial lesions (HSIL) and prior abnormal Paps.

STUDY DESIGN

Women with biopsy-proven HSIL (cervical intraepithelial neoplasia 2 and 3) diagnosed between September 1996 and December 1997 and age-matched controls with a negative Pap obtained during the same time period were selected.

RESULTS

Sixty-three cases (mean age = 32 years) of HSIL and 69 controls (mean age = 33 years) constituted the study population. Any prior abnormal diagnosis conferred a 15-fold increased risk of HSIL on the current Pap (50/63 vs. 14/69, P < .0001). When limited to the 60 women with at least three prior Paps, the odds ratio for HSIL on the current Pap with any prior abnormal was 18 (28/31 vs. 10/29, P < .0001). Three cases had at least three consecutive negative Paps prior to the diagnosis of HSIL.

CONCLUSION

Women with one or more prior negative Pap smears had a significantly decreased risk of HSIL on the current Pap. Consecutive negative Paps did not appear to further decrease the risk; 10% of HSIL patients had had three or more consecutive prior negative Paps. To detect HSIL at its earliest stage, women should be advised to continue annual Pap screening in spite of consecutive negative results.

Two models of ethanol withdrawal kindling

The phenomenon of ethanol withdrawal kindling was examined using two different paradigms of ethanol treatment in rats and mice. In the first protocol, male Wistar rats were treated by ethanol inhalation for 14 days before withdrawal. Ethanol exposure was repeated three times with two days abstinence between treatments. In the second protocol, male C57BL/6 mice were fed liquid diet (Lieber DeCarli) containing 6.5%(v/v) ethanol for ten days. Feeding was repeated five times separated by 24 hr intervals. After both treatments, either spontaneous or handling-induced withdrawal behaviours were significantly intensified by sequential withdrawals. These results support the kindling hypothesis of ethanol withdrawal and provide models to develop potential pharmacological tools to attenuate enhanced withdrawal severity and to study the molecular mechanisms underlying this phenomenon.

Synchronous pulmonary adenocarcinoma and extranodal marginal zone/low-grade B-cell lymphoma of MALT type

A case of synchronous adenocarcinoma of lung and extranodal marginal zone/low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is reported. Primary pulmonary non-Hodgkin's lymphoma is relatively rare, however, the majority of these lesions are low-grade B-cell lymphomas of MALT. After the stomach, the lung is the second most common location for such latter lesions. Lung adenocarcinoma in selected countries is fast becoming the leading form of non small-cell lung carcinoma. To our knowledge, this synchronous occurrence in the lung has not been previously reported. Such associations have been primarily limited to gastric lesions where an association with Helicobacter pylori infection has been identified. This case report highlights the importance of adjunctive diagnostic investigations such as molecular techniques in conclusive analysis of synchronous cases such as ours.

The insulator protein CTCF represses transcription on binding to the (gt)(22)(ga)(15) microsatellite in intron 2 of the HLA-DRB1(*)0401 gene

The insulator and transcription factor CTCF is a highly conserved 11 zinc finger protein possessing multiple specifities in DNA sequence recognition. CTCF regulates transcription of several genes, like the human oncogene c-myc or the chicken lysozyme gene by binding extremely divergent DNA sequences with different sets of its 11 zinc fingers. Recently, an insulator function was demonstrated for several CTCF binding elements. Here we show that CTCF binds to the (gt)(22)(ga)(15) microsatellite repeat A9 in intron 2 of the HLA-DRB1(*)0401 gene. Reporter gene activity is repressed by the A9 element. This repression is dependent on coexpressed CTCF and is even stronger compared with the CTCF binding site F1 of the chicken lysozyme gene, for which a silencer activity has been shown. This is the first report suggesting a function for microsatellite sequences in regulating specific gene expression.

Glycerol hyperhydration improves cycle time trial performance in hot humid conditions

Eight competitive cyclists [mean peak oxygen consumption, (VO2(peak)) = 65 ml x min(-1) x kg(-1)] undertook two 60-min cycle ergometer time trials at 32 degrees C and 60% relative humidity. The time trials were split into two 30-min phases: a fixed-workload phase and a variable-workload phase. Each trial was preceded by ingestion of either a glycerol solution [1 g x kg(-1) body mass (BM) in a diluted carbohydrate (CHO)-electrolyte drink] or a placebo of equal volume (the diluted CHO-electrolyte drink). The total fluid intake in each trial was 22 ml x kg(-1) BM. A repeated-measures, double blind, cross over design with respect to glycerol was employed. Glycerol ingestion expanded body water by approximately 600 ml over the placebo treatment. Glycerol treatment significantly increased performance by 5% compared with the placebo group, as assessed by total work in the variable-workload phase (P < 0.04). There were no significant differences in rectal temperature, sweat rate or cardiac frequency between trials. Data indicate that the glycerol-induced performance increase did not result from plasma volume expansion and subsequently lower core temperature or lower cardiac frequencies at a given power output as previously proposed. However, during the glycerol trial, subjects maintained a higher power output without increased perception of effort or thermal strain.

Nutrition for sport. Getting the most out of training

BACKGROUND

Sports nutrition involves the application of eating strategies to promote good health and adaptation to the training program, to recovery quickly after each exercise session and to perform optimally during competition.

OBJECTIVE

This article explores the many myths about sports nutrition principles and provides answers to the most common questions that arise in sports nutrition.

DISCUSSION

Good nutrition practices will enhance the performance and enjoyment of sport and exercise activities at all levels.

Risk factors and correlates of dating violence: the relevance of examining frequency and severity levels in a college sample

To determine whether categorizing levels of violence along dimensions of frequency and severity would result in informative distinctions among individuals using dating violence, reported use of physical violence, along with variables theorized to be related to use of force in intimate relationships, was assessed in a sample of 617 college students (males = 290; females = 327). When participants' scores were analyzed by dichotomizing them along the lines of ever versus never using dating violence, numerous past findings were replicated. However, participants using a higher frequency of force were distinguished by needing to control their partner and by less inhibition in expressing their anger. Higher severity of force by an individual was predicted only by a need to control his/her dating partner. Implications for these findings were discussed.

Research utilization and improvement in outcomes after diagnostic cardiac catheterization

This research utilization project helped summarize the research basis of current practice related to duration of bed rest after cardiac catheterization via the femoral artery. Several physicians have changed their practice as a result of this project, and the safety of patients is being maintained. Interestingly, De Jong and Morton recently published a research analysis of interventions used to control vascular complications after cardiac catheterization. These authors concluded from the review of the literature on duration of bed rest that evidence was sufficient to support a change in practice. Because we thought that the published evidence was insufficient to be used as the sole basis for a change in practice, we continued to follow the Iowa model. Specifically, we integrated scientific principles and expert recommendations with the published research base; recommended a change in practice; and monitored patients' outcomes, which ultimately did confirm the recommendations of De Jong and Morton. We are convinced that the combination of data from our own patients and the review of the literature was helpful to assure our medical and nursing staff that this change in practice was safe. This project illustrates the benefit of using the Iowa Model for Research Based Practice to Promote Quality Care as a guide to improve patients' outcomes.

Colposcopy Quality Control: Establishing Colposcopy Criterion Standards for the National Cancer Institute ALTS Trial Using Cervigrams

OBJECTIVES

The colposcopy quality control (QC) group of the Atypical Squamous Cells of Undetermined Significance-Low-Grade Squamous Intraepithelial Lesions (ASCUS/ LSIL) Triage Study (ALTS) monitors colposcopists at four clinical centers by direct observation and indirectly by assessment of digitized computer colposcopic images transferred nightly by modem. The purpose of this preclinical study was to determine the agreement among colposcopy QC monitors' colposcopic impressions and biopsy site placement through evaluation of cervical photographic images.

MATERIALS AND METHODS

A nonparticipant selected 100 Cervigram slides representing four pathologically confirmed categories: cervical intraepihelial neoplasia 1(CIN), CIN2 and CIN3, normal, and cancer. our colposcopy QC monitors and two certified Cervigram evaluators independently interpreted the images for colpocopic impression on two separate occasions. Measures of agreement were calculated for intraobserver, pairwise interobserver, and observer versus histological diagnoses. Participants also indicated the most severe biopsy site by marking an χ on a 4 × 6-inch color print duplication. Mean distances between biopsy site annotations for each pair of evaluators were calculated.

RESULTS

The ALTS observer agreement with histology ranged from 75.3% (K = .66) to 47.4% (K = .36) for the first evaluation and 71.1 % (K = .63) to 50.5% (K = .38) for the second evaluation. ALTS interobserver agreement varied between 71 % and 57% for the first interpretation and 76% and I2% for the second evaluation. ALTS intraobserver agreement varied from 86% (K = .86) to 68.0% (K = .60). The mean listances between biopsy site annotations for each pair of ALTS observers varied from 0.99 ± 0.93 mm to 1.44 ± 1.19 nm.

CONCLUSIONS

The ALTS colposcopy QC monitors achieved poor to good observer agreement with histology, fair to excellent interobserver agreement, and good to excellent intraobserver agreement in assessing the severity of cervical images. These levels of agreement are similar to many reported by pathologists for cervical cytology and histology interpretations. Monitors also demonstrated a very narrow variation of distance (< 2 mm) for ideal biopsy site placement.

Research utilization and improvement in outcomes after diagnostic cardiac catheterization

This research utilization project helped summarize the research basis of current practice related to duration of bed rest after cardiac catheterization via the femoral artery. Several physicians have changed their practice as a result of this project, and the safety of patients is being maintained. Interestingly, De Jong and Morton recently published a research analysis of interventions used to control vascular complications after cardiac catheterization. These authors concluded from the review of the literature on duration of bed rest that evidence was sufficient to support a change in practice. Because we thought that the published evidence was insufficient to be used as the sole basis for a change in practice, we continued to follow the Iowa model. Specifically, we integrated scientific principles and expert recommendations with the published research base; recommended a change in practice; and monitored patients' outcomes, which ultimately did confirm the recommendations of De Jong and Morton. We are convinced that the combination of data from our own patients and the review of the literature was helpful to assure our medical and nursing staff that this change in practice was safe. This project illustrates the benefit of using the Iowa Model for Research Based Practice to Promote Quality Care as a guide to improve patients' outcomes.

Incidence and predictors of cervical dysplasia in patients with minimally abnormal Papanicolaou smears

OBJECTIVE

To estimate the incidence of dysplasia in patients with Papanicolaou smears showing atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (SIL) and to identify clinical predictors of dysplasia in these patients.

METHODS

Patients referred for ASCUS and low-grade SIL were reviewed retrospectively. All patients were evaluated with immediate colposcopy. A multivariate logistic regression analysis was performed to identify clinical predictors of histologic SIL and histologic high-grade SIL.

RESULTS

One hundred thirty-seven (34%) of 406 consecutive patients had histologic SIL. Regression analysis identified age (under 35 versus 35 years or above) and initial smear (low-grade SIL versus ASCUS) as statistically significant predictors of histologic SIL and high-grade SIL (P < .001). When patient outcomes were analyzed by age and initial Papanicolaou smear results, the subgroup of patients 35 years or older with ASCUS had low incidences of histologic SIL (14%) and high-grade SIL (1%). The other subgroups (under 35 years with ASCUS, under 35 years with low-grade SIL, and 35 years or older with low-grade SIL) had incidences of histologic SIL and histologic high-grade SIL of at least 28% and 14%, respectively.

CONCLUSION

The high incidence of dysplasia in patients with minimally abnormal Papanicolaou smears suggests that immediate colposcopy might be appropriate for many of these patients. Age and initial Papanicolaou smear are predictive of dysplasia and might be used to select patients who have low incidence of dysplasia and might not require immediate colposcopy.

Allelic deletion analysis of the FHIT gene predicts poor survival in non-small cell lung cancer

The fragile histidine triad (FHIT) gene at chromosome 3p14.2 is a candidate tumor suppressor gene linked to cancers of the lung, breast, colon, pancreas, and head and neck. Reports of frequent allelic deletion and abnormal transcripts in primary lung tumors plus recent evidence that it is targeted by tobacco smoke carcinogens suggest that it plays an important role in lung carcinogenesis. Non-small cell lung carcinoma still maintains a poor 5-year survival rate with the stage of disease at presentation as a major determinant of prognosis. We examined for allelic deletion at the FHIT locus in a series of 106 non-small cell lung carcinomas for which a full clinical, epidemiological, and 5-year survival profile was available. We found an allelic deletion frequency of 38% at one or two intragenic microsatellites. Allelic deletion of FHIT was related to tumor histology with 4 of 20 adenocarcinomas (20%) displaying loss of heterozygosity (LOH) compared with 12 of 22 (55%) nonadenocarcinomas (P = 0.03). We found that 63% of tumors with LOH of FHIT also had p53 missense mutations whereas only 26% with LOH had wild type p53 negative sequence (P = 0.02). We also found a significant trend toward poorer survival in patients with LOH of at least one locus of the FHIT gene (log rank, P = 0.01). This survival correlation is independent of tumor stage, size, histological subtype, degree of differentiation, and p53 mutation status. Our data support the hypothesis that the loss of the FHIT contributes to the molecular pathogenesis of human lung cancer and is an indicator of poor prognosis.

Sinusitis in the intensive care unit patient

A retrospective study was undertaken to determine the incidence of sinusitis as a source of fever in the intensive care unit (ICU) patient, evaluate the effectiveness of radiologic studies in diagnosing sinusitis, and develop guidelines that may help predict the result of antral lavage. Sixteen of 52 (30.7%) lavages in patients studied with plain films and 27 of 67 (40.3%) lavages in patients studied with computed tomography of the sinuses revealed purulence in the maxillary sinuses. Conversely, 23 of 30 (76.7%) of the cases with purulence in the middle meatus had purulence in the maxillary sinus (chi-squared = 27.1). If no purulence was seen, the results of the antral lavage were negative in 68 of 89 cases (76.4%). When physical examination was used in conjunction with computed tomography, 92.3% of lavages confirmed purulence in the maxillary sinus (chi-squared = 16.6). In conclusion, the most important factor in predicting a positive result with antral lavage is the presence of purulence in the middle meatus on physical examination in conjunction with the presence of sinus disease on computed tomography of the sinuses.

Putting Working Paper 10 into practice: education and training

Education and training: working Paper 10 (WP10) (Department of Health (DoH), 1989a) may prove to be another example of policy implementation whereby the needs of nurse education will be dominated yet again by service demands for greater resources. Alternatively, there are indications that it could result in the most significant change in nurse education since the 1949 Nurse Registration Act. Over the last 7 years, there has been relatively little discussion about WP10 in the nursing press. The aim of this article, therefore, is to evaluate the impact of WP10 on nurse education, highlighting the reasons for its inception and discussing its main proposals. The author examines the issues that have arisen from its implementation so far, and those which may emerge in the future.

Transcriptional repression by the orphan steroid receptor RVR/Rev-erb beta is dependent on the signature motif and helix 5 in the E region: functional evidence for a biological role of RVR in myogenesis

RVR/Rev-erb beta/BD73 is an orphan steroid receptor that has no known ligand in the "classical' sense. RVR binds as a monomer to an element which consists of an A/T-rich sequence upstream of the consensus hexameric half-site. However, RVR does not activate transcription and blocks transactivation of this element by ROR/RZR. The mechanism of RVR action remains obscure, hence we used the GAL4 hybrid system to identify and characterize an active transcriptional silencer in the ligand binding domain (LBD) of RVR. Rigorous deletion and mutational analysis demonstrated that this repressor domain is encoded by amino acids 416-449 of RVR. Furthermore, we demonstrated that efficient repression is dependent on the so-called LBD-specific signature motif, (F/W)AKxxxxFxxLxxxDQxxLL (which spans loop3-4 and helix 4) and helix 5 (H5; identified in the crystal structures of the steroid receptor LBDs). Although RVR is expressed in many adult tissues, including skeletal muscle, and during embryogenesis, its physiological function in differentiation and mammalian development remains unknown. Since other 'orphans', e.g. COUP-TF II and Rev-erbA alpha, have been demonstrated to regulate muscle and adipocyte differentiation, we investigated the expression and functional role of RVR during mouse myogenesis. In C2C12 myogenic cells, RVR mRNA was detected in proliferating myoblasts and was suppressed when the cells were induced to differentiate into post-mitotic, multinucleated myotubes by serum withdrawal. This decrease in RVR mRNA correlated with the appearance of muscle-specific markers (e.g. myogenin mRNA). RVR 'loss of function' studies by constitutive over-expression of a dominant negative RVR delta E resulted in increased levels of p21Cip1/Waf1 and myogenin mRNAs after serum withdrawal. Time course studies indicated that expression of RVR delta E mRNA results in the precocious induction and accumulation of myogenin and p21 mRNAs after serum withdrawal. In addition, we demonstrated that over-expression of the COUP-TF II and Rev-erbA alpha receptors in C2C12 cells completely blocked induction of p21 mRNA after serum withdrawal. In conclusion, our studies identified a potent transcriptional repression domain in RVR, characterized critical amino acids within the silencing region and provide evidence for the physiological role of RVR during myogenesis.

Antinuclear antibodies and thyroid function in sexually abused girls

Sexually abused girls manifest dysregulation of physiological stress response systems. In this exploratory investigation, 14 sexually abused and 13 control girls, ages 8-15 years, recruited from a prospective, longitudinal study, underwent plasma antinuclear antibody and thyroid function tests. Thyroid function tests and plasma antinuclear antibody titers did not differ between sexually abused and control girls. However, a significantly higher incidence of plasma antinuclear antibody titers was seen in abused subjects when compared with the frequency of positive antinuclear antibody titers in a sample of 22 adult healthy female volunteers, ages 20-58 years. These findings suggest that sexually abused girls may show evidence of an alteration in normal immune homeostatic function.

Nurses' views of the decision not to resuscitate a patient

The decision not to resuscitate a patient is a complex issue and there is little guidance for nurses on how such a decision is made. The aim of this study was, therefore, to explore the views and working practices of staff in relation to current guidelines and theories, using a situational analysis. Overall, the staff seemed to meet the criteria outlined in the guidelines, although there was little awareness of the guidelines. Nurses in the clinical area should be both educated in the recommendations for practice and should be consulted and involved in developing such recommendations.

Criteria of good dental practice generated by general dental practitioners and patients

A survey was carried out asking patients to evaluate the criteria of good dental practice proposed by patients and dentists. A total of 344 patients from 4 different general dental practices in South East England evaluated 16 criteria of good dental practice. Eight criteria were generated by 30 general dental practitioners and the other eight by 30 patients. Questionnaires containing the 8 pairs of criteria randomly assigned by a computer were drawn up, with each pair containing one patient and one general dental practitioner criterion. Patients were asked to indicate their preference. The number of times each criterion was preferred was scored and ranked. The three highest ranked criteria were explanation of procedures, sterilisation/hygiene and dentist's skills (all criteria proposed from patients), whilst the three lowest ranked criteria were up-to-date equipment, pleasant decor and surroundings and good practice image (all criteria proposed from dentists). Overall the criteria proposed by patients as a group scored significantly more highly than those proposed by dentists as a group. There was variation in rankings relating to the sex, age, pattern of attendance and social class of the respondents.

Food selection and guidance for physically active people

The everyday nutritional goals of athletes and physically active people reflect the special, and often increased, nutrient requirements arising from the commitment to regular exercise, as well as the practical challenges of achieving these goals in a busy lifestyle. Issues include achieving and maintaining a body weight and body fat level that is appropriate for optimal sports performance and health, as well as meeting increased requirements for protein and some micronutrients such as iron and calcium. While inadequate intakes of vitamins will impair exercise importance, the current view is that additional vitamin supplementation will not improve exercise performance. Attention to fluid and carbohydrate intake will be an important factor in exercise performance and recovery from exercise, particularly high intensity exercise which is carried out in hot conditions for prolonged periods. Guidelines to promote optimal fuel and fluid status include strategies before, during and after exercise. The dietary guidelines of many developed countries which emphasise dietary variety, based on high-carbohydrate, reduced-fat eating, provide an appropriate blue-print for the athletes diet'. Since sportspeople are well recognised and often hero-worshipped within the community, they provide a worthy example of the potential benefits of a well-chosen diet.