Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation

BACKGROUND

In the context that special weaning units have been advocated as effective alternatives to the ICU for weaning selected patients, we initiated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU were the following: (1) to wean ventilator-dependent patients when possible; and (2) when weaning was not possible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 212 patients managed in the ReSCU and analyzes clinical features associated with favorable clinical outcomes.

METHODS

The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary expertise; 24-h respiratory therapy supervision; bedside and central noninvasive monitoring (i.e., continuous pulse oximetry, end tidal capnometry, and ventilator alarms); and a multidisciplinary approach involving dietitians, physical therapists, occupational therapists, social workers, and speech pathologists. All ReSCU patients were cared for primarily by a pulmonary/critical care attending physician and fellow, with consultative input solicited as deemed necessary. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physician's judgment, the ability to benefit from the ReSCU.

RESULTS

Between August 23, 1993, and August 31, 1997, 212 patients were admitted to the ReSCU. The median age was 68 years old; 55% were women; 86% were white; and 55% were transferred from the medical ICU. Underlying reasons for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status post-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n = 38) died during the hospitalization. Among the 174 survivors, complete ventilator independence was achieved in 127 patients (60% of the 212 patient cohort), 28 patients were ventilator dependent (13% of 212 patients), and the remaining 19 patients (9%) required partial ventilatory support. Univariate analysis regarding the association of baseline characteristics with death identified lower albumin and transferrin levels, increasing age, and the physician's estimate of lower weaning likelihood as significant correlates of death. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cause of respiratory failure other than COPD, and a physician's estimate of higher weaning likelihood. To analyze the financial impact of the ReSCU, we assumed that ReSCU patients would have otherwise stayed in the medical ICU and compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs. ICU care. Analyses of both charges and cost differences showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]).

CONCLUSIONS

We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achieving clinical outcomes, which are comparable to the most favorable rates reported in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully selected patients.

Knowledge, attitudes, and practices related to fruit and vegetable consumption of high school students

PURPOSE

To assess the level of nutrition knowledge, attitudes and practices related to fruit and vegetable consumption of high school students attending participating parochial schools in the New Orleans area.

METHODS

The baseline data reported in this study, "Gimme 5: A Fresh Nutrition Concept for Students," represents one of the nine National Cancer Institute-funded projects from the national "5-A-Day for Better Health Program" initiated in 1991. A survey containing 22 nutrition-related items about fruit and vegetables was used to assess knowledge in 2213 students.

RESULTS

On average, adolescents reported 39% correct knowledge scores. A significant ethnic effect (p < .001) was noted, with White adolescents scoring higher than African American adolescents. Significant ethnic differences in the frequency of fruit and vegetable consumption were also observed, with African-American adolescents reporting a lower mean consumption (2.17 servings) than white adolescents (2.69 servings). Consumption by Hispanic youth (2.48 servings) was similar to those in the "other" ethnic category (2.55 servings). Girls reported being more confident in their ability to eat five servings of fruits and vegetables per day than did boys (p < .05).

CONCLUSIONS

Although the knowledge and consumption levels of adolescents with regard to fruits and vegetables were low, their attitudes toward learning about healthier eating practices were favorable.

Development of a school-based nutrition intervention for high school students: Gimme 5

PURPOSE

To describe a 4-year intervention targeting fruit/vegetable consumption by high school students.

DESIGN

This is a cohort study involving six pairs of schools (n = 12) matched on gender, race, enrollment, and location with schools randomly assigned within pairs to intervention or control conditions.

SETTING

Twelve Archdiocese of New Orleans high schools.

SUBJECTS

Cohort was defined as students (n = 2339) who were ninth-graders in the 1993-94 school year who provided baseline data.

INTERVENTION

Four components of the intervention are: (1) school-wide media-marketing campaign, (2) school-wide meal and snack modification, (3) classroom workshops and supplementary subject matter activities, and (4) parental involvement.

MEASURES

Focus groups were conducted for target population input and program development. Process evaluation included student feedback on media-marketing intervention materials and activities reported here. Process measures also included school meal participation, student characteristics, and verification of intervention activities.

RESULTS

Focus groups identified barriers to increased consumption of fruit and vegetables as lack of availability, variety, and inconsistency in taste. Student attitudes were favorable regarding a school program to improve diet and parental involvement. Low consumption of fruits/vegetables was reported. After a 2-month school-wide program introduction utilizing various media-marketing materials and activities, 93% of students were aware of the program and 96% could identify the healthy eating message.

CONCLUSIONS

Program development can be guided and enriched by student input via focus groups. Media-marketing activities effectively delivered health messages and attracted students' attention. Materials and activities used were acceptable channels for increasing awareness, positive attitudes, and knowledge about fruits/vegetables.

Changes in the nutrient content of school lunches: results from the CATCH Eat Smart Food service Intervention

BACKGROUND

The Child and Adolescent Trial for Cardiovascular Health (CATCH) tested the effectiveness of a multilevel intervention aimed at promoting a healthful school environment and positive eating and physical activity behaviors in children. The CATCH Eat Smart Program targeted the school food service staff and aimed to lower the total fat, saturated fat, and sodium content of school meals.

METHODS

The Eat Smart intervention was conducted in 56 intervention schools over a 2(1/2)-year period.+Five consecutive days of school menu, recipe, and vendor product information were collected from intervention and control schools at three intervals, Fall 1991, Spring 1993, and Spring 1994, to assess the nutrient content of school menus as offered.

RESULTS

There was a significantly greater mean reduction in the percentage of calories from total fat (adjusted mean difference -4.1%; P < 0.0001) and saturated fat (adjusted mean difference -1.3%; P = 0.003) in intervention compared with control schools from baseline to follow-up. Although the sodium content of school lunches increased in both conditions, the mean increase was significantly lower in intervention schools (adjusted mean difference -89 mg; P = 0.034). There were no statistically significant differences for total amounts of cholesterol, carbohydrate, protein, dietary fiber, total sugars, calcium, iron, vitamin A value, and vitamin C. Average total calories decreased significantly; however, the mean total calories (683 kcal) for intervention schools remained above one-third of the Recommended Dietary Allowances for this age group.

CONCLUSIONS

The CATCH Eat Smart intervention successfully lowered the total fat and saturated fat content of school lunches as offered, while maintaining recommended amounts of calories and essential nutrients.

Improving school breakfasts: effects of the CATCH Eat Smart Program on the nutrient content of school breakfasts

BACKGROUND

This paper describes the impact of the Eat Smart School Nutrition Program, the food service component of the Child and Adolescent Trial for Cardiovascular Health (CATCH), on the percentage of calories from total fat and saturated fat and the sodium content of school breakfasts.

METHODS

Fifty-nine of the 96 CATCH schools offered breakfast. We collected 5 consecutive days of school breakfast menu, recipe, and vendor product information at three periods to assess the nutrient content of the school menus as offered.

RESULTS

At baseline (Fall 1991), intervention school breakfasts provided 28% of calories from total fat and control schools 30%. Decreases occurred over time in both groups, but no significant differences were attributable to the intervention (adjusted mean difference = -0.4; P = 0.77). Saturated fat exceeded the Eat Smart goal at baseline in all schools and by follow-up (Spring 1994), the reduction in mean percentage of calories from saturated fat was greater in intervention than in control schools (adjusted mean difference = -1.6%; P = 0.052). Sodium goals were not achieved. Mean calorie levels were maintained at or above Eat Smart goals throughout the study in both groups. Differences over time in other dietary variables (percentage of calories from protein and carbohydrate and mean levels of protein, carbohydrate, calcium, iron, vitamin A value, vitamin C, total sugars, and dietary fiber) were not statistically significant between groups. No significant reductions in student participation in the School Breakfast Program (SBP) occurred.

CONCLUSIONS

The Eat Smart food service intervention improved school breakfast composition, but not significantly more so than in control schools. Fat and saturated fat in school breakfasts were lowered while maintaining calories, other essential nutrient levels, and student participation in the SBP. Secular trends and also the possibility that control schools were affected by the Eat Smart intervention may account for these findings.

Douglas-fir: a third wood-drying condensate found to exhibit in vitro cytotoxicity and genotoxicity

The present study applies the approach described in Mark et al. for the testing of toxic chemicals produced during the drying of Douglas-fir. The genotoxic potential of Douglas-fir condensate has been previously unexplored and is thus an area of appropriate concern to the forest products industry, regulatory, agencies, and the general public. Previous research conducted in this laboratory has identified two wood-drying condensates that yield positive cytotoxic and genotoxic effects. The results of testing Southern yellow pine and Eastern white pine condensates have been reported elsewhere. Douglas-fir condensate, a third wood-drying condensate, was added in vitro in concentrations ranging from 0.1 to 100 microliters/ml to cultures of Chinese Hamster Ovary (CHO-WBL) cells. A dose response curve was observed with this condensate for both cytotoxicity and genotoxicity. The number of viable cells as well as the mitotic index (MI) and proliferative rate index (PRI) varied inversely with dosage. The result of chromosome aberration (Abs) analysis and sister chromatid exchange (SCE) analysis, both cytogenetic measures of genotoxicity, also gave statistically significant results.

Fish and healthy pregnancy: more than just a red herring!

In modern Western diets we eat predominantly omega-6 essential fatty acids from vegetable oils, and too little omega-3. The Department of Health recommends doubling the amount of omega-3s we eat. Omega-3 essential fatty acids (EFAs) are derived mainly from fish oils. Omega-3s are believed to help reduce the risks of cardiovascular disease. Among the main materials required for fetal brain and CNS growth in late pregnancy are omega-3s (mainly docosahexaenoic acid [DHA]) and omega-6 EFAs (mainly arachidonic acid [AA]). These come from the mother's diet. Several formulae for preterm infants now contain DHA and AA to aid optimum brain, nerve and retinal development. One manufacturer has begun to include DHA and AA in formulae for term babies. Breast milk contains DHA and AA, derived from the mother's diet. Eating oily fish in pregnancy has been found to have a slight beneficial effect on birthweight and length of gestation. Eating fresh or canned oil-rich fish (e.g. kippers, herring, mackerel, salmon, sardine, pilchards, tuna) twice or three times a week can be encouraged as part of a healthy balanced diet, in pregnancy and for all the family. As well as containing omega-3 polyunsaturates, oily fish is a good source of protein and vitamins A and D. Alternatively, a fish-oil supplement may be taken. Cod liver oil is best avoided during pregnancy, because of concerns over the possible teratogenicity of vitamin A.

Myoblast transfer in the treatment of Duchenne's muscular dystrophy

BACKGROUND

Myoblast transfer has been proposed as a technique to replace dystrophin, the skeletal-muscle protein that is deficient in Duchenne's muscular dystrophy. Donor myoblasts injected into muscles of affected patients can fuse with host muscle fibers, thus contributing their nuclei, which are potentially capable of replacing deficient gene products. Previous controlled trials involving a single transfer of myoblasts have been unsuccessful.

METHODS

We injected donor muscle cells once a month for six months to the biceps brachii muscles of one arm of each of 12 boys with Duchenne's muscular dystrophy. The opposite arms served as sham-injected controls. In each procedure 110 million cells donated by fathers or brothers were transferred. The patients were randomly assigned to receive either cyclosporine or placebo. Strength was measured by quantitative isometric muscle testing. Six months after the final myoblast transfer, the presence of dystrophin was assessed with the use of peptide antibodies specific to the deleted exons of the dystrophin gene.

RESULTS

There was no significant difference in muscle strength between arms injected with myoblasts and sham-injected arms. In one patient, 10.3 percent of muscle fibers expressed donor-derived dystrophin after myoblast transfer. Three other patients also had a low level of donor dystrophin (< 1 percent); eight had none.

CONCLUSIONS

Myoblasts transferred once a month for six months failed to improve strength in patients with Duchenne's muscular dystrophy. The value of exon-specific peptide antibodies in the interpretation of myoblast-transfer results was demonstrated in a patient with Duchenne's muscular dystrophy who had a high percentage of donor-derived dystrophin. Specific variables affecting the efficiency of myoblast transfer need to be identified in order to improve upon this technique.