Temporal changes in factors associated with neutrophil elastase and coagulation in intensive care patients with a biphasic waveform and disseminated intravascular coagulation

Summary. The biphasic waveform is an early marker of disseminated intravascular coagulation (DIC). Neutrophil elastase (NE) cleaves coagulation factors; thus, elevated elastase levels or its dysregulation by alpha-1-protease inhibitor (Alpha1PI) may be linked to DIC. Time courses over a period were determined for factors associated with NE and coagulation in 14 Intensive Care Unit patients with a biphasic waveform who developed DIC. The data were analyzed using a random coefficient linear regression model to predict the variables' mean values on day 0 and their mean rates of change over the period in which the biphasic waveform appeared. The biphasic waveform was normal on day 0, maximized on day 1, and approached normal again by day 4. Alpha1PI/NE complex levels were 2.5-fold greater than normal for the entire period. The A1PI activity, antigen, and specific activity levels were normal on day 0 and increased thereafter by 21.0, 10.5, and 8.9% of normal per day, respectively. Factor II, V, VII, IX, and X activity levels were, respectively, 57, 46, 46, 77, and 46% of normal on day 0, whereas factor VIII and fibrinogen levels were normal. All coagulation factor levels trended upward with time but not significantly. The prothrombin time, but not the activated partial thromboplastin time, was prolonged, and the platelet counts and hematocrits were below normal on day 0 and remained so thereafter. We conclude that events associated with neutrophil activation, elastase release, and perturbations of coagulation precede both the appearance of the biphasic waveform and the diagnosis of DIC in these patients.

Refeeding syndrome: effective and safe treatment with Phosphates Polyfusor

BACKGROUND

Severe hypophosphataemia associated with refeeding syndrome requires treatment with intravenous phosphate to prevent potentially life-threatening complications. However, evidence for replacement regimens is limited and current regimens are complex and replace phosphate inadequately.

AIM

To assess the effectiveness and safety of 50 mmol intravenous phosphate infusion, given as a 'Phosphates Polyfusor', for the treatment of severe hypophosphataemia in refeeding syndrome.

METHODS

Patients with refeeding syndrome and normal renal function received a Phosphates Polyfusor infusion for the treatment of severe hypophosphataemia (< 0.50 mmol/L). The outcome measures were serial serum phosphate, creatinine and calcium concentrations for 4 days following phosphate infusion and adverse events.

RESULTS

Over 2 years, 30 patients were treated. Following treatment, 37% of cases had a normal serum phosphate concentration and 73% had a serum phosphate concentration of > 0.5 mmol/L within 24 h. Ten patients required more than one Phosphates Polyfusor infusion. Within 72 h, 93% of cases had achieved a serum phosphate concentration of > or = 0.50 mmol/L. No patient developed renal failure. Three episodes of transient mild hyperphosphataemia were recorded. Four patients developed mild hypocalcaemia.

CONCLUSIONS

This is the largest published series of the use of intravenous phosphate for the treatment of severe hypophosphataemia (< 0.50 mmol/L), and is the most effective regimen described. All patients had refeeding syndrome and were managed on general wards.

Randomized controlled trial of acute normovolaemic haemodilution in aortic aneurysm repair

Background

Previous studies have suggested that acute normovolaemic haemodilution (ANH) reduces the need for heterologous blood transfusion in abdominal aortic aneurysm (AAA) surgery and may thus improve postoperative outcome by reducing the systemic inflammatory response. Controlled studies are lacking. The aim of this randomized controlled trial was to evaluate the effects of ANH on the systemic inflammatory response, clinical outcome and use of bank blood after AAA repair.

Methods

Patients undergoing elective AAA repair were randomized to ANH (n = 16) or control (n = 18) groups. Intraoperative cell salvage and heterologous blood were used in both groups according to predetermined transfusion triggers. Inflammatory markers in serum and urine were measured to assess the acute-phase response. Clinical outcome was determined using mortality, morbidity and the incidence of the systemic inflammatory response syndrome (SIRS).

Results

There was no difference between the ANH and control group in serial measurements of median (range) white cell count (maximum at 2 days after operation: 11·9 (7·7–21·4) versus 10·3 (7·8–20·6) × 109 l−1; P = 0·25), serum C-reactive protein level (maximum at 3 days: 150 (1–274) versus 169 (7–238) mg ml−1; P = 0·76), interleukin 6 level (maximum at 6 h: 142 (32–793) versus 105 (29–509) pg ml−1; P = 0·89), total antioxidant capacity (lowest at 1 h: 0·83 (0·67–1·22) versus 0·83 (0·68–1·23) mmol l−1; P = 0·45) or urinary albumin/creatinine ratio (maximum at 30 min after clamp release: 41 (2–923) versus 124 (4–376) mg ml−1; P = 0·10). SIRS was observed in ten of 16 patients having ANH and in 11 of 18 control patients (P = 0·99). There was no significant difference in mortality and morbidity between the groups. Similarly, there was no difference in median (range) blood loss (ANH 1800 (400–12 000) ml versus control 1600 (500–7500) ml; P = 0·55), use of cell salvage (600 (0–4740) versus 520 (0–2420) ml; P = 0·60) or heterologous blood transfusion (2 (0–32) versus 2 (0–9) units; P = 0·68).

Conclusion

In the setting of a randomized controlled trial ANH added no additional benefit, when used in combination with cell salvage, in reducing the requirements for heterologous blood transfusion, and made no impact on systemic inflammatory response and clinical outcome after AAA repair.

Is your patient taking the medicine? A simple assay to measure compliance with 5-aminosalicylic acid-containing compounds

BACKGROUND

Poor compliance with 5-aminosalicylic acid therapy has been reported amongst patients with inflammatory bowel disease. Currently, there is no easy method to monitor 5-aminosalicylic acid; however, the chemical similarity between 5-aminosalicylic acid and salicylate might provide a solution.

AIM

To determine the feasibility of using salicylate levels to monitor compliance with 5-aminosalicylic acid medication.

METHODS

Thirty-six patients with inflammatory bowel disease, taking maintenance 5-aminosalicylic acid, provided either a paired serum and urine sample or an intestinal biopsy. Samples were split into two: half were sent to the hospital biochemistry department for salicylate measurement, and half were analysed for 5-aminosalicylic acid and its metabolite, N-acetyl-5-aminosalicylic acid, using high performance liquid chromatography. Correlation between the results was calculated.

RESULTS

Serum and urine were available for 25 patients. Serum salicylate was undetectable, but urinary salicylate ranged from 31 to 3254 microg/mL. The correlations between urinary salicylate and 5-aminosalicylic acid and N-acetyl-5-aminosalicylic acid were 0.96 (95% confidence interval, 0.91-0.98) and 0.9 (95% confidence interval, 0.77-0.96), respectively. Sixteen biopsies were available from 13 patients. The 5-aminosalicylic acid and N-acetyl-5-aminosalicylic acid concentrations were 0.2-657 ng/mg and 1.6-1598 ng/mg, respectively; there was no correlation with bowel salicylate.

CONCLUSIONS

The close correlation between 5-aminosalicylic acid and salicylate levels offers a simple method to assess compliance with 5-aminosalicylic acid therapy.

Function and health status outcomes in a randomized trial comparing preoperative and postoperative radiotherapy in extremity soft tissue sarcoma

PURPOSE

Morbidity associated with wound complications may translate into disability and quality-of-life disadvantages for patients treated with radiotherapy (RT) for soft tissue sarcoma (STS) of the extremities. Functional outcome and health status of extremity STS patients randomized in a phase III trial comparing preoperative versus postoperative RT is described.

PATIENTS AND METHODS

One hundred ninety patients with extremity STS were randomized after stratification by tumor size dichotomized at 10 cm. Function and quality of life were measured by the Musculoskeletal Tumor Society Rating Scale (MSTS), the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36) at randomization, 6 weeks, and 3, 6, 12, and 24 months after surgery.

RESULTS

One hundred eighty-five patients had function data. Patients treated with postoperative RT had better function with higher MSTS (25.8 v 21.3, P <.01), TESS (69.8 v 60.6, P =.01), and SF-36 bodily pain (67.7 v 58.5, P =.03) scores at 6 weeks after surgery. There were no differences at later time points. Scores on the physical function, role-physical, and general health subscales of the SF-36 were significantly lower than Canadian normative data at all time points. After treatment arm was controlled for, MSTS change scores were predicted by a lower-extremity tumor, a large resection specimen, and motor nerve sacrifice; TESS change scores were predicted by lower-extremity tumor and prior incomplete excision. When wound complication was included in the model, patients with complications had lower MSTS and TESS scores in the first 2 years after treatment.

CONCLUSION

The timing of RT has minimal impact on the function of STS patients in the first year after surgery. Tumor characteristics and wound complications have a detrimental effect on patient function.

Is fast mapping good mapping? A review of the benefits of high-speed orientation mapping using electron backscatter diffraction

Orientation mapping using automated electron backscatter diffraction (EBSD) is now a common technique for characterizing microstructures. Improvements in software and hardware have resulted in high-speed mapping capabilities above 80,000 points h(-1). For 'routine' microstructural analyses of materials such as steel and aluminium (e.g. texture and grain size measurements and high angle boundary characterization), high-speed orientation mapping is an ideal approach with minimal penalty on the final statistics. However, for the accurate analysis of very low angle boundaries and for routine analyses of more difficult materials (e.g. most rock samples), we advocate a more patient approach to orientation mapping with an emphasis on data accuracy and reliability. It is important that the objectives of any EBSD analysis are carefully considered before starting--in this way the maximum potential of an EBSD system can be achieved.

Controlling factors in the synthesis of cucurbituril and its homologues

The acid-catalyzed synthesis of cucurbit[n]urils from formaldehyde and glycoluril is poorly understood. In this paper, we examine a wide range of reaction conditions that include the effects of acid type, acid concentration, reactant concentrations, and temperature to both probe the mechanism and optimize the yields of isolated cucurbit[n]urils, where n = 5-10. A mechanism for the formation of these cucurbit[n]urils is presented. Individual cucurbit[n]urils were unambiguously identified in reaction mixtures using ESMS and (13)C NMR.

The nurse's role in managing constipation

Constipation is a problem that affects patients in many care settings. Although recommendations are made for specific groups of patients with constipation, such as older patients and children, there is less information available for general adult patients. Angela Day discusses the need for clinical audit to ensure that nurses are using the most effective options for managing and preventing constipation, and examines the treatment options currently available.

The systemic effects of intermittent claudication are reversed by angioplasty

INTRODUCTION

exercise in patients with intermittent claudication causes systemic effects, the consequences of which are unknown. This study investigates whether successful PTA reverses the systemic effects.

PATIENTS AND METHODS

ten patients with IC were recruited prior to PTA. Having emptied their bladders and rested for 1 h, pre-exercise blood and urine samples were collected. Patients underwent treadmill exercise to maximum walking time and blood samples were collected at 10, 20 and 30 min. A second urine sample was collected at 60 min. Total antioxidant capacity (TAC) and von Willebrands Factor (vWF) were measured in blood and albumin/creatinine ratio (ACR) and retinol binding protein/creatinine ratio (RBP/Cr) in urine. Patients were recalled 2 weeks after successful angioplasty and the protocol repeated. Following PTA patients walked for a maximum of 5 min.

RESULTS

there was no significant change in vWF. Exercise in claudicants induced a significant increase in median ACR (pre/post exercise=0.85 p =0.03) and in median RBP/Cr (pre/post exercise=1.8 p =0.04). These changes were no longer evident after successful PTA. TAC was significantly different before and after angioplasty at all time intervals.

CONCLUSION

successful PTA reverses glomerular effects of exercise in claudicants. Future work should investigate the use of PTA in conjunction with exercise in the treatment of peripheral vascular disease.

Differential cytokine mRNA expression in swine whole blood and peripheral blood mononuclear cell cultures

The kinetics of interleukin-2 (IL-2), IL-6, IL-8 and IL-10 gene expression in concanavalin A (Con A)-activated whole blood (WB) and peripheral blood mononuclear cell (PBMC) cultures were examined using reverse transcriptase-polymerase chain reaction (RT-PCR). Unstimulated PBMC or WB cultures failed to show increases in basal cytokine PCR amplicon levels for any cytokine examined. PBMC cultures demonstrated peak expression of IL-2, IL-6, IL-8 and IL-10 mRNA levels at 12, 24, 24 and 6h, respectively. WB cultures exhibited peak IL-2, IL-6, IL-8 and IL-10 mRNA levels at 24, 12, 6 and 24h, respectively. PBMC cultures consistently exhibited higher levels of IL-2 mRNA at all times examined than did WB cultures. WB cultures consistently had higher levels of IL-6 mRNA than PBMC cultures. IL-8 and IL-10 protein levels in PBMC cultures were first detected 12h after stimulation and continued to increase in concentration through 48h. In WB cultures, IL-8 and IL-10 protein levels were first noted at 12 and 6h, respectively. WB culture IL-8 and IL-10 levels quickly reached equilibrium after being detected and remained at levels lower than those noted in PBMC cultures. These results show WB cultures represent an approach with reduced cost and time when compared to traditional cell culture and isolation methods. It may also produce an in vitro test system that more closely resembles in vivo conditions.

Using Entonox in the community

I am a district nurse and recently requested Entonox for a patient who was suffering extreme pain at dressing changes — oramorphine was used with only moderate effect. As it is not available on FP10, I asked my manager to obtain it for me. However, she said that although she was able to do this, I would not be allowed to use it. No explanation was given. I have read that Entonox is advocated and many years ago used it in this situation with positive results. What are the contraindications for its use and are there any protocols?

Removal of antibiotic resistance genes from transgenic tobacco plastids

Removal of antibiotic resistance genes from genetically modified (GM) crops removes the risk of their transfer to the environment or gut microbes. Integration of foreign genes into plastid DNA enhances containment in crops that inherit their plastids maternally. Efficient plastid transformation requires the aadA marker gene, which confers resistance to the antibiotics spectinomycin and streptomycin. We have exploited plastid DNA recombination and cytoplasmic sorting to remove aadA from transplastomic tobacco plants. A 4.9 kbp insert, composed of aadA flanked by bar and uidA genes, was integrated into plastid DNA and selected to remove wild-type plastid genomes. The bar gene confers tolerance to the herbicide glufosinate despite being GC-rich. Excision of aadA and uidA mediated by two 174 bp direct repeats generated aadA-free T(0) transplastomic plants containing the bar gene. Removal of aadA and bar by three 418 bp direct repeats allowed the isolation of marker-free T(2) plants containing a plastid-located uidA reporter gene.

Marking cell layers with spectinomycin provides a new tool for monitoring cell fate during leaf development

Spectinomycin, an inhibitor of plastid protein synthesis, can be used to mark specific cell layers in the shoot meristem of Brassica napus. Pale yellow-green (YG) plants resulting from spectinomycin-treatment can be propagated indefinitely in vitro. Microscopic examination showed that YG-plants result from inactivation of plastids in the L2 and L3 layers and are composed of a pale green epidermis covering a white mesophyll layer. Epidermal cells of YG and normal green plants are similar and contain 10-20 small pale green plastids. YG plants are equivalent to periclinal chimeras with the important distinction that there is no genotypic difference between the white and green cell layers. Periclinal divisions of epidermal cells take place at all stages of leaf development to produce invaginations of green mesophyll located in sectors of widely varying sizes. A periclinal division rate of 1 in 3000-4000 anticlinal divisions for the adaxial epidermis, was 2-3-fold higher than that estimated for the abaxial epidermis. Analysis of white and green mesophyll showed that chloroplasts are essential for palisade cell differentiation and this requirement is cell-autonomous. Stable marking of cell lineages with spectinomycin is simple, rapid and reveals the requirement for functional plastids in cellular differentiation.

Palliative effect of chemotherapy: objective tumor response is associated with symptom improvement in patients with metastatic breast cancer

PURPOSE

Because one of the goals of chemotherapy for metastatic breast cancer is to provide symptom palliation, we were interested in identifying the relationship between tumor shrinkage and improvement in disease-related symptoms.

PATIENTS AND METHODS

Three hundred patients enrolled onto a randomized trial of metastatic breast cancer formed the basis of our study. The nine most common baseline symptoms were identified and followed. Changes from baseline (improvement, stable, worsening) were defined using patient responses to a quality-of-life (QoL) questionnaire (the European Organization for Research and Treatment of Cancer EORTC QLQ-C30) as well as using graded toxicity data collected on case report forms (CRFs). The association between symptom improvement and tumor response was assessed using a linear trend test via a logistic regression model.

RESULTS

The most commonly reported baseline symptoms were cancer pain in 38% (CRF data) and 81% of patients (QoL data) and tiredness in 26% (CRF data) and 89% (QoL data) of patients. Three symptoms-cancer pain, shortness of breath, and abnormal mood-showed a significant relationship between improvement and objective response, using both CRF and QoL assessments. Constipation, anorexia, and nausea showed a similar trend when QoL data were used but not when CRF information was used. The converse was seen for lethargy. There was no correlation between symptom change and response for cough and insomnia.

CONCLUSION

For some symptoms, we found a significant association between symptom improvement and objective tumor regression. In these cases, symptom improvement was greatest in those patients who had complete or partial responses, followed by those with stable disease and then those with progressive disease. Further work in this area will be useful in determining the surrogate value of objective tumor response in identifying the efficacy of palliative chemotherapy.

Depression and anxiety as predictors of outcome after myocardial infarction

OBJECTIVE

The objective of this study was to investigate the significance of emotional distress immediately after a myocardial infarction as a predictor of physical, psychological, and social outcomes and resource use.

METHODS

In an epidemiological survey, demographic and cardiological data were obtained for all patients from a defined geographical area who had had a myocardial infarction (according to diagnostic criteria of the Monitoring Trends and Determinants in Cardiovascular Disease [MONICA] trial). Hospital survivors were interviewed and were asked to complete self-report assessments on mental state and quality of life. Full replies were available at baseline for 347 subjects. Self-report follow-up questionnaire information was collected 3 months and 1 year later.

RESULTS

Fifteen percent of patients scored as probable cases of anxiety or depression. They were more likely than noncases to report preinfarct distress and poor adjustment (as indicated on the 36-item Medical Outcome Study short form). There was an improvement at 3 months, but there was little overall or individual change after that time. Anxiety and depression did not predict subsequent mortality but did significantly predict poor outcome at 1 year on all dimensions of the 36-item short form quality-of-life measure and on specific measures of everyday activity and reports of chest pain, use of primary care resources, and secondary prevention lifestyle changes.

CONCLUSIONS

Subjects who are distressed in the hospital are at high risk of adverse psychological and quality-of-life outcomes during the ensuing year. Our findings strengthen the argument for in-hospital identification and treatment of patients with depression and anxiety after myocardial infarction.

Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care

OBJECTIVES

To determine whether problem solving treatment combined with antidepressant medication is more effective than either treatment alone in the management of major depression in primary care. To assess the effectiveness of problem solving treatment when given by practice nurses compared with general practitioners when both have been trained in the technique.

DESIGN

Randomised controlled trial with four treatment groups.

SETTING

Primary care in Oxfordshire.

PARTICIPANTS

Patients aged 18-65 years with major depression on the research diagnostic criteria-a score of 13 or more on the 17 item Hamilton rating scale for depression and a minimum duration of illness of four weeks.

INTERVENTIONS

Problem solving treatment by research general practitioner or research practice nurse or antidepressant medication or a combination of problem solving treatment and antidepressant medication.

MAIN OUTCOME MEASURES

Hamilton rating scale for depression, Beck depression inventory, clinical interview schedule (revised), and the modified social adjustment schedule assessed at 6, 12, and 52 weeks.

RESULTS

Patients in all groups showed a clear improvement over 12 weeks. The combination of problem solving treatment and antidepressant medication was no more effective than either treatment alone. There was no difference in outcome irrespective of who delivered the problem solving treatment.

CONCLUSIONS

Problem solving treatment is an effective treatment for depressive disorders in primary care. The treatment can be delivered by suitably trained practice nurses or general practitioners. The combination of this treatment with antidepressant medication is no more effective than either treatment alone.

The Belt mutation in pigs is an allele at the Dominant white (I/KIT) locus

A white belt is a common coat color phenotype in pigs and is determined by a dominant allele (Be). Here we present the result of a genome scan performed using a Hampshire (Belt)/Pietrain (non-Belt) backcross segregating for the white belt trait. We demonstrate that Belt maps to the centromeric region of pig Chromosome (Chr) 8 harboring the Dominant white (I/KIT) locus. Complete cosegregation between Belt and a single nucleotide polymorphism in the KIT gene was observed. Another potential candidate gene, the endothelin receptor type A gene (EDNRA), was excluded as it was assigned to a different region (SSC8q21) by FISH analysis. We argue that Belt is a regulatory KIT mutation on the basis of comparative data on mouse KIT mutants and our previous sequence analysis of the KIT coding sequence from a Hampshire pig. Quantitative PCR analysis revealed that Belt is not associated with a KIT duplication, as is the case for the Patch and Dominant white alleles. Thus, Belt is a fourth allele at the Dominant white locus, and we suggest that it is denoted I(Be).

A cross-cultural analysis of the use of the Edinburgh Post-Natal Depression Scale (EPDS) in health visiting practice

This report describes a project that developed and undertook initial validation of a Punjabi version of the Edinburgh Post-Natal Depression Scale (EPDS). A multi-disciplinary and multi-ethnic project team translated the EPDS from English to Punjabi. A pilot study indicated a high level of correlation between the two scales opening the way for a larger study in which a total of 98 bi-lingual women completed both the English and Punjabi version of the scale 6-8 weeks after delivery of their child. Of these a further 52 completed the scales on a second occasion, 16-18 weeks post-partum. A small sub-group (n = 15) was subject to independent clinical assessment by a community psychiatric nurse (CPN) to determine their mental state, enabling the outcome of the assessment to be compared with the EPDS score. The scores of the English and Punjabi versions of the scale were analysed using Spearman correlation coefficient and the Bland Altman test. A high correlation was found between overall scores and most individual items on the scale. Furthermore, the independent assessment of mental health state indicated that a number of those women who scored 12 or above on the EPDS scale (the cut-off point for determining risk of post-natal depression (PND)) were diagnosed as having a post-natal depressive disorder by the CPN assessing them independently. Whilst the results to date are promising there is a need for further work to determine the validity, sensitivity and specificity of the Punjabi EPDS tool against international classification of depressive disorders and to establish optimal cut-off scores when using the Punjabi version of the EPDS.