Ethics committees and quality improvement: a necessary link

As today's health care system undergoes dramatic changes, it becomes imperative that quality improvement efforts mesh with these changes to maintain quality outcomes in patient care. The confusing flurry of health care reform, cost containment, resource allocation, and advances in medical technology raises a variety of ethical issues. In the recent past ethics committees have been one strategy used to provide direction and support to care providers facing ethical dilemmas in clinical practice. The mutual goal of quality outcomes for the patient provides the rationale for linking quality improvement programs with ethics committees. As we move toward a more integrated and seamless health care system, this link may be critical to quality outcomes in caring for the patient from cradle to grave.

Diaphragmatic activity during REM sleep in the adult cat

Diaphragmatic electromyograms from five adult cats were studied to determine whether diaphragmatic activity, like central respiratory activity, increases in rapid-eye-movement (REM) sleep. Breaths with inspiratory durations between 250 and 2,000 ms were analyzed. 1) There was a greater slope of the moving time average of diaphragmatic activity in REM than in non-REM (NREM) sleep. These greater slopes occurred whether the route of breathing was through the upper airways or through an endotracheal tube and may have resulted from early recruitment of motor units. 2) Mean diaphragmatic activity was also greater, but other variables (peak activity, the area under the curve of diaphragmatic activity, mean intratracheal pressures, inspiratory airflow rates, and tidal volumes) were not greater in REM than in NREM sleep. 3) Diaphragmatic activity was similar in REM sleep and active wakefulness. 4) Across states, slope of the moving time average varied with the duration of inspiration: greater slopes were associated with shorter breaths. These results are consistent with an increase in central respiratory drive in REM sleep that increases the rate of rise of diaphragmatic activity.

Respiratory responses to tracheobronchial stimulation during sleep and wakefulness in the adult cat

The response to tracheal stimulation (50 microliters of tap water) during wakefulness, non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep was investigated in adult cats. In wakefulness, repetitive coughing occurred on 80% of the trials. In NREM and REM sleep, the most frequent response (approximately 69% and 58% of the trials, respectively) was arousal, followed by coughing. Apneas occurred following the stimulus and before arousal in 11% and 24% of the trials in NREM and REM sleep, respectively. In NREM sleep, the tracheal stimulus sometimes evoked expiratory efforts following a normal inspiratory effort (11% of the trials). These were much weaker than the expiratory efforts during coughing in wakefulness. In REM sleep, stimulation in 11% of the trials elicited increased inspiratory efforts. Although these may have been diminutive preparatory inspirations for coughing, they were much smaller than preparatory inspirations associated with coughing in wakefulness, and they were never followed by active expiratory efforts. Arousal from either NREM or REM sleep in response to tracheal stimulation was sometimes associated with an augmented breath. This response, which is common upon spontaneous arousal, may lead to deeper aspiration of the tracheal fluid. We conclude that in cats coughing requires wakefulness and that airway stimuli in sleep cause a variety of respiratory responses, some of which may be maladaptive.

Neither motor responses nor gastric emptying vary in response to formula temperature in preterm infants

The purpose of this study was to assess gastrointestinal responses to formula temperature in preterm infants. Healthy preterm infants were fed 4,250 KJ/l formula at 6, 24, and 37 degrees C. There was no significant difference in the magnitude of antral or duodenal motor responses among the three temperatures. All infants emptied approximately one third of the bolus feeding by 20 min, but there was no difference among the temperatures. Approximately 10-20% of a bolus feeding remained in the stomach 2 h postprandially, but there was no difference among the temperatures. Thermoreceptors do not appear to be functionally present in the preterm infant, suggesting that the benefit of feeding warmed formula to the preterm infant my have a limited physiological value.

Laparoscopic colon resection: 60 cases

The first 60 successfully completed laparoscopic colectomies in our series are reported. Patients used moderate amounts of narcotic postoperatively, tolerated oral intake early postoperatively (mean, 1.5 days), and returned to work 2.5 weeks postoperatively. Mean blood loss was 127 cc. Morbidity (11.6%) and mortality (1.6%) were acceptable. Length of stay, complications, and operating time all decreased with experience suggesting a steep learning curve.

Renal artery fibromuscular dysplasia: results of current surgical therapy

PURPOSE

This retrospective review describes current surgical management of renal artery (RA) fibromuscular dysplasia (FMD) to define contemporary clinical characteristics and surgical results in patients over the age of 21 years.

METHODS

From January 1987 through March 1994, 40 consecutive adults with hypertension had operative RA repair of FMD at our center and form the basis of this report. From histologic and angiographic appearance, FMD was classified with regard to specific type, noting the presence of RA dissections, RA macroaneurysms and branch RA involvement. Associations between blood pressure response to operation and patient age, duration of hypertension, presence of extrarenal atherosclerosis, presence of branch renal artery disease, and primary or secondary procedure were examined. Clinical characteristics and blood pressure response in these contemporary patients were compared with the results reported from an earlier surgical series.

RESULTS

Unilateral RA repair was performed in 34 patients, and bilateral procedures were required in six patients. Branch renal artery repair was performed in 28 instances, including ex vivo RA repair in 11 patients. There were no perioperative or follow-up deaths; however, three RA grafts (7%) failed within 30 days of operation. Initial blood pressure response was considered cured in 33%, improved in 57%, and failed in 10%. Analysis demonstrated that patients older than 45 years of age had a significantly decreased rate of hypertension cure compared with younger patients; among patients younger than 45 years of age, duration of hypertension was inversely related to cure. Compared with earlier surgical series, our current group of patients was significantly older, with more frequent branch renal artery involvement and extrarenal atherosclerosis, and demonstrated decreased rate of hypertension cure.

CONCLUSION

A beneficial blood pressure response is currently observed in most selected patients after surgical correction of RA-FMD. Compared with earlier series, however, the present day patient differs in many respects, including a significantly decreased chance for hypertension cure after surgical repair.

Acute arcuate fiber demyelinating encephalopathy following Epstein-Barr virus infection

We describe a patient who presented with an acute monophasic illness characterized by behavioral abnormalities, visual illusions, and a seizure, who had magnetic resonance- and brain biopsy-documented evidence of multifocal central nervous system demyelination. Serological studies were diagnostic of recent Epstein-Barr virus infection and included evidence of intrathecal synthesis of Epstein-Barr virus-specific IgG antibodies against the viral capsid antigen. Viral DNA could not be amplified from cerebrospinal fluid by polymerase chain reaction, and viral antigen and genome were not detected in the brain biopsy specimen. The patient's clinical course, diagnostic studies, and neuropathological findings all support the diagnosis of a postinfectious Epstein-Barr virus-mediated demyelinating encephalopathy.

Swallowing in sleep and wakefulness in adult cats

Clinical evidence indicates that swallowing, a vital function, may be impaired in sleep. To address this issue, we elicited swallows in awake and sleeping adult cats by injecting water through a nasopharyngeal tube. Our results indicate that swallowing occurs not only in non-rapid eye movement (NREM) sleep, but also in rapid eye movement (REM) sleep. In NREM sleep, the injections often caused arousal followed by swallowing, but, in the majority of cases, swallowing occurred in NREM sleep before arousal. These swallows in NREM sleep were entirely comparable to swallows in wakefulness. In contrast, the injections in REM sleep were less likely to cause arousal, and the swallows occurred as hypotonic events. Furthermore, apneas were sometimes elicited by the injections in REM sleep, and there was repetitive swallowing upon arousal. These results suggest that the hypotonic swallows of REM sleep were ineffective.

Development of stenoses in transjugular intrahepatic portosystemic shunts

PURPOSE

To evaluate the frequency and significance of stenoses or occlusions developing within transjugular intrahepatic portosystemic shunts (TIPS) and identify predictive factors.

MATERIALS AND METHODS

Medical records of 52 patients who underwent TIPS placement between September 1991 and October 1993 were reviewed. Various shunt parameters were correlated with the development of shunt abnormalities. Findings at follow-up portography and frequency of variceal bleeding and paracentesis were also noted.

RESULTS

Twenty-four patients were followed up for at least 6 months. In eight patients, stenoses developed within 6 months; one shunt occluded. No clear correlations were found between shunt parameters and development of shunt abnormalities. Two of four patients with recurrent variceal bleeding had associated shunt abnormalities. The frequency of stenosis of TIPS was high.

CONCLUSION

Early detection and prompt revision of stenotic shunts may decrease the frequency of recurrent variceal bleeding and ascites.

Induction of antigen-specific killer T lymphocyte responses using subunit SIVmac251 gag and env vaccines containing QS-21 saponin adjuvant

Subunit vaccines based on recombinant proteins have proved useful for inducing antibody responses and they are safe for widespread use because they do not contain any live components. Unfortunately, they do not typically induce the types of cell-mediated immune responses required to control viral pathogens; specifically, they do not induce CD8+ cytotoxic T lymphocyte (CTL) responses. To increase the immunogenicity of recombinant proteins, we have used the QS-21 saponin adjuvant in subunit vaccine formulations. In the current study, experimental subunit vaccine formulations containing recombinant p55gag or gp120env proteins from the mac251 strain of the simian immunodeficiency virus (SIVmac251) and the QS-21 adjuvant were used to immunize rhesus macaques. These formulations induced SIV gag- or env-specific cellular immunity that was detectable in vitro and included killer cell activity. The induction of killer cells required prior vaccination and the responses were antigen specific for the immunogens contained in the vaccine formulations. Autologous target cells were required to detect these responses, suggesting genetic restriction, and effector cells appeared to be present in both the CD4+ and CD8+ T lymphocyte subpopulations. These data suggest that the vaccine-induced killer cell activity that was detected was mediated by both CD4+ and CD8+ lymphocytes. Despite the presence of these killer cells, all of the animals became infected with the SIVmac251 on experimental challenge. These findings demonstrated that antigen-specific killer cell responses could be induced by a subunit vaccine formulated with the QS-21 saponin adjuvant. The characteristics of the responses suggested that the effector cells were T lymphocytes, expressing either CD4 or CD8.(ABSTRACT TRUNCATED AT 250 WORDS)

Behavioral and characterological attributional styles as predictors of depression and loneliness: review, refinement, and test

The literature on self-blame and depression reveals two interrelated problems. First, although R. Janoff-Bulman's (1979) conceptualizations of self-blame are clear, empirical operationalization is difficult and has resulted in approaches that do not capture the richness of the constructs. Second, past research has produced inconsistent findings. A comprehensive literature review revealed that the inconsistencies are related to the method of assessing attributions. A correlational study designed to more accurately represent the self-blame conceptualization revealed that both behavioral and characterological self-blame contribute uniquely to depression and loneliness. Supplementary results regarding circumstantial attributions and regarding attributional styles for success were presented. Empirical issues regarding possible methodological refinements and effect size, as well as the value of categorical approaches to the study of attributional style were discussed.

Use of fixed autologous stimulator cells to correctly present human immunodeficiency virus type 1 viral peptides to nonhuman primate lymphocytes in proliferation and cytotoxic T-lymphocyte assays

Autologous, virus-transformed lymphoblastoid cell lines were established by using peripheral blood lymphocytes from rhesus monkeys that were previously immunized with recombinant human immunodeficiency virus type 1 strain IIIB glycoprotein 160. These autologous cell lines were used to present human immunodeficiency virus type 1 viral antigens in a processed and cell-associated manner to T lymphocytes. This was accomplished by either infecting the cells with recombinant vaccinia viruses or pulsing them with synthetic peptides and then subjecting them to a mild fixation step with glutaraldehyde. Fixed antigen-presenting cells were then used as stimulator cells in vitro to measure cell-mediated immune responses. Both the vaccinia virus-infected and peptide-pulsed autologous cells stimulated antigen-specific cellular proliferative responses. The magnitude of the responses correlated with the immunization histories of the animals and other measures of immunity, such as antibody titers. Autologous vaccinia virus-infected cells were also capable of inducing the in vitro maturation of CD4+ and CD8+ precursor cytotoxic T lymphocytes into antigen-specific mature cytotoxic T lymphocytes. The use of stimulator cells to present viral peptides in a cell-associated manner appeared to be a very sensitive and versatile manner in which to measure cell-mediated immune responses with peripheral blood lymphocytes from nonhuman primates. It is likely that a similar approach will function with peripheral blood lymphocytes from humans.