Multifocal neuropathy due to plasma cell infiltration of peripheral nerves in multiple myeloma

Patients with multiple myeloma (MM) can manifest a variety of neurologic complications. The authors report two patients who had development of a multifocal neuropathy related to infiltration of peripheral nerves by malignant plasma cells as the only manifestation of a relapse of MM, which was considered in full remission.

Infection risk associated with a closed luer access device

The potential for microbial contamination associated with a recently developed needleless closed luer access device (CLAD) (Q-Syte; Becton Dickinson, Sandy, UT, USA) was evaluated in vitro. Compression seals of 50 multiply activated Q-Syte devices were inoculated with Staphylococcus epidermidis NCTC 9865 in 25% (v/v) human blood and then disinfected with 70% (v/v) isopropyl alcohol followed by flushing with 0.9% (w/v) sterile saline. Forty-eight of 50 (96%) saline flushes passed through devices that had been activated up to a maximum of 70 times remained sterile. A further 25 Q-Syte CLADs that had undergone multiple activations were challenged with prefilled 0.9% (w/v) sterile saline syringes, the external luer tips of which had been inoculated with S. epidermidis NCTC 9865 prior to accessing the devices. None of the devices that had been accessed up to 70 times allowed passage of micro-organisms, despite challenge micro-organisms being detected on both the syringe tip after activation and the compression seals before decontamination. These findings suggest that the Q-Syte CLAD may be activated up to 70 times with no increased risk of microbial contamination within the fluid pathway. The device may also offer protection from the external surface of syringe tips contaminated with micro-organisms.

Evaluating the costs of mosquito resistance to malaria parasites

Costly resistance mechanisms have been cited as an explanation for the widespread occurrence of parasitic infections, yet few studies have examined these costs in detail. A malaria-mosquito model has been used to test this concept by making a comparison of the fitness of highly susceptible lines of mosquitoes with lines that are resistant to infection. Malaria infection is known to cause a decrease in fecundity and fertility of mosquitoes; resistant mosquitoes were thus predicted to be fitter than susceptible ones. Anopheles gambiae were selected for refractoriness/resistance or for increased susceptibility to infection by Plasmodium yoelii nigeriensis. Additional lines that acted as controls for inbreeding depression were raised in parallel but not exposed to selection pressure. Selections were made in triplicate so that founder effects could be detected. Resistance mechanisms that were selected included melanotic encapsulation of parasites within 24 h postinfection and the complete disappearance of parasites from the gut. Costs of immune surveillance were assessed after an uninfected feed, and costs of immune deployment were assessed after exposure to infection and to infection and additional stresses. Mosquito survivorship was unaffected by either resistance to infection or by an increased burden of infection when compared with low levels of infection. In most cases reproductive fitness was equally affected by refractoriness or by infection. Resistant mosquitoes did not gain a fitness advantage by eliminating the parasites. Costs were consistently associated with larval production and egg hatch rate but rarely attributed to changes in blood feeding and never to changes in mosquito size. No advantages appeared to be gained by the offspring of resistant mosquitoes. Furthermore, we were unable to select for refractoriness in groups of mosquitoes in which 100% or 50% of the population were exposed to infection every generation for 22 generations. Under these selection pressures, no population had become completely refractory and only one became more resistant. Variations in fitness relative to control lines in different groups were attributed to founder effects. Our conclusion from these findings is that refractoriness to malaria is as costly as tolerance of infection.

Tear film lipid layer thickness and ocular comfort after meibomian therapy via latent heat with a novel device in normal subjects

AIM

This study measures changes in tear film lipid layer thickness (LLT) and ocular comfort in normal subjects after 10 min use of a novel device, which delivers meibomian therapy with latent heat. The device is designed to promote the release of meibomian sebum into the tear film by delivering latent heat to the eyelids, thus thickening the lipid layer. Normal lid movements are maintained, facilitating resurfacing of the tear film.

METHOD

A prospective, controlled, observer masked, single intervention trial in which 24 normal subjects were randomised into three groups. Group I underwent 10 min treatment with the activated device, Group II used the inactivated device for the same duration of time, and Group III had no intervention. The LLT of each subject was measured with a Keeler Tearscope prior and subsequent to the 10-min period. Subjective alteration in ocular comfort was also assessed.

RESULTS

Seven of eight subjects (87.5%) in Group I exhibited an increase in LLT. The mean LLT in this group showed a statistically significant increase (left eyes 1.0 levels, P<0.001, right eyes 0.9 levels, P<0.003) compared to Groups II and III. Six of eight subjects (75%) using the activated device experienced subjective improvement in ocular comfort.

CONCLUSION

Meibomian therapy with this device increases LLT in normal individuals. This implies a more stable tear film, reflected in subjective improvement in ocular comfort.

Evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant

The efficacy of a new skin disinfectant, 2% (w/v) chlorhexidine gluconate (CHG) in 70% (v/v) isopropyl alcohol (IPA) (ChloraPrep), was compared with five commonly used skin disinfectants against Staphylococcus epidermidis RP62A in the presence or absence of protein, utilizing quantitative time-kill suspension and carrier tests. All six disinfectants [70% (v/v) IPA, 0.5% (w/v) aqueous CHG, 2% (w/v) aqueous CHG, 0.5% (w/v) CHG in 70% (v/v) IPA and 10% (w/v) aqueous povidone iodine (PI)] achieved a log(10) reduction factor of 5, in colony-forming units/mL, in a suspension test (exposure time 30s) in the presence and absence of 10% human serum. Subsequent challenges of S. epidermidis RP62A in a biofilm (with and without human serum) demonstrated reduced bactericidal activity. Overall, the most effective skin disinfectants tested against S. epidermidis RP62A were 2% (w/v) CHG in 70% IPA and 10% (w/v) PI. These results suggest that enhanced skin antisepsis may be achieved with 2% (w/v) CHG in 70% (v/v) IPA compared with the three commonly used CHG preparations [0.5% (w/v) aqueous CHG, 2% (w/v) aqueous CHG and 0.5% (w/v) CHG in 70% (v/v) IPA].

A new Mother-to-Infant Bonding Scale: links with early maternal mood

Some mothers find it hard to relate to their new baby, and such failure may have long-term effects on the infant. This has been a neglected area of research. A new simple 8 item self-rating mother-to-infant bonding questionnaire has been designed to assess the feelings of a mother towards her new baby. A principal components and reliability analysis demonstrated an alpha score of 0.71. One hundred and sixty two women filled in the Kennerley Blues Scale, the Edinburgh Postnatal Depression Scale (EPDS) the Highs Scale and the new Mother to Infant Bonding Scale on day 3 postpartum. Twelve weeks later they were sent the EPDS and the Bonding scales again. One hundred and forty four returned all questionnaires. There was a strong correlation between the Bonding scores at 3 days and at 12 weeks (r(s)=0.54 p<0.001). Multiple regression analysis showed that those with raised Blues scores had worse, and those with raised Highs scores had better bonding at 3 days. Those with raised EPDS scores at 3 days (13 and over) had worse bonding scores in the "first few weeks" (median 4 versus 1, p = 0.028), as recalled at 12 weeks. This simple questionnaire is acceptable for use with mothers and gives significant correlations with their early mood.

Fetal plasma testosterone correlates positively with cortisol

BACKGROUND

Fetal exposure to testosterone has been implicated in programming childhood behaviour, but little is known about the determinants of fetal testosterone concentrations.

AIMS

To investigate the relation between fetal testosterone and maternal and fetal cortisol.

METHODS

Clinically indicated blood samples taken from 44 human fetuses (mean gestational age 27 weeks, range 15-38), together with paired maternal samples, were analysed for testosterone and cortisol concentrations.

RESULTS

Male fetuses had significantly higher concentrations of testosterone than females. Female but not male fetal concentrations rose significantly with gestational age. Fetal testosterone correlated positively with both fetal cortisol and maternal testosterone concentrations. Multiple regression showed that maternal testosterone and fetal cortisol were independently correlated with fetal plasma testosterone in both sexes.

CONCLUSION

Unlike the norm in the adult, where testosterone production is often inhibited by cortisol, in the fetus there is a positive link between the two.

Type 2 diabetes mellitus--genes or intrauterine environment? An embryo transfer paradigm in rats

AIMS/HYPOTHESIS

The familial predisposition to Type 2 diabetes mellitus is mediated by both genetic and intrauterine environmental factors. In the normal course of events, maternal genes always develop in the same uterus, thus restricting studies aimed at investigating the relative contribution of these factors. We have developed an embryo transfer paradigm in rats to overcome this difficulty.

METHODS

Euglycaemic female Wistar rats were superovulated and mated with male Wistar rats. The following day, fertilised eggs were transferred into pseudo-pregnant female Wistar rats or hyperglycaemic Goto Kakizaki (GK) rats. Pregnancies were allowed to go to term. Offspring were weighed at 6 weeks, 3 months and 6 months of age and an intravenous glucose tolerance test was carried out at 6 months of age.

RESULTS

Offspring from Wistar into Wistar embryo transfers (n=20) were not significantly hyperglycaemic compared to the non-manipulated Wistar stock colony (n=26). However, offspring from Wistar gametes reared in hyperglycaemic GK mothers (n=51) were significantly lighter at 6 weeks of age (156+/-4.1 g vs 180+/-6.1 g [mean +/- SEM], p<0.01) and significantly more hyperglycaemic at 6 months of age (fasting glucose 6.6+/-0.18 mmol/l vs 4.8+/-0.21 mmol/l, mean blood glucose during glucose tolerance test 14.3+/-0.31 mmol/l vs 11.1+/-0.28 mmol/l, p<0.01) than Wistar gametes transferred back into euglycaemic Wistar mothers. When GK rats were superovulated and mated together, transfer of 1-day-old embryos into pseudo-pregnant Wistar dams did not alleviate hyperglycaemia in adult offspring.

CONCLUSIONS/INTERPRETATION

In GK rats, a euglycaemic intrauterine environment cannot overcome the strong genetic predisposition to diabetes. However, in Wistar rats with a low genetic risk of diabetes, exposure to hyperglycaemia in utero significantly increases the risk of diabetes in adult life.

Is human Type 2 diabetes maternally inherited? Insights from an animal model

AIMS

Patients with Type 2 diabetes mellitus more often report a history of an affected mother than father. However, in the few studies where both parents and offspring have been directly tested, this apparent maternal excess has not been confirmed. Rodent models of diabetes have the advantage that all parents and offspring can undergo glucose tolerance testing at a specific age in adult life. The aim of this study was to gain insights into the inheritance of human Type 2 diabetes by using a rat model.

METHODS

Goto Kakizaki (GK) rats (a model of Type 2 diabetes) were mated with non-diabetic Wistar rats. Offspring were produced from 20 GK female vs. Wistar male and 20 Wistar female vs. GK male crosses. Fasting blood glucose was measured at 6 weeks and 3 months of age and an intravenous glucose tolerance test (0.8 g/kg) performed at 6 months of age.

RESULTS

Wistar mothers produced litters with almost twice as many viable offspring as GK mothers (14.1 vs. 7.4, P < 0.001). Despite the larger litter size, offspring in the two groups were of comparable weight at 6 weeks and 6 months of age. At 3 months of age, male offspring of Wistar mothers were heavier than offspring of GK mothers (415.7 g vs. 379.5 g, P = 0.016) but this difference was not sustained at 6 months of age. Fasting blood glucose at all ages and average blood glucose during the glucose tolerance test were similar in both groups.

CONCLUSIONS

We therefore conclude that there is no evidence for maternal transmission of diabetes in the GK rat. Mothers were able to adjust their supply of milk so that offspring attained similar weights independent of litter size. The weight of the offspring remained independent of litter size into adult life.

IRM du plexus brachial

Magnetic resonance imaging is the method of choice for the evaluation of brachial plexopathy. Knowledge of the anatomy and normal imaging appearance is required. High-resolution imaging technique is necessary with the use of adequate coils. Evaluation of the brachial plexus requires T1 weighted sequences in three plans, T2 weighted sequences with fat suppression and if necessary the study is completed with gadolinium injection sequences with fat suppression. A CISS sequence is used if a nerve root avulsion is suspected. The spatial resolution must be optimized with the use of adapted parameters. We illustrate a variety of pathologies that can involve the brachial plexus. The pathology includes trauma, primary (neurogenic tumors, lymphomatosis) or secondary tumors, radiation plexopathy or inflammatory polyneuropathy.

High EPDS scores in women from ethnic minorities living in London

BACKGROUND

The aim of this study was to determine whether women from ethnic minorities and/or birth in a non-English speaking country were at increased risk for postnatal depression.

METHOD

The Edinburgh Postnatal Depression Scale (EPDS) was used to screen a sample of 830 primiparous women 4 weeks after delivery. Ethnicity data was available on 743, and from these, 530 responses were received (71.3%).

RESULTS

Two independent variables were found to be significantly associated with high EPDS scores. These were being non White (especially Asian; adjusted Odds Ratio 2.7, 95% CI 1.3-5.8) and being born in a non-English speaking country (Odds Ratio 1.9; 95% CI 1.0-3.5).

LIMITATIONS

The study was conducted using self rating questionnaires. There was only a 71% response overall, and a 50% response rate among the ethnic minority group.

CONCLUSIONS

Women from ethnic minorities or from a non-English speaking background should be regarded at high risk group for postnatal depression.

Otolaryngology consultations by real-time telemedicine

We aimed to assess the value of real-time telemedicine using low cost videoconferencing equipment for otorhinolaryngology consultations. A general practitioner, using low cost videoconferencing equipment, presented patients to an otorhinolaryngologist. After history taking and clinical examination, investigations were requested if required and a diagnosis and management plan formulated. The patients were then seen, by the same otorhinolaryngologist, for a conventional face-to-face consultation. Differences in the history, clinical examination and investigation requests were reported. The accuracy of diagnosis and correlation of management plans between the two consultations were analysed. Forty-three patients were admitted to the study but one, a young child, refused examination either by tele-link or the conventional approach and had to be excluded. There were thus 42 patients with 55 diagnoses included in the trial, 26 (62%) females and 16 (38%) males. Age range was 5 months to 70 years. There was no difficulty with any of the patients in obtaining an accurate history and ordering investigations, if required, via the telelink. Clinical examination during the tele-link consultation was inadequate for eight out of the first 20 patients, resulting in a wrong diagnosis in three patients and a missed diagnosis in five patients. All of the next 22 patients had a correct diagnosis and management plan. Comparison of data from the two types of consultation showed that a correct diagnosis and management plan was made in 34 patients. Low cost real-time telemedicine is a useful technique, providing reliable otorhinolaryngology consultations in a general practice setting. However initial difficulties due to inexperience in using the equipment need to be overcome.

Interrater reliability of three clock drawing test scoring systems

This study demonstrates the reliability of 3 Clock Drawing Test (CDT) scoring systems when applied to the protocols of stroke patients. The sample included 20 randomly selected sets of both freehand and predrawn circle versions ofthe CDT completed by patients undergoing comprehensive stroke rehabilitation. The protocols were scored independently by 2 raters using each of 3 published scoring systems (Freedman et al., 1994; Libon, Malamut, Swenson, Sands, & Cloud, 1996; Rouleau, Salmon, Butters, Kennedy, & McGuire, 1992). Interrater agreement and intrarater consistency were measured using the intraclass correlation coefficient (ICC). The results demonstrate that the raters used comparable criteria for each score (high interrater reliability) and that each applied similar scoring criteria throughout the set of protocols (high intrarater consistency). Scores related to the overall contour of the clockface tended to have lower ICCs. Reliability coefficients were comparable for both CDT versions. The results provide evidence for the accurate and consistent scoring of the CDT in stroke.

Myocardial muscarinic receptor upregulation and normal response to isoproterenol in denervated hearts by familial amyloid polyneuropathy

BACKGROUND

Patients with familial amyloid polyneuropathy, a rare hereditary form of amyloidosis, have progressive autonomic neuropathy. The disease usually does not induce heart failure but is associated with sudden death, conduction disturbances, and an increased risk of complications during anesthesia. Although cardiac sympathetic denervation has been clearly demonstrated, the postsynaptic status of the cardiac autonomic nervous system remains unelucidated.

METHODS AND RESULTS

Twenty-one patients were studied (age, 39+/-11 years; normal coronary arteries; left ventricular ejection fraction 68+/-9%). To evaluate the density and affinity constants of myocardial muscarinic receptors, PET with (11)C-MQNB (methylquinuclidinyl benzilate), a specific hydrophilic antagonist, was used. Cardiac beta-receptor functional efficiency was studied by the heart rate (HR) response to intravenous infusion of isoproterenol (5 minutes after 2 mg of atropine, 5, 10, and 15 ng/kg per minute during 5 minutes per step). The mean muscarinic receptor density was higher in patients than in control subjects (B'(max), 35.5+/-8.9 versus 26.1+/-6.7 pmol/mL, P=0.003), without change in receptor affinity. The increase in HR after injection of atropine as well as of MQNB was lower in patients compared with control subjects despite a similar basal HR (DeltaHR after atropine, 11+/-21% versus 62+/-17%; P<0.001), consistent with parasympathetic denervation. Incremental infusion of isoproterenol induced a similar increase in HR in patients and control subjects.

CONCLUSIONS

Cardiac autonomic denervation in familial amyloid polyneuropathy results in an upregulation of myocardial muscarinic receptors but without change in cardiac beta-receptor responsiveness to catecholamines.

CMX-8933, a peptide fragment of the glycoprotein ependymin, promotes activation of AP-1 transcription factor in mouse neuroblastoma and rat cortical cell cultures

An 8-amino acid peptide fragment (CMX-8933) of Ependymin, a glycoprotein component of the extracellular fluid and cerebrospinal fluid of goldfish brain, was synthesized and tested for its capacity to activate AP-1 transcription factor in cell cultures. Dose-response and time-course studies of AP-1's binding to DNA were carried out in neuroblastoma (NB2a/dl) and primary rat brain cortical cultures using an electrophoretic mobility shift assay (EMSA). A 13-14-fold increase in AP-1's DNA binding was obtained when NB2a cells were incubated for 4 h with 6-10 microg/ml CMX-8933. Primary rat brain cortical cultures were much more sensitive to the effects of CMX-8933 than transformed (NB2a) cultures; here a 26.7+/-5.2-fold increase in binding was observed following a 3-h treatment with as little as 10 ng/ml peptide. These findings are consistent with an activation of this transcription factor, a characteristic that has been previously correlated with functional aspects of full-sized neurotrophic factors (nerve growth factor and brain-derived nerve growth factor) in neuronal differentiation and regeneration. Such data suggest a role for Ependymin in transcriptional control.

A double-blind placebo-controlled crossover study of phenytoin in individuals with impulsive aggression

The present study examines the behavioral and psychophysiological effects of phenytoin (PHT) in individuals who display impulsive-aggressive outbursts. In a double-blind placebo-controlled crossover design, individuals meeting previously established criteria for impulsive aggression were administered PHT and placebo during separate 6-week conditions. The efficacy measures used were the Overt Aggression Scale (OAS) and the Profile of Mood States (POMS). Psychophysiological measures (evoked potentials) were taken at baseline and at the end of each 6-week condition. Photic stimulation was used to evoke the mid-latency P1-N1-P2 waveform complex. Analysis indicated a significant decrease in the frequency of impulsive-aggressive outbursts during PHT administration compared to baseline and placebo. Analysis of the psychophysiological data showed significantly increased P1 amplitude and significantly longer N1 latency during PHT administration. In addition, a reduction in N1 amplitude during PHT administration was also suggested. These findings indicate reparation of physiological abnormalities previously observed in impulsive-aggressive individuals and imply more efficient sensory processing and effective orienting of attention. Taken together, these results provide insight as to the physiological mechanisms by which PHT serves to ameliorate impulsive-aggressive behavior.

The impact of host plant on the abundance and function of symbiotic bacteria in an aphid

The black-bean aphid Aphis fabae bears populations of coccoid symbiotic bacteria Buchnera spp. at 2.0–3.2×107cellsmg−1aphidmass and rod-shaped secondary symbionts of uncertain taxonomic affiliation at 0.1–0.6×107cellsmg−1aphidmass. Buchnera provides essential amino acids, supplementing the poor supply in the aphid diet of plant phloem sap. Comparison of the performance of A. fabae containing and experimentally deprived of their bacteria showed that the bacteria caused increased larval mass of aphids reared on Chenopodium album and Papaver dubium plants, but not when reared on Lamium purpureum. In the aphids reared on L. purpureum, the density of the bacteria, especially the secondary symbionts, was significantly elevated, and bacterial-mediated production of the essential amino acid threonine was reduced, even though the essential amino acid content of phloem exudates from L. purpureum had a low threonine content. It is proposed that the shortfall in threonine, possibly compounded by the high density of secondary symbionts, may contribute to the poor performance of the aphids on L. purpureum. This study offers the first evidence to suggest plant-mediated interference with the nutritional function of symbiotic bacteria in any phytophagous insect.

Assessing the need for reactive behaviour management strategies in children with intellectual disability and severe challenging behaviour

The need for reactive behavioural management strategies for aggressive behaviours in adults with intellectual disability has been clearly established, but equivalent information concerning children with challenging behaviour is lacking by comparison. The present study was conducted in order to assess this need. A retrospective study was conducted to ascertain the nature of aggressive behaviours amongst a cohort children referred to a specialist support service. Aggressive behaviours were found to occur at high rates within the study group. Almost 60% of the children displayed aggression that occurred at least daily, and the behaviours resulted in serious consequences for carers in almost one-third of the group. Physical interventions were already in use in 56% of cases, but were largely improvised by carers. The need to include reactive behavioural training as part of an overall intervention package for carers of children with challenging behaviour appeared to be supported by the present results. The implications for training design are discussed.

Hereditary and acquired amyloid neuropathies

Amyloid neuropathies occur in a context of hereditary (FAP) or acquired amyloidosis. They present usually as severe and progressive polyneuropathy and carry a poor prognosis. Most FAP are associated with endoneurial deposits of variant transthyretin (TTR) with substitution of one aminoacid and are secondary to a point mutation of the TTR gene. Portugal is the main endemic area of TTR-FAP, secondary to point mutation of exon 2. However, around the world, 50 other TTR gene mutations have been recently reported, each one in few families. Genetic studies are useful for diagnosis of FAP in patients with a positive family history and for identification of the cause of seemingly sporadic cases. TTR gene analysis is also useful for genetic counselling including antenatal diagnosis in variants with early onset. Gel-solin-FAP are the second variety and present as a benign cranial and sensory polyneuropathy and affect essentially Finnish patients. Acquired amyloid neuropathy concerns only immunoglobulin light chain amyloidosis (AL) and are frequently associated with renal manifestations and monoclonal protein in serum or urine. Specific treatment of amyloid polyneuropathy varies with the variety of amyloidosis including liver transplantation in TTR-FAP, at the onset of the disease or chemotherapy for immunoglobulin light chain amyloidosis.

Construct validity and predictive value of the Hooper Visual Organization Test in stroke rehabilitation

The Hooper Visual Organization Test (HVOT; Hooper, 1958) is a commonly used measure of visual perceptual function. However, serious questions have recently been raised about its construct validity (i.e., the role of object naming). This study further examined the HVOT's construct validity and began exploring its contribution to outcome prediction in stroke rehabilitation. Participants were 101 rehabilitation inpatients suffering from recent cerebrovascular accidents. Each participant was administered the HVOT as part of a comprehensive neuropsychological evaluation. Wechsler Adult Intelligence Scale-Revised (Wechsler, 1981) Object Assembly, Picture Completion, and Cognistat Naming were significantly and uniquely correlated with the HVOT and accounted for about 45% of its variance. The HVOT's value in outcome prediction was examined by correlating HVOT with admission and discharge Functional Independence Measure (FIM; Granger & Hamilton, 1990; Hamilton, Granger, Sherwin, Zielezny, & Tashman, 1987) scores. While correlating weakly with some FIM domains, when admission FIM was controlled, the relation between HVOT and discharge FIM became nonsignificant. Implications of these data for the HVOT's clinical utility are discussed.

Professionalism in nursing behaviors of nurse practitioners

Little research on the level of professionalism of nurse practitioners has been published to date. These nurses are expected to practice relatively autonomously in delivering client care and therefore must monitor their own levels of professionalism. At a national conference, 502 nurse practitioners completed the Professionalism in Nursing Behaviors Inventory. Participants represented all of the states and the most common specialties of nurse practitioners. Nearly 68 per cent had been practitioners less than 5 years and were primarily employed in physicians' offices. The majority had received their master's degrees from schools with nurse practitioner curricula, and 8 per cent held doctorates. More than one half of the practitioners had written a research proposal or participated in a project within the past 2 years. In terms of autonomy, nearly 50 per cent of the nurses had written their own job descriptions. Maintaining certification motivated them to engage in some professionalism behaviors. Results indicated these nurse practitioners had high levels of professionalism. J Prof Nurs 17:203-210, 2001.

Ruptured abdominal aortic aneurysms: clinical presentation in Auckland 1993-1997

BACKGROUND

Rupture of an abdominal aortic aneurysm (RAAA) carries a reported mortality rate in the range of 32-95%. Survival requires prompt diagnosis and surgical management. The presenting features, however, are varied, often insidious and potentially misleading with Osler noting nearly 100 years ago that a correct premortem diagnosis was achieved in only 33% of cases. The present study aims to review our present accuracy in diagnosing this condition and outline demographic and presenting features of patients with RAAA.

METHODS

A review was undertaken of hospital and Coroner's files of all patients residing in the Auckland Coronial region who had RAAA between 1 January 1993 and 31 December 1997.

RESULTS

Three hundred and twenty-nine cases of RAAA were identified, and they occurred most commonly in the 8th decade. The male:female ratio was 3:1 and at least 73% of patients were Caucasian. The overall mortality was 71%. Nearly half underwent surgery and the hospital averaged mortality rate was 46%. No patient survived without surgery. Classic presenting features of RAAA were absent in many cases. Abdominal pain, back pain and a palpable mass occurred in only 49%, 36% and 18% of patients, respectively. Other common presenting symptoms included vomiting, general malaise and pelvic or hip pain. Forty-three patients (16%) were initially misdiagnosed.

CONCLUSIONS

Although our ability to correctly diagnose a RAAA has improved since Osler's time, the initial misdiagnosis rate of 16% leaves no room for complacency. Ruptured abdominal aortic aneurysms must be included in the differential diagnosis of any patient over the age of 55 years who presents with shock, even if the pain is non-specific or atypical.

Cytokines and chemokines in the immune response to hepatitis C infection

Over 170 million people are infected with the hepatitis C virus worldwide, resulting in a large disease burden and significant mortality. Hepatitis C virus is rarely cleared in the acute phase of the infection and most patients become chronically infected; a proportion of these patients develop progressive liver disease and fibrosis. The outcome of infection depends on the immune responses of both the innate and cognate immune systems, and these in turn are orchestrated by networks of cytokines and chemokines. There is evidence that a vigorous type 1 immune response to viral proteins is required for viral elimination, and the recruitment of such effector cells to the liver is dependent on the local activity of specific inducible chemokines. Multiple factors determine the ability of the hepatitis C virus to survive host immune responses, including an ability to alter the cytokine profile secreted by T cells and to cause resistance to the effects of antiviral cytokines such as interferon. In the present review, we briefly cover the important advances made in this area over the past 12 months.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part 2--Interventions

Delirium, a disorder of consciousness that may afflict over one-half of elderly surgical orthopaedic patients is a common sequela of surgery in the elderly. Agitation, either as an element of the delirium or dimension of a preexisting dementia, is another common behavioral problem that can confront the orthopaedic nurse in acute care. It is time now to tear down the barriers to intelligent and compassionate care of patients with agitation and delirium, including late or missed recognition and diagnosis, biases about what is "normal" and acceptable behavior in the elderly, and lack of familiarity with pharmacologic strategies. In Part 1 (Jan/Feb issue), current thinking about the phenomena was presented, including hypotheses about causation and pathophysiology. That foundation is intended to serve as the basis for the current discussion. The triad of interventions available to manage disorganized behavior in elderly orthopaedic patients is presented in Part 2. They include an extensive selection of pharmacologic options, a discussion of therapeutic use of self and environmental-organizational issues to address and consider on a case-by-case basis. Though it may be impossible to prevent behavioral decompensation during an acute orthopaedic admission, it is certainly possible to improve our performance to date, using a compassionate, intelligent, and inclusive approach with every patient.

Infant massage improves mother-infant interaction for mothers with postnatal depression

BACKGROUND

Postnatal depression can have long term adverse consequences for the mother-infant relationship and the infant's development. Improving a mother's depression per se has been found to have little impact on mother-infant interaction. The aims of this study were to determine whether attending regular massage classes could reduce maternal depression and also improve the quality of mother-infant interaction.

METHOD

Thirty-four primiparous depressed mothers, median 9 weeks postpartum, identified as being depressed following completion of the Edinburgh Postnatal Depression Scale (EPDS) at 4 weeks postpartum, were randomly allocated either to an infant massage class and a support group (massage group) or to a support group (control group). Each group attended for five weekly sessions. Changes in maternal depression and mother-infant interaction were assessed at the beginning and the end of the study by comparing EPDS scores and ratings of videotaped mother-infant interaction.

RESULTS

The EPDS scores fell in both groups. Significant improvement of mother-infant interaction was seen only in the massage group.

LIMITATION

The sample size was small and had relatively high dropout. It was not possible to distinguish which aspects of the infant massage class contributed to the benefit.

CONCLUSION

This study suggests that learning the practice of infant massage by mothers is an effective treatment for facilitating mother-infant interaction in mothers with postnatal depression.

Association of whole blood aggregation response with immunogold-labeled glycoproteins in adult and neonatal platelets

A growing body of recent data has provided specifics about the hemostatic system in infants, emphasizing differences from adults. Although platelet structure in newborns and adults appears to be quite similar, precise information about platelets in the first week of life indicates functional hyporeactiveness. This study was designed with a twofold purpose: one was to determine if aggregation results corresponded to immunogold-labeled activation markers; the second was to use immunogold labeling to determine if infant platelets circulate in an activated state. The results showed significant differences in ristocetin (P = .03) and collagen (P = .003) impedance, and whole blood aggregation lag times in infants when compared to adults. Treatment of neonatal platelets with collagen yielded decreased ATP release compared with adults. Immunogold labeling of specific activation markers CD62 (P-selectin) and CD63 (GP53) revealed that neonatal platelets were not circulating in an activated state. Significant (P = .04) anti-CD41 (GPIIb) immunogold labeling differences were observed after thrombin stimulation, with adults binding more particles. These data suggest that hyporeactivity of neonatal platelets is not due to a circulating preactivated state, but instead may be a consequence of impaired intracellular signaling that affects both aggregation and membrane activation labeling. Whether this signaling is secondary to an intrinsic neonatal alteration or a maternal (in utero) environmental effect is yet to be determined.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I--Theoretical aspects

Managing behavioral disorders such as delirium and agitation while simultaneously attending to the acute needs of elderly patients is a challenge that confronts orthopaedic nurses on a daily basis. This will only increase in frequency and complexity as the new century dawns. Delirium and agitation affect morbidity, mortality, length of stay, and costs--in short, outcomes. To manage and care for these patients, orthopaedic nurses must first update their knowledge of acute disorders that can disrupt mental status and behavior, and the effects of systemic events on brain function. With the knowledge of the pathophysiology of delirium and agitation, nurses then need to refine their assessment and intervention skills. This article describes the phenomena of agitation and delirium in the elderly acute orthopaedic patient, outlines current perceptions regarding pathophysiology, and offers guidelines for prevention and intervention. An algorithm has been developed that can assist with the identification of at-risk individuals, causes of delirium, and early assessments in the acute care setting.

Purification of salmon clotting factors and their use as tissue sealants

Fibrin sealant prepared from the blood of farmed Atlantic salmon (Salmo salar) represents a potential source of well-controlled natural material with utility in a variety of clinical settings. A potential advantage of this material is a lower probability of viral or bacterial infection that has limited general approval of fibrin glues made from human or bovine proteins. This report describes the purification of fibrinogen from salmon blood, the use of fibrin glues derived from this material to promote wound healing in rats, and the antigenic response to this material. While the low ambient temperature of these cold water fish significantly lessens the probability of infectious transmission to humans, fibrinogen and factor XIII derived from S. salar are activated by human thrombin at 25 degrees C and 37 degrees C to form clots equivalent to those formed by human fibrin. We compare the reactivity of salmon and human fibrinogen with human and bovine thrombin and the structure and viscoelastic properties of the resulting fibrin gels over a range of pH and salt concentrations. The efficacy of salmon fibrin glues in a wound healing assay and the low antigenic response to salmon fibrinogen suggest that this material may substitute for proteins derived from mammalian sources with lower probability of infections.

Induction of long-term protective effects against heterologous challenge in SIVhu-infected macaques

A group of three rhesus macaques were inoculated with SIV isolated from a human (SIVhu) accidentally exposed and infected with SIVsm. Extensive sequence analyses of SIVhu obtained from the human and macaques following infection indicated the presence of truncated nef. Not only did nef fail to repair itself in vivo postinfection (p.i.), but instead, further mutations added additional stop codons with increasing time p.i. Infection of these animals was associated with minimal acute viral replication, followed by undetectable plasma viral loads and only intermittent PCR detection up to 5 years p.i. The three SIVhu infected and three control monkeys were then challenged with the heterologous highly pathogenic SHIV89.6p. All three controls became infected and showed rapid declines in peripheral CD4(+) lymphocytes, disease, and death at 10 and 32 weeks p.i., respectively. In contrast, all three animals previously infected with SIVhu are healthy and exhibit stable CD4(+) lymphocyte levels and undetectable plasma viral loads at >20 months post-SHIV89. 6p challenge. Only transient, low levels of SHIV replication were noted in these animals. Whereas responses to SIVgag/pol were noted, no evidence for SIV/SHIV envelope cross-reactivity was detected by antibody or CTL analyses, suggesting that the protective immune mechanisms to the heterologous challenge isolate were most likely not directed to envelope but rather to other viral determinants.

Vascular control for resection of suprahepatic intracaval Wilms' tumor: technical considerations

The surgical resection of Wilms' tumor can be complicated by tumor thrombus extension into the inferior vena cava. In cases of suprahepatic Wilms' tumor thrombus that may extend into the right atrium, a median sternotomy and cardiopulmonary bypass (CPB) are used to facilitate tumor resection. However, if the tumor can be localized and controlled below the atrium, resection without the use of cardiopulmonary bypass may limit morbidity. The authors describe a novel approach to tumor thrombectomy for a Wilms' tumor extending to the suprahepatic vena cava without the use of CPB. The authors used transesophageal echocardiography to localize the tumor thrombus and detect any tumor or air embolization and a minimal lower sternotomy to obtain intrapericardial control of the inferior vena cava. This technique may be useful in selected cases of Wilms' tumor as an alternative to median sternotomy and use of cardiopulmonary bypass.

Real-time volumetric echocardiography: the technology and the possibilities

The heart is a dynamic organ with complexities in its shape. As such, it places special demands on three-dimensional techniques for reconstruction. Real-time volumetric echocardiography, which is based on phased array and parallel processing principles to enhance line density within a scan volume, provides rapid image acquisition. We introduce the principle, potential clinical importance, current limitations, and future of volumetric imaging methods.