Family partnership in care: integrating families into the coronary intensive care unit

Since the introduction of Family Partnership in Care in the CICU and other pilot units, many changes have been made. Education sessions are now unit specific rather than in groups with multiple units. This facilitates the discussion of unit-specific educational and implementation needs. In addition, unit-specific sessions allow for some case scenario/role playing activities to facilitate learning and application of the FPCP elements to the unique culture of the unit. Finally, less emphasis is placed on the documentation, while greater emphasis is placed on the philosophy behind the program and the nurses values and attitudes towards families. Overall, the implementation of the FPCP in CICU has had a positive impact on staff and patients. Staff awareness regarding the importance of involving family in the patient's care and the benefits of this has been heightened. Staff who were initially very skeptical have become strong advocates for the program. The successful shift with families in "doing for" to "working with" has enhanced the professional practice of many nursing staff and contributed to the overall unit functioning. Finally, the feedback from patients and their care partners and the independence and informed decision-making fostered by designing a plan of care with staff validates the importance of this program in a critical care area.

The effect of a novel orally active selective PDE4 isoenzyme inhibitor (CDP840) on allergen-induced responses in asthmatic subjects

Recent studies have suggested that theophylline, a nonspecific phospho-diesterase inhibitor, has useful anti-inflammatory actions in asthma. Phosphodiesterase 4 (PDE4) represents the predominant PDE isoenzyme present in inflammatory cells. PDE4 inhibitors might, therefore, have beneficial effects in asthma. Side-effects, specifically nausea, have limited the use of existing agents. CDP840 is an orally active, potent and selective PDE4 inhibitor. We have examined the effect of CDP840 on the allergen-induced asthmatic response, its possible modes of action, and its tolerability at therapeutic doses. A total of 54 patients were recruited to three double-blind, placebo-controlled studies. The first study examined the effect of CDP840 (15 mg b.i.d. for 9.5 days) on the allergen-induced asthmatic response in patients with known dual response to allergen. A second study examined the effect of CDP840 (15 mg b.i.d. for 9.5 days) on airway responsiveness to histamine. A third study examined whether single dose CDP840 (15 and 30 mg) had significant bronchodilatory effects. In all studies, CDP840 was well-tolerated, with no patients reporting nausea. CDP840 did not lead to changes in baseline forced expiratory volume in one second (FEV1) as compared to placebo. The late asthmatic response (LAR) to allergen, expressed as area under the curve at 3-8 h (AUC3-8h), was inhibited by 30% (p=0.016), an effect which persisted to the end of the observation period. The early asthmatic response (EAR) was unaffected, and there was no bronchodilatory effect at the doses used. Treatment with CDP840 did not affect bronchial hyperresponsiveness to histamine. In conclusion, CDP840 significantly attenuated the late asthmatic response to allergen challenge in the absence of any bronchodilatory or histamine antagonist effect. This suggests that CDP840 may exert its effects via an anti-inflammatory mechanism.

Complete remission of extensive metastatic renal cancer following immunotherapy

The authors describe the case history of a 54-year-old female patient, who presented with breathlessness, deteriorating general health and a 12 kg weight loss due to extensive metastatic renal cancer. Pulmonary emboli complicated the presentation. The patient entered a remarkable complete radiological remission by 18 weeks following the introduction of interleukin-2/alpha-interferon immunotherapy. The possibility of immediate nephrectomy or warfarin contributing to the augmentation of the effects of the immunotherapy is discussed.

Low-dose theophylline modulates T-lymphocyte activation in allergen-challenged asthmatics

Theophylline has been shown by several investigators to attenuate the late asthmatic response (LAR) to inhaled allergen, suggesting that it has anti-inflammatory or immunomodulatory properties. We have, therefore, undertaken a double-blind, placebo-controlled study to examine the effects of low-dose theophylline on bronchoalveolar lavage (BAL) and blood T-lymphocyte profile and activation in asthmatics following antigen challenge and the development of a LAR. Peripheral blood and BAL samples were obtained from 17 subjects with mild atopic asthma before and after 6 weeks of treatment with either oral theophylline or placebo. The mean serum theophylline concentration achieved was 6.6 micrograms.mL-1, which is below the currently accepted therapeutic range. Following theophylline therapy, there was a significant decrease in the number of BAL lymphocytes compared to placebo. On flow cytometric analysis of BAL cells, a significant loss of CD3+ T-lymphocytes, comprising both CD4+ and CD8+ subsets, was demonstrated. Moreover, there was a decrease in the number of BAL CD4+ T-cells expressing the activation marker very late activation antigen-1 (VLA-1), and an apparent reduction in human leucocyte antigen-DR (HLA-DR). Correspondingly, this was accompanied in the blood by an elevation in the proportion of activated CD4+ T-lymphocytes, in particular those expressing HLA-DR. These findings provide further evidence that theophylline has an anti-inflammatory action in asthma.

Identification of a killer by a definitive sneaker pattern and his beating instruments by their distinctive patterns

A 39-year-old male service station attendant was found murdered on the floor of a gasoline service area by a passing motorist who had stopped for gas. The victim had been brutally beaten all over his entire body. After carefully examining the body and scene and taking selective photographs, special procedures were implemented in an attempt to preserve and transport the body without disturbing any items of evidence. In addition, specific evidentiary items were noted and collected for processing. The victim was meticulously examined externally at autopsy using a special protocol to locate clues that might assist in identifying a suspect or instrument of injury or death. Patterned impressions and subsequent DNA analysis proved successful in identifying the perpetrator of the crime and the instruments used in inflicting the beating. It is the purpose of this paper to show how a meticulous examination of the body for the presence of patterned injuries and critical studies of these patterns and impressions led to the identification of a killer and the instruments he used in a brutal beating.

Helping relatives cope with the grieving process

Grief may be a natural reaction to loss, felt by those most affected, within their own cultural context. Stage-theory approaches to grief may encourage people to think of grief in a simplistic or inflexible way. It is important to allow patients to make their own responses and to express their feelings.

Mortality of a cohort of U.S. workers employed in the crushed stone industry, 1940-1980

The mortality of 3,246 males who had been employed 1 or more years during 1940-1980 at 20 crushed stone operations was evaluated for possible association between employment and death from lung cancer, pneumoconiosis, and other respiratory diseases. Four deaths were attributed to pneumoconiosis. Based on available work histories, at least two of these deaths were probably due to dust exposures in the crushed stone industry. Mortality attributed to pneumoconiosis and other nonmalignant respiratory diseases, including chronic obstructive lung disease, was significantly increased overall (SMR: 1.98; 95% CI: 1.21-3.05), and especially so for a subcohort of crushed stone workers that processed granite (SMR: 7.26; 95% CI: 1.97-18.59). With regard to lung cancer, overall SMRs were elevated (although not statistically significant). Analyzed by rock type, there was a significantly elevated lung cancer SMR among granite workers with at least 20 years latency (SMR: 3.35; 95% CI: 1.34-6.90). Although not definitive, results of this study are consistent with the hypothesis that exposure to respirable silica dust is a risk factor for lung cancer.

Occupational exposures to fibers and quartz at 19 crushed stone mining and milling operations

From 1979 to 1982, the National Institute for Occupational Safety and Health (NIOSH) conducted a cross-sectional exposure assessment and mortality study of selected crushed stone facilities in the United States. This study was undertaken in part to address concerns that asbestos exposures could be occurring in some crushed stone operations due to the presence of amphibole and serpentine minerals. The investigation was also designed to characterize exposures to crystalline silica and other mineral compounds. Nineteen crushed stone operations, mining limestone, granite, or traprock were surveyed to assess exposures to respirable and total dusts, mineral compounds including crystalline silica, asbestos, and mineral fibers. At the initiation of the study, crushed stone operations were selected from a Mine Safety and Health Administration (MSHA) listing of the active industry in 1978. With the exception of requiring inclusion of the traprock operation in Maryland where asbestos fibers were initially discovered, a stratified sample of operations was randomly selected by rock type (granite, limestone, traprock, or sandstone). However, because of reluctance or refusal of some companies to participate and because of the closures of some of the selected operations, replacements were randomly selected. Some replacement selections were likewise replaced due to lack of cooperation from the companies. The studied sample included only 10 of the 27 randomly selected operations in the original sample. Asbestos fibers were detected at one traprock facility, the Maryland operation where asbestos was originally found. Measured personal exposures to fibers exceeded the NIOSH Recommended Exposure Limit (REL) for two out of 10 samples. All of the samples were below the MSHA Permissible Exposure Limit (PEL), which was in effect at the time of the survey. However, due to the presence of nonasbestos mineral fibers in the environment, it could not be stated with certainty that all of the fibers counted by phase contrast microscopy were asbestos. A variety of silicate mineral fibers (other than those classified by NIOSH as asbestos) were detected in the traprock operations and at one granite operation. Crystalline silica was detected at 17 of the 19 surveyed crushed stone operations. Overexposures to crystalline silica were measured at 16 of the crushed stone operations; approximately one in seven personal-respirable dust samples (14%) exceeded the MSHA PEL for crystalline silica. Approximately 25% of the respirable dust samples exceeded the NIOSH REL for crystalline silica. Mill operators and mill laborers consistently had the highest and most frequent overexposures to crystalline silica.

Identification of a homicide victim by a Casio data bank watch

A positive identification of a homicide victim was made possible by observing an inconspicuous Casio watch worn by the deceased. Identification of deceased individuals are usually made by fingerprints or dental matching, visual means, DNA studies, X-rays of other bodily structures, tattoos, etc. When all of these methods fail and no suspects are known, medical examiners are caught between Charybdis and Scilla. This assumes greater importance in cases of homicides. It is the purpose of this paper to present a homicide case in which an identification was made by observing an inconspicuous object, a small Casio watch worn by the deceased.

Anti-inflammatory effects of low-dose oral theophylline in atopic asthma

Theophylline, in addition to its bronchodilator effect, may attenuate inflammation in asthma. We did a double-blind placebo-controlled study of the effect of oral theophylline on the inflammatory response of the bronchial mucosa to inhalation of allergen in 19 atopic asthmatic subjects. Bronchoscopy and bronchial biopsy were done 24 hours after allergen inhalation before and after six weeks of treatment with oral slow-release theophylline, 200 mg 12 hourly. The mean serum concentration was 36.6 mumol/L, which is below the currently-accepted therapeutic range. After treatment with theophylline there was a significant reduction in the number of EG2-positive activated eosinophils (5.9 before and 2.1 after treatment, Wilcoxon signed rank p < 0.05) and total eosinophils (16.7 before and 7.6 after treatment, p < 0.05) beneath the epithelial basement membrane. We conclude that low-dose oral theophylline attenuates airway inflammatory response to allergen inhalation in atopic asthma.

Regional cerebral perfusion abnormalities after cardiac operations. Single photon emission computed tomography (SPECT) findings in children with postoperative movement disorders

Despite the clinical and pathologic indicators implicating injury to the basal ganglia in children with hyperkinetic movement disorders, we were previously unable to identify lesions in these structures by means of cranial computed tomography or magnetic resonance imaging. We evaluated regional cerebral perfusion measured by single photon emission computed tomography (SPECT) with technetium 99m hexamethyl propylene amine oxime as a technique to localize functional cerebral abnormalities in eleven children who had a movement disorder after hypothermic cardiac surgery. Perfusion defects of the deep gray matter were noted in six of these eleven patients and cortical perfusion defects in nine. For both cortical and subcortical defects a strong right-sided predilection was present. Our findings suggest functional brain injury not detectable by conventional cranial computed tomography and magnetic resonance imaging in these patients. We speculate that these perfusion defects might relate to the behavioral and developmental sequelae in survivors of this syndrome. SPECT may identify subclinical injury in patients at risk for future neurodevelopmental problems and contribute to our understanding of the mechanisms of cerebral injury in the patient operated on for cardiac disease.

Myocardial perfusion, function and exercise tolerance after the arterial switch operation

OBJECTIVES

This study was conducted to determine the prevalence of myocardial perfusion abnormalities at rest and exercise and to assess exercise capacity in children after the arterial switch operation.

BACKGROUND

There have been sporadic reports of myocardial ischemia or sudden death in children after the arterial switch operation for transposition of the great arteries, possibly related to inadequate coronary perfusion due to kinking or stenosis of the translocated coronary arteries.

METHODS

Myocardial perfusion at rest and peak exercise was assessed using the scintigraphic agent technetium-99m methoxyisobutyl isonitrile (sestamibi). Exercise capacity was determined with a modified Bruce protocol. Ambulatory electrocardiographic (ECG) Holter monitoring was performed. Ventricular function, contractility and wall motion were assessed echocardiographically.

RESULTS

Twenty-three children (aged 4.2 to 7.9 years) underwent evaluation. Abnormalities were found on the rest perfusion scans in 22 children (95.6%). The left ventricular myocardium was divided into 13 segments for analysis. Of 299 rest segments, 225 (75.3%) were normal, 11 (3.7%) showed mild defects, 45 (15%) moderate defects and 18 (6%) severe defects at rest. At peak exercise, 237 segments (79.3%) were normal, 24 (8%) showed mild defects, 33 (11%) moderate defects and 5 (1.7%) severe defects. Compared with rest studies, myocardial perfusion grade at exercise was unchanged in 246 segments (82.3%), improved in 42 (14%) and worsened in 11 (3.7%). All patients had normal exercise tolerance without symptoms or ischemic ECG changes. No ventricular tachycardia was seen on Holter monitoring. All patients had a shortening fraction > or = 27%. Left ventricular contractility was normal in 12 children in whom it was assessed. Regional wall motion was normal in 17 children with adequate echocardiographic images for this analysis.

CONCLUSIONS

Myocardial perfusion scan abnormalities assessed by technetium-99m sestamibi are common after an arterial switch operation. These abnormalities are of uncertain clinical significance and generally lessen with exercise. The normal exercise tolerance without symptoms or ECG changes suggests that myocardial perfusion is adequate during the physiologic stress of exercise in children up to 8 years after an arterial switch operation.

Transdermal nicotine patches with low-intensity support to aid smoking cessation in outpatients in a general hospital. A placebo-controlled trial

OBJECTIVE

To assess whether transdermal nicotine patches combined with low-intensity support can help outpatients in a general hospital stop smoking.

DESIGN

Randomized, double-blind, placebo-controlled trial with 12 weeks of follow-up.

SETTING

Department of Thoracic Medicine in an inner-city public general hospital, London, England.

SUBJECTS

Two hundred forty-eight outpatients in a general hospital, who smoked at least 10 cigarettes per day (the majority were being treated for smoking-related diseases), referred by clinicians at the hospital.

INTERVENTION

Brief advice to stop smoking and daily application of transdermal nicotine patches (delivering 15 mg over 16 hours) or placebo, with follow-up appointments at 1, 3, 6, and 12 weeks, with a doubling of the dosage for continuing smokers at week 1.

MAIN OUTCOME MEASURE

Sustained abstinence from tobacco from week 3 to week 12 validated with measurement of expired-air carbon monoxide concentration at weeks 3, 6, and 12.

RESULTS

Twenty-nine (23.4%) of 124 subjects assigned to the nicotine group were validated as having abstained from smoking at both weeks 3 and 6, compared with 16 (12.9%) of 124 subjects receiving placebo (P = .008). At week 12, 22 (17.7%) of the subjects in the nicotine group were validated as having abstained at all three points as were 15 (12.1%) of the subjects in the placebo group (P = .058).

CONCLUSION

Transdermal nicotine patches combined with low-intensity support are effective in helping outpatients in a general hospital stop smoking but do not prevent relapse after 6 weeks.