Successful treatment of rhino-orbital mucormycosis without exenteration: the use of multiple treatment modalities

PURPOSE

To describe the successful management of rhino-orbital mucormycosis without the use of orbital exenteration.

METHOD

Case report.

RESULTS

The patient had successful eradication of the fungal infection with retention of normal vision and ocular function.

CONCLUSIONS

The use of multiple treatment modalities including aggressive surgical debridement guided by intraoperative frozen section monitoring, intravenous liposomal amphotericin B, intraorbital regular amphotericin B and hyperbaric oxygen may allow complete resolution of orbital phycomycosis and spare the patient from the blindness and disfigurement associated with exenteration.

A 2020 vision for American health care

We enter this century with an unprecedented federal budget surplus-$4.6 trillion over the next 10 years. A substantial portion of the surplus comes from savings in the health care sector. The 1997 Balanced Budget Act cut payments to Medicare providers and raised the premiums for individual beneficiaries, but we overshot the mark. Instead of balancing the budget, we generated a huge surplus. We underestimated the magnitude of Medicare savings. Medicare savings over the period from 1998 to 2007 represent an estimated 15% of the total budget surplus. Fifteen percent of the 10-year budget surplus from 2001 to 2010 comes to $680 billion. We also underestimated the drop-off in Medicaid coverage, as welfare reform took hold. In the year 2000 Medicare and Medicaid outlays were an estimated $104 billion less than projected just 5 years ago-representing an estimated 45% of the budget surplus this year, or about $1 trillion of the 10-year surplus.

Mechanical comparison of fixation techniques for the tibial tubercle osteotomy

Tibial tubercle osteotomies currently are used as an exposure technique for revision total knee arthroplasty and for distal patellofemoral realignment. A review of the literature reveals no biomechanical studies that evaluate methods of osteotomy fixation in terms of static strength. This study evaluates the fixation strength of common techniques used to repair tibial tubercle osteotomies. Bevel and stepcut tibial tubercle osteotomies were created in 36 anatomic specimen knees and were repaired with either two 4.5-mm cortical screws or 18-gauge stainless steel cerclage wire. The failure load for the bevelcut osteotomies repaired with two-screws was 1,654 +/- 359 N; for the bevelcut osteotomies repaired with three cerclage wires, 622 +/- 283 N; for the stepcut osteotomies repaired with three cerclage wires, was 984 +/- 441 N; and for the stepcut osteotomy repaired with four cerclage wires, 1,099 +/- 632 N. This study shows that two bicortical screws provide the greatest static fixation strength for repairing tibial tubercle osteotomies. When repairing tibial tubercle osteotomies for distal patellofemoral realignment, screw fixation would provide the most reliable fixation. However, the placement of screws around the stem of a revision arthroplasty tibial component is difficult. Cerclage wires are easier to place and provide solid static fixation, especially with the addition of a proximal stepcut osteotomy.

Prone positioning for acute respiratory distress syndrome in the surgical intensive care unit: who, when, and how long?

BACKGROUND

We evaluated the effects of prone positioning (PP) on surgery and trauma patients with acute respiratory distress syndrome (ARDS).

METHODS

Patients with ARDS were studied. Exclusion criteria were contraindications to PP. Patients were evaluated in the supine position and after being turned to the PP. After 6 hours, patients were returned to the supine position for 3 hours. One hour after each position change, arterial and mixed venous blood was drawn and analyzed for blood gases and pH, and hemodynamics were measured.

RESULTS

Over 20 months, 27 patients met the criteria, and 20 of the patients were entered into the study. On day 1, 18 of 20 patients (90%) responded with an increase in PaO(2) during PP. On day 2, 16 of 17 patients (94%) responded; on day 3, 15 of 16 patients responded (94%); on day 4, 11 of 13 patients responded (85%); on day 5, 8 of 8 patients responded (100%); and on day 6, 4 of 5 patients responded (80%). Pao(2)/Fio(2) and Qs/Qt were significantly improved (P<.05) during PP. There were 91 periods of PP, lasting 10.3+/-1.2 hours. Of 91 changes to PP, 78 changes (86%) resulted in an improvement in Pao(2)/Fio(2) of more than 20%.

CONCLUSIONS

PP improves oxygenation in ARDS for 6 days with few complications.

The risk assessment profile score identifies trauma patients at risk for deep vein thrombosis

BACKGROUND

The identification of trauma patients at risk for the development of deep venous thrombosis (DVT) at the time of admission remains difficult. The purpose of this study is to validate the risk assessment profile (RAP) score to stratify patients for DVT prophylaxis.

METHODS

All patients admitted from November 1998 thru May 1999 were evaluated for enrollment. We prospectively assigned patients as low risk or high risk for DVT using the RAP score. High-risk patients received both pharmacologic and mechanical prophylaxis. Low-risk patients received none. Surveillance duplex Doppler scans were performed each week of hospitalization or if symptoms developed. Hospital charges for prophylaxis were used to determine the savings in the low-risk group. Statistical differences between the risk groups for each factor of the RAP and development of DVT were determined by the chi-squared test, with significance at a probability value of less than .05.

RESULTS

There were 102 high-risk (64%) and 58 low-risk (36%) individuals studied. Eleven of the high-risk group (10.8%) experienced the development of DVT (asymptomatic, 64%). None of the low-risk group was diagnosed with DVT. Five of the 16 RAP factors were statistically significant for DVT. Eliminating prophylaxis and Doppler scans in low-risk patients resulted in a total savings of $18,908 in hospital charges.

CONCLUSIONS

The RAP score correctly identified trauma patients at increased risk for the development of DVT. Despite prophylaxis, the high-risk group warrants surveillance scans. Withholding prophylaxis in low-risk patients can reduce hospital charges without risk.

Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture

BACKGROUND

The purpose of this study was to evaluate the use of dynamic helical computed tomography (CT) scan for screening patients with pelvic fractures and hemorrhage requiring angiographic embolization for control of bleeding.

METHODS

Patients admitted to the trauma service with pelvic fractures were identified from the trauma registry. Data retrieval included demographics, hemodynamic instability, Injury Severity Score, blood transfusion requirement, length of stay, and mortality. CT scans obtained during the initial evaluation were reviewed for the presence of contrast extravasation and correlated with angiographic findings. Data are reported as mean +/- SEM, with P<.05 considered significant.

RESULTS

Seven thousand seven hundred eighty-one patients were admitted from June 1994 to May 1999. A pelvic fracture was diagnosed in 660 (8.5%). Two hundred ninety (44.0%) dynamic helical CT scans were performed, of which 13 (4.5%) identified contrast extravasation. Nine (69%) were hemodynamically unstable and had pelvic arteriography performed. Arterial bleeding was confirmed in all and controlled by embolization. Patients with contrast extravasation had significantly greater Injury Severity Score, blood transfusion requirement and length of stay. Sensitivity, specificity, and accuracy of CT scan for identifying patients requiring embolization were 90.0%, 98.6%, and 98.3%, respectively.

CONCLUSIONS

Early use of dynamic helical CT scanning in the multiply injured patient with a pelvic fracture accurately identifies the need for emergent angiographic embolization.

The parental origin of new mutations in neurofibromatosis 2

Neurofibromatosis 2 (NF2) is an autosomal dominant disorder characterized by schwannomas and meningiomas that develop after inactivation of both copies of the NF2 gene. Approximately half of all patients with NF2 have unaffected parents and the disease results from new mutations at the NF2 locus. Loss of heterozygosity (LOH) in tumor specimens due to deletions covering the normal NF2 allele can be used to infer the haplotypes surrounding underlying mutations and determine the allelic origin of new mutations. We studied 71 sporadic NF2 patients using both LOH and pedigree analysis and compared the parental origin of the new mutation with the underlying molecular change. In the 45 informative individuals, 31 mutations (69%) were of paternal and 14 (31%) were of maternal origin (P=0.016). Comparison with corresponding constitutional mutations revealed no correlation between parental origin and the type or location of the mutations. However, in 4 of 6 patients with somatic mosaicism the NF2 mutation was of maternal origin. A slight parent of origin effect on severity of disease was found. Further clinical and molecular studies are needed to determine the basis of these unexpected observations.

A temperature-sensitive Krp1 allows in vivo characterization of kexin activation

Members of the kexin family of processing enzymes are responsible for the cleavage of many proproteins during their transport through the secretory pathway. The enzymes are themselves made as inactive precursors and we have investigated the activation of Krp1, a kexin from the fission yeast Schizosaccharomyces pombe. As Krp1 is essential for cell growth, we have used a krp1ts strain to investigate the role of the prosequence in the activation process. Mutations that reduce either the efficiency with which the prosequence is released or the rate at which the released prosegment is subsequently cleaved at an internal site are less active when assayed in vivo. We also show that prosegments lacking an internal dibasic motif can act as autoinhibitors and prevent activation of the catalytic fragment. Krp1 constructs containing prosequences based on these inhibitors do not become active in vitro. Surprisingly, the same constructs do become active in the intact cell and appear to suggest that alternative activation processes can be used by these enzymes.

Binding of beta-carbolines and related agents at serotonin (5-HT(2) and 5-HT(1A)), dopamine (D(2)) and benzodiazepine receptors

A large series of beta-carbolines was examined for their ability to bind at [3H]agonist-labeled 5-HT(2A) serotonin receptors. Selected beta-carbolines were also examined at 5-HT(2C) serotonin receptors, 5-HT(1A) serotonin receptors, dopamine D(2) receptors, and benzodiazepine receptors. Indolealkylamines and phenylisopropylamines were also evaluated in some of these binding assays. The beta-carbolines were found to bind with modest affinity at 5-HT(2A) receptors, and affinity was highly dependent upon the presence of ring substituents and ring saturation. The beta-carbolines displayed little to no affinity for 5-HT(1A) serotonin receptors, dopamine D(2) receptors and, with the exception of beta-CCM, for benzodiazepine receptors. Examples of beta-carbolines, indolealkylamines (i.e. N,N-dimethyltryptamine analogs), and phenylisopropylamines have been previously shown to produce common stimulus effects in animals trained to discriminate the phenylisopropylamine hallucinogen DOM (i.e. 1-(2, 5-dimethoxy-4-methylphenyl)-2-aminopropane) from vehicle. Although the only common receptor population that might account for this action is 5-HT(2A), on the basis of a lack of enhanced affinity for agonist-labeled 5-HT(2A) receptors, as well as on their lack of agonist action in the PI hydrolysis assay, it is difficult to conclude that the beta-carbolines behave in a manner consistent with that of other classical hallucinogens.

Clinical and molecular studies in a unique family with autosomal dominant limb-girdle muscular dystrophy and Paget disease of bone

PURPOSE

To characterize the clinical features and perform linkage analysis of candidate loci in a large Illinois family with autosomal dominant limb-girdle muscular dystrophy (LGMD) and Paget disease of bone (PDB).

METHODS

The family includes 11 affected individuals (8 M, 3 F). Clinical, biochemical and radiologic evaluations were performed to delineate clinical features of the disorder. Linkage analysis with polymorphic markers was performed for previously identified LGMD, PDB and cardiomyopathy loci.

RESULTS

Onset of PDB is early, at a mean age of 35 y, with classic distribution involving the spine, pelvis, and skull. Muscle weakness and atrophy is progressive with mildly elevated to normal creatine phosphokinase levels. Muscle biopsy in the oldest male revealed vacuolated fibers, however, in others revealed nonspecific myopathy. Affected individuals die from progressive muscle weakness, and respiratory and cardiac failure in their 40s-60s. Linkage analysis excluded autosomal dominant and recessive LGMD, PDB, and cardiomyopathy loci.

CONCLUSION

Autosomal dominant LGMD associated with PDB is an unusual disorder. Linkage analysis indicates a unique locus in this family.

Probing Balitsky-Fadin-Kuraev-Lipatov dynamics in the dijet cross section at large rapidity intervals in pp collisions at sqrt[s]=1800 and 630 GeV

Inclusive dijet production at large pseudorapidity intervals (Deltaeta) between the two jets has been suggested as a regime for observing Balitsky-Fadin-Kuraev-Lipatov (BFKL) dynamics. We have measured the dijet cross section for large Deltaeta in pp collisions at sqrt[s]=1800 and 630 GeV using the D0 detector. The partonic cross section increases strongly with the size of Deltaeta. The observed growth is even stronger than expected on the basis of BFKL resummation in the leading logarithmic approximation. The growth of the partonic cross section can be accommodated with an effective BFKL intercept of alphaBFKL(20 GeV)=1.65+/-0.07.

Measurement of the W-->taunu production cross section in pp collisions at square root s=1.8 TeV

We report on a measurement of sigma(pp-->W+X)B(W-->taunu) in pp collisions at sqrt[s]=1.8 TeV at the Fermilab Tevatron. The measurement is based on an integrated luminosity (lum) of 18 pb-1 of data collected with the D0 detector during 1994-1995. We find that sigma(pp-->W+X)B(W-->taunu)=2.22+/-0.09 (stat)+/-0. 10 (syst)+/-0.10 (lum) nb. Lepton universality predicts that the ratio of the tau and electron electroweak charged current couplings to the W boson, gWtau/gWe, be unity. We find gWtau/gWe=0.980+/-0.031, in agreement with lepton universality.

Institutional and individual learning curves for focused abdominal ultrasound for trauma: cumulative sum analysis

OBJECTIVE

To evaluate both institutional and individual learning curves with focused abdominal ultrasound for trauma (FAST) by analyzing the incidence of diagnostic inaccuracies as a function of examiner experience for a group of trauma surgeons performing the study in the setting of an urban level I trauma center.

SUMMARY BACKGROUND DATA

Trauma surgeons are routinely using FAST to evaluate patients with blunt trauma for hemoperitoneum. The volume of experience required for practicing trauma surgeons to be able to perform this examination with a reproducible level of accuracy has not been fully defined.

METHODS

The authors reviewed prospectively gathered data for all patients undergoing FAST for blunt trauma during a 30-month period. All FAST interpretations were validated by at least one of four methods: computed tomography, diagnostic peritoneal lavage, celiotomy, or serial clinical evaluations. Cumulative sum (CUSUM) analysis was used to describe the learning curves for each individual surgeon at target accuracy rates of 85%, 90%, and 95% and for the institution as a whole at target examination accuracy rates of 85%, 90%, 95%, and 98%.

RESULTS

Five trauma surgeons performed 546 FAST examinations during the study period. CUSUM analysis of the aggregate experience revealed that the examiners as a group exceeded 90% accuracy at the outset of clinical examination. The level of accuracy did not improve with either increased frequency of performance or total examination experience. The accuracy rates observed for each trauma surgeon ranged from 87% to 98%. The surgeon with the highest accuracy rate performed the fewest examinations. No practitioner demonstrated improved accuracy with increased experience.

CONCLUSIONS

Trauma surgeons who are newly trained in the use of FAST can achieve an overall accuracy rate of at least 90% from the outset of clinical experience with this modality. Interexaminer variations in accuracy rates, which are observed above this level of performance, are probably related more to issues surrounding patient selection and inherent limitations of the examination in certain populations than to practitioner errors in the performance or interpretation of the study.

The elderly in five nations: the importance of universal coverage

This paper reports 1999 survey results on the population age sixty-five and older in five nations--Australia, Canada, New Zealand, the United Kingdom, and the United States. The majority of respondents were generally satisfied with the quality, affordability, and availability of health services in their nations. In many measures of access to and cost of care, the United States looks much like the other nations surveyed. However, as the elderly view their health systems, the direction they have taken in recent years with respect to caring for the elderly, and the future affordability of care in old age, U.S. respondents tended to be more pessimistic than were those in other nations.

Prolonged use of heat and moisture exchangers does not affect device efficiency or frequency rate of nosocomial pneumonia

OBJECTIVE

To determine whether use of a single heat and moisture exchanger (HME) for < or =120 hrs affects efficiency, resistance, level of bacterial colonization, frequency rate of nosocomial pneumonia, and cost compared with changing the HME every 24 hrs.

DESIGN

Prospective, controlled, randomized, unblinded study.

SETTING

Surgical intensive care unit at a university teaching hospital.

PATIENTS

A total of 220 consecutive patients requiring mechanical ventilation for >48 hrs.

INTERVENTIONS

Patients were randomized to one of three groups: a) hygroscopic HME (Aqua+) changed every 24 hrs (HHME-24); b) hydrophobic HME (Duration HME) changed every 120 hrs (HME-120); and c) hygroscopic HME (Aqua+) changed every 120 hrs (HHME-120). Devices in all groups could be changed at the discretion of the staff when signs of occlusion or increased resistance were identified.

MEASUREMENTS AND MAIN RESULTS

Daily measurements of inspired gas temperature, inspired relative humidity, and device resistance were made. Additionally, daily cultures of the patient side of the device were accomplished. The frequency rate of nosocomial pneumonia was made by using clinical criteria. Ventilatory support variables, airway care, device costs, and clinical indicators of humidification efficiency (sputum volume, sputum efficiency) were also recorded. Prolonged use of both hygroscopic and hydrophobic devices did not diminish efficiency or increase resistance. There was no difference in the number of colony-forming units from device cultures over the 5-day period and no difference between colony-forming units in devices changed every 24 hrs compared with devices changed after 120 hrs. The average duration of use was 23+/-4 hrs in the HHME-24 group, 73+/-13 hrs in the HME-120 group, and 74+/-9 hrs in the HHME-120 group. Mean absolute humidity was greater for the hygroscopic devices (30.4+/-1.1 mg of H2O/L) compared with the hydrophobic devices (27.8+/-1.3 mg of H2O/L). The frequency rate of nosocomial pneumonia was 8% (8:100) in the HHME-24 group, 8.3% (5:60) in the HME-120 group, and 6.6% (4:60) in the HHME-120 group. Pneumonia rates per 1000 ventilatory support days were 20:1000 in the HHME-24 group, 20.8:1000 in the HME-120 group, and 16.6:1000 in the HHME-120 group. Costs per day were $3.24 for the HHME-24 group, $2.98 for the HME-120 group, and $1.65 for the HHME-120 group.

CONCLUSIONS

Changing the hydrophobic or hygroscopic HME after 3 days does not diminish efficiency, increase resistance, or alter bacterial colonization. The frequency rate of nosocomial pneumonia was also unchanged. Use of HMEs for >24 hrs, up to 72 hrs, is safe and cost effective.

Effects of body temperature on accuracy of continuous cardiac output measurements

Intermittent measurement of cardiac output is routine in the critically ill surgical patient. A new catheter allows real-time continuous measurement of cardiac output. This study evaluated the impact of body temperature variation on the accuracy of these measurements compared to standard intermittent bolus thermodilution technique. This prospective study in a university hospital surgical intensive care unit included 20 consecutive trauma patients. Data were collected with pulmonary artery catheters, which allowed both continuous (COC) and bolus (COB) thermodilution measurements. The catheter was placed through either the subclavian or internal jugular vein. Measurements for COB were performed using a bolus (10 cm3) of ice-cold saline with a closed-injectate delivery system at end-expiration. Computer-generated curves were created on a bedside monitor, and the average of three measurements within 10% of one another was used as COB. COC was determined as the average of the displayed CO before and after thermodilution CO measurements. Body temperature was measured from the pulmonary artery catheter and was grouped as < or =36.5 degrees C, 36.6-38.4 degrees C, and > or =38.5 degrees C. COB and COC were compared for agreement by plotting the mean of the differences (COB - COC) between the methods. The differences were plotted against the average of each pair and analyzed with linear regression. One hundred seventy-eight paired measurements were made over a period of 1 to 3 days. CO ranged from 3.7 to 15.5 L/min. Eighty-one percent of measurements were at a temperature of 36.5-38.4 degrees C. Approximately 7% of measurements were at a temperature below 36.5 degrees C and 11.2% were in patients with a core temperature above 38.5 degrees C. Correlation between the two techniques was 0.96, 0.91, and 0.82 for temperatures of < or =36.5 degrees C, 36.6-38.4 degrees C, and > or = 38.5 degrees C, respectively. In conclusion, the COC measurements correlate well with COB in trauma patients with a core temperature < or =38.5 degrees C. The accuracy degraded at higher temperatures, which may be related to the smaller signal-to-noise ratio at elevated body temperatures.

Flow cytometric analysis of immunoprecipitates: high-throughput analysis of protein phosphorylation and protein-protein interactions

BACKGROUND

Activation-induced protein phosphorylation can be studied by Western blotting, but this method is time consuming and depends on the use of radioactive probes for quantitation. We present a novel assay for the assessment of protein phosphorylation based on latex particles and flow cytometry.

METHODS

This method employs monoclonal antibodies coupled to latex particles to immobilize protein kinase substrates. Their phosphorylation status is assessed by reactivity with phosphoepitope-specific antibodies. The amount of immobilized protein on the particles was analyzed by direct or indirect immunofluorescence with antibodies to nonphosphorylated epitopes.

RESULTS

The assay allowed measurement of phosphorylation of multiple protein kinase substrates in stimulated T cells, including the zeta chain of the T-cell receptor, ZAP-70, CD3, CD5, SHP-1, and ERK-2, using 1-3 microg of total cell protein per sample. The assay provided high resolution of kinetics of phosphorylation and dephosphorylation. Interactions of protein kinase substrates with associated signaling molecules were demonstrated.

CONCLUSIONS

The novel assay allows high-throughput quantitative measurement of protein modifications during signal transduction.

Male systemic sclerosis and occupational silica exposure-a population-based study

BACKGROUND

The continuing uncertainty about the silica-systemic sclerosis relationship led to the investigation of its role as a disease determinant in a large population-based study of systemic sclerosis.

AIMS

To compare the frequency, socioeconomic and educational status, age-specific prevalence and duration of occupational silica exposure in males with and without systemic sclerosis. To assess the temporal relationship between exposure and disease onset. To estimate disease latency. To compare disease characteristics between silica-exposed and non-silica-exposed male cases.

METHODS

The study was case-control in design. The exposure variable was occupational silica exposure as assessed by an occupational health officer blinded to case/control status and the outcome variable was systemic sclerosis. The employed instrument comprised either a standardised telephone questionnaire (interviewed cases and controls) or medical records (deceased or living-status-unknown cases).

RESULTS

Sixty of 160 cases (37.5%) and 11 of 83 (13.3%) controls had occupational silica exposure (OR=3.93; 1.84-8.54). Comparison of data between 64 interviewed cases and all controls demonstrated initial occupational silica exposure occurring before age 40, comparable educational status but significantly different cumulative socioeconomic status with cases being over-represented in semi-skilled and unskilled occupations. Cross-sectional 'current' occupational data underestimated cumulative silica exposure by more than 50%. Silica exposure uniformly preceded onset of second disease symptoms and disease diagnosis. In most, it also preceded onset of first disease symptoms. Disease latency approximated two decades. No disease features distinguished silica-associated systemic sclerosis from idiopathic systemic sclerosis. The duration of silica exposure in the interviewed silica-exposed cases did not significantly exceed that of silica-exposed controls.

CONCLUSIONS

Male systemic sclerosis displays socioeconomic dependence. Silica is a disease determinant in male systemic sclerosis, with disease features including a long latency and clinical characteristics indistinguishable from idiopathic disease. Cross-sectional 'current' occupational data underestimate cumulative occupational silica exposure.

Positive end-expiratory pressure and response to inhaled nitric oxide: changing nonresponders to responders

BACKGROUND

Inhaled nitric oxide (INO) has been shown to improve oxygenation in two thirds of patients with acute respiratory distress syndrome (ARDS). Failure to respond to INO is multifactorial. We hypothesized that the addition of positive end expiratory pressure (PEEP) might modify the response to INO in patients who had previously failed to respond to INO.

METHODS

Patients with ARDS who failed to respond to INO at 1 ppm (PaO2 increase of < 20%) were selected. Each patient underwent a PEEP trial using an improvement in static lung compliance as the end point. One hour after the new PEEP level was reached, hemodynamic and blood gas values were obtained. INO was then reinstituted at 1 ppm, and hemodynamic and blood gas variables were obtained 1 hour later.

RESULTS

Six of nine patients demonstrated an increase in PaO2/FIO2 (161 +/- 27 to 186 +/- 29) with a mean increase in PEEP of 3.7 cm H2O. Each patient responding to PEEP further improved PaO2/FIO2 (186 +/- 29 to 223 +/- 36) with INO at 1 ppm. The three patients who failed to improve after the PEEP increase also failed to respond to a second trial of INO. There were no changes in cardiac output or systemic vascular resistance. Pulmonary artery pressures decreased slightly (39 +/- 5 vs 38 +/- 7 vs 35 +/- 9 mm Hg). Pulmonary vascular resistance decreased significantly after reintroduction of INO (298 +/- 131 vs 310 +/- 122 vs 249 +/- 105 dynes/sec/cm-5) in patients who responded positively.

CONCLUSIONS

The response of ARDS patients to INO can be improved if optimum alveolar recruitment is achieved by the addition of PEEP. PEEP and INO have a synergistic effect on PaO2/FIO2. Patients who fail to respond to INO may benefit from an optimum PEEP trial.

Nicotinic receptor subtypes in human brain ageing, Alzheimer and Lewy body diseases

Human brain ageing is associated with reductions in a variety of nicotinic receptors subtypes, whereas changes in age-related disorders including Alzheimer's disease or Parkinson's disease are more selective. In Alzheimer's disease, in the cortex there is a selective loss of the alpha4 (but not alpha3 or 7) subunit immunoreactivity and of nicotine or epibatidine binding but not alpha-bungarotoxin binding. Epibatidine binding is inversely correlated with clinical dementia ratings and with the level of Abeta1-42, but not related to plaque or tangle densities. In contrast, alpha-bungarotoxin binding is positively correlated with plaque densities in the entorhinal cortex. In human temporal cortex loss of acetylcholinesterase catalytic activity is positively correlated with decreased epibatidine binding and in a transgenic mouse model over expressing acetylcholinesterase, epibatidine binding is elevated. In Parkinson's disease, loss of striatal nicotine binding appears to occur early but is not associated with a loss of alpha4 subunit immunoreactivity. Tobacco use in normal elderly individuals is associated with increased alpha4 immunoreactivity in the cortex and lower densities of amyloid-beta plaques, and with greater numbers of dopaminergic neurons in the substantia nigra pars compacta. These findings indicate an early involvement of the alpha4 subunit in beta-amyloidosis but not in nigro-striatal dopaminergic degeneration.

Understanding the diverse needs of the Medicare population: implications for Medicare reform

Meeting the health care needs of millions of elderly and disabled Americans is central to the debate over Medicare's future. Using data from a nationally representative survey of 3,309 beneficiaries, Medicare's most vulnerable beneficiaries were profiled, examining variations in coverage, satisfaction, access, and financial difficulties. A substantial portion of the Medicare population--two thirds--were found to have health problems or low incomes. The analysis found that about 40% of beneficiaries with incomes below the poverty level, in fair or poor health, or with ADL limitations, have difficulties paying their medical bills or getting needed health care. Medicare's disabled, under-65 beneficiaries are at even higher risk: nearly half (47%) have health care access problems or deal with financial hardship due to medical bills. The diverse needs and experiences of the Medicare population are underscored, providing new insights into the challenge of maintaining or improving protection for those with greatest need while assuring the long-term fiscal viability of the program.

The effects of passive humidifier dead space on respiratory variables in paralyzed and spontaneously breathing patients

BACKGROUND

Passive humidifiers have gained acceptance in the intensive care unit because of their low cost, simple operation, and elimination of condensate from the breathing circuit. However, the additional dead space of these devices may adversely affect respiratory function in certain patients. This study evaluates the effects of passive humidifier dead space on respiratory function.

METHODS

Two groups of patients were studied. The first group consisted of patients recovering from acute lung injury and breathing spontaneously on pressure support ventilation. The second group consisted of patients who were receiving controlled mechanical ventilation and were chemically paralyzed following operative procedures. All patients used 3 humidification devices in random order for one hour each. The devices were a heated humidifier (HH), a hygroscopic heat and moisture exchanger (HHME) with a dead space of 28 mL, and a heat and moisture exchanger (HME) with a dead space of 90 mL. During each measurement period the following were recorded: tidal volume, minute volume, respiratory frequency, oxygen consumption, carbon dioxide production, ratio of dead space volume to tidal volume (VD/VT), and blood gases. In the second group, intrinsic positive end-expiratory pressure was also measured.

RESULTS

Addition of either of the passive humidifiers was associated with increased VD/VT. In spontaneously breathing patients, VD/VT increased from 59 +/- 13 (HH) to 62 +/- 13 (HHME) to 68 +/- 11% (HME) (p < 0.05). In these patients, constant alveolar ventilation was maintained as a result of increased respiratory frequency, from 22.1 +/- 6.6 breaths/min (HH) to 24.5 +/- 6.9 breaths/min (HHME) to 27.7 +/- 7.4 breaths/min (HME) (p < 0.05), and increased minute volume, from 9.1 +/- 3.5 L/min (HH) to 9.9 +/- 3.6 L/min (HHME) to 11.7 +/- 4.2 L/min (HME) (p < 0.05). There were no changes in blood gases or carbon dioxide production. In the paralyzed patient group, VD/VT increased from 54 +/- 12% (HH) to 56 +/- 10% (HHME) to 59 +/- 11% (HME) (p < 0.05) and arterial partial pressure of carbon dioxide (PaCO2) increased from 43.2 +/- 8.5 mm Hg (HH) to 43.9 +/- 8.7 mm Hg (HHME) to 46.8 +/- 11 mm Hg (HME) (p < 0.05). There were no changes in respiratory frequency, tidal volume, minute volume, carbon dioxide production, or intrinsic positive end-expiratory pressure.

DISCUSSION

These findings suggest that use of passive humidifiers with increased dead space is associated with increased VD/VT. In spontaneously breathing patients this is associated with an increase in respiratory rate and minute volume to maintain constant alveolar ventilation. In paralyzed patients this is associated with a small but statistically significant increase in PaCO2.

CONCLUSION

Clinicians should be aware that each type of passive humidifier has inherent dead space characteristics. Passive humidifiers with high dead space may negatively impact the respiratory function of spontaneously breathing patients or carbon dioxide retention in paralyzed patients. When choosing a passive humidifier, the device with the smallest dead space, but which meets the desired moisture output requirements, should be selected.

Health insurance markets and income inequality: findings from an international health policy survey

OBJECTIVE

To assess disparities in access to health care, financial burden of medical bills and perceived quality of care between those with above average incomes and those with below average incomes in five nations and to examine the relationship inequities in care experiences to health insurance coverage.

DESIGN

Cross-sectional analysis of a random survey of adults in 1998.

SUBJECTS

5059 adults ages 18 and over in five English-speaking countries: Australia, Britain, Canada, New Zealand and the United States (approximately 1000 per country).

MAIN OUTCOME MEASURES

Failure to receive needed care, difficulty getting care, waiting for elective surgery, problems paying medical bills, failure to fill prescriptions due to cost, perceived quality of medical care received and of most recent doctor visit.

RESULTS

There were two to three-fold differences between those with above and below average incomes on measures of access to care in the US, Australia and New Zealand. In Britain and Canada indicators of access of to care were similar for the two income groups. Problems paying medical bills were most prevalent in the US, yet significant differences by income also existed in Australia, Canada and New Zealand. Those with below average incomes were more likely to have not filled a prescription due to cost in Australia, Canada, New Zealand and the US, with gaps by income most severe in the US. Ratings of quality of doctor visit were significantly different for the two income groups in the US, but not other countries.

CONCLUSIONS

The analysis finds striking differences among countries in the relative equity of health care experiences. In general, care experiences are more unequal in three countries such as the US, Australia and New Zealand where systems have relatively greater reliance on private health insurance and markets. Greater inequality in care experiences is also associated with more divided public opinion regarding the need for system reform and the direction of recent policy changes. In Canada and Britain where care experiences are more equal of the health system are similar across income groups. Reliance on private insurance and patient user fees appears to lead to more divided views of the overall health system as well as inequity in access to care.

Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans

This report addresses diabetes care in the managed care setting and improvement in care brought about by collaboration between 6 Medicare managed care plans (MCPs) and a Peer Review Organization (PRO). The objective was to improve the quality of care of outpatient diabetes patients provided by primary care physicians through the mutual collaboration of 6 Medicare managed care plans and a Medicare Peer Review Organization. The design involved pre-post intervention trial based on 2 random samples, a baseline sample drawn in 1995 and a remeasurement sample drawn in 1996. Medical records of patients in both samples were reviewed by the PRO to determine provision of 14 quality indicator services over a 1-year period. The setting was 6 Arizona Medicare managed care plans comprising approximately 40% of the Arizona Medicare population. Two random samples were drawn from type 2 diabetes patients continuously enrolled in the same managed care plan for at least 1 year. The intervention was comparative feedback of baseline data by the PRO, enabling each plan to compare itself to any other plan on any or all indicators. Each plan developed and implemented its own intervention in response to the 1995 baseline results. The main outcome measures were mean HbA1c, the proportion of HbA1c values below 8%, and positive change in provision of 14 quality indicator services. At postintervention remeasurement, mean HbA1c values fell from 8.9 +/- 2.2 to 7.9% +/- 2.1, and the proportion of patients with HbA1c values below 8.0% rose from 40% to 61.6%. The proportion of the 14 indicator services provided to patients rose from 35% to 55%. The mean number of physician office visits fell 13% and the number of services provided per visit doubled. We conclude that improving the process of care improves glycemic control. Better outpatient diabetes management in competing, capitated managed care plans is an attainable goal when mediated through a neutral third party such as a PRO.

Alpha1 connexin 43 gap junctions are decreased in human adrenocortical tumors

Gap junctional communication disorders have been implicated in the etiology of benign and malignant tumors. Understanding the type, distribution, and frequency of gap junctions in adrenal disorders should provide insight into the role of gap junctions in adrenal carcinogenesis as well as information that may be useful in developing improved diagnosis and treatment of adrenal diseases. Using immunocytochemical techniques, we have characterized and compared alpha1 connexins 43 gap junction protein levels in normal adrenal glands to those in benign and malignant adrenocortical human tumors. In addition, gap junction protein levels were studied in a human adrenal cancer cell line (H295). In both normal and neoplastic adrenal tissues, only alpha1 connexin 43 could be detected, whereas beta1 connexin 32 and beta2 connexin 26 were not found. In the normal adrenal gland, the zona fasciculata was demonstrated to have the highest number of gap junctions per cell (mean +/- SEM, 13.78 +/- 1.93). In contrast, in benign adrenocortical adenomas, the number of gap junctions per cell compared to that detected in normal adrenal glands was significantly reduced (mean +/- SEM, 4.6 +/- 1.17; P < or = 0.05), and the lowest number was found in malignant adrenocortical tumors (1.42 +/- 0.58; P < or = 0.05). Similarly, there were few or no alpha1 connexin 43 gap junctions in the H295 population. There was a progressive decrease in gap junction plaques in adrenocortical cancer cell populations compared to those in normal cell populations. Therefore, analysis of gap junction protein may be helpful for the differential diagnosis of benign and malignant adrenal tumors. The induction of gap junctions in malignant cells may provide a novel therapeutic strategy for adrenal cancer.

Cellular signaling with nitric oxide and cyclic guanosine monophosphate

The understanding of the formation and biological actions of nitric oxide (NO) has grown extensively during the past two decades. With the discoveries of the biological effects of NO and nitrovasodilators on cyclic guanosine monophosphate, with the elucidation of the biochemical mechanisms of NO synthesis, and with the growing knowledge of regulation of NO synthases, the complexities of this signal transduction cascade and its participation in numerous cell signaling processes continues. NO can be recognized as an intracellular second messenger, a local substance for regulation of neighboring cells, a neurotransmitter, and probably a hormone acting at distant sites.

Attribution of injury to alcohol involvement in young adults seriously injured in alcohol-related motor vehicle crashes

BACKGROUND: Approximately 40% of all traffic fatalities are associated with the use of alcohol. Hospitalization for serious injury after a motor vehicle crash related to use of alcohol may be an opportunity to change drinking behaviors in non-alcohol-dependent drinkers, thereby reducing the risk for future disability and death. OBJECTIVES: To determine the degree to which non-alcohol-dependent adults aged 18 to 45 years with alcohol-related vehicular trauma attributed their injury to use of alcohol. METHODS: During hospitalization, 132 subjects involved in alcohol-related motor vehicle crashes were interviewed. The interviews included the question, "To what extent do you believe your alcohol consumption was responsible for this injury?" Responses were measured on a 7-point scale ranging from 1 (not at all) to 7 (totally). RESULTS: In response to the question about attribution of injury to alcohol, 37.8% of subjects responded "not at all," 24.3 responded "somewhat," and 37.9% responded "mostly" or "totally." Spearman rank correlation between attribution of injury to alcohol involvement and blood alcohol content at admission was r = 0.440 (P &lt; .001). CONCLUSIONS: More than 60% of patients injured in alcohol-related motor vehicle crashes attributed their injury partly or totally to use of alcohol. When alcohol-free, hospitalized patients with higher blood levels of alcohol on admission were more likely than those with lower levels to attribute their injury to alcohol. Hospitalization for a motor vehicle crash related to use of alcohol provides an opportunity for interventions to decrease drinking.

Attribution of injury to alcohol involvement in young adults seriously injured in alcohol-related motor vehicle crashes

BACKGROUND

Approximately 40% of all traffic fatalities are associated with the use of alcohol. Hospitalization for serious injury after a motor vehicle crash related to use of alcohol may be an opportunity to change drinking behaviors in non-alcohol-dependent drinkers, thereby reducing the risk for future disability and death.

OBJECTIVES

To determine the degree to which non-alcohol-dependent adults aged 18 to 45 years with alcohol-related vehicular trauma attributed their injury to use of alcohol.

METHODS

During hospitalization, 132 subjects involved in alcohol-related motor vehicle crashes were interviewed. The interviews included the question, "To what extent do you believe your alcohol consumption was responsible for this injury?" Responses were measured on a 7-point scale ranging from 1 (not at all) to 7 (totally).

RESULTS

In response to the question about attribution of injury to alcohol, 37.8% of subjects responded "not at all," 24.3 responded "somewhat," and 37.9% responded "mostly" or "totally." Spearman rank correlation between attribution of injury to alcohol involvement and blood alcohol content at admission was r = 0.440 (P < .001).

CONCLUSIONS

More than 60% of patients injured in alcohol-related motor vehicle crashes attributed their injury partly or totally to use of alcohol. When alcohol-free, hospitalized patients with higher blood levels of alcohol on admission were more likely than those with lower levels to attribute their injury to alcohol. Hospitalization for a motor vehicle crash related to use of alcohol provides an opportunity for interventions to decrease drinking.

The 100 most-cited articles from JMB

Over the last 40 years, JMB has published many thousands of articles, all of which have been important in some way. Compiling a list of the 'most important' however, is an invidious task. Friendships can falter on such an undertaking, but the Institute of Scientific Information has provided us with an objective methodology for 'ranking' articles, according to the number of times any paper is cited in other publications. This evaluation can of course be criticised for its bias towards papers describing novel techniques or methods. Often, the true intellectual milestones may be found in the reference list of the most cited papers. With increasing age, each paper also has more time in which to have been cited, and so the group of highest scoring articles is also dominated by some of the oldest. On the other hand, with increasing time, papers have an increasing chance of being forgotten, and the citation rates of these are therefore also a measure of their persisting importance. On balance, it does represent a value in some way related to how often that paper has been used. With many caveats, we present the list of the 100 most cited papers in JMB over the past 40 years. Many of these papers have helped or influenced both a great many people, and a great many subsequent advances in molecular biology.

Zone I retroperitoneal hematoma identified by computed tomography scan as an indicator of significant abdominal injury

OBJECTIVE

All zone I retroperitoneal hematomas (Z1RPHs) identified at laparotomy for blunt trauma traditionally require exploration. The purpose of this study was to correlate patient outcome after blunt abdominal trauma with the presence of Z1RPH diagnosed on admission computed tomography (CT) scan.

METHODS

This is a retrospective review of patients with blunt trauma who were admitted to a Level 1 trauma center and who underwent CT scan during a 40-month period. All scans with a traumatic injury were reviewed to identify and grade Z1RPH as mild, moderate, or severe. Patients requiring operative treatment were compared with those who were observed. Statistical analysis was performed with Student's t test and chi-square test, with P < .05 considered significant.

RESULTS

Eighty-five (15.5%) of the CT scans were positive for Z1RPH. None of the 50 patients with a mild Z1RPH had their treatment altered. Of the 29 patients with a moderate or severe Z1RPH, 8 required celiotomy. The patients requiring celiotomy had significant elevations of solid viscus score (SVS) (4.9 +/- 1.6 versus 1.8 +/- 0.3), abdominal Abbreviated Injury Scale (3.8 +/- 0.3 versus 2.6 +/- 0.3), and transfusion requirements (13 +/- 4 versus 2 +/- 1). All patients (N = 4) with an SVS >4 required operative treatment. Seventy-two percent of patients with more than 1 intra-abdominal injury required abdominal exploration.

CONCLUSIONS

The presence of a moderate or severe Z1RPH and more than 1 intra-abdominal injury or an SVS >4 on admission CT scan is an important radiographic finding. This injury pattern should be considered a contraindication for nonoperative treatment of the associated solid organ injury.

Gene disruption in Schizosaccharomyces pombe using a temperature-sensitive Ura4p

We have generated a temperature-sensitive form of the Ura4p protein from the fission yeast Schizosaccharomyces pombe. A single T-to-C mutation at nucleotide 782 (relative to the initiator ATG codon of ura4) changes the leucine residue at position 261 in Ura4p to a proline. The mutant Ura4p(ts) supports growth at 30 degrees C but is unable to allow growth at 37 degrees C in the absence of uracil when a single copy of the gene is integrated into the host chromosome. Using the ura4(ts) cassette for gene replacements simplifies the identification of transformants in which the disruption construct has undergone homologous integration into the host chromosome, as these individuals contain a single copy of the ura4(ts) gene and fail to grow when replicated to 37 degrees C in the absence of uracil.

Functional characterization of the S. cerevisiae genome by gene deletion and parallel analysis

The functions of many open reading frames (ORFs) identified in genome-sequencing projects are unknown. New, whole-genome approaches are required to systematically determine their function. A total of 6925 Saccharomyces cerevisiae strains were constructed, by a high-throughput strategy, each with a precise deletion of one of 2026 ORFs (more than one-third of the ORFs in the genome). Of the deleted ORFs, 17 percent were essential for viability in rich medium. The phenotypes of more than 500 deletion strains were assayed in parallel. Of the deletion strains, 40 percent showed quantitative growth defects in either rich or minimal medium.

An RGS protein regulates the pheromone response in the fission yeast Schizosaccharomyces pombe

The rate and extent of a cell's response to an extracellular stimulus is influenced by regulators that act on the intracellular signalling machinery. Although not directly involved in propagating the intracellular signal, regulators control the activity of the proteins that transmit the signals. To understand this aspect of cell signalling, we have studied the pheromone response pathway in the fission yeast Schizosaccharomyces pombe, a relatively simple signalling system in a genetically tractable organism. We demonstrate this approach by investigating the role of Rgs1, a member of the Regulator of G protein Signalling (RGS) family of proteins. The rgs1 gene was identified through the Sz. pombe genome sequencing project (accession number Q09777) and recognized as having similarity to RGS proteins [Tesmer et al. (1997) Cell 89: 251-261], but this is the first report concerning the activity of the protein. Strains lacking rgs1 (Deltargs1) are hypersensitive to pheromone stimulation and unable to conjugate with a mating partner. Inhibition of mating occurs at a relative late stage in the process as Deltargs1 strains exhibit pheromone-dependent transcription and form shmoos. Expression of SST2 (an RGS protein that regulates pheromone signalling in the budding yeast Saccharomyces cerevisiae) overcomes the hypersensitivity of the Deltargs1 strains but fails to rescue their mating defect.

A prospective comparison of laparoscopic ultrasound vs intraoperative cholangiogram during laparoscopic cholecystectomy

BACKGROUND

The laparoscopic ultrasound (US) probe provides a new modality for evaluating biliary anatomy during laparoscopic cholecystectomy (LC).

METHODS

We performed a laparoscopic US examination in 65 patients without suspected common bile duct (CBD) stones prior to the performance of a laparoscopic cholangiogram (IOC). We then compared the cost, time required, surgeon's assessment of difficulty, and interpretations of findings.

RESULTS

There was a significant difference in the cost of US versus the cost of IOC ($362 +/- 12 versus $665 +/- 12; p < 0.05). Surgeons who had performed >10 US (EXP) were compared with those who had performed </=10 (NOV). There were significant differences between the EXP and NOV groups in ease of examination, visualization of biliary anatomy, and accuracy of measurement of the CBD.

CONCLUSIONS

The use of laparoscopic US for the accurate evaluation of the CBD and biliary anatomy requires that the surgeon has surpassed the learning curve, which we have defined as having performed >10 US exams.

Nitrotyrosine formation with endotoxin-induced kidney injury detected by immunohistochemistry

The presence of nitrotyrosine in the kidney has been associated with several pathological conditions. In the present study, we investigated nitrotyrosine formation in rat kidney after animals received endotoxin for 24 h. With lipopolysaccharide (LPS) treatment, immunohistochemical data demonstrated intense nitrotyrosine staining throughout the kidney. In spite of marked nitrotyrosine formation, the architectural appearance of tubules, glomeruli, and capillaries remained intact when examined by reticulin staining. Our data suggested that the marked staining of nitrotyrosine in proximal tubular epithelial cells was in the subapical compartment where the endocytic lysosomal apparatus is located. Thus a large portion of nitrotyrosine may come from the hydrolysis of nitrated proteins that are reabsorbed by the proximal tubule during the LPS treatment. We also found the colocalization of nitric oxide synthase (NOS-1) and nitrotyrosine within the macula densa of LPS-treated rats by using a double fluorescence staining method. In renal arterial vessels, vascular endothelial cells were more strongly stained for nitrotyrosine than vascular smooth muscle cells. Control animals without LPS treatment showed much less renal staining for nitrotyrosine. The general distribution of nitrotyrosine staining in control rat renal cortex is in the proximal and convoluted tubules, whereas the endothelial cells of vasa recta are major areas of nitrotyrosine staining in inner medulla. The renal distribution of nitrotyrosine in control and LPS-treated animals suggests that protein nitration may participate in renal regulation and injury in ways that are yet to be defined.

Contemporary theories and contemporary nursing--advancing nursing care for those who are marginalized

This paper critiques the topic of postmodernism and how it is represented in nursing and social science literature. This critique classified the debates into three identifiable constructs, those being: dissatisfaction; fragmentation and integration. The authors propose a solution from the integration debate by putting forward the notion of an 'integrated postmodern turn'. The 'solution' is situated within feminism and draws on modernist and postmodernist theory. The integrated model is grounded in nursing clinical examples which demonstrate the usefulness and workability of this approach when caring for those who are marginalized by nurses because of their ethnicity, gender, cultural and/or spiritual beliefs.