Giardiasis in pinnipeds from eastern Canada

Cysts of Giardia sp. were detected in feces from the rectum of 20 of 74 pinnipeds examined from the eastern coast of Canada in 1997 and 1998 using a monoclonal antibody technique. Infected pinnipeds included 15 adult harp seals (Phoca groenlandica), four adult grey seals (Halichoerus grypus), and one juvenile harbor seal (Phoca vitulina). Cysts were not detected in 15 seal pups <1-yr-old. The highest prevalence (50%) occurred in adult harp seals collected near the Magdalen Islands in the Gulf of St. Lawrence. The overall prevalence of Giardia sp. in grey and harbor seals, excluding pups, from the Gulf and St. Lawrence estuary was 23%. Feces from 11 beluga (Delphinapterus leucas) and one northern bottle-nosed whale (Hyperoodon ampullatus) stranded in the St. Lawrence estuary were negative for Giardia sp. cysts. The significance of Giardia sp. in marine mammals, shown here for the first time in eastern coastal Canada, is unknown.

Adenosquamous carcinoma of the pancreas

BACKGROUND

Adenosquamous carcinoma of the pancreas most probably represents squamous metaplasia of an adenocarcinoma. Metastases are typically an admixture of both elements, but more frequently, adenocarcinoma.

METHODS

A review of 102 pancreaticoduodenectomies for masses of the head of the pancreas done between 1994 and 1998 revealed two patients with adenosquamous carcinoma of the pancreas.

RESULTS

Both patients underwent successful pancreaticoduodenctomy, but were found to have nodal metastasis. One patient lived 13 mo and the other lived 14 mo with both dying from metastatic disease.

CONCLUSION

Adenosquamous carcinoma of the pancreas is a rare tumor, and because its presentation, clinical features, and course are identical to adenocarcinoma of the pancreas, it should be considered in the differential diagnosis for any mass of the head of the pancreas. Survival is poor for these patients. In this series, it was 13 and 14 mo, respectively.

The coming age. What's ahead for hospitals and health systems

The health care delivery system is a reactive instrument: it conforms to the demands of the most powerful drivers. How the system responds to these drivers in terms of design of coverage and delivery of care represents in large part the major challenge of the coming decade. This article presents an overview of some of the major drivers of health care today--cost, customers and technology--and how hospitals and health systems are responding.

How can sharing clinical information be made to work?

There is a recognised need to share clinical information in order to improve integrity, continuity, safety and speed of delivering patient care. This remains a serious weakness in the conceptualisation of existing health information management systems. The evolution of structured (e.g., HL7) messaging standards has been driven largely from an administrative information viewpoint, as have many of the initiatives driving the development of electronic patient record (EPR) systems. Neither appears to address crucial needs for clinical data exchanges often across wide areas to meet the needs of best quality, cost-effective and low risk patient care delivery. The present reality is that clinical messaging is complex, rigid and ineffective, and the business case for its users is not compelling. Administrative and financial arrangements need to be developed which support the more widespread use of clinical data exchanges. This paper underlines the importance of web technology as a key element in the communications strategy and as an adjunct (or alternative) to more structured messaging environments. It also raises some of the fundamental structural problems, which impact the use of messaging in healthcare, and puts forward proposals as to how these may best be addressed and resolved.

External validation of the Ottawa knee rules in an urban trauma center in the United States

OBJECTIVE

We evaluated the Ottawa knee rules in a high-volume teaching hospital in the United States to determine whether the rules could be safely used to decide whether patients with acute blunt knee trauma should undergo radiography.

SUBJECTS AND METHODS

During a 13-month period, 378 patients with acute blunt knee trauma were prospectively examined using the Ottawa knee rules. Data collected included the presence or absence of fracture predictors and the results of radiography.

RESULTS

A fracture was seen in 43 (11%) of the 378 patients who met inclusion criteria. The knee rules predicted 42 of the 43 fractures; sensitivity was 98%, and specificity was 19%. Radiography of 65 patients (17%) who had no predictors for fracture could have been avoided if the knee rules had been used to screen for radiography.

CONCLUSION

The Ottawa knee rules are highly sensitive for fracture in this setting and may safely be used to decide whether patients with acute blunt knee trauma should undergo radiography.

Nanosecond optical parametric oscillator based on large-aperture periodically poled RbTiOAsO(4)

We report on optical parametric oscillators (OPO's) based on periodically poled RbTiOAsO(4) (PP RTA), which are pumped by Q -switched solid-state lasers. With a diode-pumped Nd:YVO(4) laser (pulse energy, 800microJ ; pulse duration, 5.5 ns; repetition rate, 1 kHz) the PP RTA OPO generated 1.58-microm signal and 3.26-microm idler radiation with a signal pulse energy of 45microJ . The large aperture of 3 mmx3 mm of the PP RTA crystal also permitted OPO operation with pump pulse energies as high as 65 mJ, provided by a flash-lamp-pumped Q -switched Nd:YAG laser (pulse duration, 20 ns; repetition rate, 10 Hz). With this pump source the OPO generated signal pulse energies as high as 17 mJ, corresponding to an efficiency of 26%. The performance of this OPO shows that large-aperture PP RTA crystals are well suited for pulsed nanosecond OPO operation with pump pulse energies of tens of millijoules.

Does the choice of anesthetic technique affect the recovery of bowel function after radical prostatectomy?

OBJECTIVES

Return of bowel function after radical prostatectomy surgery may be the limiting factor in discharging these patients from the hospital. Recent studies have shown that postoperative epidural infusion of bupivacaine decreases time to return of bowel function compared with intravenous and epidural morphine in patients after abdominal surgery. This study focuses on the role of the intraoperative anesthetic technique on recovery of bowel function, intraoperative blood loss, and the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing radical retropubic prostatectomy and pelvic lymphadenectomy.

METHODS

Forty patients undergoing prostatectomy were randomized to either group A (general endotracheal anesthesia, including muscle relaxation and mechanical ventilation, followed by postoperative intravenous morphine patient-controlled analgesia) or group B (thoracic epidural anesthesia using bupivacaine, combined with "light" general anesthesia using a laryngeal mask airway and spontaneous ventilation, followed by epidural morphine analgesia). Intra- and postoperative data were collected on blood loss, volumes of crystalloid and colloid infused, blood transfused, duration of anesthesia and surgery, anesthetic and surgical complications, time to recovery of bowel function, quality of postoperative pain control, and time to discharge from hospital. Each patient underwent lower extremity venous ultrasonography to detect DVT.

RESULTS

Twenty-one patients received general anesthesia and 19 received combined epidural and general anesthesia. Intraoperative blood loss was significantly lower in the epidural group, and times to first flatus and first bowel movement were also shorter in this group. There were no significant differences in duration of anesthesia or surgery, quality of postoperative analgesia, side effects of analgesia, or time to discharge from hospital. There was no DVT detected in any patient.

CONCLUSIONS

The combined anesthetic technique of thoracic epidural anesthesia and "light" general anesthesia with spontaneous ventilation decreased intraoperative blood loss and shortened the time to return of bowel function. However, this earlier return of bowel function was not great enough to realize a difference in time to hospital discharge. There was no evidence of increased complications secondary to epidural anesthesia or of prolonged anesthetic time necessary to place epidural catheters.

Cardiac troponin I measurement with the ACCESS immunoassay system: analytical and clinical performance characteristics

We evaluated the ACCESS cardiac troponin I (cTnI) immunoassay as a marker for myocardial infarction (MI). Total imprecision was 6.0% to 13.5%, the minimum detectable concentration was 0.007 microg/L, and the limit of quantitation was 0.046 microg/L. Comparison of cTnI measurement between the ACCESS and Stratus systems (n = 114) showed a proportional difference: ACCESS cTnI = 0.0996 Stratus cTnI + 0.049 microg/L (r = 0.811). Fifty-nine of 61 ambulatory patients without cardiac symptoms had no detectable cTnI (95% range, 0.00 to 0.025 microg/L). The optimum cutoff for discriminating MI (n = 289, 45 with MI) was 0.15 microg/L by receiver operator characteristic curve analysis; at this cutoff, the ACCESS cTnI assay showed a sensitivity of 88.9% (95% CI, 79.7-98.1%) and specificity of 91.8% (95% CI, 88.4-95.2%). The ACCESS cTnI assay results showed 89.4% and 93.0% concordance with the MB isoenzyme of creatine kinase (CK-MB) mass and Stratus cTnI results, respectively, for classification of patients with suspected MI. The ACCESS cTnI assay appears to show sensitivity and specificity comparable with those of both CK-MB mass and Stratus cTnI assays for the diagnosis of MI in patients presenting within 12 h of onset of symptoms.

The experience of therapeutic touch for novice recipients

This study explored the experience of receiving Therapeutic Touch (TT) from the point of view of recipients with no prior experience with TT. Eleven female graduate students who were part of a larger study were interviewed after the second of two TT sessions and statements from the transcripts were analyzed for words, phrases, or sentences that fell into one of five categories: (a) relaxation, (b) physical sensations, (c) cognitive activity, (d) emotional (feelings), and (e) spiritual/transcendent. All participants reported feeling relaxed and had physical sensations and cognitive activity during the TT sessions, and most of the statements fit into these categories. Fewer statements reflected emotional or spiritual experiences and not all participants had these experiences. The sensations associated with TT may occur developmentally. Initially, physical and cognitive experiences are identified. The deeper, meaningful sensations may occur after an individual has more experience with the intervention.

Stress-induced immunosuppression and therapeutic touch

OBJECTIVE

The specific aim of this study was to evaluate the effectiveness of therapeutic touch in reducing the adverse immunological effects of stress in a sample of highly stressed students. Long-term goals are to develop methods by which a variety of stress-reduction techniques can be tested for efficacy.

DESIGN

Experimental.

SETTING

A large urban medical university in a southern coastal city.

SUBJECTS

Healthy medical and nursing students who are taking professional board examinations.

INTERVENTION

Therapeutic touch.

MAIN OUTCOME MEASURES

T-lymphocyte function (CD25) and immunoglobulin levels.

RESULTS

Subjects who received therapeutic touch and subjects who did not had significantly different levels of IgA and IgM; CD25 (mitogen-stimulated T-lymphocyte function) and IgG levels differed in the expected direction between the two groups, but the differences were not statistically significant. Apoptosis (programmed cell death) was significantly different between the two groups.

CONCLUSIONS

The small sample size requires cautious interpretation of the results. This is a pilot study designed to provide evidence to show that further study of therapeutic touch as an intervention that may be useful in reducing the adverse immunologic consequences of anxiety related to stress in otherwise healthy students is warranted. Change in immune function related to anxiety and the relief of anxiety can be measured. Subsequent power analysis suggests sample sizes of 90 subjects per group are required to confirm the conclusions.

Measures implemented to project personal privacy for an on-line national patient index: a case study

Increasing use of electronic data storage and exchange is inevitable. Although of considerable benefit to all concerned, they pose a potential threat to personal privacy. Measures to protect personal privacy in national information networks are essential. These and related security issues require the highest priority in strategic planning because experience shows that poor handling of security is the single factor most likely to lead to rejection of a system. It is increasingly important to be able to identify individuals uniquely for health-related purposes, and implementation of an on-line master index is the approach that has been adopted in New Zealand to address this need. Such an index, however, contains personal information, the privacy of which must be respected. Substituting the unique identifier for all personal details in electronic messages can provide a degree of security as long as access to the index is controlled and usage is monitored. The article outlines the measures, technical and otherwise, implemented to manage security concerns successfully in that context.

Limited efficacy of preoperative computed tomographic scanning for the evaluation of lymph node metastasis in patients before radical prostatectomy

OBJECTIVES

To evaluate the efficacy of preoperative computed tomographic (CT) scanning in patients with presumed localized prostatectomy prior to radical retropubic prostatectomy.

METHODS

A retrospective study of 173 consecutive patients believed to be candidates for radical retropubic prostatectomy who underwent preoperative CT scanning regardless of preoperative prostate-specific antigen (PSA) value, clinical stage, or Gleason grade was undertaken. All patients underwent radical retropubic prostatectomy with bilateral pelvic lymph node dissection or aspiration needle biopsy of abnormal nodes on CT scanning.

RESULTS

One hundred sixty-five of 173 patients (95.4%) were believed to have normal CT scans preoperatively. Of these 165 patients, 156 (94.5%) were found to have negative lymph nodes confirmed histologically at the time of lymphadenectomy. Nine patients (5.5%) were found to have lymph node metastases confirmed histologically, despite a negative CT scan. Computed tomographic scanning understaged 9 of 12 (75%) patients with proven metastases. Incidental abdominal pathology of clinical significance was documented in 4 patients (2.3%), including 2 with renal cell cancers, 1 with colon cancer, and 1 with a large (8 cm) abdominal aortic aneurysm. Prostate-specific antigen levels in patients with metastatic lymph nodes ranged from 0.7 to 130 ng/mL (Hybritech Tandem assay), with a mean level of 42 ng/mL. Although 9 of 33 patients (27.3%) with PSA levels greater than 25 ng/mL had node metastases, only 3 of these 33 patients (9.1%) were correctly diagnosed by CT scanning.

CONCLUSIONS

Although additional numbers of patients with high PSA levels need to be evaluated, we could not find any justification for routine preoperative CT scanning in patients with a PSA of less than 25 ng/mL. These results suggest that significant savings can be realized by abandoning the practice of routine CT scanning for lymph node metastasis in all patients with newly diagnosed prostate cancer.

Dietary satisfaction correlated with adherence in the Modification of Diet in Renal Disease Study

OBJECTIVE

To measure satisfaction with modified protein eating patterns and the relationship of satisfaction to adherence and sociodemographic factors in a clinical trial.

DESIGN

Participants completed the Dietary Satisfaction Questionnaire at baseline, at 6-month follow-up visits, at annual visits, and at the final visit. Satisfaction with diet was rated on a visual analog scale from 1 (dislike extremely) to 5 (like very much). Adherence to protein goals was assessed using urine urea nitrogen excretion from monthly 24-hour urine samples.

SUBJECTS

840 adults with chronic renal disease.

INTERVENTION

Individual participants, randomly assigned to a usual-protein, low-protein, or very-low-protein group, received monthly counseling from a dietitian for an average of 26 months.

STATISTICS

Analyses of variance and two-sample t tests compared, among study/diet groups, satisfaction with diet, its relationship to adherence and sociodemographic characteristics, and changes in satisfaction over time. Paired t tests compared changes within diet groups from baseline to final visit.

RESULTS

From the baseline visit to the final visit, satisfaction with the prescribed eating pattern increased slightly in the usual-protein group, declined slightly in the low-protein group, and declined significantly in the very-low-protein group. Participants in all of the eating pattern groups who were more satisfied at the final visit had mean protein intakes closer to their assigned protein goals. This relationship was significant in the low-protein group (P < .05). In men, satisfaction with diet declined significantly from baseline to the final follow-up visit in the very-low-protein group.

APPLICATIONS

The Modification of Diet in Renal Disease Study Dietary Satisfaction Questionnaire may be useful in other research and clinical settings to assess and enhance dietary adherence.

Anxiety and therapeutic touch

This four-group, repeated-measures experimental design divided 40 healthy professional caregivers/students into high- and low-anxiety groups and further into "therapeutic touch" and comparison groups. The effectiveness of the use of therapeutic touch in reducing anxiety was evaluated, as were the methodologies used. Three self-report measures of anxiety (Profile of Mood States, Spielberger's State/Trait Anxiety Inventory, and visual analogue scales) were evaluated for equivalence and concurrent validity to determine their potential for use in future studies. The correlations among these instruments were highly significant. The small sample size prevented differences between groups from reaching statistical significance, but the reduction of anxiety in the high-anxiety group was greater for those who had received therapeutic touch than for those who did not. Using variability data, the sample size necessary to find statistically significant differences between those who had therapeutic touch and those who did not was determined.