Educational instruction on a hospital information system for medical students during their surgical rotations

OBJECTIVE

To evaluate the benefit, for medical students on their surgical rotations, of real-time educational instruction during order entry on a hospital information system.

DESIGN

Prospective controlled trial.

INTERVENTION

Access to educational information during computerized order entry.

SUBJECTS

Medical students in their final year at the University of Calgary.

MAIN OUTCOMES

Attainment of the surgery rotation educational objectives, as measured by performance on a multiple-choice examination.

METHODS

Before they began their surgical rotations, students at two hospitals took a multiple-choice examination to measure their knowledge of surgery. One hospital had an information system with computerized order entry; students at this hospital had access, while composing orders, to educational material on the system. The other hospital did not have an information system; students there wrote orders on a paper chart. At the end of the rotation, all students took another multiple-choice examination.

RESULTS

Of 50 eligible students, 45 agreed to participate in the project, 21 in the treatment group and 24 in the control group. Pre-rotation scores were similar for the two groups (43 percent in the treatment group and 40 percent in the control group; SD, 10 percent). Post-rotation scores were identical for the two groups (65 percent in the treatment group and 65 percent in the control group; SD, 12 percent). A t-test analysis revealed no significant difference in performance on the examinations between the two groups.

CONCLUSION

This study did not demonstrate a learning advantage for medical students who have access to educational material on a hospital information system.

Impact of allergic rhinitis treatment on quality of life

Allergic rhinitis is a chronic inflammatory disorder of the nasal passages. It affects approximately 20% of the population, is a significant health and economic burden, and severely impairs quality of life. Two main instruments, Medical Outcomes Study 36-Item Short Form health survey (SF-36) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) have been used to assess quality of life in patients with allergic rhinitis. Antihistamines, corticosteroids, anticholinergic agents, decongestants, cromoglycates, and immunotherapy are used to treat patients with allergic rhinitis. Of these, antihistamines and intranasal corticosteroids are the most efficacious and frequently utilised medications. Studies have demonstrated improvements in quality of life with both of these medications in patients with allergic rhinitis.

Small bowel obstruction from internal hernia as a complication of colonoscopy

After colonoscopy with polypectomy, a patient developed a surgically acute abdomen. Although abdominal radiology did not show free air, a presumptive diagnosis of bowel perforation was made and laparotomy performed. At the time of surgery the colon was normal, and there was no peritoneal contamination. A loop of ileum was discovered incarcerated into an internal paracecal hernia. The bowel was freed, and the operation was completed without need for resection. Several cases of incarcerated inguinal hernia resulting from endoscopy are described in the medical literature; this is the first reported case of an incarcerated internal hernia as a complication of colonoscopy.

Multicenter, double-blind, placebo-controlled, multiple-challenge evaluation of reported reactions to monosodium glutamate

BACKGROUND

The frequency of reactions reported to occur after the consumption of monosodium glutamate (MSG) is the subject of controversy.

OBJECTIVE

We conducted a multicenter, multiphase, double-blind, placebo-controlled study with a crossover design to evaluate reactions reportedly caused by MSG.

METHODS

In 3 of 4 protocols (A, B, and C), MSG was administered without food. A positive response was scored if the subject reported 2 or more symptoms from a list of 10 symptoms reported to occur after ingestion of MSG-containing foods within 2 hours. In protocol A 130 self-selected reportedly MSG-reactive volunteers were challenged with 5 g of MSG and with placebo on separate days (days 1 and 2). Of the 86 subjects who reacted to MSG, placebo, or both in protocol A, 69 completed protocol B to determine whether the response was consistent and dose dependent. To further examine the consistency and reproducibility of reactions to MSG, 12 of the 19 subjects who responded to 5 g of MSG but not to placebo in both protocols A and B were given, in protocol C, 2 challenges, each consisting of 5 g of MSG versus placebo.

RESULTS

Of 130 subjects in protocol A, 50 (38. 5%) responded to MSG only, 17 (13.1%) responded to placebo only (P <. 05), and 19 (14.6%) responded to both. Challenge with increasing doses of MSG in protocol B was associated with increased response rates. Only half (n = 19) of 37 subjects who reacted to 5 g of MSG but not placebo in protocol A reacted similarly in protocol B, suggesting inconsistency in the response. Two of the 19 subjects responded in both challenges to MSG but not placebo in protocol C; however, their symptoms were not reproducible in protocols A through C. These 2 subjects were challenged in protocol D 3 times with placebo and 3 times with 5 g of MSG in the presence of food. Both responded to only one of the MSG challenges in protocol D.

CONCLUSION

The results suggest that large doses of MSG given without food may elicit more symptoms than a placebo in individuals who believe that they react adversely to MSG. However, neither persistent nor serious effects from MSG ingestion are observed, and the responses were not consistent on retesting.

Endotoxin (lipopolysaccharide)-induced nitric oxide production in 2,3,7,8-tetrachlorodibenzo-p-dioxin-treated Fischer rats: detection of nitrosyl hemoproteins by EPR spectroscopy

Electron paramagnetic resonance (EPR) spectroscopy was used to study the effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) on endotoxin (lipopolysaccharide)-induced nitric oxide (NO) production in Fischer rats. We found that rats treated with 50 microg/kg TCDD had increased sensitivity to endotoxin, resulting in an approximately 2-fold increase in the level of NO production detected as nitrosylhemoglobin (HbNO) in venous blood. At lower concentrations (< or = 5 microg/kg), TCDD did not affect the endotoxin-induced NO production. The TNF-alpha serum concentration was found to parallel that of NO. TCDD alone did not induce the production of detectable HbNO or TNF-alpha. We found that TCDD induced a dose-dependent increase in the EPR signal intensity of (Fe(3+)) low-spin methemoprotein complexes found in the liver and kidney. These species with EPR resonance at g = 2.43, 2.26, and 1.92 are attributed to low-spin Fe(3+) in cytochromes P450 and P420. Our data confirm previous studies that have shown that TCDD induces a dose-dependent increase in the production of some cytochrome P450 enzymes. However, in rats that were subsequently challenged with endotoxin, a smaller increase in the EPR intensity of these species was observed. The decrease in the low-spin Fe(3+) cytochrome P450 EPR signal in endotoxin-challenged rats could be due to one or more of the following occurring: (1) cytochrome destruction, (2) reduction of the ferric to the ESR-silent ferrous oxidation state of cytochromes by nitric oxide, and/or (3) formation of ferrous nitrosyl cytochrome complexes that contribute, in part, to the characteristic five-coordinate nitrosyl hemoprotein triplet also observed in these tissues. Since low concentrations of endotoxin can leak from the gut lumen into the systemic circulation, this investigation explores the possibility that endotoxin interaction with TCDD may be, in part, responsible for the effects of TCDD observed in these tissues.

The "Peter Pan" syndrome and allergy practice: facilitating adherence through the use of social support

The complexity of care of some patients in an allergy-immunology practice may be increased by behavioral abnormalities of the patients. Facilitating adherence through the use of social support may be the most effective treatment strategy for some of the most difficult of these patients. We report three patients whose medical management problems were alleviated largely because of the participation of their support system. All three patients were stabilized because of the acceptance of responsibility and support of the physician by the designated member of the patient's support system. The range of social support used to manage nonadherent patients ranged from directly providing instructions to a family member to the consistent presence of a spouse or companion at multiple clinical visits. In all cases, the success in management was attributed largely to the presence of a support system.

Effects of fingernail length on finger and hand performance

The purpose of this study was to investigate effects of fingernail length on active range of motion (AROM) of the fingers, speed of finger manipulation, number of words typed, and grip strength. Fifteen normal women (mean age, 30 years) performed measurements under four conditions--with no attached fingernails and with fingernails extending 2, 1, and 0.5 cm beyond the tip of the finger. Analyses of variance showed that: 1) with fingernails of all extended lengths, grip strength measured on the first setting of the Jamar hand dynamometer decreased; 2) with fingernails 1 and 2 cm in length, AROM, grip strength on the second dynamometer setting, and finger manipulation decreased; and 3) with fingernails 2 cm in length, typing speed decreased (p < 0.05). Long fingernails limit flexion of the finger joints, particularly the metacarpophalangeal joints. Lack of finger flexion will limit excursion of long flexors and extensors in patients. It is recommended that patients cut their fingernails to a length of 0.5 cm to achieve optimal functional outcomes.

Cross-domain adaptation reveals that a common mechanism computes stereoscopic (cyclopean) and luminance plaid motion

Across three experiments, this study investigated the visual processing of moving stereoscopic plaid patterns (plaids created with cyclopean components defined by moving binocular disparity embedded in a dynamic random-dot stereogram). Results showed that adaptation to a moving stereoscopic plaid or its components affected the perceived coherence of a luminance test plaid, and vice versa. Cross-domain adaptation suggests that stereoscopic and luminance motion signals feed into a common pattern-motion mechanism, consistent with the idea that stereoscopic motion signals are computed early in the motion processing stream.

Idiopathic anaphylaxis: variants as diagnostic and therapeutic problems

Idiopathic anaphylaxis presents a problem requiring rapid diagnosis and initiation of therapy. Some cases are complex and difficult to assess. We present four cases of unusual complexity to illustrate diagnostic and therapeutic problems. Two cases were found not to be idiopathic anaphylaxis, one being undifferentiated somatoform idiopathic anaphylaxis and the other very severe urticaria. Various conditions can be or mimic idiopathic anaphylaxis, and patience and observation can result in reasonable outcomes.

Review of alleged reaction to monosodium glutamate and outcome of a multicenter double-blind placebo-controlled study

Monosodium glutamate (MSG) has a long history of use in foods as a flavor enhancer. In the United States, the Food and Drug Administration has classified MSG as generally recognized as safe (GRAS). Nevertheless, there is an ongoing debate exists concerning whether MSG causes any of the alleged reactions. A complex of symptoms after ingestion of a Chinese meal was first described in 1968. MSG was suggested to trigger these symptoms, which were referred to collectively as Chinese Restaurant Syndrome. Numerous reports, most of them anecdotal, were published after the original observation. Since then, clinical studies have been performed by many groups, with varying degrees of rigor in experimental design ranging from uncontrolled open challenges to double-blind, placebo controlled (DBPC) studies. Challenges in subjects who reported adverse reactions to MSG have included relatively few subjects and have failed to show significant reactions to MSG. Results of surveys and of clinical challenges with MSG in the general population reveal no evidence of untoward effects. We recently conducted a multicenter DBPC challenge study in 130 subjects (the largest to date) to analyze the response of subjects who report symptoms from ingesting MSG. The results suggest that large doses of MSG given without food may elicit more symptoms than a placebo in individuals who believe that they react adversely to MSG. However, the frequency of the responses was low and the responses reported were inconsistent and were not reproducible. The responses were not observed when MSG was given with food.

Corticosteroid therapy in an additional 13 cases of Stevens-Johnson syndrome: a total series of 67 cases

Stevens-Johnson syndrome (SJS) is a severe cutaneous eruption that can be a life-threatening emergency. Previously, we have reported our favorable experience in treating 54 patients with SJS with systemic corticosteroids. We continued our prospective analysis of consecutive patients with SJS treated with corticosteroids. Possible etiologic factors and clinical outcomes of the patients are described. All 13 patients improved with initiation of systemic corticosteroid therapy. There was no mortality or permanent sequelae attributable to SJS. Drugs were the offending agents in all 13 cases. There was one death unrelated to SJS. In conclusion, prompt treatment with systemic corticosteroids reduces morbidity and improves outcome of SJS patients. This analysis extends our series to 67 consecutive patients with SJS who were treated with corticosteroids and had a favorable outcome.

Hypersensitivity pneumonitis resulting from community exposure to Canada goose droppings: when an external environmental antigen becomes an indoor environmental antigen

BACKGROUND

In the past, hypersensitivity pneumonitis has been attributed to occupational, agricultural, or home environmental exposure.

OBJECTIVE

This report describes the first case of hypersensitivity pneumonitis due to community exposure to droppings from Canada geese migrating through a suburban environment.

METHOD

Clinical and serologic information was used in making the diagnosis of hypersensitivity pneumonitis.

RESULTS

Serologic analysis demonstrated precipitating antibodies against goose droppings and against an extract made from washings from a filter taken from the patient's office. These studies also showed that the antigens in the office filter were goose dropping antigens.

CONCLUSION

Hypersensitivity pneumonitis can result from exposure to goose dropping antigens in the community that enter buildings through ventilation systems. This represents a new form of an old disease.

Immunologic tolerability profile of celecoxib

Celecoxib is primarily an inhibitor of cyclooxygenase (COX) 2 and, at therapeutic concentrations in humans, does not inhibit the COX-1 isoenzyme. The present meta-analyses explore the incidence of allergic reactions with celecoxib in patients in the North American and international arthritis trials, in patients with a history of hypersensitivity reactions to sulfonamides, and in patients receiving medications containing sulfonamides. Data were obtained from 11,008 patients in 14 double-masked trials of celecoxib in arthritis ranging from 4 to 24 weeks in duration. Results demonstrate that the incidence of allergic reactions with celecoxib was not statistically different from that seen with placebo or active comparators (nonsteroidal anti-inflammatory drugs [NSAIDs]) when data from the entire cohort were analyzed. The subset of patients with a history of sulfonamide hypersensitivity reactions had a 3-fold to 6-fold higher incidence of dermatologic reactions than did the entire arthritis trial cohort. Although dermatologic reactions occurred with greater frequency in patients with a history of sulfonamide hypersensitivity, the trend was consistent across all 3 treatment groups (celecoxib, NSAIDs, and placebo). According to these data and structural and metabolic differences between sulfonamides, the potential for cross-allergenicity between celecoxib and other sulfonamide-containing medications appears comparable to that of placebo and nonsulfonamide-containing NSAIDs. Additionally, the risk of allergic reactions with celecoxib appears comparable to that of placebo and comparator NSAIDs. Prospective trials are needed to confirm these findings.

The stereoscopic (cyclopean) motion aftereffect is selective for spatial frequency and orientation of disparity modulation

Across two experiments, this study investigated the spatial frequency tuning and orientation tuning (both in the disparity domain) of the stereoscopic (cyclopean) motion aftereffect. In Experiment 1, observers adapted to a moving stereoscopic grating of a given cyclopean spatial frequency and tested for the motion aftereffect with a static grating of the same or different spatial frequency. Robust motion aftereffects were induced only when the spatial frequency of the adapt and test stimuli was the same. In Experiment 2, observers adapted to a moving stereoscopic grating of a given cyclopean orientation and tested for the motion aftereffect with a static grating of the same or different orientation. Robust motion aftereffects were induced only when the orientation of the adapt and test stimuli was the same. Together, these results suggest that the stereoscopic motion aftereffect is tuned for cyclopean spatial frequency and orientation which, in turn, suggest that the stereoscopic motion aftereffect is mediated by low-level oriented spatial-frequency mechanisms.

Stereoscopic (cyclopean) motion sensing

This paper reviews literature on the motion processing of dynamic change in binocular disparity, called stereoscopic (cyclopean) motion. Studies investigating the visual processing of stereoscopic motion in the Z-axis, stereoscopic motion in the X/Y plane, and cyclopean motion are discussed. It is concluded that stereoscopic motion is processed by a motion-sensing system composed of special-purpose mechanisms that function like low-level motion sensors. For animals with binocular vision, low-level motion processing may involve, at least in part, stereoscopic processing.

Idiopathic anaphylaxis

Anaphylaxis is an acute, life threatening event that can progress extremely rapidly. External allergens as causations have been identified over the last century. The most recently identified type of anaphylaxis is not caused by any external allergen and has been termed Idiopathic Anaphylaxis (IA). Two major types are Generalized or Angioedema with airway obstruction. IA is also classified by frequency of episodes and response to therapy. Therapy consists of acute emergency therapy and induction of remissions using prednisone, beta agonists, and H1 blockers. Control and remission are usually induced. IA occurs at all ages, and pediatric and geriatric IA are often special problems, as is a psychogenic form where no true reactions occur. Although appropriate management of IA, in general, has a good prognosis, several problems exist. Among these are failure to accept IA as an entity or in an individual case by physicians and patients. A different problem occurs when the recommended treatment is used and there is control of IA, but only with persisting high doses of prednisone. This is corticosteroid dependent IA. The lack of defined mechanisms that will lead to improved therapies and wider acceptance of IA as an entity remains a major problem. Undifferentiated Somatoform IA is a serious management problem for physicians.

Rush immunotherapy in a dog with severe ragweed and grass pollen allergy

BACKGROUND

Forty years of study of naturally occurring IgE-mediated allergy in animals is briefly reviewed. These studies provided models for study of bioactive mediators and innovative pharmacologic therapies for IgE-mediated asthma.

OBJECTIVE

Based on our experience with canine allergy we evaluated and treated a dog with severe grass and ragweed allergy whose allergic dermatitis was uncontrolled by H1 blockers and topical corticosteroids. The dog was miserable during the Chicago grass and ragweed pollen seasons.

METHODS

Rush immunotherapy was initiated during the ragweed season of 1997.

RESULTS

Dramatic improvement was seen which persisted through the grass and ragweed seasons of 1998 after maintenance immunotherapy.

CONCLUSION

The case is presented not as a model for canine immunotherapy but as an example of how animal research can be of value to both animals and humans.

Allergen immunotherapy: historical perspective and current status. The first annual SWAF Dora Bastiani Redmon Memorial Foundation Lectureship

There was a time when there was no way of managing allergic diseases except by avoidance of allergens. Avoidance could not be effectively managed against some aeroallergens such as pollens, mold spores, and house dust. Allergists, particularly in the United States, began to use injection therapy and the treatment evolved to modern methodology for allergen immunotherapy (IT). As new treatments for allergy appeared, including H1 blockers and topical corticosteroids, many allergists thought there was no future for IT. However, IT has persisted and efficacy has been proven. Allergen IT remains a valuable therapy for allergic rhinitis and prevention of asthma. The true allergic asthmatic will often have chest symptoms improve with IT. Allergen IT can prevent the development of asthma in children with allergic rhinitis. Multiseasonal allergic rhinitis in a young person can require years of symptomatic therapy that is costly, tedious, and results in control but no alteration of the course of the allergic disease. Our approach should be proper education of the appropriate use of IT.