Establishing a PNP faculty practice clinic for Medicaid EPSDT screening

Faculty practice added a new dimension to teaching clinical skills in a Pediatric Advanced Practice Nursing program. It offered the student immediate feedback concerning didactic knowledge and clinical skills and added consistency to learning obtained in the classroom setting. Inclusion of the Medicaid EPSDT program further enhanced student learning by offering a framework of comprehensive services that the student could offer to the patient in providing holistic well-child care. Research opportunities for faculty and students are also prevalent with the large quantity of data available from administration of the EPSDT program. In addition, many children from indigent settings who would not otherwise receive routine well-child care have been given the opportunity because of this program. The use of a faculty practice model that provides the Medicaid EPSDT screening seems to meet the well-child needs of faculty, students, and patients alike and provides an education/service model congruent with the preventative goals of health care reform today.

Anti-emetic profile of a non-peptide neurokinin NK1 receptor antagonist, CP-99,994, in ferrets

In the ferret, 5-HT3 receptor antagonists are effective in controlling emesis produced by cytotoxic agents or radiation. To investigate the possibility that substance P has a role, as well as 5-HT, in the emetic reflex pathway, we have examined the anti-emetic effects of a NK1 receptor antagonist (racemic CP-99,994) in the ferret. Racemic CP-99,994 was effective against a range of emetogens, comprising cytotoxic drugs, radiation, morphine, ipecacuanha and copper sulphate.

The pediatric nurse practitioner and the physician assistant: how are we different?

Changing health care needs over the past 30 years have created new roles for professionals in advanced health care practice settings. As new roles continue to evolve, educational preparation and clinical experiences must be considered when determining the most appropriate health care provider for a particular specialization. Although similarities exist between the PA and PNP, the extent of pediatric didactic and clinical experiences is limited in most PA programs. Only one program is identified by the American Academy of PAs as a child health PA program. PNP education provides the nurse in an advanced practice role with an extensive background in normal growth and development, family counseling, health promotion, and management of common pediatric problems and chronic illnesses. The PNP is a registered nurse who is experienced in the care of children before pursuing an advanced degree as a PNP. In comparison, many PAs are not required to hold a professional degree before enrollment in a PA program. Although students entering PA programs may have experience in health-related fields before enrollment, few are specialized in the care of children. The PA program is designed to prepare the student to assist the physician with diagnosis and treatment in primary care with limited exposure to pediatrics. In comparison, the PNP spends the entire educational program of study gaining expertise in the care of children from infancy to adolescence. Because of advanced educational preparation, the PNP is in a unique position to contribute substantially to the total care of the child and family.

Auditory evoked response and awareness: a study in volunteers at sub-MAC concentrations of isoflurane

We have investigated the relationship between the auditory evoked response (AER) and simple tests of conscious awareness at four end-expiratory concentrations (0.0, 0.1, 0.2 and 0.4 MAC) of isoflurane in oxygen in each of eight anaesthetist volunteers, in random order, at least 1 week apart. The early cortical AER was recorded from electrodes at the vertex and inion. Amplitudes of the waves Pa, Nb and Pc and latencies of the waves Na, Pa, Nb, Pb and Nc were measured. All the AER variables were highly significantly related to end-expiratory anaesthetic concentration. Amplitudes decreased and latencies increased progressively with increasing anaesthetic concentration. The AER variables were also highly significantly related to the level of response. Amplitudes were greatest and the latencies shortest when there was full response to command. (Nb latency increased from 47.5 to 54.5 ms between partial and no response.) The close correlation between the effects of concentration and level of response, and between concentration and the AER implied that it was difficult to demonstrate those changes in the AER which specifically relate to changes in response. At 0.2 MAC, however, which was the concentration at which all subjects showed some deficit, the response to a shock word was distinguished clearly by Nb latency. In eight of 24 possible comparisons (eight AER variables and three types of psychological test) the AER fitted the response more closely than concentration.

Age-related asymmetry on a cued-listening task

We report results on a cued-listening task designed to simulate the listening problems commonly described by individuals with sensorineural hearing loss, especially those experienced by elderly persons. Against a background of multitalker babble, the subject detected targets embedded in continuous discourse. Noncoherent segments of this discourse were presented simultaneously from loudspeakers on the right and left sides. A signal light cued the side to be monitored during a listening trial. The overall difficulty of the task was manipulated by variation of the message to competition intensity ratio. A sequence of listening trials, half-cued to the right side, half cued to the left side, was executed at each of four message to competition intensity ratios. Nineteen young adults with normal hearing and 28 elderly persons with presbyacusic hearing loss were evaluated. All subjects, young and elderly, were able to complete the cued-listening task successfully. Results showed a small but significant right-side advantage in the young group and a substantial right-side advantage in the elderly group. The application of the testing technique to the evaluation of hearing aid performance is illustrated in two elderly persons.

Prophylactic intravenous immunoglobulin in HIV-infected children with CD4+ counts of 0.20 x 10(9)/L or more. Effect on viral, opportunistic, and bacterial infections. The National Institute of Child Health and Human Development Intravenous Immunoglobulin Clinical Trial Study Group

OBJECTIVE

To evaluate the efficacy of intravenous immunoglobulin (IVIG) for prevention of viral, opportunistic, and minor bacterial infections in children infected with human immunodeficiency virus (HIV).

DESIGN

Randomized, double-blind, placebo-controlled, outpatient clinical trial comparing subjects treated with 400 mg of IVIG per kilogram of body weight every 28 days with those given albumin placebo.

SETTING

Twenty-eight clinical centers in mainland United States and Puerto Rico.

PATIENTS

Three hundred seventy-six children infected with human immunodeficiency virus with clinical or immunologic evidence of HIV disease, 313 of whom had entry CD4+ counts of at least 0.20 x 10(9)/L (greater than or equal to 200/mm3).

MAIN OUTCOME MEASURES

The incidence of laboratory-proven and clinically diagnosed viral, opportunistic, and bacterial infections.

MAIN RESULTS

Viral infections and minor bacterial infections contributed more frequently to morbidity in children with entry CD4+ counts of at least 0.20 x 10(9)/L (together over five times as frequent) than did serious bacterial infection, the primary outcome measure of the trial. Opportunistic infections occurred at a similar rate as laboratory-proven serious bacterial infections. In this group of children, IVIG was significantly associated with a decrease in the rate of viral infections and minor bacterial infections per 100 patient-years (36.0 vs 54.0 episodes of viral infection per 100 patient-years, IVIG vs placebo, P = .01; and 115.1 vs 159.7 episodes of minor bacterial infection per 100 patient-years, IVIG vs placebo, P = .02), as well as a decrease in the rate of serious bacterial infections per 100 patient-years (26.4 vs 48.2 episodes per 100 patient-years; P = .002). There was no apparent difference in the rate of opportunistic infections between treatment arms.

CONCLUSIONS

Beneficial effect of IVIG was seen across multiple infectious outcome measures, with reductions in serious and minor viral and bacterial infections observed in children with entry CD4+ counts of at least 0.20 x 10(9)/L.

Hairy cell leukemia and autoimmune hemolytic anemia

A case of hairy cell leukemia (HCL) presenting as autoimmune hemolytic anemia (AHA) is described. A 40-year-old woman presented with severe hemolytic anemia. The morphological and immunological studies of bone marrow and spleen revealed a hairy cell leukemia. Although autoimmune diseases are a well known complication of HCL this is the first description of AHA as a complication of HCL.

Somatosensory and auditory evoked responses recorded simultaneously: differential effects of nitrous oxide and isoflurane

Auditory (AER) and somatosensory evoked responses (SSER) were recorded simultaneously in eight patients under anaesthesia before surgery. We studied the effects of equi-MAC end-expiratory concentrations of isoflurane (0.65-0.75%) and nitrous oxide (60-65%). The anaesthetics were changed at random in three consecutive 10-min periods so that each patient received both drugs. From the AER recorded from the vertex and inion, Pa and Nb latency and amplitude were measured. N13, P20 latency and N13 amplitude were measured from SSER recordings from the neck and P15, N20, P25, N35, P45 latency and P15-N20, N20-P25, P25-N35 and N35-P45 amplitude from the scalp over the hand area of the sensory cortex. Compared with nitrous oxide, isoflurane significantly increased the latencies of the AER waves Pa (P = 0.02) and Nb (P = 0.02), and the SSER waves N20 (P = 0.001) and P25 (P = 0.04). We were unable to demonstrate significant differences in Pa and Nb amplitude between isoflurane and nitrous oxide that we had seen previously. However, the amplitude of the SSER wave N20 was reduced significantly by nitrous oxide compared with isoflurane (P = 0.0004). This wave (N20) is thought to emanate from the thalamo-cortical radiations, and our findings may be explained by an analgesic effect of nitrous oxide mediated by endogenous opioids.

Acoustic reflex abnormalities in cranial-cervical dystonia

Previous anatomic and physiologic studies suggest brainstem dysfunction in cranial-cervical dystonia. To further explore this, we studied suprathreshold acoustic reflex waveforms in 15 such patients. A unique feature of this technique is its ability to reject movement artifacts before averaging the acoustic reflex waveforms. Thirteen patients (87%) showed some abnormality in reflex waveform morphology. There were both amplitude and latency abnormalities. These findings support the hypothesis that cranial-cervical dystonia reflects dysfunction of the brainstem.

Memory deficits in workers suffering from hard metal disease

This study examined memory functioning on the Wechsler Memory Scale-Revised in a group of adult tungsten carbide workers with hard metal disease and a group of matched controls. The hard-metal-exposed group of workers showed memory deficits related to difficulties in attention and verbal memory, with an apparent sparing of visual-spatial memory. Implications of this finding for future research are discussed.

Anti-mouse IgM immunoglobulin protects weanling mice from Coxsackievirus infection

Mice treated from birth with rabbit anti-mouse IgM antiserum (anti-mu), although immunosuppressed in regard to B cell function, may paradoxically be protected when challenged with certain viruses. Our early studies indicated that short term treatment of weanling mice protected against Semliki forest virus, herpes simplex virus, and Coxsackievirus B1. For this study, the murine model of Coxsackievirus B1 infection was chosen to determine if specific anti-mu immunoglobulin (anti-mu Ig) would protect and whether protection could be correlated with antiviral activity in certain organs. Weanling Balb/c mice were treated intraperitoneally (i.p.) with either affinity purified anti-mu Ig or purified normal rabbit (NR) Ig two consecutive days prior to i.p. challenge with Coxsackievirus B1. Mortality of anti-mu Ig treated mice was significantly lower than controls (3.4% vs 89%, P less than 0.001). Importantly, this purified anti-mu-induced protection correlated well with reduced levels of virus in blood and certain organs, especially brain. This decrease was not attributed to interferon (IFN) or virus-specific neutralizing (NT) antibody or enhanced cellular cytotoxicity. Anti-mu treatment appears to inhibit virus replication and/or enhance clearance of virus from target organs. The data indicate that a unique antiviral activity is activated by anti-mu treatment, and can be passively transferred to and protect recipient mice. The murine model of Coxsackievirus disease appears to be well suited for use in the elucidation of the mechanism of this protection.

In vitro galactosylation of a 110-kDa glycoprotein by an endogenous cell surface galactosyltransferase correlates with the invasiveness of adrenal carcinoma cells

We have examined the role of a cell surface galactosyltransferase, laminin, and laminin-binding protein (receptor) in the invasion of clonal derivatives of a murine adrenal carcinoma cell line. Although a 10-fold variation was found in the ability to invade a reconstituted basement membrane matrix, levels of intracellular laminin and the laminin-binding protein were shown to be present and secreted equally in all lines. Of the eight lines tested, seven showed a correlation between invasion and the incorporation of [3H]galactose from UDP-[3H]galactose into a 90- to 110-kDa protein. One noninvasive line (clone HSR), however, retained high galactosyltransferase activity yet could not galactosylate the endogenous 90- to 110-kDa substrate. Interestingly, this clone was unable to attach to laminin. Although high galactosyltransferase activity can be consistent with cells of high invasiveness, our results suggest that the galactosylation status of a 90- to 110-kDa Y1 cell surface glycoprotein is most indicative of invasion potential.

Rehabilitation of the mastectomy patient: a randomized, blind, prospective study

After biopsy confirmation of breast carcinoma, women who were scheduled to undergo a modified radical mastectomy had demographic data collected, goniometric measurements of shoulder flexion and abduction, and functional evaluation of the ipsilateral shoulder performed, and upper extremity circumferential measurements at five levels determined. Patients were then randomly assigned either to a group that received immediate postoperative physical therapy or to one that did not. Results represent the combination of data from a pilot study and this subsequent study following appropriate statistical analysis. Sixty-four women in the treatment group showed a statistically significant increase in shoulder range of motion in both abduction and flexion as compared to 51 women who received no physical therapy. The treated group also had fewer problems with five of the six upper extremity functional tasks that were assessed. There were no significant differences between the groups for length of hospital stay, postoperative complications, or upper extremity edema. The authors conclude that early physical therapy intervention makes a significant contribution to return to normal function without increasing the incidence of postoperative complications or prolonging hospital stay.

In situ hybridization analysis of myelin gene transcripts in developing mouse spinal cord

We analyzed the location and abundance of transcripts for the 4 CNS myelin protein genes, myelin basic protein (MBP), proteolipid protein (PLP), myelin-associated glycoprotein (MAG), and 2',3'-cyclic nucleotide phosphohydrolase (CNP), in the mouse cervical spinal cord from the time of rapid myelination until adulthood (8-45 d). In the white matter, maximal levels of transcripts were found for each of the myelin genes at the peak of myelination (8 d). Total MBP and PLP mRNAs stayed high until 20 d and showed a minor decrease thereafter. In contrast, MAG and the MBP exon 2 containing transcripts (coding for the 21.5 and 17 kDa MBP isoforms) decreased sharply between 8 and 20 d, suggesting that high levels of these transcripts are needed primarily during the initiation of myelination. CNP transcripts were less abundant, maintained high expression until 20 d, and then decreased sharply. PLP, MAG, and CNP transcripts were clustered in the oligodendrocyte cell body, while MBP mRNAs were scattered throughout the cell body and processes. In contrast to the white matter, all these myelin specific transcripts in the gray matter showed a marked increase from 8 to 20 d, as did the number of oligodendrocytes identified by CNP immunostaining. MAG transcripts were found in white matter and in satellite and other oligodendrocytes of the gray matter but not in neurons identified by their expression of neurofilament transcripts. The results of our quantitative in situ hybridization study are in good agreement with those of previous molecular studies and provide new information on the cellular and topographic distribution of myelin-specific mRNAs during myelination.

Hamstring release for knee flexion contracture in spastic adults

Thirty adults (17 male and 13 female patients) with spastic disorders were treated by hamstring releases of 46 extremities. The diagnoses were stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, and anoxia. The mean age at surgery was 38.6 years. Three extremities had partial release of the hamstring tendons behind the knee; the remaining 43 extremities had a complete release. The average position of the knee was 61.4 degrees of flexion preoperatively and 6 degrees postoperatively. The follow-up period averaged 21.3 months. Preoperatively, 87% of patients were nonambulatory. Following hamstring release 43% became ambulatory and 17% had gained the ability to transfer. Complications included two stroke patients with severe peripheral vascular disease; one developed a large nonhealing sore of the ankle and the other developed gangrene of the foot. Both patients required amputation. Three other patients developed recurrent flexion contractures that have since been rereleased with good results.

Influence of acute isocapnic hypoxia on bronchial calibre and "expiratory reserve" volume in dogs

The effects of hypoxia on bronchial calibre were investigated in anaesthetized dogs using a computer-aided forced airflow oscillation technique which derived specific lower airways conductance (sGlaw) and "expiratory reserve volume" (ERV). Measurements were made with inspired oxygen concentrations varying from 40% to 10%. sGlaw tended to be slightly reduced (indicating bronchoconstriction) by decreasing the oxygen concentration from 40% to 15%, these changes being statistically significant after the administration of atropine. ERV was unaffected by changes in oxygen concentration from 40% to 15%, but was significantly reduced during ventilation with 10% oxygen. This effect was reversed by re-oxygenation and was not abolished by prior administration of atropine. It was concluded that both bronchoconstriction and changes in lung volume may be responsible for changes in airway resistance during hypoxia.

Approaches to senior care #3. Orthopaedic management of the stroke patient. Part II: Treating deformities of the upper and lower extremities

Cerebrovascular accidents are among the most serious medical problems in the United States. In Part I of this report, the pathophysiology, types of impairment, and evaluation of the stroke patient were discussed. In this report, Part II, the management of extremity deformities will be reviewed.

Antagonism of morphine-induced respiratory depression with nalmefene

The duration of respiratory depression induced by morphine 10 mg/70 kg was studied following the administration of one of two opioid antagonists. Respiratory measurements included: (i) the ventilatory response to carbon dioxide, described in two ways--the minute ventilation at an end-tidal carbon dioxide partial pressure of 8 kPa (VE8) and the log slope of the ventilatory response to carbon dioxide; (ii) resting end-tidal carbon dioxide partial pressure; (iii) rate of ventilation. One hour after administration of morphine, one of the following was given i.v.: nalmefene 0.4 mg/70 kg; naloxone 0.4 mg/70 kg (low dose); naloxone 1.6 mg/70 kg (high dose); or saline placebo. The depression of VE8 by morphine was antagonized by all three treatments for the 1.5 h after the injection. However, for the 1.5-6 h after antagonist, VE8 following naloxone became depressed, whereas VE8 after nalmefene remained significantly increased compared with other treatments. Nalmefene restored the slope of the ventilatory response to baseline for 6 h and differed significantly from low but not high dose naloxone. Resting end-tidal carbon dioxide measurements demonstrated that nalmefene activity exceeded that of low but not high dose naloxone over the 1.5-4.5 h period. Rate of ventilation was not different between treatments.

Current status of functional lower extremity surgery in adult spastic patients

Ten percent of upper motor neuron spastic patients are candidates for functional surgery. If the main cause of the disability is abnormal muscle tone and not sensation, balance, cognition, or perceptual problems, good results from tendon lengthening or transfers are to be expected. The preoperative work-up should consist of examination, trial orthoses, nerve blocks, and most importantly dynamic electromyography. Releases or neurectomies are generally done in nonfunctional patients. Phenol blocks are a temporizing procedure during the phase of neurologic recovery. The patients all tolerated the anesthesia well, and the surgical risks are the same as in other lower extremity procedures.

Group A streptococcal infection in children younger than three years of age

We evaluated 758 sick children younger than 3 years of age for Group A beta-hemolytic streptococcal (GABHS) upper respiratory infection (URI) to determine the usual clinical presentation of the disease in this age group, indications for culture and the optimal site(s) from which to isolate the organism. GABHS infection was documented in 35 subjects (4.6%). The classic presentation (as proposed in the 1940s) of GABHS URI in children younger than 3 years of age was not confirmed by this study. In 32 of the GABHS cases there were pharyngitis, common cold symptoms or both, and these were associated with acute otitis media 10 times and with otitis media with effusion 3 times. Clinical impetigo was associated with GABHS URI (4 of 32 cases). GABHS URI would not have been documented in 6 of 32 cases if cultures of the anterior nares had not been performed. Children between 18 and 36 months of age were more likely to have GABHS disease than were younger children. Hoarseness and vomiting occurred less frequently in children younger than 36 months with GABHS infection than in those of that age who had non-beta-hemolytic streptococcal illnesses. A history of two or more siblings at home or a family member with a recent streptococcal infection and the presence of irritability, a reddened throat or palate or uvular edema were each associated with GABHS URI. We concluded that sick children between 18 and 36 months of age with a reddened throat should have cultures taken of the throat and anterior nares for GABHS.(ABSTRACT TRUNCATED AT 250 WORDS)

Approaches to senior care #2. Orthopaedic management of the stroke patient. Part I. Pathophysiology, limb deformity, and patient evaluation

Cerebrovascular accidents remain one of the most serious medical problems in the United States. They are responsible for 200,000 deaths per year and are the leading cause of hemiplegia in the adult. The purpose of these reports is to review the orthopaedic aspects of stroke rehabilitation, with emphasis on functional defects, evaluation of the patient, and methods of treatment. Part I will discuss the pathophysiologic changes and patient evaluation. Part II will discuss the surgical and nonsurgical management of extremity deformities.