The cost of health system change: public discontent in five nations

Many nations have undergone changes in health care financing and services. The public notices policy changes in health care and frequently bears new and unexpected costs or barriers to care unwillingly. This paper presents data from surveys of about 1,000 adults conducted during April-June 1998 in each of five countries--Australia, Canada, New Zealand, the United Kingdom, and the United States--to measure public satisfaction with health care. In no nation is a majority content with the health care system. Different systems pose different problems: In systems with universal coverage, dissatisfaction is with the level of funding and administration, including queues. In the United States, the public is primarily concerned with financial access.

Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma

OBJECTIVE

To evaluate systemic versus epidural opioid administration for analgesia in patients sustaining thoracic trauma.

SUMMARY BACKGROUND DATA

The authors have previously shown that epidural analgesia significantly reduces the pain associated with significant chest wall injury. Recent studies report that epidural analgesia is associated with a lower catecholamine and cytokine response in patients undergoing elective thoracotomy compared with patient-controlled analgesia (PCA). This study compares the effect of epidural analgesia and PCA on pain relief, pulmonary function, cathechol release, and immune response in patients sustaining significant thoracic trauma.

METHODS

Patients (ages 18 to 60 years) sustaining thoracic injury were prospectively randomized to receive epidural analgesia or PCA during an 18-month period. Levels of serum interleukin (IL)-1beta, IL-2, IL-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) were measured every 12 hours for 3 days by enzyme-linked immunosorbent assay. Urinary catecholamine levels were measured every 24 hours. Independent observers assessed pulmonary function using standard techniques and analgesia using a verbal rating score.

RESULTS

Twenty-four patients of the 34 enrolled completed the study. Age, injury severity score, thoracic abbreviated injury score, and length of hospital stay did not differ between the two groups. There was no significant difference in plasma levels of IL-1beta, IL-2, IL-6, or TNF-alpha or urinary catecholamines between the two groups at any time point. Epidural analgesia was associated with significantly reduced plasma levels of IL-8 at days 2 and 3, verbal rating score of pain on days 1 and 3, and maximal inspiratory force and tidal volume on day 3 versus PCA.

CONCLUSIONS

Epidural analgesia significantly reduced pain with chest wall excursion compared with PCA. The route of analgesia did not affect the catecholamine response. However, serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury, were significantly reduced in patients receiving epidural analgesia on days 2 and 3. This may have important clinical implications because lower levels of IL-8 may reduce infectious or inflammatory complications in the trauma patient. Also, tidal volume and maximal inspiratory force were improved with epidural analgesia by day 3. These results demonstrate that epidural analgesia is superior to PCA in providing analgesia, improving pulmonary function, and modifying the immune response in patients with severe chest injury.

Discovery of self: exploring, interconnecting and integrating self (concept) and nursing

Self concept of individual nurses is still largely unexplored in nursing. While the role of self-knowledge and self-actualisation are recognised as integral to nursing practice, little has been done to examine their relationships to self concept and nursing practice. The aim of this research study was to explore the role and significance that self concept plays in women nurses' experience of their beginning practice. The exploration examined factors which contribute to and impact on self concept within a nursing practice environment. Self concept relates to how an individual experiences oneself and is integrally linked to one's interactions and relationships with others. This two phase research was situated in critical and feminist theory using reflective journalling (phase one) and story telling/narrative (phase two) as the research methods. This paper discusses the three major themes which arose in phase one of the research. Those were: exploring experiences; interconnecting personal and professional worlds; and, integrating self 'into' nursing. The paper also explores inter-subjectivity in terms of the contribution this concept makes to our understanding of research findings.

Primitive human hematopoietic progenitor cells express receptors for granulocyte-macrophage colony-stimulating factor

Most cytokines act only synergistically in assays of primitive progenitor cell proliferation, and effects have usually been observed first after prolonged cell culture. Studies reporting that primitive progenitors lack receptors for a number of cytokines, including granulocyte-macrophage colony stimulating factor (GM-CSF), could indicate that several "synergistic" cytokines primarily affect cells that have differentiated in vitro. Here, however, we show that freshly isolated primitive progenitor cells (CD34hi CD38-) express receptors for GM-CSF at levels 20%-30% of granulo-monocytic progenitors. Although GM-CSF had minimal effects on the survival or proliferation of primitive progenitors when added alone, the cytokine enhanced stem cell factor (SCF) induced cell cycle entry in the first generation. The effect was not observed when cells were incubated sequentially with SCF and GM-CSF. The results suggest that the synergistic effects of GM-CSF are mediated directly on primitive progenitor cells and that the cytokine may be useful to enhance cell cycle entry of hematopoietic stem cells.

Shaping the future of Medicare

This article suggests that further major changes in Medicare at this time are unwarranted. The enactment of the Balanced Budget Act (BBA) has eliminated the need for quick action to assure solvency of the Part A Trust Fund, which is projected to be in balance for at least ten years. It will take time to implement and assess the effects of the BBA. The uncertainties of future trends in the health sector and Medicare suggest a go-slow approach. Future reforms to finance health care as the baby boom generation retires should be guided by the goals of continuing to assure health and economic security to elderly and disabled beneficiaries, with particular attention to the financial burdens on lower-income beneficiaries and those with serious illnesses or chronic conditions. Employers are cutting back on retiree health coverage, and the appropriate contribution of employers will need to be addressed. The BBA included major provisions to expand Medicare managed care choices. Special attention will need to be given to how well these innovations work, their cost impact on Medicare, the extent to which beneficiaries are able to make informed choices, and whether risk selection among plans and between traditional Medicare and plans can be adequately addressed. Most of the savings of BBA came from tighter payment rates to managed care plans and fee-for-service providers; it is unclear whether these will lead to rates well below the private sector or whether further savings can be achieved by extending these changes beyond 2002.

Systemic sclerosis prevalence and mortality in Sydney 1974-88

BACKGROUND

Systemic sclerosis prevalence and mortality estimates have demonstrated wide variability. The sole Australian study published to date demonstrated high prevalence rates when compared to overseas estimates. The prevalence and mortality findings reported in this paper derive from a larger study which addressed the distribution and determinants of systemic sclerosis within Sydney.

AIMS

To determine systemic sclerosis prevalence and mortality rates within Sydney over 15 years, 1974-88.

METHODS

Cases were ascertained from multiple sources including death certificates, hospitals, physicians, vascular surgeons' and dermatologists' private practices, a systemic sclerosis self-help group and private medical laboratories.

RESULTS

Overall, 715 cases were identified. Females comprised 77% (95% CI: 74-80) of cases. Disease of the limited subtype accounted for 79% (95% CI: 76-82) of all systemic sclerosis, being relatively more frequent in living than deceased cases, and in females than males. Crude prevalence estimates appeared to rise between 1975 (4.52/100,000 95% CI:3.75-5.29/100,000) and 1988 (8.62/100,000 95% CI:7.64-9.60/100,000) as did estimates of diffuse disease. However, diffuse disease prevalence, when expressed as a proportion of total disease prevalence, showed no significant temporal change. Although crude mortality rates also showed apparent temporal increases (0.24/100,000 in 1975 to 0.80/100,000 in 1988) standardised mortality rates showed less convincing trends (0.41/100,000 in 1976 and 0.40/100,000 in 1988). Death certificate-derived mortality rates provided relatively large underestimates of total mortality. However, these underestimates were relatively constant over time.

CONCLUSIONS

This study has demonstrated systemic sclerosis prevalence and mortality rates comparable to overseas estimates, consistently higher prevalence and mortality rates in females than males, proportionally higher rates of diffuse disease in males than females and in deceased cases than living cases, a diffuse: limited disease ratio apparently stable over time, apparently increasing temporal prevalence and mortality rates and, by implication, rising incidence rates. The observed temporal rise in diffuse disease prevalence and the absence of a convincing fall in diffuse disease mortality suggests a rising temporal incidence rate of diffuse disease. Standardised mortality rates demonstrated less consistent trends than did crude mortality rates and failed to demonstrate convincing declines in mortality subsequent to the introduction of ACE inhibitors for management of systemic sclerosis renal disease. Death certificate-derived systemic sclerosis mortality rates considerably and consistently underestimated systemic sclerosis-all cause mortality.

A mouse model for evaluation of prophylaxis and therapy of Ebola hemorrhagic fever

The Zaire subtype of Ebola virus (EBO-Z) is lethal for newborn mice, but adult mice are resistant to the virus, which prevents their use as an animal model of lethal Ebola infection. We serially passed EBO-Z virus in progressively older suckling mice, eventually obtaining a plaque-purified virus that was lethal for mature, immunocompetent BALB/c and C57BL/6 inbred and ICR (CD-1) outbred mice. Pathologic changes in the liver and spleen of infected mice resembled those in EBO-Z-infected primates. Virus titers in these tissues reached 10(9) pfu/g. The LD50 of mouse-adapted EBO-Z virus inoculated into the peritoneal cavity was approximately 1 virion. Mice were resistant to large doses of the same virus inoculated subcutaneously, intradermally, or intramuscularly. Mice injected peripherally with mouse-adapted or intraperitoneally with non-adapted EBO-Z virus resisted subsequent challenge with mouse-adapted virus.

Familial risk estimation in systemic sclerosis

BACKGROUND

Familial systemic sclerosis has been rarely reported. Assumptions have therefore been made implying no familial disease aggregation. This study critically challenges the assumption using a methodical population-based epidemiological approach to quantify the prevalence and characteristics of familial systemic sclerosis.

METHODS

In this retrospective cohort study the systemic sclerosis prevalence in first degree family members was compared between 715 systemic sclerosis patients (710 families) and 371 randomly ascertained age and gender group-matched general practice controls (371 families). These data, obtained by telephone questionnaire (living patients) or medical records review (deceased patients and untraceable patients of unknown living status), were validated, where necessary, and expressed in terms of relative risk, absolute risk and population point prevalence.

RESULTS

Systemic sclerosis affecting first degree members was validated in ten of 710 families. Reporting of systemic disease in another four more distant family members, and the co-occurrence of systemic and localised disease in three families was also documented. Observed and expected disease subtype concordance was 80% (44-97%) and 68% respectively and the female predominance among familial cases was similar to that for non-familial disease. The risk of disease in a subsequent first degree relative was compared to the risk in an initial first degree family member. Its estimated magnitude was wide (11-158). However, use of population prevalence data to determine the expected number of systemic sclerosis patients in the negative cohorts' families suggests the higher estimate is more realistic. Despite the high magnitude, the absolute disease risk in first degree family members remained low--approximating 1%. The population prevalence of familial systemic sclerosis approximated 1.4/million.

CONCLUSIONS

This study substantially increases the otherwise small list of documented instances of familial systemic sclerosis. More importantly, it quantifies the risk for the first time, ranking it as the disease's most powerful determinant identified to date.

CASS Registry long term surgical survival. Coronary Artery Surgery Study

OBJECTIVES

To show the effect of clinical, angio and demographic traits on late survival of Coronary Artery Surgery Study (CASS) patients following coronary artery bypass grafting (CABG) and introduce Hazard Function analysis to CASS survival data.

METHODS

Patients were reached by mail survey with 94% response. By National Death Index, vital status was obtained in 99.7% (n = 8221) with a mean follow up of 15 years. Cox proportional hazard and Blackstone Hazard Function regressions were used to assess effects of preoperative traits.

RESULTS

Ninety percent of patients were alive at 5, 74% at 10 and 56% at 15 years. Of those age 65 and age 75 at operation, 74% and 59% were living at 10 years and 54% and 33% at 15 years (now age 90), survival exceeding the matched U.S. population. Hazard Function falls rapidly after CABG to 9 to 12 months, then rises, doubling by 15 years. Young patients, below age 35, had lower late survival. The time-segmented Cox model (divided at time suggested by the Hazard Function) identified traits showing predictive power early, throughout and late. Female sex, small body surface, ischemic symptoms and emergency status affected survival early. Heavier weight, infarct(s), diuretics, diabetes, smoking, left main and LAD stenosis and use of vein grafts only increased hazard late only.

CONCLUSIONS

There are still lessons from the CASS database. CABG in the elderly is supported by the survival pattern of our patients age 75 at operation. Time-segmented Cox analysis and Hazard Function analysis separate baseline variables into those that predict early mortality and those that predict long survival.

Changes in respiratory mechanics after tracheostomy

OBJECTIVE

To determine the effects of tracheostomy on respiratory mechanics and work of breathing (WOB).

DESIGN

A before-and-after trial of 20 patients undergoing tracheostomy for repeated extubation failure.

SETTING

Surgical intensive care unit at a university teaching hospital and a level I trauma center.

PATIENTS

A consecutive sample of 20 patients who met extubation criteria (Pa(O2), >55 mm Hg; pH >7.30; and respiratory rate, <30/min on room air continuous positive airway pressure after 20 minutes) but failed extubation on 2 occasions were eligible for the study.

INTERVENTIONS

Respiratory mechanics, lung volumes, and WOB were measured before and after tracheostomy.

MAIN OUTCOME MEASURES

Patients in whom extubation fails often progress to unassisted ventilation after tracheostomy. The study hypothesis was that tracheostomy would result in improved pulmonary function through changes in respiratory mechanics.

RESULTS

Data are given as means +/- SDs. After tracheostomy, WOB per liter of ventilation (0.97+/-0.32 vs. 0.81+/-0.46 J/L; P<.09), WOB per minute (8.9+/-2.9 vs. 6.6+/-1.4 J/min; P<.04), and airway resistance (9.4+/-4.1 vs. 6.3+/-4.5 cm H20/L per second; P<.07) were reduced compared with breathing via an endotracheal tube. These findings, however, do not fully explain the ability of patients to be liberated from mechanical ventilation after tracheostomy. In 4 patients who were extubated before tracheostomy, WOB was significantly greater during extubation than when breathing through an endotracheal or tracheostomy tube (1.2+/-0.19 vs. 0.81+/-0.24 vs. 0.77+/-0.22 J/L).

CONCLUSIONS

We believe that the rigid nature of the tracheostomy tube represents reduced imposed WOB compared with the longer, thermoliable endotracheal tube. The clinical significance of this effect is small, although as respiratory rate increases, the effects are magnified. In patients in whom extubation failed, WOB may be elevated because of incomplete control of the upper airway. Future studies should evaluate the cause of increased WOB after extubation.

Primary care and psychiatry: anticipating an interfaith marriage

The emergence of a managed-care--driven health delivery system in the United States has had a major impact on both primary care physicians and psychiatrists. Since a significant portion of psychiatric disorders present in primary care settings and a significant number of patients with emotional disorders receive their care from primary care physicians, the convergence of the two fields of medicine seems likely. Surveys document that both the diagnosis and the treatment of emotional disorders are inadequate in primary care. The authors review possible approaches to rectifying this situation and show that the attachment of the psychiatrist to the primary care team offers many advantages to the provision of clinical services, the education of a diverse group of trainees, and the collaboration of two categories of physician not typically seen as working closely together. The authors also describe an outpatient county medical clinic in which the concept of "attachment-liaison" of the psychiatrist to the primary care setting is tested on a daily basis. The authors (a psychiatrist and an internist), who met in this setting, detail their initial expectations and the observed outcomes of having a psychiatrist join the clinic team. The various tasks of the psychiatrist in this primary care setting are enumerated, along with several typical case presentations.

An activity in rat tissues that modifies nitrotyrosine-containing proteins

Homogenates from rat spleen and lung could modify nitrotyrosine-containing BSA. With incubation, nitrotyrosine-containing BSA lost its epitope to a monoclonal antibody that selectively recognized nitrotyrosine-containing proteins. In the presence of protease inhibitors, the loss of the nitrotyrosine epitope occurred without protein degradation and hydrolysis. This activity was found in supernatant but not particulate fractions of spleen homogenates. The factor was heat labile, was sensitive to trypsin treatment, and was retained after passage through a membrane with a 10-kDa retention. The activity was time- and protein-concentration dependent. The activity increased about 2-fold in spleen extracts with endotoxin (bacterial lipopolysaccharide) treatment of animals, suggesting that the activity is inducible or regulatable. Other nitrotyrosine-containing proteins also served as substrates, while free nitrotyrosine and some endogenous nitrotyrosine-containing proteins in tissue extracts were poor substrates. Although the product and possible cofactors for this reaction have not yet been identified, this activity may be a "nitrotyrosine denitrase" that reverses protein nitration and, thus, decreases peroxynitrite toxicity. This activity was not observed in homogenates from rat liver or kidney, suggesting that there may also be some tissue specificity for the apparent denitrase activity.

An emancipatory impulse: a feminist postmodern integrated turning point in nursing research

This article critiques the current debates regarding feminism, postmodernism, and feminist/postmodernism within nursing research. The critique classified the debates into three identifiable constructs: dissatisfaction, fragmentation, and integration. The authors propose a solution from the integration debate as an emancipatory "workable" turning point for nursing research. The solution is situated within feminism and draws on the epistemological constructs of both modernism and postmodernism. Nursing research is framed within the proposed ontological links that characterize the integrated solution.

A mouse model for evaluation of prophylaxis and therapy of Ebola hemorrhagic fever

The Zaire subtype of Ebola virus (EBO-Z) is lethal for newborn mice, but adult mice are resistant to the virus, which prevents their use as an animal model of lethal Ebola infection. We serially passed EBO-Z virus in progressively older suckling mice, eventually obtaining a plaque-purified virus that was lethal for mature, immunocompetent BALB/c and C57BL/6 inbred and ICR (CD-1) outbred mice. Pathologic changes in the liver and spleen of infected mice resembled those in EBO-Z-infected primates. Virus titers in these tissues reached 10(9) pfu/g. The LD50 of mouse-adapted EBO-Z virus inoculated into the peritoneal cavity was approximately 1 virion. Mice were resistant to large doses of the same virus inoculated subcutaneously, intradermally, or intramuscularly. Mice injected peripherally with mouse-adapted or intraperitoneally with non-adapted EBO-Z virus resisted subsequent challenge with mouse-adapted virus.

Mutational analysis of exoribonuclease I from Saccharomyces cerevisiae

Exoribonuclease I from yeast is a 175 kDa protein that is responsible for the majority of cytoplasmic mRNA degradation. Alignment of the Xrn1p sequence with homologs from yeast as well as from higher eukaryotes suggests that the protein is composed of several domains: two acidic N-terminal domains which likely contain the exonuclease, a basic middle domainand a basic C-terminal domain. Deletion analysisdemonstrated that the C-terminus is dispensable for most in vivo and in vitro functions but confers a dominant negative growth inhibition when expressed at high levels. This growth inhibition is not due to the exonuclease function of the protein. To identify specific residues responsible for in vivo function, a screen was carried out for non-complementing missense mutations. Fourteen single point mutations were identified that altered highly conserved amino acids within the first N-terminal domain of Xrn1p. All of the mutations reduced exonuclease activity measured in vivo and in vitro using affinity-purified proteins. The mutants fell into two phenotypic classes, those that reduced or abolished exonuclease activity without qualitatively changing the products of RNA degradation and those that gave rise to novel degradation intermediates on certain RNAs.

Dignified dying as a nursing outcome

The goal for humanistic end-of-life care is to maintain quality of life and personal dignity. The nursing outcome called "dignified dying" is defined as maintaining personal control and comfort with the approaching end of life and lists indicators for measuring this. These criteria enable nurses to measure the effectiveness of their nursing interventions, monitor patient progress over time, and summarize research data. This article describes the development of this outcome and illustrates its use with a case study.

An in-house coordinator program to increase organ donation in public trauma hospitals

A 4-year retrospective study was conducted regarding the donor potential, consent rates, and organ recovery at a large 500-bed public trauma hospital. An independent organ procurement organization hired two in-house coordinators, one white and one black, to work exclusively in the hospital. The duties of the in-house coordinators included the following: working with nurses, physicians, and residents to identify donors; closely managing and coordinating the consent process; and assisting organ procurement coordinators in donor management. Following the program's implementation and the use of race-specific requesters, a 64% increase in consent rate resulted along with an overall increase of 94% in the number of organ donors. The consent rate of blacks increase 115%, whereas the number of black organ donors increased 154%. The Hispanic consent rate increased 48% with a corresponding increase of 83% in the number of Hispanic organ donors. In addition, the white consent rate increased from 55% (the 3-year average from 1993 to 1995) to 75% in 1996, resulting in a 36% increase following the implementation of the program. The investment of dedicated race-sensitive personnel in large urban county trauma facilities can result in a significant increase in donor conversion rates.

Anaesthesia circuits, humidity output, and mucociliary structure and function

We compared the effects of humidity delivered by the circle system at low fresh gas flows (FGF) with a conventional two-limb and coaxial circuit on the structure and function of the tracheobronchial epithelium in dogs. Animals were anaesthetized and mechanically ventilated using an anaesthesia ventilator to maintain normocarbia. Group I (control) animals received a FGF equal to the required minute ventilation mimicking an open circuit technique. Group II and III animals had FGF set at 20% of the required minute ventilation. Group II used a two-limb circuit and Group III used a coaxial circuit. Relative humidity and temperature of inspired gases were measured at baseline and hourly afterwards. In the first experiment, biopsies of the tracheobronchial tree were obtained bronchoscopically at baseline and then hourly for six hours. Microscopic examination of these samples allowed calculation of mean ciliary length. In the second experiment, tracheal mucus flow velocity (TMFV) was measured at baseline and hourly afterward, using a cinebroncho-fibrescopic method. Delivered absolute humidity was greatest with low FGF and the coaxial circuit, followed by low FGF and a conventional circuit, and high FGF (15 +/- 1.4 vs 9 +/- 0.8 vs 5 +/- 0.4 mg H2O, P < 0.01) after two hours. Mean cilia length (micron) and TMFV (mm/min) fell during the first hour in all three groups. At hour two TMFV returned to baseline in Group III and was significantly greater than Groups I and II (0.8 +/- 0.4 vs 8.6 +/- 1.1 vs 15.4 +/- 2.1, P < 0.001). Mean ciliary length demonstrated a similar pattern with reductions from baseline in all three groups for the first two hours. Groups II and III had an increase in cilia length beginning at hour three and were both significantly greater than Group I at hours 3 through 6 (1.3 +/- 0.5 vs 3.2 +/- 1.1 vs 4.2 +/- 0.8, P < 0.001). Alterations in tracheobronchial structure and function result from exposure to dry gases and are amplified by the duration of exposure. Our findings suggest a minimum of 12 to 15 mg H2O/l is necessary to prevent these alterations. In this study, the combination of low FGF and a coaxial anaesthesia circuit reached this minimum threshold more quickly than a conventional two-limb circuit.

An in-house coordinator program to increase organ donation in public teaching hospitals

The organ donor referral rates at Ben Taub General Hospital, a level 1 county trauma facility in Houston, Tex, were in the high 90s from 1993 through 1996. However, organs were procured from only 25% of those potential donors who were medically suitable. LifeGift Organ Donation Center identified two issues concerning the hospital's organ donor referrals: early medical management problems and a low consent rate. The hospital and LifeGift developed an in-house coordinator program along with specific protocols that have markedly increased the quantity of organ donors. In fiscal year 1994, 15 organ donors were recovered; in fiscal year 1995, following the implementation of the program, 25 organ donors were recovered. In fiscal year 1996, 39 organ donors were recovered. The in-house coordinators' consent rate was 72% of medically suitable potential donors. Early referrals for evaluation contributed to these successes.

Listening to parents. A national survey of parents with young children

OBJECTIVE

To document the child-rearing needs and pediatric health care experiences of parents with children from birth to 3 years old.

DESIGN

A nationally representatives sample of 2017 parents with children younger than 3 years using a 25-minute structured telephone questionnaire. Interviews were completed by 68% of the screened eligible respondents. The margin of sampling error for results at the 95% confidence level was +/- 3 percentage points.

RESULTS

Seventy-six percent of children younger than 3 years were reported by parents to be in excellent health; 88% had a regular source of pediatric health care. Seventy-one percent of parents who received special pediatric services rated their child's physician as excellent in providing good health care. Seventy-nine percent of parents reported they could use more information in at least 1 of 6 areas of child rearing, and 53% wanted information in at least 3 areas. Forty-two percent had talked with their child's physician about "nonmedical" concerns; 39% of parents read to or looked at a picture book with their child on a daily basis; 51% of parents set daily routines for meals, naps, and bedtime. Breast-feeding and reading to the child on a daily basis were much more likely if a physician encouraged parents to do so.

CONCLUSIONS

Most parents view the pediatric health care system as meeting the physical health needs of their young children. Parents want more information and support on child-rearing concerns, yet pediatric clinicians often fail to discuss nonmedical questions with them. The interventions of pediatric clinicians can positively affect parental behavior. Pediatric practices should consider creative ways to reconstitute and augment their current services and systems of care.

The processing of yeast pheromones

Yeast provides an attractive system in which to study proprotein processing. Many of their processing events are remarkably similar to those in higher eukaryotes and their amenability to experimental manipulation permits approaches that are not always feasible in multicellular organisms. Analysing the biosynthesis of the yeast mating pheromones has been particularly rewarding and has provided insights into both the proteolytic aspects of processing and other post-translational events such as prenylation and carboxymethylation.

Look to the future

With the UKCC and the national boards up for review, a consultation document proposes a radical overhaul of these governing bodies. Professional organisations have until the end of next month to respond. Here, their leaders give Nursing Times a hint of what they may say.

Effects of inhaled nitric oxide in patients with acute respiratory distress syndrome: results of a randomized phase II trial. Inhaled Nitric Oxide in ARDS Study Group

OBJECTIVES

To evaluate the safety and physiologic response of inhaled nitric oxide (NO) in patients with acute respiratory distress syndrome (ARDS). In addition, the effect of various doses of inhaled NO on clinical outcome parameters was assessed.

DESIGN

Prospective, multicenter, randomized, double-blind, placebo-controlled study.

SETTING

Intensive care units of 30 academic, teaching, and community hospitals in the United States.

PATIENTS

Patients with ARDS, as defined by the American-European Consensus Conference, were enrolled into the study if the onset of disease was within 72 hrs of randomization.

INTERVENTIONS

Patients were randomized to receive placebo (nitrogen gas) or inhaled NO at concentrations of 1.25, 5, 20, 40, or 80 ppm.

MEASUREMENTS AND MAIN RESULTS

Acute increases in PaO2, decreases in mean pulmonary arterial pressure, intensity of mechanical ventilation, and oxygenation index were examined. Clinical outcomes examined were the dose effects of inhaled NO on mortality, the number of days alive and off mechanical ventilation, and the number of days alive after meeting oxygenation criteria for extubation. A total of 177 patients were enrolled over a 14-month period. An acute response to treatment gas, defined as a PaO2 increase > or =20%, was seen in 60% of the patients receiving inhaled NO with no significant differences between dose groups. Twenty-four percent of placebo patients also had an acute response to treatment gas during the first 4 hrs. The initial increase in oxygenation translated into a reduction in the FIO2 over the first day and in the intensity of mechanical ventilation over the first 4 days of treatment, as measured by the oxygenation index. There were no differences among the pooled inhaled NO groups and placebo with respect to mortality rate, the number of days alive and off mechanical ventilation, or the number of days alive after meeting oxygenation criteria for extubation. However, patients receiving 5 ppm inhaled NO showed an improvement in these parameters. In this dose group, the percentage of patients alive and off mechanical ventilation at day 28 (a post hoc analysis) was higher (62% vs. 44%) than the placebo group. There was no apparent difference in the number or type of adverse events reported among those patients receiving inhaled NO compared with placebo. Four patients had methemoglobin concentrations >5%. The mean inspired nitrogen dioxide concentration in inhaled NO patients was 1.5 ppm.

CONCLUSIONS

From this placebo-controlled study, inhaled NO appears to be well tolerated in the population of ARDS patients studied. With mechanical ventilation held constant, inhaled NO is associated with a significant improvement in oxygenation compared with placebo over the first 4 hrs of treatment. An improvement in oxygenation index was observed over the first 4 days. Larger phase III studies are needed to ascertain if these acute physiologic improvements can lead to altered clinical outcome.

Organization, development, and effects of infraorbital nerve transection on galanin binding sites in the trigeminal brainstem complex

Previous experiments from this laboratory have indicated that transection of the infraorbital nerve (ION, the trigeminal [V] branch that supplies the mystacial vibrissae follicles) at birth and in adulthood has markedly different effects on galanin immunoreactivity in the V brainstem complex. Adult nerve transection increases galanin immunoreactivity in the superficial layers of V subnucleus caudalis (SpC) only, while neonatal nerve transection results in increased galanin expression in vibrissae-related primary afferents throughout the V brainstem complex. The present study describes the distribution of binding sites for this peptide in the mature and developing V ganglion and brainstem complex and determines the effects of neonatal and adult ION damage and the associated changes in galanin levels upon their distribution and density. Galanin binding sites are densely distributed in all V brainstem subnuclei and are particularly dense in V subnucleus interpolaris and the superficial layers of SpC. They are present at birth (P-0) and their distribution is similar to that in adult animals. Transection of the ION in adulthood and examination of brainstem 7 days later indicated marked reductions in the density of galanin binding sites in the V brainstem complex. With the exception of the superficial laminae of SpC, the same reduction in density remained apparent in rats that survived > 45 days after nerve cuts. Transection of the ION on P-0 resulted in no change in the density of galanin binding sites in the brainstem after either 7 or > 60 days survival. These results indicate that densely distributed galanin binding sites are present in the V brainstem complex of both neonatal and adult rats, that they are located in regions not innervated by galanin-positive axons, and that their density is not significantly influenced by large lesion-induced changes in the primary afferent content of their natural ligand.

Molecular analysis of the NF2 tumor-suppressor gene in schwannomatosis

Patients with multiple schwannomas without vestibular schwannomas have been postulated to compose a distinct subclass of neurofibromatosis (NF), termed "schwannomatosis." To compare the molecular-genetic basis of schwannomatosis with NF2, we examined the NF2 locus in 20 unrelated schwannomatosis patients and their affected relatives. Tumors from these patients frequently harbored typical truncating mutations of the NF2 gene and loss of heterozygosity of the surrounding region of chromosome 22. Surprisingly, unlike patients with NF2, no heterozygous NF2-gene changes were seen in normal tissues. Examination of multiple tumors from the same patient revealed that some schwannomatosis patients are somatic mosaics for NF2-gene changes. By contrast, other individuals, particularly those with a positive family history, appear to have an inherited predisposition to formation of tumors that carry somatic alterations of the NF2 gene. Further work is needed to define the pathogenetics of this unusual disease mechanism.

Inhaled nitric oxide in acute respiratory distress syndrome

BACKGROUND

Inhaled nitric oxide has been shown to improve oxygenation in select patients with acute respiratory distress syndrome (ARDS).

OBJECTIVE

The purpose of this study was to evaluate the clinical response to four concentrations of inhaled nitric oxide (NO) in 20 patients with ARDS.

METHODS

All patients with ARDS were eligible for the study. ARDS was defined as (1) the presence of a predisposing factor; (2) a PaO2/FiO2 ratio < 200; (3) bilateral infiltrates on chest radiograph; and (4) absence of evidence of congestive heart failure and pulmonary artery wedge pressure < 18 mm Hg. Patients received each of four doses (1, 15, 30, and 60 ppm) in random order, each for a 3-hour period. Cardiovascular variables were continuously monitored, and arterial and mixed venous blood gas measurements were obtained at 30 minutes and 3 hours.

RESULTS

Thirteen of the 20 patients demonstrated a significant increase in their PaO2/FiO2 (> 20% increase) when treated with inhaled NO. The administration of inhaled NO was associated with an increase in oxygenation at doses of 1, 15, and 30 ppm, but not 60 ppm. Increasing NO dose to more than 1 ppm did not significantly improve response. Mean pulmonary artery pressure decreased with increasing NO concentration, but this did not reach statistical significance. Nine of the 13 responding patients and 2 of the 7 nonresponding patients survived.

CONCLUSION

Inhaled NO was successful in increasing PaO2/FiO2 by > 20% in 65% of the surgical patients in this trial. Response to NO could not be predicted by initial PaO2/FiO2 or pulmonary artery pressures. A trial of inhaled NO at a dose of < 10 ppm may be helpful in ARDS patients requiring increasing FiO2 and positive end-expiratory pressure.

Use of the rapid/shallow breathing index as an indicator of patient work of breathing during pressure support ventilation

BACKGROUND

Measuring patient work of breathing (WOBpt) has been suggested to provide safe, aggressive weaning from mechanical ventilation. We compared WOBpt and pressure-time-product (PTP) to routine weaning parameters [breath rate (f), tidal volume (VT), frequency/tidal volume ratio (f/VT)] at different levels of pressure support ventilation (PSV).

METHODS

Fifteen patients in the surgical intensive care unit requiring prolonged weaning (more than 3 days) were entered in the study. A balloon-tipped esophageal catheter was placed and position confirmed by inspection of pressure and flow waveforms. Each patient was randomly assigned to breathe with 5, 10, 15, and 20 cm H2O of PSV. After 30 minutes, 40 breaths were recorded and analyzed. Measurement of WOBpt PTP, f, VT, and f/VT were made using the Bicore CP-100 monitor. Mean values for each parameter were calculated. PTP and WOBpt were plotted against f/VT to determine correlation coefficient.

RESULTS

PTP, WOBpt and f/VT decreased in a stepwise fashion as PSV was increased. The f/VT correlated most closely with WOBpt (r = 0.983) and PTP (r = 0.972). Monitoring f alone also correlated with WOBpt (r = 0.894) and PTP (r = 0.881). All patients were weaned from the ventilator (mean duration, 22 +/- 5.9 days). Nine patients required tracheostomy before final liberation from the ventilator (mean duration, 22 +/- 5.9 days). Nine patients required tracheostomy before final liberation from the ventilator.

CONCLUSIONS

Direct measurement of WOBpt is invasive, expensive, and' may be confusing to clinicians. Monitoring f/VT may be useful when changing PSV during weaning.

The effect of early versus late fasciotomy in the management of extremity trauma

BACKGROUND

Recent reports have demonstrated an increase in the number of complications associated with delayed timing of fasciotomy for trauma. This study examines the effectiveness of early (less than 12 hours) versus late (more than 12 hours) fasciotomy in the injured extremity.

METHODS

This is a retrospective review of 88 patients undergoing fasciotomy for extremity trauma admitted to the University of Cincinnati from January 1990 through December 1995. Records were reviewed for demographics, compartment pressures, time and type of fasciotomy, complications, limb salvage, and mortality. Statistical analysis was determined with chi-squared, multivariant regression analysis, and Student's t test with significance at p less than 0.05.

RESULTS

Sixty-one (69%) patients had fasciotomy performed before 12 hours and twenty-seven (31%) after 12 hours. Although the rates of infection differed significantly between the two groups (7.3% for early versus 28% for late), the rates of limb salvage and neurologic sequelae were similar. Age, mechanism, shock, associated injuries, and time to fasciotomy were not predictive of complications.

CONCLUSIONS

Fasciotomy for trauma is most efficacious when performed early. However, when performed late, it results in similar rates of limb salvage as compared with early fasciotomy but at the increased risk of infection. These results support aggressive use of fasciotomy in extremity trauma regardless of time of diagnosis.

Carbamoylation of brain glutamate receptors by a disulfiram metabolite

S-Methyl-N,N-diethylthiolcarbamate sulfoxide (DETC-MeSO), a metabolite of the drug disulfiram, is a selective carbamoylating agent for sulfhydryl groups. Treatment of glutamate receptors isolated from mouse brain with DETC-MeSO blocks glutamate binding. In vivo, carbamoylated glutathione, administered directly to mice or formed by reaction of DETC-MeSO with glutathione in the blood, also blocks brain glutamate receptors. Carbamoyl groups appear to be delivered to brain glutamate receptors or to liver aldehyde dehydrogenase in vivo by a novel glutathione-mediated mechanism. Seizures caused by the glutamate analogs N-methyl-D-aspartate and methionine sulfoximine, or by hyperbaric oxygen, are prevented by DETC-MeSO, indicating that carbamoylation of glutamate receptors gives an antagonist effect. These observations offer an explanation for some of the previously reported neurological effects of disulfiram, such as its ability to prevent O2-induced seizures. Furthermore, some of the physiology of the disulfiram-ethanol reaction, that could not be accounted for based on the known inhibition of aldehyde dehydrogenase alone, may be explained by disulfiram's effect on glutamate receptors.

Insurance matters for low-income adults: results from a five-state survey

Using survey data from 2,000 low-income adult respondents in each of five states, this DataWatch assesses how uninsured, low-income adults differ from low-income adults who have public or private insurance and how Medicaid expansions have affected insurance coverage patterns across states with different eligibility policies. Findings show that the proportion of low-income uninsured adults is two to three times higher in states that have not expanded Medicaid eligibility beyond relatively low welfare levels. Compared with persons who have either Medicaid or private insurance, uninsured persons report more difficulties getting needed care, are less likely to have a regular provider, and rate the care they do receive as lower quality.

Effect of citrate concentration in specimen collection tubes on the International Normalized Ratio

PROBLEM

Does citrate concentration in specimen collection tubes affect the International Normalized Ratio?

METHODS

The International Normalized Ratio was determined on quadruplicate plasma specimens from 32 patients treated long term with oral anticoagulants-two from tubes with 3.2% citrate and two with 3.8% citrate. Two laboratories, using two different coagulometers, tested the specimens.

RESULTS

International Normalized Ratios of plasma from tubes with 3.8% citrate were significantly higher than those from tubes with 3.2% citrate when tested with either coagulometer. Patients given adequate anticoagulation on the basis of the International Normalized Ratio at one concentration of citrate appeared either overanticoagulated and at risk of bleeding or underanticoagulated and at risk of thromboembolism at the other concentration of citrate.

CONCLUSION

Results emphasize the need for using a single concentration of citrate for prothrombin time testing. We recommend 3.2% citrate.