Is the postanesthesia care unit becoming an intensive care unit?

The increasing number of critically ill patients requiring prolonged lengths of stay in the surgical intensive care unit has led hospitals to examine ways of using the PACU as a short-term area for critically ill patients. This article identifies common problems associated with this situation, and offers suggestions/guidelines to facilitate a smooth transition and ensure competent care of these patients. This article will not focus on financial issues related to patient charges. The criteria established in this article are based on personal experience.

The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1--a meta-analysis of 15 prospective cohort studies

BACKGROUND

To evaluate the relation between elective cesarean section and vertical transmission of human immunodeficiency virus type 1 (HIV-1), we performed a meta-analysis using data on individual patients from 15 prospective cohort studies.

METHODS

North American and European studies of at least 100 mother-child pairs were included in the meta-analysis. Uniform definitions of modes of delivery were used. Elective cesarean sections were defined as those performed before onset of labor and rupture of membranes. Multivariate logistic-regression analysis was used to adjust for other factors known to be associated with vertical transmission.

RESULTS

The primary analysis included data on 8533 mother-child pairs. After adjustment for receipt of antiretroviral therapy, maternal stage of disease, and infant birth weight, the likelihood of vertical transmission of HIV-1 was decreased by approximately 50 percent with elective cesarean section, as compared with other modes of delivery (adjusted odds ratio, 0.43; 95 percent confidence interval, 0.33 to 0.56). The results were similar when the study population was limited to those with rupture of membranes shortly before delivery. The likelihood of transmission was reduced by approximately 87 percent with both elective cesarean section and receipt of antiretroviral therapy during the prenatal, intrapartum, and neonatal periods, as compared with other modes of delivery and the absence of therapy (adjusted odds ratio, 0.13; 95 percent confidence interval, 0.09 to 0.19). Among mother-child pairs receiving antiretroviral therapy during the prenatal, intrapartum, and neonatal periods, rates of vertical transmission were 2.0 percent among the 196 mothers who underwent elective cesarean section and 7.3 percent among the 1255 mothers with other modes of delivery.

CONCLUSIONS

The results of this meta-analysis suggest that elective cesarean section reduces the risk of transmission of HIV-1 from mother to child independently of the effects of treatment with zidovudine.

IkappaBalpha degradation and nuclear factor-kappaB DNA binding are insufficient for interleukin-1beta and tumor necrosis factor-alpha-induced kappaB-dependent transcription. Requirement for an additional activation pathway

Two closely related IkappaBalpha kinases as well as the upstream kinase, NIK, which integrates interleukin-1beta (IL-1beta)- and tumor necrosis factor (TNF)-alpha-dependent activation of the transcription factor NF-kappaB have recently been described. However, in this emerging pathway the role of previously identified components of cytokine-induced NF-kappaB activation, namely phosphatidylcholine-specific phospholipase C and protein kinase C, remains unclear. We now show that, in A549 human alveolar epithelial cells, the activation of a stably transfected NF-kappaB-dependent reporter gene by TNF-alpha and IL-1beta is completely blocked by the phosphatidylcholine-specific phospholipase C inhibitor D609 and the protein kinase C inhibitor RO31-8220. However, IL-1beta-induced IkappaBalpha degradation as well as NF-kappaB nuclear translocation and DNA binding, as determined by Western blot and electro-mobility shift assay, respectively, are not affected by these inhibitors. A similar effect, although less pronounced, is observed with the p38 mitogen-activated protein kinase inhibitor SB 203580. On the basis of these data we propose the existence of a second signaling pathway induced by IL-1beta and TNF-alpha that is activated in parallel to the cascade leading to IkappaBalpha degradation and is specifically required for NF-kappaB-dependent transcriptional competency.

Impact of zidovudine use on risk and risk factors for perinatal transmission of HIV. Perinatal AIDS Collaborative Transmission Studies

OBJECTIVES

To evaluate the impact of perinatal zidovudine use on the risk of perinatal transmission of HIV and to determine risk factors for transmission among women using perinatal zidovudine.

DESIGN

Prospective cohort study of 1533 children born to HIV-infected women between 1985 and 1995 in four US cities.

METHODS

The association of potential risk factors with perinatal HIV transmission was assessed with univariate and multivariate statistics.

RESULTS

The overall transmission risk was 18% [95% confidence interval (CI), 16-21]. Factors associated with transmission included membrane rupture > 4 h before delivery [relative risk (RR), 2.1; 95% CI, 1.6-2.7], gestational age < 37 weeks (RR, 1.8; 95% CI, 1.4-2.2), maternal CD4+ lymphocyte count < 500 x 10(6) cells/l (RR, 1.7; 95% CI, 1.3-2.2), birthweight < 2500 g (RR, 1.7; 95% CI, 1.3-2.1), and antenatal and neonatal zidovudine use (RR, 0.6; 95% CI, 0.4-0.9). For infants exposed to zidovudine antenatally and neonatally, the transmission risk was 13% overall but was significantly lower following shorter duration of membrane rupture (7%) and term delivery (9%). The transmission risk declined from 22% before 1992 to 11% in 1995 (P < 0.001) in association with increasing zidovudine use and changes in other risk factors.

CONCLUSIONS

Perinatal HIV transmission risk has declined with increasing perinatal zidovudine use and changes in other factors. Further reduction in transmission for women taking zidovudine may be possible by reducing the incidence of other potentially modifiable risk factors, such as long duration of membrane rupture and prematurity.

Superinduction of COX-2 mRNA by cycloheximide and interleukin-1beta involves increased transcription and correlates with increased NF-kappaB and JNK activation

Many primary response genes, including cyclooxygenase-2 (COX-2), exhibit mRNA superinduction following agonist stimulation in the presence of translational blockers such as cycloheximide. This is widely assumed to result from mRNA stabilisation. However, superinduction of IL-1beta-induced COX-2 mRNA levels by cycloheximide in pulmonary type II A549 cells occurred by increased transcription and not by mRNA stabilisation. Furthermore, equivalent effects were observed on NF-kappaB binding to COX-2 promoter kappaB sites and activation of the Jun N-terminal kinases (JNK), p54 and p46. These signalling pathways play important roles in COX-2 induction and may therefore account for the observed increases in COX-2 transcription. These data are consistent with negative feed-back involving down-regulation of NF-kappaB by de novo IkappaB alpha synthesis and suggest that JNK activation may also be down-regulated by a cycloheximide sensitive process.

Controlled trial of exposure and response prevention in obsessive-compulsive disorder

BACKGROUND

Exposure and response prevention is considered a treatment of choice for obsessive-compulsive disorder (OCD). Yet there have been very few randomised controlled trials employing credible placebo conditions. This study compares exposure and response prevention with a general anxiety management intervention.

METHOD

Eighteen patients meeting DSM-IV criteria for OCD were randomly assigned to either exposure and response prevention or anxiety management. Both treatments involved approximately 15 hours of therapy over a three-week period.

RESULTS

There was a significant reduction in obsessive-compulsive symptoms following treatment with exposure and response prevention, while no change occurred in the control group. This was found to be statistically significant using a composite measure of OCD symptom severity, patient ratings of interference and therapist ratings of symptom severity.

CONCLUSIONS

These findings suggest that the symptom reductions associated with behaviour therapy for OCD are a result of the specific techniques of exposure and response prevention, rather than non-specific aspects of the therapy process. General anxiety management techniques are not effective in the treatment of OCD.

Isolation and molecular identification of planctomycete bacteria from postlarvae of the giant tiger prawn, Penaeus monodon

Bacteria phenotypically resembling members of the phylogenetically distinct planctomycete group of the domain Bacteria were isolated from postlarvae of the giant tiger prawn, Penaeus monodon. A selective medium designed in the light of planctomycete antibiotic resistance characteristics was used for this isolation. Planctomycetes were isolated from both healthy and monodon baculovirus-infected prawn postlarvae. The predominant colony type recovered from postlarvae regardless of viral infection status was nonpigmented. Other, less commonly observed types were pink or orange pigmented. A planctomycete-specific 16S rRNA-directed probe was designed and used to screen the isolates for their identity as planctomycetes prior to molecular phylogenetic characterization. 16S rRNA genes from nine prawn isolates together with two planctomycete reference strains (Planctomyces brasiliensis and Gemmata obscuriglobus) were sequenced and compared with reference sequences from the planctomycetes and other members of the domain Bacteria. Phylogenetic analyses and sequence signatures of the 16S rRNA genes demonstrated that the prawn isolates were members of the planctomycete group. Five representatives of the predominant nonpigmented colony type were members of the Pirellula group within the planctomycetes, as were three pink-pigmented colony type representatives. Homology values and tree topology indicated that representatives of the nonpigmented and pink-pigmented colony types formed two discrete clusters within the Pirellula group, not identical to any known Pirellula species. A sole representative of the orange colony type was a member of the Planctomyces group, virtually identical in 16S rDNA sequence to P. brasiliensis, and exhibited distinctive morphology.

General practice referrals to a department of neurology

OBJECTIVE

Assessment of general practitioner (GP) new referrals to a neurology department in terms of satisfaction for patient and doctor.

DESIGN

Prospective study by questionnaire of patients, GPs and specialists.

SETTING

Neurology hospital outpatient clinics.

SUBJECTS

339 consecutive new outpatients.

MAIN OUTCOME MEASURES

Overall patient satisfaction with clinic attendance, with allocated time and waiting times after referral; GP's reasons for referral, and satisfaction with outcome; specialists' actions in the clinic, views on referral.

RESULTS

Some 67% of patients found the referral helpful; 23% felt there was insufficient time to explain fully their problem. Nearly half of the patients had waited > or = 6 months for an appointment. The GP was uncertain of the diagnosis at referral in 76% of cases and found information from the clinic useful in 89%. Specialists made a new diagnosis in 40% of referrals, discharged 73% (with or without investigation) and admitted 11%; 76% of referrals were felt to be appropriate.

CONCLUSIONS

Patients and GPs usually found the referral helpful. Seeing patients more briefly is inappropriate since almost a third already felt consultation time to be short. Although some referrals may have been inappropriate, the dominant deficiency in the service was the time they had to wait after the referral. To satisfy local need, it is estimated that twice the present number of consultant neurologists would be required.

A prospective population-based study of HIV perinatal transmission

OBJECTIVE

To estimate the perinatal HIV transmission rate and describe the natural history of infant HIV infection in a situation in which HIV status is known in more than 95% of delivering women.

DESIGN

A cohort of HIV-exposed infants born between 7 July 1987 and 30 June 1990, whose mothers were identified by routine voluntary universal HIV testing, were followed using clinical and laboratory measures.

SETTING

Grady Memorial Hospital, a major health-care site for individuals of lower socioeconomic status in Atlanta, Georgia, USA, with approximately 7000 deliveries per year.

PATIENTS

HIV-exposed infants (n = 165), 98% of whom were African American.

RESULTS

Annual maternal HIV seroprevalence increased from 0.58 to 0.86%. The annual proportion of HIV-positive women having a second delivery increased from 4.3 to 25%. Clinical outcome was known for 132 out of 165 infants (22 infected and 110 uninfected), the transmission rate was 17% (confidence interval, 11-24%). The rate declined to 11% by the third year of the study. Gestational growth, prematurity and mode of delivery were unrelated to infant outcome. There was a trend for intravenous drug use to be more common in mothers of infected infants (P = 0.08). After 35 months median follow-up of infected infants, eight out of 22 (36%) had an opportunistic infection (seven Pneumocystis carinii pneumonia); three out of 22 (14%) had lymphocytic interstitial pneumonia, and 10 out of 22 (45%) were asymptomatic or had only nonspecific symptoms. Cumulative mortality in infected infants was 9, 32 and 32% by 1, 2 and 3 years of age, respectively.

CONCLUSION

In this cohort of HIV-exposed infants, perinatal HIV transmission was 17% overall. Factors affecting the transmission rate and possible future changes in the rate require further study.

Effect of peritoneal dialysis effluent on superoxide anion production by polymorphonuclear neutrophils

Peritoneal dialysis effluent (PDE) contains at least 2 factors capable of affecting superoxide generation by polymorphonuclear neutrophils (PMN) in response to both particulate and soluble stimuli. A low molecular weight fraction (< 1.2 kD) enhanced the response to the chemotactic peptide fMLP and to preopsonised Staphylococcus epidermidis and Candida guilliermondii. A higher molecular weight fraction (> 1.2 kD) inhibited superoxide production in response to phorbol myristate acetate (PMA). The effects of PDE were dose dependent over the range of 10-70% (v/v) and simply augmented and reduced the dose-response curve to fMLP and PMA, respectively. There was no alteration in the concentration of stimulus required to give maximal superoxide production in either case. These data suggest that factors capable of affecting superoxide production by PMN accumulate in uraemia and are removed from the circulation into dialysis fluid.

Diagnosis of human immunodeficiency virus infection by enzyme-linked immunospot assays in a prospectively followed cohort of infants of human immunodeficiency virus-seropositive women

The enzyme-linked immunospot (ELISPOT), a method for quantifying specific and total antibody-secreting cells, was used for the diagnosis of human immunodeficiency virus (HIV) infection in a prospectively followed cohort of infants born to HIV-infected women. From July 1, 1987, to June 1, 1990, 127 infants with known HIV infection status were studied. Seventeen of 22 HIV-infected infants had specific HIV-specific antibody-secreting cells (ASC). Among the infected infants rates of ASC positivity increased during the first year of life, from 25% in the first 5 days of life to 78% after 6 months. Two of the five ASC-negative infected infants were further characterized as hypo- or dysgammaglobulinemic by an adjunct ELISPOT assay for total immunoglobulin-secreting cells. Excluding hypo- or dysgammaglobulinemic infants from the analysis, the rate of ASC positivity among infected infants was 85% (17 of 20) after the age of 6 months. None of the 95 uninfected infants had a positive ELISPOT assay, including 55 who were tested in the first 3 months of life. Thus in this series the specificity was 100%. ELISPOT methodology can be a useful technique for the diagnosis of HIV infection in infants of HIV-seropositive mothers.

Identification and partial characterization of parathyroid hormone-related protein in human and bovine milk

Parathyroid hormone-related protein (PTHrP) was measured in human and bovine milk by radioimmunoassay (RIA) and bioassay, and the molecular forms characterized by gel chromatography and immunoblotting of affinity-purified PTHrP. Mean immunoreactive PTHrP(1-34) concentrations were 23 and 87 micrograms/l in human and bovine milk respectively. Bioactive (BIO) PTHrP concentrations determined by cyclic AMP production by ROS 17/2.8 cells correlated significantly (P less than 0.001) with those obtained by RIA (BIO = 1.04RIA--3.4, r = 0.939). Gel filtration of human and bovine milk identified several peaks with immunoactivity and bioactivity. Immunoblotting of affinity-purified PTHrP revealed multiple molecular species including components with mobilities similar to those of PTHrP and its subfragments. These studies confirm the presence of immuno- and bioactive PTHrP in milk and suggest that post-translational processing is complex and variable.

Peritoneal cestodiasis in a dog

An unusual case of progressive abdominal distention due to massive infection with proliferating cestode larvae is reported in an imported Italian Greyhound. Cystic parasites, first detected incidentally at ovariohysterectomy, eventually infiltrated most abdominal organs and entered the pericardium. Morphologic, histologic, and electromicroscopic observations did not permit definitive identification of the parasites; however, they were not typical of the larval forms of species of either Taenia or Mesocestoides, which have been associated with this rare condition in the United States.