The teaching of cardiopulmonary resuscitation in schools in Hampshire

In order to maximise the number of potential providers of cardiopulmonary resuscitation (CPR) in the community, it has been suggested that a programme of basic life support (BLS) training should be included within the school curriculum. Using a questionnaire sent to 275 schools in south east Hampshire (representing 71,716 pupils), we discovered that BLS was taught at only 26% of schools which replied. The age at which teaching commenced ranged from 7-16 years (mode = 10 years). We estimated that almost 5000 children might currently be trained annually in these schools. Consequently, each year approximately 40% of children in south east Hampshire schools might be exposed to BLS training. On average, schools offering BLS tuition were larger, had more teaching staff and employed a higher proportion of staff who were themselves BLS providers. The majority of BLS teaching was undertaken by school staff (50.9% of schools) and members of the Red Cross, The St. John Ambulance Brigade or statutory ambulance service (30.9%). One school utilised members of the local fire brigade. Only one school offering BLS training to its pupils did not have a staff member trained in CPR.

Orientation program for a hospital-based dual case manager and educator role

The nurse case manager role is continually evolving. Case managers are being challenged to perform new functions. There are few articles concerning orientation programs for case managers. This article provides a successful orientation program and clinical orientation schedule for a unique unit-based nurse case manager/educator role. The orientation program is outlined based on the four competency domains of the nurse case manager/educator clinical expertise, resource management, staff education, and patient/family education. Program topics and an orientation schedule are provided.

The laryngeal mask airway and the tracheal route for drug administration

We undertook a study to observe if a preformed curved plastic cannula, the Trachojet, could be passed blindly down a laryngeal mask airway into the trachea in 100 anaesthetized patients. Using air aspiration and a fibreoptic scope to confirm placement of the cannula, it passed into the trachea in only 27% of patients. The air aspiration technique used for detecting tracheal cannulation was 100% successful when the cannula was inserted fully. We conclude that it may not be possible to gain access to the trachea with a Trachojet for drug administration if a laryngeal mask airway is used to maintain the patient's airway.

Critical pathway and patient and family teaching protocol for major depression

The pressures to contain cost, reduce resource consumption, and articulate outcomes will continue in psychiatric-mental health care. Case management and critical pathways focused on outcome management are systems and tools used to provide care in a cost-effective manner while maintaining the quality of patient care.

Prediction of outcome from intensive care: a prospective cohort study comparing Acute Physiology and Chronic Health Evaluation II and III prognostic systems in a United Kingdom intensive care unit

OBJECTIVE

To evaluate the ability of two prognostic systems to predict hospital mortality in adult intensive care patients.

DESIGN

Prospective cohort study.

SETTING

A mixed medical and surgical intensive care unit (ICU) in the United Kingdom.

PATIENTS

A total of 1,144 patients consecutively admitted to the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Acute Physiology and Chronic Health Evaluation (APACHE) II and III prognostic systems were applied to assess probabilities of hospital mortality, which were compared with the actual outcome. The overall goodness-of-fit of both models was assessed. Hospital death rates were higher than those predicted by each system. Risk estimates showed a strong positive correlation between both systems (nonsurvivors r2 = 0.756, p < .0001; survivors r2 = 0.787, p < .0001). Calibration of APACHE II (chi 2 = 98.6, Lemeshow-Hosmer) was superior to that of APACHE III (chi 2 = 129.8, Lemeshow-Hosmer). The total correct classification rate of APACHE III was greater for all decision criteria applied; the best overall total correct classification rate was 80.6% for APACHE III and 77.9% for APACHE II (both for a decision criterion of 40%). The areas under the receiver operating characteristic curves were 0.806 and 0.847 for APACHE II and III, respectively, confirming the better discrimination of APACHE III. When patients were classified by diagnostic categories, risk predictions did not fit uniformly across the spectrum of disease groups. For both models, mortality ratios were highest for trauma patients and lowest for the group with respiratory disease. APACHE II predictions for patients with gastrointestinal disease were significantly better. Risk estimates for surgical admissions were superior with APACHE II (MR = 1.27) compared with APACHE III (MR = 1.56), but were similar for medical patients (1.22 vs. 1.28 for APACHE II and III, respectively). Bias induced by factors reflecting the clinical practice in an individual ICU (e.g., admission criteria, treatment before admission) may have considerable impact on risk estimates. The identification of such factors appears to be a prerequisite for the meaningful interpretation of observed and predicted death rates on the individual ICU level.

CONCLUSIONS

Both predictive models demonstrated a similar degree of overall goodness-of-fit. APACHE II showed better calibration, but discrimination was better with APACHE III. Hospital mortality was higher than predicted by both models, but was underestimated to a greater degree by APACHE III. Risk estimates by both models showed considerable variation across the disease spectrum of ICU patients. Risk predictions for surgical patients and patients with gastrointestinal disease were better with APACHE II. Factors reflecting the clinical practice of an individual ICU are not accounted for by APACHE II and III. Overall, the performance of APACHE III was not superior to that of its predecessor for a cohort of United Kingdom ICU patients; for certain diagnostic categories, APACHE III performed worse than APACHE II despite an improved system of disease classification.

Drug substance manufacture process control: application of flow injection analysis and HPLC for monitoring an enantiospecific synthesis

Effective process control can only be achieved through an understanding of the operating issues of the reaction. The development and use of effective and rugged analytical methods is necessary to monitor these parameters. The intent of this paper is to present some key analytical issues encountered in the synthesis of MK-0679, an LTD4 antagonist. In a key step of the compound's synthesis, a prochiral diester intermediate undergoes an enantioselective enzymatic hydrolysis (in the presence of Triton X-100) leading to the (S)-ester acid. Subsequent processing transforms the ester acid into the final product. The residual amount of the detergent in the final product, the rapid determination of the enzymatic activity and the optical purity of the final product emerged as key issues in the control of the reaction. As a solution, two techniques were utilized and are presented: flow injection analysis and HPLC.

Rapid adaptation of myocardial calcium homeostasis to short episodes of ischemia in isolated rat hearts

Short episodes of ischemia and reperfusion (ischemic preconditioning) have been shown to attenuate the detrimental rise in intracellular free Ca2+ ([Ca2+]i) caused by subsequent sustained ischemia. The purpose of this study was to investigate the detailed time course of [Ca2+]i during such short episodes of ischemia and reperfusion. [Ca2+]i was measured at a high time resolution by surface fluorometry and indo-1 in isolated perfused rat hearts during three episodes of 5 minutes of ischemia followed by 5 minutes of reperfusion. We found that the rise in systolic [Ca2+]i was significantly smaller during the second (191% +/- 67%) and third (194% +/- 75%) episodes of ischemia than during the first episode (289% +/- 75%, P < 0.05 vs both subsequent episodes). This attenuated rise in systolic [Ca2+]i was preserved during perfusion with low extracellular Na+ (105.5 mmol/L [Na+]o). During short episodes of ischemia and reperfusion, [Ca2+]i rises less during the second and third ischemic episode than during the first episode. Thus one transient ischemic stimulus led to a rapid adaptation of [Ca2+]i homeostasis to subsequent ischemic conditions. Such a rapid adaptation might be an important mechanism of the ischemic preconditioning phenomenon in protecting against ischemic injury.

Continuous ascitic recirculation in severe ovarian hyperstimulation syndrome

Massive ascites, hydrothorax, acute renal failure and thromboembolism are clinical manifestations of severe ovarian hyperstimulation syndrome (OHSS) which may complicate the induction of ovulation with exogenous gonadotrophins. We report a case of severe OHSS with ascites formation in excess of five litres per day. Massive ascites and bilateral pleural effusions resulted in respiratory failure. Continuous ascitic recirculation (AR) was commenced after repeated paracentesis and i.v. fluid therapy failed to improve the patient's condition. The procedure was undertaken for a total of 15 days and rapidly resulted in marked improvement of impaired respiratory function. Febrile episodes occurred on 3 occasions, but we did not observe coagulation disturbances or adverse haemodynamic effects. Continuous AR is a safe and effective treatment of complicated severe OHSS.

Tyrosine kinase phosphorylation of GABAA receptors

Phosphorylation of purified bovine brain GABAA receptors by the tyrosine kinase, pp60v-src was examined. pp60v-src phosphorylated two bands of 54-62 kDa and 48-51 kDa that migrated to approximately the same position as bands recognized by antisera against the beta 2 and gamma 2 GABAA receptor subunits, respectively. Bacterially expressed proteins containing the putative large cytoplasmic loops of the beta 1 and gamma 2L subunits were phosphorylated by pp60v-src, indicating that the phosphorylation sites are located in these subunit domains. The tyrosine kinase inhibitors, genistein and the tyrphostins B-42 and B-44, inhibited muscimol-stimulated 36Cl- uptake in mouse brain membrane vesicles (microsacs). magnitude of the tyrphostin B-44-induced inhibition of muscimol-stimulated 36Cl- uptake was significantly reduced in microsacs that were lysed and resealed under conditions that inhibit phosphorylation. GABA-gated Cl- currents were also inhibited by genistein and tyrphostin B-44 in Xenopus oocytes expressing alpha 1 beta 1 and alpha 1 beta 1 gamma 2L subunits. Consequently, protein tyrosine kinase-dependent phosphorylation appears to be another mechanism of regulating the function of GABAA receptors.

Functional domains of GABAA receptors

The transmitter-gated ion channels mediate rapid synaptic transmission, for example, at the neuromuscular junction using acetylcholine and in the CNS using primarily the amino acids glutamate and GABA. GABAA-receptor Cl- channels share sequence homology with a superfamily of these channels including nicotinic acetylcholine receptor and inhibitory glycine receptor. In this article, Geoffrey Smith and Richard Olsen discuss recent affinity labelling and site-directed mutagenesis studies on GABAA receptors that have identified amino acid residues essential for binding of agonists and allosteric modulators as well as the ion channel wall formation. The structural domains identified are consistent with results obtained with other members of the transmitter-gated ion channel superfamily and suggest that structural models for one member of the family may apply to the others as well.