Avoidance of 20% carbon dioxide-enriched air with humans

Four college students were exposed to a Sidman avoidance procedure to determine if an avoidance contingency involving 20% carbon dioxide-enriched air (CO2) would produce and maintain responding. In Phase 1, two conditions (contingent and noncontingent) were conducted each day. These conditions were distinguished by the presence or absence of a blue or green box on a computer screen. In the contingent condition, CO2 presentation were delivered every 3 s unless a subject pulled a plunger. Each plunger pull postponed CO2 presentations for 10 s. In the noncontingent condition, CO2 presentations occurred on the average of every 5 min independent of responding. Following stable responding in Phase 1, condition-correlated stimuli were reversed. In both conditions, plunger response rate was high during the contingent condition and low or zero during the noncontingent condition. Furthermore, subjects avoided most CO2 presentations. However, CO2 presentations did not increase verbal reports of fear. Overall, the results from the present study suggest that CO2 can be used effectively in basic studies of aversive control and in laboratory analogues of response patterns commonly referred to as anxiety.

Information technology in accident and emergency departments

The aim of this study was to assess the availability and use of information technology in accident and emergency departments (A&E) in the UK. A postal questionnaire was sent to every general A&E department in the UK which sees more than 25,000 new attendances/year (n = 217). Responses were obtained from 159 (73.3%) departments, of which 129 (81.1%) were computerized. Computer data was used for administration in 96.9%, for audit in 79.1% and for research in only 41.1%. Most used several sources of toxicology information, but telephone advice from the poisons information bureau was the main source. Of the hospitals, 74.2% offered courses in computer technology to their staff. The availability of information technology varies widely between departments. If the most is to be made of available technology, staff training must be more widely available and more actively promoted.

Cardiac troponins in patients with renal dysfunction

Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) were measured in 198 patients with renal dysfunction [132 men: median (range) age 66.1 (8.2-90.3) years]. cTnT was measured by two methods: ELISA and Enzymun (Boehringer Mannheim UK, Lewes, UK), both with a detection limit of 0.05 microgram/L in 179 and 78 patients, respectively. cTnI was measured in 80 patients by the OPUS plus and OPUS Magnum systems (Dade-Behring, Milton Keynes, UK) with a detection limit of 0.5 microgram/L. Patients were classified as having chronic renal impairment (CRI), chronic renal failure (CRF), acute renal failure including those with multiple organ failure on renal replacement therapy (ARF), and patients with chronic renal failure treated with haemodialysis (HD). Cardiac troponins were detectable in the serum of patients with renal dysfunction. cTnT was detectable in 113/179 (63.1%) and 33/78 (42.3%) by the ELISA and Enzymun methods respectively. cTnI was detectable in 17/80 (21.3%). cTnT (ELISA and Enzymun methods) and cTnI were detectable with increased frequency in the CRF, HD and ARF patient groups compared with the CRI group. Cardiac troponin concentrations did not correlate with serum creatine kinase (CK) activity, CK-MB, or urea or creatinine levels. Serial cardiac troponin measurements may be required to confirm or exclude a diagnosis of acute coronary syndromes in patients with renal dysfunction.

Planning and implementing an anesthesia crisis resource management course for student nurse anesthetists

Development of Anesthesia Crisis Resource Management (ACRM) skills is a highly desirable outcome of a nurse anesthesia educational program. Access to an ACRM course is limited by a variety of factors including cost, availability of a center, time constraints, and the lack of adequately prepared CRNA faculty. The authors describe a Nurse Anesthesia Program's planning and implementation of an ACRM course by using a high fidelity human simulator. Key supportive and logistical elements necessary to implement an ACRM course are described. The authors address administrative concerns, faculty preparation needs, and explain the process of course design. Strengths of the course and problems encountered during the implementation of the experience are described. Feedback from participating students, faculty perceptions, and lessons learned from the experience are shared.

Anesthesia for an achondroplastic dwarf with bilateral vocal cord granuloma: use of a Xomed Hunsaker Mon-Jet ventilation tube

Technological advances have greatly improved the management of the patient undergoing microlaryngeal surgery. The use of a laser, high frequency jet ventilation (HFJV), total intravenous anesthetic techniques (TIVA), and specially designed endotracheal tubes (Xomed Hunsaker Mon-Jet ventilation tube [Xomed Surgical Products, Jacksonville, FL]) are recognized as cutting edge approaches to the management of these cases. The use of high technology adjuncts requires considerable skill and knowledge from the perspective of the anesthesia provider. This case report describes an approach to anesthetic management for a patient with a history of achondroplastic dwarfism having laser excision of bilateral vocal cord granulomas. Further increasing the complexity of the case was the surgical use of an autogenous tissue glue, which required a period of 'airway silence' during the application process.

Severe cardiac dysrhythmia in patients using bromocriptine postpartum

Used worldwide since 1980 for the prevention of breast engorgement in the puerperium, in 1994 bromocriptine mesylate was withdrawn from the American market as an agent suitable for ablactation. The relevant recommendation of the Food and Drug Administration rested on case reports that described severe vasospastic reactions among users of the drug. Some patients so affected suffered stroke, intracranial bleeding, cerebral edema, convulsions, myocardial infarction, and puerperal psychosis. More recently, it has been suggested that the side effects of the drug may also include circulatory collapse secondary to cardiac dysrhythmia. This report describes two additional cases in this category. The antepartum clinical evaluation of these women suggested that they were predisposed to arrhythmias.

Donor-derived Plasmodium vivax infection following volunteer unrelated bone marrow transplantation

A 14-year-old girl from the UK underwent volunteer unrelated donor bone marrow transplant (VUD BMT) for accelerated phase chronic myeloid leukaemia. On day +40 she became febrile, and peripheral blood smears demonstrated a 1% Plasmodium vivax parasitaemia. Although she had never been outside the UK, her male donor had documented Plasmodium vivax infection during a vacation in Papua New Guinea. Following appropriate treatment, he had been asymptomatic for 11 months before marrow harvesting. This is the first case report of malarial transmission by VUD BMT, and illustrates the potential problem of recrudescence of latent, dormant forms of Plasmodium vivax infection following transplantation into an immuno-compromised recipient. Even after appropriate therapy, malarial infection should be included in the differential diagnosis for all post-transplant febrile episodes.

Successful second bone marrow transplant for Fanconi's anaemia following escalation of conditioning

Allogeneic bone marrow transplantation represents the treatment of choice for severe bone marrow failure in patients with Fanconi's anaemia (FA). In view of the increased sensitivity to alkylating agents documented in this condition, much attention has focused on reducing the conditioning chemotherapy. We present a 13-year-old girl in whom sibling allogeneic BMT after conditioning with low-dose cyclophosphamide only resulted in graft rejection. However, a second transplant using the same donor proved successful following a more intensive conditioning regimen. This case demonstrates the phenotypic variability of FA, and highlights the need for tailoring the conditioning regimen for a given patient.

Use and effectiveness of hypothermia blankets for febrile patients in the intensive care unit

We performed a prospective observational (noninterventional) study of hypothermia blanket use in a population of adult intensive care unit patients with body temperatures of > or = 102.5 degrees F. Thirty-nine of ninety-four febrile episodes (in 83 patients) were treated with hypothermia blankets. Logistic regression revealed that the strongest independent predictors of hypothermia blanket use were a temperature of > or = 103.5 degrees F (odds ratio [OR] = 17), mechanical ventilation (OR = 25), and acute central nervous system illness (OR = 7.5). Hospitalization in the medical intensive care unit was strongly associated with avoidance of this therapy (OR = 0.023). Treatment with a hypothermia blanket was ordered by a physician in only 15% of cases. The mean cooling rate was the same (0.028 degree F/h) for blanket-treated and control patients. Multivariate Cox regression and factorial and repeated measures of analysis of variance revealed that blanket treatment was not more effective than other cooling methods. However, this treatment was associated with more "zigzag" temperature fluctuations of > or = 3 degrees F (56% of blanket-treated patients vs. 18% of control patients; P < .001) and rebound hypothermia (18% vs. 0; P = .001). Hypothermia blanket therapy is primarily a nursing decision. We conclude that in addition to being no more effective than other cooling measures, hypothermia blanket therapy was associated with more temperature fluctuations and with more episodes of rebound hypothermia.

High prevalence of elevated factor VIII levels in patients referred for thrombophilia screening: role of increased synthesis and relationship to the acute phase reaction

A recent report from the Leiden Thrombophilia Survey identified high factor VIII activity levels as an independent risk factor for venous thromboembolism in a population survey. As the study measure for factor VIII was a one-stage coagulation assay, and since markers for the acute phase reaction were not assessed, it remained uncertain whether the increase was due to a constitutional increased rate of synthesis, to circulating activated factor VIII, or to an acute phase response. We added factor VIII activity assay (FVIII:C), factor VIII antigen (FVIII:Ag), vWF antigen (vWF:Ag), ABO blood group, fibrinogen and C-reactive protein to our routine thrombophilia screen of patients referred because of unexplained thromboembolism. Elevated FVIII:C (> 1.5 iu/ml) emerged as the single commonest abnormality detected in 25.4% of a group of 260 such patients. FVIII:C and FVIII:Ag were highly correlated (p = 0.003), showing that this represented a true increase in FVIII. In 4 of 46 patients this was clearly attributable to an acute phase reaction. Eleven others showed minor elevation of ESR and one of CRP. Neither FVIII:C or FVIII:Ag showed significant correlation with fibrinogen, ESR or C-reactive protein by non parametric analysis. Although there was an excess of patients with B blood group (known to be associated with FVIII:C levels which are approximately 15% higher than those in blood group O), this could not account for the marked elevation of factor VIII observed in these patients. We conclude that factor VIII activity assay should be a routine part of thrombophilia screening. We are investigating the cause of the increased synthesis, initially by means of family studies and linkage analysis with polymorphic markers of the FVIII locus. We postulate that it may be constitutive in some cases and in others an abnormal or exaggerated response to inflammatory stimuli.

The ability of A&E personnel to demonstrate inhaler technique

OBJECTIVE

To determine the ability of accident and emergency (A&E) personnel to demonstrate metered dose inhaler technique.

METHODS

25 senior house officers and 25 nurses working in A&E were individually interviewed and assessed on their knowledge of inhaler technique and competence in demonstrating the correct use of a metered dose inhaler.

RESULTS

Demonstration of inhaler technique was generally poor by the staff assessed. Although 22 (88%) of the senior house officers were aware of the British Thoracic Society guidelines, only 10 (40%) routinely checked inhaler technique when discharging asthmatic patients.

CONCLUSIONS

The A&E department offers an important opportunity for patient assessment and reinforcement of metered dose inhaler technique. Staff should be made aware of the British Thoracic Society guidelines and be competent at assessing and teaching inhaler technique.

Canavirgella banfieldii Needlecast of Pinus strobus in Michigan

In the winter of 1995 to 1996, browning and dieback of the 1995 needle complement of Pinus strobus L., resembling needlecast caused by Canavirgella banfieldii Merrill et al. (1), was observed in Antrim County, MI. (Needle dieback = distal portions of the needles die, but short basal segments remain living and diseased needles remain attached until normal shedding of the entire complement.) Affected needles at that time had not developed ascomata, but bore spent pycnidia resembling those of C. banfieldii. About 25% of the symptomatic needles collected on 7 June 1996 bore hysterothecia of C. banfieldii in various stages of development. On wetting about 8% of these opened and released mature ascospores. Voucher specimens are in BPI and PACMA. Heretofore, C. banfieldii has been known from western North Carolina to central New York, northern Vermont, and central and eastern Maine. This is the first report of this pathogen in the Lake States, a significant extension of its known distribution, and substantiates in part our belief that this long-overlooked fungus probably occurs throughout the natural range of P. strobus. Reference: (1) W. Merrill et al. Can. J. Bot. 74:1476, 1996.

Necrotising fasciitis as a complication of steroid injection

Necrotising fasciitis is described as a complication of steroid injection of a painful shoulder in a previously well female. This case highlights a very rare life threatening emergency after steroid injection. Early recognition, resuscitation, and aggressive surgical management are essential to prevent mortality in this condition.

What do family members expect from the family physician of a deceased loved one?

BACKGROUND AND OBJECTIVES

This study examined what actions are expected from a family physician by the family members of a deceased patient immediately following the death of the patient.

METHODS

Those listed as next of kin on the charts of deceased patients of a suburban family practice residency were asked to complete a questionnaire about their expectations of their family member's family physician after the death.

RESULTS

Expectation of the surveyed actions was surprisingly low, with attendance at the funeral the least expected, followed closely by acknowledgment of the anniversary of the family member's death. Nearly half of the respondents expected a telephone call shortly after the death, while close to one third expected the physician to ask about their emotional well-being at their next visit.

CONCLUSIONS

The results suggest that family members do not expect or rarely expect any action from their family member's family physician after the death. However, comments received with the survey indicate that any gesture of sympathy or show of concern from the family physician was greatly appreciated by the survivors.

Identification of the GalNAc kinase amino acid sequence

A new kinase that forms GalNAc-1-P was purified from pig kidney cytosol and identified on gels by labeling with N3-[32P]ATP (Pastuszak, I., Drake, R., and Elbein, A. D. (1996) J. Biol. Chem. 271, in press). A 50-kDa labeled protein was eluted, digested with trypsin, and the sequences of four peptides representing 49 amino acids showed 90% identity to sequence of human galactokinase reported to be on chromosome 15. To resolve this dilemma, activities and substrate specificities of galactokinase and GalNAc kinase from human and pig kidney, as well as of galactokinase from the yeast clone transfected with the cDNA from presumptive human galactokinase, were compared. The purified galactokinases phosphorylated galactose, but not GalNAc, whereas GalNAc kinase also phosphorylated galactose when this sugar was present at millimolar concentrations. Extracts of gal 1(-) yeast clone, transfected with presumptive human galactokinase cDNA, had very low galactokinase activity even when yeast were grown on galactose, but good activity with GalNAc. On the other hand, the wild type yeast phosphorylated galactose, but not GalNAc. These data indicate that the sequence reported for galactokinase on chromosome 15 is that of GalNAc kinase, which can phosphorylate galactose when this sugar is present at millimolar concentrations. This transfection thus allows the yeast mutant to grow slowly on galactose-containing media.

Predicting serious delinquency and substance use among aggressive boys

Early aggressive behavior puts boys at increased risk for involvement in a variety of later problem behaviors, including delinquency and drug abuse. However, not all boys who evidence aggressive behavior in childhood continue to engage in problem behaviors in adolescence. This 3.5-year prospective study examined the role of factors hypothesized by the social development model to inhibit or increase the likelihood of subsequent involvement in serious delinquency and substance use within a sample of boys identified as aggressive by teacher report at ages 10 and 11. At ages 12 and 13, a combination of the constructs of skills for prosocial involvement, school bonding and achievement, family bonding and management practices, norms against substance use, and interaction with peers and adults involved in antisocial behavior significantly discriminated between boys who were and were not involved in serious delinquent behavior and substance use at ages 13 and 14, although family bonding and management practices appeared to contribute little to the discriminant function. Implications of the results for preventive interventions with aggressive boys are discussed.

Dacarbazine, cisplatin and carmustine, with or without tamoxifen, for metastatic melanoma: 5-year follow-up

Metastatic melanoma has a grim prognosis. Response rates and survival of patients treated with combination chemotherapy are not superior to single-agent chemotherapy. This study seeks to evaluate the objective response rate and survival of patients with metastatic melanoma treated with multiagent chemotherapy, with or without tamoxifen. Forty-two patients with metastatic melanoma were treated from March 1982 to February 1988 with dacarbazine, cisplatin and carmustine, with or without tamoxifen. An overall objective response rate of 43% was seen (complete response rate 17%; partial response rate, 26%). The response rate was 54% for patients treated with tamoxifen and 25% for patients treated without tamoxifen, but the results did not achieve statistical significance. Median overall survival was 412 days, and was significantly longer in the tamoxifen-treated group. Combination chemotherapy as described in this study is well-tolerated. The observation that tamoxifen appears to impact on survival should be interpreted with great caution due to the deficiencies in the design of the trial and small patient numbers. A randomized trial of this regimen vs single-agent chemotherapy is indicated and is currently being conducted.

Expert panel method for nurse staffing and resource management

The Expert Panel Nurse Staffing and Resource Management Method is a bold new approach for the identification of nurse staffing requirements and the management of resources. Expert panels comprised of those most knowledgeable of the patient population and the uniqueness of specific patient care areas identify staff needed to meet clinical, administrative, education, continuous quality improvement, and research needs. In addition, the expert panels explore opportunities for systems improvements, work redesign, and administrative restructuring within the context of budgetary realities.

Predicting serious delinquency and substance use among aggressive boys

Early aggressive behavior puts boys at increased risk for involvement in a variety of later problem behaviors, including delinquency and drug abuse. However, not all boys who evidence aggressive behavior in childhood continue to engage in problem behaviors in adolescence. This 3.5-year prospective study examined the role of factors hypothesized by the social development model to inhibit or increase the likelihood of subsequent involvement in serious delinquency and substance use within a sample of boys identified as aggressive by teacher report at ages 10 and 11. At ages 12 and 13, a combination of the constructs of skills for prosocial involvement, school bonding and achievement, family bonding and management practices, norms against substance use, and interaction with peers and adults involved in antisocial behavior significantly discriminated between boys who were and were not involved in serious delinquent behavior and substance use at ages 13 and 14, although family bonding and management practices appeared to contribute little to the discriminant function. Implications of the results for preventive interventions with aggressive boys are discussed.