Outcome of diabetic patients treated in the prehospital arena after a hypoglycaemic episode, and an exploration of treat and release protocols: a review of the literature

OBJECTIVES

This review examines current treat and release protocols adopted by the ambulance service, and factors that may predispose patients to hypoglycaemia.

METHODS

Online database searches and hand searches of journals led to 241 articles being found, of which eight were used for this article.

RESULTS

Out of hospital treatment of hypoglycaemia is safe for most patients, but further studies are needed if positive improvements are to be made.

DISCUSSION

There is potential for further research in this area and clarification is needed in the treat and release debate. A definitive set of protocols would be beneficial to the ambulance service.

Interventions for post-traumatic stress disorder and psychological distress in emergency ambulance personnel: a review of the literature

A literature review was carried out to establish the extent of the literature on interventions for psychological distress and post-traumatic stress disorder in emergency ambulance personnel. A total of 292 articles were identified. Of these, 10 were relevant to this review. The primary intervention used with this population was critical incident stress debriefing, although there was some debate in the literature about the effectiveness of this intervention and the quality of the research conducted. More high quality research is needed on critical incident stress debriefing before being confident of its effectiveness.

An email audit of prehospital doctor activity in an area of the West Midlands

OBJECTIVES

To describe the nature and extent of prehospital doctor activity in an area of the West Midlands by review of group email. To explore the use of email as a means of data collection among a group of prehospital doctors.

METHODS

A retrospective review of data collected by a prehospital organisation's email based internet group.

RESULTS

Nearly half of prehospital doctor calls were to road traffic accidents and nearly half of these were "serious". Road traffic accidents involving pedestrians, trees, and motorcycles often resulted in fatalities. Doctors frequently performed medical interventions at scene. Midazolam and ketamine were administered commonly; the indications for their use varied. At two cases on scene anaesthesia was maintained for over an hour with ketamine.

CONCLUSIONS

There remains a role for prehospital doctors. Email provides a very useful medium to share information and facilitate audit among a group of doctors who do not meet on a regular basis or work in the same institution. A computerised proforma to be filled by doctors after each prehospital call is proposed in an attempt to standardise and gather information for future audit and discussion.

ETV6/AML1 fusion by FISH in adult acute lymphoblastic leukemia

Dual-color interphase fluorescence in situ hybridization (FISH) with ETV6 and AML1 probes was used for the first time on a series of 159 adult patients with acute lymphoblastic leukemia (ALL), for detection of the t(12;21)(p13;q22) translocation. Seven patients (4.4%) were found, with 50-100% of positive cells, of whom one of two tested, proved negative for the fusion product by RT-PCR. Two of them, aged 43 and 50 years, are the oldest patients so far confirmed to have the translocation. Three who relapsed at 10, 11 and 24 months, suggest that adults may not enjoy the good short-term prognosis reported for t(12;21)-positive children. Thirty-one-negative cases had signal numbers differing from the two expected for each gene. In 15 cases these results were consistent with the karyotype. In nine cases with uninformative cytogenetics, the numbers were consistent with those for centromeres and indicated a hidden aneuploidy. Loss of ETV6 genes in two cases and AML1 amplification in three others were not suspected from the cytogenetics. In conclusion, FISH proved to be reliable in defining ETV6/AML1 positivity in this group of patients as well as providing valuable insights into negative cases.

A comparison of a traditional and an accelerated basic nursing education program

In this study, the grade point average of graduates of a traditional three-year and an accelerated two-year pre-service nursing education program was compared, using comparison points of the divergence and the finish of the two programs. Results showed that while the accelerated program students had a significantly higher grade point average at the point of divergence, by the end of the two programs there was no significant difference. The accelerated program resulted in academically equivalent graduates in a shorter time but graduates paid a price in terms of stress and under-achievements.

The role of CD28-B7 costimulation in allergen-induced cytokine release by bronchial mucosa from patients with moderately severe asthma

BACKGROUND

T cells play an important role in airway inflammation in asthma through the release of T(H)2 cytokines. Optimal T-cell activation by antigen-presenting cells requires co-stimulatory signaling, such as the interaction of CD80, CD86, or both with CD28. In patients with mild allergic asthma, the fusion protein cytotoxic T-lymphocyte antigen 4Ig (CTLA-4Ig), which inhibits CD28-mediated signaling, blocks the release of IL-5 and IL-13 from bronchial explant cultures exposed to the allergen Dermatophagoides pteronyssinus.

OBJECTIVES

To assess costimulation in more severe forms of atopic asthma, we have compared the ability of CTLA-4Ig to block allergen-induced cytokine responses of bronchial explants and PBMCs from patients with moderately severe asthma.

METHODS

Bronchial explants and PBMCs were cultured in vitro, and cytokine expression was measured by means of quantitative RT-PCR and ELISA.

RESULTS

Constitutive mRNA transcripts for IL-5, IL-13, and GM-CSF were detected in the tissue explants, but only IL-5 mRNA increased significantly with allergen stimulation. Consistent with increased transcription, allergen-stimulated IL-5 protein release into explant supernatants, but this was not blocked by CTLA-4Ig. Allergen did not induce GM-CSF release, and IL-13 protein could not be detected in the explant supernatants under any condition. In contrast, allergen enhanced production of IL-5 and IL-13 by PBMC cultures from the same subjects, and this was inhibited effectively by CTLA-4Ig.

CONCLUSIONS

These data suggest that IL-5 production in the airways of subjects with moderately severe asthma is largely independent of CD28-mediated costimulation. The different requirements for CD28-mediated costimulation in PBMC cultures and bronchial tissue cultures emphasizes the importance of the tissue microenvironment in pulmonary inflammatory responses in severe asthma.

Claiming in the name of fairness: organizational justice and the decision to file for workplace injury compensation

This article explored the relationship among injured workers' perceptions of workplace justice (i.e., distributive, interactional, and procedural), perceptions of employers' disability-related policies, and the decision to file a workers' compensation claim. Using a 2-wave sample of 1,077 workers with repetitive motion injuries, the authors tested a structural equation model. Results revealed that Time 1 interactional justice was negatively related to filing a claim, whereas Time 1 distributive justice was positively related to perceptions of employer disability-related practices measured a year after the date of injury report. At Time 2, the claim decision was unrelated to perceptions of justice, yet perceptions of disability-related practices were significantly related to all 3 types of justice.

Differential expression of cell-wall-related genes during the formation of tracheary elements in the Zinnia mesophyll cell system

Plants, animals and some fungi undergo processes of cell specialization such that specific groups of cells are adapted to carry out particular functions. One of the more remarkable examples of cellular development in higher plants is the formation of water-conducting cells that are capable of supporting a column of water from the roots to tens of metres in the air for some trees. The Zinnia mesophyll cell system is a remarkable tool with which to study this entire developmental pathway in vitro. We have recently applied an RNA fingerprinting technology, to allow the detection of DNA fragments derived from RNA using cDNA synthesis and subsequent PCR-amplified fragment length polymorphisms (cDNA-AFLP), to systematically characterize hundreds of the genes involved in the process of tracheary element formation. Building hoops of secondary wall material is the key structural event in forming functional tracheary elements and we have identified over 50 partial sequences related to cell walls out of 600 differentially expressed cDNA fragments. The Zinnia system is an engine of gene discovery which is allowing us to identify and characterize candidate genes involved in cell wall biosynthesis and assembly.

Approaches to understanding the functional architecture of the plant cell wall

Cell wall polysaccharides are some of the most complex biopolymers known, and yet their functions remain largely mysterious. Advances in imaging methods permit direct visualisation of the molecular architecture of cell walls and the modifications that occur to polymers during growth and development. To address the structural and functional relationships of individual cell wall components, we need to better characterise a broad range of structural and architectural alterations in cell walls, appearing as a consequence of developmental regulation, environmental adaptation or genetic modification. We have developed a rapid method to screen large numbers of plants for a broad range of cell wall phenotypes using Fourier transform infrared microspectroscopy and Principal Component Analysis. We are using model systems to uncover the genes that encode some of the cell-wall-related biosynthetic and hydrolytic enzymes, and structural proteins.

Acknowledging the extra care parents give their disabled children

Around 150,000 families in the UK care for a severely disabled child under the age of 16. Many of these families receive assistance from the Family Fund Trust, which provides grants and information relating to the care of a severely disabled child. The aim of this study was to identify patterns of extra care needs among severely disabled children known to the Trust. Extra care needs are requirements for care not experienced by similarly aged non-disabled children. The research comprised analysis of 40,000 records from the Trust database and qualitative exploration of the extra care needs of disabled children with parents and Trust staff. Although all children require parenting, the care parents give disabled children generally exceeds that given to a non-disabled child. Quantitative analysis showed that the majority of children in the sample required extra assistance or supervision with multiple areas of daily life. With each of five activities (washing, dressing, meal times, during the night and keeping occupied), >70% of children needed extra help and, on average, each child needed extra help or supervision in six areas of daily life. Cluster analysis indicated distinctive combinations of extra care needs. Qualitative material indicated variety in extra care tasks undertaken (physical help, supervision, guidance) and causal factors (physical limitations, cognitive difficulties, behavioural problems). The findings confirm that severely disabled children have considerable extra care needs in many areas of daily life. Parents want professionals to recognize and offer explicit acknowledgement of the extra care they give their disabled children.

Moxifloxacin versus amoxicillin clavulanate in the treatment of acute maxillary sinusitis: a primary care experience

In this prospective, multicentre, randomised, non-blinded phase III clinical trial, 475 adult patients with acute sinusitis received a 10-day oral regimen of either moxifloxacin (400 mg once daily) or amoxicillin clavulanate (875 mg twice daily). The primary measure of efficacy was clinical resolution. Secondary outcome measures included clinical relapse at follow-up and evaluation of patient reported outcomes. Of 471 adults comprising the intent-to-treat population (234 moxifloxacin, 237 amoxicillin/clavulanate), moxifloxacin treatment was statistically equivalent to amoxicillin/clavulanate at the test-of-cure visit (85% vs 82%; 95% CI -6%, 13%). Analysis of the efficacy evaluable population, confirmed statistical equivalence (86% vs 84%; 95% CI -7%, 13%). Of note, by day 3 of treatment, significantly more moxifloxacin-treated patients (n = 47; 24%), than amoxicillin/clavulanate-treated patients (n = 28; 14%), reported feeling better (p < 0.02). Frequency of drug-related adverse events were similar between groups: nausea (11% moxifloxacin, 5% amoxicillin/clavulanate) and diarrhoea (3% moxifloxacin, 10% amoxicillin clavulanate). In conclusion, once-daily moxifloxacin is as effective and safe as twice-daily amoxicillin/clavulanate in the treatment of acute sinusitis. Moxifloxacin is associated with more rapid symptomatic relief.

Including qualitative research in systematic reviews: opportunities and problems

Qualitative research has been increasingly recognized in recent years as having a distinctive and important contribution to make to health care research. It is capable of being used as a methodologically sufficient approach in its own right, as a precursor to quantitative studies, during or after trials to explain processes and outcomes, and as a means of enhancing the link between evidence and practice. However, qualitative research has been little used as an evidence resource for systematic reviews. We argue that formal synthesis of both qualitative and quantitative forms of research is essential, and we discuss some of the problems that need to be overcome in carrying out such syntheses. These include methodological prejudice, problems in searching for qualitative evidence, and issues in synthesizing qualitative data. We call for progress to be made on the science and methods of including qualitative research in the evidence base of medicine.

Magnetic resonance lipid signals in rat brain after experimental stroke correlate with neutral lipid accumulation

Proton magnetic resonance spectroscopy (MRS) signals from lipids in brain have been observed to increase after ischemic brain injury. However, neither the chemical identity nor the cellular location of these lipids has been established. The aim of the present study was to identify the origin of MRS lipid signals in rat brain after temporary (90 min) middle cerebral artery occlusion (MCAO). Fatty acyl proton signals were detected by short-echo one and two dimensional (1)H MRS in superfused brain slices from the infarcted hemisphere 1-5 days after MCAO. The intensities of these signals were strongly correlated with the amount of triacylglyceride and cholesterol ester in lipid extracts from the samples (r(2)=0.96, P<0.05) and were not correlated with the amount of free fatty acids in the tissue. Histological staining of tissue revealed the presence of neutral lipid droplets in infarcted regions. Dual labeling by immunohistochemistry demonstrated that these droplets were localized to microglia/macrophage (OX-42-labeled cells). These results strongly suggest that (1)H MRS lipid signals from brain after stroke arise from microglia/macrophage phagocytosis of cellular membranes.

Across the health-social care divide: elderly people as active users of health care and social care

Several ways in which elderly people may assume an active role when using welfare services are discussed here. Selected findings are presented from a study that explored the experience and behaviour of elderly people on discharge from inpatient care with regard to criteria indicating user influence or control (namely participation, representation, access, choice, information and redress). Data were collected via semistructured interviews with service users (n = 30) soon after their return home from hospital. A number of differences were revealed between health care and social care in relation to users being provided with opportunities to assume an active role and in being willing and able to assume an active role. These differences were manifest in elderly service users accessing services, seeking information, exercising choice and acting independently of service providers. It appeared paradoxical that contact points were more easily defined with regard to health care yet users were more likely to exercise choice and act independently in securing social care. It is suggested that social care needs and appropriate service delivery are more easily recognised than making the link between perceived health care needs and appropriate services. In addition, it appeared that informal and private providers are more widely available and accessible for social care. If comprehensive continuing care is to be provided, incorporating both health and social care elements, greater uniformity appears to be required across the welfare sector. Lessons for social care provision from the delivery of health care suggest the clear definition of contact points to facilitate service use. Making health care more accessible, however, does not appear to be easily attainable due to the monopoly provision of health care and the lack of direct purchasing power by potential users.

DcAGP1, a secreted arabinogalactan protein, is related to a family of basic proline-rich proteins

A cDNA corresponding to the core protein of an immunoaffinity-purified arabinogalactan protein (AGP) secreted aucus carota (carrot) cells in liquid culture was isolated. This cDNA, DcAGP1, encodes a new class of non-classical' AGP with strong similarity to a family of basic proline-rich proteins. The protein is rich in proline (17%), alanine (10%) and lysine (11%) and contains four distinct domains: a signal peptide, a proline-rich domain, a histidine-rich basic domain and a cysteine-containing 'PAC' domain that is found in a range of other cell wall proteins. The protein contains several sequence motifs found in otherwise unrelated cell wall proteins, but also displays some unique features. Northern blot analyses show that while the DcAGP1 transcript is abundant in the suspension-culture cells from which the AGP was obtained; in carrot seedlings the gene is only expressed at low levels in the roots and it is neither wound- nor stress-inducible. Furthermore, northern and western blot analyses demonstrate that the core polypeptide of DcAGP1 is differentially glycosylated in two different carrot suspension cultures. The unusual features of the protein sequence suggest that the DcAGP1 protein is a member of a family of basic proline-rich proteins defined by the C-terminal PAC domain, and the possible function(s) of the DcAGP1 protein is considered in the light of current views on AGP structure and function.

Induction of type 2 activity in adult human CD8(+) T cells by repeated stimulation and IL-4

Repeated administration or chronic presence of antigen during CD4(+) T cell activation and a cytokine milieu enriched in IL-4 favour the generation and maintenance of a T(h)2 population. However, there is little data on how these factors affect adult human CD8(+) T cell functions. We established in vitro conditions to culture purified human CD8(+) T cells, and investigated how repeated stimulation and exogenous IL-4 modulated their functions. Repeated TCR-CD3 stimulation of CD8(+) T cells increased the number of CD25-, CD30- and CD40 ligand-expressing cells, and their capacity to secrete IL-4 and IL-5. In addition, repeatedly stimulated CD8(+) T cells had cytotoxic activity and provided help to resting B cells for IgE synthesis. The presence of exogenous IL-4 during repeated stimulation further increased the number of CD25(+) and CD30(+) CD8(+) T cells, up-regulated the number of IL-5(+) cells, and increased IL-5 levels released. These observations demonstrate that repeated TCR-CD3 stimulation of normal human CD8(+) T cells favoured the growth of cells with a type 2 phenotype and that this was further amplified by the presence of IL-4. These mechanisms may be important in virus-induced lung eosinophilic inflammation in healthy subjects and virus-induced exacerbations of asthma.

Remifentanil versus meperidine for monitored anesthesia care: a comparison study in older patients undergoing ambulatory colonoscopy

Colonoscopy is one of the most frequently performed outpatient procedures in the United States. This study was designed to test the hypothesis that a remifentanil infusion would be superior to boluses of meperidine in older patients undergoing ambulatory colonoscopy. One hundred ASA physical status I-IV patients undergoing colonoscopy were randomized in this double-blinded study to receive either remifentanil infusions (n = 49) or titrated boluses of meperidine (n = 51). Patient tolerance was assessed using physiologic variables and side effects associated with opioid analgesia. Verbal pain/anxiety and patient/operator satisfaction were also assessed. As a group, the physiologic characteristics demonstrated no significant differences in the response to the colonoscopy procedure. Although the patient and operator satisfaction surveys were similar between groups, the incidences of tachycardia, hypotension, and nausea were less and the adjusted verbal pain and anxiety scores were more in the Remifentanil group compared with the Meperidine group. This study demonstrates that remifentanil and meperidine were equally well tolerated in older patients undergoing ambulatory colonoscopy when administered by an anesthesia provider. The differences in the pharmakinetics of remifentanil and meperidine most likely account for the differences noted between the two treatment groups.

IMPLICATIONS

Remifentanil infusions and meperidine boluses are equally well tolerated in older patients undergoing ambulatory colonoscopy when administered by an anesthesia provider.

Xylogenesis: the birth of a corpse

Xylogenesis is a complex developmental process culminating in programmed cell death as a truly terminal differentiation event. In Arabidopsis, the availability of vascular-patterning mutants, and the identification of genes and their products that are involved in cell specification, secondary-wall deposition and lignification, are providing clues to the functions of some of the sequences in the large expressed sequence tag databases derived from the xylem-rich tissues of trees. An in vitro system, the Zinnia mesophyll cell system, provides an alternative system for those cell-biological experiments that are difficult to tackle in intact plants. In particular, a combination of molecular-genetic and cell-biological approaches has made possible the elucidation of some of the features of plant programmed cell death.