Step-by-step guide to selecting mobile wireless devices

Make sense out of choosing portable radio frequency devices with these easy-to-follow steps for clinicians, information systems computing staff, and administrators.

Ovarian cancer in young women in Sweden, 1989-1991

The present study is an evaluation of the symptoms and gynecological status, at the time of seeking medical advice, among women of reproductive age diagnosed with ovarian malignancies. The study was based on the medical records of all women in Sweden between 15 and 40 years of age who were diagnosed with ovarian malignancies during a 3-year period (1989-1991). The study focused on the diagnosis and panorama of symptoms. These data were compared to the records of more than 10,000 women in this age group during the same period of time who underwent surgery for ovarian changes that resulted in benign diagnoses. The 152 cases of ovarian cancer included only 1 patient who was without symptoms, had normal pelvic status upon manual examination, and a sonographically diagnosed simple cyst. These data support the conclusion that the majority of young women with ovarian cancer have symptoms and/or clinically detectable adnexal masses at the time when medical advice is sought. These studies suggest that diagnosis of ovarian cancer is unlikely in young healthy women lacking subjective symptoms and an adnexal mass upon pelvic examination. In conclusion, programs for the management of simple cysts and development of noninvasive diagnostic methods for ovarian changes found in patients in the reproductive age group are needed in order to reduce the number of patients subjected to operative intervention.

Wound care. Points of friction

This article aims to identify optimum management strategies for hypergranulation of gastrostomy, tracheostomy and suprapubic catheter sites. It discusses the aetiology of hypergranulation and gives an overview of the available literature on existing treatments. It concludes that the optimum choice of management may be to tape the tube to the body to prevent friction and to use a polyurethane foam dressing with a high moisture vapour transmission rate.

Liposomal prostaglandin E1 (TLC C-53) in acute respiratory distress syndrome: a controlled, randomized, double-blind, multicenter clinical trial. TLC C-53 ARDS Study Group

OBJECTIVE

To evaluate the safety and efficacy of an intravenous liposomal dispersion of prostaglandin E1 as TLC C-53 in the treatment of patients with acute respiratory distress syndrome (ARDS).

DESIGN

Randomized, prospective, multicenter, double-blind, placebo-controlled, phase III clinical trial.

SETTING

Forty-seven community and university-affiliated hospitals in the United States.

PATIENTS

A total of 350 patients with ARDS were enrolled in this clinical trial.

INTERVENTION

Patients were prospectively randomized in a 1:1 ratio to receive either liposomal prostaglandin E1 or placebo. The study drug was infused intravenously for 60 mins every 6 hrs for 7 days starting with a dosage of 0.15 microg/kg/hr. The dose was increased every 12 hrs until the maximal dose (3.6 microg/kg/hr) was attained or intolerance to further increases developed. Patients received standard aggressive medical/surgical care during the infusion period.

OUTCOME MEASURES

The primary outcome measure was the time it took to wean the patient from the ventilator. Secondary end points included time to improvement of the PaO2/FIO2 ratio (defined as first PaO2/FIO2 > 300 mm Hg), day 28 mortality, ventilator dependence at day 8, changes in PaO2/FIO2, incidence of and time to development/resolution of organ failure other than ARDS.

RESULTS

A total of 348 patients could be evaluated for efficacy. The distribution of variables at baseline describing gender, lung injury scores, Acute Physiology and Chronic Health Evaluation II scores, PaO2/FIO2, pulmonary compliance, and time from onset of ARDS or from institution of mechanical ventilation to the first dose of study drug was similar among patients in the liposomal prostaglandin E1 (n = 177) and the placebo (n = 171) treatment arms. There was no significant difference in the number of days to the discontinuation of ventilation in the liposomal prostaglandin E1 group compared with the placebo group (median number of days to off mechanical ventilation, 16.9 in patients receiving liposomal prostaglandin E1 and 19.6 in those administered placebo; p = .94). Similarly, mortality at day 28 was not significantly different in the two groups (day 28 mortality, 57 of 176 (32%) in the liposomal prostaglandin E1 group and 50 of 170 (29%) in patients receiving placebo; p = .55). In contrast, treatment with liposomal prostaglandin E1 was associated with a significantly shorter time to reach a PaO2/FIO2 ratio of >300 mm Hg (median number of days to reaching a PaO2/FIO2 ratio >300 mm Hg: 9.8 days in the liposomal prostaglandin E1 group and 13.7 days in patients receiving the placebo; p = .02). Among the subgroups examined, time to off mechanical ventilation was significantly reduced in patients who received at least 85% of a full dose (i.e., > 45.9 microg/kg) of liposomal prostaglandin E1 (median number of days to discontinuation of ventilation, 10.3 in the liposomal prostaglandin E1 group and 16.3 days in patients receiving placebo; p = .05). The overall incidence of serious adverse events was not significantly different in the liposomal prostaglandin E1 (40%) or placebo-treated (37%) groups. Drug-related adverse events of all kinds were reported in 69% of the patients receiving liposomal prostaglandin E1 compared with 33% of the placebo group, with hypotension and hypoxia (occurring in 52% and 24% of the liposomal prostaglandin E1-treated patients, respectively, and 17% and 5% of the placebo-treated patients, respectively) being noted most frequently.

CONCLUSIONS

In the intent-to-treat population of patients with ARDS, treatment with liposomal prostaglandin E1 accelerated improvement in indexes of oxygenation but did not decrease the duration of mechanical ventilation and did not improve day 28 survival.

The effect of biphasic defibrillation on the immediate pacing threshold of a dedicated bipolar, steroid-eluting lead

It is apparent that pacing threshold increases following an ICD shock, although the degree of change observed is dependent on the method used to assess pacing and the lead design used. We previously demonstrated a rise in postshock pacing threshold using a lead with integrated bipolar pacing in which the distal shocking coil also serves as the pacing anode. In this study, we sought to investigate whether the postshock pacing threshold increased significantly in an endocardial, steroid-eluting lead with dedicated bipolar pacing electrodes. Twenty patients (16 men, 4 women; median age 73, ejection fraction [EF] 0.17-0.58) were studied during pectoral ICD implantation (Medtronic active can model 7221Cx or 7223Cx with model 6932-65 lead). The diastolic pulse width pacing threshold at 1 or 2 V was determined. Pacing rate was set > or = 100/min at twice diastolic threshold output to assess pacing immediately following the first DFT test shock. For subsequent shocks, the output was adjusted to establish postshock thresholds as 1, 2, 3, or 4 times the diastolic threshold. The postshock threshold was defined as the output yielding 100% capture > or = 2.5 seconds following a shock. In 8 of 20 patients (ratio 0.40 +/- 0.11), a rise in the post-shock threshold was shown by failure of consistent capture when pacing at 2 times diastolic threshold > or = 2.5 seconds after a DFT test shock. Two of these patients failed at 3 times threshold, but none failed at 4 x threshold. Five of 12 patients with successful capture of 2 times threshold failed to capture at threshold. The postshock threshold increased by a mean factor of 2.83 +/- 0.83 in the group of patients with a threshold rise. Following ICD shock in an active can, steroid-eluting lead system with dedicated bipolar pacing, the post-shock threshold increases significantly. Our studies suggest a need for postshock pacing to be set at least 4 x threshold regardless of the lead design.

Ingested interferon alpha induces Mx mRNA

We have demonstrated that ingested murine interferon alpha (IFN-alpha) suppressed clinical relapse in chronic relapsing experimental autoimmune encephalomyelitis (CR-EAE), decreased inflammation and suppressed the adoptive transfer of EAE, and is a biological response modifier in patients with multiple sclerosis. We examined the relative levels of the Mx mRNA signal using semiquantitative reverse transcription-polymerase chain reaction analysis on splenocytes from mice and peripheral blood mononuclear cells from man after IFN-alpha ingestion. Both mice and man demonstrated inducible levels of Mx mRNA after ingesting IFN-alpha. Murine spleen T cells and CD8(+)T cells also demonstrated upregulation of Mx mRNA. Murine whole splenocytes demonstrated upregulation of Mx mRNA after IFN-alpha ingestion of 10 and 100 U, but not after 0, 1000, 5000 U. Ingested IFN-alpha acts via established pathways of type 1 IFN signalling.

The spread of state any willing provider laws

OBJECTIVE

To describe the growth of any willing provider (AWP) and freedom of choice (FOC) laws applicable to managed care firms and to explore empirically the determinants of their enactment.

STUDY SETTING

A 1996 compendium of state laws and state-level data from the 1991-1994 period.

STUDY DESIGN

Pooled cross-section time-series logistic regression of the decision to enact various types of AWP and FOC laws. Analysis uses a public choice framework to examine enactment. Key variables include proxy measures of proponent and opponent strength and the political environment.

PRINCIPAL FINDINGS

The model works well for laws affecting hospitals, but performs poorly for physician and pharmacy laws. More providers are associated with the enactment of AWP and FOC laws. More large employers are associated with a reduced likelihood of enactment of some forms of the laws but not others. Conservative states are more likely to enact laws limiting selective contracting with hospitals and physicians. States with greater interparty competition are also more likely to adopt some types of legislation.

CONCLUSIONS

The empirical results generally are consistent with the view that AWP and FOC laws are often enacted as a defensive strategy on the part of providers, but additional research is needed to provide a more definitive assessment of the determinants of these laws. Suggestions for future research are provided.

Factor V Leiden is not common in patients diagnosed with primary pulmonary hypertension

Substantial evidence suggests that thrombosis contributes to the pathogenesis of primary pulmonary hypertension (PPH). An abnormal factor V (factor V Leiden) may contribute to thrombosis in the pulmonary microcirculation of PPH patients. A point mutation in which adenine is substituted for guanine at nucleotide 1691 (1691A) alters factor V so that it resists cleavage by activated protein C. Heterozygosity for the 1691A mutation is more common (2-8%) in Caucasian Europeans and Americans than in Africans (1%) and Asians (<1%). The aim of the study was to examine the prevalence of the mutation that codes for factor V Leiden in individuals with PPH. We identified 42 Caucasians diagnosed with PPH. We extracted deoxyribonucleic acid (DNA) from whole blood and assayed DNA samples for the point mutation (1691 A) that codes for factor V Leiden. One out of 42 (2.4%; 95% confidence interval=0.1-12.6) Caucasians diagnosed with PPH was heterozygous for the normal 1691G and mutant 1691A allele. All 10 individuals with familial PPH were homozygous for the normal 1691G allele. The prevalence of heterozygosity for the 1691A allele and the normal 1691G allele does not differ from that observed in reference (control) populations. The low prevalence of the 1691A mutation among individuals diagnosed with primary pulmonary hypertension provides evidence that factor V Leiden does not contribute to the pathogenesis of the disease in most patients.

Myotonic dystrophy is a significant cause of idiopathic polyhydramnios

OBJECTIVE

Myotonic dystrophy, the most common form of muscular dystrophy seen in pregnant women, may be a significant cause of middle trimester polyhydramnios. Our purpose was to determine the prevalence of myotonic dystrophy in women with idiopathic polyhydramnios and to characterize the ultrasonographic findings associated with cases.

STUDY DESIGN

We examined the cases of 67 patients who were delivered of infants at the University of Utah between 1992 and 1996 with a diagnosis of idiopathic polyhydramnios (amniotic fluid index >25). Women with diabetes mellitus, hydrops, or fetal anomalies known to cause polyhydramnios were excluded from the study. Amniotic fluid samples or cord blood samples were obtained from 41 patients, and polymerase chain reaction amplification and Southern blot analysis were performed to detect the presence of the myotonic dystrophy mutation. Ultrasonographic findings, prenatal course, and neonatal outcomes were reviewed in all cases.

RESULTS

Four of the 41 patients tested had the myotonic dystrophy mutation, yielding a prevalence in our population of 9.7%. Three of the 4 patients reported a family history of myotonic dystrophy. Ultrasonographic findings associated with a positive result included abnormal posturing of extremities (3/4) and unilateral clubbed foot (3/4). No other structural or growth abnormalities were seen. Two of the patients were delivered before term, 1 at 26 weeks and 1 at 32 weeks. Three of the 4 infants were severely affected, necessitating admission to the intensive care unit, and 1 died on day 11 after birth. One infant, whose myotonic dystrophy mutation consisted of between 800 and 900 triplet repeats, did not require admission to the intensive care unit.

CONCLUSION

Myotonic dystrophy may be seen as idiopathic polyhydramnios and should be considered as part of the differential diagnosis in these cases. Women with a familial history of myotonic dystrophy or ultrasonographic evidence of hypotonia, including positional abnormalities of the extremities, should be offered deoxyribonucleic acid testing for the myotonic dystrophy mutation.

Analysis of prenatal and gestational care given to women with epilepsy

OBJECTIVE

To assess past care practices of neurologists and obstetricians to identify areas in which practice patterns differ from currently accepted optimal care.

METHODS

Retrospective chart review of 155 women identified as having a diagnosis of epilepsy (or seizure disorder) who had been pregnant any time between January 1988 and December 1995 and were admitted to Stanford University Hospital for delivery. A total of 161 pregnancies (132 women) were selected for study.

RESULTS

An obstetrician was seen at some point during the pregnancy in 99% of the pregnancies, whereas a neurologist was seen at least once in only 64% of the pregnancies. In the 3 months before conception, an obstetrician was seen in 5% of the pregnancies and a neurologist was seen in 15%. Seventy-five percent of the patients taking antiepileptic medication and 65% of the untreated patients had documentation of folate supplementation at any time during pregnancy. Vitamin K supplementation in the final month of pregnancy was documented for only 41% of those receiving antiepileptic drugs. In over one-third of the pregnancies the mother did not have a maternal serum alpha-fetoprotein measure documented and a similar percentage did not receive genetic counseling. Monitoring of the maternal serum concentration of the non-protein-bound fraction of the prescribed antiepileptic drugs was not documented.

CONCLUSIONS

We identified specific omissions of appropriate vitamin supplementation, genetic counseling, and drug level monitoring. Educational efforts should be targeted to improve the management of pregnancy in women with epilepsy.

Ingested interferon alpha suppresses type I diabetes in non-obese diabetic mice

Type I diabetes mellitus is a chronic disorder that results from autoimmune destruction of the insulin-producing pancreatic beta cell. The non-obese diabetic mouse is a model of the human autoimmune disease Type I diabetes [1-3]. We have previously shown that ingested type 1 interferon inhibits chronic relapsing experimental autoimmune encephalomyelitis and the adoptive transfer of experimental autoimmune encephalomyelites by T cells, and decreases both antigen-specific and mitogen-induced pro-inflammatory cytokine secretion in this disorder. We therefore tried to determine whether ingested murine interferon alpha inhibits insulinitis and suppresses Type I diabetes mellitus in non-obese diabetic mice. Murine interferon alpha, given daily, decreased islet inflammation and suppressed diabetes. It increased the concanavalin A and ionomycin plus myristic acid palmitic ester-induced production of interleukin 4 and 10 and interferon gamma-secretion in spleen cells from treated mice. Adoptive transfer of unstimulated splenocytes secreting interleukin 4 and interleukin 10 from fed interferon alpha donors suppressed spontaneous diabetes mellitus in recipients. The protective effect of adoptively transferred unstimulated splenocytes shows the presence of ingested interferon alpha-activated regulatory splenic cell populations that may work via increased interleukin 4 or interleukin 10 production. Ingested interferon alpha administered during vulnerable periods in at-risk populations may potentially provide a continuous, convenient, non-toxic and effective treatment for Type I diabetes.

Surfing the wave of clinical laboratory science evolution in Hawai'i

OBJECTIVE

To describe the steps taken by the Hawaii Society for Clinical Laboratory Science, an affiliate of the American Society for Clinical Laboratory Science, to inform local laboratory professionals of current trends and to prepare for the future.

RESULTS

A Strategic Planning workshop was conducted at the 1997 Hawaii Society for Clinical Laboratory Science Annual Meeting where participants reviewed the essential (but non-traditional) functions of clinical laboratory scientists, and described current realities, identified forces and players affecting the changes, and envisioned the future of our profession.

CONCLUSION

As the way health care is provided changes in response to economics and advances in technology, the role of clinical laboratory scientists needs to be redefined. The Hawaii Society for Clinical Laboratory Science continues to provide timely support for members, and plans to work collaboratively with the local chapter of the Clinical Laboratory Managers' Association to advance clinical laboratory science to an appropriate place in the health care community.

Embalming fluid-soaked marijuana: new high or new guise for PCP?

A growing trend of smoking marijuana soaked in what is purported to be embalming fluid has been reported in the literature since the mid-1980s. This article describes several cases of intoxication, gives regional epidemiological data on this phenomenon, and includes current nomenclature. The authors also analyze a sample of fluid said to be embalming fluid and discover PCP (phencyclidine) and multiple congeners and by-products of PCP manufacture. The implications of this finding are discussed, and the hypothesis that most embalming fluid-soaked marijuana likely contains PCP is considered.

Elderly patients' satisfaction with hospital care

OBJECTIVES

The aim of this study was to assess patient satisfaction with the geriatric services of a district general hospital and to examine whether there was a difference in satisfaction between patients in hospital and those who had been recently discharged.

METHODS

A structured and validated patient satisfaction questionnaire was administered before discharge to hospitalised patients with a mental test score of 8 or more. It was also administered to a group of patients in the community who had been discharged from hospital not more than 72 hours earlier. The questionnaire was designed to assess seven separate areas, and contained 51 statements with which patients were asked to agree or disagree. Statistical analysis was by the Mann-Whitney U test and p < 0.05 was taken as significant. A total of 134 elderly patients (> 72 years) were surveyed over a four-month period.

RESULTS

Satisfaction with the hospital geriatric service was high in both groups of patients. However, patient satisfaction differed between the two groups in three areas: interpersonal aspects; access, availability and convenience of the health services; and financial aspects.

Different excitation-contraction coupling mechanisms exist in squid, cuttlefish and octopod mantle muscle

Excitation-contraction (EC) coupling was studied in central zone mantle muscle fibres of a squid (Alloteuthis subulata), a cuttlefish (Sepia officinalis) and an octopod (Eledone cirrhosa). Thin slices of muscle were used for twitch experiments and enzymatic isolation of single fibres for whole-cell patch-clamp studies. The current required for a supramaximal twitch response during direct stimulation of muscle slices was lower for squid than for cuttlefish. In squid, but not in cuttlefish, the current-response relationship was independent of slice thickness (range 0.1-0.5 mm). Twitches of squid and cuttlefish slices were reversibly abolished by removal of extracellular Ca2+. In squid, but not in cuttlefish, the current-response relationship was Na+-dependent, and in the absence of Na+ higher current strengths were required to generate a supramaximal response. In whole-cell voltage-clamp experiments on isolated muscle fibres from squid, cuttlefish and Eledone cirrhosa, a sustained inward current was recorded upon depolarisation. This current was blocked by 5 mmol l-1 Co2+ and suppressed by 10 micromol l-1 nifedipine. In squid, an additional inward fast-activating transient current was seen which was blocked by 2 micromol l-1 tetrodotoxin and depolarised holding potentials. The fast current represents a voltage-activated Na+ channel, and the slow currents represent L-type Ca2+ channels. We conclude that squid possess a specialised rapid EC coupling mechanism in central zone fibres that is absent in cuttlefish and Eledone cirrhosa.

Primary, secondary, and tertiary prevention capabilities of selected HMOs: findings of an employer survey

PURPOSE

To survey Health Maintenance Organizations (HMOs) of a major employer regarding the extent of their health promotion and disease prevention capabilities.

DESIGN

A one-time cross-sectional survey.

SETTING

The setting involved in this study was managed care organizations.

SUBJECTS

The subjects were 22 HMOs located in the western part of the United States.

MEASURES

The study involved completion of a survey grid on a fairly comprehensive range of primary, secondary, and tertiary prevention activities.

RESULTS

Twenty-two HMOs were surveyed and 20 responded, providing a response rate of 90.9%. Analysis of distribution of responses and simple means were used. If a "perfect score" included addressing all 52 prevention targets across all 13 intervention modalities (minus inappropriate combinations) and that represented a score of 100%, the highest scoring HMO indicated that it provided or addressed 36.8% of all possible modalities and prevention target combinations. The composite average score for all three areas of prevention for all responding HMOs was slightly less than 13%. Additionally, five of the HMO respondents provided approximately 59% of all the prevention activity reported in the survey. Nonrepresentativeness of the HMOs in the sample represents the most significant study limitation.

CONCLUSIONS

Results suggest that prevention capabilities among the HMOs surveyed are unevenly distributed and somewhat concentrated.

Angiotensinogen T235 expression is elevated in decidual spiral arteries

Preeclampsia is associated with a common molecular variant of angiotensinogen (Met235Thr). This variant is in tight linkage disequilibrium with a mutation in the angiotensinogen promoter, G(-6)A, which leads to elevated expression in vitro. Since angiotensin II levels could play a role in atherotic changes of the uterine spiral arteries associated with preeclampsia, we investigated angiotensinogen expression in the first trimester uterus. We localized angiotensinogen transcription in uterine decidua using in situ reverse transcription PCR. We then compared decidual T235 expression levels to M235 levels in heterozygous women using an allele-specific ligation assay and a single nucleotide primer extension assay. In human decidua, angiotensinogen is expressed only in spiral artery smooth muscle cells. Heterozygous women have significantly elevated expression of the T235 allele compared to the M235 allele (P < 0.0001). These observations suggest that elevated expression of the T235 allele in decidual spiral arteries may cause first trimester atherotic changes leading to preeclampsia.