Laryngeal Structural Dysphagia in Children

The upper aerodigestive system is closely intertwined from an embryologic and functional perspective. Laryngotracheal anatomic abnormalities, such as laryngomalacia, stenosis, vocal cord paralysis, and laryngeal clefts, affect not only the respiratory function but also the swallow function. Laryngotracheal pathology can interfere with the suck-swallow-breathe mechanism in infants. It can also exacerbate gastroesophageal reflux. Chronic aspiration secondary to laryngotracheal anomalies can result in respiratory and pulmonary complications. Surgical treatment of laryngotracheal anomalies can also cause transient or long-term swallow dysfunction. Multidisciplinary approaches and clinical assessment of swallowing are important in patients with laryngotracheal pathology.

Oral Structural Dysphagia in Children

Oral causes of dysphagia in infancy may involve the lips, the tongue, or the palate. Whereas ankyloglossia is commonly diagnosed in infants with dysphagia, assessment of the need for surgical intervention may be less straightforward. Tongue size (macroglossia) may be associated with dysphagia as it may cause limitation of movement of the food or milk bolus by the lips or cheeks. Congenital conditions such as cleft lip and palate, micrognathia, or craniofacial microsomia may also be associated with dysphagia. Diagnosis and treatment of these conditions can be improved with the engagement of lactation and feeding experts as well as multidisciplinary craniofacial teams.

Postoperative Urinary Complications in Head and Neck Free Flap Reconstructive Surgery

OBJECTIVE

The purpose of this study is to evaluate the postoperative urinary complications and the optimal timing of foley catheter removal in patients who underwent free flap reconstructive surgery for head and neck pathology.

METHODS

A retrospective case-control study of head and neck patients who underwent free flap reconstructive surgery at a single institution between January 2009 and December 2021 was conducted. Patient risk factors for postoperative urinary retention (POUR) were analyzed. Fisher Exact and Wilcoxon Rank Sum tests were used to evaluate rates of foley replacement, straight catheterization, and catheter-associated urinary tract infection (CAUTI) and associated risk factors.

RESULTS

Two hundred and eleven patients were included in this study. Older age, lower BMI, lower intraoperative fluid volumes, and need for straight catheterization were statistically significant for POUR requiring foley replacement. Shorter total (P = .04) and postoperative (P = .01) foley duration showed statistical significance for POUR requiring straight catheterization. About 60% of patients who had straight catheterization required a foley replacement (P < .001). Only one patient (0.5%) developed a urinary tract infection (UTI).

CONCLUSION

Foley catheter duration impacts the risk of POUR requiring straight catheterization and subsequently, foley replacement. Optimal timing for foley catheter removal in the postoperative period remains to be elucidated. Removal of catheters between 21 and 48 hours after surgery may decrease the risk of POUR without increasing the rate of CAUTI in patients with head and neck pathology undergoing free flap reconstructive surgery.

Guidelines and practice of breastfeeding in women living with HIV-Results from the European INSURE survey

INTRODUCTION

Antiretroviral therapy (ART) is integral to HIV prevention, including averting vertical transmission. The World Health Organization (WHO) recommends ART and breastfeeding for all women living with HIV for at least 12 months post-partum [1, 2]. Much of the data on HIV transmission through breastfeeding comes from low-resource settings, with a paucity of data on breastfeeding-related HIV transmission in women living with HIV in other settings. Women Against Viruses in Europe (WAVE), part of the European AIDS Clinical Society (EACS), aims to improve the standard of care for women living with HIV and sought to gain an understanding of breastfeeding guidelines and practice in women living with HIV across Europe.

METHODS

A steering group convened by WAVE developed a survey to collate information on breastfeeding trends, practice, and guideline recommendations for women living with HIV in Europe and to establish interest in becoming involved in a collaborative breastfeeding network. The survey was disseminated to 31 countries in March 2022.

RESULTS

In total, 25 eligible responses were received: 23/25 (92%) countries have HIV and pregnancy guidelines; 23/23 (100%) guidelines refer specifically to breastfeeding; 12/23 (52%) recommend against breastfeeding; 11/23 (48%) offer an option if certain criteria are met; 12/25 (48%) reported that the number of women living with HIV who breastfeed is increasing; 24/25 (96%) respondents were interested in joining a network on breastfeeding in women living with HIV.

CONCLUSIONS

Recommendations vary, and nearly half of the guidelines recommend against breastfeeding. Many countries report an increase in breastfeeding. WAVE will establish a collaborative network to bridge data gaps, conduct research, and improve support for women living with HIV who choose to breastfeed.

Opioid versus non-opioid postoperative pain management in otolaryngology

BACKGROUND

The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC).

METHODS

A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017-2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups.

RESULTS

The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (p < 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (P < 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (P < 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (P < 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (p < 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (p < 0.0001). Dipyrone was prescribed to 78% of patients in Israel.

CONCLUSIONS

HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.

Phrenic nerve schwannoma presenting as an asymptomatic neck mass

Phrenic nerve schwannomas of the head and neck are exceedingly rare pathologies that can present as an asymptomatic neck mass. Surgery is the definitive treatment, and a conservative surgical approach is preferred if a benign pathology is suspected.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Evaluation of the impact of human immunodeficiency virus pre-exposure prophylaxis on new human immunodeficiency virus diagnoses during the COVID-19 pandemic

AIMS

The national PrEP programme launched in Ireland in November 2019 with tenofovir/emtricitabine free to those meeting eligibility criteria. We assessed the impact of the first year of the PrEP programme on new HIV diagnoses in the largest sexual health and HIV service in Ireland.

METHODS

A free PrEP service was established in November 2019. We reviewed the number of new diagnoses of HIV between November 2018-2019, before the introduction of the national PrEP programme and compared this with the number of new HIV diagnosis between November 2019-2020.

RESULTS

There were 95 new HIV diagnoses (63.3% MSM) between November 2018 and 2019 and 73 new HIV diagnoses (65.7% MSM) between November 2019 and 2020. There was a statistically significant decline in new HIV diagnoses between the 2 years (P = 0.0003). 546 patients were prescribed PrEP as of December 2020.106 patients (19.4%) changed their PrEP dosing regimen due to lockdown. 178 individuals (32.6%) had a rectal infection diagnosed.

CONCLUSION

There has been a reduction in new HIV diagnoses in our cohort (although this has occurred during a global pandemic). It is too early to say if PrEP reduces late presentations of HIV based on our findings. A significant number of rectal infections were identified in the PrEP clinic suggesting ongoing risk despite pandemic restrictions. Further research into sexual practices during COVID-19 is needed to assess if this had an impact on the lower rates of HIV acquisition.

HPV-positive oral papillomas in an adolescent-A diagnostic dilemma

Human papillomavirus oral papilloma is often sexually transmitted, but non-sexual modes of transmission should be considered, including autoinoculation from skin lesions. A patient-centered multimodality approach should be utilized in the pediatric population.

Comparison of tracheoscopy and portable chest X-Ray in the evaluation of infant tracheostomy tube position

OBJECTIVE

To compare tracheoscopy and chest radiograph measurements of tracheostomy tube position in infants.

STUDY DESIGN

Retrospective chart review.

SETTING

Otolaryngology Department at Penn State Milton S. Hershey Medical Center.

SUBJECTS AND METHODS

All cases of pediatric patients who underwent tracheotomy at less than 1 year of age from 2014 to 2019 were reviewed. Patients were included if they had both intraoperative measurement of tracheostomy tube position relative to the carina by tracheoscopy and postoperative chest radiograph. Documented intraoperative findings were compared to measurements made on chest radiograph by an attending radiologist blinded to the intraoperative measurements.

RESULTS

The study included 66 patients; 30 patients (14:16, M:F) had available data. The mean distance from the distal tracheostomy tube to the carina measured by tracheoscopy was 8.88 mm (range, 3.5-20 mm) and measured radiographically was 11.71 mm (range, 2.4-23.3 mm). The mean difference between the measurements was 2.82 mm (p-value = 0.016). Ninety percent (n = 27) of patients had measurements that differed by greater than 2 mm; 53% (n = 16) had measurements that differed by 5 mm and 1% (n = 3) had measurements differing by greater than 10 mm.

CONCLUSION

In the infant population, significant discrepancy was found between direct tracheoscopy and chest radiograph measurements of the tracheostomy tube position. Measurements obtained by chest radiographs tend to overestimate the relative distance of the distal tracheostomy tube to the carina as compared to that of tracheoscopy. Clinical decisions regarding changes to tracheostomy tube sizes should mostly rely on tracheoscopy performed with the patient supine.

Microscopic tumor invasion of contralateral mucosa in cancer involving unilateral septum

BACKGROUND

Preservation of contralateral mucosa with microscopic tumor invasion in unilateral septal involvement increases the recurrence risk. The purpose of this study was to analyze the risk of invasion of contralateral mucosa in unilateral septal involvement of cancer and to risk stratify patients.

METHODS

Retrospective chart review of patients with histologically proven malignancy with unilateral septal involvement and absence of gross septal tumor involvement on the contralateral side were included.

RESULTS

Among 40 patients, majority (55%) belonged to sixth and seventh decade. The most common type was squamous cell carcinoma (63%). Approximately one-fourth (23%) showed microscopic contralateral invasion. Females (OR 12; 95% CI 2.01-71.35) and patients with septal bone invasion (OR 28.5; CI 3.35-242.0) had a higher risk of developing contralateral mucosal invasion.

CONCLUSION

Complete resection of contralateral mucosa is preferred in areas along the bony septum. When complete resection is not performed, intraoperative frozen section is strongly recommended.

Gastric ulceration causing thoracic spondylodiscitis: a first case of a rare complication post oesophagectomy

We report the case of an 84-year-old male, who presented with septicaemia, abdominal and back pain. The patient had a background of oesophageal carcinoma and had undergone previous oesophagectomy and gastric pull-up operation 10 years ago. A computerised topography scan demonstrated a probable gastro-vertebral communication with a destructive process at the T8/T9 vertebral level. Further evaluation with MRI clearly showed the tract between the two structures and confirmed the diagnosis of spondylodiscitis at the adjacent spinal level. The patient was resuscitated, treated with intravenous antibiotics and kept nil by mouth. A subsequent gastroscopy demonstrated an eroding gastric ulcer at the enteric opening of the tract between the tubal stomach and the spinal column. The diagnosis was discussed with the patient, his family and the surgical multidisciplinary team. Given the extent of disease and his multiple medical co-morbidities, the decision was made for conservative management and symptom control. This is the first case of a gastro-vertebral communication causing spondylodiscitis to be described in the literature.

Abstract OT3-4-04: InVite: an observational pilot study evaluating the feasibility of genome-wide association studies using self-reported data from patients with metastatic breast cancer treated with bevacizumab

Background: Personalized healthcare tailors treatments to patients and their disease characteristics through the use of genetics and other biomarkers. Genetic differences among individuals may explain variations in drug treatment response, including side effects. With such information physicians could make more informed decisions about drugs and dosing for a given individual, thereby improving patient care. Although there has been some success, to a large extent genetic variation related to drug response remains unexplained.

Bevacizumab, a humanized monoclonal antibody against the angiogenic factor VEGF, has demonstrated activity in patients with metastatic breast cancer (MBC). The InVite study will evaluate the feasibility of performing genomewide association studies using self-reported information collected via an online platform from patients with MBC who have been treated with bevacizumab. Using novel methodology in a convenient, user-friendly, and scientifically rigorous format, InVite ultimately aims to identify potential pharmacogenetic associations in this patient population.

Trial design: InVite is a pilot, non-interventional, observational, web-based, prospective cohort study designed to collect patient-reported safety, efficacy, and genetic data from patients with MBC treated with bevacizumab. Data on demographics, breast cancer disease status, cancer treatment history, bevacizumab-related outcomes, and certain safety events will be collected directly from patients entirely via online surveys. Patients will be asked to complete surveys at the time of enrollment and then every 3 months for 1 year after enrollment. A saliva sample for DNA collection will be gathered using an at-home kit. Evaluations of data quality and collection feasibility will be conducted intermittently. There will be an optional substudy to allow for blood sample collection for DNA analysis.

Eligibility criteria: ≥18 years of age, residing in the US, locally recurrent breast cancer or MBC, currently being or having been treated with bevacizumab starting on or before Dec 31, 2011, fluent in English, and access to a computer with an internet connection.

Specific aims: The primary objective is to assess the feasibility of recruiting subjects and collecting biospecimens and self-reported data online. The secondary objective is to characterize the patient population. Exploratory objectives include analyzing potential associations between genetic polymorphisms and 1) bevacizumab-induced hypertension, the most common bevacizumab-related adverse event, and 2) patient-reported time-to-progression.

Statistical methods: Baseline demographics, clinical and treatment characteristics of enrolled patients will be summarized. Each polymorphism genotyped will be tested for association with the defined endpoint using appropriate statistical modeling.

Present and target accrual: Accrual as of May 23, 2012 is 82 patients. Target accrual is 1000 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-4-04.

Characterization of a new solvent-responsive gene locus in Pseudomonas putida F1 and its functionalization as a versatile biosensor

A new gene cluster, designated sepABC and a divergently transcribed sepR, was found downstream of the two-component todST phosphorelay system that regulates toluene degradation (the tod pathway) in Pseudomonas putida F1 (PpF1). The deduced amino acid sequences encoded by sepABC show a high homology to bacterial proteins known to be involved in solvent efflux or multidrug pumps. SepA, SepB and SepC are referred to be periplasmic, inner membrane and outer membrane efflux proteins respectively. Effects on growth of various PpF1 mutants compared to that of the wild type in the presence of toluene indicated a possible protective role of the solvent efflux system in a solvent-stressed environment. Growth tests with the complemented mutants confirmed the involvement of the Sep proteins in conferring solvent tolerance. The sepR gene encodes a 260-residue polypeptide that is a member of the E. coli IclR repressor protein family. The repressor role of SepR was established by conducting tests with a sep-lacZ transcriptional fusion in Escherichia coli and PpF1, expression of SepR as a maltose-binding fusion protein in a DNA binding assay, and mRNA analysis. Southern hybridization experiments and analysis of the P. putida KT2440 genome sequence indicated that sepR is a relatively rare commodity compared to homologues of the sepABC genes. We developed a whole-cell bioluminescent biosensor, PpF1G4, which contains a chromosomally based sep-lux transcriptional fusion. The biosensor showed significant induction of the sepABC genes by a wide variety of aromatic molecules, including benzene, toluene, ethylbenzene, and all three isomers of xylene (BTEX), naphthalene, and complex mixtures of aliphatic and aromatic hydrocarbons. PpF1G4 represents a second-generation biosensor that is not based on a catabolic promoter but is nonetheless inducible by aromatic pollutants and moreover functional under nutrient-rich conditions.

Quality Enhancement Research Initiative in ischemic heart disease: a quality initiative from the Department of Veterans Affairs. QUERI IHD Executive Committee

Despite the dramatic fall in ischemic heart disease (IHD) mortality rates over the last 3 decades, it remains the number one cause of death in the United States, and one of the most frequent indications for care by the US Department of Veterans Affairs. National practice guidelines have been developed and disseminated both by societies that specialize in cardiology and within the Veterans Health Administration. Despite these efforts, a substantial minority remains of patients with IHD who are not treated with guideline-recommended therapies. The Quality Enhancement Research Initiative in IHD is a Veterans Health Administration-sponsored initiative to address the gap between guideline-recommended therapies and actual Department of Veterans Affairs practice. Because guideline development for patients with IHD is relatively mature, the Quality Enhancement Research Initiative in IHD will concentrate on measuring existing practices, implementing interventions, and evaluating outcomes in veterans with IHD. Measurement of existing practices will be evaluated through analyses of existing Veterans Affairs databases developed for the Continuous Improvement in Cardiac Surgery Program, as well as data collected at the Center for the Study of Practice Patterns in veterans with acute myocardial infarction. To measure existing practices in outpatients with IHD, we plan to develop a new database that extracts electronic data from patient laboratory and pharmacy records into a relational database. Interventions to address gaps between guideline recommendations and actual practice will be solicited and implemented at individual medical centers. We plan to emphasize point-of-care electronic reminders as well as online decision support as methods for improving guideline compliance.

A typology of residential fire survivors' multidimensional needs

This article presents an analysis of the tangible, psychological, and general needs of adults and their children reported by residential fire survivors approximately 14 weeks postfire. Three hundred and seven survivors, who identified that they needed help for themselves or their children, differed from 133 survivors who did not request help. Those needing help were more likely to be women with children younger than age 18 living in their household, have low-income status, less education, and to have already received services from church groups. The classification of self-identified needs of fire survivors included the need for specific tangible and social service assistance, psychological and spiritual support, and nonspecific assistance. This classification contributes to our understanding of the relationship between needs and loss, grief, and changes in family and life situations postfire.

Language plus for international graduate students in nursing

PURPOSE

To provide information about an English-language support program that focuses on the needs of international graduate nursing students. The growing presence of these students coincides with the increasing numbers of universities committed to world health. Crucial social and language competence affect the success and progress of international students in graduate nursing programs.

DESIGN

Reviewed literature was 1980 to 1998, in nursing and applied linguistic research including second-language acquisition, phonology, discourse analysis, and language pragmatics to identify social and language phenomena.

FINDINGS

Investigators suggest essential elements such as conventions of academic writing, reading comprehension, vocabulary, and pronunciation skills be included in the supportive Language Plus program.

CONCLUSIONS

Ongoing development of the Language Plus program can promote collaboration between nurses and linguists and increase the success of international graduate nursing students.

Child safety seat misuse: home visiting assessment and intervention

This project piloted the use of nurse-initiated home visits for child safety seat (CSS) assessment and intervention. Nurses made home visits to 149 rural and suburban Wisconsin women with children under 2 years of age, and assessed CSS misuse through observation and physical manipulation. Over three-quarters of CSSs were misused, although mothers were aware of only one-quarter of the instances of incorrect use. Nurses taught proper CSS use through verbal instruction, demonstration with parent's own vehicle and CSS, and supervised parental manipulation of CSS. While mothers were receptive to home visiting for CSS assessment and education, this project involved substantial nurse training. Because thorough CSS assessment and intervention during home visits is resource-intensive, other options for improving correct CSS use and parental awareness are discussed.

A model of survivors' psychological responses following a residential fire

Residential fires result in loss of life, property, and displacement from one's neighborhood. It would be expected that grief experienced in the aftermath of residential fires has a significant impact on survivor's recovery and reintegration into the community. Although there is some research on psychological responses to community-wide fires and large scale disasters, little is known about such responses among survivors of home fires that occur episodically. Appropriate interventions cannot be developed until more is learned about variables influencing survivors' psychological response to a residential fire. A theoretical model of survivors' psychological response post-fire is proposed.

Evaluation of internal alpha-particle radiation exposure and subsequent fertility among a cohort of women formerly employed in the radium dial industry

This study examined the effect of internal exposure to alpha-particle radiation on subsequent fertility among women employed in the radium dial industry prior to 1930, when appreciable amounts of radium were often ingested through the practice of pointing the paint brush with the lips. The analysis was limited to women for whom a radium body burden measurement had been obtained and who were married prior to age 45 (n = 603). Internal radiation dose to the ovary was calculated based on initial intakes of radium-226 and radium-228, average ovarian mass, number and energy of alpha particles emitted, fraction of energy absorbed within the ovary, effective retention integrals and estimated photon irradiation. Time between marriage and pregnancy, number of pregnancies and number of live births served as surrogates for fertility. Radiation appeared to have no effect on fertility at estimated cumulative ovarian dose equivalents below 5 Sv; above this dose, however, statistically significant declines in both number of pregnancies and live births were observed. These trends persisted after multivariable adjustment for potential confounding variables and after exclusion of subjects contributing a potential classification or selection bias to the study. Additionally, the high-dose group experienced fewer live births than would have been expected based on population rates. There were no differences in time to first pregnancy between high- and low-dose groups. These results are consistent with earlier studies of gamma-ray exposures and suggest that exposure to high doses of radiation from internally deposited radium reduces fertility rather than inducing sterility.

Experiences of African American and Caucasian women who survive urban residential fires

This study examined differences in socioeconomic characteristics, traumatic experiences suffered, and psychological distress in African American and Caucasian women 3 months after urban residential fires. Distress was measured by the Brief Symptom Inventory (BSI). The sample included 310 women (224 African Americans and 86 Caucasians). The African American women had lower levels of education and income than the Caucasian women, and were more likely to be unmarried. Injury and deaths of loved ones were similar in the two groups; African American women reported greater loss of possessions, less insurance coverage, and less displacement than Caucasian women. African American and Caucasian women scored similarly on the BSI. Scores on the BSI for both groups were higher than the norms reported in the literature.

Demographic characteristics, fire experiences, and distress of residential fire survivors

The United States has one of the highest per capita fire death rates in the world. Death rates alone, however, fail to reflect the breadth of loss experienced by residential fire survivors. Despite the frequency of home fires and the potential for loss, little is known about this vulnerable population. Interviews were conducted with 440 fire survivors 14 weeks after fires. Demographic characteristics of residential fire survivors, survivors' fire experiences, psychological distress after fires and the interrelationships among these variables were examined. This sample of urban fire survivors largely comprised poor, middle-aged African American women. Psychological distress was measured by the General Severity Index of the Brief Symptom Inventory, and the results showed that survivors were highly distressed, even in the absence of fire-related death or physical injury.

Synthesis of a tetravalent sialyl Lewis x glycan, a high-affinity inhibitor of L-selectin-mediated lymphocyte binding to endothelium

Kidney transplant rejection is an inflammatory process characterized by lymphocyte infiltration. Our earlier observations have shown that peritubular capillary endothelium (PTCE) is the site of lymphocyte entry into the rejecting renal allograft. During rejection, PTCE begins to express sialyl Lewis x de novo, and binds lymphocytes by a mechanism largely dependent on L-selectin. Hence, inhibiting the lymphocyte-endothelial interaction with oligosaccharide ligands of L-selectin offers an attractive possibility to prevent the inflammation and rejection. Here, we report enzyme-assisted synthesis of N-acetyllactosamine-based tetra-, deca-, and docosameric saccharides carrying one, two or four distally located sialyl Lewis x groups [Neu-NAc alpha 2-3Gal beta 1-4(Fuc alpha 1-3)GlcNAc] (sLex), respectively. When tested for their ability to inhibit lymphocyte-endothelial interaction during rat kidney transplant rejection, all sLex-saccharides were inhibitors in the Stamper-Woodruff binding assays; the analogues lacking fucose showed no inhibitory potency. The tetravalent sLex glycan proved to be a high-affinity adhesion inhibitor with an IC50 < 50 nM. While less powerful than the tetravalent glycan, also the divalent sLex saccharide was a much better inhibitor than the monovalent glycan. Hence, increasing multivalency and, possibly, increasing chain length of the polylactosamine backbone, enhances the inhibitory potency of sLex bearing glycans in the lymphocyte-endothelial adhesion assay. This suggests that L-selectin behaves as a "functional oligomer" on lymphocyte surfaces.

Perioperative nurse practitioners

Perioperative nursing roles are evolving in response to health care reform, technological developments, and changing opportunities for advanced practice nursing. One response to these changes is the development of the perioperative nurse practitioner role. The perioperative base for this new advanced practice role is described in this article. The advanced practice role is effective in other specialty settings and can be developed readily in a variety of surgical settings. This role requires a master's degree in nursing to provide the academic and practice preparation for clinical decision making and patient management in the perioperative setting. Future opportunities for perioperative advanced practice nursing are discussed.

Enzymatic synthesis of octadecameric saccharides of multiply branched blood group I-type, carrying four distal alpha 1,3-galactose or beta 1,3-GlcNAc residues

Radiolabeled oligosaccharide constructs were prepared to evaluate carbohydrate determinants involved in gamete adhesion in mice. The octasaccharide primer GlcNAc beta 1-3Gal beta 1-4GlcNAc beta 1-3(GlcNAc beta 1-3Gal beta 1-4GlcNAc beta 1-6)Gal beta 1-4GlcNAc (1) was incubated with UDP-GlcNAc and beta 1,6-GlcNAc-transferase of hog gastric microsomes, producing the tetraantennary decasaccharide GlcNAc beta 1-3(GlcNAc beta 1-6)Gal beta 1-4GlcNAc beta 1-3[GlcNAc beta 1-3(GlcNAc beta 1-6)Gal beta 1-4GlcNAc beta 1-6]Gal beta 1-4GlcNAc (2). The decasaccharide was then incubated with UDP-Gal and beta 1,4-galactosyltransferase from bovine milk, yielding the tetradecasaccharide Gal beta 1-4GlcNAc beta 1-3(Gal beta 1-4GlcNAc beta 1-6)Gal beta 1-4GlcNAc beta 1-3[Gal beta 1-4GlcNAc beta 1-3(Gal beta 1-4GlcNAc beta 1-6)Gal beta 1-4GlcNAc beta 1-6]Gal beta 1-4GlcNAc (3). Incubation of the tetradecasaccharide 3 with UDP-Gal and alpha 1,3-galactosyltransferase from bovine thymus gave the octadecameric glycan Gal alpha 1-3Gal beta 1-4GlcNAc beta 1-3(Gal alpha 1-3Gal beta 1-4GlcNAc beta 1-6)Gal beta 1-4GlcNAc beta 1-3[Gal alpha 1-3Gal beta 1-4GlcNAc beta 1-3(Gal alpha 1-3Gal beta 1-4GlcNAc beta 1-6)Gal beta 1-4GlcNAc beta 1-6]Gal beta 1-4GlcNAc (4).(ABSTRACT TRUNCATED AT 250 WORDS)

Building consensus for nephrology nursing practice

Building consensus for nephrology nursing practice was the theme for the American Nephrology Nurses' Association's (ANNA's) 1994 Clinical Concerns Meetings in Chicago and LaJolla, California respectively. This article emphasizes the importance of consensus building, traditional approaches to consensus conferences, and the inherent risks in conducting such a conference. Additionally, the consensus conference design and steps leading to a final working document are presented by members of the Clinical Concerns Planning Committee.

Consensus for practice in the 21st century: setting a framework

The American Nephrology Nurses' Association (ANNA) broke ground in specialty nursing last Fall by holding two Consensus Development Conferences in La Jolla, CA, and Chicago. In this opening presentation to conference attendees, Facilitator Anne Keane, EdD, MSN, RN, laid the groundwork to reach consensus for practice in the 21st century. Topics explored included how health care reform will influence nephrology nursing in the 21st century and what consumers and practitioners will expect and demand.

Stepwise transfer of alpha-D-Galp-(1-->3)-beta-D-Galp-(1-->4)-beta-D-GlcpNAc sequences to 3-OH and 6-OH of distal galactose residues in bi-, tri-, and tetra-antennary asialo-glycans of N-linked complex type

The hydroxyl groups 3 and 6 of distal galactose units in bi-, tri-, and tetra-antennary asialo-glycans of N-linked complex type were substituted stepwise by transferase reactions with the sequence alpha-D-Galp-(1-->3)-beta-D-Galp-(1-->4)-beta-D-GlcpNAc. The products of each transferase reaction were purified chromatographically and the structures were confirmed by 1H NMR spectroscopy. Molecular weights of the final products were determined by matrix-assisted laser-desorption mass spectrometry (MALDI-MS).

Tryptic mapping of human chorionic gonadotropin by matrix-assisted laser desorption/ionization mass spectrometry

The potential of matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry for use in the identification of human chorionic gonadotropin (hCG) seized by law enforcement agencies is investigated. Analysis of untreated hCG revealed signals corresponding to the molecular ions of the intact hCG heterodimer and both its non-covalently linked subunits. Unfortunately, due to carbohydrate heterogeneity, the peaks are broad which makes accurate mass assignment, and consequently identification, difficult. Peptide mapping by MALDI-TOF following tryptic digestion gave sequence coverage of 59% and 52% for the alpha- and beta-subunits respectively. Nevertheless, the tryptic map was considered to provide unambiguous identification of hCG. This was confirmed by searching peptide-mass databases with the experimentally determined masses. Our data suggest that peptide mapping by proteolytic digestion followed by MALDI-TOF mass spectrometry is a suitable analytical technique for the identification of hCG seized by the legal authorities.

Critical care nurse practitioners: evolution of the advanced practice nursing role

This literature review was done to explore the use of master's-prepared nurse practitioners to manage critically ill patients. Data-based, anecdotal, clinical, analytic, and position papers published over the past 10 years in the medical and nursing literature were reviewed. This article synthesizes findings on the use of nurse practitioners in clinical settings including primary and specialty care settings, describes favorable outcomes of advanced practice nurses, and identifies factors that must be addressed as these roles increase in use in critical care settings. Nurse practitioners' movement into critical care settings should be undertaken. Additional federal support to ensure the preparation of these practitioners in adequate numbers is needed. Attention to issues of direct reimbursement, salaries, impact of changing role boundaries, malpractice coverage, and prescription privileges must be addressed. Research programs to examine the effect of nurse practitioners in specialized care should continue.

Critical care nurse practitioners: evolution of the advanced practice nursing role

This literature review was done to explore the use of master's-prepared nurse practitioners to manage critically ill patients. Data-based, anecdotal, clinical, analytic, and position papers published over the past 10 years in the medical and nursing literature were reviewed. This article synthesizes findings on the use of nurse practitioners in clinical settings including primary and specialty care settings, describes favorable outcomes of advanced practice nurses, and identifies factors that must be addressed as these roles increase in use in critical care settings. Nurse practitioners' movement into critical care settings should be undertaken. Additional federal support to ensure the preparation of these practitioners in adequate numbers is needed. Attention to issues of direct reimbursement, salaries, impact of changing role boundaries, malpractice coverage, and prescription privileges must be addressed. Research programs to examine the effect of nurse practitioners in specialized care should continue.

Psychological distress in survivors of residential fires

This paper presents preliminary findings from an ongoing study of survivors of residential fires. The purpose of this study was to examine psychological distress and extent of loss in order to provide a psychological profile of survivors overtime. The sample (N = 69) was drawn consecutively from the database of residential fires available through the Philadelphia Fire Department. Levels of psychological distress were measured as well as reports of symptoms consistent with the diagnostic criteria for Post-traumatic Stress Disorder. The major findings indicate that residential fires caused significant and sustained distress. An agenda for further research and for services to survivors of these fires is presented.

Tertiary nurse practitioners

Tertiary nurse practitioners are proposed to meet the specialized health care needs of complex patients. Societal changes, increasing numbers of medically vulnerable people and increased costs of health care demand innovative responses to health care delivery. Nurse practitioners' effectiveness in primary care settings supports their introduction into acute care settings. Nurse practitioners are involved in tertiary care in response to a need for the delivery of care to patients with specialized needs. The evolution of the tertiary nurse practitioner role pre-dated the response of educational institutions to provide appropriate preparation for practitioners in tertiary care. Curricular imperatives and policy issues that will influence professional practice of the tertiary nurse practitioner are discussed.

A study on in vitro glycation processes by matrix-assisted laser desorption ionization mass spectrometry

The number of glucose molecules condensed on glycated bovine serum albumin have been easily determined by means of matrix-assisted laser desorption/ionization mass spectrometry. Measurements were carried out on samples from incubation of the protein with glucose at different concentrations (0.02 M, 0.2 M, 2 M and 5 M). A clear increase in molecular mass of BSA with respect to incubation time is detected. In contrast to what is observed with fluorescence, the plots of molecular mass increase vs. incubation time show the occurrence of a steady state, corresponding to the complete saturation of all the protein sites reactive against glucose. Comparison of fluorescence and molecular mass data reveals that some further reactions, different from condensation, must take place, which could be in principle either intramolecular or originated by reactivity of modified condensed glucose moieties vs. free glucose.

Prescribed fenoterol and death from asthma in New Zealand, 1981-7: a further case-control study

The association between inhaled fenoterol and death from asthma has been investigated further by studying 112 asthma deaths (cases) during 1981-7 in patients aged 5-45 years who had been admitted to a major hospital for asthma during the 12 months before death. Two age matched control groups were chosen. Control group A comprised 427 patients who had been admitted to hospital for asthma during the calendar year that the corresponding death occurred and who had also had a previous admission for asthma in the previous 12 months. Control group B comprised 448 patients admitted to hospital for asthma during the calendar year in which the admission of the corresponding case occurred. The inhaled fenoterol odds ratio was 2.11 (95% confidence interval (CI) 1.37-3.23, p less than 0.01) when group A was used as the control (the approach used in previous studies), and 2.66 (95% CI 1.74-4.06, p less than 0.01) with group B as the control (the approach recommended by critics of previous studies). Markers of chronic asthma severity were associated with asthma death when control group B was used, but not when control group A was used (which indicates that these markers were indirectly matched for when control group A was used). Information was also collected on various markers of acute asthma severity and prescription of psychotropic drugs, but it was found that these were not important confounders. These findings address the major criticisms of previous case-control studies of this issue, and add support to the hypothesis that inhaled fenoterol increases the risk of death in patients with severe asthma.