PNP roles and interventions with children with special needs and their families

Pediatric nurse practitioners (PNPs) can create excellent professional roles caring for children with special health care needs (CSHCN) and their families. Children with chronic conditions represent an estimated 31% of the US population younger than 18 years (approximately 20 million children in 1988). Five percent of all children who have multiple special needs account for approximately 40% of all pediatric health care expenditures. Skill building is needed for PNPs who have traditionally focused on wellness and common acute illnesses in primary care settings. Role theory and research can guide PNPs in creating roles and interventions to improve the health, safety, and developmental outcomes for CSHCN and their families. Two roles are described, with examples of specific nursing interventions. Assisting child care centers to serve children and families with special needs is an ideal role for PNPs who have knowledge of health and regulatory issues. Another important PNP role is working with adolescents with special health care needs as they transition from pediatric to adult care. Many resources (such as those from the Maternal and Child Health Bureau) are available to assist PNPs to create new roles and interventions for CSHCN and their families.

Osteomyelitis and possible endocarditis secondary to Lactococcus garvieae: a first case report

Although osteomyelitis is commonly caused by staphylococcal infection, the first case of a lumbar osteomyelitis secondary to Lactococcus garvieae is reported. The case was complicated by possible endocarditis of an aortic valve prosthesis.

Anti-coagulant monitoring service delivery: a comparison of costs of hospital and community outreach clinics

Anti-coagulated patients are monitored at regular intervals to ensure that their warfarin dosage is appropriate for their target International Normalized Ratio. The traditional setting for this monitoring has been the hospital clinic. Technological advances allow-- and with growing numbers of anti-coagulated patients, are leading to-- greater provision of monitoring clinics outside the hospital, at a more convenient location nearer patients' homes. This paper discusses the differences in organization between a hospital clinic and one set in the community (although provided by the hospital), and compares their costs. The comparison demonstrates the greater average cost per appointment in outreach of pound sterling 13.12 under current arrangements. Estimates are presented of incremental cost per appointment of pound sterling 3.93 and pound sterling 15.88 for a 10% increase in weekly patient numbers put through hospital and outreach clinics, respectively. Cost estimates are also presented for suggested alterations to hospital clinics that may reduce patient inconvenience, and the conditions under which outreach provision might be expanded at comparable cost to hospital provision are also examined.

Prediction of the international normalized ratio and maintenance dose during the initiation of warfarin therapy

AIMS

A pharmacokinetic/pharmacodynamic model, with Bayesian parameter estimation, was used to retrospectively predict the daily International Normalized Ratios (INRs) and the maintenance doses during the initiation of warfarin therapy in 74 inpatients.

METHODS

INRs and maintenance doses predicted by the model were compared with the actual INRs and the eventual maintenance dose. Cases with drugs or medical conditions interacting with warfarin or receiving concurrent heparin therapy were not excluded. As the study was retrospective, model predictions of the maintenance dose were not those that were administered. Mean prediction error (MPE) and percentage absolute prediction errors (PAPE) were used to assess the model predictions.

RESULTS

INR MPE ranged from -0.07 to 0.06 and median PAPE from 10% to 20%. Dose MPE ranged from -0.7 to 0.17 mg and median PAPE from 16.7% to 37.5%. Accurate and precise dose predictions were obtained after 3 or more INR feedback's.

CONCLUSIONS

This study shows that the model can accurately predict daily INRs and the maintenance dose in this sample of cases. The model can be incorporated into computer decision-support systems for warfarin therapy and may lead to improvement in the initiation of warfarin therapy.

Use of a light-addressable potentiometric sensor for the detection of Escherichia coli O157:H7

We describe the development of an immunoligand assay (ILA) in conjunction with a light-addressable potentiometric sensor (LAPS) for the rapid detection of Escherichia coli O157:H7 cells in buffered saline. The ILA protocol consists of "sandwiching" bacterial analyte between biotinylated and fluoresceinated antibodies, indirect enzyme labeling of the bacteria with urease-labeled anti-fluorescein antibody, and active capture of the immune complex at a biotinylated bovine serum albumin-blocked nitrocellulose filter membrane with streptavidin. Using live E. coli O157:H7, the efficiency of the ILA was compared using various ratios of the biotinylated and fluoresceinated antibodies. Simultaneous addition of equimolar biotinylated and fluoresceinated antibodies effected optimal urease labeling and subsequent active capture of the bacteria in the ILA. Equimolar concentrations of the antibodies were varied to achieve optimal LAPS detection response for the live bacteria. Using ILA with LAPS, a minimum detectable level of ca. 7.1 x 10(2) cells/ml of heat-killed or ca. 2.5 x 10(4) cells/ml of live E. coli O157:H7 bacteria was achieved in Tris-buffered saline in an assay time of ca. 45 or ca. 30 min, respectively.

Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth

Lesbian, gay, bisexual, and transgender youth are at risk for a multitude of physical, emotional, and social health problems. During the past decade it has been well documented that these youth have higher-than-average rates of depression, suicide attempts, substance abuse, sexually transmitted diseases, school failure, family rejection, and homelessness. The focus of this article is to outline skills and strategies that can assist the health practitioner in creating an optimal health care experience for sexual minority youth. Models of individual and family adaptation, a clinical path, and a referral list are presented. Current health care delivery sites are examined, and recommendations are given for improvement of both practitioner skills and health care programs targeting these youth.

Comparison of oral anticoagulant control by a nurse-practitioner using a computer decision-support system with that by clinicians

With increasing work-loads in anticoagulant clinics different methods of service delivery need evaluation. The quality of anticoagulant control achieved by a nurse-practitioner using a computer decision-support system (CDSS) was compared with that achieved by trainee doctors without CDSS. Eighty-one out-patients (group A, therapeutic range 2-3) and 96 out-patients (group B, therapeutic range 3-4.5) were randomized to management by a nurse-practitioner or by trainee doctors (clinicians). Thirty-seven patients in group A and 50 patients in group B were randomized to be managed by the nurse-practitioner. In group A, patients in the nurse-practitioner group spent a longer time in the therapeutic range than those in the clinician group (60.7% compared with 51.6%). Dose suggestion acceptance in the nurse-practitioner group (88%) was higher compared with agreement between the CDSS and the clinicians (60%). In group B, patients in the clinician group spent a slightly longer time in the therapeutic range (70% compared with 67.6%). Acceptance of dose suggestion was lower in the nurse-practitioner group (67%) compared with agreement between the CDSS and the clinicians (73%). In conclusion, the CDSS can improve the quality of control of warfarin therapy by a nurse-practitioner over that by trainee doctors for the therapeutic range 2-3. Similar quality of control is achieved for the therapeutic range 3-4.5. The CDSS may be used by nurse-practitioners to achieve safe and effective anticoagulation in hospital-based or out-reach anticoagulant clinics.

Adolescent mothering: child-grandmother attachment

This study explored the involvement of maternal grandmothers with children of adolescent mothers and child-grandmother attachment. In a sample of 32 children whose grandmothers were involved in child care, 44% were securely attached to mothers and 72% securely attached to grandmothers. Of the 18 children insecurely attached to mothers, 82.4% were securely attached to grandmothers. A significant relationship existed between attachment security and the time the child was with grandmother, sleeping time excluded. In contrast, time with mother was not related. Based on attachment theory, findings are presented and implications for nursing practice are made.

Evaluation of a decision support system for initiation and control of oral anticoagulation in a randomised trial

OBJECTIVE

To determine whether a computerised decision support system for initiation and control of oral anticoagulant treatment improves quality of anticoagulant control achieved by trainee doctors.

DESIGN

Randomised controlled trial.

SETTING

District general hospital in North London.

SUBJECTS

148 inpatients requiring start of warfarin treatment.

INTERVENTIONS

Management by trainee doctors (to achieve therapeutic range of international normalised ratio of 2 to 3) with indirect assistance from computerised decision support system (intervention group) or without such assistance (control group).

MAIN OUTCOME MEASURES

Median time to therapeutic range, stable dose, and first pseudoevent (excessive international normalised ratio after therapeutic range has been reached) and person time spent in the therapeutic range.

RESULTS

72 patients were randomised to the intervention group and 76 to control group. Median time to reach international normalised ratio of > or = 2 was not significantly different in the two groups (3 days). Median time to achieve a stable dose was significantly lower in intervention group than in controls (7 days v 9 days, P = 0.01) without excessive overtreatment or undertreatment with anticoagulant. Patients in intervention group spent greater proportion of time in therapeutic range, both as inpatients (59% v 52%) and outpatients (64% v 51%).

CONCLUSION

The computerised decision support system was safe and effective and improved the quality of initiation and control of warfarin treatment by trainee doctors.

Proinsulin-like molecules and plasminogen activator inhibitor type 1 (PAI-1) activity in diabetic and non-diabetic subjects with and without myocardial infarction

Elevated plasminogen activator inhibitor type 1 (PAI-1) activity has been shown to correlate with plasma insulin, proinsulin-like molecules, serum triglycerides and insulin sensitivity in both non-insulin dependent diabetic (NIDDM) subjects and subjects with coronary heart disease. We examined the relative roles of these variables in determining PAI-1 activity in four groups of male caucasian subjects: non-diabetic subjects with (n = 38) and without (n = 38) previous myocardial infarction (MI) and NIDDM subjects with (n = 26) and without (n = 30) previous MI. Insulin and proinsulin-like molecules were measured using specific two-site immunometric assays and insulin sensitivity estimated using the Homeostasis Model Assessment (HOMA) model. Subjects were comparable in age and body mass index. In univariate analysis, there were significant correlations of PAI-1 activity with intact and des-31,32-proinsulin and serum triglycerides in non-diabetic subjects with (r = 0.52, P = 0.001; r = 0.58, P < 0.001; r = 0.41, P = 0.010) and without (r = 0.31, P = 0.056; r = 0.46, P = 0.006; r = 0.41, P = 0.011) MI, but not with plasma insulin or insulin sensitivity. In NIDDM subjects, PAI-1 activity correlated significantly with intact and des-31,32-proinsulin and serum triglyceride (r = 0.47, P = 0.015; r = 0.58, P = 0.002; r = 0.44, P = 0.026) only in subjects with MI. In multiple regression analysis, MI was the most important determinant of PAI-1 activity levels (r2 = 0.31, F = 55.6, P < 0.001). In conclusion, concentrations of proinsulin-like molecules and serum triglycerides appear to be stronger determinants of PAI-1 activity than plasma insulin or insulin sensitivity in both NIDDM subjects and non-diabetic subjects with and without MI. However, the relationship of MI with PAI-1 activity is independent of these variables.

Validation of an algorithm for oral anticoagulant dosing and appointment scheduling

Computer clinical decision-support systems require validation before clinical use. This study compared recommendations on warfarin dosage adjustment and timing of the next appointment made by an algorithm with those made by experienced and inexperienced clinicians. Data abstracted from the records of 125 patients seen regularly in the anticoagulant clinic were used. The algorithm recommended dose changes and next appointment for cases with INRs between 1.8 to 4.2 (therapeutic range 2.0-3.0) and between 2.3 to 5.3 (therapeutic range 3.0-4.5). Beyond these values the algorithm referred the cases to "see doctor'. Compared to experienced clinicians, the algorithm was better at "recognising' difficult patients than inexperienced clinicians (kappa = 0.43 and 0.32 respectively). There was no statistically significant difference between all decision makers in dosage recommendations for the non-difficult cases, but there was much more variation amongst the inexperienced clinicians. The interval recommendations were statistically different between and within the different decision-makers. The inexperienced clinicians tended to give relatively longer intervals for a given dose change. In conclusion, the algorithm performs better than inexperienced clinicians and as well as experienced clinicians for the non-difficult cases.

Displaying the long-term progression of patients with coronary artery disease

Cardiac clinicians are often faced with the problem of trying to assimilate details of a patient's long-term history. Case notes are often lengthy, making this process difficult if not impossible in the time available during an outpatient examination. A computer system has been developed to assist with this task. This generates a graphical summary of the principal features of a patient's long-term progression. It gives an overview of how the patient's anginal status has changed, his or her drug treatment and any surgical interventions. The system also allows the clinican to display summaries of diagnostic tests carried out. The system can be used to assist clinical management and speed up outpatient examination. It can also be used to facilitate case conference sessions and has potential for being used in medical education.

Personal aerosol protection devices: caring for victims of exposure

The increased incidence of violence in our society has led to a concern for personal safety. For self-protection, many individuals are turning to personal aerosol protection devices (PAPDs), which are readily accessible to the general public. The greater use and misuse of these noxious chemicals has led to an increase in injuries associated with exposure. Health care providers need to be aware of the modes of action of PAPDs, the presenting exposure symptoms, first aid measures, and decontamination procedures of the environment and the victim's belongings. This article provides a thorough discussion of PAPDs and will assist the clinician in delivering primary care and health education to victims of PAPD exposures.

Anaphylaxis induced by the carboxymethylcellulose component of injectable triamcinolone acetonide suspension (Kenalog)

BACKGROUND

Allergic reactions to various corticosteroids are rare but have been reported previously.

OBJECTIVE

We wished to determine the etiology of an anaphylactic reaction in a patient who had received intracutaneous Kenalog (triamcinolone acetonide).

METHODS

Skin testing and serologic testing for allergen-specific IgE antibodies was performed for triamcinolone acetonide, its individual components, and three other corticosteroid preparations in both the patient and six other nonallergic persons.

RESULTS

The patient had positive skin tests to only the carboxymethylcellulose component of triamcinolone acetonide. He had negative skin test reactions to three other steroid preparations which did not contain carboxymethylcellulose. Specific IgE antibodies to carboxymethylcellulose were also elevated by immunoassay and immunoblotting. Control patients had negative skin tests to triamcinolone acetonide, its components, and three other corticosteroid preparations, and their sera lacked significant specific IgE antibodies to these materials.

CONCLUSIONS

Our results indicate that the triamcinolone acetonide component responsible for the patient's reaction was the suspending agent carboxymethylcellulose. We urge physicians to consider component testing when patients experience allergic-type reactions to drugs.

Determinants of plasminogen activator inhibitor-1 activity in survivors of myocardial infarction

A significant relationship has been described between plasminogen activator inhibitor-1 (PAI-1) and plasma insulin concentrations. However, most radioimmunoassays (RIA) substantially overestimate plasma insulin concentrations because of cross reaction with proinsulin-like molecules and it has been proposed that proinsulin-like molecules may be important determinants of PAI-1 activity. We measured fasting plasma immunoreactive insulin by conventional RIA, fasting plasma insulin (EIMA) by specific two site immunoenzymometric assay, and intact proinsulin and des-31,32-proinsulin by two site immunoradiometric assay (IRMA) in 74 (50 nondiabetic and 24 diabetic) subjects who had survived a myocardial infarction between 6 and 24 months previously. In univariate analysis, PAI-1 activity correlated with serum triglycerides (rs = 0.43; p < 0.0001), insulin sensitivity (rs = -0.30; p = 0.004), and immunoreactive insulin (rs = 0.45; p < 0.0001). However, the relationship between PAI-1 activity and plasma specific insulin (IEMA) was weaker (rs = 0.24; p = 0.019) than those with intact proinsulin (rs = 0.53; p < 0.0001) and des-31,32-proinsulin (rs = 0.54; p < 0.0001) despite the low concentrations of these proinsulin-like molecules. In multiple regression analysis, only des-31,32-proinsulin (p = 0.001) and serum triglycerides (p = 0.013) were significant determinants of PAI-1 activity. In conclusion, these results suggest that proinsulin-like molecules and serum triglycerides are important determinants of PAI-1 activity in survivors of myocardial infarction.

Severe asthma complicated by bilateral diaphragmatic paralysis attributed to Parsonage-Turner syndrome

Progressive dyspnea that developed in a 52-year-old woman with a lifelong history of asthma did not respond to high-dose orally administered glucocorticoids. Initially, a diagnosis of allergic bronchopulmonary aspergillosis or hypersensitivity pneumonia was suggested as the cause of the worsening dyspnea. Pulmonary function tests demonstrated severe airway obstruction; substantial improvement was noted after bronchodilator therapy. Maximal inspiratory pressure was decreased, and the diffusing capacity of the lungs was abnormal. Computed tomography of the chest showed no parenchymal or mediastinal abnormalities. During a sniff test, fluoroscopy of her diaphragm disclosed paradoxical motion of both hemidiaphragms during inspiration, consistent with bilateral hemidiaphragmatic paralysis. Parsonage-Turner syndrome was diagnosed. The dose of glucocorticoids was tapered. Follow-up of the patient by telephone contact in March 1994 (9 months after her initial examination at our clinic) revealed that the dyspnea was still severe.

"Spontaneous" platelet aggregation in whole blood in diabetic and non diabetic survivors of acute myocardial infarction

There is increasing evidence that platelet thrombi play an important role in the pathogenesis of acute myocardial infarction (AMI). We compared "spontaneous" platelet aggregation in whole blood in 17 non-diabetic and 12 diabetic subjects on admission with AMI. There was no significant difference in the fall in platelet count between the two groups, expressed as platelets remaining (75.2 +/- 7.9% vs 77.3 +/- 6.9% at 10 min, 66.6 +/- 8.9% vs 68.5 +/- 6.3% at 20 min, 63.5 +/- 8.2% vs 64.9 +/- 6.7% at 30 min and 59.4 +/- 10.3% vs 61.3 +/- 7.6% at 60 min). The rate of "spontaneous" aggregation was increased in subjects with evidence of heart failure on admission compared to those without (59.9 +/- 7.9% vs 66.2 +/- 6.6% at 30 min [p = 0.05] and 55.4 +/- 9.6% vs 63.1 +/- 7.7% at 60 min [p = 0.04]). There was no correlation between the fall in platelet count and admission plasma glucose, glycated haemoglobin or peak aspartate amino-transferase. The subjects studied on admission with AMI had greater rates of "spontaneous" aggregation than 8 subjects studied between 6 and 12 months after acute myocardial infarction (75.9 +/- 7.4% vs 85.8 +/- 5.4% at 10 min; p = 0.001 and 64.3 +/- 7.5% vs 75.0 +/- 7.8% at 30 min; p = 0.006) and compared to normal controls (90.7 +/- 4.4% at 10 min; p < 0.001 and 83.4 +/- 6.5 at 30 min; p < 0.001). This study provides evidence of increased "spontaneous" platelet aggregation in subjects admitted with acute myocardial infarction but no difference between diabetic and non-diabetic subjects was observed.

Enzymatic evidence of impaired reperfusion in diabetic patients after thrombolytic therapy for acute myocardial infarction: a role for plasminogen activator inhibitor?

OBJECTIVE

To compare the activity of plasminogen activator inhibitor (PAI-1) in diabetic and non-diabetic patients admitted with acute myocardial infarction and to determine whether PAI-1 activity influences reperfusion after thrombolytic therapy.

DESIGN

Prospective study of patients admitted with acute myocardial infarction.

SETTING

District general hospital.

MAIN OUTCOME MEASURES

Reperfusion assessed by time to peak release of creatine kinase-MB isoenzyme.

RESULTS

Baseline PAI-1 activity and antigen concentrations were significantly higher in diabetic patients (n = 45) than in non-diabetic patients (n = 110) (24.6 (6.9) v 18.6 (7.9) AU/ml (AU = arbitrary units) (p = 0.0001) and 58.8 (13.1-328.8) v 41.0 (10.9-125.4) ng/ml (p = 0.004). Time to peak release of creatine kinase-MB was calculated in 123 (80%) patients. In 98 who received thrombolytic therapy the median time to peak enzyme release was 15.5 h (7.5-24 h) in diabetic patients (n = 26) and 12 h (5-26 h) in non-diabetic patients (n = 72) (p = 0.005). In those with a time to peak release of < or = 12 h, indicating likely successful reperfusion, PAI-1 activity was 17.5 (7.8) AU/ml compared with 22.8 (7.7) AU/ml in those with a time to peak release of > 12 h (p = 0.001). In multiple regression analysis both diabetes (p = 0.0001) and PAI-1 activity at admission (p = 0.029) were independently related to successful reperfusion. In 13 patients with evidence of reinfarction in hospital PAI-1 activity on day 3 was 26.7 (6.4) AU/ml compared with 21.7 (6.3) AU/ml in those without evidence of reinfarction (p = 0.032).

CONCLUSION

Both raised PAI-1 activity on admission and diabetes were associated with a reduced likelihood of enzymatic evidence of reperfusion after thrombolytic therapy. Increased PAI-1 activity on day 3 was associated with an increased risk of reinfarction. Diabetic patients had higher PAI-1 activity on admission. This may partly explain their reduced likelihood of reperfusion.

Free-radical activity after reperfusion in diabetic and non-diabetic patients with acute myocardial infarction

1. Oxygen-derived free radicals have been implicated in reperfusion injury after thrombolytic therapy in acute myocardial infarction. To test the hypothesis that diabetic patients may have increased oxidative stress which may lead to increased reperfusion damage and thereby contribute to a poorer outcome in these patients, we measured two indices of free-radical activity, diene conjugate molar ratios as an index of lipid isomerization and thiobarbituric acid-reactive material as an index of lipid peroxidation, in 66 non-diabetic and 26 diabetic patients admitted with acute myocardial infarction who received thrombolytic therapy and in whom reperfusion was assessed using early time to peak creatine kinase-MB isoenzyme release. 2. Baseline diene conjugate molar ratios or thiobarbituric acid-reactivity did not differ significantly between diabetic and non-diabetic patients (1.97 +/- 0.98 versus 2.16 +/- 1.34; not significant and 2.10 +/- 0.60 versus 1.99 +/- 0.73 mumol/l; not significant). In patients with enzymic evidence of reperfusion (i.e. time to peak enzyme release < or = 12 h) diene conjugate molar ratios peaked at 6 h compared with 12h in those with unsuccessful reperfusion (i.e. time to peak enzyme release > 12 h). In patients with unstable angina the maximum increase in the diene conjugate molar ratios was significantly less than in patients with acute myocardial infarction (6.80 +/- 12.3 versus 15.82 +/- 22.55%; P = 0.035). There was a significant fall in thiobarbituric acid-reactivity at 24 h in patients with enzymic evidence of reperfusion (P = 0.017). There were no major differences in these rises and falls between diabetic and non-diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between functional status and health-related quality-of-life after myocardial infarction

Despite increasing use in clinical and economic studies, no gold standard exists for the measurement of health-related quality of life (HRQL). One approach to assessing the validity of an HRQL instrument for a particular disease population is to examine the empirical relationship between HRQL patient scores and other accepted measures of health or functional status. In 185 patients (mean age 60 years, 79% male) at six months after myocardial infarction, we examined the relationship between patient responses to the Nottingham Health Profile (NHP), a generic HRQL instrument, and physician classification of patients by two widely used functional status indicators: the New York Heart Association (NYHA) classification and the Karnofsky Performance Status Scale. Analysis of NHP scores by NYHA strata confirms that lower HRQL is associated with poorer cardiac functional status (P < 0.0001) and this gradient is observed over all six NHP domains. Statistically significant (P < 0.001) associations were observed between patients' NYHA class and NHP domain scores for energy (Spearman r = 0.52), physical mobility (r = 0.45) and pain (r = 0.43). NHP scores for patients in NYHA Class I were similar to male population controls. A similarly consistent relationship was found between NHP and Karnofsky. We conclude that the NHP is able to discriminate between patients with differing levels of cardiac functioning as classified by NYHA and patient functioning as classified by Karnofsky. Demonstration of such discriminative properties is one important component in assessing the construct validity of HRQL measures.

Traumatic rupture of an aortic ulcerative atherosclerotic plaque producing aortic dissection: a complication of interscapular back blows used to dislodge objects from the esophagus

Penetrating atherosclerotic ulcer of the aorta is a rare entity which usually occurs in the descending thoracic aorta. Herein, we report an unusual case of penetrating aortic ulcer which ruptured into the mediastinum. Interscapular back blows were performed on our patient in an attempt to dislodge an aspirin which she thought was lodged in her esophagus. Unlike previously reported cases of this entity, the penetrating aortic ulcer in our patient was located in the distal thoracic ascending aorta. Diagnosis of penetrating aortic ulcer can be made by utilizing aortography, contiguous dynamic contrast-enhanced computed tomography or magnetic resonance imaging. Treatment consists of adjunctive medical therapy until surgery can be performed.

Carmustine toxicity presenting as a lobar infiltrate

Carmustine is a chemotherapeutic agent frequently employed in the treatment of malignant brain tumors. The side effect of pulmonary fibrosis occurs in 20 to 30 percent of patients receiving this drug. Herein we report a case of presumed carmustine-induced pulmonary fibrosis occurring with an unusual lobar distribution.

Dose titration of sustained-release recombinant bovine somatotropin in lactating dairy cows

Lactating dairy cows (n = 264) were used in seven dose titration experiments at four geographic locations in the United States. A sustained-release formulation of recombinant bST was evaluated for a 30-wk treatment period that began 14 wk postpartum. The first series of four experiments evaluated doses of 0, 140, 350, or 700 mg of bST/14 d (series A); the second series evaluated doses of 0, 56, 140, or 350 mg of bST/14 d (series B). Milk yield, DMI, milk composition, body condition, health, and reproductive parameters were measured. Multiparous cows in series A that were administered 700 mg of bST/14 d yielded 3.0 kg/d more milk and 3.5% FCM than control cows. When all seven experiments were combined, multiparous cows that were administered 350 mg of bST/14 d yielded 2.7 and 2.6 kg/d more milk and 3.5% FCM than control cows. Dry matter intake was not significantly affected by bST administration. In series A, an increase in milk yield with no increase in DMI resulted in lower adequacy of dietary NEL and CP to meet maintenance and yield requirements among multiparous cows administered 700 mg of bST/14 d. Primiparous cows that were administered bST in series A and both parity groups in the combined seven experiments were not different from control cows in the adequacy of dietary NEL or CP to meet maintenance and yield requirements. No adverse effects of bST on health parameters were significant, and doses of 350 mg of bST/14 d or less caused no changes in reproductive parameters. Conception rate was decreased by administration of 700 mg of bST/14 d. These data suggest that 350 mg of bST/14 d increased yields of milk and FCM with no adverse effects on DMI, health, or reproduction in dairy cows.

Plasminogen activator inhibitor: a risk factor for myocardial infarction in diabetic patients

OBJECTIVE

To determine whether diabetic patients admitted with acute myocardial infarction have impaired fibrinolytic activity due to raised plasminogen activator inhibitor compared with non-diabetic patients.

SETTING

A district general hospital.

PATIENTS

90 non-diabetic and 38 diabetic patients admitted with acute myocardial infarction.

RESULTS

Both plasminogen activator inhibitor activity and antigen were significantly higher in diabetic than in non-diabetic patients (24.7 (6.8) v 18.5 (6.8) AU/ml; p = 0.0001 and 64.2 (range 13.1 to 328.8) v 38.5 (range 10.9 to 173.7 ng/ml; z = 3.3; p = 0.0008) with a positive correlation between activity and antigen (rs = 0.51; p = 0.0001). In both groups, activity and antigen concentrations were significantly higher than in diabetic and non-diabetic subjects without coronary artery disease (p = 0.002 to 0.0001 for each comparison). Plasminogen activator inhibitor activity correlated significantly with admission plasma glucose (r = 0.32; p = 0.0001), glycated haemoglobin (r = 0.32; p = 0.0001), admission plasma insulin (rs = 0.48; p = 0.001), and Killip grade of heart failure both on admission (rs = 0.27; p = 0.001) and on discharge (rs = 0.22; p = 0.006), but not with cumulative creatine kinase MB isoenzyme release (rs = -0.08). There were similar but weaker correlations between tissue plasminogen activator antigen and admission plasma glucose, glycated haemoglobin, and insulin. In 18 patients (12 non-diabetic and six diabetic) plasminogen activator inhibitor activity was measured between six and 12 months (8.3 (1.6)) after the acute infarct and remained similar to activity on admission (24.8 (1.9) AU/ml (NS) for diabetic and 17.9 (6.9) AU/ml (NS) for non-diabetic patients) and was still significantly higher in diabetic than in non-diabetic patients (p = 0.007).

CONCLUSION

These results show that diabetic patients have higher plasminogen activator inhibitor activity than non-diabetic patients both on admission with acute myocardial infarction and at follow up six to 12 months later. Raised plasminogen activator inhibitor activity may predispose diabetic patients to myocardial infarction and may also impair pharmacological and spontaneous reperfusion after acute myocardial infarction thus contributing to the poor outcome in these subjects.

Plasminogen activator inhibitor activity in diabetic and nondiabetic survivors of myocardial infarction

Recent studies suggest that plasminogen activator inhibitor (PAI-1) may be a risk factor for recurrent myocardial infarction. We measured PAI-1 activity and antigen and tissue-type plasminogen activator (t-PA) antigen in 35 (20 nondiabetic and 15 diabetic) subjects with no clinical or electrocardiographic evidence of ischemic heart disease and in 74 (50 nondiabetic and 24 diabetic subjects) who had survived a myocardial infarction in the preceding 6-24 months. Levels of PAI-1 activity (18.7 +/- 5.6 versus 12.0 +/- 3.8 arbitrary units [AU] per milliliter, p = 0.001) and t-PA antigen (7.0 +/- 1.9 versus 4.6 +/- 2.0 ng/mL, p = 0.001) were significantly higher in diabetic compared with nondiabetic control subjects. Survivors of myocardial infarction had higher levels of PAI-1 activity and antigen and t-PA antigen than control subjects, and the diabetic survivors had higher levels of PAI-1 activity (25.3 +/- 6.7 versus 20.1 +/- 7.1 AU/mL, p = 0.004) and t-PA antigen (10.6 +/- 4.3 versus 8.4 +/- 3.3 ng/mL, p = 0.03) than the nondiabetic survivors. No difference in PAI-1 antigen levels was found between the diabetic subjects and either the nondiabetic control subjects or survivors of myocardial infarction. After venous occlusion in control subjects, there was a significant increase in PAI-1 antigen (mean 26.7%, range 14.1-58.1% in nondiabetics and mean 25.2%, range 6.2-39.7% in diabetics) and t-PA antigen (mean 78.3%, range 13.6-186.2% for nondiabetic and mean 40.7%, range 17.5-76.2% for diabetic subjects), but in the survivors of myocardial infarction, no significant effect of venous occlusion was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Lactational response of Jersey cows to bovine somatotropin administered daily or in a sustained-release formulation

Twenty-four Jersey cows were administered either 0 or 15.5 mg of bST/d or 310 mg of bST/14 d to determine the effect on milk yield, milk composition, feed intake, and body weight. Administration of bST was from wk 14 through 42 postpartum. Cows were housed in a tie-stall barn and fed for ad libitum intake a TMR adjusted to one of two energy protein densities according to milk yield. Milk yield of cows administered bST daily or by sustained-released vehicle increased 27.6 and 24.7%, respectively, over that of control cows; FCM increased by 30.3 and 26.7%. Percentages of fat and protein in milk were unaffected by bST treatment. Dry matter intake of cows administered bST was greater than that of control cows, whether expressed as kilograms per day or as a percentage of body weight. Apparent efficiency of yield increased in cows administered bST. No significant change in body weight occurred; however, cows administered bST had lower body condition scores at 42 wk postpartum. This trial demonstrated comparable effects of bST on lactational performance when administered daily or in a 14-d sustained-release vehicle.

Achieving excellence in nursing

The critical shortage of nurses has placed a heavy burden on managers. Because they are responsible for ensuring that pediatric staff members maintain high professional standards, the promotion excellence within the staff remains imperative; it is essential that managers assist themselves and others to strive for excellence. How do you strive for excellence? A commitment to excellence requires a lifelong commitment to nursing, research, learning, scholarship, and personal balance and well-being. Pursuit of excellence in nursing is difficult, especially in a society marked by its satisfaction with mediocrity. Yet by this pursuit, not only will the nurse benefit, but so will the staff, the children, and maternal-child nursing.

A data model for intensive care

The paper describes a model of clinical management data in a typical general intensive care unit, intended as a generic database specification for advanced intensive care computer systems. The data model was developed as part of the INFORM project. The INFORM project is summarised and the relevance of the data model to the objectives of the project are discussed. An object oriented extension to the entity relationship diagram methodology is presented. The methodology is illustrated with reference to some specific aspects of the data model including: the principle clinical entities; classification of patient state related data and the homogeneous patient group system. It is suggested that such a model will contribute to the better understanding of the data in the system, to the better design of future intensive care computer systems and to the setting of standards for medical data.

Angiotensin converting enzyme inhibitors and magnesium conservation in patients with congestive cardiac failure

OBJECTIVE

To investigate whether angiotensin converting enzyme inhibitors reduce diuretic induced magnesium excretion in patients in congestive cardiac failure.

DESIGN

Cohort analytic study.

SETTING

A London district general hospital.

SUBJECTS

Thirty four patients with chronic congestive cardiac failure caused by ischaemic heart disease or cardiomyopathy selected consecutively from inpatients under the care of two consultant cardiologists. Nineteen patients (group 1) on diuretics alone were compared with 15 patients (group 2) taking diuretics plus either enalapril or captopril. All drug regimens were stable for at least three months before the study. Patients with impaired renal function (plasma creatinine greater than 120 mumol/l) were excluded.

INTERVENTIONS

An intravenous loading dose of magnesium sulphate was given to minimise the variability in baseline magnesium state.

MAIN OUTCOME MEASURE

Total urine magnesium excretion and creatinine clearance in 24 hour urine collections.

RESULTS

Plasma magnesium was similar in the two groups. However, 24 hour urine magnesium excretion was significantly lower in group 2 than in group 1. Furthermore, creatinine clearance was also significantly lower in group 2 and correlated strongly with magnesium excretion. There was no such relation in group 1. There was no difference in fractional clearance of magnesium between groups.

CONCLUSION

Angiotensin converting enzyme inhibitors have an important magnesium conserving action, possibly via their effect on glomerular filtration rate.

Ventricular fibrillation due to lithium withdrawal--an interaction with chlorpromazine?

We report a case of primary ventricular fibrillation following withdrawal of lithium in a patient concurrently taking chlorpromazine. A potentially important drug interaction is discussed.

Biophysical studies of the cellular elements of the rabbit carotid body

The carotid body is a major sensor of oxygen partial pressure in the arterial blood, and plays a role in the control of respiration. Despite extensive investigation of the structure, the cellular basis of the transduction mechanism remains poorly understood. We have developed a preparation of freshly dissociated cells from the rabbit carotid body, in which two cell types may be identified using morphological criteria. The preparation allows application of the patch clamp technique to characterize the properties of the cells which have otherwise proved difficult to study in situ. Carotid bodies of rabbits were dissociated using a combination of enzymatic and mechanical procedures. The dissociated preparation obtained consisted of clusters of spherical or ovoid cells of 12-15 microns in diameter and a distinct population of spherical cells of 8-10 microns diameter. Electron microscopic techniques were used to identify the cells present in the preparation. Again two populations of cells could be distinguished. A population of cells 10-12 microns in diameter, often found in clusters, possessed the dense-cored vesicles characteristic of Type I cells, while a population of smaller cells (diameter 5-7 microns) had peripherally condensed nuclear chromatin and fine cytoplasmic surface extensions characteristic of Type II cells. Patch clamp study of the cells showed that they represent two electrophysiologically distinct populations. The larger cells, corresponding to Type I cells, were found to be excitable, generating fast, sodium-dependent action potentials that were recorded both in the cell attached and whole cell recording configurations. The smaller Type II cells did not generate action potentials. Voltage clamp study of Type I cells allowed definition of a range of voltage-gated currents. These included an inactivating, tetrodotoxin-sensitive inward sodium current, a high threshold sustained inward calcium current, and outward potassium currents. A component of the outward current showed a dependence on voltage-gated calcium entry, and was blocked by cobalt or cadmium. Of the calcium-dependent current, a component was sensitive to apamin, and the remaining current was blocked by tetraethylammonium. Type II cells showed only a high threshold outward potassium current. These studies have thus revealed an electrophysiological differentiation that parallels the morphological differentiation of the cells of the carotid body. The Type I cell is essentially neuron-like in its properties, while the Type II cell appears to have properties resembling those of glial elements elsewhere in the nervous system.(ABSTRACT TRUNCATED AT 400 WORDS)

Fatal rhabdomyolysis associated with hyperosmolar diabetic decompensation

A patient is described who developed fatal acute rhabdomyolysis in association with hyperosmolar diabetic decompensation. The delay in making the diagnosis of acute rhabdomyolysis may have contributed to the outcome as the use of dantrolene may be of benefit in such patients.

Effects of acute and chronic dimethylamine exposure on the nasal mucociliary apparatus of F-344 rats

Dimethylamine (DMA) is a highly water soluble gas with many industrial applications. Male F-344 rats were exposed to 175 ppm DMA 6 hr per day for 1, 2, 4, or 9 days or 2 years. Gross changes in nasal structure were recorded, effects of DMA on the mucociliary apparatus were assessed using video analysis, and tissues were evaluated for histopathology. In vitro nasal mucociliary flow patterns, mucus flow rates, and ciliary activity were studied and recorded for video motion analysis. There were distinct and generally consistent differences in the shape of the naso-, maxillo-, and ethmoid turbinates between young and old animals. Acute and chronic DMA exposures resulted in erosion of the anterior margins of the naso- and maxilloturbinates and fenestration of the adjacent septum. Ciliastasis and mucostasis were observed only on the anteromedial aspect of the maxilloturbinate. In the chronically exposed rats, mucociliary activity was present in areas adjacent to erosions of the turbinates and septum. Abnormal mucus flow patterns, including altered or reversed direction of flow and "whirlpool-like" formation, were observed in all treated rats, but were more severe following chronic exposure. There was a good correlation between the distribution of responses as assessed by histopathology and abnormal mucociliary function at all time points. In conclusion, the mucociliary apparatus continues to function in the nasal passages of rats having localized destruction of nasal epithelium, induced by DMA exposure, and this clearance system responds to alterations of nasal structure by modification of mucus flow patterns.

Distribution, progression, and recovery of acute formaldehyde-induced inhibition of nasal mucociliary function in F-344 rats

A previous report of inhalation exposure of F-344 rats to formaldehyde gas, using a whole-body exposure system, described the induction of regional inhibition of nasal mucociliary function, with a clear concentration-response relationship. A head-only exposure system was subsequently developed in order to facilitate the present study of reversibility of acute effects of formaldehyde on the nasal mucociliary apparatus. This study also included an examination of more extensive areas of the nose than those reported in the previous work. Male F-344 rats were exposed to 2 or 15 ppm formaldehyde gas for 10, 20, 45, or 90 min or 6 hr with recovery groups examined 1 hr after the end of the 90-min and 6-hr exposures. No effects were observed in rats exposed to 2 ppm formaldehyde. In rats exposed to 15 ppm, the extent of formaldehyde-induced inhibition of mucociliary function detected in specific regions of the nose was time dependent, with increasing areas of mucostasis and ciliastasis being induced during a 6-hr exposure period. A 1-hr room-air exposure, following exposure to 15 ppm formaldehyde, resulted in marked recovery of mucociliary function, indicating the value of a head-only exposure system for rapid examination of mucociliary function following exposure. Recovery of mucociliary function occurred especially in the more posterior areas of affected regions of the nose. However, in areas of recovery mucus flow rate was reduced compared to unexposed control rates, indicating incomplete recovery of function in these areas. Regions of formaldehyde-induced inhibition of mucociliary function correlated well with the previously reported distribution of formaldehyde-induced nasal squamous cell carcinomas, with the exception of effects on the medial aspect of the maxilloturbinate. These findings were considered to provide further support for the proposal that both regional exposure and local tissue susceptibility may be responsible for the distribution of formaldehyde-induced nasal squamous cell carcinomas. It was also postulated, on the basis of mucus flow patterns derived from control animals in this study, that flow relationships between nasal mucus and inspired air form a countercurrent system which may optimize clearance of inhaled air contaminants.

The extent of coronary artery disease in diabetic patients with myocardial infarction: an ECG study

In 91 non-diabetics (age 63 +/- 12, mean +/- SD, years range 31-94 years) and 85 patients with known diabetes or clearly abnormal levels of HbA1c (age 66 +/- 10 years, range 36-87 years) electrocardiograms were analysed sequentially after acute myocardial infarction (AMI). There was no significant difference in infarct site between the two groups. Generalized ischaemic change without ST elevation was seen in 33% of diabetics and 22% of non-diabetics (p greater than 0.1). In patients with transmural AMI, cardiogenic shock (CGS) was significantly commoner in diabetics (relative risk 3.1, CL 1.2-8.1) but there was no difference in the frequency of reciprocal change between the two groups. In both diabetic and non-diabetic patients the development of cardiogenic shock was more frequently associated with the presence of reciprocal change, the difference reaching significance in the diabetic group (chi 2 = 4.4, p less than 0.05). Thus cardiogenic shock in both diabetic and non-diabetic patients with AMI may be associated with the presence of extensive coronary artery disease, but differences in the prevalence of extensive disease do not explain the predisposition of diabetic patients to CGS.

Shoshin beriberi: an underdiagnosed condition?

Shoshin beriberi, a fulminant form of heart failure due to thiamine deficiency has a different presentation to the classical form of beriberi heart failure. It is characterized by a cold periphery, low blood pressure, renal shutdown and a severe metabolic acidosis. The true incidence is unknown. Two patients were seen within a few months in a general hospital and in both dietary deficiency of thiamine was a major factor.

Responses of the nasal mucociliary apparatus of F-344 rats to formaldehyde gas

The nasal mucociliary apparatus is an important component of the airway defenses. Studies were undertaken to determine the nature and distribution of acute effects of inhaled formaldehyde on the nasal mucociliary apparatus of male F-344 rats using whole body exposures. Formaldehyde exposures ranged from a single 6-hr period up to multiple 6-hr exposures daily for 3 weeks, with exposure concentrations of 15, 6, 2, 0.5, and 0 ppm. Within 1 hr of the last exposure, the rats were killed and the nasal passages examined for effects on nasal mucociliary function. Exposure to 15 ppm formaldehyde induced inhibition of mucociliary function in specific regions of the nose, and mucostasis was generally more extensive than ciliastasis. These effects, which were initially confined to the anterior regions of the nose, became progressively more extensive for up to 2 weeks of exposure with only very slight progression during the third week. Inhibition of mucociliary function was much less severe with 6 ppm, minimal at 2 ppm, and not detected in rats following exposure to 0.5 ppm. The distribution of epithelial lesions, identified by histopathology, correlated well with the distribution of defective mucociliary function, but mucociliary function was a more sensitive indicator of toxicity. Localized defects in mucociliary function represent a potentially important consequence of exposure to formaldehyde.

The nasal mucociliary apparatus. Correlation of structure and function in the rat

Rats are used extensively in inhalation toxicologic studies, but little information is available on the rat nasal mucociliary apparatus. The function of the rat nasal mucociliary apparatus was studied in vitro by video analysis, and its structure was examined by light and electron microscopy. Video analysis permitted determination of mucus flow rate and ciliary beat frequency without disrupting mucociliary function. In different regions of the nose, there was a characteristic mucus flow rate, flow pattern, and ciliary beat frequency, with minimal interanimal variation. Analysis of data pairs revealed no evidence of a correlation between mucus flow rate and ciliary beat frequency, ciliary length, density of the ciliated cell population, or the products of these factors. Mucus was seen to flow over certain nonciliated areas, and it is proposed that the mucus is pulled over these areas. Mucus flow characteristics indicated that the hypophase was less viscous than, and moved in the same direction as, the epiphase. The nasal mucus was present as a continuous layer over the respiratory epithelium, and had an osmiophilic surface film, which was found to be made up of 2 separate membranous components. On the basis of these studies, it was concluded that the rat nasal mucociliary apparatus represents a useful and readily accessible model for in vitro studies of nasal mucociliary function.