The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

Zirconium arene triple-decker sandwich complexes: synthesis, electronic structure and bonding

Reduction of a permethylpentalene zirconium(iv) chloride complex [η⁸-Pn*Zr(μ-Cl)_3/2]₂(μ-Cl)₂Li·THF_x with KC₈ in benzene results in activation of the aromatic solvent to yield an "inverted sandwich" complex, [η⁸-Pn*Zr]₂(μ-η⁶:η⁶-C₆H₆) (1). The reactions in toluene, cumene, o-xylene and m-xylene also yield analogous solvent activated triple-decker sandwich complexes, which have been structurally characterised by single-crystal X-ray diffraction. Edge energies in the Zr K-edge XANES spectra are not distinguishable between 1 and formally Zr(ii) and Zr(iv) reference compounds, suggesting a broad edge structure. DFT calculations best describe the bonding in 1 as highly covalent with frontier molecular orbitals showing almost equal contributions from benzene and the Zr-permethylpentalene fragments.

Situational awareness ability and cognitive skills training in a complex real-world task

Successful performance in complex dynamic environments depends on domain-dependent factors, such as situational awareness (SA). Underlying SA in a domain are domain-independent cognitive abilities in perception, memory, attention and executive control. Individuals with lower underlying ability perform relatively poorly in complex dynamic real-world tasks. The first experiment examined whether cognitive skills training could overcome limitations in underlying SA ability that impact on complex dynamic task performance. Participants were taught a mix of cognitive management strategies (e.g. divided and focused attention and visual search) in a simulated air traffic control task. A second experiment investigated the link between underlying SA ability, TRACON and SAGAT, a widely used measure of domain-specific SA. In a third experiment, the focus was on encouraging participants to plan ahead and consider the interrelations of elements (aircraft) in the environment. Whilst both training methods ameliorated the negative impact that lower SA ability had on complex dynamic task performance, the results of the third study indicated that this may have been achieved through improved planning behaviour. Finally, participants with higher underlying SA ability performed well irrespective of training condition.

Developing a tissue perfusion sensor

The development of a electrochemical tissue perfusion sensor is presented. The sensor is a platinum/platinum ring-disc microelectrode that relies on the principle of collector-generator to monitor mass transport within its vicinity. Tissue perfusion is a mass transport mechanism that describes the movement of respiratory gases, nutrients and metabolites in tissue. The sensor's capability of detecting perfusion at the cellular level in a continuous fashion is unique. This sensor will provide insight into the way nutrients and metabolites are transported in tissue especially in cases were perfusion is low such as in wounds or ischemic tissue. We present experimental work for the development and testing of the sensors in vitro. Experimental flow recordings in free steam solutions as well as the flow through tissue-like media are shown. Tests on post operative human tissue are also presented. The sensor's feature such as the continuous recoding capacities, spatial resolution and the measurement range from ml/min to microl/min are highlighted.

Effects of age on feeding behavior and chemosensory processing in the pond snail, Lymnaea stagnalis

This study used behavioral and electrophysiological techniques to examine age-related changes in the feeding behavior and chemosensory processing in the pond snail, Lymnaea stagnalis. Increasing age was associated with a 50% decrease in long-term food consumption. Analysis of short-term sucrose-evoked feeding bouts showed an age-related increase in the number of animals that failed to respond to the stimulus. Of the animals that did respond increasing age was associated with a decrease in the number of sucrose-evoked bites and a increase in the duration of the swallow phase. These changes were observed with both 0.01 and 0.05M sucrose stimuli but were not seen when 0.1M sucrose was used as the stimulus. Electrophysiological analysis of the chemosensory pathway in semi-intact lip-CNS preparations failed to demonstrate a significant change in the neuronal information entering the cerebral ganglia from the lips via the median lip nerve, but did demonstrate an age-related deficit in the neuronal output from the cerebral ganglia. This deficit was also dependent on the sucrose concentration and mirrored the concentration-dependent changes in feeding behavior. In summary, aging appeared to affect central but not peripheral processing of chemosensory information and suggests that this deficit contributes to the age-related changes in feeding behavior.

Case-control study of risk factors for fatal and non-fatal injury in crashes of rotary-wing aircraft

INTRODUCTION

There have been few studies of the risk factors for fatal injury in air crashes of rotary-wing aircraft, and none of risk factors for all serious injury (fatal and non-fatal) in these aircraft. The aim of the study was to identify the potentially modifiable risk factors for injury in civil rotary-wing aircraft crashes in New Zealand.

METHOD

We analyzed records from all reported civil rotary-wing aircraft crashes in New Zealand between 1988 and 1994. Air crash data from the official databases were merged with nationwide injury records and information obtained from Coroner's files. Crashes where the pilot-in-command was fatally injured were compared with crashes where the pilot-in-command was not fatally injured on 50 variables, covering pilot, aircraft, environmental, and operational characteristics. A second analysis compared crashes where the pilot-in-command was seriously injured (either fatally or non-fatally) with crashes where the pilot-in-command was not hospitalized with an injury. A series of multivariate logistic regression analyses were conducted to estimate the odds associated with each of the factors identified by the univariate analyses.

RESULTS

The most significant risk factors for all serious injury were: (a) not obtaining a weather briefing, (b) off-airport location of the crash site, (c) flights carried out for air transport purposes, and (d) non-solo flights. Other risk factors, significant for fatal injury only, included post-crash fire and the nature of the crash terrain. Factors within the control of the pilot, environmental, and flight characteristics are the key determinants of the injury outcome of civil rotary-wing aircraft crashes.

Changes in the properties of the modulatory cerebral giant cells contribute to aging in the feeding system of Lymnaea

This study examined whether electrophysiological changes in the endogenous properties and connectivity of the modulatory serotonergic cerebral giant cells (CGCs) contributed to the age-related changes in feeding behavior of the pond snail, Lymnaea. With increasing age there was a decrease in spontaneous CGC firing rates and decreased excitability of the CGCs to both chemosensory stimulation (0.05M sucrose applied to the lips) and direct intracellular current injection. These changes could be accounted for by a decrease in the input resistance of the neuron and an increase in the amplitude and the duration of the after-hyperpolarization. Decreases were also seen in the % of CGC pairs that were electrically coupled causing asynchronous firing. Together these changes would tend to reduce the ability of the CGCs to gate and control the frequency of the feeding behavior. Part of the ability of the CGCs to gate and frequency control the feeding network is to provide a background level of excitation to the feeding motor neurons. Recordings from B1 and B4 motor neurons showed an age-related hyperpolarization of the resting membrane potential consistent with a deficit in CGC function. Increases were seen in the strength of the evoked CGC-->B1 connection, however, this increase failed to compensate for the deficits in CGC excitability. In summary, age-related changes in the properties of the CGCs were consistent with them contributing to the age-related changes in feeding behavior seen in Lymnaea.

Direct and indirect cost of general aviation crashes

BACKGROUND

There have been few well-designed studies which estimate the costs inflicted on society from injuries, fatalities, and property damage caused by aviation crashes. Furthermore, indirect cost estimates from the human capital (HC) approach tend to be substantially smaller than those obtained from the willingness-to-pay (WTP) approach.

OBJECTIVES

To estimate the direct and indirect costs of general aviation crashes in New Zealand, and to contrast the HC and WTP approaches used to estimate indirect costs.

METHODS

The incidence, morbidity, and mortality from aviation crashes between 1988 and 1997 were estimated from national health and aviation records. Direct costs included medical treatment, damage to aircraft and property, and the cost of crash investigation. For the HC approach, we valued losses to society as the value of lost production from both employed work and household activity. For the WTP approach, we used the Land Transport Safety Authority's estimated values of society's willingness to pay to avoid a fatality or injury.

RESULTS

The annual average direct cost of aviation crashes was $9.1 m (range: $8.0 m to $11.4 m). The annual average indirect cost using the HC approach was $13.6 m ($5.6 m to $32.2 m). Using the WTP approach the annual average indirect costs was $49.3 m ($20.6 m to $106.5 m). Indirect costs from premature deaths were the key cost drivers. A sensitivity analysis showed that these values were relatively robust to changes in parameters.

CONCLUSION

The annual average cost of general aviation crashes in New Zealand was between $22.6 m and $58.4 m. Indirect costs using the WTP approach were 3.5 times greater than those estimated using the HC approach.

Real time observation of the hydrothermal crystallization of barium titanate using in situ neutron powder diffraction

The hydrothermal crystallization of barium titanate, BaTiO3, has been studied in situ by time-resolved powder neutron diffraction methods using the recently developed Oxford/ISIS hydrothermal cell. This technique has allowed the formation of the ferroelectric ceramic to be followed in a noninvasive manner in real time and under genuine reaction conditions. In a first set of experiments, Ba(OD)2-8D2O was reacted with two different titanium sources, either crystalline TiO2 (anatase) or amorphous TiO2-H2O in D2O, at 100-140 degrees C and the reaction studied using the POLARIS time-of-flight neutron powder diffractometer, at the ISIS Facility. In a second series of experiments, the reaction between barium chloride and crystalline TiO2 (anatase) in NaOD/D2O was studied at temperatures between 100 and 200 degrees C and at different deuterioxide concentrations using the constant-wavelength D20 neutron powder diffractometer at the Institut Laue Langevin. Quantitative growth and decay curves were determined from analysis of the integrated intensities of Bragg reflections of starting materials and product phases. In both sets of experiments the rapid dissolution of the barium source was observed, followed by dissolution of the titanium source before the onset of crystallization of barium titanate. Using a nucleation-growth model we are able to simulate the growth curve of barium titanate at three temperatures. Our results indicate the predominance of a homogeneous dissolution-precipitation mechanism for the hydrothermal formation of barium titanate, rather than other possible mechanisms that have been discussed in the literature. Analysis of the line widths of the Bragg reflections in the neutron diffraction data indicates that the particle size of the BaTiO3 product phase prepared from the amorphous TiO2-H2O is smaller than that prepared from crystalline TiO2 (anatase).

Intercalation and controlled release of pharmaceutically active compounds from a layered double hydroxide

A series of pharmaceutically active compounds including diclofenac, gemfibrozil, ibuprofen, naproxen, 2-propylpentanoic acid, 4-biphenylacetic acid and tolfenamic acid can be reversibly intercalated into a layered double hydroxide, initial studies suggest that these materials may have application as the basis of a novel tuneable drug delivery system.

High resolution imaging of the distribution and permeability of methyl viologen dication in bovine articular cartilage using scanning electrochemical microscopy

Scanning electrochemical microscopy (SECM) has been used in the induced transfer (SECMIT) mode to image the permeability of a probe cation, methyl viologen (MV(2+)), in samples of articular cartilage. An ultramicroelectrode (UME), scanned just above the surface of a sample, is used to amperometrically detect the probe solute. The resulting depletion of MV(2+) in solution induces the transfer of this cation from the sample into the solution for detection at the UME. The current provides quantitative information on local permeability, provided that the sample-UME distance is known. It is shown that the necessary topographical information can be obtained using the amperometric response for the oxidation of Ru(CN)(4-)(6), which does not permeate into the cartilage matrix. This procedure was validated by marking samples in situ, after electrochemical imaging, with subsequent examination by ex situ interferometry and optical microscopy. Wide variations in the permeability of MV(2+) have been detected by SECMIT. These observations represent the first demonstration of the inhomogeneous permeability of a cation in cartilage on a micrometre scale. The permeability maps show similar features to the proteoglycan distribution, identified by toluidine blue staining, and it is likely that proteoglycans are the main determinant of MV(2+) permeability in articular cartilage.

(eta 5-Cyclopentadienyl)(kappa 3-hydrotris(pyrazolyl)borate)cobalt(II)--the first high-spin cobalt organometallic complex

(eta 5-Cyclopentadienyl)(kappa 3-hydrotris(pyrazolyl)borate)-cobalt(II) has been synthesised; magnetic and crystallographic data indicate this to be the first example of a high-spin cobalt organometallic complex whilst its pentamethylcyclopentadienyl analogue is found to have a low-spin electronic configuration.

Synthesis and characterisation of (C4N2H12)(UO2)2(PO3H)2(PO2(OH)H)2: a three dimensionally connected actinide framework

The material (C4N2H12)(UO2)2(PO3H)2(PO2(OH)H)2 (MUPH-1) has been prepared hydrothermally; it is a three dimensional structure consisting of four intersecting elliptical shaped one-dimensional channels, the largest channel has dimensions of 13.1 x 7.2 A.

Direct in situ observation of increasing structural dimensionality during the hydrothermal formation of open-framework zinc phosphates

The first time-resolved in situ X-ray diffraction studies of the hydrothermal crystallisation of open-framework zinc phosphates reveal a pathway of sequential crystallisation involving formation of a metastable low dimensional chain phase before the growth of three-dimensional zeolitic architectures.

Variable coordination modes of hydrotris(3-isopropyl-4-bromopyrazolyl)borate (Tp') in Fe(II), Mn(II), Cr(II), and Cr(III) Complexes: formation of MTp'Cl (M = Fe and Mn), structural isomerism in CrTp'(2), and the observation of Tp' (-) as an uncoordinated anion

The syntheses of the 4-coordinate Tp'MCl complexes (where M = Fe (1), Mn (2); and Tp' = hydrotris(3-isopropyl-4-bromopyrazolyl)borate) are described. The single-crystal X-ray structures show that the metal centers have distorted tetrahedral coordination. Analogous reaction of CrCl(2)(MeCN)(2) with TlTp' gave Cr(kappa(3)-Tp')(kappa(2)-Tp') (3) as the initial product. The 5-coordinate structure was assigned by single-crystal X-ray crystallography, and it was found that the kappa(3) ligand had isomerized to hydro(3-isopropyl-4-bromopyrazolyl)(2)(5-isopropyl-4-bromopyrazolyl)borate). 3 is labile in solution: in pentane it slowly converts to the 6-coordinate isomer Cr(kappa(3)-Tp')(2) (4), whose structure was determined by X-ray crystallography. In 4 both ligands are isomerized. Both 3 and 4 display Jahn-Teller distorted structures expected for high-spin d(4) configurations. Variable temperature magnetic susceptibility measurements confirm that 1, 2, and 3 all have high-spin electronic configurations in the range 5-300 K. In benzene solution 3 decomposes; one product [Cr(kappa(3)-Tp')(2)](+)[Tp'](-) (5), was identified by X-ray crystallography. 5 contains a pseudooctahedral Cr(III) cation with both ligands in the isomerized form and an uncoordinated Tp' ligand as counterion. Mechanistic studies reveal that this reaction is light rather than heat induced. IR spectroscopy is utilized to confirm the ligand hapticity in all complexes from the value of nu(B)(-)(H), and comparison is made with similar compounds.

Arterial blood sampling practices in intensive care units in England and Wales

A postal survey of arterial blood sampling practices in 280 intensive care units throughout England and Wales found that very few measures are taken to reduce diagnostic blood loss in adult intensive care patients from arterial sampling. The average volume of blood withdrawn to clear the arterial line before sampling is 3.2 ml; subsequently returned to the patient in only 18.4% of intensive care units. Specific measures to reduce the blood sample size by the routine use of paediatric sample tubes in adult patients occurs in only 9.3% of intensive care units. In paediatric units, the average volume withdrawn was 1.9 ml and this was routinely returned in 67% of units. Some aspects of arterial blood sampling practices identified in this survey may contribute to iatrogenic anaemia in intensive care patients.

The use of botulinum toxin in otorhinolaryngology

In recent years, the use of botulinum toxin has become more popular for the treatment of a wide variety of diseases in the head and neck. It offers the possibility of non-invasive treatment of conditions whose aetiology lies in neuromuscular dyskinesis.

The 'Wheel of Misfortune': a taxonomic approach to human factors in accident investigation and analysis in aviation and other complex systems

The analysis and reporting of the human factors aspects of accidents in aviation and other complex systems continues to present difficulties for investigators and analysts alike. Reason's 'latent conditions' model has had a major impact on the way accidents are conceptualized but it has proven difficult to apply as a practical tool. Recent attempts to overcome these difficulties are discussed and an alternative conceptualization is proposed. This conceptualization is based on a blend of several well-supported theoretical models in cognitive engineering and can be used to formulate a parsimonious analysis system for the investigation and reporting of the human factors aspects of accidents. Two well-known examples of transportation disasters are briefly described and related to the proposed conceptual framework. The proposed framework serves three important functions in accident investigation and analysis: a heuristic function, an investigative function, and an integrative function.

Hydrothermal synthesis of (C6N2H14)2(UVI2UIVO4F12), a mixed-valent one-dimensional uranium oxyfluoride

A new hybrid organic-inorganic mixed-valent uranium oxyfluoride, (C6N2H14)2(U3O4F12), UFO-17, has been synthesized under hydrothermal conditions using uranium dioxide as the uranium source, hydrofluoric acid as mineralizer, and 1,4-diazabicyclo[2.2.2]octane as template. The single-crystal X-ray structure was determined. Crystals of UFO-17 belonged to the orthorhombic space group Cmcm (no. 63), with a = 14.2660(15) A, b = 24.5130(10) A, c = 7.201(2) A, and Z = 4. The structure reveals parallel uranium-containing chains of two types: one type is composed of edge-sharing UO2F5 units; the other has a backbone of edge-sharing UF8 units, each sharing an edge with a pendant UO2F5 unit. Bond-valence calculations suggest the UF8 groups contain UIV, while the UO2F5 groups contain UVI. EXAFS data give results consistent with the single-crystal X-ray structure determination, while comparison of the uranium LIII-edge XANES of UFO-17 with that of related UIV and UVI compounds supports the oxidation-state assignment. Variable-temperature magnetic susceptibility measurements on UFO-17 and a range of related hybrid organic-inorganic uranium(IV) and uranium(VI) fluorides and oxyfluorides further support the formulation of UFO-17 as a mixed-valent UIV/UVI compound.

Scanning electrochemical microscopy as a local probe of oxygen permeability in cartilage

The use of scanning electrochemical microscopy, a high-resolution chemical imaging technique, to probe the distribution and mobility of solutes in articular cartilage is described. In this application, a mobile ultramicroelectrode is positioned close ( approximately 1 microm) to the cartilage sample surface, which has been equilibrated in a bathing solution containing the solute of interest. The solute is electrolyzed at a diffusion-limited rate, and the current response measured as the ultramicroelectrode is scanned across the sample surface. The topography of the samples was determined using Ru(CN)(6)(4-), a solute to which the cartilage matrix was impermeable. This revealed a number of pit-like depressions corresponding to the distribution of chondrocytes, which were also observed by atomic force and light microscopy. Subsequent imaging of the same area of the cartilage sample for the diffusion-limited reduction of oxygen indicated enhanced, but heterogeneous, permeability of oxygen across the cartilage surface. In particular, areas of high permeability were observed in the cellular and pericellular regions. This is the first time that inhomogeneities in the permeability of cartilage toward simple solutes, such as oxygen, have been observed on a micrometer scale.

Cognitive task analyses for decision centred design and training

This paper presents three case studies of Cognitive Task Analysis (CTA) for defining systems design and training requirements. The approach taken involves a modification of the critical decision method of Klein et al. The authors utilized the revised CDM to obtain information from expert white-water rafting guides, general aviation pilots, and emergency ambulance dispatchers. The information obtained was used to develop multi-media tools for training rafting guides and general aviation pilots, and to redesign the VDU display requirements for the ambulance dispatchers. The examples demonstrate the utility of an approach to CTA that is closely based on relevant theory, and provides guidance to practitioners wishing to apply CTA techniques.

Measurement of the charge properties of articular cartilage by an electrokinetic method

The charge structure of the surface of articular cartilage determines its interactions with the macromolecules and cells of synovial fluid. It may thereby be important to the physiological function and pathological degeneration of the tissue. To determine whether the electrokinetic properties of the surface differ from those of the bulk tissue, we measured the streaming potential generated by the flow of electrolyte over the surface of a cartilage plug mounted in a chamber built for that purpose. We then calculated the effective surface charge density. In nonfibrillated cartilage from the human femoral head, the surface charge density, 0.037+/-0.004 Cm(-2) (mean+/-SD), was approximately half that measured at the surface of slices cut from the middle and deep zones. In addition, the surface charge density fell relatively little at low pH; this is consistent with a higher proportion of strongly acidic groups. The variations in surface charge density were found to be similar to those in total fixed charge density in the slices by the tracer cation method. Therefore, no evidence exists that the actual surface differs in composition from the immediately underlying matrix. The addition of synovial fluid (0.0025 ml/ml) to the superfusing solution reduced the surface charge density by 25+/-9% (n=5), and we attributed this to the binding of synovial-fluid macromolecules.

Cognitive ability determinants of elite pilot performance

The role of the modern pilot requires a high degree of situational awareness. This involves the ability to search for relevant information, assess opportunities and priorities, and maintain performance under stress. The PC-based WOMBAT test has been designed to measure individual aptitude to cope with such demands. In the first experiment performance on the WOMBAT test was compared with performance on a battery of tests of specific underlying abilities. In the second experiment the performance of elite soaring pilots was compared with that of matched pilot and control groups. The results support the theory that the WOMBAT test measures individual ability to maintain situational awareness and that this ability is found in high levels in elite pilots.

Quantitative spatially resolved measurements of mass transfer through laryngeal cartilage

The scanning electrochemical microscope (SECM) is a scanned probe microscope that uses the response of a mobile ultramicroelectrode (UME) tip to determine the reactivity, topography, and mass transport characteristics of interfaces with high spatial resolution. SECM strategies for measuring the rates of solute diffusion and convection through samples of cartilage, using amperometric UMEs, are outlined. The methods are used to determine the diffusion coefficients of oxygen and ruthenium(III) hexamine [Ru(NH3)6(3+)] in laryngeal cartilage. The diffusion coefficient of oxygen in cartilage is found to be approximately 50% of that in aqueous electrolyte solution, assuming a partition coefficient of unity for oxygen between cartilage and aqueous solution. In contrast, diffusion of Ru(NH3)6(3+) within the cartilage sample cannot be detected on the SECM timescale, suggesting a diffusion coefficient at least two orders of magnitude lower than that in solution, given a measured partition coefficient for Ru(NH3)6(3+) between cartilage and aqueous solution, Kp = [Ru(NH3)6(3+)]cartilage/[RU(NH3)6(3+)]solution = 3.4 +/- 0.1. Rates of Ru(NH3)6(3+) osmotically driven convective transport across cartilage samples are imaged at high spatial resolution by monitoring the current response of a scanning UME, with an osmotic pressure of approximately 0.75 atm across the slice. A model is outlined that enables the current response to be related to the local flux. By determining the topography of the sample from the current response with no applied osmotic pressure, local transport rates can be correlated with topographical features of the sample surface, at much higher spatial resolution than has previously been achieved.

Determinants of the willingness to endorse assisted suicide. A survey of physicians, nurses, and social workers

The authors surveyed 1,137 physicians, nurses, and social workers (overall response = 48%) to characterize the willingness to endorse assisted suicide. Willingness to endorse varied among disciplines and was negatively correlated with level of religious belief (r = -0.35, P < 0.0001), knowledge of symptom management (r = -0.21, P < 0.0001), and time managing symptoms (r = -0.21, P < 0.0001). On multivariate analysis, the significant predictors were lesser religious belief (P < 0.0001), greater concern about analgesic toxicity (P = 0.001), diminished empathy (P = 0.03), lesser knowledge of symptom management (P < 0.04), and the interaction between religious belief and knowledge of symptom management (P = 0.04). Professionals' attitudes toward assisted suicide are influenced by diverse personal attributes, among which may be competence in symptom management and burnout.

Measurements of oxygenation and perfusion in skeletal muscle using multiple microelectrodes

This paper describes an apparatus to measure tissue oxygenation and perfusion (as measured by the wash-in rate of gaseous hydrogen) simultaneously at multiple points in muscle using needle microelectrodes. The development of suitable electrodes and apparatus is described, as well as the development of the method and its validation. In particular, the potential for tissue damage secondary to electrode insertion, the need for in vivo voltammetric determination of the operating potential and the extent of any electrode-tissue and of electrode-electrode interactions are explored, and are shown to be insufficient in magnitude to affect the technique. Its subsequent use to characterise oxygenation and perfusion in rabbit skeletal muscle at rest is also described. In resting tibialis anterior muscle of the rabbit the mean pO2 was 18 +/- 13.3 mm Hg and the mean perfusion was 4.4 +/- 1.3 ml s-1 100 g-1. There was a heterogeneity in simultaneously-measured values of pO2 and perfusion at different points within muscle, and also a temporal variation at the same site. The spans between the highest and lowest simultaneously-measured values of pO2 in muscle ranged from 14 to 80 mm Hg, and for perfusion, from 1 to 12 mls-1 100 g-1. No significant correlation was evident from histological examination between either pO2 or perfusion and surrounding fibre type or capillary density.

Myocardial tissue perfusion determined by particulate and diffusible tracers during ischaemia: what is measured?

OBJECTIVE

Myocardial perfusion can be determined by many techniques which can be broadly divided into those employing particulate tracers and those employing diffusible tracers. The most commonly used particulate tracer is radioactive microspheres. However, as with other particulate tracers, they only determine convective transport from pre-capillary arterioles. If convective transport is the limiting factor in solute exchange, then particulate tracers will give comparable measurements to diffusible tracer techniques. However, if solute transport becomes diffusion-limited or alternative pathways of convective transport become more important, which may occur during regional ischaemia, perfusion visualised with clearance techniques using diffusible tracers may be greater than that determined with particulate tracers. This study set out to investigate this possibility in the rabbit myocardium under normal and ischaemic conditions.

METHODS

A pentobarbitone-anaesthetised rabbit model of regional ischaemia was used. Ischaemia of the apical region was induced by ligation of the large left ventricular branch of the circumflex artery. Tissue perfusion was determined by radioactive microspheres (n = 5) and the clearance of hydrogen, which was detected voltammetrically by platinum microelectrodes (n = 5). Measurements were made prior to and following coronary ligation and the ischaemic region was demarcated using the particulate tracer monastral blue. The exchange of diffusible solutes was visualised using digital fluorescence microscopy on histological sections of tissue following systemic administration of the fluorophore Evans blue labelled albumin (n = 4).

RESULTS

Coronary ligation produced an ischaemic zone occupying 50 +/- 13% of the left ventricle. In ischaemic tissue, flow determined by microspheres fell to 3.9 +/- 4.1% of its pre-ligation value, but solute exchange fell only to 22 +/- 10% (adjusted for changes in the partition coefficient of H2 during ischaemia, P < 0.05). Perfusion measured by microspheres and hydrogen clearance was unchanged in the non-ischaemic area during coronary ligation. There was preferential uptake of Evans blue albumin towards the endocardial surface in the ischaemic region and areas of local uptake through the ventricular wall, which were possibly associated with vessels.

CONCLUSION

This work demonstrates that under normal physiological conditions nutrient supply is determined by pre-capillary delivery. However, during ischaemia diffusive transport plays an increasingly important role. The alternative pathways for solute exchange are likely to have an important influence on the rate and extent of myocardial necrosis during coronary occlusion.

An audit of aneurysmal subarachnoid haemorrhage: earlier resuscitation and surgery reduces inpatient stay and deaths from rebleeding

OBJECTIVE

To audit the outcome in patients with subarachnoid haemorrhage (SAH) after a change in management strategy.

METHODS

A retrospective analysis of patients with aneurysmal subarachnoid haemorrhage over a 20 month period (phase 1) was followed by a prospective analysis of patients presenting during the next 20 months (phase 2) in which a protocol driven management regime of immediate intravenous fluid resuscitation and earlier surgery was pursued. Patients in this phase were grouped into those receiving early (within four days of subarachnoid haemorrhage) and late (after four days of subarachnoid haemorrhage) surgery. In phase 1, 75 out of a total of 92 patients underwent surgery on (median) day 12. From phase 2, 109 patients out of a total of 129 underwent surgery on (median) day 4, 58 of which had their surgery within 4 days of the subarachnoid haemorrhage. Patients in each phase/group were well matched for demographic features, site of aneurysm, and severity of subarachnoid haemorrhage.

RESULTS

The surgical morbidity and mortality were no different in the two phases (P < 0.92; chi2 test). The management outcomes in the two phases of the study were also no different (P < 0.52). However, there was a significant reduction in the rebleed rate in patients undergoing surgery within four days of the subarachnoid haemorrhage in phase 2 (P < 0.0001) with an associated trend towards reduced incidence of postoperative ischaemia (P = 0.06) and mortality (P = 0.11). Operating earlier in phase 2 of the trial resulted in a lower total hospital inpatient stay of 15.8 (95% CI 13.1-18.5) days for survivors compared with 25.7 (95% CI 21.6-29.8) days in the late group (P < 0.00001; t test).

CONCLUSIONS

surgical morbidity and mortality seemed independent of the timing of aneurysm surgery. Early surgery within four days was associated with a highly significant reduction in rebleed rate, and in the duration of total hospital inpatient stay.

Cardiac hypertrophy impairs recovery from ischaemia because there is a reduced reactive hyperaemic response

OBJECTIVE

The aim was to investigate whether impaired coronary flow reserve associated with cardiac hypertrophy could significantly limit the flow debt repayment following short periods of coronary occlusion and exacerbate or prolong episodes of myocardial ischaemia.

METHODS

Left ventricular hypertrophy was induced in guinea pigs by aortic constriction and the hearts were isolated six weeks later for Langendorff perfusion. Sham operated animals served as controls. The reactive hyperaemic response was studied following various lengths of occlusion of flow and the extent of aerobic and anaerobic metabolism was assessed in each group.

RESULTS

Heart weight/body weight ratio was increased by approximately 25% (P < 0.001) with aortic constriction. The reactive hyperaemic flow response in isolated hearts was impaired by hypertrophy in both magnitude (P < 0.05) and duration. The repayment of flow debt was also significantly reduced, suggesting an inadequate recovery of the myocardium following the occlusion. The total amount of O2 consumed by the heart throughout the duration of hyperaemia was less in hypertrophy than in sham operated controls, suggesting a decrease in aerobic metabolism. Total lactate discharge expressed as a ratio of O2 consumed, which provides an estimation of the degree of anaerobic in relation to aerobic metabolism, was greater in hypertrophy than in sham operated controls.

CONCLUSIONS

The hypertrophied heart is more vulnerable to brief periods of ischaemia because of an impaired reactive hyperaemic response which results in delayed metabolic recovery. These abnormalities may contribute to the increased morbidity associated with cardiac hypertrophy.

Dye laser treatment of port-wine stains: comparison of the continuous-wave dye laser with a robotized scanning device and the pulsed dye laser

BACKGROUND

Despite good results in the treatment of most port-wine stains (PWS) with continuous-wave visible-light lasers, light PWS and those in certain locations respond less favorably and have a higher risk of scarring. Robotized scanning devices such as the Hexascan device have been developed for continuous-wave laser sources to produce greater target specificity, to increase reproducibility of results, and to decrease the incidence of adverse effects.

OBJECTIVE

The purpose of this study was to compare the effects of the same wavelength of light (585 nm) on test sites within PWS with the flashlamp-pumped pulsed dye laser and a continuous-wave tunable dye laser scanned through a Hexascan robotized scanning device.

METHODS

Two adjacent, noncontiguous sites within PWS were treated in 29 patients, one site with the flashlamp-pumped pulsed dye laser and the other with an argon-pumped continuous-wave tunable dye laser affixed to a Hexascan device.

RESULTS

Twenty-eight patients completed the study. The pulsed dye laser was found to be superior to the continuous-wave dye laser with the Hexascan device in 45% of patients, whereas the continuous-wave tunable dye laser with the Hexascan device was considered superior in 15%. There was no difference in the remaining 40%. Undesirable side effects were infrequent with both treatments. There was no significant difference in hypopigmentation or atrophic and hypertrophic scarring, but hyperpigmentation was more frequent with the continuous-wave dye laser with the Hexascan device.

CONCLUSION

Both the pulsed dye laser and continuous tunable-wave dye laser with the Hexascan device produce slight lightening after one treatment. The pulsed dye laser produces slightly greater lightening than the continuous-wave tunable dye laser with the Hexascan device 6 weeks after treatment of test areas within PWS in 40% of those treated. It also produced slightly less hypopigmentation and hyperpigmentation.

Compliance with New York State's do-not-resuscitate law at Memorial Sloan-Kettering Cancer Center. A review of patient deaths

We reviewed the case records of 141 patients (134 with cancer and seven with acquired immunodeficiency syndrome) who died at Memorial Sloan-Kettering Cancer Center between July 11 and September 19, 1991. Do-not-resuscitate orders had been written on 115 (85.8%) of the patients with cancer and all of the patients with acquired immunodeficiency syndrome. The do-not-resuscitate orders appeared to be valid, in that evidence of informed consent was documented in all but two of the cases. Six additional patients who died had family consent not to resuscitate, although no do-not-resuscitate orders were written. Two other patients died unexpectedly. The remaining 11 patients all received aggressive attempts at resuscitation, which were felt to be medically appropriate in all but two cases. The interval between the do-not-resuscitate order and death was between zero and 60 days, with an average of 8.4 days and a median of 6 days; it exceeded 20 days in 14 cases. We attribute the high degree of compliance with the New York State do-not-resuscitate law observed in this study to an intensive program of consultation and education begun in 1987 by the Ethics Committee of Memorial Sloan-Kettering Cancer Center.

Simplified treatment of vascular lesions using the argon laser

Treatment of mucosal lesions and abnormalities using the carbon dioxide laser is well documented in the dental literature; however, use of the argon laser for the ablation of intraoral vascular malformations is not. This article discusses the argon laser-soft tissue interaction and illustrates by case reports its application in the treatment of vascular lesions.

Tuberculosis in children 10 years of age and younger: three decades of experience during the chemotherapeutic era

The 863 patients, aged 10 years and younger, treated at the Children's Chest Clinic of Bellevue Hospital during three decades (1953 through 1981) clearly indicated the success of antituberculosis therapy. There were no deaths from tuberculosis. Early treatment is associated with a reduction in the serious forms of disease, eg, meningitis, miliary disease, and bone infections, and with preventing death. Medication was well tolerated: only 1.1% of the patients had adverse reactions, all of which were reversible. Consistent compliance with medication of only 62% of patients is a challenge to the medical profession. Only 22.5% of mycobacterial cultures were positive. Long-term follow-up of patients was rewarding: seven pregnancies with healthy mothers and babies, and no reactivation of tuberculosis by later infections, even those such as measles or pneumonia. The severity of disease was related largely to patient's age (3 years and younger) and intimacy of contact, the highest rate being when the mother was the contact. The long-term experiences emphasizes the value of early identification, therapeutic compliance, and comprehensive contact, tracing in the future elimination of tuberculosis. Prophylactic therapy and close observation should be considered for contacts, especially those exposed to human immunodeficiency virus infections and addicted to drugs.

Electrochemical method for direct measurement of oxygen concentration and diffusivity in the intervertebral disc: electrochemical characterization and tissue-sensor interactions

A method was developed for the in vivo measurement of oxygen concentration and diffusivity in the intervertebral disc using a bare gold cathode. The effects of surface adsorption were quantified using electrochemical methods and it was demonstrated that valid data can be obtained despite interactions between the electrode and the macromolecules of the intervertebral disc. The technique is used to show the dependence of the oxygen transport properties on tissue water content.