Core content for venous and Lymphatic Medicine: 2022 revision

The core content for a medical specialty outlines the scope of the discipline as well as the categories of knowledge considered essential to practice in the field. It provides a template for the development of curricula for medical school, graduate, and postgraduate education, as well as for creating certification standards. Venous and Lymphatic Medicine (VLM) is a specialty that has benefitted from contributions from specialists from several medical disciplines. Optimally, the societies, boards, and residency review committees representing these disciplines would uniformly recognize the scope of VLM to develop education and assessment standards to allow training and identification of qualified practitioners. In order to inform the standard setting bodies and other stakeholders of the current scope of VLM, a task force of VLM experts from cardiology, dermatology, emergency medicine, general surgery, interventional radiology, vascular medicine, and vascular surgery was formed to revise a 2014 consensus document defining the core content of the specialty of VLM.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

The 2016 ENFSI Fingerprint Working Group testing programme

In 2016, the Fingerprint Working Group (EFP-WG) of the European Network of Forensic Science Institutes (ENFSI), officially established an advisory group with the task of organising proficiency tests (PTs), as well as collaborative exercises (CEs) as a way of raising standards within the fingerprint profession. This article will provide an overview of the Visualisation collaborative exercise and the Comparison proficiency test, which were carried out in 2016. Both the exercise and the test were organised and co-funded by the Prevention of and Fight against Crime Programme of the European Union [1-3], Direct Grant "Towards the Vision for European Forensic Science 2020 (TVEFS-2020)" HOME/2013/ISEC/MO/ENFSI/4000005962, work package T3 "Proficiency Tests and Collaborative Exercises for the Fingerprint Domain". The characteristics of the testing programme are summarised, followed by an overview of the knowledge that has been gained, including lessons learnt.

The 2015 ENFSI Fingerprint Working Group testing programme

As early as 2004, the Fingerprint Working Group (EFP-WG) of the European Network of Forensic Science Institutes (ENFSI) has organised proficiency tests (PT's), as well as collaborative exercises (CE's), as a way of raising standards within the fingerprint profession. This article provides an overview of the three collaborative exercises carried out in 2015. The characteristics of the testing programme are summarised, followed by an overview of the knowledge that has been gained, including depicting what lessons have been learnt.

Exploring lesbian, gay and bisexual patients' accounts of their experiences of cancer care in the UK

Despite greater recognition of rights and responsibilities around the care of cancer patients who identify as lesbian, gay or bisexual (LGB) within healthcare systems in the United Kingdom, recent quantitative evidence suggests that they experience poorer care than heterosexual counterparts and qualitative findings are limited. Therefore, in the present study, we present an analysis of the accounts of fifteen British LGB cancer patients (diagnosed with different forms of the disease) of the care received. Data were collected through in-depth individual interviews and analysed using thematic analysis. Three of the emerging themes are discussed. These include an examination of what we conceptualise as the 'awkward choreography around disclosure' opportunities and dilemmas for LGB patients, we describe 'making sense of sub-optimal care' which included instances of overt discrimination but was more frequently manifested through micro-aggressions and heteronormative systems and practices, and explore accounts of 'alienation from usual psychosocial cancer support'. We employ Meyer's Minority Stress Theory (2003) as a lens to interrogate the data and explore the ways in which actual or anticipated prejudice affected their experiences of treatment and support. We close with recommendations to enhance LGB-affirmative cancer care including enhanced training of healthcare professionals and explicit articulation of institutional commitment to LGB equality.

Using video ratings to assess multitasking performance in a naturalistic paradigm

BACKGROUND

Multitasking measures, in which a series of tasks must be completed within a naturalistic setting not fully under the experimenter's control, have been shown to be more sensitive than traditional measures in detecting organisational problems in people with difficulties in executive functioning. There are a number of drawbacks to such tasks however. They can take considerable time to administer and are demanding in terms of examiners noting and recording all relevant aspects of performance. This potentially leaves them more open to subtle bias. One method that could offset these limitations is to video record performance.

OBJECTIVES

The practicality and outcome of using video ratings to accurately score performance off-line is investigated here.

METHODS

Nineteen participants completed a Multiple Errands Task (MET) while wearing a body-worn camera. Their performance was scored "live" and by an independent rater who had only access to video footage of the task.

RESULTS

Significant relationships were seen on all variables of the MET between the live and video ratings. The inter-rater reliability of the measure appears strong.

CONCLUSION

We provide initial support for the use of a video rater when assessing performance on an MET.

Minimally invasive therapy for fetal sacrococcygeal teratoma: case series and systematic review of the literature

OBJECTIVE

Large solid sacrococcygeal teratomas (SCT) can cause high-output cardiac failure and fetal or neonatal death. The aim of this study was to describe the outcomes of minimally invasive antenatal procedures for the treatment of fetal SCT.

METHODS

A case review was performed of five fetuses with a large SCT treated antenatally using minimally invasive techniques, and a systematic literature review on fetal therapy for solid SCTs was carried out.

RESULTS

Five women were referred between 17 + 5 and 26 + 4 weeks' gestation for a large fetal SCT with evidence of fetal cardiac failure. Vascular flow to the tumors was interrupted by fetoscopic laser ablation (n = 1), radiofrequency ablation (RFA; n = 2) or interstitial laser ablation  ±  vascular coiling (n = 2). There were two intrauterine fetal deaths. The other three cases resulted in preterm labor within 10 days of surgery. One neonate died. Two survived without procedure-related complications but had long-term morbidity related to prematurity. The systematic literature review revealed 16 SCTs treated minimally invasively for (early) hydrops. Including our cases, six of 20 hydropic fetuses survived after minimally invasive therapy (30%). Survival after RFA or interstitial laser ablation was 45% (5/11). Of 12 fetuses treated for SCT without obvious hydrops and for which perinatal survival data were available, eight (67%) survived. Mean gestational age at delivery after minimally invasive therapy was 29.7 ± 4.0 weeks. Survival after open fetal surgery in hydropic fetuses was 6/11 (55%), with a mean gestational age at delivery of 29.8 ± 2.9 weeks.

CONCLUSIONS

Fetal therapy can potentially improve perinatal outcomes for hydropic fetuses with a solid SCT, but is often complicated by intrauterine death and preterm birth.

The Ribosomal Database Project: improved alignments and new tools for rRNA analysis

The Ribosomal Database Project (RDP) provides researchers with quality-controlled bacterial and archaeal small subunit rRNA alignments and analysis tools. An improved alignment strategy uses the Infernal secondary structure aware aligner to provide a more consistent higher quality alignment and faster processing of user sequences. Substantial new analysis features include a new Pyrosequencing Pipeline that provides tools to support analysis of ultra high-throughput rRNA sequencing data. This pipeline offers a collection of tools that automate the data processing and simplify the computationally intensive analysis of large sequencing libraries. In addition, a new Taxomatic visualization tool allows rapid visualization of taxonomic inconsistencies and suggests corrections, and a new class Assignment Generator provides instructors with a lesson plan and individualized teaching materials. Details about RDP data and analytical functions can be found at http://rdp.cme.msu.edu/.

Compensatory strategies for acquired disorders of memory and planning: differential effects of a paging system for patients with brain injury of traumatic versus cerebrovascular aetiology

BACKGROUND

Previous studies have demonstrated the effectiveness of paging systems in compensating for everyday memory and planning problems after brain injury, including in individuals with traumatic brain injury (TBI).

METHODS

Here, in addition to further analyses of the TBI data from a previous randomised control crossover trial, results are reported from a sub-group of 36 participants with brain injury from cerebrovascular accident (CVA).

RESULTS

Results indicate that, as with the TBI group, the pager was effective. However, the pattern of results following cessation of treatment differed. At a group level, TBI participants demonstrated maintenance of pager-related benefits, whereas CVA participants' performance returned to baseline levels. Comparisons of demographic and neuropsychological characteristics of the groups showed that the CVA group was older, had a shorter interval post-injury, and had poorer executive function than the TBI group. Furthermore, within the TBI group, maintenance was associated with executive functioning, such that executive dysfunction impeded maintenance. This correlation remained after controlling for demographic differences between groups.

CONCLUSIONS

Together, these findings suggest that executive dysfunction may affect treatment-for example, whether or not temporary use of the pager is sufficient to establish a subsequently self-sustaining routine.

Understanding lesbians' healthcare behaviour: the case of breast self-examination

Lesbians' risk of breast cancer is a much-debated issue in health research because lesbians are believed to be at higher risk of the disease than are heterosexual women. This belief is based upon particular risk factors for breast cancer, which are said to be more prevalent in lesbians; and upon differences in preventive health behaviours: in particular, lesbians are said to be less likely to practise breast self-examination (BSE). This paper presents data collected as part of the UK Lesbians and Healthcare Survey (n = 1066) focusing on lesbians who report never practising BSE (n = 218, 20%) and the explanations they offer for their healthcare behaviours. It identifies six types of explanation for not practising BSE: (i) "I don't know what I'm looking for"; (ii) "I've never got into the habit"; (iii) "I'm frightened in case I find something"; (iv) "I don't think I'm at much risk"; (v) "I'm uncomfortable with my body"; and (vi) "My partner does it for me". These findings are important for increasing understanding of lesbians' healthcare behaviour and for developing health promotion materials relevant to their needs.

Electrical heterogeneity within the ventricular wall

Recent studies have established the presence of three distinct cell types in the ventricular myocardium: epicardial, M and endocardial cells. Epicardial and M cell action potentials differ from endocardial cells with respect to the morphology of phase 1. These cells possess a prominent transient outward current (I(to))-mediated notch responsible for the 'spike and dome' morphology of the epicardial and M cell response. M cells are distinguished from the other cell types in that they display a smaller slowly activating delayed rectifier current (I(Ks)), but a larger late sodium current (late I(Na)) and sodium-calcium exchange current (I(Na-Ca)). These ionic distinctions underlie the longer action potential duration (APD) and steeper APD-rate relationship of the M cell, which is more pronounced in the presence of antiarrhythmic agents with class III actions. The preferential prolongation of the M cell action potential results in the development of a transmural dispersion of repolarization (TDR), which can be estimated from the electrocardiogram (ECG) as the interval between the peak and the end of the T wave (QTpeak-QTend interval). Using the canine arterially perfused ventricular wedge model, transmembrane action potentials of the various cardiac cell types can be correlated to the waveforms of the ECG, providing insight into the cellular etiology of ECG abnormalities. Two congenital syndromes of sudden cardiac death that have been modeled using this technique are the long QT and Brugada syndromes. The long QT syndrome has been linked to 5 gene mutations on chromosomes 3, 7, 11, and 21. Mutations in the cardiac sodium channel SCN5A have been linked to families with a history of the Brugada syndrome. Although the etiologies of these two syndromes are different, lethal arrhythmias in both are thought to arise due to amplification of intrinsic electrical heterogeneities. Similar mechanisms are likely responsible for life-threatening arrhythmias in a variety of other cardiomyopathies ranging from heart failure and hypertrophy, which involve mechanisms similar to those operative in LQTS, to ischemia and infarction, which may involve mechanisms more closely resembling those responsible for the Brugada syndrome.

Estrogen receptors in the normal adult and developing human inner ear and in Turner's syndrome

The influence of estrogens, the female sex hormone, on the ear and hearing is yet not fully investigated, though some studies have suggested that estrogens may influence hearing functions. The presence of estrogen receptors alpha and beta has earlier been shown in the inner ear of mice and rats. The aim of this study was to map possible estrogen receptors in the human inner ear. Inner ear tissue from human adults, aborted human normal fetuses and fetuses with Turner's syndrome were collected. Paraffin embedded sections of adult and fetal inner ears were immunostained with antibodies against estrogen receptors alpha and beta. Estrogen receptor alpha containing cells were found in the adult human inner ear only in the spiral ganglion, and estrogen receptor beta in the stria vascularis solely. The human fetal inner ear tissue from both normal and Turner fetuses showed a very weak staining of estrogen receptor alpha in the spiral ganglion cells, but no specific labeling of the Kölliker's organ of Corti at 13, 14 and 18 weeks of age. No staining of estrogen receptor beta was seen in the fetal inner ear.

Minimizing blood loss in burn surgery

BACKGROUND

Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound outcome in burn surgery.

METHODS

An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds.

RESULTS

Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p = 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outcome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%.

CONCLUSION

The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

The 2000 Moyer Award. The relevance of base deficits after burn injuries

The relevance of an elevated base deficit (BD) during the fluid resuscitation of a thermally injured patient is not completely understood. After nonthermal trauma, early elevation of the BD represents insufficient cellular perfusion and is ultimately associated with a higher incidence of organ dysfunction and death. However, this relationship has not been completely examined after burn injuries. The purpose of this study was to determine if elevation of the BD during burn resuscitation was associated with potential consequences of malperfusion, such as systemic inflammatory response syndrome, acute respiratory distress syndrome, and multiple organ dysfunction. The records of 72 patients with burn injuries (mean age, 46 +/- 17 years; mean total body surface area burned, 44% +/- 18%) who required fluid resuscitation on admission to an adult regional burn center were analyzed. Patients with a mean BD of less than -6 mmol/L during the first 24 hours were compared with patients with a mean BD of more than -6 mmol/L. Despite adequate resuscitation with good maintenance of urinary output, the patients in the group with a mean BD of less than -6 mmol/L had more florid systemic inflammatory response syndrome (P = .004), had more prevalent acute respiratory distress syndrome (P = .012), and experienced more severe multiple organ dysfunction (P < .001) compared with patients in the group with a mean BD of more than -6 mmol/L. The results suggest that abnormal elevation of the BD after burn injuries represents a malperfusion state, which may not be recognized if only "traditional" parameters, such as UO, are followed. Furthermore, this state appears to be related to the onset of more severe systemic inflammation and organ dysfunction.

The use of inhaled nitric oxide as adjuvant therapy in patients with burn injuries and respiratory failure

Inhaled nitric oxide (NO) is a relatively new modality in the management of acute respiratory distress syndrome. The purpose of this study was to examine our experience with inhaled NO in 10 adult patients with burn injuries and acute respiratory distress syndrome-related oxygenation failure. The patients had a mean age of 50 +/- 19 years and a mean burn size of 41% +/- 20% of the total body surface area. Seven patients died and 3 survived. The survivors and nonsurvivors did not differ with respect to age, burn size, pre-NO ventilator settings, or indices of oxygenation including PaO2, oxygen saturation in arterial blood, PaO2/fraction of inspired oxygen (FIO2) ratio, and alveolar-arterial oxygen tension difference. The concentration of NO administered ranged between 5 ppm and 30 ppm. PaO2, oxygen saturation in arterial blood, and the PaO2/FIO2 ratio increased in all patients. Although it was not statistically significant, survivors tended to have a more vigorous and sustained response than non-survivors; this was best exemplified by the change in PFR. During the first hour of therapy, the PaO2/FIO2 ratio increased from 64.3 +/- 12.7 to 231.8 +/- 154.5 in survivors and from 93.9 +/- 44.0 to 161.5 +/- 81.8 in the nonsurvivors. After 12 hours of therapy, the PaO2/FIO2 ratio was 306.2 +/- 333.7 in the survivors and 178.9 +/- 69.9 in the nonsurvivors. There were no complications associated with the use of inhaled NO. Although a stronger early response to NO seems to occur in survivors, we cannot definitely conclude that the early response pattern is predictive of recovery. Nonetheless, we believe that inhaled NO has a useful role in the treatment of patients with burn injuries and severe acute respiratory distress syndrome-related oxygenation failure.

Recent developments in home total parenteral nutrition

Home parenteral nutrition (HPN) support has been an advancing therapy in the past 30 years. Patients who previously had no options to sustain their lives are now able to live at home, maintain employment, and continue with most daily activities. Although this therapy has been innovative and successful, it requires great financial and professional resources. The expense of HPN makes most patients dependent on third-party payment, and the complications can result in frequent hospitalizations and may be life-threatening. For these reasons, extensive training of the patient and caregivers is necessary. Thorough and time-consuming monitoring by a multidisciplinary team of professionals is also essential. Home care and supply companies offer services that make the process of home TPN easier for the patient and the healthcare team. Advances in the area of home nutrition support are expected to continue as the demand for this therapy rises.

The role of autopsy on patients with burns

Burn center verification requires the use of autopsy as one method of quality assurance in a burn center. Because of the decreasing rates of autopsies worldwide and improved diagnostic accuracy in our critical care units, we tested the hypothesis that autopsy diagnosis would not alter our clinical diagnosis. A chart review of all deaths (N = 94) that occurred during a 6-year period (1989-1994) was performed. The clinical diagnoses from the hospital charts and autopsy reports for the patients were reviewed, and diagnostic discrepancies were classified as class I or class II errors. Class I diagnostic errors might have altered the clinical outcome. Class II errors were attributable to the burn injuries but were believed to have had little impact on the clinical outcome. The overall autopsy rate was 93.6% (n = 88). Clinical diagnostic errors were found in 16 (18%) of 88 patients. Five class I errors were found in 4 patients (4.5%), and 15 class II errors were found in 13 patients (14.7%). Although the rate of potentially serious errors was low (only 4.5% of the patients in this study) postmortem examinations revealed clinical diagnostic errors. The results of this study support the continued use of autopsies as a means of quality assurance, despite our ability to closely monitor our critically ill patients with burns.

ARDS in patients with thermal injury

OBJECTIVE

To determine the time to onset of the adult respiratory distress syndrome (ARDS) in patients with thermal injury requiring mechanical ventilation. Secondarily, to consider the burn-related risk factors, demographics, incidence, and mortality for ARDS in this population.

DESIGN

Retrospective chart review; ARDS defined according to the American-European Consensus Conference and the Lung Injury Severity Score definitions.

SETTING

Regional, tertiary referral, adult burn unit in a university teaching hospital.

PATIENTS AND PARTICIPANTS

Patients with thermal injury requiring mechanical ventilation, admitted between 1 January 1991 and 28 February 1995.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Of 469 consecutive admissions, 126 (26.9%) received intubation and mechanical ventilation. ARDS was defined according to the American-European Consensus and Lung Injury Severity Score (score > 2.5) definitions. The mean time to onset of ARDS from admission to the burn unit was 6.9 +/- 5.2 and 8.2 +/- 10.7 days when defined by the American-European Consensus and Lung Injury Severity Score definitions respectively (p = 0.41). Of the intubated patients, 53.6 and 45.2% developed ARDS according to the American-European Consensus and Lung Injury Severity Score definitions, respectively (p = 0.19). Using multivariate logistic analysis, only age proved to be an independent risk factor for the development of ARDS (p = 0.03), although there was a trend toward an increased incidence of inhalation injury in patients with ARDS. Mortality was not significantly greater (41.8 vs 32.2%) in those with ARDS compared to those without (p = 0.27).

CONCLUSIONS

According to the American-European Consensus Conference and the Lung Injury Severity Score definitions, ARDS is common in the adult burn population and has a delayed onset compared to most critical care populations. We found age to be a major predisposing factor for ARDS.

Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges

This study was intended to characterize a rural population of older persons through nutrition screening and relate screening items to functional limitations and health care charges. There were 5373 participants (2522 males and 2851 females, mean age 71 y) screened over a 22-mo period by using a self-administered questionnaire adapted from the Nutrition Screening Initiative. Height and weight and cholesterol and albumin concentrations were measured, and health care claims data were obtained. The most frequent screening items reported were use of > or = 3 medications (41%) and food group intakes below recommended frequencies (> 50%). There were significant (P < 0.05) sex differences in affirmative responses to screening items and in likelihood of exceeding proposed threshold values for risk status assigned for body mass index (BMI; in kg/m2), albumin, or cholesterol. Overweight status was notable, with one-half of all subjects having BMIs > 27. Stepwise modeling procedures were used to identify screening items with the ability to predict self-reported functional limitation (logistic regression) and monthly average recorded health care charges (linear regression on logged charges). Age > or = 75 y, use of > or = 3 medications, and an albumin concentration < 35.0 g/L were significant predictors of both functional limitation and health care charges. Poor appetite, eating problems, income < $6000/y, eating alone, and depression were significant predictors of functional limitation but not health care charges. Being male, loss of 10 lb (4.5 kg), BMI > 27, cholesterol concentration < 4.14 or > 6.21 mmol/L, and functional limitation were significant predictors of health care charges only. These findings suggest that selected screening items may have be useful in the identification of subjects at potential risk for these outcomes.

Nutrition and health for older persons in rural America: a managed care model

Health care services and resources for older persons living in rural areas may be highly variable, and integrated service-delivery models are often lacking. This article presents a managed-care model of nutrition risk screening and intervention for older persons in rural areas. Nutrition risk screening was implemented by the Geisinger Health Care System, Danville, Pa, to target all eligible enrollees in a regional Medicare risk program. A single remote clinic site participating in the managed health care system was chosen for further study of a linked screening and case-management effort for undernourished persons. Screening and intervention at the clinic site selected for this study were guided by centralized expertise and resources. Individualized evaluation and intervention plans were developed with the aid of a dietitian and implemented by the clinic case manager. Of the 417 subjects who completed screening at the remote site, 68 met the risk criteria for undernutrition and were selected for case management. Many of the targeted persons received interventions that included evaluations by a physician or physician extender (eg, physician assistant, nurse practitioner) at the clinic and consultations with nutrition, mental health, or social services professionals. Twenty-six of the subjects who took part in the intervention completed a follow-up screening 6 months later. Ten of those persons no longer exhibited risk criteria. This demonstrates the feasibility of a linked screening and case management program for nutrition risk in the managed-care setting.

Fibroblast growth factor-2 potentiates vascular smooth muscle cell migration to platelet-derived growth factor: upregulation of alpha2beta1 integrin and disassembly of actin filaments

Fibroblast growth factor-2 (FGF-2) has been implicated in vascular smooth muscle cell (SMC) migration, a key process in vascular disease. We demonstrate here that FGF-2 promotes SMC motility by altering beta1 integrin-mediated interactions with the extracellular matrix (ECM). FGF-2 significantly increased surface expression of alpha2beta1, alpha3beta1, and alpha5beta1 integrins on human SMCs, as assessed by flow cytometry. The greatest increase was for the collagen-binding alpha2beta1 integrin. Despite this, FGF-2 did not increase SMC adhesion to type I collagen but instead promoted SMC elongation and SMC motility. The latter was evaluated by using a microchemotaxis chamber and by digital time-lapse video microscopy. Although FGF-2 was not chemotactic for human SMCs, cells preincubated with FGF-2 displayed a 3.1-fold increase in migration to the undersurface of porous type I collagen-coated membranes and a 2.1-fold increase in migration speed on collagen. Furthermore, chemotaxis to platelet-derived growth factor-BB on collagen was significantly greater in SMCs exposed to FGF-2. FGF-2-induced elongation and migration on collagen were inhibited by a blocking anti-alpha2beta1 antibody; however, SMC adhesion to collagen was unaffected. SMC migration on fibronectin was also enhanced by FGF-2, although less prominently: migration through porous membranes increased 1.8-fold, and migration speed increased 1.3-fold. Also, FGF-2 completely disassembled the smooth muscle alpha-actin-containing stress fiber network contemporaneously with the change in integrin expression and cell shape. We conclude that (1) exogenous FGF-2 promotes SMC migration and potentiates chemotaxis to PDGF-BB; (2) the promigratory effect of FGF-2 is especially prominent on type I collagen and is mediated by upregulation of alpha2beta1 integrin; and (3) FGF-2 disassembles actin stress fibers, which may promote differential utilization of alpha2beta1 integrin for motility but not adhesion. This dynamic SMC-ECM interplay may be an important mechanism by which FGF-2 facilitates SMC motility in vivo.

A prospective randomized study of glutamine-enriched parenteral compared with enteral feeding in postoperative patients

Plasma amino acids were measured in 17 postoperative subjects randomly assigned to receive for > or = 5 d tube feeding or total parenteral nutrition (TPN) that had identical energy, nitrogen, and glutamine contents. Subjects required gastric or pancreatic surgery for malignancy and were well-matched for age and body mass index. Tube feeding or TPN began on postoperative day 1 and advanced in daily 25% increments to meet goals of 105 kJ . kg body wt-1 . d-1, 1.5 g protein . kg body wt-1 . d-1, and 0.3 g glutamine . kg body wt-1 . d-1. Delivered energy, nitrogen, and glutamine were closely matched on day 4. Nitrogen balance and plasma proteins did not differ significantly between feeding groups. Total indispensable amino acids, branched-chain amino acids, and glutamine declined 25% on postoperative day 1 compared with preoperative day 0. Indispensable and branched-chain amino acid concentrations were restored with 5 d of either tube feeding or TPN. Glutamine concentrations did not differ significantly by feeding group, though a trend suggested that glutamine recovered more slowly in the tube-fed than in the TPN-fed subjects. Plasma amino acids otherwise reflected formula composition with ratios of valine to leucine of 1.24 and 3.69 mumol/L in subjects receiving 5 d of tube feeding or TPN, respectively. These findings suggest that glutamine-enriched tube feeding and TPN can result in similar profiles for most plasma amino acids at carefully matched doses.

A double-blind, prospective, randomized study of glutamine-enriched compared with standard peptide-based feeding in critically ill patients

Arterial and venous plasma amino acids were determined in 28 intensive care patients randomly assigned to receive 10 d of isoenergetic, isonitrogenous feedings that differed sixfold in glutamine content. Subjects were generally well-matched for age, injury severity, and disease diagnoses. Nasojejunal feedings were started within 48 h of admission. Data were analyzed from those 19 subjects still receiving > or = 50 mL feeding/h on day 5. Both groups had comparable gastric residuals, stool frequency, and delivered nitrogen and energy. At study initiation, all subjects had relative hypoaminoacidemia, with day 1 venous glutamine concentrations down 26% compared with reference values. Plasma glutamine rose to comparable concentrations with feeding of either diet. There were, however, significant (P < 0.05) increases in arterial or venous plasma total, indispensable, and branched-chain amino acids of 125-144% by day 5 only in patients fed the standard control diet. The phenylalanine-tyrosine ratio was elevated on day 1 in both groups (1.3-1.4) but decreased significantly only in the glutamine-supplemented group (1.1 compared with 1.4) by day 5. Glutamine supplementation blunted the hyperaminoacidemia and elevated aromatic amino acid response to injury.

The impact of reducing junior doctors' hours on nursing

In 1993, the Trent Regional Taskforce (TRT) allocated £500000 to hospitals in the region to fund a number of innovative nursing posts (Read and Graves, 1994). These were primarily designed to help reduce the workload of doctors in training. The services that have been established as a result of this project include nurse-led preadmission clinics, minor injury services, emergency psychiatric assessment and cardiology day care.

Distribution of M cells in the canine ventricle

INTRODUCTION

M cells and transitional cells residing in the deep structures of the ventricular free walls are distinguished by the ability of their action potentials to prolong disproportionately to those of other ventricular cells at relatively slow rates. This feature of the M cell due, at least in part, to a smaller contribution of the slowly activating component of the delayed rectifier current (IKs) is thought to contribute to the unique pharmacologic responsiveness of M cells, making them the primary targets in ventricular myocardium for agents that cause action potential prolongation and induce early and delayed afterdepolarizations and triggered activity. Previous studies dealt exclusively with the characteristics and distribution of M cells in the canine right and left ventricular free wall near the base of the ventricles. The present study uses standard microelectrode techniques to define their behavior and distribution in the apical region of the ventricular wall as well as in the endocardial structures of the ventricle, including the interventricular septum, papillary muscles, and trabeculae.

METHODS AND RESULTS

Action potentials recorded from the M region (deep subepicardium) displayed similar characteristics (steep action potential duration [APD]-rate relations) in the base and apex. However, important differences were apparent in the other regions. In epicardium, the spike and dome morphology of the action potential was less accentuated and the rate dependence of APD more pronounced in the apex versus the base. In endocardium, and especially deep subendocardium, rate dependence of APD was considerably more pronounced in the apex. Transmembrane recordings from the subsurface layers of the septum, trabeculae, and papillary muscles revealed M cell behavior (steep APD-rate relations) in the deep subendocardium. Epicardial and transitional behavior were also observed in the deep layers of these endocardial structures.

CONCLUSION

Our results indicate that M cells reside throughout the deep subepicardial layers of the free wall of the canine left ventricle as well as in the deep subendocardial layers of the septum, papillary muscles, and trabeculae. The data also demonstrate prominent transmural as well as apicobasal gradients of phase 1 and phase 3 repolarization. These findings may have implications relative to our understanding of the electrocardiographic J wave, T wave, U wave, and long QTU intervals.