Use of transoesophageal echocardiography during the peri-operative period for trauma patients

The medical facility at Camp Bastion continues to evolve as a consequence of the increased throughput of battlefield trauma patients. There is a requirement for rapid and accurate diagnosis of haemodynamic instability and continued haemodynamic monitoring throughout the peri-operative period. Transoesophageal echocardiography (TOE) has been used for this purpose in the arena of cardiac anaesthesia since the mid 1980s. It is being introduced to other peri-operative settings where severe haemodynamic instability is expected. The old proverb: 'There are none so blind as those who cannot see' (Jeremiah 5:21) is applicable to this topic, in that TOE is proven to be a rapid, portable, safe and effective tool in the assessment of the haemodynamically unstable patient. This paper explores the application of TOE for the assessment of the major causes of haemodynamic instability in the trauma population.

Hepatitis C seropositivity is not a risk factor for sensory neuropathy among patients with HIV

BACKGROUND

Sensory neuropathy (SN) is common in patients with HIV. Hepatitis C (HCV) coinfection is often cited as an HIV-SN risk factor, but data to support this are lacking. This collaboration aimed to examine the association between HCV serostatus and SN risk among ambulatory HIV-positive patients.

METHODS

Patients with HIV were assessed in cross-sectional studies in Baltimore, Jakarta, Johannesburg, Kuala Lumpur, Melbourne, and Sydney for SN (defined by both supportive symptoms and signs). HCV seropositivity was assessed as an SN risk using a chi(2) test, followed by logistic regression modeling to correct for treatment exposures and demographics.

RESULTS

A total of 837 patients of African, Asian, and Caucasian descent were studied. HCV seroprevalence varied by site (Baltimore n = 104, 61% HCV+; Jakarta 96, 51%; Johannesburg 300, 1%; Kuala Lumpur 97, 10%; Melbourne 206, 16%; Sydney 34, 18%). HCV seropositivity was not associated with increased SN risk at any site, but was associated with reduced SN risk in Melbourne (p = 0.003). On multivariate analyses, the independent associations with SN were increasing age, height, and stavudine exposure. HCV seropositivity was not independently associated with an increased SN risk at any site, but associated independently with reduced SN risk in Baltimore (p = 0.04) and Melbourne (p = 0.06).

CONCLUSIONS

Hepatitis C (HCV) seropositivity was not associated with increased sensory neuropathy risk among HIV-positive patients at any site. While we were unable to assess HCV RNA or liver damage, the data suggest that HCV coinfection is not a major contributor to HIV-SN. HCV = hepatitis C; SN = sensory neuropathy.

Active case finding of undetected tuberculosis among chronic coughers in a slum setting in Kampala, Uganda

SETTING

Kisenyi slum in peri-urban Kampala, Uganda.

OBJECTIVES

Using chronic cough (> or = 2 weeks) inquiry as a screening tool to identify undetected smear-positive tuberculosis (TB) cases and to describe the characteristics of smear-positive TB cases detected by active case finding.

DESIGN

A house-to-house survey was conducted in five randomly selected villages in Kampala between June and August 2005. A sample of households was visited; adults aged > or = 15 years were consecutively interviewed to identify those with chronic cough. Three sputum specimens were collected and examined by smear microscopy.

RESULTS

Among 930 individuals, we identified 189 (20%) chronic coughers. Of these, we found 33 (18%) undiagnosed smear-positive cases. The newly detected cases had an even sex distribution (P = 0.47), a median age of 30 years, a median cough duration of 1 month and 55% had acid-fast bacilli 1+ sputum smear grade.

CONCLUSION

These findings suggest that active case finding could supplement DOTS to yield additional smear-positive TB cases, lead to early diagnosis and thus shorten the duration of infectiousness before effective chemotherapy is initiated. In communities such as Kisenyi, this is a feasible strategy that may prove useful for TB control, but its cost-effectiveness needs to be evaluated. Early health care seeking for cough should be emphasized.

Prevalence of and risk factors for HIV-associated neuropathy in Melbourne, Australia 1993-2006

OBJECTIVES

The aim of the study was to describe the prevalence of and risk factors for HIV-associated sensory neuropathy (HIV-SN) in 2006 [the era of stavudine, didanosine and zalcitabine (dNRTI)-sparing highly active antiretroviral therapy (HAART)] and to compare our findings with data obtained in the same clinic in 1993 (pre-HAART) and 2001 (frequent use of dNRTI-containing HAART).

METHODS

This was a cross-sectional comparative study using convenience sampling. HIV-positive adults attending a tertiary referral clinic over a 2-week period were screened for HIV-SN using the AIDS Clinical Trials Group screening tool. HIV-SN was defined as present if the patient had both neuropathic symptoms and abnormal signs. Demographic, clinical, laboratory and treatment data were considered as possible risk factors for HIV-SN, and results were compared with data obtained in the same clinic in 1993 and 2001.

RESULTS

One hundred patients were screened. The prevalence of HIV-SN was 42%, which was unchanged since 2001 (44%) despite a significant reduction in the use of dNRTIs. HIV-SN remained much more common than in 1993 (42% vs 13%; P<0.0001). The only independent associations with HIV-SN in 2006 were increasing patient age and a history of exposure to either stavudine or indinavir. This compares with 1993 when neuropathy was increased in those with Mycobacterium avium complex infection, and 2001 when patient age and use of stavudine and didanosine were the independent associations with HIV-SN in this clinic.

CONCLUSIONS

HIV-SN remained common among ambulatory patients in 2006 (42% prevalence) despite a significant reduction in the use of dNRTIs. In addition to patient age and stavudine exposure, indinavir use may be a risk factor for HIV-SN.

Factor analysis of the Ways of Coping Questionnaire for African American women

The purpose of this study was to determine the factorial structure of the Ways of Coping Questionnaire for African American women. A sample of 656 African American women living in the southeastern United States, ranging in age from 22 to 64 years (M = 39.6 years), completed the questionnaire. All were employed, with a mean annual income of $24,300. Factor analysis produced three factors, Active Coping, Avoidance, and Minimize the Situation, that accounted for 67% of the total variance. These factors were compared with the eight factors of the Ways of Coping questionnaire reported by Folkman and Lazarus (1980), which was derived from a sample of middle-aged White subjects. The factors that emerged suggest the need for possible revision of the instrument or the development of a new one.

Elders' attitudes and behavior regarding ComputerLink

ComputerLink is a set of telecommunications modules designed to provide information, decision making assistance, and communications support to caregivers of persons with Alzheimer's disease. Over 19 months, each of the 47 AD caregivers had 12 consecutive months of access. There were a total of 3875 accesses to the AD caregivers' ComputerLink. Attitudes toward ComputerLink were assessed. Subjective and objective measures of use also were captured. ComputerLink users held generally positive attitudes towards the use of the computer network and tended to under-report the number of times they accessed the system.

Epidemiology, diagnosis, and management of Alzheimer's disease and related disorders: implications for minority populations

The experience of Alzheimer's disease (AD) and related dementias in minority populations must be understood in the epidemiological, diagnostic, treatment, and care contexts which surround it. This article describes those contexts, and offers an analysis of how efforts to improve the management of dementia among minorities are likely to be affected by them. An overview of the etiology, diagnosis, and treatment of AD and related disorders is presented; current and proposed health care services are described; and planning and policy considerations which result from the nature, epidemiology and care demands of dementia are reviewed. We conclude with a series of recommendations for the enhancement of our healthcare system to meet the needs of minorities with dementia.

Analysis of a decade of nursing practice research: 1977-1986

The purpose of this study was to analyze the research focus, theoretical bases, research designs, statistical methods, and research findings of nursing practice research, 1977-1986. A secondary purpose was to assess the fit of nursing practice research topics within the North American Nursing Diagnosis Association's (NANDA) taxonomy. The sample consisted of 720 articles that met the definitional criteria of nursing practice research from six major refereed journals in nursing that primarily publish nursing research. Findings showed that 95% of research in nursing in the last decade was conducted by nurses as first authors, over half with doctoral degrees. Funded research increased as well as the trend toward multidisciplinary research and multisite studies. One-third of the studies focused on nursing intervention, and two-thirds were assessment-oriented. Although use of nursing conceptual models increased over the decade, theories or models from psychology, physiology, and sociology were used most often. There was an increase in use of sophisticated research methods and better reporting of reliability and validity. The use of NANDA as a taxonomy for classifying nursing practice research was assessed.

Engagement-involvement and blood pressure change: a methodological inquiry

In a study that examined further Singer's model of engagement-involvement in a community nursing setting, 31 black inner-city women conversed informally with a nurse while their blood pressure was monitored at two-minute intervals using a Hoffman-LaRoche Arteriosonde. Type A (coronary-prone) and hypertensive subjects were judged to not display greater engagement than type B and normotensive subjects, respectively. Within-subject correlations between observers' ratings of engagement and blood pressure showed substantial differences across subjects. Nevertheless, for correlations based on engagement judgments corresponding to the minute immediately preceding the blood pressure determination the mean within-subject values ranged from .14 to .32 (mean = .20) and were all significantly different from zero. Attention is directed to the need for refining the criteria used for judging engagement and to identifying patients for whom increased engagement may invalidate blood pressure measurements in a clinical setting.

Type A (coronary-prone) behavior and transient blood pressure change

A study was conducted to delineate further the physiological mechanisms underlying the type A behavior pattern's influence on coronary heart disease. It was suggested that while chronically elevated blood pressure is apparently not associated with overall A--B distinctions (at least not for males), acting in a type A fashion may be accompanied by temporary increases in blood pressure. Changes in the speech characteristics of 33 black inner-city women during the A--B interview and subsequent unstructured dialogue were analyzed at one-minute intervals and correlated with concomitant blood pressure measurements. Differences in the speech characteristics of women classified type A as opposed to B were consistent with recent studies of white males (e.g., type As spoke significantly faster than type Bs). Further, within-subject blood pressure elevations were significantly associated with louder/more explosive, longer speech episodes. Additional research is urged which examines biochemical and physiological changes as a function of type A behavior considered as a transient state as well as a relatively enduring trait.

Type A behavior pattern and hypertension among inner-city black women

Inner-city Black women were administered Rosenman and Friedman's A-B interview and invited to discuss stress experiences and traditional coronary heart disease risk factors while their blood pressure was monitored at two-minute intervals. Results revealed the essential reliability of the A-B classification for the sample and demonstrated a general congruence with type A behaviors reported in previous (mostly white male) samples. While type A Black women were not significantly more likely to be hypertensive than type B women, analyses of the intrasubject blood pressure variability revealed an interaction between A-B and hypertensive-normotensive status. Consistent with earlier findings, hypertensives were more variable than normotensives, but this was true only for type Bs; type As were intermediate and not differentiated in their variability. This finding calls attention to the possible adaptive function of type A behavior among stress inner-city Black females and raises the question of whether Rosenman and Friedman's personality theory might be objectionably simplistic.