Rooting carbon dioxide removal research in the social sciences

Reports from a variety of bodies have highlighted the role that carbon dioxide removal (CDR) technologies and practices must play in order to try to avoid the worst effects of anthropogenic climate change. Research into the feasibility of these technologies is primarily undertaken by scholars in the natural sciences, yet, as we argue in this commentary, there is great value in collaboration between these scholars and their colleagues in the social sciences. Spurred by this belief, in 2019, a university and a non-profit organization organized and hosted a workshop in Washington, DC, intended to bring natural and physical scientists, technology developers, policy professionals and social scientists together to explore how to better integrate social science knowledge into the field of CDR research. The workshop sought to build interdisciplinary collaborations across CDR topics, draft new social science research questions and integrate and exchange disciplinary-specific terminology. But a snowstorm kept many social scientists who had organized the conference from making the trip in person. The workshop went on without them and organizers did the best they could to include the team remotely, but in the age before daily video calls, remote participation was not as successful as organizers had hoped. And thus, a workshop that was supposed to focus on social science integration moved on, without many of the social scientists who organized the event. The social scientists in the room were supposed to form the dominant voice but with so many stuck in a snow storm, the balance of expertise shifted, as it often does when social scientists collaborate with natural and physical scientists. The outcomes of that workshop, lessons learned and opportunities missed, form the basis of this commentary, and they collectively indicate the barriers to integrating the natural, physical and social sciences on CDR. As the need for rapid, effective and successful CDR has only increased since that time, we argue that CDR researchers from across the spectrum must come together in ways that simultaneously address the technical, social, political, economic and cultural elements of CDR development, commercialization, adoption and diffusion if the academy is to have a material impact on climate change in the increasingly limited window we have to address it.

Cost Analysis of Direct Air Capture and Sequestration Coupled to Low-Carbon Thermal Energy in the United States

Negative emissions technologies will play an important role in preventing 2 °C warming by 2100. The next decade is critical for technological innovation and deployment to meet mid-century carbon removal goals of 10-20 GtCO₂/yr. Direct air capture (DAC) is positioned to play a critical role in carbon removal, yet remains under paced in deployment efforts, mainly because of high costs. This study outlines a roadmap for DAC cost reductions through the exploitation of low-temperature heat, recent U.S. policy drivers, and logical, regional end-use opportunities in the United States. Specifically, two scenarios are identified that allow for the production of compressed high-purity CO₂ for costs ≤$300/tCO₂, net delivered with an opportunity to scale to 19 MtCO₂/yr. These scenarios use thermal energy from geothermal and nuclear power plants to produce steam and transport the purified CO₂ via trucks to the nearest opportunity for direct use or subsurface permanent storage. Although some utilization pathways result in the re-emission of CO₂ and cannot be considered true carbon removal, they would provide economic incentive to deploying DAC plants at scale by mid-century. In addition, the federal tax credit 45Q was applied for qualifying facilities (i.e., producing ≥100 ktCO₂/yr).

Development of a framework for international certification by the OIE of diagnostic tests validated as fit for purpose

Historically, the OIE has focussed on test methods applicable to trade and the international movement of animals and animal products. With its expanding role as the World Organisation for Animal Health, the OIE has recognised the need to evaluate test methods relative to specific diagnostic applications other than trade. In collaboration with its international partners, the OIE solicited input from experts through consultants meetings on the development of guidelines for validation and certification of diagnostic assays for infectious animal diseases. Recommendations from the first meeting were formally adopted and have subsequently been acted upon by the OIE. A validation template has been developed that specifically requires a test to be fit or suited for its intended purpose (e.g. as a screening or a confirmatory test). This is a key criterion for validation. The template incorporates four distinct stages of validation, each of which has bearing on the evaluation of fitness for purpose. The OIE has just recently created a registry for diagnostic tests that fulfil these validation requirements. Assay developers are invited to submit validation dossiers to the OIE for evaluation by a panel of experts. Recognising that validation is an incremental process, tests methods achieving at least the first stages of validation may be provisionally accepted. To provide additional confidence in assay performance, the OIE, through its network of Reference Laboratories, has embarked on the development of evaluation panels. These panels would contain specially selected test samples that would assist in verifying fitness for purpose.

Development of a framework for international certification by OIE of diagnostic tests validated as fit for purpose

Historically, the OIE has focused on test methods applicable to trade and the international movement of animals and animal products. With its expanding role as the World Organisation for Animal Health, the OIE has recognised the need to evaluate test methods relative to specific diagnostic applications other than trade. In collaboration with its international partners, the OIE solicited input from experts through consultants' meetings on the development of guidelines for validation and certification of diagnostic assays for infectious animal diseases. Recommendations from the first meeting were formally adopted and have subsequently been acted upon by the OIE. A validation template has been developed that specifically requires a test to be fit or suited for its intended purpose (e.g. as a screening or a confirmatory test). This is a key criterion for validation. The template incorporates four distinct stages of validation, each of which has bearing on the evaluation of fitness for purpose. The OIE has just recently created a registry for diagnostic tests that fulfil these validation requirements. Assay developers are invited to submit validation dossiers to the OIE for evaluation by a panel of experts. Recognising that validation is an incremental process, tests methods achieving at least the first stages of validation may be provisionally accepted. To provide additional confidence in assay performance, the OIE, through its network of Reference Laboratories, has embarked on the development of evaluation panels. These panels would contain specially selected test samples that would assist in verifying fitness for purpose.

Discovery of 12 satellites of Saturn exhibiting orbital clustering

The giant planets in the Solar System each have two groups of satellites. The regular satellites move along nearly circular orbits in the planet's orbital plane, revolving about it in the same sense as the planet spins. In contrast, the so-called irregular satellites are generally smaller in size and are characterized by large orbits with significant eccentricity, inclination or both. The differences in their characteristics suggest that the regular and irregular satellites formed by different mechanisms: the regular satellites are believed to have formed in an accretion disk around the planet, like a miniature Solar System, whereas the irregulars are generally thought to be captured planetesimals. Here we report the discovery of 12 irregular satellites of Saturn, along with the determinations of their orbits. These orbits, along with the orbits of irregular satellites of Jupiter and Uranus, fall into groups on the basis of their orbital inclinations. We interpret this result as indicating that most of the irregular moons are collisional remnants of larger satellites that were fragmented after capture, rather than being captured independently.

Celiac disease presenting with microcephaly

A 15-month-old girl with celiac disease presented with microcephaly and developmental delay. Head growth resumed during a gluten-free diet. Subsequent gluten ingestion resulted in no head growth, areflexia, and increased celiac antibodies. All resolved with gluten elimination. Poor head growth may precede other clinical manifestations of celiac disease.

Should locally excised T1 rectal cancer receive adjuvant chemoradiation?

BACKGROUND

Local excision of low-lying adenocarcinoma of the rectum is increasingly utilized, but the benefit of adjuvant treatment in T1 lesions with otherwise favorable pathology remains controversial.

METHODS

A retrospective review was performed on patients who underwent local excision of invasive rectal cancer with curative intent from 1991 to 1999.

RESULTS

Forty-eight patients were treated with local surgical excision. Twenty-seven T1 lesions were identified, 10 received postoperative chemoradiation, and no local recurrences were identified. Seventeen T1 patients did not receive adjuvant treatment and local recurrence occurred in 4 patients (24%). In all cases of local recurrence, the lesions had been excised to negative margins, none were poorly differentiated, and none exhibited vascular or lymphatic invasion.

CONCLUSION

These data suggest a trend toward improved local control with adjuvant therapy after local excision of T1 rectal cancer. This is an important consideration in patients with negative surgical margins and favorable pathology who are traditionally not treated.

Flood disaster preparedness: a retrospect from Grand Forks, North Dakota

Natural disasters often come without warning. The clinical, financial, and business risks can be enormous. Grand Forks' (ND) healthcare systems experienced a flooding disaster of unprecedented proportions in April of 1997. Planned and practiced disaster and evacuation procedures can significantly reduce a healthcare facilities' risk to life, health, and safety. This article retrospectively analyzes disaster preparation and the complete evacuation of the facilities' patients.

Methylprednisolone disposition kinetics in patients with acute spinal cord injury

STUDY OBJECTIVE

To evaluate the pharmacokinetics of high-dose methylprednisolone in patients with acute spinal cord injury (ASCI).

DESIGN

Open-label study of consecutive patients with ASCI, and retrospective review of able-bodied controls.

SETTING

Emergency Medicine Department of a large, urban, university-affiliated, tertiary care trauma center.

PATIENTS

Eleven men with ASCI.

INTERVENTIONS

Methylprednisolone sodium succinate 30 mg/kg intravenous bolus, followed by 5.4 mg/kg/hour for 23 hours, administered according to the second National Acute Spinal Cord Injury Study (NASCIS 2) protocol.

MEASUREMENTS AND MAIN RESULTS

The total systemic clearance of methylprednisolone was significantly less in acutely injured patients (mean +/- SD 30.04 +/- 12.03 L/hr) than in historically reported able-bodied controls (44.70 +/- 4.90 L/hr). An inverse correlation between the neurologic level of injury and systemic clearance was seen. No differences in volume of distribution were discernible between patients (126.90 L) and controls (135.45 L).

CONCLUSION

Patients with acute spinal cord injury administered methylprednisolone according to the NASCIS 2 protocol had an apparent decrease in total systemic clearance of the drug without a commensurate change in volume of distribution. Additional studies are warranted to confirm these findings and assess the potential impact of diminished clearance on the efficacy of the agent in ASCI.

Genetic relatedness of Burkholderia (Pseudomonas) cepacia isolates from five cystic fibrosis centers in Michigan

Burkholderia cepacia isolates from patients with cystic fibrosis (CF) attending five CF centers were studied for relatedness by cellular fatty acid methyl esters (FAME) and by chromosomal DNA restriction analysis. Twenty-eight of 32 (87.5%) isolates tested were grouped in cluster group 1 based on their FAME profiles. DNA analysis revealed that 29 of 32 (90.6%) B. cepacia isolates from five CF centers had one closely related DNA pattern. To examine strain variation over a time period, FAME profiles and DNA patterns of isolates from serial cultures on seven patients from center D were studied. For four patients, all serial B. cepacia isolates belonged to a single FAME cluster group; for the remaining three patients, all serial isolates belonged to any two of the four cluster groups. On serial culture isolates, a single DNA pattern (pattern A) was found in 31 of 32 isolates demonstrating a close genetic relatedness. These data corroborate the observations that the majority of patients colonised with B. cepacia in a CF center harbor strains genetically closely related as determined by FAME profiles and DNA patterns.

Long-term hyperglycemia is related to peripheral nerve changes at a diabetes duration of 4 years. The Wisconsin Diabetes Registry

OBJECTIVE

To examine longitudinal hyperglycemia and peripheral nerve responses in a population-based incident cohort.

RESEARCH DESIGN AND METHODS

A sample from an incident cohort of young people was comprehensively followed from diagnosis of IDDM. Participants were invited to submit blood samples three times per year for central testing of GHb. During their 4th year of diabetes, nerve conduction studies were performed on the median sensory and motor, peroneal motor, and sural sensory nerves. Relationships between mean GHb and nerve latencies, velocities, and amplitudes were explored.

RESULTS

GHb was positively related to all nerve latencies and negatively related to all nerve velocities. The relationships between mean GHb and nerve conduction latencies and velocities differed by sex for the peroneal nerve latency (beta = 0.17 male subjects, beta = -0.01 female subjects; P < 0.001). Pubertal participants had lower velocities and longer latencies than prepubertal participants (beta = 0.37; P = 0.05 peroneal latency), after adjustment for GHb, height, and extremity temperature. Sensory and motor nerve amplitudes were related to GHb, and these relationships did not differ by sex.

CONCLUSIONS

Our study indicates that sustained hyperglycemia is related to functional changes, at the minimum, in peripheral sensory and motor nerve conduction at a diabetes duration of 4 years. Our findings are consistent with a dying-back neuropathy, and there is some suggestion that chronic hyperglycemia may be more detrimental to nerves in male subjects than in female subjects.

Induction of inflammatory cytokines in placental monocytes of gravidae infected with the human immunodeficiency virus type 1

Placental mononuclear cells (PMC) are susceptible to infection with the human immunodeficiency virus (HIV). PMC secreted tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta), and IL-6 among other factors, which, in turn, regulate HIV replication in latently infected cells. We assessed the induction of these cytokines in PMC from HIV-infected (HIV+) and uninfected (control) gravidae following exposure to lipopolysaccharide (LPS), HIV lysate (iHIV), recombinant HIV env (GP160) and HIV gag (gag55), and synthetic HIV p17 (HGP30) antigens. In comparison to control PMC, HIV+ PMC constitutively secreted higher levels of IL-1beta and IL-6 and were refractory to stimulation by iHIV, GP160, gag55, and HGP30. Control PMC IL-1 beta levels were boosted by LPS; gag55 and HGP30 augmented IL-6 but not IL-1 beta. Both groups exhibited low basal TNF-alpha production that was augmented by LPS. HIV+ PMC exhibited higher constitutive levels of IL-1 beta, IL-6, and TNF-alpha gene transcription than control PMC. These levels could be further augmented by LPS, yet the incremental levels were lower than those obtained from PMC of uninfected women. The high basal constitutive secretion of cytokines by HIV+ PMC and their refractoriness to activation may reflect a virus-mediated dysregulation of cytokine expression culminating in compromised host defenses against secondary opportunistic infections associated with AIDS.

Regulation of AE2 Cl-/HCO3- exchanger during intestinal development

The Na(+)-independent Cl-/HCO3- exchangers in many tissues are encoded by AE2, which is a member of the anion-exchanger (AE) gene family. Molecular regulation of AE2 remains mostly unknown. In this study, AE2 mRNA levels during enterocyte differentiation and intestinal development were examined in rat small intestines. AE2 mRNA levels did not show obvious segmental variation or vary along the crypt-villus axis. In contrast, AE2 mRNA decreased between days 14 and 21 after birth, the period corresponding to the transition period between the suckling and weanling stages in rats. Effects of L-thyroxine and dexamethasone on AE2 expression were examined because these hormones play important roles in gene regulation during development. L-Thyroxine administration starting on day 9 after birth led to an approximately 60% decrease (P < 0.001) in AE2 mRNA on day 13. Dexamethasone had no effect on AE2 mRNA level regardless of whether the hormone was administered alone or in conjunction with L-thyroxine. Our results indicate that AE2 mRNA in the intestine is regulated during development and that this regulation may in part be related to hormonal changes.

A pilot study of prednisone in Alzheimer's disease

Preliminary to a multicenter trial, an open-label study was conducted of prednisone treatment in Alzheimer's disease. Prednisone was given at an initial dose of 10 mg (part 1) or 20 mg (part 2) and tapered over 7 weeks. There were no serious adverse events attributed to the medication, and there were no significant changes in either mean cognitive or behavioral assessment scores with treatment during either part. Serum levels of the acute phase proteins alpha-1-antichymotrypsin and C-reactive protein did not change significantly during part 1, but were suppressed by the higher dose given in part 2. Thus, a prednisone regimen with an initial dose of 20 mg is tolerable and results in suppression of the acute phase response in Alzheimer's disease.

Recombinant human erythropoietin therapy for anemic cancer patients receiving cisplatin chemotherapy

PURPOSE

To assess whether the administration of recombinant human erythropoietin (r-HuEPO) would increase the hematocrit, reduce the requirement for transfusion, and improve the quality of life in anemic cancer patients receiving myelosuppressive, cisplatin-based chemotherapy.

PATIENTS AND METHODS

One hundred thirty-two anemic cancer patients receiving cyclic, cisplatin-containing, myelosuppressive chemotherapy were evaluated. Patients received either r-HuEPO (150 U/kg) or placebo, subcutaneously, three times a week for 3 months. Responses were assessed by measuring changes in hemoglobin/hematocrit, transfusion requirement, and quality of life.

RESULTS

The mean hematocrit increased by 6.0 percentage points in the r-HuEPO group versus 1.3 in the placebo group. A decrease in transfusion requirement did not reach significance over all 3 months, but there was a significant reduction in the percentage of patients transfused in the second and third months (27% r-HuEPO vs. 56% placebo) and a trend toward reduction in the mean total number of units transfused (1.20 units r-HuEPO vs. 2.02 units placebo), suggesting a lag of 1 month before r-HuEPO can affect the transfusion requirement. Pretreatment serum erythropoietin levels were lower in responders than in nonresponders (73.5 IU/L and 86.3 IU/L means, respectively). However, the magnitude of this difference was not helpful in defining which patients were likely to respond. There was a significant improvement in overall quality of life between the two treatment arms in favor of the r-HuEPO-treated group. There were no significant adverse effects associated with r-HuEPO.

CONCLUSIONS

r-HuEPO is safe and can cause a significant improvement in the hematocrit and quality of life of anemic cancer patients receiving myelosuppressive, cisplatin-based chemotherapy. After 1 month of r-HuEPO, there is also a reduction in transfusion requirement.

L-deprenyl and physostigmine for the treatment of Alzheimer's disease

The present study evaluated the safety of and obtained preliminary data on the cognitive effects of L-deprenyl and physostigmine in patients with Alzheimer's Disease. Seventeen outpatients with Alzheimer's Disease participated in a double-blind crossover study in which they received 4 weeks of L-deprenyl at a dose of 10 mg p.o., q.d., and 4 weeks of placebo in random order. During both the L-deprenyl and placebo periods, patients received cognitive assessments during physostigmine (0.5 mg) and placebo infusions separated by 2 days. The cognitive effects of these agents alone and in combination were measured with digit span, verbal fluency, list learning, praxis, delayed recall, and delayed recognition tasks. Fifteen patients completed the study. The two drugs, used alone or in combination, were safe and well tolerated. Analyses of variance demonstrated that neither physostigmine nor L-deprenyl, whether given alone or in combination, significantly improved cognition, when compared with the double placebo condition.

Bystander vs EMS first-responder CPR: initial rhythm and outcome in witnessed nonmonitored out-of-hospital cardiac arrest

OBJECTIVES

To assess whether outcome and first-monitored rhythm for patients who sustain a witnessed, nonmonitored, out-of-hospital cardiac arrest are associated with on-scene CPR provider group.

METHODS

A retrospective, cohort analysis was conducted in a suburban, heterogeneous EMS system. Patients studied were > or = 19 years of age, had had an arrest of presumed cardiac origin between July 1989 and January 1993, had gone into cardiac arrest prior to ALS arrival, and had received CPR on collapse. First-monitored rhythms and survival rates were compared for two patient groups who on collapse either: 1) had received CPR by nonprofessional bystanders (BCPR) or 2) had received CPR by on-scene EMS system first responders (FRCPR).

RESULTS

Of 217 cardiac arrest victims, 153 (71%) had received BCPR and 64 (29%) had received FRCPR. The BCPR patients were slightly younger (62.4 vs 68.4 years, p = 0.01) and had slightly shorter ALS response intervals (6.4 vs 7.7 minutes, p = 0.02). There was no difference in BLS response time intervals or automatic external defibrillator (AED) use rates. The percentage of patients with a first-monitored rhythm of pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) and the percentage of patients grouped by CPR provider who survived to hospital admission or to hospital discharge were: [see text]

Bystander CPR, ventricular fibrillation, and survival in witnessed, unmonitored out-of-hospital cardiac arrest

STUDY OBJECTIVE

To assess whether bystander CPR (BCPR) on collapse affects initial rhythm and outcome in patients with witnessed, unmonitored out-of-hospital cardiac arrest (OHCA).

DESIGN

Prospective cohort study. Student's t test, the chi 2 test, and logistic regression were used for analysis.

SETTING

Suburban emergency medical service (EMS) system.

PARTICIPANTS

Patients 19 years or older with witnessed OHCA of presumed cardiac origin who experienced cardiac arrest before EMS arrival between July 1989 and July 1993.

RESULTS

Of 722 patients who met the entry criteria, 153 received BCPR. Patients who received BCPR were younger than those who did not: 62.5 +/- 15.4 years versus 66.8 +/- 15.1 years (P < .01). We found no differences in basic or advanced life support response intervals or in frequency of AED use. More patients initially had ventricular fibrillation (VF) in the BCPR group: 80.9% versus 61.4% (P < .01). The interval to definitive care for ventricular tachycardia (VT)/VF was longer for the BCPR group (8.59 +/- 5.3 versus 7.45 +/- 4.7 minutes; P < .05). The percentage of patients discharged alive who were initially in VT/VF was higher in the BCPR group: 18.3% versus 8.4% (P < .001). In a multivariate model, BCPR is a significant predictor for VT/VF and live discharge with adjusted ORs of 2.7 (95% CI, 1.7 to 4.4) and 2.4 (95% CI, 1.5 to 4.0), respectively. For those patients in VT/VF, BCPR predicted live discharge from hospital with an adjusted OR of 2.1 (95% CI, 1.2 to 3.6).

CONCLUSION

Patients who receive BCPR are more often found in VT/VF and have an increased rate of live discharge, with controls for age and response and definitive care intervals. For VT/VF patients, BCPR is associated with an increased rate of live discharge.

Pharmacology of epidural fentanyl, alfentanil, and sufentanil in volunteers

BACKGROUND

Despite a large number of clinical investigations in postoperative patients, the pharmacology of epidural fentanyl, alfentanil, and sufentanil has not been well characterized in a human laboratory setting. In this double-blind, placebo-controlled crossover study, we evaluated analgesia and side effects produced by epidural fentanyl (30 and 100 micrograms), alfentanil (300 and 1,000 micrograms), and sufentanil (3 and 10 micrograms) in volunteers.

METHODS

Each of 12 volunteers participated in four separate study sessions. The pain model was cutaneous electrical stimulation of intensity sufficient to produce a pain report of 5 on a 0-5 scale, delivered alternately to the finger and tow. Ventilatory drive, pupil size, and subjective ratings of alertness, nausea, and pruritus were measured using visual analog scales. On each study day, after baseline measurements, an epidural catheter was placed at the L2-L3 or L3-L4 interspace. Subjects received the small dose of study drug, and the tests were repeated at 2, 55, and 95 min after drug administration. Subjects then received the large dose of the same study drug, and the series of tests was repeated at 2, 55, and 95 min later. Plasma opioid concentrations were measured using gas chromatography-mass spectrometry.

RESULTS

Dose-dependent analgesia was found for all study opioids. For both doses of all opioids, toe analgesia was significantly greater than finger analgesia. Epidural fentanyl and alfentanil provided greater analgesia than sufentanil at the doses investigated. Sedation, increased end-tidal carbon dioxide, and pupillary constriction occurred only after the large epidural doses of all opioids. Overall, the incidence of subjective side effects was low, but four subjects experienced pruritus after 100 micrograms fentanyl, and four were nauseated after 1,000 micrograms alfentanil. Plasma opioid concentrations were near minimum effective analgesic plasma concentrations only after larger epidural doses.

CONCLUSIONS

Lumbar epidural fentanyl, alfentanil, and sufentanil produce selective lower-extremity analgesia. Low plasma opioid concentrations measured after small epidural opioid doses suggest a spinal mechanism for analgesia. Larger doses of epidural opioids result in systemic absorption and are likely to produce supraspinal analgesia and other side effects.

Recurrent benign intracranial hypertension due to iron deficiency anemia. Case report and review of the literature

PURPOSE

Iron deficiency anemia (IDA) causes benign intracranial hypertension (BIH).

PATIENTS AND METHODS

A case of an 11-year-old girl with severe IDA and benign intracranial hypertension is presented.

RESULTS

Treatment of iron deficiency resulted in the resolution of BIH. Recurrence of BIH is observed with the recurrence of IDA. Chronic intermittent blood loss from the intestinal polyps was the etiology of recurrent IDA.

CONCLUSIONS

A thorough search to determine the etiology of IDA is essential for proper treatment. Although BIH is a rare complication of IDA, its association with IDA should be recognized for prompt treatment before an extensive and costly workup for BIH is done.

Public health applications of Hansen's disease research and treatment

Because of the similarities in causative agents of Hansen's disease and tuberculosis, Hansen's disease research is now being used in the identification, treatment, and prevention of tuberculosis. Numerous studies are under way to screen and develop new drugs to combat the threat of multiple drug-resistant tuberculosis. Additional studies focus on factors to reduce the transmission of tuberculosis and on the development of techniques for early diagnosis and identification of drug resistance. Advances in Hansen's disease research and treatment also are being applied to the prevention of ulcers and amputations in diabetics and others without protective sensation in their feet. The Lower Extremity Amputation Prevention Program, developed at the Gillis W. Long Hansen's Disease Center in Carville, LA, is a multidisciplinary approach that includes screening, risk assessment, and the development of a treatment plan with an emphasis on patient involvement. Expected to prevent up to 90 percent of diabetes-related amputations, the program is being implemented in Jackson, MS, in a community-based diabetic foot program and will be replicated throughout the United States.

Reference accuracy in the emergency medicine literature

STUDY OBJECTIVE

To determine the incidence and nature of errors in the citation and quotation of references contained in the emergency medicine literature.

DESIGN

A retrospective analysis of a random sample of articles and references found in the three major emergency medicine journals.

SETTING

A university/county hospital.

METHODS

We examined single issues of three emergency medicine journals: Annals of Emergency Medicine, Journal of Emergency Medicine, and American Journal of Emergency Medicine.

INTERVENTIONS

None.

MEASUREMENTS

Four independent reviewers assessed 145 references from 46 referring authors for citational and quotational accuracy.

MAIN RESULTS

Major and minor citation errors were found in 10.3% and 17.2% of reference listings, respectively. Qualitative quotational errors were found in 35.2% of references. Eighty-two percent of these errors were considered to be major. Quantitative quotational errors were found in 47% of references reviewed. Secondary rather than primary reference sources were used in 41.4% of references reviewed.

CONCLUSION

This study demonstrates a substantial error rate in the citation and quotation of reference sources in the emergency medicine literature. In addition, verification of primary source material was not done by a large percentage of the authors reviewed. Recommendations for improving the accuracy of the emergency medicine literature are offered.

Evaluation of the accuracy of a pharmacokinetically-based patient-controlled analgesia system

Bone marrow transplant patients having severe, prolonged oral mucositis pain (expected to last for one to three weeks) used a computer-controlled infusion system to self-administer morphine for pain control. Individual patient pharmacokinetic information, derived from a pretreatment bolus morphine dose, was used in a new bolus-elimination transfer algorithm to produce rapid adjustments of steady plasma morphine concentrations when the patient requested more or less drug. We evaluated the performance characteristics (bias and precision) of this pharmacokinetically based patient-controlled analgesic infusion system (PKPCA) in a group of 15 cancer patients over six to 14 days. Although we found a three- to fivefold pharmacokinetic variability in the tailoring morphine dose data, the PKPCA system was free of systematic bias (insignificant overall prediction error) during the patient-controlled infusions in this study population. The absolute prediction error was 19.9% for the group on the first study day and 25.6% over the entire study period (aggregate results; 6-14 days of continuous use). Two-thirds of the patients exhibited no bias throughout the study period, and individual bias in the others was symmetrically distributed (three patients with underpredictions and two overpredicted). Magnitude of prediction error during the patient-controlled morphine infusions was not related to the magnitude of pharmacokinetic deviation of individual subjects from group parameters. Our results indicate that this PKPCA system provides accurate control of plasma morphine concentration when used by patients to self-administer opioid for prolonged pain relief continuously over 1 to 2 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibacterial properties of investigational, new, and commonly used antibiotics against isolates of Pseudomonas cepacia in Michigan

Microdilution antimicrobial susceptibility testing was performed with 73 isolates of Pseudomonas cepacia collected from the sputum of patients throughout Michigan with cystic fibrosis. Susceptibility testing was done using new and investigational antibiotics (loracarbef, cefixime, cefpirome, desacetyl-cefotaxime, cefpodoxime, cefmetazole, cefepime, cefprozil, and fleroxacin) and commonly used antibiotics (ceftazidime, mezlocillin, piperacillin, ciprofloxacin, tobramycin, and amikacin). Ceftazidime was the most active antibiotic, and 91.8% of isolates were susceptible to it with MIC50 and MIC90 values of < or = 4 and 16 micrograms/ml, respectively. For mezlocillin, piperacillin, and ciprofloxacin 84.9, 89 and 39.7% of the isolates, respectively, were mostly moderately susceptible. Loracarbef, cefixime, cefprozil, cefmetazole, cefepime, fleroxacin, cefpodoxime, tobramycin, and amikacin did not show activity against P. cepacia. For cefpirome and desacetylcefotaxime 24.7 and 60.3% of the isolates, respectively, were moderately susceptible. Both MIC50 and MIC90 were > 32 micrograms/ml for cefpirome and 32 and > 64 micrograms/ml for desacetylcefotaxime.

Comparison of a urine spot test and blood tests as indicators of patient compliance

Irregular drug intake has been a concern of leprosy control programmes for many years and various methods have been used to monitor and encourage patient compliance. This study compares the results of a urine spot test for dapsone as proposed by Huikeshoven, with blood levels measured in the same patients by the modified Bratton Marshall method and by high performance liquid chromatography. Two hundred-sixty urine and blood specimens were obtained from subjects who were taking supervised and unsupervised medications as well as from controls who were taking no medications. The results indicate that the urine spot test is simple and easily performed, and for monitoring patient compliance under routine clinical conditions (hospital or field work) it compares favourably with blood levels of dapsone estimated by the Bratton Marshall method or by high performance liquid chromatography. The study also shows that dapsone level is not a good indicator of compliance in patients who are also taking daily rifampicin but the urine spot test remains useful in such patients.

Capgras' syndrome with organic disorders

Capgras' syndrome, one form of the delusional misidentification syndromes, is described. Three patients with the syndrome are reported. The first had a right cerebral infarction, the second had nephrotic syndrome secondary to severe pre-eclampsia in the puerperium, and the third had uncontrolled diabetes mellitus with dementia. Evidence is reviewed regarding an organic aetiology for Capgras' syndrome. We conclude that, when the syndrome is present, a thorough search for organic disorder should be made.

Steady-state infusions of opioids in human volunteers. I. Pharmacokinetic tailoring

We report a method for controlling and adjusting plasma opioid concentration to preselected target values in individual human subjects in order to study analgesic and other effects of opioids at steady state. The method employs a computer-controlled infusion pump and an algorithm that utilizes individual subject pharmacokinetic parameters predetermined with tailoring bolus opioid doses. We used this approach to produce 3-step increases in plasma concentrations of alfentanil, fentanyl and morphine in each of 15 subjects. We maintained each plasma concentration plateau for 70 min, measured plasma opioid concentrations achieved during the infusions and analyzed the results for bias and precision of the individually tailored infusions. Our results show that pharmacokinetically tailored opioid infusions produce stable plasma opioid concentrations within 10 min for alfentanil and morphine; with each drug overall prediction error was 20% or less. Fentanyl was somewhat more difficult to control by this method than were the other 2 opioids. We conclude that individual tailoring of opioid infusions minimizes the impact of individual pharmacokinetic differences on achieving preselected plasma opioid concentrations and provides an accurate means of controlling steady-state drug concentrations for studies of concentration-effect relationships and comparisons of side-effect intensities produced by equianalgesic plasma opioid concentrations.

Clonazepam treatment of tardive dyskinesia: a practical GABAmimetic strategy

Because of the efficacy of specific gamma-aminobutyric acid (GABA) agonists in tardive dyskinesia, the authors tested the benzodiazepine clonazepam in a 12-week, double-blind, placebo-controlled, randomized crossover trial in 19 chronically ill patients with tardive dyskinesia who were being treated with neuroleptics. They found a 35% decrease in dyskinesia ratings with clonazepam treatment. The six patients with predominantly dystonic symptoms showed greater benefit than the 13 patients with predominantly choreoathetoid dyskinesias. Tolerance developed to the antidyskinetic effect of clonazepam in the five patients whose long-term use of the drug was followed, but a 2-week clonazepam-free period recaptured its antidyskinetic effect.

Morphology of the fibrinogen exudate during evolution of a mycobacterial-induced murine eye granuloma

The intent of this study was to visualize changes in the density and location of fibrinogen-related antigen (FRA) depositions within the murine vitreous space during the formation of a chronic mycobacterial-induced uveitis (CMIU) granuloma. Concurrent changes in cellular morphology of the granuloma were also examined. Fibrinogen derivatives within the exudates of granulomatous cell-mediated inflammations may induce physical induration and numerous other phlogistic effects. However, technical limitations of conventional FRA staining methods have tended to underestimate the extent of their presence within this category of inflammatory lesions. Conventional H and E sections of the CMIU granuloma confirmed the classic progression-early PMN influx, monocyte maturation and final macrophage and epithelioid cell dominance-described for such lesions. Avidin-biotin-complex staining utilizing a polyclonal mouse antifibrinogen then revealed a progressive increase in amorphous extracellular fibrinogen-FRA-positive staining material as the granuloma evolved. Thus, on day one the PMN influx showed no evidence of fibrinogen-FRA staining; at one week heavy staining was evident in the anterior chamber and in consolidated (i.e. macrophage) regions of the granuloma; at one month a heavy uniform staining appeared throughout the indurated granuloma where macrophages and epithelioid cells predominated. Patterns of heavy deposition on macrophage surfaces were suggested. The likelihood that bulky accumulations of FRA in mature granulomas are not solely fibrin, and may account for granulomatous induration and persistence, is discussed.

Selective subcortical abnormalities in autism

Nine physically healthy, adult autistic men, with normal or near normal intelligence, and 13 healthy male controls were examined in a CT brain scan study. CT scans were analysed with a fully automated computer-assisted program, and regional brain radiodensities were measured with careful attention to artefacts. Autistic patients revealed significantly larger third, but not lateral, ventricular size and significantly lower mean caudate, but equivalent mean frontal and thalamic, radiodensities compared to controls. The sizes of the Sylvian fissures and interhemispheric fissure were equivalent between groups. The findings are consistent with selective subcortical abnormalities in autism.