Informing Utstein-style reporting guidelines for prehospital thrombolysis: A scoping review

BACKGROUND

Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT.

METHODS

A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting.

RESULTS

After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services.

CONCLUSIONS

Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.

Prone Positioning of Ventilated Patients During Air Medical Evacuation: A Case Series

OBJECTIVE

The purpose of this study was to investigate patient safety implications of transporting prone-positioned mechanically ventilated patients in the air medical environment (AME).

METHODS

A retrospective health record review of patient encounters from 2019 to 2021 was conducted using British Columbia Emergency Health Services air medical electronic patient care reports.

RESULTS

A total of 633 patients were identified as intubated, mechanically ventilated, and transported by British Columbia Emergency Health Services air medical teams. Ten patients were identified as having been transported in the prone position. Oxygen saturation, arterial blood oxygen levels, and carbon dioxide measurements from 8 cases indicated that patients remained stable or improved during transport. Cardiovascular episodes including hypotension and tachycardia were observed. In 2 patients, a mean 17.5% decline in oxygen saturation was identified. It could not be determined if this was a result of prone positioning during AME or due to a deteriorating physiological condition related to the patient's underlying disease. There were no identified tube dislodgments during AME transport.

CONCLUSION

Although proning did not compromise patient safety with respect to tube or line displacement in our study, we cannot draw definitive conclusions regarding the safety implications of proning on patient vital signs during transport.

Virtual reality for the rehabilitation and prevention of intimate partner violence - From brain to behavior: A narrative review

Rehabilitation and prevention strategies to reduce intimate partner violence (IPV) have limited effectiveness in terms of improving key risk factors and reducing occurrence. Accumulated experimental evidence demonstrates that virtual embodiment, which results in the illusion of owning a virtual body, has a large impact on people's emotional, cognitive, and behavioral responses. This narrative review discusses work that has investigated how embodied perspective - taking in virtual reality has been used as a tool to reduce bias, to enhance recognition of the emotional state of another, and to reduce violent behaviors, in particular in the realm of IPV. Some of the potential neurological mechanisms behind these affective and behavioral changes are also discussed. The process of rehabilitation and prevention is complex and not always effective, but the integration of neuroscience-inspired and validated state-of-the-art technology into the rehabilitation process can make a positive contribution.

On the Practical Use of Immersive Virtual Reality for Rehabilitation of Intimate Partner Violence Perpetrators in Prison

Virtual reality (VR) allows the user to be immersed in environments in which they can experience situations and social interactions from different perspectives by means of virtual embodiment. In the context of rehabilitation of violent behaviors, a participant could experience a virtual violent confrontation from different perspectives, including that of the victim and bystanders. This approach and other virtual scenes can be used as a useful tool for the rehabilitation of intimate partner violence (IPV) perpetrators, through improvement of their empathic skills or for training in non-violent responses. In this perspective, we revise and discuss the use of this tool in a prison environment for the rehabilitation of IPV perpetrators with a particular focus on practical aspects based on our experience.

Canadian paramedic experience with intramuscular ketamine for extreme agitation: A quality improvement initiative

BackgroundThere are no published reports in Canada examining paramedic use of ketamine for highly agitated patients or excited delirium syndrome. We employed a Plan, Do, Study, Act (PDSA) quality improvement approach to evaluate the safety and effectiveness of advanced care paramedic administered intramuscular (IM) ketamine for patients with extreme agitation in the out-of-hospital setting.MethodsData were prospectively collected from July 2018 to January 2019 when advanced care paramedics with specific training administered IM ketamine as an alternative to midazolam. Paramedics used a clinical audit form to document the ketamine dose, patient response on the Richmond Agitation Sedation Scale (RASS) at time intervals, adverse effects, and any airway management interventions they performed. ResultsThirty-three patients received either 4 mg/kg or 5 mg/kg of ketamine. Combining data for both doses, the median change in RASS score at 5 minutes post-ketamine was 3 (range 0 to 8) and statistically significant for each dose. There were seven cases (21%) with reported adverse effects including SpO2 <90% (3/7), hypersalivation (3/7), trismus or teeth grinding (2/7), muscular rigidity (1/7) and laryngospasm (1/7). Statistical analysis confirmed that the incidence of adverse events was not dose dependent. Basic airway management was performed in one-third of all cases.ConclusionWe piloted the implementation of ketamine for sedation in our paramedic system by employing a PDSA cycle. Ketamine 5 mg/kg IM provided effective control of acutely agitated patients with adequate sedation at 5 minutes post-delivery. Any adverse events that occurred as a result of IM ketamine were readily managed with basic airway management interventions.

The diagnostic yield of computed tomography in the management of acute flank pain and the emergency intervention rate for a proven acute ureteric stone

INTRODUCTION

The diagnostic and management pathways for patients presenting with acute flank pain are complex. Although computed tomography (CT) of the kidneys, ureters and bladder (KUB) is the gold standard investigation for urolithiasis, the multitude of differential diagnoses must also be considered in the context of long-term risk from ionising radiation. This study investigated the integrated role and diagnostic yield of non-contrast CT in cases of acute flank pain.

METHODS

A retrospective cohort study was undertaken of 1,442 consecutive patients investigated with CT KUB between March 2013 and February 2015. The primary outcome was diagnostic yield of CT with secondary outcomes being predictors of need for urological intervention.

RESULTS

A cause for acute flank pain was identified in 717 patients (50%), there was an incidental finding in 389 patients (27%) and normal imaging was reported in 336 patients (23%). A diagnosis was more commonly made in male than in female patients (70% vs 40%) and with increasing age (46% in patients aged <30 years, 56% in those aged 30-49 years and 63% in those aged ≥50 years). The overall rate for an ipsilateral urinary tract stone was 41%. Factors strongly associated with emergency intervention included stone size >10mm (odds ratio [OR]: 11.7, 95% confidence interval [CI]: 3.3-42.7), stones located at the pelviureteric junction (OR: 7.8, 95% CI: 2.6-22.9), C-reactive protein >50mg/l and ≤100mg/l (OR: 15.2, 95% CI: 5.1-45.3), and estimated glomerular filtration rate ≤30ml/min (OR: 5.8, 95% CI: 1.5-21.8).

CONCLUSIONS

This contemporary study identifies age and sex as independent variables affecting the diagnostic yield of CT KUB in cases of acute flank pain, and highlights factors associated with a need for emergency intervention in proven ureteric stones.

Combined antegrade and retrograde access to difficult ureters: revisiting the rendezvous technique

INTRODUCTION

Complex ureteric strictures present a significant challenge to the endourologist and uro-radiologist. Multiple separate interventions to try to cross the stricture are often attempted. We describe our experience managing a heterogenous patient group using the 'rendezvous' procedure.

METHODS AND MATERIALS

16 patients and 18 ureters (one bilateral procedure, and two separate procedures in one patient) underwent rendezvous procedures. Seven patients had coexisting ureteric calculi treated. Each case was followed up for between 3 months and 5 years.

RESULTS

In 16/18 ureters there was technical success at time of surgery; successfully crossing the stricture, allowing ureteroscopic access to the ureter, dilating and/or stenting the ureter. 2/18 were unsuccessful; one secondary to advanced malignancy resulting in a uretero-vaginal fistula and the second a failure to remove a retained, displaced ureteric stent. Of the 18 ureteric procedures; 7/18 were stent free at 3 months, improving to 8/18 stent free at 6 months. 4/18 remained nephrostomy dependent (failure of drainage despite stent or failure to stent) at 3 months, increasing to 6/18 being nephrostomy dependent at 6 months. 1/16 remained dialysis dependent with a nephrostomy tube. For those procedures involving ureteric calculi, 6/7 were stone free and 1/5 had a persistent stone fragment requiring further intervention.

CONCLUSIONS

A combined approach may decrease the number of separate interventions required, with the aim of removing the need for a long-term nephrostomy, as well as providing opportunity to treat ureteric calculi in the context of stricture disease. Our experience has been that where the rendezvous has been required to treat strictures caused by malignant extrinsic compression, stenting has not been successful; this information is key to informed consent in a group of patients who may have a limited life expectancy.

Clinical management and research priorities for high-risk prostate cancer in the UK: Meeting report of a multidisciplinary panel in conjunction with the NCRI Prostate Cancer Clinical Studies Localised Subgroup

The management of high-risk prostate cancer has become increasingly sophisticated, with refinements in radical therapy and the inclusion of adjuvant local and systemic therapies. Despite this, high-risk prostate cancer continues to have significant treatment failure rates, with progression to metastasis, castrate resistance and ultimately disease-specific death. In an effort to discuss the challenges in this field, the UK National Clinical Research Institute’s Prostate Cancer Clinical Studies localised subgroup convened a multidisciplinary national meeting in the autumn of 2014. The remit of the meeting was to debate and reach a consensus on the key clinical and research challenges in high-risk prostate cancer and to identify themes that the UK would be best placed to pursue to help improve outcomes. This report presents the outcome of those discussions and the key recommendations for future research in this highly heterogeneous disease entity.

Using a sociological approach to answering questions about paramedic professionalism and identity

With evidence based practice now the norm, paramedics today can confidently and easily search for answers to clinical questions. For anyone seeking to better understand the non-clinical aspects of paramedic practice, however; looking to social theory can be a starting point. Understanding social theory gives paramedic researchers a lens through which to closely examine every day events and behaviours that affect paramedic practice within the context of society. Arguably, the move towards professionalisation  is one of the most significant events impacting paramedicine today. The process of professionalisation described by Wilensky (1964) is summarised by Williams et al. as involving five steps:Development of a full-time occupation and formation of occupational territory;Establishment of training schools or colleges; linkage to university education;Occupational promotion to national and international parties;Professional licensing and accreditation;Code of ethics is implemented.Australian paramedics have been moving through these steps with support for professional registration heightened in recent months. Alongside this professional evolution, the practitioner identity is gradually being challenged and reshaped, raising a number of important questions. Examples include, do paramedics feel that they are a discipline in transition? Do they see themselves as ‘more professional’ in the current climate? How do paramedics now see their role and how would they define themselves? A starting point to explore these and other non-clinical questions raised by professionalisation begins with appreciating how social theory can both inform the questions and guide the research to answer them. The purpose of this article is to explore how two prominent social theorists, Bourdieu and Goffman, can be used by paramedic researchers to explore inevitable questions related to professions and professional identity.  

Bridging the gap: Reflections on teaching interprofessional communication to undergraduate paramedic and nursing students

IntroductionThe literature emphasises the vital importance of interprofessional communication during clinical handover as being paramount to patient safety. At Charles Sturt University we explored how simulation can be employed in an interprofessional education (IPE) exercise exposing paramedic and nursing students to a high-pressure emergency department wherein they must engage in patient handover.MethodsOver a 4-day period in April 2012, 200 paramedic and nursing students participated in an intensive simulation exercise where they practised interprofessional communication. The project team subsequently debriefed all student and staff members to gain insight through the participants’ experiences.ResultsOur results demonstrated that students become more comfortable interacting and communicating with other team members during scenarios. In addition to experiencing first hand that IPE is an effective tool for developing communication skills, we determined that this could be successfully facilitated in a large-scale simulated IPE to help students develop a shared understanding between disciplines.ConclusionAcademics can work horizontally across disciplines to employ IPE in simulation as an educational tool to teach vital communication skills; and with paramedicine now being taught alongside nursing in tertiary centres, universities are well positioned to support collaborative interprofessional practice and communication.

Learning safe practice by improving care: student-led intervention on oxygen prescribing in a respiratory ward

BACKGROUND AND OBJECTIVE

The primary aim of this intervention was to improve oxygen prescribing in accordance with the 2008 British Thoracic Society guidelines for the prescription of emergency oxygen in adults.

METHODS

Eight final year medical students reviewed the drug charts of all patients admitted to the respiratory ward on a daily basis in order to collect data on five audit questions: (1) Has oxygen (O2) been prescribed? (2) Has an O2 target saturation level been indicated? (3) Has O2 been prescribed as an 'as required' (PRN) or 'continuous therapy'? (4) Has the prescription been signed? (5) Has O2 been signed for in every drug round since the original prescription? Following an initial audit cycle an educational poster was distributed to all clinical staff via email and hard copies of the poster were placed strategically throughout the ward before its effectiveness was measured.

RESULTS

During the pre-intervention phase, compliance with all five measures varied from 0 to 25%. There was an increase in the variation in compliance after the poster intervention to 14-44%; however, this masked better overall compliance with all five investigative questions with figures of 44%, 39% and 42% being recorded in three of the four post-intervention days. Overall there was increased compliance with four of the five audit questions. Indeed compliance with question 3 rose from 14% to 83%.

CONCLUSIONS

The poster intervention was marginally effective while also showing that students can improve prescribing in a clinical setting.

Standard- or high-dose oxytocin for nulliparous women with confirmed delay in labour: quantitative and qualitative results from a pilot randomised controlled trial

OBJECTIVE

Evidence suggests that a high dose of oxytocin for nulliparous women at 37-42 weeks of gestation with confirmed delay in labour increases spontaneous vaginal birth. We undertook a pilot study to test the feasibility of this treatment.

DESIGN

Pilot double-blind randomised controlled trial.

SETTING

Three teaching hospitals in the UK.

POPULATION

A total of 94 consenting nulliparous women at term with confirmed delay in labour were recruited, and 18 were interviewed.

METHODS

Women were assigned to either a standard (2 mU/min, increasing every 30 minutes to 32 mU/minute) or a high-dose regimen (4 mU/minute, increasing every 30 minutes to 64 mU/minutes) oxytocin by computer-generated randomisation. Simple descriptive statistics were used, as the sample size was insufficient to evaluate clinical outcomes. The constant comparative method was used to analyse the interviews.

MAIN OUTCOMES MEASURES

The main outcome measures: number of women eligible; maternal and neonatal birth; safety; maternal psychological outcomes and experiences; health-related quality of life outcomes using validated tools and data on health service resource use; incidence of suspected delay of labour (cervical dilatation of <2 cm after 4 hours, once labour is established); and incidence of confirmed delay of labour (progress of <1 cm on repeat vaginal examination after a period of 2 hours).

RESULTS

We successfully developed systems to recruit eligible women in labour and to collect data. Rates of spontaneous vaginal birth (10/47 versus 12/47, RR 1.2, 95% CI 0.6-2.5) and caesarean section (15/47 versus 17/47, RR 1.1, 95% CI 0.6-2.0) were increased, and rates of instrumental birth were reduced (21/47 versus 17/47, RR 0.8, 95% CI 0.5-1.3). No evidence of increased harm for either mother or baby was found. The incidences of suspected delay (14%) and confirmed delay (11%) in labour were less than anticipated. Of those who did not go on to have delayed labour confirmed, all except one woman gave birth vaginally.

CONCLUSIONS

A pilot trial assessing the efficacy of high-dose oxytocin was feasible, but uncertainty remains, highlighting the need for a large definitive trial. The implementation of national guidance of suspected and confirmed delay in labour is likely to reduce intervention.

Successful management of short gut due to vanishing gastroschisis - case report and review of the literature

Vanishing gastroschisis is a rare in utero complication of gastroschisis. It is associated with a high mortality. We present a case report of an infant with vanishing gastroschisis that was managed with a combination of reconstructive bowel surgery and hepatosparing parenteral nutrition. The technique is described and a review of the literature is provided.

Everolimus plus reduced-exposure CsA versus mycophenolic acid plus standard-exposure CsA in renal-transplant recipients

Everolimus allows calcineurin-inhibitor reduction without loss of efficacy and may improve renal-transplant outcomes. In a 24-month, open-label study, 833 de novo renal-transplant recipients were randomized to everolimus 1.5 or 3.0 mg/day (target troughs 3-8 and 6-12 ng/mL, respectively) with reduced-exposure CsA, or mycophenolic acid (MPA) 1.44 g/day plus standard-exposure CsA. Patients received basiliximab +/- corticosteroids. The primary endpoint was composite efficacy failure (treated biopsy-proven acute rejection, graft loss, death or loss to follow-up) and the main safety endpoint was renal function (estimated glomerular filtration rate [eGFR], by Modification of Diet in Renal Disease [MDRD]) at Month 12 (last-observation-carried-forward analyses). Month 12 efficacy failure rates were noninferior in the everolimus 1.5 mg (25.3%) and 3.0 mg (21.9%) versus MPA (24.2%) groups. Mean eGFR at Month 12 was noninferior in the everolimus groups versus the MPA group (54.6 and 51.3 vs 52.2 mL/min/1.73 m(2) in the everolimus 1.5 mg, 3.0 mg and MPA groups, respectively; 95% confidence intervals for everolimus 1.5 mg and 3.0 mg vs MPA: -1.7, 6.4 and -5.0, 3.2, respectively). The overall incidence of adverse events was comparable between groups. The use of everolimus with progressive reduction in CsA exposure, up to 60% at 1 year, resulted in similar efficacy and renal function compared with standard-exposure CsA plus MPA.

Comparison of mandibular motion in horses chewing hay and pellets

REASONS FOR PERFORMING STUDY

Previous studies have suggested that temporomandibular joint (TMJ) kinematics depend on the type of food being masticated, but accurate measurements of TMJ motion in horses chewing different feeds have not been published.

HYPOTHESIS

The temporomandibular joint has a larger range of motion when horses chew hay compared to pellets.

METHODS

An optical motion capture system was used to track skin markers on the skull and mandible of 7 horses as they chewed hay and pellets. A virtual marker was created on the midline between the mandibles at the level of the 4th premolar teeth to represent the overall motion of the mandible relative to the skull during the chewing cycle.

RESULTS

Frequency of the chewing cycles was lower for hay than for pellets. Excursions of the virtual mandibular marker were significantly larger in all 3 directions when chewing hay compared to pellets. The mean velocity of the virtual mandibular marker during the chewing cycle was the same when chewing the 2 feeds.

CONCLUSIONS

The range of mediolateral displacement of the mandible was sufficient to give full occlusal contact of the upper and lower dental arcades when chewing hay but not when chewing pellets.

POTENTIAL RELEVANCE

These findings support the suggestion that horses receiving a diet high in concentrate feeds may require more frequent dental prophylactic examinations and treatments to avoid the development of dental irregularities associated with smaller mandibular excursions during chewing.

A phase I study of imatinib mesylate and paclitaxel in patients with advanced (stage IIIC/IV) or recurrent uterine papillary serous carcinoma (UPSC)

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Background: Uterine serous carcinoma (USC) is a rare, aggressive uterine tumor biologically distinct from typical endometrial cancers. Imatinib mesylate (IM)-associated kinases (kit, abl, PDGFR-B) are overexpressed and activated in most tumors from patients (pts) with USC. Single agent paclitaxel (TAX) has a good response rate but short duration of response in pts with USC. The purpose of this study was to determine the maximum tolerated dose (MTD) and dose limiting toxicity (DLT) of escalated doses of IM with a fixed dose of TAX. Methods: Pts with newly diagnosed (stage IIIC/IV) or recurrent USC were eligible (pts were required to have tumors that expressed at least one of the IM-targeted kinases by immunohistochemistry). Measurable disease was not required. TAX was administered at 175 mg/m2 every three weeks. One dose reduction to 135 mg/m2 was allowed. IM was given daily (400 mg, 500 mg or 600 mg). A 3+3 design was implemented. Pts with measurable disease were treated until progression or treatment associated toxicity. Pts with no measurable disease were treated for six cycles. Results: 11 pts were enrolled. The median age was 62 years (47–79). A total of 50 cycles were administered. Three pts were treated at the first dose level (400 mg), 6 pts treated at the second dose level (500 mg), and 2 pts were treated at the highest dose level (600 mg). Three DLTs were observed (1 at 500 mg level and 2 at 600 mg level) including: rash, neutropenia, and fatigue. IM 500 mg daily and TAX 175 mg/m2 every three weeks was the MTD. There were 3 serious adverse events not related to treatment (infection, dyspnea, pain). Neutropenia was the most common grade 3 or 4 toxicity but only one patient required TAX dose reduction. 8 pts were evaluated for efficacy (2 with measurable disease, 6 with no measurable disease). 1 (of 2) pts with measurable disease had a partial response and was treated for 13 cycles. Of the 6 pts with no measurable disease, 2 recurred (5 and 10 months). The median disease free interval for the pts without recurrent disease was 22 months (6–30). Conclusion: Combination therapy of IM and TAX is well tolerated with minimal side effects in pts with advanced or recurrent USC. Initiation of the phase II component of this study is warranted to better evaluate efficacy.

No significant financial relationships to disclose.

A phase I trial of the proteosome inhibitor PS-341 in combination with carboplatin in platinum and taxane resistant ovarian cancer patinets

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Background. PS-341 (Millenium Pharmaceuticals, Inc.), a proteosome inhibitor, affects p53, NFκB, cell adhesion molecules, and sensitivity to cytotoxic agents to promote apoptosis and inhibit metastasis in cancer cells. PS-341 alone rarely causes myelosupression or renal toxicity, and therefore is an attractive agent to use in combination with cytotoxic chemotherapy. This phase I study evaluates the safety, dose-limiting toxicities (DLTs), and optimal dose of PS-341 when combined with carboplatin in ovarian cancer patients with recurrent, platinum- and taxane-resistant disease. Methods: After IRB approval, patients with recurrent ovarian cancer, platinum and taxane resistant (progression on platinum and/or taxane therapy or recurrence within 6 months of completing platinum and/or taxane therapy), measurable disease, and performance status 0–2 were eligible and enrolled after giving informed consent. As guided by toxicity and pharmacokinetic data from single-agent phase I trials, PS-341 was administered on days 1, 4, 8, and 11 by IV push every 28 days with carboplatin (AUC 5) on day 1. Four dose levels were evaluated: 0.8, 1.0, 1.3, and 1.5 mg/m2. Dose was escalated if 0 of 3 or 1 of 6 patients had a DLT. The MTD was defined as 2 or more patients out of 6 with a DLT. Results: 21 women (median age 63, range 43–83), were treated with carboplatin and PS-341 at 0.8mg/ m2 (n=6), 1.0 mg/m2 (n=3), 1.3 mg/m2 (n=6), or 1.5 mg/m2. (n=6). At each level, respectively, there were 1, 0, 1, and 3 DLT’s attributable to PS- 341; all were grade 3, consisting of fatigue (n=3), nausea/vomiting/dehydration (n=1), and anorexia/dehydration/syncope (n=1). There were no Grade 4 toxicities. Common grade 2 toxicities included fatigue (n=12), nausea (n=10), anorexia, anemia, and dyspnea (n=7 each). 18 patients evaluable for response had stable disease (SD) or progression of disease (PD): at 0.8 mg/m2, SD=2, PD=3; at 1.0 mg/m2, PD=3; at 1.3 mg/m2, SD=3, PD=3; at 1.5 mg/m2, SD=3, PD=1. Median duration of stable disease was 4 months (range 3–10). Conclusions: The recommended dose of PS-341 in combination is 1.3 mg/m2. Treatment was well-tolerated with reversible side effects and no grade 4 toxicities, and at the optimal dose, there was a 50% rate of stable disease.

No significant financial relationships to disclose.

Use of a virtual human performance laboratory to improve integration of mathematics and biology in sports science curricula in Sweden and the United States

New fields such as bioengineering are exploring the role of the physical sciences in traditional biological approaches to problems, with exciting results in device innovation, medicine, and research biology. The integration of mathematics, biomechanics, and material sciences into the undergraduate biology curriculum will better prepare students for these opportunities and enhance cooperation among faculty and students at the university level. We propose the study of sports science as the basis for introduction of this interdisciplinary program. This novel integrated approach will require a virtual human performance laboratory dual-hosted in Sweden and the United States. We have designed a course model that involves cooperative learning between students at Göteborg University and Stanford University, utilizes new technologies, encourages development of original research and will rely on frequent self-assessment and reflective learning. We will compare outcomes between this course and a more traditional didactic format as well as assess the effectiveness of multiple web-hosted virtual environments. We anticipate the grant will result in a network of original faculty and student research in exercise science and pedagogy as well as provide the opportunity for implementation of the model in more advance training levels and K-12 programs.

Financial analysis of potential donor management at a medicare-approved transplant hospital

The purpose of this study was to perform a financial analysis of severe brain injured (SBI) patient management to determine potential reimbursement versus net losses in relation to organ donation and transplantation at a transplant center. We undertook a retrospective analysis of financial records of medically suitable referrals to the organ procurement organization (OPO) from our institution for fiscal years 2002-2003. This included (1) hospital cost and reimbursement, (2) OPO reimbursement for actual donors, (3) financial returns on local transplant activity solely supported by local donor activity and (4) Medicare incentives for local organ donation. There were 48 potential and 18 organ donors for this period. The consent rate reduced from 50% to 25% if family was offered withdrawal of care. After reimbursements from OPO, Medicare incentives and kidney transplant activity solely supported by local organ donation were figured in, the total returns were 244% of total cost of SBI patient management. Aggressive proactive management of severely brain injured patients remains a good medical practice. For Medicare-approved transplant centers, there are additional financial incentives to aggressively treat these patients and pursue organ donation. Prematurely offering withdrawal of care negatively impacts on the organ donation process and hurts institutions financially.

Changes in GABA(B) receptor mRNA expression in the rodent basal ganglia and thalamus following lesion of the nigrostriatal pathway

Loss of striatal dopaminergic innervation in Parkinson's disease (PD) is accompanied by widespread alterations in GABAergic activity within the basal ganglia and thalamus. Accompanying changes in GABA(B) receptor binding have been noted in some basal ganglia regions in parkinsonian primates, suggesting that plasticity of this receptor may also occur in PD. However, the molecular mechanisms underlying the changes in receptor binding and the manner and extent to which different GABA(B) receptor mRNA subunits and splice-variants are affected remain unknown. This study used in situ hybridisation to examine the full profile of changes in expression of the known rat GABA(B) receptor genes and gene variants in the basal ganglia and thalamus of rats, brought about by degeneration of the nigrostriatal tract. All of the GABA(B) mRNA species examined showed unique expression patterns throughout the basal ganglia and thalamus. In addition, all exhibited a marked loss of expression (between 46 and 80%) in the substantia nigra pars compacta of animals bearing a complete 6-hydroxydopamine-induced lesion of the nigrostriatal tract, confirming the presence of these variants in dopaminergic neurones in this region. Further analysis of autoradioagrams revealed additional changes only in GABA(B(1a)) mRNA in discrete anatomical regions. Expression of the GABA(B(1a)) variant was significantly increased in the substantia nigra pars reticulata (33+/-2%), entopeduncular nucleus (26+/-1%) and the subthalamic nucleus (16+/-1%). Since these regions all receive reduced GABAergic innervation following nigrostriatal tract lesioning, it is possible that the increased expression occurs as a compensatory measure. In conclusion, these data demonstrate that GABA(B) receptor genes exhibit regional- and subunit/variant-specific plasticity at the molecular level under parkinsonian conditions.

Characterization of cationic amino acid transporters and expression of endothelial nitric oxide synthase in human placental microvascular endothelial cells

We investigated the expression and activity of arginine transporters and endothelial nitric oxide synthase (eNOS) in human placental microvascular endothelial cells (HPMEC). Using RT-PCR amplification products for eNOS, CAT1, CAT2A, CAT2B, CAT4, 4F2hc (CD98), rBAT and the light chains y+LAT1, y+LAT2, and b0+T1 were detected in HPMEC, but not B0+. Immunohistochemistry and Western blotting confirmed the presence of 4F2hc and CAT1 protein in HPMEC. 4F2hc-light chain dimers were indicated by a shift in molecular mass detected under nonreducing conditions. L-Arginine transport into HPMEC was independent of Na+ or Cl- and was inhibited by the neutral amino acid glutamine, but not by cystine. The Ki for glutamine inhibition was greater in the absence of Na+. Kinetic analysis supported a two-transporter model attributed to system y+L and system y+. Expression of eNOS in HPMEC was detectable by immunohistochemistry and ELISA but not by Western blotting. Activity of eNOS in HPMEC, measured over 48 h, either as the basal production of nitric oxide (NO) or as the accumulation of intracellular cGMP was not detectable. We conclude that HPMEC transport cationic amino acids by systems y+ and y+L and that basal eNOS expression and activity in these cells is low.

Multiple renal arteries do not pose an impediment to the routine use of laparoscopic donor nephrectomy

Since the first description by Ratner and collegues in 1996, laparoscopic live-donor nephrectomy is gaining wide acceptance in an attempt to minimize the donor morbidity, length of hospital stay and length of time to return to work. It is unknown whether multiple renal arteries pose additional problems with laparoscopic donor nephrectomy. In November 1998, our institution initiated laparoscopic donor nephrectomy program. In the ensuing 19 months, we performed 25 living donor renal transplants, 24 of them using laparoscopic donor nephrectomy. The left kidney was procured in all cases. Eight donor candidates (33%) had two or more renal arteries (two arteries in five patients and three patients).

RESULTS

In six cases (25%), findings at surgery differed from the CT angography results (in four cases, CT angiogram reported fewer arteries than were found at surgery and in two cases it reported more). We found no significant differences in both donor outcomes and recipient, based on the presence or absence of multiple renal arteries. Among donor outcomes, we found equivalent results for donor warm ischemia time total donor operating time, and donor length of stay. For recipient outcomes, we found no significant differences between groups for the incidence of acute tubular necrosis (ATN), graft survival and most recent serum creatinine. In one case, we constructed two arteries into a single conduit on the backtable prior to transplantation. However, in most cases with multiple arteries, we implanted the arteries separately into the recipient external iliac artery. Based on this experience, we do not find the presence of multiple renal arteries to be a barrier to the successful use of kidney grafts procured by laparoscopic donor nephrectomy.

Nouns and verbs in Australian sign language: an open and shut case?

Results of the noun-verb pair comprehension and production tests from the Test Battery for Auslan Morphology and Syntax (Schembri et al., 2000) are re-presented, re-analyzed, and compared to data from two other cases also dealing with noun-verb pairs: the Auslan lexical database and a comparison of Auslan and American Sign Language (ASL) signs. The data elicited through the test battery and presented in this article confirm the existence of formationally related noun-verb pairs in Auslan in which the verb displays a single movement and the noun displays a repeated movement. The data also suggest that the best exemplars of noun-verb pairs of this type in Auslan form a distinct set of iconic (mimetic) signs archetypically based on inherently reversible actions (such as opening and shutting). This strong iconic link perhaps explains why the derivational process appears to be of limited productivity, though it does appear to have "spread" to a number of signs that appear to have no such iconicity. There appears to be considerable variability in the use of the derivational markings, particularly in connected discourse, even for signs of the "open and shut" variety. Overall, the derivational process is apparently still closely linked to an iconic base, is incipient in the grammar of Auslan, and is thus best described as only partially grammaticalized.

Innovative programs for children and adolescents with spinal cord injury

A few innovative programs have enabled children with SCI to surpass traditional levels of independence defined solely on preservation of motor function. Implementation of unique upper extremity and bladder surgical programs has provided children with tetraplegia the ability to manipulate objects without equipment and to independently empty their bladder, respectively. Innovative surgical programs have also restored privacy, dignity, and spontaneity. These are important gains previously unachievable by young persons with tetraplegia. Functional electrical stimulation has advanced children's abilities in upright mobility and has made significant impact on their quality of life by restoring hand and bladder capacities. Nurses play a leadership role in the delivery and integration of these dynamic programs.

Climate change and the adaptability of agriculture: a review

The assessment of climate change impacts on agriculture has emerged as a recognizable field of research over the past 15 years or so. In a relatively short period, this area of work has undergone a number of important conceptual and methodological developments. Among many questions that have been debated are the adaptability of agriculture to climate change and the importance of land management adjustments in reducing the adverse effects of climate change. In turn, this latter focus has spawned a discussion regarding the nature of adaptation and the ability of agriculture to respond to sudden and rapid climatic changes. In this paper we present an overview of this debate. It is argued that the first generation of climate change impact studies generally ignored the possibility that agriculturalists may adjust their farming practices in order to cope with climate change or to take advantage of new production opportunities. This conceptual oversight has been largely eliminated over the past five years or so. However, questions remain surrounding the likelihood that various adaptive strategies will actually be deployed in particular places. In this paper, we stress the importance of studying adaptation in the context of decision-making at the individual farm level and beyond.

Taxometric analysis of impression management and self-deception on the MMPI-2 in child-custody litigants

The typology of impression management (IM), a deliberate attempt to create a positive social image, and self-deceptive positivity (SDP), an unintentional concealment of symptoms, were examined using taxometric procedures with MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) underreporting scales in several custody-litigant samples. IM was identified as a taxon using several procedures and estimates of the base rate that were consistent (.40, .37, .31, .36, .37). SDP was better characterized as a dimensional construct. Means and estimated validities for MMPI-2 underreporting scales in this sample are reported. IM and SDP appear to be distinct and measurable underreporting constructs on the MMPI-2.

High performance laser diode bars with aluminum-free active regions

We present operating and lifetest data on 795 and 808 nm bars with aluminum-free active regions. Conductively cooled bars operate reliably at CW power outputs of 40 W, and have high efficiency, low beam divergence, and narrow spectra. Record CW powers of 115 W CW are demonstrated at 795 nm for 30% fill-factor bars mounted on microchannel coolers. We also review QCW performance and lifetime for higher fill-factor bars processed on identical epitaxial material.

In vivo assessment of failed trophoblastic invasion of the spiral arteries in pre-eclampsia

OBJECTIVE

To assess the ability of colour/pulsed Doppler ultrasound to detect failed physiologic change of the spiral arteries in pregnancies complicated by pre-eclampsia.

DESIGN

Prospective matched-pairs case controlled study.

SETTING

Tertiary referral teaching hospital.

SAMPLE

Sixteen women with severe pre-eclampsia and 16 normotensive controls.

METHODS

Colour/pulsed Doppler assessment of blood flow in the uterine arteries and spiral arteries in central and peripheral parts of the placental bed.

MAIN OUTCOME MEASURES

Impedance to blood flow in the spiral arteries in pre-eclamptic group compared with normotensive controls.

RESULTS

In women with pre-eclampsia there is significantly higher impedance to blood flow in spiral arteries compared with normotensive women.

CONCLUSIONS

Ultrasound colour/pulsed Doppler based investigation of blood flow in the spiral arteries in ongoing pregnancy can detect failed physiological change of these vessels in pre-eclampsia. This is in concordance with histologic data.

Expect the worse or hope for the best? Prenatal diagnosis of geleophysic dysplasia

Geleophysic dysplasia is a rare, autosomal recessive disorder which causes disproportionate short stature associated with severe physical handicaps, but is compatible with survival into adulthood. We present a case, a first-born child, where genetic counselling difficulties arose following ultrasound recognition of short-limbed dwarfism in association with polyhydramnios and an initial incorrect prenatal diagnosis of lethal chondrodysplasia. After birth of the surviving affected infant, the parents had great difficulty accepting that there had been a prenatal misdiagnosis and they were greatly disappointed by our inability to predict the postnatal survival of an infant to whom no hope of life had previously been given. The correct diagnosis was not made until the proband was nearly 1 year old, and the true prognosis then became clearer. This experience underlines the relative ease of prenatal recognition of skeletal growth abnormalities compared with the considerable difficulties experienced in reaching a precise diagnosis. Thus, following prenatal diagnosis of unspecified chondrodysplasia when parents seek definite information about the prognosis, the temptation to be either overpessimistic or overoptimistic should be avoided.