Systematic review of topical interventions for the management of pain in chronic wounds

Chronic wounds adversely affect quality of life. Pain is associated with chronic wounds, and its impact can vary according to wound aetiology, condition, and patient factors. This systematic review examined the effectiveness of topical interventions in the management chronic wound-related pain guided by PRISMA recommendations of randomised controlled trials (RCTs) where pain reduction is the primary outcome. Inclusion criteria were adults (older than 18 years) with chronic venous, arterial, diabetic, or pressure ulcers where pain has been managed through topical administration of pharmacological/nonpharmacological agents. Searches were conducted in Ovid Embase, Ovid MEDLINE, EBSCOhost, CINAHL, CENTRAL, PubMed, Web of Science, and Scopus. Studies were screened for eligibility; risk of bias and data were extracted by 2 independent assessors. Searches retrieved 10,327 titles and abstracts (7760 after deduplication). Nine full texts (1323 participants) examining ibuprofen (n = 4), morphine (n = 2), BWD + PHMB [polihexanide-containing biocellulose wound dressing] (n = 1), and EMLA (n = 2) were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Meta-analysis was not possible, but initial exploration suggests improved outcomes (reduced pain) for ibuprofen when compared with controls. Two studies involving morphine showed conflicting findings. Included studies often had small samples, and considering confounding factors (eg, comorbidities), the results should be interpreted with caution. Review of included studies suggests that topical interventions may provide pain relief in individuals with chronic wounds. Further adequately powered RCTs are recommended to assess the efficacy of topical interventions for the management of chronic wound-related pain.

Emergency uncross-matched blood transfusions in a tertiary neonatal unit

AIM

To determine the neonatal incidence, indications and outcomes following transfusions with emergency uncross-matched O-negative blood.

METHODS

A five-year retrospective review in a single tertiary neonatal unit was conducted. The blood transfusion laboratory's database was analysed for all infants who had received an emergency released blood transfusion (ERBT) between January 2010 and December 2014.

RESULTS

We calculated a total ERBT rate of 0.91 per 1000 live births (39/42 657) and a rate of 0.43 per 1000 in infants >34 weeks' gestation (18/41 637). A rate of 0.14 per 1000 births (6/42 657) received an ERBT as part of newborn stabilisation despite almost half of our infant cohort having intrapartum haemorrhages (n = 18, 46%). One-third (13/39) of all infants who were transfused died. Outcome varied depending on underlying aetiology, gestation and birthweight. The highest mortality was in preterm infants weighing <1000 g, of whom 70% died.

CONCLUSION

This study establishes an ERBT rate of <1 per 1000 births, and 0.14 per 1000 infants received an ERBT as part of newborn delivery room stabilisation. ERBTs are associated with a high mortality rate. This study highlights the need for further research and guidelines that clarify the role of ERBTs in newborn stabilisations.

Development and Implementation of a Collaborative Team Care Model for Effective Insulin Use in an Academic Medical Center Primary Care Network

Improving glycemic control across a primary care diabetes population is challenging. This article describes the development, implementation, and outcomes of the Diabetes Care Collaborative Model (DCCM), a collaborative team care process focused on promoting effective insulin use targeting patients with hyperglycemia in a patient-centered medical home model. After a pilot, the DCCM was implemented in 18 primary care practices affiliated with an academic medical center. Its implementation was associated with improvements in glycemic control and increase in insulin prescription longitudinally and across the entire population, with a >1% reduction in the proportion of glycated hemoglobin >9% at 2 years after the implementation compared with the 2 years prior ( P < .001). Facilitating factors included diverse stakeholder engagement, institutional alignment of priorities, awarding various types of credits for participation and implementation to providers, and a strong theoretical foundation using the principles of the collaborative care model.

Environmental tobacco smoke in the nonsmoking section of a restaurant: a case study

This study tested the concentrations of environmental tobacco smoke (ETS) components in a small restaurant/pub with smoking and nonsmoking areas-a facility outfitted with a heat-recovery ventilation system and directional airflow. The ETS levels in the nonsmoking area were compared with those in other similar restaurants/pubs where indoor smoking is altogether prohibited. The results indicate that ETS component concentrations in the nonsmoking section of the facility in question were not statistically different (P < 0.05) from those measured in similar facilities where smoking is prohibited. The regulatory implications of these findings are that ventilation techniques for restaurants/pubs with separate smoking and nonsmoking areas are capable of achieving nonsmoking area ETS concentrations that are comparable to those of similar facilities that prohibit smoking outright.

Contingent reinforcement or defending the self? A review of evolving models of aggression in people with mild learning disabilities

This paper examines the changing approaches to working with people with a moderate to mild learning disability, who are frequently aggressive. Long-held assumptions about the lack of inter-personal understanding and impulsiveness continue to play a central role in clinical assessment and intervention for this group. Yet, there is a lack of controlled studies indicating the influence of such factors in frequent aggression. The dominant behavioural tradition has long encouraged such assumptions, but has focused on people with more severe disabilities where such assumptions are arguably more appropriate. The current review of the literature shows a clear evolution away from a strict behavioural approach towards cognitive-behavioural therapy (CBT) approaches that take account of the heterogeneous psychosocial causes of aggression. We find support for CBT in the child-development literature, which examines inter-personal difficulties from an information-processing perspective. Finally, we argue that much of the literature implicitly utilizes the concept of self, and we suggest that this should be made explicit in a reformulated theory of the 'person', incorporating the self concept and embedding individual cognitive processes and behaviour in a social context.

Sampling artifacts from the use of denuder tubes with glycerol based coatings in the measurement of atmospheric particulate matter

Chemical speciation studies use sampling configurations that often require the deployment of denuder tubes of various types to measure certain species or control particulate sampling artifacts. Concurrent sets of measurements on Teflon membrane and quartz filters in specific sampling configurations were used to evaluate the potential influence of denuder tubes with glycerol-based coatings on particulate mass and carbon measurements on downstream filters. Positive biases were observed in the measurement of gravimetric mass and carbon on Teflon and quartz filters, respectively, downstream of sodium carbonate/ glycerol and citric acid/glycerol coated denuder tubes relative to those without upstream denuder tubes. The magnitude of the bias is dependent on the level of ambient particulate loading.

Windblown dust contributes to high PM2.5 concentrations

The revised National Ambient Air Quality Standards for PM include fine particulate standards based upon mass measurements of PM2.5. It is possible in arid and semi-arid regions to observe significant coarse mode intrusion in the PM2.5 measurement. In this work, continuous PM10, PM2.5, and PM1.0 were measured during several windblown dust events in Spokane, WA. PM2.5 constituted approximately 30% of the PM10 during the dust event days, compared with approximately 48% on the non-dusty days preceding the dust events. Both PM10 and PM2.5 were enhanced during the dust events. However, PM1.0 was not enhanced during dust storms that originated within the state of Washington. During a dust storm that originated in Asia and impacted Spokane, PM1.0 was also enhanced, although the Asian dust reached Washington during a period of stagnation and poor dispersion, so that local sources were also contributing to high particulate levels. The "intermodal" region of PM, defined as particles ranging in aerodynamic size from 1.0 to 2.5 microns, was found to represent a significant fraction of PM2.5 (approximately 51%) during windblown dust events, compared with 28% during the non-dusty days before the dust events.

Asthma aggravation, combustion, and stagnant air

BACKGROUND

The relationship between current concentrations of ambient air pollution and adverse health effects is controversial. We report a meteorological index of air stagnation that is associated with daily visits to the emergency department for asthma in two urban areas.

METHODS

Data on daily values of a stagnation persistence index and visits to the emergency department for asthma were collected for approximately two years in Spokane, Washington, USA and for 15 months in Seattle, Washington, USA. The stagnation persistence index represents the number of hours during the 24 hour day when surface wind speeds are less than the annual hourly median value, an index readily available for most urban areas. Associations between the daily stagnation persistence index and daily emergency department visits for asthma were tested using a generalised additive Poisson regression model. A factor analysis of particulate matter (PM(2.5)) composition was performed to identify the pollutants associated with increased asthma visits.

RESULTS

The relative rate of the association between a visit to the emergency department for asthma and the stagnation persistence index was 1. 12 (95% CI 1.05 to 1.19) in Spokane and 1.21 (95% CI 1.09 to 1.35) in Seattle for an increase of 11 and 10 hours, respectively, of low wind speed in a given day. The stagnation persistence index was only correlated with one set of factor loadings; that cluster included the stagnation persistence index, carbon monoxide, and organic/elemental carbon.

CONCLUSION

Increased air stagnation was shown to be a surrogate for accumulation of the products of incomplete combustion, including carbon monoxide and fine particulate levels of organic and elemental carbon, and was more strongly associated with asthma aggravation than any one of the measured pollutants.

Churg-Strauss syndrome in patients receiving montelukast as treatment for asthma

STUDY OBJECTIVES

We previously reported eight patients who developed Churg-Strauss syndrome in association with zafirlukast treatment for asthma and postulated that the syndrome resulted from unmasking of a previously existing condition due to corticosteroid withdrawal and not from a direct drug effect. The availability of montelukast, a new leukotriene receptor antagonist with a different molecular structure, permitted us to test this hypothesis. Our goals were to ascertain whether the Churg-Strauss syndrome developed in patients taking montelukast and other novel asthma medications, and to describe potential mechanisms for the syndrome.

DESIGN

Case series.

SETTING

Outpatient and hospital practices of pulmonologists in the United States and Belgium.

PATIENTS

Four adults (one man, three women) who received montelukast as treatment for asthma; two women who received salmeterol/fluticasone therapy, but not montelukast.

RESULTS

Churg-Strauss syndrome developed in the four asthmatic patients who received montelukast. In each case, there was a long history of difficult-to-control asthma characterized by multiple exacerbations that had required frequent courses of oral systemic corticosteroids or high doses of inhaled corticosteroids for control. Two other asthmatics who received fluticasone and salmeterol but not montelukast therapy developed the same syndrome with tapering doses of oral or high doses of inhaled corticosteroids.

CONCLUSIONS

The occurrence of Churg-Strauss syndrome in asthmatic patients receiving leukotriene modifiers appears to be related to unmasking of an underlying vasculitic syndrome that is initially clinically recognized as moderate to severe asthma and treated with corticosteroids. Montelukast does not appear to directly cause the syndrome in these patients.

An immunohistochemical and in situ hybridisation study of the postnatal development of uncoupling protein-1 and uncoupling protein-1 mRNA in lamb perirenal adipose tissue

In the lamb, the uncoupling protein-1 (UCP1) content of perirenal adipose tissue at birth is an important factor in heat production by non-shivering thermogenesis and the prevention of hypothermia. This study examines UCP1 gene expression and protein content in perirenal adipose tissue over the first 15 days of life by in situ hybridisation and immunohistochemistry. UCP1 mRNA was detected at birth in 30% of adipocytes, and in approximately 24% of fat cells at 2 days of life. However, by 5 days of age and thereafter UCP1 mRNA was undetectable. Immunoreactive UCP1 was present in all adipocytes at birth and at 2 days of age, and remained detectable in a decreasing proportion of cells until day 10 of life. By 15 days of age no immunoreactive UCP1 was detected and the perirenal adipose tissue had the appearance of white fat. It is concluded that UCP1 gene expression is suppressed in most adipocytes in perirenal adipose tissue of newborn lambs, and gene expression rapidly falls in the remaining adipocytes over the first 5 days of postnatal life. In contrast, immunoreactive UCP1, a characteristic of brown adipose tissue, was present in many adipocytes for up to 10 days of age, suggesting that UCP1 has a long half-life in lambs. All adipocytes in perirenal adipose tissue of newborn lambs appear to be functionally brown, but over the first 2 weeks of postnatal life there is a complete transformation to white adipocytes.

Acute 3,4-methylenedioxymethamphetamine(MDMA) administration produces a rapid and sustained suppression of immune function in the rat

(+)-3,4-Methylenedioxymethamphetamine (MDMA;'Ecstasy') is a ring substituted phenylisopropylamine that is structurally related to both amphetamines and hallucinogens. The unique behavioural activating properties of MDMA have led to its widespread abuse. MDMA induces many neurochemical, behavioural and endocrine alterations which closely resemble those elicited by exposure to acute stress, suggesting that MDMA could be regarded as a 'chemical stressor'. In addition to the neurochemical, behavioural and endocrine effects of stressor exposure, it has been reported that stress produces alterations in immune function. However, to date the effects of MDMA on immune function have been restricted to in vitro investigations. In this study we report, for the first time, that acute in vivo administration of MDMA (20 mg/kg, i.p.) produced a rapid (within 30 min) suppression of Con A-induced lymphocyte proliferation and a profound reduction in the total leucocyte count in rats that persisted for at least 6 h following injection. These alterations in immune function were accompanied by a significant increase in plasma corticosterone concentrations 30 min post MDMA administration which had returned to baseline values within 6 h of drug administration. In addition, there was a significant depletion in cortical 5-HT concentrations both 30 min and 6 h after MDMA administration. The results of this study provide evidence that in addition to the well established toxic effects of MDMA on the central serotonergic system, a single administration of this widely abused drug induces a rapid and sustained suppression of immune function.

The hospital cost and the cost of the implant for total knee arthroplasty. A comparison between 1983 and 1991 for one hospital

The hospital cost of total knee arthroplasty at the Lahey Clinic was evaluated by a comparison of the data for twenty-eight patients who had had the operation in 1983 with the data for forty-two patients who had had the same operation in 1991. The hospital bills were analyzed for each patient. Each hospital charge was converted to cost with the use of government-mandated hospital-specific cost-to-charge ratios. The average actual hospital cost for total knee arthroplasty increased 17 per cent, from $10,122 in 1983 to $11,826 in 1991. However, in inflation-adjusted dollars, the hospital cost for total knee arthroplasty decreased 15 per cent during this period. When the costs for total knee arthroplasty in 1983 and 1991 were allocated to various service centers in the hospital, the cost for a hospital room was found to have decreased from 47 per cent of the hospital cost in 1983 to 31 per cent of that in 1991. The cost of a hospital room decreased 23 per cent in actual dollars and 46 per cent in inflation-adjusted dollars during this period. In sharp contrast, the cost of a knee implant increased from 13 per cent of the hospital cost for total knee arthroplasty in 1983 to 25 per cent of that in 1991. The average cost of the prosthesis increased from $1359 in 1983 to $2960 in 1991. This represents a 118 per cent increase in actual dollars. The inflation-adjusted increase in the cost of the implant was 59 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of the enantiomers of cis-N-[2-(3,4-dichlorophenyl)ethyl]-N-methyl-2-(1- pyrrolidinyl)cyclohexylamine (BD737 and BD738): novel compounds with high affinity, selectivity and biological efficacy at sigma receptors

A novel class of compounds with very high affinity and selectivity for sigma receptors has been discovered. BD614 [(+/-)-cis-N-[2-(3,4-dichlorophenyl)ethyl]-N-methyl-2-(1- pyrrolidinyl)cyclohexylamine] and its optically pure 1S,2R-(-)-[BD737] and 1R,2S-(+)-[BD738]enantiomers bound to sigma receptors of guinea pig brain with Ki = 2.0 +/- 0.4, 1.3 +/- 0.3 and 6 +/- 3 nM, respectively. These compounds exhibited little or no affinity for dopamine-D2, kappa opiate or phencyclidine receptors and displayed high biological efficacy in assays of sigma receptor function, ability to produce alterations in motor behavior and inhibition of the muscarinic cholinergic phosphoinositide response. Microinjection of BD614 into the rat red nucleus or substantia nigra produced a dose-dependent alteration in head position and contralateral circling, respectively. BD614, BD737 and BD738 inhibited stimulation of inositol phosphate production by carbachol or oxotremorine-M in a dose-dependent manner. Thus, N-substituted cis-2-(1-pyrrolidinyl)cyclohexylamines may prove useful in studies of sigma receptor structure and function.

A technique for routine calibration of thermoluminescent dosimeters in the diagnostic energy range

Four different techniques for calibrating lithium fluoride thermoluminescent dosimeters were compared at two beam qualities in the diagnostic energy range. The techniques included in-air, saturation backscatter, and Bureau of Radiological Health (BRH) test stand geometry with and without an ionization chamber. The results indicate that there are no statistical differences between any of the calibration techniques evaluated. Hence, the technique using the BRH test stand with an ionization chamber is a simple and reproducible calibration procedure which may be used in a routine diagnostic radiology quality assurance program.

Fluid bridge test in the evaluation of male urinary continence

Graphic documentation of the competence (or incompetence) of the sphincteric regions was attempted in 25 male subjects using the fluid bridge test. The objective of the test was to recognize urodynamically the urinary fluid bolus that escapes through an incompetent outlet and tends to act as a fluid bridge between the bladder and a urethral test point distal to the sphincteric region. Our studies indicate that the fluid bridge test can be included in the urodynamic armamentarium for recognizing the integrity of the proximal and the distal sphincteric regions of the male patient. We herein describe the technique and pitfalls of the interpretation.

An evaluation of two antigen nonspecific assays for circulating immune complexes using a model system

Two methods of detecting circulating immune complexes (CIC) in serum, the Protein A-glass fiber filter assay (PA-GFF) and the polyethylene glycol (PEG) insolubilization assay, were compared using a model system of BSA/anti-BSA. Supernatants of the quantitative precipitin curve from extreme antigen excess through antibody excess were tested by both methods. The PEG assay detected soluble CIC in all areas where expected by comparison with the Farr Test; the filter assay did not, although it did detect aggregated globulins quantitatively. The PEG assay detected high levels of CIC in serum of rheumatoid arthritis patients and low levels in normal human serum. Postprandial samples and plasma with heparin or EDTA caused unpredictable increases in results in the PEG assay so that for best results the PEG assay should be run on serum from fasting individuals. PEG insolubilized complexes were analyzed and found to contain expected serum components. A slight modification of the original method was made and tested using two other model complex systems and known CIC-containing sera. The PEG turbidity assay it fast, easy, reproducible, and suitable for quantitating and isolating immune complexes in serum.

Palmar primary hyperhidrosis in children

Palmar Primary Hyperhidrosis, though an uncommon problem in the paediatric age group, is an unpleasant and socially disabling one for the affected child. Although the condition occurring in adults has been extensively documented, little, if any, attention has been given to the problem in children. We describe the clinical presentation of four such patients who presented in our unit over the past 4 yr. All had an upper dorsal sympathectomy performed with excellent results.

Morbidity and mortality after surgery in patients with disseminated or locally advanced cancer receiving systemic chemotherapy

All postoperative complications and mortality were analyzed in a diverse group of patients operated upon by the authors during a ten-year period. These patients shared only two common factors: 1) known locally advanced or disseminated cancer, and 2) systemic chemotherapy within three weeks (either pre- or postoperatively) of major surgery. One hundred eighty-six operations were performed on 175 patients. The overall mortality in this series was 2.2% (four patients), with a complication rate of 5.9% (11 patients). Despite the known detrimental effects of widespread cancer and cytotoxic agents on wound healing, appropriate surgical intervention can be accomplished with an acceptable mortality and morbidity in patients with locally advanced or disseminated cancer who are receiving systemic chemotherapy.

Circulating immune complexes in patients following clinically curative resection of colorectal cancer

Sixty-nine patients have been followed prospectively after curative resection of Dukes-Kirklin B-2 or C colorectal cancer. Serial plasma samples were studied in selected patients to determine changes in circulating immune complex concentrations (CIC) following primary tumor resection, and to compare serial plasma CIC and carcinoembryonic antigen (CEA) levels. CIC was determined in an average of seven serial samples per patient by inhibition of antibody-dependent cell-mediated cytotoxicity (ADCC). CEA assays were performed by the Hanson Z-gel method. Two distinct patterns of serial CIC have emerged. In seven patients with no known tumor recurrences, serial CEA levels and CIC oscillated regularly and were inversely related. In seven of eight patients whose tumors recurred, both CEA and CIC rose together. In three patients with elevated plasma CEA levels due to inflammatory bowel disease, serial Ag-Ab complex concentrations did not vary, nor did separated Ag or Ab fractions inhibit ADCC. These data suggest that, in patients following curative resection of colorectal cancer, serial changes in circulating immune complexes may discriminate between transient CEA elevations which occur despite no known tumor recurrence and tumor recurrence which is beyond the capacity of adequate host antitumor defense.

GaAs optical waveguide structures at 10.6-microm wavelength

A comparison of GaAs/n(+)GaAs, GaAs/GaAsP, and GaAs/AlGaAs waveguide structures is presented. Their fabrication processes and their transmission properties at 10.6-microm wavelength are described. The loss due to the free carrier absorption of the substrate is analyzed. Experimentally, an attenuation rate of 2 dB/cm in a single mode (~7 microm) GaAs/GaAsp waveguide with a maximum dimension of the order of 7 cm has been achieved.