Neuroinvasive West Nile Virus Infection in Immunosuppressed and Immunocompetent Adults

Importance

West Nile virus (WNV) is the leading cause of human arboviral disease in the US, peaking during summer. The incidence of WNV, including its neuroinvasive form (NWNV), is increasing, largely due to the expanding distribution of its vector, the Culex mosquito, and climatic changes causing heavy monsoon rains. However, the distinct characteristics and outcomes of NWNV in individuals who are immunosuppressed (IS) and individuals who are not IS remain underexplored.

Objective

To describe and compare clinical and radiographic features, treatment responses, and outcomes of NWNV infection in individuals who are IS and those who are not IS.

Design, Setting, and Participants

This retrospective cohort study used data from the Mayo Clinic Hospital system collected from July 2006 to December 2021. Participants were adult patients (age ≥18 years) with established diagnosis of NWNV infection. Data were analyzed from May 12, 2020, to July 20, 2023.

Exposure

Immunosuppresion.

Main Outcomes and Measures

Outcomes of interest were clinical and radiographic features and 90-day mortality among patients with and without IS.

Results

Of 115 participants with NWNV infection (mean [SD] age, 64 [16] years; 75 [66%] male) enrolled, 72 (63%) were not IS and 43 (37%) were IS. Neurologic manifestations were meningoencephalitis (98 patients [85%]), encephalitis (10 patients [9%]), and myeloradiculitis (7 patients [6%]). Patients without IS, compared with those with IS, more frequently reported headache (45 patients [63%] vs 18 patients [42%]) and myalgias (32 patients [44%] vs 9 patients [21%]). In contrast, patients with IS, compared with those without, had higher rates of altered mental status (33 patients [77%] vs 41 patients [57%]) and myoclonus (8 patients [19%] vs 8 patients [4%]). Magnetic resonance imaging revealed more frequent thalamic T2 fluid-attenuated inversion recovery hyperintensities in individuals with IS than those without (4 patients [11%] vs 0 patients). Individuals with IS had more severe disease requiring higher rates of intensive care unit admission (26 patients [61%] vs 24 patients [33%]) and mechanical ventilation (24 patients [56%] vs 22 patients [31%]). The 90-day all-cause mortality rate was higher in the patients with IS compared with patients without IS (12 patients [28%] vs 5 patients [7%]), and this difference in mortality persisted after adjusting for Glasgow Coma Scale score (adjusted hazard ratio, 2.22; 95% CI, 1.07-4.27; P = .03). Individuals with IS were more likely to receive intravenous immunoglobulin than individuals without IS (12 individuals [17%] vs 24 individuals [56%]), but its use was not associated with survival (hazard ratio, 1.24; 95% CI, 0.50-3.09; P = .64).

Conclusions and Relevance

In this cohort study of individuals with NWNV infection, individuals with IS had a higher risk of disease complications and poor outcomes than individuals without IS, highlighting the need for innovative and effective therapies to improve outcomes in this high-risk population.

Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert

The cornerstone of every health care profession is decision making. Historically, the decisions made by pharmacists have focused on ensuring the accuracy and physical integrity of the pharmaceutical product delivered to the patient in strict compliance with the prescriber's order. As the role of the pharmacist evolved over the past half century, the focus of decision making progressively shifted from a product-centric orientation to optimizing the interaction that occurs between the pharmaceutical product and the patient. Toward that end, prospective drug utilization review (pro-DUR) represents, perhaps, the quintessential expression of the pharmacist's contemporary clinical role. Fueled by evolving practice standards, innovations in information technology, and legal mandates such as The Omnibus Budget Reconciliation Act of 1990, computer-assisted pro-DUR systems have become a ubiquitous component of pharmacy practice. While these data-driven clinical decision support systems have clearly demonstrated their ability to improve the quality and safety of medication delivery and use, they have yet to fully achieve their promised potential. Doing so will require recognition of continuing shortcomings and a shared commitment by all stakeholders to develop and adhere to best practice guidelines that will better ensure that alerts received by practitioners are valid, interpretable, clinically significant, and actionable.

DISCLOSURES

The authors received no funding for this article. Rupp discloses consultancy fees from Surescripts unrelated to this manuscript. Both authors contributed equally to concept, analysis, and manuscript preparation.

Effect of castration timing and oral meloxicam administration on growth performance, inflammation, behavior, and carcass quality of beef calves

Beef bull calves (n = 62) were assigned randomly, within sire breed, to 1 of 4 treatments at birth. Treatments were 1) surgical castration near birth, 2) surgical castration near birth with oral administration of meloxicam (1 mg/kg BW), 3) surgical castration at weaning (WNG), or 4) surgical castration at weaning with oral administration of meloxicam (1 mg/kg BW; WMX). A subset of calves (n = 7/treatment group) were selected randomly near birth for blood collection, behavioral analyses, and rectal temperature (RT) records for a 7-d postcastration period on d 0 (birth), 1, 3, and 7, and on d 214 (weaning), 214 + 6 h, 215, 217, 221, and 228. Calf standing and lying activity were monitored from the same subsets by recording x- and y-axis positions of an accelerometer attached to the right metatarsus for 7 d postcastration. Calf BW was recorded throughout the entire production cycle, and carcass data were collected at slaughter. For statistical analyses, bulls left intact at birth were considered a positive control (BUL) for observations that occurred before their treatment application at weaning; likewise, bulls castrated at birth were considered a negative control (STR) during postweaning observations. No difference (P > 0.88) occurred in ADG between treatments throughout the preweaning period (d 0 to 214); however, 56-d postweaning ADG was greatest ( P= 0.02) in STR, intermediate in WMX, and least in WNG. At weaning, haptoglobin (Hp) was greater (P ≤ 0.005) for WNG and WMX compared to STR on d 214+6 h, 215, and 217, and Hp was greater (P = 0.05) in WNG compared to WMX on d 217. Neutrophils increased (P < 0.001) and red blood cells decreased (P ≤ 0.03) for WNG and WMX on d 214+6 h and 217, respectively. Postweaning behavior observations indicated that STR calves spent the least proportion of time standing (P = 0.002) when compared to WNG and WMX. Furthermore, WMX calves exhibited a greater proportion of time spent standing (P = 0.03) compared to WNG. Grazing and finishing phase ADG and carcass measurements did not differ (P ≥ 0.24) across treatments. In this study, surgical castration at weaning, but not near birth, altered the acute phase response, behavior, and growth performance. Oral meloxicam reduced serum Hp and improved ADG briefly when administered to calves castrated at weaning. Oral administration of meloxicam may be efficacious for mitigating some of the stress and inflammation associated with castration of weaning-age bull calves.

Galectin-1 suppresses methamphetamine induced neuroinflammation in human brain microvascular endothelial cells: Neuroprotective role in maintaining blood brain barrier integrity

Methamphetamine (Meth) abuse can lead to the breakdown of the blood-brain barrier (BBB) integrity leading to compromised CNS function. The role of Galectins in the angiogenesis process in tumor-associated endothelial cells (EC) is well established; however no data are available on the expression of Galectins in normal human brain microvascular endothelial cells and their potential role in maintaining BBB integrity. We evaluated the basal gene/protein expression levels of Galectin-1, -3 and -9 in normal primary human brain microvascular endothelial cells (BMVEC) that constitute the BBB and examined whether Meth altered Galectin expression in these cells, and if Galectin-1 treatment impacted the integrity of an in-vitro BBB. Our results showed that BMVEC expressed significantly higher levels of Galectin-1 as compared to Galectin-3 and -9. Meth treatment increased Galectin-1 expression in BMVEC. Meth induced decrease in TJ proteins ZO-1, Claudin-3 and adhesion molecule ICAM-1 was reversed by Galectin-1. Our data suggests that Galectin-1 is involved in BBB remodeling and can increase levels of TJ proteins ZO-1 and Claudin-3 and adhesion molecule ICAM-1 which helps maintain BBB tightness thus playing a neuroprotective role. Galectin-1 is thus an important regulator of immune balance from neurodegeneration to neuroprotection, which makes it an important therapeutic agent/target in the treatment of drug addiction and other neurological conditions.

Demonstration of ignition radiation temperatures in indirect-drive inertial confinement fusion hohlraums

We demonstrate the hohlraum radiation temperature and symmetry required for ignition-scale inertial confinement fusion capsule implosions. Cryogenic gas-filled hohlraums with 2.2 mm-diameter capsules are heated with unprecedented laser energies of 1.2 MJ delivered by 192 ultraviolet laser beams on the National Ignition Facility. Laser backscatter measurements show that these hohlraums absorb 87% to 91% of the incident laser power resulting in peak radiation temperatures of T(RAD)=300 eV and a symmetric implosion to a 100 μm diameter hot core.

Genomic and proteomic analysis of the effects of cannabinoids on normal human astrocytes

Delta-9-tetrahydrocannabinol (Delta(9)-THC), the main psychoactive component of marijuana, is known to dysregulate various immune responses. Cannabinoid (CB)-1 and -2 receptors are expressed mainly on cells of the central nervous system (CNS) and the immune system. The CNS is the primary target of cannabinoids and astrocytes are known to play a role in various immune responses. Thus we undertook this investigation to determine the global molecular effects of cannabinoids on normal human astrocytes (NHA) using genomic and proteomic analyses. NHA were treated with Delta(9)-THC and assayed using gene microarrays and two-dimensional (2D) difference gel electrophoresis (DIGE) coupled with mass spectrometry (MS) to elucidate their genomic and proteomic profiles respectively. Our results show that the expression of more than 20 translated protein gene products from NHA was differentially dysregulated by treatment with Delta(9)-THC compared to untreated, control NHA.

An antidepressant mechanism of desipramine is to decrease tumor necrosis factor-alpha production culminating in increases in noradrenergic neurotransmission

The monoamine theory of depression proposes decreased bioavailability of monoamines, such as norepinephrine (NE), as the underlying cause of depression. Thus, the antidepressant efficacy of NE-reuptake inhibitors such as desipramine is attributed to increases in synaptic concentrations of NE. The time difference between inhibition of reuptake and therapeutic efficacy, however, argues against this being the primary mechanism. If desipramine elicits its therapeutic efficacy by increasing NE release, in turn, increasing activation of the alpha(2)-adrenergic autoinhibitory receptor, then mimicking this increase with an exogenous agonist (clonidine) should support or even enhance the efficacy of the antidepressant. Intriguingly, simultaneous administration of clonidine with desipramine prevented the cellular and behavioral effects elicited by desipramine alone, in both acute and chronic administration paradigms. These results suggest the involvement of additional factor(s) in the mechanism of antidepressant action of this drug. Desipramine administration results in a virtual ablation of neuron-derived tumor necrosis factor-alpha (TNF), thus implicating an essential role of TNF in the therapeutic efficacy of this antidepressant. Additionally, following chronic administration of desipramine, TNF-regulation of NE release is transformed, from inhibition to facilitation. Here, we demonstrate that a transformation in TNF-regulation of NE release in the brain is a key element in the efficacy of this antidepressant. Interestingly, an increase in neurotransmission prior to the antidepressant's effect on TNF production prevents the efficacy of the antidepressant drug. Thus, the efficacy of desipramine is due to decreased levels of TNF in the brain induced by this drug, ultimately modifying noradrenergic neurotransmission.

Antidepressant drug-induced alterations in neuron-localized tumor necrosis factor-alpha mRNA and alpha(2)-adrenergic receptor sensitivity

The pleiotropic cytokine tumor necrosis factor-alpha (TNF) and alpha(2)-adrenergic receptor activation regulate norepinephrine (NE) release from neurons in the central nervous system. The present study substantiates the role of TNF as a neuromodulator and demonstrates a reciprocally permissive relationship between the biological effects of TNF and alpha(2)-adrenergic receptor activation as a mechanism of action of antidepressant drugs. Immunohistochemical analysis and in situ hybridization reveal that administration of the antidepressant drug desipramine decreases the accumulation of constitutively expressed TNF mRNA in neurons of the rat brain. Superfusion and electrical field stimulation were applied to a series of rat hippocampal brain slices to study the regulation of [(3)H]NE release. Superfusion of hippocampal slices obtained from rats chronically administered the antidepressant drug zimelidine demonstrates that TNF-mediated inhibition of [(3)H]NE release is transformed, such that [(3)H]NE release is potentiated in the presence of TNF, an effect that occurs in association with alpha(2)-adrenergic receptor activation. However, chronic zimelidine administration does not alter stimulation-evoked [(3)H]NE release, whereas chronic desipramine administration increases stimulation-evoked [(3)H]NE release and concomitantly decreases alpha(2)-adrenergic autoreceptor sensitivity. Collectively, these data support the hypothesis that chronic antidepressant drug administration alters alpha(2)-adrenergic receptor-dependent regulation of NE release. Additionally, these data demonstrate that administration of dissimilar antidepressant drugs similarly transform alpha(2)-adrenergic autoreceptors that are functionally associated with the neuromodulatory effects of TNF, suggesting a possible mechanism of action of antidepressant drugs.

Accelerated ventricular rhythm in children: a review and report of a case with congenital heart disease

We report a child with accelerated ventricular rhythm (AVR) and congenital heart disease. Three children with congenital heart defect associated with AVR were previously reported, but in each AVR occurred only postoperatively. Because our patient's 24-hour electrocardiograph recording showed AVR rates, and differences between sinus and AVR rates, exceeding published childhood limits, we reviewed the topic. On the basis of our review, we suggest guidelines for diagnosing AVR and differentiating it from ventricular tachycardia.

Practice tips. Intracutaneous sterile water injections for low back pain during labour

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Spaceflight alters microtubules and increases apoptosis in human lymphocytes (Jurkat)

Alteration in cytoskeletal organization appears to underlie mechanisms of gravity sensitivity in space-flown cells. Human T lymphoblastoid cells (Jurkat) were flown on the Space Shuttle to test the hypothesis that growth responsiveness is associated with microtubule anomalies and mediated by apoptosis. Cell growth was stimulated in microgravity by increasing serum concentration. After 4 and 48 h, cells filtered from medium were fixed with formalin. Post-flight, confocal microscopy revealed diffuse, shortened microtubules extending from poorly defined microtubule organizing centers (MTOCs). In comparable ground controls, discrete microtubule filaments radiated from organized MTOCs and branched toward the cell membrane. At 4 h, 30% of flown, compared to 17% of ground, cells showed DNA condensation characteristic of apoptosis. Time-dependent increase of the apoptosis-associated Fas/ APO-1 protein in static flown, but not the in-flight 1 g centrifuged or ground controls, confirmed microgravity-associated apoptosis. By 48 h, ground cultures had increased by 40%. Flown populations did not increase, though some cells were cycling and actively metabolizing glucose. We conclude that cytoskeletal alteration, growth retardation, and metabolic changes in space-flown lymphocytes are concomitant with increased apoptosis and time-dependent elevation of Fas/APO-1 protein. We suggest that reduced growth response in lymphocytes during spaceflight is linked to apoptosis.

Histamine in human breast cancer

BACKGROUND

Histamine inhibits lymphocyte function in vitro at concentrations of greater than 10(-6) mol/l. The aim of this study was to determine whether histamine concentrations in breast cancers were sufficient to produce an immunological effect.

METHODS

Tumour and adjacent normal breast content of histamine was measured using a radioenzymatic assay in 29 patients having surgery for breast cancer.

RESULTS

The median content of histamine in breast cancer tissue was 5.4 (range 0.9-27.3) microg/g (median concentration 4.5 x 10(-5) mol/l), and was significantly greater than that in adjacent breast tissue (P = 0.007).

CONCLUSION

The concentration of histamine in breast cancer was sufficient to inhibit lymphocyte function and could be locally immunosuppressive.

Trends in vasectomy. Analysis of one teaching practice

PROBLEM BEING ADDRESSED

How can a teaching practice develop a referral service and incorporate educational opportunities for family medicine residents, clinical clerks, and community family physicians?

OBJECTIVE OF PROGRAM

To develop a high-quality vasectomy service within a teaching practice to change the surgical procedure to the no-scalpel vasectomy (NSV) technique; to educate family medicine residents, clinical clerks, and community family physicians about vasectomy and the NSV technique; and to monitor outcomes and compare them with published results.

MAIN COMPONENTS OF PROGRAM

The program took place in an urban family medicine residency program. Data on number of procedures, types of patients choosing vasectomy, and outcomes are presented, along with information on number of learners who viewed, assisted with, or became competent to perform NSV.

CONCLUSIONS

A few family medicine residents and some interested community physicians could be trained to perform NSV competently. Involving learners in the procedure does not seem to change the rate of complications.

Role and regulation of phospholipase D activity in normal and cancer cells

PLD is regulated by the small GTP binding proteins Rho and Arf, though predominantly by the latter. The PA product of PLD activation is an activator of Rho-regulated actin stress fibre formation and in invasive cells of MMP-9 synthesis and activation. Together this may explain the increased invasion of cells in response to PA.

Histamine content in colorectal cancer. Are there sufficient levels of histamine to affect lymphocyte function?

Histamine has been found to stimulate growth of colorectal cancer in vitro and in vivo. Histamine has also been found to inhibit lymphocyte activity in vitro at concentrations greater than 10(-7) M. The aim of our study was to determine if the histamine concentrations in human colorectal cancer were sufficient to achieve these effects. We measured the histamine content in 31 colorectal cancer specimens using a radioenzymatic assay. Results were expressed as microgram histamine per gram of fresh tissue weight. Recovery and reproducibility studies were also carried out. The median histamine concentration in colorectal cancer tissue was 8.4 micrograms/g [7.6 x 10(-5)M], ranging from 0.3 microgram/g to 20.6 micrograms/g. The high concentration of histamine in colon cancer is enough to be locally immunosuppressive.

Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth

CHILDBIRTH CAN BE A VERY PAINFUL EXPERIENCE, often associated with feelings of being out of control. It should not, therefore, be surprising that childbirth may be traumatic for some women. Most women recover quickly post partum; others appear to have a more difficult time. The author asserts that post-traumatic stress disorder (PTSD) may occur after childbirth. He calls this variant of PTSD a "traumatic birth experience." There is very little literature on this topic. The evidence available is from case series, qualitative research and studies of women seeking elective cesarean section for psychologic reasons. Elective cesarean section exemplifies the avoidance behaviour typical of PTSD. There are many ways that health care professionals, including physicians, obstetric nurses, midwives, psychologists, psychiatrists and social workers, can address this phenomenon. These include taking a careful history to determine whether a woman has experienced trauma that could place her at risk for a traumatic birth experience; providing excellent pain control during childbirth and careful postpartum care that includes understanding the woman's birth experience; and ruling out postpartum depression. Much more research is needed in this area.

Deletion of individual muscles alters rat walking-track parameters

Rat walking-track analysis has been employed extensively to quantify motor recovery in studies of hindlimb nerve injury and repair. In order to clarify the relationship between individual print measurements and the function of specific hindlimb muscles, 40 young adult rats were assigned to one of five groups (n = 8/group) in which specific deletions of motors were created as follows: Group 1--division of the tendon of insertion of the gastrocnemius, soleus, and plantaris muscles (GSP); Group 2--division of the extensor digitorum longus muscles tendons of insertion (EDL); Group 3--division of the extensor hallicus longus muscle tendon of insertion (EHL); Group 4--division of the tibialis anterior muscle tendon of insertion (TA); or Group 5--division of the tibial nerve at the ankle (TNA). Parameters for print length (PL), intermediate toe spread (IS), and total toe spread (TS) were calculated from walking tracks recorded before and again five days after deletion of the motors. Specific, predictable patterns of change in footprint parameters were observed for each group. It was concluded that triceps surae and tibialis anterior muscle function directly affects print length; EHL function directly influences total toe spread; and EDL function is directly related to intermediary toe spread. These data demonstrate a direct relationship between individual print measurements and the function of individual rat hindlimb muscles.

In vitro effect of histamine and histamine H1 and H2 receptor antagonists on cellular proliferation of human malignant melanoma cell lines

Histamine is an established growth factor for gastric and colorectal cancer. Contradictory data for response of melanoma to histamine have been reported. Our aims were to determine the effect of histamine and H1 and H2 receptor antagonists on cell growth and cyclic AMP production. Four human melanoma cell lines were cultured with a range of concentrations of histamine, and with the H2 receptor antagonists cimetidine, ranitidine or famotidine, or the H1 receptor antagonist diphenhydramine. Cellular proliferation was measured by the uptake of [3H]-thymidine. Cyclic AMP production was also measured to determine the receptor status of the cell lines. Histamine significantly stimulated growth in two of four cell lines, with maximal stimulation at 1 x 10(-8) M. This effect was inhibited by all four antagonists in a dose-dependent manner. Histamine [10(-7) to 10(-4) M] also induced a dose-dependent increase in cyclic AMP production in the two histamine-responsive cell lines, suggesting that these cell lines express H2 receptors. We conclude that there may be a role for histamine receptor antagonists in melanoma treatment and that further investigation is warranted.

Reducing the frequency of episiotomies through a continuous quality improvement program

OBJECTIVE

To determine the effectiveness of a continuous quality improvement (CQI) program in reducing episiotomy rates.

DESIGN

Before-and-after study; CQI methods were used to examine the process of care during labour and birth.

INTERVENTIONS

Identification of care factors that would increase the probability of episiotomy. Implementation of initiatives that would change the process of care to minimize the probability of episiotomy. Educational strategies included promotion of better understanding of what constitutes an appropriate episiotomy rate and ways to reduce maternal exhaustion and true fetal distress as well as manoeuvres to protect the perineum during birth.

SETTING

Low-risk family practice obstetrics service in a tertiary care hospital in southwestern Ontario.

PARTICIPANTS

All 102 family physicians at the study hospital who provided intrapartum care in the year before and the year during which the CQI program was implemented and the women for whom the care was provided (approximately 1,400 per year).

OUTCOME MEASURES

Episiotomy rates (overall, among primiparous and multiparous women, and among individual family physicians) and rates of perineal tear, perineal infection and postpartum readmission.

RESULTS

Although the planned reduction in the episiotomy rate was not achieved during the study period, the overall rate decreased significantly from 44.5% to 33.3% (p < 0.001). Among the primiparous women the rate decreased from 57.6% to 46.2% (p < 0.001) and among the multiparous women from 34.3% to 23.6% (p < 0.001). The reduced episiotomy rate among the primiparous women was associated with a significant decrease in the rate of third- and fourth-degree perineal tears and a significant increase in the number of women giving birth with an intact perineum or a minor (first-degree) tear. These benefits were not seen among the multiparous women, whose decreased episiotomy rate was associated with a significant increase in the number of women experiencing a second-degree perineal tear. During the intervention period, there was no increase in the rates of vaginal trauma or postpartum bleeding, infection or readmission because of complications related to perineal trauma. The episiotomy rates for most physicians decreased significantly during the intervention period.

CONCLUSIONS

The CQI model may be useful in modifying clinical practices such as episiotomy because it focuses on understanding the process of care and the environment in which care is provided, both of which may have a major impact on physician behaviour. Further study is needed to ascertain the sustainability of the effects of this approach and which components of the model had the greatest effect.

Factors associated with the decision of family physicians to provide intrapartum care

OBJECTIVE

To investigate which characteristics and beliefs of family physicians determine their decision to provide intrapartum care.

DESIGN

Confidential survey questionnaire mailed in spring 1993.

SETTING

Alberta and Ontario.

SUBJECTS

Random selection of 207 physicians who had graduated from medical school between 1953 and 1990 and were thought to be in family or general practice. Of 178 eligible physicians, usable replies were received from 104 (58.4%).

OUTCOME MEASURES

Beliefs (measured on a 7-point Likert scale) about the relevance of 16 primary factors to the type of obstetric care provided; demographic, training and practice characteristics.

RESULTS

The respondents who provided intrapartum care differed from those who did not in their beliefs about the availability of a local hospital suitable for intrapartum care (p < 0.001), their practice partners' views on the role of family physicians in providing obstetric care (p < 0.002), their own concept of the role of family physicians in providing obstetric care (p < 0.001) and women's views on the type of obstetric care they want (p < 0.002). They also differed, although less significantly, in their beliefs about the adequacy of their obstetric training before entering family practice (p < 0.04), the expected effects of providing obstetric care on their free time (p < 0.006), their fear of malpractice litigation (p < 0.028) and their perceived competence in performing practical obstetric procedures (p < 0.05). Logistic regression analysis revealed that certain secondary factors were particularly relevant to the respondents' provision of intrapartum care at present. These included the physician's perceived competence at managing postpartum maternal hemorrhage (odds ratio [OR] 48.90, 90% confidence interval [CI] 4.70 to 509), the belief that medical insurance premiums should not be affected by the type of obstetric care provided (OR 3.55, 90% CI 1.67 to 7.57]) and the number of practice partners who provided intrapartum care (OR 10.08, 90% CI 2.31 to 44.10).

CONCLUSION

Several factors appear to influence family physicians in their decision to provide intrapartum care. This information will help to focus efforts to provide appropriate obstetric training for family practice residents and to retain involvement of family physicians in intrapartum care.

Family practice maternity care in America: ruminations on reproducing an endangered species--family physicians who deliver babies

BACKGROUND

The majority of family physicians do not deliver babies. One reason might be the family physician's intrinsic comfort with person- or patient-centered care compared with the common obstetric approach of disease or physician-centered maternity care. Another reason might be the uncritical intrusion of technology into maternity care. In addition, family physicians often are made to feel unwelcome in many maternity care systems.

METHODS

The medical literature from 1984 to 1994 was searched for the topics of obstetrics, maternity care, family-centered birthing, and family practice education. Reasons to argue whether family physicians should provide maternity care were selected, and articles were chosen that described the self-reported reasons students, residents, or physicians give whether to provide maternity care.

RESULTS AND CONCLUSIONS

There is no scientifically supportable reason for excluding family physicians from maternity care in any setting, and the current maternity care system, in many locations, creates an attitude of taught helplessness among family physicians. In addition, family practice educators must for a variety of reasons be the primary role models and teachers of family-centered birthing for family practice learners. Generally, the groups that should be involved in providing maternity care in the future should include (1) better informed and more independent pregnant patients, (2) maternity care nurses, (3) doulas, (4) midwives, (5) family physicians, and (6) specialized physicians. Specifically, family physicians and midwives have a historic and philosophic similarity that would argue for a much closer working and practicing relationship between these two professionals. Family-centered birthing provides excellent outcomes. Birthing is both foundational and intrinsic to family practice. Conversely, without family physicians maternity care in America might not be able to reach its full potential.

Intracutaneous sterile water for back pain in labour

Intracutaneous sterile water appears to be a simple, effective, and harmless technique for relieving back pain. This technique has been used to relieve pain of renal colic, whiplash, and back pain in labour. Family doctors often practise obstetrics in small or isolated units that have limited options for pain relief in labour. This technique is simple, is easy to learn, and appears effective for relieving back pain, which complicates about one third of all labours.

A field methodology for the control of musculoskeletal injuries

A methodology is presented for the evaluation of jobs prone to cumulative trauma disorders (CTDs) and manual material handling (MMH) injuries, which combines various tested ergonomics methodologies into a single, coherent programme. This multi-step procedure is based upon the collection of quantitative data that are used to evaluate ergonomic changes with respect to biomechanical risk, perceived comfort, productivity and quality. A method for prioritizing changes, related to cost-benefit analysis, is proposed to guide the selection of ergonomic changes in order to maximize the potential for injury reduction under specified cost constraints. The ten-step methodology has been extensively applied in industry, leading to examples and a case study.

Doing obstetrics and staying alive

Many family physicians have a love-hate relationship with childbirth care and struggle to balance their personal and family needs with the need to provide high-quality personal care during labour and birth. Many false assumptions undermine family practice obstetrics. Strategies are presented to simplify obstetric care for women and families while promoting reasoned self-care for physicians.

Design and evaluation of an optical disk handling tool for a cleanroom environment

In this paper, we present an application of engineering and ergonomics principles in the design of an optical disk handling tool for use in a cleanroom environment. A qualitative model which considers the task, operator, machines and environment (TOME model) was utilized to guide the design process. A 'before-after' evaluation found a significant improvement in the proposed tool over the existing tool with respect to mechanical, biomechanical and subjective measures. Product yield has improved considerably, as measured after the implementation of the proposed tool in December 1989 until the end of the observation period in June 1991.

Minnesota workplace drug testing. Analysis of policy and procedures

1. An employer's decision whether to drug test or not was found to correlate with the size of the company and how extensively the employer perceives a drug abuse problem exists among its work force. 2. A company's drug testing program must be designed, implemented, and evaluated within a medical-legal framework. This includes issues of: confidentiality, employee actions that trigger a drug test, the presence of a drug and alcohol policy, communicating the program to employees and unions, the employee's rights, the consequences of an employee's positive drug test, and the procedures to be followed when collecting a specimen. 3. Future studies need to explore the issue of dealing with job performance problems; in particular, the cost and effectiveness of employee drug testing vs. the use of discipline alone.

Primitive Delivery Positions in Modern Obstetrics: Were the wise women wiser wiser than we?

Fifty patients of an academic family medicine unit tried standing and squalting in second stage. Almost all (84.0%) of the women were able to deliver in an upright posture. They rated the upright position as safer, more comfortable, and more effective than the recumbent position. When compared with 136 similar deliveries from the same population, the study group had significantly fewer episiotomies and showed a trend toward more spontaneous deliveries.

Influence of perinatal asphyxia on neurologic outcome: consequences for family practice accoucheurs

Inappropriate concern with perinatal asphyxia, based on false notions about causes, may be behind the decision of some family physicians to avoid obstetrics. Asphyxia can cause motor or mental deficits, but only if the insult was severe and prolonged (when there will be evidence of hypoxia in systems other than the CNS). Even abnormal CNS signs do not necessarily reflect clinically important neurologic damage. Intrapartum care has much less impact on neonatal outcome than previously believed, and most bad outcomes have their origins in events occuring long before the onset of labour and outside the detection capabilities of current technology. Nevertheless, family physicians require resuscitation skills because vigorous, effective management of even very hypoxic neonates can improve and normalize outcome.

Hearing conservation programs (HCPs): the effectiveness of one company's HCP in a 12-hr work shift environment

An existing hearing conservation program (HCP), originally designed when an 8-hr work shift schedule was in effect, was evaluated at a plant site where a 12-hr work shift schedule is now utilized. The study included the following phases: a noise analysis of the work environment, HCP evaluation through the use of audiometric data base analysis (ADBA), applying ADBA procedures and a comparison of the shift in hearing threshold levels (HTLs) for the 8-hr and 12-hr work shifts, and an evaluation of the hearing protection devices (HPDs) being used at the facility over the 12-hr work shift by measuring temporary threshold shift (TTS). The mean measured employee time-weighted average (TWA) in the process area where the TTS study was conducted was 92 dBA. It was found that the existing HCP is at best marginal. The most likely causes of this less-than-desirable rating are inadequate audiometric testing procedures and inadequate HPD utilization. Furthermore, it was concluded that, at this time, the introduction of the 12-hr work shift has had no impact on the level of effectiveness of the HCP. In evaluating the three HPDs in use at the facility (3-M foam earplug, E-A-R foam earplug, and Bilsom Soft earplug), it was found that they all offered effective protection from noise at all audiometric test frequencies (0.5 to 6 kHz) except 0.5 kHz. All three HPDs exhibited TTS at 0.5 kHz with the TTS measured significant at the p less than 0.05 level for the E-A-R and 3-M wearer groups.

Precordial catch syndrome in children

Precordial catch syndrome was diagnosed in ten children whose primary complaint was chest pain. From published reports, nine characteristics of the pain were derived and their occurrence rate determined retrospectively in the ten patients. A close correspondence in type of pain was found between patients in previous reports and those I studied. Precordial catch pain typically is sudden, brief, periapical, easily localized, nonradiating, nonexertional, and importantly, intensified by inspiration. This study further validates the syndrome, reports its occurrence in children in the United States for the first time, and indicates more certainly the pain attributes one seeks for diagnosis.