Evaluation of amoxicillin, metronidazole and gentamicin dosage regimens for use in antibiotic prophylaxis in colorectal surgery

OBJECTIVES

To evaluate amoxicillin, metronidazole and gentamicin dosage regimens for antibiotic prophylaxis in colorectal surgery.

METHODS

The study was conducted in 20 patients undergoing colorectal surgery. Patients received one or two doses of amoxicillin 1000 mg, metronidazole 500 mg and gentamicin 3 mg/kg ideal body weight, banded by height. Antibiotic concentrations were measured up to 7 h post dose. Population pharmacokinetic (PopPK) analysis with NONMEM followed by Monte Carlo simulation of different dosage regimens was used to estimate the PTA for potential organisms associated with surgical site infections (SSIs).

RESULTS

A median of 5 (range 3-6) concentrations were available per patient. CL and V of all antibiotics were related to weight; gentamicin CL was also related to CLCR. The administered doses maintained the desired PTA up to 8 h for the Streptococcus anginosus group but not for enterococci, Bacteroides fragilis group, MSSA, and Escherichia coli. An additional 500 mg amoxicillin every 4 h was sufficient to achieve the PTA for most relevant organisms but 2 hourly dosing was required for patients at risk of infective endocarditis. A metronidazole dose of 1000 mg was required for patients >85 kg. In patients with CLCR >50 mL/min, 5 mg/kg gentamicin (with an additional 2.5 mg/kg in prolonged surgery at 6 h) maintained PTA targets for >10 h.

CONCLUSIONS

PopPK analysis with Monte Carlo simulation identified prophylactic antibiotic regimens that would maintain the PTA for organisms associated with SSIs during short- and long-duration colorectal surgery.

The Stirling Protocol - Putting the environment at the heart of prosperity and social inclusion

While the global coronavirus crisis impacts society and the economy in a myriad of ways, it provides, what is likely to be, a once in a lifetime opportunity for us to rethink our response to climate change. According to the 2020 Global Risk Register, extreme weather and climate action failure are the two most likely and impactful risks to the global economy, which now more than ever needs to be avoided. Addressing the major challenges that we face from climate change can often appear to conflict with economic priorities. Add to this the fact that environmental mitigation steps can inadvertently exclude sections of the population and the enormity and complexity of climate change responses can result in paralysis. In contrast, the Stirling Protocol provides the framework for rapid, effective action and comprises three pillars: Environment, Economy & Inclusion. By addressing and balancing these three pillars, the simple protocol can be adopted throughout organisations putting the environment at the heart of sustainable prosperity and inclusion and provide a benchmark for positive action.

Potential emerging chemical risks in the food chain associated with substances registered under REACH

A screening procedure for the identification of potential emerging chemical risks in the food and feed chain developed in a previous EFSA-sponsored pilot study was applied to 15021 substances registered under the REACH Regulation at the time of evaluation. Eligible substances were selected from this dataset by excluding (a) intermediates handled under strictly controlled conditions, (b) substances lacking crucial input data and (c) compounds considered to be outside the applicability domain of the models used. Selection of eligible substances resulted in a considerable reduction to 2336 substances. These substances were assessed and scored for environmental release (tonnage and use information from REACH registration dossiers), biodegradation (predictions from BIOWIN models 3, 5 and 6 evaluated in a battery approach), bioaccumulation in food/feed (ACC-HUMANsteady modelling) and chronic human health hazards (classification according to the CLP Regulation for carcinogenicity, mutagenicity, reproductive toxicity and repeated dose toxicity as well as IARC classification for carcinogenicity). Prioritisation based on the scores assigned and additional data curation steps identified 212 substances that are considered potential emerging risks in the food chain. Overall, 53% of these substances were prioritised due to chronic hazards identified in REACH registrations dossiers only (i.e. hazards not identified in classifications from other sources). Bioaccumulation in food and feed predicted on the basis of ACC-HUMANsteady modelling identified many substances that are not considered bioaccumulative in aquatic or terrestrial organisms based on screening criteria of the relevant ECHA guidance documents. Furthermore, 52% of the priority substances have not yet been assessed for their presence in food/feed by EU regulatory agencies. This finding and illustrative examples suggest that the screening procedure identified substances that have the potential to be emerging chemical risks in the food chain. Future research should investigate whether they actually represent emerging chemical risks as defined in EFSA's mandate.

Design and demonstration of a seabird-inspired fixed-wing hybrid UAV-UUV system

This paper looks to the natural world for solutions to many of the challenges associated with the design of fixed-wing cross-domain vehicles. One example is the common murre, a seabird that flies from nesting locations to feeding areas, dives underwater to catch prey and returns. This hunting expedition provides an outline of a possible mission for a cross-domain vehicle. While the challenges of cross-domain vehicles are many, the focus of this paper was on buoyancy management and propulsion. Potential solutions to each challenge, inspired by multiple animals that cross between aerial and underwater domains, are investigated. From these solutions, three design concepts are considered, a quadrotor/fixed-wing hybrid, a vertical takeoff and landing (VTOL) tailsitter aircraft, and a waterjet-assisted takeoff vehicle. A comparison was made between the capability of each concept to complete two missions based on the common murres' hunting expedition. As a result of this comparison, the VTOL tailsitter design was selected for further study. In-depth design was conducted and a prototype vehicle was built. The completed vehicle prototype successfully conducted submerged operation as well as four air flights. Flights consisted of egress from water, flight in air, ingress into water in each flight, and water locomotion. A total of 11 min, 23 s of flight time was recorded as well as underwater swims down to 12 ft (3.7 m) below the surface.

Development of a novel scoring system for identifying emerging chemical risks in the food chain

The European Food Safety Authority (EFSA) is responsible for risk assessment of all aspects of food safety, including the establishment of procedures aimed at the identification of emerging risks to food safety. Here, a scoring system was developed for identifying chemicals registered under the European REACH Regulation that could be of potential concern in the food chain using the following parameters: (i) environmental release based on maximum aggregated tonnages and environmental release categories; (ii) biodegradation in the environment; (iii) bioaccumulation and in vivo and in vitro toxicity. The screening approach was tested on 100 data-rich chemicals registered under the REACH Regulation at aggregated volumes of at least 1000 tonnes per annum. The results show that substance-specific data generated under the REACH Regulation can be used to identify potential emerging risks in the food chain. After application of the screening procedure, priority chemicals can be identified as potentially emerging risk chemicals through the integration of exposure, environmental fate and toxicity. The default approach is to generate a single total score for each substance using a predefined weighting scenario. However, it is also possible to use a pivot table approach to combine the individual scores in different ways that reflect user-defined priorities, which enables a very flexible, iterative definition of screening criteria. Possible applications of the approaches are discussed using illustrative examples. Either approach can then be followed by in-depth evaluation of priority substances to ensure the identification of substances that present a real emerging chemical risk in the food chain.

Application of the WFD cost proportionality principle to diffuse pollution mitigation: a case study for Scottish Lochs

The Water Framework Directive (WFD) aims to deliver good ecological status (GES) for Europe's waters. It prescribes the use of economic principles, such as derogation from GES on grounds of disproportionate costs of mitigation. This paper proposes an application of the proportionality principle to mitigation of phosphorus (P) pollution of 544 Scottish lochs at national and local water body scales. P loading estimates were derived from a national diffuse pollution screening tool. For 293 of these lochs (31% of the loch area), GES already occurred. Mitigation cost-effectiveness was assessed using combined mitigation cost curves for managed grassland, rough grazing, arable land, sewage and septic tank sources. These provided sufficient mitigation (92% of national P load) for GES to be achieved on another 31% of loch area at annualised cost of £2.09 m/y. Mitigation of the residual P loading preventing other lochs achieving GES was considered by using a "mop-up" cost of £200/kg P (assumed cost effectiveness of removal of P directly from lochs), leading to a total cost of £189 m/y. Lochs were ranked by mitigation costs per loch area to give a national scale marginal mitigation cost curve. A published choice experiment valuation of WFD targets for Scottish lochs was used to estimate marginal benefits at national scale and combined with the marginal cost curve. This gave proportionate costs of £5.7 m/y leading to GES in 72% of loch area. Using national mean marginal benefits with a scheme to estimate changes in individual loch value with P loading gave proportionate costs of £25.6 m/y leading to GES in 77% of loch area (491 lochs).

Genotype, dietary manipulation and food allocation affect indices of welfare in broiler breeders

1. An experiment was performed to compare the welfare of three broiler breeder genotypes (Label Rouge (LA), experimental dwarf (ER) and standard (SR)) fed on a Control or high Fibre diet. The LA birds were fed ad libitum and the other groups were reared to their recommended body weight targets. A group of standard broiler breeders was also fed a restricted amount of food, but to a lesser degree than SR, to achieve the same proportion of body weight (SE) as ER relative to ad libitum-fed dwarfs based on previous research. LA, ER, SR and SE are referred to as 'groups' in the text. 2. Welfare was assessed by comparing time budgets and heterophil-lymphocyte ratios (HL ratios) at 5, 10 and 15 weeks and immune responses at 15 weeks of age. In addition the weight and water content of the gastrointestinal tract at 4-h intervals at the end of the experiment were studied in LA and SR fed on both diets. 3. Body weights of LA, ER and SR fed on the Fibre diets were depressed and LA ate less of the Fibre than the Control diet. The coefficient of variation of body weight at 15 weeks was 7.9% in LA and similar (10.8 to 11.6%) in the other groups. 4. Drinking, litter-directed behaviour, resting and standing were affected by a group x age interaction with restricted birds showing increased drinking over time and less time spent resting compared to LA. The behaviour of ER birds was similar to SE. 5. HL ratios were within the normal biological range although all restricted-fed birds had an elevated HL ratio at 10 weeks of age relative to week 5 whereas LA birds had a reduced HL ratio at 15 weeks relative to 5 and 10 weeks of age. Immune responses were lower in ER and SE and the highest response was in SR. 6. No effects of diet were identified on behaviour, white blood cell counts or HL ratio. 7. With the exception of the crop, the dry weights of digesta in each section of the gut were similar in LA and SR birds. The results suggest that drinker-directed activity might be a substitute for foraging rather than an attempt to increase gut fill. 8. It is concluded that the replacement of standard with dwarf broiler breeders may improve the welfare of commercial flocks of broiler breeders by decreasing the degree of food restriction resulting in favourable changes in behaviour, for example, reduced 'drinker-directed' behaviour.

BETR-World: a geographically explicit model of chemical fate: application to transport of alpha-HCH to the Arctic

The Berkeley-Trent (BETR)-World model, a 25 compartment, geographically explicit fugacity-based model is described and applied to evaluate the transport of chemicals from temperate source regions to receptor regions (such as the Arctic). The model was parameterized using GIS and an array of digital data on weather, oceans, freshwater, vegetation and geo-political boundaries. This version of the BETR model framework includes modification of atmospheric degradation rates by seasonally variable hydroxyl radical concentrations and temperature. Degradation rates in all other compartments vary with seasonally changing temperature. Deposition to the deep ocean has been included as a loss mechanism. A case study was undertaken for alpha-HCH. Dynamic emission scenarios were estimated for each of the 25 regions. Predicted environmental concentrations showed good agreement with measured values for the northern regions in air, and fresh and oceanic water and with the results from a previous model of global chemical fate. Potential for long-range transport and deposition to the Arctic region was assessed using a Transfer Efficiency combined with estimated emissions. European regions and the Orient including China have a high potential to contribute alpha-HCH contamination in the Arctic due to high rates of emission in these regions despite low Transfer Efficiencies. Sensitivity analyses reveal that the performance and reliability of the model is strongly influenced by parameters controlling degradation rates.

Bladder dysfunction in Duchenne muscular dystrophy

Although bladder function is thought to be unaffected in Duchenne muscular dystrophy, 46/88 boys interviewed had urinary problems. Nine underwent video urodynamics, showing in eight a small capacity, hyperreflexic bladder, and in the ninth (post spinal surgery) hyperreflexia and detrusor sphincter dyssynergia. Urinary dysfunction is a treatable feature of DMD.

Evaluation and comparison of multimedia mass balance models of chemical fate: application of EUSES and ChemCAN to 68 chemicals in Japan

The European Union System for Evaluation of Substances (EUSES) and the ChemCAN chemical fate model are applied to describe the fate of 68 chemicals on two spatial scales in Japan. Emission information on the chemicals has been obtained from Japan's Pollutant Release and Transfer Registry and available monitoring data gathered from government reports. Environmental concentrations calculated by the two models for the four primary environmental media of air, water, soil and sediment agree within a factor of 3 for over 70% of the data, and within a factor of 10 for over 87% of the data. Reasons for certain large discrepancies are discussed. Concentrations calculated by the models are generally consistent with the lower range of concentrations that are observed in the environment. Agreement between modeled and observed concentrations is considerably improved by including an estimate of the advective input of chemicals in air from outside Japan. The agreement between the EUSES and ChemCAN models suggests that results of individual chemical assessments are not likely to be significantly affected by the choice of chemical fate model. Primary sources of discrepancy between modeled and observed concentrations are believed to be uncertainties in emission rates, degradation half-lives, and the lack of data on advective inflow of contaminants in air.

On the validity of classifying chemicals for persistence, bioaccumulation, toxicity, and potential for long-range transport

It is argued that chemical substances can be meaningfully ranked or classified according to their persistence (P), bioaccumulation (B), toxicity (T), and potential for long-range transport (LRT) only if these attributes can be shown to be intensive, as distinct from extensive, properties of the substance, i.e., they are independent of quantity of substance. It is shown that P, B, and LRT can be considered intensive or quasi-intensive properties, but toxicity is more problematic. To obtain an intensive metric of toxicity requires selection of one of several possible extensive quantities that define exposure or dose. Ranking of a group of chemicals by toxicity is shown to be very dependent on which quantity is selected. It is suggested that toxicity metrics, such as lethal concentration to 50% of the population (LC50), lethal dose to 50% of the population (LD50), and threshold limit value (TLV) suffer the severe disadvantage of being dependent on the efficiency of delivery of the substance to the site(s) of toxic action in the organism. The use of measured or calculated internal dose is a preferable measure of toxicity since it reduces ambiguities inherent in the other metrics. Also, the primary concern is not the quasi-intensive property of toxicity; rather, it is the risk of toxic effects, an extensive quantity. To adequately assess the risk of toxic effects, both the toxic hazard and the degree of exposure must be characterized. Since exposure cannot be estimated without knowledge of the emission rate of chemicals to the environment, a compelling case can be made that screening to identify priority P, B, T, and LRT substances should be expanded to include quantity released to the environment as an additional factor.

An exploratory study of clinical decision-making in five countries

PURPOSE

To identify the cognitive processes nurses use in their decision-making in long- and short-term care settings in five countries, and the demographic variables associated with their decision-making. METHOD AND SAMPLES: The instrument used was a 56-item questionnaire that has been shown to be reliable in earlier studies. The sample consisted of five convenience samples of registered nurses working in either geriatric wards (n = 236) or acute medical-surgical wards (n = 223) in hospitals or nursing homes in Canada, Finland, Sweden, Switzerland, and the United States.

FINDINGS

Five models of decision-making were identified on the basis of factor analysis. They represent both analytical and intuitive cognitive processes. Analytical cognitive processes were emphasized in information collection, problem definition, and planning of care, and intuitive cognitive processes were emphasized in planning, implementing, and evaluating care. Professional education, practical experience, field of practice, and type of knowledge were significantly associated with decision-making models as well as with country of residence of the participants. The highest proportion of analytically oriented decision-makers was found among nurses in long-term care, the decision-making of nurses in short-term care was more intuitively oriented.

CONCLUSIONS

The results indicate that decision-making of participants varied from country to country and in different nursing situations. Future research should be focused on reasons for these differences, the relationship between the task and the nurses' type of knowledge, and how nurses use their knowledge to make decisions in different nursing situations.

The control of body orientation and center of mass location under asymmetrical loading

This study examined how whole body center of mass (COM) in the medial-lateral direction and spatial orientation of body segments changed during quiet stance when a weight was loaded on asymmetrically on the right side of the pelvis. The load corresponded to 10 and 30% of body weight (BW) of each individual subject, and the stance width was varied from narrow (7.6 cm) to normal (20 cm) and to wide (33 cm). A total of 10 healthy young subjects (18-30 years of age) participated in the study. The results indicated that the COM location was significantly shifted towards the loaded side (about 1.2 cm with a 10% BW load and 3 cm with a 30% BW load). In addition, COM was closer to the center with a narrow stance (0.38 cm to the right of the center) than both normal and wide stance (about 1 cm to the right). However, the COM shifts for all test conditions were smaller (<50%) than that of the theoretically predicted values. The smaller shift in COM position appeared to be mostly due to the change in spatial orientation of the pelvis and lower extremity (about 2.5 degrees change with a 10% BW load, and 4.5 degrees change with a 30% BW load), while maintaining the upper body orientation relatively unchanged (less than 2 degrees with a 30% BW load). This strategy may allow increased stability of the upright stance with minimal amount of muscle activation.

BETR North America: a regionally segmented multimedia contaminant fate model for North America

We present the Berkeley-Trent North American contaminant fate model (BETR North America), a regionally segmented multimedia contaminant fate model based on the fugacity concept. The model is built on a framework that links contaminant fate models of individual regions, and is generally applicable to large, spatially heterogeneous areas. The North American environment is modeled as 24 ecological regions, within each region contaminant fate is described using a 7 compartment multimedia fugacity model including a vertically segmented atmosphere, freshwater, freshwater sediment, soil, coastal water and vegetation compartments. Inter-regional transport of contaminants in the atmosphere, freshwater and coastal water is described using a database of hydrological and meteorological data compiled with Geographical Information Systems (GIS) techniques. Steady-state and dynamic solutions to the 168 mass balance equations that make up the linked model for North America are discussed, and an illustrative case study of toxaphene transport from the southern United States to the Great Lakes Basin is presented. Regionally segmented models such as BETR North America can provide a critical link between evaluative models of long-range transport potential and contaminant concentrations observed in remote regions. The continent-scale mass balance calculated by the model provides a sound basis for evaluating long-range transport potential of organic pollutants, and formulation of continent-scale management and regulatory strategies for chemicals.

Development of continental scale multimedia contaminant fate models: integrating GIS

The incentives and approaches for modelling chemical fate at a continental scale are discussed and reviewed. It is suggested that a multi-media model consisting of some 20-30 regions, each of which contains typically seven environmental compartments represents a reasonable compromise between the issues of the need for detailed resolution, avoidance of excessive data demands and inherent complexity and transparency. Strategies adopted in compiling the Berkley-Trent (BETR) model for North America are discussed and used to illustrate the issues of selecting appropriate number and nature of segments, treatment of air and water flows and the acquisition of environmental data. It is suggested that GIS software can play a valuable role in gathering and processing such data and in the display and interpretation of the results of the model assessment. The BETR model will be a useful tool for describing the nature of persistence and long-range transport of chemicals of concern in the North American environment.

First Report of Plum Pox Potyvirus in Ontario, Canada

Plum pox potyvirus (PPV) causes plum pox (sharka) disease, which is considered the most serious disease of stone fruits including peach, plum, nectarine, and apricot (2). The disease may cause losses as high as 80 to 100% of some crops (2). A survey was initiated in the Niagara region of Ontario, Canada, after it was reported that PPV was detected in Pennsylvania (1). The initial survey focused on Prunus material imported into Canada from the Pennsylvania region. Where imported trees could be identified, every tree was sampled. In cases where the imported trees were growing in mixed blocks with plants from other sources, 25% of the trees were sampled and tested as composites of four trees. PPV was detected in three symptomless Fantasia nectarine (Prunus persica var. nectarina) trees by triple-antibody sandwich (TAS) ELISA using the REAL Durviz kit (Valencia, Spain), which contains the universal PPV monoclonal 5B. PPV infection was confirmed by western blot analyses (a PPV polyclonal antibody and PPV 5B monoclonal were used as primary antibodies), reverse transcription polymerase chain reaction (RT-PCR), and TC/RT-PCR. In western blot analyses, the coat protein subunit sizes of the Canadian PPV isolates were estimated at 32 kDa based on electrophoretic mobility in 12% SDS-PAGE. RFLP analysis of the 243-bp fragment amplified using PPV specific primers P1 and P2 (4) indicated the presence of RsaI and AluI enzyme restriction sites, which is characteristic of PPV D strains. In RT-PCR analysis using D and M specific primers (3), only the D specific primers amplified a fragment 198 bp in size. This data provided conclusive evidence that the PPV isolates detected in Canada were PPV D, similar to the strain detected in Pennsylvania. The survey is continuing and is being expanded to determine the extent of spread and the exact distribution of the virus. References: (1) L. Levy et al. Phytopathology (Abstr.) 90:46, 2000. (2) M. Nemeth. Virus, Mycoplasma, and Rickettsia Diseases of Fruit Trees. Akademiai Kiado, Budapest. (3) A. Olmos et al. J. Virol. Methods 68:127-137, 1997. (4) T. Wetzel et al. J. Virol. Methods 33:355-365, 1991.

Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review

INTRODUCTION

Seventeen patients with an average age of fifty-five years (range, thirty-two to seventy-seven years) who had ongoing pain and impaired function following failed operative treatment of a massive tear of the rotator cuff were managed with a transfer of the latissimus dorsi muscle as a salvage operation.

METHODS

The patients were examined at an average of fifty-one months (range, twenty-four to seventy-two months) after the operation. Pain, function, and satisfaction were assessed with use of a questionnaire, visual analog and ordinal scales, physical examination, and the University of California at Los Angeles shoulder score.

RESULTS

Fourteen of the seventeen patients were found to have significant relief of pain (p<0.0001) and a significant improvement in function (p<0.001 for all activities except lifting more than fifteen pounds [6.8 kilograms], for which the p value was <0.0036) and were satisfied with the result of the operative procedure. Fifteen patients stated that they would have the operative procedure again under similar circumstances. Seven of eight patients with a detached or nonfunctional anterior portion of the deltoid had substantial improvement. Three operations were classified as failures because the patients were not satisfied with the result and had ongoing pain and impaired function. All three failures were in patients who had a work-related injury. Overall, six patients had a work-related injury, and only three of them had a satisfactory result. There were three complications, all related to contracture of a hypertrophic axillary scar.

CONCLUSIONS

The results in this series indicate that transfer of the latissimus dorsi muscle is a reasonable approach for salvage after failed operative treatment of a massive tear of the rotator cuff.

An assessment of the environmental fate and exposure of benzene and the chlorobenzenes in Canada

Systematic modelling of the fate of benzene and the chlorobenzenes is presented which follows a four-stage process of chemical classification, quantifying discharge rates and environmental concentrations, evaluative assessment of fate and regional mass balance modelling has been carried out for the southern Ontario region. The EQC model was applied to determine the principal transport and transformation processes experienced by this group of chemicals, which vary considerably in volatility and hydrophobicity. Observed environmental concentrations are in satisfactory agreement with the predictions of the steady state Level III ChemCAN model of chemical fate. A multiple pathway human exposure model which estimates intake of contaminants by residents of southern Ontario has been developed and applied to these chemicals. A novel method of deducing maximum tolerable environmental concentrations is presented. Results suggest that benzene and 1,4-dichlorobenzene are present in the environment at levels sufficient to cause exposures near allowable daily intake (ADI) levels for the general population, but the other substances are present at levels which result in exposure ranging from 1/10 to 1/1000 of the ADI.

Issues for nurses in rural and remote Canada

Canada is a vast country with great diversity in its landscape, industry, culture and communities. The healthcare issues and concerns of people living in rural and remote areas are as fully diverse as the people and the landscape. This article describes the context of rural and remote nursing practice in Canada and discusses issues of health status and the social determinants of health, geographical isolation, professional isolation and cultural safety. It concludes with current initiatives in practice, education, research and policy. Particular issues facing nurses in rural and remote First Nations communities are highlighted.

'Being there': learning through active participation

Students engagement in learning is predicated not only on interest but on the perception of relevance to their needs. A hermeneutic interpretation of narrative student evaluation data from an introduction to nursing lecture course that was taught by means of a practice-based phenomenological approach revealed a pattern of student learning in which students moved from detachment to active participation in their learning. The stories shared by nurses in the practice setting were instrumental in introducing students to the world of nursing and facilitating a sense of belonging. Once engaged in the experience, students looked for opportunities to become active participants in their learning. A practice-based phenomenological approach to a theory course maximizes opportunities for student participation. Active reflection and integration allow students to make their own connections between theory and practice.

Decision making of nurses practicing in intensive care in Canada, Finland, Northern Ireland, Switzerland, and the United States

In this study, our intention was to describe the decision making of nurses practicing in intensive care, and the differences of nurses' decision making in Canada, Finland, Northern Ireland, Switzerland, and the United States. The instrument used in the study was a 56-item Likert-type questionnaire that has been used in previous studies and has proved to be a reliable tool. The target group comprised a nonrandom sample of nurses (N = 314) from five countries. The samples are not representative; therefore, the results in these cases cannot be generalized. The results showed that the decision making of nurses practicing in intensive care was broadly based, and that there were some country differences in data collection, problem definition, and planning. In contrast, decision making related to the implementation and evaluation of nursing is quite similar in the different countries. Canada and the United States on the one hand, and Finland, Northern Ireland, and Switzerland on the other, showed more similarities with each other in data collection, problem definition, and nursing planning related to decision making. Neither experience nor nurse's knowledge structure was associated with different decision-making approaches.

Evaluation of pelvic fractures. Clinical and radiologic

This article gives the orthopedic surgeon a framework to use during the initial evaluation of a patient with a pelvic fracture in the emergency room. The essential elements of the assessment of instability, both clinically and radiologically, are given in this article. Examples of the major patterns of instability are provided.

A phase I study of combined radiation therapy with 5-fluorouracil and low dose folinic acid in patients with locally advanced pancreatic or biliary carcinoma

PURPOSE

To evaluate the toxicities of a Phase I study of radiation therapy with concurrent 5-fluorouracil (5FU) and low dose folinic acid in patients with locally advanced pancreatic or biliary carcinoma.

METHODS AND MATERIALS

Twenty-seven patients with locally advanced carcinoma of the pancreas (n = 19), bile duct (n = 7), and gall bladder (n = 1) were entered into a Phase I study of combined radiation therapy, 5FU, and folinic acid. Radiation was given as a split course of 40 Gy in 20 daily fractions with a gap of 2 weeks after 20 Gy. 5-Fluorouracil, 300 to 375 mg/m2/day and folinic acid, 20 mg/m2/day were given as an i.v. bolus daily for 5 days beginning on day 1 and again on day 29.

RESULTS

Eight patients developed Grade 3 or 4 toxicities (National Cancer Institute common toxicity criteria) including nausea and vomiting (n = 4), oral mucositis (n = 4), myelosuppression (n = 2), infection (n = 2), and diarrhea (n = 1). Four patients did not complete the planned protocol due to treatment toxicities. There were two treatment deaths secondary to septic neutropenia. Treatment toxicity appeared to be related to age (> 70), performance status (ECOG = 2), and 5FU dose (> 350 mg/m2/day).

CONCLUSION

This protocol is poorly tolerated by elderly patients or those with poor performance status, and 350 mg/m2/day is our recommended dose for 5FU as given in this protocol.

Psychosocial adjustment in children with port-wine stains and prominent ears

OBJECTIVE

To evaluate psychosocial adjustment in children with port-wine stain (PWS) and children with prominent ears (PE).

METHOD

Thirty-two children aged 7 to 16 years with facial PWS and 42 children with PE were evaluated using the Harter Self-Perception Profile, the Revised Children's Manifest Anxiety Scale, the Children's Depression Inventory, the Disfigurement Perception Scale, and the Child Behavior Checklist. Results were compared with normative data for the local population or with a control group. Profile scores were correlated with severity of the PWS or prominence of the ears.

RESULTS

Children with PE had poorer self-perception, higher concentration anxiety, and more internalizing and externalizing symptoms, and they were more withdrawn and had more social problems than children with PWS. The children with PWS functioned as well as or better than nondisfigured peers on measurements of psychosocial adjustment, while children with PE scored lower than nondisfigured peers on measures of self-perception and parent-rated social and attention problems. There was no correlation between degree of disfigurement and level of psychosocial adjustment.

CONCLUSIONS

Psychosocial adjustment varied according to the nature of the disfigurement or deformity and was unrelated to the severity of the disfigurement.

Renal artery stenosis managed by Palmaz stent insertion: technical and clinical outcome

OBJECTIVE

To assess the technical and clinical outcome of Palmaz renal artery stent insertion in patients with renal artery stenosis.

DESIGN

Twenty-nine patients with radiological evidence of renal artery stenosis and hypertension (16 patients, mean +/- SD diastolic blood pressure 100.5 +/- 8.16 mmHg) and/or renal impairment (17 patients, mean +/- SD serum creatinine 376 +/- 169 mu mol/l) were referred for radiological intervention. Of these, 22 had ostial atheromatous lesions, six had atheromatous non-ostial lesions and one patient had fibromuscular dysplasia. Palmaz stent insertion was performed where either previous or concomitant percutaneous transluminal renal angioplasty (PTRA) had been unsuccessful. Technical success was defined primarily as <30% residual stenosis. A prospective radiological and clinical follow-up was performed and the results compared with the outcome following PTRA alone in a similar group of patients from our centre.

RESULTS

Immediate technical success was achieved in all 29 patients. Follow-up angiography in 24 patients after a mean of 7 months showed restenosis in four patients. The hypertension was not 'cured' in any patient; a blood pressure fall was observed in seven patients (44%) and no change in the remaining nine subjects (56%). Renal function improved in four patients (24%), two of whom had angiotensin converting enzyme inhibitor-exacerbated renal impairment. This compares with an immediate technical success of 81% for PTRA alone, with cure in 50% and improvement in 32% of patients with hypertension and improvement in renal function in 64.7% of patients with renal impairment.

CONCLUSIONS

Palmaz renal artery stent insertion has a higher technical success rate than PTRA, but the clinical improvement is disappointing in our patient population.

'It's the little things that count': the hidden complexity of everyday clinical nursing practice

This article reports on one aspect of a phenomenological study of everyday experience in nursing and how it contributes to the development of nursing expertise. The study was carried out with 10 'excellent, experienced' surgical ward sisters in two Scottish teaching hospitals. The ward sisters were found to help individual patients towards recovery by making the ward work for all. When moment-by-moment nursing practice, the context of nursing experience, is examined, it is found to be patient-centred and complex, geared towards multilayered goals. Three distinct yet inextricably intertwined processes--noticing, understanding and acting--characterize how nurses practise nursing. The quality of these processes contributes to the effectiveness of nurses' caring practices. The 'little things' of nursing practice make a difference to patients because they are imbued with nursing knowledge and skill.

Thoracic chordoma with unusual radiographic features

A case of chordoma involving the thoracic spine (T12) is reported. The plain film findings included lytic obstruction and partial collapse of a single vertebral body. Noncontrast CT and CT following Metrizamide myelography revealed vertebral body destruction with paravertebral and intraspinal soft tissue masses. Unusual findings in the case included a photon deficient area on nuclear medicine corresponding to the lesion and normal vascularity on spinal angiography. We know of no previous report describing chordoma as a "cold" defect on bone scanning.

A cloned fragment of HeLa DNA containing consensus sequences of satellite II and III DNA hybridizes with the Drosophila P-element and with the 1.8 kb family of human KpnI fragments

We have cloned a repetitive EcoRI fragment from the human genome which displays weak homologies with the Drosophila melanogaster transposable P-element. This cloned DNA appeared not to be a mobile element but, instead, a divergent member of human satellite II or III DNAs. We present here the first complete nucleotide sequence of a 1.797 kilobase pair (kb) satellite-like DNA. Moreover, this EcoRI satellite monomer contains a unique sequence of 49 basepairs (bp) that is devoid of the satellite consensus repeat 5'TTCCA3'. Southern hybridization analysis revealed that the cloned insert is closely related to a highly repetitive 1.8 kb KpnI family of tandemly organized satellite DNAs. Thus, the relationships among these satellite DNA families appear to be complex and may be a factor in their copy number, position and spatial organization.