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Steroids in allergic disease.

From the experience above, it may be concluded that corticosteroid therapy in allergic disease has become more effective than ever before. The expected variations in usage of new important pharmacologic agents is seen with special clarity in the use of corticosteroids. The wide acclaim for the "miracle drug of the 1950's", which followed penicillin of the 1940's, soon gave away to anguish about side-effects that threatened to abolish its use entirely in the late 1950's. The 1960's brought alternate day therapy for chronic usage and recognition that short term usage was relatively safe. The 1970's saw proliferation of topically active steroids similar to those so important to the practice of Dermatology in the previous decade. Results in treating asthma and nasal diseases have been excellent and extensive research for adverse effects has been largely unrevealing.

Administration, Intranasal↗

Satisfaction with practices: emergency physicians versus internists.

No comparison has been made of satisfaction with practices of emergency physicians versus other specialists. We used a previously tested questionnaire that measures differences between current and preferred practice conditions, and with items regarding training and practice, and intention to change positions. It was sent to 250 physicians practicing emergency medicine and 250 practicing internal medicine in a metropolitan area. Both specialty types were defined by type of practice, rather than by specialty training or board certification. Ninety-five (38%) emergency physicians and 79 (32%) internists responded. Factor and correlation analyses identified six satisfaction indexes: resources, professional autonomy, administrative autonomy, patient relationships, professional relationships, and status. Physicians practicing emergency medicine were less satisfied, that is, reported more difference between current and preferred conditions, than physicians practicing internal medicine with professional autonomy, patient relations, and status (by t tests, P less than .01 for each). Emergency physicians were more satisfied with professional relationships (P less than .01). Only 40% of emergency physicians, versus 60% of internists, reported no intention to leave their present position within the next two years (P less than .02). Expectation of position change by physicians practicing emergency medicine was predicted by dissatisfaction with professional autonomy, lack of board certification, recency of graduation from medical school, and belief that monetary compensation would be higher elsewhere (R square, 0.35; P less than .01), while variables such as patient load, hours worked per week, and hospital size proved unimportant. We identified areas of dissatisfaction among emergency physicians that differed from those among internists.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Intracoronary basic fibroblast growth factor enhances myocardial collateral perfusion in dogs.

OBJECTIVE: In preparation for clinical trials of basic fibroblast growth factor (bFGF) to treat ischemic heart disease, we sought to identify a clinically feasible method of bFGF administration. BACKGROUND: Basic FGF has been shown to promote collateral development after experimentally induced coronary occlusion; however, methods of bFGF delivery that have been shown to be effective in previous investigations would not be practical for clinical use. METHODS: Four randomized, blinded, controlled investigations were conducted independently and sequentially in an established canine model. For all studies, dogs underwent operative placement of proximal left circumflex coronary artery ameroid constrictors. The four investigational regimens included: 1) bFGF by central venous bolus injection, 1,740 microg/day for one, two or seven days; 2) bFGF by intravenous infusion, 100 microg/kg body weight per day for seven days; 3) bFGF by pericardial instillation, 2,000 microg/day for 7 days; and 4) bFGF by intracoronary injection (Judkin's technique), 100 microg/kg per day for one or two days. Each substudy included a contemporaneous vehicle control group. Collateral perfusion (microspheres) was assessed during maximal coronary vasodilation during the first month after ameroid placement. RESULTS: Maximal collateral perfusion in dogs that received intracoronary bFGF for two days exceeded that of concurrent control dogs by 31% (p < 0.01). Perfusion was not increased in dogs that received single-dose intracoronary bFGF. Basic FGF administration by central venous bolus injection, intravenous infusion and pericardial injection failed to enhance collateral perfusion. CONCLUSIONS: Administration of bFGF by the intracoronary route, an intervention that is feasible in patients, augments collateral development in dogs. These data provide a rationale for clinical testing of intracoronary bFGF in ischemic heart disease.

Animals↗

A nursing practice paradigm for depressed rural women: the Women's Affective Illness Treatment Program.

Major depressive disorder (MDD) results from a complex interplay of biological, psychological, and social factors that act as historical and contemporary antecedents. To promote and maintain recovery from depression women with MDD must understand their depression risk, act to reduce symptoms, and maintain a lifetime program of relapse prevention. This requires self-care skills including self-assessment, stress response reduction, and health behavior modification. The Women's Affective Illness Treatment Program (WAIT) is a skill-based depression recovery program that addresses the complex cause of major depressive disorder in women. WAIT is based on the Nursing Practice Paradigm described in a previously published article.

Depressive Disorder↗

An epidemic without illness. Using dna markers to model infection.

PURPOSE: Combining molecular biology with infection control interventions can increase compliance and allow objective measurement of effectiveness. We developed a group of PCR detectable non-infectious DNA markers that can be used to model infection and provide immediate feedback on hygiene practices in institutional settings. In previous studies, we illustrated that the markers were spread in the environment in the same manner as infectious particles.METHODS: We are conducting a prospective study in 10 child care centers in order to 1) confirm that the DNA markers are valid surrogates for bacteria and viruses; 2) identify specific foci of contamination and modes of transmission; 3) illustrate the effectiveness of infection control programs utilizing the DNA markers. Centers are randomized to receive an interactive educational infection control intervention or a standard immunization intervention. The DNA markers are introduced into the center and the rate of dispersion of the DNA markers is compared with directly observed changes in hygiene behavior among the staff.RESULTS: Initial results indicate that the markers can be removed mechanically by hand washing and that common over-the-counter cleaners are effective in inactivating the markers. Toys, countertops and doorknobs appear to be more important as infectious reservoirs than brief casual contact. Data from the prospective study will be available prior to September, 2000.CONCLUSIONS: This novel approach utilizing an objective measurement will be used to identify the interaction between behavior and environmental reservoirs of infection and drive future strategies for infection control.

Journal Article↗

Further evaluation of an in vivo micronucleus test on rat and mouse skin: results with five skin carcinogens.

In a previous paper, we presented a practical in vivo micronucleus (MN) test that used rat skin as the target organ. To evaluate the test, as well as to determine the reproducibility and applicability of the method to mice, we used it to test the effect of five skin carcinogens (N-ethyl-N'-nitro-N-nitrosoguanidine (ENNG), N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), 4-nitroquinoline 1-oxide (4NQO), 7,12-dimethylbenz[a]anthracene (DMBA), and benzo[a]pyrene (B[a]P)) on rat and mouse skin. All five compounds significantly and dose-dependently increased the MN frequencies in the basal cells of the chemical-treated skin. These results indicated the reproducibility of the test results and also the applicability of the test to mice as well as rats.

4-Nitroquinoline-1-oxide↗

Methodological considerations in estimating speed of cognitive operations.

Individuals infected with Human Immunodeficiency Virus (HIV) and having cognitive impairment have been described as having slow mentation. Data supporting this proposition come from a variety of sources, including Sternberg's (1966) item recognition memory task. The procedure nominally provides an index of speed of mental operations, independent from input/output demands. However, since the original use of this procedure in the 1960s, advances in cognitive psychology have revealed many of its limitations. The purpose of the present study was to examine the psychometric characteristics of this task. Each participant performed the Sternberg item recognition task twice, 6 mo apart. The stability of the estimate of the slope of regression equations and for zero intercept ranged from excellent (r = .87) to poor (r = .30), and the data from many individual subjects could not be reliably modelled using multiple linear regression techniques. These data, as well as those from previous research, demonstrate the limited practical use of this task in clinical samples. Furthermore, as cognitive psychological theory has advanced in the past 30 yr, the conceptual underpinnings of the procedure have essentially evaporated.

AIDS Dementia Complex↗

Selection of smart aptamers by methods of kinetic capillary electrophoresis.

We coin the term "smart aptamers" -- aptamers with predefined binding parameters (k(on), k(off), Kd) of aptamer-target interaction. Aptamers, in general, are oligonucleotides, which are capable of binding target molecules with high affinity and selectivity. They are considered as potential therapeutic targets and also thought to rival antibodies in immunoassay-like analyses. Aptamers are selected from combinatorial libraries of oligonucleotides by affinity methods. Until now, technological limitations have precluded the development of smart aptamers. Here, we report on two kinetic capillary electrophoresis techniques applicable to the selection of smart aptamers. Equilibrium capillary electrophoresis of equilibrium mixtures was used to develop aptamers with predefined equilibrium dissociation constants (Kd), while nonequilibrium capillary electrophoresis of equilibrium mixtures facilitated selection of aptamers with different dissociation rate constants (k(off)). Selections were made for MutS protein, for which aptamers have never been previously developed. Both theoretical and practical aspects of smart aptamer development are presented, and the advantages of this new type of affinity probes are described.

Aptamers, Nucleotide↗

Influence of the order of reagent addition on NDMA formation during chloramination.

The formation of the potent carcinogen, N-nitrosodimethylamine (NDMA), during chlorine disinfection has caused significant concern among drinking water and wastewater recycling utilities practicing intentional or unintentional chloramination. Previous research modeled NDMA formation as arising from a reaction between monochloramine and organic nitrogen precursors, such as dimethylamine, via an unsymmetrical dimethylhydrazine (UDMH) intermediate. Contrary to the importance of monochloramine indicated by previous studies, hypochlorite formed an order of magnitude more NDMA than monochloramine when applied to a secondary municipal wastewater effluent containing excess ammonia. Experiments involving variation of the order that each reagent (i.e., hypochlorite, ammonium chloride, and dimethylamine) was added to solution suggest two factors that may be more important for NDMA formation than the presence of monochloramine: (i) the chlorination state of organic nitrogen precursors and (ii) the partial formation of dichloramine. Although dichloramine formation was most influenced by the pH conditions under which inorganic chloramine formation was performed, mixing effects related to the order of reagent addition may be important at full-scale plants. Chloramination strategies are suggested that may reduce NDMA formation by nearly an order of magnitude.

Ammonium Chloride↗

Management of familial breast cancer risk.

Women who are members of breast cancer families are at increased risk for breast cancer. The cloning of BRCA1 and BRCA2 has made it possible to identify mutation carriers within some of these families. Management of breast cancer risk in these families, which presents enormous challenges to patients and clinicians, is addressed. Management should begin with a full evaluation of the patient, including construction of a three-generation pedigree, ascertainment of non-genetic factors that may impact on risk, information on previous and current breast health, practice of and attitudes toward screening, and the psychosocial impact of family history on the individual. Patient priorities in risk management should be explicitly reviewed; these may include survival, cancer prevention, breast preservation, optimization of quality of life or minimization of disruption of day-to-day activities. Approaches to risk management involve screening (usually considered the mainstay), anti-estrogens, prophylactic surgery and/or lifestyle modifications. Specific gene therapy may become available in the future. Management decisions should be individualized to reflect risk levels and patient priorities and goals, within bounds that are medically and scientifically reasonable. An explicit examination of different time-frames (1, 5, 10 years) is recommended given the rapid evolution of knowledge in this area.

Adult↗

Labial piercing resulting in gingival recession. A case series.

Several complications of oral piercing have been recently reported in the medical and dental literature. Even though few people have had problems related to oral piercing, dentists should familiarise themselves with the potential associated oral and dental problems. We present three cases of young people with gingival recession in the mandibular incisor area related to labial piercing. The clinical examination and the dental history of the three cases revealed the relationship between the gingival recession and the presence of labial piercing. In particular, a stud in the lower lip was held in place by a metal disk on the inner labial mucosa in each case. The metal disk was in close proximity to the mandibular front teeth and it would appear that it was responsible for local trauma and recession. This case series reinforces previously reported concerns regarding the practice of piercing and the role of the dentist, both in advising patients with oral or facial piercing and in the treatment of related oral, gingival and dental problems.

Adult↗

Conformational analysis of oleandomycin and its 8-methylene-9-oxime derivative by NMR and molecular modelling.

Conformations of the 14-membered macrolide antibiotic oleandomycin and its 8-methylene-9-oxime derivative were determined in various solvents. The experimental NMR data--coupling constants and NOE contacts--were compared with the results of molecular modelling--molecular mechanics calculations and molecular dynamics simulations. The conformational changes, on the right-hand side of the 14-membered ring, affected mostly the 3JH2,H3 values and NOE crosspeaks H3 or H4 to H11. Oleandomycin was found to be present predominantly in the C3-C5 folded-in conformations in DMSO-d6 solution, whereas in buffered D2O, acetone-d6 and CDCl3, there was a mixture of folded-in and folded-out conformational families. The predominant conformation of the 8-methylene-oleandomycin-9-oxime derivative in solution was a folded-out one although different amounts of folded-in conformation were also present depending on the solvent. Oleandrose and desosamine sugar moieties adopted the usual and expected chair conformation. The conformation around the glycosidic bonds, governing the relative orientation of sugars vs. the lactone ring, showed a certain flexibility within two conformationally close families. We believe that by combining the experimental NMR data and the molecular modelling techniques, as reported in this paper, we have made significant progress in understanding the conformational behaviour and properties of macrolides. Our belief is based on our own current studies on oleandomycins as well as on the previously reported results and best practices concerning other macrolides. A rational for macrolide conformational studies and advances in methodology has been suggested accordingly.

Carbon Isotopes↗

Shared decision making observed in clinical practice: visual displays of communication sequence and patterns.

UNLABELLED: The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding METHOD: The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.

Adult↗

Nursing workload: an unquantifiable entity.

BACKGROUND: In the increasingly prominent drives towards cost containment and efficiency nursing is under pressure to justify its value to healthcare. On the surface nursing workload assessment methods would appear to offer a means to quantify the nursing input to patient care. AIMS: To examine the validity of nursing workload methods with respect to nursing practice and nursing knowledge. FINDINGS: Previous studies and the conclusions of subject reviews have cast doubt on the reliability and validity of most methods and indicate that they have no clear theoretical base. CONCLUSION: It appears that nursing is more concerned with knowledge processing and nurses' intentions than just with the activities of caring. It is suggested that patients control the time element of nursing care. The need for nursing workload information, despite its validity problems, is discussed and a pragmatic solution is suggested.

Diagnosis-Related Groups↗

Preparing teams for low-frequency emergencies in Norwegian hospitals.

BACKGROUND: Medical emergencies and major trauma require optimal team function. Leadership, co-operation and communication are the most essential issues. Due to low caseloads such emergencies occur rarely in most Norwegian hospitals. Team training of personnel between real emergencies is expected to improve performance in comparable settings. Most hospitals have cardiac arrest teams, but it is known that the training of such multiprofessional teams varies widely. We wanted to know if this also was the case for trauma teams and resuscitation teams for newborns. METHODS: A telephone survey of training practices in all the Norwegian hospitals with acute cover was conducted in 2002. Information was obtained on whether trauma teams and neonatal resuscitation teams had participated in practical multiprofessional training during the previous 6 or 12 months. RESULTS: Information was obtained from all 50 hospitals. Of the acute care hospitals, 30% had trained their trauma teams during the previous 6 months, and an additional 18% when considering the previous year, while 38% of neonatal wards had multiprofessional training during the previous 6 months, and additionally 13% had had training during the previous year. Additionally four neonatal wards had had regular training of nurses only. More than 80% of all respondents judged regular team training to be achievable, and none considered this training impossible. CONCLUSION: Only half the Norwegian acute care hospitals reported at least yearly training of trauma and neonatal resuscitation teams. Regular team training represents an underused potential to improve handling of low-frequency emergencies.

Emergency Service, Hospital↗

Bilevel anesthesia and blunt dissection: rapid and safe surgery.

BACKGROUND: A new concept of bilevel anesthesia, initially instilling a subcutaneous tumescent solution followed by surface anesthesia, and then dissection limited to blunt instrumentation has been developed. OBJECTIVE: The purpose of these developments has been to evolve more rapid and safe surgical intervention. METHODS: This work has included a wide variety of surgeries on patients over several years, including grafts, flaps, and hair transplantation. RESULTS: Excellent anesthesia with virtually bloodless surgical fields has followed the adoption of bilevel anesthesia with blunt dissection practices. CONCLUSION: Adoption of the previously described tumescent anesthetic infiltration with blunt dissection principles combined now with stronger epidermal-dermal anesthetic and epinephrine solutions allows the safest and most rapid surgery described to date.

Anesthesia, Local↗

Ovarian aging and hormone replacement therapy. Hormonal levels, symptoms, and attitudes of African-American and white women.

OBJECTIVES: To characterize reproductive hormone levels, symptoms, and attitudes related to menopause among healthy, menstruating white and African-American women aged 44 to 49 years. DESIGN: Pilot study; cross-sectional survey. SETTING: Community-based convenience sample of women in the Philadelphia metropolitan area. PARTICIPANTS: Thirty-three African-American and 35 white women. MEASUREMENTS: The survey instrument collected demographic data, medical and reproductive history, health practices and behaviors. It included previously validated function, depression, and quality-of-life instruments, and a Menopause Attitude Scale that included two factors, attitudes toward the menopause and attitudes toward medical therapy. Anthropometric measurements were taken at enrollment, and reproductive hormones and daily symptom logs were followed over two menstrual cycles. MAIN RESULTS: The two groups were comparable in mean age (African-American 46.2 years, white 46.9 years). Serum levels of estradiol, follicle-stimulating hormone, dihydroepiandrosterone-sulfate, and progesterone were comparable. Symptoms were similar in type and frequency. However, the African-American women had significantly more positive attitudes toward menopause, were more likely to rely on family for information about menopause, and were less likely to have been recommended hormone replacement therapy by their physicians. A majority of women in each group expressed satisfaction with the care they had received. CONCLUSIONS: Perimenopausal African-American and white women have different expectations of menopause and the role of medical care in menopause. This bears directly on women's acceptance of hormone replacement therapy. Conclusions are limited by the small sample size and convenience nature of the study population: further work with larger samples is needed to confirm these apparent differences.

Black or African American↗

Atrial thrombus and central venous dialysis catheters.

A native arteriovenous fistula is the first choice for hemodialysis access. Despite improved catheter designs and the use of internal jugular veins, thrombotic complications still occur when tunneled central venous catheters are used as an alternative. Although right atrial thrombus (RAT) is a well-characterized complication of long-term central venous cannulation, particularly when used for parenteral nutrition and chemotherapy in pediatric practice, only 9 reported cases previously have been associated with the long-term use of central venous catheters for hemodialysis. We report five cases of RAT seen at our unit between 1994 and 1998 in patients who had been dialyzed using tunneled catheters. In four of five cases, the diagnosis was made during the investigation of hemoptysis or dyspnea. In the fifth case, a screening transthoracic echocardiogram revealed the thrombus. Three of five of the patients suffered pulmonary emboli, and a fourth patient had an unexplained electromechanical dissociation cardiac arrest without definite evidence of pulmonary embolus. Our experience suggests that anticoagulated patients with RAT remain at risk of pulmonary embolism. One of our patients successfully underwent atrial thrombectomy. In four of five of our cases and four of nine cases in the literature, the central venous catheter tip was within the right atrium. Positioning of the central venous catheter tip low down in the superior vena cava or in the right atrium has been advocated to improve dialysis adequacy and to reduce the incidence of catheter thrombosis. However, placement of the catheter tip within the right atrium may be associated with an increased risk of RAT.

Adolescent↗