Intensive care in Australia and New Zealand. No nonsense "down under"

The year 1996 was the 21st birthday of the Australian and New Zealand Annual Scientific Meeting on Intensive Care. With this maturity many of the issues that were so troublesome to intensive care in the early years relating to identity, training, recognition, and standards have largely resolved. There are, however, no signs of complacency. We need to improve the image of a career in intensive care to trainees, expand research opportunities, and respond to the ever-changing challenges coming from administrative reorganization, budgeting constraints, and increasing public expectations. I believe the foundations have been well laid to ensure a continuing contribution by Australian and New Zealand intensivists to clinical intensive care, their hospitals, ANZICS, and a place in the global research effort in intensive care.     

Diversity "down under": monogeneans in the Antipodes (Australia) with a prediction of monogenean biodiversity worldwide

There are approximately 25,000 species of fishes known in the world. The Monogenea are believed to be among the most host-specific of parasites and if each species of fish is host to a different species of monogenean, there could be almost 25,000 monogenean species on Earth. Currently, I estimate that between 3000 and 4000 of these are described. Australia has a rich marine fish fauna with approximately 3500 species of teleosts. If the same formula of one monogenean species per host fish species is applied, Australia marine fishes could host potentially 3500 species of monogeneans. The first monogenean species described from Australia was Encotyllabe pagrosomi MacCallum, 1917 and approximately 300 more species have since been described from the continent. Even in a region of Australia such as Heron Island on the Great Barrier Reef that has been a focus of sustained research on these parasites, only about 85 species are described from 40 of the most common, easily-caught species of fish. Reasons are discussed for the relatively small numbers of monogenean species described so far from Australia. Endemicity is difficult to judge, but only one is certain: Concinnocotyla australensis (Polystomatidae) from Neoceratodus forsteri (Dipnoi). Despite reductions in research funding, the value of parasite taxonomy must not be underestimated, particularly in regions of the world that have a rich diversity of potential hosts.     

Taking down the walls: a nurse manager's experience in acute care and home care

Changes in the health care system are stimulating trends in where and how nursing services are delivered. Nurse managers are responsible for the overall management of the nursing work unit and must be prepared to practice in settings other than acute care. Home care is a rapidly growing practice that emerges as patients are discharged from the hospital sooner with ongoing medical and nursing needs. The job responsibilities of a nurse manager remain similar across practice settings, including the transition from acute care to home care. A detailed checklist highlights specific similarities and differences in the nurse manager's role in acute care and home care settings. As the walls of the practice setting are taken down, nurse managers must build on current knowledge and creatively develop new skills to remain successful in ongoing job responsibilities.     

alpha-Crystallin polymers and polymerization: the view from down under

Several models have been proposed for the quaternary structure of alpha-crystallin. Some suggest the subunits are arranged in concentric shells. Others propose that the subunits are in a micelle-like arrangement. However, none is able to satisfactorily account for all observations on the protein and the quaternary structure of alpha-crystallin remains to be established. In this review, factors contributing to the assembly and polymerization are examined in order to evaluate the different models. Consideration of the variations in particle size and molecular weight under different conditions leads to the conclusion that alpha-crystallin cannot be a micelle or a layered structure. Instead, it is suggested that the protein may be assembled from a 'monomeric' unit comprising eight subunits arranged in two tetramers with cyclic symmetry. The octameric unit is proposed to be disc-like particle with a diameter of 9.5 nm and a height of 3 nm. The larger particles, chains and sheet-like structures commonly observed are assembled from the octamers. Structural predictions indicate that the polypeptide may be folded into three independent domains which have different roles in the structural organization and functions of the protein. It is suggested that the tetramers are stabilized through interactions involving the second domain (residues 64-104) while assembly into the octamers and higher polymers requires hydrophobic interactions involving the N-terminal domain. Deletion of parts of this domain by site directed mutagenesis revealed that residues 46-63 play a critical role in the assembly. Current research aims to identify the specific amino acids involved.     

"All fall down": the mechanism of orthostatic hypotension in multiple systems atrophy and Parkinson''s disease

A rare case of rheumatoid vasculitis and responses to a 15-year supervised exercise program. This patient presented with significant impairment in mobility and physical work capacity. His exercise tolerance improved considerably and he benefited emotionally.     

Renal drug targeting using a vector "alkylglycoside"

Cirrhosis and portal hypertension may be associated with pulmonary hypertension and pulmonary dysfunction. However, morphological pulmonary vascular lesions in patients with cirrhosis have not been well characterized morphometrically. We morphometrically evaluated pulmonary vessels in liver transplant recipients with pretransplantation cirrhosis and correlated our findings with pretransplantation cardiopulmonary function, postoperative course, and postmortem cardiopulmonary findings. Autopsy lung slides from 23 transplant recipients with pretransplantation cirrhosis were examined. External vessel diameter, intimal thickness, and arterial medial thickness were measured with a micrometer after pentachrome staining. The percent of total diameter comprised by intima or media was calculated for each vessel. Medical records were reviewed for smoking history, pretransplantation cardiopulmonary function testing, and postoperative course. Autopsy cases without liver or significant cardiopulmonary diseases, matched for age, sex, and smoking history, served as controls. Transplant recipients had significantly more pulmonary venous intimal thickening than matched controls (P <.0001). Sixty-five percent (15 of 23) of these patients had some degree of pretransplantation pulmonary dysfunction, defined by abnormalities in pulmonary function tests, oxygen saturation, and/or increased pulmonary artery pressures. However, the severity of venous intimal thickening did not correlate with the severity of pretransplantation pulmonary dysfunction. Arterial intimal and medial thickness were not statistically significantly different from controls. Pulmonary venous intimal thickening and resultant luminal impingement are morphological findings not previously described in this population. The arterial lesion, when present, is similar to that seen in pulmonary hypertension from other causes. These pulmonary vascular lesions may be implicated in pulmonary dysfunction in patients with cirrhosis and may be associated with increased posttransplantation cardiopulmonary morbidity and mortality.     

Change in the land vertebrate community under new conditions in nature]

PURPOSE: To report bilateral congenital optic nerve head pits in monozygotic siblings. METHOD: Case reports. RESULTS: Pits were found in abnormally large optic disks in both eyes of two otherwise healthy female monozygotic siblings aged 15 years. Pit size increased and visual acuity decreased with increased optic disk area. In one eye, nonrhegmatogenous retinal detachment developed that eventually necessitated pars plana vitrectomy. The siblings' parents were unremarkable. CONCLUSIONS: Congenital optic nerve head pits can occur bilaterally in otherwise healthy monozygotic siblings with ophthalmologically unremarkable parents. Associated nonrhegmatogenous retinal detachment may be treated by pars plana vitrectomy. Pit size is positively correlated with disk area.     

Spirituality "importance for care"

The causes of red eye range from trivial to life-threatening, and many general practitioners are uncertain of their ability to diagnose them with the aid of an ophthalmoscope. We tested the hypothesis that, in the assessment of a patient with red eye, a doctor using a slit lamp biomicroscope would not differ in diagnostic accuracy from a doctor using a direct ophthalmoscope. A cross-over study was conducted in 98 patients newly attending an eye casualty department. 71% of diagnoses agreed exactly, and all potentially sight-threatening lesions were either diagnosed correctly or managed appropriately by doctors using an ophthalmoscope. We conclude that the initial diagnosis and management of patients with an acute red eye is not prejudiced by the lack of a slit lamp biomicroscope.     

"Stand down for the homeless". Podiatric screening of a homeless population in Cleveland

The reliability of helical CT as sole preoperative diagnostic technique for abdominal aortic aneurysms (AAA) and its accuracy in detecting vascular anomalies in the abdominal region was evaluated retrospectively in 42 patients with asymptomatic AAA > 40 mm. A single breath-holding helical scan was performed with 5 mm slice thickness, during a single injection of contrast medium, resulting in a 20 cm z-axis coverage. Axial images were reconstructed and used to generate high quality multiplanar reformatted images. Digital subtraction angiography (DSA) was performed in the first 18 patients and then in case of associated peripheral vascular disease (6 patients). Helical CT exactly showed, in all cases, the proximal and distal extent of the AAA. The visceral vessels as well as the inferior vena cava and renal veins were always clearly depicted, showing anatomical variants or pathological involvement in 19 patients. DSA gave sufficient details on the distal run-off but did not allow a reliable visualization of the visceral branches, venous anomalies and true extent of AAA. In our experience helical CT should be considered as the sole method for preoperative imaging of AAA. It allows a complete and precise evaluation; it is fast, with low doses of radiations and does not require hospitalization.     

A patient under the influence of alcohol under acute care in the emergency department

The authors of this paper paid special attention to the problem of treatment patients being under influence of drink, which was very often left out in the past. Investigation shows the cases contains patients treated in Clinic of Traumatology CM UJ in years 1990-1994 and pays attention to difference between these patients to the others. The authors included difficulties, that physicians usually meet in process of diagnosis and treatment. Data was analysed under sort of injuries and their causes. Complement data is lawful, toxicological and economical aspect of the question. This work means to make easier taking the decision about diagnosis and treatment for the physicians, who meet such kind of patients during emergency service.     

Using literature in health care: reflections on "the yellow wallpaper"

OBJECTIVE: To discuss how literature can be used to educate healthcare practitioners and students about the patient's physical and emotional response to treatment. DATA SOURCES: A MEDLINE search (January 1975-November 1997) of English-language literature pertinent to using literature in health care was performed. Additional literature was obtained from a search of the New York University Web site on medicine and humanities, biographies of Charlotte Perkins Gilman, and a search of the MLA and INFOTRAC database. SELECTION AND DATA EXTRACTION: All articles and literature were considered for possible inclusion in this article. Pertinent information, as judged by the author, was selected for discussion. SUMMARY: Literature can pose a wealth of information to the healthcare professional. The short story "The Yellow Wallpaper" is analyzed in this article as one example of how literature portrays the patient's emotional response to disease. This short story describes a 19th-century woman's "descent into madness" and the ineffective treatment attempted by her well-meaning physician husband. The author, Charlotte Perkins Gilman, loosely based the story on her own experience with the respected physician, S Weir Mitchell and his famous rest cure. Some biographical information about Mitchell and Perkins is included, as well as a commentary on the treatment of depression in the 19th century. CONCLUSIONS: Short stories such as "The Yellow Wallpaper," novels, and other short stories can help to remind the healthcare professional of the subjective nature of even our most proven therapies. As we strive to teach and deliver pharmaceutical care, we can use literature to help us understand the emotional impact of our drug therapies.     

HEDIS for the primary care provider: getting an "A" on the managed care report card

In 1999, quality in primary care will be measured more closely than ever before. Quality will not only be measured--but also reported-- and reported in a form that consumers can use to compare health plans. A health plan's accreditation will depend on its performance on a series of 14 performance measures, referred to as the Health Plan Employer Data and Information Set, Version 3.0 (HEDIS 3.0), which the National Committee for Quality Assurance, an organization that accredits health plans, has developed, quantified, refined, and publicized. This article introduces the primary care clinician to HEDIS quality measures and recommends tools clinicians can use to score well in performance evaluations.