Congenital toxoplasmosis and seroconversion at the end of pregnancy: clinical observations

OBJECTIVE: To determine the knowledge of HIV-disease management and the adherence to contemporary guidelines among British Columbia physicians whose practices focused on HIV/AIDS. DESIGN: Self-administered mail survey. PARTICIPANTS: All 659 physicians registered in a province-wide HIV/AIDS drug treatment program. OUTCOME MEASURES: Data on demographic and personal characteristics of respondents, level of HIV-related experience, use of preventive vaccinations and tests, and preferred approaches to the prophylaxis and treatment of common opportunistic infections. Knowledge scores in 4 areas of patient care, as well as an overall score, were computed by comparing respondents' answers with the therapeutic strategies recommended at the time of the survey. Associations between physician characteristics and knowledge scores were identified by linear regression analysis. RESULTS: Of the 659 physicians surveyed, 65% returned responses: only 38% returned completed surveys while a further 27% returned a follow-up survey that asked nonrespondents about their demographic characteristics and HIV-related experience. Scores for specific areas of patient management ranged from 29% for the treatment of opportunistic infections to 62% for preventive measures, with a mean overall score of 47%. Physician knowledge in all areas of patient care was associated with the number of HIV-positive patients in the practice (p = 0.003 to p < 0.001). Physicians who were younger were more knowledgeable regarding preventive measures (p = 0.001); those whose practice location was in Vancouver had a greater knowledge of prophylaxis (p = 0.047); and those who had medical specialty training were more knowledgeable about the treatment of opportunistic infections (p = 0.009). CONCLUSIONS: There is substantial disparity in how physicians approach the management of HIV and related conditions. Deviations from therapeutic guidelines are common and may be associated with physician characteristics, particularly lack of experience in managing HIV.     

Peculiarities of the osmotic response in dehydrated erythrocytes

The regulation of glycogen synthase (GS) and glycogen phosphorylase (GP) activity by phosphorylation/ dephosphorylation has been proposed to be via changes in activities of several different protein (serine/threonine) phosphatases and kinases, including protein phosphatase (PP) 1/2A, PP2C, and cAMP-dependent protein kinase (PKA). In order to determine whether PP1/2A, PP2C, and/or PKA activities are related to GS and/or GP activities, these enzymes were measured in freeze-clamped liver biopsies obtained under basal fasting conditions from 16 obese monkeys. Four monkeys were normoglycemic and normoinsulinemic, five were hyperinsulinemic, and seven had type 2 diabetes (NIDDM). Liver glycogen and glucose 6-phosphate (G6P) contents were also determine. Basal enzyme activities and basal substrate concentrations were not significantly different between the three group of obese monkeys; however, there were several significant linear relationships observed when the monkeys were treated as one group. Therefore, multiple regression was used to determine the correlation between key variables. GS fractional activity was correlated to GP fractional activity (p < 0.05) and to PP2C activity (p = 0.005) (adjusted R2, 53%). GP independent activity was correlated to GS independent activity (p < 0.07) and to PKA fractional activity (p = 0.005) (adjusted R2, 64%). PP2C activity was correlated to GS fractional activity (p < 0.0005) and to PP1/2A activity (p < 0.0001) (adjusted R2, 83%). PKA fractional activity was correlated to GP total activity (p < 0.0005) and to age (p = 0.001) (adjusted R2, 82%). G6P content was correlated to glycogen content (p < 0.05) and to PP2C activity (p = 0.0005) (adjusted R2, 73%). In conclusion, PP2C and PKA are involved in the regulation of GS and GP activity in the basal state in liver of obese monkeys with a wide range of glucose tolerance.     

Factors associated with an atherogenic lipid profile in premenopausal women without clinical cardiovascular disease

BACKGROUND: To investigate different factors associated to a non desirable lipid profile in premenopausal women without cardiovascular disease. To determine the independent factors of lipid profile as a whole of the sample, for planning preventive studies. PATIENTS AND METHODS: We study (March 1994 to June 1996) premenopausal women with alcohol consumption less than 14 g/day and normal serum level of glucose. Group I: women with a non desirable lipid profile (total cholesterol [TCH, mg/dl]/high density lipoprotein cholesterol [HDL-C, mg/dl] > or = 5). Group II: with a desirable lipid profile (TCH/HDL-C < 5). The following factors were analyzed: age, body mass index (BMI), waist/hip ratio (W/H), systolic blood pressure (SBP, mmHg), fasting plasma insulin (fpI, microU/ml), cigarette smoke (CS) and presence of parents with history of non insulin dependent diabetes mellitus (NIDDM) or hypertension. Statistical methods: Mann-Whitney and Student statistics. Contingency-table analysis (chi 2 statistic). Pearson correlation and multiple linear regression. RESULTS: We analyzed 126 women (age = 30 +/- 8.2; 95% CI, 29-32; TCH = 197 +/- 36; 95% CI, 190-203 mg/dl), with 20 women (group I) and 106 (group II). Women from group I had higher values of W/H (0.83 +/- 0.04 vs 0.78 +/- 0.06; p < 0.001), BMI (29.9 +/- 9 vs 24.6 +/- 4.9; p < 0.03), fpI (12.9 +/- 10.4 vs 7.8 +/- 3.5; p < 0.05), SBP (125.9 vs 117; p < 0.02), as well as higher percentage of smokers (75 vs 40%; p < 0.01) and parents with NIDDM (60 vs 26%; p < 0.01) or hypertension (60 vs 49%; NS). No differences of age were detected (32 +/- 7.3 vs 30 +/- 8.3; NS). BMI (0.32; p < 0.01), W/H (0.50; p < 0.01), SBP (0.27; p < 0.01) and fpI (0.33; p < 0.01) were positively correlated with TCH/HDL-C ratio (n = 126). In multiple regression analysis (n = 126), W/H (regression coefficient = 6.1; 95% CI, 3.1-9.1), fpI (regression coefficient = 0.045; 95% CI, 0.018-0.072) and CS (regression coefficient = 0.5; 95% CI, 0.336-0.667) were the only independent predictors (p < 0.01) of the TCH/HDL-C ratio, controlling a 46% of the variance (R2 = 0.46). CONCLUSIONS: Our data indicates that central obesity, hyperinsulinemia and cigarette smoke are independently associated to a high risk cardiovascular lipid profile in premenopausal women without cardiovascular disease. This study suggests the importance of these factors in the management of early lipid control in these women.     

Analysis of a genetic factor of metal allergy--polymorphism of HLA-DR, -DQ gene

To reveal immunogenetic factors involved in the pathogenesis of metal allergy, 30 unrelated Japanese patients with histories of metal allergy were typed for HLA. They were confirmed by an unequivocal positive patch-test reaction to mercury, nickel or palladium. The HLA-DR and -DQ DNA were typed by using the polymerase chain reaction-sequence specific oligonucleotide probe (PCR-SSO) method. The frequency of each allele in the patient groups was compared to that in normal Japanese subjects. In mercury sensitive patients, there was no significant HLA association. In nickel sensitive patients, there was a significant increase of DRB4 (p < 0.05) but no significant association of DRB1 nor DQ locus, although there was an increase of DRB1*0405 (R.R = 2.36). In palladium sensitive patients, there were significant increases of DRB4 (R.R. = 15.48, p < 0.05), DR4(R.R. = 13.27, p < 0.005), DRB1*0405(R.R. = 4.43, p < 0.05), and DQB1*0401 (R.R. = 4.59, p < 0.05), and significant decreases of DRB5 (R.R. = 0.09, p < 0.05), and DQA1*0103 (R.R. = 0, p < 0.05).     

Impaired perception of dyspnea in patients with severe asthma. Relation to sputum eosinophils

Poor dyspnea perception might be a risk factor for developing asthma exacerbations. We investigated whether severe asthmatics with recurrent exacerbations (brittle asthma) have different dyspnea perception and sputum cells compared with equally severe, but stable asthmatics, or patients with mild steroid-naive asthma. Fifteen brittle asthmatics (13 female, median age 28 yr [range, 20 to 47 yr]), 15 matched severe-stable asthmatics (14 female, median age 26 yr [range, 17 to 52 yr]), and 11 mild asthmatics (8 female, median age 25 yr [range, 19 to 43 yr]) underwent inhalation tests with methacholine (MCh), and hypertonic saline combined with sputum induction. Dyspnea was assessed by Borg and Visual Analogue Scale (VAS), plotted against the percent fall in FEV1, and expressed as the slope of the regression line (Slope-Borg and Slope-VAS). The brittle and stable asthmatics had poorer perception than patients with mild asthma (Slope-Borg [p = 0.036], Slope-VAS [p < 0.001] for MCh). In patients with brittle asthma the perception was less as compared with severe-stable asthma (Slope-Borg for MCh: p = 0.05). In the severe asthmatics there was an inverse correlation between sputum eosinophilia and Slope-Borg and Slope-VAS (R = -0.55, p = 0. 002 and R = -0.37, p = 0.049), whereas this correlation was a positive one in the mild asthmatics (R = 0.79, p = 0.012 and R = 0. 67, p = 0.05). In conclusion, patients with severe asthma, particularly those with recurrent exacerbations, have blunted perception of dyspnea, which is related to the degree of sputum eosinophilia. This suggests that increased sputum eosinophilia is an indicator of clinical instabililty, and that eosinophilic airways inflammation might affect dyspnea perception in severe asthma.     

The application of transmeatal exploratory tympanotomy

BACKGROUND: Rhodococcus equi (formerly Corynebacterium) has been long considered an exclusively zoopathogenic microbe causing mainly granulomatous pneumonias and lung abscesses in young foals. The aim of this paper was to analyse substantial features of R, equi infections hitherto reported in man. METHODS AND RESULTS: MEDLINE database was searched for relevant reports. When the original source was not obtained the data from reviews were employed. Together, 105 cases of R, equi infection in man were reported. Median age was 35 years with a range from 9 months to 83 years. The male: female ratio was 3.3. Lungs were involved in 72 cases (69%), extrapulmonary abscesses as the only symptom of infection were described in 9 cases, septic state in 7 cases. Clinical outcome was known in 98 cases, being fatal in 41 (42%). Therapy was mentioned in 70 reports, the most often used drugs being erythromycin (30 cases, 12 deaths), rifampicin (19 cases, 7 deaths) and vancomycin (18 cases, 6 deaths). R. equi was isolated from the sputum of 69% patients with the pulmonary involvement. Blood cultures were positive in 35% of cases. Out of total, 49% persons were HIV positive. Median age for HIV positive patients was 32 years with a range from 18 to 71 years, for HIV negative patients 52 years with a range from 9 months to 83 years. There were 97% males in the HIV positive group in contrast to 59% in the HIV negative group (p < 0.01). Lungs were involved in 90% of HIV positive and 48% of HIV negative cases (p < 0.01). Extrapulmonary abscesses as the only sign of infection were seen in 2% of HIV positive persons and in 15% of HIV negative ones (p < 0.05). Outcome was fatal for 60% of the HIV positive hosts and for 28% of the HIV negative individuals (p < 0.01). R. equi was isolated from the sputum of 80% pneumonic HIV positive patients and of 50% of pneumonic patients without HIV infection (p < 0.05). R. equi was detected in the blood of 67% of HIV positive patients and of 33% of HIV negative ones (p < 0.01). CONCLUSIONS: The analysis of published reports shows that whereas R. equi causes mainly pneumonia in persons with HIV infection, in HIV negative individuals extrapulmonary manifestations slightly prevail, most often abscesses, sepsis, eye involvement and wound infections.     

Eosinophil cationic protein in the asthmatic infant: correlation with the clinic and pulmonary function

PATIENTS AND METHODS: Serum eosinophil cationic protein (ECP) was measured in 99 chronic asthmatic patients (51 males and 48 females) with a mean age of 10.59 years and correlated with the number of eosinophils, lung function, symptoms in the last 6 months and clinical scoring (that reflecting the clinical situation during the last 15 days). RESULTS: Serum ECP showed a significant correlation with the total number of eosinophils (p < 0.001, R = 0.44), clinical scoring (p < 0.05, R = 0.26), number of inhaled beta 2-agonist doses needed in the last 15 days (p < 0.05, R = 0.26), forced expiratory volume during 1 second (FEV1; p < 0.01, R = -0.27), forced vital capacity (FVC; p < 0.05, R = -0.23), maximal mid-expiratory flow (FEF25-27; p < 0.001, R = -0.37). However, there was no significant correlation between the total number of eosinophils and the clinical situation of the children or the FEV1, but we found a significant correlation with the FEF25-27. Patients with ECP < 20 had better results on lung function tests than patients with ECP > 20 (FEV1: 108.89 +/- 17.7 vs 100.5 +/- 22 (p < 0.05), FEF25-27: 93.81 +/- 24.4 vs 75.21 +/- 24.5 (p < 0.001). CONCLUSIONS: The findings of this study suggest that the ECP level is a good marker of the situation of asthma in childhood. The levels of ECP will probably be able to help us to evaluate the degree of bronchial inflammation that neither the clinical state nor the lung function define completely.     

Distinguishing features of focal cemento-osseous dysplasia and cemento-ossifying fibromas. II. A clinical and radiologic spectrum of 316 cases

The distinguishing histopathologic features of focal cemento-osseous dysplasia (FCOD) (including lesions occurring in both anterior and posterior jaws) and cemento-ossifying fibroma (COF) (ossifying fibroma and cementifying fibroma) were demonstrated in our earlier work. The aim of the current study was to further refine their clinical and radiographic features. We have assessed 18 clinical and radiographic parameters by univariate comparisons (chi-squared and Student t tests), and a multivariate assessment (logistic regression) in 241 cases of FCOD and 75 of COF. These cases were diagnosed from a combination of clinical, radiographic, and histopathologic information. FCOD was seen predominantly in black women, with a peak incidence in the fourth and fifth decades, whereas COF showed no female predilection except in the fourth decade (p < 0.005). COF occurred in patients an average of 10 years younger than patients with FCOD (p < 0.0001). Most patients with FCOD were asymptomatic (62%); the average lesion size was 1.8 cm. More than half of patients with COF displayed jaw expansion and a considerably larger size lesion (mean 3.8 cm, p < 0.001). The mandible was the most frequent site for both FCOD (86%) and COF (70%). Radiographically, a well-defined border was observed in 53% of cases of FCOD and 85% of cases of COF (p < 0.01). Cases of FCOD mostly demonstrated an irregularly mixed radio-opacity (69%), whereas 53% of COFs presented as a radiolucency (p < 0.005). In FCOD, there was a close association with tooth apices (70.6%, p < 0.0001) or with previous extraction sites (21%, p < 0.05); however, the majority of COF cases (86%) showed no relationship with either. Combining the radiographic feature of a periapical location with the pathology of multiple curetted fragments and "ginger root" bony trabeculae, allowed 90% sensitivity and 89% specificity in a logistic regression model to predict the lesion to be an FCOD. These findings provide guidelines not only to distinguish these two entities clinically, but also aid in reaching an accurate diagnosis histopathologically.     

Establishing norms for age-related changes in proton T1 of human brain tissue in vivo

The goal of this study was to determine the expected normal range of variation in spin-lattice relaxation time (T1) of brain tissue in vivo, as a function of age. A previously validated precise and accurate inversion recovery method was used to map T1 transversely, at the level of the basal ganglia, in a study population of 115 healthy subjects (ages 4 to 72; 57 male and 58 female). Least-squares regression analysis shows that T1 varied as a function of age in pulvinar nucleus (R2 = 56%), anterior thalamus (R2 = 51%), caudate (R2 = 50%), frontal white matter (R2 = 47%), optic radiation (R2 = 39%), putamen (R2 = 36%), genu (R2 = 22%), occipital white matter (R2 = 20%) (all p < 0.0001), and cortical gray matter (R2 = 53%) (p < 0.001). There were no significant differences in T1 between men and women. T1 declines throughout adolescence and early adulthood, to achieve a minimum value in the fourth to sixth decade of life, then T1 begins to increase. Quantitative magnetic resonance imaging provides evidence that brain tissue continues to change throughout the lifespan among healthy subjects with no neurologic deficits. Age-related changes follow a strikingly different schedule in different brain tissues; white matter tracts tend to reach a minimum T1 value, and to increase again, sooner than do gray matter tracts. Such normative data may prove useful for the early detection of brain pathology in patients.     

Characteristics of patients less than 45 years of age compared with older patients undergoing coronary artery bypass grafting

BACKGROUND: Coronary artery disease (CAD) was not recognized as common among young patients until the study by Yater in 1948. Subsequent studies further elucidated the nature of the disease, which had become more apparent in the younger groups. HYPOTHESIS: The study was undertaken to determine the prevalence of risk factors and severity of coronary disease among young patients aged < or = 45 years undergoing coronary artery bypass grafting (CABG) compared with older patients. METHODS: In all, 112 young patients aged < or = 45 years (Group 1) and 798 older patients aged > 45 years (Group 2) were analyzed for trends to hypertension, smoking, diabetes, family history of heart disease, hypercholesterolemia, obesity, and history of previous myocardial infarction (MI). The severity of disease was examined in terms of number of diseased vessels, vessel size, number of grafts performed, performance of endarterectomies, and left ventricular function. RESULTS: Group 1 had a higher incidence of positive family history (68.5 vs. 51.2%, p < 0.05), and lower incidences of hypertension (62.7 vs. 81.5%, p < 0.05), obesity (42.9 vs. 83.9%, p < 0.05), and history of previous MI (54.5 vs. 94.6%, p < 0.05). Group 2 had a higher incidence of left main disease (22.6 vs. 11.4%, p < 0.05). The distribution of the affected vessels of the young patients was most commonly the left anterior descending (90.4%) followed by the right coronary (79.8%) and circumflex arteries (69.2%). Group 2 had more grafts per patient (3.82 vs. 3.37, p < 0.05). The size of the diseased vessels measured intraoperatively was similar (1.56 vs. 1.58 mm, p = NS) in both groups. Endarterectomy was performed almost three times more often in Group 1 patients (8.2 vs. 3.0%, p < 0.05). Operative mortality was less in Group 1 mean (1.8 vs. 6.3%, p < 0.05). Group 2 had a greater mean left ventricular ejection fraction (53.8 vs. 49.7%, p < 0.05). CONCLUSION: Compared with the older population, patients < or = 45 years of age who underwent CABG had (1) a higher incidence of positive family history of CAD, (2) a higher likelihood of requiring an endarterectomy, and (3) lower operative mortality rate despite a slightly poorer ventricular function.     

The impact of language as a barrier to effective health care in an underserved urban Hispanic community

BACKGROUND: Language barriers between patient and physician impact upon effective health care. This phenomenon is not well studied in the literature. METHODS: A survey was created in English and Spanish, and administered at the ambulatory site for medical housestaff and faculty at a teaching hospital. "Cases" were defined as patients who reported using a translator or as having poor English skills. Patients who reported not using a translator and having good English skills served as controls. Both groups were predominantly of Hispanic origin. RESULTS: Analysis revealed 68 cases and 193 controls. The survey completion rate was 96%. The data were predominantly categorical. Chi-square analysis was utilized. Both groups responded that understanding medication side effects corresponds to compliance (87% cases vs 93% controls, p = 0.18). More cases responded that side effects were not explained (47% vs 16%, p < 0.001). More controls reported satisfaction with medical care (93% vs 84%, p < 0.05). More controls agreed that their doctors understood how they were feeling, with statistical significance in Hispanic subset analysis (87% vs 72%, p < 0.05). Both groups felt they had enough time to communicate with their doctors (89% vs 88%, p = 0.86). More cases than controls reported having had a mammogram within the last 2 years (78% vs 60%, p < 0.05). CONCLUSIONS: Lack of explanation of side effects to medication appeared to correlate negatively with compliance with medication. The language barrier correlated negatively with patient satisfaction. Cases reported more preventive testing; test ordering may replace dialogue.     

Impaired regional fatty acid uptake and systolic dysfunction in hypertrophied right ventricle

Little information is available regarding the determinants of systolic contractile function of the hypertrophied right ventricle (RV). The purpose of this study was to clarify the relationship between myocardial metabolism and contractile function in the hypertrophied RV due to pulmonary hypertension (PH). METHODS: Iodine-123-labeled 15-(p-iodophenyl)-3-(R,S)-methylpentadecanoic acid (BMIPP) and 99mTc-sestamibi (MIBI) SPECT were performed to calculate the RV-to-left ventricle (LV) tracer uptake ratio (RV/LV) in 21 patients with PH (6 with primary PH and 15 with chronic thromboembolic PH). The patients also underwent electron-beam CT to assess RV ejection function (RVEF) and percentage systolic wall thickening (%SWT) and right heart catheterization to measure mean pulmonary arterial pressure (mPAP). RESULTS: There were significant positive correlations between mPAP and MIBI-RV/LV (r = 0.89, p < 0.001) and between mPAP and BMIPP-RV/LV (r = 0.86, p < 0.001). However, 8 patients showed lower BMIPP-RV/LV than MIBI-RV/LV, indicating the impairment of myocardial fatty acid uptake in the RV. These patients had lower RVEF and %SWT compared to those with normal myocardial fatty acid uptake (RVEF = 28% +/- 10% compared to 40% +/- 9% and %SWT = 33% +/- 27% compared to 74% +/- 30%, respectively; p < 0.05 for both comparisons). Although mPAP did not differ between the groups, the RVEF-mPAP and %SWT-mPAP regression lines drawn from the patients with impaired myocardial fatty acid uptake were located below the lines from the patients with normal myocardial fatty acid uptake, suggesting disproportionately decreased RV myocardial contractility for a given mPAP in patients with impaired myocardial fatty acid uptake. The patients with the impaired fatty acid uptake in the RV had a significantly higher death rate (log-rank test, p < 0.05). CONCLUSION: The results from this preliminary study suggest that myocardial fatty acid uptake is impaired in the failing hypertrophied RV due to PH.     

Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome (TTP/HUS). Description of a series of 35 patients

Subsequent to the implementation of a severity marker stamp in case notes, an audit was performed in 86 admissions with acute asthma to a specialist centre over a 12 month period. Compared to previous audit the documentation of severity markers was significantly better (PEFR: 52% vs 83% p = 0.001, Respiratory rate: 44% vs 81% p = 0.001, ABG: 72% vs 80% p = 0.04, air entry: 58% vs 86% p = 0.001, speech: 27% vs 86% p = 0.001, exhaustion: 4% vs 86% p = 0.001). In contrast to the previous audit where no patient received FiO2 > 0.35, 66% of the cases in the repeat audit received FiO2 0.60 (p = 0.001). The mean duration of admission was five days and showed highest partial correlation (r = 0.6) to the time in hours for the pulse to fall to 80/min. Multiple linear regression showed that this was the only variable best predicting the duration of admission (R2 = 0.3). Admission pulse rate (p = 0.04) and serum K+ (p = 0.04) best discriminated between patients admitted for over and under five days. Logistic regression identified only the admission pulse as significant in calculating the odds of the patient staying in the hospital for > 5 days.     

Cultured astrocytes express functional receptors for galanin

OBJECTIVE: Inflammatory bowel disease (IBD) is characterized by T cell activation. Activated T cells shed interleukin-2 receptors (IL-2R) in a soluble form. A positive correlation between sIL-2Ralpha (CD25) and disease activity is well documented in IBD, whereas IL-2Rgamma (CD132) has not been investigated in this respect. Sera from 42 patients with ulcerative colitis (UC), 34 with Crohn's disease (CD), 31 healthy volunteers, and 12 patients with infectious enterocolitis were obtained. METHODS: Disease activity was scored according to a semiquantitative score for UC and CD. sIL-2R alpha chain and gamma chain were assessed by sandwich ELISA techniques using monoclonal antibodies specific for CD25 and CD132, respectively. RESULTS: The concentration of IL-2Ralpha chain (CD25) was found to be median 3.8 ng/ml in healthy volunteers versus 7.0 ng/ml in UC patients (p < 0.001), and 9.6 ng/ml in CD patients (p < 0.001). With respect to IL-2Rgamma (CD132), significantly higher amounts were found in CD patients: 6.6 ng/ml as compared with healthy controls <1.0 ng/ml (p < 0.004). A Kruskal-Wallis test revealed a significant correlation between alpha chain and disease activity in CD (p < 0.001), and further significantly higher gamma chain levels were found in active CD (p = 0.03). For UC patients, a statistically significant increase of the alpha chain with increasing disease activity (p < 0.01) was observed, whereas no significant changes of the gamma chain levels were found (p > 0.05). A difference of gamma chain levels were found between CD and UC in moderate and severe disease activity (p < 0.05). Further analyses revealed that mesalazine did not influence the IL-2Ralpha or -gamma concentration either in UC or in CD patients. CONCLUSION: An increased circulating level of the soluble common gamma chain (CD132) seems to be found in CD, and an overlap exists between CD and UC.     

A comparison of operating room crowding between open and laparoscopic operations

BACKGROUND: The clutter of equipment and lines in today's operating room (O.R.) is increasing. Endoscopic surgical procedures are particularly afflicted by this problem because they require additional equipment. Increasing O.R. crowding may present unnecessary hazards to traffic and adversely affect the performance of the surgical team. The purpose of this study is to provide a quantitative summary of the furniture, equipment, cables, and tubes present during open and laparoscopic operations. METHODS: We prospectively studied an unselected series of general surgical open (OP, n = 10) and laparoscopic (LAP, n = 10) operations performed at a major university teaching hospital. We recorded the location of all furniture and equipment as well as the source, course, and destination of all cables and tubes in the O.R. Cables and tubes touching the surgeon or the assistant were particularly noted. Results are expressed as median values for each group. RESULTS: The percent of O.R. space occupied increased from OP = 36% to LAP = 41% (p < 0.002). The median number of cables and tubes present increased from OP = 27 to LAP = 34 (p < 0.0002), with the number of these lines touching a member of the surgical team increasing from OP = 2 to LAP = 6 (p < 0.0003). CONCLUSIONS: We conclude that there is a significant trend toward increasing O.R. crowding during laparoscopic surgery. Innovative designs will be needed to reduce clutter in the O.R. of the future.     

Early complications and value of initial clinical and paraclinical observations in victims of smoke inhalation without burns

OBJECTIVE: To evaluate the incidence of early pulmonary complications and the value of initial clinical signs and paraclinical investigations in victims of smoke inhalation not suffering from burns following structural fires. DESIGN: Retrospective chart review. SETTING: Thirteen-bed ICU. PATIENTS: Sixty-four victims of smoke inhalation following household fires were admitted to the ICU between January 1987 and December 1992. Exclusion criteria from the study were patients with cutaneous burns or multiple trauma or blast injury, and patients found in cardiac arrest. METHODS: Clinical, biological, and radiologic parameters were collected over a 5-day period. RESULTS: The mortality rate in relation to progressive respiratory failure was 3.1%. Mean ICU stay was 5.8 days (range, 1 to 33 days), and was longer in the patients presenting with soot deposits in the oropharynx (p = 0.02), dysphonia (D) (p = 0.05), or ronchi (R) (p = 0.0004) at the first examination, and in those having a positive sputum bacteriologic analysis (p = 0.003) or requiring parenteral bronchodilator agents for more than 24 h (p = 0.04). Thirty-five patients underwent mechanical ventilation (MV) for a mean of 101.2 h (range, 8 to 648 h). Mean MV duration was higher in the patients presenting initially with R (p = 0.003), high carbon monoxide (but not cyanide) levels (p = 0.02), or a positive bacteriologic sample (p = 0.0001). Positive bacteriologic sampling correlated with the presence of D (p = 0.02) or R (p = 0.04) and with immediate intubation (p = 0.0003). No correlation was found with chest radiograph. CONCLUSIONS: In this selected series of fire victims without cutaneous burns, respiratory injury was frequent. The initial clinical signs may be helpful to predict pulmonary complications.     

Emergency nurses'' perceptions of critical incidents and stress debriefing

The efficacy of examining antinuclear antibody (ANA) was investigated as a screening test detecting subclinical immune disorders in infertility and sterility. ANA was measured in 116 unexplained infertile or sterile patients. The ANA positive rate was 43.5% in group A (habitual abortion, n = 23), 38.1% in group B (consecutive miscarriages, n = 21), 30.0% in group C (one miscarriage, n = 10), 16.7% in group D (one or more deliveries n = 12) 22.0% in group E (primary sterility, n = 50), and 22.4% in the control group (n = 54). The positive rate for all the infertile patients (group A+B) was 40.9% and significantly higher than that in for the control group (p < 0.05). Ten patients with positive ANA had 12 deliveries and 20 patients with negative ANA had 23 deliveries. The frequency of preeclampsia in the patients with positive ANA was higher than in those with negative ANA (41.7% versus 4.3%, p < 0.05). A higher incidence of premature deliveries was recognized in the patients with positive ANA than in those with negative ANA (41.7% versus 8.7%, p < 0.1). Average birth weight (> 35 week) for patients with and without positive ANA was 2,976g (n = 8) and 3,122g (n = 19) respectively. The former tends to be smaller than the latter (p < 0.1).     

Effect of pravastatin (10 mg/day) on progression of coronary atherosclerosis in patients with serum total cholesterol levels from 160 to 220 mg/dl and angiographically documented coronary artery disease. Coronary Artery Regression Study (CARS) Group

To evaluate the effect of pravastatin on progression of coronary atherosclerosis in normocholesterolemic patients with coronary artery disease (CAD), 90 patients with CAD and serum cholesterol levels of 160 to 220 mg/dl were randomized into a pravastatin (10 mg/day) group (n = 45) and control group (n = 45) in a 2-year study. The proportions of patients with progression (an increase of > or = 15% in percent stenosis) and regression (a decrease of > or = 15% in percent stenosis) of coronary atherosclerosis were compared between the 2 groups. Of 90 patients, 80 (89%) had a final angiogram: the pravastatin (n = 39) and control group (n = 41). Percent changes in total cholesterol, low-density lipoprotein cholesterol, and apoprotein B levels were significantly greater in the pravastatin group than in the control group (total cholesterol -11 +/- 12% vs 3 +/- 15%, p < 0.01; low-density lipoprotein cholesterol -18 +/- 16% vs 4 +/- 21%, p < 0.01; apoprotein B -5 +/- 20% vs 6 +/- 20%, p < 0.05). The proportion of patients with progression of coronary atherosclerosis was significantly smaller in the pravastatin group than in the control group (21% vs 49%, p < 0.05). The proportion of patients with disease regression did not differ in the 2 groups (3% vs 2%, p = NS). In conclusion, this study indicates that cholesterol-lowering therapy with pravastatin can prevent the progression of coronary atherosclerosis even in normocholesterolemic patients with established CAD.     

Is psychoprophylaxis a valid approach for heart surgery in children?

PURPOSE: To validate the hypothesys that a psycological preparation for children who will undergo cardiac surgery may improve the outcome. METHODS: Sixty patients, with ages ranging between 3 and 10 years, submitted to heart surgery for treatment of congenital heart defects, were evaluated. They were divided in 2 groups: experimental and control. A questionnaire was designed for collecting data about psychological and clinical aspects of each patient. RESULTS: The following data was found to be of statistical significance: acceptance of peripheral vein puncture in the surgical group (chi 2 = 11.59, p < 0.05), calm awakening following general anesthesia (chi 2 = 9.64 p < 0.05), cooperation with the physiotherapy staff (chi 2 = 13.30, p < 0.05), coping with parents absence (chi 2 = 9.64, p < 0.05), acceptance of fluid restriction (chi 2 = 17.78, p < 0.05) and cooperation with removal of stitches and pacemaker electrodes (chi 2 = 19.20, p < 0.05). There was not statistical significance on demand of sedation, cooperation at removal of the orotracheal tube and during examination, necessity of reintubation and occurrence of clinical complications. However, the prepared group showed a slight tendency to have less postoperative complications (20%) than the control (27%). CONCLUSION: It was found that children who had adequated psychologic preparation prior to the correction of congenital heart defects had better psychological results with the imposed trauma.