Effectiveness of salt versus glass bead sterilizers

From 1982 to 1997, 12 Chinese children were admitted to Chang Gung Memorial Hospital with acetaminophen overdose. Six subjects (one young child, and five adolescents) developed liver damage which was severe in three cases (AST > 1000 IU/L). Acetaminophen-induced liver function abnormalities were characterized by elevation of transaminase levels with ALT higher than AST(6/6), coagulopathy(5/6), thrombocytopenia (1/6), but absence of jaundice(6/6). Fortunately, none of the six patients with liver damage developed fulminant liver failure, and all recovered completely. Acetaminophen overdose can cause significant morbidity in children and adolescents. Caretakers should be well instructed to give the drug correctly. So far, acetaminophen is still considered as the drug-of-choice for antipyresis in pediatric practice. However, multicentered collaborative study is necessary to determine whether acetaminophen intoxication causes less hepatic failure in Chinese children than in Western children.     

Treatment of complex anterior urethral stricture disease with mesh graft urethroplasty

In this report we describe the toxicokinetics of the Tylenol Extended Relief (TER) preparation of acetaminophen in human overdose. We collected 41 cases of TER overdose from five regional poison centers. Patients who met the following criteria were studied: a single ingestion of TER alone; confirmed time of ingestion; at least four acetaminophen determinations; and normal concentrations of liver function enzymes. With the exception of standard decontamination measures, treatment with N-acetylcysteine (NAC) if any acetaminophen level was above the treatment line of the Rumack-Matthew nomogram, and additional acetaminophen determinations, no interventions were recommended. Our study group comprised 13 patients, 12 female and 1 male, with single overdoses of 10.4 to 65 g TER. The acetaminophen elimination half-life was 3.1 +/- .8 hours (mean +/- SD; range, 1.3 to 4.0 hours; n = 12). The elimination phase for patients 2, 3, 4, 6, 8, 9, 11, 13 was delayed until 8.0 +/- 2.8 hours (range, 5 to 14 hours) after ingestion. Patients 3, 8, and 11--who had initial acetaminophen levels below the "possible toxicity" line of the Rumack-Matthew nomogram--later had acetaminophen levels above this line. No patient demonstrated a late or second acetaminophen peak. We conclude that the elimination half-life of TER acetaminophen is similar to that reported in overdose of immediate-release acetaminophen overdose. In a subgroup of patients, drug absorption continued beyond the 2 to 4 hours previously reported in immediate-release acetaminophen overdose. On the basis of our data, the use of a single 4-hour acetaminophen determination may lead to failure to recognize patients with potentially toxic TER ingestion. Until more toxicokinetic data are available, a reasonable approach would be to obtain at least one additional acetaminophen determination at least 4 to 6 hours after the first, if the first is obtained 4 to 8 hours after ingestion. NAC treatment should be initiated if either level is above the nomogram line but not if both levels fall below the nomogram line.     

Estrogen-receptor expression and function in thymocytes in relation to gender and age

INTRODUCTION: The mechanism of action of N-acetylcysteine in early acetaminophen poisoning is well understood, but much remains to be learned of the mechanism of its possible benefit in acetaminophen poisoning presenting beyond 15 hours. METHODS: Selective review of medical literature. N-acetylcysteine should be used in all cases of early acetaminophen poisoning where the plasma acetaminophen concentration lies "above the line;" which line is chosen depends on individual preference and whether enzyme induction is suspected. Particular care should be taken with the use of the nomogram for patients with chronic excess ingestion of acetaminophen or for those who have taken slow-release formulations. CONCLUSIONS: While there is a trend suggesting a beneficial effect of N-acetylcysteine in some patients presenting beyond 15 hours, further research is necessary to establish just how effective N-acetylcysteine is, particularly in patients presenting with fulminant hepatic failure. Candidate mechanisms for a beneficial effect in-clude improvement of liver blood flow, glutathione replenishment, modification of cytokine production, and free radical or oxygen scavenging. Hemody-namic and oxygen delivery and utilization parameters must be monitored carefully during delayed N-acetylcysteine treatment of patients with fulminant hepatic failure, as unwanted vasodilation may be deleterious to the maintenance of mean arterial blood pressure.     

Practical considerations of outpatient infusion therapy in the HIV arena

In conclusion, OPAT is a cost-effective, quality-controlled alternative setting for treating patients with HIV. The program provides a desirable situation for the patient, physician, and nurse. Continuity of care provided by the health care team in the physician's office is a unique situation that can meet the treatment modalities necessary to care for the HIV patient with dignity and pride. In short, OPAT offers an attractive alternative to long-term hospitalization for a variety of HIV-related infections. Such therapy is rapidly becoming a standard of treatment that provides both cost savings and efficacious medical care to patients with HIV-related complications.     

Analog-digital conversion using pCLAMP and DOS/V

Multiply injured trauma patients present a major challenge for the critical care nurse. Should the patient survive the initial injuries, the third phase of mortality (five to seven days following injury) is sepsis. Research findings document a strong link between trauma and immune dysfunction. This article highlights the main immunological defects and underlying mechanisms for trauma-induced immune dysfunction. It provides the theoretical foundation that underlies the rationale for current and future immune-based therapy for trauma patients. Because of the complexity of caring for and preventing septic complications in the trauma patient, advanced practice nurses and nurse educators can use this material to update the knowledge and skills of critical care nurses.     

No net splanchnic release of glutathione in man during N-acetylcysteine infusion

Glutathione and amino acid concentrations were measured in arterial and hepatic vein plasma in four healthy volunteers and two patients with cirrhosis. There was no significant splanchnic efflux of glutathione (95% confidence limits, -0.501 to 0.405 mumol/min). After infusion of N-acetylcysteine (NAC) in a high dose (150 mg/kg body weight primer plus 15 mg/(h x kg BW), corresponding to treatment of acetaminophen overdose, there was no change in the splanchnic glutathione efflux (95% confidence limits, -0.531 to 0.375 mumol/min). NAC increased hepatic plasma flow rate from 0.90 +/- 0.531 min-1 to 0.97 +/- 0.11 (mean +/- SEM; p < 0.05). The effects of NAC treatment on plasma amino acids corresponded to an increased load on hepatic metabolic N conversion and transamination among nonessential amino acids. Splanchnic uptake of serine, alanine, cystine, isoleucine, and phenylalanine increased after NAC compatible with stimulated hepatic glutathione synthesis. In contrast to the rat, plasma glutathione in man probably originates mainly from extrahepatic tissues.     

Administering conscious sedation. Operational guidelines

The nurse must be aware of her or his role and responsibilities when implementing IVCS guidelines. Nurses performing IVCS must be knowledgeable of state and institutional guidelines for IVCS, medications included in IVCS, and the assessment, monitoring, and documentation required in caring for the patient receiving IVCS. The process of IVCS may seem tedious, but if an institution has clearly defined expectations, as provided in the IVCS guidelines, the process is much more understandable and can be readily instituted. The patient undergoing IVCS deserves the highest quality care possible with the fewest complications, a situation that can be achieved with proper preparation and implementation of an IVCS program.     

Bronchoalveolar lavage studies in children without parenchymal lung disease: cellular constituents and protein levels

The hepatotoxicity of acetaminophen overdose depends on the metabolic activation to a toxic reactive metabolite by the hepatic mixed function oxidases. There is evidence that an increase in cytosolic Ca2+ is involved in acetaminophen hepatotoxicity. The effects of the Ca2+-antagonists nifedipine (NF), verapamil (V), diltiazem (DL) and of the calmodulin antagonist trifluoperazine (TFP) on the activity of some drug-metabolizing enzyme systems, lipid peroxidation and acute acetaminophen toxicity were studied in male albino mice. No changes in the drug-metabolizing enzyme activities studied and in the cytochrome P-450 and b5 contents were observed 1 h after oral administration of V (20 mg/kg). DL (70 mg/kg) and TFP (3 mg/kg). NF (50 mg/kg) increased cytochrome P-450 content, NADPH-cytochrome c reductase and ethylmorphine-N-demethylase activities. DL and TFP significantly decreased lipid peroxidation. NF, V, DL and TFP administered 1 h before acetaminophen (700 mg/kg orally) increased the mean survival time of animals. A large increase of serum aspartate aminotransferase(AST), and liver weight and depletion of liver reduced glutathione (GSH) occurred in animals receiving toxic acetaminophen dose. NF, V and DL prevented and TFP decreased the acetaminophen-induced hepatic damage measured both by plasma AST and by liver weight. NF, V, DL and TFP changed neither the hepatic GSH level nor the GSH depletion provoked by the toxic dose of acetaminophen. This suggests that V, DL and TFP do not influence the amount of the acetaminophen toxic metabolite formed in the liver. The possible mechanism of the protective effect of NF, V, DL and TFP on the acetaminophen-induced toxicity is discussed.     

Major causes of death and hospitalization in Canadian seniors

The case management approach is described for children with nonorganic failure to thrive in the pediatric tertiary care setting. An advanced practice nurse facilitated the organization of a planning committee, the construction of a care path, and the evaluation of the case management model. A 4-day care path is presented to show staff nursing functions in the nurse case manager role. Special issues are discussed for developing care paths for organic-based failure to thrive where parent reports can help guide health care interventions.     

Misoprostol protection against acetaminophen-induced hepatotoxicity in the rat

The hepatoprotective effects of misoprostol on acetaminophen (APAP)-induced toxicity were studied in the rat. Liver injury was evaluated at 36 hr after APAP administration by measuring serum ornithine carbamoyltransferase (OCT) and alanine aminotransferase (ALT) levels, by using tetranitroblue tetrazolium (TNBT) staining and by histological analysis. After APAP administration, peak serum levels of the drug were detected at 15 min. Liver GSH was depleted from control levels of 448 +/- 48 micrograms/g to 82 +/- 2 micrograms/g (P < 0.01) within 3 hr. Serum ALT levels increased significantly after 16 hr and H&E staining revealed significant hepatic necrosis after 12 hr. Rats treated with misoprostol before and after APAP administration showed reduced OCT and ALT levels at 36 hr of overdose (454 +/- 446 IU/liter and 2571 +/- 2944 IU/liter, respectively) compared to those without misoprostol treatment (1348 +/- 480 IU/liter and 6077 +/- 3025 IU/liter, respectively, P < 0.01). TNBT staining showed a reduced area of damage from 28.6 +/- 22.3% to 7.3 +/- 8.9% (P < 0.01), and H&E staining also showed less extensive hepatic necrosis in rats treated with misoprostol before and after the overdose. In a time sequence study, misoprostol treatment starting within 10 hr of overdose showed the same protective effect as when it was given before and after APAP ingestion. No protection was detected when the treatment was started during the development of hepatic injury. However, misoprostol given when injury was established seemed to be protective. Our results show that misoprostol protects the liver against APAP-induced injury if given within 10 hr of overdose.(ABSTRACT TRUNCATED AT 250 WORDS)     

Carbon dioxide volume and intra-abdominal pressure determination before the creation of a pneumoperitoneum

The associated stress of an ostomy experience can threaten a patient's security and sense of control. One major stressor is the influence of uncertainty, when patients lack a clear perception of what will happen and are unable to define meaning or personally interpret information bombarding them from the complex health care system. Mishel's Uncertainty in Illness Theory offers the ET nurse a practical framework for understanding how the patient attaches meaning to illness cues and how the ET nurse can positively affect the desired adaptation process. Because the patient trusts the ET nurse's expertise and experience, the nurse can help the patient to understand the ostomy experience and perceive its structure. As a credible authority, the ET nurse has the expert power to facilitate patient coping and adaptation by minimizing ambiguity through individualized education, counseling, and support while simultaneously constructing a sense of order and predictability for both patient and family.     

The perinatal nurse's role in obstetric emergencies: legal issues and practice issues in the era of health care redesign

The perinatal nurse is charged with providing safe and effective care in both routine and emergency situations. This duty arises from the states' nurse practice acts and American Nurses Association's Code for Nurses, and it has been affirmed by a growing body of case law. Current changes in health care systems have created new challenges for the perinatal nurse. In some instances, the transformations occurring in health care may actually hinder the nurse's ability to provide care when faced with an obstetric emergency. These changes do not, however, alter the nurse's affirmative duty to take some positive action when complications arise. The article elaborates essential nursing actions required when an obstetric emergency occurs within the context of redesigned maternity settings.     

Nurse turnover with special reference to factors relating to nursing itself

The function of the peritoneum in severe abdominal sepsis involves specific properties and defence mechanisms: large surface, efficient barrier, continuous mobility, capacity of migration, multiplication, secretion and absorption. The development of peritonitis supposes an initial lesion of the peritoneal surface by septic or biochemical mechanism. Peritoneal response consists of: septation of the abdominal wall, adhesion of the omentum to damaged surfaces or visceral perforation, massive stepping up of cellular and humoral defence mechanism. In our opinion therapeutic procedures consist of: early surgical approach and management of the patient in an intensive care unit. The aim of the medical therapy is: treatment of multiple organ failure (anti-infectious therapy, hemodynamic support, treatment of respiratory and renal failure, support of the hepatic failure and balancing of metabolic changes) and prevention of the most common complications: bleeding from upper gastrointestinal tract and thromboembolic risks.     

Reflecting on the knowledge used when caring for an intensive care patient and his/her family

Carper's four ways of knowing are used to structure a reflection on the knowledge used by an associate nurse in intensive care when caring for her patient, his wife and son. John, the patient, had previously undergone a sex change operation as well as cardiac surgery. His current period in intensive care was due to pancreatitis and involved numerous returns to theatre. He eventually died following multi-organ failure. The reflection focuses on the associate nurse's feelings when trying to act as an advocate for both John and his wife at the time of the patient's pending death.     

Finding value in nursing care: a framework for quality improvement and clinical evaluation

Fiscal constraints have heightened attention to health care costs and patient outcomes as measures of health care system effectiveness. Determining which patient and costs outcomes nurses may be held accountable for requires differentiating the impact of dependent, independent and interdependent nursing activities. A nursing role effectiveness model that includes a number of structural variables is offered to help track quality improvement and research activities. Some of the nurse-sensitive patient outcomes that have been identified include: freedom from complications, clinical outcomes, functional health outcomes, knowledge outcomes, perceived health benefit (or satisfaction), and costs outcomes. This model can be used to evaluate the effectiveness of current as well as evolving nurse roles, processes, and structural changes.     

A prospective evaluation of the effect of activated charcoal before oral N-acetylcysteine in acetaminophen overdose

STUDY OBJECTIVE: To evaluate whether activated charcoal (AC) reduces the efficacy of subsequent oral N-acetylcysteine therapy during acute acetaminophen overdose. DESIGN: Prospective observational case series of all acute acetaminophen overdoses reported to three certified regional poison centers. TYPES OF PATIENTS: All patients with acute acetaminophen overdose in whom N-acetylcysteine therapy was initiated within 16 hours after ingestion. INTERVENTIONS: All patients were treated with oral N-acetylcysteine therapy for 72 hours. The decision to use AC was left to the treating physician without input from the investigator. MEASUREMENTS AND RESULTS: One hundred twenty-two patients were evaluated. Maximum recorded SGOT levels of more than 125 U/mL were defined as evidence of hepatotoxicity. AC was used in addition to N-acetylcysteine in 82 of 122 patients. Hepatotoxicity developed in four of 82 patients who received AC versus ten of 40 patients who did not receive AC (P < .005). An increasing dose of N-acetylcysteine provided no additional benefit (P > .05). Spacing the administration of AC and oral N-acetylcysteine less than or more than two hours apart did not affect outcome (P > .05). CONCLUSION: Administration of AC before the administration of oral N-acetylcysteine in acetaminophen overdose does not reduce the efficacy of N-acetylcysteine therapy and may provide some additional hepatoprotective benefit. The practice of increasing the dose of oral N-acetylcysteine therapy after the administration of AC appears unwarranted.     

Risk factors of severe hypoglycaemia in adult patients with Type I diabetes--a prospective population based study

Novel thiazolidine prodrugs were prepared by the condensation of L-cysteine with aldose disaccharides. Using a disaccharide in prodrug construction allows for a terminal cyclic sugar moiety to be present on the prodrug, which may allow the delivery of the agent to specific receptors, such as the asialoglycoprotein receptor (ASGPR) of hepatocytes, that require specific structural motifs for recognition. Three L-cysteine prodrugs were synthesized with a pendant cyclic galactose moiety; two related glucose-bearing prodrugs were synthesized for comparison. The prodrugs were designed to release L-cysteine, which is then available to support glutathione (GSH) biosynthesis and provide cytoprotection against a variety of toxic insults. Protection studies in Swiss-Webster mice used acetaminophen (575 mg/kg), a well-documented hepatotoxin which depletes GSH at overdose. Three prodrugs performed exceptionally well against acetaminophen-induced hepatotoxicity, as measured by increased survival and improved histological profiles of liver tissue after 48 h. In further experimentation, two of the disaccharide-based prodrugs, prepared from alpha- and beta-lactose, were compared with the monosaccharide-based compound prepared from ribose. Co-administration of the selected prodrugs with a 400 mg/kg dose of acetaminophen to Swiss-Webster mice prevented the short-term depletion in hepatic GSH and also reduced hepatotoxicity as determined by histological damage and serum levels of alanine aminotransferase. A single dose of the prodrugs alone had no effect on hepatic drug metabolizing enzymes [glutathione S-transferase (GST), NAD(P)H:quinone oxidoreductase (QOR), UDP-glucuronosyltransferase (UGT), and cytochrome P450], but, concordant with the reduction of hepatotoxicity, the latentiated forms prevented the significant elevation in QOR activity and mRNA and GST mRNA elicited by acetaminophen itself. GST activity, UGT activity and mRNA, and cytochrome P450 concentration were all unaffected by acetaminophen or the prodrugs. These studies identified novel L-cysteine prodrugs with potentially useful hepatoprotective activity. However, no structure-activity relationships were obvious. In addition, the occurrence of targeted delivery to hepatocytes remains ambiguous.     

Psychotherapies in psychosocial centers in Lombardia: a point of view of psychiatrists and psychologists

OBJECTIVES: To provide a review of the use of blood cell transplantation (BCT) in pediatric patients, the psychological and developmental issues related to BCT, and guidelines for supportive care. DATA SOURCES: Review articles, research studies, and book chapters pertaining to BCT in children with cancer. CONCLUSIONS: BCT is a safe and reliable source of support after myeloablative regimens for children with disseminated disease, relapse or failure after chemotherapy, or children with high-risk features at diagnosis. IMPLICATIONS FOR NURSING PRACTICE: The pediatric oncology nurse is an integral part of the multidisciplinary team in providing long-term care for children undergoing BCT. Astute clinical monitoring, supportive care, and management of complications is of utmost importance to recovery.     

Liver transplantation in acute liver failure

Acute hepatic failure is characterized by jaundice and hepatic encephalopathy within eight weeks after the onset of disease. Although acute hepatic failure is a rare occurrence, its rapid progression and high mortality (50 to 90%, depending on the etiology of disease) necessitate immediate intervention. In the absence of causal therapy, orthotopic liver transplantation is currently the only definitive and effective means of treating acute hepatic failure in Europe, acute hepatic failure accounts for 11% of all liver transplantations. At the University department of transplantation surgery in Vienna a total of 27 patients with acute hepatic failure underwent 31 liver transplantations in the last 10 years (1.1.1987 to 31.12.1996). Twenty (74%) of the 27 patients survived the acute event and were discharged from hospital in good general condition after a median postoperative stay of 25 days (range 14-81 days). Seven patients (26%) died between the first and 34th postoperative day (median 26 days) in the intensive care unit, although all potential modern options of intensive care and surgery were used. The causes of death were irreversible cerebral edema (n = 3), multiple organ failure due to bacterial sepsis (n = 3) and uncontrollable haemolysis (n = 1). With a 3-year graft survival rate of 70% the 3-year patient survival rate was 74%. A retrospective analysis of our patients revealed that the postoperative graft function and the incidence of re-transplantation were significant prognostic factors (p < 0.05) for survival following orthotopic liver transplantation for acute hepatic failure. In the absence of further prognostically relevant preoperative indices and in consideration of the potentially fulminant progression of disease, we strongly recommend that any patient, in whom acute hepatic failure is suspected, is immediately transferred to a specialized center with experience both in the conservative treatment of acute hepatic failure and emergency liver transplantation.