Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation

A prospective study of 66 consecutive patients with cardiac wounds seen over a 27-month period is reported. No patient was excluded. Patients were stratified by injury mechanism and by physiologic scoring at admission using the cardiovascular-respiratory elements of the Trauma Score (CVRS). Admission cardiac rhythm was obtained in patients with a CVRS of 0 and a Glasgow Coma Scale (GCS) score of 3. Information concerning the anatomic extent of the cardiac wound, the presence or absence of tamponade, and the degree of injury to other structures was also collected prospectively. Seventy percent of the cardiac wounds were caused by gunshots. The probability of successful resuscitation was significantly related to mechanism of injury and physiologic condition on arrival. Among patients arriving with a CVRS of 0 and a GCS score of 3, survival correlated with cardiac rhythm. Pericardial tamponade did not prove to be an independent predictor of early survival. The presence of tamponade was statistically linked to the mechanism of injury. Transport by non-official conveyance was associated with a higher CVRS on arrival. Intoxication with alcohol or cocaine had no evident effect on resuscitation probability.     

Reduced speed of sound in tibial bone of haemodialysed patients: association with serum PTH level

BACKGROUND: In end-stage renal disease, average bone mineral density has been reported to be normal or only modestly reduced, more so in the cortical bone. The purpose of the present study was to explore the potential use of quantitative ultrasound, a method reflecting both quantitative and qualitative properties of bone, in assessing bone status in patients on maintenance haemodialysis. METHODS: We studied 71 patients (age 17-81 years, time on dialysis 0-18 years). The speed of sound waves (tSOS; m/s) propagating along the cortical bone has been determined at the tibial shaft. tSOS results were expressed as Z scores, i.e. units of standard deviations from age- and sex-matched normal mean values, and correlated with relevant clinical and biochemical variables. RESULTS: SOS Z score averaged -2. 0 (range -6.8 to 0.6; P<0.001) and was negative in 93% of the patients. Significant inverse correlations were found between SOS Z score and both time on dialysis (r=-0.52; P<0.0001) and serum PTH (r=-0.39; P=0.0002). Markedly reduced SOS Z score, below -2, was found in 80% of the patients whose PTH levels exceeded 34 pmol/l (five times the upper normal limit), compared with 43% of the patients whose PTH levels were below 34 pmol/l(P=0.04). Compared to patients without bone pain (n=51), subjects with bone pain (n=20) had somewhat lower SOS Z scores -2.5+/-2.0 versus -1.8+/-1.4; P=0. 08), but this could be accounted for by longer time on dialysis. CONCLUSIONS: tSOS is substantially reduced in the majority of haemodialysed patients and is related to time on dialysis and serum PTH level. The clinical value of this novel method needs further exploration.     

Phenotypic analysis of antigen-specific T lymphocytes

Identification and characterization of antigen-specific T lymphocytes during the course of an immune response is tedious and indirect. To address this problem, the peptide-major histocompatability complex (MHC) ligand for a given population of T cells was multimerized to make soluble peptide-MHC tetramers. Tetramers of human lymphocyte antigen A2 that were complexed with two different human immunodeficiency virus (HIV)-derived peptides or with a peptide derived from influenza A matrix protein bound to peptide-specific cytotoxic T cells in vitro and to T cells from the blood of HIV-infected individuals. In general, tetramer binding correlated well with cytotoxicity assays. This approach should be useful in the analysis of T cells specific for infectious agents, tumors, and autoantigens.     

A manual on pediatric telephone triage

In 1985 in Zaire, a 12-week training course began in Kasongo district to prepare physicians to use sound management of primary and secondary health services, supervision of health centers, and commitment to team work to operate districts in an integrated way. Only 1 new physician trainee was accepted every 4 weeks. During the first week, trainees observed work at an outpatient clinic for 2-3 hours/day to learn about the links between the primary and secondary levels of health care. During the second week, they observed staff at an urban health center in Kasongo city so they could become familiar with strategies for diagnosis and treatment in curative consultations and with instructions for follow-up. During the third week, the trainees returned to the outpatient clinic to practice interviewing patients. During the fourth week, they observed work in a rural health center and in remote villages. During the second 4-week period, trainees worked in a hospital department of their choice to learn how to use files and to evaluate quality of care. They visited health centers 1-2 times/week to examine supervisory techniques of different resident physicians. Trainees were part of the health team during the third 4-week period. They were responsible for a hospital department and supervised health centers under a resident physician. The trainees also attended management committee meetings addressing quality of care, staff management, and feedback from health center supervisions. The cost for this health district management training was US $100/trainee. Between mid-1985 and mid-1988, 18 physicians underwent this training. 12 of these physicians are now working in health districts in Zaire. A follow-up survey in 1995 showed that most trainees were applying the requisite skills and knowledge acquired during the training. Further supervision or self-training, involving team analysis of problems and possible solutions, are needed. Factors contributing to the course's success include: an integrated health system under the direction of a health team, a large enough team to do student training but small enough to maintain communication, and active participation of trainees.     

Molecular characterization of erythrocyte glucose-6-phosphate dehydrogenase deficiency in Al-Ain District, United Arab Emirates

Operational skills involved in controlling a motor vehicle were measured in two groups of very healthy elderly drivers and a young control group to test the hypothesis that there are age-related declines in operational performance that may influence driver safety. An actual behind-the-wheel, standardized road test was employed using a motor vehicle equipped with sensors to record speed, braking activity, and lane position, as well as direction and magnitude of front-wheel and eye-movement excursions. The data from these sensors were used as dependent measures of operational performance. Older drivers made fewer steering and eye-movement excursions and drifted across the center line more frequently than the young control group. Younger drivers drove significantly faster and executed more braking applications than did their older counterparts. The motor-vehicle operational performance of older healthy drivers was related to visual-spatial attentional declines and the useful field of vision associated with the normal aging process.     

Lung cancer among steelworkers in Ontario

A population-based case-control study was carried out to follow up observations of increased lung cancer risk in the steel pouring areas of two Ontario steel mills. Study subjects were all men, aged 45-75 years, who died of lung cancer in the cities of Hamilton or Sault Ste-Marie, Ontario from 1979-1988. Nine hundred sixty-seven lung cancer victims were matched with 2,827 control subjects who died of other causes. Work histories were provided by the employers of steelworkers. In comparison with other residents of their cities, the relative risk of death from lung cancer was 0.85 (95% confidence interval [CI]: 0.58-1.23) for steelworkers in Sault-Ste Marie and was 1.10 (95% CI: 0.89-1.37) for steelworkers in Hamilton. In internal comparisons within the steel companies, increased lung cancer risk was observed among foundry, coke oven, and pouring pit workers. Retrospective hygiene assessment suggested that the increased risk of lung cancer among steel pourers might be related to the use of tar-based mold coating agents or to exposure to mineral fibers.     

Pancreaticoduodenectomy for selected periampullary neuroendocrine tumors: fifty patients

BACKGROUND: Most resectable pancreatic or peripancreatic neuroendocrine tumors are treated by enucleation or distal pancreatectomy. A minority of tumors may require pancreaticoduodenectomy for complete tumor excision because of their large size, location, or lymph node involvement. METHODS: This study reviews the management of 50 patients treated by pancreaticoduodenectomy for periampullary neuroendocrine tumors between 1962 and 1996 at a single institution. RESULTS: There were 30 men and 20 women with a mean age of 52 +/- 2 years. Functional tumors were resected in 17 patients: insulinoma, seven tumors; gastrinoma, eight tumors; vipoma, one tumor; and glucagonoma, one tumor. Tumors were classified as malignant in 29 patients and benign in 21. The median intraoperative blood loss was 800 ml, and the median number of units of blood transfused was zero. The postoperative length of stay was 20 +/- 2 days. Postoperative morbidity included 11 patients (24%) with a pancreatic fistula and four patients (8%) with a biliary fistula. There was one in-hospital death (2%), in 1967. The actuarial survival rates at 2, 5, and 7 years are 81%, 73%, and 65%, respectively. Patients with benign tumors had a significantly improved 5-year survival rate (94%) compared with those with malignant tumors (61%; p = 0.03). CONCLUSIONS: Selected patients with periampullary neuroendocrine tumors can be managed successfully by pancreaticoduodenectomy, with low mortality and acceptable morbidity rates.     

The effectiveness of ovarian cancer screening. A decision analysis model

OBJECTIVE: To estimate the effectiveness of ovarian cancer screening with CA 125 and transvaginal sonography. DESIGN: Decision analysis was used to examine the no-screen compared with the screen strategy. SETTING: Estimates of cancer incidence, survival, and life expectancy were derived from population-based data and clinical series. SUBJECTS: A cohort of 40-year-old women of all races and residing in the United States. INTERVENTIONS: A one-time screening intervention. The criterion standard for diagnosis of ovarian cancer was evaluation with exploratory laparotomy. MAIN OUTCOME MEASURE: Average years of life expectancy gained by women in the screened group. RESULTS: Screening for ovarian cancer with a combination of CA 125 and transvaginal sonography increases the average life expectancy in the population by less than 1 day. CONCLUSIONS: Given the limited effect on overall life expectancy, it is unlikely that mass screening for ovarian cancer with CA 125 and transvaginal sonography would be an effective health policy.     

Short-term handling of the slimming agent oleoyl-estrone in liposomes (Merlin-2) by the rat

Female adult rats were injected in the jugular vein with oleoyl-3H-estrone incorporated into liposomes. The label rapidly disappeared from the blood, being taken up by the tissues, mainly liver, spleen and lung, which filtered most of the label. However, many other tissues, such as the heart, brown adipose tissue, adrenals and visceral fat incorporated significant amounts of oleoyl-estrone. The analysis of the form in which the label remained 10 min after the injection showed that it was hydrolysed in a large proportion even in liver and lungs. However, in most tissues (brain, brown and white - periovaric - adipose tissues and ovaries), intact oleoyl-estrone accounted for less than one quarter of all tissue label, and less than 10% in the case of subcutaneous adipose tissue and uterus. This rapid destruction of oleoyl-estrone is in agreement with the active role of this compound in the control of body weight.