Challenges of traction in critical care: a case study

PROBLEM/CONDITIONS: Despite widespread availability of a safe and effective vaccine against tetanus, 124 cases of the disease were reported during 1995-1997. Only 13% of patients reported having received a primary series of tetanus toxoid (TT) before disease onset. Of patients with known illness outcome, the case-fatality ratio was 11%. REPORTING PERIOD COVERED: 1995-1997. DESCRIPTION OF SYSTEM: Physician-diagnosed cases of tetanus are reported by state and local health departments to CDC's National Notifiable Diseases Surveillance System. In addition, since 1965, supplemental clinical and epidemiologic information for cases has been provided to CDC's National Immunization Program. RESULTS: From 1995 through 1997, a total of 124 cases of tetanus were reported from 33 states and the District of Columbia, accounting for an average annual incidence of 0.15 cases per 1,000,000 population. Sixty percent of patients were aged 20-59 years; 35% were aged > or =60 years; and 5% were aged <20 years, including one case of neonatal tetanus. For adults aged > or =60 years, the increased risk for tetanus was nearly sevenfold that for persons aged 5-19 years and twofold that for persons aged 20-59 years. The case-fatality ratio varied from 2.3% for persons aged 20-39 years to 16% for persons aged 40-59 years and to 18% for persons aged > or =60 years. Only 13% of patients reported having received a primary series of TT before disease onset. Previous vaccination status was directly related to severity of disease, with the case-fatality ratio ranging from 6% for patients who had received one to two doses to 15% for patients who were unvaccinated. No deaths occurred among the 16 patients who previously had received three or more doses. Tetanus occurred following an acute injury in 77% of patients, but only 41% sought medical care for their injury. All patients who sought care were eligible for TT as part of wound prophylaxis, but only 39% received it. Tetanus in injecting-drug users (IDUs) with no known acute injury comprised 11% of all cases, compared with 3.6% during 1991-1994. None of the IDU-associated tetanus cases occurred among persons who were known to have been vaccinated. Sixty-nine percent of IDU-associated tetanus cases were reported from California, and 77% of these cases occurred in heroin users. INTERPRETATION: Tetanus remains a severe disease that primarily affects unvaccinated or inadequately vaccinated persons. Adults aged > or =60 years continue to be at highest risk for tetanus and for severe disease. However, the overall incidence of tetanus has decreased slightly since the late 1980s and early 1990s, from 0.20 to 0.15, a result primarily of a decreased incidence among persons aged > or =60 and <20 years. ACTIONS TAKEN: Tetanus is preventable through both routine vaccination and appropriate wound management. In addition to decennial booster doses of diphtheria and tetanus toxoids during adult life, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination visits for adolescents at age 11-12 years and for adults at age 50 years to enable health-care providers to review vaccination histories and administer any needed vaccine. Every contact with the health-care system, particularly among older adults and IDUs, should be used to review and update vaccination status as needed.     

Microholes of the macula

OBJECTIVE: To describe the clinical syndrome of microholes of the macula. PATIENTS: Fourteen patients with acute symptoms caused by full-thickness microholes of the macula. RESULTS: Patients with macular microholes had the acute onset of central scotoma with mild to moderate visual acuity loss. Examination revealed a detachment of the vitreous over the fovea, often with an operculum or a total posterior vitreous detachment, and a sharply demarcated, 50- to 133-micrometer round hole in the center of the macula. On follow-up, all patients had a stable or improved scotoma and visual acuity. CONCLUSIONS: Macular microholes appear to be caused by an acute detachment of the vitreous from the fovea and can be distinguished from Gass stage 2 idiopathic macular holes.     

Surgical technique. Intracorporeal laparoscopic-guided feeding jejunostomy

Laparoscopic feeding jejunostomy is a safe and reproducible method of establishing enteral feeding in patients in whom percutaneous endoscopic gastrostomy is contraindicated. Current technology enables the jejunostomy to be achieved within the peritoneal cavity, without retrieval of the small bowel through the abdominal wall. This quick and simple technique is described.     

规整填料的工业应用

Gempak规整填料应用于200kt／a气体分馏装置，提高处理能力20％，分馏精度有所改善；Mellapak填料应用于2．8Mt／a常减压蒸馏装置减压塔，提高处理能力约18％，改善了VGO质量。     

Minimally invasive esophageal surgery

OBJECTIVE: This study aimed to assess patient satisfaction and change in functional status after surgery for epiretinal membrane (ERM), rhegmatogenous retinal detachment (RRD), and complex retinal detachment (CRD). This study also aimed to determine whether objective measures of vision are predictive of subjective improvement after surgery. DESIGN: The study design included patient interviews and retrospective chart review. PARTICIPANTS: Participants were those patients who underwent surgery for ERM, RRD, or CRD by one surgeon at the Bascom Palmer Eye Institute between January 1, 1993, and December 31, 1994. INTERVENTION: Patient satisfaction and patients' perceptions of the impact of surgery on their functional status were assessed by telephone interviews conducted by one interviewer at least 6 months after surgery. MAIN OUTCOME MEASURES: Responses to patient satisfaction survey and subjective change in patients' functional status were measured. RESULTS: Of 187 eligible patients, 146 (78.1%) could be contacted and all agreed to participate. Ninety patients (61.6%) reported improved functioning after surgery in 2 or more of the 5 activities investigated. Twenty-one patients (14.4%) reported worse postoperative vision than expected, but only 5 patients (3.4%) thought surgery had not been worthwhile. One hundred forty-three patients (97.9%) reported adequate explanation of surgery and its expected results. Patients with preoperative study eye visual acuity between 20/40 and 20/200 were most likely to improve in two or more activities. Lower preoperative worse eye vision and better final study eye vision were associated with a greater likelihood of satisfaction after surgery. Diagnostic category was not predictive of change in functional status or patient satisfaction. CONCLUSIONS: There is a high rate of patient satisfaction and improved functional status after surgery for ERM, RRD, and CRD, even among patients with good fellow eye vision.     

Rapid genotypic diagnosis of type 2A von Willebrand''s disease by heteroduplex analysis

We report a case of hypoglycaemic shock which occurred in a patient 18 h after injury. The patient was involved in a road traffic accident and sustained multiple rib fractures and bruising in the (R) lumbar region. Eleven hours after his last meal he developed sudden weakness, profuse sweating, air hunger, thirst, disorientation and suddenly lapsed into coma 18 h after admission. Administration of 50 ml of 50% dextrose resulted in immediate restoration of consciousness. This case shows that this complication can occur in trauma patients even though the metabolic response to trauma is usually assumed to be hyperglycaemic.     

Insulin stimulates pp120 endocytosis in cells co-expressing insulin receptors

pp120, a substrate of the insulin receptor tyrosine kinase, is a plasma membrane glycoprotein that is expressed in the hepatocyte as two spliced isoforms differing by the presence (full-length) or absence (truncated) of most of the intracellular domain including all phosphorylation sites. Co-expression of full-length pp120, but not its phosphorylation-defective isoforms, increased receptor-mediated insulin endocytosis and degradation in NIH 3T3 fibroblasts. We, herein, examined whether internalization of pp120 is required to mediate its effect on insulin endocytosis. The amount of full-length pp120 expressed at the cell surface membrane, as measured by biotin labeling, markedly decreased in response to insulin only when insulin receptors were co-expressed. In contrast, when phosphorylation-defective pp120 mutants were co-expressed, the amount of pp120 expressed at the cell surface did not decrease in response to insulin. Indirect immunofluorescence analysis revealed that upon insulin treatment of cells co-expressing insulin receptors, full-length, but not truncated, pp120 co-localized with alpha-adaptin in the adaptor protein complex that anchors endocytosed proteins to clathrin-coated pits. This suggests that full-length pp120 is part of a complex of proteins required for receptor-mediated insulin endocytosis and that formation of this complex is regulated by insulin-induced pp120 phosphorylation by the receptor tyrosine kinase. In vitro GST binding assays and co-immunoprecipitation experiments in intact cells further revealed that pp120 did not bind directly to the insulin receptor and that its association with the receptor may be mediated by other cellular proteins.     

Adrenal neuropeptide Y mRNA but not preproenkephalin mRNA induction by stress is impaired by aging in Fischer 344 rats

The purpose of this study was to examine factors predicting the practice of breast self-examination behaviour among Chinese women in Hong Kong using a cross-sectional survey research design. The Health Belief Model was used as the theoretical framework for the study to examine differences between breast self-examination practicers and non-practicers and among breast self-examination frequency groups. Data were collected from a convenience sample of 124 women using self-administrated questionnaires. Less than half of the sample practised breast self-examination and only 16% of the practicers performing breast self-examination monthly. There were differences between practicers vs. non-practicers and among breast self-examination frequency groups and some support of the predictive power of the Health Belief Model was found. Logistic regression showed that practicers perceived health as important, having fewer barriers and higher susceptibility to breast cancer. Discriminant function analysis revealed that barriers and children status were strong predictors of frequency of breast self-examination practice explaining 21.1% of the total variance in breast self-examination practice.