The impact of true partnership between a university Level I trauma center and a community Level II trauma center on patient transfer practices

OBJECTIVE: To examine the effect of a clinical and administrative partnership with an academic urban Level I trauma center on the patient transfer practices at a suburban/rural Level II center. METHODS: Data for 2 years before affiliation (PRE) abstracted from inpatient charts and the trauma registry were compared with that for 2 years after (POST). The following data were collected: number of, reason for, and destination and demographics of transfers. Chi(2) test and t test analyses were used; p < 0.05 defined significance; data are mean +/- SEM. RESULTS: Transfer rate increased from 4% PRE to 6.9% (p = 0.001) POST with no significant difference in age, Glasgow Coma Scale score, Injury Severity Score, or Revised Trauma Score. Repatriation occurred in 12.8% POST (none PRE). The current Level I facility accepted 1.8% of all transfers PRE and 36.4% POST (p = 0.0001). PRE/POST rates by reason are as follows: pediatric, 14.6%/9.0% (p = 0.04); intensive care unit, 0.4%/1.7% (p = 0.13); complex orthopedic, 100%/0% (p = 0.005); vascular, 50%/0% (p = 0.008); spinal cord injury, 100%/100%; and ophthalmologic, 0%/100% (p = 0.005). CONCLUSIONS: In this experience of Level I/II partnership (1) transfer patterns were altered, (2) select patient cohort transfers decreased (pediatric, complex orthopedic, vascular), whereas others increased (aortic work-up), and (3) repatriation rates were low.     

Carcinoma of the male breast: a review and recommendations for management

OBJECTIVES: To investigate whether occupational exposure to organic solvents increases the risk of dementia. METHODS: Cases of dementia were identified from the computed tomography records of eight neuroradiology centres in England and Wales, and were compared with two sets of controls investigated at the same centres. The first set of controls were patients with brain cancer and the second set were patients with other disorders that were not chronically disabling. Lifetime occupational histories were obtained through a postal questionnaire completed by the subjects or their next of kin. Associations between dementia and occupation were examined by logistic regression. RESULTS: Usable questionnaires were returned for 204 (61%) of the cases, 225 (51%) of the controls with brain cancer, and 441 (61%) of the other controls. The findings with each of the two sets of controls were similar. In comparison with all controls combined, cases had less often worked ever as a painter or printer (odds ratio (OR) 0.6, 95% confidence interval (95% CI) 0.3 to 1.2), and were less likely to have worked for > 1 year as a printer, painter, or launderer or dry cleaner (OR 0.6, 95% CI 0.3 to 1.4). CONCLUSIONS: These findings provide no support for the hypothesis that occupational exposure to solvents is a cause of dementia. An excess risk in subsets of workers with extremes of exposure cannot be discounted, but the data indicate that any influence of exposure to solvents on the overall incidence of severe dementia in the general population of England and Wales is small.     

The efficacy and safety of mivacurium in children in Singapore

AIM: The aim of this study was to evaluate the clinical use of mivacurium, a short-acting, non-depolarising muscle relaxant, in the paediatric population in Singapore. METHODS: Twenty children between the ages of 2 and 12 years were given mivacurium to maintain neuromuscular blockade during nitrous oxide-halothane anaesthesia. Reversal from neuromuscular blockade was spontaneous. The onset, ease of intubation after different doses of mivacurium, and the ease of reversal were evaluated. RESULTS: Different intubating doses of mivacurium did not result in significantly different times of onset. The mean recovery index (25% to 75% recovery) was 4.1 minutes. There were no adverse reactions. CONCLUSIONS: Mivacurium provided rapid and efficacious onset of neuromuscular blockade in the local paediatric population. Rapid spontaneous recovery obviated the need for reversal agents.     

Complete unfolding of the titin molecule under external force

Titin (also known as connectin) is a giant filamentous protein that spans the distance between the Z- and M-lines of the vertebrate muscle sarcomere. Several earlier studies have implicated titin as playing a fundamental role in maintaining sarcomeric structural integrity and generating the passive force of muscle. The elastic properties of titin were characterized in recent single-molecule mechanical works that described the molecule as an entropic spring in which partial unfolding may take place at high forces during stretch and refolding at low forces during release. In the present work titin molecules were stretched using a laser tweezer with forces above 400 pN. The high external forces resulted in complete mechanical unfolding of the molecule, characterized by the disappearance of force hysteresis at high forces. Titin refolded following complete denaturation, as the hysteresis at low forces reappeared in subsequent stretch-release cycles. The broad force range throughout which unfolding occurred indicates that the various globular domains in titin require different unfolding forces due to differences in the activation energies for their unfolding.     

Importance of peripheral insulin levels for insulin-induced suppression of glucose production in depancreatized dogs

It is generally believed that glucose production (GP) cannot be adequately suppressed in insulin-treated diabetes because the portal-peripheral insulin gradient is absent. To determine whether suppression of GP in diabetes depends on portal insulin levels, we performed 3-h glucose and specific activity clamps in moderately hyperglycemic (10 mM) depancreatized dogs, using three protocols: (a) 54 pmol.kg-1 bolus + 5.4 pmol.kg-1.min-1 portal insulin infusion (n = 7; peripheral insulin = 170 +/- 51 pM); (b) an equimolar peripheral infusion (n = 7; peripheral insulin = 294 +/- 28 pM, P < 0.001); and (c) a half-dose peripheral infusion (n = 7), which gave comparable (157 +/- 13 pM) insulinemia to that seen in protocol 1. Glucose production, use (GU) and cycling (GC) were measured using HPLC-purified 6-[3H]- and 2-[3H]glucose. Consistent with the higher peripheral insulinemia, peripheral infusion was more effective than equimolar portal infusion in increasing GU. Unexpectedly, it was also more potent in suppressing GP (73 +/- 7 vs. 55 +/- 7% suppression between 120 and 180 min, P < 0.001). At matched peripheral insulinemia (protocols 2 and 3), not only stimulation of GU, but also suppression of GP was the same (55 +/- 7 vs. 63 +/- 4%). In the diabetic dogs at 10 mM glucose, GC was threefold higher than normal but failed to decrease with insulin infusion by either route. Glycerol, alanine, FFA, and glucagon levels decreased proportionally to peripheral insulinemia. However, the decrease in glucagon was not significantly greater in protocol 2 than in 1 or 3. When we combined all protocols, we found a correlation between the decrements in glycerol and FFAs and the decrease in GP (r = 0.6, P < 0.01). In conclusion, when suprabasal insulin levels in the physiological postprandial range are provided to moderately hyperglycemic depancreatized dogs, suppression of GP appears to be more dependent on peripheral than portal insulin concentrations and may be mainly mediated by limitation of the flow of precursors and energy substrates for gluconeogenesis and by the suppressive effect of insulin on glucagon secretion. These results suggest that a portal-peripheral insulin gradient might not be necessary to effectively suppress postprandial GP in insulin-treated diabetics.     

Psychological research of children with craniofacial anomalies: review, critique, and implications for the future

We conducted a 25-year follow-up study of 50 children of schizophrenic mothers, consisting of 25 children reared by their mothers and 25 children reared apart. The children's adult psychiatric status was evaluated in a 3-h structured interview employing a battery of syndrome check-lists and scales. A slightly higher incidence of psychopathology (including schizophrenia-spectrum disorders) was found among the reared-apart subjects. This may possibly be attributed to their greater genetic predisposition, as suggested by their mothers' more severe illnesses. Lifetime diagnoses do not provide evidence that psychopathology in offspring at genetic risk is increased by rearing by a schizophrenic mother.     

Presence of enamel on the incisors of the llama (Lama glama) and alpaca (Lama pacos)

Cytoplasmic aggregation is an early resistance-associated event that is observed in potato tissues either after penetration of an incompatible race of Phytophthora infestans, the potato late blight fungus, or after treatment with hyphal wall components (HWC) prepared from P. infestans. In potato cells in suspension culture, the number of cells with cytoplasmic aggregation increased upon treatment with HWC, but such an increase was suppressed by treatment with cytochalasin D prior to treatment with HWC. This result suggested that cytoplasmic aggregation in cultured potato cells might be connected with the association of actin filaments. To identify the molecular basis of cytoplasmic aggregation, we purified actin and actin-related proteins by affinity chromatography on a column of immobilized DNase I from cultured potato cells and isolated proteins of 43 kDa, 32 kDa and 22 kDa. Analysis of the amino-terminal amino acid sequences indicated that the 43 kDa, 32 kDa and 22 kDa proteins were potato actin, basic chitinase and osmotin-like protein, respectively. This conclusion was supported by the results of Western blotting analysis of the 43 kDa and 32 kDa proteins with antibodies against actin and basic chitinase. Binding analysis with actin coupled to actin-specific antibodies and biotinylated actin suggested that the 32 kDa and 22 kDa proteins had actin-binding activity. In addition, examination of biomolecular interactions using an optical biosensor confirmed the binding of chitinase to actin. These results imply the possibility that basic chitinase and osmotin-like protein might be involved in cytoplasmic aggregation, hereby participating. In the potato cell's defense against attack by pathogen.     

Infection with T-lymphotropic virus in Dutch blood donors, 1993-1996]

Infection with human T-lymphotrophic virus (HTLV) type 1 causes a neurological disorder or leukaemia in a minority of infected persons. Since January 1993 the Dutch blood banks screen each donation for presence of HTLV-1 infection. Approximately 4,000,000 donations from 700,000 donors have been tested. The numbers of confirmed HTLV-1 positive donors were: 1993: 15; 1994: 6; 1995: 8; 1996: 3. In 1995 one case of HTLV-2 infection was detected as well. In 26/32 (81%) of the HTLV-1 positive cases either the donor or his/her partner originated from HTLV-1 endemic areas. The introduction of HTLV screening prevents the silent spread of HTLV via blood transfusion.     

Mutation in the M1 domain of the acetylcholine receptor alpha subunit decreases the rate of agonist dissociation

We describe the kinetic consequences of the mutation N217K in the M1 domain of the acetylcholine receptor (AChR) alpha subunit that causes a slow channel congenital myasthenic syndrome (SCCMS). We previously showed that receptors containing alpha N217K expressed in 293 HEK cells open in prolonged activation episodes strikingly similar to those observed at the SCCMS end plates. Here we use single channel kinetic analysis to show that the prolonged activation episodes result primarily from slowing of the rate of acetylcholine (ACh) dissociation from the binding site. Rate constants for channel opening and closing are also slowed but to much smaller extents. The rate constants derived from kinetic analysis also describe the concentration dependence of receptor activation, revealing a 20-fold shift in the EC50 to lower agonist concentrations for alpha N217K. The apparent affinity of ACh binding, measured by competition against the rate of 125I-alpha-bungarotoxin binding, is also enhanced 20-fold by alpha N217K. Both the slowing of ACh dissociation and enhanced apparent affinity are specific to the lysine substitution, as the glutamine and glutamate substitutions have no effect. Substituting lysine for the equivalent asparagine in the beta, epsilon, or delta subunits does not affect the kinetics of receptor activation or apparent agonist affinity. The results show that a mutation in the amino-terminal portion of the M1 domain produces a localized perturbation that stabilizes agonist bound to the resting state of the AChR.