Preventability of infant mortality in a rural community

Preventability of infant mortality in a rural southern county was examined with a Delphi technique using case summaries of infant deaths during a selected four-year period. The first two rounds were aimed at developing a consensus of panelists' opinions about problems leading to the high infant mortality rate in the study area. From these opinions, an Infant Mortality Preventability Decision Tree and a Problem List was developed. Panelists used these in Rounds III and IV to evaluate the case summaries. There were significant differences in the preventability ratings between physicians and nurses, indicating the importance of assessing individuals' philosophies of preventability when working with an interdisciplinary team of health care providers.     

Relation between impedance and electrode temperature during radiofrequency catheter ablation of accessory pathways and atrioventricular nodal reentrant tachycardia

OBJECTIVES: To evaluate and compare the clinical efficacy, impact on hemodynamics, safety profiles, and cost of combined administration of propofol and midazolam (synergistic sedation) vs. midazolam and propofol administered as sole agents, for sedation of mechanically ventilated patients after coronary artery bypass grafting. DESIGN: Prospective, controlled, randomized, double-blind clinical trial. SETTING: Intensive care unit of SCIAS-Hospital de Barcelona. PATIENTS: Seventy-five mechanically ventilated patients who underwent coronary artery bypass graft surgery under low-dose opioid anesthesia. INTERVENTIONS: According to the double-blind method, patients were randomly assigned to receive propofol (n = 25), midazolam (n = 25), or propofol combined with midazolam (n = 25). Infusion rates were adjusted to stay between 8 and 11 points on Glasgow Coma Score modified by Cook and Palma. MEASUREMENTS AND MAIN RESULTS: Mean +/- SD duration of sedation was 14.4 +/- 1.5 hrs, 14.1 +/- 1.1 hrs, and 14.7 +/- 1.9 hrs for the propofol, midazolam, and synergistic groups, respectively. The induction dose was 0.55 +/- 0.05 mg/kg for propofol as sole agent, 0.05 +/- 0.01 mg/kg for midazolam as sole agent, and 0.22 +/- 0.03 mg/kg for propofol administered in combination with 0.02 +/- 0.00 mg/kg of midazolam (p = .001). The maintenance dose was 1.20 +/- 0.03 mg/kg/hr for propofol as sole agent, 0.08 +/- 0.01 mg/kg/hr for midazolam as sole agent, and 0.50 +/- 0.09 mg/kg/hr for propofol administered in combination with 0.03 +/- 0.01 mg/kg/hr of midazolam (p < .001). All sedative regimens achieved similar efficacy in percentage of hours of adequate sedation (93% for propofol, 88% for midazolam, and 90% for the synergistic group, respectively). After induction, both propofol and midazolam groups had significant decreases in systolic blood pressure, diastolic blood pressure, left atrial pressure, and heart rate. Patients in the synergistic group had significant bradycardia throughout the study, without impairment in other hemodynamic parameters. Patients sedated with propofol or synergistic regimen awoke sooner and could be extubated before those patients sedated with midazolam (0.9 +/- 0.3 hrs and 1.2 +/- 0.6 hrs vs. 2.3 +/- 0.8 hrs, respectively, p = .01). Synergistic sedation produced cost savings of 28% with respect to midazolam and 68% with respect to propofol. CONCLUSIONS: In the study conditions, the new synergistic treatment with propofol and midazolam administered together is an effective and safe alternative for sedation, with some advantages over the conventional regimen with propofol or midazolam administered as sole agents, such as absence of hemodynamic impairment, >68% reduction in maintenance dose, and lower pharmaceutical cost.     

Education and training of medical informatics in the medical curriculum

The teaching of medical informatics is of importance for students in medicine and health care, realizing that they will be the health professionals of the future. Training in medical informatics is also of value for practicing clinicians who are overwhelmed by the avalanche of systems that are available on the market. Some examples of operational systems are presented here to indicate that health care has changed dramatically over the last decades. This paper intends to contribute to the drafting of IMIA guidelines for teaching medical informatics by (1) reporting on the experience at the Faculty of Medicine and Health Sciences of the Erasmus University Rotterdam as part of the curriculum, (2) reporting on the implementation of guidelines for teaching medical informatics in The Netherlands since these guidelines were drafted in 1986, and (3) by introducing the teaching material contained in the new Handbook of Medical Informatics and on its Web site.     

Oral topotecan given once or twice daily for ten days: a phase I pharmacology study in adult patients with solid tumors

The development of a highly sensitive method for detection of telomerase activity, telomeric repeat amplification protocol (TRAP), has provided knowledge on telomerase activity in normal and cancer tissues. Subsequent several modifications have been achieved, including an introduction of the internal standard and hybridization protection technique that leads to simplicity and improvement of reproducibility and linearity of this method, and application of TRAP to in situ analysis to identify the cells responsible for telomerase activity. As for measurement of telomere length, fluorescence in situ hybridization technique appeared to give an information of telomere length on an individual chromosome in contrast to analysis of terminal restriction fragment, a conventional method which can express mean telomere length of all chromosomes. Further methodological improvement in this field is ongoing and showing a new sight on cell mortality and immortality.     

Effects of central and peripheral administration of kynurenic acid on hippocampal evoked responses in vivo and in vitro

Kynurenic acid is an excitatory amino acid antagonist with preferential activity at the N-methyl-D-aspartate subtype of glutamate receptors. It is produced endogenously in the brain, but is synthesized more effectively in the periphery. The influence of peripheral kynurenic acid on brain function is unclear because kynurenic acid is likely to penetrate the blood-brain barrier poorly. To determine the potential central effects of peripheral kynurenic acid, we compared its effects in the hippocampus after peripheral or direct administration. The hippocampus of the rat was chosen as a test system because this region receives glutamatergic inputs, and because responses to stimulation of these inputs can be compared after peripheral drug administration in vivo, and after direct administration of drugs in vitro. Peripherally-administered kynurenic acid was injected via a catheter in the jugular vein. Bath-application to hippocampal slices was used to test effects of direct administration. Area CA1 pyramidal cells and dentate gyrus granule cells were examined by extracellular recording and stimulation of area CA3 or the perforant path, respectively. Pairs of identical stimuli were used to assess paired-pulse inhibition and paired-pulse facilitation. Kynurenic acid decreased evoked responses in area CA1 and the dentate gyrus, both in vivo and in vitro. Effective concentrations were in the low micromolar range, and therefore were likely to be mediated by antagonism of N-methyl-D-aspartate receptors. In both preparations, area CA1 was more sensitive than the dentate gyrus, and paired-pulse facilitation was affected, but not paired-pulse inhibition. Control solutions had no effect. We conclude that kynurenic acid can enter the brain after peripheral administration, and that peripheral and direct effects in the hippocampus are qualitatively similar. Therefore, we predict that effects of endogenous kynurenic acid that was synthesized peripherally or centrally would be similar. Furthermore, the results suggest that modulation of the glycine site of the N-methyl-D-aspartate receptor, for example by kynurenic acid, may vary considerably among different brain areas.     

Hematuria and sickle cell disorders

To examine the relationship between gross hematuria and sickle cell disorders, all patients admitted to Grady Memorial Hospital with the diagnosis of a sickle cell disorder during a 14-month period were reviewed. Of 115 such patients, 65% had sickle cell disease and 35% had sickle cell trait. None of the former but seven of the latter group had gross hematuria. Mean age of the seven was 30 years. Comprehensive examinations and laboratory studies showed that all were free of concomitant disease. Physical findings, diagnostic modalities, and treatment were reviewed. Findings suggest that conservative therapy (bed rest, hydration, and diuresis) is usually effective.