Simplifying care plans.
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Efficiency, Organizational↗
Biomedical subjects
B Johnston
Publications and source records attributed to B Johnston.
Kaiser Permanente Medical Center's pilot Tele-Home Health Project.
This is an interim report of a Kaiser Home Health Department study of the use of telemedicine technology in the home care setting. We present our study design and some early findings from the first six months of the project. Preliminary findings indicate the technology is dependable, and that average telehealth video visits are cost-effective and are about 60% shorter (18 minutes vs. 45 minutes) than on-site visits, with no decrease in patient satisfaction. The study will be completed in September of 1997. This study was initiated in 1996 to explore improving access to health services while maintaining quality of care, and to demonstrate the cost effectiveness of remote consultation technology in the home health setting. The the study, which began in May 1996, employs a randomized design approved by the Institutional Review Board and will be completed in approximately one year. This project was titled Tele-Home Health to acknowledge that a multi-disciplinary team would be composed mainly of nurse case managers, but would also include physical therapists, speech therapists, occupational therapists, home health aides, licensed
Aged↗
Reversible modification of the Goldmann perimeter for the assessment of the field of binocular single vision.
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Adolescent↗
The alpha 4-integrin supports leukocyte rolling and adhesion in chronically inflamed postcapillary venules in vivo.
A role for the alpha 4-integrin (alpha 4 beta 1 or alpha 4 beta 7), has been implicated in the recruitment of peripheral blood mononuclear cells (PBMCs) to sites of inflammation. However, the adhesive interactions (i.e., tethering, rolling, and adhesion) mediated by the alpha 4-integrin have not been characterized in vivo. The objective of this study was to establish a model wherein postcapillary venules were chronically inflamed, and then use intravital microscopy to identify the adhesive interactions mediated by the alpha 4-integrin in vivo. Between 4 and 20 d after immunization with Mycobacterium butyricum, animals developed a systemic vasculitis characterized by large increases in the numbers of rolling and adhering leukocytes within mesenteric venules. The selectins could only account for approximately 50% of the leukocyte rolling whereas the remaining cells rolled exclusively via the alpha 4-integrin. Anti-alpha 4 therapy also eliminated the increase in leukocyte adhesion observed in this model, whereas selectin therapies and an anti-CD18 (beta 2-integrin) monoclonal antibody (mAb) did not reduce adhesion. A serum against polymorphonuclear leukocytes (PMNs) was used to confirm that a significant proportion of rolling cells, and most of the adhering cells were PBMCs. Sequential treatment with anti-PMN serum and the anti-alpha 4 mAb demonstrated that alpha 4-dependent rolling was distinct from PMN rolling populations. Initial leukocyte tethering via the alpha 4-integrin could not be demonstrated in this model, whereas L-selectin did support leukocyte tethering. These data suggest that the alpha 4-integrin can mediate both rolling and adhesion in the multistep recruitment of PMBCs in vivo, and these interactions occur independently of the selectins and beta 2-integrins.
Animals↗
Preclinical trial of a bioartificial liver support system in a porcine fulminant hepatic failure model.
BACKGROUND: This study describes the pre-clinical trials of an extracorporeal bioartificial liver support system (BALSS). It includes the biochemical changes which occur in the plasma and blood of pigs with devascularized livers when the plasma is treated in a BALSS, and the testing of the system for presence or absence of infective agents, pyrogens and for toxicity. METHODS: Hepatic cells were prepared from littermate juvenile white landrace pigs with a double-step collagenase digest technique. The cell preparations were incubated with collagen-coated dextran microspheres (CDM) for 3 h and the medium was tested to determine cellular metabolic activity. Incubation continued for a further 20 h during which the hepatic cells attach to the CDM. The CDM-attached cells were inoculated into a hollow fibre bioreactor which was part of an extracorporeal liver support system. RESULTS: Hepatic cell content of the bioreactor was 6 x 10(9) +/- 3 x 10(8) cells, equivalent to those present in half a pig's liver. The system was tested in a controlled trial with the plasma of pigs with fulminant hepatic failure (FHF) due to devascularized livers. When plasma from FHF pigs was circulated through the device there was significantly less of an increase in the accumulation of ammonia, lactate and most amino acids when hepatic cells were included in the circuit compared with those in control experiments when they were excluded. Similar changes occurred in procine blood. There were few infections diagnosed and an absence of pyrogens, endotoxins and toxicity in the bioreactor contents or in the terminating reservoir or animal blood samples. CONCLUSIONS: We believe that the results, demonstrating function of the porcine hepatic cells in the circuit, together with low risks, justify a clinical trial of use of the BALSS in Australia.
Amino Acids↗
Hydrogen peroxide induces leukocyte rolling: modulation by endogenous antioxidant mechanisms including NO.
In this study, intravital microscopy was used to examine the mechanisms that regulate H2O2-induced leukocyte rolling within rat mesenteric venules in vivo. H2O2 elicited leukocyte rolling within a narrow response window between 10 and 500 microM H2O2. Continuous superfusion with 100 microM H2O2 induced a large but transient increase in the flux of rolling leukocytes, whereas a short 5-min pulse elicited a sustained increase in rolling flux. Both treatments caused increases in leukocyte adhesion. H2O2-induced increases in leukocyte flux and adhesion could be prevented with an anti-P-selectin antibody. Inhibition of endogenous catalase (aminotriazole), glutathione (diethyl maleate), or nitric oxide (NG-nitro-L-arginine methyl ester) shifted the effective concentration of H2O2; continuous superfusion with 10 microM H2O2 now elicited large and sustained increases in leukocyte rolling flux, whereas 100 microM H2O2 elicited less than optimal responses. Dual antioxidant inhibition further reduced the effective H2O2 concentration to 1 microM H2O2. A nitric oxide donor prevented the increased rolling flux induced by 100 microM H2O2. These findings suggest that endogenous antioxidants are important regulators of H2O2-induced, P-selectin-dependent leukocyte rolling in vivo.
Animals↗
Delayed vasodilation and altered oxygenation after cerebral ischemia in fetal sheep.
The study investigated the hypothesis that delayed cerebral injury after transient cerebral ischemia is associated with vasoconstriction and decreased cerebral oxygenation. Eight chronically instrumented, late gestation fetal sheep were subjected to 30 min of cerebral ischemia in utero. Cortical impedance (CI) and electrocorticogram (ECoG) were recorded to determine the time course of cellular dysfunction. Histologic outcome was assessed 4 d postischemia. Changes in cerebral vascular tone and oxygenation were observed during and for 4 d after the insult using near infrared spectroscopy to measure changes in total cerebral Hb ([tHb]), oxyhemoglobin ([Hbo2]), and oxidized cytochrome aa3 ([Cyto2]). Results are expressed as mean +/- SEM. CI increased transiently during ischemia; then a delayed increase commenced 17.5 +/- 2.3 h postischemia and peaked at 42.3 +/- 2.4 h. ECoG was depressed during and after the insult. Seizures started 13.6 +/- 3.0 h postinsult and persisted for 25.4 +/- 3.2 h. Increases in [tHb] indicated two periods of cerebral vasodilation: immediately after early reperfusion, lasting 2.3 +/- 0.4 h and peaking to 20 +/- 2.0 mumol.L-1; and a later phase, commencing 12.8 +/- 2.0 h postischemia, peaking to 43 +/- 4.0 mumol.L-1 and lasting 43.1 +/- 5.2 h. [Hbo2] was relatively elevated (18 +/- 3.0 mumol.L-1) during d 4 postischemia, demonstrating a delayed increase in mean cerebral oxygen saturation. [Cyto2] fell during the insult (-0.7 +/- 0.2 mumol.L-1); and, commencing at 28-30 h postischemia, fell progressively to reach a minimum of -5.0 +/- 2.8 mumol.L-1 at 78-80 h postischemia. A greater fall in [Cyto2] was related to worse cerebral injury (p < 0.05). Delayed cerebral injury is accompanied by vasodilation and increased mean cerebral oxygen saturation, although a progressive fall in [Cyto2] might indicate a fall in mitochondrial oxygenation, cell loss, or changes in tissue optical characteristics.
Animals↗
Cross-species chimerism and graft-versus-host disease (GVHD) induced by transplantation of mouse fetal hematopoietic cells into newborn rats.
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Animals↗
Biofeedback: a noninvasive treatment for incontinence after radical prostatectomy.
OBJECTIVE: Will a program using biofeedback help patients with post radical prostatectomy incontinence to achieve continence by increasing their ability to contract pelvic floor muscles? STUDY DESIGN: Twenty-seven patients who had undergone incontinent radical prostatectomy were evaluated for urinary incontinence and treated at the Urology Biofeedback Laboratory at our institution. Patients were assessed by urodynamic studies including uroflow, postvoid residual measurement, and cystometrogram before biofeedback was initiated. The protocol provided for 10 weekly sessions of 15 minutes' duration with additional reinforcement sessions at 1, 3, 6, and 12 months. Subjective symptoms related to urgency, frequency, nocturia, and number of pad changes were reported by patients before treatment and at each visit. Digital evaluation of the pelvic floor muscle contraction was objectively graded from 0 to 3 (nil to strong) and was completed before and after treatment. These subjective and objective findings were used to determine success of treatment. RESULTS: Of the 27 patients completing the full treatment course, 13 (48%) had complete success, 7 (26%) had significant improvement but were not completely dry, and 7 (26%) had failure, for a total improvement rate of 74%. CONCLUSIONS: A biofeedback training program is an effective, minimally invasive, and well-accepted method that can be offered as a first-line option to patients who have undergone radical prostatectomy and want to improve the postsurgical problem of urinary incontinence. Patient motivation is an important factor in success. Nurses have an opportunity to use their expertise in this program to assist these patients to return to continence.
Aged↗
Enhancement of erectile responses to vasoactive drugs by a variable amplitude oscillation device.
The limitations of intracavernosal injection (ICI) of vaso-active drugs as a diagnostic tool in the evaluation of erectile dysfunction are well recognized and, prominently, include the artifacts induced by the unfamiliar environment on the patient. We report on the benefits of adding a vibratory stimulus to ICI to improve the sensitivity of this test in a population of 170 patients with erectile dysfunction who were evaluated using a standard protocol. Intracavernosal pressure was measured following ICI alone and ICI with vibratory stimulation of the penis. A statistically significant improvement in intracavernosal pressure (ICP) with the addition of vibration was observed in 87% of the subjects as compared to ICI. In 52% the improvement in ICP was greater than 20% over that achieved by ICI. This study showed that the addition of vibration to intracavernosal administration of vaso-active drugs significantly increases the erectile response in a controlled and reproducible manner. Vibratory stimulation provides a better reflection of erectile potential than the pharmacological challenge alone.
Adult↗
Perinatal brain injury. Pathophysiology and therapeutic intervention.
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Animals↗
Mechanisms underlying acute mast cell-induced leukocyte rolling and adhesion in vivo.
It has been proposed that a primary detector mechanism for tissue infection or injury may be the mast cell that releases agents that recruit leukocytes to the appropriate site at risk. The objective of this study was to evaluate the early mechanisms involved in mast cell-induced leukocyte recruitment. We used intravital microscopy to visualize leukocyte-rolling flux and adhesion in single 25 to 40 microns venules in mesenteric preparations that were treated with the mast cell-degranulating agent, compound 48/80 (CMP 48/80). Superfusion of the rat mesentery with CMP 48/80 caused a dose-dependent rise in the number of rolling and adherent cells, events significantly reduced by: 1) mast cell stabilizers, ketotifen, or cromolyn, and 2) chronic treatment with CMP 48/80 to deplete mast cell constituents. The increase in leukocyte flux associated with CMP 48/80 was blocked by diphenhydramine (H1-receptor antagonist) and an anti-P-selectin Ab (PB1.3), but not by the 5-lipoxygenase inhibitor, MK 886. The reduction in the flux of rolling leukocytes translated into fewer adherent leukocytes with diphenhydramine or PB1.3. The CMP 48/80-induced rise in leukocyte adhesion, but not leukocyte flux, was reduced by the platelet-activating factor (PAF)-receptor antagonist (WEB 2086) and an anti-CD18 Ab (CL26). MK 886 did not prevent the increased leukocyte adhesion. In vitro data revealed that mast cell-derived PAF induced essentially all of the leukocyte adhesion to endothelium or protein-coated plastic. These data suggest that mast cell degranulation induces P-selectin-dependent leukocyte rolling and CD18-dependent leukocyte adhesion via histamine and PAF, respectively.
Animals↗
Recovery of erectile function by the oral administration of apomorphine.
OBJECTIVES: Apomorphine has been reported to be effective in causing erections in animals and man when administered parenterally. The side effects, notably nausea, have seriously limited its clinical usefulness. We formulated apomorphine for controlled sublingual absorption and herein report on four preliminary studies evaluating efficacy and side effects in men with no documentable organic cause of erectile dysfunction. METHODS: Patients complaining of erectile dysfunction underwent a careful evaluation. Those with measurable organic dysfunction or known organic factors were excluded. Men with primarily psychogenic impotence were tested with one of four protocols of an apomorphine preparation (preliminary sublingual liquid, preliminary 5 mg tablet, aqueous nasal spray, and new 3 and 4 mg controlled absorption tablets). The erectile response of these men to the drug with visual erotic or sexually neutral stimulation was studied with the Rigiscan. RESULTS: Seven of 10 evaluable patients responded to the sublingual liquid preparation but the majority experienced significant nausea. The preliminary 5 mg tablet and aqueous forms did not produce useful responses free of side effects. The newly formulated controlled absorption 3 and 4 mg tablets were tested in 12 men. Eight of 12 (67%) developed erections in response to apomorphine. Erectile activity was seen during sexually neutral visual stimulation to a significantly greater extent than with placebo. Home trial use was found to be successful and sustained by 7 of 11 (64%) patients. CONCLUSIONS: We have shown that apomorphine will act as an erectogenic agent when absorbed through the oral mucosa. In a carefully selected group of impotent patients with no documentable organic causes of erectile dysfunction, but with proven erectile potential, 67% will experience significantly durable erections with a dose of 3 or 4 mg of apomorphine when formulated for controlled absorption. The results in these small groups appear to justify larger clinical studies of this proprietary formulation.
Administration, Sublingual↗
Effect of timing of ketorolac administration on patient-controlled opioid use.
In order to investigate the analgesic effect of timing of administration of ketorolac 10 mg i.v., we recorded patient-controlled use of diamorphine at 2, 4 and 12 h after abdominal hysterectomy. In a randomized, double-blind trial, 30 patients received ketorolac before skin incision and 28 after skin closure. A control group of 32 patients did not receive ketorolac. We measured operative blood loss and assessed nausea, vomiting and pruritus. After 2 h of patient-controlled analgesia, the median cumulative diamorphine dose in the group given ketorolac before operation was less than that of the control group (95% confidence interval 8-66 micrograms kg-1; P = 0.01). There were no other statistically significant differences in diamorphine consumption between the groups. The frequency of nausea and vomiting was similar in all groups Median blood loss in the group given ketorolac before operation exceeded that of the patients who did not receive ketorolac before operation (95% confidence interval 20-149 ml; P = 0.01). We conclude that the diamorphine-sparing effect of ketorolac attributable to timing of administration was small, conferred no clinical benefit and was accompanied by increased bleeding. No patient given ketorolac complained of pruritus.
Adult↗
Inter-observer agreement of the assessment of coma scales and brainstem signs in non-traumatic coma.
The authors evaluated the inter-observer agreement between two experienced clinicians examining 19 unconscious children who were not paralysed or ventilated. Inter-observer reliability was assessed by proportion of agreement, disagreement rate and kappa statistics. Corneal reflexes, pupillary responses to light and motor responses were the most reliably elicited. Reduction of the number of categories improved inter-observer agreement. Some of the disagreement may be attributed to changes in the child's condition during the period of assessment. There was more agreement about the five-category 0-IV scale than the summated Adelaide (10-category) and Jacobi (13-category) scales. The ability of these scales to follow changes in the patient's condition and to predict outcome needs to be evaluated in a prospective trial.
Brain Stem↗
Structure and function of Tn5467, a Tn21-like transposon located on the Thiobacillus ferrooxidans broad-host-range plasmid pTF-FC2.
A 3.5-kb region of plasmid pTF-FC2, which contains a transposon-like element designated Tn5467, has been sequenced, and its biological activity has been investigated. The transposon is bordered by two 38-bp inverted repeat sequences which have sequence identity in 37 of 38 and in 38 of 39 bp to the tnpA distal and tnpA proximal inverted repeats of Tn21, respectively. Within these borders, open reading frames with amino acid similarity to a glutaredoxin-like protein, a MerR regulatory protein, and a multidrug-resistant-membrane transport-like protein were found. The gene for the glutaredoxin-like protein was expressed in Escherichia coli and enabled growth of a glutathione-requiring E. coli trxA gshA mutant on minimal medium and the reduction of methionine sulfoxide to methionine. In addition, there were two regions which, when translated, had homology to 85% of the N-terminal region of the Tn21 resolvase (tnpR) and to 15% of the C terminus of the Tn21 transposase (tnpA). A region containing res-like sites was located immediately upstream of the partial tnpR gene. Neither the partial transposase nor the resolvase genes of Tn5467 were biologically active, but Tn5467 was transposed and resolved when the Tn21 transposase and resolvase were provided in trans. Tn5467 appears to be a defective transposon which belongs to the Tn21 subgroup of the Tn3 family.
Amino Acid Sequence↗
Leukotriene C4/D4 induces P-selectin and sialyl Lewis(x)-dependent alterations in leukocyte kinetics in vivo.
The objective of this study was to assess the effect of leukotriene C4 (LTC4) on the flux of rolling leukocytes, leukocyte rolling velocity, and leukocyte adhesion in postcapillary venules in vivo and to study the underlying molecular mechanisms involved. LTC4 (20 nmol/L) induced a rapid and significant increase in leukocyte rolling flux that was inhibitable by an anti-P-selectin antibody and soluble sialyl Lewis(x) (sLe(x)). LTC4 also induced a significant reduction in leukocyte rolling velocity, an event that was independent of P-selectin but entirely dependent on sLe(x). This LTC4-induced reduction in leukocyte rolling velocity was independent of any hemodynamic alterations. Another P-selectin effector, histamine, did not affect leukocyte rolling velocity even at > 5000 times the concentration of LTC4. Treatment with an anti-L-selectin antibody had no effect on the LTC4-induced increase in leukocyte rolling or reduction in rolling velocity. Inhibition of LTC4 bioconversion to LTD4 by pretreatment with L-serine (100 mumol/L) prevented the LTC4-induced increase in leukocyte rolling flux and the LTC4-induced reduction in leukocyte rolling velocity. A subtle, yet significant, increase in leukocyte adhesion was also observed with LTC4. Pretreatment with a platelet-activating factor receptor antagonist returned the LTC4-induced leukocyte rolling velocity to baseline levels. The addition of a very low concentration of platelet-activating factor (1 nmol/L) induced significant leukocyte adhesion in the presence of LTC4 but not histamine.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Psychometric profiling of the elderly using the Cambridge Cognitive Examination.
OBJECTIVES: To (1) build a psychometric profile of elderly subjects attending specialists day care centers and residential homes using the Cambridge Cognitive Examination (CAMCOG); (2) identify factors that are predictive of the score obtained; and (3) determine whether scores from CAMCOG and the less time-consuming Mini-Mental State Examination (MMSE) were correlated sufficiently for the latter to replace the former for general cognitive screening. DESIGN: Nonrandom convenience sampling of elderly subjects attending specialist day care centers, residential homes, and units for the elderly mentally ill. SETTING: Belfast, Northern Ireland. MAIN OUTCOME: CAMCOG and MMSE scores with age, sex, educational level, marital status, visual and hearing ability, various central nervous system diseases, and handedness as independent variables. RESULTS: Age, sex, the wearing of glasses, Parkinson's disease, stroke, and epilepsy were found to be significant predictors of the CAMCOG score. This pattern held true for the MMSE score, except for stroke. CAMCOG and MMSE scores were correlated closely, even after deletion of overlapping scores. However, the CAMCOG score showed an increasing bias when the mean score increased. The cognitive function of the subjects attending the 3 types of establishment differed significantly, with those in the residential homes being the most heterogenous. CONCLUSIONS: The subjects profiled showed significant cognitive impairment. The MMSE score appears to give much the same information as the CAMCOG score in this general screening of our patient group. The population considered is probably representative of subjects attending similar units in the United Kingdom.
Aged↗