Biomedical subjects
J Warren
Publications and source records attributed to J Warren.
Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Society of Critical Care Medicine.
OBJECTIVE: The development of practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit (ICU) setting for the purpose of guiding clinical practice. PARTICIPANTS: A task force of more than 40 experts in disciplines related to the use of analgesic and sedative agents in the ICU was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM). EVIDENCE: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, pharmacopeias, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four predetermined categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times as a whole, and numerous times in smaller groups by teleconference, over a 1-yr period to identify the pertinent literature and arrive at consensus recommendations for the whole task force to discuss. Consideration was given to the relationship between the weight of scientific information and the experts' viewpoints. Over the next year, draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft was then reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. DATA SYNTHESIS: To facilitate rapid communication of the six recommendations contained within the complete and unabridged practice parameter document, an executive summary was prepared for publication by the ACCM Board of Regents, and this executive summary was approved by the task force steering committee and the SCCM Executive Council. CONCLUSIONS: A consensus of experts provided six recommendations with supporting data for intravenous analgesia and sedation in the ICU setting: a) morphine sulfate is the preferred analgesic agent for critically ill patients; b) fentanyl is the preferred analgesic agent for critically ill patients with hemodynamic instability, for patients manifesting symptoms of histamine release with morphine, or morphine allergy; c) hydromorphone can serve as an acceptable alternative to morphine; d) midazolam or propofol are the preferred agents only for the short-term (< 24 hrs) treatment of anxiety in the critically ill adult; e) lorazepam is the preferred agent for the prolonged treatment of anxiety in the critically ill adult; f) haloperidol is the preferred agent for the treatment of delirium in the critically ill adult. This executive summary selectively presents supporting information and is not intended as a substitute for the complete document.
Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary. Society of Critical Care Medicine.
OBJECTIVE: The development of practice parameters for achieving sustained neuromuscular blockade in the adult critically ill patient for the purpose of guiding clinical practice. PARTICIPANTS: A task force of more than 40 experts in disciplines related to the use of neuromuscular blocking agents in the intensive care unit was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM). EVIDENCE: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, pharmacopeias, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four predetermined categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times as a whole, and numerous times in smaller groups by teleconference, over a 1-yr period to identify the pertinent literature and arrive at consensus recommendations for the whole task force to discuss. Consideration was given to the relationship between the weight of scientific information and the experts' viewpoints. Over the next year, draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft was then reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. DATA SYNTHESIS: To facilitate rapid communication of the three recommendations contained within the complete and unabridged practice parameter document, an executive summary was prepared for publication by the ACCM Board of Regents, and this executive summary was approved by the task force steering committee and the SCCM Executive Council. CONCLUSIONS: A consensus of experts provided three recommendations with supporting data for achieving sustained neuromuscular blockade in critically ill patients: a) pancuronium is the preferred neuromuscular blocking agent for most critically ill patients; b) vecuronium is the preferred neuromuscular blocking agent for those patients with cardiac disease or hemodynamic instability in whom tachycardia may be deleterious; c) patients receiving neuromuscular blocking agents should be appropriately assessed for the degree of blockade that is being sustained. This executive summary selectively presents supporting information and is not intended as a substitute for the complete document.
Comparison of a fungal (family I) and bacterial (family II) cellulose-binding domain.
A family II cellulose-binding domain (CBD) of an exoglucanase/xylanase (Cex) from the bacterium Cellulomonas fimi was replaced with the family I CBD of cellobiohydrolase I (CbhI) from the fungus Trichoderma reesei. Expression of the hybrid gene in Escherichia coli yielded up to 50 mg of the hybrid protein, CexCBDCbhI, per liter of culture supernatant. The hybrid was purified to homogeneity by affinity chromatography on cellulose. The relative association constants (Kr) for the binding of Cex, CexCBDCbhI, the catalytic domain of Cex (p33), and CbhI to bacterial microcrystalline cellulose (BMCC) were 14.9, 7.8, 0.8, and 10.6 liters g-1, respectively. Cex and CexCBDCbhI had similar substrate specificities and similar activities on crystalline and amorphous cellulose. Both released predominantly cellobiose and cellotriose from amorphous cellulose. CexCBDCbhI was two to three times less active than Cex on BMCC, but significantly more active than Cex on soluble cellulose and on xylan. Unlike Cex, the hybrid protein neither bound to alpha-chitin nor released small particles from dewaxed cotton fibers.
Public health risks from motor vehicle emissions.
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The use of third-party information in forensic assessments: a two-state comparison.
There is virtually no research on the normative characteristics of forensic mental health assessment, despite the significant increase in conceptual and empirical attention devoted to such assessment within the last 10 years. The present study addressed this deficit by examining the use of third-party information, a crucial component of forensic mental health assessment, by forensic clinicians in two states: Florida (a total of 277 evaluations on the issues of competency to stand trial and sanity at the time of the offense) and Virginia (316 evaluations addressing the same legal issues). Evaluations in each state were performed in either a community or a hospital setting. Basic information about the offense, records of prior mental health evaluation or treatment, and specific statements by victims or witnesses were the variables examined comprising "third-party information" in this study. More than three fourths of all evaluations across states and settings incorporated this information. There was less consistency in the use of mental health records and victim/witness statements, with significant differences observed across settings and states. Results are discussed in light of potential influences of state, setting, and study methodology.
D-dimer: a useful marker of disease stage in surgery for colorectal cancer.
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International Commission for Protection Against Environmental Mutagens and Carcinogens. Power frequency electric and magnetic fields: a review of genetic toxicology.
Epidemiologic studies have reported a modestly increased risk of childhood leukemia associated with certain electric power wire configurations. Since cancer likely involves DNA damage, this review discusses the evidence of direct and indirect genetic toxicity effects for both electric and magnetic fields at 50- and 60-Hz and miscellaneous pulsed exposures. Exposure conditions vary greatly among different end points measured, making comparisons and conclusions among experiments difficult. Although most of the available evidence does not suggest that electric and/or magnetic fields cause DNA damage, the existence of some positive findings and limitations in the set of studies carried out suggest a need for additional work.
A bifunctional affinity linker to couple antibodies to cellulose.
We have constructed a fusion protein between the staphylococcal A protein and the cellulose binding domain of an exoglucanase (Cex) from Cellulomonas fimi that can be directly immobilized on cellulose while retaining its capacity to bind immunoglobulin G molecules. The cellulose domain provides binding that does not interfere with the biological activity of the fusion partner, does not involve hazardous chemicals and the matrix does not need to be chemically activated which reduces its cost. We have tested some of the possible applications of the fusion protein and show that it can be used in immunoassays, affinity chromatography and immunoprecipitations.
Courage and the quiet art: night thoughts of a doctor-to-be.
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HEI's mobile air toxics project.
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Sperm typing allows accurate measurement of the recombination fraction between D3S2 and D3S3 on the short arm of human chromosome 3.
The interval between the D3S2 and D3S3 loci on human chromosome 3p is a frequent site of deletions in a number of different cancers and contains the most common fragile site in man. Both loci have been physically mapped to 3p but because heterozygosity for D3S3 is so infrequent, recombination between them could not be determined accurately by using family studies. Sperm typing can measure recombination between DNA polymorphisms even in a single individual and thus can make use of polymorphisms with a low PIC. The recombination fraction between D3S2 and D3S3 was estimated to be 0.28 based on analyzing 189 and 77 sperm from two doubly heterozygous donors, respectively. These results demonstrate one of the ways in which sperm typing can complement pedigree analysis in constructing genetic maps.
Steady state measurement of glomerular proteoglycan synthesis in streptozotocin-induced diabetes.
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A nurse-directed protocol using pulse oximetry to wean mechanically ventilated patients from toxic oxygen concentrations.
The usual method of weaning mechanically ventilated patients from high FIO2 in our ICU, in which housestaff ordered all ventilator changes in an unstandardized manner (control group), was compared to a nurse-directed protocol that used a single arterial blood gas (ABG) analysis and multiple pulse oximetry measurements. The protocol required an ABG to be obtained upon the initiation of intubation/mechanical ventilation, followed by pulse oximetry measurements obtained in accordance with a standardized timetable. Decreases in FIO2 were guided by these results. It was concluded that a nurse-directed oxygen weaning protocol utilizing a combination of a single ABG and multiple pulse oximetry measurements was safe, reduced the need for ABGs, and decreased the duration of patient exposure to toxic oxygen concentrations.
Diagnosis and management of irritable bowel syndrome, constipation, and diarrhea in pregnancy.
Irritable bowel syndrome, constipation, and diarrhea may complicate a pregnancy. Complaints of IBS and constipation may be managed by nonpharmaceutical methods. A careful history should be conducted to determine whether these complaints are of an acute or a long-standing nature. Conservative treatment of IBS is recommended and may include stool-bulking agents, a high-fiber diet, elimination of offensive foods, and the behavioral treatment of passive muscle relaxation, biofeedback or supportive psychotherapy. Constipation is generally self-limiting. It also may be treated conservatively with stool-bulking agents, increases in dietary fiber, and the addition of pelvic muscle exercises, preferably using electromyographic biofeedback. Laxatives should be used judiciously (Table 1). Diarrhea is caused most often by infectious agents in pregnancy but may also be from food poisoning or a viral disease. Infectious diarrhea may be treated by mild antidiarrheal agents and safe antibiotics. Fluid replacement is the mainstay of treatment, and care should be taken, remembering that the treatment involves two patients. These complaints can generally be managed conservatively, but persistent cases should be investigated as in a nonpregnant patient.
Metabolism of glyphosate in Sprague-Dawley rats: tissue distribution, identification, and quantitation of glyphosate-derived materials following a single oral dose.
Five groups of male Sprague-Dawley rats were orally administered a mixture of [14C]- and [12C]-glyphosate (N-phosphonomethylglycine) at a dose level of 10 mg/kg body weight. The majority of radioactivity 2 hr after administration was associated with the gastrointestinal contents and small intestinal tissue. Approximately 35-40% of the administered dose was absorbed from the gastrointestinal tract, and urine and feces were equally important routes of elimination. The total body burden 7 days after administration was approximately 1% of the administered dose and was primarily associated with the bone. Total recovery for this study ranged from 95 to 102% of the administered dose. Metabolic profiles of tissues containing greater than 1% of the administered dose at various times after administration indicated that nearly 100% of the body burden of radioactivity was present as unmetabolized parent glyphosate. A minor component constituting less than 0.1% of the administered dose (less than 0.4 ppm) was observed in colon tissue from animals 2 hr after the administration of glyphosate and was also present in the GI contents of one animal 28 hr after administration of the radiolabel. The retention time for this metabolite was similar, but not identical, to the retention time for AMPA (aminomethylphosphonic acid), the major bacterial metabolite of glyphosate found in soil. Tissue extraction efficiency was always greater than 90% and stability assays indicated no significant effect of storage on either parent glyphosate or AMPA. The results from this study indicate that virtually no toxic metabolites of glyphosate were produced since there was little evidence of metabolism and essentially 100% of the body burden was parent compound with no significant persistence of material.
The Coventry thermal injury study.
Two hundred and fifty-six consecutive new patients seen in the weekly burns outpatient clinic were questioned, concerning details of their injury and first aid measures taken, and the information was recorded on a questionnaire. Following computer analysis, an interesting pattern of incidence, susceptible age groups, 'danger zones', and first aid given in the community emerged. Conclusions regarding burn prevention and first aid have been drawn.
Apathy: development of a nursing diagnosis.
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