Tumour necrosis factor as predictor for pulmonary dysfunction after cardiac surgery.
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Adult↗
Biomedical subjects
M A Armstrong
Publications and source records attributed to M A Armstrong.
Monitoring women at risk for preterm labor.
BACKGROUND: Preterm birth is a major cause of perinatal morbidity and mortality. Whether the rate of preterm birth can be reduced by frequent contact between nurses and pregnant women or home monitoring of uterine activity is not known. METHODS: We randomly assigned 2422 pregnant women with known risk factors for preterm labor (including 844 women who were pregnant with twins) to receive education and to have one of the following: weekly contact with a nurse, daily contact with a nurse, or daily contact with a nurse and home monitoring of uterine activity. The nurses elicited the women's own assessments of their symptoms and signs of preterm labor. The primary end point was the incidence of birth at less than 35 weeks' gestation. Secondary end points included cervical status at the time preterm labor was diagnosed and birth weight. RESULTS: There were no significant differences among the groups in the incidence of birth at less than 35 weeks (14 percent in the weekly-contact group, 13 percent in the daily-contact group, and 14 percent in the home-monitoring group), in the mean amount of cervical dilatation at the time preterm labor was diagnosed (1.8 cm, 1.5 cm, and 1.4 cm, respectively), or in such neonatal outcomes as birth weights of less than 1500 g or less than 2500 g. However, daily contact with a nurse increased the mean number of unscheduled visits to obstetricians (1.2 in the weekly-contact group, 1.8 in the daily-contact group, and 2.3 in the home-monitoring group) and the proportion of women who received prophylactic tocolytic drugs (12 percent, 14 percent, and 19 percent, respectively). CONCLUSIONS: Women who have daily contact with a nurse, with or without home monitoring of uterine activity, have no better pregnancy outcomes than women who have weekly contact with a nurse.
Adult↗
Structured review of neonatal deaths in a managed care organisation.
We sought to quantify neonatal mortality (< 28 days) in a 10-hospital system, determine what proportion was associated with suboptimal neonatal care and make recommendations on how neonatal mortality rates (NMRs) could be used in quality improvement efforts. Deaths were identified using electronic linkage to the State of California Death Certificate Tapes. Individual fatalities were reviewed by a minimum of two physicians who did not care for the infant. Deaths were classified as either being associated with suboptimal care or not. For deaths where suboptimal care was an issue, emphasis was on delineating the process involved in the death. Subjects were all neonatal deaths among 64,469 babies born in 1990-91 in the 10 birth facilities of the Kaiser Permanente Medical Care Program, Northern California Region. A total of 241 neonatal deaths were identified. Adjusting for prematurity by increasing the follow-up period in preterm babies (included as neonatal deaths if they died up to 40 weeks corrected gestational age + 27.9 days) increased overall mortality rates by 5%. Birthweight-specific NMRs in Kaiser Permanente are similar to those of other published reports. Among the 198 deaths in babies weighing > or = 500 g at birth, only 14 (7%) were possibly associated with suboptimal care. In populations with access to health insurance, reporting only aggregate NMRs is of limited use. The number of deaths that could be ascribed to suboptimal neonatal care is very small and measuring variations in rates of such deaths is difficult. Future measurements of quality of care will require more sophisticated measures, database systems, review strategies and dissemination methods.
Adolescent↗
Alcohol consumption and utilization of health services in a health maintenance organization.
OBJECTIVES: This study examined the relation between alcohol use and utilization of health services during a 3-year period in a sample of 4,264 adult respondents to a member health survey in a health maintenance organization. METHODS: Respondents were categorized as abstainers (no drinks in the past year, n = 1,139), lighter drinkers (less than seven drinks/week, n = 2,330), moderate drinkers (seven to 13 drinks/week, n = 498), and heavier drinkers (> or =14 drinks/week, n = 297). Each drinker group was compared with abstainers on outpatient visits, hospital days, and number of hospitalizations controlling for age, race, and health plan membership. RESULTS: The mean number of outpatient visits was inversely related to the amount of alcohol consumed. Significant differences also were found for mean number of hospitalizations and mean days hospitalized per year. Compared with the three drinker groups, abstainers were significantly higher on both inpatient measures. CONCLUSIONS: These results might be explained by the inclusion in the abstainer group of exdrinkers who quit because of illness, inattention to health problems by heavier drinkers, or lower rates of illness among drinkers. The findings underscore the importance of replicating our study in other cohorts in which problem drinkers can be identified and compared with non-problem drinkers and in which lifelong abstainers can be separated from exdrinkers in the analysis.
Adult↗
Developmentally supportive care in a neonatal intensive care unit: a research utilization project.
PURPOSE: To implement three aspects of developmental care: lower noise levels, decreased light levels, and flexed, midline positioning. DESIGN: Research utilization project. The developmental care interventions were implemented on a daily basis for two hours of "quiet time" during each eight-hour shift. SAMPLE: 49 infants with mean gestational ages of 35.1 +/- 3.2 weeks and mean weights of 2,107 +/- 464 gm. MAIN OUTCOME VARIABLE: Noise levels, light levels, and flexed midline positioning. RESULTS: Mean light levels and mean noise levels decreased during "quiet time" on all three shifts during the project. Optimal positioning was achieved 78 percent of the time during the project period observations.
Child Development↗
Red wine, white wine, liquor, beer, and risk for coronary artery disease hospitalization.
International comparison data suggest that wine may be more protective against coronary artery disease than beer or liquor. There are potentially protective antioxidants in wine, especially red wine. However, prospective population studies suggest that each beverage type may reduce coronary risk. The role of alcoholic beverage choice in coronary risk remains unresolved. We performed a prospective study of coronary disease hospitalizations among 128,934 adult members of a Northern California prepaid comprehensive health care program. Alcohol data were supplied at health examinations. Using Cox proportional-hazards models with 9 covariates, analyses were performed of the roles of each major beverage type (wine, beer, and liquor) and of drinking only table wine (red, white, or both). Generally, coronary risk traits were most favorable for wine drinkers and least favorable for liquor drinkers. Among 3,931 persons hospitalized for coronary disease, total alcohol drinking was inversely related to risk in both sexes. Uncontrolled for total alcohol, each beverage type showed evidence for coronary protection, weakest for liquor and strongest for beer in men and wine in women. Controlled for total alcohol, these relations were much reduced, and lost statistical significance except for beer in men and both red and white wine (combined) in all persons. We conclude that (1) drinking ethyl alcohol apparently protects against coronary disease, and (2) there may be minor additional benefits associated with drinking both beer and wine, but not especially red wine.
Adult↗
The choice of anesthetic maintenance technique influences the antiinflammatory cytokine response to abdominal surgery.
UNLABELLED: Outcome in some diseases is determined by the relationship between pro- and antiinflammatory cytokines. Surgery may also provoke a cytokine response, which has both pro- and antiinflammatory components. The aim of this study was to ascertain whether anesthetic technique can modify the balance of cytokines associated with abdominal surgery. Twenty patients scheduled to undergo elective abdominal hysterectomy were randomly allocated to receive maintenance of anesthesia with isoflurane (IH group) or propofol (IV group). Venous blood samples for measurement of tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), interleukin-10 (IL-10), and interleukin-1 receptor antagonist (IL-1ra) were taken before the induction of anesthesia and at set intervals until 24 h postoperatively. TNF-alpha levels remained low throughout the study; however, all patients showed a significant postoperative increase in IL-6, IL-10, and IL-1ra (P < 0.05). Levels of the proinflammatory cytokine IL-6 were similar in both groups, whereas the antiinflammatory cytokine IL-10 was higher in the IV group at 4 h postoperatively (P < 0.02). The difference between groups in terms of IL-1ra production just failed to reach significance (P < 0.06). We conclude that the cytokine response to abdominal surgery has both pro- and antiinflammatory components and that the choice of anesthetic may modify the balance of these cytokines. IMPLICATIONS: This study demonstrates that in addition to the widely reported proinflammatory cytokine response, elective abdominal surgery provokes an antiinflammatory response, which may be enhanced by total intravenous anesthesia. The ability of anesthetics to modify the cytokine response to surgery may have therapeutic potential.
Adult↗
Peripheral edema.
Distribution of accumulated fluid is the important element in the differentiation of peripheral edema resulting from different etiologies. Isolated upper extremity edema is rare and is usually caused by obstruction of the superior vena cava by a malignancy. The cause of unilateral edema of a lower limb can usually be determined by the history (heart, liver or kidney disease, trauma, malignancy, radiation or surgery), a physical examination (distribution of edema, stigmata of infection, trauma, malignancy or organ failure) and appropriate laboratory and other tests. Determining the etiology of bilateral lower extremity edema requires a similar approach; this condition may be the result of systemic conditions, drug use, lipidema or idiopathic edema, in addition to obstructive causes and chronic venous states. Algorithms, based on the patient's history, physical examination and diagnostic tests, can help guide physicians to the correct diagnosis.
Algorithms↗
The balance of pro and anti-inflammatory cytokines in plasma and bronchoalveolar lavage (BAL) at paediatric cardiac surgery.
During adult cardiac surgery the plasma pro-inflammatory cytokine response is balanced by a phased anti-inflammatory cytokine response. Whether a similar balanced plasma pro- and anti-inflammatory cytokine response occurred in paediatric cardiac surgery was investigated. Changes in intra-pulmonary cytokine balance by measuring bronchoalveolar lavage (BAL) cytokine content were also estimated. Plasma and BAL samples were obtained from 10 children (aged 15 months to 10 years) 10 min after induction of anaesthesia (sample 0), 5 min after the onset of cardiopulmonary bypass (CPB) (sample 1), 10 min after release of the aortic cross clamp (sample 2), and 2 and 24 h after the end of CPB (samples 3 and 4). BAL and plasma was assayed for interleukin 1 beta (IL-1 beta), tumour necrosis factor alpha (TNF-alpha), IL-8, IL-10, interleukin 1 receptor antagonist (IL-1ra) and the TNF soluble receptors (TNFsrs). There was a phased plasma anti-inflammatory response commencing with IL-10 (sample 2), and followed by significant increases in IL-1ra (samples 3, 4 and 5) and TNF soluble receptors (sample 5). Plasma TNF-alpha and IL-1 beta concentrations were not significantly elevated from baseline. Mean baseline plasma IL-8 was 30 (SEM 9) pg/ml. This was significantly elevated at sample 4 (112 (SEM 68) pg/ml). In BAL, only IL-8 and IL-10 were significantly elevated after CPB as compared with baseline. During paediatric cardiac surgery there is a significant increase in plasma and BAL IL-8. This is balanced within the plasma by a phased anti-inflammatory cytokine response, and within the lung by IL-10.
Bronchoalveolar Lavage Fluid↗
Patients' experience of a planned admission program: implications for nursing practice and research.
Various treatment modalities have been used with the population of individuals with serious and persistent mental illness. Variations of day treatment programs, including partial day hospitalization and planned admission programs, are examples of alternatives to extended inpatient treatment. A Veterans Affairs Medical Center initiated a Planned Admission Program. Using qualitative methodology, the researcher interviewed six patients participating in the program to discover information about their experiences in the program. Major themes are identified and discussed, implications for nursing practice and research are articulated.
Adult↗
Immunomodulation: an important concept in modern anaesthesia.
This review summarises evidence for immunomodulatory effect of drugs administered peri-operatively. The clinical significance of the balance of pro- and anti-inflammatory cytokines may be seen in certain disease states, for example, meningococcal meningitis and Lyme arthritis. This balance may be altered peri-operatively. Traditionally, these changes are considered to be due to the stress response of surgery, the response to cardiopulmonary bypass, or endotoxaemia. This review presents in vitro evidence suggesting that drugs modulating this cytokine balance include non-steroidal anti-inflammatory agents, phosphodiesterase inhibitors and opioids, acting through effects on intracellular cyclic nucleotide messenger systems. An important consequence of the pro-inflammatory cytokine activity is increased adhesion of neutrophils. Aspects of this process may be inhibited by avoiding low blood flow states, by reducing adhesion molecule expression (for example by use of pentoxifylline), or by use of negatively charged anions such as heparin. Neutrophil activity is generally depressed by intravenous anaesthetic induction agents, but is enhanced by opioids. Natural killer cell activity, which is involved in immunity against tumour cells and virally infected cells is transiently depressed by volatile anaesthetic agents and opioids. In contrast catecholamines enhance natural killer cell activity. Whereas decrease in immunoglobulin levels occur peri-operatively, this is not thought to be as a result of drugs at clinically used concentrations but rather due to haemodilution.
Anesthesia↗
An investigation of the effects of heparin, low molecular weight heparin, protamine, and fentanyl on the balance of pro- and anti-inflammatory cytokines in in-vitro monocyte cultures.
We report a study conducted to determine if drugs given peri-operatively during cardiac surgery could themselves modulate the balance of pro- and anti-inflammatory cytokines. We determined the cytokine response of 10 separate in vitro monocyte cultures to the administration of drugs at concentrations used during cardiac 'surgery:fentanyl (25 ng.ml-1), heparin 2.5 i.u.ml-1, heparin with an equal concentration of protamine, and enoxaparin 2.5 i.u.ml-1. Fentanyl, heparin and low molecular weight heparin (enoxaparin) led to increased tumour necrosis factor alpha but this did not reach statistical significance. Tumour necrosis factor soluble receptor 1 and 2 was not elevated. Interleukin-1 beta was increased by heparin (p < 0.05), whereas interleukin-1 receptor antagonist was increased by fentanyl (p < 0.05). Protamine blocked the heparin-induced increase in tumour necrosis factor alpha and interleukin-1 beta. These data raise the possibility that endogenous and exogenously administered opioids may be partly contributing to the interleukin-1 receptor antagonist response seen during major surgery.
Analgesics, Opioid↗
Assessment of fetal anatomy at 12 to 13 weeks of gestation by transabdominal and transvaginal sonography.
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Female↗
Cardiovascular risk factors among Asian Americans.
MANY ASIANS HAVE RECENTLY IMMIGRATED to the United States, but there have been few studies of cardiovascular risk factors in these groups. Researchers analyzed data from 13,031 people who described themselves as Chinese, Filipino, Japanese, and other Asians, and used regression analyses controlled for age, alcohol use, education, and marital status. Adjusted mean body mass index and smoking prevalence were lowest in Chinese men and women. Adjusted total cholesterol levels were highest in Japanese men and women. Hypertension prevalence was highest in Filipino men and women. Comparisons of Asians born outside the United States with those U.S.-born showed 1) no major cholesterol differences; 2) higher body mass index in U.S.-born men, but not in women of most races; 3) more hypertension only in U.S.-born Chinese men; and 4) a lower smoking prevalence in U.S.-born men but generally higher smoking prevalence in U.S.-born women. These data show important ethnic differences in cardiovascular risk factors among Asian Americans and have implications for targeting public health efforts.
Adult↗
More than the sum of their parts: Martha Rogers and Hildegard Peplau.
Nursing practice is guided by a variety of theoretical models. Therefore, nursing theories are commonly selected by service institutions to focus practice. Both Rogers and Peplau made major contributions to the theory and practice of nursing, and both are appropriate models for the discipline of psychiatric and mental health nursing. This article explores the grand theory of Martha Rogers in conjunction with the use of the middle-range theory of Hildegard Peplau. Points of resonance, theoretical fit, and differences between theories are discussed. Appropriateness to practice of both theories are identified and the need for both perspectives is articulated.
Models, Nursing↗
Cytokine balance and immunosuppressive changes at cardiac surgery: contrasting response between patients and isolated CPB circuits.
In vitro work suggests that IL-10 plays a pivotal role in controlling the balance of pro- and anti-inflammatory cytokines and monocyte HLA-DR expression. In 20 patients undergoing cardiac surgery, we investigated elaboration of interleukin 10 (IL-10) and its relationship to pro- and anti-inflammatory cytokines and leucocyte expression of HLA-DR and adhesion molecules. There were small increases in pro-inflammatory cytokines (IL-1, IL-8 and tumour necrosis factor (TNF) after induction, returning to baseline on induction of cardiopulmonary bypass (CPB). After CPB another transient increase in IL-8 occurred (P < 0.05). The anti-inflammatory response began with elevated IL-10 during CPB (P < 0.001), which peaked early in recovery (P < 0.001), by which time IL-1 receptor antagonist (IL-1ra) and the TNF soluble receptors (TNFsr) had also increased (P < 0.01). The next day IL-10 and IL-1ra were decreasing but TNFsr continued to increase. Induction of anaesthesia caused HLA-DR downregulation. The IL-10 peak was associated with further monocyte HLA-DR downregulation (P < 0.001) and return towards baseline of granulocyte adhesion molecule expression which transiently increased during CPB (P < 0.001). To determine which aspects of the immune response arose from the interaction of blood with the CPB apparatus, the above variables were studied within an isolated CPB circuit and the influence of fentanyl on the magnitude of any such changes determined. Five healthy volunteers donated two, 250-ml samples of blood to which was added either fentanyl 175 micrograms with heparin 1050 u. or heparin alone 1050 u. These were used to prime two identical isolated CPB circuits and circulation was conducted under identical conditions for 90 min. Of the pro-inflammatory cytokines, only IL-8 was elevated at 90 min CPB (P < 0.05). There was no increase in anti-inflammatory cytokines and TNFsr decreased (P < 0.001). Granulocyte adhesion molecules were increased during CPB. In the fentanyl group, the CD11b increase was greater and preceded CPB. The reduction in lymphocyte HLA-DR expression, observed throughout the study period (P < 0.01), was greater with fentanyl (P < 0.05). Monocyte HLA-DR expression increased (P < 0.05), but to a lesser extent with fentanyl (P > 0.05). In contrast with the in vivo response where there was a phased anti-inflammatory response beginning with IL-10, in the isolated CPB model no anti-inflammatory cytokine response occurred.
Adult↗
Score for neonatal acute physiology: validation in three Kaiser Permanente neonatal intensive care units.
BACKGROUND: Measurement of the severity of illness is a research area of growing importance in neonatal intensive care. Most severity of illness scales have been developed in tertiary care settings. Their applicability in community neonatal intensive care units has not been tested. OBJECTIVES: Our goal was to assess the operational characteristics of the score for neonatal acute physiology (SNAP): the relationship to birth weight, the length of total hospital stay, and in-hospital mortality. METHODS: We assigned SNAP scores prospectively to all inborn admissions at three community neonatal intensive care units during an 11-month period. Data on other neonatal predictors (eg, birth weight and the presence of congenital heart disease) were also collected. We measured in-hospital mortality, the experience of interhospital transport to a higher level of care, and total hospital stay. RESULTS: We found that the SNAP's relationship to birth weight was similar to previous reports. The SNAP's perinatal extension is a reliable predictor of newborn in-hospital mortality, with an area under the receiver operator characteristic curve of 0.95. The SNAP is also a good predictor of total hospital length of stay, whether by itself (by which it can explain 31% of the total stay) or in combination with other variables. Its predictive ability is better among infants of low birth weight (<2500 g) than among those of normal birth weight (> or = 2500 g). The SNAP's predictive power was most limited among infants admitted to rule out sepsis. The predictive ability of a model containing birth weight, the SNAP, and transport status was not improved by the inclusion of two major diagnostic categories, the presence of congenital heart disease or complex illness. CONCLUSION: Although it has definite limitations among infants who weight 2500 g or more, the SNAP is a potent tool for outcomes research. Modification of some of its parameters could result in a multifunctional scale suitable for use with all birth weights.
Birth Weight↗
Alcohol consumption, smoking, and other risk factors and prostate cancer in a large health plan cohort in California (United States).
Alcohol consumption and cigarette smoking have been suggested as possible causes of prostate cancer. We therefore examined this relation in a cohort of 43,432 men who were members of a prepaid health plan in northern California (United States) and who had received a health examination in the period from 1979 through 1985. Detailed information on demographic variables, alcohol consumption, smoking habits, medical complaints and conditions, occupation, and surgery (including vasectomy) was assessed. Symptoms of prostatism and a history of sexually transmitted diseases were abstracted from the medical records of all prostate cancer patients and of a matched subsample of randomly selected control-subjects. Alcohol consumption was associated with no elevated prostate cancer risk for the 238 men in our study in whom prostate cancer developed, but smoking one or more packs of cigarettes per day was associated with an adjusted relative risk (RR) of 1.9 (95 percent confidence interval [CI] = 1.2-3.1). Prostate cancer risk for Black men was 2.2 (CI = 1.6-3.1) when compared with that for White men, and education level was associated positively in an increasing trend (P < 0.020) up to an RR of 1.4 (CI = 0.9-2.1) among men with postgraduate education. Symptoms of prostate hypertrophy were not associated with elevated risk of prostate cancer if they occurred two or more years before the diagnosis. The finding that smoking increased the risk of prostate cancer confirms the observations of others but needs cautious interpretation because we were unable to adjust for the potential confounding effect of dietary and hormonal factors.
Adenocarcinoma↗