Biomedical subjects
Publications and source records attributed to M Brown.
The primary goal of treatment in acute myocardial infarction is reperfusion of the infarct-related artery in as short a time as possible. Present strategies for acute reperfusion include the use of thrombolytic agents and a variety of catheter-based interventions. This article presents a brief review of these strategies and discusses the patient subsets better served by a particular type of intervention.
STUDY OBJECTIVES: To determine the approximate incidence of transient neurologic symptoms (TNS) [formerly known as transient radicular irritation (TRI)] associated with procaine spinal anesthesia, and whether fentanyl prolongs the duration of procaine spinal anesthesia. DESIGN: Unrandomized pilot study. SETTING: Community teaching hospital. PATIENTS: 106 consecutive patients scheduled for spinal anesthesia for procedures anticipated to last less than 90 minutes. INTERVENTIONS: All patients received 5% procaine for spinal anesthesia. Fentanyl 20 micrograms was added for procedures anticipated to last longer than 45 minutes (but less than 90 min). Intraoperatively the adequacy of duration, level, and intensity of anesthesia were observed. Time from injection of local anesthetic until knee-bending was recorded. Three days postoperatively, patients were questioned intensively in an effort to determine whether back pain and/or symptoms consistent with TNS had occurred. MEASUREMENTS AND MAIN RESULTS: Duration of anesthesia was adequate in all but one instance. The intensity and the sensory level of anesthesia were satisfactory with one exception, a woman who had an unexpectedly low sensory level (L1) after 60 mg of procaine for cerclage, and who was also was the only patients to develop TNS. The incidence of TNS (0.9%) was markedly less than that reported after lidocaine and similar to the incidence observed after bupivacaine. Mild back pain without radiation occurred in 11 patients (10%), an incidence that is similar to that seen after bupivacaine and lidocaine. Compared with procaine alone, the addition of fentanyl significantly (p = 0.0001) prolonged the time to bending knees from 72 minutes to 97 minutes. CONCLUSIONS: Procaine may be a useful alternative to lidocaine for short procedures, and it is less likely to produce TNS. Fentanyl prolongs motor block when added to procaine.
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In 1992 we set up a peer review system to address all the steps involved in the production of a cytopathology report. The aim of the study was to generate accurate, timely and clinically relevant cytopathology reports. During a four year period we monitored and recorded activities such as turnaround time and adequacy of sampling as well as errors including typographical, SNOMED, coding, technical, labelling of slides, clerical, macroscopic and microscopic errors. The findings were discussed at weekly laboratory meetings attended by technical, scientific, clerical and medical staff. Minor errors not needing immediate action were discussed and incorporated as future improvements into the workings of the laboratory. For major discrepancies with potential implications for patient management, supplementary reports were issued and the relevant clinician was informed of the outcome. Detailed peer review of 1.3% of the total workload, during the period of the study, led to comments on some aspects of the original report in 24.9% of the reviewed cases. The majority of comments (57%) were minor, concerning issues related to the pre-analytical (clinical history, demographics, clerical and technical) aspects of the cases. The post analytical (microscopic description, diagnosis, recommendation and coding) phase of cases attracted 43% of the comments. In 1.1% of cases, the reviewer made suggestions regarding the diagnosis, and in 0.4% of cases a different recommendation was made. Cost-benefit analysis revealed that our internal quality assurance (IQA) activities added $1.20 to the total cost of each cytopathology case received and processed in the laboratory. On the benefit side, analysis of the data showed a continuous fall in the number of errors in both the pre-analytical and post-analytical phases of report generation. Furthermore, the turnaround time fell from 3.0 days at the beginning of the study to 1.7 days at present. These IQA activities have highlighted the importance of such a review system in detecting errors in cytopathology reporting. Recognition of the fact that cytopathology suffers from observer variability has led to the adoption of a uniform approach to cytological reporting among cytotechnologists and pathologists.
Neutrophils isolated from AIDS patients have demonstrated improved growth inhibition of Mycobacterium avium when incubated with exogenous granulocyte colony-stimulating factor (G-CSF). In this clinical study, 30 AIDS patients without M. avium infection were randomized to receive 5 days of treatment with rifabutin, G-CSF, or both agents. The M. avium killing capacity of neutrophils harvested from each patient before intervention, during (day 4), and after therapy (day 7) was assessed. The mean change in human immunodeficiency virus load in the group receiving G-CSF alone was -0.07 log of viral RNA. There was a 90% reduction in M. avium growth after therapy for patients treated with G-CSF alone (P=.01), 59% for patients treated with both agents (P=.06), and 11% for patients treated with rifabutin alone (P=.84). Thus, neutrophils isolated from AIDS patients treated with G-CSF demonstrated a significant enhancement of killing of M. avium; there was no notable effect on virus load.
BACKGROUND: Anesthesia personnel are at risk for occupational infection with bloodborne pathogens from contaminated percutaneous injuries (CPIs). Additional information is needed to formulate methods to reduce risk. METHODS: The authors analyzed CPIs collected during a 2-yr period at 11 hospitals, assessed CPI underreporting, and estimated risks of infection with human immunodeficiency virus and hepatitis C virus. RESULTS: Data regarding 138 CPIs were collected: 74% were associated with blood-contaminated hollow-bore needles, 74% were potentially preventable, 30% were considered high-risk injuries from devices used for intravascular catheter insertion or obtaining blood, and 45% were reported to hospital health services. Corrected for injury underreporting, the CPI rate was 0.27 CPIs per yr per person; per full-time equivalent worker, there were 0.42 CPIs/yr. The estimated average 30-yr risks of human immunodeficiency virus or hepatitis C virus infection per full-time equivalent are 0.049% and 0.45%, respectively. Projecting these findings to all anesthesia personnel in the United States, the authors estimate that there will be 17 human immunodeficiency virus infections and 155 hepatitis C virus infections in 30 yr. CONCLUSIONS: Performance of anesthesia tasks is associated with CPIs from blood-contaminated hollow-bore needles. Thirty percent of all CPIs would have been high-risk for bloodborne pathogen transmission if the source patients were infected. Most CPIs were potentially preventable, and fewer than half were reported to hospital health services. The results identify devices and mechanisms responsible for CPIs, provide estimates of risk levels, and permit formulation of strategies to reduce risks.
Timely repair of mandibular fractures remains an effective means to reduce pain, restore function, and prevent complications. This study addresses the effect of the time interval between injury and treatment on the overall complication rate, the complication rate between various treatment modalities (mandibular-maxillary fixation [MMF] alone, MMF with intraosseous wire bone fixation, and MMF with rigid internal fixation), and the relationship of inpatient vs. outpatient management. Cost was also examined with respect to choice of management. We report a retrospective series of 308 consecutive patients managed at the University of Miami/Jackson Memorial Hospital. Patients who received treatment 3 to 10 days following injury were found to have a lower complication rate than earlier or later repair. We postulate that most patients with mandibular fractures may be managed on an outpatient basis, which represents a considerable savings in cost.
OBJECTIVES: To provide a conceptual overview of approaches to quality of life (QOL) measurement and an extensive review of research relating to QOL after TBI; to document subjective QOL of individuals with traumatic brain injury (TBI); to explore how subjective QOL differs for people with TBI in comparison to individuals with no disability (ND) and those with spinal cord injury (SCI); and to document the perceptions of unmet important needs and the relationship between such perceptions and subjective QOL. DESIGN: Interview-based data focusing on current perceptions of QOL and unmet important needs, obtained from individuals with TBI, SCI, or ND. Covariance and partial regression analyses were used to explore group differences and to document relationships between variables. SETTING: Individuals drawn from diverse communities across New York State. PARTICIPANTS: TBI group: 430 individuals who identified themselves as having TBI; SCI group: 101 individuals with spinal cord injury; ND group: 187 people who identified themselves as having no disability. Participants were recruited through recruitment ads in general circulation newspapers and newsletters and through contacting a wide variety of community agencies. MAIN OUTCOME MEASURES: Two summary QOL indicators: a Global QOL Measure based on two items tapping the individual's emotion-based view of QOL, and a summary score adapted from Flanagan"s Scale of Needs, reflecting the individual's perceptions of total unmet important needs. RESULTS: Both summary QOL indicators were correlated with demographic characteristics. Unmet important needs were stronger in the TBI group than in the SCI and ND groups. Most areas of unmet important need were moderately correlated with the summary QOL indicators. Analyses of covariance showed that severity of injury was a more powerful modulator of post-TBI QOL judgments than the mere fact of TBI. For example, those with the most severe injury (ie, loss of consciousness [LOC] >1 month) rated their QOL similar to that in the ND group, whereas individuals who had experienced only a brief LOC (<20 minutes) viewed their QOL as significantly lower than that in the ND and SCI groups and lower than other TBI severity subgroups. CONCLUSIONS: This exploration of subjective QOL strengthens the argument that after TBI, the insider"s reaction to injury varies greatly within the population. Thus, severity of injury strongly affects perceptions of QOL. The use of a multimethod approach for exploring the reactions and perceptions of QOL has proven useful in this study.
OBJECTIVES: To investigate the effect of employment on perceived quality of life (QOL), social integration, and home and leisure activities for individuals with traumatic brain injuries (TBIs). DESIGN: A number of demographic and injury-related variables (age at injury, time since injury, severity of injury, education, gender, preinjury household income, and marital status) were analyzed for their association first with employment and then with the QOL, social integration, and home and leisure activities. Any of these variables showing significant associations were then included along with level of employment in three final multivariate analyses of variance (MANOVAs), again predicting QOL, social integration, and home and leisure activities. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 337 adults with TBI who resided in New York state and were between the ages of 18 and 65 years. MAIN OUTCOME MEASURES: The Craig Handicap Assessment Capacity Technique, the Bigelow Quality of Life Questionnaire, the Flanagan Scale of Needs (adapted), and a global QOL measure. RESULTS: Employment showed a strong and consistent relationship with perceived QOL, social integration within the community, and home and leisure activities. Part-time employment may have been superior to full-time employment for individuals with TBI: part-time workers had fewer unmet needs, were more socially integrated, and were more engaged in home activities than full-time workers. Loss of consciousness, as a measure of severity, was unexpectedly predictive of diminished sense of QOL for individuals with less severe injuries. CONCLUSIONS: Being employed contributes to one"s sense of well-being, social integration, and pursuit of leisure and home activities. Select advantages of working part-time for individuals with TBI were identified.
OBJECTIVE: To examine individuals with "hidden" traumatic brain injury (TBI), defined in this study as those who sustained a blow to the head, with altered mental status, and experienced a substantial number of the cognitive, behavioral, and emotional sequelae typically associated with brain injury but did not make the causal connection between the injury and its consequences. DESIGN: Comparison of four groups of individuals matched for age, gender, years of education, and duration of loss of consciousness. SETTING: This study of hidden TBI followed the identification of 143 individuals who, within a larger study of people with TBI who live in the community, identified themselves as "nondisabled" (they were to be part of the comparison sample) but who had experienced a blow to the head that left them at minimum dazed and confused. PARTICIPANTS: 21 of these 143 individuals also reported large numbers of symptoms (eg, headaches, memory problems) associated with TBI. This group (Hidden TBI-High Symptoms group) was compared to three other matched samples: one with known TBI (Known Mild TBI group) and one with no disability (No Disability group) (both of which were drawn from the larger study), and one group of individuals who identified themselves as having no disability but who had experienced a blow to the head that resulted in a few symptoms (Head Trauma-Low Symptoms group). MAIN OUTCOME MEASURES: All study participants were administered an interview that incorporated several existing instruments documenting levels of reported symptoms, emotional well-being/distress, and vocational/social handicaps. RESULTS: The Hidden TBI-High Symptoms group was found to be similar to the Known Mild TBI group in terms of the number and types of symptoms experienced, whereas the Head Trauma-Low Symptoms group was similar in this respect to the No Disability group. The two former groups also evidenced high levels of emotional distress, whereas the two latter groups did not. However, on measures of handicap, the Hidden TBI-High Symptoms and Head Trauma-Low Symptoms groups were similar to the No Disability group and dissimilar from the Known Mild TBI group in that the last group experienced vocational handicap, in particular, whereas the other groups did not. CONCLUSIONS: We conclude that hidden TBI occurs at a nontrivial level (7% of our nondisabled sample). Also, individuals with hidden TBI (with persistent symptoms), unlike those with known mild TBI, are likely to experience emotional distress but not vocational handicap following injury.
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In Australia, Vietnamese women are at greater risk of cervical cancer than other Australian women. To increase their participation in cervical screening, the Vietnamese community was exposed to a media campaign about the advantages of cervical smear screening which was delivered in Vietnamese through Vietnamese newspapers and radio. In addition, 689 Vietnamese (18-67 years) were selected from the electoral roll. They were randomly assigned to either receive a personal letter written in Vietnamese promoting cervical screening, or not. We report on the effect of the letter on smear rates. Being randomised to be sent such a letter was not associated with any increase in screening (relative rate of appropriate screening in the intervention versus the control group was 0.85, 95% CI 0.55-1.3). It is important to carefully evaluate untested health promotion interventions.
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AIM: To assess the role of a quality assurance programme in improving the service provided by a surgical pathology department. METHODS: A continuous internal quality assurance study of the activities of an anatomical pathology department in an Australian teaching hospital was undertaken over a five year period. This addressed all steps involved in the production of a surgical pathology report. These were addressed in an open forum which included technical, scientific, clerical, and medical staff. Minor errors not needing immediate action were discussed and incorporated into laboratory practice. For major discrepancies with potential implications for patient management supplementary reports were issued and the relevant clinician informed of the outcome. RESULTS: Comprehensive peer review of 8.9% of the total workload of the department (3530 cases) and all the frozen sections (916 cases) over a period of five years, beginning in 1991, led to comments on some aspects of the original report by the reviewer in 19.6% of the cases. The great majority of the comments were minor, concerning issues related to the microscopic findings (4%), macroscopic description (3.1%), clerical aspects (3%), typographical errors (3%), coding errors (2.7%), technical errors including poor sections and incorrect labelling (1.7%), inadequate clinical history (1.2%), and incomplete or incomprehensible diagrams (0.9%). In two cases (0.05%) the original report did not state proximity of the tumour to surgical margins and in three of the frozen sections (0.3%) the original diagnosis was incorrect. However, in these cases the frozen section assessment did not alter the overall management of the cases. CONCLUSIONS: This study highlights the importance of a review system in detecting errors in surgical pathology reporting. Recognition of the fact that surgical pathology is not infallible has improved the end product. It has also minimised interobserver variability in the department, resulting in a uniform approach among the pathologists to macroscopic description, specimen sampling, special stains, and histological reporting.
Female rats (7-8 mo old, n = 40) were randomly placed into the intact control (Int) and ovariectomized control (Ovx) groups. Two weeks after ovariectomy, animals were further divided into intact 2-wk hindlimb unloaded (Int-HU) and ovariectomized hindlimb unloaded (Ovx-HU). We hypothesized that there would be greater hindlimb unloading-related atrophy in Ovx than in Int rats. In situ contractile tests were performed on soleus (Sol), plantaris (Plan), peroneus longus (Per), and extensor digitorum longus (EDL) muscles. Body weight and Sol mass were approximately 22% larger in Ovx than in Int group and approximately 18% smaller in both HU groups than in Int rats (Ovx x HU interaction, P < 0.05), and there was a similar trend in Plan muscle (P < 0.07). There were main effects (P < 0.05) for both ovariectomy (growth) and hindlimb unloading (atrophy) on gastrocnemius mass. Mass of the Per and EDL muscles was unaffected by either ovariectomy or hindlimb unloading. Time to peak twitch tension for EDL and one-half relaxation times for Sol, Plan, Per, and EDL muscles were faster (P < 0.05) in Ovx than in Int animals. The results suggest that 1) ovariectomy led to similar increases of approximately 20% in body weight and plantar flexor mass; 2) hindlimb unloading may have prevented ovariectomy-related muscle growth; 3) greater atrophy may have occurred in Sol and Plan of Ovx animals compared with controls; and 4) removal of ovarian hormonal influence decreased skeletal muscle contraction times.
Feeding beta-guanidinopropionic acid (GPA), a competitive inhibitor of creatine transport, decreases mortality and increases brain ATP stability in hypoxic mice. To study brain ATP metabolism in GPA-fed animals, respiratory rates were measured in grey matter and white matter slices as well as cerebral hemisphere mitochondria from GPA-fed mice and rats. Creatine kinase and adenylate kinase activities were measured in rat cerebral grey matter and white matter. Respiratory rates and oxidative phosphorylation were the same in GPA-fed mice and control mice. The adenylate kinase activity increased 50% and creatine kinase showed a small decrease in grey matter. In white matter, creatine kinase increased 50% while adenylate kinase decreased. Thus, GPA produces opposite adaptive changes in adenylate kinase and creatine kinase in grey matter and in white matter. These results suggest that the creatine kinase reaction in grey matter acts to regulate cellular ADP and ATP concentrations.
SHP (short heterodimer partner) is an unusual orphan receptor that lacks a conventional DNA-binding domain. Previous results have shown that it interacts with several other nuclear hormone receptors, including the retinoid and thyroid hormone receptors, and inhibits their ligand-dependent transcriptional activation. Here we show that SHP also interacts with estrogen receptors and inhibits their function. In mammalian and yeast two-hybrid systems as well as glutathione-S-transferase pull-down assays, SHP interacts specifically with estrogen receptor-alpha (ERalpha) in an agonist-dependent manner. The same assay systems using various deletion mutants of SHP map the interaction domain with ERalpha to the same SHP sequences required for interaction with the nonsteroid hormone receptors such as retinoid X receptor and thyroid hormone receptor. In transient cotransfection assays, SHP inhibits estradiol -dependent activation by ERalpha by about 5-fold. In contrast, SHP interacts with ERbeta independent of ligand and reduces its ability to activate transcription by only 50%. These data suggest that SHP functions to regulate estrogen signaling through a direct interaction with ERalpha.