Biomedical subjects
Publications and source records attributed to S Piper.
A 12 year old boy presented with severe hypertension and was diagnosed with renal artery stenosis requiring balloon angioplasty. Takayasu's arteritis was subsequently diagnosed, but he also developed acute panuveitis, an entity not previously reported in a child with this condition.
In order to develop transgenic animal models that selectively overexpress various Abeta peptides, we have developed a novel expression system that selectively expresses Abeta40 or Abeta42 in the secretory pathway. This system utilizes fusion constructs in which the sequence encoding the 23-amino-acid ABri peptide at the carboxyl terminus of the 266-amino-acid type 2 transmembrane protein BRI is replaced with a sequence encoding either Abeta40 or Abeta42. Constitutive processing of the resultant BRI-Abeta fusion proteins in transfected cells results in high-level expression and secretion of the encoded Abeta peptide. Significantly, expression of Abeta42 from the BRI-Abeta42 construct resulted in no increase in secreted Abeta40, suggesting that the majority of Abeta42 is not trimmed by carboxypeptidase to Abeta40 in the secretory pathway.
Due to declining federal, state, and local government budgets, there is an increasing need to analyze the benefits of government funded programs to determine where increasingly limited funds would best be spent. The benefits transfer technique is analyzed for the development of a rural water supply system and guidelines for successful benefits transfer are presented. Benefit transfer appears to provide reasonably accurate estimates of natural resource benefits if a broad based benefit model is used. The benefits-transfer-based estimates are accurate as long as a model based on data from a wide variety of conditions is used or the model is based on data from a very similar region. The wide-based data modeling approach has the greatest practical application. These findings are based upon contingent valuation data obtained from four sites in the western USA.
Breastfeeding behavior in a sample of 1863 mother-infant pairs was examined using data from the 1988 National Maternal-Infant Health Survey. Breastfeeding behavior was operationalized as an intensity ratio, calculated as the number of breast milk feeds (on average in 24 hours) divided by the total number of all liquid feeds (on average in 24 hours), with a range from 0 to 1.0. During the first month postpartum, 61% of the sample reported exclusive breastfeeding, declining to 31% during months 2-3 postpartum and to 13% during months 4-6 postpartum. This decline was consistent with the linear decline in the mean intensity ratio, .82, .55, and .31, respectively, during the same three time periods. A higher breastfeeding intensity ratio was significantly associated with longer duration of breastfeeding, up to 1 year of life. Intensity ratio, as a measure of exclusivity, is a useful outcome measure for monitoring breastfeeding behavior.
Infantile botulism classically presents with a triad of clinical features: Bulbar palsies (slow/absent pupil response) Alert Absent fever Other common features are: Constipation, ptosis and poor feeding The diagnosis is a clinical one, confirmed by EMG and by testing stool for the organism, C. botulinum, or its toxin. Parents should be advised not to dip pacifiers in honey. In future Botulinum Immune Globulin may be available and should be considered if further trials are published showing benefit. Nosocomial infections, such as RSV, are important and should be carefully avoided, particularly in patients recovering from botulism.
OBJECTIVE: To study the time course of coagulation data in intensive care patients. DESIGN: Prospective, descriptive study. SETTING: Clinical investigation on a surgical and neurosurgical intensive care unit of a university hospital. PATIENTS: Fifteen patients with severe trauma (injury severity score, 15 to 25), 15 sepsis patients secondary to major surgery, and 15 neurosurgery patients (cancer surgery) were studied. INTERVENTIONS: Standardized intensive care therapy. MEASUREMENTS AND MAIN RESULTS: Standard coagulation data and molecular markers of coagulation activation and fibrinolytic activity (soluble thrombomodulin, protein C, free protein S, thrombin/antithrombin III complex, plasmin-alpha 2-antiplasmin complex, tissue plasminogen activator, platelet factor 4, beta-thromboglobulin were measured from arterial blood samples on the day of admission to the intensive care unit (trauma/neurosurgery patients) or on the day of diagnosis of sepsis (baseline value) and serially during the next 5 days. Antithrombin III, fibrinogen, and platelet counts were highest in neurosurgery patients but without significant differences between sepsis and trauma patients. Thrombin/antithrombin III complex increased in the sepsis patients (from 22.6+/-4.2 microg/L to 39.9+/-6.8 microg/L), but decreased in trauma (from 40.2+/-5.1 microg/L to 17.6+/-4.0 microg/L) and neurosurgery patients (from 28.2+/-4.2 microg/L to 16.2+/-3.8 microg/L). Tissue plasminogen activator increased in the sepsis patients (from 14.4+/-3.9 microg/L to 20.7+/-3.8 microg/mL) and remained almost unchanged in the other two groups. Soluble thrombomodulin plasma concentration increased significantly in the sepsis group (max, 131.8+/-22.5 ng/mL), while it remained elevated in the trauma (max, 75.5+/-5.9 ng/mL) and was almost normal in the neurosurgery patients. Protein C and free protein S remained decreased only in the sepsis group. CONCLUSIONS: Alterations of the hemostatic network were seen in all three groups of critically ill patients. Hemostasis normalized in the neurosurgery patients and posttraumatic hypercoagulability recovered within the study period. By contrast, monitoring of molecular markers of the coagulation process demonstrated abnormal hemostasis in the sepsis patients during the entire study period indicating ongoing coagulation disorders and abnormalities in fibrinolysis in these patients.
Nursing work force analysis gives crucial data for administrators, allowing them to anticipate employment opportunities and areas of limited growth. Using an economic model of supply and demand, this study examined the employment and educational needs for nurses. In many areas of data collection, the District of Columbia data paralleled national trends, indicating the nationwide relevance of the conclusions. Projected mismatches between the type of nurses (by educational preparation) entering the work force and the skills required for the job vacancies could lead to increased demand for nurses with certain credentials as well as shortages of nurses in certain types of facilities.
BACKGROUND: Pulmonary resection is associated with considerable risk of infection, so antibiotic prophylaxis has become routine practice in pulmonary operations. We studied two standard flash antibiotic prophylaxis regimens and matched them to preoperatively acquired microorganisms. METHODS: In 120 patients scheduled for elective pulmonary resection, aspirates were taken separately from the left and the right lung using a double-lumen tube. Then the patients received either 1.5 g of sulbactam plus ampicillin (n = 60; group 1) or 2 g of cefazolin (n = 60; group 2) intravenously as a single-shot antibiotic prophylaxis according to a prospective randomized sequence. When bacteria were found in the aspirates, both antibiotics were tested for susceptibility. The patients were monitored for the first 3 postoperative days with regard to bronchopulmonary infections. RESULTS: Fifty-eight pathogens were isolated from the 120 patients. The cultured bacteria did not differ significantly between the two groups. In group 1 all found bacteria were susceptible to the used antibiotic prophylaxis, whereas in group 2 eight of the 25 found bacteria were not susceptible to antibiotic prophylaxis. Postoperatively, group 2 showed significantly more signs of bronchopulmonary infections than the group 1 and subsequently needed additional antibiotics more often. Intensive care unit stay was longer in patients of group 2 and costs were higher for these patients. CONCLUSIONS: Preoperative microbiologic examination could be helpful to evaluate efficacy of the antibiotic prophylaxis regimen. Sulbactam plus ampicillin was significantly more effective than cefazolin.
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UNLABELLED: With the development of new computer-assisted target-controlled infusion (TCI) systems and the availability of short-acting anesthetics, total IV anesthesia (TIVA) has become increasingly popular. The aim of this study was to compare costs of TCI-based anesthesia with two standard anesthesia regimens. Sixty patients undergoing elective laparoscopic cholecystectomy were randomly divided into three groups. Group 1 (TIVA/TCI) received TIVA using a propofol-based TCI system and continuous administration of remifentanil; Group 2 (isoflurane) underwent inhaled anesthesia with isoflurane, fentanyl, and N2O; Group 3 (standard propofol) received fentanyl and N2O and a continuous infusion of propofol using a standard delivery system. Maintenance doses for anesthetics were adjusted according to the patient's need. Isoflurane consumption was measured by weighing the vaporizer by using a precision weighing machine. Duration of surgery and of anesthesia was similar in the three groups. Time from stopping administration of anesthetics until tracheal extubation (6+/-2 min) and stay in the postanesthesia care unit (PACU; 70+/-12 min) were shorter in Group 1 than in the Groups 2 (15+/-3 and 87+/-13 min, respectively) and 3 (10+/-4 and 81+/-14 min, respectively) (P < 0.05). Episodes of postoperative nausea and vomiting in the PACU and on the surgical ward were less common in Group 1 than in the other two groups. Intraoperative costs were higher in Group 1 ($62.19/patient; $0.55/min of anesthesia) than in Groups 2 ($16.97/patient; $0.13/min of anesthesia) and 3 ($34.68/patient; $0.32/min of anesthesia). Cost for discarded anesthetic drugs accounted for almost 18% of total intraoperative costs in Group 1. We conclude that TIVA/TCI anesthesia using propofol/remifentanil was associated with the highest intraoperative costs but the fewest postoperative side effects. An overall cost-effectiveness analysis of new anesthetic regimens must balance the direct cost of anesthetics and beneficial effects leading to improved patients' comfort. IMPLICATIONS: In today's climate of cost-consciousness, careful economic evaluation of new anesthetic regimens is necessary. A target-controlled infusion (TCI)-based total IV anesthesia (TIVA) regimen using propofol and remifentanil was compared with a standard propofol anesthesia regimen and an inhaled anesthetic technique using isoflurane. Target-controlled infusion/total IV anesthesia was associated with the largest intraoperative costs but allowed the most rapid recovery from anesthesia, was associated with fewest postoperative side effects, and permitted earlier discharge from the postanesthesia care unit.
UNLABELLED: Elderly patients are at risk of developing renal dysfunction. Synthetic colloids are often used perioperatively, but they may have detrimental effects on renal function. In a prospective, randomized study, we assessed the influence of different intravascular volume replacement regimens on renal function in elderly (>65 yr) and younger (< 65 yr) patients without preoperative renal dysfunction who were undergoing major abdominal surgery. Either 6% low molecular weight hydroxyethyl starch (HES) solution (mean molecular weight 70,000 D, degree of substitution 0.5; HES 70/0.5) [each group n = 10]), 6% medium-molecular weight HES (molecular weight 200,000 D, degree of substitution 0.5 (HES 200/0.5) [each group n = 10]), or modified gelatin (molecular weight 35,000 D [each group n = 10]) was administered to maintain mean arterial blood pressure >65 mm Hg and central venous pressure between 10 and 14 mm Hg. After the induction of anesthesia (T0); at the end of surgery (T1); 4 h after surgery (T2); and on the first (T3), second (T4), and third postoperative days (T5), alpha1-microglobulin (alpha1-M), N-acetyl-beta-glucosaminidase, fractional sodium clearance, and creatinine clearance (CC) were measured. Colloids (1300-3000 mL) were infused until the first postoperative day. At T0, urine concentrations of alpha1-M were higher in the elderly than in the younger patients in all groups (P < 0.05). alpha1-M remained increased only in the gelatin group. N-acetyl-beta-glucosaminidase and fractional sodium clearance were not affected during the study period in any groups. At baseline, CC was significantly higher in the younger than in the elderly patients, but CC did not decrease in any of the intravascular volume replacement groups. We conclude that intravascular volume therapy with gelatin and two different HES preparations did not adversely affect renal function in elderly patients without preoperative renal malfunction. IMPLICATIONS: We studied the influence of three different intravascular volume replacement regimens on renal function in elderly patients without renal dysfunction who were undergoing major abdominal surgery. Two hydroxyethyl starch and one gelatin preparation were administered perioperatively to maintain stable hemodynamics. As assessed by sensitive markers of renal function, all three regimens can be used safely for volume replacement without risking significant renal dysfunction.
OBJECTIVE: To assess the effects of the angiotensin-converting enzyme inhibitor enalaprilat on endothelial cells in septic patients. DESIGN: Prospective, randomized, placebo-controlled, blinded study. SETTING: Clinical investigation on a surgical intensive care unit of a university hospital. PATIENTS: Forty surgical septic patients (noncardiac/nonneurosurgical patients). INTERVENTIONS: After inclusion in the study and after baseline data were obtained, either 0.25 mg/hr (enalaprilat group, n = 20) or saline solution as placebo (control group, n = 20) was continuously given and continued throughout the following 5 days. MEASUREMENTS AND MAIN RESULTS: Extensive hemodynamic monitoring was carried out in all patients. Plasma concentrations of endothelin-1, angiotensin II, soluble thrombomodulin, and soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and granule membrane protein-140) were measured from arterial blood samples. All measurements were carried out before the start of the infusion ("baseline" values) and daily during the following 5 days. All endothelial-derived substances (thrombomodulin, endothelin-1, and all soluble adhesion molecules) were similarly increased beyond normal in both group. Endothelin-1 increased only in the untreated control patients (from 6.9 +/- 0.7 to 14.3 +/- 1.4 mg/mL). Soluble thrombomodulin increased in the untreated control patients (from 58 +/- 9 to 79 +/- 14 ng/mL [p < .05]), but significantly decreased in the enalaprilat-treated patients. Soluble adhesion molecules increased in the untreated control group (endothelial leukocyte adhesion molecule from 92 +/- 14 to 192 +/- 29 ng/mL; intercellular adhesion molecule-1 from 480 +/- 110 to 850 +/- 119 ng/ mL) and returned almost to normal values in the enalaprilat patients. The survival rate did not differ significantly between the two groups. Control patients developed severe sepsis and septic shock more often than the enalaprilat-treated group. CONCLUSIONS: The complex pathogenesis of endothelial function abnormalities in sepsis may offer a large number of pharmacologic interventions. Administration of the angiotensin-converting enzyme inhibitor enalaprilat resulted in a reduced release of soluble endothelial-derived substances into the circulating blood, which may indicate an improved endothelial function. The specific actions of enalaprilat on the endothelium have to be elucidated in further studies.
BACKGROUND: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. METHODS: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 micrograms.kg-1.min-1 of dopexamine (n = 15) or placebo (n = 15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. RESULTS: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61 +/- 0.41 to 4.57 +/- 0.78 l.min-1.m-2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO2I) and oxygen consumption index (VO2I) were also significantly increased in the dopexamine group (DO2I: from 416 +/- 91 to 717 +/- 110 ml/m2.m2; VO2I: from 98 +/- 25 to 157 +/- 22 ml/m2.m2), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37 +/- 1.1 to 35.9 +/- 12.1 pg/ml; ET-1: from 2.88 +/- 0.91 to 6.91 +/- 1.20 pg/ml). CONCLUSION: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.
In seeking to change health-related behaviour, such as smoking and poor diet, well mer clinics may be asking too much of their clients. This article explores the conflict between male socialisation and health education against a background of male mortality and morbidity. To achieve health gain for men, the author suggests a shift in emphasis is required from individual behavioural factors to wider socio-structural change.
BACKGROUND: Despite caregiver and policy support for breastfeeding, rates for initiating and duration of breastfeeding fell far short of Healthy People 2000 goals during the 1980s. METHODS: Data from the 1988 National Maternal-Infant Health Survey, collected from January 1989 through June 1991, were analyzed to examine predictors of duration of lactation for a sample of 2372 breastfeeding women. We conducted comparisons between women who fully breastfed and those who partially breastfed using logistic regression analysis. RESULTS: Mothers were more likely to breastfeed for longer than six months if they fully breastfed during the first month postpartum, were nonsmokers, were of higher parity, were consistent in their prenatal intent to breastfeed fully or partially and in their postpartum behaviors, participated in childbirth education classes, and delayed their return to work postpartum. CONCLUSIONS: In this study sample, although rates did not meet Healthy People 2000 goals for duration of breastfeeding, some predictors of duration were identified that can be affected by programmatic support or public policy. Our findings indicated that variables that are associated with breastfeeding and longer duration of the practice are typically correlated with social status. To support the development of breastfeeding as the cultural norm, interventions targeting breastfeeding outcomes should consider social status, ethnicity, and cultural factors.
Personal interviews add spice to publications--a well-written interview can inspire as well as inform. Here are 17 tips on writing by interview that will come in handy whether you are interviewing one person or several.
Two hundred and thirty-seven patients with systemic sclerosis were followed prospectively in a scleroderma clinic. The overall 3, 6, and 9-year survival rates were 86, 76 and 61 per cent respectively. Renal, cardiac and pulmonary disease, and older age at enrollment were adverse prognostic factors associated with reduced survival. There were no significant differences in survival between males and females or in patients with restricted compared to those with diffuse skin thickening. Death from systemic sclerosis was most frequently due to pulmonary hypertension, with fewer than expected deaths from renal or cardiac causes. Twenty-eight per cent of deaths were due to causes unrelated to systemic sclerosis, most commonly cancer and ischaemic heart disease, and in older patients.
Forty patients who were admitted to hospital with rheumatoid arthritis received a total of 3.9 g/d of enteric-coated acetylsalicylic acid (ASA) (Entrophen) according to one of four dosing schedules: group 1 (n = 13), three 325-mg tablets four times daily; group 2 (n = 11), two 650-mg tablets three times daily; group 3 (n = 10), three 650-mg tablets twice daily; and group 4 (n = 6), two 975-mg tablets twice daily. Five to seven days after the start of therapy, when steady-state plasma salicylate levels had been achieved, 10 blood samples, 1 per hour, were collected. Three healthy volunteers who received plain ASA formed a control group. There was little fluctuation in the salicylate levels over the sampling period, regardless of the dosing interval, and no significant difference in the fluctuations between the five groups. Likewise, there was no significant difference in the mean salicylate levels at each sampling time, regardless of the dosing interval or tablet strength. These results suggest that different tablet strengths of enteric-coated ASA and different dosing intervals produce comparable plasma salicylate levels. Less frequent dosing may improve patient acceptance of salicylate therapy in the treatment of arthritis.