Infliximab inhibits activation and effector functions of peripheral blood T cells in vitro from patients with clinically active ulcerative colitis.

Many patients with inflammatory bowel disease (IBD) are undergoing therapy with infliximab, an antibody specific for TNF. However, the exact mechanisms of action of infliximab are not completely understood. The aim of this study was to determine the in vitro effects of infliximab on blood T cells derived from anti-TNF therapy-naïve ulcerative colitis (UC) patients with clinically active disease. Peripheral blood mononuclear cells were stimulated polyclonally or by antigen in the presence or absence of infliximab. The T cell phenotype was investigated by flow cytometry, cytokine secretion was determined by ELISA, and cell proliferation was determined by thymidine assay or CFSE dye. Presence of infliximab resulted in reduced expression of CD25 in CD4(+) and CD8(+) T cell populations and inhibited secretion of IFN-γ, IL-13, IL-17A, TNF as well as granzyme A. Infliximab also suppressed CD4(+) and CD8(+) T cell proliferation. These effects of infliximab were recorded both in T cells activated by polyclonal and antigen-specific stimulation. The effects of infliximab on T cell apoptosis and induction of FOXP3(+) CD4(+) T regulatory cells were ambiguous and depended on the originating cellular source and/or the stimulation mode and strength. In conclusion, infliximab is able to reduce T cell activation as measured by CD25, proliferation and cytokine secretion in vitro from UC patients with clinically active disease. These data suggest that suppression of T cell activity may be important for infliximab-mediated disease remission in patients with UC.

Assessment of energy content of low-solubles corn distillers dried grains and effects on growth performance, carcass characteristics, and pork fat quality in growing-finishing pigs.

Two studies were conducted to assess the energy content of low-solubles distillers dried grains (LS-DDG) and their effects on growth performance, carcass characteristics, and pork fat quality in grow-finish pigs. In Exp. 1, 24 barrows (Yorkshire-Landrace × Duroc; 80 to 90 d of age) in 2 successive periods were assigned to 1 of 6 dietary treatments. In individual metabolism stalls, pigs were fed a corn-soybean meal diet (control); control replaced by 30, 40, or 50% LS-DDG; or control replaced by 30 or 40% distillers dried grains with solubles (DDGS) at 3% of their initial BW for 12 d. All diets contained 0.25% CrO(2). During the 5-d collection period, feces and urine were collected from each pig. Feed, feces, and urine were analyzed for DM, GE, and N concentrations, and feed and feces were analyzed for Cr content. The ME content of LS-DDG (2,959 ± 100 kcal/kg of DM) was similar to that determined for DDGS (2,964 ± 81 kcal/kg of DM). In Exp. 2, 216 Yorkshire-Landrace × Duroc pigs were blocked by initial BW (18.8 ± 0.76 kg) and assigned to 1 of 24 pens (9 pigs/pen). Pens within block were allotted to 1 of 3 dietary treatments (8 pens/treatment) in a 4-phase feeding program: a corn-soybean meal control (control), control containing 20% LS-DDG, or control containing 20% DDGS. Treatment had no effect on final BW, ADG, ADFI, or HCW. Pigs fed LS-DDG had similar G:F (0.367) compared with pigs fed DDGS (0.370), but tended (P = 0.09) to have decreased G:F compared with pigs fed the control (0.380; pooled SEM = 0.004). Dressing percent was less (P < 0.01) for pigs fed LS-DDG (72.8%) and DDGS (72.8%) compared with the control (73.8%; pooled SEM = 0.22). Pigs fed LS-DDG (54.8%) had greater (P = 0.02) carcass lean compared with pigs fed DDGS (53.4%), but were similar to pigs fed control (54.1%; pooled SEM = 0.33). Bellies from pigs fed DDGS (12.9°) were softer (P < 0.01) than those from pigs fed control (17.7°; pooled SEM = 1.07) as determined by the belly flop angle test. Feeding LS-DDG (14.1°) tended (P < 0.10) to create softer bellies compared with control-fed pigs. The PUFA content of belly fat was reduced (P < 0.01) by LS-DDG (14.0%) compared with DDGS (15.4%), but was increased (P < 0.05) compared with pigs fed the control (9.4%; pooled SEM = 0.34). In conclusion, LS-DDG and DDGS had similar ME values and inclusion of 20% LS-DDG in diets for growing-finishing pigs supports ADG and ADFI similar to that of diets containing 20% DDGS, and may reduce negative effects on pork fat compared with DDGS.

MR evaluation of vestibulocochlear anomalies associated with large endolymphatic duct and sac.

BACKGROUND AND PURPOSE: Large endolymphatic duct and sac (LEDS) is one of the most common anomalies seen in patients with congenital sensorineural hearing loss (SNHL), and is known to occur with other inner ear findings. Our purpose was to use high-resolution T2-weighted fast spin-echo (FSE) MR imaging to describe the features and prevalence of specific anomalies that occur in association with LEDS. METHODS: We retrospectively reviewed MR images of the inner ear obtained in 63 patients with LEDS and in 60 control subjects. We evaluated each image for features of cochlear and vestibular dysplasia, including deficiency of the cochlear modiolus, gross cochlear dysmorphism, asymmetry of the cochlear scalar chambers, enlargement of the membranous vestibule, gross vestibular dysmorphism, and abnormality of the semicircular canals (SCC). RESULTS: Cochlear anomalies were present in 76% of ears with LEDS. Modiolar deficiency, gross dysmorphism, and scalar asymmetry were seen in 94%, 71%, and 65% of abnormal cochleas, respectively. Vestibular abnormalities were present in 40% of ears with LEDS. Simple enlargement, gross dysmorphism, and distortion of the lateral SCC were seen in 84%, 16%, and 32% of abnormal vestibules, respectively. CONCLUSION: Coexistent cochlear anomalies, vestibular anomalies, or both are present in most ears with LEDS, and appear as a spectrum of lesions, ranging from subtle dymorphism to overt dysplasia. The presence of coexistent anomalies in LEDS affects treatment decisions and prognosis. Newer techniques of high-resolution FSE MR imaging provide a means of exquisite characterization of LEDS, as well as more sensitive detection of associated vestibulocochlear anomalies.

Preoperative embolization of anastomoses of the jugular bulb: an adjuvant in jugular foramen surgery.

We describe the technique of preoperative embolization of the inferior petrosal sinus/anterior condylar vein complex and the posterior condylar vein in three patients undergoing skull base surgery that required opening of the jugular bulb. Contrary to the usual situation, essentially no blood was lost during the operation, resulting in decreased surgical time and reduced risk to the lower cranial nerves.

Large vestibular aqueduct syndrome: a genetic disease?

OBJECTIVE: Our objective was to determine the familial incidence of large vestibular aqueduct syndrome (LVAS) detected by CT and MR imaging and to propose the genetic inheritance of LVAS. MATERIALS AND METHODS: We retrospectively reviewed cases of LVAS revealed by temporal-bone CT and MR imaging at the University of Utah Health Sciences Center. We interviewed 25 patients with LVAS regarding family history of hearing loss. Any family members with onset of hearing loss before 30 years old also underwent CT and MR imaging. The vestibular aqueduct (on CT scans) or the endolymphatic duct (on MR images) was measured at the midpoint of the distal limb. A measurement greater than 1.5 mm in diameter was considered abnormally large. Diagnosis of LVAS was made if the patient had hearing loss and positive imaging findings. RESULTS: Of the 25 patients, five were found to have familial involvement, resulting in subsequent study of eight additional symptomatic individuals. A total of 33 patients had positive CT or MR imaging findings. Twenty-nine underwent both studies, two underwent CT only, and two underwent MR imaging only. Among the 33 patients with LVAS, 39% familial occurrence was observed (13 patients). In four of the five different families, the involvement occurred among siblings in one generation. In one of the five families, the involvement occurred in two generations, affecting an uncle and a cousin of the patient. CONCLUSION: In patients with LVAS, a significant subgroup had familial involvement. Based on the pedigrees of the familial cases, the pattern was most consistent with autosomal recessive inheritance, although a smaller component of autosomal dominant or multifactorial inheritance may exist.

Supporting hope in congestive heart failure patients.

Critically ill patients want to maintain hope in their life. The need for hope and a sense of hopefulness does not end when the patient is hospitalized. The nursing diagnosis of hopelessness is common for many critical care patients, and especially cardiac problems such as congestive heart failure. These author describe a model of hopelessness that suggests strategies for increasing the patient's sense of hope.

Overlapping thin-section fast spin-echo MR of the large vestibular aqueduct syndrome.

PURPOSE: To evaluate a high-resolution, thin-section fast spin-echo MR imaging technique of the inner ear to identify the large vestibular aqueduct syndrome seen on temporal bone CT scans. METHODS: We retrospectively reviewed the temporal bone CT scans of 21 patients with hearing loss and enlarged bony vestibular aqueducts by CT criteria. High-resolution fast spin-echo MR imaging was then performed on these patients using dual 3-inch phased-array receiver coils fixed in a temporomandibular joint holder and centered over the temporal bones. MR imaging included axial and oblique sagittal fast spin-echo sequences. The diameter of the midvestibular aqueduct on CT scans and the signal at the level of the midaqueduct on MR images were measured on axial sequences, then compared. High-resolution MR imaging with the same protocol was performed in 44 control subjects with normal ears, and similar measurements were taken. RESULTS: The average size of the enlarged bony vestibular aqueduct on CT scans was 3.7 mm, and the average width of the signal from within the enlarged aqueduct on MR images was 3.8 mm. Statistical analysis showed excellent correlation. MR images alone displayed the enlarged extraosseous endolymphatic sac, which accompanies the enlarged aqueduct in this syndrome. Five ears in three patients with enlarged bony vestibular aqueducts on CT scans showed no evidence of an enlarged endolymphatic duct or sac on MR images. An enlarged endolymphatic sac was seen on MR images in one patient with a bony vestibular aqueduct, which had normal measurements on CT scans. MR imaging alone identified a single case of mild cochlear dysplasia (Mondini malformation). In the 88 normal ears studied, the average size of the endolymphatic sac at its midpoint between the common crus and the external aperture measured on MR images was 0.8 mm (range, 0.5 to 1.4 mm). In 25% of the normal ears, no signal was seen from within the vestibular aqueduct. CONCLUSION: Thin-section, high-resolution fast spin-echo MR imaging of the inner ear is complementary to CT in studying patients with the large vestibular aqueduct syndrome, as MR imaging better displays the soft tissue and fluid of the membranous labyrinth.

Acute congestive heart failure: preventing complications.

Acute congestive heart failure (CHF) is a common clinical problem with a serious prognosis for the patient. For acute care hospitals, it is also the number one "money loser" for its diagnostic related group. For these reasons, it is important to understand how the critical care nurse can implement nursing measures and work within a multidisciplinary team to prevent complications in CHF patients. This article identifies the determinants of myocardial performance and nursing interventions that help lessen or prevent complications in CHF patients.

Advanced techniques in magnetic resonance imaging in the evaluation of the large endolymphatic duct and sac syndrome.

The purpose of this report is to compare temporal bone computed tomography (CT) to high-resolution magnetic resonance (MR) imaging using a novel thin-section fast spin echo (FSE) pulse sequence in identifying and characterizing patients with large vestibular aqueduct syndrome. Sixteen patients with sensorineural hearing loss and a CT diagnosis of large vestibular aqueduct(s) underwent high-resolution fast spin echo magnetic resonance imaging with dual, 3-in phased array receiver coils centered over the external auditory canals. Magnetic resonance imaging parameters included axial and oblique sagittal fast spin echo with an effective slice thickness of 1 mm contiguous. Thirty-eight patients with 76 normal inner ears who underwent MR imaging using this technique had their endolymphatic duct measured. MR alone identified the enlarged endolymphatic sac seen along with the large endolymphatic duct in all cases. Three cases (five inner ears) with enlarged bony vestibular aqueducts on CT showed no evidence of endolymphatic duct or sac enlargement on MR. MR alone identified a single case of mild cochlear anomaly in conjunction with an enlarged endolymphatic duct and sac. In the normal population the size of the normal endolymphatic duct at its midpoint measured from 0.1 to 1.4 mm. Thin-section, high-resolution fast spin echo MR imaging of the inner ear may be superior to CT in the evaluation of patients with the large vestibular aqueduct syndrome.

Nursing management of congestive heart failure. Part I.

Congestive heart failure (CHF) is a common clinical problem and in its advanced stage has a poor prognosis. Approximately 400,000 individuals develop heart failure each year (Parmley 1989). CHF can be caused by coronary artery disease such as myocardial infarction, ischemia and hypertension. Should heart failure occur as a result of acute myocardial infarction, a classification tool developed by Killip can be used to assess the degree of CHF. Killip's classification is organised into the following four categories: Class I: no heart failure Class II: mild to moderate failure Class III: acute pulmonary oedema Class IV: cardiogenic shock (Killip, as cited by Benz 1989). This system helps in organising clinical signs and symptoms of heart failure. Due to the fact that CHF is now the most common hospital discharge diagnosis for those over the age of 65, critical care nurses need to be able to recognise complications and intervene rapidly (Parmley 1989) in collaboration with medical staff. The purpose of this paper is first to discuss cardinal signs and symptoms and clinical data associated with CHF. Second, critical care nurses' management of CHF is organised around common nursing diagnoses.

Acute congestive heart failure: pathophysiological alterations.

The goal of a healthy heart is to transfer blood coming to the ventricles from the low pressure venous system into the high pressure arterial system. In acute congestive heart failure (CHF), impaired cardiac function leads to failure to empty venous reservoirs and therefore to reduce delivery of blood into the arterial circulation (Michaelson 1983). Once heart failure occurs it has a high mortality rate. According to the Framingham Heart Study, 50% of patients with New York Heart Association class II or III heart failure died within 5 years. With class IV patients, 50% survived less than 1 year (Cupples 1987). The purpose of this article is first to define acute CHF. Secondly, the pathophysiological alterations that occur as a result of strained and misdirected compensatory mechanisms will be discussed to help critical care nurses to recognise why certain patients are at risk of developing acute CHF.

Sharing and communicating health care information: summary and recommendations.

Sharing and communicating information is a fundamental task in modern medicine. The health care system of the western world is based on teamwork of professionals who participate in the care of patients. Exchange of information (not just data) requires the communicating parties to agree on a communication channel, an exchange protocol, and a common language. The language includes an alphabet, words, phrases, and symbols that express and assign meaning, understood by all. The most common forms of communication are the spoken word and the paper-based patient record. Computers and communication systems improve the sharing of health care information by overcoming the limitations imposed by the dimensions of time and location. However, natural language is still too complex and too ambiguous for current computing devices to handle the complex interactions between health care professional and patients. A simpler 'language' is needed that uses domain specific vocabularies (and/or codes), well-defined exchange protocols for data, information, knowledge, and, in the future, perhaps even wisdom. This simpler 'language' is expected to handle most of the routine information exchange but not eliminate natural language. It is essential that health care information systems preserve and incorporate natural language expressions and integrate them with structured vocabularies. Today, agreeing on standard data exchange protocols and domain specific vocabularies and codes is our greatest challenge. However, standards alone are not sufficient. Acceptance of the standards by the health care professionals, verifications in clinical environments, and implementation agreements by the medical informatics industry are essential. The group on 'Sharing and Communication of Health Care Information' addressed the issues raised above and unanimously recommends a number of steps that will improve the sharing of information. In addition, specific recommendations are offered to governments, health care institutions, and to developers of health care information systems.

A prehospital approach to multiple-victim incidents.

Although most prehospital systems have well-developed protocols for single-victim rescues and mass casualties, multiple-victim incidents falling between the two in scope have not been analyzed in detail. Forty-one audio tapes of incidents with four or more victims were evaluated for techniques and decisions that affected the runs' speed and efficiency. Common problems both in the field and at the base hospital were identified. Recommendations for management in the field and for paramedic and base station transmissions are given.