Implementing nitrous oxide cracking technology in the labour ward to reduce occupational exposure and environmental emissions: a quality improvement study.

Nitrous oxide, a potent greenhouse gas, is a common labour analgesic. One method which may reduce its carbon footprint is to 'crack' the exhaled gas into nitrogen and oxygen using catalytic destruction. In this quality improvement project, based on environmental monitoring and staff feedback, we assessed the impact of nitrous oxide cracking technology in the maternity setting. Mean ambient nitrous oxide levels were recorded during the final 30 minutes of uncomplicated labour in 36 cases and plotted on a run chart. Interventions were implemented in four stages, comprising: stage 1, baseline (12 cases); stage 2, cracking with nitrous oxide delivered and scavenged via a mouthpiece (eight cases); stage 3, cracking with nitrous oxide via a facemask with an air-filled cushion (eight cases); stage 4, cracking with nitrous oxide via a low-profile facemask, and enhanced coaching on the use of the technology (eight cases). The median ambient nitrous oxide levels were 71% lower than baseline in stage 2 and 81% lower in stage 4. Staff feedback was generally positive, though some found the technology to be cumbersome; successful implementation relies on effective staff engagement. Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure.

Toxicogenomics. Toxicologists brace for genomics revolution.

According to researchers who gathered here at a high-powered summit this month, toxicology may be on the verge of changing the way it collects raw data--adopting a process that could reduce animal use and improve test results. The new approach, called "toxicogenomics," uses DNA arrays to profile gene expression in cells exposed to test compounds. But some leaders in the field warn against rushing too quickly to embrace DNA tests, which are still difficult to interpret.

PLANETARY SCIENCE: 'Spiders' Channel Mars Polar Ice Cap.

Scientists studying the latest high-resolution photos of the martian south polar ice cap think they may have found additional clues to its ebb and flow. These hints of the planet's bizarre atmosphere come from a new class of dramatic-looking terrain features whose dark, multilimbed, vaguely radial designs have earned them the moniker "black spiders," and another group of dusky, spreading features called "dark fans." At a recent gathering here of Mars researchers, a planetary scientist proposed that the spiders might be subsurface gas channels, visible through an unusually transparent section of the martian ice.

Intergenerational and early life influences on the well-being of Australian Aboriginal and Torres Strait Islander children: overview and selected findings from Footprints in Time, the Longitudinal Study of Indigenous Children.

Footprints in Time: The Longitudinal Study of Indigenous Children (LSIC) is a national study of 1759 Australian Aboriginal and Torres Strait Islander children living across urban, regional and remote areas of Australia. The study is in its 11th wave of annual data collection, having collected extensive data on topics including birth and early life influences, parental health and well-being, identity, cultural engagement, language use, housing, racism, school engagement and academic achievement, and social and emotional well-being. The current paper reviews a selection of major findings from Footprints in Time relating to the developmental origins of health and disease for Australian Aboriginal and Torres Strait Islander peoples. Opportunities for new researchers to conduct further research utilizing the LSIC data set are also presented.

External irradiation of epithelial skin cancer.

A total of 339 consecutively treated, biopsy proven squamous and basal cell carcinomas of the skin treated from January 1966 to December 1986 were retrospectively analyzed to determine the patterns of local recurrence. There were 242 basal cell carcinomas, 92 squamous cell carcinomas, and 5 variants of squamous cell carcinoma in various locations. Radiotherapy was the initial treatment modality in 212 patients and 127 were treated after failing initial surgical excision. Lymph nodes were involved in 1/242 patients (.4%) with basal cell carcinoma, 14/92 patients (15%) with initially treated squamous cell carcinoma, and 20/51 (39%) with recurrent squamous cell lesions. Distant metastasis was found in one patient. Superficial X rays were given to 187 patients, electrons to 57 patients, megavoltage photons to 15, and a combination of modalities to the remainder. Overall local tumor control was achieved in 292 of 339 patients (86%), 220 of 242 (91%) with basal cell and 73 of 97 (75%) with squamous cell carcinoma. Tumor control was closely related to the size of the primary lesion. For lesions less than 1 cm tumor control was 97% (86/89) for basal cell and 91% (21/23) for squamous cell carcinoma. For 1 to 5 cm, tumor control was 87% (116/133) for basal cell and 76% (39/51) for squamous cell carcinoma and for lesions greater than 5 cm, the tumor control was 87% (13 of 15) and 56% (9/16), respectively. Tumor control was related to the modality used to treat the patient in spite of stratification of primary lesion size. For superficial X rays, tumor control was 98% (81/83) for lesions less than 1 cm, 93% (94/101) for lesions 1-5 cm and 100% (5/5) for lesions greater than 5 cm. For electrons tumor control was 88% (14/16), 72% (23/32), and 78% (7/9), respectively. For mixed beams tumor control was 90% (9/10), 76% (32/42), and 64% (9/14), respectively, and for 60Co-4 MV X rays, tumor control was 100% (3/3), 67% (6/9), and 33% (1/3), respectively. Cosmesis and complications were analyzed in 261 patients. An excellent or good cosmetic result was found in 92% (239/261) of the patients. There were 8 of 261 patients (3.1%) with fair and 19 of 261 (7.3%) with poor cosmesis. Cosmesis had an inverse relation to the primary lesion size with 97 of 99 patients (98%) with tumors 1 cm or less, 123 of 140 patients (88%) with lesions 1 to 5 cm and 13 of 16 patients (82%) with larger tumors having excellent or good cosmetic results. Cosmesis is also related to treatment modality.(ABSTRACT TRUNCATED AT 400 WORDS)

Observations on the clinical value of emission tomography.

Data comparing emission computed tomography (ECT), transmission computed tomography (TCT), and radionuclide scintigraphy suggest that in many patients more accurate diagnostic information may be available from emission tomography. ECT was performed during a 4-mo period on 200 of 235 patients referred for brain scans. The data suggest that ECT has a 10% greater sensitivity than scintigraphy, and better specificity. The accuracy of ECT was comparable to that of TCT performed in this group of patients. Selected cases demonstrate areas in which ECT improved lesion detection.

A comparison of two cerebral perfusion tracers, N-isopropyl I-123 p-iodoamphetamine and I-123 HIPDM, in the human.

Both N-isopropyl I-123 p-iodoamphetamine (IMP) and I-123 HIPDM have been advocated as radiotracers for assessing regional cerebral perfusion. We compared the biodistribution of the two tracers in 19 patients without evidence of neurological disease. Following intravenous injection, both tracers accumulated initially in the lung. Early after injection the fraction of the total brain uptake was higher for I-123 HIPDM than for I-123 IMP. The peak brain activity for I-123 IMP was higher than for I-123 HIPDM . Brain activity was unchanged with both tracers between 30 and 60 min after injection. Tomographic images were similar in appearance for both tracers. No eye uptake greater than background was observed with either tracer in any patient at 2, 24, and 48 hr. I-123 IMP is superior for tomographic imaging because of its higher brain uptake, whereas I-123 HIPDM may be superior for studies performed during rapid changes in blood flow.

Single-photon transaxial emission computed tomography of the heart in normal subjects and in patients with infarction.

Resting computerized transaxial tomography was performed after the i.v. injection of thallium-201 in six normal subjects and in five patients who had had myocardial infarctions 3 mo to 4 yr before scintigraphy. Decreased myocardial activity corresponded to the site of previous infarction in all cases and was clearly separated from adjacent myocardium with normal activity. With tomography, the left ventricle was clearly separated from surrounding structures such as the left-ventricular cavity, the lungs, and the liver. This study demonstrates the feasibility for the assessment of myocardial perfusion using single-photon transaxial emmission computed tomography.

Initial experience with SPECT (single-photon computerized tomography) of the brain using N-isopropyl I-123 p-iodoamphetamine: concise communication.

Forty-six patients were studied with N-isopropyl I-123 p-iodoamphetamine (IMP) and the Harvard Scanning Multidetector Brain System. In nine control patients, good differentiation between the gray and white matter of the cerebral cortex and the basal ganglia was evident. Regional uptake was affected by physiologic maneuvers (visual stimulation). In 24 patients studied for stroke, IMP images demonstrated areas that were involved in acute infarction in eight patients whose initial transmission computerized tomography (TCT) was normal; IMP also showed perfusion abnormalities larger than the TCT abnormality in ten patients. Perfusion abnormalities were present in 23/24 of these patients. Seven patients studied with a history of TIA had normal TCT and IMP images. In three patients studied during seizure activity, regions of hyperperfusion corresponded to the EEG seizure focus. Markedly decreased activity was present in three patients with brain tumor and corresponded to the focal abnormality on the TCT study. Our study demonstrates the feasibility of assessing regional brain perfusion using a radiopharmaceutical that is lipid soluble and has a high extraction fraction in the brain, together with single-photon ECT.

Controlled drug delivery in the treatment of diabetes mellitus.

Diabetes not only requires correction of an insulin deficiency but it also demands adequate insulin delivery. A short historical review is given over the first 60 years of insulin treatment, where emphasis was mainly on the correction of insulin deficiency. Despite concerted efforts, metabolic results were often poor, and there was a high incidence of late complications, which will be described briefly. A major aim of new treatment approaches, which emphasizes better routes of insulin delivery, is the prevention or reversal of these late complications. Closed-loop systems are infusion systems located outside the body which deliver insulin according to glucose values that are measured continuously. The state of the art for such systems will be described with examples of clinical applications and results. These systems aid and stimulate research, but offer no long-term application for treatment. Open-loop systems are portable, both external and implantable, and lack an accurate glucose sensor so that the loop can be closed. A number of insulin delivery systems have been developed in this category ranging from highly complex, fully implantable units, programable from outside, to simple basal-rate infusion pumps. Various pumps are designed to be used with varying delivery routes, and the evaluation of different routes will be a vital topic in this article. Pros and cons of the intravenous, intraperitoneal, and subcutaneous routes will be discussed, with supporting research referenced. Clinical experience will be cited for both the complex and the simple infusion systems. Other topics to be covered include feasibility of long-term treatment, complications of this new treatment approach, guidelines for patient instruction and supervision, requirements for treatment of large patient groups with pumps in a modern diabetes center, requirements for the physician, the influence of improved metabolic control on late complications (prevention or regression), the possibility for a portable closed-loop system, and future outlook. The primary author is the founder of an international study group on diabetes treatment with implantable insulin delivery devices. The common goals of this study group will also be presented. Special emphasis will be placed on a differentiated approach to treatment of Type I and Type II diabetes with a family of devices. Clinical work and results from a large patient group will be included throughout.

Phase I/II study of definitive radiotherapy and chemotherapy (cisplatin and 5-fluorouracil) for advanced or recurrent gynecologic malignancies. Preliminary report.

Twenty-three patients with advanced gynecologic malignancy were treated with definitive irradiation and synchronous sensitizing chemotherapy (CT) consisting of cisplatin (CDDP), 50 mg/m2 i.v. rapid infusion, and a 5-day continuous infusion of 5-fluorouracil (5-FU), 750 mg/m2/day. A total of three cycles were administered every 3-4 weeks. Fifteen patients had primary cervical epidermoid carcinoma (three bulky stage IIB, one stage IIIA, ten stage IIIB, one stage IV), four had pelvic recurrences of carcinoma of the cervix, two had endometrial adenocarcinomas (stage IV), and two had vulvar epidermoid carcinoma (one stage III and one stage IV). Radiotherapy (RT) for implantable tumors consisted of 2,000 cGy whole pelvis, 3,000-4,000 cGy split field, and two intracavitary or interstitial insertions, resulting in a total dose of 7,500-8,000 cGy to point A. Three courses of CT were delivered simultaneously with irradiation of the central bulk of tumor: during the first week of whole pelvis RT and with each of the two brachytherapy procedures. Nonimplantable tumors were treated with protracted external beam RT (5,500 cGy tumor dose) and three courses of CT during weeks 1, 4, and 7 of RT. Twenty-one of 23 patients completed RT and 18 of 23 patients completed CT as planned, but half had delays in either RT or CT. Grade 2 or 3 late sequelae consisted of leg edema (one patient), proctosigmoiditis (one patient), bowel obstruction (one patient), vesicovaginal fistula (one patient), and pulmonary embolus (two--one fatal). The incidence of grade 2 and 3 sequelae were 18 and 22%, respectively. With 1-3 years of follow-up evaluation, 12 of 23 (52%) patients are free of disease, and 9 of 22 evaluable patients (41%) have had failure within the pelvis. We conclude that high-dose definitive RT can be delivered with synchronous CDDP and 5-FU at the doses given, with acceptable toxicity. Further study is required to evaluate the impact of radiosensitization on tumor control and late morbidity of therapy. Optimization of irradiation and drug doses as well as the best schedules that may enhance the interaction of these two modalities should be further investigated.

Validity and reliability of a bone marrow transplant acuity tool.

The purpose of this project was to develop a valid and reliable patient-acuity tool for patients undergoing bone marrow transplant (BMT) as part of an overall patient-acuity system. A survey of other cancer centers and a review of the literature revealed no acuity tools that were designed for patients undergoing BMT. A four-level, nursing-diagnosis-based tool was developed with multiple indicators in each level, and its validity and reliability were studied. Content validity indexes (CVIs) were generated for each indicator by a panel of content experts. CVIs ranged from 0.4 to 1.0 with an overall CVI of 0.93 for the tool. Interrater reliability using two raters for 79 patients was high (r = 0.94, p < 0.001). Results of the study provide sufficient evidence of validity and reliability to warrant use of the tool, but further study is needed.

Validity and reliability of an oncology critical care patient acuity tool.

PURPOSE/OBJECTIVES: To test the reliability and validity of a patient acuity tool for use on a critical care oncology unit. DESIGN: Prototype classification system using therapeutic indicators to describe a patient's acuity. SETTING: Intensive care unit of a research and academic oncology hospital in the Southeastern United States. SAMPLE: Critical care nursing staff including management-level personnel at the research site. METHODS: An acuity tool for critical care was developed using the Johns Hopkins Oncology Center's patient classification system as a model. Content validity indexes were calculated based on ratings of nurse experts. interrater reliability was calculated based on two independent raters: a staff nurse and a patient care manager. MAIN RESEARCH VARIABLES: Appropriateness of language and categorization of therapeutic indicators developed for the tool. FINDINGS: The content validity index of the entire tool was 0.85; 24/25 indicators were retained. Reliability was r = 0.84. CONCLUSIONS: The tool is reliable and valid. IMPLICATIONS FOR NURSING PRACTICE: Acuity tools can be used to calculate unit productivity and assist with determination of staffing needs. In this age of healthcare reform, it is imperative that personpower needs in all care settings be accurately determined to provide cost-effective and safe care levels.

Validity and reliability of medical and surgical oncology patient acuity tools.

PURPOSE/OBJECTIVES: To develop valid and reliable medical and surgical acuity tools as part of an overall classification system for patients with cancer. SETTING: An acute care, tertiary, research, academic oncology hospital in the southeastern United States. SAMPLE: Clinical nursing experts in medical and surgical oncology; 125 patient observations for the surgical oncology acuity tool, and 75 patient observations for the medical oncology acuity tool. METHOD: The nursing division developed a medical oncology acuity tool and a surgical oncology acuity tool using the Johns Hopkins Oncology Patient Classification System as a model. They then studied the validity of developed tools using content validity indexes (CVIs). Two independent raters studied the interrater reliability of each tool. FINDINGS: CVIs for items on the surgical tool ranged from 0.57-1.0; the overall CVI for this tool was 0.86. CVIs for items on the medical tool ranged from 0.25-1.0. The overall CVI for this tool was 0.88. Pearson correlation coefficients were r = 0.95 (p < 0.001) for the surgical oncology acuity tool and r = 0.92 (p < 0.001) for the medical tool. Interrater reliability, tested continually for four years, was greater than 95%. CONCLUSIONS: The tools are reliable and valid. IMPLICATIONS FOR NURSING PRACTICE: Medical and surgical oncology acuity tools that are nursing diagnosis based, interface with nursing standards of care, are easy to use, and require no calculation provide reliable quantification of nursing work loads based on the care needs of patients with cancer. Supervisors use data from these tools to determine variable nursing hours per patient per day, establish productivity for units, make staffing and scheduling decisions, assign patients, work on budgets, and, ultimately, establish charges for nursing services. As the needs of medical and surgical oncology patients evolve, continued refinement of indicators and acuity levels will be needed. As other medical and surgical oncology tools are developed, further comparison will be warranted. Additional study would determine if the tools could be modified for these nursing uses in other cancer centers as well as in designated medical and surgical oncology units of other types of hospitals. Oncology acuity systems also could be established in the future as the basis for third-party reimbursement.

The treatment of longitudinal ulnar deficiency.

Longitudinal ulnar deficiency, whose detailed anatomy is varied, is often accompanied by other abnormalities and appears as part of several syndromes. The history of its classification is reviewed, and the treatments, which have been offered, described. Follow-up of a series shows that the function achieved is good and is optimised by aids, occupational therapy and some hand surgical procedures. The more elaborate surgical reconstructions are unlikely to be beneficial.

The AB-York crescent of sound: an apparatus for assessing spatial-listening skills in children and adults.

Modern health services need efficient tools for measuring outcomes from interventions, that is, tools of proven efficacy which make minimal demands on the time of clinicians in learning to administer tests and in interpreting results. This paper describes an apparatus designed to meet those requirements. The apparatus administers performance tests of spatial listening for children and adults with unilateral and bilateral cochlear implants. The apparatus was designed with guidance from clinicians. It possesses three key attributes: it is simple to use; the results of tests are scored automatically and are compared with reference data; the apparatus generates comprehensive personalized reports for individual participants that can be included in clinical notes. This paper describes the apparatus and reports results of a test measuring spatial release from masking of speech which illustrates the compatibility between the new apparatus and an older apparatus with which the reference data were gathered.

Bilateral or unilateral cochlear implantation for deaf children: an observational study.

OBJECTIVE: Cochlear implantation in one ear (unilateral implantation) has been the standard treatment for severe-profound childhood deafness. We assessed whether cochlear implantation in both ears (bilateral implantation) is associated with better listening skills, higher health-related quality of life (health utility) and higher general quality of life (QOL) than unilateral implantation. DESIGN: Cross-sectional observational study. SETTING: University of York. PARTICIPANTS: Fifty severely-profoundly deaf and 56 normally-hearing children recruited via a charity, the UK National Health Service and schools. INTERVENTIONS: Thirty of the deaf children had received bilateral cochlear implants; 20 had unilateral cochlear implants. MAIN OUTCOME MEASURES: Performance measures of children's listening skills; parental-proxy valuations of the deaf children's health utility obtained with the Health Utilities Index Mark 3 and of their QOL obtained with a visual analogue scale. RESULTS: On average, bilaterally-implanted children performed significantly better than unilaterally implanted children on tests of sound localisation and speech perception in noise. After conservative imputation of missing data and while controlling for confounds, bilateral implantation was associated with increases of 18.5% in accuracy of sound localisation (95% CI 5.9 to 31.1) and of 3.7 dB in speech perception in noise (95% CI 0.9 to 6.5). Bilaterally-implanted children did not perform as well as normally-hearing children, on average. Bilaterally- and unilaterally-implanted children did not differ significantly in parental ratings of health utility (difference in medians 0.05, p>0.05) or QOL (difference in medians 0.01, p>0.05). CONCLUSIONS: Compared with unilateral cochlear implantation, bilateral implantation is associated with better listening skills in severely-profoundly deaf children.