Satisfaction rates with the current Special Type Consultation (STC) reimbursement scheme among General Practitioners - A Mixed Methods Study.

The Special Type Consultation (STC) scheme is a fee-for-service reimbursement scheme for General Practitioners (GPs) in Ireland. Introduced in 1989, the scheme includes specified patient services involving the application of a learned skill, e.g. suturing. This study aims to establish the extent to which GPs believe this scheme is appropriate for current General Practice. This is an embedded mixed-methods study combining quantitative data on GPs working experience of and qualitative data on GPs attitudes towards the scheme. Data were collected by means of an anonymous postal questionnaire. The response rate was 60.4% (n=159.) Twenty-nine percent (n=46) disagreed and 65% (n=104) strongly disagreed that the current list of special items is satisfactory. Two overriding themes were identified: economics and advancement of the STC process. This study demonstrates an overwhelming consensus among GPs that the current STC scheme is outdated and in urgent need of revision to reflect modern General Practice.

Food Allergy Emergencies in Children - To what extent are Early Years Services Prepared? A cross-sectional survey.

Food allergies are common in preschool children. This study's aims are to establish prevalence, to clarify management practices, levels of preparedness and the perceived role of General Practitioners amongst Early Years Services providers. This study is an anonymous, quantitative, cross sectional study. An online questionnaire was distributed to 282 Early Years Service providers. Data were analysed using SPSS. Response rate was 35% (n=98). Prevalence of food allergy was 3% (n=119). Allergic reactions to food had occurred on site in 16% (n=15). Written emergency action plans were available in 47% of facilities (n=46). Medications were not kept on site in 63% (n=62) of facilities. General practitioners were felt to have an important role in the management of food allergies by 76% of respondents (n=61). This study identifies significant areas for improvement in the management of food allergic child in Early Years Services.

Intercellular adhesion molecule 1 (ICAM-1) expression and its role in neutrophil-induced ischemia-reperfusion injury in rat liver.

The potential role of intercellular adhesion molecule-1 (ICAM-1) in the pathogenesis of reperfusion injury was investigated in male Fischer rats subjected to 45 min of hepatic ischemia and 24 h of reperfusion. ICAM-1 mRNA levels increased during ischemia in the ischemic liver lobes; however, during reperfusion mRNA levels increased in both the ischemic and nonischemic lobes. Immunohistochemical evaluation indicated ICAM-1 expression only on sinusoidal lining cells in controls; ischemia-reperfusion enhanced ICAM-1 expression in the sinusoids and induced some expression on hepatocytes. The monoclonal anti-ICAM-1 antibody 1A29, but not an immunoglobulin G control antibody, administered at 1 h and 8 h of reperfusion (2 mg/kg) significantly attenuated liver injury as indicated by 51% lower plasma alanine aminotransferase activities and 32-36% less hepatic necrosis at 24 h without affecting reactive oxygen formation by Kupffer cells and hepatic neutrophils. Although 1A29 reduced neutrophil extravasation in a glycogen peritonitis by 60%, the antibody had no significant effect on hepatic neutrophil infiltration during reperfusion. These data suggest that ICAM-1 plays a significant role during the neutrophil-dependent injury phase after hepatic ischemia and reperfusion and therefore blocking this adhesion molecule may have therapeutic potential against postischemic acute liver failure.

Neutrophil-induced lung damage after hepatic ischemia and endotoxemia.

Administration of Salmonella enteritidis endotoxin (0.5 mg ET/kg) during reperfusion (RP) after short-term hepatic ischemia (20 min) caused severe liver injury induced by Kupffer cells and neutrophils and a high mortality rate. To investigate potential lung damage in this model, lung wet-to-dry weight ratios (W/D) and broncho-alveolar lavage (BAL) protein content were determined after 4 h of reperfusion. Both parameters increased significantly during RP/ET (W/D: 4.4 +/- 0.1; BAL: 639 +/- 30 micrograms/ml) compared to controls (W/D: 3.5 +/- 0.1; BAL: 332 +/- 17). The antioxidants Trolox or tirilazad mesylate (U-74006F) effectively reduced the BAL protein increase. Alveolar macrophages were not activated; however, neutrophils isolated from the lung microvasculature of RP/ET animals showed a 300% increase of spontaneous and PMA-induced superoxide formation compared to controls (spontaneous: 1.4 +/- 0.5 nmol O2-/h/10(6) cells; PMA: 2.2 +/- 0.4). Complement factors and TNF-alpha injection induced a similar priming of vascular neutrophils for superoxide generation. Vascular neutrophil activation highly correlated with the severity of lung injury. It is concluded that neutrophils accumulated in the lung microvasculature were the major source of the oxidant stress and mainly responsible for lung injury under these conditions. Antioxidants such as tirilazad mesylate (U-74006F) may have therapeutic potential for attenuating lung injury induced by remote organ trauma and a systemic inflammatory response.

Hospice care of the intravenous drug user AIDS patient in a skilled nurse facility.

We report on the initial experience in hospice care for a predominantly poor, black and Hispanic intravenous drug user AIDS population in New York City. Hospice care was provided in a skilled nursing facility with a certified hospice program delivering home care and inpatient care. A formal education program preceded patient admission to familiarize the staff and institution with AIDS issues. Between February 1986 and January 1988, 62 of 175 referred patients were accepted for hospice admission. The patients' mean age was 39 years and all had AIDS dementia complex. The mean length of stay was 35 days (range 1-280 days) and a total of 2011 days of hospice care was provided. Ninety-one percent of hospice days were spent on the inpatient unit; only 9% of hospice days were provided at home. Despite the requirement of expensive inpatient hospice care for most patient days, the estimated savings in decreased costs compared to acute hospital inpatient care was $751,488 for these 62 patients. Continuing fear of transmission among hospice staff was not a major problem; however, several unanticipated problems arose including (a) inability to provide home services, (b) continued drug abuse, (c) increased staff stress, (d) difficulty maintaining confidentiality, (e) difficult interactions with funeral directors, and (f) unsupportive and inappropriate funding requirements. Hospice care of AIDS patients is feasible, humane, and cost effective but problems of the intravenous drug using population require special attention and program modifications if hospice care is to be provided for this substantial and growing AIDS population.

A Bayesian model for detecting past recombination events in DNA multiple alignments.

Most phylogenetic tree estimation methods assume that there is a single set of hierarchical relationships among sequences in a data set for all sites along an alignment. Mosaic sequences produced by past recombination events will violate this assumption and may lead to misleading results from a phylogenetic analysis due to the imposition of a single tree along the entire alignment. Therefore, the detection of past recombination is an important first step in an analysis. A Bayesian model for the changes in topology caused by recombination events is described here. This model relaxes the assumption of one topology for all sites in an alignment and uses the theory of Hidden Markov models to facilitate calculations, the hidden states being the underlying topologies at each site in the data set. Changes in topology along the multiple sequence alignment are estimated by means of the maximum a posteriori (MAP) estimate. The performance of the MAP estimate is assessed by application of the model to data sets of four sequences, both simulated and real.

Activation of Kupffer cells and neutrophils for reactive oxygen formation is responsible for endotoxin-enhanced liver injury after hepatic ischemia.

The potential role of reactive oxygen species generated by Kupffer cells and neutrophils was investigated in a model of endotoxin-enhanced liver injury after hepatic ischemia. Male Fischer rats were subjected to 20 min ischemia and reperfusion of up to 24 h; .5 mg/kg Salmonella enteritidis endotoxin was injected at 30 min of reperfusion. The animals developed severe liver injury resulting in 50% hepatocellular necrosis at 24 h. Isolated Kupffer cells and neutrophils from the postischemic liver generated 10-fold more superoxide than cells from control livers. Treatment with gadolinium chloride (GdCl3) selectively reduced the capacity of Kupffer cells to generate superoxide by 65% and attenuated liver injury by 73% at 4 h and 58-69% at 24 h. Monoclonal antibodies against neutrophil adhesion molecules (CD11/CD18) had no effect on the early injury but reduced hepatocellular necrosis by 90-95% at 24 h. The antioxidant Trolox and the iron-chelator deferoxamine attenuated liver injury by 71 and 80%, respectively. It is concluded that Kupffer cells are mainly responsible for the initial injury, and neutrophils are the dominant cytotoxic cell type during the later phase. Reactive oxygen generated by both cell types is critical for this pathogenesis.

Delayed diagnosis of disseminated strongyloidiasis.

We report the case of a 51-year-old woman who presented with a confusing spectrum of systemic symptoms after starting steroid therapy for a rheumatological disorder. The diagnosis of disseminated strongyloidiasis was made after a delay of 2 weeks. This paper outlines the symptom complex with which this critically ill woman presented, the course of her disease and the treatment of her disseminated strongyloidiasis.

Swim training alters renal and cardiovascular responses to stress in borderline hypertensive rats.

The present study assessed the effects of 40 min of tail shock stress (1-s shock, 0.2 mA every 30 s) on renal and cardiovascular function in swim-trained (T), water-immersed (IM), and untrained (UT) borderline hypertensive rats (BHR). T BHR swam for 2 h/day 5 days/wk for 10-12 wk, whereas IM BHR on the same schedule were placed in water at neck level and were not permitted to swim. Age-matched sedentary controls were paired one each with the exercise group (group 1) and the immersion group (group 2). Heart rate was significantly greater in UT than in T BHR (P = 0.09) during baseline (rest). Heart rate responses during stress were not different between UT and IM BHR (group 2). Systolic and diastolic blood pressures during stress and recovery were not different between UT BHR and T or IM BHR. Urine flow rate was significantly increased from baseline during the first 20 min of stress in UT and IM BHR only. Changes in glomerular filtration rate were not consistent across studies. Renal blood flow decreased significantly from baseline during tail shock stress in UT but not T BHR. Plasma glucose levels were significantly increased above baseline during the second 20 min of stress in UT BHR only and were significantly greater than those in the T BHR. Plasma insulin levels in UT BHR were significantly decreased from baseline during tail shock stress and recovery but were unchanged from baseline in T BHR. These observations suggest that swim training independent of water immersion alters the effect that stress exerts on renal and cardiovascular function in BHR, which results in better fluid and electrolyte conservation in T BHR.

Effect of blood and albumin on pulmonary hypertension and edema in perfused rabbit lungs.

Perfusate composition may alter pulmonary hemodynamics and edema formation in perfused lungs. Perfusion for 3 h with Krebs-Henseleit solution with 3% bovine serum albumin did not produce pulmonary hypertension, pulmonary edema (assessed by lung wet-to-dry wt ratio), or increased macromolecular permeability (assessed by 125I-albumin uptake). Addition of blood to hematocrit levels of 10 or 20% resulted in pulmonary hypertension during the final hour of perfusion but not pulmonary edema or increased macromolecular permeability. Pulmonary hypertension during blood perfusion was primarily due to increased precapillary resistance. Perfusion with buffer solution without albumin produced edema and increased macromolecular permeability but not pulmonary hypertension. In lungs perfused with blood (20% hematocrit), thromboxane B2 levels increased in parallel with the pulmonary hypertension, and inhibition of cyclooxygenase or thromboxane synthase with indomethacin or dazmegrel prevented pulmonary hypertension. Perfusion with leukopenic blood (from prior nitrogen mustard administration or from filtration) also prevented pulmonary hypertension. We conclude that blood perfusion produces pulmonary hypertension via thromboxane A2 generation, which depends on leukocyte activation, and that perfusion with buffer solutions without albumin produces edema and increased permeability without pulmonary hypertension.

Reoperative surgery for periampullary adenocarcinoma.

In recent years, the morbidity, mortality, and long-term survival of patients undergoing surgery for periampullary adenocarcinoma have improved. These changes have prompted us to reoperate on patients who have previously undergone pancreatobiliary surgery, many of whom were initially considered to have unresectable lesions. From 1979 to 1990, 38 patients with pancreatic and 17 patients with nonpancreatic periampullary adenocarcinoma underwent reexploratory surgery at The Johns Hopkins Hospital, Baltimore, Md. Thirty-three (60%) of these 55 patients had resection at the time of second laparotomy. Of the 46 patients undergoing reexploratory surgery with an intent to resect, the overall resection rate was 72% (33), 64% (16/25) for pancreatic and 100% for nonpancreatic periampullary adenocarcinoma. Postoperative complications occurred in 21 patients (38%), but only one patient (2%) died following surgery. Mean survivals from reexploratory surgery were 6.9 months for the 22 patients with pancreatic cancer undergoing palliative surgery, 20.5 months for the 16 patients with resectable pancreatic cancer, and 33.0 months for the 17 patients with nonpancreatic periampullary adenocarcinoma undergoing resection. We conclude that in carefully selected patients, reoperative surgery for periampullary cancer (1) provides a significant resection rate, (2) can be performed safely, and (3) offers a chance for long-term survival.

PAF formation by H2O2-stimulated perfused canine carotid arteries.

Perfusion of noncytotoxic concentrations of hydrogen peroxide (H2O2) through canine carotid arteries potentiates neutrophil adhesion to vessel endothelium. Platelet-activating factor (PAF) receptor antagonists block neutrophil adhesion to vessels pretreated with low millimolar concentrations of H2O2. We have used a specific gas chromatographic-mass spectrometric (GC-MS) assay for PAF and applied this to studies of canine carotid arteries perfused with H2O2. Vessels perfused with 1 and 10 mM H2O2 for 20 min produced PAF in a dose-dependent manner, 331 +/- 67 pg/g tissue with 1 mM H2O2 and 1160 +/- 194 pg/g with 10 mM. Vessels that had been denuded of endothelium with a balloon catheter prior to H2O2 perfusion produced similar quantities of PAF in response to H2O2 (220 +/- 72 pg/g and 960 +/- 210 pg/g with 1 and 10 mM, respectively). Cultured canine jugular venous endothelial cells produced PAF in response to 10 mM H2O2 (809 +/- 117 pg/10(7) cells) but carotid arterial smooth muscle cells did not. These results suggest that vascular cells other than endothelial cells may produce PAF following H2O2 perfusion of canine carotid arteries.

Gas chromatographic-mass spectrometric analysis of lipoxygenase products in post-ischemic rabbit myocardium.

Leukotriene B4 (LTB4) is a potent chemotactic compound for neutrophils and is thought to be an important mediator of myocardial ischemia-reflow injury. We have measured LTB4 in rabbit cardiac tissue following ischemia-reflow using a sensitive and specific gas chromatographic-mass spectrometric (GC-MS) assay. The concentration of LTB4 in rabbit myocardium following 45 min ischemia and 3 h reflow was 48.7 +/- 12.5 pg/g, significantly higher than in non-ischemic tissue from the same animal (17.5 +/- 3.9 pg/g). These concentrations were at least an order of magnitude lower than previously reported values assessed by radioimmunoassay (RIA). Compared with the GC-MS method, RIA greatly overestimated LTB4 concentrations in cardiac tissue. The capacity of post-ischemic myocardium to produce lipoxygenase products, LTB4, 5-, 12- and 15-HETEs was also assessed following incubation of myocardium ex vivo with calcium ionophore. In all animals ischemic cardiac tissue produced greater amounts of LTB4, 5-, and 12-HETEs than non-ischemic myocardium and 12-HETE was the major product. Neutrophils that have accumulated in the injured tissue may be a major source of these products. However, in contrast to cardiac tissue, isolated rabbit neutrophils stimulated with A23187 produced 5-HETE as the major product with very little 12-HETE formed. These latter findings suggest that cells other than neutrophils may contribute to the production of lipoxygenase products during myocardial ischemia-reflow injury.

Raised liver associated enzyme activity and post-prandial bile acid concentrations in sera from treated diabetic outpatients.

Aspartate aminotransferase, alanine aminotransferase and gamma-glutamyl transferase activities were measured in sera from 411 diabetic outpatients and were raised in 26 (6.4%), 34 (8.3%) and 62 (15.2%) patients, respectively. Serum total bile acid concentrations were raised in 4 patients (1%). Percentage glycated hemoglobin A1, serum fructosamine concentration and plasma glucose concentration were also measured. No relationship between the presence of raised enzyme activity and mature age, short duration of diabetic treatment regimen or glycemic control was found. Twenty-six patients with an alanine aminotransferase activity greater than 60 U/l were reviewed at 23 +/- 6.5 weeks. The activity of this enzyme had fallen to within the reference interval in 15 (58%). In the other 11 patients, its median activity was 75 U/l (range 51-181 U/l). Median gamma-glutamyl transferase activity had risen in these 11 patients from 78 U/l to 93 U/l (P less than 0.01). No statistical differences in treatment regimen or glycemic control were found between these two groups. Raised liver-associated enzyme activity in treated stabilised diabetic outpatients should therefore not be attributed to poor glycemic control or diabetic treatment regimen.

Why does somatostatin cause gallstones?

Long-term administration of the somatostatin analogue, octreotide, is complicated by gallstone formation. Somatostatin is known to inhibit hepatic bile secretion and gallbladder emptying. However, the effect of octreotide on gallbladder bile composition remains unknown. Therefore, we tested the hypothesis that octretide would alter hepatic bile composition and cause gallbladder stasis, thereby increasing gallbladder bile solute concentrations. Fourteen control prairie dogs received daily saline injections, whereas 10 animals received 1 micrograms of octreotide subcutaneously three times per day for 5 days. Cholecystectomy and common bile duct cannulation were then performed. Octreotide increased hepatic bile concentrations of bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.05), and total protein (p less than 0.01). Rsa, an index of gallbladder stasis, was decreased (p less than 0.01) in the octreotide group. Gallbladder bile total calcium (p less than 0.05), bilirubin monoglucuronide (p less than 0.05), total bilirubin (p less than 0.01), total protein (p less than 0.05), and total lipids (p less than 0.05) were increased in the octreotide group. Animals receiving octreotide also had decreased hepatic (p less than 0.05) and gallbladder (p less than 0.001) bile pH. No differences in cholesterol saturation index were observed. These data suggest that in the prairie dog, octreotide (1) alters hepatic bile composition, (2) causes gallbladder stasis, and (3) increases gallbladder bile calcium, bilirubin, protein, lipid, and hydrogen ion concentrations. We conclude that octreotide causes alterations in gallbladder bile composition that increase the likelihood of cholesterol and calcium bilirubinate precipitation.

The excitability of human corticospinal neurons is depressed by thiopental.

BACKGROUND: We tested the effect of thiopental on the excitability of the corticospinal-motoneuron axis in normal human subjects. METHODS: Magnetic stimulation was used to excite the neurons in the motor cortex which give rise to the fast conducting corticospinal pathway. The characteristics of the composite excitatory post-synaptic potentials (EPSPs) produced in individual spinal motoneurons by cortical stimulation were derived from changes in the firing probability of voluntarily activated motor units of the first dorsal interosseous muscle. RESULTS: In 5 normal subjects, we found that thiopental, in incremental doses sufficient to sustain drowsiness (total dose 75 to 175 mg), significantly reduced the amplitude of these composite EPSPs. CONCLUSIONS: Thiopental reduced the facilitation of motoneurons from the cortex most likely by depressing cortical neurons.

Sepsis and the trauma patient.

Conventional therapy for septic shock concentrates on correcting circulatory perfusion defects by optimizing hemodynamic parameters and oxygen delivery to the periphery. In the face of ongoing sepsis, the central abnormality of nutrient acquisition and energy production at the cellular level remains and the patient often progresses to MSOF despite our best efforts. Currently, surgical drainage and antibiotic therapy are the mainstays for eradication of infection. In the future, as we understand more of the mediators and metabolic consequences of septic shock, we anticipate that a more specific, directed therapy will be developed to reduce the high mortality rate.

Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery.

BACKGROUND AND OBJECTIVES: Although interscalene brachial plexus block (ISBPB) is often used to provide anesthesia for arthroscopic shoulder surgery, its selective analgesic effect, provided by low-dose local anesthetic, has not been studied. We hypothesized that ISBPB using a low volume and low concentration of bupivacaine can provide effective postoperative analgesia for shoulder surgery without producing significant sensory or motor block elsewhere. METHODS: In this double-blind study, 30 outpatients scheduled to undergo shoulder arthroscopy were randomly assigned to receive either an ISBPB with 10 mL 0.125% bupivacaine with epinephrine 1:400,000 (n = 15) or 10 mL of normal saline (n = 15). The block was performed preoperative, prior to a standardized general anesthetic. Postoperative pain scores, imorphine and oral analgesic consumption, recovery profile, and patient satisfaction were recorded. RESULTS: In the ISBPB group, verbal analog pain scores within 120 minutes after surgery were lower, morphine consumption in the postanesthesia care unit was significantly lower (2.7+/-2.6 mg vs 9.5+/-5.2 mg), the time to postoperative administration of the first systemic or oral analgesic was significantly longer (141+/-182 minutes vs 13+/-10 minutes), the degree of motor and sensory block 120 minutes after surgery was minimal, time to reach hospital discharge criteria was earlier, and patient satisfaction with postoperative analgesia at 24-hour follow-up was greater. Thirty-three percent of the patients receiving ISBPB did not require any analgesic prior to hospital discharge. CONCLUSIONS: Interscalene brachial plexus block with low-dose bupivacaine is a useful and selective analgesic technique for outpatient shoulder arthroscopic surgery.