Identifying potentially eligible subjects for research: paper-based logs versus the hospital administrative database.

INTRODUCTION: The Canadian Perinatal Network (CPN) is a national database focused on threatened very pre-term birth. Women with one or more conditions most commonly associated with very pre-term birth are included if admitted to a participating tertiary perinatal unit at 22 weeks and 0 days to 28 weeks and 6 days. METHODS: At BC Women's Hospital and Health Centre, we compared traditional paper-based ward logs and a search of the Canadian Institute for Health Information (CIHI) electronic database of inpatient discharges to identify patients. RESULTS: The study identified 244 women potentially eligible for inclusion in the CPN admitted between April and December 2007. Of the 155 eligible women entered into the CPN database, each method identified a similar number of unique records (142 and 147) not ascertained by the other: 10 (6.4%) by CIHI search and 5 (3.2%) by ward log review. However, CIHI search achieved these results after reviewing fewer records (206 vs. 223) in less time (0.67 vs. 13.6 hours for ward logs). CONCLUSION: Either method is appropriate for identification of potential research subjects using gestational age criteria. Although electronic methods are less time-consuming, they cannot be performed until after the patient is discharged and records and charts are reviewed. Each method's advantages and disadvantages will dictate use for a specific project.

Lung vascular targeting using antibody to aminopeptidase P: CT-SPECT imaging, biodistribution and pharmacokinetic analysis.

BACKGROUND/AIMS: Aminopeptidase P (APP) is specifically enriched in caveolae on the luminal surface of pulmonary vascular endothelium. APP antibodies bind lung endothelium in vivo and are rapidly and actively pumped across the endothelium into lung tissue. Here we characterize the immunotargeting properties and pharmacokinetics of the APP-specific recombinant antibody 833c. METHODS: We used in situ binding, biodistribution analysis and in vivo imaging to assess the lung targeting of 833c. RESULTS: More than 80% of 833c bound during the first pass through isolated perfused lungs. Dynamic SPECT acquisition showed that 833c rapidly and specifically targeted the lungs in vivo, reaching maximum levels within 2 min after intravenous injection. CT-SPECT imaging revealed specific targeting of 833c to the thoracic cavity and co-localization with a lung perfusion marker, Tc99m-labeled macroaggregated albumin. Biodistribution analysis confirmed lung-specific uptake of 833c which declined by first-order kinetics (t(½) = 110 h) with significant levels of 833c still present 30 days after injection. CONCLUSION: These data show that APP expressed in endothelial caveolae appears to be readily accessible to circulating antibody rather specifically in lung. Targeting lung-specific caveolar APP provides an extraordinarily rapid and specific means to target pulmonary vasculature and potentially deliver therapeutic agents into the lung tissue.

What is SNOMED CT and why should the ISSHP care?

SNOMED CT (Systematized NOmenclature of MEDicine Clinical Terms) is a standardized multilingual healthcare terminology. It was developed to meet the needs of our electronic world so that care can be documented and clinicians can retrieve and transmit data in electronic format. It is anticipated that SNOMED CT will provide the core general terminology for electronic health records and, as such, replace existing classification systems such as the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). At present, there is no special interest group for the hypertensive disorders of pregnancy (HDP) within the SNOMED CT initiative. We believe that members of the ISSHP, and others interested in the HDP, should take a leadership role in this regard for a number of reasons.

Interference of ascorbic acid with chemical analytes.

BACKGROUND: Ascorbic acid can interfere with methodologies involving redox reactions, while comprehensive studies on main chemistry analysers have not been reported. We therefore attempted to determine the interference of ascorbic acid with analytes on the Beckman Synchron LX20. METHODS: Various concentrations of ascorbic acid were added to serum, and the serum analytes were measured on the LX20. RESULTS: With a serum ascorbic acid concentration of 12.0 mmol/L, the values for sodium, potassium, calcium and creatinine increased by 43%, 58%, 103% and 26%, respectively (P<0.01). With a serum ascorbic acid concentration of 12.0 mmol/L, the values for chloride, total bilirubin and uric acid decreased by 33%, 62% and 83%, respectively (P<0.01), and were undetectable for total cholesterol, triglyceride, ammonia and lactate. There was no definite influence of ascorbic acid on analytical values for total CO(2), urea, glucose, phosphate, total protein, albumin, amylase, creatine kinase, creatine kinase-MB, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total iron, unbound iron-binding capacity or magnesium. CONCLUSIONS: Ascorbic acid causes a false increase in sodium, potassium, calcium and creatinine results and a false decrease in chloride, total bilirubin, uric acid, total cholesterol, triglyceride, ammonia and lactate results.

Vitreous humor biochemical constituents: evaluation of between-eye differences.

The present study was conducted to investigate the differences in the vitreous humor biochemical concentrations for vitreous electrolytes and calcium in the same pair of eyes at identical postmortem interval (PMI). The vitreous humor samples were collected independently in both eyes from 48 autopsies (PMI range, 4.5-84.3 hours) with documented time of death. The samples were analyzed for potassium, sodium, chloride, and calcium using a Beckman Coulter LX20 Automated Analyzer based on ion-selective electrode methodology. There were no statistically significant between-eye differences at identical postmortem interval. A significantly high correlation was observed between paired potassium concentrations of both the eyes. A highly significant linear correlation was observed between the individual eye and mean potassium concentrations of both the eyes with postmortem interval. The observed differences were not significantly correlated with postmortem interval. The results demonstrated that the between-eye differences for vitreous electrolytes and calcium are insignificant. Therefore, the utility of vitreous biochemistry, particularly potassium in postmortem interval estimation and other forensic applications, cannot be questioned solely on the basis of these differences.

Effect of high-dose intravenous eletriptan on coronary artery diameter.

The goal of this study was to evaluate the coronary vasoconstrictive effects of high doses of eletriptan compared with a standard dose of sumatriptan. Patients with no clinically significant coronary artery disease were randomized to receive high-dose intravenous eletriptan (n = 24) vs a standard dose of sumatriptan (n = 18; 6 mg subcutaneously) vs placebo (n = 18). Serial angiograms were obtained. The primary non-inferiority analysis found equivalence between the mean maximum change in left anterior descending coronary artery diameter for eletriptan, -22%[95% confidence interval (CI) -26, -19], and sumatriptan, -19% (95% CI -22, -16). The change due to placebo was -16% (95% CI -20, -12). No individual cases of clinically significant vasoconstriction were observed. The results confirm that eletriptan has a broad cardiovascular safety margin, with plasma concentrations comparable to three to five times the Cmax of an oral 80-mg dose associated with modest vasoconstriction equivalent to standard therapeutic doses of sumatriptan.

A randomized controlled trial to prevent patient lift and transfer injuries of health care workers.

STUDY DESIGN: Randomized controlled trial (RCT). OBJECTIVES: To compare the effectiveness of training and equipment to reduce musculoskeletal injuries, increase comfort, and reduce physical demands on staff performing patient lifts and transfers at a large acute care hospital. SUMMARY OF BACKGROUND DATA: Back injury to nursing staff during patient handling tasks is a major issue in health care. The value of mechanical assistive devices in reducing injuries to these workers is unclear. METHODS: This three-armed RCT consisted of a "control arm," a "safe lifting" arm, and a "no strenuous lifting" arm. A medical, surgical, and rehabilitation ward were each randomly assigned to each arm. Both intervention arms received intensive training in back care, patient assessment, and handling techniques. Hence, the "safe lifting" arm used improved patient handling techniques using manual equipment, whereas the "no strenuous lifting" arm aimed to eliminate manual patient handling through use of additional mechanical and other assistive equipment. RESULTS: Frequency of manual patient handling tasks was significantly decreased on the "no strenuous lifting" arm. Self-perceived work fatigue, back and shoulder pain, safety, and frequency and intensity of physical discomfort associated with patient handling tasks were improved on both intervention arms, but staff on the mechanical equipment arm showed greater improvements. Musculoskeletal injury rates were not significantly altered. CONCLUSIONS: The "no strenuous lifting" program, which combined training with assured availability of mechanical and other assistive patient handling equipment, most effectively improved comfort with patient handling, decreased staff fatigue, and decreased physical demands. The fact that injury rates were not statistically significantly reduced may reflect the less sensitive nature of this indicator compared with the subjective indicators.

Demography and pedigree structure of an SPF colony of rhesus monkeys (Macaca mulatta).

The SPF rhesus colony at the M.D. Anderson Cancer Center in Bastrop, Texas, was analyzed with the aim of determining the demographic and genetic effects of stringent selection for virus-free breeders, permanent quarantine, continued surveillance, and culling of animals that show evidence of viral infection. The analysis shows minimal effects on population viability and loss of genetic variability in comparison with the traditionally managed (non-SPF) portion of the population.

The pulmonary and systemic distribution and elimination of perflubron from adult patients treated with partial liquid ventilation.

OBJECTIVE: To assess the pulmonary and systemic distribution and elimination of perflubron (C(8)F(17)Br(1); LiquiVent; Alliance Pharmaceutical; San Diego, CA) during and following the period of partial liquid ventilation. DESIGN: Prospective phase I and II clinical trial. SETTING: Adult surgical ICU. PATIENTS: Eighteen adult patients (mean +/- SEM age, 37.9 +/- 3.4 years) with severe respiratory failure, some of whom required extracorporeal life support (72%), and who were managed with partial liquid ventilation with perflubron. INTERVENTIONS: Perflubron was administered into the trachea, and gas ventilation of the perfluorocarbon-filled lung (partial liquid ventilation) was then performed. Additional doses were administered daily for from 1 to 7 days, with a median cumulative dose of 31 mL/kg (range, 3 to 60 mL/kg). MEASUREMENTS AND MAIN RESULTS: Patient blood samples were evaluated by gas chromatography for serum perflubron levels. Sequential lateral and anteroposterior radiographs were assessed, using a 5-point rating scale, for the degree of perflubron fill following the final dose. Samples of expired gas were collected, and the rate of loss of perflubron in the expired gas was measured by gas chromatography. Mean serum perflubron levels increased to 0.16 +/- 0.05 mg/dL at 24 h following administration of the initial dose. A mean maximum level of 0.26 +/- 0.05 mg/dL of perflubron was present in the serum 24 h following the administration of the last dose. This level slowly trended downward to 0.18 +/- 0.06 mg/dL over the ensuing 7 days (p = 0.281). Perflubron elimination via expired gas occurred at a mean rate of 9.4 +/- 3.0 mL/h at 1 h, and 1.0 +/- 0.4 mL/h at 48 h after the last dose (p = 0.012). By radiologic evaluation, perflubron was eliminated from the lungs progressively from 4.2 +/- 0.2 at the time of administration of the last dose, to 2.8 +/- 0.3 at 4 days later (p < 0.001). Perflubron tended to distribute and remain for longer periods in the dependent regions of the lung when compared to the nondependent regions (96-h perflubron fill score: posterior, 3.8 +/- 0.5; anterior, 1.9 +/- 0.4; p = 0.004). CONCLUSIONS: Perflubron is eliminated at a maximum rate of 9.4 +/- 3.0 mL/h by evaporative loss from the airways and is retained in greater amounts in the dependent lung regions when compared to the nondependent lung regions. There is a low but measurable maximum blood concentration of 0.26 +/- 0.05 mg/dL in patients after perflubron administration, which did not decrease significantly after cessation of partial liquid ventilation.

An overview of chemotherapy-induced peripheral sensory neuropathy, focusing on oxaliplatin.

When treating patients for metastatic cancer, there is always a balance between the benefits of treatment and resulting side-effects. Peripheral sensory neuropathy (PSN) is a side-effect of many anticancer agents used in routine practice. Oxaliplatin is a relatively new agent currently licensed in over 50 countries including France, Germany and the UK for the treatment of metastatic colorectal cancer. Although it is a new agent, it is from the same family of drugs as cisplatin, an agent that has been used for many years. PSN is the most commonly discussed side-effect associated with oxaliplatin. Oxaliplatin-induced PSN is characterized by two distinct syndromes: a transient acute dysaesthesia and a cumulative distal neurotoxicity. Importantly, both are generally reversible after stopping treatment. Oxaliplatin-induced acute PSN is triggered and exacerbated by cold and can be greatly reduced in affected patients simply by avoiding cold conditions. Oxaliplatin-induced cumulative PSN may also be managed by temporary cessation of treatment.

High-fat diet elevates blood pressure and cerebrovascular muscle Ca(2+) current.

Dietary fat contributes to the elevation of blood pressure and increases the risk of stroke and coronary artery disease. Previous observations have shown that voltage-gated Ca(2+) current density is significantly increased in hypertension and can be affected by free fatty acids (FAs). We hypothesized that a diet of elevated fat level would lead to an increase in blood pressure, an elevation of L-type Ca(2+) current, and an increase in saturated FA content in vascular smooth muscle cell membranes. Male Osborne-Mendel rats were fed normal rat chow or a high-fat diet (Ob/HT group) for 8 weeks. Blood pressures in the Ob/HT group increased moderately from 122.5+/-0.7 to 134.4+/-0.8 mm Hg (P<0.05, n=26). Voltage-clamp examination of cerebral arterial cells revealed significantly elevated L-type Ca(2+) current density in the Ob/HT group. Voltage-dependent inactivation of the Ob/HT L-type channels was significantly delayed. Total serum FA contents were significantly elevated in the Ob/HT group, and HPLC analyses of fractional pools of FAs from segments of abdominal aorta revealed that arachidonic acid levels were elevated in the phospholipid fraction in Ob/HT. No differences in vascular membrane cholesterol contents were noted. Plasma cholesterol was significantly elevated in portal venous and cardiac blood samples from Ob/HT rats. These findings suggest that an elevation of plasma FAs may contribute to the development of hypertension via a process involving the elevation of Ca(2+) current density and an alteration of channel kinetics in the vascular smooth muscle membrane.

Pneumatic ankle tourniquets: physiological factors related to minimal arterial occlusion pressure.

This study investigates several physiological measurements for their correlation to the minimal arterial occlusion pressure using the pneumatic ankle tourniquet. Blood pressure (brachial), height, weight, body fat percentage, ankle circumference, and leg circumference measurements were collected from 50 normotensive healthy subjects. Ankle brachial index (ABI) was also compared. A pneumatic ankle tourniquet was applied to the right ankle and inflated until Doppler insonation confirmed that arterial occlusion had occurred. Mean arterial occlusion pressure was 161.7 mm Hg (N = 50, Nmales = 33, Nfemales = 17), and statistically less than 170 mm Hg (p < .05). The authors present a data model to predict the lowest necessary ankle tourniquet pressure for this study group. Forward stepwise linear regression (critical significance = .01) yields two variables, ankle brachial index and systolic blood pressure, which are used to predict occlusion pressure in this study group.

The effect of a right-to-left intracardiac shunt on the rate of rise of arterial and end-tidal halothane in children.

UNLABELLED: In this prospective study, we evaluated the effect of a right-to-left intracardiac shunt on the rate of rise of end-tidal and arterial halothane concentration in children. Six children aged 23-43 mo undergoing surgical closure of atrial fenestration after Fontan procedure were given 0.8% inspired halothane. End-tidal halothane was recorded at 1-min intervals after the introduction of halothane. Arterial halothane concentrations were determined 0, 1, 3, 5, 10, and 15 min after the introduction of halothane. The sampling was performed before and after closure of the atrial fenestration. The ratio of pulmonary to systemic blood flow (Qp/Qs) increased in this patient population, from 0.58 +/- 0.04 to 0.88 +/- 0.12 (P = 0.01). The rate of rise of end-tidal halothane did not change significantly with a decrease in the magnitude of the right-to-left intracardiac shunt after closure of the atrial fenestration. The ratio of arterial to inspired halothane concentrations at 1, 3, 5, 10, and 15 min were lower before closure of the atrial fenestration compared with after closure (P < 0.05). We conclude that the presence of a right-to-left intracardiac shunt significantly slows the rate of rise of arterial halothane in the face of a constant inspired concentration. The rate of rise of end-tidal halothane is not significantly affected in the presence of a right-to-left intracardiac shunt. IMPLICATIONS: In this prospective study, we found a slower rate of rise of halothane in arterial blood in children with right-to-left intracardiac shunting. Induction of anesthesia by inhalation of volatile anesthetics may therefore be slower in these children.

Possible therapeutic effects of growth hormone on wound healing in the diabetic patient.

Growth factors are increasingly investigated for their role in wound healing. The authors present evidence from human and animal studies suggesting that growth hormone induces a positive nitrogen balance, enhances connective-tissue synthesis, and increases lean body mass. The physiology of diabetes and wound healing is reviewed in the context of how growth hormone therapy could benefit this patient population.

Knowledge-based test result in interpretation in laboratory medicine.

The medical interpretation of laboratory test results aims for an optimization of the diagnostic decision process to improve the quality of medical care. It is of growing importance in Clinical Chemistry and Laboratory Medicine. Interpretation is an active process that depends on patient history, experience of the interpreter and local disease prevalences. For the field of Laboratory Medicine the tool Pro.M.D. was developed that enables the medical expert to formulate his knowledge and experience in a knowledge-based system. Nine Pro.M.D. systems are in routine use for knowledge-based test result interpretation at several hospital laboratories today. Our experience in providing clinicians with interpretive reports shows that a medical dialogue on individual findings can be established or improved. With the development of a new, highly differentiated and extensive knowledge base our group introduced a concept called NOTABENE as the basis for new maintenance tools.

A review of physiological and metabolic effects of essential amino acids.

The authors review ten essential amino acids with regard to their metabolic, physiologic and therapeutic effects throughout the human body. Physical properties of these biologically active compounds are discussed as a foundation for their diverse roles in special nitrogen containing products, neurotransmitters, and as alternative energy sources. Both normal and abnormal amino acid metabolism are considered in the areas of digestion, elimination of metabolic products, metabolic intermediates, and defects in these systems. Recent developments in therapeutic applications are further examined for clinical utility and as an economical alternative to traditional clinical treatment modalities.

Sounds of silence.

Strategies are described for dealing with three categories of reportable occurrences: inappropriate peer behavior, including substance abuse and behavioral problems; abuse, neglect and exploitation of patients; and issues concerning treatment orders. The American Nurses Association's (ANA) Code for Nurses, individual State Departments of Nursing License Regulations and State Intervention Projects for Nurses provide some direction for identifying, reporting and resolving occurrences.

Effect of vehicle on the nasal absorption of epinephrine during cardiopulmonary resuscitation.

STUDY OBJECTIVES: We have shown in previous studies that epinephrine administered intranasally is a feasible route of administration during cardiopulmonary resuscitation (CPR). To promote the absorption of epinephrine we administered phentolamine prior to epinephrine and used a bile salt as a vehicle to dissolve the epinephrine. The purpose of this study was to compare the effect of two different vehicles (bile salt vs surfactant) in promoting the absorption of nasally administered epinephrine during CPR and to determine their effects on the nasal mucosa. STUDY DESIGN: A randomized, blinded study. SETTING: A controlled laboratory environment. SUBJECTS: Eleven mongrel dogs. INTERVENTIONS: Each dog underwent 3 minutes of unassisted ventricular fibrillation (VF) followed by 7 minutes of VF with CPR. Five minutes after the start of VF, 10 dogs received intranasal phentolamine 0.25 mg/kg/nostril followed 1 minute later by intranasal epinephrine 7.5 mg/kg/nostril. The epinephrine was dissolved in a randomly assigned vehicle consisting of either taurodeoxycholic acid (group A, bile salt) or polyoxyethylene-9-lauryl ether (group B, surfactant). One animal acted as a control and received 0.9% sodium chloride nasally. MEASUREMENTS AND MAIN RESULTS: Data from eight dogs (one control) were included for analysis. Histology of the nasal cavity demonstrated severe multifocal erosion and ulceration of the respiratory epithelium for groups A and B compared with the control. The severity was similar between the two groups. In addition, no significant differences in plasma epinephrine concentrations or blood pressure responses were seen between the groups. CONCLUSION: Based on histology, polyoxyethylene-9-lauryl ether offered no advantage over taurodeoxycholic acid in its effect on the nasal mucosa. The data available for changes in epinephrine concentration and pressure also suggest no difference between the two vehicles in promoting the absorption of epinephrine during CPR in an animal model.