Epoetin in the 'untransfusable' anaemic patient: a retrospective case series and systematic analysis of literature case reports.

BACKGROUND: Erythropoiesis stimulating agents [erythropoietin (EPO)] have been recommended to treat anaemic patients who cannot receive or refuse blood tranfusion ('untransfusable' patients). OBJECTIVE: The objective of the study was to quantify the association of EPO use with haemoglobin (Hgb) recovery in anaemic untransfusable hospitalised patients. METHODS/MATERIALS: EPO treated anaemic untransfusable patients were identified through the combination of a retrospective case review and a systematic review of the medical literature. Literature reports of untransfusable patients not treated with any EPO were used as a comparator group. Hgb concentrations before and following EPO use were abstracted and used to determine the rate of Hgb recovery for each case. Multilevel mixed effects modelling was used to determine the association of Hgb recovery with EPO use. RESULTS: A total of 76 EPO treated cases (19 cases from the retrospective hospital case review and 57 from the literature), and 33 non-EPO treated comparator patients from the literature were included in the study. Hgb increased similarly over time in all groups at an overall mean standard error (SE) rate of 0·13 (0·01) g dL(-1) day(-1) . The Hgb recovery rate was higher in patients with lower baseline Hgb, regardless of EPO use. No association was found between the rate of Hgb recovery and EPO use, dose or therapy duration. CONCLUSIONS: In anaemic, 'untransfusable' hospitalised patients, EPO use was not associated with increased Hgb recovery at anytime within 28 days.

The additive nature of the human multisensory evoked pupil response.

Pupillometry has received increased interest for its usefulness in measuring various sensory processes as an alternative to behavioural assessments. This is also apparent for multisensory investigations. Studies of the multisensory pupil response, however, have produced conflicting results. Some studies observed super-additive multisensory pupil responses, indicative of multisensory integration (MSI). Others observed additive multisensory pupil responses even though reaction time (RT) measures were indicative of MSI. Therefore, in the present study, we investigated the nature of the multisensory pupil response by combining methodological approaches of previous studies while using supra-threshold stimuli only. In two experiments we presented auditory and visual stimuli to observers that evoked a(n) (onset) response (be it constriction or dilation) in a simple detection task and a change detection task. In both experiments, the RT data indicated MSI as shown by race model inequality violation. Still, the multisensory pupil response in both experiments could best be explained by linear summation of the unisensory pupil responses. We conclude that the multisensory pupil response for supra-threshold stimuli is additive in nature and cannot be used as a measure of MSI, as only a departure from additivity can unequivocally demonstrate an interaction between the senses.

Association of the dopamine transporter (SLC6A3/DAT1) gene 9-6 haplotype with adult ADHD.

ADHD is a neuropsychiatric disorder characterized by chronic hyperactivity, inattention and impulsivity, which affects about 5% of school-age children. ADHD persists into adulthood in at least 15% of cases. It is highly heritable and familial influences seem strongest for ADHD persisting into adulthood. However, most of the genetic research in ADHD has been carried out in children with the disorder. The gene that has received most attention in ADHD genetics is SLC6A3/DAT1 encoding the dopamine transporter. In the current study we attempted to replicate in adults with ADHD the reported association of a 10-6 SLC6A3-haplotype, formed by the 10-repeat allele of the variable number of tandem repeat (VNTR) polymorphism in the 3' untranslated region of the gene and the 6-repeat allele of the VNTR in intron 8 of the gene, with childhood ADHD. In addition, we wished to explore the role of a recently described VNTR in intron 3 of the gene. Two hundred sixteen patients and 528 controls were included in the study. We found a 9-6 SLC6A3-haplotype, rather than the 10-6 haplotype, to be associated with ADHD in adults. The intron 3 VNTR showed no association with adult ADHD. Our findings converge with earlier reports and suggest that age is an important factor to be taken into account when assessing the association of SLC6A3 with ADHD. If confirmed in other studies, the differential association of the gene with ADHD in children and in adults might imply that SLC6A3 plays a role in modulating the ADHD phenotype, rather than causing it.

No Acute Effects of Choline Bitartrate Food Supplements on Memory in Healthy, Young, Human Adults.

Choline is a dietary component and precursor of acetylcholine, a crucial neurotransmitter for memory-related brain functions. In two double-blind, placebo-controlled cross-over experiments, we investigated whether the food supplement choline bitartrate improved declarative memory and working memory in healthy, young students one to two hours after supplementation. In experiment 1, 28 participants performed a visuospatial working memory task. In experiment 2, 26 participants performed a declarative picture memorization task. In experiment 3, 40 participants performed a verbal working memory task in addition to the visuospatial working memory and declarative picture task. All tasks were conducted approximately 60 minutes after the ingestion of 2.0-2.5g of either choline bitartrate or placebo. We found that choline did not significantly enhance memory performance during any of the tasks. The null hypothesis that choline does not improve memory performance as compared to placebo was strongly supported by Bayesian statistics. These results are in contrast with animal studies suggesting that choline supplementation boosts memory performance and learning. We conclude that choline likely has no acute effects on cholinergic memory functions in healthy human participants.

A common source outbreak of gastroenteritis in a teaching hospital.

An outbreak of gastroenteritis at a large teaching hospital affected at least 52 workers. Investigation implicated a tuna salad, and the circumstances suggested Clostridium perfringens as the etiologic agent. The risk of such outbreaks may be reduced by cooling of ingredients prior to mixing and refrigeration in small steel containers.

Fever in the first six months of life: risks of underlying serious infection.

The age-specific rate of elevated temperature over 37.8 C was evaluated in all infants less than 6 months of age (n = 1341) seen from July 1, 1974 to June 30, 1978 in a family practice clinic. Mild elevations (37.8 C-38.3 C) were common even in the first few months of life, and accounted for 20.7 per cent of infant visits. Temperatures greater than 38.3 C are uncommon in the first months of life but are seen more frequently with each succeeding month. Temperature elevation over 38.3 C was associated with a significantly higher rate of meningitis (p less than .01), otitis media (p less than .001) and lower respiratory infection (p less than .05). Significantly higher laboratory usage was documented in infants less than 3 months and for infants with temperature more than 38.3 C. The high rate of mild temperature elevations in young infants suggests that a selective diagnostic strategy directed at high-risk infants is important. Infants less than three months of age with a fever exceeding 38.3 C are calculated to have 21.5 times the risk of a serious underlying infection as infants older than three months with a similar temperature elevation. Clinical evaluation must remain an important tool in determining which febrile infants should be evaluated by further laboratory and diagnostic tests.

[Characteristics of alcohol withdrawal delirium in surgical patients and recommendations for treatment]. / Besonderheiten des Alkoholentzugsdelirs beim chirurgischen Patienten und Hinweise zur Behandlung.

An alcohol withdrawal syndrome affects the patient in a 'vulnerable phase' either after an operation or posttraumatically. It can be shown pathophysiologically, that the symptoms are caused by a hyperactivity of the central sympathetic nervous system and a disbalance of the neurotransmitters. As for these complex symptoms, a multi-layered treatment is required. We report on our experiences with 23 patients who were treated in our intensive care unit. The treatment included a benzo-diazepine and a drug effecting central alpha 2-receptors. Only three of these patients had to be intubated or ventilated. Because of the induced bradycardia monitor observation was required in all cases. The patients could be wakened up at any time and thus were co-operative for basic care. One patient died of pulmonary embolism, a second patient died of cardiovascular failure as a consequence of cardiac insufficiency.

[Immunoglobulin in the blood and peritoneal secretions during the early postoperative phase]. / Immunoglobuline im Serum und im peritonealsekret in der frühen postoperativen phase.

After abdominal surgery the immunoglobulins in the peritoneal fluid and in the serum were measured in the early postoperative period in 34 patients with benign and malignant lesions. In comparison with the preoperative value there was postoperatively a serum decrease of 30% of the immunoglobulins. In the serum there was no difference in the cancer and no cancer group. An important difference was noted in the concentration of the peritoneal cavity fluid values. After operation in the biliary tract the peritoneal immunoglobulins fell to 50% of the serum level but improved rapidly after the patient recovered. After cancer surgery on the colon, the IG level fell without any later improvement. Purulent abdominal infections led to levels of the IG in the peritoneal fluid that were almost impossible to measure.

Louder than words. A multi-institutional system sets ethical standards for corporate action.

After establishing its Resource Center for Ethical concerns, Wheaton Franciscan Services, Inc. (WFSI), Wheaton, IL, set out to develop corporate ethics standards. The standards were to manifest a vision that acknowledged the mutuality of relationships among providers and those they serve, and among local and global communities. To establish "ownership" of the standards, WFSI wanted to involve as many people as possible in the planning process. Center staff established a 25-member working task force with broad representation of disciplines and system institutions, then prepared a position paper to serve as a basis for the formulation of the standards. The paper examined current issues in corporate ethics, the theoretical basis of corporate ethics, the appropriateness of corporate ethics for Catholic-sponsored institutions, and the role ethics standards play in an institutional setting. Staff then prepared the first draft of corporate standards. At the first workshop in October 1988, task force members critiqued the draft and modified the proposed corporate standards. Staff sent the draft for critique to a total of 157 persons throughout the system and encouraged them to pass it around to get the advice of others. From the feedback, staff compiled a third draft, which was ultimately approved. WFSI's Corporate Ethics Standards addresses provision of services, relationship with employees, social responsibility, confidentiality, and conflict of interest.

Experimental and clinical experience with the different possibilities of preserving splenic tissue after rupture of the spleen.

From clinical observation in adults, it is obvious that the preservation of the ruptured spleen is only possible in about 80% of all cases. Current evidence indicates that only the completely or partially intact spleen protects against pneumococcal sepsis. The best method of reimplantation has not yet been found.

Successful treatment of tumor embolism of a hypernephroma with complete occlusion of the left pulmonary artery.

A tumor embolism with occlusion of the left pulmonary artery was the first manifestation of a hypernephroma. After angiographic diagnosis, embolectomy was performed successfully using the heart-lung-machine. Four days later, nephrectomy followed. In the meantime, the patient has experienced a period of 3 years free of symptoms and metastases.

[The effect of immunoglobulins in experimental peritonitis (author's transl)]. / Beitrag zur Effektivität der Immunglobuline bei der experimentellen Peritonitis.

We measured the influence of different drugs on mortality and lung weights in a well known and standardized peritonitis model in rats. The results are: 1. Intraperitoneal injection of immune globulin in high dosage had little effect on our parameters. High mortality and interstitial pulmonary edema were observed. 2. The same results followed injection of 20% human albumin. 3. All animals injected intraperitoneally with a modern antibiotic (Securopen) survived. Interstitial pulmonary edema was observed. 4. The combined injection of an antibiotic and immune globulin (Gamma-Venin) had the best results. None of the rats came down with a lung injection or died.

Neonatal integrated home care: nursing without walls.

A Neonatal Integrated Home Care Program was developed to cross-train NICU staff nurses to provide follow-up care for high-risk neonates in the home. Implementation required collaboration of the NICU and the Center for Home Care and Hospice. Initial target populations were premature infants in transition to oral feeds and oxygen-dependent neonates. Staff, parent, and insurer enthusiasm for this innovative program resulted in expansion to serve infants and families with many other care needs. Continuity of care provides an invaluable resource for families at home with their high-risk infants. Outcomes include reduction in NICU length of stay and readmission for this population. The NICU home care team shares experiences with staff, increasing awareness of and sensitivity to family strengths and discharge realities. The program has fostered revisions in practice regarding preparation for discharge and education of families, facilitating the transition to home following NICU hospitalization.

Perinatal grief: response to the loss of an infant.

The grief response of parents following loss of an infant from a multiple gestation pregnancy was explored to describe the experience, compare and contrast mother's and father's responses, and analyze the properties of the Perinatal Grief Scale. Twenty-seven parents participated. Parental responses were complex and variable. Most parents disagreed with experiencing difficulty coping and despair. Confrontive, self reliant, and supportant coping strategies were used most frequently, while supportant, confrontive and optimistic strategies were reported the most effective. Anxiety, depression and alterations in activities of daily living were reported. The total impact of life events was slightly positive for this group. Although the instruments were reliable in this population of parents, sensitivity was reduced. A model of grief associated with multiple gestation perinatal loss was generated. Selection and effectiveness of coping strategies appear to be not only interrelated, but dependent on the time since the infants death and the length of the infants life. The length of an infant's life and time since death were affirmed as related to both the strength and type of relationship between variables associated with the grief response and to use and effectiveness of coping strategies. Responses of mothers and fathers appear to be similar.

[Autopsy in neonatal death]. / Apport de l'autopsie lors du décès néonatal.

Among 125 neonatal deaths which occurred between 1985 and 1987 in a neonatal intensive care unit, 90 autopsies (72%) were performed. Autopsies in 58 cases (64%) confirmed antemortem conclusions. In 26 cases (28%) post-mortem examination rectified antemortem findings whereas in 6 cases (6.6%) it did not contribute to a better understanding of the cause of death. When there was a risk of an heritable disease and genetic counselling was necessary (31 cases), the autopsy permitted to provide the diagnosis in 4 cases and to reassure the family in 17. In 23 cases the post-mortem examination had to be completed by perimortem studies to be contributive. As no antemortem data allowed to predict the value of the autopsy, a postmortem study should by systematically requested in cases of death during the neonatal period.