Elevated serum creatinine in the context of HIV - who is the culprit? Over-the-counter supplements vs. antiretrovirals.

We present a case of a 53-year-old male living with well-controlled HIV who, as part of routine monitoring, was noted to have an unexpected decline in renal function. His antiretrovirals were switched accordingly. It subsequently transpired that he had recently started taking creatine supplements in order to build muscle mass. He underwent specialist renal review and further investigation with a chromium-labelled scan which revealed his renal function was, in fact, stable. He continues under renal and HIV follow-up. It is now more widely recognised that creatine can affect renal function, and result in difficulty in interpretation of traditional renal blood tests. However, the further investigations that may be undertaken in such settings and HIV treatment considerations are not as widely reported. This case serves as a reminder to ensure over-the-counter and herbal supplements are part of routine questioning in HIV clinics, and outlines the specialist investigations that may be undertaken in cases of apparent renal decline.

Models of cancer survivorship health care: moving forward.

The population of cancer survivors in the United States and worldwide is rapidly increasing. Many survivors will develop health conditions as a direct or indirect consequence of their cancer therapy. Thus, models to deliver high-quality care for cancer survivors are evolving. We provide examples of three different models of survivorship care from a cancer center, a community setting, and a country-wide health care system, followed by a description of the ASCO Cancer Survivorship Compendium, a tool to help providers understand the various models of survivorship care available and integrate survivorship care into their practices in a way that fits their unique needs.

Ropivacaine plasma levels following local infiltration analgesia for primary total hip arthroplasty.

We measured total and free plasma concentrations of ropivacaine following high-volume, high-dose local infiltration analgesia in 19 patients aged 65 years or over undergoing unilateral total hip arthroplasty. The patients received 180 ml ropivacaine 0.2% (360 mg), which was injected into the deep and peri-capsular tissues, the gluteal muscles and fascia lata, and the subcutaneous tissues and skin. Patients were monitored for clinical symptoms and signs of systemic local anaesthetic toxicity. Total levels of plasma ropivacaine varied from 0.081 to 1.707 µg.ml(-1) (mean (SD) 0.953 (0.323) µg.ml(-1) ). Free levels of plasma ropivacaine varied from 0.000 to 0.053 µg.ml(-1) (mean (SD) 0.024 (0.011) µg.ml(-1) ). No samples reached the toxic threshold for venous ropivacaine concentration, although four patients exhibited mild symptoms consistent with local anaesthetic toxicity. One patient had episodes of complete heart block on ECG monitoring, but plasma ropivacaine levels were below toxic levels. We conclude that plasma levels for ropivacaine associated with toxicity in a volunteer population (total 2.2 µg.ml(-1) , free 0.15 µg.ml(-1) ) are not reached during local infiltration analgesia for hip arthroplasty in elderly patients.

Reactions to threatening health messages.

BACKGROUND: Threatening health messages that focus on severity are popular, but frequently have no effect or even a counterproductive effect on behavior change. This paradox (i.e. wide application despite low effectiveness) may be partly explained by the intuitive appeal of threatening communication: it may be hard to predict the defensive reactions occurring in response to fear appeals. We examine this hypothesis by using two studies by Brown and colleagues, which provide evidence that threatening health messages in the form of distressing imagery in anti-smoking and anti-alcohol campaigns cause defensive reactions. METHODS: We simulated both Brown et al. experiments, asking participants to estimate the reactions of the original study subjects to the threatening health information (n = 93). Afterwards, we presented the actual original study outcomes. One week later, we assessed whether this knowledge of the actual study outcomes helped participants to more successfully estimate the effectiveness of the threatening health information (n = 72). RESULTS: Results showed that participants were initially convinced of the effectiveness of threatening health messages and were unable to anticipate the defensive reactions that in fact occurred. Furthermore, these estimates did not improve after participants had been explained the dynamics of threatening communication as well as what the effects of the threatening communication had been in reality. CONCLUSIONS: These findings are consistent with the hypothesis that the effectiveness of threatening health messages is intuitively appealing. What is more, providing empirical evidence against the use of threatening health messages has very little effect on this intuitive appeal.

Establishing neonatal networks: the reality.

Managed clinical networks for neonatal care were established in England from 2004. Their structure and effectiveness varies widely over the country. Changes in medical manpower and the scarcity of neonatal nurses make the move towards networks urgent, but there is little evidence of a coordinated approach to improving capacity in the tertiary centres, who will have to absorb the activity that follows reconfiguration. Changes in the governance of hospitals, NHS authority boundaries and in commissioning specialist services, with the drive towards reducing health costs, places the process at some considerable risk. Despite these challenges, the development of coordinated clinical networks will be an important force in improving outcome for very preterm babies in the UK. The development of some form of national coordination of network activities and greater sharing of good practice would enhance the value of the managed clinical neonatal networks.

Inhibition of membrane bound ATPases of Escherichia coli and Listeria monocytogenes by plant oil aromatics.

Previous studies have reported that the mechanism of bactericidal action of the plant oil aromatics, eugenol, carvacrol and cinnamaldehyde involves inhibition of adenosine triphosphate generation and membrane disruption. In this study the capacity of the aromatics to inhibit the membrane bound ATPase activity of Escherichia coli and Listeria monocytogenes was investigated by experiments on isolated membranes. Inhibition of the ATPase activity of E. coli membranes was observed with 5 mM or 10 mM eugenol or carvacrol. Progressively greater inhibition by cinnamaldehyde was observed as concentration increased from 0.1 to 10 mM. L. monocytogenes ATPase activity was significantly inhibited by eugenol (5 or 10 mM), carvacrol (10 mM) and cinnamaldehyde (10 mM). Lactobacillus sakei is highly resistant to cinnamaldehyde compared to E. coli and L. monocytogenes. To determine whether this resistance was related to the relative hydrophobicity of the cell surface and hence the ability of the cell to take up the aromatics, the percentage of the three organisms partitioning in dodecane was compared. No significant difference was found between the partitioning percentage of L. monocytogenes (17.2%) and L. sakei (13.8%), indicating that surface hydrophobicity does not explain the differing sensitivity to cinnamaldehyde of these two organism. The percent partitioning of E. coli was significantly greater than both other organisms (23.3%) and may explain the greater sensitivity of E. coli to all three aromatics.

A midwife program of newborn resuscitation.

A very small proportion of newborns fail to establish a normal respiratory pattern without some assistance at birth and newborns requiring resuscitative measures at birth should have a skilled practitioner able to provide it. In this small hospital midwives felt unskilled in newborn resuscitation and paediatricians were not always immediately available. A stakeholder group gathered to discuss the problem. A training program was implemented that improved the skills, confidence and support of the attending midwife to resuscitate the newborn effectively. The aim was to improve the outcome for the infant whilst maintaining the mother's choice of birthing in a small local hospital close to family and friends.

Disruption of Escherichia coli, Listeria monocytogenes and Lactobacillus sakei cellular membranes by plant oil aromatics.

The role of membrane disruption in the bactericidal activity of the plant oil aromatic compounds eugenol, carvacrol and cinnamaldehyde was investigated using confocal laser scanning microscopy, changes in ATP levels and cell viability. In 25 mM HEPES buffer pH 7 at 20 degrees C, 10 mM eugenol or carvacrol increased uptake of propidium iodide by Escherichia coli, Listeria monocytogenes and Lactobacillus sakei over a 10-min period. The same treatments resulted in lowered viability, rapid depletion of cellular ATP and release of ATP, with the exception of Lb. sakei treated with carvacrol. Eugenol or carvacrol at 5 mM to 10 mM inhibited E. coli and L. monocytogenes motility. Lb. sakei was resistant to cinnamaldehyde. Thus, its effects were only studied on E. coli and L. monocytogenes. At 10 mM, cinnamaldehyde caused a slight but statistically significant increase in propidium iodide staining of E. coli, but had no effect on L. monocytogenes. Cinnamaldehyde treatment of E. coli at 10 mM and L. monocytogenes at 40 mM resulted in decreased cellular ATP, but there was no concomitant release of ATP. Cinnamaldehyde at 5 and 10 mM inhibited E. coli and L. monocytogenes motility. Results for eugenol and carvacrol are consistent with non-specific permeabilization of the cytoplasmic membrane. Evidence for increased membrane permeability by cinnamaldehyde is less conclusive. The release of ATP from eugenol and carvacrol-treated cells and absence of release from cinnamaldehyde-treated cells could indicate that eugenol and carvacrol possess ATPase inhibiting activity. Secondary effects would also be consistent with membrane disruption.

Models of care for survivors of childhood cancer.

With improvements in therapy for childhood cancer, the expectation that most childhood cancer patients will survive and enter adulthood is a reality. There is clear evidence that survivors are at risk for adverse health-related long-term sequelae associated with their cancer and its treatment, requiring appropriate health care resources. What is less clear is how this health care should optimally be delivered. We review the functional and operational needs for long-term follow-up for childhood cancer survivors and present alternatives for models of care. Programs for childhood cancer survivors should provide mechanisms for monitoring and management of late effects, as well as support and advocacy for addressing psychosocial issues, health education, and assistance with financial concerns. Access to research is an important component as clinical care and research are integrally related. A multidisciplinary model that provides continuity of care throughout the disease course is optimal, providing transitions from acute anti-neoplastic therapy to follow-up and primary care, as well as from pediatric care to adult-oriented care. There is no single best model of care for all childhood cancer survivors. In evaluating different models, considerations include available resources as well as the particular cancer population being served. Not all survivors require the same level of services and the service level requirement for individual patients may change with time. As outcome research progresses for childhood cancer survivors, methodological issues of optimal health care delivery for this population deserve to be the subject of such research.

Evaluation of antilisterial action of cilantro oil on vacuum packed ham.

Cilantro oil is an essential oil preparation extracted from the plant Coriandrum sativium. A series of experiments were conducted to evaluate the ability of cilantro oil to control the growth of Listeria monocytogenes on vacuum-packed ham. The in vitro minimal inhibitory concentration for five strains of L. monocytogenes was found to vary from 0.074% to 0.018% depending on strain. Cilantro oil treatments were then tested on ham disks inoculated with a cocktail of the five L. monocytogenes strains. The treatments studied were 0.1%, 0.5%, and 6% cilantro oil diluted in sterile canola oil or incorporated into a gelatin gel in which lecithin was used to enhance incorporation of the cilantro oil. Gelatin gel treatments were also conducted with 1.4% monolaurin with or without 6% cilantro oil to determine if an interaction between the antimicrobials could increase inhibition of L. monocytogenes. Treated ham was then vacuum-packed and stored at 10 degrees C for up to 4 weeks. The only cilantro oil treatment which inhibited growth of L. monocytogenes on the ham samples was 6% cilantro oil gel. Samples receiving this treatment had populations of L. monocytogenes 1.3 log CFU/ml lower than controls at week 1 of storage, though there was no difference between treatments from week 2 onward. It appears that immobilization of the antimicrobial in a gel enhanced the effect of treatments. Cilantro oil does not appear to be a suitable agent for the control of L. monocytogenes on ham. The possible reasons for reduced effectiveness of cilantro oil against L. monocytogenes on ham are discussed.

Primary care in Cuba: a public health approach.

Cuba's primary health care model is presented. Unlike ambulatory care services, which are but one component of primary care, Cuba's model is a comprehensive public health approach that meets the World Health Organization's definition of primary care. The history of the development of Cuba's model is presented, including an update on the innovative neighborhood/home clinics. Achievements in health outcomes as a result of Cuba's model and the consequences for women's health care are discussed. Examples are presented of the effects on health care delivery of the economic hardship that Cuba has experienced since 1991 as a result of the loss of 85% of its trade with the former Soviet Union and the intensified U.S. embargo. A critique of Cuba's model concludes the article.

PIP: Cuba has been able to achieve some things that few Western countries have been able to achieve: equal access to health services for the entire population and equity in health status. After the 1959 revolution, community organizations conducted a census to obtain baseline demographic and epidemiologic data about the population, a literacy campaign, and sanitary and immunization campaigns. Polyclinics provided various social, environmental, and community health services free of charge. They were geographically distributed. Cuba instituted its neighborhood/home clinic model in 1984, a holistic, family, and neighborhood approach to comprehensive health care of the community. The family physician and nurse live in the neighborhood. Health education and health promotion are central to this model. The physicians and nurses are expected to conduct research and to present their findings at congresses or in journals. Cuba's infant mortality rate is not much higher than that of the US (1993, 9.4 vs. 8.3). Major causes of death in Cuba match those in developed countries, mainly heart disease and cancer. More than 95% of pregnant women attend their first prenatal visit during the first trimester. They receive prenatal care monthly unless they have a high-risk pregnancy when they receive prenatal care once a week. Infants receive well-baby care once a month. Sex education is available to everyone. All primary care facilities provide contraception. Nevertheless, the induced abortion rate is high, which concerns the government and health providers. Key effects of the economic hardship Cuba faces caused by the fall of the Soviet Union include food rationing, emigration, increased use of traditional herbs, lack of exchange of professional literature between the US and Cuba, and lack of enough paper to continue publications of medical and nursing journals. Cuba has prioritized health and education over economic development.

Comprehensive care and the sanatoria: Cuba's response to HIV/AIDS.

The authors present an overview of Cuba's response to HIV/AIDS including: (a) the development of comprehensive health care in Cuba; (b) the epidemiology of AIDS in Cuba; (c) the sanatoria approach to treatment and recent changes; (d) the idea of comprehensive HIV/AIDS care as a basic human right; (e) the effects of the special period on the HIV/AIDS program and containment of the epidemic; and (f) a critique of Cuba's HIV/AIDS program.

Taking the heat out of burns. Nursing management of burns.

Burns constitute a serious and distressing injury. It is essential that nursing care takes on an holistic approach, focusing jointly on the physical and psychological effects.

Reduced sympathetic nervous system responsivity associated with the relaxation response.

Sympathetic nervous system activity was assessed in experimental and control subjects who were exposed to graded orthostatic and isometric stress during monthly hospital visits. After the first session, the experimental subjects practiced a technique that elicited the relaxation response. Their concentrations of plasma norepinephrine during subsequent graded stresses were significantly higher. No such changes were noted in the control group. These results were than replicated in the control group in a crossover experiment. The groups did not differ in their heart rate and blood pressure responses. These observations are consistent with reduced norepinephrine end-organ responsivity after regular elicitation of the relaxation response.