First Exploration of Monopole-Driven Shell Evolution above the N=126 Shell Closure: New Millisecond Isomers in

Isomer spectroscopy of heavy neutron-rich nuclei beyond the N=126 closed shell has been performed for the first time at the Radioactive Isotope Beam Factory of the RIKEN Nishina Center. New millisecond isomers have been identified at low excitation energies, 985.3(19) keV in ^{213}Tl and 874(5) keV in ^{215}Tl. The measured half-lives of 1.34(5) ms in ^{213}Tl and 3.0(3) ms in ^{215}Tl suggest spins and parities 11/2^{-} with the single proton-hole configuration πh_{11/2} as leading component. They are populated via E1 transitions by the decay of higher-lying isomeric states with proposed spin and parity 17/2^{+}, interpreted as arising from a single πs_{1/2} proton hole coupled to the 8^{+} seniority isomer in the ^{A+1}Pb cores. The lowering of the 11/2^{-} states is ascribed to an increase of the πh_{11/2} proton effective single-particle energy as the second νg_{9/2} orbital is filled by neutrons, owing to a significant reduction of the proton-neutron monopole interaction between the πh_{11/2} and νg_{9/2} orbitals. The new ms isomers provide the first experimental observation of shell evolution in the almost unexplored N>126 nuclear region below doubly magic ^{208}Pb.

An effect of gene dosage on production of human chorionic somatomammotropin.

The gene deletions responsible for isolated partial deficiency of fetal human chorionic somatomammotropin (hCS) production were characterized by restriction endonuclease analysis of genomic DNA prepared from the leukocytes of an affected child. The phenotypically normal child was the product of a 38-week pregnancy characterized by peak maternal hCS levels of 1.1 micrograms/microliter (normal, 3-9.2 micrograms/ml) and normal levels of other pregnancy-associated hormones. Two genes, termed hCS-A and hCS-B, specify the same mature hCS peptide and are responsible for fetal hCS production. Digestion of the child's DNA with the enzymes Hind III, Eco RI, Bam HI, Bgl II, Hinc II and Msp I disclosed absence of the restriction fragments that normally contain the hCS-A gene. However, the hCS-B gene was present in the child's DNA. The child's DNA digests contained an abnormally large Eco RI fragment of 10.0 kb containing the hCS-L gene. This abnormal fragment is a marker for a deletion that is responsible for complete deficiency of hCS when present in the homozygous state. The child's DNA restriction patterns were consistent with heterozygosity for two different deletions involving hCS genes. The paternal hGH gene cluster lacked the hCS-A, human GH variant, and hCS-B genes, while the maternal cluster lacked only the hCS-A gene. Thus, the child's DNA contained only one of the normal complement of four functional hCS genes per diploid genome. Material hCS levels approximately one fourth as great as those present at comparable stages of normal pregnancies indicated that there was no compensatory increase in expression of the remaining hCS gene.

Genetic characterization of a large, historically significant Utah kindred with facioscapulohumeral dystrophy.

In 1950, Tyler and Stephens reported a remarkable kindred affected with facioscapulohumeral dystrophy (FSHD), consisting of 1249 descendants of a man who emigrated to Utah in 1840. Members of this kindred are still seen in our clinic and, to our knowledge, no member had been tested for deletions at the FSHD1A locus on chromosome 4q35, the common chromosomal rearrangement associated with FSHD. We have identified 971 additional members of this kindred who either were not included in or unborn at the time of the report by Tyler and Stephens, and have identified 120 living members as affected by history or by examination. Members of this kindred contribute to a disease prevalence of nearly 1:15 000 in the Utah/southern Idaho region. We have demonstrated that affected members carry a disease-associated 20 kb deletion allele at the FSHD1A locus. This allele is the same size in multiple, distantly-related branches of the kindred, confirming the meiotic stability of the FSHD1A deletion. This large, genetically homogeneous population of patients represents a unique resource with which to study current questions about FSHD, including the possibilities of anticipation and parental transmission effects.

Progressive changes in LH and FSH and LH: FSH ratio in women throughout reproductive life.

Gonadotropin secretion during the post-menopausal period is considerably higher than during the reproductive years. In this study, we present evidence that changes in the hypothalamic-pituitary-ovarian unit occur over a period of years before the onset of menstrual irregularity which heralds the menopause. FSH and LH were measured in blood samples taken on 6 days during the mid-follicular phase from 127 regularly cycling women aged between 23 and 49 yr. The women aged 23-30 yr were taken as the control group and the remainder were grouped in 2-yr age bands. A significant increase in FSH underwent a further increase in the oldest group (48-49 yr) in whom LH also became significantly elevated. The difference in the timing of the change in FSH and LH concentrations was related not only to chronological age but also to the number of years before the menopause. The increase in FSH occurred 5-6 yr pre-menopause, that in LH not until 3-4 yr before the cessation of menstruation. It is concluded that an early sign of the aging of the reproductive mechanism can be detected in women who are having normal ovulatory cycles. The regulation of FSH and LH secretion appears to be sufficiently independent to permit the observed differences in the age of onset of these premenopausal increases.

Infusion protocol improves delivery of enteral tube feeding in the critical care unit.

BACKGROUND: Numerous factors may impede the delivery of enteral tube feedings (ETF) in the intensive care unit (ICU). We designed a prospective study to determine whether the use of an infusion protocol could improve the delivery of ETF in the ICU. METHODS: In a prior prospective study, we monitored all patients admitted to the medical intensive care unit (MICU) or cardiac care unit (CCU) who were made nil per os and placed on ETF (control group). We found that critically ill patients received only 52% of their goal calories, primarily due to physician underordering (66% of goal), frequent cessations of ETF (22% of the time), and slow advancement (14% at goal by 72 hours). Based on these findings, we developed an ETF protocol that incorporated standardized physician ordering and nursing procedures, rapid advancement, and limited ETF interruption. After extensive educational sessions, the ETF protocol was begun. Again, all patients admitted to the MICU or CCU who were made nil per os and placed on ETF were prospectively followed (protocol group). RESULTS: Thirty-one patients in the protocol group were followed during 312 days of ETF and compared with the control group (44 patients with 339 days of ETF). Despite efforts by the nutritional support team, the infusion protocol was used in only 18 patients (58%). The main reasons for noncompliance with the protocol were physician preference and system failure (ETF order sheet not placed in chart). When used, the infusion protocol improved physician ordering (control 66% of goal volume, noncompliant 68%, compliant 82%, p < .05); delivery of calories (control 52% of goal, noncompliant 55%, compliant 68%, p < .05); and advancement of ETF (control 14% at goal by 72 hours, noncompliant 31%, compliant 56%, p < .05). Although significant reduction in ETF cessation due to nursing care was noted, it represented only a fraction of the total time ETF were stopped. Cessation due to residual volumes, patient tolerance, and procedure continued to be a frequent occurrence and was often avoidable. CONCLUSIONS: An evidence-based infusion protocol improved the delivery of ETF in the ICU, primarily because of better physician ordering and more rapid advancement. The nursing staff rapidly assimilated these changes. However, physicians' reluctance to use the protocol limited its efficacy and will need continued educational efforts.

Laser education. Are current programs meeting perioperative nurses' needs?

As we expected, our surveys found that advanced-level respondents were more highly trained and more experienced, and they perceived themselves as more knowledgeable and more skilled than basic-level laser nurses. Respondents surveyed in 1991 were better educated and more experienced, and they perceived themselves as more knowledgeable and slightly more skilled than those surveyed in 1989. Though these apparent trends are encouraging, other findings indicate that there are large gaps in the knowledge base of even advanced-level laser nurses, particularly in the area of basic laser physics. Of those responding to the item on attendance at educational programs on lasers, 91% had attended some type of laser inservice or education program. Far more respondents, however, had attended manufacturer-provided operational inservice programs or hospital inservice programs on safety compared to those who reported having attended in-depth continuing education courses. In addition, wide discrepancies were observed between the percentages of respondents who had experience with a given type of laser and those who had education beyond the level of operational inservice programs. Apparently, a significant number of nurses who are involved in laser procedures have had no training beyond a very basic level. Respondents rated themselves most knowledgeable about areas related to laser safety and operation. When asked to identify the most important areas of laser education, patient and personnel safety was the paramount concern for all four groups. At the same time, they identified laser physics and tissue interaction as difficult-to-understand, yet important, areas of laser education.

Understanding alpha-hydroxy acids.

This self-study activity has been developed for nurses, estheticians, and other health care professionals whose patients use alpha-hydroxy acid (AHA) products. Skin anatomy and physiology are reviewed and information is presented on the mechanisms of action of AHAs. Cosmetic and therapeutic benefits of AHA-containing products are detailed. Factors that influence the safety and effectiveness of AHA products are explored, including concentration, pH, and the amount of free acid present. A method is detailed for applying AHA-containing chemexfoliating agents, and guidelines are offered for taking a patient history, post-procedure skin care, and applying subsequent peels.

Minimizing the impact of a hospital strike.

The 1991 nursing strike in Manitoba lasted 31 days and affected 87 facilities. In professionally based health care facilities, such work stoppages can cause lasting conflicts. Simply returning to business as usual is not realistic. St. Boniface General Hospital was the first affected facility in the province to formulate a formal strike recovery process.

Components of job satisfaction in psychiatric social workers.

A survey of 188 psychiatric social workers indicated an overall positive level of job satisfaction. Overall job satisfaction was found to be primarily determined by position satisfaction. The major correlate of position satisfaction was the professional respect received from other disciplines and not the specific tasks performed. These findings were interpreted as reflecting the obfuscating effect of hospital team interactions on job satisfaction. In these settings, the social workers were often so dependent on the quality of these team interactions to derive the variety, autonomy, and value in their work that it was difficult for them to keep subjectively clear the actual level of satisfaction with the work itself. Social work supervisors need to focus on developing a stronger sense of practice excellence and forging a subjective separation between task-derived achievement and interpersonal enjoyment. Results also showed the importance of educational and professional development opportunities in maintaining overall job satisfaction.

Normal variation in the length of the luteal phase of the menstrual cycle: identification of the short luteal phase.

Normal probability plots were used to assess the homogeneity of a population of 327 luteal phases from apparently ovulatory menstrual cycles. The length of the luteal phase was defined as the interval (in days) following but not including, the luteinizing hormone peak, up to and including the day before onset of menstruation. A small sub-set of the population consisted of cycles with abnormally short luteal phases but the majority of the data followed a normal frequency distribution which gave a mean (+/- SD) for normal luteal phase length of 14.13 (+/- 1.41) days. It was estimated that all cycles with a luteal phase less than or equal to 9 days were abnormal, and that 74%, 22% and 2% respectively of cycles with luteal phases of 10, 11 and 12 days were also abnormal. The total incidence of short luteal phases defined as above was 5.2%.

Perioperative nursing care of the patient experiencing laser surgery.

Perioperative nursing care for patients undergoing laser procedures must reflect the six-step nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Recommended practices, guidelines, and institutional policies and procedures offer additional guidance for an optimal level of practice by nurses involved with patients having laser procedures.

The effect of age on the cyclical patterns of plasma LH, FSH, oestradiol and progesterone in women with regular menstrual cycles.

Luteinizing hormone (LH), follicle-stimulating hormone (FSH), oestradiol and progesterone concentrations in plasma were obtained daily throughout the menstrual cycles of 94 regularly cycling women, aged between 24 and 50 years. Although mean LH concentrations changed little with advancing age, mean FSH concentrations were significantly (P less than 0.001) elevated from the age of 39 years. FSH concentrations in the oldest women studied (48-50 years) were approximately 3-fold greater than in the younger controls (women aged 23-35 years). LH concentrations rose slightly (P less than 0.05) during the last 5 years only. The increase in FSH concentration was not, however, uniform across the cycle, but was confined predominantly to the mid-follicular and post-ovulatory phases (i.e. those times in the normal menstrual cycle when circulating inhibin concentrations appear to be minimal). Despite the clear increases in FSH concentration, there was little alteration in the mean steroid profiles which remained within the normal fertile range throughout the last decade of reproductive life. The only exception to this was a small, transient, but significant (P less than 0.05) decrease in preovulatory oestradiol concentration between the ages of 36 and 38 years, which was followed by a transient increase (P less than 0.01) in oestradiol concentration between 39 and 44 years. However, no corresponding significant changes in mean progesterone concentrations were observed.

Clinical nutrition in pancreatitis.

In patients with acute pancreatitis or an acute flare of chronic pancreatitis, a discrepancy exists between increased protein/calorie requirements induced by a hypermetabolic stress state and reduced ingestion/assimilation of exogenous nutrients, which promotes progressive nutritional deterioration. Patients with severe pancreatitis (defined by > or =3 Ranson criteria, an APACHE II score of > or =10, development of major organ failure, and/or presence of pancreatic necrosis) are more likely to require aggressive nutritional support than patients with mild disease. The type of formula and level of the gastrointestinal tract into which nutrients are infused determine the degree to which pancreatic exocrine secretion is stimulated. Animal studies and early prospective randomized controlled trials in humans suggest that total enteral nutrition via jejunal feeding may be the preferred route to parenteral alimentation in this disease setting.

Normal variation in the length of the follicular phase of the menstrual cycle: effect of chronological age.

Normal probability plots were used to analyse the distribution of follicular phase length in a population of 293 apparently ovulatory menstrual cycles from women aged between 18 and 39 years. The length of the follicular phase was defined as the interval (in days) from the onset of menstruation up to, but not including, the day of the LH peak. Follicular phase length appeared to be log-normally distributed and graphical inspection of the probability plot suggested that the geometric mean (and 95% confidence limits) of follicular phase length in this study group was 12.9 (10.3 to 16.3) days. There was a significant decrease (P less than 0.001) in follicular phase length with chronological age, from 14.2 days in women aged 18-24 years to 10.4 days in women aged 40-44 years.

Oestradiol secretion in men and pre-menopausal women.

Blood samples were obtained from a group of regularly-cycling normal women (n = 13) and a group of normal men (n = 5) at 15 min intervals for periods ranging from 9-14 h whilst the subjects remained resting quietly in bed. The concentration of plasma oestradiol was measured in a radioimmunoassay which had been carefully optimised and the mean concentration and coefficient of variation calculated for each subject. Plasma oestradiol concentrations were found to fluctuate rapidly in all subjects. The largest sample-to-sample variation was found in regularly cycling women near mid-cycle, and the least variation occurred in the male subjects. The coefficients of variation were approximately twice the intra-assay variation confirming that the observed pulsatile patterns of secretion were not due to technical errors. An analysis of variance performed on the mean hourly concentrations from each subject showed a significant variation (P less than 0.001) between sampling periods with peaks occurring during the first hour of sampling (08.00-09.00 hours). This result is suggestive of the presence of a circadian rhythm although it is not conslusive.

Chromosomal assignment of human sequences encoding arginine vasopressin-neurophysin II and growth hormone releasing factor.

Complementary DNA clones encoding bovine vasopressin and human pancreas growth hormone releasing factor have been used to map homologous sequences in the human genome. Assignment of both cloned sequences to human chromosome 20 was accomplished by hybridization of insert DNAs to a panel of human-rodent somatic cell hybrids. Both these probes have been used to examine the structure of their respective genes in DNA from various individuals. No restriction fragment variants for growth hormone releasing factor have yet been found. Analysis of populations for restriction fragment length polymorphisms associated with disease states involving arginine vasopressin is underway.

Plasma equilin concentrations in an oophorectomized woman following ingestion of conjugated equine oestrogens (Premarin).

The plasma equilin concentration was 25.2 nmol/l (6.7 ng/ml) 4 h after an oral dose of Premarin (1.25 mg), and a maximum concentration of 20.5 nmol/l (5.5 ng/ml) was recorded 3 h after a smaller dose (0.625 mg) was given. 24 h later, the plasma equilin was still considerable, being 6.1 nmol/l (1.6 ng/ml) and 3.7 nmol/l (1.2 ng/ml) for the larger and smaller dosages respectively. The findings for equilin are considerably higher than physiological oestrogen concentrations and in addition show that daily therapy with Premarin could lead to cumulation of the steroid.

The Acute Physiology and Chronic Health Evaluation II classification system is a valid marker for physiologic stress in the critically ill patient.

OBJECTIVE: To compare the Acute Physiology and Chronic Health Evaluation (APACHE II) score with resting energy expenditure obtained from indirect calorimetry to determine whether the APACHE II scoring system is an accurate, objective measure of the degree of critical illness and physiologic stress between groups of patients. DESIGN: Prospective study. SETTING: University hospital, tertiary referral center. PATIENTS: Seventy critically ill patients, consecutively sampled from burn, surgical, and medical intensive care units. INTERVENTIONS: Indirect calorimetric studies were performed on each patient using a metabolic cart. The acute physiologic score component of the APACHE II scoring system was determined at the time of metabolic testing, a mean of 15.9 days after hospital admission. MEASUREMENTS AND MAIN RESULTS: True resting energy expenditure was calculated by adjusting the measured energy expenditure for diet-induced thermogenesis and fever. A predicted resting energy expenditure was calculated for each patient using the Harris-Benedict equation alone, and by using the Harris-Benedict value corrected for previously published metabolic activity factors. To eliminate differences in body composition and size, true resting energy expenditure was divided by weight, body surface area, and Harris-Benedict resting energy expenditure. Results showed no significant correlation between APACHE II scores and either the Harris-Benedict resting energy expenditure or the Harris-Benedict value corrected by metabolic activity factors. However, there was a significant (p < or = .001; r2 = .18 to .20) relationship between increasing APACHE II scores and both increasing measured and true resting energy expenditure. The true resting energy expenditure divided by body surface area, kilogram body weight, and Harris-Benedict predicted value, were all shown to be significantly (p < .01) related to APACHE II score, but showed no better degree of correlation (r2 = .12 to .23) than comparison of APACHE II score with measured or true resting energy expenditure. CONCLUSIONS: The APACHE II classification may be a valid marker of physiologic stress as demonstrated by its statistically significant (although weak) relationship with indirect calorimetric measures of energy expenditure associated with varying degrees of critical illness.

Enteral tube feeding in the intensive care unit: factors impeding adequate delivery.

OBJECTIVE: To evaluate those factors that impact on the delivery of enteral tube feeding. DESIGN: Prospective study. SETTING: Medical intensive care units (ICU) and coronary care units at two university-based hospitals. PATIENTS: Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding. INTERVENTIONS: Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented. MEASUREMENTS AND MAIN RESULTS: Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes. CONCLUSIONS: The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.

Clinical application of the metabolic cart to the delivery of total parenteral nutrition.

In critically ill patients, the inaccuracy of predictive formulas for nutritional assessment often leads to inappropriate and potentially detrimental feeding regimens. This study evaluates the clinical utility of the metabolic cart in an urban university hospital setting. Twenty-six studies were performed on each of 26 patients (18 surgical, 8 medical) using an MMC Horizon metabolic cart. Although 58% of patients were overweight, 42% were still shown to have a kwashiorkorlike pattern of malnutrition. Three patients demonstrated a marasmic-like pattern. Fifteen percent of studies showed patients to be hypometabolic and 62% hypermetabolic. Harris-Benedict resting energy expenditure, based on actual or ideal body weight, underestimated needs; however, addition of a metabolic activity factor overestimated needs. Only 32% of patients were fed appropriately; 41% were underfed, and 27% were overfed. Urine area nitrogen correlated poorly with energy expenditure. Measured RQ appropriately reflected substrate utilization in 77% of studies; multiple factors may have caused differences between measured and predicted RQ in 23%. Use of the metabolic cart determines precisely the metabolic state, identifies problems with substrate utilization, and enables the physician to design the most efficacious nutritional regimen.