A rare case of mycobacterial pseudoaneurysm of the superficial femoral artery.

OBJECTIVE: Extrapulmonary localization of tuberculosis accounts for about 15-20% of cases. Several cases of Mycobacterium tuberculosis with vascular involvement have been described, but only few cases for limb vessels. CASE REPORT: We report the case of a 33-year-old man from Gambia with a symptomatic pseudoaneurysm of the right superficial femoral artery. Total body positron emission tomography/computed tomography with [18F]FDG revealed an active infection. The patient underwent vascular reconstruction with a straight reversed vein graft. Molecular testing for Mycobacterium tuberculosis was non-diagnostic. Cultures of the pseudoaneurysm wall and thrombus removed during surgery grew Mycobacterium tuberculosis. CONCLUSIONS: The diagnosis of vascular tuberculosis infection due to Mycobacterium tuberculosis is a challenge. Epidemiology remains the primary criterion for maintaining a high index of suspicion.

High serum tryptase value in massive acute myocardial infarction with ventricular arrhythmia exortion in a cocaine abuser.

A 38-year-old cocaine abuser was admitted to the Emergency Department with a one hour history of precordial chest pain associated with shortness of breath and extreme discomfort. On admission his blood pressure was 90/60 mmHg, the resting 12-lead ECG showed ventricular tachycardia at about 300 beats per minute, and oxygen saturation was 86 percent in room air. After electrical cardioversion, the 12-lead ECG revealed sinusal rhythm and a significative ST segment elevation in leads I, aVL and V1-V6, that was about 0.5 mV in leads I and aVL and more than 1 mV in leads V2, V3 and V4. Laboratory determinations showed elevated creatine-chinase MB (CK-MB) and troponin I. An emergency coronary angiogram was normal. Cocaine use is a major cause of acute myocardial infarction in patients with normal epicardial coronary arteries but the exact mechanism still remains unclear. We hypothesize a non-IgE mediated mast-cell activation, with a direct action played by cocaine, and consequent massive expression of several factors effecting the microcirculatory system, including pro-inflammatory cytokines and chemokines. Our hypothesis is supported by an elevated serum tryptase levels in the patient.

Ulcerative colitis masked by giant urticaria.

The occurrence of giant urticaria and ulcerative colitis is very infrequent. A 23 year-old female reported the initial eruption of short-lived cutaneous itchy weals on her arms. Then lesions ran together and became confluent, extending to her legs, followed by undefined abdominal pain and a slight increase of body temperature. Exams showed hystologically confirmed ulcerative colitis, with perinuclear anti-neutrophil cytoplasmic antibody positivity. Ulcerative colitis therapy led not only to the remission of the colitic symptoms, but also to the prompt recovery of skin manifestations. Urticaria was the epiphenomenon of ulcerative colitis.

Enhanced monocyte expression of tissue factor by oxidative stress in patients with antiphospholipid antibodies: effect of antioxidant treatment.

In a first study, we performed a cross-sectional analysis of urinary excretion of isoprostanes, IPF(2alpha-III) and (VI), and monocyte tissue factor (TF) antigen and activity between 11 antiphospholipid (APL) antibody-positive patients and 13 APL negative subjects. In a second study, 11 APL positive patients were randomly supplemented either with (n = 6) or without (n = 5) antioxidants (vitamin E at 900 IU day(-1), vitamin C at 2000 mg day(-1)) for 6 weeks. In a third study, TF and superoxide anion were measured in human monocytes incubated with anti-beta(2) glycoprotein 1 (beta(2)GP(1)) or control IgG, either with or without vitamin E. APL-positive patients had higher values of isoprostanes (P < 0.05) and monocyte TF antigen (P = 0.001) and activity (P = 0.0001) than APL-negative subjects. Only in APL positive patients did monocyte TF antigen correlate significantly with IPF(2alpha-III) (rho 0.79; P < 0.003) and IPF(2alpha-VI) (rho = 0.87; P < 0.0001). In patients who received antioxidant supplementation, we found a significant decrease of isoprostanes (P < 0.05) and monocyte TF antigen (P < 0.01) and activity (P < 0.007). In vitro experiments demonstrated that anti-beta(2)GP(1) antibodies dose-dependently enhanced the monocyte production of the superoxide anion and TF, which were significantly inhibited by vitamin E. This study demonstrates that in APL-positive patients, oxidative stress contributes to activate the clotting system via over-expression of monocyte TF. We suggest that anti-beta(2)GP(1) antibodies could play a pivotal role by enhancing the monocyte production of oxygen free radicals.

Protein profile of Helicobacter pylori strains by isoelectrofocusing in patients affected by chronic gastritis.

BACKGROUND: To understand if relapse, following antimicrobial treatment was due to re-infection or to recrudescence. METHODS: Fifty patients with dyspepsia were studied prospectively. They were followed up by endoscopy and biopsy of antral mucosa before and after treatment with anti-microbial therapy. Gel isoelectrofocusing was used to characterize protein profile of Hp. RESULTS: At baseline 40 patients were affected by chronic gastritis associated with Hp. At the end of treatment 75% patients given omeprazole, amoxicillin and clarithromycin were Hp infected: 43% showed the same protein profile and 57% different. CONCLUSIONS: Our data suggest that the relapse is due to recrudescence or to reinfection.

Enhanced expression of monocyte tissue factor in patients with liver cirrhosis.

BACKGROUND: Previous studies have shown that cirrhotic patients produce increased amounts of thrombin but the underlying mechanism is still unknown. AIMS: To analyse the relation between the rate of thrombin generation and monocyte expression of tissue factor (TF) in cirrhosis. PATIENTS: Thirty three cirrhotic patients classified as having low (n = 7), moderate (n = 17), or severe (n = 9) liver failure according to Child-Pugh criteria. METHODS: Prothrombin fragment F1 + 2, monocyte TF activity and antigen, and endotoxaemia were measured in all patients. Polymerase chain reaction (PCR) analysis of TF mRNA was performed in monocytes of five cirrhotic patients. RESULTS: Prothrombin fragment F1 + 2 was higher in cirrhotic patients than in controls (p < 0.0001). Monocytes from cirrhotic patients had higher TF activity and antigen than those from controls (p < 0.001) with a progressive increase from low to severe liver failure. Monocyte expression of TF was significantly correlated with plasma levels of F1 + 2 (TF activity: r = 0.98, p < 0.0001; TF antigen: r = 0.95, p < 0.0001) and with endotoxaemia (TF activity: r = 0.94, p < 0.0001; TF antigen: r = 0.91, p < 0.0001). PCR analysis of TF mRNA showed TF expression only in three patients with endotoxaemia (more than 15 pg/ml). CONCLUSIONS: Cirrhotic patients have enhanced expression of TF which could be responsible for clotting activation, suggesting that endotoxaemia might play a pivotal role.

A review of the power as knowing participation in change literature.

In the 15 years since the introduction of Barrett's theory of power as knowing participation in change and its accompanying measurement instrument, a rapidly growing number of research studies have been conducted using the theory and instrument. This article presents a critical review of this literature, as well as recommendations for further research.

Methodological ponderings related to the power as knowing participation in change tool.

Based on 15 years of research using the Power as Knowing Participation in Change Tool, the authors summarize tool development, including reliability and validity, and discuss specific methodological issues and insights. These include clarity of instructions and complexity of language used in the PKPCT along with response set, norms, and sensitivity of the instrument to detect differences between groups. Problems of linear measurement are discussed along with the appropriateness of both qualitative and quantitative methods of studying power from the view of the science of unitary human beings. Recommendations for further psychometric studies of power are proposed.

Coexistence of anti-phospholipid antibodies and endothelial perturbation in systemic lupus erythematosus patients with ongoing prothrombotic state.

BACKGROUND: Anti-phospholipid antibodies (aPLs) were associated with an ongoing prothrombotic state in patients with systemic lupus erythematosus (SLE). Because aPLs are able to shift endothelial function toward procoagulant activity in vitro, we investigated the relationship among aPLs, ongoing prothrombotic state, and endothelial perturbation in SLE patients. METHODS AND RESULTS: We measured aPLs, anti-EC antibodies, circulating levels of prothrombin fragment F1 + 2 (F1 + 2), tumor necrosis factor-alpha (TNF-alpha), tissue-type plasminogen activator (TPA), and von Willebrand factor (vWF) in 43 SLE patients and 25 healthy subjects. Patients positive for aPLs (n = 23) had a higher prevalence of anti-EC antibodies (P = .02) and higher levels of F1 + 2 (P = .003) than aPL(-) patients. Endothelial perturbation, defined by elevated plasma levels of both TPA and vWF, was significantly associated with aPL positivity (P = .001). F1 + 2 > 1 nmol/L (mean +/- 2 SD of controls) was detected in all but one patient in whom aPL positivity and endothelial perturbation coexisted and in no aPL(+) patient without endothelial perturbation (P = .0039). F1 + 2 was significantly correlated with vWF (rho = .6, P = .004) and TPA (114 = .70, P = .0006) only in aPL(+) patients. Endothelial perturbation was closely associated with high values of TNF-alpha (P = .0001), anti-phospholipid (P = .001), and anti-EC antibodies (P = .012). In 31 patients without a clinical history of thrombosis followed up for 3 years, aPL(+) patients with endothelial perturbation showed higher F1 + 2 and TNF-alpha values than aPL(+) patients without endothelial dysfunction. CONCLUSIONS: This study shows that in SLE patients, aPL positivity is associated with an ongoing prothrombotic state only in the presence of endothelial perturbation. Our findings also suggest that aPLs and TNF-alpha might cooperate in inducing endothelial perturbation.

Diverse decisions. How culture affects ethical decision making.

Even under optimal conditions, assisting patients and families in making ethical decisions is difficult at best. Often these decisions revolve around the end-of-life issues that require acknowledgement that the patient is unlikely to survive, which may be perceived as a failure to both the family and the staff. At the very least, it can be a sad time, fraught with uncertainty and indecision. When these difficulties are coupled with ineffective communication related to cultural insensitivity or unawareness, the effects can be devastating to the decision-making process. All CCNs are expected to master the skills necessary for assisting patients and families through the harrowing experience of life-threatening illness. Whereas much of critical care focuses on managing pathophysiologic disturbances, emotional needs are equally important. It follows then that the CCN must assume responsibility for assisting patients and families in coping with the crisis of critical illness and working through ethical issues, which often include end-of-life decisions and organ donation. Culturally competent care is required when addressing patient needs holistically, but it is so much more. It is an opportunity to enrich and deepen the CCN/patient/family relationship, advocate for the patient, and broaden the opportunities for communication among staff. This article has provided some beginning steps for increasing nursing cultural awareness and has offered some initial strategies to consider when designing a plan of care. Through continuing efforts, CCNs and organizations can do much to decrease the alienation that many patients and families have traditionally encountered in the CCU, an estrangement that is exacerbated when their culture is different from the predominant culture of the unit. The effort to become more culturally aware may appear to require extraordinary effort; however, the rewards of optimizing patient care are unsurpassed.

Economic awareness of nurses: relationship to budgetary control.

Cost savings, a goal in most health care settings, could be achieved by strategies leading to greater economic awareness. Nurse manager participation in budgeting, staff nurse awareness, and costs relative to linen and supply use were evaluated in this study. Staff who are aware of and use information about the relationship between their clinical behavior and cost savings could make a major impact on the financial health of their units.

Research utilization: reducing the pain.

While the thought of a research utilization project may inspire intimidation and anxiety in many nurses, applying the findings of research studies to clinical practice can be an exciting way to invigorate patient care. This article describes ways of getting started in research utilization. Suggestions are included for discovering resources, as well as some practical tips for taking the first steps in what can be a satisfying way to implement cost-effective, high quality care in an era of health care reform.

Power and feminism: a nursing science perspective.

Nurse executives are in an influential position to engineer health care reform and service delivery if their resources are fully maximized. Derived from Rogers' science and Barrett's power theory, this exploratory study demonstrated a weak relationship between power and feminism in female nurse executives, yet showed a modest correlation between feminism and the power subscale, freedom to act intentionally. Suggestions are provided for further development of the theoretical foundations of a nursing science perspective for nursing administration.

Assessment of organizational culture: a tool for professional success.

Assessing the culture, or shared norms, of an institution to learn about its values, beliefs, and practices can be very useful in determining one's "fit" within an organization. It can also be helpful to those engineering change and to those interested in shaping an institutional image that attracts and retains qualified staff. This article discusses the concept of organizational culture, provides suggestions for assessment, and explicates this information through some familiar examples. Implications of organizational culture assessment are also discussed as they apply to the roles of staff nurse, nurse manager, clinical nurse specialist, faculty member, and nurse executive. Consideration is also given to nursing as a profession.