Acute neurological problems: frequency, consultation patterns and the uses of a rapid access neurology clinic.

In secondary care, some patients with acute neurological symptoms are never seen by a neurologist. Rapid access neurology clinics could provide patients with timely access to neurology services. We analysed a retrospective cohort of 12,024 consecutive patients attending the 'immediate care' area of the emergency department or the acute medical admissions unit of the Royal Infirmary of Edinburgh. A total of 1,036 patients (9%) presented with a neurological complaint, of whom 680 (66%) did not have any contact with neurology services. The most common problems were epileptic seizure, cerebrovascular diseases and headache. Of the patients with epileptic seizure or headache who were not seen by a neurologist, about 40% might have benefited from neurological assessment. Following the introduction of a weekly rapid access neurology clinic, the most common problems seen were headache, symptoms that turned out to be medically unexplained and epileptic seizure.

Carbon monoxide treatments to impart and retain muscle color in tilapia fillets.

Carbon monoxide (CO) has been used for improving the color of muscle foods. In the current study, we compared the postmortem treatment of tilapia fillets with 100% CO and euthanasia of live tilapia with CO for their ability to stabilize the color of white and red muscle of tilapia fillets. Both postmortem CO treatment and CO euthanasia were effective in increasing the redness (a* value) and lightness (L* value) of tilapia white and red muscle. Fillets obtained from CO-euthanized tilapia showed significantly higher a* and L* values during 1 mo of frozen storage at -20 degrees C and subsequent thawing and storage at 4 degrees C for 18 d. The amount of CO present in the red and white muscles decreased during the 18 d of storage at 4 degrees C. There was no significant difference in the pH, drip, or thaw loss of CO-treated tilapia fillets compared to the untreated fillets.

The performance of standard vertical S-1 flight maneuvers by student U.S. Naval helicopter pilots.

BACKGROUND: During flight training, student U.S. Naval helicopter pilots learn the use of flight instruments through a prescribed series of simulator training events. We recorded the training flights of 76 student U.S. Naval helicopter pilots undergoing the simulator phase of basic flight instrument training. From the final basic instrument simulator flight, the Vertical S-I (VS) flight maneuver, a standard flight maneuver required of the students, was selected for analysis. This maneuver was chosen because the ideal performance was well described. METHODS: The training simulator is the 2B42 training device, a 6 degrees of freedom, motion-based, high-fidelity instrument trainer. The quality of the flight performance of the cohort of student aviators executing the VS was described using objective measures of deviation from the ideal flight path. The measures included air speed, altitude, and heading average error from target values and standard deviations. RESULTS: The distributions of these scores for the 76 student pilots were described and used to calculate a composite score that summarized a student's overall performance of the maneuver. The worst four, the best four, and a group of four average pilots were identified from their composite scores and their relative performance was compared. CONCLUSIONS: A graphical summary of each pilot's flight performance was developed, and from this performance summary a pattern became evident that suggested that differences in performance levels were related to the use of flight instruments.

The performance of the standard rate turn (SRT) by student naval helicopter pilots.

BACKGROUND: During flight training, student naval helicopter pilots learn the use of flight instruments through a prescribed series of simulator training events. The training simulator is a 6-degrees-of-freedom, motion-based, high-fidelity instrument trainer. From the final basic instrument simulator flights of student pilots, we selected for evaluation and analysis their performance of the Standard Rate Turn (SRT), a routine flight maneuver. METHODS: The performance of the SRT was scored with air speed, altitude and heading average error from target values and standard deviations. These average errors and standard deviations were used in a Multiple Analysis of Variance (MANOVA) to evaluate the effects of three independent variables: 1) direction of turn (left vs. right), 2) degree of turn (180 vs. 360 degrees); and 3) segment of turn (roll-in, first 30 s, last 30 s, and roll-out of turn). RESULTS: Only the main effects of the three independent variables were significant; there were no significant interactions. This result greatly reduces the number of different conditions that should be scored separately for the evaluation of SRT performance. The results also showed that the magnitude of the heading and altitude errors at the beginning of the SRT correlated with the magnitude of the heading and altitude errors throughout the turn. This result suggests that for the turn to be well executed, it is important for it to begin with little error in these two response parameters. CONCLUSIONS: The observations reported here should be considered when establishing SRT performance norms and comparing student scores. Furthermore, it seems easier for pilots to maintain good performance than to correct poor performance.

A comparison of biphasic and monophasic shocks for external defibrillation. Physio-Control Biphasic Investigators.

BACKGROUND AND OBJECTIVE: The ability of a shock to defibrillate the heart depends on its waveform and energy. Past studies of biphasic truncated exponential (BTE) shocks for external defibrillation focused on low energy levels. This prospective, randomized, double-blind clinical trial compared the first-shock efficacies of 200-joule (J) BTE, 130-J BTE, and 200-J monophasic damped sine wave shocks. METHODS: Ventricular fibrillation (VF) was induced in 115 patients during evaluation of implantable cardioverter-defibrillator function and 39 patients during electrophysiologic evaluation of ventricular arrhythmias. After 19 +/- 10 seconds of VF, a randomized transthoracic shock was administered. Mean first-shock success rates of the three groups were compared using a "Tukey-like" statistical test, adjusting for multiple comparisons. Blood pressures and arterial oxygen saturations were measured before VF induction and 30, 90, and 150 seconds after successful defibrillation. RESULTS: First-shock success rates were 61/68 (90%) for 200-J monophasic, 39/39 (100%) for 200-J biphasic, and 39/47 (83%) for 130-J biphasic shocks. The 200-J biphasic shocks were simultaneously superior in first-shock efficacy to both 200-J monophasic and 130-J biphasic shocks (experimentwise error rate, alpha < 0.01). There was no significant difference between the efficacies of 200-J monophasic and 130-J biphasic shocks, nor was there any significant difference between the three groups in hemodynamic parameters after successful shocks. CONCLUSIONS: Biphasic shocks of 200 J provide better first-shock defibrillation efficacy for short-duration VF than 200-J monophasic and 130-J biphasic shocks and thus may allow earlier termination of VF in cardiac arrest patients.

Association among visual hallucinations, visual acuity, and specific eye pathologies in Alzheimer's disease: treatment implications.

OBJECTIVE: Studies suggest a link between visual acuity and visual hallucinations in dementia, but links with specific eye pathologies have not been evaluated. METHOD: Fifty patients (20 with visual hallucinations, 30 without) with probable Alzheimer's disease had an evaluation of psychotic symptoms. Visual acuity was measured before and after refractions, and ophthalmological examinations included standardized assessments for cataracts and macular degeneration. RESULTS: Impaired visual acuity and the severity of cognitive impairments were significantly associated with visual hallucinations. No patients with normal acuity (6/5 or 6/6 on the Snellen chart) experienced these symptoms. Impaired acuity improved with refraction in 60% (N = 12) of the patients with visual hallucinations. Of specific eye pathologies, only cataracts were significantly associated with visual hallucinations. Descriptive follow-up information suggests that an optician's assessment for glasses improves outcome. CONCLUSIONS: Glasses and cataract surgery need evaluation as prophylactic or adjunctive treatments for visual hallucinations in patients with probable Alzheimer's disease.

B lymphocyte antigen D8/17 and repetitive behaviors in autism.

OBJECTIVE: Monoclonal antibody D8/17 identifies a B lymphocyte antigen with expanded expression in rheumatic fever, Sydenham's chorea, and subgroups of obsessive-compulsive disorder and Tourette's syndrome with repetitive behaviors. The authors examined the rate of D8/17 expression in children with autism and its correlation with severity of repetitive behaviors. METHOD: Blood samples from 18 patients with autism and 14 comparable medically ill children were evaluated for percentage of D8/17-positive B cells by immunofluorescence and for streptococcal antibodies. Severity of repetitive behaviors was also determined. RESULTS: The frequency of individuals with > or =11% D8/17-positive cells was significantly higher in the autistic patients (78%) than the comparison subjects (21%), severity of repetitive behaviors significantly correlated with D8/17 expression, and D8/17-positive patients had significantly higher compulsion scores than D8/17-negative patients. CONCLUSIONS: D8/17 expression is high in patients with autism and may serve as a marker for compulsion severity within autism.

A flow cytometric assay for D8/17 B cell marker in patients with Tourette's syndrome and obsessive compulsive disorder.

D8/17 is proving to be an important diagnostic and treatment tool in patients with Tourette's syndrome (TS) and obsessive compulsive disorder (OCD). The present study represents a direct comparison of immunofluorescence microscopy and flow cytometry in terms of their relative efficiency in the detection of the DB/17 B cell marker. Analysis of 41 patients with OCD or TS and 31 control subjects by immunofluorescence microscopy and flow cytometer demonstrated an average of 6.5% of D8/17-positive B cells in controls with an average of 19.6% in OCD patients. Using the flow cytometer, values of 6.2% for controls and 22.4% for OCD patients were obtained. The flow cytometer test was able to count many more cells, induce less operator error and offer faster analysis while correlating strongly with the microscopic technique. Overall in our sample, the FACS assay test has a sensitivity of 77% and a specificity of 87%. The ease of use and close correlation to disease activity makes this an ideal test for clinical laboratories.

Relative efficacy of monophasic and biphasic waveforms for transthoracic defibrillation after short and long durations of ventricular fibrillation.

BACKGROUND: Recently, interest has arisen in using biphasic waveforms for external defibrillation. Little work has been done, however, in measuring transthoracic defibrillation efficacy after long periods of ventricular fibrillation. In protocol 1, we compared the efficacy of a quasi-sinusoidal biphasic waveform (QSBW), a truncated exponential biphasic waveform (TEBW), and a critically damped sinusoidal monophasic waveform (CDSMW) after 15 seconds of fibrillation. In protocol 2, we compared the efficacy of the more efficacious biphasic waveform from protocol 1, QSBW, with CDSMW after 15 seconds and 5 minutes of fibrillation. METHODS AND RESULTS: In protocol 1, 50% success levels, ED50, were measured after 15 seconds of fibrillation for the 3 waveforms in 6 dogs. In protocol 2, defibrillation thresholds were measured for QSBW and CDSMW after 15 seconds of fibrillation and after 3 minutes of unsupported fibrillation followed by 2 minutes of fibrillation with femoral-femoral cross-circulation. In protocol 1, QSBW had a lower ED50, 16.0+/-4.9 J, than TEBW, 20.3+/-4.4 J, or CDSMW, 27.4+/-6.0 J. In protocol 2, QSBW had a lower defibrillation threshold after 15 seconds, 38+/-10 J, and after 5 minutes, 41.5+/-5 J, than CDSMW after 15 seconds, 54+/-19 J, and 5 minutes, 80+/-30 J, of fibrillation. The defibrillation threshold remained statistically the same for QSBW for the 2 fibrillation durations but rose significantly for CDSMW. CONCLUSIONS: In this animal model of sudden death and resuscitation, these 2 biphasic waveforms are more efficacious than the CDSMW at short durations of fibrillation. Furthermore, the QSBW is even more efficacious than the CDSMW at longer durations of fibrillation.

A strategic information system to facilitate the use of performance indicators in hospitals.

Hospital management teams receive voluminous data from a wide variety of sources, but are unable to distill the essential data they require to make good decisions. We have used a methodology which helps teams define and use important management data coupled with an information system that makes this data accessible. Results of our evaluation indicate that the process of developing a balanced scorecard (BSC) indicator system helps management teams to define meaningful strategic objectives and measurable performance indicators. The framework combined with the information acts as an integrating force, providing a shared understanding of the unit's goals. We conclude that a customized decision support system which integrates multiple measures in a BSC framework is a powerful tool for enabling complex decision making by a management team.

Identification of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections by a marker associated with rheumatic fever.

OBJECTIVE: The authors' goal was to determine whether a trait marker of rheumatic fever susceptibility (labeled D8/17) could identify children with pediatric autoimmune neuropsychiatric disorders (obsessive-compulsive disorder and tic disorders) associated with streptococcal infections (PANDAS). METHOD: Blood samples obtained from 27 children with PANDAS, nine children with Sydenham's chorea, and 24 healthy children were evaluated for D8/17 reactivity. Individuals were defined as D8/17 positive if they had 12% or more D8/17+ cells. RESULTS: The frequency of D8/17-positive individuals was significantly higher in both patient groups than it was among the healthy volunteers: 85% of the children with PANDAS and 89% of the children with Sydenham's chorea, compared with 17% of the healthy children, were D8/17 positive. Further, the mean number of D8/17+ cells was similar in the two patient groups and was significantly higher in these groups than in the group of healthy children. CONCLUSIONS: These results suggest that there may be a subgroup of D8/17-positive children who present with clinical symptoms of obsessive-compulsive disorder and Tourette's syndrome, rather than Sydenham's chorea, but who have similar poststreptococcal autoimmunity.