Synchronized Cardioversion Performed During Cold Water Immersion of a Heatstroke Patient.

We report a case of cardioversion that was successfully performed on a patient during cold water immersion. The patient deteriorated into unstable ventricular tachycardia while being treated for heatstroke. We elected to perform synchronized cardioversion without first removing the patient from the immersion body bag. The patient survived and was discharged neurologically intact on hospital day 5. There were no evident deleterious effects to the staff, the patient, or the equipment. To our knowledge, this is the first case report in the literature demonstrating the electrical cardioversion of a patient immersed in water.

Early Clinical Exposure to Geriatric Psychiatry and Medical Students' Interest in Caring for Older Adults: A Randomized Controlled Trial.

OBJECTIVE: In the next 25 years, the population aged 65 and older will nearly double in many countries, with few new doctors wishing to care for older adults. The authors hypothesize that early clinical exposure to elderly patient care could increase student interest in caring for older adults during their future career. METHODS: The authors conducted a pragmatic medical education randomized controlled trial (RCT) at the Jewish General Hospital and the Douglas Mental Health Institute, McGill University, in Montreal, Canada. Third-year medical students undergoing their mandatory 16-week half-time clerkship rotation in psychiatry were randomly assigned to the equivalent of 2-4 weeks of full-time exposure to clinical geriatric psychiatry (n = 84). RESULTS: Being randomly assigned to geriatric psychiatry exposure (n = 44 of 84) was associated with increased "comfort in working with geriatric patients and their families" at 16-week follow-up (59.1% versus 37.5%, χ2 (1) = 3.9; p = 0.05). However, there was no significant association found between geriatric psychiatry exposure and change "in interest in caring for older adults," or change in "interest in becoming a geriatric psychiatrist." CONCLUSION: The results of this pragmatic education RCT suggest that exposing third-year medical students to 2-4 weeks of geriatric psychiatry did not increase their interest to care for older adults or become a geriatric psychiatrist. However, it did increase their comfort level in working with older adults and their families. However, more research is necessary to identify potential interventions that could inspire and increase medical student interest in caring for older adults as part of their future careers.

Catheter-Related Bloodstream Infections (CR-BSI) in Geriatric Patients in Intensive Care Units.

Catheter-related bloodstream infections (CR-BSIs) are bloodstream infections that, through specific laboratory testing, identify the intravascular catheter as the source of the bloodstream infection. By 2015, the rate of elderly patients 80 years of age and older admitted to the intensive care unit (ICU) will represent 1 in 4 admissions. Approximately 80 000 CR-BSIs occur in ICUs annually, potentially resulting in as many as 56 000 CR-BSIs occurring in the geriatric ICU patient, with 20% of these cases resulting in death. To minimize the occurrence of CR-BSIs in these patients, specific knowledge about the geriatric patient will have to be factored into the ICU health care professional's practice, including the development of a vascular access plan, which includes selection of the correct device and proper insertion of that device along with an evidence-based care and maintenance program. Intensive care unit health care professionals may be at a loss when it comes to navigating the vast array of vascular access medical devices available today. The Healthcare and Technology Synergy framework can assist the ICU health care professional to logically review each vascular access device and select those devices that best meet patient needs.

BapC autotransporter protein is a virulence determinant of Bordetella pertussis.

A protein designated Bap-5 (GenBank accession no. AF081494) or BapC (GenBank accession no. AJ277634) has been identified as a member of the Bordetella pertussis autotransporter family and the present work suggests that this protein, like the previously characterised BrkA, is a Bvg-regulated serum resistance factor and virulence determinant. B. pertussis bapC and brkA, bapC mutants were created and, like a brkA mutant, showed greater sensitivity to killing by normal human serum than their parent strains but they were not as sensitive as a bvg mutant. Competition assays also showed an important role for BapC, like BrkA, in virulence of B. pertussis in mice after intranasal infection. Moreover, the bapC and brkA, bapC mutants, like the brkA mutant, were found to be more sensitive to the antimicrobial peptide cecropin P1 than the parent strains. In the genome sequence of B. pertussis strain Tohama, bapC is designated as a pseudogene due, in part, to a frameshift in a poly(C) tract near the 5' end of the gene which creates a truncated BapC protein. Sequence analyses of the bapC region spanning the poly(C) tract of a number of B. pertussis strains showed minor nucleotide and amino acid polymorphisms but it appeared that all had an ORF that would be able to produce BapC.

The chemokine receptor D6 constitutively traffics to and from the cell surface to internalize and degrade chemokines.

The D6 heptahelical membrane protein, expressed by lymphatic endothelial cells, is able to bind with high affinity to multiple proinflammatory CC chemokines. However, this binding does not allow D6 to couple to the signaling pathways activated by typical chemokine receptors such as CC-chemokine receptor-5 (CCR5). Here, we show that D6, like CCR5, can rapidly internalize chemokines. However, D6-internalized chemokines are more effectively retained intracellularly because they more readily dissociate from the receptor during vesicle acidification. These chemokines are then degraded while the receptor recycles to the cell surface. Interestingly, D6-mediated chemokine internalization occurs without bringing about a reduction in cell surface D6 levels. This is possible because unlike CCR5, D6 is predominantly localized in recycling endosomes capable of trafficking to and from the cell surface in the absence of ligand. When chemokine is present, it can enter the cells associated with D6 already destined for internalization. By this mechanism, D6 can target chemokines for degradation without the necessity for cell signaling, and without desensitizing the cell to subsequent chemokine exposure.

Creating permanent 3D arrangements of isolated cells using holographic optical tweezers.

We report the creation of permanent 3D configurations of cells, at predefined positions, within a gelatin matrix. The technique used holographic optical tweezers to manipulate individual E. coli within a solution comprising monomer precursors. The matrix was then set and after the laser beam was removed, we were able to demonstrate that the structures remained intact for many days. We were also able to demonstrate that, in the presence of appropriate nutrients, the E. coli survived within the gelatin matrix for several days. The technique could have a number of potential future applications, including the arrangement of a variety of different cell types in complex architectures, as motifs for promoting tissue differentiation and growth within the field of cell engineering.

Purification and biochemical characterization of the D6 chemokine receptor.

There is much interest in chemokine receptors as therapeutic targets in diseases such as AIDS, autoimmune and inflammatory disorders, and cancer. Hampering such studies is the lack of accurate three-dimensional structural models of these molecules. The CC-chemokine receptor D6 is expressed at exceptionally high levels in heterologous transfectants. Here we report the purification and biochemical characterization of milligram quantities of D6 protein from relatively small cultures of transfected mammalian cells. Importantly, purified D6 retains full functional activity, shown by displaceable binding of 125I-labelled MIP-1beta (macrophage inflammatory protein-1beta) and by complete binding of the receptor to a MIP-1alpha affinity column. In addition, we show that D6 is decorated on the N-terminus by N-linked glycosylation. Mutational analysis reveals that this glycosylation is dispensable for ligand binding and high expression in transfected cells. Metabolic labelling has revealed the receptor to also be sulphated and phosphorylated. Phosphorylation is ligand independent and is not enhanced by ligand binding and internalization, suggesting similarities with the viral chemokine receptor homologue US28. Like US28, an analysis of the full cellular complement of D6 in transfected cells indicates that >80% is found associated with intracellular vesicular structures. This may account for the high quantities of D6 that can be synthesized in these cells. These unusual properties of D6, and the biochemical characterization described here, leads the way towards work aimed at generating the three-dimensional structure of this seven-transmembrane-spanning receptor.

Investigation of polymerase chain reaction assays to improve detection of bacterial involvement in bovine respiratory disease.

Bovine respiratory disease (BRD) causes severe economic losses to the cattle farming industry worldwide. The major bacterial organisms contributing to the BRD complex are Mannheimia haemolytica, Histophilus somni, Mycoplasma bovis, Pasteurella multocida, and Trueperella pyogenes. The postmortem detection of these organisms in pneumonic lung tissue is generally conducted using standard culture-based techniques where the presence of therapeutic antibiotics in the tissue can inhibit bacterial isolation. In the current study, conventional and real-time polymerase chain reaction (PCR) assays were used to assess the prevalence of these 5 organisms in grossly pneumonic lung samples from 150 animals submitted for postmortem examination, and the results were compared with those obtained using culture techniques. Mannheimia haemolytica was detected in 51 cases (34%) by PCR and in 33 cases (22%) by culture, H. somni was detected in 35 cases (23.3%) by PCR and in 6 cases (4%) by culture, Myc. bovis was detected in 53 cases (35.3%) by PCR and in 29 cases (19.3%) by culture, P. multocida was detected in 50 cases (33.3%) by PCR and in 31 cases (20.7%) by culture, and T. pyogenes was detected in 42 cases (28%) by PCR and in 31 cases (20.7%) by culture, with all differences being statistically significant. The PCR assays indicated positive results for 111 cases (74%) whereas 82 cases (54.6%) were culture positive. The PCR assays have demonstrated a significantly higher rate of detection of all 5 organisms in cases of pneumonia in cattle in Northern Ireland than was detected by current standard procedures.

Intravenous needle-free injection devices: new information for compounding pharmacists.

By educating their clients (especially prescribing physicians, nurses, and home healthcare aides) about the advantages of using needle-free devices to administer intravenous medications, compounding pharmacists can help prevent complications associated with vascular access devices and needlestick injuries. Despite state and federal efforts to reduce the incidence of sharps injuries among healthcare workers, percutaneous needle-stick injuries remain a source of emotional stress, morbidity, and possible mortality in those individuals. According to the Centers for Disease Control and Prevention, 50% or more of surveyed healthcare personnel do not report their occupational percutaneous injuries, and an estimated 385,000 sharps-related injuries occur annually among healthcare workers in hospitals alone. Because sharps injuries are associated with the transmission of more than 20 pathogens, including hepatitis B and C viruses and the human immunodeficiency virus, the potential burden of disease is great. For the intgravenous administration of medications, however, devices safer than those requiring the use of needles are available, and pharmacists have a key role in educating caregivers about needle-free equipment and its use. In this article, we explain the types of intravenous needle-free devices of interest to compounding pharmacists and the clients they serve, and we answer frequently asked questions about that equipment. Compounders who understand the design features and capabilities of such products, their clients' intended use of those devices, patients' specific needs can improve treatment outcomes and protect healthcare workers against needlestick injury.

GAVeCeLT* consensus statement on the correct use of totally implantable venous access devices for diagnostic radiology procedures.

The use of totally implantable venous access devices in radiology may be associated with complications such as occlusion of the system (because of the high density of some contrast), infection (if the port is not handled in aseptic conditions, using proper barrier protections), and mechanical complications due to the high-pressure administration of contrast by automatic injectors (so-called power injector), including extravasation of contrast media into the soft tissues, subintimal venous or myocardial injection, or serious damage to the device itself (breakage of the external connections, dislocation of the non-coring needle, or breakage of the catheter). The last problem - i.e., the damage of the device from a power injection - is not an unjustified fear, but a reality. A warning by the US Food and Drug Administration of July 2004 reports around 250 complications of this kind, referring to both port and central venous catheters and peripherally inserted central catheter systems, which occurred over a period of several years; in all cases, the damage occurred during the injection of contrast material by means of power injectors for computed tomography or magnetic resonance imaging procedures. Though the risk associated with the use of ports in radiodiagnostics is thus clear, it has been suggested that administration of the contrast material via the port may have some advantage in terms of image quality, increased comfort for the patient, and maybe more accurate reproducibility of the patient's own follow-up exams. This contention needs to be supported by evidence. Also, since many cancer patients who need frequent computed tomography studies already have totally implantable systems, it would seem reasonable to try to define how and when such systems may safely be used. The purpose of this consensus statement is to define recommendations based on the best available evidence, for the safe use of implantable ports in radiodiagnostics.

Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors.

OBJECTIVES: To determine the existing patterns of sign-out processes prevalent in emergency departments (EDs) nationwide. In addition, to assess whether training programs provide specific guidance to their trainees regarding sign-outs and attitudes of emergency medicine (EM) residency and pediatric EM fellowship program directors toward the need for the development of standardized guidelines relating to sign-outs. METHODS: A Web-based survey of training program directors of each Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency and pediatric EM fellowship program was conducted in March 2006. RESULTS: Overall, 185 (61.1%) program directors responded to the survey. One hundred thirty-six (73.5%) program directors reported that sign-outs at change of shift occurred in a common area within the ED, and 79 (42.7%) respondents indicated combined sign-outs in the presence of both attending and resident physicians. A majority of the programs, 119 (89.5%), stated that there was no uniform written policy regarding patient sign-out in their ED. Half (50.3%) of all those surveyed reported that physicians sign out patient details "verbally only," and 79 (42.9%) noted that transfer of attending responsibility was "rarely documented." Only 34 (25.6%) programs affirmed that they had formal didactic sessions focused on sign-outs. A majority (71.6%) of program directors surveyed agreed that specific practice parameters regarding transfer of care in the ED would improve patient care; 80 (72.3%) agreed that a standardized sign-out system in the ED would improve communication and reduce medical error. CONCLUSIONS: There is wide variation in the sign-out processes followed by different EDs. A majority of those surveyed expressed the need for standardized sign-out systems.

Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin?

OBJECTIVE: To examine whether literature supports the use of Rh immune globulin in Rh-negative women with first trimester spontaneous abortions to prevent maternal sensitization to the fetal Rh antigen and subsequent fetal morbidity and mortality. METHODS: We searched MEDLINE (1966-2005), the Cochrane Central Register of Controlled Trials, EMBASE (1990 to 2005), and the reference sections of the articles found. The search is considered updated to December of 2005. Search terms included vaginal bleeding, Rh negative, Rh immune globulin, RhoGAM, isoimmunization, sensitization, first trimester pregnancy, threatened, and spontaneous abortion. RESULTS: The evidence to support the use of Rh immune globulin for a diagnosis of first trimester spontaneous abortion is minimal. There is a paucity of well-designed research that examines maternal sensitization or hemolytic disease of the newborn as an outcome in patients receiving, versus not receiving, Rh immune globulin in first trimester bleeding. There is significant evidence to demonstrate fetomaternal hemorrhage in first trimester spontaneous abortions; yet, no studies demonstrate subsequent maternal sensitization or development hemolytic disease in the fetus as a result of this hemorrhage. CONCLUSION: In summary, there is minimal evidence that administering Rh immune globulin for first trimester vaginal bleeding prevents maternal sensitization or development of hemolytic disease of the newborn. The practice of administering Rh immune globulin to Rh-negative women with a first trimester spontaneous abortion is based on expert opinion and extrapolation from experience with fetomaternal hemorrhage in late pregnancy. Its use for first trimester bleeding is not evidence-based.