Emergency department observation of poisoned patients: how long is necessary?

OBJECTIVE

To compare the emergency physician disposition decisions after observation periods of two, four, and six hours in a single cohort of ED patients with acute intentional ingestion to determine the accuracy of disposition decisions at two and four hours relative to the six-hour period of observation.

METHODS

This was a prospective observational study at two university hospital EDs. Study participants were patients with potentially toxic oral ingestions occurring less than six hours prior to ED presentation. Patients with isolated recreational drug or ethanol use were excluded. Structured data forms were completed at presentation, and two, four, and six hours later. Data included signs and symptoms consistent with toxic ingestion, physical examination, laboratory determinations, medications ingested, treatment, and suicide risk. At two and four hours, physicians were asked to determine whether they thought the patient was safe for medical clearance. These patients continued to be observed for six hours. The main outcome was whether patients initially thought to be appropriate for early medical clearance were ultimately cleared at six hours.

RESULTS

There were 260 patients enrolled: 28 were immediately admitted to the hospital and 17 were immediately discharged; 215 entered ED observation. Patients had a mean age of 24 years; 55% were female; 50% were suicidal; 17% had toxidromes. Of the 215 observed patients, 106 (49%) were deemed safe for early medical clearance at two hours. All 106 were ultimately cleared at six hours (100%, 95% CI = 97% to 100%). Of the 109 not safe for early medical clearance at two hours, 61 (56%) were deemed safe for early medical clearance at four hours; all 61 were subsequently discharged at six hours (100%; 95% CI = 95% to 100%). Overall, 167 of 215 (77%) observed overdose patients were deemed safe for early medical clearance after two or four hours of observation. All 167 were ultimately cleared at six hours (100%; 95% CI = 98.2% to 100%).

CONCLUSIONS

A large subset of overdose patients who are medically cleared after six hours of observation can be identified within two to four hours of presentation. No patient who was believed to be safe for medical clearance at either two or four hours had a complication within the six-hour time period (95% CI = 0% to 1.8%). These data suggest that asymptomatic patients with selected acute intentional ingestions can be released from medical observation in less than six hours.

Screening for hand osteoarthritis (OA) using a postal survey

OBJECTIVE

The aim of this study was to determine the feasibility of screening for hand osteoarthritis (OA) using a postal survey.

METHODS

Men and women aged 40-79, selected at random from a general practice in Nottingham, were sent a postal survey concerning arm pain. Subjects were asked to identify presence of any nodes, based on a diagrammatic example, and to document specific distal (DIP) and proximal (PIP) nodes. One hundred and thirty-nine subjects were subsequently assessed by a nurse metrologist, blinded to the subjects assessment. Subject-observer agreement was measured by calculating unweighted kappa (kappa). In addition, sensitivity and specificity were calculated, taking observer-identified nodes as the 'gold standard'. Intraobserver reproducibility was assessed on 10 subjects with nodes.

RESULTS

Intraobserver reproducibility was reasonable at all sites (kappa>/=0.59). Of the 56 subjects with observer-identified 'any nodes', 40 subjects had correctly identified them (sensitivity 71.4%); with three subjects incorrectly identifying nodes (specificity 96.4%). Corresponding kappa was 0.70. Subject-observer agreement was higher for presence/absence of any DIP nodes than PIP nodes (kappa=0.67 and 0.36 respectively). As with nodes overall, specificity was high (100% and 96.6% respectively). Agreement was generally poor for specific joint involvement.

CONCLUSION

A postal survey is a useful screening tool for identifying subjects with nodes. Although sensitivity may not be sufficient to permit assessment of prevalence of hand OA in the community, it has potential applications in terms of identifying and defining cases for further study.

Interstitial pneumonitis following mitozantrone, chlorambucil and prednisolone (MCP) chemotherapy

We describe two cases of interstitial lung disease in patients with non-Hodgkin's lymphoma who were treated with combination chemotherapy including mitozantrone. In both we had radiological and histological evidence of interstitial lung disease, with patterns of organizing pneumonia and hypersensitivity without a clear aetiological agent. Clinical resolution occurred on withdrawal of chemotherapy. One patient required a course of corticosteroid treatment. To date, both patients are well and in remission, and there has been no recurrence of their respiratory disease. We postulate that these observations are hitherto undescribed pulmonary abnormalities secondary to mitozantrone therapy.

Practice parameters for the use of light therapy in the treatment of sleep disorders. Standards of Practice Committee, American Academy of Sleep Medicine

These clinical guidelines were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. The guidelines provide recommendations for the practice of sleep medicine in North America regarding the use of light therapy for treatment of various sleep disorders. This paper is based on a series of articles in the Journal of Biological Rhythms and also includes evidence tables from an updated Medline review covering the period January 1994 to December 1997. Evidence is presented by grade and level. Recommendations are identified as standards, guidelines, or options. Recommendations are provided for delayed sleep phase syndrome (DSPS), advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome, jet lag, shift work, dementia, and sleep complaints in the healthy elderly. Light therapy appears generally safe if used within recommended intensity and time limits. Light therapy can be useful in treatment of DSPS and ASPS. Benefits of light therapy are less clear and treatment is an option in jet lag, shift work, and non-24-hour sleep-wake syndrome in some blind patients.

The care pathway: a tool to enhance clinical governance

A care pathway defines in detail the individual components of treatment for a group of patients. A well-written pathway can lead to consistent care of the highest quality. There are both educational and audit advantages to the approach. The authors detail the means by which groups are selected and the care pathways written. An example of the benefits that can accrue comes from their experience at Ashford Hospital of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved, costs contained and clinical governance enhanced.

A direct comparison of the activities of two humanized respiratory syncytial virus monoclonal antibodies: MEDI-493 and RSHZl9

Two humanized monoclonal antibodies, MEDI-493 and RSHZ19, were developed independently as potential improvements over RSV-IGIV for prevention of respiratory syncytial virus (RSV) infection. RSV-IGIV is a polyclonal human antibody preparation for intravenous infusion enriched for RSV neutralizing activity. A phase III clinical trial showed that MEDI-493 significantly reduced hospitalizations due to RSV infection. In a separate trial, RSHZ19 failed to show significant efficacy. In new studies, the in vitro and in vivo activities of MEDI-493 and RSHZ19 were compared to determine whether the different clinical results are related to differences in biologic activity. MEDI-493 was consistently 4- to 5-fold more potent than RSHZ19 in antigen binding, RSV neutralization, and fusion inhibition assays. Although both MEDI-493 and RSHZ19 were effective against A and B subtypes of RSV in the cotton rat model of RSV infection, 2- to 4-fold higher doses of RSHZ19 were required for similar protection. The enhanced activity of MEDI-493 compared with RSHZ19 may, in part, explain its better clinical effect.

Changes in the morphology and the distribution of rat intestinal eosinophils during infection with the nematode Nippostrongylus brasiliensis

Increases in the numbers of eosinophil leukocytes present in the lamina propria of intestines infected with nematodes is a well described phenomenon, yet the role of these leukocytes and their actions in this situation are not yet fully understood. Morphologic changes in these cells occur with the course of the infection, as do alterations in their location within the gut; these findings may give important clues to the function of this prominent cell. We observed changes in intestinal eosinophils in the August rat during infection with the nematode Nippostrongylus brasiliensis and found, together with the well known increases in number infiltrating the lamina propria at Day 20 (three times the levels in normal animals), a distinct change in the morphology of individual cells which included increase of the cell's overall size and changes in shape, as well as a dissemination of cytoplasmic granules in relationship to the cell's nucleus. No ultrastructural evidence of extracellular degranulation or intact eosinophil cytoplasmic granules outside the bounds of cell cytoplasmic membranes was seen. This finding is important considering the light microscopic appearance of individual eosinophil granules apparently distributed extracellularly, and lying in the connective tissue of the lamina propria, a common histopathologic observation in eosinophilic conditions. Eosinophils within the lamina propria changed their location as the infection progressed, tending to move to line up along the subepithelial zones. In addition, eosinophils were observed both at the light and electron microscopic levels to be passing through the basement membrane and into the epithelial layer. This latter phenomenon was confirmed using confocal optical slicing where eosinophils were commonly observed on the luminal side of the nuclei of the gut epithelium. These observations strongly suggest that morphologic alterations occur in eosinophils in the lamina propria and these changes may be associated with functional alterations in these cells akin to the putative phenomenon of "activation." Our findings indicate that eosinophils have the capacity to enlarge and extend their cytoplasmic processes between various components of the lamina propria and move toward the basement membrane during an active infection, as well as into, and possibly through, the intestinal epithelium. These findings emphasize the need for careful consideration of the changing morphologic status of eosinophils when investigating biologic changes associated with the activation of these cells in tissue inflammatory responses.

Phase I trial of multiple cycles of high-dose chemotherapy supported by autologous peripheral-blood stem cells

PURPOSE

To determine the safety and feasibility of delivering multiple cycles of front-line high-dose carboplatin and paclitaxel with hematopoietic peripheral-blood stem cell (PBSC) support.

PATIENTS AND METHODS

Patients were required to have a malignant solid tumor for which they had received no prior chemotherapy. Mobilization of PBSC was achieved with cyclophosphamide, etoposide, and granulocyte-macrophage colony-stimulating factor (GM-CSF). After one cycle of conventional-dose carboplatin and cyclophosphamide with GM-CSF, patients received multiple cycles of high-dose carboplatin (area under the concentration-time curve [AUC], 12 to 20) and paclitaxel (250 mg/m(2)) with PBSC and GM-CSF repeated every 28 days.

RESULTS

Twenty-four of 28 patients were assessable for toxicity and clinical outcome. Dose-limiting toxicities were dehydration, diarrhea, and electrolyte imbalances. The maximum-tolerated dose of carboplatin was AUC 16 (equivalent to a median of 1,189 mg/m(2)). The relationship of target AUC to measured AUC was linear (r(2) =. 29; P =.0011). The overall response rate was 96%, with a complete clinical response rate of 67%. The median time to progression from the first PBSC reinfusion was 49.5 weeks (range, 8 to 156+ weeks).

CONCLUSION

Multiple cycles of high-dose carboplatin (AUC 16) and paclitaxel (250 mg/m(2)) can be safely administered with GM-CSF and PBSC support. Although this regimen is safe, feasible, and active, the use of multiple cycles of high-dose chemotherapy as front-line treatment remains experimental and should only be used in the context of a clinical trial.

Improving support for mental health staff: a qualitative study

BACKGROUND

High levels of both burnout and job satisfaction have been found in recent studies of mental health professionals. A qualitative methodology was used in a related study to explore reasons for these findings and to investigate staff's accounts of their strategies for coping with their work, and their views of support provided for them and how their jobs might be made less stressful and still more satisfying.

METHOD

A semi-structured schedule was used to interview a purposive sample of 30 mental health staff drawn from three South London geographical sectors, selected to include junior and senior members of each profession in both hospital and community settings. Interviews were transcribed and analysed using QSR NUD.IST software.

RESULTS

Informal contacts with colleagues were the most frequently mentioned way of coping with the difficult and demanding aspects of work in both hospital and community settings, closely followed by time management techniques. The main formal sources of support described by staff were individual supervision and staff support groups. Accounts of the former were generally positive, but there was great variation in opinions about whether support groups are useful. Almost all the interviewees believed that their jobs could be improved by further training. For community mental health staff the main training gaps were the development of skills in various forms of clinical intervention, whilst ward staff identified the need for further skills in diffusing potentially confrontational and aggressive situations.

Explanations for stress and satisfaction in mental health professionals: a qualitative study

BACKGROUND

High levels of burnout and poor psychological well-being, but also relatively high levels of job satisfaction, have been found among mental health staff, especially those based in community settings.

AIMS

In order to investigate the basis of these findings, a qualitative interview study was carried out, exploring mental health staff's views of their work and of its effects on them.

METHOD

A semi-structured interview was administered to a purposive sample of 30 professionals, including junior and senior members of each profession in both hospital and community settings. Interviews were transcribed verbatim and analysed using QSR NUD.IST software.

RESULTS

For most professionals, contact with colleagues was one of the major rewards of the job. There was surprisingly little evidence of conflict or difficulties defining roles between disciplines, except for the social workers, for whom difficulty in defining roles in relation to other professions was a major preoccupation. Reported stresses differed between community and hospital staff. Community staff tended to find their contacts with patients highly rewarding, but also to feel burdened by a strong and uncomfortable sense of being constantly responsible for their clients' well-being and actions. Ward staff, on the other hand, identified as central difficulties in their job lack of autonomy, responsibility and scope for developing an independent therapeutic role. They felt demoralised by revolving door' patients and by violence and the need to restrain patients.

Mental health, "burnout" and job satisfaction in a longitudinal study of mental health staff

BACKGROUND

This study examines whether the adoption of a more community based model in an inner city psychiatry service is accompanied by increasing "burnout", deteriorating mental health and decreasing job satisfaction amongst staff.

METHOD

Questionnaires were sent annually for 3 consecutive years to all mental health staff working in three adult mental health sectors in inner London. Main outcome measures were the 12-item General Health Questionnaire, Maslach Burn-out Inventory and a general job satisfaction measure.

RESULTS

There was no significant change over time in the outcome measures, once confounding by job and demographic variables was examined. Being based in the community was associated with higher GHQ-12 scores (P = 0.02) when compared to in-patient staff over the 3 years.

CONCLUSIONS

These results suggested that working in the community may be more stressful than working in in-patient services. However, there was no evidence to suggest that levels of stress are increasing over time, either in community-based or hospital-based staff.

Globular domains of agrin are functional units that collaborate to induce acetylcholine receptor clustering

Agrin, an extracellular matrix protein involved in neuromuscular junction formation, directs clustering of postsynaptic molecules, including acetylcholine receptors (AChRs). This activity resides entirely in the C-terminal portion of the protein, which consists of three laminin-like globular domains (G-domains: G1, G2 and G3) and four EGF-like repeats. Additionally, alternate mRNA splicing yields G-domain variants G2(0,4) with 0- or 4-amino-acid inserts, and G3(0, 8,11,19) with 0-, 8-, 11- or 19-amino-acid inserts. In order to better understand the contributions of individual domains and alternate splicing to agrin activity, single G-domains and covalently linked pairs of G-domains were expressed as soluble proteins and their AChR clustering activity measured on cultured C2 myotubes. These analyses reveal the following: (1) While only G3(8) exhibits detectable activity by itself, all G-domains studied (G1, G2(0), G2(4), G3(0) and G3(8)) enhance G3(8) activity when physically linked to G3(8). This effect is most pronounced when G2(4) is linked to G3(8) and is independent of the order of the G-domains. (2) The deletion of EGF-like repeats enhances activity. (3) Increasing the physical separation between linked G1 and G3(8) domains produces a significant increase in activity; similar alterations to linked G2 and G3(8) domains are without effect. (4) Clusters induced by two concatenated G3(8) domains are significantly smaller than all other agrin forms studied. These data suggest that agrin G-domains are the functional units which interact independently of their specific organization to yield AChR clustering. G-domain synergism resulting in biological output could be due to physical interactions between G-domains or, alternatively, independent interactions of G-domains with cell surface receptors which require spatially localized coactivation for optimal signal transduction.

A phase I study of oral uracil/ftorafur (UFT) plus leucovorin and bis-acetato-ammine-dichloro-cyclohexylamine-platinum IV (JM-216) each given over 14 days every 28 days

PURPOSE

To determine the feasibility, maximal tolerated doses, and response rates for a combined regimen of the platinum and 5-fluorouracil oral analogues bis-acetato-ammine-dichloro-cyclohexyl-amine platinum(IV) (JM-216) and uracil/ftorafur (UFT) coadministered as a 14 consecutive-day every 28-day schedule.

METHODS

Of 20 patients enrolled in this investigation, 17 on the following dose escalation scheme were evaluable for toxicity and/or response: I UFT 300 mg/day, JM-216 5 mg/day (three patients), II UFT 300 mg/day, JM-216 10 mg/day (four patients), III UFT 300 mg/day, JM-216 20 mg/day (ten patients).

RESULTS

All 17 evaluable patients were evaluable for toxicity. At dose level III dose-limiting nausea and emesis were observed in one patient despite maximal antiemetic support. Importantly, neurotoxicity and nephrotoxicity were not observed at the JM-216 dose levels examined in this study. This observation is consistent with results seen with single agent JM-216.

CONCLUSION

For JM-216 and UFT administered at 20 mg/day and 300 mg/day over 14 days, nausea and emesis were observed as the principal dose-limiting toxicities. These doses are considerably below the maximally tolerated doses of single agent JM-216 and UFT. Shorter administration schedules should be explored in an attempt to increase the dose intensity and minimize the toxicity of this combination oral regimen.

Outcomes and costs of a community support worker service for the severely mentally ill

There has recently been an expansion of paraprofessional staff involved in the provision of care for the severely mentally ill. In this paper we shall evaluate the effects of a community support worker (CSW) service in South London. A sample of patients with severe mental illness receiving the service was assessed over a 6-month period in order to examine the effects of continuing use of CSWs on outcomes, service use and costs. During the study period there were improvements in outcome reflecting service satisfaction, needs, quality of life and social behaviour. Whilst provision of the CSW service did not lead to extra total service costs, service use and cost data suggest that CSWs are associated with the substitution of in-patient use by community-based services.

Combination therapy with fludarabine and cyclophosphamide as salvage treatment in lymphoproliferative disorders

Seventeen patients (aged 50-85 years) with relapsed or refractory non-Hodgkin's lymphoma (NHL, 10 patients) or chronic lymphocytic leukaemia (CLL, seven patients) were treated with a combination of fludarabine 25 mg/m2/d and cyclophosphamide 250 mg/m2/d for 3 d repeated every 4 weeks. 12 patients had previously received purine analogue therapy of which four had progressive disease during treatment. The overall response rate of patients with CLL was 71% (28% CR, 43% PR) and for NHL was 50% (0% CR, 50% PR). Toxicity consisted of nausea and vomiting which was maximal in the 3 d after therapy, infections and haematological suppression which was prolonged in some patients. This combination, which is based on a rational prediction of synergistic activity, is highly effective but associated with significant problems with tolerance.

The abundance of cell cycle regulatory protein Cdc4p is controlled by interactions between its F box and Skp1p

Posttranslational modification of a protein by ubiquitin usually results in rapid degradation of the ubiquitinated protein by the proteasome. The transfer of ubiquitin to substrate is a multistep process. Cdc4p is a component of a ubiquitin ligase that tethers the ubiquitin-conjugating enzyme Cdc34p to its substrates. Among the domains of Cdc4p that are crucial for function are the F-box, which links Cdc4p to Cdc53p through Skp1p, and the WD-40 repeats, which are required for binding the substrate for Cdc34p. In addition to Cdc4p, other F-box proteins, including Grr1p and Met30p, may similarly act together with Cdc53p and Skp1p to function as ubiquitin ligase complexes. Because the relative abundance of these complexes, known collectively as SCFs, is important for cell viability, we have sought evidence of mechanisms that modulate F-box protein regulation. Here we demonstrate that the abundance of Cdc4p is subject to control by a peptide segment that we term the R-motif (for "reduced abundance"). Furthermore, we show that binding of Skp1p to the F-box of Cdc4p inhibits R-motif-dependent degradation of Cdc4p. These results suggest a general model for control of SCF activities.