Uncommon cause of cardiac arrest in the emergency department

A previously healthy 48-year-old woman presented to a peripheral ED with non-specific signs and symptoms, including vomiting, abdominal cramping, shortness of breath, tachycardia and hypertension. Despite supportive measures the patient rapidly deteriorated, resulting in a cardiac arrest during an interhospital transfer. This required aggressive resuscitation, but without success. The case represents a diagnostic dilemma in the ED regarding the diagnosis and initial management of the patient's presentation.

Effect of nitinol wire surface properties on albumin adsorption

The superelastic, shape memory alloy nitinol ( approximately 50% nickel and approximately 50% titanium) is an important medical device material used for stent applications. However, the role specific surfaces properties have in protein adsorption remain controversial. In this study the effects of nitinol wire surface roughness, hydrophobicity and elemental composition upon albumin adsorption are investigated. In particular, we demonstrate that the technique of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in the so-called surface mode can be used for the direct detection of albumin on the wire surfaces. In addition, albumin adsorbing to the wires was determined by using (125)I-labelled albumin. Albumin was detected on all wire samples. Surface roughness and hydrophobicity appeared to have no effect on albumin adsorption. There was however a clear correlation between the surface nickel and oxygen concentration and the amount of albumin adsorbed. Samples with higher levels of nickel and less oxygen in the surface oxide layer of the wires showed increased albumin adsorption, which could lead to improved biocompatibility. However, nickel is a toxic substance and can cause many adverse effects on humans, and thus nitinol with a slightly enriched surface nickel concentration that does not exhibit nickel release may have potential as a medical device material.

Is undergraduate otorhinolaryngology teaching relevant to junior doctors working in accident and emergency departments?

Undergraduate ENT teaching provides junior doctors with skills and knowledge useful for the practice of medicine. However, ENT has been removed from the curriculum of nine of the 29 medical schools in the United Kingdom, as it was not deemed relevant to general medical practice. A telephone survey was performed of 20 senior house officers working in accident and emergency (A&E) departments across the United Kingdom. The results showed that 90 per cent felt their undergraduate ENT teaching was directly beneficial to working in A&E, 75 per cent felt they had not received enough undergraduate ENT teaching and 45 per cent currently received no postgraduate teaching whilst working in A&E. These results illustrate the importance of ENT teaching in the undergraduate curriculum and its value to practising doctors. They highlight the fact that prospective studies are required to examine the effect on junior doctors of changing the curriculum.

Current provision of rheumatology education for undergraduate nursing, occupational therapy and physiotherapy students in the UK

OBJECTIVES

Rheumatological conditions are common and all health professionals (HPs) therefore need sufficient knowledge and skills to manage patients safely and effectively. The aim of this study was to examine current undergraduate education in rheumatology for HPs in the UK.

METHODS

A questionnaire was sent to curriculum organizers and clinical placement officers for all undergraduate courses in adult nursing, occupational therapy (OT) and physiotherapy (PT) in the UK to ascertain the nature and amount of rheumatology theory and clinical exposure provided.

RESULTS

Of the 47 adult nursing, 26 OT and 30 PT undergraduate courses surveyed, 85-90% responded. Overall, rheumatology teaching is 5-10 h over 3 yr. Nursing students receive moderate/in-depth teaching on rheumatoid arthritis (RA) in only 52% of courses (OT 91%, PT 96%) and on osteoarthritis (OA) in 63% (OT 91%, PT 92%). Clinical experience of RA is probably/definitely available in only 56% of nursing courses (OT 72%, PT 88%), with similar results in OA. Overall, nursing students receive the least rheumatology exposure, particularly in psychosocial issues and symptom management, while PT students receive the most. OT students have limited opportunities for clinical exposure to psychosocial and joint protection issues. Use of local rheumatology clinical HP experts is variable (18-93%) and cross-disciplinary exposure is limited (0-36%). Many educators consider their rheumatology training to be insufficient (nursing 50%, PT 42%, OT 24%).

CONCLUSIONS

Rheumatology training for undergraduate HPs is limited in key areas and often fails to take advantage of local clinical expertise, with nursing students particularly restricted. Clinical HP experts should consider novel methods of addressing these shortfalls within the limited curriculum time available.

Potentially toxic element release by fenton oxidation of sewage sludge

The presence, in sewage sludge, of excess levels of the potentially toxic elements (PTE) copper, zinc, chromium, cadmium, nickel, lead and mercury, could impact on our ability to recycle these residues in the future. Far stricter limits on the levels of PTEs are likely in proposed legislation. A method involving the dosing of Fenton's reagent, a mixture of ferrous iron and hydrogen peroxide, under acidic conditions was evaluated for its potential to reduce metal levels. The [Fe]:[H2O2] (w/w) ratio was found to give a good indication of the percentage copper and zinc elution obtainable. Sites with no iron dosing as part of wastewater treatment required extra iron to be added in order to initiate the Fenton's reaction. A significant reduction, in excess of 70%, of the copper and zinc was eluted from both raw primary and activated sludge solid fractions. Cadmium and nickel could be reduced to below detection limits but elution of mercury, lead and chromium was less than 40%. The iron catalyst concentration was found to be a crucial parameter. This process has the potential to reduce the heavy metal content of the sludge and allow the recycling of sludge to continue in a sustainable manner.

Influence of Nitinol wire surface treatment on oxide thickness and composition and its subsequent effect on corrosion resistance and nickel ion release

Medical implants and devices are now used successfully in surgical procedures on a daily basis. Alloys of nickel and titanium, and in particular Nitinol are of special interest in the medical device industry, because of their shape memory and superelastic properties. The corrosion behavior of nitinol in the body is also of critical importance because of the known toxicological effects of nickel. The stability of a NiTi alloy in the physiological environment is dependant primarily on the properties of the mostly TiO(2) oxide layer that is present on the surface. For the present study, a range of nitinol wires have been prepared using different drawing processes and a range of surface preparation procedures. It is clear from the results obtained that the wire samples with very thick oxides also contain a high nickel content in the oxide layer. The untreated samples with the thicker oxides show the lowest pitting potential values and greater nickel release in both long and short-term experiments. It was also found that after long-term immersion tests breakdown potentials increased for samples that exhibited lower values initially. From these results it would appear that surface treatment is essential for the optimum bioperformance of nitinol.

Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound

OBJECTIVE

Until recently, magnetic resonance was the only imaging method capable of assessing the levator ani in vivo. Three-dimensional (3D) ultrasound has recently been shown to be able to demonstrate the pubovisceral muscle. The aim of this study was to define the anatomy of the levator hiatus in young nulliparous women with the help of 3D ultrasound.

METHODS

In a prospective observational study, 52 nulligravid female Caucasian volunteers (aged 18-24 years) were assessed by two-dimensional (2D) and 3D translabial ultrasound after voiding whilst supine. Pelvic organ descent was assessed on Valsalva maneuver. Volumes were acquired at rest and on Valsalva maneuver, and biometric indices of the pubovisceral muscle and levator hiatus were determined in the axial and coronal planes.

RESULTS

In the axial plane, average diameters of the pubovisceral muscle were 0.4-1.1 cm (mean 0.73 cm). Average area measurements were 7.59 (range, 3.96-11.9) cm2. The levator hiatus at rest varied from 3.26 to 5.84 (mean 4.5) cm in the sagittal direction, and from 2.76 to 4.8 (mean 3.75) cm in the coronal plane. The hiatus area at rest ranged from 6.34 to 18.06 (mean 11.25) cm2 increasing to 14.05 (6.67-35.01) cm(2) on Valsalva maneuver (P = 0.009). There were significant correlations between pelvic organ mobility and hiatus area at rest (P = 0.018 to P < 0.001) and on Valsalva maneuver (all P < 0.001).

CONCLUSIONS

Biometric indices of the pubovisceral muscle and levator hiatus can be determined by 3D ultrasound. Significant correlations exist between hiatal area and pelvic organ descent. These data provide support for the hypothesis that levator ani anatomy plays an independent role in determining pelvic organ support.

Bladder neck mobility is a heritable trait

OBJECTIVE

Congenital connective tissue dysfunction may partly be responsible for female pelvic organ prolapse and urinary incontinence. We undertook a heritability study to determine whether mobility of the bladder neck, one of the main determinants of stress urinary incontinence, is genetically influenced.

DESIGN

Heritability study using a twin model and structural equation modelling.

SETTING

Queensland Institute of Medical Research, Brisbane, Australia.

POPULATION

One hundred and seventy-eight nulliparous Caucasian female twins and their sisters (46 monozygotic pairs, 24 dizygotic pairs and 38 sisters) aged 18-24 years.

METHODS

We performed translabial ultrasound, supine and after bladder emptying, for pelvic organ mobility. Urethral rotation and bladder neck descent were calculated using the best of three effective Valsalva manoeuvres.

MAIN OUTCOME MEASURES

Bladder and urethral mobility on Valsalva assessed by urethral rotation, vertical and oblique bladder neck descent.

RESULTS

Genetic modelling indicated that additive genes accounted for up to 59% of the variance for bladder neck descent. All remaining variance appeared due to environmental influences unique to the individual, including measurement error.

CONCLUSION

A significant genetic contribution to the phenotype of bladder neck mobility appears likely.

Pelvic organ descent in young nulligravid women

OBJECTIVE

There is little information available on what constitutes "normal" pelvic organ mobility. This study presents normal values for urethral, bladder, cervical, and rectal descent on Valsalva.

STUDY DESIGN

One hundred eighteen nulligravid white women aged 18 to 24 years were recruited for a prospective observational study. Translabial ultrasound was undertaken supine and after voiding, with the most effective of at least 3 Valsalva maneuvers used for evaluation.

RESULTS

Urethral rotation on Valsalva varied from 0 to +90 degrees (mean 32 degrees), bladder neck descent from 1.2 to 40.2 mm (mean 17.4 mm). The cervix descended to between 59 and 0 mm above the symphysis pubis (mean 30.8 mm); the rectal ampulla descended to between 54 mm above and 22 mm below the symphyseal margin (mean 7.8 mm). In a test-retest series, intraclass correlations were between 0.64 and 0.89, implying good-to-excellent repeatability of the ultrasound assessment.

CONCLUSION

A wide range of values was obtained for all parameters. A significant congenital contribution to the phenotype of female pelvic organ prolapse appears likely.

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery

OBJECTIVES

To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD).

DESIGN

Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility.

SETTING

Four tertiary cardiothoracic surgery centres in England.

PARTICIPANTS

Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel.

INTERVENTIONS

Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB.

MAIN OUTCOME MEASURES

The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs.

RESULTS

A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively.

CONCLUSIONS

The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

Microsatellite analysis of early stage (Ia-IIb) uterine cervical squamous carcinoma

Cervical cancer is the most common gynecologic malignancy of the developing world. The oncogenic role of human papilloma virus (HPV) is well known. Attention is now focusing on the complicit genetic changes, which allow progression of these tumors. Regarding these changes, deletion of tumor suppressor genes (loss of heterozygosity [LOH]) is the preferred pathway of progression with only a subset manifesting microsatellite instability (MSI). Implicated loci include 3p14.1-22. Several studies suggest that the mutator phenotype in cervical cancer may correlate with higher grade tumors, more advanced disease stage, and poor outcome. Unlike colorectal cancer, in which an inverse relationship has been demonstrated between microsatellite instability and loss of heterozygosity, cervical cancers expressing MSI have been found to coexpress LOH at other loci. In this study we analyzed 8-microsatellite loci including p53, DCC, APC, the MMR gene hMLH1 and 2 regions of interest on chromosome 3 in a high-risk population group in which HPV infection is endemic.

System, environmental, and policy changes: using the social-ecological model as a framework for evaluating nutrition education and social marketing programs with low-income audiences

A variety of nutrition education interventions and social marketing initiatives are being used by the Food Stamp Program to improve food resource management, food safety, dietary quality, and food security for low-income households. The Social-Ecological Model is proposed as a theory-based framework to characterize the nature and results of interventions conducted through large public/private partnerships with the Food Stamp Program. In particular, this article suggests indicators and measures that lend themselves to the pooling of data across counties and states, with special emphasis on systems, environment, and public policy change within organizations at the community and state levels.

Prescribing practices in an Irish Long Term Care Setting

The elderly constitute 11.4% of the Irish Population and are prescribed 47% GMS prescription medications. Polypharmacy is well described in studies as being the norm and not the exception in the elderly. A long term care setting represents a particular group of these patients having medical problems that are both complex in nature and copious in number. Prescribing practices have not been well documented in the Irish Long Term Care setting. We therefore determined a need to describe prescribing patterns in the Irish Long Term Care Setting. Seventy-six patients were identified in two Long Term Care units. Data collected per patient included type of diagnosis, age, and medication prescribed. Paired data was available on 52 patients at baseline and again at six months. The impact of regular consultant review on prescribing was assessed during this period. We found that the average age of the residents was 80.9 years. Female residents accounted for 75% of the patients and males 25%. There was an average of 8.8 diagnoses per patient. At baseline there was an average of 9.2 medications prescribed per patient. The vast majority of prescriptions were for CNS preparations (42%), followed by Cardiovascular (16%) Gastrointestinal (16%) and Respiratory (6%). Medication prescribed changed in nature but numerically was not reduced by regular consultant review. The number of scheduled medications did not change over six months of review, at 5.5 per patient. However there was an increase in the number of PRN prescriptions from 3.7 to 4.25 per patient. We concluded that there is a higher than expected number of medications prescribed to patients in Long Term Care. On the basis of this descriptive study we recommend that standards be set for Prescribing in Long Term Care.

A clinical, histopathological, and genetic study of Avellino corneal dystrophy in British families

AIMS

To establish a clinical, histopathological, and genetic diagnosis in two unrelated British families with Avellino corneal dystrophy (ACD).

METHODS

Genomic DNA was extracted from peripheral blood leucocytes of all members participating in the study. Exons 4 and 12 of the human transforming growth factor beta induced (BIGH3) gene were amplified by polymerase chain reaction. The mutation and polymorphism were identified by direct sequencing and restriction digest analysis. A review of the patients' clinical symptoms and signs was undertaken and a histopathological study on corneal specimen obtained from the proband of one family after keratoplasty was performed.

RESULTS

A heterozygous G to A transition at the second nucleotide position of codon 124 of BIGH3 gene was detected in all affected members of both families. This mutation changes an arginine residue to a histidine. The clinical diagnosis for ACD was more evident with advancing age. Histopathological study revealed granular deposits in the anterior stroma and occasional positive Congo red areas of amyloid deposition in the mid to deep stroma typical of ACD.

CONCLUSIONS

This is the first report of ACD families in the United Kingdom and, furthermore, of BIGH3 gene mutation in British patients with this rare type of corneal dystrophy. The results indicate that BIGH3 gene screening along with clinical and histopathological examinations is essential for the diagnosis and clinical management of corneal dystrophies.

The sugary-type isoamylase gene from rice and Aegilops tauschii: characterization and comparison with maize and arabidopsis

Genes for an isoamylase-like debranching enzyme have been isolated from rice and Aegilops tauschii, the donor of the D genome to wheat. The structures of the genes are very similar to each other and to the maize SU1 isoamylase gene and consist of 18 exons spread over approximately 7.5 kb. Southern analysis and fluorescent in situ hybridization showed the Ae. tauschii gene to be located in the proximal region of the short arm of chromosome 7D, thus showing synteny with the localization of the rice isoamylase gene on rice chromosome 8. Analysis of the expression pattern of wheat sugary isoamylase genes indicates that they are strongly expressed in the developing endosperm 6 days after flowering. Three distinct Sugary-type cDNA sequences were isolated from the wheat endosperm that are likely to correspond to the products of the three genomes. The deduced amino acid sequence of rice and wheat Sugary-type isoamylase is compared with other sequences available in the database and the results demonstrate that there are three types of isoamylase sequences in plants: those containing 18 exons (the Sugary-type isoamylase gene), those containing 21 exons, and those containing only 1 exon. It is possible that different combinations of isoamylase genes are expressed in different tissues.

Bladder neck mobility and urethral closure pressure as predictors of genuine stress incontinence

Two hundred and seventy-five consecutive patients with symptoms of lower urinary tract dysfunction underwent urodynamic evaluation, including multichannel urodynamics, urethral pressure profilometry, X-ray and ultrasound imaging. After women with previous incontinence or prolapse surgery or pelvic radiotherapy and those with evidence of urethral kinking on ultrasound had been excluded, 179 datasets were analyzed. Both bladder neck descent ( P<0.0001) and maximum urethral closure pressure ( P<0.0001) were strongly associated with a fluoroscopic diagnosis of GSI. Only weak correlations between bladder neck mobility and urethral pressure parameters (highest r = -0.17) were observed. Regression analysis yielded a mathematical model that demonstrated a wide spread of odds ratios for GSI for the measured values (from <0.2 to >100). Bladder neck descent explained 29% and urethral closure pressure 12% of overall variability. Both bladder neck mobility and maximum urethral closure pressure are strong predictors of the diagnosis of GSI, provided major confounders are excluded. Bladder neck mobility appears to be the stronger predictor.

Vaginal childbirth and bladder neck mobility

OBJECTIVE

Hypermobility of the bladder base is a predictor of stress urinary incontinence (SUI) in the female and at least partly due to pregnancy and vaginal childbirth. The purpose of this study was to quantify the effect of vaginal parity and birthweight on anterior compartment relaxation.

DESIGN

Retrospective observational study.

SETTING

Outpatient uroynaecological clinics.

POPULATION

Five hundred and seventy three women seen for primary urogynaecological assessment.

METHODS

Files of patients seen by the first author for assessment and translabial ultrasound imaging at urogynaecological units in Brisbane and Sydney, Australia, were reviewed for routinely-collected obstetric data and imaging results.

MAIN OUTCOME MEASURES

Ultrasound parameters of anterior vaginal wall descent such as urethral rotation on Valsalva manoeuvre, bladder neck position on Valsalva, bladder neck descent and maximal descent of a cystocele on Valsalva.

RESULTS

ANOVA analysis demonstrated a highly significant relationship between vaginal childbirth and bladder neck position on Valsalva (p < 0.001), bladder neck descent (p = 0.002) and maximal descent of a cystocele (p = 0.001). A large part of this effect was seen after one vaginal delivery. There was a trend towards increased bladder neck mobility (p = 0.065) with vaginal operative deliveries. Maximal recorded birthweight did not correlate with parameters of hypermobility.

CONCLUSION

Vaginal childbirth is strongly associated with increased anterior vaginal wall descent, with most of this effect being due to the first vaginal delivery.