Reducing medication errors in the neonatal intensive care unit

BACKGROUND

Medication errors are common in the neonatal intensive care unit (NICU). Various strategies to reduce errors have been described in adult and paediatric patients but there are few published data on their effect in the NICU.

AIM

To describe the medication errors occurring within an NICU, and assess the impact of a combined risk management/clinical pharmacist led education programme on these errors.

METHODS

Medication errors were identified prospectively over one year by critical incident reporting. Four months into the study, a pharmacist led education programme was instituted. This involved a daily, cot side, pharmacist led review of medication orders. Each new member of pharmacy, nursing, or medical staff was also required to successfully complete a series of dose calculations. In addition, a risk management approach was used to make several changes in practice during the study period.

RESULTS

A total of 105 errors were identified, four serious, 45 potentially serious, and 56 minor. The four serious errors included two tenfold dose miscalculations. Most (71%) of the errors were due to poor prescribing. After the introduction of our interventions, monthly medication errors fell from a mean (SD) of 24.1 (1.7) per 1000 neonatal activity days to 5.1 (3.6) per 1000 days (p < 0.001) in the following three months. The subsequent change over of junior medical staff was associated with a significant increase in medication errors to 12.2 (3.6) per 1000 neonatal activity days (p = 0.037). However, the number remained significantly less than before our interventions (p < 0.001). Three serious errors occurred in the first four months compared with one in the second eight month period, the latter corresponding to the six monthly change over of junior medical staff.

CONCLUSIONS

Medication errors are common in NICUs. Fortunately, actual harm to an infant is rare. Interventions to reduce errors, particularly within the context of a risk management programme, are effective.

Basaltic rocks analyzed by the Spirit Rover in Gusev Crater

The Spirit landing site in Gusev Crater on Mars contains dark, fine-grained, vesicular rocks interpreted as lavas. Pancam and Mini-Thermal Emission Spectrometer (Mini-TES) spectra suggest that all of these rocks are similar but have variable coatings and dust mantles. Magnified images of brushed and abraded rock surfaces show alteration rinds and veins. Rock interiors contain </=25% megacrysts. Chemical analyses of rocks by the Alpha Particle X-ray Spectrometer are consistent with picritic basalts, containing normative olivine, pyroxenes, plagioclase, and accessory FeTi oxides. Mössbauer, Pancam, and Mini-TES spectra confirm the presence of olivine, magnetite, and probably pyroxene. These basalts extend the known range of rock compositions composing the martian crust.

Surgical management of incompletely excised basal cell carcinomas of the head and neck

We made a retrospective audit of all basal cell carcinomas excised in the Maxillofacial Units at St. Richard's Hospital, Chichester and the Worthing and Southlands NHS Trust between 1990 and 1999. A total of 3795 BCCs were excised. Of these, 3560 were completely excised (93.8%) and 235 were incompletely excised (6.2%), which compares favourably with other series. Of these, 84 patients had further excision, 11 had radiotherapy, and 140 were kept under review. Residual tumour was present in 45% of the re-excised specimens. Of the 140 cases managed by observation, 21% recurred. Notably, 31% of patients in the observation cohort died of other causes without recurrence. Incomplete excision was significantly more likely (P < 0.001) if multiple lesions were excised at the time of operation. Involvement of multiple margins was not a significant risk factor for recurrence in the 'observed' cohort. This study shows that a flexible strategy, which balances observation, further excision and radiotherapy, is superior to any single approach.

[A pilot community study of subjective memory in over and under 65 years old]

Elderly adults are appropriate targets for objective memory assessment and cognitive testing in the promotion of earlier recognition of people with symptoms of a dementing process. The major change in memory with age is the decline in ability to recall things explicitly. There is a need for education of the general public and health professionals about memory impairment and its relationship with stress, depression, anxiety and dementia.

Covictimization and inner city youth: a review

Covictimization represents a real and present danger to inner city youth. This paper reviews the scope of this problem and a potential emergency mental health response.

In vitro studies indicate that acid catalysed generation of N-nitrosocompounds from dietary nitrate will be maximal at the gastro-oesophageal junction and cardia

BACKGROUND

Dietary nitrate increases saliva nitrite levels and swallowed saliva is the main source of nitrite entering the acidic stomach. In acidic gastric juice, this nitrite can generate potentially carcinogenic N-nitrosocompounds. However, ascorbic acid secreted by the gastric mucosa can prevent nitrosation by converting the nitrite to nitric oxide.

METHODS

To study the potential for N-nitrosocompound formation in a model simulating salivary nitrite entering the acidic stomach and the ability of ascorbic acid to inhibit the process. Concentrations of ascorbic acid, total vitamin C, nitrite, nitrosomorpholine, oxygen and nitric oxide were monitored during the experiments.

RESULTS

The delivery of nitrite into HCl containing thiocyanate resulted in nitrosation of morpholine, with the rate of nitrosation being greatest at pH 2.5. Under anaerobic conditions, ascorbic acid converted the nitrite to nitric oxide and prevented nitrosation. However, in the presence of dissolved air, the ascorbic acid was ineffective at preventing nitrosation. This was due to the nitric oxide combining with oxygen to reform nitrite and this recycling of nitrite depleting the available ascorbic acid. Further studies indicated that the rate of consumption of ascorbic acid by nitrite added to natural human gastric juice (pH 1.5) was extremely rapid with 200 micromol/l nitrite consumed 500 micromol/l ascorbic acid within 10 s.

CONCLUSIONS

The rapid consumption of ascorbic acid in acidic gastric juice by nitrite in swallowed saliva indicates that the potential for acid nitrosation will be maximal at the GO junction and cardia where nitrite first encounters acidic gastric juice. The high incidence of mutagenesis and neoplasia at this anatomical location may be due to acid nitrosation arising from dietary nitrate.

Wheat germ supplement reduces cyst and trophozoite passage in people with giardiasis

The protozoan parasite Giardia lamblia is a major cause of waterborne enteric disease worldwide. Lectins are proteins that bind to carbohydrate (sugar) moieties. Potential targets for lectins are found on the surface of most single-celled organisms. Modest concentrations of wheat germ agglutinin (WGA) have been shown to inhibit G. lamblia excystation and trophozoite growth in vitro and can reduce cyst passage in mice infected with the closely related protozoan parasite, G. muris. Commercial preparations of wheat germ (WG) contain 13-53 microg of WGA per gram. We performed a double-masked, placebo-controlled study of dietary supplementation with WG in 63 subjects with giardiasis in Montreal and Lima (25 asymptomatic patients passing cysts; 38 patients with symptoms). Asymptomatic subjects received WG (2 g, 3 times a day) or placebo (cornstarch, 2 g, 3 times a day) for 10 days, followed by metronidazole (250 mg 3 times a day) for 7 days. Symptomatic subjects received metronidazole (250 mg 3 times a day) plus either WG or placebo for 7 days. Stool specimens were collected every day (Montreal) or every other day (Lima) for 10 days and on Day 35 for microscopic examination and coproantigen determination. Subjects kept a diary of symptoms for 10 days after recruitment. In asymptomatic subjects, both cyst passage and coproantigen levels were reduced by approximately 50% in those taking WG compared with the placebo group (P < 0.01 and P = 0.06, respectively). In symptomatic subjects, cyst passage and coproantigen levels fell precipitously in response to metronidazole therapy, and there were no clinically important differences between those receiving supplemental WG or placebo. However, symptoms appear to have resolved more rapidly in the subjects taking WG in addition to metronidazole. The WG supplement was well tolerated in both symptomatic and asymptomatic subjects. These data suggest that components of WG, possibly WGA, either alone or in combination with antiprotozoal agents, can influence the course of human giardiasis.

Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder

It appears that many individuals with body dysmorphic disorder (BDD) receive nonpsychiatric medical treatment and surgery; however, this topic has had little systematic investigation. This study assessed the nonpsychiatric treatment sought and received by 289 individuals (250 adults and 39 children/adolescents) with DSM-IV BDD. Such treatment was sought by 76.4% and received by 66.0% of adults. Dermatologic treatment was most often received (by 45.2% of adults), followed by surgery (by 23.2%). These treatments rarely improved BDD symptoms. Results were similar in children/adolescents. These findings indicate that a majority of patients with BDD receive nonpsychiatric treatment but tend to respond poorly.

Genetic correlation between the P300 event-related brain potential and the EEG power spectrum

Previous studies have demonstrated moderate heritability of the P300 component of event-related brain potentials (ERPs) and high heritability of background electroencephalogram (EEG) power spectrum. However, it is unclear whether EEG and ERPs are influenced by common or independent genetic factors. This study examined phenotypic and genetic correlations between EEG spectral power and P300 amplitude using data from 206 Dutch twin pairs, age 16 years. Multivariate genetic models (Cholesky decomposition) were fitted to the observed twin covariances using Mx software. In males, genetic correlations between P300 and EEG power measures were high (0.54-0.74); 30% of the total P300 variance could be explained by genetic factors influencing EEG delta power and 26% by P300-specific genetic factors (total heritability 56%). In females, 45% of P300 variance could be attributed to familial influences that were shared with the EEG. However, it was not possible to distinguish between the genetic versus shared environmental factors, consistent with previous analysis of P300 in this sample (van Beijsterveldt et al., 1998). The results suggest that a substantial proportion of genetic influences on P300 amplitude can be explained by strong heritability of slow EEG rhythms contributing to P300.

Learning to read in Williams syndrome: looking beneath the surface of atypical reading development

In this paper, we make a fundamental distinction between literacy attainment scores and the actual process of learning to read, and examine these two aspects of reading in atypical development. Reading skills in a group of children and adults with the genetic disorder Williams syndrome (WS) were compared to a group of typically developing children matched for reading age and receptive vocabulary scores. Study 1 focused on the product of reading and explored the relationship between reading, general cognition, and phonological skills. Phonological skills were shown to be related to individual differences in reading attainment in both groups, although more weakly in the WS group. Experiment 2 examined the process of learning to read. The two groups were taught to associate abbreviated spellings (cues) with spoken words. The cues differed in their phonetic closeness to the target words, whereas the target words differed on the semantic variable of imageability. Compared to controls, the WS group showed slower learning, less sensitivity to the phonetic quality of the cue, and reduced influence from the imageability of words. The results support the hypothesis that although reading levels in WS depend on phonological skills, the full development of their reading is compromised by weak semantics. The studies highlight the importance in atypical populations of examining both reading levels and the actual process of learning to read.

International gastroenterology research: subject areas, impact, and funding

AIMS

To examine the volume and potential impact of gastroenterology research outputs from 1985 to 1998 from 14 developed countries; the overlap with research in cancer, infectious diseases, and genetics; and the funding sources for this research. To determine if countries' research outputs correlated with their burden of corresponding diseases and inputs to their research.

METHODS

Selective retrieval of papers from the Science Citation Index and manual look up of a sample to determine funding sources. Classification of journals by four categories of research level (clinical/basic) and potential impact (low/high).

RESULTS

Gastroenterology represents about 8% of world biomedical research but over 11% in Italy, Japan, and Spain. Its potential impact is highest (but declining) for the USA. It has increased noticeably in most European countries, particularly in Finland. Gastroenterology research has become more clinical in Japan, Spain, Australia, and the Netherlands but more basic in Canada, Germany, Finland, Israel, and South Africa. Funding comes primarily from national governments, followed by national private non-profit sources and industry but little industrial funding occurs in some countries. There is a strong and positive correlation between reported deaths from gastrointestinal neoplasms and countries' outputs of research in gastrointestinal oncology.

CONCLUSIONS

Bibliometric analysis can reveal differences between countries in their research in a subject when a common methodology is applied to an international database. Variations in research methods in different countries can plausibly explain some of the variation in the potential impact of the work.

Effect of acute exposure to ammonia on glutamate transport in glial cells isolated from the salamander retina

A rise of brain ammonia level, as occurs in liver failure, initially increases glutamate accumulation in neurons and glial cells. We investigated the effect of acute exposure to ammonia on glutamate transporter currents in whole cell clamped glial cells from the salamander retina. Ammonia potentiated the current evoked by a saturating concentration of L-glutamate, and decreased the apparent affinity of the transporter for glutamate. The potentiation had a Michaelis-Menten dependence on ammonia concentration, with a K(m) of 1.4 mM and a maximum potentiation of 31%. Ammonia also potentiated the transporter current produced by D-aspartate. Potentiation of the glutamate transport current was seen even with glutamine synthetase inhibited, so ammonia does not act by speeding glutamine synthesis, contrary to a suggestion in the literature. The potentiation was unchanged in the absence of Cl(-) ions, showing that it is not an effect on the anion current gated by the glutamate transporter. Ammonium ions were unable to substitute for Na+ in driving glutamate transport. Although they can partially substitute for K+ at the cation counter-transport site of the transporter, their occupancy of these sites would produce a potentiation of < 1%. Ammonium, and the weak bases methylamine and trimethylamine, increased the intracellular pH by similar amounts, and intracellular alkalinization is known to increase glutamate uptake. Methylamine and trimethylamine potentiated the uptake current by the amount expected from the known pH dependence of uptake, but ammonia gave a potentiation that was larger than could be explained by the pH change, and some potentiation of uptake by ammonia was still seen when the internal pH was 8.8, at which pH further alkalinization does not increase uptake. These data suggest that ammonia speeds glutamate uptake both by increasing cytoplasmic pH and by a separate effect on the glutamate transporter. Approximately two-thirds of the speeding is due to the pH change.

Acceptability of marketing in health services

There is more to the operation of health care than patients and doctors. Alternative sources of income may be derived from taking a broader view of the marketing function. The overall success of a health facility's total operation may be affected by the administrator's view of the role and view of marketing.

Effects of excess vitamin A on development of cranial neural crest-derived structures: a neonatal and embryologic study

BACKGROUND

Vitamin A and its metabolites have been shown to be teratogenic in animals and humans producing defects of neural crest derived structures that include abnormalities of the craniofacial skeleton, heart, and thymus. Our prior studies with retinoic acid have established that gestational day (gd) 9 is a sensitive embryonic age in the mouse for inducing craniofacial and thymic defects.

METHODS

We exposed pregnant mice to variable doses of vitamin A (retinyl acetate) on gd 9 and embryos were evaluated for changes in developing pharyngeal arch and pouch morphology, neural crest cell migration and marker gene expression. Additionally, we investigated whether a single organ system was more sensitive to low doses of vitamin A and could potentially be used as an indicator of vitamin A exposure during early gestation.

RESULTS

High (100 mg/kg) and moderate (50 and 25 mg/kg) doses of vitamin A resulted in significant craniofacial, cardiac outflow tract and thymic abnormalities. Low doses of vitamin A (10 mg/kg) produced craniofacial and thymic abnormalities that were mild and of low penetrance. Exposed embryos showed morphologic changes in the 2nd and 3rd pharyngeal arches and pouches, changes in neural crest migration, abnormalities in cranial ganglia, and altered expression of Hoxa3.

CONCLUSIONS

These animal studies, along with recent epidemiologic reports on human teratogenicity with vitamin A, raise concerns about the potential for induction of defects (perhaps subtle) in offspring of women ingesting even moderate to low amounts of supplemental vitamin A during the early gestational period.

Evaluating "payback" on biomedical research from papers cited in clinical guidelines: applied bibliometric study

OBJECTIVES

To develop a methodology for evaluating the impact of research on health care, and to characterise the papers cited on clinical guidelines.

DESIGN

The bibliographic details of the papers cited in 15 clinical guidelines, developed in and for the United Kingdom, were collated and analysed with applied bibliometric techniques.

RESULTS

The median age of papers cited in clinical guidelines was eight years; most papers were published by authors living in either the United States (36%) or the United Kingdom (25%)-this is two and a half times more than expected as about 10% of all biomedical outputs are published in the United Kingdom; and clinical guidelines do not cite basic research papers.

CONCLUSION

Analysis of the evidence base of clinical guidelines may be one way of tracking the flow of knowledge from the laboratory to the clinic. Moreover, such analysis provides a useful, clinically relevant method for evaluating research outcomes and different strategies in research and development.

Watching anaesthetists work: using the professional judgement of consultants to assess the developing clinical competence of trainees

One of the responsibilities of a consultant is to identify the clinical competence of trainees by observing them at work. The attributes of clinical competence in anaesthesia were defined by interviewing a group of consultants and trainees. Observation of practice was believed to be important in monitoring competence and the supervising consultants all believed that they could recognize competent performance. The account of the structure of observation provided by the anaesthetists is used as the basis of advice on how to conduct an assessment of trainees' developing professionalism by use of the specialist's professional judgement.

Effect of hepatobiliary disease, chronic hepatitis C and hepatitis B virus infections and interferon-alpha on porphyrin profiles in plasma, urine and faeces

BACKGROUND

Documentation of the profiles of porphyrins in hepatobiliary disease is limited. Strong associations of hepatitis B and C virus infections with porphyria cutanea tarda have suggested causal relationships. This study aimed to determine the nature of porphyrin abnormalities in hepatobiliary disease and the effect of interferon-alpha on porphyrin profiles.

METHODS

Total porphyrins were measured in the plasma, urine and faeces of 83 patients with hepatobiliary disease (37 hepatitis C, 20 hepatitis B, 26 other causes) and 12 clinical controls, and porphyrin profiles were determined by high-performance liquid chromatography.

RESULTS

Porphyrins were elevated in the plasma of 11 and urine of 23 patients with hepatobiliary disease, as a result of elevated coproporphyrin I. This was reflected in increased coproporphyrin I:III ratios. Abnormal total porphyrin levels had a significant negative correlation with plasma albumin, and a positive correlation with bilirubin and alkaline phosphatase, but not with aminotransferases. Total urinary porphyrins were elevated in three control patients, but coproporphyrin I:III ratios were normal. Although not seen in plasma or urine, porphyrins that are specific for porphyria cutanea tarda were found in the faeces of six patients, but this occurred with similar frequency in hepatitis B or C infection (four of 50) as in the clinical controls (two of 12). Interferon-alpha had no effect during or after therapy in six patients with hepatitis C.

CONCLUSIONS

Reduced biliary excretion of coproporphyrin I occurs in more severe cholestasis and/or hepatic dysfunction. A causal relationship between viral liver disease and porphyria cutanea tarda which is unlikely to be precipitated by interferon-alpha, is not supported.

Multiple recurrent gram-negative cerebrospinal fluid shunt infections associated with a patient with a retained ventricular foreign body

A 3-year-old boy experienced 10 recurrent gram-negative ventriculoperitoneal shunt (VPS) infections with identical strains over a 17-month period. Multiple cranial MRI and CT scans to identify a retained foreign body were negative. CT myelography and pressure infusion radionuclide cisternography were also unhelpful. Ventriculoscopy revealed a small retained foreign body which was successfully removed, and cultures subsequently yielded gram-negative organisms identical to the previously identified bacteria by pulsed field gel electrophoresis. No further infections were noted after removal of the retained fragment. Exploratory ventriculostomy should be considered in patients with recurrent VPS infections where other techniques fail to reveal a cause.

Genetic and environmental influences on forced expiratory volume in midlife: a cross-cultural replication

Previous research has shown that forced expiratory volume (FEV) is a useful predictor of remaining life in older adults. The present analyses are an attempt to replicate results from a study of Swedish twins which demonstrated substantial heritability of FEV with a sample of middle-aged Russian adult twins. Data were collected from 116 pairs of Russian twins (monozygote = 71, dizygotic = 45, mean age = 40.9 years). Phenotypic correlations between FEV, age, gender, height, and cigarette consumption (in pack years) were all significant, ranging from -.72 to .31. After the effects of age, gender, height, and smoking were partialled out of FEV, quantitative genetic analyses were conducted. Shared environmental effects were significant, accounting for 47% of the variance in FEV. Genetic effects, which accounted for about 28% of the variance, could be dropped from the model without a significant decrease in the fit. These results are discussed in relation to previous research conducted in other countries.

Heterogeneity of chemosensitivity of metastatic cutaneous melanoma

Advanced melanoma has a poor prognosis and chemotherapy provides little benefit for most patients. This may be related to heterogeneity of chemosensitivity as well as frequent constitutive resistance to individual cytotoxic drugs. We have therefore examined the heterogeneity of chemosensitivity in metastatic cutaneous melanoma specimens using an ex vivo ATP-based chemosensitivity assay (ATP-TCA). Melanoma deposits (n=55) in skin or lymph node were tested using the ATP-TCA, performed in three separate laboratories. Analysis of the data collected (based on an arbitrary sensitivity index < 300) shows considerable heterogeneity of chemosensitivity. The most active single cytotoxic agents in the assay were identified as cisplatin, treosulfan, paclitaxel, vinblastine, gemcitabine and mitoxantrone. There was also a limited direct inhibition of melanoma cell growth by interferon-alpha2b, although this agent is known to have a number of indirect biological antitumor effects. Exposure of tumor cells to combinations of drugs at the concentrations tested as single agents showed the most active combinations to be treosulfan+gemcitabine, cisplatin+paclitaxel and vinblastine+paclitaxel. There was considerable heterogeneity of chemosensitivity: some tumors responded well to one agent or combination, while others showed no response to this and instead responded to one of the alternatives tested. Occasional highly resistant tumors showed no response to any of the single agents or combinations tested. The degree of heterogeneity observed suggests that the ATP-TCA could be used to select patients who might benefit from specific chemotherapeutic agents alone or in combination. This provides the rationale for future randomized controlled trials of ATP-TCA-directed chemotherapy versus physician's choice to determine whether assay-directed chemotherapy can improve patient response and survival.

Approaches to experiential learning, course delivery and validation in medicine. A background document

Educational models and approaches change over time in their dominance and use, offering a wide selection to educational planners and teachers. This paper discusses aspects of experiential learning, distance learning, learning contracts, portfolios, reflection, appraisal, assessment and validation of education. It offers triggers to further thought and enables the analysis of current educational practice.

Williams syndrome: use of chromosomal microdeletions as a tool to dissect cognitive and physical phenotypes

In Williams syndrome (WS), a deletion of approximately 1.5 Mb on one copy of chromosome 7 causes specific physical, cognitive, and behavioral abnormalities. Molecular dissection of the phenotype may be a route to identification of genes important in human cognition and behavior. Among the genes known to be deleted in WS are ELN (which encodes elastin), LIMK1 (which encodes a protein tyrosine kinase expressed in the developing brain), STX1A (which encodes a component of the synaptic apparatus), and FZD3. Study of patients with deletions or mutations confined to ELN showed that hemizygosity for elastin is responsible for the cardiological features of WS. LIMK1 and STX1A are good candidates for cognitive or behavioral aspects of WS. Here we describe genetic and psychometric testing of patients who have small deletions within the WS critical region. Our results suggest that neither LIMK1 hemizygosity (contrary to a previous report) nor STX1A hemizygosity is likely to contribute to any part of the WS phenotype, and they emphasize the importance of such patients for dissecting subtle but highly penetrant phenotypes.

Etretinate therapy for refractory sclerodermatous chronic graft-versus-host disease

Chronic graft-versus-host disease (GVHD) is the most common late complication of allogeneic bone marrow transplantation (BMT). The sclerodermatous form of the disease is often refractory to standard treatment modalities. Based on reports of response to etretinate, a synthetic retinoid, among patients with scleroderma, we have added etretinate to the treatment regimen of 32 patients with refractory sclerodermatous chronic GVHD. This case series is comprised mainly of patients who had chronic GVHD of long duration (median of 30 months before the initiation of etretinate). Most had failed to respond to three or more agents before etretinate treatment was started. Clinical response was assessed after 3 months of therapy. Five patients did not complete a 3-month trial. Among the 27 patients evaluable for response, 20 showed improvement including softening of the skin, flattening of cutaneous lesions, increased range of motion, and improved performance status. Four showed no response after 3 months of therapy and 3 had progression of their sclerosis. Overall, etretinate has been fairly well tolerated in our patients, with skin breakdown and/or ulceration leading to its discontinuation in 6 patients. We believe the results in our patients are encouraging and suggest that further evaluation of etretinate in the treatment of sclerodermatous chronic GVHD is warranted.

Effect of pravastatin on cardiovascular events in older patients with myocardial infarction and cholesterol levels in the average range. Results of the Cholesterol and Recurrent Events (CARE) trial

BACKGROUND

A majority of all myocardial infarctions occur in patients who are 65 years of age or older and have average cholesterol levels, but little information is available on whether cholesterol lowering in such patients reduces the rate of recurrent cardiovascular disease.

OBJECTIVE

To determine whether pravastatin reduces the rate of recurrent cardiovascular events in older patients.

DESIGN

Subset analysis of a randomized, controlled trial.

SETTING

80 hospitals and affiliates in the United States and Canada.

PATIENTS

1283 patients aged 65 to 75 years who had had myocardial infarction and had a plasma total cholesterol level less than 6.2 mmol/L (240 mg/dL) and a low-density lipoprotein cholesterol level of 3.0 to 4.5 mmol/L (115 to 174 mg/dL).

INTERVENTION

Pravastatin, 40 mg/d, or placebo.

MEASUREMENTS

Five-year event rates of major coronary events (coronary death, nonfatal myocardial infarction, angioplasty, or bypass surgery) and stroke.

RESULTS

Major coronary events occurred in 28.1% of placebo recipients and 19.7% of pravastatin recipients (difference, 9.0 percentage points [95% CI, 4 to 13 percentage points]; relative risk reduction, 32%; P < 0.001). Coronary death occurred in 10.3% of the placebo group and in 5.8% of the pravastatin group (difference, 4.6 percentage points [CI, 1.9 to 6.5 percentage points]; relative risk reduction, 45%; P = 0.004). Stroke incidence was 7.3% in the placebo group and 4.5% in the pravastatin group (absolute reduction, 2.9 percentage points [CI, 0.3 to 4.5 percentage points]; relative reduction, 40%; P = 0.03). The numbers of older patients needed to treat for 5 years were 11 (CI, 8 to 24) to prevent a major coronary event and 22 (CI, 15 to 53) to prevent a coronary death. For every 1000 older patients treated, 225 cardiovascular hospitalizations would be prevented compared with 121 hospitalizations in 1000 younger patients.

CONCLUSIONS

In older patients with myocardial infarction and cholesterol levels in the average range, pravastatin is associated with a clinically important reduction in risk for major coronary events and stroke. Given the high cardiovascular event rate in older patients, the potential for absolute benefit in this age group is substantial.

The history of neurological surgery at Northwestern University

The residency program in neurological surgery at Northwestern University was founded in 1924 by Loyal Davis and was formally accredited by the American Board of Neurological Surgery in 1946. Allen Kanavel, mentor to Davis, was one of the original members of the Society of Neurological Surgeons. Five individuals have served as chief of neurosurgery at Northwestern: Davis, Paul Bucy, Anthony Raimondi, Albert Butler, and H. Hunt Batjer. Davis was the first surgeon west of the Appalachians to limit his work to neurosurgery. Between 1954 and 1963, there were two independent neurosurgery residency programs at Northwestern, one headed by Davis and the other by Bucy. A master surgeon and superb teacher, Bucy trained more than 65 residents and became one of the greatest authors and leaders in the field of neurosurgery. Neurosurgical training at Northwestern has traditionally emphasized excellence of patient care, strong resident and student teaching, and basic science research. Through the years, a major strength of the program has been its clinical volume and diversity. Four hospitals have played major roles in the program: Northwestern Memorial Hospital (created by the merger of Chicago Wesley Memorial Hospital and Passavant Memorial Hospital), Children's Memorial Hospital, Evanston Hospital, and the Veterans Administration Lakeside Hospital. This article traces the development of neurological surgery at Northwestern, with an emphasis on its historical background and the contributions of Kanavel, Davis, and Bucy. The present philosophy and structure of the training program and the program's future under the direction of Batier are also described.

Burns of children caused by electric stoves

During a 2-year period, eight patients sustained burns caused by the tipping over of electric stoves. In seven of these cases, children aged 2 to 4 years stood up on the open oven door of a stove. The stove then tipped forward, and a pot of boiling liquid on the stove spilled onto the child, who fell forward across the oven door. The general area of involvement was back and buttocks, with spattered areas elsewhere on the body. In one other case, an older child, aged 8, sat on the open oven door and was burned when a pot fell on him. The weight of the children ranged from 12.7 to 20 kilograms, with a mean of 15.2 kilograms. The 8-year old weighed 14.9 kilos. Burn size ranged from 3% to 30%, with a mean of 16.75%. All burns were second-degree and were treated by debridement and coverage with either porcine grafts or Biobrane (Dow Hickman Pharmaceuticals, Inc.). Healing was satisfactory in all cases. Hospital stay ranged from 2 to 20 days. The increase in the use of electric stove has led to a situation in which children, usually toddlers, can overbalance the stove and bring down the pots sitting on the heating elements. This represents another mechanism by which young children can be injured in the kitchen; the awareness of this should be disseminated.

Brain biochemistry in Williams syndrome: evidence for a role of the cerebellum in cognition?

OBJECTIVE

To determine what biochemical changes may occur in the brain in Williams syndrome (WS) and whether these changes may be related to the cognitive deficits.

BACKGROUND

WS is a rare, congenital disorder with a characteristic physical, linguistic, and behavioral phenotype with known cognitive deficits.

METHODS

We obtained 31P magnetic resonance spectra (MRS) from a region consisting of mostly frontal and parietal lobe of 14 patients with WS (age, 8 to 37 years) and 48 similarly-aged controls. 1H MRS (27 cm3) localized to the left cerebellum obtained from the WS cohort were compared with those from 16 chronological age- and sex-matched normal controls. A battery of cognitive tests were administered to all subjects undergoing 1H MRS.

RESULTS

WS brains exhibited significant biochemical abnormalities. All 31P MRS ratios containing the phosphomonoester (PME) peak were significantly altered in WS, suggesting that PME is significantly decreased. Ratios of choline-containing compounds and creatine-containing compounds to N-acetylaspartate (Cho/NA and Cre/NA) were significantly elevated in the cerebellum in WS cf. controls, whereas the ratio of Cho/Cre was not altered. This suggests a decrease in the neuronal marker N-acetylaspartate in the cerebellum. Significant correlations were found between the cerebellar ratios Cho/NA and Cre/NA and the ability of all subjects at various neuropsychological tests, including Verbal and Performance IQ, British Picture Vocabulary Scale, Ravens Progressive Matrices, and Inspection Time.

CONCLUSIONS

The correlations can be interpreted in two ways: 1) Our sampling of cerebellar biochemistry reflects a measure of "global" cerebral biochemistry and is unrelated to cerebellar function, or 2) The relations indicate that cerebellar neuronal integrity is a requirement (on a developmental time scale or in real-time) for ability on a variety of cognitive tests.

A demographic and health survey of Spanish female sex workers: HIV prevalence and associated risk factors

In order to examine the prevalence of HIV infection and associated risk factors amongst Spanish female prostitutes a multicentre (n = 22) cross-sectional study was conducted between November 1989 and January 1991. Data collected included socioeconomic characteristics, sexual behavior and health status together with blood samples. A total of 1633 prostitutes were recruited into the study. Of these, 1433 (87.8%) consented to blood samples being taken and 180 (12.6%) were HIV positive. HIV seroprevalence was 54.7% for intravenous drug users (IVDUs) versus 3.7% for non-IVDUs. Previous imprisonment, hepatitis B and a partner who was an IVDU were significant predictors of HIV infection according to multivariate logistic regression models.

Quantitative structure-activity relationship studies of a series of sulfa drugs as inhibitors of Pneumocystis carinii dihydropteroate synthetase

Sulfone and sulfanilamide sulfa drugs have been shown to inhibit dihydropteroate synthetase (DHPS) isolated from Pneumocystis carinii. In order to develop a pharmacophoric model for this inhibition, quantitative structure-activity relationships (QSAR) for sulfa drugs active against DHPS have been studied. Accurate 50% inhibitory concentrations were collected for 44 analogs, and other parameters, such as partition coefficients and molar refractivity, were calculated. Conventional multiple regression analysis of these data did not provide acceptable QSAR. However, three-dimensional QSAR provided by comparative molecular field analysis did give excellent results. Upon removal of poorly correlated analogs, a data set of 36 analogs, all having a common NHSO2 group, provided a cross-validated r2 value of 0.699 and conventional r2 value of 0.964. The resulting pharmacophore model should be useful for understanding and predicting the binding of DHPS by new sulfa drugs.