A stratified response system for the emergency management of the severely injured

A decade ago, there were justifiable criticisms of the delivery of emergency care for injured patients in accident and emergency departments in the UK. To address this, a trauma management system was developed in 1991 at Alder Hey Hospital, Liverpool. This includes a trauma team, communication system, management guidelines and quality assurance. On admission to the accident and emergency department, injured patients are triaged to one of three levels of injury severity, and a multidisciplinary team lead by a paediatric surgeon or senior accident and emergency department physician is activated. The level of injury severity determines the composition of the trauma team. A care pathway based on ATLS/APLS principles has been developed. The response process as well patient management are documented and reviewed at a monthly audit meeting. Currently, more than 80% of eligible patients are managed using the trauma system, with an over-triage rate of about 25%. Regular modifications to the trauma system since its inception in 1991 have resulted in an efficient and effective management structure. Stratification of the trauma response has minimised unnecessary use of the multidisciplinary trauma team and ensures that mobilisation and use of hospital staff and resources are tailored to the needs of the injured patient. Although developed in a specialist children's hospital, the system could be adapted for any acute hospital.

The treatment of convulsive status epilepticus in children. The Status Epilepticus Working Party, Members of the Status Epilepticus Working Party

There is currently little agreement between hospital protocols when treating convulsive status epilepticus in children, and a working party has been set up to produce a national evidence based guideline for treating this condition. This four step guideline is presented in this paper. Its effectiveness will be highlighted and its use audited in a number of centres.

Sleep apnea

Progress continues in the refinement of historical and physical examination findings predictive of sleep-disordered breathing. Home monitoring is becoming more widely accepted and validated. The most significant development in the diagnosis of sleep-disordered breathing this year was the American Academy of Sleep Medicine's report on "Recommendations for syndrome definition and measurement techniques in clinical research." In this report, hypopnea and respiratory effort related arousal are defined, and the term obstructive sleep apnea is appropriately changed to obstructive sleep apnea-hypopnea syndrome. Because of the importance of this report, we discuss the recommendations in detail.

Personality type and neural circulatory control

Psychosocial factors, including type A personality, anger, hostility, and anxiety, have been implicated in the pathogenesis of cardiovascular disease. Abnormal sympathetic responses to stress may help explain the link between certain behavior patterns and cardiovascular disease. We tested the hypothesis that in normal humans, type A personality characteristics are associated with exaggerated heart rate, pressor, and sympathetic nerve responses to mental and physical stress. We measured heart rate, blood pressure, and muscle sympathetic nerve activity (obtained with direct intraneural recordings) at rest and during stress in 45 healthy subjects (19 men and 26 women, age 29.2+/-8.7 years) who had no chronic diseases and were taking no medications. Subjects were divided into tertiles based on type A scores. There were no significant differences in sympathetic or hemodynamic reactivity among the 3 different intensity levels of type A characteristics. Baseline measures and responses to stress tests were similar across the 3 groups. Sympathetic and hemodynamic changes during stress tests were also similar in subject groups stratified according to anger scale and cynicism scale. Sympathetic nerve and hemodynamic measurements at rest and during stress were not different in normal subjects with type A characteristics. Abnormalities in sympathetic or cardiovascular reactivity are unlikely to be implicated in any excess of cardiovascular disease in people with type A personality characteristics.

Loss of estrogen receptor (ER) expression in endometrial tumors is not associated with de novo methylation of the 5' end of the ER gene

Normal endometrium, an estrogen-responsive tissue, expresses the estrogen receptor (ER) alpha gene. Loss of ER expression, the basis for which is currently unknown, is often seen in advanced stage, poor prognosis endometrial tumors. The ER gene undergoes de novo methylation with high frequency in a wide variety of human tumors, including ER-negative breast cancers. In this study, we used several bisulfite-based detection methods to assess whether loss of ER positivity in endometrial tumors is associated with aberrant methylation of the ER gene. Although extensive methylation of a 600-bp region at the 5' end of the gene was seen in two endometrial carcinoma cell lines, none of the 55 CpGs in this region was methylated in 25 of 26 ER-deficient endometrial carcinomas.

International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.

Epidemiology of restless legs symptoms in adults

BACKGROUND

Restless legs syndrome (RLS) is a disorder characterized by sleep-disrupting unpleasant leg sensations, often accompanied by daytime behavioral problems. Treatment for this condition is available, but it is suspected that most instances of RLS remain undiagnosed. The goal of this investigation was to assess the prevalence and health status correlates of restless legs symptoms (hereinafter referred to as restless legs) in the general population.

METHODS

A question reflecting the clinical features of RLS was added to the 1996 Kentucky Behavioral Risk Factor Surveillance Survey. Data on the frequency of experiencing restless legs, self-rated general and mental health status, demographics, and behavioral risk factors were collected by telephone interview from 1803 men and women, 18 years and older.

RESULTS

Experiencing restless legs 5 or more nights per month was reported by 3% of participants aged 18 to 29 years, 10% of those aged 30 to 79 years, and 19% of those 80 years and older. The age-adjusted prevalence for Kentucky adults is 10.0%; prevalence did not vary significantly by sex. The adjusted odds ratios (95% confidence intervals) for restless legs and diminished general health and poor mental health status were 2.4 (1.4-4.0) and 3.1 (2.0-4.6), respectively. Restless legs were significantly associated with increased age and body mass index, lower income, smoking, lack of exercise, low alcohol consumption, and diabetes.

CONCLUSIONS

The prevalence of restless legs in the general adult population is high. Restless legs may be associated with decreased well-being, emphasizing the need for further research and greater medical recognition of this condition.

Environmental factors can confound identification of a major gene effect: results from a segregation analysis of a simulated population of lung cancer families

Proper control of environmental factors can be crucial to the identification of genes that influence susceptibility to a complex trait, especially for a trait such as lung cancer, for which the environmental factor (smoking) accounts for a significant etiologic fraction of the disease. An earlier segregation analysis of 337 Louisiana families, which incorporated direct measure of tobacco consumption, provided evidence for autosomal codominant inheritance of a major gene that influenced age at onset of lung cancer. Subsequent analyses were performed in which the families were stratified into two subsets based on birth cohort of the proband; results suggested the presence of heterogeneity that were postulated to reflect the influence of cohort trends in tobacco consumption. To evaluate this hypothesis further, we simulated a population of three-generation pedigrees in which an autosomal dominant mode of susceptibility to lung cancer was transmitted, but tobacco use varied across generations corresponding to published trends in smoking. A total of 200,000 individuals in families of various sizes, ages, and cigarette smoking habits were simulated from 1900 to 1980. From this population, 324 families (2,405 individuals) with 380 cases of lung cancer were ascertained through 328 lung cancer probands. Complex segregation analysis was performed using the REGTL program of S.A.G.E. in which pack-years of tobacco exposure were incorporated directly into the likelihood calculations. Although the no major gene, environmental, and Mendelian recessive hypotheses were rejected, both dominant and codominant transmission provided a good fit to the data. Thus in a population of simulated families with autosomal dominant susceptibility to lung cancer, intergenerational differences in tobacco consumption led to the detection of autosomal codominant transmission as an acceptable hypothesis. These results underscore the potential danger of segregation analysis of complex traits in which exposure to known environmental influences may differ across generations.

Quality Enhancement Research Initiative for human immunodeficiency virus/acquired immunodeficiency syndrome: framework and plan. HIV-QUERI Executive Committee

The Veterans Health Administration (VHA) sees approximately equal to 17,000 human immunodeficiency virus (HIV)-infected patients each year, which makes it the largest provider of HIV care in the United States. HIV causes chronic progressive disease that leads to early death. Newer combination antiretro viral treatments are effective but expensive and difficult to use. The HIV Quality Enhancement Research Initiative (HIV-QUERI) uses the QUERI process to identify high-risk and high-volume populations (step 1), which includes those already under VHA care for HIV, those who do not know of their infection, and those at risk for HIV. In identifying best practices (step 2), the HIV-QUERI will benefit greatly from existing guidelines for the care of established HIV infection, but gaps in knowledge regarding adherence to medication regimens and cost-effective screening are large. To identify existing practice patterns (step 3), the HIV-QUERI will develop a clean analytic data set based on Immunology Case Registry files and expand it through a survey of veterans. Interventions to improve care (step 4) will include national, regional, and site-specific feedback on performance relative to quality standards, as well as patient-level and provider-level interventions to improve adherence and support medical decision-making. To document that best practices improve outcomes and quality of life (steps 5 and 6), HIV-QUERI will track indicators on an ongoing basis by use of the Immunology Case Registry database and possible future waves of the survey. In addition, we will require that these issues be addressed in evaluations of HIV-QUERI interventions. In the present article, we present these steps within a framework and plan.

Sleep medicine practices, training, and attitudes: a wake-up call for pulmonologists

STUDY OBJECTIVES

To determine attitudes and knowledge about sleep medicine among chest physicians.

DESIGN

: Interactive survey of self-selected respondents.

SETTING

Interactive session at the 1998 American College of Chest Physicians (ACCP) annual meeting.

PARTICIPANTS

Approximately 60 chest physicians.

INTERVENTIONS

Interactive questions about the knowledge, training, attitudes, and practice of sleep medicine.

MEASUREMENTS AND RESULTS

Response rates demonstrated that 65% of respondents directed or were on the staff of a sleep laboratory, 18% had American Board of Sleep Medicine (ABSM) certification, and only 3% had completed formal sleep medicine training, and performance on test questions about sleep-disordered breathing was better than that on questions about "nonpulmonary" sleep disorders. We polled approximately 60 participants in an interactive session called "Issues in Sleep Medicine Education and Practice" at the ACCP annual meeting in October 1998. The group was well-credentialed, with about one third of participants being board-certified in pulmonary medicine and critical care medicine, and about 17% having passed the ABSM examination. About two thirds of the group spent < or = 25% of their time in the practice of sleep medicine, but > 30% directed sleep laboratories. Respondents thought that sleep training was better addressed in pulmonary fellowship training than in medical school or other postgraduate training experiences. Forty-three percent of the group had received training in sleep medicine as part of a pulmonary fellowship. About half of the sample thought that formal training should be required for eligibility to take the ABSM examination. When presented with two "nonpulmonary" sleep disorder cases, this well-trained and self-selected group did not perform very well. The findings suggest that pulmonologists are actively involved in the practice of sleep medicine and that they both need and desire formal training in sleep disorders during pulmonary fellowship training.

CONCLUSIONS

Participants were actively involved in the practice of sleep medicine, most had trained informally, and performance on questions about nonpulmonary sleep disorders was not good.

Immediate endovascular repair for descending thoracic aortic transection secondary to blunt trauma

PURPOSE

To report the immediate endovascular treatment of a thoracic aortic tear secondary to blunt trauma.

METHODS AND RESULTS

A 39-year-old man was injured in a motor vehicle collision. In addition to significant trauma to the head, chest, and abdomen, there were signs of a deceleration injury to the thoracic aorta. After urgent celiotomy to repair a lacerated spleen, the thoracic aortic transection was treated intraluminally using an endograft made of Gianturco Z-stents covered with polytetrafluoroethylene. The patient recovered from his injuries, and the thoracic endograft shows no evidence of endoleak 7 months after treatment.

CONCLUSIONS

Endoluminal techniques can be used successfully in the immediate repair of thoracic aortic injuries.

Adjuvant therapy for melanoma in dogs: results of randomized clinical trials using surgery, liposome-encapsulated muramyl tripeptide, and granulocyte macrophage colony-stimulating factor

Spontaneous canine oral melanoma (COM) is a highly metastatic cancer, resistant to chemotherapy, and can serve as a model for cancer immunotherapy. Liposome-encapsulated muramyl tripeptide-phosphatidylethanolamine (L-MTP-PE) can activate the tumoricidal activity of the monocyte-macrophage system following i.v. injection. The objective of these studies was to evaluate the therapeutic effectiveness of L-MTP-PE administered alone and combined with recombinant canine granulocyte macrophage colony-stimulating factor (rcGM-CSF) in dogs undergoing surgery for oral melanoma. Ninety-eight dogs with histologically confirmed, clinically staged, oral melanoma were entered into two randomized, double-blind, surgical adjuvant trials. In trial 1, 50 dogs were stratified based on clinical stage and randomized to once a week L-MTP-PE or lipid equivalent (control). When all of the clinical stages were combined, no difference in disease-free survival or in survival time (ST) were detected. However, within stage I, dogs receiving L-MTP-PE had a significant increase in ST compared with control, with 80% of the dogs treated with L-MTP-PE still alive at >2 years. Within each stage II and stage III, there was no difference detected between the treatment groups. In trial 2, 48 dogs were stratified on the basis of clinical stage and extent of surgery (simple resection or radical excision), treated with L-MTP-PE two times a week, and randomized to rcGM-CSF or saline (placebo) given s.c. daily for 9 weeks. Within each stage and when all of the stages were combined, there was no difference between the treatment groups. In both studies, stage I COM is associated with a better prognosis. No effect on survival was observed with regard to tumor location in the oral cavity, sex, type/extent of surgery, or age. In a subset of dogs tested, pulmonary alveolar macrophage cytotoxicity was enhanced with combined rcGM-CSF and L-MTP-PE but not in dogs treated with L-MTP-PE alone. The present study indicates that after surgery, L-MTP-PE administered alone or combined with rcGM-CSF showed no significant antitumor activity in treating advanced stage COM. In early stage COM, L-MTP-PE was shown to result in a prolongation of ST. Furthermore, this study provides additional rationale for the use of the dog model for human malignant melanoma.

Effects of a nonlinear response of the fourier-transform infrared open-path instrument on the measurements of some atmospheric gases

The response of a Fourier-transform infrared (FTIR) instrument to changes in absorbance is inherently nonlinear for a number of reasons. One is that the interferogram acquired by the FTIR is truncated and then apodized before further processing of the data is accomplished. A commonly used apodization function in open-path FTIR research is triangular apodization, and all the research presented here has been done with that function. We calculated a set of absorption spectra by using the HITRAN database, covering ranges in both concentration and temperature for water, ammonia, and methane. Plots of these data reveal nonlinear results. The commonly used analysis technique, classical least squares, assumes that the response is linear. We describe some of the effects of this nonlinearity and present ways to address these effects.

The spectrum of sleep-disordered breathing

The term sleep-disordered breathing has been used synonymously with the term obstructive sleep apnea syndrome (OSAS). In a broader sense, however, the disorders of breathing during sleep exist along a spectrum of severity. The mildest form of sleep-related breathing disorder is intermittent snoring, which is primarily a nuisance without significant health sequelae. The most severe form of disordered breathing is the obesity-hypoventilation syndrome, which is associated with severe morbidity and very high mortality. In between these two extremes are disorders of gradually increasing impact on morbidity and mortality: persistent snoring, upper airway resistance syndrome, and OSAS.

Adequate access to posthospital home health services: differences between urban and rural areas

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.

An advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation

The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours after birth and the techniques for providing advanced life support. After careful review of the international resuscitation literature and after discussion of key and controversial issues, consensus was reached on almost all aspects of neonatal resuscitation, and areas of controversy and high priority for additional research were delineated. Consensus on resuscitation for the newly born infant included the following principles: Common or controversial medications (epinephrine, volume expansion, naloxone, bicarbonate), special resuscitation circumstances affecting care of the newly born, continuing care of the newly born after resuscitation, and ethical considerations for initiation and discontinuation of resuscitation are discussed. There was agreement that insufficient data exist to recommend changes to current guidelines regarding the use of 21% versus 100% oxygen, neuroprotective interventions such as cerebral hypothermia, use of a laryngeal mask versus endotracheal tube, and use of high-dose epinephrine. Areas of controversy are identified, as is the need for additional research to improve the scientific justification of each component of current and future resuscitation guidelines.

Resuscitation of the newly born infant: an advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation

The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours following birth and the techniques for providing advanced life support.

The risk profile of glaucoma filtration surgery

Glaucoma surgery has evolved over the past 30 years from the full-thickness procedure to the guarded filtration procedure. However, many of the risks and complications attendant with the full-thickness procedure, including endophthalmitis, hypotony, cataract progression, and filtration failure, continue to plague the glaucoma surgeon performing the guarded filtration procedure, although at lower incidences. With proper modification of technique, such as with postoperative bleb titration and use of adjunctive antifibrotic therapy based on prognosticators for failure, the success rates of trabeculectomy reoperations can approach those of primary trabeculectomy. Such risk factors for failure include African-American race, higher preoperative intraocular pressures, previously failed filters, younger age, and uveitic and neovascular glaucomas. In this paper, we review a number of studies that analyze the risks, complications, and long-term results of glaucoma filtration surgery and discuss different surgical recommendations based on risk factors for failure as well as for performing concomitant cataract and glaucoma surgery.

Resuscitation of the newly born infant: an advisory statement from the Pediatric Working Group of the International Liaison Committee on Resuscitation

The International Liaison Committee on Resuscitation (ILCOR), with representation from North America, Europe, Australia, New Zealand, Africa, and South America, was formed in 1992 to provide a forum for liaison between resuscitation organizations in the developed world. This consensus document on resuscitation extends previously published ILCOR advisory statements on resuscitation to address the unique and changing physiology of the newly born infant within the first few hours following birth and the techniques for providing advanced life support. After careful review of the international resuscitation literature and after discussion of key and controversial issues, consensus was reached on almost all aspects of neonatal resuscitation, and areas of controversy and high priority for additional research were delineated. Consensus on resuscitation for the newly. born infant included the following principles. (i) Personnel trained in the basic skills of resuscitation should be in attendance at every delivery. A minority (fewer than 10%) of newly born infants require active resuscitative interventions to establish a vigorous cry and regular respirations, maintain a heart rate greater than 100 beats per minute (bpm), and maintain good color and tone. (ii) When meconium is present in the amniotic fluid, it should be suctioned from the hypopharynx on delivery of the head. If the meconium-stained newly born infant has absent or depressed respirations, heart rate, or muscle tone, residual meconium should be suctioned from the trachea. (ii) Attention to ventilation should be of primary concern. Assisted ventilation with attention to oxygen delivery, inspiratory time, and effectiveness judged by chest rise should be provided if stimulation does not achieve prompt onset of spontaneous respirations and/or the heart rate is less than 100 bpm. (iv) Chest compressions should be provided if the heart rate is absent or remains less than 60 bpm despite adequate assisted ventilation for 30 s. Chest compressions should be coordinated with ventilations at a ratio of 3:1 and a rate of 120 'events' per minute to achieve approximately 90 compressions and 30 rescue breaths per minute. (v) Epinephrine should be administered intravenously or intratracheally if the heart rate remains less than 60 bpm despite 30 s of effective assisted ventilation and chest compression circulation. Common or controversial medications (epinephrine, volume expansion, naloxone, bicarbonate), special resuscitation circumstances affecting care of the newly born, continuing care of the newly born after resuscitation, and ethical considerations for initiation and discontinuation of resuscitation are discussed. There was agreement that insufficient data exist to recommend changes to current guidelines regarding the use of 21% versus 100% oxygen, neuroprotective interventions such as cerebral hypothermia, use of a laryngeal mask versus endotracheal tube, and use of high-dose epinephrine. Areas of controversy are identified, as is the need for additional research to improve the scientific justification of each component of current and future resuscitation guidelines.