Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

INTRODUCTION

Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.

METHODS

This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.

RESULTS

From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).

CONCLUSION

Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study

Introduction

Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated.

Methods

A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] < 0.05.

Results

Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038).

Conclusion

Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.

Nusinersen for Patients With Spinal Muscular Atrophy: 1415 Doses via an Interdisciplinary Institutional Approach

BACKGROUND

Spinal deformity and prior spinal fusion pose technical challenges to lumbar puncture (LP) for nusinersen administration for patients with spinal muscular atrophy (SMA). In this retrospective study over two study phases, we evaluated (1) factors associated with difficult LP or unscheduled requirement for image guidance and (2) effectiveness of a triage pathway for selective use of image guidance and nonstandard techniques, particularly for patients with spinal instrumentation/fusion to the sacrum.

METHODS

With institutional review board approval, electronic health records, imaging, and administrative databases were analyzed for patients receiving nusinersen from January 2012 through September 2021. Descriptive statistics and univariate analyses were used.

RESULTS

From January 2012 to March 2018 (phase 1), among 82 patients with SMA, 461 of 464 (99.4%) LP attempts were successful. Univariate analyses associated difficulty with prior spinal instrumentation, higher body mass index, and severity of the spinal deformity. Based on this experience, starting in April 2018 (phase 2), 125 patients were triaged selectively for ultrasound, fluoroscopy, or Dyna computed tomography. Patients with spinal instrumentation/fusion to the sacrum were treated primarily via intrathecal ports (137 doses) or transforaminal LP (55 doses). From April 2018 through September 2021, 704 of 709 (99.3%) LPs were successful. In total from January 2012 to September 2021, 1415 doses were administered. Over 50% of LPs were performed by neurology nurse practitioners without image guidance. Safety outcomes were excellent.

CONCLUSIONS

A stratified approach resulted in successful intrathecal nusinersen delivery and efficient resource allocation for patients with SMA, with or without complex spinal anatomy.

The Association Between Hypermobility Ehlers–Danlos Syndrome and Other Rheumatologic Diseases

Research has shown hypermobility Ehlers–Danlos syndrome (hEDS) to be associated with some complicated rheumatologic disease. In this feature paper, the authors discuss the prevalence and pathophysiology of rheumatologic conditions, specifically ankylosing spondylitis and rheumatoid arthritis, in patients with hEDS. Furthermore, the authors discuss possible reasons for the association of hEDS with these rheumatologic diseases.

Perioperative pain control and tympanostomy tube outcomes

OBJECTIVE

To evaluate perioperative pain management regimens as they relate to tympanostomy tube outcomes.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral children's hospital.

SUBJECTS

and Methods: The medical records of patients ≤18 years old who underwent tympanostomy tube placement were reviewed for indications, perioperative pain medications, post anesthesia recovery unit (PACU) measures, and tympanostomy tube occlusion rates.

RESULTS

Four hundred and fifty-five patients met inclusion criteria. Median age was 1.7 years (interquartile range: 1.2-3.3 years). Recurrent acute otitis media (n = 239, 52.5%) was the most common indication. All patients were American Society of Anesthesiologists (ASA) class 1 (n = 244, 58.1%) or 2 (n = 176, 41.9%). Fentanyl alone (n = 321, 70.6%) was the most common intraoperative analgesic administered followed by ketorolac alone (n = 40, 8.8%), and fentanyl and ketorolac together (n = 58, 12.8%). There was no significant difference in FLACC pain score at discharge and recovery time (minutes) also did not differ by intraoperative analgesia group (34.3 ± 15.2 for fentanyl; 36.2 ± 13.0 for ketorolac; 31.0 ± 12.5 for fentanyl and ketorolac together). Forty nine patients (11.6%) had an occluded tympanostomy tube at follow-up. Patients ≤1 year of age had a significantly higher risk of tube occlusion than patients >1 year of age (23.7% vs. 8.9%; p < 0.001). There was no significant difference in tube occlusion rates based on indication for tube placement, history of tube placement, intraoperative findings, or intraoperative pain regimen.

CONCLUSIONS

Ketorolac is a reasonable non-narcotic alternative to fentanyl which provides equal pain control and does not increase tube occlusion rates.

Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.

Building knowledge development and exchange capacity in Canada: lessons from Youth Excel

INTRODUCTION

Youth Excel was a 3-year pan-Canadian initiative to advance youth health through improving knowledge development and exchange (KDE) capacity. KDE capacity refers to an improvement cycle linking evidence and action. Capacities include local surveillance of youth behaviours; knowledge exchange; skills, resources and a supportive environment to use knowledge; and evaluation.

METHODS

Interviews were conducted with Youth Excel members, including 7 provincial teams and 2 national organizations. Interviews explored participant experiences with building KDE capacity.

RESULTS

Local surveillance systems were considered the backbone to KDE capacity, strengthened by co-ordinating surveys within and across jurisdictions and using common indicators and measures. The most effective knowledge exchange included tailored products and opportunities for dialogue and action planning. Evaluation is the least developed KDE component. Building KDE capacity requires frequent dialogue, mutually beneficial partnerships and trust. It also requires attention to language, vision, strategic leadership and funding.

CONCLUSION

Youth Excel reinforces the need for a KDE system to improve youth health that will require new perspectives and sustained commitment from individual champions and relevant organizations.

Frequency of interactions and hand disinfections among anesthesiologists while providing anesthesia care in the operating room: induction versus maintenance

We evaluated the behaviors of anesthesiologists during induction and maintenance of anesthesia. Contacts with surfaces occurred a mean (±standard error) of 154.8 ± 7.7 and 60 ± 3.1 times per hour during induction and maintenance, respectively (P < .0001). Hand hygiene events were 1.8 ± 0.27 per hour during induction versus 1.19 ± 0.27 during maintenance (P = .018).

Genome-wide significant associations in schizophrenia to ITIH3/4, CACNA1C and SDCCAG8, and extensive replication of associations reported by the Schizophrenia PGC

The Schizophrenia Psychiatric Genome-Wide Association Study Consortium (PGC) highlighted 81 single-nucleotide polymorphisms (SNPs) with moderate evidence for association to schizophrenia. After follow-up in independent samples, seven loci attained genome-wide significance (GWS), but multi-locus tests suggested some SNPs that did not do so represented true associations. We tested 78 of the 81 SNPs in 2640 individuals with a clinical diagnosis of schizophrenia attending a clozapine clinic (CLOZUK), 2504 cases with a research diagnosis of bipolar disorder, and 2878 controls. In CLOZUK, we obtained significant replication to the PGC-associated allele for no fewer than 37 (47%) of the SNPs, including many prior GWS major histocompatibility complex (MHC) SNPs as well as 3/6 non-MHC SNPs for which we had data that were reported as GWS by the PGC. After combining the new schizophrenia data with those of the PGC, variants at three loci (ITIH3/4, CACNA1C and SDCCAG8) that had not previously been GWS in schizophrenia attained that level of support. In bipolar disorder, we also obtained significant evidence for association for 21% of the alleles that had been associated with schizophrenia in the PGC. Our study independently confirms association to three loci previously reported to be GWS in schizophrenia, and identifies the first GWS evidence in schizophrenia for a further three loci. Given the number of independent replications and the power of our sample, we estimate 98% (confidence interval (CI) 78-100%) of the original set of 78 SNPs represent true associations. We also provide strong evidence for overlap in genetic risk between schizophrenia and bipolar disorder.

Genomewide linkage scan of schizophrenia in a large multicenter pedigree sample using single nucleotide polymorphisms

A genomewide linkage scan was carried out in eight clinical samples of informative schizophrenia families. After all quality control checks, the analysis of 707 European-ancestry families included 1615 affected and 1602 unaffected genotyped individuals, and the analysis of all 807 families included 1900 affected and 1839 unaffected individuals. Multipoint linkage analysis with correction for marker-marker linkage disequilibrium was carried out with 5861 single nucleotide polymorphisms (SNPs; Illumina version 4.0 linkage map). Suggestive evidence for linkage (European families) was observed on chromosomes 8p21, 8q24.1, 9q34 and 12q24.1 in nonparametric and/or parametric analyses. In a logistic regression allele-sharing analysis of linkage allowing for intersite heterogeneity, genomewide significant evidence for linkage was observed on chromosome 10p12. Significant heterogeneity was also observed on chromosome 22q11.1. Evidence for linkage across family sets and analyses was most consistent on chromosome 8p21, with a one-LOD support interval that does not include the candidate gene NRG1, suggesting that one or more other susceptibility loci might exist in the region. In this era of genomewide association and deep resequencing studies, consensus linkage regions deserve continued attention, given that linkage signals can be produced by many types of genomic variation, including any combination of multiple common or rare SNPs or copy number variants in a region.

Multicenter linkage study of schizophrenia loci on chromosome 22q

The hypothesis of the existence of one or more schizophrenia susceptibility loci on chromosome 22q is supported by reports of genetic linkage and association, meta-analyses of linkage, and the observation of elevated risk for psychosis in people with velocardiofacial syndrome, caused by 22q11 microdeletions. We tested this hypothesis by evaluating 10 microsatellite markers spanning 22q in a multicenter sample of 779 pedigrees. We also incorporated age at onset and sex into the analysis as covariates. No significant evidence for linkage to schizophrenia or for linkage associated with earlier age at onset, gender, or heterogeneity across sites was observed. We interpret these findings to mean that the population-wide effects of putative 22q schizophrenia susceptibility loci are too weak to detect with linkage analysis even in large samples.

Carrier risk status changes resulting from mutation testing in hereditary non-polyposis colorectal cancer and hereditary breast-ovarian cancer

CONTEXT

In hereditary cancer syndrome families with an identified cancer associated mutation, mutation testing changes the carrier risk status of the tested person and may change the carrier risk status of relatives.

OBJECTIVE

This study aimed to describe the change in the distribution of carrier risk status resulting from testing in hereditary breast-ovarian cancer (HBOC) and hereditary non-polyposis colorectal cancer (HNPCC) families.

DESIGN

This was an observational cohort study.

PATIENTS

The cohort included members of 75 HBOC and 47 HNPCC families. Of the 10 910 cohort members, 1408 were tested for a mutation and learned their test results.

OUTCOME MEASURE

Carrier risk for all cohort members was assessed before and after mutation testing.

RESULTS

There was a change in carrier risk status in 2906 subjects after testing of 1408 family members. The most common type of carrier risk change, from at risk to non-carrier status, accounted for 77% of the risk changes; 12% were a change to known carrier status from a lower risk. Sixty percent of persons with a carrier risk status change were not themselves tested; their risk status changed because of a relative's test result.

CONCLUSIONS

Carrier risk status changes from uncertainty to certainty (that is, to carrier or to non-carrier) account for 89% of risk changes resulting from testing. These risk changes affect cancer prevention recommendations, most commonly reducing their burden. Current practices do not ensure that untested family members are informed about changes in their carrier risk status which result from mutation testing of their relatives.

Dissemination of heart health promotion: lessons from the Canadian Heart Health Initiative Ontario Project

Situated in central-eastern Canada, Ontario is the largest province with a population of 11 million. Ontario is considered a fairly rich province at the centre of Canada's manufacturing and financial sectors. Public health services in Ontario are primarily delivered through public health departments, each administered by a local board of health and regulated by provincial legislation and program guidelines. The Canadian Heart Health Initiative Ontario Project (CHHIOP) was a four year project (1994 to 1998) undertaken as part of the dissemination phase of the Canadian Heart Health Initiative (CHHI) (see O'Loughlin et al., p.4). CHHIOP is one component of a long-term process to develop and implement effective heart health programs in Ontario.

Electrogastrographic norms in children: toward the development of standard methods, reproducible results, and reliable normative data

BACKGROUND

Surface electrogastrography (EGG) is a noninvasive technique that detects gastric myoelectrical electric activity, principally the underlying pacemaker activity generated by the specialized interstitial cells of Cajal. Interest in the use of this methodology has grown because of its potential applications in describing functional gastrointestinal disorders, particularly as a tool in the evaluation of nausea, anorexia, and other dyspeptic symptoms.

METHODS

Fifty-five healthy volunteers (27 female), ranging in age from 6 to 18 years (mean, 11.7 years), were studied for a 1-hour baseline preprandial period and a 1-hour postprandial period after consumption of a standard 448-kcal meal. Recordings were obtained with an EGG Digitrapper or modified Polygraph (Medtronic-Synectics, Shoreview, MN). Spectral analysis by an autoregressive moving average method was used to extract numerical data on the power and frequency of gastric electrical activity from the EGG signal.

RESULTS

The authors present normative data for healthy children and adolescents studied under a standardized protocol. Mean dominant frequency was found to be 2.9 +/- 0.40 cycles per minute preprandially and 3.1 +/- 0.35 postprandially, with 80% +/- 13% of test time spent in the normogastric range (2-4 cycles per minute) before and 85% +/- 11% after the test meal. The response of several key parameters to meal consumption was considered, and the effects of age, gender, and body mass index (BMI) on the EGG were sought.

CONCLUSIONS

There is a postprandial increase in the rhythmicity and amplitude of gastric slow waves, as other investigators have shown in adults. Key normative values are not dependent on age, gender, or BMI. The authors discuss limitations in the data set and its interpretability. The authors establish a normative data set after developing a standardized recording protocol and test meal and show that EGG recordings can be obtained reliably in the pediatric population. Development of similar norms by investigators using the EGG is crucial for future exploration of the validity and clinical application of the EGG. Differences in test conditions of signal detection and analytic methods influence EGG results substantially, and caution should be used when comparing results across centers.

Quality of life for women with physical disabilities

This article emphasizes the role of several factors on the QOL of women with disabilities. Future studies might examine ways to merge these factors to examine their long-term consequences in the lives of women with disabilities and, hence, society at large. Findings should provide a basis for policymaking and clinical rehabilitation interventions designed to promote greater QOL for women with disabilities-a QOL that offers vigorous prosperity, flourishing health, and full social participation.

Exercise training in a predominantly African-American group of stroke survivors

PURPOSE

The purpose of this study was to determine the effects of a 12-wk exercise training program in a predominantly African-American group of stroke survivors with multiple comorbidities.

METHODS

A lag-control group design was employed to provide training to all participants (N = 35). Two 12-wk training iterations were arranged. Participants trained 3 d x wk(-1) for 60 min x d(-1) (cardiovascular, 30 min; strength, 20 min; flexibility, 10 min). Outcome measures included peak VO2 (mL x min(-1), mL x kg(-1) x min(-1), maximal workload (MW), time to exhaustion (TTE), 10 RM on two LifeFitness strength machines, grip strength (GS), body weight (BW), total skinfolds (TS), waist to hip ratio (WHR), hamstring/low back flexibility (HLBF), and shoulder flexibility (SF).

RESULTS

Compared with controls, the exercise group showed significant gains in peak VO2 (P < 0.01), strength (P < 0.01), HLBF (P < 0.01), and body composition (BW and BMI, P < 0.05; TS, P < 0.01). There was no significant difference between exercise and controls on WHR, SF, and GS.

DISCUSSION

A supervised exercise training program for stroke survivors with multiple comorbidities was highly effective in improving overall fitness, potentially reducing the risk of further disease and disability. Greater effort must be made on the part of the public health community to increase access to community-based physical activity programs for persons with stroke.

Identification and characterization of an ataxin-1-interacting protein: A1Up, a ubiquitin-like nuclear protein

Expansion of a polyglutamine tract within ataxin-1 causes spinocerebellar ataxia type 1 (SCA1). In this study, we used the yeast two-hybrid system to identify an ataxin-1-interacting protein, A1Up. A1Up localized to the nucleus and cytoplasm of transfected COS-1 cells. In the nucleus, A1Up co-localized with mutant ataxin-1, further demonstrating that A1Up interacts with ataxin-1. Expression analyses demonstrated that A1U mRNA is widely expressed as an approximately 4.0 kb transcript and is present in Purkinje cells, the primary site of SCA1 cerebellar pathology. Sequence comparisons revealed that A1Up contains an N-terminal ubiquitin-like (UbL) region, placing it within a large family of similar proteins. In addition, A1Up has substantial homology to human Chap1/Dsk2, a protein that binds the ATPase domain of the HSP70-like Stch protein. These results suggest that A1Up may link ataxin-1 with the chaperone and ubiquitin-proteasome pathways. In addition, these data support the concept that ataxin-1 may function in the formation and regulation of multimeric protein complexes within the nucleus.

Effects of a short-term health promotion intervention for a predominantly African-American group of stroke survivors

BACKGROUND

The study examined the effects of a 12-week health promotion intervention for a predominantly urban African-American population of stroke survivors.

DESIGN

A pre-test/post-test lag control group design was employed.

PARTICIPANTS/SETTING

Participants were 35 stroke survivors (9 male, 26 female) recruited from local area hospitals and clinics.

MAIN OUTCOME MEASURES

Biomedical, fitness, nutritional, and psychosocial measures were employed to assess program outcomes.

RESULTS

Treatment group made significant gains over lag controls in the following areas: (1) reduced total cholesterol, (2) reduced weight, (3) increased cardiovascular fitness, (4) increased strength, (5) increased flexibility, (6) increased life satisfaction and ability to manage self-care needs, and (7) decreased social isolation.

CONCLUSION

A short-term health promotion intervention for predominantly African-American stroke survivors was effective in improving several physiological and psychological health outcomes.

Restructuring public health in Ontario: implications for heart health promotion

Community-based heart health promotion is viewed as an effective means of reducing cardiovascular disease risk. Although public health agencies have a central role in the implementation and dissemination of heart health programmes, their effectiveness is being challenged by major structural changes to Provincial public health systems across Canada, although the impacts of the changes have received relatively little attention in the research literature. As part of the Canadian Heart Health Initiative--Ontario Project (CHHIOP), this study used a qualitative approach to address the perceived implications of these changes to Ontario's public health system for heart health promotion. Interviews (n = 38) were conducted in eight public health units with staff most familiar with managing and/or delivering heart health activities. The results are mixed; that is, while many see the future of heart health promotion programming in Ontario as being at risk, others see recent changes as a step forward toward their institutionalization, particularly in light of recent funding decisions made by the Ministry of Health's Health Promotion Branch.

Halo vest effect on balance

OBJECTIVE

To determine the effect of a halo vest, a cervical orthosis, on clinically relevant balance parameters.

DESIGN

Subjects performed unipedal stance (with eyes open and closed, on both firm and soft surfaces) and functional reach, with and without the application of a halo vest.

SUBJECTS

A convenience sample of 12 healthy young subjects, with an equal number of men and women.

OUTCOME MEASURES

Seconds for unipedal stance (maximum 45); inches for functional reach.

RESULTS

Both unipedal stance times and functional reach (mean +/- standard deviation) were significantly decreased with the halo vest as compared to without it (29.1+/-5.8 vs. 32.8+/-6.4 seconds, p = .002; 12.9+/-1.4 vs. 15.1+/-2.1 inches, p<.01).

CONCLUSION

A halo vest causes an acute impairment in balance in the healthy young. It is likely that the impairment would be greater in older or injured patients, thus increasing their risk for a fall, which could have devastating consequences.

Restructuring public health in Ontario: implications for heart health promotion

Community-based heart health promotion is viewed as an effective means of reducing cardiovascular disease risk. Although public health agencies have a central role in the implementation and dissemination of heart health programmes, their effectiveness is being challenged by major structural changes to Provincial public health systems across Canada, although the impacts of the changes have received relatively little attention in the research literature. As part of the Canadian Heart Health Initiative--Ontario Project (CHHIOP), this study used a qualitative approach to address the perceived implications of these changes to Ontario's public health system for heart health promotion. Interviews (n = 38) were conducted in eight public health units with staff most familiar with managing and/or delivering heart health activities. The results are mixed; that is, while many see the future of heart health promotion programming in Ontario as being at risk, others see recent changes as a step forward toward their institutionalization, particularly in light of recent funding decisions made by the Ministry of Health's Health Promotion Branch.

Structure-activity relationships for a class of inhibitors of purine nucleoside phosphorylase

Values of inhibition constants, Ki, for a family of structurally related, competitive inhibitors of calf spleen purine nucleoside phosphorylase (PNP) have been determined employing both inosine as substrate and a manual assay and 2-amino-6-mercapto-7-methylpurine ribonucleoside (MESG) as substrate and a robot-based enzyme kinetics facility. Several of the values determined robotically were confirmed employing the same substrate and a manual assay. Surprisingly, for many of the inhibitors examined, values of Ki determined with MESG as substrate are smaller than those obtained employing inosine as substrate by a factor that varies from less than 2 to 10. Values of concentrations required for 50% inhibition of PNP, IC50, have also been determined for the same family of inhibitors employing inosine as substrate. Values of IC50ino and those for Kiino and Kimesg for subsets of the inhibitors have been employed as training sets to create quantitative structure-activity relationships (QSAR) which have substantial power to predict values of IC50 and Ki for inhibitors outside the training set. These QSAR models should be useful in guiding future medicinal chemistry efforts designed to discover inhibitors of PNP having increased potency.

Strategies for ventilatory support

Since the introduction of manual positive pressure ventilation during the Copenhagen polio epidemic of 1952, a range of mechanical devices and methods of ventilatory support have been developed to provide life-saving respiratory therapy to critically ill patients. In addition to the development of the equipment hardware to enable effective mechanical ventilation, there has been a gradual realisation that a single mode of ventilation is not universally applicable to all patients, individual pathologies, or to individual patients at various stages in the evolution of their pulmonary pathology. While mechanical ventilation can undoubtedly be life-saving, it can also cause lung damage as a result of its non-physiological method of promoting effective gas exchange. This iatrogenic problem is known as ventilator induced lung injury and, although it may be a problem in any patient requiring mechanical ventilation for any reason, is of particular importance to those patients requiring mechanical ventilation as a consequence of trauma. This chapter describes the range of ventilatory support techniques available, the problem of ventilator induced lung injury with specific reference to trauma patients and offers a strategy for ventilatory support in the trauma patient.

An electrophysiological exploration of the double crush hypothesis

The double crush hypothesis has not been rigorously evaluated in humans. We therefore analyzed cases of C6, C7, and C8 radiculopathy and exploited the fact that the median sensory response is of C6/C7 origin and the median motor response is primarily of C8 origin. We hypothesized that C6 and/or C7 cases would demonstrate an increased frequency of median mononeuropathy by sensory criteria, and C8 cases would demonstrate an increased frequency of median mononeuropathy by motor criteria. We also hypothesized that median sensory and motor response parameters among these same groups would be altered in ways consistent with a proximal influence on distal nerve conduction studies. Although median mononeuropathy was unexpectedly common (22.1%) among cases of cervical radiculopathy (which may explain the clinical acceptance of the double crush hypothesis), none of the hypotheses was supported. This study identified no evidence to support a neurophysiological explanation for the double crush hypothesis.

[A questionnaire survey of intravenous drug addicts (Moscow, May 1997-January 1998)]

Questionnaires were distributed among users of intravenous drugs (UID) on the basis of Narcological Hospital No. 17 in Moscow and in the streets of the city (altogether, respondents filled in 298 questionnaires in the hospital and 126 questionnaires in the streets). The average age of the respondents was 21-22 years. The sufficiently wide spread of the joint use of injection instruments was noted (35-41%), the ensuing risk could be consciously evaluated by 38% of the respondents in the hospital and 20% in the streets. According to the observation diaries, HIV was not a priority for many UID. Their priorities included the problems of the treatment of hepatitis, abscesses, overdosage/poisoning, etc. Among the hospital respondents and selected street respondents the spread of hepatitis B and C was noted by 30% and 34% respectively. Under hospital conditions testing for HIV gave negative results in 58% and positive results in 5% of the respondents, while 37% of the respondents stated than they had never been tested. Among street respondents, 62% stated that they had negative results of testing and 39% stated that they had never been tested. The conclusion has been made that the realization of prophylactic programs may augment the level of knowledge concerning risks linked with the intravenous use of drugs, thus giving motivation to UID either to stop their use or to avoid contamination of the blood with HIV while using them.

No evidence for linkage of chromosome 22 markers to schizophrenia in southern African Bantu-speaking families

Previous studies have demonstrated possible linkage between chromosome 22 and one of the hypothesized schizophrenia susceptibility genes. Interpretation of these data, however, is not straightforward: although not significant at the level traditionally accepted to demonstrate linkage, reported lod scores were greater than should have occurred by chance for an unlinked marker based on simulation studies. Further, these studies used sample populations which were either of mixed nationality and ethnicity, or mixed ethnic ancestry from one country. We therefore tested for linkage between highly polymorphic chromosome 22 markers and schizophrenia in a sample of southern African Bantu-speaking black families, a population known to have diverged within the last 2,000 years. We also tested one candidate locus, the gene for the soluble form of catechol-O-methyl transferase (COMT) located at 22q11, which has been suggested as the cause of psychiatric symptoms observed in velo-cardio-facial syndrome (VCFS, including DiGeorge syndrome), and which is known to be functionally as well as genetically polymorphic. There is no evidence to support the linkage of markers on chromosome 22 to susceptibility to schizophrenia in this population, using either parametric or nonparametric analysis.