A magnetic massive star has experienced a stellar merger

Massive stars (those ≥8 solar masses at formation) have radiative envelopes that cannot sustain a dynamo, the mechanism that produces magnetic fields in lower-mass stars. Despite this, approximately 7% of massive stars have observed magnetic fields, the origin of which is debated. We used multi-epoch interferometric and spectroscopic observations to characterize HD 148937, a binary system of two massive stars. We found that only one star is magnetic and that it appears younger than its companion. The system properties and a surrounding bipolar nebula can be reproduced with a model in which two stars merged (in a previous triple system) to produce the magnetic massive star. Our results provide observational evidence that magnetic fields form in at least some massive stars through stellar mergers.

Long-term water quality monitoring in agricultural catchments in Sweden: Impact of climatic drivers on diffuse nutrient loads

Water quality related to non-point source pollution continues to pose challenges in agricultural landscapes, despite two completed cycles of Water Framework Directive actions by farmers and landowners. Future climate projections will cause new challenges in landscape hydrology and subsequently, the potential responses in water quality. Investigating the nutrient trends in surface waters and studying the efficiency of mitigation measures revealed that loads and measures are highly variable both spatially and temporally in catchments with different agro-climatic and environmental conditions. In Sweden, nitrogen and phosphorus loads in eight agricultural catchments (470-3300 ha) have been intensively monitored for >20 years. This study investigated the relationship between precipitation, air temperature, and discharge patterns in relation to nitrogen (N) and phosphorus (P) loads at catchment outlets. The time series data analysis was carried out by integrating Mann-Kendall test, Pettitt break-points, and Generalized Additive Model. The results showed that the nutrient loads highly depend on water discharge, which had large variation in annual average (158-441 mm yr^-1). The annual average loads were also considerably different among the catchments with total N (TN) loads ranging from 6.76 to 35.73 kg ha^-1, and total P (TP) loads ranging from 0.11 to 1.04 kg ha^-1. The climatic drivers were highly significant indicators of nutrient loads but with varying degree of significance. Precipitation (28-962 mm yr^-1) was a significant indicator of TN loads in five catchments (loamy sand/sandy loam) while annual average temperature (6.5-8.7 °C yr^-1) was a significant driver of TN loads in six out of eight catchments. TP loads were associated with precipitation in two catchments and significantly correlated to water discharge in six catchments. Considering the more frequent occurrence of extreme weather events, it is necessary to tailor N and P mitigation measures to future climate-change features of precipitation, temperature, and discharge.

Investigating the NLRP3 Inflammasome and its Regulator miR-223-3p in Multiple Sclerosis and Experimental Demyelination

Innate immune signalling pathways are essential mediators of inflammation and repair following myelin injury. Inflammasome activation has recently been implicated as a driver of myelin injury in multiple sclerosis (MS) and its animal models, although the regulation and contributions of inflammasome activation in the demyelinated central nervous system (CNS) are not completely understood. Herein, we investigated the NLRP3 (NBD-, LRR- and pyrin domain-containing protein 3) inflammasome and its endogenous regulator microRNA-223-3p within the demyelinated CNS in both MS and an animal model of focal demyelination. We observed that NLRP3 inflammasome components and microRNA-223-3p were upregulated at sites of myelin injury within activated macrophages and microglia. Both microRNA-223-3p and a small-molecule NLRP3 inhibitor, MCC950, supressed inflammasome activation in macrophages and microglia in vitro; compared with microglia, macrophages were more prone to inflammasome activation in vitro. Finally, systemic delivery of MCC950 to mice following lysolecithin-induced demyelination resulted in a significant reduction in axonal injury within demyelinated lesions. In conclusion, we demonstrate that NLRP3 inflammasome activity by macrophages and microglia is a critical component of the inflammatory microenvironment following demyelination and represents a potential therapeutic target for inflammatory-mediated demyelinating diseases, including MS.

Primary neuroendocrine tumor of the pineal gland: a case report

INTRODUCTION

Primary intracranial neuroendocrine tumors are exceedingly rare, with few cases in the literature. We present a case of a primary neuroendocrine carcinoma of the pineal gland, which is the second that has ever been reported.

CASE PRESENTATION

A 53-year-old male patient presented with vomiting, weakness, and headaches. Imaging revealed a lesion in the pineal region, which was surgically resected. This mass was characterized by histology as a neuroendocrine carcinoma, given the presence of neuroendocrine markers and cytokeratin markers with absence of a primary lesion elsewhere on imaging.

CONCLUSIONS

There are currently no guidelines on the management of primary intracranial neuroendocrine tumors. In this case, the patient underwent surgical resection and craniospinal radiotherapy. He subsequently received one cycle of chemotherapy with temozolomide, an alkylating agent, but he unfortunately did not tolerate treatment. A multidisciplinary decision was made along with the patient and his family to focus on palliative care. Eighteen months after the initial presentation, disease recurred in the patient's neck. The patient underwent resection to control the metastases, with a plan to follow with radiotherapy and chemotherapy. Unfortunately, the patient became unwell and died at 21 months after initial diagnosis. This demonstrates a need for continued research and reporting on this uncommon disease entity.

Interleukin-1 receptor antagonist: An exploratory plasma biomarker that correlates with disability and provides pathophysiological insights in relapsing-remitting multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and neurodegenerative disorder. Interleukin-1 receptor antagonist (IL-1RA) is an endogenous soluble antagonist of the IL-1 receptor and blocks the pro-inflammatory effects of IL-1β known to contribute to MS pathology. The objectives of this study were to determine whether IL-1RA is associated with disability in MS and how this correlates with neurofilament light (NfL) levels in cerebrospinal fluid (CSF).

METHODS

Peripheral blood and CSF were collected from consenting MS patients. Patient demographic and clinical variables, including past relapse activity, were also collected. Circulating levels of IL-1RA, IL-18, and IL-1β were measured in plasma; IL-1RA and NfL were measured in the CSF via Bio-plex multiplex immunoassay kits and ELISA, respectively. IL-1RA expression was investigated in vitro using primary human macrophages and microglia, and in situ using post-mortem MS tissue.

RESULTS

Following a multiple regression analysis, IL-1RA levels in plasma correlated with expanded disability status scale score independent of all other variables. In a separate cohort, CSF IL-1RA significantly correlated with NfL. In vitro, induction of the NLRP3 inflammasome, a pathological hallmark within MS lesions, led to increased release of IL-1RA from primary human microglia and macrophages. In the CNS, IL-1RA⁺ macrophages/microglia were present at the rim of mixed active/inactive MS lesions.

CONCLUSIONS

Results presented in this study demonstrate that IL-1RA is a novel exploratory biomarker in relapsing-remitting MS, which correlates with disability and provides mechanistic insights into the regulatory inflammatory responses within the demyelinated CNS.

Late recurrence of choroid plexus carcinoma

BACKGROUND

Choroid plexus carcinomas (CPC) are rare malignant brain tumours arising from the choroid plexus epithelium. CPC are most common in the paediatric population, particularly those under 2 years of age. Common presentations include headache, diplopia and signs of increased intracranial pressure such as nausea and vomiting. Infants may present with increased head circumference, bulging fontanelles, splayed cranial sutures and/or neurological delay. Diagnosis is made via radiological and histological analysis.

MANAGEMENT AND PROGNOSIS

Gross total resection (GTR) is the preferred treatment and infers the best survival rate, but despite this, prognosis remains poor. The utility of chemotherapy and/or radiation in CPC management remains controversial, and an optimal treatment regimen has not been identified. Even with GTR, recurrence is common and usually occurs within months after resection. Delayed recurrence is exquisitely rare and has been reported very few times to date.

CASE PRESENTATION

Here, we present a rare case of delayed CPC recurrence 10 years after initial presentation. A 2-month-old male was diagnosed with CPC and received GTR, chemotherapy and stem cell transplant. The patient presented with a recurrent CPC 10 years after the initial diagnosis.

CONCLUSIONS

This case demonstrates the importance of long-term surveillance and raises questions regarding the natural history, recurrence patterns and factors contributing to long-term relapse in CPC. Further research should be targeted at identifying patient factors contributing to increased risk of late recurrence and whether adjuvant treatments play any role in decreasing this.

Long Survival of Primary Pineal Melanoma with Radiation Treatment Only

Pineal gland tumors in adults account for about 0.4 to 1 % of all intracranial tumors. A wide variety of tumors can occur in the pineal gland. The most common are the pineal parenchymal tumors (pineocytomas, pineoblastomas, and pineal parenchymal tumors of intermediate differentiation), germ cell tumors, and glial tumors. Uncommonly in the pineal gland one may encounter a metastatic tumor, a meningioma or a melanoma.

We here report a case of primary pineal gland melanoma with prolonged survival of 56 weeks after radiotherapy alone. To our knowledge, this is the first reported case of prolonged survival after radiotherapy alone, without surgical intervention or chemotherapy. Contrary to previous reports, our case demonstrates that a pineal melanoma with leptomeningeal dissemination can still yield a better survival with radiation treatment only.

June 2001: 61 year old woman with confusion and obtundation

The June COM. A 61 year old female presents with a three week history of increasing confusion, lethargy and headache. A neurological exam revealed disorientation, mild expressive aphasia, bilateral papilledema, and a right pronator drift. She had a craniotomy and resection of tumor. The tumor histologically was consistent with a solitary fibrous tumor displaying malignant features of hypercellularity, marked nuclear atypia, high mitotic activity, and a high proliferation index. This case is unique as the first malignant variant of solitary fibrous tumor to be reported intracranially.

Glomerular filtration rate is a major determinant of the relationship between 25-hydroxyvitamin D and parathyroid hormone

The reference range for 25-hydroxyvitamin D (25-OHD) remains uncertain, and it is not clear as to whether interpretation of circulating 25-OHD would be aided by simultaneous measurement of serum parathyroid hormone (PTH). We wanted to define the level of serum 25-OHD associated with a raised serum PTH and to examine the determinants of the relationship between serum 25-OHD and serum PTH concentration. We retrospectively examined data for patients who had a 25-OHD measurement and other biochemical variables over a 12-month period in our center. We found that 28% of patients had a serum 25-OHD level below 50 nmol/L and serum PTH level in the normal reference range, whereas 24% had a serum 25-OHD level below 50 nmol/L with a serum PTH value above the normal reference range. At a serum 25-OHD level of 80 nmol/L, 1.5% had an elevated serum PTH and, at 50 nmol/L, 8% had raised serum PTH. Further examination showed that for patients with low serum 25-OHD, low glomerular filtration rate (GFR) was a major determinant of the PTH response. These data confirm an inverse correlation between serum 25-OHD and serum PTH. Minimal numbers of patients (1.5% of the study group) have a raised serum PTH at a serum 25-OHD level of 80 nmol/L. GFR is a major determinant of the PTH response to decreasing serum levels of 25-OHD.

Corpora amylacea in a leiomyoma of soft tissue

A case of myxoid leiomyoma of deep soft tissue is described. The patient was a 42-year-old woman who presented with menorrhagia, and an ischiorectal mass was identified. A total hysterectomy was performed, and the mass was removed. On gross examination, the mass was 6cm x 5cm x 4cm and had a mucoid cut surface. Histologic examination revealed a myxoid leiomyoma with abundant intracellular corpora amylacea (CA). An infarcted leiomyoma was present in the hysterectomy specimen. The patient remains well, with no evidence of recurrence 3 years after surgery. Leiomyomas of deep soft tissue are rare, and, to our knowledge, none have been described containing CA.

Management of severe postpartum haemorrhage by uterine artery embolization

We report a case of postpartum haemorrhage which was successfully treated by embolization of the uterine artery. This technique is not well known and is thought to be underused in this condition. We wish to alert medical personnel to its role in this life-threatening situation.

Rupture of middle cerebral artery aneurysm in a neonate: case report and review of the literature

Intracranial hemorrhage because of rupture of a cerebral aneurysm is extremely rare in the neonatal period. Delayed diagnosis contributes to high mortality and morbidity. The authors report an extremely rare case of a middle cerebral artery aneurysm diagnosed and treated shortly after birth. Extensive review of the literature is presented. The patient died 4 years after surgery.

New criteria for the differentiation between transudates and exudates

AIMS

To investigate whether cholesterol and lactate dehydrogenase (LDH) measurements in fluids are more sensitive and specific markers for differentiating between exudates and transudates, as confirmed clinically, than the measurement of fluid total protein concentrations alone.

PATIENTS/METHODS

Serum, pleural fluid, and ascitic fluid from 61 unselected patients were analysed retrospectively for LDH, cholesterol, and total protein. Clinical classification of transudate or exudate was reached independently by reviewing clinical details and laboratory data.

RESULTS

Of 54 samples (40 pleural fluid and 14 ascitic fluid), 30 were classified clinically as exudates and 24 as transudates. Fluid LDH and fluid to serum protein ratio measurements were equally good at differentiating between exudates and transudates, with a sensitivity of 90%, a specificity of 79%, a positive predictive value (PPV) of 84%, and a negative predictive value (NPV) of 86%. A combination of these parameters improved sensitivity to 100% and NPV to 100%, but lowered the specificity to 71% and PPV to 81%. This combination achieved a higher efficiency than Light's criteria.

CONCLUSION

Routine measurement of fluid LDH values and the calculation of fluid to serum total protein ratios will aid in differentiating exudates from transudates.

Prevalence and causes of low bone density and fractures in kidney transplant patients

Osteoporosis is known to occur in patients with kidney transplants, but limited information is available about the prevalence and causes of this complication. We asked all 330 patients with kidney transplants in our unit to participate in this study of whom 165 (50%) agreed to do so. The characteristics of the participating patients were similar to the remaining 165 nonparticipants. Seventy of 165 (42%) of the participants were women of whom 40 were postmenopausal in contrast to the men of whom only one was hypogonadal. Bone mineral density (BMD) was significantly reduced at the radius (Z score, -1.5) and femoral neck (Z score, -0.7), but the lumbar spine was normal. BMD was lower in women than men at all skeletal sites. Osteoporosis was found in 10-44% and osteopenia was found in 35-50% of women depending on the site. BMD was related inversely to time since transplantation and cumulative prednisolone dose. Twenty-seven of the 165 (16%) patients had either vertebral deformities or a history of a low trauma fracture after transplantation. This fracture group consisted of 10/27 (37%) men and 17/27 (63%) women, of whom 14 were postmenopausal. Fracture patients tended to be older and have a longer duration of renal failure, dialysis, transplantation, greater cumulative steroid dose, and higher bone resorption markers than the nonfracture group. No differences were found for cumulative doses of cyclosporin or tacrolimus. Logistic regression showed that only duration of dialysis and time since transplantation significantly increased fracture risk, with odds ratio (OR) for each year of dialysis or transplantation being 1.21 (CI, 1.00-1.48) and 1.14 (CI, 1.05-1.23), respectively. These data show that low bone density and fractures are common in patients with kidney transplant and are determined by both pre- and posttransplant variables. Fracture risk was greatest in women, particularly if they were postmenopausal and we recommend that this subgroup is targeted for assessment and treatment.

Lack of effect of combined low intensity laser therapy/phototherapy (CLILT) on delayed onset muscle soreness in humans

BACKGROUND AND OBJECTIVES

This study, which was approved by the University's Ethical committee, was conducted to investigate the effectiveness of Combined Low Intensity Laser Therapy/Phototherapy (CLILT) in alleviating the signs and symptoms of Delayed Onset Muscle Soreness (DOMS) over an 11-day period.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-six subjects (18 M: 18 F) were randomly allocated, under strictly controlled double-blind conditions, to one of three experimental conditions: Control, Placebo, and CLILT (660-950 nm; 11 J/cm2; pulsed at 73 Hz). DOMS was induced in a standardised fashion in the non-dominant elbow flexors using repeated eccentric contractions until exhaustion was reached. Subjects returned on five consecutive days, and two days during the following week, for treatment according to group, and assessment of outcome variables including range of motion, pain, and tenderness.

RESULTS

While analysis of results using repeated measures and one factor ANOVA with post-hoc tests showed significant changes in all variables over time (P < 0.05) as a result of the induction procedure, there were no significant differences observed between groups.

CONCLUSIONS

CLILT failed to show any beneficial treatment effect on DOMS, at least at the parameters used here. These results therefore provide no evidence for the claimed biostimulating effects of such therapy.

Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: main and incremental effects across settings

OBJECTIVE

Although the combination of methylphenidate (MPH) and behavior modification (BMOD) has been advocated to enhance clinical outcome for children with attention-deficit hyperactivity disorder (ADHD) and comorbid disruptive disorders, few group studies have been conducted. This study evaluates the separate and incremental effects of these modalities on rating scale and observational measures in multiple settings.

METHOD

Sixteen of 22 children with ADHD and comorbid disruptive disorder completed a randomized, placebo-controlled study examining the separate and incremental effects of 2 doses of MPH and BMOD during a partial hospitalization program. Of the 6 who did not complete the study, 2 children developed significant side effects. For the 16 who did complete the study, effects were examined on measures of symptom ratings, behavioral frequencies, and stimulant side effects across program activities.

RESULTS

Based on alpha-adjusted analyses of variance, there were several main effects of MPH and BMOD on ADHD symptoms, oppositional behavior, and positive social behavior, with certain effects unique to each intervention and setting. One incremental effect each was found for MPH (positive mood/behavior) and BMOD (negative behavior). MPH and BMOD were associated with few side effects. Effect sizes for each intervention showed considerable variability in clinical response.

CONCLUSIONS

That MPH and BMOD had certain unique main and incremental effects extends findings supporting their combination and suggests that integrated studies evaluate multiple dimensions of functioning and in novel settings (e.g., home, school). The incorporation of other intervention components in combined treatments may be warranted to enhance clinical efficacy.

Study of the cell biology and biochemistry of cherubism

AIMS

To establish whether the multinucleate cells in lesions of patients with cherubism are also osteoclasts and if this is the case whether they were responsive to calcitonin; to carry out cytogenetic studies on two members of the same family affected by cherubism in an attempt to identify any major chromosomal defects; and to perform an in-depth modern biochemical study of four children in the same family.

SUBJECTS AND METHODS

Four related children with cherubism were studied. Tissue taken from one of the children at elective decompression of an optic nerve was submitted to in vitro bone resorption studies. Cytogenetic studies were done on two of the children and biochemical studies on all four.

RESULTS

The multinucleate cells in the cherubic lesions were shown to be osteoclasts since they synthesised tartrate resistant acid phosphatase, expressed the vitronectin receptor, and resorbed bone. Bone resorption by the cultured multinucleate cells was significantly inhibited by calcitonin. High resolution cytogenetic studies failed to detect any chromosomal abnormalities in two children with cherubism. The biochemistry profile of all four children with cherubism showed that serum calcium, parathyroid hormone, parathyroid related hormone, calcitonin, and alkaline phosphatase were within normal levels. Urine analysis of pyridinium and deoxypyridinium cross links, hydroxyproline, and calcium in relation to urine creatinine were measured to assess bone resorption in these children, and the values were at the upper end of the normal range in all four.

CONCLUSIONS

Further studies are required to determine whether calcitonin treatment will control this grossly deforming disease until the time when the physiological changes that occur at puberty rectify the pathology. It is not recommended that biochemical markers of bone resorption are used in isolation to monitor the activity of cherubism in individuals because the results are based on a small number of children and because of reports of marked interindividual variation in the levels of these markers, particularly in children.

How does treatment influence endocrine mechanisms in acute severe heart failure? Effects on cardiac natriuretic peptides, the renin system, neuropeptide Y and catecholamines

1. Hormones involved in cardiovascular regulation are influenced by drug treatment. It is therefore difficult to study endocrine mechanisms in heart failure as most patients are already on treatment by the time they reach hospital. 2. We studied nine hospital in-patients before and after treatment of acute New York Heart Association class IV heart failure. 3. Before treatment, plasma brain and atrial natriuretic peptides were markedly elevated (BNP 121 +/- 26 pg/ml, ANP 163 +/- 33 pg/ml; normal range: BNP 3.9 +/- 0.3 pg/ml, ANP 8.6 +/- 0.8 pg/ml) and correlated positively with serum creatinine and left ventricular end-diastolic diameter and negatively with ejection fraction. Eight patients improved and one died. 4. With improvement plasma ANP and BNP fell. Initial renin activity was within the normal range but increased on treatment. Plasma neuropeptide Y and adrenaline remained normal before and after treatment in the eight patients who improved. Initial plasma noradrenaline was in the normal range in four of these patients and just above normal in a further four. In the patient who died, initial plasma neuropeptide Y and catecholamines were very high. 5. Plasma BNP emerged as complementary to ANP as a dynamic index in severe heart failure; however, renal function is also an important determinant of plasma BNP and ANP. There is little evidence for activation of the circulating renin-angiotensin-aldosterone system or neuropeptide Y before treatment of acute heart failure.

A comparison of staff and patient perceptions of the causes and cures of physical aggression on a psychiatric unit

OBJECTIVE

The purpose of the study was to compare staff versus patient perceptions of the causes and emotional impact of verbal and physical aggression on a psychiatric inpatient unit, and the corrective measures each group would endorse.

METHODS

Fifty-four patients and 32 nursing staff members responded to similar questions about physical and verbal aggression. They also reported their emotional responses to aggression and steps they would endorse to reduce aggression at the medical center. Data was analyzed by chi-square tests for proportion comparisons between groups.

RESULTS

"Verbal Abuse" was viewed an important contributor to physical aggression. Staff stressed patient substance abuse and violent lifestyles. Patients focused on the use of involuntary procedures and cultural differences between patients and staff.

CONCLUSIONS

Patients endorsed more restrictive safety measures as long as the measures such as metal detectors and searches were applied to staff and visitors, as well as patients. Patients requested more input into decision-making processes through patient-staff workgroups.

Management of chronic fatigue syndrome: case study

1. Chronic fatigue syndrome (CFS) is a complex disorder marked by incapacitating fatigue of uncertain etiology which has resulted in a least a 50% reduction in activity and is of at least 6 months' duration. 2. Definitive diagnosis can be very challenging. Because no markers objectively identify the presence of CFS, diagnosis depends heavily on the presence of subjective complaints. 3. The current philosophy of CFS management is to use a multidisciplinary approach incorporating these rehabilitation goals: restore a sense of self efficacy and control; gradually increase physical activity; and decrease the restrictions imposed by CFS.

Comparison of Kodak Amerlite FT4 and TSH-30 with T4 and TSH as first-line thyroid function tests

OBJECTIVES

To evaluate the effect of test automation and a change in strategy for thyroid function tests (TFT) on personnel needs and turn-around time. The first-line TFT were changed from T4 and TSH to FT4 and TSH-30.

DESIGN AND METHODS

Samples received for TFT from 357 randomly selected patients were analyzed by RIA for T4, and by IRMA for TSH as first-line tests. FT3 and TBG were requested as back-up tests when indicated. Patients were classified on the basis of these results and the clinical information received. All the samples were reanalyzed for FT4 and TSH on the Amerlite Processing Center, which is a batch, semiautomated immunoassay system. The thyroid status of the patients was compared using the two protocols and available clinical data.

RESULTS

There was good correlation between TSH-IRMA and TSH-30 in the 160 patients classified as euthyroid (r = 0.956; p < 0.001) and no euthyroid patient was reclassified with the new strategy. In 21 patients with borderline raised TSH-IRMA, FT4 was found to be low in only 2. All 11 patients classified as hypothyroid had TSH results greater than 10 mU/L and all except 2 patients had FT4 less than 11 nmol/L. The status of 21 hyperthyroid as well as 40 patients on carbimazole could be determined biochemically on the basis of agreement between both the FT4 and TSH-30 results. FT3 was only required if the FT4 and TSH-30 results were not in agreement. In 42 patients on T4 therapy, adequacy of replacement was assessed better using FT4 and TSH-30. No patient required backup testing with TBG to determine thyroid status using the new testing protocol. The change in TFT protocol reduced the 95% turn-around time from 3 days to 1 day.

CONCLUSION

The introduction of FT4 and TSH-30 as first-line TFT improved the turn-around time for TFT, resulted in 25% reduction in personnel requirements, 60% reduction in FT3 assays, and discontinuation of TBG assay.

Hiring and selection: the Australian experience

The Australian health care system has forced fundamental changes in expectations of leaders and management competencies required to thrive in a cost-constrained environment. By learning from the Australian experience, US managers can incorporate new ideas into reshaping our future leaders.

Ultrasonographic diagnosis of uterine rent at 33 weeks' gestation with history of curettage

A 30-year-old pregnant woman with a history of an uncomplicated curettage for incomplete abortion was seen at 33 weeks' gestation with decreased fetal movement and intermittent abdominal pain for 1 week. Ultrasonographic evaluation demonstrated a singleton vertex pregnancy, oligohydramnios, and a fundal uterine rent continuous with a large, fluid-filled cystic mass. Laparotomy revealed a right cornual uterine rent with hourglass amniotic sac and fluid. A healthy infant was delivered by cesarean section.

Finger sudorometry and assessment of the sudomotor drive

Sudorometry of the finger was carried out using the ventilated capsule method, the aim being to use the level of relative humidity within the sudorometer as an indirect measure of the sudomotor drive. Subjects inserted a finger through a diaphragm of a finger-shaped, temperature-controlled chamber which also contained the humidity sensor. Manoeuvres known to alter the sudomotor drive produced changes in chamber humidity. The relative humidity within the sudorometer became constant after local anaesthesia of the digital nerves and after upper limb sympathectomy, suggesting that fluctuations in the sudorometer output were dependent upon an intact autonomic nervous system. In an environment in which temperature was controlled and arousal effects from the process of measurement were minimised, chamber humidity always increased during a Stroop test, providing a rapid means of indirectly assessing sudomotor drive mechanisms.

Ultrasonographic evaluation of central and end-organ hemodynamics in antepartum pyelonephritis

OBJECTIVE

Our purpose was to evaluate central and end-organ hemodynamic effects of antepartum pyelonephritis.

STUDY DESIGN

Daily duplex ultrasonographic assessments of maternal cardiac output and resistive index values of the maternal renal and uterine arteries and the fetal umbilical arteries were performed in pregnant women admitted for acute pyelonephritis. For comparison, the same measures were repeated within 2 weeks after discharge.

RESULTS

Thirty-seven women with antepartum pyelonephritis underwent serial 2-dimensional real-time and Doppler evaluation of maternal heart and duplex Doppler evaluation of maternal renal and uterine and fetal umbilical arteries. Significant differences in temperature, mean arterial pressure, and heart rate were observed during hospitalization compared with the follow-up visit. Total peripheral resistance was significantly decreased and cardiac output increased during acute infection. In women with unilateral signs and symptoms an increased resistive index was observed in the symptomatic kidney compared with the nonsymptomatic side; this difference disappeared on the follow-up study. No changes were observed in maternal uterine or fetal umbilical arteries.

CONCLUSIONS

Uncomplicated pyelonephritis is associated with measurable depression of systemic vascular resistance. This likely represents an effect of infection that in the extreme would be the septic shock syndrome. It seems reasonable to attribute the increased resistive index of the symptomatic kidney to local effects of infection.

Cost reductions Part 2: an organizational culture perspective

Part One of this series described how an Operations Improvement process, computer simulation, and a focus on the dollars per patient day or unit of service ($PPD) can enhance a hospital's cost-reduction efforts. Part Two will address the organizational culture issues that can hamper or support nursing's cost-reduction efforts.

Cost reductions. Part 1: An operations improvement process

Today's nursing leaders are commonly expected to reduce labor costs. This two-part series provides a framework for achieving significant cost reductions in the nursing labor budget. Part One describes a process that has been used to identify and implement cost savings in varied hospital settings. Part Two will address organizational culture issues that can hamper or support cost savings.

An electromyographic analysis of the elbow in normal and injured pitchers with medial collateral ligament insufficiency

Electromyography and high-speed film were used to examine the muscle activity in the elbows of pitchers with medial collateral ligament insufficiency compared to the activity in uninjured elbows. Ten competitive baseball pitchers with medial collateral insufficiency and 30 uninjured competitive pitchers were tested while throwing the fastball and the curveball. The extensor carpi radialis brevis and longus in the injured pitchers showed greater activity than in the uninjured pitchers for both pitches. The triceps, flexor carpi radialis, and pronator teres all showed less activity in the injured pitchers during the fastball, but only the triceps had less activity during the curveball. The differences were seen during the late cocking and acceleration phases, which place the greatest stress on the medial collateral ligament. If the flexor carpi radialis and pronator teres were substituting for the deficient medial collateral ligament and functioning as dynamic stabilizers, one would expect enhanced muscle activity. However, the opposite was found. This pattern of asynchronous muscle action with medial collateral ligament injury may predispose the joint to further injury. The muscular differences seen are critical to the understanding of the pathomechanics of patients with medial collateral ligament deficiency, and provide a basis for rehabilitation.