Hypoxia signatures in closed-circuit rebreather divers

INTRODUCTION

Faults or errors during use of closed-circuit rebreathers (CCRs) can cause hypoxia. Military aviators face a similar risk of hypoxia and undergo awareness training to determine their 'hypoxia signature', a personalised, reproducible set of symptoms. We aimed to establish a hypoxia signature among divers, and to investigate their ability to detect hypoxia and self-rescue while cognitively overloaded.

METHODS

Eight CCR divers and 12 scuba divers underwent an initial unblinded hypoxia exposure followed by three trials; a second hypoxic trial and two normoxic trials in randomised order. Hypoxia was induced by breathing on a CCR with no oxygen supply. Subjects pedalled on a cycle ergometer while playing a neurocognitive computer game to simulate real world task loading. Subjects identified hypoxia symptoms by pointing to a board listing common hypoxia symptoms, and were instructed to perform a 'bailout' procedure to mimic self-rescue if they perceived hypoxia. Divers were prompted to bailout if peripheral oxygen saturation fell to 75%, or after six minutes during normoxic trials. Subsequently we interviewed subjects to determine their ability to distinguish hypoxia from normoxia.

RESULTS

Ninety-five percent of subjects (19/20) showed agreement between unblinded and blinded hypoxia symptoms. Subjects correctly identified the gas mixture in 85% of the trials. During unblinded hypoxia, only 25% (5/20) of subjects performed unprompted bailout. Fifty-five percent of subjects (11/20) correctly performed the bailout but only when prompted, while 15% (3/20) were unable to bailout despite prompting. During blinded hypoxia 45% of subjects (9/20) performed the bailout unprompted while 15% (3/20) remained unable to bailout despite prompting.

CONCLUSIONS

Although our data support a normobaric hypoxia signature among both CCR and scuba divers under experimental conditions, most subjects were unable to recognise hypoxia in real time and perform a self-rescue unprompted, although this improved in the second hypoxia trial. These results do not support hypoxia exposure training for CCR divers.

The Host-Microbiome Response to Hyperbaric Oxygen Therapy in Ulcerative Colitis Patients

BACKGROUND & AIMS

Hyperbaric oxygen therapy (HBOT) is a promising treatment for moderate-to-severe ulcerative colitis. However, our current understanding of the host and microbial response to HBOT remains unclear. This study examined the molecular mechanisms underpinning HBOT using a multi-omic strategy.

METHODS

Pre- and post-intervention mucosal biopsies, tissue, and fecal samples were collected from HBOT phase 2 clinical trials. Biopsies and fecal samples were subjected to shotgun metaproteomics, metabolomics, 16s rRNA sequencing, and metagenomics. Tissue was subjected to bulk RNA sequencing and digital spatial profiling (DSP) for single-cell RNA and protein analysis, and immunohistochemistry was performed. Fecal samples were also used for colonization experiments in IL10-/- germ-free UC mouse models.

RESULTS

Proteomics identified negative associations between HBOT response and neutrophil azurophilic granule abundance. DSP identified an HBOT-specific reduction of neutrophil STAT3, which was confirmed by immunohistochemistry. HBOT decreased microbial diversity with a proportional increase in Firmicutes and a secondary bile acid lithocholic acid. A major source of the reduction in diversity was the loss of mucus-adherent taxa, resulting in increased MUC2 levels post-HBOT. Targeted database searching revealed strain-level associations between Akkermansia muciniphila and HBOT response status. Colonization of IL10-/- with stool obtained from HBOT responders resulted in lower colitis activity compared with non-responders, with no differences in STAT3 expression, suggesting complementary but independent host and microbial responses.

CONCLUSIONS

HBOT reduces host neutrophil STAT3 and azurophilic granule activity in UC patients and changes in microbial composition and metabolism in ways that improve colitis activity. Intestinal microbiota, especially strain level variations in A muciniphila, may contribute to HBOT non-response.

Is more complex safer in the case of bail-out rebreathers for extended range cave diving?

Nowhere is redundancy more indispensable than extended range cave diving. Training and practice in this discipline ensure divers are equipped with backup regulators, gauges, lights, and adequate breathing gas for a safe exit, emergencies, and decompression. Depending on penetration distances and depth, open circuit cave diving may require carrying more gas cylinders than can be logistically managed by the diver themselves while maintaining safe gas supply margins. Consequently, divers are forced to either stage cylinders in the cave prior to the dive or rely on resupply from support divers. Both scenarios have significant drawbacks. Due to the improved efficiency of breathing gas utilisation and other advantages, closed circuit rebreathers (CCR) have enabled extended range cave diving. With increasing depths, penetration distances, and bottom times, these divers must also plan for an increasing amount of open circuit bail-out gas in the event of CCR failure. Staged cylinders have traditionally been utilised, but this strategy has limitations due to the advanced dives needed to place them and equipment degradation due to prolonged water immersion, which can often result in cylinder and regulator corrosion with consequent leakage of contents over time. Consequently, a growing number of CCR divers are foregoing open-circuit bailout altogether by carrying an additional CCR system for bailout. Although these bailout rebreathers may facilitate further exploration and have certain advantages, the risks of diving with two complex machines remain to be clearly defined.

Safety proposals for freediving time limits should consider the metabolic-rate dependence of oxygen stores depletion

INTRODUCTION

There is no required training for breath-hold diving, making dissemination of safety protocols difficult. A recommended breath-hold dive time limit of 60 s was proposed for amateur divers. However, this does not consider the metabolic-rate dependence of oxygen stores depletion. We aimed to measure the effect of apnoea time and metabolic rate on arterial and tissue oxygenation.

METHODS

Fifty healthy participants (23 (SD 3) y, 22 women) completed four periods of apnoea for 60 s (or to tolerable limit) during rest and cycle ergometry at 20, 40, and 60 W. Apnoea was initiated after hyperventilation to achieve P_ETCO₂ of approximately 25 mmHg. Pulse oximetry, frontal lobe oxygenation, and pulmonary gas exchange were measured throughout. We defined hypoxia as SpO₂ < 88%.

RESULTS

Static and exercise (20, 40, 60 W) breath-hold break times were 57 (SD 7), 50 (11), 48 (11), and 46 (11) s (F [2.432, 119.2] = 32.0, P < 0.01). The rise in P_ETCO₂ from initiation to breaking of apnoea was dependent on metabolic rate (time × metabolic rate interaction; F [3,147] = 38.6, P < 0.0001). The same was true for the fall in SpO₂ (F [3,147] = 2.9, P = 0.03). SpO₂ fell to < 88% on 14 occasions in eight participants, all of whom were asymptomatic.

CONCLUSIONS

Independent of the added complexities of a fall in ambient pressure on ascent, the effect of apnoea time on hypoxia depends on the metabolic rate and is highly variable among individuals. Therefore, we contend that a universally recommended time limit for breath-hold diving or swimming is not useful to guarantee safety.

A Blacktip Reef Shark Bite to the Hand in the Remote Solomon Islands

BACKGROUND

Solomon Islands is a country in the South Pacific Ocean with excellent scuba diving, particularly among its remote islands that can be accessed by liveaboard dive boats. Blacktip reef sharks (Carcharhinus melanopterus) are found throughout the island nation and rarely attack humans.

CASE REPORT

We present the case of a 42-year-old man who sustained a hand laceration after being bitten by a blacktip reef shark. He underwent complex primary wound closure in an austere environment and received prophylactic antibiotics. No infection developed and he recovered fully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss our rationale in closing the wound aboard the dive boat, the choice of antibiotics, and review marine pathogens.

Diving after SARS-CoV-2 (COVID-19) infection: Fitness to dive assessment and medical guidance

Scuba diving is a critical activity for commercial industry, military activities, research, and public safety, as well as a passion for many recreational divers. Physicians are expected to provide return-to-diving recommendations after SARS-CoV-2 (COVID-19) infection based upon the best available evidence, often drawn from experience with other, similar diseases. Scuba diving presents unique physiologic challenges to the body secondary to immersion, increased pressure and increased work of breathing. The long-term sequelae of COVID-19 are still unknown, but if they are proven to be similar to other coronaviruses (such as Middle East respiratory syndrome or SARS-CoV-1) they may result in long-term pulmonary and cardiac sequelae that impact divers' ability to safely return to scuba diving. This review considers available literature and the pathophysiology of COVID-19 as it relates to diving fitness, including current recommendations for similar illnesses, and proposes guidelines for evaluation of divers after COVID-19. The guidelines are based upon best available evidence about COVID-19, as well as past experience with determination of diving fitness. It is likely that all divers who have contracted COVID-19 will require a medical evaluation prior to return to diving with emphasis upon pulmonary and cardiac function as well as exercise capacity.

A phase 2B randomised trial of hyperbaric oxygen therapy for ulcerative colitis patients hospitalised for moderate to severe flares

BACKGROUND

Hyperbaric oxygen has been reported to improve disease activity in hospitalised ulcerative colitis (UC) patients.

AIM

To evaluate dosing strategies with hyperbaric oxygen for hospitalised UC patients.

METHODS

We enrolled UC patients hospitalised for acute flares (Mayo score 6-12). Initially, all patients received 3 days of hyperbaric oxygen at 2.4 atmospheres (90 minutes with two air breaks) in addition to intravenous steroids. Day 3 responders (reduction of partial Mayo score ≥ 2 points and rectal bleeding score ≥ 1 point) were randomised to receive a total of 5 days vs 3 days of hyperbaric oxygen.

RESULTS

We treated 20 patients with hyperbaric oxygen (75% prior biologic failure). Day 3 response was achieved in 55% (n = 11/20), with significant reductions in stool frequency, rectal bleeding and CRP (P < 0.01). A more significant reduction in disease activity was observed with 5 days vs 3 days of hyperbaric oxygen (P = 0.03). Infliximab or colectomy was required in only three patients (15%) despite a predicted probability of 80% for second-line therapy. Day 3 hyperbaric oxygen responders were less likely to require re-hospitalisation or colectomy by 3 months vs non-responders (0% vs 66%, P = 0.002). No treatment-related adverse events were observed.

CONCLUSION

Hyperbaric oxygen appears to be effective for optimising response to intravenous steroids in UC patients hospitalised for acute flares, with low rates of re-hospitalisation or colectomy at 3 months. An optimal clinical response is achieved with 5 days of hyperbaric oxygen. Larger phase 3 trials are needed to confirm efficacy and obtain labelled approval.

Delayed hyperbaric oxygen therapy for severe arterial gas embolism following scuba diving: a case report

We present the case of a 42-year-old female who was critically ill due to an arterial gas embolism (AGE) she experienced while diving in Maui, Hawaii. She presented with shortness of breath and dizziness shortly after surfacing from a scuba dive and then rapidly lost consciousness. The diver then had a complicated hospital course: persistent hypoxemia (likely secondary to aspiration) requiring intubation; markedly elevated creatine kinase; atrial fibrillation requiring cardioversion; and slow neurologic improvement. She had encountered significant delay in treatment due to lack of availability of local hyperbaric oxygen (HBO2) therapy. Our case illustrates many of the complications that can occur when a patient suffers a severe AGE. These cases may occur even without a history of rapid ascent or risk factors for pulmonary barotrauma, and it is imperative that they be recognized and treated as quickly as possible with HBO2. Unfortunately, our case also highlights the challenges in treating critically ill divers, particularly with the growing shortage of 24/7 hyperbaric chambers able to treat these ICU-level patients.

Hyperbaric medicine simulation education curriculum: CNS toxicity during Treatment Table 6 and intubated ICU patient with mucous plugging

INTRODUCTION/BACKGROUND

The incidence of complications and number of critically ill patients in hyperbaric medicine is relatively low [1]. This poses a challenge to those tasked with educating trainees as well as maintaining the skills of staff. Hyperbaric medicine fellows may not be exposed to critical patient scenarios or complications of hyperbaric medicine during a one-year fellowship. Additional staff may be unfamiliar with these situations as well. The purpose of hyperbaric simulation curriculum is to train health care providers for rare situations. To our knowledge, this hyperbaric simulation curriculum is the first published use of simulation education in the specialty of undersea and hyperbaric medicine.

MATERIALS AND METHODS

Two simulation cases have been developed that involve a patient with oxygen toxicity during hyperbaric treatment as well as an ICU patient with mucous plugging.

RESULTS

Medical training simulations are an effective method of teaching content and training multiple roles in Undersea and Hyperbaric Medicine.

SUMMARY/CONCLUSIONS

A hyperbaric simulation curriculum is an achievable educational initiative that is able to train multiple team members simultaneously in situations that they may not encounter on a regular basis. We believe that this could be easily exported to otherinstitutions for further education.

Methicillin-Resistant Staphylococcus aureus Septic Internal Jugular Thrombophlebitis: Updates in the Etiology and Treatment of Lemierre's Syndrome

BACKGROUND

Lemierre's syndrome is classically precipitated by oropharyngeal infections that progress to suppurative internal jugular vein thrombophlebitis via direct extension. Metastatic pneumonia from septic emboli is nearly universal and bacterial seeding frequently results in disseminated septic foci. Fusobacterium necrophorum is the most commonly reported etiologic agent, though methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen and a myriad of oropharyngeal flora must be covered until blood cultures return. Prompt identification is paramount to minimizing morbidity. Empiric treatment with antibiotics exhibiting predominantly anaerobic activity has been standard, but now may be insufficient, given an evolving microbial landscape. Anticoagulation continues to be debated.

CASE REPORT

We describe an uncommon presentation of Lemierre's syndrome in a diabetic patient secondary to MRSA, where the only identifiable source of entry was atraumatic post-auricular cellulitis. Why Should an Emergency Physician Be Aware of This? Given the evolving landscape of organisms implicated in septic internal jugular thrombophlebitis, empiric treatment should entail consideration of MRSA. Patients at an elevated risk include those who are undomiciled or incarcerated, injection drug users, human immunodeficiency virus-positive, and have recently been hospitalized or completed a course of antibiotics. The existing evidence evaluating empiric anticoagulation is low-powered and retrospective and would benefit from randomized controlled trials. Although it does not appear valuable for most, those with thrombus extension, persistent bacteremia, or central venous thrombosis may benefit.

Purple Urine Bag Syndrome in a Patient with an Ileal Conduit and Clostridium Difficile Infection

Purple urine bag syndrome is a potentially alarming phenomenon caused by bacterial metabolism of urinary tryptophan into indigo (blue) and indirubin (red) pigments. We report the case of a 46-year-old female with an ileal conduit who presented with a 2 week history of abdominal pain and purple discolouration of her urine. In addition, we review the literature on purple urine bag syndrome, and identify potential new risk factors and management considerations.

A favorable outcome despite a 39-hour treatment delay for arterial gas embolism: case report

Cerebral arterial gas embolism (CAGE) occurs when gas enters the cerebral arterial vasculature. CAGE can occur during sitting craniotomies, cranial trauma or secondary to gas embolism from the heart. A far less common cause of CAGE is vascular entrainment of gas during endoscopic procedures. We present the case of a 49-year-old male who developed a CAGE following an esophagoduodenoscopy (EGD) biopsy. Due to a delay in diagnosis, the patient was not treated with hyperbaric oxygen (HBO₂) therapy until 39 hours after the inciting event. Despite presenting to our institution non-responsive and with decorticate posturing, the patient was eventually discharged to a rehabilitation facility, with only mild left upper extremity weakness. This delay in HBO₂ treatment represents the longest delay in treatment to our knowledge for a patient suffering from CAGE secondary to EGD. In addition to the clinical case report, we discuss the etiology of CAGE and the evidence supporting early HBO₂ treatment, as well as the data demonstrating efficacy even after considerable treatment delay.

Echocardiographic evaluation of intracardiac venous gas emboli following in-water recompression

Decompression sickness is a potentially fatal illness. Optimal treatment is dry recompression with hyperbaric oxygen. In-water recompression (IWR) offers expedited treatment but has insufficient evidence to recommend it as a treatment option. This trial compares IWR to standard surface oxygen treatment using 2D echocardiography as the semi-quantitative measurement for inert gas loading. Divers were randomly assigned to either IWR or normobaric oxygen (NBO2). A provocative dive profile to 33.5 meters for 25 minutes was used to stimulate bubble formation. After 60 minutes on the surface, bubble scoring was obtained using 2D echocardiography. Divers underwent either the IWR or NBO2 treatment for 82 minutes. Echocardiography was then repeated. Pre-treatment mean bubble counts were 28.1 bpf (bubbles per echo frame), [+/- 13.2 to 43.0 95% CI] for IWR, and 18.3 bpf [+/- 0.0 to 39.6 95% CI] for NBO2. After treatment, mean bubble score dropped to 0.1 bpf [+/- 0.0 to 0.2 95% CI] (p < 0.01) and 1.8 bpf [0.0 to 3.8 95% CI] (p = 0.103) respectively. IWR vs. NBO2 reduction of bubble counts was 99.7% vs. 90.1%; however, this was not found to be statistically significant. IWR reduced the central VGE load compared to NBO2, suggesting that IWR is a viable emergency treatment when a recompression chamber is unavailable.

Impact of Regional Lymph Node Dissection on Disease Specific Survival in Adrenal Cortical Carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The purpose of this study is to evaluate the impact of a more extensive regional lymph node dissection (LND) has on survival in ACC patients in the United States. Patients ≥ 15 years of age without distant metastases who underwent surgical intervention for primary ACC were identified from the SEER18 registry from 1988-2009. Patients were divided into 2 groups: having a regional LND (≥ 5 LNs removed) vs. no-LND (0-4 LNs removed). Overall survival (OS) and disease specific survival (DSS) were compared between groups. Of 259 patients with complete data on nodal resection, 243 (93.8%) underwent no-LND and 16 (6.2%) LND. There was no difference in age, sex, metastases, or ENSAT stage between groups. However, LND patients had larger tumors (p=0.004), and more frequently underwent en-bloc surgery (p=0.002). One- and 3-year OS and DSS did not differ between groups. In a cox regression model, performance of a regional LND did not significantly influence DSS. However, female gender (HR: 1.67, CI: 1.04-2.69, p=0.033) and later stage (stage III-HR: 4.78, CI: 1.14-20.00, p=0.032) or positive LNs (HR: 5.92, CI: 2.05-17.08, p=0.001) were risk factors for worse DSS. Regional LND may not improve DSS or OS in nonmetastatic ACC patients undergoing adrenalectomy. It remains controversial as an essential part of the surgical management for ACC and deserves further investigation in a larger, prospective study. However, regional LND should still be considered for staging and prognostic purposes and to standardize surgical care.

Self-sampling for community respiratory illness: a new tool for national virological surveillance

This report aims to evaluate the usefulness of self-sampling as an approach for future national surveillance of emerging respiratory infections by comparing virological data from two parallel surveillance schemes in England. Nasal swabs were obtained via self-administered sampling from consenting adults (≥ 16 years-old) with influenza symptoms who had contacted the National Pandemic Flu Service (NPFS) health line during the 2009 influenza pandemic. Equivalent samples submitted by sentinel general practitioners participating in the national influenza surveillance scheme run jointly by the Royal College of General Practitioners (RCGP) and Health Protection Agency were also obtained. When comparable samples were analysed there was no significant difference in results obtained from self-sampling and clinician-led sampling schemes. These results demonstrate that self-sampling can be applied in a responsive and flexible manner, to supplement sentinel clinician-based sampling, to achieve a wide spread and geographically representative way of assessing community transmission of a known organism.

Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury

Introduction

Evaluation recommendations for patients on anticoagulant and antiplatelet (ACAP) therapy that present after mild traumatic brain injury (TBI) are controversial. At our institution, an initial noncontrast head computed tomography (HCT) is performed, with a subsequent HCT performed six hours later to exclude delayed intracranial hemorrhage (ICH). This study was performed to evaluate the yield and advisability of this approach.

Methods

We performed a retrospective review of subjects undergoing evaluation for ICH after mild TBI in patients on ACAP therapy between January of 2012 and April of 2013. We assessed for the frequency of ICH on both the initial noncontrast HCT and on the routine six-hour follow-up HCT. Additionally, chart review was performed to evaluate the clinical implications of ICH, when present, and to interrogate whether pertinent clinical and laboratory data may predict the presence of ICH prior to imaging. We used multivariate generalized linear models to assess whether presenting Glasgow Coma Score (GCS), loss of consciousness (LOC), neurological or physical examination findings, international normalized ratio, prothrombin time, partial thromboplastin time, platelet count, or specific ACAP regimen predicted ICH.

Results

144 patients satisfied inclusion criteria. Ten patients demonstrated initial HCT positive for ICH, with only one demonstrating delayed ICH on the six-hour follow-up HCT. This patient was discharged without any intervention required or functional impairment. Presenting GCS deviation (p<0.001), LOC (p=0.04), neurological examination findings (p<0.001), clopidogrel (p=0.003), aspirin (p=0.03) or combination regimen (p=0.004) use were more commonly seen in patients with ICH.

Conclusion

Routine six-hour follow-up HCT is likely not indicated in patients on ACAP therapy, as our study suggests clinically significant delayed ICH does not occur. Additionally, presenting GCS deviation, LOC, neurological examination findings, clopidogrel, aspirin or combination regimen use may predict ICH, and, in the absence of these findings, HCT may potentially be forgone altogether.

Mycoplasma pneumoniae infection in primary care investigated by real-time PCR in England and Wales

Real-time PCR was employed to detect a conserved region of the P1 cytadhesin gene of Mycoplasma pneumoniae in combined nose and throat swabs collected from patients attending GP surgeries during 2005-2009 with symptoms of respiratory tract infection (RTI). Samples were collected as part of an annual winter epidemiological and virological linked study in England and Wales. A total of 3,987 samples were tested, 65 (1.7%, 95%CI 1.3-2.1) had detectable M. pneumoniae DNA. Positive patients were detected of both gender, aged from 9 months to 78 years, who had clinical signs of upper RTI, fever and/or myalgia, an influenza-like illness to lower RTI. Mixed infections were identified in four cases, two with influenza A H1, one with H3 and one with influenza B. Children aged 5-14 years were more likely to have detectable M. pneumoniae in samples than all other age groups (Fishers p = 0.03), attributed to the 2005-2006 season in which 6.0% (12/200, 95%CI 3.4-10.3) of 5-14 year olds had detectable M. pneumoniae in comparison to 2.2% in 2006-2007 (3/141 95%CI 0.5-6.4), 2.2% in 2007-2008 (2/89 95%CI 0.1-8.3) and 0% in 2008-2009 (0/151 95%CI 0-2.9).

An open trial of naltrexone for opiate dependence

The objective of this study was to conduct a pilot study of naltrexone in opiate-dependent patients in order to determine the sample size for a double-blind controlled trial, to identify possible confounders and to obtain experience with the drug's side effects and acceptability to patients. Opiate-dependent patients presenting to a public hospital for treatment for their dependence were invited to participate. Patients with major organic illness, another Axis I diagnosis, or who were pregnant were excluded. Naltrexone was prescribed at a dose of 50 mg daily for 6 months. Data were collected on drug use, social stability, physical and mental health before during and after the treatment programme. Patients were seen weekly for 6 months then monthly for a further 6 months. Forty-four patients were enrolled, but three stopped naltrexone early because of possible side effects. Of the remainder, 32 were followed for at least 12 months. Eight (25%) ceased opiate use from the start, and another two were no longer using at the end of 12 months giving an abstinence rate of 31% at 12 months. Retention in treatment was 34%. Of the abstinent patients however, only two took naltrexone for the whole 6 months. Naltrexone was well tolerated and associated with a significant abstinence rate, but most patients do not feel they need to take the drug for 6 months. A double-blind controlled trial would be justified.

Clinical use of a shortened alcohol withdrawal scale in a general hospital

BACKGROUND

Multi-item scales for monitoring alcohol withdrawal reactions have been used since the 1970s, and since 1985 we have used a modified version of the Clinical Institute Withdrawal Assessment (CIWA) in our general hospitals. This study was conducted to determine whether a shorter version of the scale would prove easier to use without loss of accuracy.

METHODS

A simultaneous 'crossover' clinical audit using two hospitals. The shortened scale was developed from the existing one, and had 10 items as opposed to the previous 18. The patients were followed throughout their course and the incidences of complication, the frequency of sedation, the delay in initiating monitoring and the ease of use were recorded.

RESULTS

There were 106 patients managed with the old scale and 96 with the new. The rate of complication was not different, being 16% in patients managed using the old scale and 14.5% using the new scale; the rates of sedation were 49 and 48%, respectively. Patients managed with the new scale had a shorter course with a median duration of 27.6 h compared with 40 h. The time from admission to first recording of a score was 5.4 h for the new scale and 4.8 h for the old, which is not a significant difference. Both scores were used according to instructions, but staff reported that the shortened scale was easier to use.

CONCLUSIONS

We conclude that a shortened form of the CIWA alcohol withdrawal scale works as well as the original and is simple to use.

Unwanted pregnancy and contraceptive knowledge: identifying vulnerable groups from a randomized controlled trial of educational interventions

OBJECTIVES

The aim of this study was to identify predictors of contraceptive pill knowledge and their relationship to educational interventions.

METHODS

A total of 636 women attending for a follow-up appointment for repeat prescription of the combined oral contraceptive pill with a GP or practice nurse were randomized to receive leaflets (simple summary leaflet or FPA leaflet), advice or neither. Sociodemographic details and contraceptive knowledge were determined using a validated contraceptive knowledge questionnaire sent after 3 months by post. The main outcomes were sociodemographic, contraceptive, attitudinal and educational predictors of knowledge.

RESULTS

A total of 522 (82%) had complete questionnaires. After controlling for educational intervention and other confounding variables, independent predictors of knowledge were further education (adjusted odds ratio 2.98, 95% confidence interval 1.78-4.99); number of years on the pill (0-5, 6-10, >10 years) 1.0, 0.56 (0.33-0.95) and 0.34 (0.19-0.59), respectively; past emergency contraception (1.87, 1.18-2.97); and importance attached to not falling pregnant (1.83, 1.02-3.29). These predictors are less powerful than the impact of most educational interventions (range of odds ratios for interventions: 1.85-6.81), and there was no evidence of a separate effect of educational intervention in any subgroup, except that leaflets have a larger effect in women who have needed emergency contraception in the past (no past use or simple summary and FPA leaflets, 1.74 and 0.90, respectively; with past use, 3.47 and 3.83; interaction term chi-square 6.92, P = 0.03).

CONCLUSION

Educational interventions are as important as sociodemographic features in determining knowledge. With limited time for full educational interventions in practice, priorities for intervention should be women who have used emergency contraception in the past-who will benefit most-and those on the pill for >5 years or with no further education who are at highest risk due to poor knowledge.

Molecular and immunological analyses of the Borrelia turicatae Bdr protein family

Here, we describe the molecular and immunological characterization of the bdr gene family of Borrelia turicatae, a relapsing-fever spirochete. Nine bdr alleles belonging to two different subfamilies were sequenced and localized to linear plasmids. Anti-Bdr antiserum was generated and used to analyze Bdr expression in pre- and postinfection isogenic populations. The analyses presented here provide a detailed characterization of the Bdr proteins in a relapsing-fever spirochete species, enhancing our understanding of these proteins at the genus-wide level.

Faculty practice and health promotion in a community correctional facility

Faculty practice and health promotion are topics of interest to nursing faculty to prepare students and themselves for the future. Health promotion with vulnerable populations is a focus for the 21st century health care delivery system. Faculty practice emphasizing health promotion with a vulnerable population meets the needs of faculty as they strive to meet personal and professional goals. The development of a faculty practice serving a vulnerable population represented by clients in a community corrections facility will be described. Scope of practice, the development of a research focus, teaching approaches, and future initiatives are presented.

TNF is essential for the cell-mediated protective immunity induced by the radiation-attenuated schistosome vaccine

C57BL/6 mice exposed to the radiation-attenuated schistosome vaccine exhibit high levels of protective immunity. The cell-mediated pulmonary effector mechanism involves IFN-gamma-producing CD4+ T cells in a focal response around challenge larvae. IFN-gamma can promote production of TNF and can synergize with this cytokine in its actions on responder cells. We have examined whether TNF plays a role in lung phase immunity to schistosomes using mice with a disrupted gene for TNFRI (TNFRI-/-). The most dramatic finding was that the schistosome vaccine elicited no protection whatsoever in these mice. However, this could not be attributed to a lack of responder cells, because more lymphocytes were lavaged from the airways of TNFRI-/- than wild-type mice. Furthermore, CD4+ T cells were equally represented in airway populations from the two groups and produced IFN-gamma upon Ag stimulation in vitro. In contrast, pulmonary macrophage function was defective in TNFRI-/- mice, as indicated by a failure to up-regulate inducible NO synthase mRNA. Histopathological analysis revealed that focal infiltrates were of similar size and cell composition in the two groups but that more parasites were free of foci in the TNFRI-/- mice. These animals had a greatly impaired IgG response to schistosomes, which may explain their lack of residual protection due to Ab in a situation where cell-mediated immunity is disabled. We suggest that the absence of protective immunity could result from a retarded build-up of leukocytes around migrating lung worms and/or a deficit in accessory cell function within a focus, both of which would permit parasite escape.

spe-12 encodes a sperm cell surface protein that promotes spermiogenesis in Caenorhabditis elegans

During spermiogenesis, Caenorhabditis elegans spermatids activate and mature into crawling spermatozoa without synthesizing new proteins. Mutations in the spe-12 gene block spermatid activation, rendering normally self-fertile hermaphrodites sterile. Mutant males, however, are fertile. Surprisingly, when mutant hermaphrodites mate with a male, their self-spermatids activate and form functional spermatozoa, presumably due to contact with male seminal fluid. Here we show that, in addition to its essential role in normal activation of hermaphrodite-derived spermatids, SPE-12 also plays a supplementary but nonessential role in mating-induced activation. We have identified the spe-12 gene, which encodes a novel protein containing a single transmembrane domain. spe-12 mRNA is expressed in the sperm-producing germ line and the protein localizes to the spermatid cell surface. We propose that SPE-12 functions downstream of both hermaphrodite- and male-derived activation signals in a spermatid signaling pathway that initiates spermiogenesis.

Contraceptive knowledge: development of a valid measure and survey of pill users and general practioners

AIMS

To design, pilot, and validate a questionnaire to test contraceptive knowledge in combined oral contraceptive pill users.

METHOD

To ensure face and content validity the questionnaire was developed using existing unvalidated instruments and in consultation with GPs, local and national family planning experts, and with pill users. The questionnaire was then piloted with 15 current oral contraceptive pill users and 10 local GPs, modified, and a contraceptive knowledge 'score' developed. Construct validity-that the degree of family planning training should predict contraceptive knowledge-was tested in four groups: family planning trainers (n=28), GPs (n=40), current pill users (n=53), and male medical students (n=59). Thirty current pill users were sent the questionnaire after two weeks to determine test-retest reliability.

RESULTS

The questionnaire showed construct validity: there was a gradient of scores across the four knowledge groups. Family planning trainers had the highest scores, followed by GPs, and current pill users, with male medical students having the lowest scores (Kruskal-Wallis test p<0.001). Women had good knowledge of situations when pill efficacy is reduced but poorer knowledge of what action to take subsequently. Predictors of knowledge in pill users were educational level, age, and the importance attached to not falling pregnant-thus providing further evidence for the construct validity of the questionnaire. Test-retest reliability was good (rank correlation 0. 73).

CONCLUSION

A contraceptive knowledge questionnaire suitable for use in audit or research has been developed which is reliable and has face, content and construct validity. Pill users have poor knowledge of what to do in situations of pill failure and about the details of emergency contraception. Trials are needed to assess the effectiveness of different strategies to improve contraceptive knowledge in women.

Socialization of hospice volunteers: members of the family

The purpose of this study is to examine the turning points volunteers found important in their hospice training and volunteer experiences. Seventeen individuals who had recently completed hospice training were asked about the turning points in their training and volunteering that were important in their becoming and remaining a hospice volunteer. The study finds that volunteers have a wide variety of intrapersonal, interpersonal, and group reasons for becoming and remaining a hospice volunteer. The findings suggest that hospice staff need to create a wide variety of events which volunteers can identify with to help people want to become and remain volunteers.

Effect of educational leaflets and questions on knowledge of contraception in women taking the combined contraceptive pill: randomised controlled trial

OBJECTIVE

To assess whether provision of educational leaflets or questions on contraception improves knowledge of contraception in women taking the combined contraceptive pill.

DESIGN

Randomisation of women into three groups according to type of educational leaflet on contraceptive information. These groups were subdivided into two on the basis of questions on contraception asked by the doctor or practice nurse. The women were followed up by postal questionnaire 3 months later.

SETTING

15 general practices in South and West region.

SUBJECTS

636 women attending check up appointment for repeat prescription of the combined contraceptive pill.

MAIN OUTCOME MEASURES

Knowledge of: factors causing pill failure, subsequent action, emergency contraception, and all the rules (pill rules) that apply to the contraceptive pill.

RESULTS

523 women returned completed questionnaires (response rate 82%). Knowledge of contraception with no intervention was low with only 10 (12%) women knowing all the pill rules. Educational intervention had a highly significant effect on knowledge of: factors causing pill failure (likelihood ratio chi2=22); subsequent action (21); emergency contraception (24); and all the pill rules (22) (P<0.01 in all cases). Improvement in knowledge of all the pill rules occurred with provision of the summary leaflet (28% knew all the rules, adjusted odds ratio 4.04, 95% confidence interval 1.68 to 9.75), the Family Planning Association's leaflet (27%, 3.43, 1.45 to 8.09), and asking questions (26%, 3.03, 1.30 to 7.00). Asking questions in addition to provision of leaflets improved knowledge of contraception further for the summary leaflet (39%, 6.81, 2.85 to 16.27) but not for the Family Planning Association leaflet (21%, 2.58, 1.07 to 6.18).

CONCLUSION

Women attending check ups for repeat prescriptions of the contraceptive pill should be provided with educational leaflets on contraception or asked relevant questions to help improve their knowledge of contraception. Asking questions in addition to providing a summary leaflet is time consuming, but results in the most knowledge gained.

African American women and osteoporosis

Osteoporosis is a condition that presents differing predisposing factors between European American Women and African American Women. Preventative health is commonly focused on European women because they are at higher risk. This article presents issues and facts that substantiate the need to also target African American women for osteoporosis prevention education.

Is delayed surgery really better for congenital diaphragmatic hernia?: a prospective randomized clinical trial

Delayed surgery has become widely accepted in the management of congenital diaphragmatic hernia after comparing outcomes only with historical retrospective controls. It was the aim of this study to compare early and delayed hernia repair in a randomized prospective clinical trial. Fifty-four infants were randomized to receive either early repair (within 4 hours of admission) or delayed repair (more than 24 hours after birth). The survival rate was higher for the delayed group (57% v 46%), but the difference was not significant (difference: -11; 95% confidence limits: -37.5, 15.5). There were no significant differences between the two groups with respect to length of hospital stay, ventilator dependency, or survival time. Recorded preoperative risk factors were similar for the two groups. Eight infants in the delayed repair group died without having undergone surgery. The optimum time for surgery still needs clarification.

Genetic and molecular analysis of spe-27, a gene required for spermiogenesis in Caenorhabditis elegans hermaphrodites

Hermaphrodites with mutations in the spe-27 gene are self-sterile, laying only unfertilized eggs; mutant males are fertile. Hermaphrodites make spermatids that fail to activate to crawling spermatozoa so passing oocytes sweep them out of the spermatheca. These spermatids do activate and produce self-progeny if young mutant hermaphrodites are mated by fertile (or sterile) males. Spermatids isolated from either mutant males or hermaphrodites initiate activation in vitro when treated with proteases, but then arrest with spiky membrane projections that resemble those of a normal intermediate in pseudopod formation. These phenotypes are identical to spe-8 and spe-12 mutants. They can be explained if males and hermaphrodites have distinct pathways for spermatid activation, and these three genes are necessary only for the hermaphrodite pathway. Consistent with this model, when spe-27 mutant male spermatids without seminal fluid are artificially inseminated into hermaphrodites, they fail to activate. The spe-27 gene has been isolated, sequenced and its regulatory regions identified. The sequence predicts a 131 amino acid polypeptide that has no striking structural motifs and no resemblance to known proteins. Two of the mutations in spe-27 alter mRNA splicing; a third mutation is a temperature-sensitive missense mutation.