Interactions between oxidative stress and inflammation in salt-sensitive hypertension

The goal of this study was to test the hypothesis that increases in oxidative stress in Dahl S rats on a high-salt diet help to stimulate renal nuclear factor-kappaB (NF-kappaB), renal proinflammatory cytokines, and chemokines, thus contributing to hypertension, renal damage, and dysfunction. We specifically studied whether antioxidant treatment of Dahl S rats on high Na intake would decrease renal inflammation and thus attenuate the hypertensive and adverse renal responses. Sixty-four 7- to 8-wk-old Dahl S or R/Rapp strain rats were maintained for 5 wk on high Na (8%) or high Na + vitamins C (1 g/l in drinking water) and E (5,000 IU/kg in food). Arterial and venous catheters were implanted at day 21. By day 35 in the high-Na S rats, antioxidant treatment significantly increased the renal reduced-to-oxidized glutathione ratio and decreased renal cortical H(2)O(2) and O(2)(*-) release and renal NF-kappaB. Antioxidant treatment with vitamins C and E in high-Na S rats also decreased renal monocytes/macrophages in the glomeruli, cortex, and medulla, decreased tumor necrosis factor-alpha by 39%, and decreased monocyte chemoattractant protein-1 by 38%. Vitamin-treated, high-Na S rats also experienced decreases in arterial pressure, urinary protein excretion, renal tubulointerstitial damage, and glomerular necrosis and increases in glomerular filtration rate and renal plasma flow. In conclusion, antioxidant treatment of high-Na Dahl S rats decreased renal inflammatory cytokines and chemokines, renal immune cells, NF-kappaB, and arterial pressure and improved renal function and damage.

The development of a model and implementation process for clinical governance in primary dental care

A model and an assessment tool have been developed to support clinical governance within the primary care sector. These bring together quality assurance and governance components to create a unified standard providing a single working model for service development. The model consists of 14 components that define structure, control the process and assure the outcome. Each consists of a number of indicators, which are scored in turn. The results are then weighted to emphasise those that are more critical. The model has been tested and found to be helpful in identifying weak areas to support action planning. Re-scoring will help to demonstrate that improvements have taken place. Other services and practices can now carry out baseline assessments, and demonstrate and measure improvements. General dental practitioners are provided with a scoring system, which identifies clinical governance areas in their practices that require attention and which facilitates prioritisation.

Restructuring an academic pediatric inpatient service using concepts developed by hospitalists

In an effort to increase continuity of inpatient care by attending physicians, decrease use of hospital resources, and improve medical education without compromising quality of care, an inpatient pediatric ward service was restructured by using concepts developed by hospitalists. This reorganization reduced the number of yearly inpatient attendings, added a consistent 14-day call schedule, and eliminated attending outpatient responsibilities during their ward service. The restructured ward service attending acted as the attending of record for all general and specialty patients, excluding hematology/oncology, with the subspecialists fulfilling a consultant role. To evaluate the impact of this restructuring, a baseline year of the traditional ward service (TWS) was compared with a subsequent year of the restructured ward service (RWS). Our goal was to evaluate the impact of this new system on average costs of hospitalization, length of stay, resource utilization, inpatient mortality, and 7- and 31-day readmission rates. Hospital costs per patient were lower by 13% (p=0.018) in the restructured system. Average lengths of stay in an observation bed were significantly lower on the RWS (p=0.007), but there was no significant difference in admission length of stay. There was decreased resource utilization for laboratory and radiology tests (p<0.01) on the restructured service. Readmission rates were not significantly changed, and satisfaction among attendings, housestaff, students, and patients was uniformly high in both groups. A reorganized academic pediatric medical service, which allows specific attendings to focus on inpatient care and teaching, can decrease hospital resource utilization without compromising the quality of patient care or medical education.

The importance of postprandial glucose to treatments and outcomes in patients with type 2 diabetes

A primary goal in the management of diabetes is to prevent its long-term complications through the attainment of tight glycemic control, a complex and incompletely understood metabolic process that involves the interaction of the pancreas, insulin-responsive peripheral tissues, and the liver in regulating fasting blood glucose (FBG) and postprandial glucose (PPG) levels. Whereas much of the clinical management of type 2 diabetes has focused on FBG by measurement of blood glucose levels and glycated hemoglobin levels, mounting evidence has formed strong associations between PPG, the temporally immediate physiological management of a glucose load, and diabetes progression, management, and complications. Application of the research may enable health care systems and providers to more closely mimic a normal glycemic response in individuals with type 2 diabetes, leading to improved clinical outcomes and cost control.

General and job-related alcohol use and correlates in a municipal workforce

We examined the prevalence and correlates of both general and workplace-related drinking measures using data from a telephone survey of 673 workers in a large municipal bureaucracy and tested the hypothesis that observed differences across job categories can be explained by compositional difference in terms of demographic variables known to be related to drinking behavior. Results suggest such factors account for much of the variation in general drinking measures (prior-28-day quantity, CAGE score, indicating risk for dependence), but that significant variation in a workplace-related drinking measure (times ever drank before, during, or just after work) remains even after such factors are controlled. Implications of these findings for existing theories of workplace effects on drinking are discussed, along with a consideration of appropriate levels of analysis for future studies.

Major pediatric hand trauma associated with fireworks

OBJECTIVES

To characterize the injury pattern and economic impact of major pediatric hand trauma secondary to fireworks.

DESIGN

Retrospective.

SETTING

Pediatric Level I trauma center.

INTERVENTION

N/A MAIN OUTCOME MEASUREMENTS: Fractures, amputations, soft tissue defects, length of hospitalization, number and type of procedures performed were obtained from charts, radiographs, and operative reports. Hospital charges were obtained from the billing office.

PATIENTS/PARTICIPANTS

Records of patients with a diagnosis of fireworks-related injuries admitted over a period of ten years were reviewed. Twenty-two patients were identified to have sustained twenty-two hand injuries. The group consisted of nineteen boys and three girls, with an average age of 9.3 years (range, 4 to 17 years).

RESULTS

There were thirty-one fractures, nineteen amputations, and one dislocation. The nineteen amputations occurred in nine hands. Local skin graft or flap coverage was required in six hands acutely, and delayed soft tissue procedures were performed on four hands. Four hands had digital neurovascular injuries; two required microsurgical repairs at the time of injury, and two were irreparable. Resource use included: average hospital stay of 4.3 days (range, 0 to 20), average number of trips to the operating room, 1.2 (range, 0 to 3), and average hospital charges of $11,582 (range, $1,035 to $39,489).

CONCLUSIONS

This study illustrates the severity of pediatric hand injuries associated with fireworks and the significant burden placed on medical resources in treating these injuries. Efforts toward public education and legislative reforms may help to prevent these unnecessary injuries.

Social control and workplace drinking norms: a comparison of two organizational cultures

OBJECTIVE

This article reports on an investigation of the relationship of social control mechanisms at work to drinking practices of 10,000 salaried and hourly employees working in the same U.S. industry, with the same union, but in two different work environments. One work environment reflected an organizational culture that is traditional to U.S. management; the other was based on a nontraditional Japanese transplant model.

METHOD

The research team used a combination of methods including in-home surveys (N = 1,723; 1,378 men) and ethnography (110 semistructured interviews and 200 hours of direct observation inside the plants). Respondents were asked about general and work-related drinking, perceptions of drinking norms, strengths or weaknesses of alcohol-related policies and procedures for policy enforcement.

RESULTS

Although overall consumption rates in both populations were similar, significant differences between the two samples existed regarding work-related drinking. The Traditional (i.e., U.S.) model was associated with more permissive norms regarding drinking before or during work shifts (including breaks) and higher workplace drinking rates than the Transplant (i.e., Japanese) model. Analyses revealed that alcohol policies, and the extent to which policies are actually enforced, predicted drinking norms and alcohol availability at work. Drinking norms, in turn, predicted work-related drinking and accounted for differences in alcohol consumption between the two worksites. Analyses of ethnographic data provided descriptive understandings of aspects of the two organizational cultures that disabled mechanisms for social control of drinking in one setting and enabled those mechanisms in the other.

CONCLUSIONS

These understandings of how social control mechanisms predict work-related drinking practices provide guidelines for alcohol problem prevention in a specific kind of occupational environment. However, our identification of aspects of social control that successfully regulate workplace drinking is applicable to other kinds of occupational settings as well.

Historical and cultural roots of drinking problems among American Indians

Roots of the epidemic of alcohol-related problems among many Native North Americans are sought in cultural responses to European arrival, the role of alcohol in frontier society, and colonial and postcolonial policies. Evidence from the historical record is considered within the framework of current social science. Initially, Native American's responses to alcohol were heavily influenced by the example of White frontiersmen, who drank immoderately and engaged in otherwise unacceptable behavior while drunk. Whites also deliberately pressed alcohol upon the natives because it was an immensely profitable trade good; in addition, alcohol was used as a tool of "diplomacy" in official dealings between authorities and natives. The authors argue that further research into the origins of modern indigenous people's problems with alcohol would benefit from an interdisciplinary "determinants of health" approach in which biological influences on alcohol problems are investigated in the context of the cultural, social, and economic forces that have shaped individual and group drinking patterns.

Institutionalization of community action projects to reduce alcohol-use related problems: systematic facilitators

This article reviews papers from a recent conference on community action research in order to identify factors that contribute to long-term maintenance, sustainability, or institutionalization of community project interventions. The descriptions of long-term outcomes and aftereffects of projects that emerged in the conference are valuable because relatively few instances of institutionalization have been documented in the scientific literature. After a general theoretical discussion of institutionalization in communities, the article identifies characteristics of successful community action programs that outlived their original funding. These characteristics include honoring community values and cultural relevance, cultivating key leader support, and utilizing indigenous staff. They also include developing local resources, maintaining flexibility, and leveraging prior success. The paper concludes by noting that aiming for policy and structural changes is a goal for an institutionalization of measures positively affecting desired health outcomes, even if the programs which created them are not themselves sustained.

Basal skull fracture with intracranial air

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Vascular disorders of the hand: surgeons' perspective

Vascular disorders of the upper extremity present a complex and challenging problem to the treating physician. The presentation is often subtle and the consequences of misdiagnosis or mistreatment can be severe. A thoughtful and through approach combining the history, physical findings, and use of appropriate diagnostic aids will provide the physician and patient with the greatest opportunity for a satisfactory outcome.

Keeping pace: video communications in a managed care environment. Interview by Thomas A. Rasmussen

A number of health care provider organizations, particularly those with geographically dispersed personnel, are utilizing the video medium to improve organizational performance. The key attributes of the video medium are uniformity of education delivery to multiple sites, the ability to deliver information in a timely manner, the ability to visually portray best practices for all to see, and the convenience for end-users. While the executives interviewed for this article aren't aware of any published research specifically documenting the linkage between video education and improved organizational performance, the panelists believe that informed health care professionals inherently contribute to improved organizational performance and that video education is a prudent investment of resources.

Periprosthetic humeral fractures: mechanisms of fracture and treatment options

In 20 patients, 21 periprosthetic humeral fractures were reviewed retrospectively. The mean follow-up time was 27.1 months. Mild osteopenia was present in 45% of the patients, whereas 30% had severe osteopenia. Five mechanisms of fracture were identified, including 3 intraoperative causes that are avoidable. Treatment with stable intramedullary fixation utilizing the humeral stem and cerclage wiring provided superior results in terms of time to union, adverse effect on rehabilitation, and occurrence and severity of surgical complications. Diaphyseal fractures that were treated with standard stem arthroplasty with or without supplemental fixation had a longer time to fracture union, a higher complication rate, and prolonged rehabilitation. Fractures of the proximal humeral metaphysis can be treated with standard stem arthroplasty and cerclage wiring if the stem extends distal to the fracture site by at least 3 cortical diameters. Anatomic reduction of fractures treated by surgical means results in shorter healing times. Cast or brace immobilization can be used for management of postoperative fractures that occur distal to a well-fixed and stable prosthetic stem. Cast or brace immobilization results in fracture union but rehabilitation may be greatly impaired, and there is an increased risk of complications associated with immobilization of the extremity. Long-stem intramedullary fixation with cerclage wiring is the preferred surgical option for treatment of unstable humeral shaft fractures.

The relationship of drinking and hangovers to workplace problems: an empirical study

OBJECTIVE

This article reports on the relationship between drinking patterns and workplace problems in a manufacturing facility operated by a Fortune 500 industry.

METHOD

The data come from a survey of 832 hourly employees (88% male) and from ethnographic research in the plant. This study is distinctive because it examined a large random sample of workers, rather than an impaired subpopulation. Moreover, the study is among the few that has asked employees how much they drank prior to and during working hours and how frequently they had been hungover at work. Respondents were also asked about their overall alcohol consumption and their experience of various problems in the workplace.

RESULTS

Bivariate analyses indicated that overall drinking, heavy drinking outside of work, drinking at or just before work and coming to work hungover were related to the overall number of work problems experienced by respondents, and to specific problems such as conflicts with supervisors and falling asleep on the job. Multivariate analyses revealed that workplace drinking and coming to work hungover predicted work-related problems even when usual drinking patterns, heavy drinking and significant job characteristics and background variables were controlled. Overall drinking and heavy drinking outside the workplace did not predict workplace problems in the multivariate analyses. The analyses show that workplace problems were also related to age, gender, ethnicity, work shift and departments. Survey results are explicated with findings from a plant ethnography.

CONCLUSIONS

Although the relationships are modest, they support the hypothesis that work-related drinking and hangovers at work are related to problems within the workplace and may lead to lowered productivity and morale.

Therapeutic effects of music and mother's voice on premature infants

Aversive environment auditory stimuli is a common concern in neonatal intensive care. Recently, interest has developed regarding the use of music applications to mask such stimuli and to reduce the high risk for complications or failure to thrive. In this study of 20 oxygenated, low birth weight infants in a Newborn Intensive Care Unit of a regional medical center in the Southeastern United States, 10 infants listened to lullabies and 10 infants to recordings of their mother's voice through earphones for 20 minutes across three consecutive days. Oxygen saturation levels and frequency of oximeter alarms were recorded. Results indicated a differential response to the two auditory stimuli as listening time progressed. On Day 1, the infants listening to music had significantly higher oxygen saturation levels, but these effects disappeared by Days 2 and 3. On Days 2 and 3, however, the babies hearing music had significantly depressed oxygen saturation levels during the posttest intervals after the music was terminated. Infants hearing music had significantly fewer occurrences of Oximeter alarms during auditory stimuli than did those listening to the mothers' voice. Implications for the therapeutic use of auditory stimuli in the Newborn Intensive Care Unit are discussed.

Effects of changes in colloid osmotic pressure on excretion of sodium by the ovine fetal kidney

To find out if the gestation-dependent increase in fetal oncotic pressure is responsible for the gestation-dependent increase in the capacity of the fetal proximal tubule to reabsorb sodium, the effects on renal function of increases in oncotic pressure were studied in 8 volume-expanded chronically catheterized fetal sheep aged 128 +/- 3 (s.e.) days. Fetal extracellular volume was expanded by infusion of 65 +/- 10.8 (s.e.) mliter kg-1 estimated body weight of 0-15 M saline. This caused a decrease in fetal plasma protein concentrations (P < 0.01); fetal oncotic pressure decreased (P < 0.05). A diuresis and natriuresis occurred, which was due not to an increase in glomerular filtration rate but to a decrease in the fraction of the filtered sodium load reabsorbed by the proximal tubule (P < 0.05) and a decrease in the fraction of distally delivered sodium reabsorbed (P < 0.01). Fetal plasma protein concentrations were then increased to greater than control levels (P < 0.01) by infusion of maternal plasma (28 +/- 1.6 mliter kg-1); oncotic pressure was greater than after saline expansion (P < 0.05) and similar to control. The fraction of the filtered sodium load reabsorbed by the proximal tubule remained depressed (P < 0.01) relative to control, as did the fraction of distally delivered sodium that was reabsorbed (P < 0.01). Thus the natriuresis and diuresis continued. There was, however, a small effect of oncotic pressure on proximal fractional sodium reabsorption that was unmasked by multiple regression analysis. Obviously, this effect was not sufficient to override other effects of volume expansion on fetal proximal tubular function. Therefore, the reduction in fetal proximal fractional sodium reabsorption in volume expansion was not due solely to a fall in fetal oncotic pressure. Furthermore, since infusion of maternal plasma caused a rise in fetal plasma protein concentrations that was similar to the increase that would occur between 128 and 148 days gestation, it is unlikely that any gestation-dependent increase in proximal fractional sodium reabsorption is due solely to the increase in fetal plasma protein concentrations and hence oncotic pressure.

Paediatric road accidents in two health districts

For a 1-year period from 1 January 1990 all children seen, as a result of road traffic accidents (RTAs), in two accident and emergency departments (A&E), one in Liverpool and one in Chester were studied. Simple data were collected and injury severity scores (ISS) were used to assess injuries. Progress was monitored at 3 months post-injury by a review of hospital case notes. A total of 710 children fulfilled the study criteria in the year with a male:female ratio of 1.7:1. Only 37% of children were accompanied by an adult at the time of their accident. Overall 29% of children in vehicles were restrained and only three of 75 cyclists wore cycle helmets. Most injuries were minor with ISS of less than 9 in 96% of cases. Two children died after admission as a result of severe head injuries. The results were similar to those from other centres but highlight a need for continuing public education on child supervision, safe driving habits and the need for environmental changes.

Care of the body of the recently deceased in accident and emergency departments

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Renal and metabolic effects of glucagon in the fetus

The effects of pharmacological doses of glucagon (0.5 micrograms/kg/min) were studied in 8 chronically-catheterised fetal sheep. These doses of glucagon raised fetal blood glucose, and caused a small fall in fetal arterial PO2 (P less than 0.05). Arterial PCO2 rose (P less than 0.05) and pH fell (P less than 0.05) while plasma osmolality increased (P less than 0.01). There were no effects of glucagon on fetal renal function but in the fetus, like the adult, i.v. glucagon caused increases in heart rate (P less than 0.01) which were not associated with changes in arterial pressure.

Changes in fetal and maternal plasma protein concentration and colloid osmotic pressure with gestation

In pregnant ewes, plasma protein levels over the gestation age range of 58-141 days fell progressively (r = -0.332, P less than 0.05, n = 36) but colloid osmotic pressure (COP, mmHg) did not change significantly. In fetal sheep carried by these ewes, plasma protein levels increased with age (r = 0.85, P less than 0.00001, n = 32). COP also rose (r = 0.8, P less than 0.00001, n = 23). Since maternal COP did not change and fetal COP increased, the net transplacental COP gradient between mother and fetus decreased with increasing age (r = -0.589, P less than 0.004, n = 22). Fetal plasma protein levels can be used to calculate fetal COP while maternal plasma protein levels cannot be used to calculate maternal COP.

Roundtable discussion on metabolic support of the cancer patient. Regional centers of excellence

Home TPN has undergone a dramatic evolution over a relatively short period. It is unfortunate that the current system is barely realizing the potential to enhance patient care while keeping costs reasonable. Although industry has made the mistake of not demonstrating how important quality is for outcome, third-party reimbursement policy is making a more critical mistake of encouraging the implementation of poor-quality care through reimbursement levels so low that factors that ensure high quality must be cut if the provider is to survive. We must recognize that the provision of product is only part of the large system needed to deliver this expensive therapy. The institution of centers of excellence will allow consumers to make intelligent choices in the future application of health care dollars.

Second-degree heart block associated with envenomation by Vipera berus

Evenomation by the common European adder (Vipera berus) is well known for its significant morbidity but low mortality. Cardiac complications tend to take second place to the systemic upset and usually only comprise non-specific ECG changes. This case illustrates many of the classical features of adder bite but it is also the first account of heart block as a complication.

Virus adsorption to mineral surfaces is reduced by microbial overgrowth and organic coatings

In experiments with strains of poliovirus, reovirus, echovirus, and Coxsackievirus, overgrowth with exopolymer-forming bacteria reduced virus adsorption to mineral surfaces. Adsorption was improved when organic materials adsorbed to minerals were removed by low-temperature ashing. In a soil series, virus adsorption increased with soil depth. This paralleled a decrease in organic content, but differences in charge development of the soil particles may also be involved. Prolonged (40-year) irrigation with treated sewage effluents, leading to a buildup of organic coatings, also decreased adsorption. However, saturation of the virus-binding capacity of the soil as a result of continuous exposure to virus-containing effluents was not apparent.

Aspergillus niger endocarditis complicating aortic tissue valve replacement

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Adsorption of reovirus by minerals and soils

Adsorption of [35S]methionine-labeled reovirus by 30 dry soils, minerals, and finely ground rocks suspended in synthetic freshwater at pH 7 was investigated to determine the conditions necessary for optimum virus removal during land application of wastewaters. All of the minerals and soils studied were excellent adsorbents of reovirus, with greater than 99% of the virus adsorbed after 1 h at 4 degrees C. Thereafter, virus remaining in suspension was significantly inactivated, and within 24 h a three to five log10 reduction in titer occurred. The presence of divalent cations, i.e., Ca2+ and Mg2+, in synthetic freshwater enhanced removal, whereas soluble organic matter decreased the amount of virus adsorbed in secondary effluent. The amount of virus adsorbed by these substrates was inversely correlated with the amount of organic matter, capacity to adsorb cationic polyelectrolyte, and electrophoretic mobility. Adsorption increased with increasing available surface area, as suspended infectivity was reduced further by the more finely divided substrates. However, the organic content of the soils reduced the level of infectious virus adsorbed below that expected from surface area measurements alone. The inverse correlation between virus adsorption and substrate capacity for cationic polyelectrolyte indicates that the adsorption of infectious reovirus particles is predominately a charged colloidal particle-charged surface interaction. Thus, adsorption of polyelectrolyte may be useful in predicting the fate of viruses during land application of sewage effluents and sludges.

Poliovirus adsorption by 34 minerals and soils

The adsorption of radiolabeled infectious poliovirus type 2 by 34 well-defined soils and mineral substrates was analyzed in a synthetic freshwater medium containing 1 mM CaCl(2) and 1.25 mM NaHCO(3) at pH 7. In a model system, adsorption of poliovirus by Ottawa sand was rapid and reached equilibrium within 1 h at 4 degrees C. Near saturation, the adsorption could be described by the Langmuir equation; the apparent surface saturation was 2.5 x 10(6) plaque-forming units of poliovirus per mg of Ottawa sand. At low surface coverage, adsorption was described by the Freundlich equation. The soils and minerals used ranged from acidic to basic and from high in organic content to organic free. The available negative surface charge on each substrate was measured by the adsorption of a cationic polyelectrolyte, polydiallyldimethylammonium chloride. Most of the substrates adsorbed more than 95% of the virus. In general, soils, in comparison with minerals, were weak adsorbents. Among the soils, muck and Genesee silt loam were the poorest adsorbents; among the minerals, montmorillonite, glauconite, and bituminous shale were the least effective. The most effective adsorbents were magnetite sand and hematite, which are predominantly oxides of iron. Correlation coefficients for substrate properties and virus adsorption revealed that the elemental composition of the adsorbents had little effect on poliovirus uptake. Substrate surface area and pH, by themselves, were not significantly correlated with poliovirus uptake. A strong negative correlation was found between poliovirus adsorption and both the contents of organic matter and the available negative surface charge on the substrates as determined by their capacities for adsorbing the cationic polyelectrolyte, polydiallyldimethylammonium chloride.

Influence of pH and electrolyte composition on adsorption of poliovirus by soils and minerals

The pH and the nature an concentration of simple electrolytes influenced the interaction of poliovirus type 2 with three soils, a sand, and a clay mineral. In electrolytes above pH 9 the virus was not adsorbed extensively to the substrates, but below pH 7 almost all virus was bound. For each adsorbent there was a characteristic pH region of transition from strong to weak uptake. Differences between the soils in virus uptake were shown to parallel their pH-dependent mineral. In electrolytes above pH 9 the virus was not adsorbed extensively to the substrates, but below pH 7 almost all virus was bound. For each adsorbent there was a characteristic pH region of transition from strong to weak uptake. Differences between the soils in virus uptake were shown to parallel their pH-dependent mineral. In electrolytes above pH 9 the virus was not adsorbed extensively to the substrates, but below pH 7 almost all virus was bound. For each adsorbent there was a characteristic pH region of transition from strong to weak uptake. Differences between the soils in virus uptake were shown to parallel their pH-dependent charge properties, as determined by whole-particle microelectrophoresis. Only when the pH was close to or above the critical region was uptake increased with electrolyte concentration. The transition region for all substrates was above pH 7.5 the isoelectric point of the virus. Thus, it appears that when both the virus and substrate are highly negative charged, repulsive electrostatic effects may exceed inherent attractive interactions, thereby inhibiting adsorption.