Managing chronic illness: an immigrant woman's acquisition and use of health care knowledge.

As occupational therapists increasingly encounter a multicultural clientele, there is growing interest in the influence of a person's culture on his or her interactions with the environment. This paper presents a case study of a Chinese-Canadian immigrant woman with rheumatoid arthritis. The case study illustrates how the subject's family, community networks, and workplace, coupled with the occupational therapy clinical setting, intermingled to shape the daily management of her illness. The case material focuses on the subject's acquisition and use of different types of health care knowledge as she responds to her illness. It shows that the subject's experiences and management decisions about her health are closely linked to the material and social conditions of her life as a working-class immigrant woman. This article suggests that attention needs to be paid to the broader systems of the environment in understanding the responses of immigrant women to occupational therapy, rather than on the cultural distinctiveness of the clients.


Internal-external control and temporal orientation among southeast Asians and white Americans.

This study examined ethnic group differences with the use of the Model of Human Occupation (Kielhofner, 1985b). Three groups--immigrants from Thailand, immigrants from Cambodia, and white Americans--were contrasted on two constructs--internal versus external control and temporal orientation. The study attempted to identify whether nonpatient subjects have an internal locus of control and a strong future orientation, as the Model of Human Occupation would predict. No differences were found with the use of the Internal-External Scale (Rotter, 1966). The Thai and white Americans differed significantly on the Time Reference Inventory (Roos & Albers, 1965b). The Thai selected more items referring to the past, and the white Americans chose more statements applying to the present. There were no differences for past or future time extensions between groups. All the groups had a greater past extension than future extension. It was proposed that a larger future time perspective was not a requisite for functional temporal adaptation.


Culturally competent occupational therapy in a diversely populated mental health setting.

Cultural sensitivity is a crucial component of health care provision, particularly in psychiatric settings. As society becomes more multicultural, it is essential for occupational therapists to continue to develop cultural competence, which is defined in this paper as an awareness of, sensitivity to, and knowledge of the meaning of culture. At San Francisco General Hospital, an innovative multicultural model consisting of special focus programs is used. The key to the success of such programs is a culturally competent professional staff.


An occupational therapy life skills curriculum model for a Native American tribe: a health promotion program based on ethnographic field research.

A unique, nontraditional occupational therapy role focusing on primary prevention, community health promotion, and enhancement for a nonpatient population is examined. The purpose of this ongoing consultancy project was to develop a series of life skills and prevocational programs for an ethnic population of native Americans from elementary school through high school and post-secondary adulthood levels in British Columbia, Canada, from 1986 to 1990. This consultancy evolved from a philosophy of renewing and preserving the culturally distinct ethnic heritage and tribal integrity of this native American community. Knowledge about sociocultural systems theory, anthropology, and developmental cognitive-behavioral learning theories are combined with ongoing clinical experience in psychosocial occupational therapy practice and consultancy principles to develop life skills and an educational, community-based prevention/wellness educational program model. Subsequent modifications of the original model, with consultancy recommendations for implementation of future programs, are based on tribal members' feedback and concerns elicited with psychosocial and ethnographic interviewing techniques during villager community meetings. The replicability of this primary prevention and wellness life skills program model offers numerous possibilities for occupational therapists to develop similar programs within the cultural contexts and perceived needs of specific ethnic groups in other nontraditional community-based settings.


Culture, theory, and the practice of occupational therapy in New Zealand/Aotearoa.

In the context of contemporary New Zealand, this paper discusses the need for occupational therapy to substantiate its claims of being a holistic profession with particular reference to the Maori, the indigenous people of New Zealand (referred to by the Maori as Aotearoa). In this era of accountability and consumer choice, occupational therapists need to more effectively meet the cultural needs of their clients through an understanding of both the material and nonmaterial aspects of their cultures. However, for New Zealand occupational therapists, cultural sensitivity is not enough to contribute to changing the diminished life chances of the Maori. It is proposed in this paper that the Model of Human Occupation (Kielhofner, 1985; Kielhofner & Burke, 1980), when combined with the work of radical community educators such as Freire (1972), could provide the sociopolitical dimension to New Zealand practice. The Model of Human Occupation is examined in light of current occupational therapy practice in New Zealand. It is argued that this model, when accompanied by a broader understanding of the sociopolitical processes informing monoculturalism, could be seen as a suitable framework for understanding cultural differences in New Zealand and could assist in the move toward providing culturally appropriate occupational therapy for indigenous peoples such as the Maori.


Cross-cultural occupational therapy: a critical reflection.

In the Netherlands, Dutch health care professionals, including occupational therapists, are confronted with a growing number of patients whose cultural backgrounds differ from theirs. Acknowledging this influx, the Dutch government allocated a grant for educating occupational therapy students on cross-cultural care. This paper summarizes the information we collected from a survey of Dutch occupational therapists on treatment of immigrants and briefly describes the eight educational tools we developed for the two occupational therapy curricula. Two of these tools are described fully--first, a critical essay on the white middle-class values and norms that underlie occupational therapy theory and practice, and second, the guidelines for developmental policies to use in the treatment of immigrant patients. Case studies illustrate how the values of our profession create obstacles to cross-cultural care.


Glomerular epithelial cells synthesize endothelin peptides.

Glomerular mesangial and endothelial cells have been reported to synthesize and secrete endothelin-1 (ET-1). Whether glomerular epithelial cells (GEC) have the ability to synthesize ET-peptides is not known. Employing immunocytochemistry we report that the GEC in vitro constitutively express ET-1 and ET-3. ET-1 synthesis by the GEC was further confirmed by detection of a specific 2.3kb mRNA that hybridizes with rat prepro ET-1 genomic DNA on Northern blot analysis. ET-1 is secreted into the medium in a time-dependent manner as measured by radioimmunoassay and radiobinding assay. Synthesis of endothelin peptides by the GEC may have important implications in the pathogenesis of glomerular diseases where GEC injury figures prominently.


Altered expression of a structural protein (fodrin) within epithelial proliferative disease of the breast.

Although certain histopathologic patterns of epithelial proliferative breast disease are well established as indicating an increased relative risk for the subsequent development of mammary carcinoma, the biologic characterization of these changes is not known. One evident histologic characteristic of epithelial hyperplasia is the partial or complete loss of normal cellular polarity. Nonerythroid spectrin (fodrin) is a structural protein whose function is related to maintenance of cellular polarity. By immunohistochemical analysis, normal breast luminal epithelia contain fodrin confined to a characteristic basolateral distribution. Proliferative breast disease of the common type partially loses this polarized distribution of fodrin; fodrin immunoreactivity is not limited to a basolateral location but is present around the cell membrane and is inconsistently present at luminal interfaces. Whether this change in distribution of fodrin is a permissive event in the development of proliferative disease or merely an associated finding is not known.


Detection of the t(14;18) at similar frequencies in hyperplastic lymphoid tissues from American and Japanese patients.

Follicular lymphoma shows a wide geographic variation in incidence, occurring more frequently in the U.S. than in Japan. A translocation involving the bcl-2 gene on chromosome 18 and the immunoglobulin heavy chain gene on chromosome 14 is frequently found in follicular lymphomas and is believed to play a critical role in the pathogenesis of these tumors. Recently, bcl-2/IgH rearrangements have been detected in reactive lymphoid tissue obtained from European patients, indicating that such rearrangements occur at some low but measurable background rate. In non-malignant tissues, the polymerase chain reaction was used to study the frequency of bcl-2/IgH rearrangements in reactive lymphoid tissue obtained from American and Japanese patients to find out whether geographic variation in the incidence of follicular lymphoma was caused by differences in sporadic occurrence of the t(14;18). We found such rearrangements in 5 of 15 American hyperplastic tonsils and lymph nodes and 5 of 10 Japanese tonsils, an incidence close to that previously seen in European patients. These data suggest that the background incidence of such rearrangements is similar in all populations, regardless of the incidence of follicular lymphoma.


In vivo effects of endotoxin on intraepithelial mucosubstances in rat pulmonary airways. Quantitative histochemistry.

Bacteria-induced bronchopneumonias are often characterized by an influx of neutrophils and excess mucus in pulmonary airways. This study determined how endotoxin, a component of gram-negative bacteria and a potent inflammatory agent, affects the ultrastructure of the mucociliary apparatus and the amount of stored intraepithelial mucosubstances in the main axial airways within the lung. Rats were intranasally instilled, once a day for 3 days, with endotoxin or saline (controls). Animals were sacrificed 1, 2, or 7 days after the last instillation. Microdissected intrapulmonary axial airways (generations 8-11) from the right caudal lobes of infusion-fixed lungs were processed for light and electron microscopy. Morphometric techniques were used to determine the volume densities (Vs) of histochemically stained intraepithelial mucosubstances and numerical densities of airway epithelial cells. There were marked increases, compared with controls, in the amount of intraepithelial mucosubstances in the intrapulmonary axial airways at generations 8 and 11 in the right caudal lobes from endotoxin-instilled rats sacrificed 1, 2, and 7 days after the last instillation. There were significantly greater numbers of surface epithelial cells per length of basal lamina (i.e., hyperplasia) in endotoxin-exposed airways compared with airways from controls. This endotoxin-induced hyperplasia was due primarily to an increase in the number of mucus-secretory cells, which in endotoxin-exposed epithelium were columnar and contained numerous, large confluent, electronlucent, secretory granules composed of acidic and neutral glycoproteins. In contrast, secretory cells in airway epithelium from controls were cuboidal and contained small discrete, electron-dense, granules composed of only neutral glycoproteins. The numbers of ciliated cells and basal cells were similar in both control and endotoxin-exposed epithelium. Only endotoxin-exposed epithelium, however, contained atypical epithelial cells with numerous basal bodies, few cilia, and few apical secretory granules. These results indicate that repeated airway instillations of endotoxin induce an increase in the amount of intraepithelial mucosubstances, secretory cell hyperplasia, and excess luminal mucus in pulmonary airways. Therefore, endotoxin released from gram-negative bacteria may be partially responsible for the structural alterations, in the airway surface epithelium, which result in the excess luminal mucus observed in bacteria-induced bronchopneumonias.


Recombinant interleukin-6 inhibits the growth of rat mesangial cells in culture.

Murine recombinant interleukin-6 (IL-6) inhibited [3H]thymidine uptake by cultured rat mesangial cells in a dose-dependent manner in the presence of 0.5% fetal bovine serum (FBS). The inhibitory effect of IL-6 on the growth of mesangial cells was also confirmed by a change in cell numbers. In the presence of increased concentrations of FBS (5% or 10%), the effect of IL-6 was not prominent. IL-6 showed no effects on intracellular Ca2+ levels of mesangial cells. IL-6 gene expression was rapidly induced in the "quiescent" mesangial cells by exposure to 20% FBS. These observations support the premise that IL-6 is synthesized in mesangial cells and inhibits the growth of mesangial cells in an autocrine manner.


Cytokine-induced neutrophil-derived interleukin-8.

During acute inflammation, the first line of cellular response for host defense is the neutrophil. In addition to the historic role of the neutrophil as a phagocyte, recent studies have identified this cell as an important source of a number of cytokines. In this study, we provide evidence that the neutrophil is a significant source of interleukin-8 (IL-8). Neutrophils freshly isolated from whole blood were not found to constitutively express IL-8 mRNA. In contrast, when these leukocytes were cultured on plastic they were activated, leading to the significant expression of de novo steady-state levels of IL-8 mRNA. In addition, when neutrophils were treated with cycloheximide, there was evidence for "superinduction" of steady-state levels of IL-8 mRNA and inhibition of antigenic IL-8 production. Neutrophils were subsequently stimulated with lipopolysaccharide (LPS), tumor necrosis factor-alpha, or interleukin-1-beta and were found to express IL-8 mRNA and antigen in both a time- and dose-dependent manner. Furthermore, neutrophils stimulated with traditional chemotactic/activating factors, such as the split product of the fifth component of complement (C5a), formylmethionyleucylphenylalanine (fMLP), and leukotriene B4 (LTB4) in a dose-dependent manner did not produce significant antigenic IL-8, as compared with unstimulated controls. In contrast, when neutrophils were exposed to either of these neutrophil agonists in the presence of LPS, the production of antigenic IL-8 was significantly elevated, as compared with either of the stimuli alone, suggesting a synergistic response. These data would suggest that the neutrophil can no longer be viewed as only a phagocyte or warehouse for proteolytic enzymes, but is a pivotal effector cell that is able to respond to mediators in its environment and generate cytokines. This latter neutrophil response may be important for either the elicitation of additional neutrophils or to orchestrate the conventional immune response at sites of inflammation.


Ultrastructural immunohistochemical localization of polyclonal IgG, C3, and amyloid P component on the congo red-negative amyloid-like fibrils of fibrillary glomerulopathy.

Renal biopsies from seven patients with Congo red-negative amyloid-like fibrillary glomerulopathy (FGP) were examined by protein A gold immuno-electron microscopy. Ultrastructurally, the fibrils in all cases exhibited positive immunostaining for IgG, both Ig light chains, C3, and amyloid P component (AP), but did not show positive immunostaining for glomerular basement membrane (GBM)-associated proteins (collagen type IV and heparan-sulfate proteoglycans) or microfibril-associated proteins (fibronectin and fibrillin). In a triple-label study, AP and IgG were colocalized along the same fibril, whereas the gold probes for the detection of collagen type IV were absent. The results suggest that the fibrils are comprised of polyclonal IgG and C3 that bind AP. AP was immunolocalized sparsely but regularly along the lamina rara interna of normal GBM. AP was absent in the fibrils in a case of diabetic glomerulopathy, was scattered randomly without specificity for the electron-dense deposits in the GBM of membranous glomerulopathy, and lined up regularly along the fibrils in amyloid deposits. FGP is an entity in which the fibrils bind AP but lack the beta-pleated sheet structure necessary for Congo red staining that is typical of amyloid.


Brain microvascular smooth muscle and endothelial cells produce granulocyte macrophage colony-stimulating factor and support colony formation of granulocyte-macrophage-like cells.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a potent stimulator of macrophages and neutrophils and plays a role in inflammatory diseases. In this article, we report that mouse brain-derived microvascular smooth muscle cells (SM) and endothelial cells (En) in coculture with splenocytes support the colony proliferation of immature granulocyte-macrophage-like (GM) cells. Unstimulated SM and En cells release GM-CSF as shown by ELISA assay and SM expresses mRNA for GM-CSF by polymerase chain reaction (PCR). Stimulation of SM and En by a nonspecific activator (lipopolysaccharide) results in upregulation of GM-CSF production. GM colonies cannot be grown on cultured astrocytes or on extracellular matrix alone prepared from smooth muscle or endothelium. However, colonies form on the extracellular matrix and on astrocytes, either in the presence of SM- or En-conditioned medium or after the addition of recombinant GM-CSF. The GM cells are positive for nonspecific esterase, peroxidase, and MAC-1 markers but are negative for FC gamma receptors and for Thy 1.2, CD8, CD4, MHC class II, and Asialo GM1 markers. These observations emphasize the possibility for active participation of brain microvasculature SM and En in acute inflammatory reactions of the central nervous system.


Effect of serum amyloid P component level on transthyretin-derived amyloid deposition in a transgenic mouse model of familial amyloidotic polyneuropathy.

To elucidate the pathogenesis of amyloid deposition associated with familial amyloidotic polyneuropathy (FAP), we developed several transgenic mouse lines carrying the human mutant transthyretin (TTR) gene. We found that human TTR and mouse serum amyloid P component (SAP) are deposited as amyloid in tissues of these mouse lines. Because SAP is a major acute-phase reactant in mice, we asked whether repeated injections of Escherichia coli lipopolysaccharide (LPS) would enhance the amyloid deposition in one of these transgenic mouse lines. During the course of repeated LPS injections, serum levels of SAP in the transgenic mice remained between severalfold to about 50-fold higher than seen in the absence of stimulation. As no significant difference was detected in the onset, progression, and tissue distribution of TTR-derived amyloid (ATTR) deposition between the LPS-stimulated and unstimulated transgenic mice, the induction of SAP synthesis by acute inflammation probably does not affect the onset and extent of ATTR deposition.


Calcification of allograft aortic wall in a rat subdermal model. Pathophysiology and inhibition by Al3+ and aminodiphosphonate preincubations.

Aortic allograft conduits and valves frequently undergo calcific degeneration. To study this problem, a rat subdermal model of nonvalved aortic wall allograft calcification was characterized, and experimental studies were carried out to test the hypothesis that aortic allograft preincubation in either amino-propanehydroxydiphosphonate (APDP) or AlCl3 would inhibit calcification in a rat subdermal model. Fresh thoracic aortas were harvested under sterile conditions from male Sprague-Dawley rats (350-400 g). APDP aortas were preincubated immediately in either 4 x 10(-3) mol/l, 4 x 10(-4) mol/l, or 4 x 10(-5) mol/l [14C] APDP (37 degrees C, pH 7.4) and controls were incubated in 0.05 mol/l HEPES buffer (pH 7.4, 37 degrees C, 30 min). Al3+ aortas were preincubated in either 10(-1) mol/l, 10(-2) mol/l, or 10(-3) mol/l AlCl3. Pretreated aortas were next implanted subdermally in weanling rats (3-week-old, male, Sprague-Dawley, 50-60 g) and retrieved after 21 days. Control explants retrieved at intervals up to 21 days demonstrated progressive calcification with bulk aortic allograft Ca2+ levels increasing from a preimplant value of 0.8 +/- 0.1 micrograms/mg to 129.8 +/- 12.9 micrograms/mg by 21 days. Light microscopy revealed that much of the calcium deposition was associated with elastin. Calcification was significantly inhibited in the 4 x 10(-3) mol/l and 4 x 10(-4) mol/l APDP preincubated groups was observed (Ca2+ = 0.70 +/- 0.15 micrograms/mg, 36.6 +/- 19.8 micrograms/mg, respectively versus 117.2 +/- 24.3 micrograms/mg, control). Inhibition of calcification in the groups preincubated in the two most concentrated AlCl3 solutions (Ca2+ = 13.9 +/- 4.9 micrograms/mg [10(-2) mol/l AlCl3], 36.6 +/- 7.1 micrograms/mg [10(-3) mol/l AlCl3], 171.0 +/- 13.2 micrograms/mg [control]) was also demonstrated. No adverse effects of either pretreatment, APDP, or AlCl3 were noted on bone or overall somatic growth.


Reaching vulnerable populations: a framework for primary service role expansion.

An ecological framework is presented for assessing the feasibility of expanding the roles of primary service providers. Role conflict, interprofessional tensions, role anomalies, training and supervision, practitioners' tacit knowledge, and service user acceptance are among the factors assessed. The use of this conceptual framework for reaching a broader client population is discussed, together with its implications for professional practice.


Children of survivors of the Nazi Holocaust: a critical review of the literature.

This review of published research on children of Holocaust survivors focuses on new directions taken in clinical and experimental studies during the past decade. Methodological problems persisting from earlier research are considered, and suggestions for future research strategies are offered.


The cultural consultant in mental health care: the case of an Arab adolescent.

Limited understanding by mental health providers of an immigrant's cultural background can lead to misdiagnosis and inappropriate treatment. A case involving the psychiatric hospitalization of an adolescent from Iraq is described, as are the role of a cultural consultant in clarifying cultural issues and the positive consequences for diagnosis and treatment. Implications for the training and function of cultural consultants in mental health care are discussed.


Psychological responses of rescue workers: fire fighters and trauma.

The psychological responses of two groups of fire fighters were examined following the performance of rescue work. Four types of responses were reported: identification with the victims, feelings of helplessness and guilt, fear of the unknown, and physiological reactions. Stress was found to be mediated by availability of social support, type of leadership, level of training, and use of rituals. Implications of these findings for preventive intervention measures are discussed.


Traumatized children and the news media: clinical considerations.

Child victims of catastrophic incidents are often deluged by the news media and by the consequences of instant celebrity status but little is known about the effects of such publicity on these children. Several possible negative consequences for the children are discussed, as are some potential benefits. Suggestions are made for measures to minimize potential trauma arising from media attention.


Attention deficit hyperactivity disorder: an epidemiological screening method.

Multistage identification, an epidemiological screening method of diagnostic assessment, was used to identify attention-deficit hyperactivity disorder (ADHD) in 1,490 elementary-school students. Children diagnosed with ADHD exhibited more impairment on adjustment measures and were more likely to have coexisting disruptive behavior disorders than were children diagnosed as subclinical non-ADHD.


The role of parent training in treatment of preschoolers with ADDH.

The efficacy of group parent training was assessed in improving compliance and time on task in preschoolers with attention-deficit disorder with hyperactivity. Positive effects were obtained on measures of child compliance, but not on measures of attention. Parental compliance-management skills and overall style of interaction were also positively affected. The use of parent training for early intervention with ADDH children is discussed.


Maternal and environmental characteristics as predictors of child behavior problems and cognitive competence.

Maternal and environmental characteristics as predictors of behavioral problems and cognitive competence in 505 Israeli kindergarten children were investigated. Events in closer temporal proximity to assessments of functioning appeared more predictive than those in early infancy. Findings support the need to include variables reflecting maternal characteristics in any prediction of child outcome and to consider the sex of the child in selection of variables.


Parental divorce, adolescence, and transition to young adulthood: a follow-up study.

In a long-term study of the effects of divorce, children in a Finnish town who had completed questionnaires in school at age 16 were followed up with postal questionnaires at age 22. Depression in young adulthood was found to be slightly more common among children from divorced families. In addition, the life trajectories of children in divorced families revealed more stressful paths and more distress in both adolescence and young adulthood.


Depressive affect in "normal" adolescents: relationship to life stress, family, and friends.

Self-reported depressive affect was examined in high school students in relation to stress and the quality of relationships with family and friends. Higher levels of depressive affect were connected with stress around sexuality and achievement, lower levels of family cohesion, and more problematic peer relationships. The effects of high stress were buffered for boys by positive peer relationships, and for girls by cohesive family relationships.


Runaway and homeless youth: the effects of attachment history on stabilization.

The effects of attachment antecedents on response to stabilization were examined in a group of runaway and homeless youth aged 12 to 17 years. The attachment histories of those who were not responsive to stabilization showed significant differences on several measurable criteria from the attachment histories of those who were responsive. The clinical and programmatic relevance of these findings is discussed.


Patterns of adolescent psychiatric hospitalization: implications for social policy.

Demographic and institutional patterns of psychiatric inpatient treatment of adolescents in California in 1987 were analyzed with a focus on the roles of funding sources, ethnicity, and age in access to care, type of institutionalization, and length of stay. Privately insured white youths were found to be overrepresented in private psychiatric hospitals, while minority youths were underrepresented in private hospitals and overrepresented in juvenile detention facilities. Implications for policy issues are discussed.


Optimal length of stay in child and adolescent psychiatric hospitalization: a study of clinical opinion.

Factors contributing to clinical recommendations for length of hospitalization for children and adolescents were investigated. Diagnosis, chronicity, severity of symptoms, response to prior treatment, and family resources were found to relate strongly to length-of-stay recommendations. Guidelines representing the consensus of experienced clinicians are proposed.


Adolescent suicide attempts: outcomes at follow-up.

Adolescents seen in a general hospital emergency department or psychiatrically hospitalized were followed up at one month and three months following a suicide attempt. Findings included substantial drop-out rates for psychotherapy and high rates of repeated suicide attempts by three months. Implications for disposition planning and care of such adolescents are discussed.


Omissions in assessment of work roles: implications for evaluating social functioning and mental illness.

An analysis of data from a longitudinal study of individuals during and after psychiatric hospitalization found that multiple work roles often remain unconsidered in assessments of social functioning and psychiatric status. The inclusion of such multiple roles was found to be important for adequate measurement of productive functioning and to illuminate their interaction with individuals' psychopathology.


Child sexual abuse histories among African-American college students: a preliminary study.

Data from questionnaires completed by 1,040 African-American college students were analyzed for prevalence of child sexual abuse among this population. Rates were found to be similar to those in other studies of both general populations and female college students. Results of the study are discussed and directions for further research suggested.


Comparison of cell surface antigen HBA71 (p30/32MIC2), neuron-specific enolase, and vimentin in the immunohistochemical analysis of Ewing's sarcoma of bone.

The HBA71 antigen is an M(r) 30,000/32,000 cell surface glycoprotein (p30/32MIC2), encoded by the pseudoautosomal MIC2 gene on chromosomes X and Y, that is expressed in Ewing's sarcomas. Immunohistochemical studies demonstrate a striking specificity for HBA71 among neoplasms of diverse histologic types. In the present study, 43 cases of Ewing's sarcoma of bone were tested for HBA71 expression and six additional immunohistochemical markers regularly used in the differential diagnosis of small round-cell tumors of childhood and adolescence (neuron-specific enolase, vimentin, leukocyte common antigen, cytokeratins, muscle-specific actin, desmin). The study design included (a) random selection of Ewing's sarcoma cases from the files of Memorial Hospital beginning in 1968, (b) blind review of the original histopathologic diagnoses of ES, (c) side-by-side immunohistochemical study of recut histologic specimens, and (d) statistical analysis of immunohistochemical findings in view of clinical outcome. Of the seven antigens studied, only HBA71, neuron-specific enolase and vimentin were expressed in a significant proportion of cases. Forty-one of the 43 cases were HBA71+ (95% sensitivity); of these, 21 were neuron-specific enolase+, 29 were vimentin+, and 15 were both neuron-specific enolase+ and vimentin+. One tumor lacked all antigens, and one was vimentin+ only. Comparison of tumor tissues in five patients obtained before and after cytostatic chemotherapy showed no change in HBA71 expression or in the other antigens tested. Product-limit survival analysis (median disease-free survival was 27.3 months for the study cohort) revealed no significance of neuron-specific enolase or vimentin marker status. These results raise doubts about the usefulness of neuron-specific enolase and vimentin immunohistochemistry to distinguish Ewing's sarcoma from other small round-cell tumors of childhood and adolescence or as prognostic indicators in Ewing's sarcoma. The positive identification of Ewing's sarcoma of bone now becomes a reality using HBA71 immunohistochemistry, either as a sole method or in combination with chromosomal breakpoint analysis. This may result in achieving uniform diagnostic criteria for evaluating the biologic, therapeutic, and prognostic aspects of Ewing's sarcoma and related neoplasms.


Perineurioma: an uncommon soft tissue neoplasm distinct from localized hypertrophic neuropathy and neurofibroma.

Perineurial cells, which normally surround the nerve fascicles within a nerve, can be distinguished from Schwann cells by their immunoreactivity for epithelial membrane antigen (EMA) and lack of reactivity for S-100 protein. We report two cases of perineurioma, a tumor composed exclusively of perineurial cells and distinct from other nerve sheath tumors. The first case involved a deep, soft-tissue mass of the neck, and the second involved a tumor located in the infraclavicular subcutaneous tissue. Both tumors were well circumscribed. Histologically, they were hypocellular and composed of spindle cells possessing elongated nuclei and bipolar, wavy, slender, strikingly elongated cytoplasmic processes, disposed in a background of collagen in the form of short bundles and whorls. In the first case, there were frequent calcospherites and remnants of a small nerve at the periphery. The spindle cells stained for EMA but not S-100 protein, chromogranin, neuron-specific enolase or Leu-7. Ultrastructurally, they possessed long cytoplasmic processes with incomplete basal lamina and occasional pinocytotic vesicles. Axons were not identified. Review of the literature shows that genuine perineuriomas are rare, and most cases reported as such are merely examples of localized hypertrophic neuropathy, a mononeuropathy characterized by fusiform swelling of a nerve, usually in the extremities. The involved segment in localized hypertrophic neuropathy contains distended fascicles composed of whorls of perineurial cells and fibrous tissue entrapping residual axons, probably representing a hyperplastic reaction to nerve damage. The term perineurioma should be reserved for the neoplasm composed only of perineurial cells and presenting as a soft tissue tumor.(ABSTRACT TRUNCATED AT 250 WORDS)


Angiomatosis of soft tissue. An analysis of the histologic features and clinical outcome in 51 cases.

The clinicopathologic features and clinical behavior of 51 cases of angiomatosis of soft tissue are analyzed. We have defined this lesion as a histologically benign vascular lesion that affects a large segment of the body in a contiguous fashion either by vertically involving multiple tissue types (e.g., subcutis, muscle, bone) or by involving similar tissue types (e.g., multiple muscles). Such lesions usually present in the first two decades of life and have a highly characteristic but not totally specific histologic pattern. The common pattern consists of a haphazard proliferation of vessels of varying sizes, particularly large veins. The latter have irregularly attenuated walls and intimal redundancies. However, the most distinctive feature is the presence of clusters of capillary vessels residing within or just adjacent to the vein walls. A second but uncommon pattern is that of clusters of capillary-sized vessels infiltrating the soft tissues. Both types are typically associated with large amounts of fat, suggesting that these lesions are more generalized mesenchymal proliferations rather than exclusive vascular lesions. This idea is supported by one unique case that included as part of the lesion a diffuse proliferation of glomus cells. Follow-up information in 25 cases (median 5 years; range 1-24) indicated that 22 patients experienced local recurrences. Nine patients developed more than one recurrence. There was no correlation between the age of onset of the lesion and the number of recurrences.(ABSTRACT TRUNCATED AT 250 WORDS)


Prostatic tissue in mature cystic teratomas of the ovary.

We report two examples of mature cystic teratomas of the ovary containing prostatic tissue. Both were incidental findings in teratomas that were otherwise typical at clinical and pathologic levels. The prostatic tissue contained ducts and acini in a simple branching pattern similar to that seen in the peripheral zone of the prostate gland. Transitional cell elements were present in both cases and compact acini resembling Cowper's gland were noted in one. No testicular or Wolffian duct tissue was noted. The immunohistochemical staining pattern of the glands was identical to that seen in normal prostate. In a literature review, four additional cases were identified. The presence of prostatic tissue in a 46XX tumor suggests induction by locally produced androgen. Some investigators have identified luteinized stromal cells and indicated these as the source of this androgen. Other possible androgenic origins include ovarian hilar cells, adrenal cortex, and tumor cells.


Epithelioid and spindle-cell hemangioendothelioma of the spleen. Report of a distinctive splenic vascular neoplasm of childhood.

A case of a distinctive vascular neoplasm of the spleen in a 3-year-old boy is described. The tumor was characterized histologically by a biphasic growth pattern, with discrete nodular areas composed of atypical round, epithelioid cells with large nuclei and prominent nucleoli, and areas showing an intricate proliferation of vascular channels lined by elongated spindle cells. Immunohistochemical studies showed cytoplasmic staining of the tumor cells with factor VIII-related antigen, Ulex europaeus lectin, and vimentin antibodies. Stains for keratin, actin, desmin, lysozyme, and S-100 protein were negative in the tumor cells. Electron microscopy revealed a fairly cohesive population of cells that contained mature and immature cell junctions, basal lamina material, and surface pinocytotic activity consistent with vascular endothelial cells. Five-year follow-up has shown the patient to be alive and free of disease. This case appears to represent a previously unreported primary vascular neoplasm of the spleen showing combined features of epithelioid and spindle-cell hemangioendothelioma. The lesion should be distinguished from other benign and malignant vascular proliferations of the spleen such as Kaposi's sarcoma, angiosarcoma, and the recently described littoral-cell angioma.


Elastofibromatous change of the rectum. A lesion mimicking amyloidosis.

We report the case of a 58-year-old woman who had a 7-year history of multiple myeloma and multiple rib fractures and who presented with dysphagia. She underwent thorough gastrointestinal evaluation to rule out the possibility of amyloidosis. Although upper gastrointestinal biopsies were negative, the rectal biopsy was characterized by extensive smudgy eosinophilic deposits in the submucosa that closely resembled amyloid, except that they were not congophilic. Fibers with serrated borders characteristic of those in elastofibroma were identified and confirmed by means of elastic stain and electron microscopy. Elastofibromatous change of the gastrointestinal tract is a rare lesion that has been reported once previously in association with gastric ulcer. This case illustrates that it may occur as a spontaneous or subclinical finding in the absence of other pathologic lesions. The close resemblance between elastofibromatous change and amyloid deposits necessitates the appropriate histochemical and ultrastructural studies.


Primary carcinoid tumor of the cystic and common bile ducts.

We report a case of primary carcinoid tumor arising at the confluence of the cystic and common bile ducts. The patient was a 64-year-old woman who developed a sudden onset of biliary colic and jaundice. Computerized tomography and nuclear magnetic resonance showed a mass lesion close to the head of the pancreas. At laparotomy a nodular lesion was found at the confluence of the cystic and common bile ducts. Microscopic observation revealed a type B-C carcinoid (Soga's classification) with positive immunoreactivity to chromogranin and cytokeratin. The presence of neurosecretory intracytoplasmic granules was demonstrated by electron microscopy. Flow cytometry showed diploid DNA content of the neoplastic cells with less than 5% of the nuclei in the S-phase region.


[Intraoperative awareness in balanced anesthesia. A literature review based on a randomized double blind study using fentanyl, pentazocine and ketamine].

Since the first case report by Winter-bottom [106], the problem of intraoperative awareness or recall has received increasing attention from patients, anaesthesiologists and, more recently, even law courts [4, 20, 21, 78]. Our own interest in awareness derives from a study with the opiate agonist tramadol as a supplement to balanced anaesthesia, which revealed an unexpectedly high incidence of about 65% of patients who could recall intraoperative music [55]. It was the aim of the present randomized double-blind study to evaluate, under identical experimental conditions, what the incidence would be with other analgesic supplements to balanced anaesthesia (fentanyl, pentazocine and ketamine). Because few reports on this subject are available in the German literature, it was felt that the result should be discussed within a comprehensive review. PATIENTS AND METHODS. A total of 60 patients (ASA I-II, age 27-66 years, weight 48-93 kg) undergoing elective gynaecological surgery of at least 90 min duration were each randomly assigned to one of three study groups (F, fentanyl; P, pentazocine; K, ketamine). Premedication was performed with diazepam 10 mg p.o. the evening before surgery and pethidine 1 mg/kg i.m.+promethazine 1.5 mg/kg i.m.+atropine 0.5 mg i.m. 60 min before anaesthesia. Induction was performed with alcuronium (2 + 8 mg), methohexital (1.5 mg/kg) and a bolus dose of the analgesic supplement (F, 5 micrograms/kg; P or K, 2 mg/kg), followed by continuous infusion (F, 2 micrograms kg-1 h-1, P or K 0.8 mg kg-1 h-1). Endotracheal intubation was performed with succinylcholine (1 mg/kg). Patients were ventilated to normocarbia using a Takaoka respirator (4 breaths/min, tidal volume 1600 ml, N2O/O2 75:25). If insufficient anaesthesia was suggested by increases in blood pressure or heart rate to more than 20% of preinduction values, excessive sweating or lacrimation, enflurane (0.5-2 vol.%) was added for short periods of time. At the end of surgery, patients were ventilated with 100% O2, and the neuromuscular block antagonized using atropine 0.5 mg and neostigmine 1 mg. Without prior announcement, tape-recorded music (Mantovani, 3 min followed by 3 min silence) was played to all patients via earphones throughout the time period between intubation and the end of nitrous oxide administration. Vegetative parameters, cumulative and relative enflurane application times and retrospective judgement of quality of anaesthesia by the anaesthesiologist were documented. Post-operative recovery and pain were monitored using verbal rating scales. Patients were interviewed immediately after extubation and on the day after surgery to determine the incidence of dreams and recollection of music. Patients were classified as amnestic if they could not recall the music, even with prompting, and partially amnestic if they remembered the music but were unable to define the time when they had heard it. No amnesia was assumed if patients recalled the intraoperative music spontaneously. Groups were statistically compared by means of analysis of variance, Mann-Wilcoxon rank sum test and chi-square test. RESULTS. Mean duration of anaesthesia was 129-134 min in the subgroups. The total analgesic supplement dose was F 614 +/- 129 micrograms, P 238 +/- 38 mg, and K 230 +/- 50 mg (mean +/- SD). Enflurane substitution was necessary in 45 patients, regardless of the type of analgesic supplement. Mean cumulative enflurane application time was 26-28% in the treatment groups, corresponding to about 20% of anaesthesia duration. The most important reasons for enflurane substitution were increases in blood pressure (mostly in groups F and P) or heart rate (K). Recovery was fastest with F, followed by P, and slowest with K. Retrospective judgement of the quality of anaesthesia by the anaesthesiologist did not differ significantly between the treatment groups. Most (93%) of the patients were satisfied with their anaesthesia; 2 patients each who received P and K were dis


[Spontaneous liver rupture as a rare complication of the HELLP syndrome].

The HELLP syndrome (haemolysis, elevated liver enzymes, low platelet count) was first referred to by Weinstein in 1982 as an extremely progressive form of gestosis. In addition to the more common gestotic symptoms, such as oedema, proteinuria and hypertension, the clinical picture is characterized by microangiopathic haemolysis, thrombocytopenia and, especially, impaired hepatic function. Within this clinical picture severe complications can occur, such as eclamptic attacks, renal dysfunction, intracranial haemorrhage, intrahepatic haemorrhage and coagulopathy. An imbalance in prostanoid metabolism has been implicated in the pathogenesis. A decrease in synthesis of the vasodilator and thrombocyte aggregation inhibitor prostacyclin leads to a preponderance of the vasoconstrictor thromboxane A2, which promotes thrombocyte aggregation. This results in local vascular spasms and endothelial lesions, which in the case of hypercoagulopathy are accompanied by the formation of fibrin deposits with resultant vascular constriction. Intravascular fibrin deposits indicate that the coagulation system has been compromised and can lead to consumption coagulopathy in approximately 10% of cases. In the majority of cases, however, one finds low-grade disseminated intravascular coagulation (DIC), i.e. mild hypercoagulopathy with thrombocytopenia, a tendency to thrombocyte aggregation and fibrinogen deficiency in the presence of usually normal plasmatic coagulation. These vascular changes occur particularly in organs that have high blood flow, such as liver, kidneys and placenta. In the liver, sinusoidal obstruction causes vascular congestion, leading to an increase in intrahepatic pressure, dilatation of Glisson's capsule, development of subcapsular hepatic haematomas and hepatic rupture. Hepatic haematoma virtually always requires surgical treatment, and otherwise the patient has hardly any chance of survival. Nevertheless, mortality is around 35%.(ABSTRACT TRUNCATED AT 250 WORDS)


[The action of flumazenil in combination with fentanyl on spontaneous respiration].

Whereas the efficacy of flumazenil (Fl) for improving vigilance in the presence of other benzodiazepine agonists (BZA) is undoubted, its effect on BZA- and/or opioid agonists (OA)-induced respiratory depression is the subject of controversies. Some authors describe an improvement of a midazolam (Mi)-induced increase in paCO2, whereas others cannot find any influence on diazepam-induced respiratory depression. In two studies in which Fl was used to antagonize Mi/Fentanyl (Fe) anaesthesia we found even worse oxygen saturation values than with placebo (Pl). All our previous studies indicate a slight intrinsic activity of Fl on respiration in the presence of opioids. We therefore investigated the influence of Fl and Pl on expiratory pCO2 and oxygen saturation (SAT). METHODS. A group of 15 male, healthy volunteers aged 20-30 years gave written informed consent to participate in this double blind study, which was approved by our Institutional Review Board. Each subject received 3 micrograms/kg body wt. Fe + 0.5 mg Fl and 1 week later 3 micrograms/kg body wt. Fe + 5 ml NaCl 0.9% (Pl) i.v., in random order. They were undisturbed and breathed spontaneously. The following parameters were measured: SAT, pCO2 and heart rate (HR) continuously, using a pulse oximeter (SAT, H) and CO2 infrared absorption monitor (Oscar, Messrs., Datex). The blood pressure was recorded before and after a 5-min preinjection period (baseline) and at the end of the procedure (25 min). The data were stored in a microcomputer (Multitalent, Messrs. ZAK) and transmitted to a PC after each trial. STATISTICS. The groups were compared with the Wilcoxon rank sum test. P less than 0.05 is significant. RESULTS. In trials 1 and 2 there was an increase of pCO2 and a drop in SAT. The changes in pCO2 and SAT were more pronounced after Fe+Fl in 12 subjects (80%), as against 1 subject with the opposite result. There were 2 subjects who showed no difference between trials 1 and 2. The combination of Fe and Fl caused significantly higher increases in pCO2 (P = 0.007) and more pronounced decreases in SAT (P = 0.04) than Fe and Pl. DISCUSSION. These results indicate a slight enhancement of Fe-induced respiratory depression by Fl. In a previous study it could be shown that Fl antagonized the respiratory depressive effect of Mi, but baseline paCO2 was not completely recovered. In previous studies respiratory function impaired by Mi+Fe was initially improved by Fl, but rebound effects on SAT were observed, which were more pronounced than those after Pl. Therefore, respiratory function must be closely monitored in Fl-antagonized patients after Mi/Fe anaesthesia.


[The refusal to consent to blood transfusion. Legal and medical aspects using Jehovah's Witnesses as an example].

The limited understanding of a patient, such as a Jehovah's Witness, who has consented to an operation but refuses a blood transfusion for personal or religious reasons, places the physician in a moral dilemma. According to Article 2 II of the German Constitution, the fact that the patient has withheld or expressly refused his consent, i.e., in writing, mandates that the legal right of physical integrity be upheld with final legal effect, even in the case of an emergency. If this right to self-determination is abused, the person giving treatment is guilty of bodily harm in the sense of section 223 of the German Penal Code. Intraoperative haemodilution, the cell-save procedure, and colloidal and crystalloid volume replacement represent alternative methods of blood transfusion for Jehovah's Witnesses.


[The significance of the initial respiratory parameters in assessing the severity of ARDS in children].

In adults, the course and outcome of the acquired respiratory distress syndrome (ARDS) are closely related to the initial respiratory situation. Respiratory indices are frequently used for prognostic purposes and hence for the institution of new techniques such as extracorporeal lung support. The validity of these indices to predict the outcome in pediatric ARDS patients has not been examined as yet. We studied respiratory indices in 69 pediatric ARDS patients. METHODS. Out of 69 pediatric ARDS patients with various underlying diseases (Table 1), we chose 21 with a paO2/FiO2 ratio less than 150 mm Hg at some point to test the prognostic significance of a respiratory severity index (RSI), i.e., mean airway pressure x alveolar-arterial pO2 difference (A-aDo2)/paO2, a respiratory index (RI), i.e., A-aDO2-paO2/paO2, and other respiratory parameters (Table 2). Postsurgical patients, patients with incurable diseases, clearly non-respiratory deaths, and those treated with extracorporeal membrane oxygenation were excluded. We looked for statistical differences between survivors and nonsurvivors and correlations between ventilator days, intensive care unit (ICU) days, and hospital days and these indices. RESULTS. We did not find a significant difference between all respiratory indices tested at admission to the ICU and 24 h later between survivors and nonsurvivors (Table 3). Nonsurvivors initially had significantly higher blood pressures and lower heart rates. Both RSI and RI were significantly correlated to days on the ventilator, days in the ICU, and days in the hospital (Table 4). Initial multiorgan failure was significantly more common in nonsurvivors. CONCLUSIONS. Initial lung dysfunction as indicated by respiratory indices does not predict the outcome in pediatric ARDS. The underlying disease, hemodynamic situation, and age have to be considered in relation to the degree of lung dysfunction to determine new therapeutic strategies such as extracorporeal support.


[Neonatal resuscitation in the delivery room. What role does the anesthetist play?].

Neonatal resuscitation in the delivery room of small obstetric units is problematic because of the lack of on-site personnel with adequate training and experience. In large university hospitals this task is usually fulfilled by neonatologists who are present 24 h/day. However, in medium-sized and small obstetric units neonatal resuscitation is performed by a variety of professionals: paediatricians, obstetricians, anaesthetists, midwives, nurses, and nurse anaesthetists. The degree of responsibility and involvement of the anaesthesia specialist in the resuscitation of the newborn in Switzerland is unknown, and therefore an investigation was conducted. METHOD. After a telephone inquiry at all the hospitals in Switzerland, a total of 175 obstetric units were identified. A questionnaire with items regarding organisation, responsibilities, and the extent of involvement of the anaesthesia department of the particular hospital was sent to each of the appropriate anaesthetists. RESULTS. Of the 175 questionnaires, 163 (93%) were returned; 14 could not be analysed (5 were sent to hospitals where there was in fact no obstetric unit and 9 were sent to anaesthetists who shared responsibilities for one unit). In 1988, 76,505 babies were born in Switzerland; two-thirds of these were delivered in hospitals with an annual birth rate of less than 600 births per year. Of the 149 questionnaires that were eligible for further analysis, 118 (79%) documented participation of the anaesthetic team in the resuscitation of the newborn. However, only 22% of these departments had an official contract with the hospital administration. Ninety-nine per cent of all responders agreed that every anaesthetist should have the knowledge--both theoretical and practical--to resuscitate a newborn infant. However, reservations were expressed on how to acquire and how to maintain this competence. The initial evaluation of the newborn was done by an anaesthetist in 3% (2250/76,505) of all deliveries in Switzerland in 1988; 1.2% (882/76,505) of these babies needed bag-and-mask ventilation and in 0.4% (308/76,505) endotracheal intubation was performed by the anaesthetist. Proceeding on the assumption that 5% of all newborns need some sort of resuscitation immediately after birth, it is estimated that in 1988 approximately one-third of resuscitations were performed by anaesthetists. It is therefore concluded that anaesthetists play an important role in the resuscitation of newborns in Switzerland.


[Bronchoscopy for initial care following severe thoracic trauma--basically indicated?].

The study objective was to determine the usefulness of routine early (within 24 h after admission) and late (on the 3rd posttraumatic day) flexible fiberoptic bronchoscopy in patients with severe chest trauma. By history, physical examination, and radiologic findings, we identified 15 consecutive patients, all of whom were anaesthetized, orally intubated, and mechanically ventilated. There was no change in ventilation, including FIO2, for bronchoscopy. The patients had continuous cardiovascular monitoring and peripheral pulse oximetry. The bronchoscope was inserted through a tight-fitting side port at the endotracheal tube connector. Pulse rate, mean arterial pressure, and arterial blood gases were recorded before, 1 min after, and 10 min after bronchoscopy, as were intracranial pressure (ICP) in 7 patients with an ICP probe (early bronchoscopy only) and the duration of the examination. Statistical significance was tested by means of the Wilcoxon test for correlating samples. Significance was assumed at P less than 0.05 in a two-sided test. Early bronchoscopy revealed two bronchial avulsions, two aspirations, and ruled out one suspected aspiration. Late bronchoscopy showed plugging of at least 3 segmental bronchi by clots in 4 patients, none of whom was able to expectorate effectively. In general, changes in the observed vital parameters were minimal. There was a significant but clinically irrelevant increase in mean pulse rate before and 1 min after early bronchoscopy. We conclude that bronchoscopy should always be considered in patients with severe chest trauma, the decision being based on typical radiological findings as well as clinical signs and symptoms. Given the proper indication, bronchoscopy supplies valuable information at minimal risk to the patient.


[Obstetrical peridural anesthesia with bupivacaine and buprenorphine. A randomized double-blind study in comparison with untreated controls].

Epidural anaesthesia with local anaesthetics has become a standard method of pain relief during labour. In recent years, spinal opiates, alone and in combination with local anaesthetics, have also been tried with varying degrees of success. Buprenorphine, a potent lipophilic opiate with long duration of action, has been used in several trials for caesarean section [3, 4, 6], but not yet in spontaneous labour. The aim of the present investigation was to evaluate epidural anaesthesia with bupivacaine alone and with bupivacaine+buprenorphine in comparison with no anaesthetic treatment in control parturients. METHODS. A total of 80 healthy women during labour at full term (age 18-38 years, weight 54-107 kg) were studied to evaluate the influence of 0.3 mg buprenorphine (group BB) vs placebo (group B) added to an initial dose of 15 ml plain bupivacaine 0.33% for lumbar catheter epidural anaesthesia. Plain bupivacaine 0.25% (10 ml) without any opiate admixture was used for reinjections. The control group was made up of 48 untreated parturients. After every injection, blood pressure, heart rate and respiratory rate were measured repeatedly, as were time intervals between injections, extent of blockade, duration of labour, actual and retrospective visual analogue pain score, and side effects such as pruritus, shivering or nausea and emesis. Maternal capillary blood gases were analysed three times during labour, and Apgar scores and venous and arterial umbilical blood gas analyses were obtained immediately after delivery. RESULTS. Admixture of buprenorphine 0.3 mg significantly increased the time interval between the first and second epidural doses (B: 162 +/- 47 vs BB: 224 +/- 64 min; mean, SD; Table 2) and significantly reduced the incidence of shivering (Table 9). The incidence of instrumental delivery was comparable in all groups (bupivacaine 32.5%, bupivacaine+buprenorphine 27.5%, control 21%; n.s.). No clinically relevant differences were observed between the epidural patients in onset and duration of the block (Fig. 1), analgesic efficacy (Fig. 2), duration of spontaneous labour (BB: 8.6 +/- 3.1 h, B: 8.5 +/- 2.9 h; n.s.) and vital functions of mothers and newborns. Although some statistically significant differences between the three groups were found in some parameters of the blood gas analyses (Table 7), the clinical condition of the newborns was always acceptable; Apgar scores were not significantly different. DISCUSSION AND CONCLUSIONS. The addition of buprenorphine to bupivacaine resulted in some advantages to the mother (reduced incidence of shivering) and the anaesthetist (time lapse before first reinjection was necessary) without jeopardizing the situation of the baby. Compared with untreated control parturients, retrospective pain scores during epidural anaesthesia with bupivacaine (with or without buprenorphine) were significantly lower. No clinically relevant disadvantages of epidural anaesthesia were observed. More studies are required to evaluate whether buprenorphine admixture allows a dose reduction of bupivacaine and could then claim clearer advantages than were found in the present investigation.


[Transient total motor aphasia. A complication of an axillary brachial plexus block].

Hypo- and hypertension, arrhythmias, bradycardia extending to cardiac arrest with circulatory failure, pneumothorax, allergic reactions with or without anaphylactic shock, production of methaemoglobin, vomiting, vertigo, disorientation, acoustic and visual disorders, tinnitus, slurred speech, muscle contractions, unconsciousness, and epileptic seizures are well-known complications associated with local anaesthetics. We have observed an additional central nervous system complication: a case of transient, total motor aphasia (Broca aphasia) in a 50-year-old patient after axillary blockade of the brachial plexus. Possible causes such as type and dosage of local anaesthetic or a transient ischaemic attack in the area of the prerolandic artery are discussed and related to the literature. Ultimately, however, it is still not apparent why this complication could appear although there was no overdosage intravascular injection, or abnormality of the pulse or blood pressure, and why its manifestation was limited to a motor aphasia.


[A myoclonic seizure during propofol-alfentanil anesthesia?].

Total intravenous anaesthesia with propofol and alfentanil is an established alternative to inhalation anaesthesia for intracranial neurosurgical procedures. Its usefulness has been somewhat overshadowed by reports of seizure-like movements, both during anaesthesia and in the recovery period. These can be related to the use of either anaesthetic agent, but true epileptogenic properties still remain to be demonstrated in man. Opioid-induced rigidity is a well known phenomenon and must not be mistaken for an epileptic seizure. Myoclonic motor activity can be observed even under physiological conditions, e.g. sleep. Almost all anaesthetic agents have been found to produce "epileptic" EEG changes (spikes, polyspikes, spike-wave complexes), but in man these have never been correlated to motor reactions. Propofol's pro- or anticonvulsive action is unclear. While some groups found shortened convulsing times in patients undergoing electroconvulsive therapy with propofol instead of methohexitone, others have reported activation of epileptogenic foci in the EEGs of known epileptic patients. A synergistic effect of propofol and alfentanil in the generation of seizure-like movements cannot be excluded. Whether seizure-like movements indicate a true "epileptogenic potency" of the anaesthetic drugs or are related to other phenomena remains to be studied. Electro-encephalographic monitoring during anaesthesia as well as careful observation and documentation of motor reactions may contribute to elucidation of the problem. We report a case of seizure-like movements during propofol-alfentanil anaesthesia for an elective craniotomy. A 52-year-old patient presented with a history of headaches of increasing frequency. A CT brain scan demonstrated a tumor in the left occipital region.(ABSTRACT TRUNCATED AT 250 WORDS)


Tissue expansion in pig skin--a histochemical approach.

In the present study, a porcine model for controlled skin expansion was investigated to improve our understanding of epidermal and vascular responses following stretching. The model is of outstanding importance not only for the clinical use of tissue expansion but provides interesting data for skin physiology and oncology, too. Thirteen out of 15 animals, who underwent silicone tissue expander implantation showed good clinical results. In all of them, skin biopsies were taken at the end of a controlled tissue expansion procedure (final expander volumes 350 or 500 ccm): one tissue specimen was obtained from the centre of the expanded skin area and a second from the neighbouring but nonexpanded skin. The tissue specimens were immediately frozen in liquid nitrogen and processed to 4 microns thick acetone-fixed frozen sections. Lectin histochemistry and immunohistology were performed using the following techniques: direct and indirect immunofluorescence technique (DIFT, IIFT), immunoperoxidase technique (POX) with either 3,3'-diamino-benzidine (DAB) or 3-amino-9-ethyl-carbazole (AEC). The histochemical findings were supplemented by measurements of the number of vital epidermal cell layers, the epidermal thickness (microns), and the papillary vascular count per visual field. There was a significant diminuation of the vascular count (mean +/- S.D. = 55.0% +/- 12.5%; U-test: p less than 5%). By immunohistochemistry, a loss of the basal cell reactivity for the following antibodies was noted: ACAM (against calmodulin), K 8.12 (against keratins 13 +/- 16) and A51-B/H4 (against keratins 8, 14, 18). There was a remarkable increase of filaggrin expression in the uppermost spinal cell layers in expanded skin, which was most pronounced in those specimens with the shortest interval to the last fluid injection into the expander. We gained no evidence for alterations of the expression of suprabasal epidermal keratins, lectin binding sites (UEA I, PNA, ConA, WGA), and vascular lectin- and immunoreactivity due to tissue expansion. The subdermal capsule, which had formed around the silicone expander, was strongly vimentin-reactive. In conclusion, controlled tissue expansion is capable to change the basal cell phenotype--a feature which is shared with a number of conditions with increased proliferative activity and with the epidermis covering different skin tumours. The regular expression of suprabasal keratins and epidermal lectin binding sites provides evidence for a normal epidermal cell differentiation. Furthermore, the porcine skin is a reliable model for studying physiology and pathophysiology of human skin.


Studies on the parietal region of the cervid skull. I. Remarks on the os interparietale in the skull of the roe deer (Capreolus capreolus L.).

In the roe deer skull symmetrically arranged ossa interparietalia were found to develop from paired centers of ossification. Obliteration of the sutura interinterparietalis mostly started already late in prenatal life, whereas closure of the interparietal and the interparietoparietal sutures as a rule commenced around the second week post partum. A certain degree of variability with respect to the timing of sutural closure was observed. No synostosis occurred between the os parietale resp. os interparietale and the os supraoccipitale, so that even in old animals the sutura parieto- resp. interparietooccipitalis was always present.


Sexual dimorphism of the kidney in the NMRI mouse as shown by Dolichos biflorus agglutinin labelling.

The histological affinity pattern of Dolichos biflorus agglutinin (DBA) in kidneys from mice (NMRI, Balb/c, CBA) and rats (Wistar) fixed by perfusion with formalin, Bouin, or HgCl2 was investigated with a horseradish peroxidase conjugate. The animals were examined from fetal stage to adulthood. Adult female NMRI mice exhibited constant DBA labelling, with DBA binding to cells of the proximal and collecting tubules. Moreover the vascular endothelium of the renal papilla was found to be DBA-positive in 50% of adult female animals. In contrast, there was only very little DBA binding in the kidneys of male adult NMRI mice. There was no sexual dimorphism in lectin labelling in kidneys from other strains of mice or from rats.


[Thr arteries of the male sex organs of Japanese quail (Coturnix coturnix japonica) and their development after hatching].

A total of 83 male Japanese quails of the following age groups were used for this study: 11, 18, 25, 32, 35, 37, 39, 41, 43 days, and 7, 9, 17 weeks after hatching. Neoprene-Latex, Tensol-Cement, and the china ink were injected via the aortic arch. In most of male Japanese quails, the testes are supplied by the A. testicularis originated from the Aorta descendens through a common trunk with the A. renalis cranialis. But in only 3 quails had this artery originated directly from the Aorta descendens on either side. In 9 quails had the A. testicularis accessoria originating independently from the Aorta descendens and running cranially or caudally in short distance to the normal A. testicularis. The arteries for the Ductus deferens were divided into 3 categories. The Rami ureterodeferentiales craniales were spread out from A. testicularis or Rami epididymales. The Rami ureterodeferentiales medii came from the A. renalis media and the A. renalis caudalis. The Rami ureterodeferentiales caudales originated from the A. caudae lateralis and A. pudenda. The Receptaculum ductus deferentis, the Corpus vasculare paracloacalis and the Phallus nonprotrudens in the Cloaca were supplied from the thick Ramus cloacalis of the A. pudenda. The Ramus bursalis of this artery supplied the Glandula proctodaealis and the Bursa cloacalis, and was also thick. The arteries to the genital organs were observed in the 11 day old male quail. The A. pudenda began developing at about 30 days after hatching when the quail's body matured. While the A. testicularis began developing at about 40 days after hatching when the male Japanese quail was full of the spermatogenic activity.


Immunocytochemical study of the diffuse neuroendocrine system cells in equine lungs.

This study was undertaken to investigate the presence of neuroendocrine cells (N.E.C.) by immunocytochemical means in equine lungs during three distinct evolutionary periods: fetal, neonatal and adult. The authors identified bombesin, somatostatin and calcitonin secretory cells. In the fetal lungs the N.E.C. were located in the interstitial tissue and exhibited greater immunoreactivity to bombesin than to the other two neuropeptides studied. A large number of calcitonin-producing cells and a smaller number of bombesin-positive cells were seen in the bronchial and bronchiolar epithelium of newborn Equidae. In the adult equine lungs far fewer N.E.C. were observed than in the earlier stages. Somatostatin-producing cells were not seen in neonatal or adult lung tissue.


Arrangement of the branches of the aorta abdominalis in the wood mouse (Apodemus sylvaticus).

Data on the distribution and variation of the abdominal arteries in the wood mouse, Apodemus sylvaticus, are given. Seventy specimens (44 males and 26 females) caught in the field were analyzed by injection of green latex solution and dissection. The general branching pattern of the aorta abdominalis is similar to those described in other rodents. There are certain differences, however, especially in the branching of the coeliac trunk, the origin of the genital arteries and the arrangement of the caudal mesenteric artery. Significant variability was detected in the distribution of the iliolumbar arteries about the testicular and ovaric arteries. Based on the observations and measurements carried out, some branching patterns of the aorta abdominalis are presented.


Comparative structure and morphology of the goat sternum in West African dwarf and Danish Landrace breeds.

The structure and morphology of the sternum from 33 West African dwarf (WAD) and sixteen Danish Landrace breed goats were studied radiographically. In young kids of the Danish Landrace breed (DL), the number of sternal elements (Sternebrae) was six or seven with the fifth or the last but one being double in some animals due to bilateral bodies. All the sternal elements in the WAD breed appeared to have each a single locus of ossification and the number of sternal elements varied between 5, 6 or 7 at birth. In those goats with 5 or 6 sternal segments, bilateral indentations were observed on the left and right side on either the last or the last two segments. These indentations were considered to indicate a prenatal cranial coalescence of the last segments leading to the reduced number of sternebra. The structure and morphology of the sternum in neonatal kids for the two breeds appears to be basically different. 8 sternal and 5 asternal ribs were observed in animals of both breeds. The cartilaginous attachments of the ribs on the sternal segments were variable. A floating rib was also observed in one of the WAD goats. The comparative structure and morphology of other ruminant sternum is also discussed.


Measurement of mechanical forces acting on the area pellucida of the early chick embryo.

We have designed a method for measuring mechanical forces acting on the area pellucida of the chick embryo between stages 1 to 5 of HAMBURGER and HAMILTON (1951). The coordinates of several points on the outline of the area pellucida were used as input, from which a computer program measured the changes in the position of similar points to produce a table of values which, we argue, reflect mechanical forces in the embryo. The results obtained are shown to be reproducible between embryos. The computer program and the measurements obtained were then used to predict the behaviour of surgical incisions made in the area pellucida, using the tables obtained from direct measurements of embryos and the coordinates of various points on the surface of the operated embryos. This procedure was applied to embryos cultured by the method of NEW (1955) and in-ovo. It was found that in those embryos cultured by EWS technique the computer predictions correspond very closely to shape measurements made directly from embryos. However, the correspondence is less close when applied to embryos in-ovo.


[Age-dependent development of the long hollow bones in white New Zealand meat rabbits and chinchilla-hybrid laboratory rabbits].

The age dependent development of the long bones' diaphyses (humerus, os femoris and os tibiofibulare) was examined macroscopically, morphometrically and histologically using 15 White New Zealand Rabbits (WN) and 15 Chinchilla-Bastard-Experimental-Rabbits (Chbb) in 5 different age groups. The main growth of bone occurs in the first three months of life. The remodelling from juvenile to adult bone began in the period from the 4th-12th week. The different bones show various characteristic remodelling zones for each localization. Until the 12th week the resorption of juvenile bundled bone predominates. Afterwards an increasing bone formation by osteal bone can be observed. The bone growth is terminated between the 17th and 33rd week. The os tibiofibulare in both breeds represents the major part of the compact bone area on the whole cross-section area. Principally the bone-remodelling process proceeds equally in both breeds. Breed dependent differences in the adult bone are seen in the construction of the circumferential lamellae. These are formed considerably more irregularly by the Chbb-rabbits than by the WN-rabbits.


Hypertensive intracerebral hemorrhage stimulating acute myocardial infarction.

We describe the case of a patient who presented with cardiovascular collapse and ECG changes strongly suggestive of acute MI. Our experience and that of others with patients who had sustained intracerebral hemorrhage indicate the potential for this entity to be misdiagnosed as acute MI early in a patient's clinical course. Reports of mistaken administration of thrombolytic therapy to patients with pericarditis or aortic dissection, other conditions that may be electrocardiographically mimic MI, underscore the potential for error. Clinicians should consider the possibility of intracerebral hemorrhage before treatment of MI with thrombolytic agents.


Didelphic uterus and unilaterally imperforate double vagina as an unusual presentation of right lower-quadrant abdominal pain.

Imperforate hymen should be considered in girls of menarcheal age with a history of amenorrhea and vague abdominal discomfort, particularly if associated with symptoms of urinary obstruction or constipation. Patients may present with severe dysmenorrhea and localized pain mimicking appendicitis if hematocolpometra is due to unilaterally imperforate hymen with duplicate vagina and didelphic uterus. Although this condition is exceedingly rare, the case presented stresses the importance of a careful history and physical examination of an adolescent girl presenting with symptoms of abdominal pain associated with menstruation.


Use of comparison radiographs in the diagnosis of traumatic injuries of the elbow.

To determine whether comparison radiographic views of the uninjured elbow result in increased diagnostic accuracy in elbow trauma. Physicians were provided with a short clinical summary and asked to interpret radiographs of the injured elbow or of both the injured and the uninjured elbow in a randomized fashion. The radiology department in a university hospital. Fifty sets of radiographs from 25 children with elbow injuries were reviewed by two residents, two emergency physicians, and one pediatric radiologist using a standard classification of injuries. For each child, there were two sets of radiographs: one of the injured elbow and one of both the injured and the uninjured elbow. Descriptive statistics were used to report the results. kappa statistics were used to determine interobserver and intraobserver agreement. Missed diagnoses were divided into those that were clinically relevant and those that were not. The overall percentage of correct diagnoses (one versus two elbow radiographs) were as follows: residents, 69% versus 70%; emergency physicians, 62% versus 67%; and pediatric radiologist, 74% versus 72% (P greater than .05). kappa scores for interobserver variability and intrarater agreement were in the moderate range (.383 to .805; kappa, .08). Clinically relevant diagnoses were missed by trainees and emergency physicians regardless of whether radiographs of just the injured elbow or both the injured and the uninjured elbow were interpreted. Incorrect radiograph interpretations were due to false-positives in 17 of 23 cases. Comparison radiographs of the uninjured elbow did not improve diagnostic accuracy in elbow trauma in the pediatric emergency department.


Length-based endotracheal tube and emergency equipment in pediatrics.

Pediatric endotracheal (ET) tubes can be accurately selected based on body length using a specialized emergency tape. Derivation set: Two hundred five children undergoing elective surgery. Validation set: Two hundred thirteen children undergoing elective surgery. Each child served as his or her own control. Derivation phase: Two hundred twenty-one children undergoing ET intubation for elective surgery had their body length and leak pressures measured. The 205 children who had leak pressures between 10 and 40 cm H2O constituted the derivation set. The body length for a given ET tube size was derived from the interquartile range of patient lengths in this derivation set. Sizes for other resuscitative equipment items were chosen by a panel of experts using a modified Delphi technique. This information was placed by length on a color-coded tape. Validation phase: The tape was validated by using it to select ET tube size in another group of 203 children undergoing elective surgery. Criteria for acceptable fit in this group included leak pressure as above and the anesthesiologists' decision to accept the tube size or to retintubate. In the validation phase, length-based ET tube selections were compared with age-based rules: (age + 16)/4, and (age + 18)/4. The tape selected the appropriate ET tube size by leak pressure criterion in 77% of the cases and was within +/- 0.5 mm of the "correct" size 99% of the time. This was significantly better (P less than .005) than two widely used age-based rules, which gave the correct initial size in only 47% and 9% of these cases, and were within +/- 0.5 mm for 86% and 59%. The anesthesiologists chose to continue with the tape-sized tube rather than to reintubate in 89% of cases. A system for length-based selection of emergency equipment represents a significant adjunct to emergency physicians and paramedics who must deal with critically ill children. Length-based ET tube selection is clearly superior to age-based rules, which are difficult to remember and require accurate estimation of a patient's age.


Transcutaneous cardiac pacing in the treatment of out-of-hospital pediatric cardiac arrests.

To evaluate the effectiveness of transcutaneous cardiac pacing in out-of-hospital treatment of cardiac arrests in pediatric patients. We describe the outcome of patients treated during a prospective trial of transcutaneous cardiac pacing in the field. We compare their outcome with that of out-of-hospital arrests in submersion patients who were not paced. We identified patients from Seattle and King County Emergency Medical Services reports, hospitals, and medical examiner's registries. Nine patients in cardiac arrest caused by drowning (six) and sudden infant death syndrome (three) were paced in the field. All were less than 6 years old. The one survivor was severely neurologically impaired and died six months later. Transcutaneous cardiac pacing produced electrical capture in two patients but no detectable pulse or blood pressure. Ten submersion patients less than 6 years old in cardiac arrest were not paced. One survived, with mild neurologic impairment at hospital discharge. Transcutaneous cardiac pacing was not effective and was not associated with improved survival.


Clinical predictors of bacterial versus aseptic meningitis in childhood.

To assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages. Children requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture. Emergency department of Children's Hospital of Wisconsin. One hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic). Nuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis. Despite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.


Diagnostic value of anemia, red blood cell morphology, and reticulocyte count for sickle cell disease.

To determine the diagnostic value of anemia, RBC morphology, and reticulocyte count for differentiating patients with sickle cell trait from those with sickle cell disease, who have acute medical or surgical conditions and a positive sickle cell screen. Retrospective chart review. A midwest urban children's hospital with 220 beds and 36,000 emergency department visits per year. One hundred six patients with sickle cell trait and 152 patients with sickle cell hemoglobinopathies. Anemia was observed significantly more often in patients with sickle cell disease compared with sickle cell trait (P less than .001) at all ages 3 months and older. However, anemia alone as a diagnostic test lacked high sensitivity and specificity in children less than 4 years old. Sensitivity approached 100% with the presence of anemia, abnormal RBC morphology, or reticulocyte count of more than 2%. Absence of anemia alone does not exclude the diagnosis of sickle cell disease in children less than 4 years old. To differentiate trait from sickle cell disease, we recommend determination of not only hemoglobin adjusted for age but also of RBC morphology and reticulocyte count on all children presenting with acute medical and surgical conditions and a positive sickle cell screen.


A randomized, double-blind, comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine.

To evaluate the relative efficacy of ketorolac tromethamine and meperidine hydrochloride in the emergency department treatment of severe migraine. Prospective, randomized, double-blind trial. University hospital ED. Patients presenting to the ED with an isolated diagnosis of common or classic migraine. Subjects were randomized to receive a single intramuscular injection of either 30 mg ketorolac or 75 mg meperidine. Of the 31 patients completing the trial, 15 received ketorolac and 16 received meperidine. The demographic characteristics of both groups were comparable. At one hour, ketorolac was significantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P = .01). Ketorolac also was less effective at reducing nausea, photophobia, and the need for rescue medication (P less than .05). Sustained headache relief was experienced by 44% of the patients treated with meperidine at 12- to 24-hour follow-up, compared with 13% of the patients treated with ketorolac (P = NS). No significant side effects were observed for either group. IM ketorolac tromethamine is less effective than meperidine in the ED treatment of severe migraine.


Ketorolac for sickle cell vaso-occlusive crisis pain in the emergency department: lack of a narcotic-sparing effect.

To determine if a single dose of intramuscular ketorolac given on presentation to the emergency department has a narcotic-sparing effect in adult patients with sickle cell vaso-occlusive crisis pain. A prospective, randomized, single-dose, double-blind study. ED of a university hospital and an affiliated county hospital. Eighteen adult patients who presented to the ED with sickle cell crisis pain a total of 24 times. Patients were randomized to receive either ketorolac 60 mg IM or placebo on presentation to the ED. Subjects were administered meperidine on presentation and then received a standardized dose of meperidine every 30 minutes during the four-hour observation period based on the severity of pain. The 12 subjects in the ketorolac group received an average of 231 +/- 92 mg meperidine, whereas the 12 subjects in the placebo group received an average meperidine dose of 250 +/- 85 mg (P = .61). The use of intramuscular ketorolac did not lead to a clinically significant reduction in the requirement for narcotics during the four-hour ED treatment period.


Rapid-sequence intubation of head trauma patients: prevention of fasciculations with pancuronium versus minidose succinylcholine.

Fasciculations during rapid-sequence intubation may lead to increased intracranial pressure and emesis with aspiration. Standard rapid-sequence intubation requires a nondepolarizing blocking agent before succinylcholine administration. Prevention of fasciculations during rapid-sequence intubation of head trauma patients can be accomplished as safely and effectively with minidose succinylcholine as with a defasciculating dose of pancuronium. A prospective, randomized, double-blind study. An inner-city county trauma center with 70,000 patient visits per year. Sequential adult head trauma patients requiring rapid-sequence intubation who had no contraindications to succinylcholine or pancuronium. Each head trauma patient requiring rapid-sequence intubation who met the inclusion criteria received standard rapid-sequence intubation maneuvers and lidocaine (1 mg/kg) IV. Patients were randomized to receive either minidose succinylcholine (0.1 mg/kg) or pancuronium (0.03 mg/kg) IV one minute prior to the full paralytic dose of succinylcholine (1.5 mg/kg) IV. Fasciculations were recorded using a graded visual scale. Of 46 patients, eight of 19 (42%) in the pancuronium group and six of 27 (22%) in the succinylcholine group experienced fasciculations. No statistically significant difference in fasciculations was detected between the two groups using chi 2 analysis. Complete relaxation of the cords was present in all but two patients, one in each group. No patient in either group experienced emesis or significant dysrhythmias. Pretreatment with minidose succinylcholine causes no greater incidence of fasciculations than pancuronium in rapid-sequence intubation of head trauma patients in an ED setting. Thus succinylcholine may be used as the sole paralytic agent in rapid-sequence intubation of head trauma patients.


Cervical cancer screening in an urban emergency department.

To determine the feasibility of Pap screening and follow-up of urban emergency department patients and the prevalence of cervical dysplasia and carcinoma in this group. During a four-month period, Pap smears were added to pelvic examinations performed in the ED. Follow-up, including repeat Pap smear or biopsy, was attempted on all abnormal smears. Urban county hospital-based ED. Pap screening and follow-up. Dysplasia was present in 8% of screening Pap smears. Eighty-two percent of patients with dysplasia on screening Pap smear returned for follow-up. Four percent of screened patients received a confirmed diagnosis of CIN 1 or more following repeat Pap smear or biopsy. Two invasive cervical cancers were identified. There is a high prevalence of cervical dysplasia among women screened with Pap smears in an urban ED. Routine Pap screening in urban EDs can be an important component of cervical cancer control programs for high-risk women.


A comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a Minnesota public teaching hospital: implications for assessing infection control programs.

To determine the level of universal precautions compliance in a hospital emergency department by two methods (direct observation of subjects versus self-reporting by questionnaire). A Level II trauma center located within a university-affiliated medical center in Minneapolis/St Paul, Minnesota. Glove and needle disposal containers were available in each treatment room; gowns, masks, and goggles were readily available. ED physicians (12 staff plus rotating residents), medical students, nursing staff, and ancillary personnel. Ten observers documented six specific behaviors among ED personnel: needle recap frequency, needle recap techniques, and use of gowns, gloves, masks, and goggles. After the observations, surveys were distributed to ED personnel by intrahospital mail in Fall 1989. During 270 observation hours, 1,018 patient-worker interactions were recorded. Gloves were the barrier worn most frequently when appropriate (74%), followed by goggles (13%), gowns (12%), and masks (1%). Needles were recapped 51% of the time, and most needles that were recapped (79%) were recapped by the two-hand technique; 5% of all needles used were left uncapped at bedside or in the trash. Physicians were observed to use gloves more frequently than registered nurses and nursing assistants; nurses were observed to recap more frequently than physicians. From the survey, the three most common reasons for noncompliance involved time (71%), dexterity (61%), and patient appearance (50%). Universal precautions are not consistently used by ED personnel, and ED personnel significantly overestimate their compliance with universal precautions.


Academic emergency medicine: a national profile with and without emergency medicine residency programs.

Formal data are lacking regarding emergency departments in academic medical centers, particularly those without an emergency medicine residency program. The Education Committee of the Society for Academic Emergency Medicine conducted a survey to define a national profile of academic emergency medicine. Prospective survey with telephone follow-up. Academic medical centers. One hundred twenty-three academic medical centers as defined by the Association of American Medical Colleges. Results were obtained from 94 (78%) institutions: 27 (29%) had an emergency medicine residency program and 67 (71%) had no emergency medicine residency program. Significant differences were found between those with and without emergency medicine residency programs regarding 24-hour attending coverage (96% versus 73%), mean weekly clinical faculty hours (26 versus 33), the number of emergency medicine board-certified faculty, faculty recruitment difficulties (25% versus 75%), and the presence of a curriculum for housestaff (96% versus 38%). No significant differences were noted regarding the presence of a curriculum for medical students (78% versus 64%). Of the 67 institutions with no emergency medicine residency programs, 42% were actively planning a program, and 42% would consider future development of a program. This article provides the first comprehensive profile of emergency medicine in the Association of American Medical Colleges academic medical centers. Programs with emergency medicine residency programs provided more 24-hour attending coverage, had more emergency medicine board-certified faculty, and reported less difficulty recruiting additional faculty than institutions with no emergency medicine residency program. Both need to expand their undergraduate educational activities. Many institutions with no emergency medicine residency program are attempting to develop emergency medicine residency programs.


Academic emergency medicine in United States medical schools.

To determine the current standing of academic units of emergency medicine in allopathic medical schools and to measure the attitudes of medical school deans toward the specialty. An investigator-blinded survey of the senior deans of 123 allopathic medical schools in the United States. Ninety-four of 123 (76%) survey instruments were completed. Fifty-six medical schools reported having academic units of emergency medicine (five divisions of the dean's office, 16 full departments, 35 divisions/sections of other departments). Twenty-five of 56 units were reported to be academically less productive when compared with other specialty academic units of similar size. When overall mission (academic plus clinical/administrative) was considered, 46 of 56 units were reported as adequately fulfilling or exceeding mission expectations. Thirty-eight schools reported not having an academic unit of emergency medicine. Only ten of the 38 reported have no institutional support or plans for academic emergency medicine. Medical school deans are generally satisfied with the clinical/administrative performance of academic emergency medicine units but are less so with academic productivity. Despite the small numbers of full departments and disparate status of established units, it is noteworthy that only ten of the 94 respondents to this survey reported no support whatsoever for academic emergency medicine.


Cost of care in the emergency department: impact of an emergency medicine residency program.

To evaluate the impact of an emergency medicine residency training program on the cost of care in the emergency department. A retrospective chart review was conducted of all ED encounters for a three-month period, six months before and six months after the introduction of an emergency medicine residency program into an urban community hospital. Physician staffing of this ED before the residency period was by nonemergency medicine residency-trained emergency physicians. A 27,000-visit-per-year urban community hospital ED. TYPE OF PATIENTS: A consecutive sample of all patients discharged home from the emergency center with one of six diagnoses. The diagnoses studied were viral upper respiratory infection, pharyngitis, acute asthma, seizure, lumbosacral strain, and cervical strain. Frequency of laboratory test and radiograph ordering pertinent to the evaluation of each diagnostic category were used as a marker of cost of care. The presence of the residency training program did not increase the cost of care as measured by test use and, for three of the six diagnoses, actually lowered the cost of care. This effect was most prominent in the evaluation of lumbosacral and cervical strain when the residency physicians ordered radiographs at a rate five and 2.3 times lower, respectively, than the previous group and in the approach to pharyngitis when they ordered throat cultures 2.8 times less frequently. As measured by selected test use for six common discharge diagnoses, the introduction of an emergency medicine residency program did not increase the cost of care in this urban community hospital ED.


Outpatient wound preparation and care: a national survey.

To sample the practice styles of emergency physicians caring for acute traumatic wounds. Written survey. US emergency departments obtained from the American College of Emergency Physicians mailing list. Randomly selected ACEP members. One hundred fifty-one of 285 (53%) survey mailings were returned. Eighty-six percent of respondents were primarily clinicians, and the majority (61.6%) worked in EDs with annual patient visits between 21,000 and 50,000. The majority of respondents (64.2%) were certified by the American Board of Emergency Medicine. Nineteen percent managed wounds based on provider preference despite the existence of written wound management protocols. We identified a variety of practices that are contrary to current literature and textbook recommendations. Fifty-eight (38%) soaked wounds, whereas 21% used either 10% povidone iodine or hydrogen peroxide to cleanse wounds. One hundred one (67%) scrubbed the entire wound surface using, among other methods, cotton gauze (59%) or a coarse, bristle-laden sponge (38%). Forty (27%) irrigated wounds using techniques that have not been proven to deliver the 5 to 8 psi necessary for adequate tissue cleansing. Delayed primary closure, a treatment option for lacerations at increased risk for infection, was infrequently or never practiced by 76% of respondents. All respondents administered IV antimicrobials at least occasionally for simple outpatient lacerations. Methods of preparing, treating, and following outpatient wounds vary among emergency physicians, and these results support the idea that no de facto standard of care exists for this clinical problem. Outpatient wound care techniques routinely practiced (ie, soaking, scrubbing, use of full-strength hydrogen peroxide or full-strength povidone iodine) may be harmful based on limited animal and human research, whereas other proven techniques (ie, delayed primary closure) are infrequently practiced by many emergency physicians.