Tuberculosis screening in a dialysis program.

Patients with end stage renal disease (ESRD) are at high risk for contracting tuberculosis (TB), therefore, routine screening of these patients is recommended This article describes the steps used to design and implement a TB screening protocol in a new regional dialysis program. The results showed a high rate of skin test positivity and, therefore, of infection. Over half of the patients tested were found to be anergic, necessitating a chest x-ray for 70% of the patients. In light of these findings, the annual skin testing of all patients, which was originally planned, has been changed to testing upon admission to the program, providing a baseline with which to compare subsequent skin tests.     

Dietary fiber.

It is obvious that the effects of fiber on colonic functions are complex. The typical "Western diet" which is high in fat and protein and low in fiber may alter the bacterial flora and milieu interieur of the gastrointestinal tract, particularly the colon, to produce a high incidence of colonic cancer. However, the exact nature of the interrelationships between these dietary constituents remains elusive and will undoubtedly be the subject of intense investigation in years to come.     

Intraperson variability. Magnitude, source, and influence on interpretation and diagnosis.

In a person in a steady state the set of values obtained for a test carried out on a series of samples will show fluctuation about a value (the setting). In practice a single test value is usually taken as an estimate of the setting. The general consequences of this approximation are discussed in relation to the various uses of data in diagnosis, and illustrated for the common measurements of clinical chemistry. The magnitude of these consequences depends on the proportion of the total variation in a group of persons which is caused by these fluctuations in the person--within-person variation (VarWP). When the proportion is high the aim should be to reduce VarWP. When VarWP is high because of analytical error, then improved analytical technique or replicate analysis is required. Otherwise standardised techniques and conditions for venepuncture or, as a last resort, repeated samplings are necessary. These problems are discussed in relation to the detection of hypokalaemia.     

Marine trauma, envenomations, and intoxications.

When humans encounter marine creatures a variety of maladies may occur, ranging from dermatitis to life-threatening trauma, allergy, envenomations, or intoxications. The emergency physician should be prepared to recognize quickly and address appropriately the potential life threats, which are primarily neurologic, respiratory, and cardiovascular. A high degree of suspicion for these illnesses is needed. Intoxications may be especially confusing. Although most of the syndromes are self-limited and treatment supportive, time is of the essence if neuromuscular paralysis, hypotension, or respiratory compromise is present. Much folklore exists regarding detection and prevention of these entities and should be regarded as such. The last several decades have seen a marked increase in our knowledge base regarding these fascinating envenomations and intoxications. Research in the next several decades probably will produce a variety of diagnostic and therapeutic tools, which will further our understanding of, and ability to specifically manage, these syndromes.     

Recent advances in the treatment of ARDS.

Despite more than 25 years of extensive research the mortality of ARDS patients remains high. Besides the often deleterious course of the underlying disease, another reason for this high mortality lies in the aggressive ventilatory regimen which is required to maintain arterial blood gases in a more or less normal range. Therapeutic methods which are used to reduce iatrogenic damage to the lungs are pressure controlled ventilation with permissive hypercapnia, differential lung ventilation, positioning therapy, dehydration, and extracorporeal gas exchange with membrane lungs. Nevertheless, many of these patients still die following hypoxaemia or multiple organ failure. Therefore, the need remains to develop new therapeutic strategies and to investigate their influence on the morbidity and mortality of this life-threatening disease. First experiences with nitric oxide (NO) inhalation, intravenous application of antioxidants, intratracheal instillation of surfactant, tracheal gas insufflation and combined fluid/gas ventilation with perfluorocarbon are presented. All these new methods have proved their efficacy, at least in animal studies, however, they should still be regarded as experimental.     

DIET AND TISSUE GROWTH : I. THE REGENERATION OF LIVER TISSUE ON VARIOUS ADEQUATE DIETS.

1. The toxicity of chloroform varies according to the diets used in these experiments in the following order of decreasing susceptibility of the animals: high fat > standard > high carbohydrate > high protein diets. 2. On the high fat and high carbohydrate diets there may be a more or less marked proliferation of the endothelium and the connective tissue stroma in the necrotic area producing in some instances scars resembling the picture of an early cirrhosis. 3. On the diets studied, standard, high carbohydrate, high protein, and high fat, the most active and rapid repair is observed on the standard balanced diet. On the high fat diet the reparative process is definitely delayed in comparison with the others. There are only slight differences between the high carbohydrate and high protein diets which suggest but do not conclusively show a more rapid repair with the latter diet.     

Profile analysis of blood proteins with a centrifugal analyzer.

We describe a procedure for routine analysis of a profile composed of eight blood proteins with a GEMSAEC centrifugal analyzer. The end-point technique is used and four standards are included in each run in the immunochemical analysis of the individual proteins. Additional computer programs fit the absorbance readings from the samples to the (nonlinear) standard curve and store the results in a patient's file for a final printout, which also presents the patient's data and reference values. The proteins are analyzed in a given order, which allows common blank runs to be used. Antisera are used in suitably high concentrations, so that the "antigen in excess" problem only appears for analysis of IgA and IgM when sera contain high amounts of the M-components of these two classes. The capacity, accuracy, and precision of the method are satisfactory.     

Endothelial cell tolerance to hypoxia. Potential role of purine nucleotide phosphates.

The ability of cells to tolerate hypoxia is critical to their survival, but varies greatly among different cell types. Despite alterations in many cellular responses during hypoxic exposure, pulmonary arterial endothelial cells (PAEC) retain their viability and cellular integrity. Under similar experimental conditions, other cell types, exemplified by renal tubular epithelial cells, are extremely hypoxia sensitive and are rapidly and irreversibly damaged. To investigate potential mechanisms by which PAEC maintain cellular and functional integrity under these conditions, we compared the turnover of adenine and guanine nucleotides in hypoxia tolerant PAEC and in hypoxia-sensitive renal tubular endothelial cells under various hypoxic conditions. Under several different hypoxic conditions, hypoxia-tolerant PAEC maintained or actually increased ATP levels and the percentage of these nucleotides found in the high energy phosphates, ATP and GTP. In contrast, in hypoxia-sensitive renal tubular endothelial cells, the same high energy phosphates were rapidly depleted. Yet, in both cell types, there were minor alterations in the uptake of the precusor nucleotide and its incorporation into the appropriate purine nucleotide phosphates and marked decreases in ATPase and GTPase activity. This maintenance of high energy phosphates in hypoxic PAEC suggests that there exists tight regulation of ATP and GTP turnover in these cells and that preservation of these nucleotides may contribute to the tolerance of PAEC to acute and chronic hypoxia.     

On-demand release by ultrasound from osmotically swollen hydrophobic matrices.

Ethylene-vinyl acetate copolymer (EVAc) based controlled release systems are composed of a continuous hydrophobic polymer phase and of dispersed solid drug particles. In matrices with high drug loadings (> or =50%) most drug particles are interconnected. Thus, when these matrices are immersed in water, release rates are relatively high. In matrices with low drug loadings (<40%) most drug particles are isolated within the continuous hydrophobic polymer matrix. Thus, release rates are very low. Matrices containing water soluble particles at a low loading swell intensely after immersion in water; this is caused by the osmotic force of the isolated particles which causes the water to permeate into the hydrophobic polymer. The enclosed drug particles absorb water, and at the end of the swelling process the matrices consist of an immense number of fluid pockets containing dissolved drugs. In attempt to develop on-demand release systems, we studied the effect of ultrasound (US) on the release rates of these swollen matrices. We found that low-frequency ultrasound (20 kHz) reversibly increased the release rates from these swollen matrices by a factor of 30-500, in contrast to the unswollen matrices, where the release rates increased only by a factor of 2-3. Unswollen and swollen matrices react differently to US, as unswollen matrices contain drug particles which absorb ultrasound on the surface of the matrices, causing ultrasound attenuation. On the other hand, swollen matrices contain a compact arrangement of fluid pockets separated from each other by thin membranes containing a solution of the dissolved drug, therefore ultrasound penetrates through the matrix volume. Ultrasound penetration causes tearing of these membranes within the matrices. As a result, the fluid pockets interconnect, and drug molecules diffuse out through these interconnected pockets.     

Nicotine addiction.

Nicotine maintains tobacco addiction. Nicotine acts on nicotinic cholinergic receptors, which demonstrate diversity in subunit structure, function, and distribution in the nervous system, mediating the multiple actions of nicotine described in tobacco users. Nicotine addiction is more prevalent and more severe in people with a history of major depression, schizophrenia, or alcohol or other drug abuse problems. The cigarette is a highly efficient drug delivery system, delivering nicotine rapidly and in relatively high concentrations to the brain, a situation that optimizes the likelihood of self-administration. The severity of nicotine addiction can be as- sessed using the Fagerstr?m Tolerance Questionnaire or the DSM-IV, but these instruments are imprecise predictors of the key behavior in addiction, which is the difficulty in stopping tobacco use when there are compelling reasons to do so.     

Metal-catalyzed asymmetric oxidations.

Recent advances in enantioselective metal-catalyzed oxidations are presented. Two transformations are discussed in detail: (a) asymmetric Baeyer-Villiger reactions of racemic and prochiral cyclic ketones giving optically active lactones, and (b) sulfide oxidations affording enantiomerically enriched sulfoxides. For both reactions, new metal/ligand combinations have been introduced which allow catalysis of these reactions with high enantioselectivities. For some substrates, the ee-values are above 90%. As previously demonstrated, sulfoxides can be iminated to give the corresponding sulfoximines. Under appropriate reaction conditions, this transformation is stereospecific and enantiopure sulfoximines are obtained. These highly oxidized sulfur reagents have now been modified to give beta-amino acid analogues which may be incorporated into peptides. Two variants have been realized: either the sulfoximine-containing pseudo-amino acids are connected with standard alpha-amino acids to give mixed pseudopeptides, or the sulfoxime units are mutually attached to give homooligomers, which can be regarded as beta-peptide analogues.     

Inflammation in peritoneal dialysis: a Latin-American perspective.

Peritoneal dialysis (PD) patients present an extremely high mortality rate, but the mechanisms mediating the increased risk of mortality observed in this group of patients are still largely unknown, which limits the perspective of effective therapeutic strategies. The leading hypothesis that tries to explain this high mortality risk is that PD patients are exposed to a number of traditional risk factors for cardiovascular disease (CVD) already at the onset of their chronic kidney disease (CKD), since many of these risk factors are common to both CVD and CKD. Of particular importance, chronic inflammation recently emerged as an important novel risk factor related to multiple complications of CKD. There are many stimuli of the inflammatory response in CKD patients, such as fluid overload, decreased cytokine clearance, presence of uremia-modified proteins, presence of chronic infections, metabolic disturbances (including hyperglycemia), obesity. Many of these factors are related to PD. Latin America has made some progress in economic issues; however, a large portion of the population is still living in poverty, in poor sanitary conditions, and with many health-related issues, such as an increasing elderly population, low birth weights, and increasingly high energy intake in the adult population, which, in combination with changes in lifestyle, has provoked an increase in the prevalence of obesity, diabetes, and CVD. Therefore, in Latin America, there seems to be a peculiar situation combining high prevalence of low education level, poor sanitary conditions, and poverty with increases in obesity, diabetes, and sedentary lifestyle. Since inflammation and mortality risk are intimately related to both sides of those health issues, in this review we aim to analyze the peculiarities of inflammation and mortality risk in the Latin-American PD population.     

Diabetes in minority populations.

The prevalence and incidence of diabetes are higher in several ethnic minority populations in the US, including Hispanic, Asian, African, and Native Americans. Nurse practitioners will encounter increasing numbers of patients from these population groups in the future. Of major concern is the high prevalence of additional risk factors, such as smoking, obesity, hypertension, hyperlipidemia, and low socioeconomic status, which contribute to the increased rate of complications of this disease in these groups. Emphasis must be placed on screening and risk reduction, and diabetes management in these groups must be culturally sensitive and relevant.     

Functional hemispherectomy: radical treatment for Rasmussen's encephalitis.

Rasmussen's encephalitis is a progressive, debilitating disease that usually appears in the pediatric population but also may affect adults. Uncontrolled seizures, cognitive decline, and a progressive hemiparesis accompany this disorder. Treatment options are limited and consist of medical management, which is somewhat experimental and ineffective; the use of either intravenous antiviral agents or steroids; or surgical resection of the affected hemisphere. Patients undergoing hemispherectomy for Rasmussen's encephalitis are complex. Nurses caring for these patients require a high degree of knowledge and specialized skills. Patient outcome is highly affected by the knowledge and skill of the entire team of healthcare professionals needed to manage these patients.     

Female sexual abuse survivors as patients: avoiding retraumatization.

The literature on adult female psychiatric patients who are survivors of childhood sexual abuse is reviewed. This literature shows both high rates of such abuse and a characteristic pattern of symptoms that distinguishes these survivors from other patients. A theoretical framework is discussed which explains how psychiatric symptoms may develop after childhood sexual abuse and how diagnosis and treatment may serve to maintain or intensify such symptoms. Viewing patients from a posttraumatic treatment perspective is advocated as a strategy for nursing to effectively help these patients with the healing process.     

Baseline assessment. Report of a company wide risk factor survey

CVD accounts for the highest rates of morbidity and mortality among the general population. Unhealthy lifestyle practices are largely responsible for this occurrence. Risk factor prevalence of smoking, uncontrolled high blood pressure, and high serum cholesterol levels contribute to the likelihood of developing CVD. Two or more of these risk factors can place individuals at higher risk of developing CVD. Completing a heart health survey of risk factor prevalence among a working population will give occupational health professionals a basis on which to set goals and objectives for effective CVD intervention programs.     

STUDIES ON INDIFFERENT STREPTOCOCCI : III. THE ALLERGIZING CAPACITY OF DIFFERENT STRAINS.

The indifferent streptococci are remarkably efficient allergizing agents when inoculated intradermally into rabbits. This is revealed by the high percentage of secondary reactions which occur in the lesions resulting from the inoculation of small doses of these organisms, and by the relative frequency with which positive ophthalmic reactions are obtained following sensitization with relatively small doses. This allergizing capacity is most marked in the organisms of Type I and least marked in the non-inulin-fermenting strains of Group X. The different resultants emerging from variations in allergizing capacity of streptococci and reactivity of host are clearly demonstrated in this series of experiments.     

Nurses re-entering the workforce: a special needs group.

Registered Nurses wishing to re-enter the paid workforce have been shown to experience low self-esteem and high levels of anxiety. An intensive twelve-week re-entry program was designed to address these needs through a process of critical pedagogy. In this paper the student cohort since 1995 is described and the program, its structure, style, physical environment, teaching, and course content are introduced. Evaluation of student outcomes was ascertained by a convenience survey in which a questionnaire was posted to successful students. The results included employment rates of 97.4% and high levels of work and personal satisfaction. Both the benefits and the limitations of the program are discussed in light of the questionnaire responses.     

The i.v. nurse and the i.v. drug abuser: medical and psychosocial implications

When I.V. nurses treat I.V. drug abusers, they must be aware of the medical and psychosocial issues relevant to this group. Medical issues include the I.V. drug abuser's depleted venous access and this group's high rate of infection with HIV and other blood pathogens. Psychosocial issues relate to the various social and psychological problems associated with drug abuse. Further, when caring for these patients who are at high risk for HIV and other serious blood infections, the I.V. nurse may experience a conflict between her desire to care for the patient and her fear of contracting HIV or another infection through patient contact. Education is recommended so that I.V. nurses can reduce their risk of infection with blood-borne diseases and can better understand these patients. Also suggested are a multidisciplinary approach to treatment and referral to drug rehabilitation programs.     

Sulfation of a high endothelial venule-expressed ligand for L-selectin. Effects on tethering and rolling of lymphocytes.

During lymphocyte homing, L-selectin mediates the tethering and rolling of lymphocytes on high endothelial venules (HEVs) in secondary lymphoid organs. The L-selectin ligands on HEV are a set of mucin-like glycoproteins, for which glycosylation-dependent cell adhesion molecule 1 (GlyCAM-1) is a candidate. Optimal binding in equilibrium measurements requires sulfation, sialylation, and fucosylation of ligands. Analysis of GlyCAM-1 has revealed two sulfation modifications (galactose [Gal]-6-sulfate and N-acetylglucosamine [GlcNAc]-6-sulfate) of sialyl Lewis x. Recently, three related sulfotransferases (keratan sulfate galactose-6-sulfotransferase [KSGal6ST], high endothelial cell N-acetylglucosamine-6-sulfotransferase [GlcNAc6ST], and human GlcNAc6ST) were cloned, which can generate Gal-6-sulfate and GlcNAc-6-sulfate in GlyCAM-1. Imparting these modifications to GlyCAM-1, together with appropriate fucosylation, yields enhanced rolling ligands for both peripheral blood lymphocytes and Jurkat cells in flow chamber assays as compared with those generated with exogenous fucosyltransferase. Either sulfation modification results in an increased number of tethered and rolling lymphocytes, a reduction in overall rolling velocity associated with more frequent pausing of the cells, and an enhanced resistance of rolling cells to detachment by shear. All of these effects are predicted to promote the overall efficiency of lymphocyte homing. In contrast, the rolling interactions of E-selectin transfectants with the same ligands are not affected by sulfation.