Clinical Evaluation of Atrial Synchronous Ventricular Inhibited Pacemakers

The technical specifications and the operation of two atrial synchronous ventricular inhibited (ASVIP) pacemaker designs are described along with the results of clinical evaluation of these pacemakers in 30 patients. Clinical advantages of such pacemakers are contrasted with the performance of A-V sequential (DVI) and atrial synchronous (VAT) systems.     

Inhibition of an anti-Pr1d cold agglutinin by citrate present in commercial red cell preservative solutions

A patient with known cold autoimmune hemolyticanemia was admitted for surgery. Routine cold agglutinin evaluations, using commercial red cells (RBCs) in modified Alsever's preservative solution, revealed a cold agglutinin titer of 4 to 16. However, using RBCs washed four times with saline, a high-titer (greater than 2000 at 4 degrees C) cold autoagglutinin was demonstrated. The cold agglutinin was shown to be an IgM kappa paraprotein with anti-Pr1d specificity. The addition of Alsever's solution to washed RBCs inhibited the cold agglutinin. Each major component of Alsever's solution (neomycin, chloramphenicol, inosine, dextrose, and citrate) was tested individually; only citrate inhibited the patient's cold agglutinin. Various compounds structurally related to citrate were tested and found to cause various degrees of inhibition. The strongest inhibition correlated with the presence of either three carboxyl groups on molecules devoid of double-bonded carbon atoms or two carboxyl groups in cis configuration. A panel of 54 cold agglutinins, including 7 with anti-Pr specificity, was analyzed. None was significantly inhibited by Alsever's solution, although one with anti-Pr2 specificity was weakly inhibited. In summary, these studies describe an anti-Pr1d cold autoagglutinin that was inhibited by citrate in RBC preservative solutions. The failure to detect such a cold agglutinin can result from not washing RBCs free of citrate before testing.     

A review of the Transitional Emergency Nurse Practitioner

Introduction

A retrospective exploratory study was conducted to (i) explore the practice patterns of a Transitional Emergency Nurse Practitioner (TENP) working across two urban Emergency Departments (ED); (ii) identify the demographic characteristics of the TENP patient cohort; and (iii) identify if TENP patients were appropriately and timely managed.

Method

The study was conducted across two hospital sites over two consecutive years for a 3-month period. Data collection occurred during the months of December through to February. TENP patients were identified by hospital electronic medical record and were then grouped into a model that included ‘Fast Track’ or ‘See and Treat’ cohort. The cohorts were then analysed for diagnostic groups, age, sex, length of stay, triage category, and re-presentations.

Results

The TENP worked a total of 600 h (Site 1 252 h; Site 2 348 h) across the study period. The TENP managed a total of 481 patients (262 Site 1; 220 Site 2) during the study period. The majority of patients (412; 84%) were managed in the ‘See and Treat’ cohort (Site 1 246, 94%; Site 2 166, 75%) and 70 patients (16%) were managed in the ‘Fast Track’ cohort (Site 1 16, 4%; Site 2 54, 25%). The median length of stay for TENP managed patients was 143 min, with 96% of patients leaving the ED in less than 8 h. There were no TENP unplanned re-presentations at either site. The TENP managed more male patients across both sites. The majority (75%) of patients the TENP managed had musculoskeletal and/or wound conditions or injuries.

Conclusion

TENP practice across the two Sydney metropolitan ED sites was similar. The model adapted for Tertiary Referral centres was appropriate for smaller urban EDs. The study supports existing evidence of timely and appropriate care being delivered by TENPs across Australian EDs. Given the work practice similarities, the study demonstrates that State and/or National standards and policies could be developed for emergency advanced practice roles.     

Structural abnormalities of ventrolateral and orbitofrontal cortex in patients with familial bipolar disorder

Objectives: Abnormalities of ventral prefrontal function have been widely reported in bipolar disorder, but reports of structural abnormalities in the same region are less consistent. We examined the presence and location of ventral prefrontal abnormalities in a large sample of individuals with bipolar disorder and their relationship to gender, psychotic symptoms, and age. Methods: Structural magnetic resonance imaging brain scans were carried out on 66 individuals with bipolar disorder, type I, and 66 controls. Voxel‐based morphometry was used to examine differences in grey and white matter density between the groups and their relationship with a lifetime occurrence of psychotic symptoms and age. Results: Reductions in grey matter density were seen in the left and right lateral orbital gyri and the right inferior frontal gyrus, while white matter density reductions were seen in the corona radiata and the left temporal stem. In contrast, hallucinations and positive symptoms were associated with grey matter reduction in the left middle temporal gyrus. Age was more strongly associated with the right inferior frontal gyrus grey matter reductions in the bipolar group than in the controls, but not with any other finding. Conclusion: Abnormalities of the ventral prefrontal cortex are likely to be involved in the aetiopathology of bipolar disorder, while hallucinations appear to be more closely associated with temporal lobe abnormality, extending earlier work in schizophrenia. Further prospective studies are required to comprehensively address the trajectory of these findings.     

Bone marrow transplantation for refractory acute leukemia in 34 patients with identical twins

Thirty-four patients aged 4-67 yr (median 17) with acute lymphocytic leukemia (ALL) (18 patients) or acute nonlymphocytic leukemia (ANL) (16 patients) who failed to enter complete remission (CR) or relapsed on conventional chemotherapy were treated with cyclophosphamide (CY), 60 mg/kg/day for 2 days, 1000 rad total body irradiation, and a marrow transplant from a genotypically identical normal twin. Sixteen of the patients received additional chemotherapy within the week before CY. After the transplant, 23 patients received immunotherapy consisting of killed autologous leukemic cells and/or normal twin peripheral blood lymphocytes, 16 as part of a prospectively randomized study. One moribund patient died before engraftment. Nine patients (6 ALL, 3 ANL) continued to have detectable leukemic cells. Twenty-four patients (70%) achieved CR. One of them died of viral hepatitis at 1 mo and another of viral interstitial pneumonitis at 4 mo in CR. Fourteen patients (7 ALL, 7 ANL) relapsed 2-16 mo (median 4) after transplantation. However, 8 patients (24%) (3 ALL, 5 ANL) remain in CR without any maintenance chemotherapy at 29-103 mo (median 80) after the transplant. The end results were not signficantly influenced by the type of leukemia, the immediated pre-CY chemotherapy, or the immunotherapy. The results show that this approach, even when applied to endstage patients with acute leukemia in relapse, causes tolerable morbidity, rare nonleukemic deaths, and frequent remissions, some of which represent cures.     

A SURVEY OF NEUROLOGICAL DISABILITY AT A DISTRICT GENERAL HOSPITAL

SUMMARY Neurological disease accounts for 20% of all admissions to medical wards, but the number of inpatients with neurological disability is unknown. The notes of all adult inpatients in a district general hospital were reviewed to identify all those with a neurological disorder. Over 40% of inpatients on medical wards and 4% on surgical wards had a neurological disorder. Stroke was the most common neurological diagnosis, accounting for 36% of neurological disorders and 22% of all patients on medical wards. Other neurological diagnoses included dementias 10%, degenerative disorders 10%, epilepsy 7%, demyelination 4%, and head injuries 3%. Neurological patients have long inpatient stays (mean 80 days), and often remain in hospital awaiting changes in accommodation. Seven patients under 65 years stayed more than 6 months awaiting long-term care. Neurological disorders contribute significantly to the inpatient workload. Identifying those requiring rehabilitation and concentrating them on one ward could improve the quality and efficiency of their care.     

Über den Nachweis von präcipitierenden Antikörpern gegen Leukocyten-Extrakte. Experimentelle und klinische Untersuchungen

Zusammenfassung Die Frage, ob im Serum von Kranken mit visceralem Lupus erythematodes und chronischen Blutkrankheiten präcipitierende Antikörper gegen Extrakte aus menschlichen Leukocyten auftreten können, ist bisher erst in einer Veröffentlichung vonSeligman, Grabar undBernard positiv beantwortet worden. Andere Autoren vertreten die Auffassung, daß zwar Leukocyten-Agglutinine, nicht jedoch präcipitierende Antikörper gegen lösliche Bestandteile von menschlichen Leukocyten gebildet werden können.Bei den vorliegenden Untersuchungen wurde diese Frage unter Anwendung der vonOuchterlony angegebenen Methode der Diffusion und Präcipitation im Agar-Gel untersucht. Menschliche Leukocyten wurden aus heparinisiertem Blut durch Sedimentation gewonnen. Extrakte aus Suspensionen von gewaschenen Leukocyten wurden — entsprechend einem vonAtchley angegebenen Verfahren — durch Extraktion mit 0,1 molarer Glycin-Lösung gewonnen. Die Antigen-Zusammensetzung der Extrakte wurde zunächst in Ansätzen gegenüber Immunseren von Kaninchen untersucht, die mit menschlichen Leukocyten sensibilisiert waren. Dabei wurde festgestellt, daß in den Extrakten zwei Antigen-Komponenten enthalten sind, die nicht in Extrakten aus menschlichen Organen nachgewiesen werden können. Eines der Antigene ist resistent gegenüber Behandlung mit Trypsin, Desoxyribonuclease und Ribonuclease. Nach den vorliegenden Ergebnissen besteht Wahrscheinlichkeit für die Annahme, daß es sich um ein Antigen handelt, das im Cytoplasma von menschlichen Leukocyten enthalten ist. — Untersuchungen von menschlichen Seren ergaben, daß Seren von gesunden Kontroll-Personen keine Reaktion mit Leukocyten-Extrakten zeigen. In Seren von Kranken mit Lupus erythematodes visceralis, idiopathischer Agranulocytose und chronischer lymphatischer Leukämie wurde präcipitierende Antikörper gegen Leukocyten-Extrakte nachgewiesen. Es bestand keine Korrelation zu sog. antinucleären Serumfaktoren. Leukocyten-Antikörper wurden auch in Seren von Kranken nachgewiesen, die nie eine Bluttransfusion erhalten hatten. Das Phänomen wird als Ausdruck einer Autosensibilisierung gegen ein cytoplasmatisches Antigen aus normalen menschlichen Leukocyten erklärt.

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Summary The question whether precipitating antibodies to extracts from human leucocytes can be detected in sera of patients with blood diseases has been answered positively in only one publication bySeligman, Grabar andBernard. Other authors came to the opinion that agglutinating and complement-fixing antibodies can occure but not precipitating antibodies. The subject of the present investigation was the application of Ouchterlony's method of precipitation in agar to prove the given question. A precondition however, was the preparation of an extract from human leucocytes with sufficient concentration of dissolved cell material which can form a visible precipitate.Human leucocytes were isolated from heparinised blood by differential sedimentation. Extraction was performed using 0,1 molar Glycine-solution according toAtchley. The ability of the extracts to get precipitated and the antigen structure of the extract were tested with anti-human-leucocyte-antisera from hyper-immunized rabbits. The immunsera reacted with the leucocyte-extracts forming several different precipitation lines. Absorption of the immunsera with human organ extracts and normal human sera showed that the extract contains two different soluble antigens which are not identical with tissue antigens of organ extracts. They probably contain specific soluble cell constituents of human leucocytes.Sera of 30 normal healthy control individuals did not precipitate with the leucocyte extracts. From an unselected material of 100 sera of our laboratory 11 sera gave positive reactions of precipitation. The sera were from cases with systemic lupus erythematodes, chronic myeloic leucemia, idiopathic pancytopenia and polyserositis.The reacting leucocyte antigen is not identical with desoxyribonucleic-acid and desoxyribonucleoprotein. The nature of the antigen is under investigation.

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Mit Unterstützung durch die Deutsche Forschungsgemeinschaft     

皮肤幼年性血管瘤的处理

过去对脉管疾病的描述往往将血管瘤和脉管畸形相混淆，从而导致不恰当的治疗及医学文献记录的矛盾。Mulliken和Glowacki系统描述了血管瘤和脉管畸形的差别，认为血管瘤是真正的肿瘤，在组织学上表现为细胞增殖。在治疗方面文献报道也存在不同，有人认为血管瘤可以完全自行消退，而部分文献却主张对病变进行干预。最近．对血管瘤自然病程研究增多，并对血管瘤是观察还是干预的选择进行了讨论，设计了安全有效的治疗方案。该文分2部分，第1部分结合新近文献，综述血管瘤的诊断及其自然病程，并与旧的文献作了比较。第2部分介绍了血管瘤是治疗还是观察的原则，推荐治疗方法，并着重论述了外科技术。