Transferring AAC intervention to the home

Purpose: To evaluate the acquisition of AAC skills during an initial clinical trial and assess subsequent transfer of the training to the home setting. Method: A 12-year-old male with autism was first seen in a clinical setting to establish the use of a voice-output communication device. After learning to use the device to request access to preferred objects in the clinical trial, the intervention was transferred to the home. Follow-up with the parent was conducted via e-mail and telephone. Videotapes were made of initial home-based sessions to enable evaluation of the participant's progress. Results: The programme was successful in teaching the participant to use a portable AAC device to make requests during the clinical trial and then in two home-based activities. Conclusion: An initial clinical trial with follow-up support for parents may be an efficient method for beginning AAC intervention and transferring the training procedures to the home setting.     

Acquired immunodeficiency syndrome-associated non-Hodgkin's lymphomas and other malignancies in patients with hemophilia

Non-Hodgkin's lymphoma (NHL) is the most common human immunodeficiency virus (HIV)-associated malignancy in hemophiliacs. We studied the incidence and clinicopathologic features of NHL in 3,041 hemophiliacs followed at 18 US Hemophilia Centers between 1978 and 1989. Of the 1,295 (56.6%) who were HIV(+), 253 (19.5%) developed acquired immunodeficiency syndrome (AIDS), of whom 14 (5.5%) developed NHL. Three NHL occurred in HIV(-) hemophiliacs, for a 36.5-fold greater risk in HIV(+) than HIV(-) hemophiliacs (P < .001). The NHL incidence rate was 29-fold greater than in the US population by Surveillance, Epidemiology, and End Results (SEER) estimates (P < .001). Between 0 and 4 lymphomas have been observed per year between 1978 and 1989. At presentation 13 (92.9%) of the HIV(+) NHL were extranodal. Ten were stage IV, 1 stage II, and 3 stage IE. Ten (71.4%) were high-grade, 3 (21.4%) intermediate-grade, and 1 (7.1%) was a low-grade B-cell lymphoma. Epstein-Barr virus (EBV) DNA was detected in 36% by in situ hybridization, including one central nervous system (CNS) lymphoma. The mean CD4 cell count at NHL diagnosis was 64/mm3, the mean latency from initial HIV infection was estimated to be 59 months, and the median survival was 7 months. The incidence of basal cell carcinoma in HIV(+) hemophiliacs was 18.3-fold greater than in HIV(-) hemophiliacs (P < .001) and 11.4-fold greater than in the US population (P < .001). In conclusion, incidence rates of NHL and basal cell carcinoma in HIV(+) hemophiliacs are significantly increased over rates in HIV(-) hemophiliacs and over rates in the US population. Clinicopathologic presentation of NHL in HIV(+) hemophiliacs is similar to that in HIV(+) homosexual men.     

Pneumothorax After Transbronchial Biopsy in Pulmonary Fibrosis: Lessons from the Multicenter COMET Trial

Purpose

Some patients with diffuse interstitial lung disease (ILD) undergo bronchoscopy with transbronchial biopsy (TBB) as part of their diagnostic evaluation. It is unclear what the incidence and risk factors for pneumothorax (PTX) following TBB are in this patient population.

Methods

Ninety-seven subjects with pulmonary fibrosis who underwent a research bronchoscopy with TBB as part of the multicenter correlating outcomes with biochemical markers to estimate time-progression in idiopathic pulmonary fibrosis (COMET) trial were retrospectively reviewed. We compared subjects who developed a PTX during research bronchoscopy with TBB versus those who did not.

Results

Seven patients (7.2%) experienced a PTX during research bronchoscopy with TBB. Subjects who experienced PTX during TBB had significantly lower DL_CO percent predicted (29 ± 8 vs. 45 ± 15, P = 0.006) and had lower resting room air saturation of peripheral oxygen (SPO₂) on 6-min walk testing (91 ± 10 vs. 95 ± 3, P = 0.02). No differences between groups were found with respect to age, gender, race, BMI, HRCT characteristics, or the number of transbronchial biopsies performed.

Conclusion

The incidence of PTX following research bronchoscopy with TBB in patients with pulmonary fibrosis was found to be 7.2% in this study. Patients who developed a pneumothorax had greater impairments in gas exchange at baseline evidenced by a lower DL_CO  % predicted and a lower resting room air SPO₂ compared with subjects without PTX as a complication.

     

Bench-to-bedside review: Diaphragm muscle function in disuse and acute high-dose corticosteroid treatment

Critically ill patients may require mechanical ventilatory support and short-term high-dose corticosteroid to treat some specific underlying disease processes. Diaphragm muscle inactivity induced by controlled mechanical ventilation produces dramatic alterations in diaphragm muscle structure and significant losses in function. Although the exact mechanisms responsible for losses in diaphragm muscle function are still unknown, recent studies have highlighted the importance of proteolysis and oxidative stress. In experimental animals, short-term strategies that maintain partial diaphragm muscle neuromechanical activation mitigate diaphragmatic force loss. In animal models, studies on the influence of combined controlled mechanical ventilation and short-term high-dose methylprednisolone have given inconsistent results in regard to the effects on diaphragm muscle function. In the critically ill patient, further research is needed to establish the prevalence and mechanisms of ventilator-induced diaphragm muscle dysfunction, and the possible interaction between mechanical ventilation and the administration of high-dose corticosteroid. Until then, in caring for these patients, it is imperative to allow partial activation of the diaphragm, and to administer the lowest dose of corticosteroid for the shortest duration possible.     

美托洛尔治疗右室流出道室性早搏的效果观察

目的：观察美托洛尔对起源于右室流出道室性早搏的疗效。方法：选择起源于右室流出道的室性早搏患25例，给予美托洛尔治疗，剂量从6．25mg开始，无不良反应后，逐渐加量，最大剂量每天100－150mg，疗程3个月，用药前后查12导联体表心电图、24小时动态心电图及结合临床症状进行评定。结果：①临床症状评定：胸闷心悸25例，治疗后减轻20例，有效率为80％；焦虑20例，治疗后症状均消失，有效率为100％；头晕14例，治疗后减轻12例，有效率为85．7％。②室性早搏评定：25例中达到室性早搏抑制率70％有11例，有效率为44％；平均室性早搏抑制率为45．6％，6例成对室性早搏抑制率为80％，3例短阵室速消失，平均心率降低12．6／min。③生化指标：血糖、胆固醇、甘油、三酯治疗前后无明显改变。④2例因血压低未加药量。结论：美托洛尔治疗起源于右室流出道室性早搏疗效肯定，尤其对运动后早搏增多疗效较好，临床太改善较显，观察中未发现明显不良反应，无致心律失常现象。     

Body Surface Mapping and Nontraditional ECG Leads in Patients with Wolff-Parkinson-White Syndrome

A method of ECG mapping from 90 points on the chest surface is described in 41 male and 17 female patients, aged 6 to 59 years. All also underwent invasive electrophysiological investigation and intraoperative epicardial mapping. Fifty-two patients had one, three patients two, and one patient had three anomalous accessory pathways. Two patients had nodoventricular tracts (Mahaim fibers). We distinguished seven zones along the atrioventricular groove (AVG) to compare the data derived from epicardial, endocardial, and body surface mapping. A microcomputer was used for the analysis of all ECGs to construct and analyze the isopotential maps. The criterion for localization of the anomalous accessory pathways was determined after analysis of the data from all 58 patients. The localization criterion was the appearance of a minimal deflection (-0.09 +/- 0.03 mV) on the surface isopotential maps within the first 0.28 msec of the QRS complex. This criterion for localization of anomalous accessory pathways from the chest surface was proposed on the basis of comparison of data from selective coronary angiography, the ventriculogram, and the chest X ray i.e., radiographic-topographic-anatomical data. In 20 patients, 10-20 nontraditional ECG leads were recorded from the chest to reflect the atrioventricular groove. The number of nontraditional ECG leads depended on patient age, weight, and height. Localization of the accessory pathway in one of the seven zones was established by the earliest delta wave and its maximum deviation. It was possible to localize the anomalous accessory pathway and to suspect multiple pathways in 95% of cases using nontraditional ECG leads and the listed criteria.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pregnancy augments nitric oxide-dependent dilator response to acetylcholine in the human uterine artery

The influence of pregnancy on the dilator effects of acetylcholine in the isolated human uterine artery was investigated. Acetylcholine (0.1 nM to 0.1 microM) produced concentration- and endothelium-dependent relaxation of norepinephrine (3 microM)-induced contraction. The relaxation was greater in arteries from pregnant patients (P arteries) than from non-pregnant patients (NP arteries). The maximal relaxation was 53.5+/-3.4% (n=21) in P arteries and 23.5+/-2.5% (n=35) in NP arteries. In both P and NP arteries the cholinergic relaxation was increased in the presence of superoxide dismutase and greatly reduced in the presence of the nitric oxide synthase inhibitors, NG-mono-methyl L-arginine (L-NMMA) and L-nitro-arginine-methylester (L-NAME). The effect of these nitric oxide synthase inhibitors was reversed by L- arginine. We conclude that pregnancy enhances acetylcholine-induced nitric oxide synthesis and release in the human uterine artery.