Transesophageal echocardiography and monitoring applications

Transesophageal echocardiography (TEE) is a widely used cardiac imaging technique that provides the clinician with a view of the heart as seen from the esophagus or stomach. Rapid advances in TEE transducer technology, coupled with the low-risk, semi-invasive nature of the procedure, have fueled its use for cardiac monitoring of surgical and critical care patients, in addition to diagnostic imaging. Many recent research studies have demonstrated the utility of TEE for direct, real-time evaluation of global and regional left ventricular function not achievable with current competing technologies at the bedside. As a result of these advantages, TEE has become an emerging tool in cardiac monitoring at many centers around the world.     

Comparison of Specialized and Standard Enteral Formulas in Trauma Patients

Study Objective . To compare selected nutrition and immunologic markers and infection in trauma patients receiving a specialized enteral formula with those receiving standard enteral therapy. Design . Prospective, randomized clinical trial. Setting . Level 1 trauma center at a county government hospital. Patients . Forty-one consecutive patients with major trauma who required enteral nutrition support. Thirty-seven patients completed the study. Four patients (two in each group) were excluded, as additional operative procedures prevented initiation of enteral feedings within 7 days of injury. Interventions . Nineteen patients fed the specialized enteral formula received supplemental arginine, linolenic acid, β-carotene, and hydrolyzed protein for up to 10 days. Eighteen control patients received standard enteral nutrition. Measurements and Main Results . After study entry, patients who received the specialized enteral formula had fewer infections than those receiving standard enteral nutrition (3/19 vs 10/18; p<0.05). The change in nitrogen balance was significantly better (p<0.05) from day 1 (−11.8 ± 1.8 g/day) to day 5 (−5.9 ± 2.0 g/day) for the group who received the specialized formula compared with the group who received standard enteral nutrition (-7.3 ± 1.7 g/day to −7.4 ± 2.8 g/day). Similarly, the change in C-reactive protein serum concentration was significantly better (p<0.05) from day 1 (18.0 ± 2.1 mg/dl) to day 5 (11.8 ± 1.5 mg/dl) in the group who received the specialized formula compared with the group who received standard enteral nutrition (17.6 ± 1.2 mg/dl to 14.4 ± 1.7 mg/dl). The CD4:CD8 ratio increased more in the group who received the specialized formula, although this difference did not reach statistical significance. Conclusion . Trauma patients who received the specialized enteral formula demonstrated a decreased incidence of infection and increased improvements in nitrogen balance and other indexes of stress. Additional clinical trials demonstrating positive patient outcomes are necessary before these specialized enteral formulas are used as the standard of practice in critically ill patients.     

Individual placement and support: A community mental health center approach to vocational rehabilitation

Individual Placement and Support (IPS) is a vocational rehabilitation intervention for people with severe mental disabilities. IPS draws from components and philosophies of several other models. Employment specialists, who are part of the community mental health center team, provide services in the community. IPS emphasizes client preferences, rapid job finding, continuous assessment, competitive employment, integrated work settings, and follow-along supports. Initial research on IPS shows favorable results.Presented at the 44th Institute on Hospital and Community Psychiatry, Toronto, Canada, october, 1992. Supported by US Public Health Service Grants R18-MH-47650 from the Substance Abuse and Mental Health Services Administration and K02-MH-00839 from the National Institute of Mental Health.     

Meeting information needs in health policy and public health: Priorities for the national library of medicine and the national network of libraries of medicine

Those seeking information in health policy and public health are not as well served as those seeking clinical information. Problems inhibiting access to health policy and public health information include the heterogeneity of professionals seeking the information, the distribution of relevant information across disciplines and information sources, scarcity of synthesized information useful to practitioners, lack of awareness of available services or training in their use, and lack of access to information technology or to knowledgeable librarians and information specialists. Since 1990, the National Library of Medicine and the National Network of Libraries of Medicine have been working to enhance information services in health policy and public health through expanding the coverage of the NLM collection, building new databases, and engaging in targeted outreach and training initiatives directed toward segments of the health policy and public health communities. Progress has been made, but more remains to be done. Recommendations arising from the meeting,Accessing Useful Information: Challenges in Health Policy and Public Health, will help NLM and the National Network of Libraries of Medicine to establish priorities and action plans for the next several years.     

HIV risk profile and prostitution among female street youths

The objective of this study was to compare human immunodeficiency virus (HIV) risk factors among female street youths involved in prostitution and those with no history of prostitution. Youths aged 14 to 25 years were recruited into the Montreal Street Youth Cohort. Semiannually, youths completed an interviewer-administered questionnaire. Statistical analyses comparing characteristics and HIV risk factors for girls involved in prostitution and those never involved were carried out using parametric and nonparametric methods. Of the girls, 88 (27%) reported involvement in prostitution, and 177 girls reported no history of prostitution at the baseline interview. Girls involved in prostitution were two times and five times more likely to have reported bingeing on alcohol and on drugs, respectively. A history of injection drug use was four times more likely to have been reported by girls involved in prostitution. Further, these girls were 2.5 times more likely to have reported injected cocaine as their drug of choice. Girls involved in prostitution were younger the first time they had consensual sex and were twice as likely to have reported anal sex. Consistent condom use for anal, vaginal, and oral sex was low for all girls. Girls involved in prostitution reported more risky sexual partners. In conclusion, girls involved in prostitution may be at increased risk of HIV infection due to their injection drug use and risky sexual behaviors. Unique intervention strategies are necessary for reducing HIV infection among female street youths involved in prostitution.     

Drug use frequency among street-recruited heroin and cocaine users in harlem and the bronx before and after September 11, 2001

We determined if illicit drug use frequency changes after a disaster by comparing drug use frequency in two street-recruited samples of heroin and cocaine users, ages 15–40 years. The users were interviewed between July 11 and November 11 and divided into before- and after-September 11th groups for analysis. The before and after groups were similar in the mean number of days of drug use per month (sniff cocaine 6.8 days vs. 9.4 days, respectively, P=.17; snorted heroin 13.9 vs. 14.0, respectively, P=.96; smoked crack 16.9 vs. 15.6, respectively, P=.96; and smoked marijuana 17.5 vs. 15.3, respectively, P=.36) and in the proportion of daily users: sniffed cocaine 10% versus 17%, respectively (P=.28); snorted heroin 47% versus 40%, respectively (P=.91); smoked crack 33% versus 37%, respectively (P=.68); and smoked marijuana 47% versus 40%, respectively (P=.41). Among street-recruited heroin and cocaine users in Harlem and the Bronx, the frequency of drug use did not increase following the events of September 11, 2001. Dr. Factor is from the Division of Prevention Research and Analytic Methods in the Epidemiology Program Office at the Centers for Disease Control and Prevention and is assigned to     

Is Antidepressant Use Changing? Prevalence and Clinical Correlates in Two New England Communities

We attempted to determine whether the prevalence of antidepressant use had increased in population-based samples between 1981 and 1993, and compared the characteristics of antidepressant users and nonusers. Data were derived from six biennial, random sample, cross-sectional household surveys conducted between 1981 and 1993 in two southeastern New England communities. For each survey, point prevalence estimates were determined for the major antidepressant categories. Antidepressant users were most likely to be women, slightly older, and less likely to be employed than nonusers (p<0.0001). Comorbid conditions and concurrent drug therapy were present more frequently among users. The overall prevalence of antidepressant use per 1000 population increased from 7.8 (95% confidence interval 4.3, 11.3) in 1981–1982 to 31.4 (95% CI 23.9, 38.9) in 1992–1993, especially among women and respondents between ages 40 and 59 years.     

Subcutaneous Loperamide Prevents Gastric Lesions Induced by Necrotizing Agents in Rats

The effects of subcutaneous loperamide ongastric lesions induced by necrotizing agents wereinvestigated in the rat. Loperamide produced adose-dependent increase of gastric fluid volume andinhibition of gastric lesions caused by 0.6 N HCl orabsolute ethanol. Pretreatment with naloxone almostcompletely blocked both fluid pooling effect and mucosalprotective effect of loperamide. Omeprazole reduced the acidity of the gastric fluid in ratstreated with loperamide without significantly decreasingthe fluid volume. Various volumes of acid, given orallyimmediately before 0.6 N HCl, volume-dependently prevented gastric lesions. We conclude thatsubcutaneous loperamide protects the gastric mucosaagainst necrotizing agents through luminal dilution ofirritants, which is mediated by naloxonesensitive opiate receptors.     

Necessary but not sufficient

Objective: To consider the impact on primary care patient outcomes of using both a screener to determine elevated anxiety levels among patients with previously undetected anxiety and a physician intervention to inform physicians of their patients’ conditions. Design: Participating physicians were randomized to either the demonstration or the control arm, and patients were assigned to a study arm based on the randomization of their physicians. The patients were followed for change in outcome measures during the five-month study period. Setting: A mixed-model health maintenance organization serving approximately 110,000 enrollees in central Colorado. Patients/participants: 573 patients who had unrecognized and untreated anxiety identified from the approximately 8,000 patients who completed the waiting room screening questionnaire. Interventions: A physician intervention served the dual function of 1) providing an educational demonstration of anxiety in the primary care setting and 2) providing a reporting system for summarizing the anxiety symptom levels and functioning status of the patients enrolled in the study. Measurements and main results: Patient outcomes were measured as changes in global anxiety scores, functioning and well-being, and patients’ reports of global improvements. Conclusions: The findings indicate that this method of reporting symptoms and functioning status to primary care physicians did not significantly change patient outcomes. Improvement in outcomes appeared to be more closely associated with the patient’s severity of psychological distress. Preliminary data from this study were presented at the Seventh Annual National Institute of Mental Health International Research Conference on Mental Health Problems in the General Health Care Sector, September 20–22, 1993, McLean, Virginia, and at the first Annual Symposium of Contributed Papers on Quality of Life at the Drug Information Association Workshop, April 26–27, 1993, Charleston, South Carolina. Supported by a grant from the Upjohn Company, Kalamazoo, Michigan, and Take Care, Colorado. (Note: Dr. Buesching is a former employee of the Upjohn Company but owns no stock or option to purchase further stock in the company. Ms. Mathias, Dr. Fifer, Dr. Mazonson, Dr. Lubeck, and Dr. Patrick own no stock or option in the Upjohn Company.)     

Botulinum toxin A in the management of focal muscle overactivity in children with cerebral palsy

Cerebral palsy comprises a heterogenous group of neurological disorders representing a continuum of pathologies and clinical phenotypes. Although cerebral palsy is not a focal disorder, it is appropriate to treat identified focal problems as long as the intervention is goal directed. This paper reviews principles of managing muscle imbalance in the growing, changing child using a range of complementary, carefully timed intervention options. Over the past two decades these options have increasingly included intramuscular injection of botulinum toxin-A to manage focal spasticity and dystonia. The predictable movement patterns and postures characteristic of spasticity enable a systematic clinical rationale to be developed to determine the role of botulinum toxin-A to manage the spasticity and subsequently improve function. The management of dystonia with botulinum toxin-A is more complex, particularly when spasticity and dystonia are present in combination. An active therapy programme remains central to the management of movement problems in the child with cerebral palsy, including task-specific motor training, maintenance of muscle lengths, and improved muscle strength, aiming to achieve carry over improvements that persist beyond the pharmacological effects of the botulinum toxin-A. A series of case examples are presented to highlight the role of botulinum toxin-A in the overall management of the child with focal muscle hyperactivity.