Prediction of Posttreatment Drinking Outcome in a 2-Year Out-Patient Alcoholic Treatment Program. A Follow-up Study

Fifty alcoholics who attended a 2-year out-patient treatment program with standardized evaluations every third month were followed-up 2 years after completion of the program. One patient refused to be followed-up and four were dead. Corroboration was available in 78% of the cases. The number of abuse days from the second half-year of therapy and forward was strongly related to the number of abuse days during the follow-up period as were ratings both of drinking goal fulfillment and fulfillment of other treatment goals at termination of the treatment period. On the contrary initial characteristics and background data as well as the number of abuse days during the first half-year were not related to number of abuse days during the follow-up period. Our findings indicate that improvement during long term out-patient treatment for alcoholism is stable during the following 2 years with a socially stable sample.     

CLOTBUST: Design of a Randomized Trial of Ultrasound-Enhanced Thrombolysis for Acute Ischemic Stroke

BACKGROUND: Intravenous tissue plasminogen activator (TPA) therapy can be monitored with 2 MHz transcranial Doppler (TCD). This article describes the design of CLOTBUST (combined lysis of thrombus in brain ischemia using transcranial ultrasound and systemic TPA), the first prospective international multicenter randomized clinical trial of noninvasive externally applied ultrasound to enhance systemic thrombolysis in human stroke. SUBJECTS: Patients with acute ischemic stroke eligible for intravenous TPA therapy within 3 hours of symptom onset who have detectable middle cerebral artery occlusion on a prebolus TCD are included in this trial. All patients receive standard 0.9 mg/kg TPA therapy. Patients are randomized (1:1) to either 2 hours of continuous monitoring with TCD or placebo monitoring. FDA-approved portable diagnostic TCD equipment and standard headframes (Marc series, Spencer Technologies, Seattle, WA) are used. Output of TCD units is set at 100% power achievable at depths of insonation that display the worst TIBI flow grade signals. METHODS AND END-POINTS: Acute MCA occlusion on prebolus TCD is defined as thrombolysis in brain ischemia (TIBI) flow grades 0-3. Treating physicians are blinded to randomization assignment, and certified scorers measure stroke severity using the National Institute of Health Stroke Scale (NIHSS). Safety of continuous TCD monitoring is determined by rates of symptomatic (NIHSS score increase by 4+ points) intracerebral hemorrhage within 72 hours after initial symptom onset. Potential enhancement of TPA therapy will be determined using combined primary end-point of early complete recanalization on TCD (TIBI flow grades 4-5), dramatic recovery (NIHSS < or = 3 points), or decline in the NIHSS > or = 10 points repeatedly measured every 30 minutes within 2 hours after TPA bolus. Other end-points include recovery at 24 hours and 3 months, modified Rankin scores (mRS) are obtained at 90 days, and favorable outcome is determined as NIHSS or mRS scores 0-1. CONCLUSIONS: The aim of phase II CLOTBUST trial is to determine the rates of early complete recanalization and dramatic/early clinical recovery in TPA + TCD and TPA groups. The sample size is set at 126 patients since a medium effect size (.50) is anticipated for TPA + TCD group vs TPA alone to achieve combined primary end-point.     

Full scale computer simulators in anesthesia training and evaluation

PURPOSE: With the advent of competency-based curriculum, technology such as full scale computer simulators have acquired an increasingly important role in anesthesia both in training and evaluation. This article reviews the current role of full scale computer simulators in teaching and evaluation in anesthesia. SOURCE: This review draws from existing anesthesia and medical education literature in order to examine and assess the current role of full scale computer simulators in anesthesia education today. PRINCIPAL FINDINGS: The last decade has witnessed a major increase in the use of full scale computer simulators in anesthesia. Many applications have been found for these simulators including teaching and training, evaluation and research. Despite the increasing use and application of full scale computers in anesthesia in the area of teaching and training, definitive studies evaluating its cost effectiveness, its efficacy compared to traditional training methods or its impact on patient outcome are still pending. Although there is some preliminary evidence of reliability and validity in using the simulator to evaluate clinical competence, development in this area has not progressed enough to justify its use in formal, summative evaluation of competence in anesthesia at this time. CONCLUSIONS: As technology acquires an increasingly important role in medical education, full scale computer simulators represent an exciting potential in anesthesia. However, the full potential and role of simulators in anesthesia is still in development and will require a dovetailing of clinical theory and practice with current research in medical education.     

Les plantes transgéniques (OGM végétaux) : connaissances et inconnues sur les risques d'allergénicité…

Much attention is now being focused on foods from genetically modified plants because of the risk of allergenicity. No such risk has been reported for the first generation of GM plants made resistant to herbicides and insect larvae. Current experiments with hypoallergenic GM plants are reported and discussed in the present paper. The second generation of GM plants will improve the nutritional aspects of natural foods. Transgenic proteins could reach from 4 up to 8% of the total protein content in these foods. Any potential difference in allergenicity between second generation GM plants and the natural varieties must be examined with respect to the risk for food allergy caused by food products made from these plants and the risk for respiratory allergies in the people living near the crops caused by airborne pollen originating from the plants. WHO–FAO directives as well as the Codex Alimentarius proposals and the European Food Safety Authority (EFSA) guidelines recommend that transgenic proteins be screened for homology (by in silico study) and cross-reactivity with known allergens, as well as being examined carefully for modifications of host-plant proteomes. In vivo animal studies are also to be carried out to assess any potential immunogenicity. Lacking adequate safety data, the absence of potential allergenicity of transgenic plants cannot be ruled out. This is why data that do not meet the recommended safety criteria required for commercialization of GM plants do not allow us to rule out absolutely the risk that may be associated with products that are going to be commercialized. Therefore, it is essential that commercialized GM plants be monitored. We propose the establishment of public reference serum banks based on up-to-date WHO–FAO recommendations concerning the selection of sera according to precise criteria. We also propose establishing a system of allergovigilance linking national and European health and food safety agencies and a network of university hospital-based clinical and laboratory reference centres, together with a network of clinical allergists, responsible for the creation of the serum banks. Allergists working through these networks would be able to identify new sensitizations to transgenic foods in the population, just as they now identify new types of food allergies, which, in this case, would be GM foods. Such a project is now being established in France.     

Paramedic and emergency department care of stroke: baseline data from a citywide performance improvement study.

BACKGROUND: Rapid diagnosis and transport by paramedics and efficient, effective emergency management are essential to improving care of acute stroke patients. OBJECTIVES: To measure the performance of paramedics and emergency departments providing care for patients with suspected acute stroke. METHODS: Two stroke centers and 4 other hospitals where most patients with acute stroke in Houston, Tex, are admitted participated. Hospital and paramedic performance data were collected prospectively on 446 patients with suspected acute stroke transported by paramedics between September 1999 and February 2000. RESULTS: Paramedics had a sensitivity of 66%, specificity of 98%, and overall accuracy of 72% in diagnosing stroke. For patients with suspected stroke, 58.5% arrived in the emergency department within 120 minutes of symptom onset; in confirmed cases, that percentage was 67%. Mean total transport time was 42.2 minutes and was significantly longer (P < .001) to inner-city hospitals (44 minutes) than to suburban, community-based centers (39 minutes). Door to computed tomography times were significantly (P < .001) shorter for the 2 stroke centers than the other hospitals. Overall thrombolysis treatment rate among patients with confirmed ischemic stroke was 7.4% (range, 0-19.4%); treatment rates at the 2 stroke centers were 5.9% and 19.4%. CONCLUSIONS: More than half of patients with suspected stroke arrive at hospitals while thrombolytic treatment is still feasible. Although the current rate for thrombolytic treatment in Houston exceeds the national rate, performance of paramedics and hospitals in treating acute stroke can be improved by increasing efficiency and standardizing medical practices.