A new approach to the management of Broviac catheter infection.

Infection continues to be a major complication of the use of indwelling venous catheters. In an attempt to avoid removal of the catheter and to minimize the systemic side-effects of antibiotics, the potential value of in-situ treatment of confirmed Broviac catheter infection was assessed in carefully selected patients attending an oncology unit. Fourteen episodes from 11 children were included in the study. A variety of organisms were encountered. Infective episodes were divided into two categories: (a) those occurring in patients with negative peripheral blood cultures and neutrophil count greater than 1.5 x 10(9) l-1 which were treated only by local instillation of heparinized antibiotic 8-hourly for 7-14 days (N = 8); (b) those occurring simultaneously with positive peripheral blood culture (or peripheral blood culture not performed) regardless of neutrophil count, or infection restricted to Broviac catheter but with a neutrophil count of less than 1.5 x 10(9) l-1; these were treated, with one exception, as above with the addition of systemic antibiotics (N = 6). Treatment was successful in 100% of infective episodes with negative cultures achieved between 5 and 12 days. Catheters remained in use a mean of 118 days following treatment of infection. This approach has obvious advantages but requires careful patient selection and monitoring. It prolongs the catheter life, obviates the need for systemic antibiotics for a local infection, and with appropriate instruction to parents and family practitioner, treatment may be administered on an outpatient basis.     

Attentional Bias in Posttraumatic Stress Disorder

This study investigated preferential encoding of threat material in subjects with posttraumatic stress disorder (PTSD) with a modified dot-probe paradigm. This paradigm indexes attentional bias by measuring response latency to name neutral target words that are presented adjacent to or distant from threat words. Motor vehicle accident survivors with PTSD (n = 15), subclinical PTSD (n = 15), and low anxiety (n = 15) were required to name target words that were presented either adjacent to or distant from strong threat, mild threat, positive, and neutral words. PTSD subjects named targets faster when they were in close proximity to mild threat words. Results suggested that PTSD subjects' attention was drawn to the mild threat stimuli and are discussed in the context of network models of PTSD.     

Evaluation of two ELISA's for detecting Chlamydia trachomatis from endocervical swabs.

Two enzyme immunoassays (EIAs) detecting Chlamydia trachomatis from endocervical swabs, Syva MicroTrak (MT) and Abbott Chlamydiazyme (CZ), were compared with a tissue culture (TC) standard. Initially, 8% (100 of 1250) of specimens were TC positive, yielding sensitivities of 94% (94 of 100) for MT and 79% (79 of 100) for CZ with identical 98% specificities (1129 of 1150 for MT and 1130 of 1150 for CZ). Discrepant specimens were retested by both EIAs and assayed for elementary bodies (EBs) by a fluorescent antibody test. After discrepancy analysis, 9.5% (118) of 1240 patients were either TC or EB positive, yielding sensitivities of 94.1% for MT (111 of 118) and 79.7% for CZ (94 of 118) with identical specificities of 100% (1122 of 1122). These results indicate that the MT is significantly more sensitive (p less than 0.05, McNemar test) than CZ in detecting C. trachomatis from endocervical swabs.     

Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement.

OBJECTIVES: Percentage of deliveries assisted by a skilled birth attendant (SBA) has become a proxy indicator for reducing maternal mortality in developing countries, but there is little data on SBA competence. Our objective was to evaluate the competence of health professionals who typically attend hospital and clinic-based births in Benin, Ecuador, Jamaica, and Rwanda. Methods: We measured competence against World Health Organization's (WHO) Integrated Management of Pregnancy and Childbirth guidelines. To evaluate knowledge, we used a 49-question multiple-choice test covering seven clinical areas. To evaluate skill, we had participants perform five different procedures on anatomical models. The 166 participants came from facilities at all levels of care in their respective countries. Results: On average, providers answered 55.8% of the knowledge questions correctly and performed 48.2% of the skills steps correctly. Scores differed somewhat by country, provider type, and subtopic. Conclusion: A wide gap exists between current evidence-based standards and current levels of provider competence.     

Hemodynamic Parameters Influencing Clinical Performance of Novacor Left Ventricular Assist System

The interrelationships between hemodynamic variables including right ventricular (RV) performance with filling/ejection dynamics of the Novacor left ventricular assist system (LVAS) were determined in 10 of 11 patients who received LVAS as a bridge to heart transplant. Nine were successfully transplanted. Data were obtained intraoperatively, at periodic intervals up to 48 h postimplant and at explant. The hypotheses investigated included (a) RV performance influences LVAS filling characteristics and (b) LVAS pump output is influenced by systemic vascular resistance (SVR). During the period of LVAS support (2-126 days), pumping characteristics included a mean filling volume of 51 ml (range, 24-70), residual volume of 4.9 ml (range, 1-18), pump rate of 113/min (range, 63-175), and pump output of 5.81/min (range, 2.8-8.2). Multiple regression analysis identified pulmonary vascular resistance (PVR), RV stroke work index (RVSWI), and pulmonary capillary wedge pressure, but not RV ejection fraction, pulmonary artery pressure, or central venous pressure (CVP) as the most important correlates with LVAS filling volume (p less than 0.001, R2 = 0.6). In addition, LVAS pump output was influenced mainly by RVSWI, PVR, and SVR (p less than 0.001, R2 = 0.7). It was concluded that LVAS performance is highly dependent on RV function and systemic/pulmonary vascular resistances.     

Extracorporeal shock wave lithotripsy: impact on a large diagnostic radiology department.

Extracorporeal shock wave lithotripsy is a new therapeutic technology that has received instant and widespread acceptance. The history and technical aspects of the procedure are presented, but most importantly, the authors discuss radiology's role and note the importance of management's awareness of the potential impact on departmental fiscal, equipment and personnel resources.     

Sialyltransferase activity and hepatic tumor growth in a nude mouse model of colorectal cancer metastases.

Sialyltransferase activity (EC 2.4.99.6) was measured in the microsomal fraction of colorectal cancer cell lines using an assay based on the incorporation of [14C]CMP-sialic acid into asialofetuin. In the poorly differentiated lines MIP101 and Clone A, sialyltransferase activity had a Vmax of 0.36 and 0.31 nmol/mg protein/h, respectively, while the moderately differentiated to well-differentiated cell lines HT-29, CCL188, and CX-1 had Vmaxs of 2.46, 1.05, and 1.24 nmol/mg protein/h, respectively. All cell lines tested had a Km of 15.4 (+/- 0.7)(SD) mumol/liter. The better differentiated cells had higher levels of sialyltransferase activity, which correlated with their higher levels of sialic acid and their enhanced ability to form liver metastases in the nude mouse following intrasplenic injection compared to the poorly differentiated cell lines. Treatment of the cell lines with KI-8110, a CMP-sialic acid derivative which prevents incorporation of sialic acid into glycoconjugates, resulted in reduced formation of hepatic metastases by the colorectal carcinoma cell lines in the nude mouse model. It is suggested that reduced sialylation of adhesion molecules such as carcinoembryonic antigen may change the biology of the tumor cell, one consequence of which is the prevention of implantation of the cells into distant sites, resulting in a reduced incidence of metastases.     

Elbow ganglion arising from medial epicondyle pseudarthrosis.

We present a patient with an asymptomatic painless medial elbow swelling of one year's duration, which was diagnosed as a ganglion originating from a non-united avulsion fracture of the medial epicondyle with a pseudarthrosis. Medial elbow ganglia are unusual lesions typically arising from the medial aspect of the ulnohumeral joint capsule, often in combination with symptoms of cubital tunnel syndrome. To our knowledge, a ganglion arising from a pseudarthrosis has not been reported in the literature, and should be considered in the differential diagnoses of lesions encountered over the site of fracture non-union in proximity to a joint.     

A comparison of dummy variable versus traditional multiple discriminant function analysis.

The authors compare the use of dummy variable and traditional multiple discriminant function analysis when dealing with research questions where ratio or nominal scale independent variables can be used. A healthcare-related example of using dv MDF is given and the authors conclude that it is superior to traditional MDF for determining variable importance and developing market segment profiles.     

Biological characteristics of newly diagnosed poor prognosis acute myelogenous leukemia

A pilot study was conducted of the biological characteristics of the leukemia cells of newly diagnosed patients with poor prognosis acute myelogenous leukemia (AML). This study included measurements of the pretherapy proliferative rate of the leukemia cells in vivo, assessment of differentiation in vivo during remission induction therapy, and the level of expression of the fms, myc, and IL1β genes in pretherapy leukemia cells. Short cell cycle times were characteristic of the best prognostic category and were associated with a rapid reduction in marrow leukemia cells in cytosine arabinoside (araC)-sensitive patients. Expression of c-fms was associated with rapid reduction in marrow leukemia cells during araC therapy and with a successful treatment outcome. Expression of the IL1β gene was associated with short remissions. These studies suggest that when compared to newly diagnosed standard prognosis AML, the leukemia of poor prognosis patients is more likely to exhibit long cell cycle times, low levels of fms expression, and is less likely to be associated with myeloid differentiation during remission induction therapy. © 1993 Wiley-Liss, Inc.