Consultation in the aftermath of an air tragedy

In the early morning hours of December 12, 1985, a chartered jet airliner carrying 248 soldiers crashed shortly after takeoff, killing all aboard. The day after, the authors were designated as a consultation team to the mental health staff at Fort Campbell who were providing services in the aftermath of the crash. This report describes and analyzes the experiences of this consultation on disaster management. Our consulting experience has been one of the most profound and demanding events of our professional lives. Salient lessons of the consultation include: (a) the need to clarify leadership roles among the local mental health care team; (b) the need to help the local team establish clear roles among team members; (c) the value of enabling the local team to mourn the loss of their fellow soldiers and community members; and (d) the value of establishing a clear plan of mental health services for both short-term and long-term management.     

Control of microtubule assembly-disassembly by calcium-dependent regulator protein.

The Ca2+-dependent regulator (CDR) protein of cyclic nucleotide phosphodiesterase is a low molecular weight, acidic, Ca2+-binding protein which has been implicated in a number of Ca2+-dependent enzymatic functions. Indirect immunofluorescence has revealed that CDR is specifically associated with the chromosome-to-pole region of the mitotic apparatus during metaphase-anaphase in a pattern distinctly different from that of similar cultured cells stained with antitubulin. This characteristic localization in the mitotic half-spindle suggested a role for CDR in the control of microtubule assembly-disassembly during mitosis. Thus, CDR was examined for its effects on microtubule polymerization in vitro. It was determined that stoichiometric concentrations of CDR and a homologous Ca2+-binding protein, skeletal muscle troponin C, both inhibited and reversed microtubule assembly in a Ca2+-dependent manner. CDR-dependent inhibition of in vitro microtubule assembly occurred at physiological Ca2+ concentrations (approximately 10 micron) that, in the absence of CDR, caused only a slight reduction in polymerization. At Ca2+ concentrations in the low physiological range (less than 1 micron), no inhibition was observed. These biochemical results, together with the immunofluorescent localization of CDR in the mitotic half-spindle, provide evidence that Ca2+ is an endogenous regulator of microtubule disassembly through the activity of CDR.     

Evaluation of bronchial air leaks by auscultation and phonopneumography

Bronchial fistulae in communication with atmospheric pressure can be identified by the presence of a squeaking sound heard over the chest wall during a Valsalva maneuver. Furthermore, these leak sounds can help identify the size, location, and communications of the bronchial fistulae. The size of the leak can be inferred by the pitch of the leak sound. Large leaks produce low pitched sounds, smaller leaks (or partially obstructed leaks) produce high pitched squeaks , and multiple leaking sites produce polyphonic leak squeaks . The bronchus responsible for the leak can be identified by cessation of the leak sound during balloon occlusion of the correct bronchial stump. A communication of a bronchial fistula with the chest wall facial plane produces massive subcutaneous emphysema and an early inspiratory click. This click suggests a check valve mechanism of air exiting the leaking bronchus.     

Exposure to Potentially Harmful Drug–Disease Interactions in Older Community‐Dwelling Veterans Based on the Healthcare Effectiveness Data and Information Set Quality Measure: Who Is at Risk?

OBJECTIVES: To identify prevalence and risk factors for exposure to drug–disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug–Disease Interaction (Rx‐DIS) measure. DESIGN: Cross‐sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx‐DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx‐DIS exposure were examined, including demographic, health status, and access‐to‐care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1‐year prevalence of Rx‐DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx‐DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx‐DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx‐DIS. CONCLUSION: The prevalence of Rx‐DIS was common in older VA outpatients. Future studies should examine the risk of Rx‐DIS exposure on health outcomes using separate analyses for each type of Rx‐DIS separately before combining all Rx‐DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx‐DIS exposure will also be helpful in improving the quality of care for older adults.     

Atheroablation with the Kensey catheter: a pathologic study

The mode of action of the Kensey catheter, a new atheroablation device, was investigated. Fresh above-the-knee amputated legs were used for recanalization of the superficial femoral artery. The variables used were identical to those of clinical trials, including a rotational speed of 50,000 rpm and an injection rate of 40 mL/min. The debris produced by the catheter was studied cytologically, and the arterial segments were examined histologically. The particle size in the debris ranged from 1 to 2,000 microns. The softer plaques produced a fine fibrin dust background with long strips of intima ranging from 10 to 2,000 microns. Complicated calcified plaques produced larger background material (10-120 microns) but smaller strips of intima (50-800 microns). Dissections and perforations occurred. Some of the debris produced by the atheroablation process was used to embolize a canine heart and kidney. Small focal infarctions were found in the heart, and large and multiple infarcts were seen in the kidney. In clinical studies the debris appears to be tolerated in the lower extremities. Its safety in the kidney and heart are questioned.