Grandparents raising grandchildren: stressors, social support, and health outcomes

The major purpose of this study was to identify predictors of grandparent caregiver health status. Additional purposes were to describe the physical and emotional health of grandparent caregivers and the perceived benefits of support group attendance. A convenience sample of 42 grandparents was recruited from support groups. Data were collected through telephone interviews. Grandparents who had higher parenting stress reported lower levels of physical, social, and mental health. Inverse correlations were present between life stress and mental health. Positive correlations were found between social support and physical health. No pattern emerged in a comparison of the health of caregiving grandparents and a normative sample. Emotional support was the primary benefit derived from support group attendance. There were modest inverse associations between the length of time the child had lived with the grandparent and six of the eight indicators of grandparent health.     

The role of the gastric reservoir in ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation with an incidence ranging from 9-70% and averaging around 25%. The pathogenesis of VAP requires abnormal oropharyngeal and gastric colonisation and then aspiration of these contents into the lower airways. Another co-existing mechanism could be direct oropharyngeal or lower airways inoculation of microorganisms through contaminated respiratory therapy equipment. Ventilator-associated pneumonia develops easily if aspiration or inoculation of microorganisms occur in patients with artificial airways and in whom mechanical, cellular and/or humoral defences are altered. Both host factors and treatments may alter pulmonary defence mechanisms; these too may contribute to the development of VAP. An alternative mechanism to explain VAP is bacterial translocation, although this mechanism is still under investigation. Figure 1 illustrates a schema of the pathogenesis of VAP. In this paper we review the possible role of the gastric reservoir in the aetiology of VAP, emphasising the following issues: 1. Risk factors for gastric colonisation 2. Clinical evidence of gastric aspiration to the lower airways in mechanically ventilated patients 3. Clinical evidence and controversies surrounding the role of the gastric reservoir in ventilator-associated pneumonia 4. The role of bacterial translocation as a mechanism for the development of VAP 5. A summary of prophylactic measures.     

Extracorporeal shock wave lithotripsy: review of the first 100 cases at the Kidney Stone Center of Southeast Georgia

We reviewed the first 100 consecutive patients treated with extracorporeal shock wave lithotripsy (ESWL) at one institution. A total of 115 treatments were delivered to 58 men and 42 women. Patients with calculi of various sizes were treated and compared for (1) length of hospitalization, (2) ancillary procedures, (3) repeat ESWL, (4) obstructive complications, (5) parenteral analgesic requirements, and (6) stone-free rate. Patients were grouped according to calculus length. Group A consisted of 76 patients with calculi totaling less than 3 cm. Group B contained 24 patients with calculi totaling more than 3 cm. In group A, 96% required a single ESWL procedure. Hospitalization averaged two days, and none had obstructive complications; 33% required no parenteral analgesics. In group B, 58% received a single ESWL treatment, whereas 88% required ancillary procedures. Results showed extracorporeal shock wave lithotripsy to be effective treatment of urinary calculi measuring less than 3 cm. Larger calculi required combinations of ESWL with other endourologic treatment.     

Effect of nitric oxide on megakaryocyte growth induced by thrombopoietin

The present study investigated the effect of nitric oxide (NO) on megakaryocyte (Mk) proliferation induced by thrombopoietin (TPO). Low-density mononuclear cells (MNCs) and CD34+ cells from human bone marrow (BM) were cultured in liquid medium in the presence of sodium nitroprusside (SNP) or (Z)-1-[2-(aminoethyl)-N-(2-ammonioethyl) amino] diazen-1-ium-1, 2-diolate (DETA/NO) and then stimulated with TPO. Mk number decreased in both NO donors, as identified by flow cytometry 11 to 13 days after TPO stimulation. Nitrite, cyanide, or the carrier molecule DETA failed to reproduce the inhibition caused by NO donors. When CD34+ cells were treated with DETA/NO, the inhibition of Mk growth was even more pronounced than that in MNCs. Failure of the guanosine 3',5'-cyclic monophosphate (cGMP) analog 8-bromoguanosine 3',5'-cyclic monophosphate (8-Br-cGMP) to inhibit Mk proliferation suggests that cGMP is not involved in Mk suppression mediated by NO. On the other hand, DNA analysis by flow cytometry showed that apoptosis of CD34+ cells and Mks seemed to be at least one of the mechanisms associated with the cytotoxic DETA/NO effect. Stimulation of MNCs or CD34+ cells with tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) increased endogenous NO levels and suppressed Mk growth. Treatment with NO synthesis inhibitors such as L -N(G)-monomethyl arginine (L -NMMA) or L -N(G)-nitroarginine methyl ester hydrochloride (L -NAME) partially reversed Mk growth inhibition induced by TNF-alpha and IFN-gamma, although increased NO levels returned to normal values. The results presented here strongly indicate that NO regulates the growth of Mks induced by TPO by a direct effect on both progenitors and mature Mks.     

Cancer pain management and the JCAHO's pain standards: an institutional challenge

Unrelieved pain is a major medical problem. In response to this problem, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) launched new standards for pain management in 1999. A review was conducted in five hospitals of 117 charts of 80 inpatients and 37 outpatients with cancer who had pain documented in their medical records to determine whether application of these JCAHO standards was documented. Pain assessment and management were not documented for most patients. Pain intensity was noted for 57% of outpatients and 53% of inpatients. When pain was documented, treatment was noted in 86% of outpatients' charts and 89% of inpatients' charts. Of those patients with documented pain, reassessment after treatment was reported in 34% of the outpatient charts and 44% of the inpatient charts. Work to properly manage cancer pain needs to continue, and the JCAHO standards provide a mechanism to evaluate practice documentation in order to improve care.     

Effectiveness of a gentamicin dosing protocol based on postconceptional age: comparison to published neonatal guidelines.

OBJECTIVE: To evaluate the effectiveness of a gentamicin dosing protocol based on postconceptional age in producing therapeutic serum concentrations and to compare the protocol with commonly used gentamicin dosing guidelines. DESIGN: During the initial three months of this study infants were dosed according to physician discretion (group I). In the subsequent three-month period patients were dosed according to a postconceptional age dosing schedule (group II). SETTING: Infants were enrolled after being admitted to the Newborn Intensive Care Unit at the University of Miami/Jackson Memorial Medical Center. PATIENTS: Infants less than 37 weeks gestational age with normal renal function, not receiving indomethacin, and requiring gentamicin treatment were enrolled. Fifty-nine infants were enrolled into group I (median weight 1300 g [range 720-3300]), postconceptional age 29 weeks [26-37]); and 68 infants were enrolled into group II (weight 970 g [530-3000], postconceptional age 29 weeks [24-36]). INTERVENTION: Patients in group II were dosed according to the following protocol: postconceptional age less than 30 weeks, 3.0 mg/kg q24h, and postconceptional age 30-37 weeks, 2.5 mg/kg q18h. Peak and trough serum gentamicin concentrations were obtained in all study patients. Pharmacokinetic parameters were calculated from measured serum concentrations. Using the calculated pharmacokinetic data, peak and trough serum concentrations were simulated for five published neonatal dosing guidelines and the proposed postconceptional age protocol. MAIN OUTCOME MEASURES: The number of therapeutic serum gentamicin concentrations resulting from the dosing guidelines studied were compared. RESULTS: Measured trough concentrations differed significantly between the two groups with 35 percent of patients in group I and 90 percent of patients in group II having trough values less than 2 mg/L (p less than 0.001). There was no significant difference in measured peak concentrations between groups. Simulated trough concentrations were significantly different when postconceptional age dosing was compared with commonly used protocols (p less than 0.0001) with the highest percentage of concentrations less than 2 mg/L (89 percent) resulting from the proposed postconceptional age guidelines. CONCLUSIONS: These data suggest that the proposed postconceptional age protocol is reproducible and reliable in achieving therapeutic gentamicin serum concentrations in neonates.     

Clinically inapparent status epilepticus as a cause of coma in the critically ill

Three adult patients presenting to the intensive care unit (ICU) with metabolic encephalopathy are described. Despite the absence of clinical signs of status epilepticus, this diagnosis was made on the basis of electroencephalographic recording and when effectively treated with anticonvulsant therapy, associated stupor or coma resolved. Duration of mechanical ventilation, intubation, and ICU stay were substantially shortened by this recognition and subsequent therapy. The inclusion of status epilepticus in the differential diagnosis of coma and stupor in the critically ill adult patient is emphasized.