State Mental Hospitals in Washington State in an Era of Policy Change

This paper examines changes in use of state mental hospitals in Washington State from July 1, 1990, to July 1, 1997. It focuses on the phenomenon of ongoing use of state mental hospital by patients over a period of years. Two panels of state mental hospital users were identified: one preceded and one followed implementation of state mental hospital downsizing policies. Though the number of adults per year using the state mental hospital decreased following policy implementation, there was a significant increase in the overall rate of ongoing use. A logistic regression for ongoing use with multiple individual and regional predictor variables is described.     

Single‐port surgery: Current applications and limitations

Introduction: In an attempt to further enhance the benefits of cosmesis and reduced morbidity of minimally invasive surgery, single‐port (incision) laparoscopic surgery (SPS) has emerged as a bridge between conventional laparoscopy and natural orifice transluminal endoscopic surgery. As the expertise and instrumentation required are an extension of standard laparoscopic techniques, SPS has been adapted for a variety of procedures and specialties in a short span of time. Discussion: In this article, we discuss the various SPS techniques, as well as the new devices and instrumentation available for facilitating SPS. We also review current applications reported for SPS in various surgical specialties. We present a comprehensive review of the potential benefits, limitations and risks of these novel techniques. Conclusion: Initial reports have demonstrated the technical feasibility and safety of SPS for a wide range of surgical applications. With specialized instrumentation and refinement of technique, its role will increase in coming years. Future work is necessary to improve existing instrumentation, to increase clinical experience and to assess the benefits of this surgical approach.     

Delayed discharges for medical and surgical patients in an acute care hospital

A study of social work-coordinated discharges from medical and surgical units at a 387-bed tertiary care hospital in Seattle, Washington examines social, medical and organizational factors associated with overstays. Social and medical variables included an absence of social supports, multiple diagnoses, and patient/family decision-making problems. Though organizational factors within and outside the hospital were identified, the most frequent systems delay was due to lack of post-hospital beds.     

Improved automatic analysis of ambulatory blood pressure data based on precise detection of individual night-time from diurnal profile of heart rate

BACKGROUND: Software programs sold with ambulatory blood pressure monitoring (ABPM) devices are designed to use some set 'typical' night-time (e.g. 2300-0700) to estimate daytime/night-time blood pressure (BP) with limited accuracy. Alternative use of individual periods of sleep/wakefulness from patient diaries is time consuming and subjective. We developed a simple mathematical algorithm for the detection of the 'night-time' as a period of low values in diurnal profiles of heart rate (HR) allowing accurate automatic analysis of daytime/night-time blood pressure. To test this technique we designed a software application allowing automatic analysis of ABPM data based on the different night-time definitions, including the developed algorithm and compared reproducibility of the degree of BP dipping produced by the different methods across two days of 48-h ABPM. METHODS: A 48-h ABPM study was performed in 33 patients with uncomplicated stage II hypertension. Means and standard deviations (SD) of the differences in the degree of BP dipping between two 24-h periods of 48-h ABPM were obtained separately for three methods of night-time definition: automatic detection from individual HR profiles, fixed 2300-0700 h interval and sleep time from patient diaries. RESULTS: Reproducibility of the BP dip estimation across 2 days of BP monitoring was significantly better for night-time detected from individual HR profiles than for the fixed 2300-0700 h interval or sleep time from diary. The SD of the differences was 6.7/8.2 compared with 13.5/18.3 and 13.0/14.8 respectively (systolic BP/diastolic BP, mmHg). CONCLUSIONS: Implementation of the developed method of night-time definition may significantly improve automatic analysis of ABPM data.     

Lack of significant association of an insertion/deletion polymorphism in the angiotensin converting enzyme (ACE) gene with tropical calcific pancreatitis

Background  

The genetic basis of tropical calcific pancreatitis (TCP) is different and is explained by mutations in the pancreatic secretory trypsin inhibitor (SPINK1) gene. However, mutated SPINK1 does not account for the disease in all the patients, neither does it explain the phenotypic heterogeneity between TCP and fibro-calculous pancreatic diabetes (FCPD). Recent studies suggest a crucial role for pancreatic renin-angiotensin system during chronic hypoxia in acute pancreatitis and for angiotensin converting enzyme (ACE) inhibitors in reducing pancreatic fibrosis in experimental models. We investigated the association of ACE gene insertion/deletion (I/D) polymorphism in TCP patients using a case-control approach. Since SPINK1 mutations are proposed a modifier role, we also investigated its interaction with the ACE gene variant.     

Adhesion of malaria-infected red blood cells to chondroitin sulfate A under flow conditions

Adhesion of parasitized red blood cells (PRBCs) to microvascular endothelial cells (ECs) is a distinctive feature of Plasmodium falciparum malaria and is a central event in the development of life- threatening complications such as cerebral malaria. PRBCs adhere to several EC-expressed molecules in vitro, but the relative importance of these interactions in vivo remains unclear. Chondroitin sulfate A (CSA) is the most recent EC surface-associated molecule to be implicated in the adhesive process. Accordingly, we have studied adhesion of PRBCs to CSA in vitro using a parallel-plate flow chamber. Under controlled flow conditions, PRBCs adhered to CSA in a concentration-dependent manner at wall-shear stresses up to 0.2 Pa, a value that is within the physiological range for venules. Once adhered, PRBCs remained stationary (rather than rolling) and continued to remain stationary even when the wall-shear stress was raised to supravenular levels. The adhesive interaction was strong and a proportion of adherent PRBCs could withstand detachment at stresses up to 2.5 Pa. Soluble CSA at pharmacological concentrations prevented adhesion of flowing PRBCs in a concentration-dependent manner but failed to reverse established adhesion. Adhesion of PRBCs to CSA could contribute to the pathogenesis of malaria, and soluble CSA may have a useful therapeutic effect.     

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

Introduction

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited.

Methods

We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa.

Results

Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19).

Conclusions

The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.     

Cytogenetic features and serum lactic dehydrogenase level predict a poor treatment outcome for children with pre-B-cell leukemia

Leukemic cells from 89 (24%) of 369 children with newly diagnosed acute lymphoblastic leukemia (ALL) were found to have a pre-B immunophenotype. By comparison with blasts having the common ALL phenotype, the pre-B cells were more likely to have a DNA index less than 1.16 (P = 0.02), a pseudodiploid karyotype (P less than 0.001), and a chromosomal translocation (P = 0.001). Increased serum lactic dehydrogenase levels (P = 0.001) were also characteristic of pre-B ALL; otherwise, the clinical and laboratory features of the two groups were similar. A nonrandom chromosomal translocation, t(1;19)(q23;p13.3), was identified in blast cells from 16 (23%) of the 70 patients with pre-B ALL and adequate chromosome banding studies; different translocations were found in 11 of the remaining patients. The presence of any chromosomal translocation in the pre-B group was significantly related to a higher leukocyte count, an increased level of serum lactic dehydrogenase, an increased percentage of S-phase cells, black race, and a blast cell DNA index less than 1.16. Four presenting features were found to confer an increased risk of treatment failure among pre-B patients: pseudodiploidy, chromosomal translocation, black race, and higher serum lactic dehydrogenase level. In a multivariate analysis, pseudodiploidy emerged as the strongest factor for predicting relapse in pre-B ALL. The frequent association of chromosomal abnormalities of known adverse prognostic significance and high serum lactic dehydrogenase levels with pre-B-cell ALL explains, at least in part, the poor treatment outcome reported for children with this subtype of leukemia.