Transesophageal Doppler Analysis of Coronary Sinus Flow A New Method to Assess the Severity of Tricuspid Regurgitation

Background: Severe mitral regurgitation induces reversal of flow in the pulmonary veins. We hypothesized that severe tricuspid regurgitation may disrupt normal coronary sinus flow. The purpose of this study was to analyze the Doppler flow pattern of the coronary sinus and to determine its value in the assessment of the severity of tricuspid regurgitation. Methods: The coronary sinus flow was analyzed in 70 consecutive patients with some degree of tricuspid regurgitation (27 mild, 14 moderate, and 29 severe) and in 35 patients without tricuspid regurgitation. The coronary sinus flow was obtained by pulsed-Doppler transesophageal echocardiography in a transverse plane, which showed its drainage into the right atrium. Results: The number of patients with adequate studies of the coronary sinus tended to increase with the severity of the tricuspid regurgitation. In patients without or with only mild tricuspid regurgitation the coronary sinus Doppler flow pattern was formed by two negative waves, a late systolic wave and another diastolic one with higher velocity and longer duration. The systolic wave became reversed in 21 (96%) of the patients with severe tricuspid regurgitation. The sensitivity, specificity, and diagnostic accuracy of the presence of a reversed systolic wave in the coronary sinus for the diagnosis of severe tricuspid regurgitation was 95%, 82%, and 80%, respectively. Conclusions: Significant tricuspid regurgitation modifies the coronary sinus flow pattern as assessed by transesophageal echocardiography. The presence of a reversed systolic flow in the coronary sinus appears to be a reliable new sign with good sensitivity, specificity, and diagnostic accuracy for the diagnosis of severe tricuspid regurgitation .     

Lupus anticoagulant: a clinical and laboratory study of 100 cases

Summary The clinical and laboratory features of 100 patients with lupus anticoagulant (LA) are reviewed. Subjects were divided into three groups according to their age (1–5, 15–35, 45–89 years). Female prevalence was observed in each group and overall F/M ratio was 3/1. An underlying autoimmune disease (principally lupus erythematosus) was found in 47 cases (10% of the children, 80% of the 15–35-year-old patients and 37% of the elderly patients). Biological criteria for the LA diagnosis were prolonged activated partial thromboplastin time and diluted thromboplastin time (1.3 × control), not corrected after addition of control to patient's plasma. Thromboplastin time was normal in 77 patients. Other types of coagulation inhibitors were eliminated by specific factor assays (with a 10-fold increase of cephalin concentration when necessary). Twenty-three thrombotic episodes were observed. No significant difference was found in the incidence of thrombosis between the autoimmune and non-autoimmune disease group, but the age when first thrombosis occurred was clearly lower in the former. Fourteen obstetrical accidents were noted in eight women but 13 pregnancies terminated without accident. Four patients experienced haemorrhagic complications; they all presented with a severe thrombocytopenia associated with the LA. In our experience, LA is a frequent coagulation abnormality, associated in about half of the cases with a clearly defined autoimmune disease. Clinical presentation appears as notably different according to the patient's age; it is particularly noteworthy that in nine out of 10 children, LA disappeared spontaneously within 6 months.     

Synthesis of Thiazolotriazine Derivatives and Their Antinociceptive Effects in Mice

A series of 2-(4-arylpiperazin-1-yl-methyl)-4-methyl-1-oxo-5,6,8,8a-tetrahydro-thiazolo[3,4-d] [1,2,4]triazines was prepared and tested for antinociceptive activity. The compounds were prepared by the Mannich reaction from the corresponding 2-unsubstituted thiazolotriazines. When administered intraperitoneally most were found to have potent analgesic activity in the mouse during tests of phenylbenzoquinone-induced abdominal constriction; ED50 values (doses resulting in half the maximum effect) ranged from 10 to 87 mg kg^?1. Derivatives with a 3-chloro- or 4-fluorophenylpiperazinylmethyl side-chain in the 2-position of the bicyclic system were, when administered intraperitoneally at doses greater than 25 mg kg^?1, also effective in the hot-plate test without associated sedative effects. The compounds have a large therapeutic index; intraperitoneal LD50 values (doses which result in the death of half the animals) were > 700 mg kg^?1. Naloxone attenuated the analgesic activity of the 3-chloro derivative, suggesting the participation of μ-receptors in the antinociceptive effects of this drug. In addition, a non-opioid mechanism, probably related to enhancement of the release of 5-hydroxytryptamine and noradrenaline, or inhibition of the neuronal re-uptake of these compounds, has been evinced to explain the analgesic properties of the 3-chloro or 4-fluoro derivatives. These results provide evidence for the involvement of noradrenergic and 5-hydroxytryptaminergic pathways in the analgesic activity of 3 and 4. Because of their potential effectiveness, the 3-chloro- or 4-fluorophenylpiperazinylmethyl derivatives might be suitable for treatment of a wide variety of painful conditions and could be attractive reserve agents for patients dissatisfied with opioids.     

Patient advocacy: a role for nurses?

There is much controversy surrounding the issue of nurses in the role of patient advocate. Cancer patients are vulnerable due to their diagnoses, the anxiety that it generates, the nature of the disease and subsequent treatment and may have diminished autonomy as a result. It is questionable whether the nurse is able to promote the best interests of the patient in this situation. Models of advocacy and the nurse-patient relationship are discussed. The main arguments for taking on the role of patient advocate include: reference to long periods of time spent with the patient and the chance to build a relationship; the duty to care and the duty to do no harm. Criticisms of the appropriateness of the advocacy role for nurses include: inability for the patient to choose his or her nurse; promotion of self interests; charges of paternalism; challenges from other health care professionals and multiple and/or conflicting obligations. It is concluded that perhaps the most ethical way of caring is by empowering patients and promoting selfadvocacy. This concept needs to be further explored.     

How does the mode of delivery affect the cost of maternity care?

Summary. In this paper we present estimates of the difference in the cost of hospital care for women having different modes of singleton delivery. The estimates are based on observation of resources used in different procedures, and on data from the North West Thames Region Maternity Information System. For vaginal delivery the average cost is £363, but could fall between £189 and £773, and for caesarean section the average cost is £1123, with a likely range from £837 to £1560. The wide ranges in the costs of the two modes of delivery reflect variation in the length of stay and in the intensity of care required. The average cost for intrapartum care and postnatal stay is estimated to be £451 for all singleton births. Variation in operative delivery rates between hospitals implies differences in the overall cost of care at different maternity units. This partly reflects differences in the needs of the population served by the units, but also differences in clinical practice. It is important for decision makers to consider the balance between the costs and outcomes of different policies of care.     

Women Gain Weight 1 Year After Smoking Cessation While Dietary Intake Temporarily Increases

Objective To examine the relationship of dietary change to weight change in women who quit smoking and remained abstinent for 1 year.Methods For 1 year, 582 women participating in smoking cessation classes were studied. Weight, diet, and physical activity were measured at baseline and at 1, 6, and 12 months after smoking cessation. Multivariate regression models were used to predict 1-year weight change for the 139 women who remained abstinent.Results Women gained, on average, 9.9 lb over a 1-year period while increasing their intake of energy for 1 and 6 months but returning to baseline levels by 1 year. Sucrose, total carbohydrate, and fat intake increased significantly for the first month; fat and total carbohydrate intake remained at an increased level for 6 months. In unadjusted analyses, older women and those who smoked more cigarettes gained more weight than younger women and lighter smokers; lighter and heavier women gained more weight than women of intermediate weight. In adjusted analyses, age remained a significant factor and number of cigarettes remained of borderline significance. Change in energy intake was predictive of weight change only in women with the highest energy intake at baseline.Applications Dietitians should acknowledge that most women who quit smoking gain weight in the short term. Although many women increase their energy intake, change in energy level is only one factor in weight change. Over the long term, women with high baseline intakes appear to be able to affect their weight change by reducing their energy intake. J Am Diet Assoc. 1996; 96:1150-1155.     

Combining methods to identify new measures of women's drinking problems Part I: the ethnographic stage

In recent years, some researchers in the alcohol survey field have raised concerns about the shortcomings in severity/frequency scales for drinking and drinking problems used for both clinical and household survey purposes, especially with regard to women. This article reports on Part I of a two-part study that used ethnographic and survey methods to assess indicators of drinking problems among women across various US subcultures. Methodology for the ethnographic component consisted of three steps: analysis of findings in literature on indicators of women's drinking problems, and analysis of indicators addressed in the most commonly used standard instruments for alcohol assessment; semi-structured interviews with 12 specialists in treatment and/or research who focused on alcohol problems of women; and semi-structured interviews with 65 women from four ethnic populations who were clients in alcohol treatment centers. Analysis of these data from the ethnographic component produced a taxonomy of indicators of women' s drinking problems and fourteen novel indicators that are not included or are inadequately examined in the most commonly used alcohol assessment instruments. The novel indicators were then incorporated into a questionnaire used for a county-wide survey of men and women that assessed indicators of drinking problems. Report of findings from the survey are presented in the second paper of this series.     

In Vitro Fertilization and Embryo Transfer

The technique of in vitro fertilization and embryo transfer is explained, and nurses are given an overview of this new technique for treating infertility. The role of the nurse in each phase of the process is described, with emphasis on meeting the educational and emotional needs of couples.