Far forward gynecologic care of the female soldier

OBJECTIVE: To evaluate the value, unit cost and medical effectiveness of providing specialized obstetric and gynecologic care far forward, at echelon III, the combat support hospital (CSH), in the operating theater of Afghanistan during Operation Enduring Freedom (OEF), rotation 5. STUDY DESIGN: Between April 2004 and September 2004, records were reviewed from the outpatient gynecology clinic at Bagram Air Field (BAF), in Afghanistan, through an approved protocol request. Cohort analysis was performed on all gynecologic patients. Significant differences in distribution of clinical factors were determined by Student's t test. RESULTS: A total of 62 cases were extracted for analysis over the 6-month period. Fifty-seven total patients were seen at echelon III, the CSH at BAF, while 5 were sent to level IV or V echelon care in Landstuhl, Germany. The average distance traveled for the patients coming to BAF was 158 km, while those sent to Germany averaged 5,204 km. The mean travel time in days was significantly lower among patients seen at BAF, 0.5 versus 7 days for patients sent to Germany. The time to appointment was also significantly lower among those patients seen at BAF: 0.04 versus 13 days for patients sent to Germany. CONCLUSION: We devised and implemented the concept of far forward specialized gynecologic care for women participating in OEF. This substantially decreased the woman-hours lost by their individual units. The far forward availability of gynecologic care and the supplies to evaluate and treat abnormal Pap smears should be considered by all military services in their plans for providing health care for the modern female soldier.     

Postnatal manganese exposure attenuates cocaine-induced locomotor activity and reduces dopamine transporters in adult male rats

In the present study, we examined whether exposing rats to manganese (Mn) during the preweanling period would affect basal or cocaine-induced locomotor activity in adulthood and reduce the number of striatal dopamine transporter binding sites. On postnatal day (PD) 1-21, rats were given oral supplements of vehicle or Mn chloride (250 or 750 microg/day). Striatal Mn and iron (Fe) accumulation as well as serum Fe levels were measured on PD 14, PD 21, and PD 90. Throughout the dosing period, rats were evaluated on standard measures of sensory and motor development. During adulthood, the basal and cocaine-induced locomotor activity of vehicle- and Mn-exposed rats was assessed using automated testing chambers. After completion of behavioral testing, striatal dopamine transporter binding sites were measured using [(3)H]GBR 12935. Results showed that early Mn exposure enhanced striatal Mn accumulation on PD 14 and PD 21, while depressing serum Fe levels on PD 21. Exposure to Mn on PD 1-21 did not affect striatal or serum Mn or Fe levels on PD 90. During the second postnatal week, Mn-exposed rat pups performed more poorly than controls on a negative geotaxis task, however basal motor activity of preweanling rat pups was not affected by Mn treatment. When tested in adulthood, basal locomotor activity of vehicle- and Mn-exposed rats also did not differ. In contrast, adult rats previously exposed to 750 microg/day Mn showed an enhanced locomotor response when challenged with 10 mg/kg cocaine. A different pattern of results occurred after treatment with a higher dose of the psychostimulant, because Mn-exposed rats showed an attenuated locomotor response when given 20 mg/kg cocaine. Importantly, Mn-exposed rats exhibited long-term reductions in striatal dopamine transporter binding sites. Considered together, these results indicate that postnatal Mn exposure has long-term behavioral and neurochemical effects that can persist into adulthood.     

Are Patients with Multiple Endocrine Neoplasia Type I Prone to Premature Death?

Multiple endocrine neoplasia type I (MEN-I) is an autosomal dominant disorder characterized by endocrinopathies involving the anterior pituitary gland, parathyroid glands, and pancreas. The long-term prognosis for patients affected with this disorder is uncertain. To better characterize this prognosis, we performed a retrospective review of all patients with MEN-I treated at a single institution during the period 1951–1997. A group of 233 patients served as the study population. Their records were analyzed for confirmation of diagnosis, treatments received, long-term survival, and cause of death. Altogether, 108 eight male patients (46%) and 125 female patients (54%) were identified. At the conclusion of the study, 164 (70%) were alive and 69 (30%) were deceased, with a median follow-up for patients alive at last contact of 13.4 years (range < 1 month to 54.3 years). The cause of death was reliably obtained in 60 patients. Of these patients, 17 (28%) died of causes related to MEN-I, most commonly metastatic islet cell tumors (10 patients). The remaining patients died of causes unrelated to MEN-I, most commonly coronary artery disease and nonendocrine malignancies (14% each). The overall 20-year survival of MEN-I patients was 64% (95% CI was 56–72%), and that of an age- and gender-matched upper Midwest population was 81% (p < 0.001). Patients with MEN-I appear to be at increased risk of premature death. Earlier diagnosis and treatment of potentially malignant pancreatic islet cell neoplasms may result in a decrease of this premature mortality.     

Delirium part one: clinical features, risk factors and assessment

Delirium is a common and under-reported problem in older adults. A lack of consensus over the terminology used to describe delirium may contribute to its underdiagnosis, and a number of predisposing factors are linked to it. This article, the first of two, aims to define delirium, describe the different types and identify risk factors associated with its development. Delirium is an important condition as it has a deleterious effect on patient outcomes and quality of life if it is not detected early and managed effectively. The detection of delirium and a variety of assessment tools are also considered. Part two, to be published in next week's Nursing Standard, examines the nursing management of delirium.     

Eliminating catheter-related bloodstream infections in the intensive care unit

OBJECTIVE: To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). DESIGN: Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. SETTING: The Johns Hopkins Hospital. PATIENTS: All patients with a central venous catheter in the ICU. INTERVENTION: To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. MEASUREMENT: The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. MAIN RESULTS: Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. CONCLUSIONS: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.     

Mucus altering agents as adjuncts for nonviral gene transfer to airway epithelium

Nonviral vectors have been shown to be a safe and valid alternative to recombinant viruses for gene therapy of cystic fibrosis (CF). Nevertheless, gene transfer efficiency needs to be increased before clinical efficacy is likely in man. One barrier to increased efficacy is normal airway mucus. Using an ex vivo model of sheep tracheal epithelium, we show that this barrier can, in part, be overcome by treatment with the mucolytic agents, Nacystelyn or N-acetylcysteine using either a cationic lipid or a cationic polymer as the gene transfer agent. Further, in vivo application of either Nacystelyn or the anticholinergic glycopyrrolate, both clinically used agents, resulted in increased reporter gene expression in the mouse lung, but no significant correction of the bioelectric defect in CF null mice. These results, whilst unlikely to be sufficient in themselves to achieve clinically relevant gene therapy, may be a further useful step in the attainment of this goal.