Experience with sonography as an adjunct to amniocentesis for prenatal diagnosis of fetal genetic disorders.

This report summarized our experience with a consecutive series of 800 women referred for midtrimester amniocentesis for prenatal diagnosis of a fetal genetic abnormality. The results are compared before and after introduction of sonography immediately prior to the tap as a routine adjunct of the procedure. Following use of sonography there was a statistically significant reduction in the frequency of bloody taps, and an increase in the proportion of successful and informative initial taps. Moreover, in many instances sonography provided information useful for identification of fetal abnormalities or for management of pregnancy. These findings support the recommendation that examination by sonography should be utilized routinely as an adjunct to amniocentesis, despite the uncertainities relating to possible long-term adverse effects of intrauterine exposure to ultrasound.     

Diaspirin cross-linked hemoglobin (DCLHb) in the treatment of severe traumatic hemorrhagic shock: a randomized controlled efficacy trial

CONTEXT: Severe, uncompensated, traumatic hemorrhagic shock causes significant morbidity and mortality, but resuscitation with an oxygen-carrying fluid might improve patient outcomes. OBJECTIVE: To determine if the infusion of up to 1000 mL of diaspirin cross-linked hemoglobin (DCLHb) during the initial hospital resuscitation could reduce 28-day mortality in traumatic hemorrhagic shock patients. DESIGN AND SETTING: Multicenter, randomized, controlled, single-blinded efficacy trial conducted between February 1997 and January 1998 at 18 US trauma centers selected for their high volume of critically injured trauma patients, but 1 did not enroll patients. PATIENTS: A total of 112 patients with traumatic hemorrhagic shock and unstable vital signs or a critical base deficit, who had a mean (SD) patient age of 39 (20) years. Of the infused patients, 79% were male and 56% were white. An exception to informed consent was used when necessary. INTERVENTION: All patients were to be infused with 500 mL of DCLHb or saline solution. Critically ill patients who still met entry criteria could have received up to an additional 500 mL during the 1-hour infusion period. MAIN OUTCOME MEASURES: Twenty-eight day mortality, 28-day morbidity, 48-hour mortality, and 24-hour lactate levels. RESULTS: Of the 112 patients, 98 (88%) were infused with DCLHb or saline solution. At 28 days, 24 (46%) of the 52 patients infused with DCLHb died, and 8 (17%) of the 46 patients infused with the saline solution died (P = .003). At 48 hours, 20 (38%) of the 52 patients infused with DCLHb died and 7 (15%) of the 46 patients infused with the saline solution died (P = .01). The 28-day morbidity rate, as measured by the multiple organ dysfunction score, was 72% higher in the DCLHb group (P = .03). There was no difference in adverse event rates or the 24-hour lactate levels. CONCLUSIONS: Mortality was higher for patients treated with DCLHb. Although further analysis should investigate whether the mortality difference was solely due to a direct treatment effect or to other factors, DCLHb does not appear to be an effective resuscitation fluid.     

Magnetic Resonance Imaging of Traumatic Cervical Nerve Injuries

Posttraumatic cervical injuries represent a spectrum of injuries ranging from simple traction to frank nerve root avulsion with meningocele formation . The authors describe 3 patients with cervical nerve injuries, depicted by magnetic resonance imaging, highlighting unusual imaging manifestations.     

Continuous infusion cisplatin and etoposide chemotherapy for cancer of unknown primary site (CUPS) in Taiwan, a region with a high prevalence of endemic viral infections

BACKGROUND: To evaluate the efficacy and toxicity of cisplatin/etoposide continuous infusion chemotherapy for cancer of unknown primary site in Taiwan, a region with a high prevalence of endemic viral infections. METHOD: Between April 1994 and February 1996, 20 patients with a diagnosis of CUPS were treated, including 15 males and five females, of average age 63.3 years (range 41-83 years). Continuous intravenous infusion of etoposide 80 mg/m2 and cisplatin 25 mg/m2 was given for 3 days every 3 weeks. Pretreatment tumor marker and viral serology studies were performed for baseline evaluation. Nearly two-thirds of the patients had poorly differentiated carcinoma. The average number of metastatic sites was 2.65 (range 1-4), with liver and lymph node involvement predominating. RESULTS: The overall response rate was 25% (95% CI 17.7-32.3%); 30.7% for poorly differentiated cancers and 25% for well differentiated cancers. Median survival was 4 months (range 1-12 months), 4.8 months for patients attaining partial response. Toxicity was moderate, grade 3 and 4 neutropenia occurred in 55% and grade 3 and 4 thrombocytopenia in 40%; other toxicities were mild. CA125 and CA199 were elevated in more than 50% of patients. Viral serology studies were not significantly different from those of the indigenous population. CONCLUSION: Etoposide and cisplatin combination chemotherapy has modest activity in patients with extensive CUPS and, at the schedule and dosage given, it is associated with moderate toxicity.      

Detection of reactive oxygen species (ROS) and apoptosis in human fragmented embryos

In human in-vitro fertilization (IVF)-embryo transfer, the in-vitro culture environment differs from in-vivo conditions in that the oxygen concentration is higher, and in such conditions the mouse embryos show a higher concentration of reactive oxygen species (ROS) in simple culture media. ROS are believed to cause damage to cell membranes and DNA fragmentation in somatic cells. This study was conducted to ascertain the level of H2O2 concentration within embryos and the morphological features of cell damage induced by H2O2. A total of 62 human oocytes and embryos (31 fragmented, 15 non-fragmented embryos, 16 unfertilized oocytes) was obtained from the IVF-embryo transfer programme. The relative intensity of H2O2 concentrations within embryos was measured using 2',7'-dichlorodihydrofluorescein diacetate by Quanti cell 500 fluorescence imaging and DNA fragmentation was observed with transmission electron microscopy and an in-situ apoptosis detection kit. The H2O2 concentrations were significantly higher in fragmented embryos (72.21 +/- 9.62, mean +/- SEM) compared to non-fragmented embryos (31.30 +/- 3.50, P < 0.05) and unfertilized oocytes (30.75 +/- 2.67, P < 0.05). Apoptosis was observed only in fragmented embryos, and was absent in non-fragmented embryos. Electron microscopic findings confirmed apoptotic bodies and cytoplasmic condensation in the fragmented blastomeres. We conclude that there is a direct relationship between increased H2O2 concentration and apoptosis, and that further studies should be undertaken to confirm these findings.      

Clinimetric quality of the fire fighting simulation test as part of the Dutch fire fighters Workers' Health Surveillance

Background  

Clinimetric data for the fire fighting simulation test (FFST), a new test proposed for the Workers' Health Surveillance (WHS) of Dutch fire fighters, were evaluated.     

The clinical significance of command hallucinations

Patients with command hallucinations (voices ordering particular acts, often violent or destructive ones) are commonly assumed to be at high risk for dangerous behavior. The authors reviewed 789 consecutive inpatient admissions. Of 151 patients with auditory hallucinations, 58 (38.4%) heard commands. The presence of auditory hallucinations was significantly associated with diagnosis, demographic variables, and use of maximal observation and seclusion. However, patients with command hallucinations were not significantly different from patients without commands on demographic and behavioral variables, including suicidal ideation or behavior and assaultiveness. These findings suggest that command hallucinations alone may not imply greater risk for acute, life-threatening behavior.     

Medical control of mass gatherings: can paramedics perform without physicians on-site?

OBJECTIVE: Evaluate the experience of paramedic personnel at mass gatherings in the absence of on-site physicians. DESIGN: Retrospective review of patients evaluated by paramedics with emergency medical services (EMS) medical control. SETTING: First-aid facility operated by paramedics at an outdoor amphitheater involving 32 (predominantly rock music) concerts in accordance with the Chicago EMS System, June through September 1990. PARTICIPANTS: A total of 438 patients (< or = 0.1% on-site population) were evaluated. INTERVENTIONS: Presentations to the first-aid facility were viewed as if the patient was presenting to an ambulance. Transportation to an emergency department was strongly recommended for all encounters. Time from presentation to the first-aid facility until disposition was limited to 30 minutes in the absence of on-line [direct] medical control. Refusal of care was accepted. On-line [direct] medical control with the EMS resource hospital was initiated as needed. Off-line [indirect] medical control consisted of weekly reviews of all patients records and periodic site visits. RESULTS: Of the 438 patients, 366 (84%) refused further care, including 31 patients (7%) who refused advanced life support (ALS) level care. Seventy-two patients (16%) were transported; 37 by ALS and 35 by basic life support (BLS) units. On-line [direct] medical control was initiated in all ALS patients that were transported as well as for those who refused care. No known deaths or adverse outcomes occurred, based on lack of inquiries or complaints from the local EMS system, emergency departments receiving transported patients, law enforcement agencies, 9-1-1 emergency response providers, venue management, or security. No request for medical records from law firms have occurred. Problems noted initially were poor documentation and a tendency not to document all encounters (e.g., dispensing band-aids, tampons, earplugs, etc.). Concerns noted included: initial and subsequent vital signs, times of arrival, interventions, dispositions, and patient conditions of refusal. Specific problems with documentation of refusals at disposition included: appropriate mental status, speech, and gait; release with an accompanying family member or friend; and parental notification and approval of care for minors. There also was an initial tendency not to establish on-line [direct] medical control for ALS refusal or BLS medicolegal issues. CONCLUSIONS: The medical system configuration modeled after practices of prehospital care, demonstrates physicians did not need to be on-site when adequate EMS medical control existed with less than 30 minutes on-scene time.     

亲属活体肾移植18例报告

目的：总结亲属活体肾移植的临床经验，以期提高该技术的安全性及疗效。方法：选择2005—11／2006—12解放军第一七五医院收治的亲属活体肾移植患者18例，均知情同意。受体均为慢性肾小球肾炎；供体年龄24-74岁，17例有血缘关系，另一例为妻子供肾。均行经腰开放手术取肾，左侧供肾15例，右侧供肾3例。术后受体采用环孢素A＋霉酚酸酯＋激素三联低剂量免疫抑制剂方案。结果：①所有供体在术后10d左右出院，均无严重并发症且肾功能正常。②16例受体均在术后1-3d内移植肾功能恢复正常，另2例因供肾迷走血管损伤在术后5d左右血肌酐下降到200μmol／L，1个月左右稳定在160μmol／L。1例他克莫司仅服0．5-0．75mg／d，于术后5个月出现急性排斥反应。1例术后2个月出现环孢素A急性肾毒性（血药浓度谷值为343μg，L）。2例出现药物性肝炎。结论：亲属活体肾移植术较为安全，排斥反应少，结果满意。免疫抑制剂宜采用低剂量方案。