Tourniquets: A Review of Current Use with Proposals for Expanded Prehospital Use

Objective. To perform an initial screening study of methicillin-resistant Staphylococcus aureus (MRSA) contamination in an ambulance fleet. Methods. This was a cross-sectional study of MRSA contamination in an ambulance fleet operating in the western United States in June 2006. Five specific areas within each of 21 ambulances (n = 105) were tested for MRSA contamination using dacron swabs moistened with a 0.85% sterile saline solution. These samples were then plated onto a screening media of mannitol salt agar containing 6.5% NaCl and4 mcg/mL oxacillin. Results. Thirteen samples isolated from 10 of the 21 ambulances (47.6%) in the sample group tested positive for MRSA. Conclusions. The results of this preliminary study suggest that ambulances operating in the emergency medical services (EMS) system may have a significant degree of MRSA contamination andmay represent an important reservoir in the transmission of potentially serious infections to patients.     

SELF-EFFICACY AND LOCUS OF CONTROL AFFECT MANAGEMENT OF AGGRESSION BY MENTAL HEALTH NURSES

The safe and effective management of aggression has become an increasingly critical skill for mental health nurses, particularly those working in acute inpatient settings. There is considerable evidence to suggest that the psychological constructs of self-efficacy and locus of control are closely related to work performance in a variety of occupations. By drawing upon literature published in the past 15 years, this paper highlights this evidence and draws attention to the relationship between self-efficacy and locus of control. The central argument of the paper is that there may be direct relationships among mental health nurses” self-efficacy, their degree of internality or externality in relation to locus of control, and their ability to safely and effectively manage aggressive incidents. We argue the need to further investigate these relationships and discover whether these variables can be modified through professional development activities.     

Effect of apolipoprotein E genotype on hematoma volume after trauma.

OBJECT: The apolipoprotein E-epsilon4 (APOE-epsilon4) allele is associated with poor outcome after head injury and spontaneous intracerebral hemorrhage (SICH). The aims of this study were to determine if patients in whom one or more APOE-epsilon4 alleles are present are more likely to sustain intracranial mass lesions after head injury and to determine whether there is an isoform-specific effect on the size of the intracranial hematoma. METHODS: The authors performed a computerized volumetric analysis of 142 hematomas visible on computerized tomography (CT) scans obtained in 129 patients. The APOE genotype was determined by subjecting buccal smear samples to polymerase chain reaction and restriction enzyme digestion. Allele frequencies were similar in head-injured patients with and without intracranial hematomas (p = 0.36). Univariate analysis revealed that in those patients with one or more APOE-epsilon4 alleles hematoma volume was greater (cube root-transformed values) than that found in patients without the APOE-epsilon4 allele (3.1 cm compared with 2.5 cm, p = 0.0039). The results of univariate analysis also suggested significant effects of patient age, injury severity (mild, moderate, or severe according to admission Glasgow Coma Scale scores) and hematoma location (extraaxial, intraaxial, or both) on hematoma volume. The mechanism of injury (assault, fall, or other) was marginally associated with hematoma volume (p = 0.052). Time from injury to CT scan, hypoxia, and hypotension had no significant effect on hematoma volume. The results of multiple linear regression analysis showed that the presence of an APOE-epsilon4 allele and an extraaxial hematoma location were independent predictors of hematoma volume, after adjusting for patient age, hours between injury and CT scan, injury severity, and injury mechanism. CONCLUSIONS: Larger hematomas were found in head-injured patients with one or more APOE-epsilon4 alleles than in patients without the allele. This may contribute to the poorer outcomes observed in these patients.     

Reassessment of CD62L as a marker of pre-effector T cells in the tumor draining lymph nodes of head and neck cancer patients.

OBJECTIVES: CD62L was evaluated as a determinant of human pre-effector T cells. STUDY DESIGN AND SETTING: Phenotype and cytokine secretion profiles of CD62L cells were determined based on activation status. RESULTS: CD62L(Low) T cells demonstrated significantly higher secretion of interleukin (IL)-10 and interferon (IFN)-gamma than did CD62L(High) T cells. After activation, the majority of cells expressed high levels of the CD62L surface marker. Postactivation levels of IL-10 production remained elevated or unchanged. In a murine B16 melanoma model, freshly isolated CD62L(Low) tumor draining lymph nodes (TDLN) T cells showed increased secretion of IL-2 and IL-4 but not of IL-10 or IFN-gamma. The surface expression of CD62L and cytokine secretion patterns were maintained after activation with concomitant increases in IL-10. CONCLUSION: Our results provide evidence that CD62L(Low) T cells in TDLNs of progressively growing squamous cell carcinoma of the head and neck differ phenotypically and functionally from those of mouse origin. SIGNIFICANCE: Characterization of this human CD62L(Low) T cell population provides initial insight regarding novel surface markers in TDLN T cells that might correlate with antitumor reactivity.     

Job negotiation

A new job is a great opportunity to change and enhance your professional and personal life. Your new position will be defined through negotiation with the parties supporting your new position. Whether your new job is your first or your last, with a large organization or solo, urban or rural, the goal is the same, to define your expectations and communicate clearly to create a situation that you will find professionally and personally fulfilling.     

Revisiting Traditional Risk Factors for Rejection and Graft Loss After Kidney Transplantation

Single‐antigen bead (SAB) testing permits reassessment of immunologic risk for kidney transplantation. Traditionally, high panel reactive antibody (PRA), retransplant and deceased donor (DD) grafts have been associated with increased risk. We hypothesized that this risk was likely mediated by (unrecognized) donor‐specific antibody (DSA). We grouped 587 kidney transplants using clinical history and single‐antigen bead (SAB) testing of day of transplant serum as (1) unsensitized; PRA = 0 (n = 178), (2) third‐party sensitized; no DSA (n = 363) or (3) donor sensitized; with DSA (n = 46), and studied rejection rates, death‐censored graft survival (DCGS) and risk factors for rejection. Antibody‐mediated rejection (AMR) rates were increased with DSA (p < 0.0001), but not with panel reactive antibody (PRA) in the absence of DSA. Cell‐mediated rejection (CMR) rates were increased with DSA (p < 0.005); with a trend to increased rates when PRA>0 in the absence of DSA (p = 0.08). Multivariate analyses showed risk factors for AMR were DSA, worse HLA matching, and female gender; for CMR: DSA, PRA>0 and worse HLA matching. AMR and CMR were associated with decreased DCGS. The presence of DSA is an important predictor of rejection risk, in contrast to traditional risk factors. Further development of immunosuppressive protocols will be facilitated by stratification of rejection risk by donor sensitization.     

Characterization of ultrastructural and metabolic abnormalities in semen from men with spinal cord injury

BACKGROUND: In men with spinal cord injury (SCI), fertility is impaired because of a combination of ejaculatory dysfunction and poor semen quality. We hypothesized that ultrastructural and metabolic abnormalities of sperm could be an underlying factor in infertility in these men. METHODS: To investigate mechanisms contributing to the abnormal sperm parameters, we analyzed seminal constituents and sperm ultrastructure in ejaculates from 7 men with SCI and compared them with 5 control subjects. Sperm adenosine triphosphate (ATP) content was measured using a firefly luciferase bioluminescent assay kit, and ultrastructure was evaluated by electron microscopy. Seminal oxidative stress (8-iso-prostaglandin F-2alpha [8-iso-PGF2alpha]) and transforming growth factor-beta1 (TGF-beta1) levels were measured by specific enzyme-linked immunoabsorbent assay kits. RESULTS: Semen samples from men with SCI showed azoospermia (3) and severe asthenospermia (2; motility 0-5%). A majority (65%) of sperm from asthenospermic samples showed degenerative changes and significant axonemal defects. Incubation of normal sperm with SCI seminal plasma induced a concentration-dependent decrease in sperm motility (43%) accompanied by a significant drop in intracellular ATP content (33%). Semen samples from men with SCI exhibited levels of 8-iso-PGF2alpha 3.5-fold higher than those from controls and levels of TGF-beta1 that were 10% higher than those from controls. CONCLUSION: Our results suggest that seminal constituents of men with SCI are detrimental to sperm movement and that ultrastructural degenerative changes may contribute to the impaired sperm motility and viability seen in these patients. These preliminary results must be confirmed in larger patient populations and longitudinal studies.     

2,500 living donor kidney transplants: a single-center experience

OBJECTIVE: To review a single center's experience and outcome with living donor transplants. SUMMARY BACKGROUND DATA: Outcome after living donor transplants is better than after cadaver donor transplants. Since the inception of the authors' program, they have performed 2,540 living donor transplants. For the most recent cohort of recipients, improvements in patient care and immunosuppressive protocols have improved outcome. In this review, the authors analyzed outcome in relation to protocol. METHODS: The authors studied patient and graft survival by decade. For those transplanted in the 1990s, the impact of immunosuppressive protocol, donor source, diabetes, and preemptive transplantation was analyzed. The incidence of rejection, posttransplant steroid-related complications, and return to work was determined. Finally, multivariate analysis was used to study risk factors for worse 1-year graft survival and, for those with graft function at 1 year, to study risk factors for worse long-term survival. RESULTS: For each decade since 1960, outcome has improved after living donor transplants. Compared with patients transplanted in the 1960s, those transplanted in the 1990s have better 8-year actuarial patient and graft survival rates. Death with function and chronic rejection have continued to be a major cause of graft loss, whereas acute rejection has become a rare cause of graft loss. Cardiovascular deaths have become a more predominant cause of patient death; infection has decreased. Donor source (e.g., ideally HLA-identical sibling) continues to be important. For living donor transplants, rejection and graft survival rates are related to donor source. The authors show that patients who had preemptive transplants or less than 1 year of dialysis have better 5-year graft survival and more frequently return to full-time employment. Readmission and complications remain problems; of patients transplanted in the 1990s, only 36% never required readmission. Similarly, steroid-related complications remain common. The authors' multivariate analysis shows that the major risk factor for worse 1-year graft survival was delayed graft function. For recipients with 1-year graft survival, risk factors for worse long-term outcome were pretransplant smoking, pretransplant peripheral vascular disease, pretransplant dialysis for more than 1 year, one or more acute rejection episodes, and donor age older than 55. CONCLUSIONS: These data show that the outcome of living donor transplants has continued to improve. However, for living donors, donor source affects outcome. The authors also identify other major risk factors affecting both short- and long-term outcome.