Thermal injury in the elderly: when is comfort care the right choice?

The factors contributing to a higher mortality rate in elderly thermal injury victims are not well delineated. The purpose of this study is to determine the impact of the initial injury, medical comorbidities, and burn size on patient outcome and to determine a level of injury in this population when comfort care is an appropriate first choice. Individual medical records of patients over 65 years of age admitted to our burn center over a 10-year interval were reviewed for patient demographics, mechanism of injury, total body surface area (TBSA) burned, medical comorbidities, use of Swan-Ganz catheters, evidence of inhalation injury, level of support, and patient outcome. The mechanisms of thermal injury were flame (68%), scald (21%) and electrical or chemical contact (11%). Twenty-six preventable bathing, cooking, and smoking-related injuries were seen (33%). The average TBSA was 25 per cent. Average length of stay varied depending on outcome. The overall mortality rate for this group was 45 per cent. Patients older than 80 years with 40 per cent or greater TBSA burned had a 100 per cent mortality rate despite aggressive treatment. Burn wound size correlated better with probability of poor outcome than age. Thermal injuries in the elderly are becoming more important with the aging of our population. Underlying medical problems--specifically chronic obstructive pulmonary disease--do play a role in increased patient morbidity and mortality. This study shows that age greater than 80 years in combination with burns greater than 40 per cent TBSA are uniformly fatal despite aggressive therapy. We believe that delaying the start of comfort-only measures in this situation only prolongs the pain and suffering for the patient, the family, and the physician.     

Fetal-to-maternal transfer of thyroid hormone metabolites in late gestation in sheep

3,3'-Diiodothyronine sulfate (T2S) derived from T3 of fetal origin is transferred to the maternal circulation and contributes significantly to the maternal urinary pool. The present study quantitatively assesses the fetal to maternal transfer of T4 metabolites compared with those of T3. Labeled T4 or T3 was infused intravenously to four singleton fetuses in utero in each group at gestational age 138 +/- 3 d. Maternal and fetal serum and maternal urine samples were collected hourly for 4 h and at 24 h (serum) or in pooled 4-24 h samples (urine). Radioactive metabolites were identified by HPLC and by specific antibody in serum and urine extracts and expressed as percentage infusion dose per liter. The results demonstrate a rapid clearance of labeled T3 from fetal serum (disappearance T(1/2) of 0.7 h versus 2.4 h for T4 in the first 4 h). The metabolites found in fetal serum after labeled T3 infusion were T2S > T3 > T3S; in maternal urine, T2S > unconjugated iodothyronines (UI) > T3S > unknown metabolite (UM). After labeled T4 infusion, the metabolites in fetal serum were rT3 > T3 > T2S > T4S in the first 4 h, and rT3 = T3 = T4S = T2S > T3S at 24 h; in maternal urine we found T2S > UM > UI > T4S > T3S in the first 4 h and UM > T2S > UI in 4-24 h pooled sample. In conclusion, the conversion of T3 to T2S followed by fetal to maternal transfer of T2S and other iodothyronines appears to contribute importantly to maintaining low fetal T3 levels in late gestation.     

Human health and performance for long-duration spaceflight

Future long-duration spaceflights are now being planned to the Moon and Mars as a part of the "Vision for Space Exploration" program initiated by NASA in 2004. This report describes the design reference missions for the International Space Station, Lunar Base, and eventually a Mars Expedition. There is a need to develop more stringent preflight medical screening for crewmembers to minimize risk factors for diseases which cannot be effectively treated in flight. Since funding for space life sciences research and development has been eliminated to fund program development, these missions will be enabled by countermeasures much like those currently in use aboard the International Space Station. Artificial gravity using centrifugation in a rotating spacecraft has been suggested repeatedly as a "universal countermeasure" against deconditioning in microgravity and could be an option if other countermeasures are found to be ineffective. However, the greatest medical unknown in interplanetary flight may be the effects of radiation exposure. In addition, a Mars expedition would lead to a far greater level of isolation and psychological stress than any space mission attempted previously; because of this, psychiatric decompensation remains a risk. Historically, mortality and morbidity related to illness and injury have accounted for more failures and delays in new exploration than have defective transportation systems. The medical care system on a future Mars expedition will need to be autonomous and self-sufficient due to the extremely long separation from definitive medical care. This capability could be expanded by the presence of a physician in the crew and including simple, low-technology surgical capability.     

Relationship of Carbapenem Restriction in 22 University Teaching Hospitals to Carbapenem Use and Carbapenem-Resistant Pseudomonas aeruginosa

Many hospital antimicrobial stewardship programs restrict the availability of selected drugs by requiring prior approval. Carbapenems may be among the restricted drugs, but it is unclear if hospitals that restrict availability actually use fewer carbapenems than hospitals that do not restrict use. Nor is it clear if restriction is related to resistance. We evaluated the relationship between carbapenem restriction and the volume of carbapenem use and both the incidence rate and proportion of carbapenem-resistant Pseudomonas aeruginosa isolates from 2002 through 2006 in a retrospective, longitudinal, multicenter analysis among a consortium of academic health centers. Carbapenem use was measured from billing records as days of therapy per 1,000 patient days. Hospital antibiograms were used to determine both the incidence rate and proportion of carbapenem-resistant P. aeruginosa isolates. A survey inquired about restriction policies for antibiotics, including carbapenems. General linear mixed models were used to examine study outcomes. Among 22 hospitals with sufficient data for analysis, overall carbapenem use increased significantly over the 5 years of study (P < 0.0001), although overall carbapenem resistance in P. aeruginosa did not change. Hospitals that restricted carbapenems (n = 8; 36%) used significantly fewer carbapenems (P = 0.04) and reported lower incidence rates of carbapenem-resistant P. aeruginosa (P = 0.01) for all study years. Fluoroquinolone use was a potential confounder of these relationships, but hospitals that restricted carbapenems actually used fewer fluoroquinolones than those that did not. Restriction of carbapenems is associated with both lower use and lower incidence rates of carbapenem resistance in P. aeruginosa.Hospital antimicrobial stewardship programs (ASPs) attempt to improve antibacterial prescribing, commonly using formulary restrictions and by requiring preauthorization (7). Carbapenems are restricted in some hospitals for treatment of gram-negative bacterial infections resistant to first-line drugs, although carbapenem resistance among Pseudomonas aeruginosa and Enterobacteriaceae is increasing (3, 14, 18-20).Individual hospitals have reported improvement in bacterial susceptibilities to carbapenems after implementing ASPs that restricted carbapenem use (1, 11, 22). However, these “before and after” study designs have been criticized, and it is not known if the results are generalizable (6). There are no multihospital investigations that have assessed the effect of carbapenem restriction on carbapenem use and carbapenem-resistant P. aeruginosa over multiple years. In this study we evaluated the association between carbapenem restriction in academic health centers and the volume of carbapenem use and both the incidence rate and proportion of carbapenem-resistant P. aeruginosa from 2002 through 2006.(This study was presented in part at the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, IL, September 2007.)     

The differential mediating effects of pain and depression on the physical and mental dimension of quality of life in Hong Kong Chinese adults

Objective  

The impact of pain and depression on health-related quality of life (QoL) is widely investigated, yet the pain-depression interactions on QoL remain unclear. This study aims to examine the pain-depression-QoL mediation link.     

Discordance Between Adolescent Real and Ideal Sex Partners and Association With Sexually Transmitted Infection Risk Behaviors

PurposeEpidemic levels of sexually transmitted infections (STIs) among urban youth have drawn attention to the potential role of sex partner selection in creating risk for STIs. The objectives of this study were to describe the ideal preferences and real selection of sex partners, to evaluate sex partner ideal versus real discordance using quantitative methods, and to determine the association between discordance and STI risk behaviors.MethodsData are obtained from an urban, household sample of 429 individuals aged 15–24 years. Trait clusters were developed for participants' ratings of their real and ideal sex partners and tested for reliability. Discordance between the ratings of real and ideal partners was measured. Logistic regression was used to assess associations between sex partner discordance and STI risk behaviors.ResultsRatings of the real sex partners were often lower than participants' ideal sex partner ratings. A total of 33% of male adolescents and young men and 66% of female adolescents and young women were discordant on at least one trait cluster. Male adolescents and young men who were discordant on the emotional support they expected of their partner were more likely to report more than two sex partners in the past 90 days (odds ratio = 2.13, 95% confidence interval: 1.06–4.26) and perceived partner concurrency (odds ratio = 3.85, 95% confidence interval: 1.53–9.72). For female adolescents and young women, discordance on fidelity or emotional support significantly increased the odds of all risk behaviors.ConclusionMale and female adolescents with discordant real and ideal sex partner ratings were more likely to report STI-related risk behaviors. Further steps should involve identification of factors associated with ideal versus real sex partner discordance, such as features of the social context.     

Broad-based general surgery training is a model of continued utility for the future

SUMMARY BACKGROUND DATA: Our program has emphasized broad-based training that potentially allows residents to pursue a variety of career paths, with or without additional surgical training. Diverse experiences have emphasized a variety of rotations, including a university hospital with a large trauma service, several tertiary private institutions, and suburban and rural experiences with private practitioners. Our faculty includes surgeons with both broad-based and narrowly focused practices. In light of duty-hour restrictions and proposed changes in surgical training, we assessed the results of this model over an extended period. MATERIALS AND METHODS: The case volume from the Residency Review Committee (RRC) operative logs, ABSITE scores, ABS performance, fellowship training, and subsequent career choices were examined for all graduating chief residents in general surgery from our program over the past 17 years. The impact of specialty faculty was assessed and data from 5 index (aortic, major esophagogastric, liver, pancreatic, and pelvic resections) cases were also abstracted from the logs. A survey was then sent to all 208 of the 212 surgeons who had completed the program since 1971. RESULTS: Of the 115 residents who completed training in the last 17 years, 60 pursued fellowship training and 55 went directly into general surgical practice in 20 states. Fifteen of the 29 residents who had an elective laboratory experience were among the 23 who remained in academic careers. The operative experience has been excellent (1090 +/- 42 total major; 240 +/- 21 surgeon chief). Experience did not vary, even though the number of graduating chiefs ranged from 5 to 8 per year, and there have been no deficiencies in RRC index cases. The addition of specialty faculty (n = 5) at various intervals promptly increased the volume of complex cases in pelvic, liver, pancreas, and vascular surgery. Since all residents promptly passed the ABS examinations, it was not possible to discern factors associated with Board performances other than broad-based training. The survey demonstrated that most continued to practice broad-based general surgery and believed that such training was highly relevant to their current practice. CONCLUSIONS: The provision of broad-based training with generalists and specialty faculty has allowed for excellent breadth and depth in case volume. While many residents pursued fellowships, those who did not have indeed achieved successful careers. Most continue to practice general surgery, indicating the value of complete training in this field. It will be important to monitor these outcomes as changes in residency training occur.     

Silencing women’s sexuality: global AIDS policies and the case of the female condom

Introduction

The female condom is the only evidence-based AIDS prevention technology that has been designed for the female body; yet, most women do not have access to it. This is remarkable since women constitute the majority of all HIV-positive people living in sub-Saharan Africa, and gender inequality is seen as a driving force of the AIDS epidemic. In this study, we analyze how major actors in the AIDS prevention field frame the AIDS problem, in particular the female condom in comparison to other prevention technologies, in their discourse and policy formulations. Our aim is to gain insight into the discursive power mechanisms that underlie the thinking about AIDS prevention and women’s sexual agency.

Methods

We analyze the AIDS policies of 16 agencies that constitute the most influential actors in the global response to AIDS. Our study unravels the discursive power of these global AIDS policy actors, when promoting and making choices between AIDS prevention technologies. We conducted both a quantitative and qualitative analysis of how the global AIDS epidemic is being addressed by them, in framing the AIDS problem, labelling of different categories of people for targeting AIDS prevention programmes and in gender marking of AIDS prevention technologies.

Results

We found that global AIDS policy actors frame the AIDS problem predominantly in the context of gender and reproductive health, rather than that of sexuality and sexual rights. Men’s sexual agency is treated differently from women’s sexual agency. An example of such differentiation and of gender marking is shown by contrasting the framing and labelling of male circumcision as an intervention aimed at the prevention of HIV with that of the female condom.

Conclusions

The gender-stereotyped global AIDS policy discourse negates women’s agency in sexuality and their sexual rights. This could be an important factor in limiting the scale-up of female condom programmes and hampering universal access to female condoms.