Is the IV obstructed or infiltrated? A simple clinical test

Objective. The objective of our study was to determine if clinical observation of pressure-flow relationships (PFR) can differentiate between partial external obstruction (obstruction) and infiltration as a cause of poor performance of gravity-fed infusions.Methods. A total of 24 patients with functional intravenous cannulae in situ had obstruction simulated by the application of a tourniquet proximal to the cannula. The change in flow (F) for a discrete change in pressure (P) was determined in each case by counting drop rates at two different elevations of the fluid reservoir level, 10 cm apart. The same process was repeated in 15 patients in whom the cannula was in an extra vascular location (infiltration). Three sizes of cannula—16-gauge, 18-gauge, and 20-gauge—were examined, with equal distribution of sizes in each group. The effect on flow rates of inflating a blood pressure (BP) cuff proximally on the cannulated limb was assessed. The ratio P/F is the total resistance of the infusion system, and by subtracting known values for resistance of infusion tubing and cannula, the venous or tissue resistance was calculated.Results. There was a statistically significant difference between the change in flow for obstructed compared with infiltrated cannulae for the same change in pressure for each cannula size. The mean venous resistance was 23 mm Hg/L/hr, while that of tissue was 280 mm Hg/L/hr, with no overlap between groups. There was no effect on flow rate with blood pressure cuff inflation in the infiltrated group whereas flow progressively fell in the obstructed group.Conclusions. Clinical observation of PFRs in poorly functioning gravity-fed IV infusions can assist in detecting infiltration as a cause. Inflation of a blood pressure cuff will further impair flow where the cannula is intravascular, but will have no effect in an extravascular location.     

Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands

OBJECTIVE: To document long-term results associated with an coordinated plan of care for acutely burned hands in children. SUMMARY AND BACKGROUND DATA: Optimal hand function is a crucial component of a high-quality survival after burn injury. This can be achieved only with a coordinated approach to the injuries. Long-term outcomes associated with such a plan of care have not been previously reported. METHODS: Over a 10-year period, 495 children with 698 acutely burned hands were managed at a regional pediatric burn facility; 219 children with 395 injured hands were followed in the authors' outpatient clinic for at least 1 year and an average of >5 years. The authors' approach to the acutely burned hand emphasizes ranging and splinting throughout the hospital stay, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. Long-term follow-up, hand therapy, and reconstructive surgery are emphasized. RESULTS: Normal functional results were seen in 97% of second-degree and 85% of third-degree injuries; in children with burns involving underlying tendon and bone, 70% could perform activities of daily living and 20% had normal function. Reconstructive hand surgery was required in 4.4% of second-degree burns, 32% of third-degree burns, and 65% of those with injuries involving underlying bone and tendon. CONCLUSIONS: When managed in a coordinated long-term program, the large majority of children with serious hand burns can be expected to have excellent functional results.     

Percutaneous endoscopic gastrostomy in burn patients

Background: Prolonged enteral feedings are required occasionally in seriously burned individuals. We have employed percutaneous endoscopic gastrostomy (PEG) in selected patients who require particularly prolonged access, thus prompting this review. Methods: The PEG procedure was performed under general anesthesia in combination with another surgical procedure using a variety of commercially available needle and guidewire kits in 14 patients. Results: These 14 patients had an average age of 55.2 ± 6.6 years and a burn involving 38 ± 8% of the body surface. Eleven of these patients had suffered an inhalation injury. The tubes were placed an average of 57 ± 10.5 days after injury through unburned and unharvested skin in four patients (28%), healed donor sites in five patients (35%), healed burn in one patient (1%), and grafted burn in four patients (28%). One patient, whose catheter was placed through a grafted fascial excision, developed moderate local wound erosion. Tubes were known to have been left in place as long as 155 days. However, most were removed in rehabilitation hospitals, and we were unable to determine how long most were left in place. We are unaware of any problems with the tubes occurring after discharge from the acute care setting. Conclusions: In selected patients, PEG can provide more comfortable access for prolonged enteral feedings than nasogastric tubes and can be placed with minimal morbidity. Received: 29 March 1998/Accepted: 1 August 1998     

Solid organ procurement from burned children

BACKGROUND: Burns have constituted a traditional contraindication to solid organ procurement because of concerns that such organs may be damaged by burn shock associated splanchnic ischemia and contaminated by burn wound manipulation associated bacteremia. METHODS: Over a 5-year period, we attempted solid organ procurement from five burned children who had suffered concurrent anoxic brain injury. RESULTS: These four boys and one girl had an average age of 8.1 years (range, 2.5-12 years) and burn size of 29% (range, 4-70%). All were injured in house fires and four of five (80%) required prehospital external cardiac compressions. Brain death was declared an average of 35 hours (range, 2.75-77 hours) after injury. Solid organs procured and successfully transplanted from this group were 4 livers, 10 kidneys, and 2 hearts. Two of the livers and one heart were placed into pediatric recipients. Procured tissues included three sets of cardiac valves, and two corneas. All solid organs transplanted were functional at 6 months, although longer follow-up is not available. CONCLUSION: Early identification and diagnosis of brain death during resuscitation of burn patients with anoxic brain injury, combined with careful resuscitation and support of the brain dead potential organ donor, can result in the recovery of suitable solid organs and tissues for transplantation.     

Synthesis and antispasmodic activity of analogues of natural pterosins

The synthesis of an extensive range of analogues of natural pterosins using modified Heck coupling is reported. The smooth muscle relaxant activity of these compounds has been examimed. Several compounds with significant smooth muscle relaxant activity have been identified.     

Modulation of retinal pigment epithelial cell behavior by Agaricus bisporus lectin.

PURPOSE: To determine whether Agaricus bisporus lectin (ABL) binds retinal pigment epithelial cells (RPEs), to conduct a preliminary viability study of RPEs exposed to ABL, and to evaluate the effects of ABL on RPE proliferation and RPE-mediated matrix contraction in vitro. METHODS: Using cultured bovine RPEs, immunohistochemistry was used to study ABL binding. Morphologic and trypan blue exclusion techniques were used for toxicity studies. The effect of ABL on RPE proliferation was investigated by [methyl-3H]-thymidine incorporation. The effect of ABL on RPE-mediated matrix contraction was evaluated with RPE-populated three-dimensional collagen matrices. RESULTS: ABL bound to RPE cells. This binding was inhibited by asialomucin. No change in RPE morphology or trypan blue exclusion compared with controls was observed in RPEs incubated with 5 to 60 microg/ml ABL for 3 days. Twenty-four-hour incubations of RPEs with ABL significantly inhibited RPE proliferation in a dose-dependent way, 40 microg/ml ABL inhibited proliferation by 83% (SE 14, P<0.05). ABL showed a dose-dependent significant inhibition of RPE-mediated collagen matrix contraction over 3 days, with 93% inhibition compared with controls by 40 microg/ml lectin (P<0.05). The inhibitory effect of ABL on proliferation and gel contraction was partly reversible after eliminating ABL from the culture medium. CONCLUSIONS: Bovine RPE cells bind ABL, and preliminary evaluations suggest that levels of ABL that are nontoxic to the cells potently inhibit RPE proliferation and RPE-mediated matrix contraction. ABL deserves further investigation as a potential inhibitor of RPE proliferation and cell-mediated matrix contraction in anomalous reparative processes such as proliferative vitreoretinopathy and as a laboratory tool for RPE behavioral studies.     

SQ: a program for rapidly producing pharmacophorically relevent molecular superpositions

A new method SQ has been developed to provide fast, automatic, and objective pairwise three-dimensional molecular alignments. SQ uses an atom-based clique-matching step followed by an alignment scoring function that has been parametrized to recognize pharmacologically relevant atomic properties. Molecular alignments from SQ are consistent with known drug-receptor interactions. We demonstrate this with six pairs of receptor-ligand complexes from the Brookhaven Protein Data Bank. The SQ-generated alignment of one isolated ligand onto another is shown to approximate the alignment of the ligands when the receptors are superimposed. SQ appears to be better than its predecessor SEAL (Kearsley and Smith, Tetrahedron Comput. Methodol. 1990, 3, 615-633) in this regard. SQ has been tailored so that, given one molecule as a probe, it can be used to routinely scan large chemical databases for which precomputed conformations have been stored. The SQ score, a measure of 3D similarity of each candidate molecule to the probe, can be used to rank compounds for the purposes of chemical screening. We demonstrate this with three probes (a thrombin inhibitor, an HIV protease inhibitor, and a model for angiotensin II). In each case SQ can preferentially select from the MDDR database other compounds with the same activity as the probe. We further show, using the angiotensin example, how SQ can identify topologically diverse compounds with the same activity.     

Smooth muscle relaxant activity of pterosin Z and related compounds

The natural products pterosin Z, acetylpterosin Z, originally from the fern Pteridium aquilinum, and their isopterosin analogues have been synthesized and their smooth muscle relaxation activity has been measured. All of the test compounds show activity with pterosin Z being the most active (EC50 = 1.3 +/- 0.1 x 10(-6) M), exhibiting 100 times the activity reported for the related fern metabolites onitin (EC50 = 1 x 10(-4) M), onotisin (EC50 = 2 x 10(-3) M) and otninoside (EC50 = 7 x 10(-4) M). The smooth muscle relaxant activity of pterosin Z is approximately equipotent with that of the related fungal pterosin (EC50 of 2.9 +/- 1.6 x 10(-6) M). These results suggest that smooth muscle relaxant activity is reduced when a phenol group is present in the pterosin nucleus and when one of the dimethyl groups is derivatized.     

Comparison of in vivo and in vitro mouse bioassays for botulinum toxin antagonists

Measurements of the efficacy of novel botulinum toxin antagonists can be based on classical bioassays of toxin concentration. However, the relative sensitivities of in vivo and in vitro assays to the effects of antagonists are not necessarily correlated with the sensitivities of the assays to toxin. Comparisons of the sensitivity of an in vitro mouse muscle contraction assay with an in vivo mouse survival assay indicated that the in vivo assay was more sensitive to botulinum toxin serotype A by more than one order of magnitude at equivalent molar concentrations. However, in studies of toxin neutralization with equine antisera, the in vitro muscle assay was more than three times more sensitive to the presence of antisera than the equivalent mouse survival assay. For the development of new drugs to treat botulism, antagonist sensitivity is a primary consideration in determining relative efficacy during structure-activity studies. Thus, in studies of toxin antagonists, the in vitro assay appears to be superior for initial testing.