Circadian pattern of intubation rates in ED patients with congestive heart failure

Purpose

A previous study showed that pulmonary edema patients presenting between noon and 4 pm have the highest rates of myocardial infarction and death. We hypothesized that the highest intubation rates would also occur at these times.

Basic Procedures

We performed a retrospective cohort study of consecutive patients seen by emergency department physicians in 15 hospital emergency departments (1996-2003).

Main Findings

Of 3.6 million visits in the database, 39,795 (1.1%) patients had congestive heart failure. We found statistically significant circadian variations in intubation rates. Patients arriving between midnight and 4 am had the highest intubation rates (4.1%), and those arriving between noon and 4 pm had the lowest (1.2%) (difference, 2.9%; 95% confidence interval, 2.4%-3.4%; P < .0001).

Conclusion

We found significant circadian variation in intubation rates, with a marked increase around midnight. Pathological mechanisms causing patients with congestive heart failure to require intubation may differ from those resulting in myocardial infarction or death.     

Genetic variation in radiation and platinum pathways predicts severe acute radiation toxicity in patients with esophageal adenocarcinoma treated with cisplatin-based preoperative radiochemotherapy: results from the Eastern Cooperative Oncology Group

Purpose

Germline genetic variations may partly explain the clinical observation that normal tissue tolerance to radiochemotherapy varies by individual. Our objective was to evaluate the association between single-nucleotide polymorphisms (SNPs) in radiation/platinum pathways and serious treatment-related toxicity in subjects with esophageal adenocarcinoma who received cisplatin-based preoperative radiochemotherapy.

Methods

In a multicenter clinical trial (E1201), 81 eligible treatment-na?ve subjects with resectable esophageal adenocarcinoma received cisplatin-based chemotherapy concurrent with radiotherapy, with planned subsequent surgical resection. Toxicity endpoints were defined as grade ??3 radiation-related or myelosuppressive events probably or definitely related to therapy, occurring during or up to 6?weeks following the completion of radiochemotherapy. SNPs were analyzed in 60 subjects in pathways related to nucleotide/base excision- or double stranded break repair, or platinum influx, efflux, or detoxification.

Results

Grade ??3 radiation-related toxicity (mostly dysphagia) and myelosuppression occurred in 18 and 33% of subjects, respectively. The variant alleles of the XRCC2 5?? flanking SNP (detected in 28% of subjects) and of GST-Pi Ile-105-Val (detected in 65% of subjects) were each associated with higher odds of serious radiation-related toxicity compared to the major allele homozygote (47% vs. 9%, and 31% vs. 0%, respectively; P?=?0.005). No SNP was associated with myelosuppression.

Conclusions

This novel finding in a well-characterized cohort with robust endpoint data supports further investigation of XRCC2 and GST-Pi as potential predictors of radiation toxicity.     

Child life in the 1990s: Changing roles,changing times

This article presents an overview of the many changes that have occurred in the health care delivery system in the United States over the past few decades and their impact on the child life profession. It focuses upon four key factors: changing technology, rising health care costs, risk, management and liability, and alternative health care delivery systems. Throughout the discussion, potential threats to the traditional child life model are described, as well as opportunities for the survival, growth, and expansion of the child life profession and its commitment to the provision of high‐quality psychosocial care for children in health care settings.     

Constituents of salivary supernatant responsible for stimulation of oxygen uptake by the bacteria in human salivary sediment

The 10,000 g supernatant of wax-stimulated whole saliva was fractionated by gel filtration and its components were tested along with amino acids, small peptides and urea for their ability to stimulate this oxygen uptake, and for their effects on pH. Fractions containing the larger components, the proteins and large peptides, stimulated much less oxygen uptake than unfractionated supernatant, and caused a small decrease in pH. Analysis with anthrone indicated that both these effects were due mainly to the carbohydrate associated with these constituents. In contrast, fractions containing the remaining lower molecular-weight components stimulated substantial oxygen uptake and a rise in pH; both effects were like those seen with whole saliva supernatant. The oxygen effects were attributed mainly to certain amino acids and small peptides in the small molecular-weight fractions. Ornithine, arginine, proline and glutamic acid consistently stimulated oxygen uptake by the oral microflora in a test of 23 amino acids with the sediments of 13 subjects. Ornithine and arginine at the same time stimulated a significant rise in pH, whereas the other two amino acids showed no such effect. Variable and sometimes significant oxygen uptake was seen with alanine, aspartic acid, asparagine, glutamine and cysteine in 4-7 of the subjects; infrequent or no effects were seen with the remainder of the amino acids tested. There was some evidence to suggest that amino acid stimulation of oxygen uptake may be inducible. Urea had no effect on uptake but did contribute significantly to the pH rise. Small peptides containing those amino acids that could stimulate oxygen uptake also stimulated such uptake; peptides without such acids did not.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arginolytic and ureolytic activities of pure cultures of human oral bacteria and their effects on the pH response of salivary sediment and dental plaque in vitro

Thirty-nine different microorganisms commonly found in supragingival plaque and salivary sediment were screened for their ability to raise the pH by producing base from arginine, lysylarginine and urea. Only Actinomyces naeslundii and Staphylococcus epidermidis showed significant pH-rise activity with all three compounds. Eleven bacteria demonstrated such activity with arginine and lysylarginine but not with urea. Only one, Actinomyces viscosus, produced a pH-rise with urea but not with the two arginine compounds. The remaining 26 bacteria showed little or no base-forming activity with any of the three test substrates. The ability of the different oral bacteria to produce base (especially from urea) was a less universal function than their ability to produce acid from fermentable carbohydrate. Substituting pure cultures of arginolytic or non-arginolytic bacteria for portions of the mixed bacterial populations of plaque or sediment in test incubations containing glucose and arginine altered their ability to produce pH-fall-pH-rise responses shaped like those of the Stephen curve in vivo. In general, addition of arginolytic bacteria made these in vitro pH responses less acidic, whereas addition of non-arginolytic bacteria made the responses more acidic. Because of the relatively high arginolytic activity of the plaque harvested in this study, the effect of adding non-arginolytic bacteria was more readily seen than the converse. Similar changes in levels of ureolytic microorganisms and incubation with glucose and urea had little effect on sediment or plaque being able to produce a pH-fall-pH-rise type of response. When increasing proportions of the mixed bacteria in salivary sediment were replaced with the highly cariogenic Lactobacillus casei or Streptococcus mutans, the pH minimum became slightly more acidic and then slightly more alkaline, whereas the pH-rise became progressively and significantly less. Thus arginolytic bacteria have a different and greater effect on shaping the pH response of plaque or sediment than ureolytic bacteria. A large change in the proportions of arginolytic or non-arginolytic microorganisms may be needed to make a plaque microflora potentially non-cariogenic or cariogenic, respectively.     

The effect of age and sex on the relationship between crevicular fluid flow and gingival inflammation in humans

In a study on 120 subjects (60 males and 60 females) between the ages of 12 and 69 years, it was found that the relationship between gingival inflammation and crevicular fluid flow was not affected by age or sex. Because of their relationship to gingival disease, the effect of age and sex on crevicular pH, urea content, and concentration and crevice depth were also examined. Whereas, aging had no significant effect, sex may have had a slight effect since males exhibited slightly deeper pockets and a higher crevicular pH at most levels of inflammation. However, this may be due to poorer home care in males. The results have confirmed the inflammation-crevicular fluid relationship in a large number of adults of both sexes and add support for the use of crevicular fluid flow measurements as an objective technique for monitoring gingival inflammation.