Alcohol consumption patterns and predictors of use following liver transplantation for alcoholic liver disease.

For patients who receive a liver transplant (LTX) for alcoholic liver disease (ALD), investigators are focusing beyond survival to determine specific alcohol use outcomes. Studies suggest the use of alcohol ranges from 8 to 22% for the first post-transplant year with cumulative rates reaching 30 to 40% by 5 years following transplantation. Yet while investigators are interested in determining specific rates of alcohol use and predictors of use, only three studies since 1990 have been prospective. In 1998, we began a prospective study of post-LTX alcohol consumption in ALD recipients using multiple repeated measures of alcohol use. After 5 years of follow-up, we found that 22% had used any alcohol by the first year and 42% had a drink by 5 years. By 5 years, 26% drank at a heavier use (binge) pattern and 20% drank in a frequent pattern. In a univariate model, predictors of alcohol use included pre-transplant length of sobriety, a diagnosis of alcohol dependence, a history of other substance use, and prior alcohol rehabilitation.     

Chimeric cytotoxin IL2-PE40 inhibits relapsing experimental allergic encephalomyelitis.

IL2-PE40 is a chimeric protein composed of human interleukin-2 (IL2) genetically fused to a modified form of Pseudomonas exotoxin lacking the cell recognition domain. IL2-PE40 is cytotoxic for IL2 receptor-bearing lymphocytes in culture and can inhibit activation of T cells in vivo. IL2-PE40 can significantly diminish antigen-stimulated proliferation of lymphocytes sensitized to myelin basic protein. Intraperitoneal administration of IL2-PE40 not only markedly inhibits the clinical manifestations of adoptively transferred relapsing experimental allergic encephalomyelitis but also dramatically reduces both inflammation and demyelination characteristic of the disease.     

Undergraduate surgical training: variations in program objectives and curriculum implementation across Canada.

BACKGROUND: Although nationally recognized learning objectives for undergraduate surgical education exist, the extent to which Canadian medical schools follow these guidelines has never been established. METHODS: We distributed a survey to all program directors and clinical-teaching-unit coordinators for undergraduate surgery at Canada's 16 medical schools, and subsequently assessed the perceived emphasis placed on learning objectives and student performance, and the impact of instructional tools and teaching locations. RESULTS: Program directors in 15 medical schools responded to the survey. We identified a wide variation in the emphasis placed on basic learning objectives as well as specialty specific learning objectives. The length of rotations, methods of instruction and tools used to grade student performance also varied widely. CONCLUSIONS: Our findings suggest significant variation in the design and implementation of undergraduate surgical education in Canada. This study may serve as a basis for reassessing learning objectives in Canadian undergraduate surgical education.     

Changing patterns of hip fracture care before and after implementation of the prospective payment system

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.     

Incorrect positioning of nasogastric feeding tubes and the development of pneumothorax.

The authors describe 12 patients in whom feeding tubes were inadvertently placed in the bronchial tree a total of 14 times. All but four of the misplacements were complicated by pneumothorax. No deaths were directly attributable to the misplacements, although one cardiac arrest occurred as a late complication of intrapleural feeding. Careful, controlled insertion of feeding tubes and radiographic confirmation of their placement are essential to reduce morbidity and mortality.     

Bacteraemia in diabetics

During a period of 22 months one or more episodes of bacteraemia were detected in 168 patients in hospital. Of these, 29% also had diabetes compared with 10% of the total number of patients admitted to hospital during this time (P less than 0.001). The diabetics with bacteraemia were elderly and diabetes had usually been present for many years. Most of them were not receiving insulin at the time bacteraemia was diagnosed. Escherichia coli was the commonest pathogen (33%) in the diabetics, the main source of infection being the urinary tract. This finding may be due to diabetic autonomic neuropathy, which leads to a poorly emptying, chronically infected bladder. Urinary tract infections with bacteraemia in elderly diabetics are often accompanied by vague non-specific symptoms and poor diabetic control. Fever is infrequent. Prompt antibiotic therapy and insulin injections to control the diabetes usually cure these serious infections.     

Stability of famotidine 20 and 40 mg/L and amino acids in total parenteral nutrient solutions

The stability of famotidine in total parenteral nutrient (TPN) solutions and the concentrations of amino acids in the presence of famotidine were determined. Two famotidine concentrations (20 mg/L and 40 mg/L) and two amino acid concentrations (20 g/L and 42.5 g/L) were studied under the following storage conditions: refrigerated for 24 hours and then kept at room temperature (20-22 degrees C) for 24 hours, at room temperature for 48 hours, or refrigerated for seven days. Control TPN solutions were studied under the same storage conditions. TPN solutions also contained dextrose 25%, electrolytes, trace elements, and vitamins. Famotidine concentration was determined at 0, 24, and 48 hours and at seven days by high-performance liquid chromatography. Amino acid concentration was determined in the TPN solutions containing 42.5 g/L of amino acids without famotidine and with famotidine 40 mg/L under both 48-hour storage conditions. At 24 hours, all solutions retained at least 95% of the initial famotidine concentration. Seven of the eight famotidine solutions retained more than 95% of the initial famotidine concentration at 48 hours. All samples refrigerated for seven days retained more than 95% of the initial famotidine concentration. The concentration of amino acids in TPN solutions containing 42.5 g/L of amino acids was not affected by the addition of famotidine 40 mg/L under either 48-hour storage condition. Famotidine in concentrations of 20 mg/L and 40 mg/L is stable under the studied 48-hour storage conditions in TPN solutions containing amino acid concentrations of either 20 g/L or 42.5 g/L.(ABSTRACT TRUNCATED AT 250 WORDS)