A randomized controlled trial of sedation in the critically ill

A randomized controlled trial comparing: a) a combination of oral chloral hydrate and promethazine to b) a continuous intravenous midazolam infusion, for maintenance sedation in critically ill children, was carried out. The level of sedation was assessed four hourly using a specifically devized sedation scale. Forty-four children entered the study of whom two were subsequently excluded. The number of satisfactory assessments (desired and actual levels of sedation equal) was significantly greater in the chloral hydrate and promethazine group (Chi-squared P <0.01; confidence intervals of the difference 0.06 to 0.20). The number of assessments at level 5 on the sedation scale (patient restless/distressed) was significantly greater in the midazolam group (Chi-squared P <0.05). The total number of satisfactory assessments in the two groups were only 61 and 48% respectively, suggesting that sedation can be considerably improved. Chloral hydrate and promethazine are more effective than midazolam as maintenance sedation in critically ill children. It is possible to prospectively study the efficacy of sedative drugs in critically ill children.     

What Can Health Communication Science Offer for ACA Implementation? Five Evidence-Informed Strategies for Expanding Medicaid Enrollment

Context: Implementing the Affordable Care Act (ACA) in 2014 will require effective enrollment and outreach efforts to previously uninsured individuals now eligible for coverage.Methods: From 1996 to 2013, the Health Communication Research Laboratory conducted more than 40 original studies with more than 30,000 participants to learn how to improve the reach to and effectiveness of health information for low-income and racial/ethnic minority populations. We synthesized the findings from this body of research and used them to inform current challenges in implementing the ACA.Findings: We found empirical support for 5 recommendations regarding partnerships, outreach, messages and messengers, life priorities of low-income individuals and families, and the information environment. We translated these into 12 action steps.Conclusions: Health communication science can inform the development and execution of strategies to increase the public''s understanding of the ACA and to support the enrollment of eligible individuals into Medicaid or the Health Insurance Marketplace.     

CLINICAL EVALUATION OF A RADIOIMMUNOASSAY FOR β-MSH-RELATED PEPTIDES (LIPOTROPHINS) IN HUMAN PLASMA

A radioimmunoassay for β-MSH related peptides (‘β-MSH’) which measures βh- and γh-lipotrophin (LPH) and β-MSH, was used to assess LPH status and the stability of ‘β-MSH’ in blood and plasma.‘β-MSH’ concentrations correlated well with ACTH levels in paired snap-frozen plasma samples from normal subjects, from patients with pathologically elevated hormone levels (except those with chronic renal failure), and during acute stimulation and suppression tests (r= 0.913, P > 0.001). The mean ratio of ‘β-MSH’ and ACTH levels in most situations was approximately unity. In chronic renal failure,‘β-MSH’ concentrations were significantly higher than ACTH (mean ratio 4.1). Lesser degrees of dissociation of hormone levels were also found in patients with the ectopic ACTH syndrome (mean ratio 2.8). Basal ‘β-MSH’ levels were uniformly elevated in patients with Cushing's disease after bilateral adrenalectomy, Nelson's syndrome, ectopic ACTH syndrome, and Addison's disease and overlapped the normal range in patients with untreated Cushing's disease. There was complete separation of ‘β-MSH’ levels in ACTH-dependent and ACTH-independent (adrenal tumour) causes of Cushing's syndrome. Endogenous ‘β-MSH’ immunoactivity was more stable than ACTH in blood and plasma. There was no significant decrease of ‘β-MSH’ immunoactivity in samples kept at ambient temperature for 24 h or after four cycles of freezing and thawing plasma.‘β-MSH’ levels also did not change significantly in unhaemolysed blood samples transported at ambient temperature by first class mail. It is concluded that the ‘β-MSH’ assay provides at least as good discrimination as the ACTH assay in situations in which the latter is diagnostically valuable. Determination of the ratio of ‘β-MSH’ to ACTH levels may help to distinguish between untreated Cushing's disease and the ectopic ACTH syndrome. The stability of ‘β-MSH’ immunoactivity allows unhaemolysed blood and plasma samples to be transported at ambient temperature without loss of diagnostic value.     

THE RADIOIMMUNOASSAY OF 3,3',5'-TRHODOTHYRONINE (REVERSE T3) IN UNEXTRACTED HUMAN SERUM

A specific, sensitive and simple double antibody radioimmunoassay for total serum 3,3′,5′,-triiodothyronine (reverse T3, rT3) in small volumes of unextracted human serum is described. High titre antisera were raised in rabbits using dl -rt 3 or l -rT3 conjugated to bovine serum albumin. The selected antisera cross reacted less than 0–003% with triiodothyronine (T3) and 0–14% with thyroxine (T4). A stable high activity rT3 tracer was prepared by iodination of 3,3′-diiodo-l -thyronine by the chloramine-T method, and purified by column chromatography on Sephadex LH-20. Binding of rT3 to endogenous serum proteins was blocked by including 8-anilino-l-naphthalene sulphonic acid (ANS) in the assay. Mean rT3 levels in healthy euthyroid adults are 0.27 nmol/1 (range 015–0.42); in euthyroid patients 0.29 nmol/1 (range 0.11–0.80); in thyrotoxic subjects 1.26 nmol/1 (range 0.41–4.66); in T3 thyrotoxic subjects 0.47 nmol/1 (range 0.21–1.18); in cord sera 3.67 nmol/1 (range 2.30–7.45) and in amniotic fluid taken during the second trimester 4.70 nmol/1 (range 2.22–8.00). In approximately half the hypothyroid subjects, rT3 levels were undetectable (<0.05 nmol/1) and in the remaining subjects the mean rT3 level was 0.10 nmol/1 (range 0.05–0.25).     

Tuberculosis induced by droplet nuclei infection; initial homogeneous response of small mammals (rats,mice, guinea pigs,and hamsters) to human and to bovine bacilli,and the rate and pattern of tubercle development

Separate groups of rats, mice, hamsters, and guinea pigs were caused to inhale virulent tubercle bacilli, of human or bovine strains, as single cells in fine droplet nuclei. Members of each of these eight host-parasite combinations were killed for study at stated intervals after infection. For approximately 3 weeks after the bacilli were deposited in the lungs the progress of the infection, and the reaction of all species to it, followed a highly uniform developmental pattern. During the 4th week the rate and pattern of tubercle formation became distinctive for the species of host and the strain of parasite, but within any host-parasite combination this rate and pattern continued uniform for a time. The duration of this period of homogeneous response after the 4th week varied with the host-parasite combination, ranging from less than 5 weeks to more than 12 weeks after the induction of infection. It is concluded that the highly uniform initial response is evidence that these animals do not differ in their inherent resistance to inhaled infection by the bacilli of human or bovine tuberculosis. Instead, they differ widely in their capacity to acquire resistance to these organisms, as shown by the variation in the later stages of the disease.     

Prediction of lethal pulmonary hypoplasia and chorioamnionitis by assessment of fetal breathing

Summary. Twenty-three pregnancies with fetuses at risk for pulmonary hypoplasia were studied weekly until delivery. The amount of time spent in fetal breathing activity was recorded under controlled conditions during 1 h using real-time ultrasound. An amniotic fluid index was determined. The clinicians and the pathologist were unaware of the ultrasound findings. Eight of 23 fetuses did not breathe at the last ultrasound examination. Three babies died of pulmonary hypoplasia and two of these showed fetal breathing before birth. The three deaths were associated with rupture of the membranes at <20 weeks gestation and of ≥44 days duration. One infant developed bronchopulmonary dysplasia. The amniotic fluid index in these four pregnancies was low and the newborn infants had limb contractures. Chorioamnionitis/funisitis was noted in 13 placentas. Eight fetuses were assessed for fetal breathing within 2 days of birth. The lack of fetal breathing had sensitivity, specificity, positive and negative predictive values of 0.75 for chorioamnionitis/funisitis. In this pilot study the absence of fetal breathing was of no value in predicting lethal pulmonary hypoplasia, but was related to chorioamnionitis/funisitis. We recommend further studies of fetal breathing in relation to fetal/neonatal infections.     

Classical versus low-segment transverse incision for preterm caesarean section: maternal complications and outcome of subsequent pregnancies

Summary. In a retrospective, controlled, follow-up study of 326 women who had a primary preterm caesarean section, the risks of postoperative maternal morbidity and uterine rupture or dehiscence in subsequent pregnancies were investigated in relation to the mode of incision (classical compared with low-segment transverse incision). The classical incision was associated with a higher frequency of postpartum fever in the immediate postoperative period (16% compared with 6%, P<0·01). Of the 326 patients reviewed 286 (88%) were contacted for information about subsequent pregnancies. Information was obtained for 70 pregnancies subsequent to a classical caesarean section, and 71 pregnancies subsequent to a low-segment transverse caesarean section, which had continued for more than 20 weeks gestation. Of the pregnancies after the classical operation 13% had abnormal scars compared with none of those after the low-segment transverse operation ( P =0·0014). The frequency of scar dehiscence was 6% after a classical scar compared with none after a low-segment transverse scar (P=0·0581).     

The teaching of interviewing skills: comparison of experienced and novice trainers

During a clerkship in psychiatry thirty-six medical students were randomly allocated to one of three teachers who differed widely in their experience of teaching essential interviewing skills. Each teacher taught two groups of six medical students using videotape feedback and discussion of practice interviews. Independent raters who were blind to the teachers to whom the students had been assigned rated pre and post-training interviews. All three teachers proved effective in teaching interviewing skills and it is concluded that most teachers could probably be taught to carry out this training.     

AUTONOMIC NEURAL CONTROL MECHANISMS OF SUBSTRATE and HORMONAL RESPONSES TO ACUTE HYPOGLYCAEMIA IN MAN

The contributions of adrenergic and cholinergic mechanisms to recovery from acute hypoglycaemia induced by insulin (0.15 units/kg i.v.) were examined in eleven normal subjects, six subjects with a pre-ganglionic sympathectomy (adrenergic denervation) and six sympathectomized subjects given atropine (combined adrenergic denervation and cholinergic blockade). Blood glucose recovery was impaired only in the sympathectomized subjects given atropine. The blood lactate response was reduced and the rise in free fatty acids was delayed in both groups of sympathectomized subjects, in whom the normal rises of plasma cyclic AMP and noradrenaline were absent. The plasma pancreatic glucagon response was appropriate to the prevailing blood glucose concentrations in all three groups. The cortisol response was impaired and the pattern of ACTH secretion was abnormal in sympathectomized subjects given atropine. Growth hormone levels were higher in both sympathectomized groups. Blood glucose homeostasis was impaired during combined adrenergic denervation and cholinergic blockade. Glucagon secretion was activated independently of vagal control. In the sympathectomized group given atropine, the rise in plasma cortisol was blunted despite a greater degree of hypoglycaemia. A blockade of central cholinergic receptors producing impaired activation of ACTH secretion at hypothalamic level may explain, at least in part, this delayed restoration of normoglycaemia.