Pulmonary Embolism: Epidemiology,Patient Presentation,Diagnosis, and Treatment

Pulmonary embolism is a significant health concern, affecting mainly the adult and elderly population. The focus of this review article will be on the epidemiology, presentation, treatment, and outcomes of PE arising from deep venous thrombosis.     

GVHD after transfusion of stored RBC concentrates in a solution of mannitol, adenine, phosphate, citrate, glucose, and NaCl following trauma

BACKGROUND: It has not previously been reported that WBC-reduced RBC preparations can cause transfusion-associated GVHD, even in an immunocompetent individual. CASE REPORT: A 74-year-old man suffered a hemorrhage from the mesentery of the transverse colon after a traffic accident. During surgery, he received 10 units of RBCs from 10 donors in a solution containing mannitol, adenine, phosphate, citrate, glucose and NaCl (MAP). MAP RBCs had been stored for 7 to 8 days before use. On the 27th day after surgery, an erythematous, pruritic rash appeared over the face, neck, and trunk, which was associated with low-grade fever and pancytopenia. Transfusion-associated GVHD was strongly suspected and was confirmed by skin biopsy. To determine the origin of lymphocytes causing GVHD, several microsatellite loci were amplified from DNA of the patient's nails and blood and from blood samples of all 10 RBC donors by using PCR. Amplified alleles derived from the patient's blood were identical to those from one of the 10 samples. CONCLUSION: These findings indicate that transfusions of MAP-RBCs can cause transfusion-associated GVHD in an elderly but immunocompetent host.     

Experiences and Perceptions Toward Integrative,Complementary, and Alternative Medicine Among Conventional Medicine Practitioners of Mangalore,India

ObjectivesThe purpose of this study was to identify experiences and perception of conventional (Western, allopathic) medical practitioners toward integrative, complementary, and alternative medicine (ICAM).MethodsThere are approximately 1200 conventional medical doctors in Mangalore, India. In February 2017, semistructured self-administered questionnaires were distributed to 200 medical practitioners. The association between categorical variables was analyzed using a χ² test and those involving continuous variables using unpaired t test, analysis of variance, and Karl Pearson’s coefficient of correlation. A P value ≤ .05 was considered statistically significant.ResultsOf the surveys, 163 were returned and 129 were satisfactorily completed, giving a response rate of 64.5%. Mean age was 39.9 ± 11.9 years, and most 94 (72.9%) were male. A majority, 96 (74.4%), recommended ICAM to their patients. Nine had some training in ICAM modalities, and 76 (58.9%) participants reported personal usage of ICAM. Regarding perception toward effectiveness of ICAM, 33 (25.6%) felt that it was effective or somewhat effective. However, 82 (63.6%) participants felt that lack of sufficient scientific evidence was a major drawback of ICAM. However, 39 (30.2%) participants felt that ICAM should be part of Bachelor of Medicine and Bachelor of Surgery curricula. Favorable perception toward ICAM (P < .001) and personal usage of ICAM (P < .001) was associated with participants recommending any ICAM for their patients. Elderly practitioners (aged above 65 years) (P = .003) and practitioners with favorable perception regarding effectiveness of ICAM (P = .033) recommended a higher number of types of ICAM to their patients. Favorable perception toward effectiveness of ICAM was associated with favorable perception toward inclusion of ICAM in medical curriculum among participants (P = .002).ConclusionMost participants recommended ICAM to their patients and also reported personal usage of the same.     

Rapid, accurate, and sensitive fatty acid ethyl ester determination by gas chromatography-mass spectrometry

Background: Fatty acid ethyl esters (FAEEs) are useful markers of ongoing alcohol use and may be associated with alcohol-induced damage to the liver and pancreas. In this article, we describe a novel method for rapid determination of the three major FAEEs found in human plasma. Methods: Internal standard, ethyl heptadecanoate, was added to plasma samples, and FAEEs were isolated by acetone precipitation, hexane lipid extraction, and amino-propyl silica solid phase extraction. FAEEs were quantitated by gas chromatography-mass spectrometry (GC-MS) using a nonpolar dimethylpolysiloxane column. The accuracy, precision, specificity, and sensitivity of the assay were defined from plasma samples from recently drinking and abstinent persons, with and without the addition of FAEEs. Results: Individual FAEE peaks demonstrated excellent resolution. Instrument time was reduced by more than 60%. The lower limit of detection was 5 to 10 nM, and the lower limit of quantitation for each FAEE was 60 nM (for 22 samples with known concentration 60 nM, x +/-SD: 61 +/- 5.7, 57 +/- 5.7, and 57 +/- 5.9 nM, for ethyl palmitate, ethyl oleate, and ethyl stearate, respectively). Instrument precision (coefficient of variance, CV) for these three FAEEs was 0.3%, 0.4%, and 0.7%, respectively. Intra-assay precision (CV) for total FAEEs was less than 7%. FAEEs were absent in 49 samples from abstinent persons. FAEEs were detected in all 76 samples with associated positive blood alcohol levels. Conclusions: Our method of FAEE analysis is rapid and potentially useful in research and clinical studies. FAEE determination using this method is precise, accurate, sensitive, and specific and deserves broader application.     

Nocardiosis in persons with human immunodeficiency virus infection, transplant recipients, and large, geographically defined populations

To quantify the risk of nocardiosis in various populations, I systematically reviewed articles published between 1966 and 2004. The incidence of nocardiosis in 3 large, geographically defined populations ranged from 0.35 to 0.4 cases per 10(5) persons year. In contrast, the incidence of nocardiosis among people with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) in 1 study was 53 nocardiosis cases per 10(5) persons x year, approximately 140 times greater than that in the geographically defined populations. The frequency of nocardiosis cases in 4 populations of HIV-infected people averaged 608 cases per 10(5) persons. The incidence of nocardiosis in bone marrow-transplant recipients at 1 hospital was 128 cases per 10(5) persons x year, an incidence approximately 340 times greater than that in the geographically defined populations and in the same range as in HIV-infected people. The frequency of nocardiosis in 21 series of cases in recipients of a variety of transplanted organs averaged 1122 cases per 10(5) persons. These estimated incidence rates are imprecise because they were not collected through prospective surveillance systems, but the estimates for the 3 groups were internally consistent and provide useful information for clinicians.     

细节管理在护理质量监控中的影响

【】目的：探讨细节管理在护理质量监控中的作用。方法：选取2013年4月-2014年3月我院20个内科病房为对照组,采用常规管理方式监控护理质量,选取2013年4月-2014年3月我院15个外科病房为实验组,采用细节管理对护理质量进行监控。对两组的护理质量评分、患者满意度和护理不良事件发生率进行比较。结果：实验组各类护理质量评分均高于对照组,两组的患者满意度、患者投诉表扬次数和护理不良事件发生率比较有统计学意义(P<0.05)。结论：采用细节管理监控护理质量能提升护理质量,提高患者满意度,减少临床护理不良发生率。     

The effect of urine, pyrophosphate, citrate, magnesium and glycosaminoglycans on the growth and aggregation of calcium oxalate crystals in vitro

The effects of pyrophosphate, citrate, magnesium, heparin and chondroitin sulphate on the growth and aggregation of calcium oxalate crystals were measured at concentrations likely to be found in 1% urine. The degrees of inhibition of growth and of aggregation caused by these compounds were related to the effects of normal 1% urine on these processes. It was concluded that chondroitin sulphate is responsible for the major portion of the inhibitory effect of urine on crystal aggregation, but that the effect on crystal growth is probably due to the additive or synergistic effects of a number of urinary constituents.     

系统化护士跌倒安全教育对护士跌倒预防知识、态度、行为的影响分析

目的：探讨《住院患者跌倒预防临床实践指南》在我院试点应用,实施系统化的护士跌倒安全教育对临床护士跌倒预防知识、态度、行为的影响分析。方法：选取8个病区护士104人,随机分为对照组和实验组,调查分析两组护士跌倒预防知识、态度、行为自评的差异;调查分析实验组护士在干预6个月前后跌倒评估、预防行为实施(他评)的差异;结果：对照组和实验组护士跌倒预防知知识、态度、行为自评总分比较,差异有统计学意义(P＜0.01);实验组护士在干预6个月前后跌倒评估、预防行为实施(他评)的总分比较,差异有统计学意义(P＜0.01);结论：依据《住院患者跌倒预防临床实践指南》相关证据,实施系统化的护士跌倒安全教育,可提高临床护士跌倒预防知识、态度和行为的实施,自觉实施跌倒预防的各项安全措施,保障护理安全。     

Familial hypertryptophanemia,tryptophanuria and indoleketonuria

Two patients presenting with mental subnormality and severe emotional lability were examined for possible inborn errors of metabolism. Amino acid and organic acid analyses of their plasma and urine revealed a novel and grossly abnormal metabolism of tryptophan. Basal levels of plasma tryptophan were ten times that of controls and the 24-hour urinary excretion of tryptophan was up to 50 times greater than normal. Both patients excreted about 100 times the normal amounts of indoleacetic, indolelactic and indolepyruvic acids. Administration of oral antibiotic to one of the patients to eliminate intestinal bacteria did not result in any reduction in the excretion of the indoleic acids. The results are interpreted in terms of a possible congenital defect in the normal conversion of tryptophan to kynurenine.     

Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine

Aim

We review (1) scientific evidence questioning the validity of declaring death and procuring organs in heart-beating (i.e., neurological standard of death) and non-heart-beating (i.e., circulatory-respiratory standard of death) donation; (2) consequences of collaborative programs realigning hospital policies to maximize access of procurement coordinators to critically and terminally ill patients as potential donors on arrival in emergency departments; and (3) ethical and legal ramifications of current practices of organ procurement on patients and their families.

Data sources

Relevant publications in peer-reviewed journals and government websites.

Results

Scientific evidence undermines the biological criteria of death that underpin the definition of death in heart-beating (i.e., neurological standard) and non-heart-beating (i.e., circulatory-respiratory standard) donation. Philosophical reinterpretation of the neurological and circulatory-respiratory standards in the death statute, to avoid the appearance of organ procurement as an active life-ending intervention, lacks public and medical consensus. Collaborative programs bundle procurement coordinators together with hospital staff for a team-huddle and implement a quality improvement tool for a Rapid Assessment of Hospital Procurement Barriers in Donation. Procurement coordinators have access to critically ill patients during the course of medical treatment with no donation consent and with family or surrogates unaware of their roles. How these programs affect the medical care of these patients has not been studied.

Conclusions

Policies enforcing end-of-life organ procurement can have unintended consequences: (1) erosion of care in the patient's best interests, (2) lack of transparency, and (3) ethical and legal ramifications of flawed standards of declaring death.     

Meta-analysis: Methods, strengths, weaknesses, and political uses

The general methodology, strengths and weaknesses, and political uses of meta-analysis are examined. As a systematic study of all studies that have been conducted to answer a specific question or hypothesis, meta-analysis is strong in revealing structural flaws and sources of bias in primary research and in posing promising research questions for future study. It cannot exceed, however, the limits of what is reported by primary researchers. Meta-analysis is particularly challenged to quantify the size of a common effect of treatment across reported trials because of (1) the clinical diversity of the trials and (2) the myriad of potential differences among patients with varying characteristics within the trials. Without access to the original data of reported trials, meta-analysis cannot overcome the bias of underpowered trials toward overstatement of the size of main treatment effects, nor the tendency for such trials to falsely conclude there were no statistically significant adverse events. Although severely compromised by ghost-written or honorary-authored reports of primary research, meta-analysis can make use of its methods to focus on the conflicts of interest and likely sources of bias of such research and make known what precautions should be taken by would-be consumers. Examples show how meta-analysis has clarified thinking about the off-label use of selective serotonin reuptake inhibitors for treating child and adolescent depression, use of low-tidal volume respirator assistance for acute lung injury and acute respiratory distress syndrome patients, and the long-term use of COX-2 inhibitors for relieving arthritic pain. Recommendations are made for Congressional action.     

Searching for an efficient institutional review board review model: Interrelationship of trainee-investigators, funding, and initial approval

In this study we sought to identify variables associated with institutional review board (IRB) decisions to develop an efficient "pre-IRB" review model. We explored several variables, including relationships among the identification of trainees as investigators, external sources of funding, and initial approval. The sample consisted of all new submissions reviewed by the 2 medical IRBs at the University of Miami (UM) during a 1-year period. Trainees included students, residents, and fellows. At least 1 trainee had to be identified for a proposal to be considered a trainee submission. The medical-science committees (MSCs) were similar with regard to the numbers of new submissions they reviewed during convened meetings (MSC-A 242, MSC-B 241) and the percentages of proposals that were initially approved (MSC-A 52.9%, MSC-B 53.1%). Approved submissions were defined as those initially approved or conditionally approved pending minor modifications. We noted a robust statistical difference between the percentages of trainee submissions initially approved (39.9%) and submissions that did not identify a trainee (59.4%) ( P <.0001). Of the proposals that were initially not approved (tabled [deferred] or rejected [not approved]), 28.9% of those including a trainee were rejected, compared with 11.0% without a trainee ( P <.001). Proposals in which the source of funding was identified were more likely to be approved (64.2%) than were those in which it was not (30.8%) ( P <.0001). Funding also seemed to influence the trainee and initial-approval interaction. Our results show that new submissions that identified trainee investigators were more likely to be deferred or not approved than those that did not. Nonapproved proposals that identified a trainee were 3.8 times more likely to be initially rejected than those that did not. A prereview model could target those submissions that list a trainee, lack funding, or both.     

A rapid, safe, and low-cost technique for the induction of mild therapeutic hypothermia in post-cardiac arrest patients

Aim of study

The benefits of inducing mild therapeutic hypothermia (MTH) in cardiac arrest patients are well established. Timing and speed of induction have been related to improved outcomes in several animal trials and one human study. We report the results of an easily implemented, rapid, safe, and low-cost protocol for the induction of MTH.

Methods

All in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients admitted to an intensive care unit meeting inclusion criteria were cooled using a combination modality of rapid, cold saline infusion (CSI), evaporative surface cooling, and ice water gastric lavage. Cooling tasks were performed with a primary emphasis on speed. The main endpoints were the time intervals between return of spontaneous circulation (ROSC), initiation of hypothermia (IH), and achievement of target temperature (TT).

Results

65 patients underwent MTH during a 3-year period. All patients reached target temperature. Median ROSC-TT was 134 min. Median ROSC-IH was 68 min. Median IH-TT was 60 min. IH-TT cooling rate was 2.6 °C/h. Complications were similar to that of other large trials. 31% of this mixed population of IHCA and OHCA patients recovered to a Pittsburgh cerebral performance score (CPC) of 1 or 2.

Conclusion

A protocol using a combination of core and surface cooling modalities was rapid, safe, and low cost in achieving MTH. The cooling rate of 2.6 °C/h was superior to most published protocols. This method uses readily available equipment and reduces the need for costly commercial devices.     

Reprint of "Epigenetics,maternal prenatal psychosocial stress,and infant mental health"

This paper provides a summary of literature on epigenetic effects and infant health outcomes of maternal psychosocial stress during pregnancy. A search of literature yielded a large body of publications between 2008 and 2018. Relevant articles were selected, and additional sources were located from ancestry searches of reference lists. Results implicate maternal prenatal stress as a source of epigenetic mechanisms that affect fetal brain development and program risk for emotional dysregulation and mental disorders over a lifetime and across generations. Implications for nursing practice are explored at multiple levels of policy advocacy, public education, primary prevention, screening and intervention.