Background and Objectives
Emergency situations often elicit a generous response from the public. This occurred after attacks on the US on September 11, 2001 when many new blood donors lined up to donate. This study was performed to compare return rates for first time donors (FTD) after September 11th, 2001 to FTD during a comparable period in 2000.
Materials and Methods
3315 allogeneic whole blood donations from FTD at a regional blood center were collected between September 11th and 30th, 2001. Subsequent donations by the FTD before March 31, 2002 were reviewed. This (test) group was compared to 1279 FTD(control group) donating during the same time period in September 2000 and to their return rate in the subsequent six months.
Following September 11, 2001, 1087/3315 (32.8%) FTD returned by March 31, 2002. This return rate was similar to the control group (427/1279 (33.4%)). The deferral rate during the donor screening process for the control group was significantly higher than the deferral rate for the September 11–30, 2001 group (p < 0.01). The odds of an individual FTD returning increased with age, and the chance of a female donor returning was 1.13 times higher than a male (p = 0.06). There was a carryover effect after Sept. 11, 2001 too.
A national emergency, September 11, 2001, inspired people to donate blood for the first time. However, the proportion of return donations amongst them was not increased. Females and males in certain age groups were more likely to become repeat donors due to the residual effect of September 11, 2001. Additional efforts are needed to retain eligible FTD in donor pools.
blood donor; donor retention; national emergency; 9/11
Methods: The LexisNexis database of newspaper reports were used to identify incidents of hate related violent acts against Middle Easterners or those perceived to be Middle Easterners in the US between September 1 and October 11, 2001. A total of 100 incidents of hate related violence were identified in the 2659 news articles that were reviewed.
Results: Of the 100 incidents of violent victimization that took place during the period September 1 to October 11, only one incident occurred before September 11. The 99 incidents that occurred after September 11 involved at least 128 victims and 171 perpetrators. Most violent victimizations occurred within 10 days of the attacks, involved male perpetrators and male victims, and occurred in convenience stores, on the streets, at gas stations, at schools/colleges, and at places of worship.
Discussion: Most violent victimizations occurred in the 10 days immediately following the terrorist attacks indicating that interventions that promote tolerance and understanding of diversity need to be implemented quickly in order to be effective. In addition, patrolling by police and Neighborhood Watch programs around convenience stores and gas stations may also be effective strategies for reducing hate related violent crimes.
The higher stress associated with the World Trade Center (WTC) attacks on September 11, 2001, may have resulted in more cardiac events particularly in those living in close proximity. Our goal was to determine if there was an increase in cardiac events in a subset of emergency departments (EDs) within a 50-mi radius of the WTC. We performed a retrospective analysis of consecutive patients seen by ED physicians in 16 EDs for the 60 days before and after September 11 in 2000–2002. We determined the number of patients admitted to an inpatient bed with a primary or secondary diagnosis of acute myocardial infarction (MI) or tachyarrhythmia. In each year, we compared patient visits for the 60 days before and after September 11 using the chi-square statistic. For the 360 days during the 3 years, there were 571,079 patient visits in the database of which 110,766 (19.4%) were admitted. Comparing the 60 days before and after September 11, 2001, we found a statistically significant increase in patients with MIs (79 patients before versus 118 patients after, P=.01), representing an increase of 49%. There were no statistically significant differences for MIs in 2000 and 2002 and in tachyarrhythmias for all three years. For the 60-day period after September 11, 2001, we found a statistically significant increase in the number of patients presenting with acute MI but no increase in patients admitted with tachyarrhythmias.
Acute myocardial infarction; Emergency care; Tachyarrhythmia; Terrorism
To describe physical symptoms in those local residents, local workers, and cleanup workers who were enrolled in a treatment program and had reported symptoms and exposure to the dust, gas, and fumes released with the destruction of the World Trade Center (WTC) on September 11, 2001.
Symptomatic individuals underwent standardized evaluation and subsequent treatment.
One thousand eight hundred ninety-eight individuals participated in the WTC Environmental Health Center between September 2005 and May 2008. Upper and lower respiratory symptoms that began after September 11, 2001 and persisted at the time of examination were common in each exposure population. Many (31%) had spirometry measurements below the lower limit of normal.
Residents and local workers as well as those with work-associated exposure to WTC dust have new and persistent respiratory symptoms with lung function abnormalities 5 or more years after the WTC destruction.
After the collapse of the World Trade Center (WTC) on 11 September 2001, a dense cloud of dust containing high levels of airborne pollutants covered Manhattan and parts of Brooklyn, New York. Between 60,000 and 70,000 responders were exposed. Many reported adverse health effects.
In this report we describe clinical, pathologic, and mineralogic findings in seven previously healthy responders who were exposed to WTC dust on either 11 September or 12 September 2001, who developed severe respiratory impairment or unexplained radiologic findings and underwent video-assisted thoracoscopic surgical lung biopsy procedures at Mount Sinai Medical Center. WTC dust samples were also examined. We found that three of the seven responders had severe or moderate restrictive disease clinically. Histopathology showed interstitial lung disease consistent with small airways disease, bronchiolocentric parenchymal disease, and nonnecrotizing granulomatous condition. Tissue mineralogic analyses showed variable amounts of sheets of aluminum and magnesium silicates, chrysotile asbestos, calcium phosphate, and calcium sulfate. Small shards of glass containing mostly silica and magnesium were also found. Carbon nanotubes (CNT) of various sizes and lengths were noted. CNT were also identified in four of seven WTC dust samples.
These findings confirm the previously reported association between WTC dust exposure and bronchiolar and interstitial lung disease. Long-term monitoring of responders will be needed to elucidate the full extent of this problem. The finding of CNT in both WTC dust and lung tissues is unexpected and requires further study.
bronchiolitis; carbon nanotubes; interstitial lung disease; small airway disease; WTC
OBJECTIVE: To report a clinical association between vulvar irritation or contact dermatitis and the use of Always sanitary napkins. DESIGN: Case series. SETTING: A gynecology practice in Montreal. PATIENTS: Women presenting between September 1991 and September 1994 with itching or burning of areas that would be in contact with a sanitary napkin (mons pubis, external surfaces of the vulva and perineum) beginning at least 1 day after the use of the napkins was started and less than 5 days after the use was stopped. RESULTS: Twenty-eight women experienced vulvar itching and burning, often associated with eruptions resembling contact dermatitis, of the vulvar and perineal surfaces after using Always sanitary napkins. Twenty-six reported that symptoms disappeared after they stopped using that brand of sanitary napkin. Seven women who later used the same brand again reported a recurrence of the vulvar irritation. CONCLUSION: The findings of this case series reveal Always sanitary napkins as a potentially important cause of recurrent vulvitis. Physician awareness of the association will enable effective advice and relief for a large number of women suffering "chronic vaginitis".
Background: Fever of unknown origin (FUO) is a diagnostic challenge. Rheumatologists are often in charge of patients with FUO because the vasculitides, especially, are potential and common causes of FUO.
Objective: To evaluate the value of a standardised investigation to identify the cause of FUO.
Methods: A standardised work-up programme for patients with FUO was started at the beginning of September 1999. The rate of identified causes of FUO was compared between all patients with FUO admitted to a tertiary care centre of rheumatology between January 1996 and August 1999 (control group) and September 1999 and January 2003 (work-up group). In January 2002 magnetic resonance imaging (MRI) was added to the investigation.
Results: 67 patients with FUO were identified—32 before and 35 after institution of the work-up programme. Before implementation 25% of all patients with FUO remained undiagnosed, after implementation 37%. After institution of the investigation the percentage of patients with vasculitides increased significantly from 6% (n = 2) to 26% (n = 9, p = 0.047, Fisher's exact test). This increase could be attributed to the addition of MRI in 2002. When all patients with FUO before 2002 (n = 55) and thereafter (n = 12) were compared the prevalence of systemic vasculitis increased from 11% (n = 6) to 42% (n = 5, p = 0.021).
Conclusion: Implementation of a standardised work-up programme for FUO did not improve the overall rate of diagnosis. Addition of MRI significantly increased the diagnosis of systemic vasculitis as the underlying cause of FUO. MRI should be included in the investigation of patients with FUO when vasculitis is suspected.
To study the prospective effects of post‐myocardial infarction (MI) depressive disorder on health status, including self reported cardiac symptoms, disability, and health related quality of life, at 12 months after MI while controlling for cardiac condition and health status at three months after MI.
Longitudinal study of a cohort of 468 adults with MI recruited from four hospitals in the north of the Netherlands between September 1997 and September 2000. Assessment of depressive disorder in the year after MI according to International classification of disease, 10th revision criteria. Assessment of health status at three and 12 months by the RAND 36 item health survey, the health complaints scale, self rated cardiac complaints, and disability.
Patients with post‐MI depressive disorder were more likely than those without to have poor quality of life, more health complaints, more cardiac complaints, and more disability at 12 months' follow up. In multivariate analyses adjusted for cardiac condition, health status at three months, age, sex, and pre‐MI depression, the prospective association of post‐MI depression with poor health status remained for most of the indicators. Severity of the post‐MI depression further contributed to aspects of poor health status.
In a prospective study design, post‐MI depression had strong effects on poor health status exceeding the effects of cardiac condition and its short term consequences. Efforts to improve health status after MI should therefore include standard assessment and guideline based treatment of post‐MI depressive disorder.
depression; myocardial infarction; health status; quality of life
To determine the peripheral mechanisms involved in thermal sweating during the hot summers in July before acclimatization and after acclimatization in September, we evaluated the sweating response of healthy subjects (n=10) to acetylcholine (ACh), a primary neurotransmitter involved in peripheral sudomotor sensitivity. The quantitative sudomotor axon reflex test (QSART) measures sympathetic C fiber function after iontophoresed ACh evokes a measurable reliable sweat response. The QSART, at 2 mA for 5 min with 10% ACh, was applied to determine the directly activated (DIR) and axon reflex-mediated (AXR) sweating responses during ACh iontophoresis. The AXR sweat onset-time by the axon reflex was 1.50±0.32 min and 1.84±0.46 min before acclimatization in July and after acclimatization in September, respectively (p<0.01). The sweat volume of the AXR(1) [during 5 min 10% iontophoresis] by the axon reflex was 1.45±0.53 mg/cm2 and 0.98±0.24 mg/cm2 before acclimatization in July and after acclimatization in September, respectively (p<0.001). The sweat volume of the AXR(2) [during 5 min post-iontophoresis] by the axon reflex was 2.06±0.24 mg/cm2 and 1.39±0.32 mg/cm2 before and after acclimatization in July and September, respectively (p<0.001). The sweat volume of the DIR was 5.88±1.33 mg/cm2 and 4.98±0.94 mg/cm2 before and after acclimatization in July and September, respectively (p<0.01). These findings suggest that lower peripheral sudomotor responses of the ACh receptors are indicative of a blunted sympathetic nerve response to ACh during exposure to hot summer weather conditions.
Heat acclimatization; Sweating; QSART; ACh
Functional tricuspid regurgitation (TR) occurs in patients with rheumatic mitral valve disease even after mitral valve surgery. The aim of this study was to analyze surgical results of TR after previous successful mitral valve surgery.
From September 1996 to September 2008, 45 patients with TR after previous mitral valve replacement underwent second operation for TR. In those, 43 patients (95.6%) had right heart failure symptoms (edema of lower extremities, ascites, hepatic congestion, etc.) and 40 patients (88.9%) had atrial fibrillation. Twenty-six patients (57.8%) were in New York Heart Association (NYHA) functional class III, and 19 (42.2%) in class IV. Previous operations included: 41 for mechanical mitral valve replacement (91.1%), 4 for bioprosthetic mitral valve replacement (8.9%), and 7 for tricuspid annuloplasty (15.6%).
The tricuspid valves were repaired with Kay's (7 cases, 15.6%) or De Vega technique (4 cases, 8.9%). Tricuspid valve replacement was performed in 34 cases (75.6%). One patient (2.2%) died. Postoperative low cardiac output (LCO) occurred in 5 patients and treated successfully. Postoperative echocardiography showed obvious reduction of right atrium and ventricle. The anterioposterior diameter of the right ventricle decreased to 25.5 ± 7.1 mm from 33.7 ± 6.2 mm preoperatively (P < 0. 05).
TR after mitral valve replacement in rheumatic heart disease is a serious clinical problem. If it occurs or progresses late after mitral valve surgery, tricuspid valve annuloplasty or replacement may be performed with satisfactory results. Due to the serious consequence of untreated TR, aggressive treatment of existing TR during mitral valve surgery is recommended.
Tricuspid regurgitation; Annuloplasty; Tricuspid valve replacement; Mitral valve surgery; Rheumatic heart disease
Estimates of acute mental health symptoms in the general population after disasters are scarce. We assessed the prevalence and correlates of acute posttraumatic stress disorder (PTSD) in residents of Manhattan 5–8 weeks after the terrorist attacks of September 11, 2001. We used random-digit dialing to contact a representative sample of adults living in Manhattan below 110th Street. Participants were interviewed about prior life events, personal characteristics, exposure to the events of September 11th, and psychological symptoms after the attack. Among 988 eligible adults, 19.3% reported symptoms consistent with PTSD at some point in their life, and 8.8% reported symptoms consistent with a diagnosis of current (within the past 30 days) PTSD. Overall, 57.8% of respondents reported at least one PTSD symptom in the past month. The most common past-month symptoms were intrusive memories (27.4%) and insomnia (24.5%). Predictors of current PTSD in a multivariable model were residence below Canal Street, low social support, life stressors 12 months prior to September 11th, perievent panic attack, losing possessions in the attacks, and involvement in the rescue efforts. These findings can help guide resource planning for future disasters in densely populated urban areas.
The explosion and collapse of the World Trade Center (WTC) was a catastrophic event that produced an aerosol plume impacting many workers, residents, and commuters during the first few days after 11 September 2001. Three bulk samples of the total settled dust and smoke were collected at weather-protected locations east of the WTC on 16 and 17 September 2001; these samples are representative of the generated material that settled immediately after the explosion and fire and the concurrent collapse of the two structures. We analyzed each sample, not differentiated by particle size, for inorganic and organic composition. In the inorganic analyses, we identified metals, radionuclides, ionic species, asbestos, and inorganic species. In the organic analyses, we identified polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls, polychlorinated dibenzodioxins, polychlorinated dibenzofurans, pesticides, phthalate esters, brominated diphenyl ethers, and other hydrocarbons. Each sample had a basic pH. Asbestos levels ranged from 0.8% to 3.0% of the mass, the PAHs were > 0.1% of the mass, and lead ranged from 101 to 625 microg/g. The content and distribution of material was indicative of a complex mixture of building debris and combustion products in the resulting plume. These three samples were composed primarily of construction materials, soot, paint (leaded and unleaded), and glass fibers (mineral wool and fiberglass). Levels of hydrocarbons indicated unburned or partially burned jet fuel, plastic, cellulose, and other materials that were ignited by the fire. In morphologic analyses we found that a majority of the mass was fibrous and composed of many types of fibers (e.g., mineral wool, fiberglass, asbestos, wood, paper, and cotton). The particles were separated into size classifications by gravimetric and aerodynamic methods. Material < 2.5 microm in aerodynamic diameter was 0.88-1.98% of the total mass. The largest mass concentrations were > 53 microm in diameter. The results obtained from these samples can be used to understand the contact and types of exposures to this unprecedented complex mixture experienced by the surviving residents, commuters, and rescue workers directly affected by the plume from 11 to 12 September and the evaluations of any acute or long-term health effects from resuspendable dust and smoke to the residents, commuters, and local workers, as well as from the materials released after 11 September until the fires were extinguished. Further, these results support the need to have the interior of residences, buildings, and their respective HVAC systems professionally cleaned to reduce long-term residential risks before rehabitation.
Several evidences suggested that ovarian cancer (OC) patients showing isolated lymph node recurrence (ILNR) have an indolent evolution. The aim of the study was to retrospectively review ILNR observed in our Institution over the past 11 years in order to investigate: the pattern of disease progression after the first diagnosis of ILNR, and their clinical outcome.
Between September 1995 and September 2006, 523 epithelial OC were diagnosed in our centers, and 301 of these relapsed. Cases with a diagnosis of ILNR, and at least 12 months of follow up after the diagnosis of ILNR were included. Post-relapse survival (PRS) was recorded from the date of the diagnosis of ILNR to the date of death or date last seen. Survival probabilities were estimated according to the method of Kaplan and Meier and compared by the log rank test. Cox's regression model with stepwise variable selection was used to analyse the role of clinico-pathological parameters as prognostic factors for PRS.
Thirty-two cases were identified as ILNR (10.6% of the recurrences, and 6.1% of the OC population). Most of the patients continued to exhibit the same pattern of progression during follow up, with 75% of the patients free from peritoneal disease after 2 years from the diagnosis of ILNR. Median Post-Relapse Survival (PRS) was 37 months, and median Overall Survival (OS) was 109 months, with all patients surviving more than 2 years after the initial diagnosis. In multivariate analysis only Platinum-Free Interval (PFI) retained a prognostic role for PRS (p value = 0.033).
ILNR represents a less aggressive pattern of OC relapse which keeps progressing in the lymph nodes in a relatively high percentage of cases. On the other hand, the occurrence of peritoneal spreading after ILNR is associated with a rapidly fatal outcome.
The effects of prenatal exposure to pollutants from the World Trade Center (WTC) disaster on fetal growth and subsequent health and development of exposed children remain a source of concern. We assessed the impact of gestational timing of the disaster and distance from the WTC in the 4 weeks after 11 September on the birth outcomes of 300 nonsmoking women who were pregnant at the time of the event. They were recruited at delivery between December 2001 and June 2002 from three hospitals close to the WTC site. Residential and work addresses of all participants for each of the 4 weeks after 11 September 2001 were geocoded for classification by place and timing of exposure. Average daily hours spent at each location were based on the women’s reports for each week. Biomedical pregnancy and delivery data extracted from the medical records of each mother and newborn included medical complications, type of delivery, length of gestation, birth weight, birth length, and head circumference. Term infants born to women who were pregnant on 11 September 2001 and who were living within a 2-mile radius of the WTC during the month after the event showed significant decrements in term birth weight (−149 g) and birth length (−0.82 cm), compared with infants born to the other pregnant women studied, after controlling for sociodemographic and biomedical risk factors. The decrements remained significant with adjustment for gestational duration (−122 g and −0.74 cm, respectively). Women in the first trimester of pregnancy at the time of the WTC event delivered infants with significantly shorter gestation (−3.6 days) and a smaller head circumference (−0.48 cm), compared with women at later stages of pregnancy, regardless of the distance of their residence or work sites from the WTC. The observed adverse effects suggest an impact of pollutants and/or stress related to the WTC disaster and have implications for the health and development of exposed children.
birth length; birth weight; geographic information systems; gestational duration; head circumference; newborns; World Trade Center
This study was designed to determine whether prenatal mercury exposure, including potential releases from the World Trade Center (WTC) disaster, adversely affects fetal growth and child development.
We determined maternal and umbilical cord blood total mercury of nonsmoking women who delivered at term in lower Manhattan after 11 September 2001, and measured birth outcomes and child development.
Levels of total mercury in cord and maternal blood were not significantly higher for women who resided or worked within 1 or 2 miles of the WTC in the month after 11 September, compared with women who lived and worked farther away. Average cord mercury levels were more than twice maternal levels, and both were elevated in women who reported eating fish/seafood during pregnancy. Regression analyses showed no significant association between (ln) cord or maternal blood total mercury and birth outcomes. Log cord mercury was inversely associated with the Bayley Scales of Infant Development psychomotor score [Psychomotor Development Index (PDI)] at 36 months (b = –4.2, p = 0.007) and with Performance (b = –3.4, p = 0.023), Verbal (b = –2.9, p = 0.023), and Full IQ scores (b = –3.8, p = 0.002) on the Wechsler Preschool and Primary Scale of Intelligence, Revised (WPPSI-R), at 48 months, after controlling for fish/seafood consumption and other confounders. Fish/seafood consumption during pregnancy was significantly associated with a 5.6- to 9.9-point increase in 36-month PDI, and 48-month Verbal and Full IQ scores.
Blood mercury was not significantly raised in women living or working close to the WTC site in the weeks after 11 September 2001. Higher cord blood mercury was associated with reductions in developmental scores at 36 and 48 months, after adjusting for the positive effects of fish/seafood consumption during pregnancy.
birth weight; child development; fish consumption; mercury; pregnancy; WTC
To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter.
Before and after study.
UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999.
People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates.
Main outcome measures
Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates.
Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change.
Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.
What is already known on this topicParacetamol and salicylate overdoses are very common in the United Kingdom and are associated with high levels of mortality and morbidityInternational comparison shows that national mortality from paracetamol overdose may be related to the maximum number of tablets in individual preparationsLegislation to limit the size of packs of paracetamol and salicylates was introduced in the United Kingdom in September 1998What this study addsThe number of tablets in packets of paracetamol and salicylate preparations decreased markedly in the 12 months after the legislationThe number of deaths from self poisoning with paracetamol alone and with salicylates alone decreased after the legislationThere was also a decrease in the number of liver transplants and admissions to liver units with hepatic paracetamol poisoning and in the number of overdoses of paracetamol and salicylates in which large numbers of tablets were taken
A combination of the plant infection-soil dilution technique (most-probable-number [MPN] technique) and immunofluorescence direct count (IFDC) microscopy was used to examine the effects of three winter cover crop treatments on the distribution of a soil population of Rhizobium leguminosarum bv. trifolii across different size classes of soil aggregates (<0.25, 0.25 to 0.5, 0.5 to 1.0, 1.0 to 2.0, and 2.0 to 5.0 mm). The aggregates were prepared from a Willamette silt loam soil immediately after harvest of broccoli (September 1995) and before planting and after harvest of sweet corn (June and September 1996, respectively). The summer crops were grown in soil that had been either fallowed or planted with a cover crop of red clover (legume) or triticale (cereal) from September to April. The Rhizobium soil population was heterogeneously distributed across the different size classes of soil aggregates, and the distribution was influenced by cover crop treatment and sampling time. On both September samplings, the smallest size class of aggregates (<0.25 mm) recovered from the red clover plots carried between 30 and 70% of the total nodulating R. leguminosarum population, as estimated by the MPN procedure, while the same aggregate size class from the June sampling carried only ∼6% of the population. In June, IDFC microscopy revealed that the 1.0- to 2.0-mm size class of aggregates from the red clover treatment carried a significantly greater population density of the successful nodule-occupying serotype, AR18, than did the aggregate size classes of <0.5 mm, and 2 to 5 mm. In September, however, the population profile of AR18 had shifted such that the density was significantly greater in the 0.25- to 0.5-mm size class than in aggregates of <0.25 mm and >1.0 mm. The populations of two other Rhizobium serotypes (AR6 and AS36) followed the same trends of distribution in the June and September samplings. These data indicate the existence of structural microsites that vary in their suitabilities to support growth and protection of bacteria and that are influenced by the presence and type of plant grown in the soil.
Despite the development of evidence-based practice guidelines in many countries for asthma treatment in children, there is limited evidence that using such guidelines improves patient care.
Our aim was to evaluate whether the implementation of an evidence-based asthma clinical practice guideline (CPG) worksheet changes clinical practice.
The study was a before and after study of the implementation of a paediatric asthma CPG in a tertiary paediatric emergency department (ED). All children aged 2–16 years who had a diagnosis of asthma were included. Clinical data were obtained by retrospective chart review for time periods before (May to September 2003) and after (May to September 2005) the introduction of the CPG worksheet. Primary outcomes were: use of spacers for salbutamol instead of nebulisers, use of ipratropium and use of corticosteroids. Secondary outcomes were use of an ED action plan, ordering chest X-rays (CXR) and admission rate.
Before implementation, 240 children presented with asthma and after implementation, 286 children presented. The two groups had similar ages, asthma severity, admission respiratory rate (RR) and oxygen saturation. Following implementation there was an increase in spacer use from 17 to 26% [+9%; 95% confidence interval (CI): 2–16%; p = 0.015] and a reduction in ipratropium use from 58 to 44% (−13%; 95% CI: −22 to −5%; p = 0.0029). The proportion of patients treated with corticosteroids did not change. The number of patients with an ED action plan increased. The number of CXR ordered decreased and the hospital admission rate decreased.
The study demonstrates that implementation of an asthma CPG worksheet in a tertiary paediatric ED resulted in modest changes in clinical practice, mainly by increasing clinician adherence to the guidelines.
Asthma; Clinical guidelines; Guidelines implementation
The first specimen of Ammocoetes branchialis that showed histologically any atrophic changes in the endostyle was taken on July 16. These changes proceeded relatively rapidly for about a month, after which the endostyle as such was no longer recognized. All specimens examined after August 15 showed in cross section the characteristic ductless follicles more or less completely formed. More gradual and minor changes in the way of further absorption of cell remnants and completion of the follicles continued at least until September 1. Two specimens taken from the creek on September 4, 1911. showed complete follicle formation with some stainable colloid (figures 14 and 15). There was still yellow granular pigment in the fibrous tissue between the follicles. In two specimens taken on October 14, 1909, the pigment was absent and the follicles were more closely set, larger, and contained homogenous colloid. In the twenty-four specimens of ammocoetes studied, there were variations in the time of the onset of metamorphosis. There may also be variations in the rate of progress of the changes in different specimens. There is no evidence that removal of the animals from their native environment to the laboratory either increases or decreases the rate of metamorphosis. Schneider states that he was unable to get specimens kept in the laboratory to undergo metamorphosis. Gage, however, has repeatedly observed the metamorphosis under laboratory conditions, and the six of our specimens kept in the laboratory—some for forty days—remained in excellent condition and the metamorphosis proceeded as well as in those living in the creek. I know of no observations bearing on the question as to whether the metamorphosis may be hastened or delayed as it can be in tadpoles and other amphibia. It is probable, however, that physical conditions greatly influence the transformation. These observations as to the length of time from the inception to the completion of metamorphosis indicate that a month and probably longer is necessary for the lake and brook lampreys of Central New York. This is in agreement with the observations of Gage and of Muller on metamorphosis in general, but is at variance with the views of Bujor, who states that the process takes place within three to four days. The first endostylar changes are a gradual shrinkage in the whole organ with thickening of the capsule and septum and proliferation of the connective tissue in the periendostylar zone. The tongue anlage is developed in this thickening just dorsal to the endostyle and anterior to the gland orifice. The size of the chambers progressively decreases and with the thickening of the septum the halves of the endostyle are both absolutely and relatively more separated. All the five types of epithelia are affected, the first to show the change being type I, the four fan-shaped bundles of cuneiform cells of each half of the endostyle. These disappear totally quite early. The next type to show marked changes is type III, or the cells with yellow pigment granules. Here the change is progressive and these cell groups in different stages of atrophy may be traced through to the fully developed follicles. The epithelium of type V, or the endothelial-like lining of the parietal walls of the chambers, is piled up and extruded laterally as the chambers contract or shrink. These cells in different stages of atrophy may be followed until the metamorphosis is nearing completion. It is certain that the cells of types I, III, and V play no part in the formation of the ductless follicles. With types II and IV the question is not so easily settled as it is from one or the other or from both of these types that the permanent follicles arise. One can say definitely that type IV plays the major role, but whether the cells of type II after fusion with the basal group of type IV do not also share in the formation of the ventral follicle of the given chamber, I cannot decide, but from the evidence obtainable this seems probable. It is significant that the cells of type IV are continuous with, and indistinguishable from, the cells lining the orifice and are continued anteriorly in the deep pharyngeal groove and peripharyngeal grooves as well as posteriorally from the orifice in the small pharyngeal groove. As to the fate of this extraglandular epithelium of type IV I have no data save that with the closing of the orifice and the formation of the permanent branchial sac these grooves with their ciliated epithelium disappear and the whole sac comes to be lined with plain stratified epithelium. The fact that the cells of the pharyngeal grooves and the lining cells of the gland orifice are continuous with the cells of the endostyle from which the permanent thyroid follicles are formed is not without significance in relation to the development of the thyroid of the higher chordates. One or more very large follicles are formed from the lower portion of this orificial epithelium of type IV. Four ductless follicles are the maximum number that may be formed primarily in each half of the endostyle from the four areas of epithelium of type IV. From the specimens studied this maximum is frequently not obtained. Posterior to the orifice where four chambers exist, each corresponding to one half of an anterior chamber, but two follicles may be formed from each chamber, but in the coil these are proportionately increased, in cross section. Most of the detailed studies here recorded have been made on the part of the endostyle posterior to the coil where the simplest conditions exist. Here two follicles are ordinarily formed from each chamber. In cross sections the follicles are at first only long tubules whose cavities are the remnants of the original endostyle chambers, but when the metamorphosis is completed each of these primary tubules is cut up into several elongated closed sacs corresponding to the true ductless follicles of all higher chordates. New follicles also arise by budding from these primary ones, and this process is probably of normal occurrence at the metamorphosis.
Glyceryl trinitrate (GTN) has been shown to be able to relax the sphincter of Oddi (SO) both in animals and humans. Theoretically, the use of these compounds during and after endoscopic retrograde cholangiopancreatgraphy (ERCP) could relax the biliary and pancreatic sphincters, facilitating cannulation of common bile duct (CBD) during the procedure, or minimizing potential pancreatic outflow obstruction after the procedure. However, clinical trials evaluating the protective effect of GTN on the post-endoscopic retrograde cholangiopancreatgraphy pancreatitis (PEP) have yielded inconclusive results. This meta-analysis is to systematically assess the effect of prophylactic administration of glyceryl trinitrate (GTN) on the prevention of PEP and the effect on the cannulation of bile ducts.
By searching PubMed (1966 to September 2009), CENTRAL (Cochrane Controlled trials Register; issue 3, 2009) and EMBASE.com (1984 to September 2009), two independent reviewers systematically identified prospective randomized controlled trials (RCTs) detecting the effect of prophylactic GTN on the incidence of PEP and on the cannulation of bile ducts. A meta-analysis of these clinical trials was then performed.
There are 55/899(6.1%) patients suffering PEP in the treatment group versus 95/915(10.4%) patients in the placebo group. The overall pooled risk of PEP was significantly lower in the GTN group than in the placebo group (OR 0.56, 95% CI: 0.40 to 0.79, p = 0.001). Subgroup analyses suggested that GTN administered by the sublingual form (OR 0.34,95% CI:0.16 to 0.75, p = 0.007) is more effective than transdermal route(OR 0.64,95% CI:0.40 to 1.01, p = 0.05), and the protective effect of GTN was far more obvious in the centers with high incidence of PEP (OR 0.40, 95% CI:0.24 to 0.67, p = 0.0006) than those centers with a low incidence of PEP (OR 0.75, 95% CI: 0.47 to 1.20, p = 0.22). Additionally, the meta-analysis suggests that GTN was not helpful for the cannulation of bile ducts.
We concluded that prophylactic administration of GTN may significantly reduce the incidence of PEP and not be helpful for the cannulation of bile ducts.
Know that the rate of asthma exacerbations are increased in September after summer vacation with the beginning of school year. Investigators have been studied this problem and it was supposed that the main cause could be the stress associated with school return what can worsen asthma symptoms. Beside this children returning to school after summer vacation are reexposed to respiratory viral infections, sensitizing allergens in the school enviroment, and can be connected with poor compliance in the medication in the summer period.
We stared to investigate that what could be the causative factors in children who suffered dyspnoe and other signs of asthmatic exacerbation from September 2008, could we present the increasing number of these patients in hospitalization rate, and could we confirm the changing compliance of the regular medication during the summer period? A short questionaire was constructed and was given the patients who were admitted to hospital (162) with asthma exacerbation symptoms. Then 45 patients were selected for a longer follow up to investigate their compliance in medication. We investigate from the database of our Hospital the asthmatic patient's admission rate from 2006.
We could present from 2006 the increasing number of patients admitted because of asthma exacerbation in September in every year. We could present the increased number of schoolage patient among all of the admitted patients in the fall season. We compared the genders which were similar. We found that the symptom of asthma was worse in the fall season. We confirmed the higher number of patients suffering from viral infections. But the changing rate among patient who stopped the medication during summer was low as 13%.
We could confirm the September epidemic of asthma exacerbation among our patients as well. Compare the international investigations the main cause of the September epidemic of asthma connecting with the beginning of the school year and the increasing number of viral infections at this period of the year. Fortunately our patient compliance was good but we have to continue our patients’ education from time to time.
Insecticide treated materials remain the mainstay for malaria prevention. The current study reports on the entomological impact of cyfluthrin impregnated bed nets on malaria transmission in Mbandjock, a semi urban locality in southern Cameroon. Several findings pertaining to the recent distribution of LLINs across Cameroon are discussed.
Malaria transmission and vector bionomics were monitored before and after impregnated net coverage. Bed nets were distributed in Mbandjock, whereas the locality of Nkoteng was free of bed nets during the entire study period. January to June 1997 represented the period before bed net coverage and September 1997 to September 1998 was the period after bed net coverage. Adult mosquitoes were collected by human landing catches. Mosquito genus and species were identified with morphological and molecular diagnostic tools. Anopheline salivary glands and ovaries were dissected to determine female infectious status and parity rates respectively.
A total of 6959 anophelines corresponding to 6029 in Mbandjock and 930 in Nkoteng were collected in the course of the study. Seven species were recorded in both cities : Anopheles coustani, An. funestus, An. gambiae sl, An. moucheti, An. ziemanni, An. nili and An. paludis. An. gambiae s.l. (>95% An. gambiae S molecular form) was the most abundant species representing 75.6% and 86.6% of the total anophelines caught in Mbandjock before and after bed net coverage respectively. The human biting rate (HBR) in Mbandjock decreased from 17 bites/human/night before bed net coverage to less than 4 bites/human/night during the first 7 months following impregnated bed net coverage. A significant decrease of mosquito parity rate was recorded when comparing the period before (52%) and after (46.5%) bed net distribution. The average infection rate of malaria vectors significantly decreased from 5.3% before to 1.8% after bed net coverage (p < 0.0001). The entomological inoculation rate in Mbandjock was reduced by 74% varying from 124.1 infected bites/human/year before bed net distribution, to 32.5 infected bites/human/year after bed net coverage. All entomological indexes were relatively stable in Nkoteng and no reduction of malaria transmission was recorded in this locality.
The study confirms the effectiveness of cyfluthrin impregnated nets in reducing malaria transmission. Lessons from this study could be essential to draw guidelines for the management of the recent nationwide distribution of LLINs across Cameroon in 2011.
Cyfluthrin; Impregnated nets; Malaria; Transmission; Anopheles; Cameroon
Today, early diagnosis of upper gastrointestinal (GI) tract malignancies and their surgical resection is becoming more feasible. One of the important side effects in upper GI tract malignancies is malnutrition which has direct relationship with postoperative complications. Nonetheless, there is no easy regimen of nutrition for these patients especially for the first week after operation. Accordingly we present a simple method for improving feeding such patients via tube jejunostomy. The aim of this study was to investigate the impact of early enteral feeding (EEF) on postoperative course after complete resection of upper gastrointestinal tract malignancy and reconstruction.
Between September 2005 to September 2008, 60 consecutive patients (22 female, 38 male) with upper GI tract malignancies who had undergone complete resection and reconstruction enrolled in this study. The patients randomly divided equally in two groups of control and EEF. Control group was treated with traditional management of nil by mouth and intravenous fluids for the first five postoperative days and then with liquids and enteral regular diet when tolerated. In EEF group the patients were fed by tube jejunostomy from 1st postoperative day and assessed for nutritional status before surgery and 5 days after surgery. Both groups were monitored on the basis of weight gain, clinical and paraclinical parameters and postoperative complications.
Sixty patients were randomly divided to two equal groups. Surgical procedures were similar in two groups and no significant difference in demographic and basic nutritional status were found. On 5th postoperative day serum albumin was 4.2±0.4 g/dl in EEF and 3.6±0.3 g/dl in control group (p= 0.041). Also serum transferrin was 260.8±2.5 mg/dl and 208±1.8 mg/dl in EEF and control group respectively (p < 0.001). Moreover, hospital stay was shorter in EEF group (7.7±3.1 vs. 14±2.5 days, p = 0.009).There were four (13.3%) anasatomotic leakages in control group and one (3.3%) in EEF group (p = 0.353). Also there was six (20%) wound infection in control group and three (10%) in EEF group (p = 0.472).
The EEF by tube jejunostomy can be an effective method of feeding patients in postoperative days of resection of GI malignancies. Postoperative hospital stay would be shorter and the level of laboratory parameters especially serum transferrin is higher in EEF in comparison with control group. It also may reduce postoperative complications such as wound infection and enterocutaneous fistula.
Nutrition; Postoperative Complications; Enteral feeding; Tube jejunostomy
The collapse of the World Trade Center (WTC) on 11 September 2001 exposed New York City firefighters to smoke and dust of unprecedented magnitude and duration. The chemicals and the concentrations produced from any fire are difficult to predict, but estimates of internal dose exposures can be assessed by the biological monitoring of blood and urine. We analyzed blood and urine specimens obtained from 321 firefighters responding to the WTC fires and collapse for 110 potentially fire-related chemicals. Controls consisted of 47 firefighters not present at the WTC. Sampling occurred 3 weeks after 11 September, while fires were still burning. When reference or background ranges were available, most chemical concentrations were found to be generally low and not outside these ranges. Compared with controls, the exposed firefighters showed significant differences in adjusted geometric means for six of the chemicals and significantly greater detection rates for an additional three. Arrival time was a significant predictor variable for four chemicals. Special Operations Command firefighters (n = 95), compared with other responding WTC firefighters (n = 226), had differences in concentrations or detection rate for 14 of the chemicals. Values for the Special Operations Command firefighters were also significantly different from the control group values for these same chemicals and for two additional chemicals. Generally, the chemical concentrations in the other firefighter group were not different from those of controls. Biomonitoring was used to characterize firefighter exposure at the WTC disaster. Although some of the chemicals analyzed showed statistically significant differences, these differences were generally small.
Electronic evaluation portfolios may play a role in learning and evaluation in clinical settings and may complement other traditional evaluation methods (bedside evaluations, written exams and tutor-led evaluations).
133 third-year medical students used the McGill Electronic Evaluation Portfolio (MEEP) during their one-month clerkship rotation in Geriatric Medicine between September 2002 and September 2003. Students were divided into two groups, one who received an introductory hands-on session about the electronic evaluation portfolio and one who did not. Students' marks in their portfolios were compared between both groups. Additionally, students self-evaluated their performance and received feedback using the electronic portfolio during their mandatory clerkship rotation. Students were surveyed immediately after the rotation and at the end of the clerkship year. Tutors' opinions about this method were surveyed once. Finally, the number of evaluations/month was quantified. In all surveys, Likert scales were used and were analyzed using Chi-square tests and t-tests to assess significant differences in the responses from surveyed subjects.
The introductory session had a significant effect on students' portfolio marks as well as on their comfort using the system. Both tutors and students reported positive notions about the method. Remarkably, an average (± SD) of 520 (± 70) evaluations/month was recorded with 30 (± 5) evaluations per student/month.
The MEEP showed a significant and positive effect on both students' self-evaluations and tutors' evaluations involving an important amount of self-reflection and feedback which may complement the more traditional evaluation methods.