Quality of vision with presbyopic contact lens correction: subjective and light sensitivity rating.

PURPOSE: To quantify the quality of vision achieved with multifocal and bifocal contact lenses. METHODS: We analyzed differential light sensitivity by computerized automatic perimetry in 21 patients wearing monofocal soft contact lenses (group 1, controls) and multifocal and bifocal contact lenses (groups 2 and 3, respectively). Seven patients each were fitted with multifocal or bifocal contact lenses; seven patients were without contact lenses (without correction for testing the visual periphery and with near-vision correction using monofocal contact lens for testing the central 30 degrees of vision). The type of correction was randomly changed in a crossover fashion so that each eye was examined at different times with different corrections. Humphrey 640 VFA computerized automated perimetry was used to test visual fields at baseline, 45 days, and 3, 4.5, and 6 months. RESULTS: A statistically significant difference was found between the global sensitivities (GS) of the central visual field in patients with near-vision monofocal contact lenses and with bifocal contact lenses (P=0.0273) and between the GS of the central visual fields with multifocal contact lenses and with bifocal contact lenses (P=0.0261). In both cases, the GS were significantly reduced with bifocal contact lenses (total GS: group 1, 11256 dB (Decibels); group 2, 11154 dB; group 3, 10679 dB). CONCLUSIONS: The results indicate that there is reduced differential light sensitivity in the central 30 deg of the visual field with bifocal contact lenses compared with multifocal contact lenses and monofocal contact lenses (controls).

[Approach to the patient in vegetative state. Part I: diagnosis]. / Approccio al paziente in stato vegetativo. Parte I: La diagnosi.

Coma is the condition in which both components of consciousness, wakefulness and awareness, are lost. Therefore, the comatose patient neither opens the eyes, nor utters comprehensible words or follows commands. In the vegetative state (VS), awareness (including all cognitive function and emotion) is lost, while the vegetative functions, including breathing and sleep-wake cycles (the wakefulness), persist. Usually VS follows a state of coma caused by traumatic or anoxic brain damage. Pathologic brain examination demonstrates extensive subcortical, white matter, bilateral thalamic, and brainstem lesions in various combinations. Bilateral cerebral cortical lesions are rare, and therefore cortex can be "out of action" despite unaltered structure. More rarely, VS is caused by brain developmental malformations in children, or metabolic or degenerative diseases in children and adults. These are the only cases in which patients are not comatose before VS becomes apparent. After 6-8 weeks of coma, patients regain the eye opening. In such a condition, the term coma is no longer appropriate. If awareness is absent, the patient can be defined as in VS. Finally, the VS is defined as persistent (PVS) when it has continued for at least 1 month. The diagnosis of VS and PVS are clinical and require assessment over an adequate period of time and the skills of a multidisciplinary experienced team. Diagnosis is very complex in infants younger than 3 months, and is not applicable to preterm neonates, with the unique exception of infants with anencephaly. Among ancillary diagnostic tools, dynamic PET studies show promise.

[Approach to the patient in vegetative state. Part III: prognosis]. / Approccio al paziente in stato vegetativo. Parte III: La prognosi.

To define a vegetative state (VS) as permanent is to declare its irreversibility. In 1994 a North-American multidisciplinary task force, by extensively analysing the literature, concluded that the recovery of consciousness from a post-traumatic or non-traumatic VS is unlikely after 12 and 3 months respectively. These conclusions did not obtain unanimous consent. The term permanent was in fact inappropriately used to define either the loss of consciousness or of function. Furthermore, patients with traumatic brain injury have been shown to recover the consciousness in a substantial greater percentage (6-7%) than previously appreciated (1.6%). This is hardly compatible with the peremptoriness of the term permanent, which should be used only in case of certainty. Ancillary tests are important in defining the prognosis. Patients in deep coma after an anoxic brain injury can be predicted as having a poor prognosis (death or permanent VS) with 100% specificity within one week of the insult. Magnetic resonance of the brain can predict patients at high risk of permanent VS within 6-8 weeks of a traumatic brain injury. In conclusion, the available evidence does not permit to define with certainty the patients who have irremediably lost their consciousness after a devasting brain insult. However, it seems possible to reliably define the risk of severe disability. Whether or not this knowledge might or should be used to titrate the intensity of therapeutic approach is to be defined. In this respect, it is central the definition of what an "acceptable outcome" is, certainly not an exclusive medical attribution.

Acute neuromuscular respiratory failure after ICU discharge. Report of five patients.

OBJECTIVE: To describe a syndrome of acute neuromuscular respiratory failure (NM-ARF) caused by ICU-acquired acute myopathy and neuropathy. DESIGN: Case series. SETTING: General Regional University Hospital in Brescia, Italy. PATIENTS: Five adult patients with NM-ARF after prolonged ICU stay and successful weaning from the ventilator and ICU discharge. INTERVENTIONS: None. MEASUREMENTS: Clinical signs of NM-ARF, electroneurography and electromyography (ENMG) of peripheral nerves and muscles, and functional assessment of respiratory muscles. RESULTS: NM-ARF was diagnosed at the time of (one case), or 1-3 days after, ICU discharge. Limb weakness alarmed the physicians, while the signs of the NM-ARF were initially undetected. In the first observed case the acute respiratory failure was near fatal, and necessitated ICU readmission, while in the other cases 2 weeks of aggressive chest physiotherapy permitted resolution of the respiratory failure. History, clinical course and ENMG indicated the diagnosis of critical illness myopathy and neuropathy (CRIMYNE). Three patients recovered fully, while two had persisting evidence of axonal polyneuropathy several months after the onset. CONCLUSIONS: Critically ill patients with prolonged ICU stay, sepsis and MOF are at great risk of developing CRIMYNE, which in turn may be responsible for NM-ARF. This latter complication may arise after resolution of the respiratory and cardiac dysfunctions and successful weaning from the ventilator. As NM-ARF may cause unplanned ICU readmission or even unexpected death, strict clinical surveillance and monitoring of respiratory muscle function is recommended after discharge to the general ward of patients with proven NM-ARF. Early intensive chest physiotherapy can resolve the condition.

Bacterial load and protein deposits on 15-day versus 1-day disposable hydrophilic contact lenses.

PURPOSE: This study quantified the bacterial load and protein deposits on 1- and 15-day disposable contact lenses after use in normal wearers. METHODS: Sixteen patients were randomly assigned to a 1-day contact lens (1-Day Acuvue) in one eye and to a 15-day contact lens (Acuvue) in the contralateral eye. Only one specified solution was allowed for the care of 15-day lenses. All patients were evaluated every month for 6 months (at times T1, T2, T3, T4, T5, T6). At times T1, T3, and T5, the lenses were removed in a sterile fashion and sent for laboratory quantification of Staphylococcus aureus and Pseudomonas aeruginosa. At T2, T4, and T6, quantification of protein deposits was determined, and at T0 and T6, impression cytology of the conjunctiva was performed. RESULTS: P. aeruginosa was not identified on any lens. At T1, T3, and T5, S. aureus was significantly greater on the 1-day versus 15-day lenses (p < 0.001). In contrast, protein deposits were significantly greater on the 15-day lenses at all time points (T2, T6: p < 0.01; T4: p < 0.05). Impression cytology of the 15-day lens eyes revealed a worsening trend compared to the 1-day lens; however, no statistically significant differences were found between the two groups (p = 0.29). CONCLUSION: Results of this study suggest that the use of cleaning and preservative solutions can alter the ocular surface bacterial environment of the contact lens wearer and that these changes are not a direct consequence of contact lens wear. The bactericidal activity of these solutions could, with time, also affect ocular surface cells, leading to contact lens intolerance and ocular surface disease.

The prognostic value of the eosinophil in acute renal allograft rejection.

A case report of marked peripheral blood eosinophilia and eosinophilic infiltration of a rejected renal allograft in a transplant recipient stimulated our review of the clinical course of 132 consecutive renal transplant recipients. A total of 187 acute rejections occurred in 112 patients. Diagnosis was made by renal biopsy in 124 cases. The percentage of eosinophils in the leukocyte differential of patients with irreversible rejection was 5.2 +/- 5.7 (mean +/- SD) versus that seen in patients with reversible rejection, 2.9 +/- 3.5 (P less than .05). The difference in the total eosinophil counts in each group was not statistically significant. Patients with peripheral blood eosinophil percentages greater than or equal to 4% had a 37.9% irreversible rejection rate, whereas those who had less than 4%, had a 22.4% loss rate (P less than .01). Six of seven patients with greater than or equal to 2% eosinophils in the inflammatory infiltrate of their renal allograft lost their kidney, whereas grafts with less than 2% eosinophils had a 36.8% loss rate (P less than .02). We conclude that the increased presence of eosinophils in the peripheral blood and/or renal allograft biopsy specimen is an adverse prognostic factor for acute rejection outcome.

Patient profile and effect of dietary therapy on post-transplant hyperlipidemia.

The effect of dietary therapy on the serum lipid profile was examined in 32 post-transplant patients. Patients were transplanted more than 4 months before the study and had stable renal function and no other condition affecting lipid metabolism. Serum lipid profiles were determined on two serum samples obtained after a 12-hour fast. Seventeen patients who had pre-transplant hyperlipidemia (HLP) had similar HLP after transplantation. Of the 14 patients with normal pre-transplant profiles, 9 remained normal and 5 developed HLP. Twelve patients with HLP received out-patient dietary therapy providing less than 500 mg of cholesterol, less than 35% of calories from fat, less than 50% of calories from carbohydrate, and a P:S ratio greater than 1. Maintenance calories were based on the Harris-Benedict standard except for 9 overweight patients who were given less. After 3 months of therapy, serum cholesterol and triglycerides decreased to normal in 8 of 9 patients in whom both were elevated before dietary treatment and were unchanged in one patient. In 3 patients who had normal triglyceride but elevated cholesterol levels before therapy, cholesterol decreased but remained above normal; triglyceride increased in one patient and remained normal in two. High-density lipoprotein cholesterol (HDL-C) increased in all 12 patients and became normal in 11. Body weight fell in 11 of 12 patients receiving dietary therapy. Cholesterol, triglyceride, and HDL-C remained unchanged in 11 patients who did not undergo dietary treatment. Dietary therapy is a safe and effective way to treat post-transplant HLP.

Erythrocytosis after renal allotransplantation: treatment by removal of the native kidneys.

A patient with end-stage renal disease had erythrocytosis after kidney transplantation, with a hematocrit level that ranged between 52 and 60%. Selective catheterization of venous blood from his native kidneys and the transplanted kidney revealed a threefold increase of erythropoietin activity in blood from his own kidney over systemic blood and blood from the transplanted kidney. Bilateral nephrectomy cured the condition. Postoperative hematocrit and erythropoietin levels were within normal limits.

Infectious complications in renal transplant recipients.

Infections complicated the course of 59 of 111 renal transplantations (53%) performed on 93 patients at the University of Maryland Hospital. Infections and resultant deaths were more common among the patients with cadaver transplants. The transplant wound and the urinary tract were the most common sites of infection, occurring in 33% and 24% respectively. Septicemia developed in 11 patients (10%), secondary to urinary tract infection in six and to surgical wound infection in three. Opportunistic viral, fungal, and actinomycotic infections occurred in ten patients (9%). A total of nine patients (8%) died as a result of infection. This experience with sepsis and mortality, substantially lower than previously reported, may have resulted from (1) rigorous screening and detailed histories of recipients and donors for infection at the time of transplantation, as well as bacteriologic and serologic studies; (2) discontinuation of azathioprine whenever the WBC fell to less than 5,000/cu mm; (3) aggressive surveillance and early management of infections; and (4) prompt removal of a nonviable kidney when detected by radionuclide scan and percutaneous renal biopsy.

Are the native kidneys responsible for erythrocytosis in renal allorecipients?

The development of erythrocytosis following renal transplantation has been reported to be caused by a number of factors. These include acute and chronic rejection, hydronephrosis and renal artery stenosis. In this study, seven patients were noted to have erythrocytosis with hematocrits ranging between 53.5 and 66%. Serum erythropoietin levels were elevated and ranged between 11 and 60 mU/ml with a mean of 31.9 mU/ml in six of seven patients. Selective catheterization of veins of native and transplanted kidneys in three patients revealed mean serum levels of 40.9 and 13.0 mU/ml, respectively. This suggests that excess erythropoietin is being produced from the diseased native kidneys. Bilateral nephrectomy in one patient cured erythrocytosis and dropped systemic levels of erythropoietin (EP) to 6.1 mU/ml. In four of the remaining five patients, hematocrits came down spontaneously to within normal over a 1- to 3-year period. Consequently, it appears that in a number of transplant patients the retained diseased kidneys, having lost all excretory and concentrating function, may remain capable of functioning as endocrine erythropoietin-producing organs.

Physician and patient acceptance of emergency nurse practitioners.

Patient and physician attitudes toward emergency nurse practitioners (ENP) were surveyed in our emergency medical service. The responses to the questionnaires indicated a high degree of satisfaction with the ENP similar to that reported in a survey of patient reaction to physician assistants (PA) in the emergency department. In our emergency medical service, physicians expressed a concern over the practitioner's care of the emergent patient. Their confidence in the practitioner's clinical judgment was greater in their care of nonurgent and urgent patients.

Bacterial studies of leg ulcers.

--Bacteriologic studies of 30 chronic leg ulcers were studied in 18 adult patients before and after treatment with a local cleansing agent, Debrisan.--Results show that all ulcers, whether clinically inflamed or not, are secondarily infected.--The majority of ulcers grew more than 1 type of organism, up to 6 different types in 1 single ulcer.--The use of Debrisan reduces the types of organisms and colony counts in ulcers, allowing healthy granulation and epithelialization to proceed normally.--Control of infection reduces surrounding local edema and erythema.--By reducing types of organisms and colony counts in chronic leg ulcers successful skin grafting was readily achieved.

Emergency nurse practitioner: an answer to an emergency care crisis in rural hospitals.

During the last three years, a nine-month training program at the University of Virginia was designed and implemented to prepare the nurse to assume an expanded role in the emergency department. The course provides the student with sufficient knowledge and skill to diagnose and treat patients in the emergency department setting while under the supervision of a physician. Graduates of the program are certified by the State of Virginia as "emergency nurse practitioners". Qualified candidates who had identified a physician preceptor or were from an area with embryonic emergency medical systems were given priority in the selection process. The training program was divided into three-month modules which dealt first with teaching interview techniques and physical assessment skills, then clinical experiences in rural and urban emergency departments, and finally a preceptorship in the community hospital where the nurses work with the physician preceptors.

Self-instructional emergency medicine program for medical students.

A self-instructional program in emergency medicine has been developed for freshmen medical students at the University of Virginia School of Medicine. The cognitive objective of the course is to give the student the minimum level of knowledge to diagnose emergency medical conditions. Performance of the appropriate practical treatment is the course's psychomotor objective. Evaluation of the student's grasp of the program's cognitive and psychomotor objectives is accomplished by the written and practical examination for certification of emergency medical technicians and practical tests in basic life-support. Self-instructional guides, algorithms, videotapes and reading materials are the educational resources for the course. As a result of successful completion of the training program, the student is certified as an emergency medical technician in the Commonwealth of Virginia.