Delirium screening in intensive care: A life saving opportunity.

BACKGROUND: Delirium is described as 'acute brain failure' and constitutes a medical emergency which presents a hazard for people cared for in intensive care units. The Scottish intensive care society audit group recommend that all people cared for in intensive care units be screened for signs of delirium so that treatment and management of complications can be implemented at an early stage. CLINICAL IMPLICATION: There is inconsistent evidence about when and how the assessment of delirium is carried out by nursing staff in the intensive care setting. AIM: This narrative review explores the pathophysiology and current practices of delirium screening in intensive care. Consideration is given to the role of the nurse in detecting and managing delirium and some barriers to routine daily delirium screening are critically debated. CONCLUSION: It is argued that routine delirium screening is an essential element of safe, effective and person centred nursing care which has potential to reduce morbidity and mortality.

Towards high-accuracy primary spectral radiometry from 400 K to 1300 K.

We describe the design, construction, calibration and use of a near-infrared thermodynamic radiation thermometer to measure blackbodies from 400 K to 1300 K. The motivation for this work is the pending redefinition of the kelvin and the need for direct, thermodynamic temperature measurements of the fixed-point blackbodies presently used in the realization of the temperature scale. The challenges of accurately measuring Planck radiances which vary greatly in radiance level and spectral shape are discussed. Methods to characterize the components used in the radiation thermometer design are described. The use of this radiation thermometer as a relative primary thermometer and the resulting residuals are shown. We describe radiometric calibration procedures for using the radiation thermometer as an absolute primary thermometer. Preliminary data showing the initial radiometric calibration steps are discussed.

The distribution and transport of Sellafield derived 137 Cs and 241 Am to western Irish Sea sediments.

Sellafield derived (137)Cs and (241)Am were analysed in surficial sediments at 23 sites in the western Irish Sea. Concentrations varied between 3-175 Bq (137)Cs/kg and 1-147 Bq (241)Am/kg. There are two distinct basins in the western Irish Sea separated by an area of restricted depth and this bathymetry is reflected in the radionuclide concentrations. Highest concentrations were found in the northerly samples and substantially lower concentrations further south. This pattern of distribution can be explained by the predominantly northerly residual flow and the existence of seasonal stratification in this area of weak tides. (137)Cs/(241)Am ratios were also highest in the northern basin, and it is suggested that this is caused by differences in the mechanisms of transport of the two elements. The direct physical migration of contaminated particles from the eastern Irish Sea is the dominant transport mechanism in the north of the study area, whereas transport in the dissolved phase is most important to the southern region. Concentrations of both elements were best correlated with the percentage <15 microm particulate fraction suggesting that particles within this range are most important for direct transport and scavenging from the soluble phase.

Changing perspectives on the importance of urban phosphorus inputs as the cause of nutrient enrichment in Lough Neagh.

The scale and chronology of the phosphorus (P) enrichment of Lough Neagh, a large hypertrophic lake, was assessed using, as enrichment proxies, published palaeocological studies on diatoms and chironomid head capsules preserved in the lake sediments and, from 1974, monitoring data from the lake and its inflowing rivers. Enrichment commenced in 1880, and the scale and chronology of the diatom and chironomid records were similar up to 1960, but in the 1960s, chironomid accumulation rates increased dramatically, whereas diatom rates remained unchanged. From subsequent lake monitoring, the absence of a diatom response after 1960 was attributed to silica limitation so that P could be considered as the driver of increased diatom production only up to 1960. Using a coefficient for the demand for P by diatoms of 4 microg P mg SiO(2)(-1), it was calculated that the increased diatom production between 1881 and 1961 required an increase in lake P of 26 microg P l(-1). This value is close to the predicted increase of 22.5 microg P l(-1) in the lake caused by inputs of P from sewage treatment works and septic tanks. There was no evidence that diffuse source P contributed to enrichment over this period. Enrichment up to 1960 appears modest in comparison to subsequent years. From 1961 to 1974, lake P was estimated to have increased by 62 microg P l(-1), but only 25 microg P l(-1) of this increase was attributable to greater loadings of P from urban and septic tank sources. The enrichment response of chironomids at this time was also much greater than expected from a regression-derived relationship between urban P inputs and chironomid accumulation rates suggesting additional sources of P. The larger than expected increase in lake P was attributed to the onset of a significant internal loading of P and the commencement of an increase in diffuse source loadings of P. River monitoring has shown that diffuse P has increased steadily since 1974, more than counterbalancing a 40% reduction in urban P loadings that has taken place since 1980. By the end of the 20th century urban sources contributed only 19.7% of inflow P to Lough Neagh but lake P was 145 microg P l(-1) compared to an estimated concentration of 20 microg P l(-1) in 1881. Failure to control diffuse P sources has therefore been instrumental in the continued increase of lake P in Lough Neagh.

Chemical forms and extractability of iron in sediments of three contrasting lakes of China and UK.

Iron is a limiting factor for the eutrophication of lakes, especially those lakes that are enriched with phosphorus. Extractability of iron in sediments of West Lake and Taihu Lake in China and Lower Lough Erne in Northern Ireland of UK was comparatively investigated on the basis of analysing chemical forms of iron using different extractants. It was shown that extractable iron in sediments of the lakes was greatly different using various extractants. Reactive iron or easily released iron such as "active" iron oxides, total free iron oxide and water-soluble iron was not high, only accounting for 0.01%-0.15% of total iron. The efficiency of the extractants for exchangeable iron was decreased in the sequence 0.1 mol/L HCl >> DTPA + TEA mixed solution > 1 mol/L NH4OAc > 0.5 mol/L MgCl2 = 0.5 mol/L CaCl2. It seems that the complexion of iron by organic matter was not strong because the concentration of organically bound iron was significantly lower than the concentration it was forecasted. Extractable iron is not entirely consistent with or dependent on total iron in lake sediments. To a certain extent, phosphate can inhibit the release of iron in sediments of the lakes. The selection of extractants is thus the first key step to evaluate bioavailability of iron in lake sediments.

PAH contamination of western Irish Sea sediments.

Concentrations of the sum of 15 PAHs in 22 surficial sediment samples from the western Irish Sea ranged from below 100 ng g(-1) in sandy sediments to a maximum of 1422 ng g(-1) in the centre of the mud basin. The concentrations are typical of coastal shelf sediments, but greater than those observed for aquatic sediments remote from known anthropogenic sources. Organic C and the % sediment <15 microm were positively correlated with sigmaPAH. sigmaPAH was normalised to organic C and particle size (i.e. expressed as sigmaPAH/C(org) and sigmaPAH/% < 15 microm) and significant relationships were still observed with organic C and % < 15 microm. The results are discussed in the context of using organic C to normalise concentrations of PAHs to assess contamination levels in sediments.

The importance of catchment and lake processes in the phosphorus budget of a large lake.

Total phosphorus (P) river inputs and lake concentrations for the Neagh system in Northern Ireland are compared from the period 1974-1997. The main routes of P transfer between the lake water and the sediment are settlement of abiotic particles and planktonic diatoms, summer sediment release and re-sedimentation in the last months of the year. The annual river loading to the lake varied between 0.7 and 1.8 g P m(-2), and sediment release can be as much as 1.4 g P m(-2). A simple model evaluated the effect of sediment-water exchanges on the phosphorus available for spring phytoplankton growth. It showed that re-sedimentation of released P and washout over the winter greatly mitigated its effect. Correlation analysis demonstrated that the very large summer releases of sediment P were not related directly to the spring inputs from diatom settlement. No long-term trends in P release were seen.

Evaluation of phosphorus bioavailability in sediments of three contrasting lakes in China and the UK.

The bioavailability of phosphorus (P) in sediments from West Lake and Lake Tai (China) and Lough Erne (Northern Ireland) was evaluated using total P (TP), water soluble P (WSP), readily desorbable P (RDP), algal available P (AAP) and Olsen-P. The results indicated that the TP content, the amounts of phosphorus extracted by each method and their proportions to TP varied widely between sediments of the three lakes. TP and chemical extractable phosphorus in the sediments of Lough Erne were considerably higher than those of the two lakes in China. Although TP in the West Lake sediments was similar to that of Lake Tai, the extractable phosphorus data suggested that the bioavailability of P in West Lake sediments was higher than that in sediments from Lake Tai. Nevertheless, the rank order of extraction efficiency was the same in all lakes and the amount extracted was in the sequence AAP > Olsen-P > WSP > RDP. There was a good correlation between extracted and TP in all the methods examined.

The Kelvin and Temperature Measurements.

The International Temperature Scale of 1990 (ITS-90) is defined from 0.65 K upwards to the highest temperature measurable by spectral radiation thermometry, the radiation thermometry being based on the Planck radiation law. When it was developed, the ITS-90 represented thermodynamic temperatures as closely as possible. Part I of this paper describes the realization of contact thermometry up to 1234.93 K, the temperature range in which the ITS-90 is defined in terms of calibration of thermometers at 15 fixed points and vapor pressure/temperature relations which are phase equilibrium states of pure substances. The realization is accomplished by using fixed-point devices, containing samples of the highest available purity, and suitable temperature-controlled environments. All components are constructed to achieve the defining equilibrium states of the samples for the calibration of thermometers. The high quality of the temperature realization and measurements is well documented. Various research efforts are described, including research to improve the uncertainty in thermodynamic temperatures by measuring the velocity of sound in gas up to 800 K, research in applying noise thermometry techniques, and research on thermocouples. Thermometer calibration services and high-purity samples and devices suitable for "on-site" thermometer calibration that are available to the thermometry community are described. Part II of the paper describes the realization of temperature above 1234.93 K for which the ITS-90 is defined in terms of the calibration of spectroradiometers using reference blackbody sources that are at the temperature of the equilibrium liquid-solid phase transition of pure silver, gold, or copper. The realization of temperature from absolute spectral or total radiometry over the temperature range from about 60 K to 3000 K is also described. The dissemination of the temperature scale using radiation thermometry from NIST to the customer is achieved by calibration of blackbody sources, tungsten-strip lamps, and pyrometers. As an example of the research efforts in absolute radiometry, which impacts the NIST spectral irradiance and radiance scales, results with filter radiometers and a high-temperature blackbody are summarized.

Calibration of High Heat Flux Sensors at NIST.

An ongoing program at the National Institute of Standards and Technology (NIST) is aimed at improving and standardizing heat-flux sensor calibration methods. The current calibration needs of U.S. science and industry exceed the current NIST capability of 40 kW/m2 irradiance. In achieving this goal, as well as meeting lower-level non-radiative heat flux calibration needs of science and industry, three different types of calibration facilities currently are under development at NIST: convection, conduction, and radiation. This paper describes the research activities associated with the NIST Radiation Calibration Facility. Two different techniques, transfer and absolute, are presented. The transfer calibration technique employs a transfer standard calibrated with reference to a radiometric standard for calibrating the sensors using a graphite tube blackbody. Plans for an absolute calibration facility include the use of a spherical blackbody and a cooled aperture and sensor-housing assembly to calibrate the sensors in a low convective environment.

Cell surface determinants on typhoid-specific B cells isolated from peripheral blood after oral Ty21a typhoid vaccination in humans.

Antigen specific B cells (ASC) that circulate after oral immunization with the typhoid vaccine Ty21a display cell surface determinants which are potentially involved in B cell differentiation and homing to mucosal sites. These ASC were isolated from peripheral blood after oral Ty21a, and dual labelled for binding of typhoid antigen and expression of various cell surface determinants: alpha 4 integrin (CD49d), CD45RO, CD45RA, L-selectin, CD44 and CD11a. Of particular interest was the finding of CD45RO expression on ASC. A comparison of cell surface determinants on typhoid-specific cells was also made following binding to high endothelial venules on peripheral and mesenteric lymph nodes, and venules in the lamina propria of the small intestine. Generally more typhoid ASC bound to mesenteric compared with peripheral lymph node. More ASC expressing CD45RO and alpha 4 integrin (CD49d) were bound to mesenteric lymph node and small intestine than to peripheral lymph node. When expressed as a fraction of total ASC, the difference was statistically significant only for CD45RO binding to small intestine versus peripheral lymph node. No differences in expression of other homing markers on bound ASC were seen.

Antigen-specific B cells in tissues after oral typhoid vaccination.

Six human subjects who were to receive elective bowel surgery for a variety of diseases were vaccinated with the oral typhoid vaccine, Ty21a. Intestinal tissue (ileum in two, large intestine in four) removed 7-26 days after the first dose of vaccine was examined for the presence and distribution of antigen-specific B cells. This was compared with intestinal tissue derived from two unvaccinated controls. A number of B cell differentiation antigens were also assessed on these cells by immunofluorescence using dual-labelling. Antigen-specific cells were found randomly distributed in the lamina propria of all the vaccinated subjects in low frequency (6 +/- 0.5 to 37 +/- 31 [mean +/- s.e.m.] antigen specific cells/10 mm2 of tissue). The lymphocyte differentiation antigens CD45RA, CD45RO, L-selectin, CD-11a CD-38, CD-44 and VLA-4 were all found on antigen-specific cells, but no particular pattern was recognizable in this small series of six subjects with different disease processes affecting the intestine.

Dual staining of lymphocyte membrane antigens with colloidal gold and biotinylated horseradish peroxidase.

Double immunoenzymatic labelling procedures for the localization of antigens on cells in tissue sections using horseradish peroxidase (HRP) and alkaline phosphatase have been described previously, but mainly for detecting antigens on different cells. With this type of staining when two antigens are present on the same cell, an optimal colour combination that shows a high contrast between the basic colour of each enzyme substrate product is difficult to achieve and the interpretation of their mixed colour intermediate is subjective. We present a method for the simultaneous demonstration of two antigens on the same cell. The method can be used to label either single cells in suspension, or cells in paraffin fixed tissue, using a combination of a particulate label, colloidal immunogold-silver, and an enzymatic label HRP-DAB. The method is easy to perform and utilises commercially available staining kits.

Cellular and humoral responses in coeliac disease. 1. Wheat protein fractions.

The humoral and cellular immune response of coeliac individuals to various wheat protein fractions was studied using serum antibody ELISA assays and the indirect leucocyte migration inhibition factor (LMIF) assays. Greater migration inhibition factor activity was seen in coeliacs on a gluten-free-diet having low serum antibody titres, and using purified T-cells instead of total peripheral blood mononucleocytes. Gliadin was the most active fraction in both assays. Raised antibodies to low-molecular weight and high-molecular weight glutenin polypeptides was observed, though these proteins had little migration inhibition factor activity. No cellular or humoral response was seen to albumins or globulins. Proteins associated with the granules of well-washed wheat starch are distinct from gluten proteins and had little T-cell activity, correlating with clinical observations that properly prepared wheat starch is devoid of coeliac toxicity. The greater specificity of the humoral response for individual wheat protein fractions in this study, compared with the earlier reports, likely results from cross-contamination in the earlier work of each fraction with gliadin.

Phenotype and activation of milk-derived and peripheral blood lymphocytes from normal and coeliac subjects.

The phenotype of milk-derived and peripheral blood lymphocytes from normal and coeliac subjects was assessed for CD3, alpha beta-TcR (T cell receptor), gamma delta-TcR, CD4, CD8, HML-1 (human mucosal lymphocyte) determinants, and activation was measured by interleukin-2 receptor (IL-2R) expression. Milk cells from normal and coeliac subjects were analysed by manual immunofluorescence and milk and blood cells from normal subjects were analysed by flow cytometry. Milk cells from two coeliac subjects were tested for proliferation to gluten antigen. The CD4:CD8 ratio of milk lymphocytes from both normal and coeliac subjects was similar (0.78-1.1), but lower than that present in blood (1.5-2.1). The IL-2R expression of milk lymphocytes from both coeliac and normal subjects was increased by 3-6 times compared with peripheral blood cells. For example, IL-2R was present on 27.3% of milk CD3+ lymphocytes and on 8.0% of blood CD3+ lymphocytes from normal subjects. gamma delta- and HML-1+ T cells were increased 4.2-fold and 12-fold respectively compared with blood lymphocytes. Milk cells from coeliac subjects showed specific proliferation to gluten but not to soya bean antigen. We conclude that milk cells have a 'mucosal' phenotype, with increased gamma delta-TcR, CD8+ and HML-1+ T cells, and have an increased proportion of activated cells. Milk cells from coeliac subjects have no 'toxic' phenotype, but show functional reactivity by specific proliferation to gluten antigen.

Lymphocyte activation as measured by interleukin-2 receptor expression to gluten fraction 111 in coeliac disease.

Lymphocyte activation was examined by interleukin-2 (IL-2) receptor expression on peripheral blood mononuclear cells from coeliac and control subjects. Purified T cells were incubated with gluten fraction 111 (a known toxic peptide for coeliac subjects), soyabean hydrolysate (an unrelated hydrolysed food antigen), and Concanavalin-A (Con-A, a non-specific mitogen). After 1-5 days incubation, expression of IL-2 receptors was assessed using a cellular enzyme-linked immunosorbent assay (ELISA). Gluten fraction 111 induced expression of IL-2 receptors on T lymphocytes from coeliac but not from normal subjects (P = 0.0005), whereas soyabean hydrolysate did not induce IL-2 receptor expression. Lymphocytes from both coeliac and normal subjects had similar increased IL-2 receptor expression after incubation with Con-A. Flow cytometry was also used to confirm specific expression of IL-2 receptor expression of lymphocytes from coeliac subjects. Interleukin-2 receptor expression increased from 0 to 5.4% of cultured mononuclear cells after 7 days incubation with gluten fraction III. These cells were CD3-positive and CD4-positive. We conclude that peripheral blood lymphocytes from coeliac subjects are sensitized specifically to gluten fraction III.

Caudal block: cost effective primary treatment for back pain.

Therapeutic caudal block was applied as primary treatment to 81 consecutive patients. The 26 who were completely relieved of symptoms were older, were predominantly women, and usually had had no previous surgery. Multiple blocks were required in some, but there were no complications. Because considerable financial benefit accrued to the patients whose pain was relieved, therapeutic caudal block is suggested as primary treatment for back or back and leg pain, particularly in older patients not previously operated on.