Constant observation practices in the general hospital setting: a national survey.

The authors conducted a national survey of 355 general medical/surgical hospitals to assess constant observation (CO) practices. The authors assessed overall use, expense, staffing patterns, funding strategies, and cost-saving interventions. Virtually all responding hospitals (N = 102) reported using some form of CO. Several hospitals reported significant decreases in CO expenditures after the implementation of cost-saving interventions (the largest annual decrease reported was $340,000). Cost-saving interventions included utilizing consolidated bed spaces, relocating patients near nursing stations, placing at-risk patients in bed enclosure devices, and regularly assisting patients to the toilet. In addition, less costly personnel were hired, and volunteers and/or patient family members provided CO (or were required to assist with the cost of CO). Finally, hospital staff were educated about the costs and the appropriate use of CO. They were also taught to recognize and effectively treat delirium.

Clients and therapists confidence and attendance at planned individual therapy sessions.

85 of 217 clients who reported retrospectively that their intake therapist seemed confident of being helpful also reported cancelling and missing fewer follow-up sessions regardless of the length of treatment. Clients' reported confidence during the first session and clients' attendance at later sessions were also associated with three measures of satisfaction with individual therapy.

Repetitive nocturnal arterial oxygen desaturation and silent myocardial ischemia in patients presenting for vascular surgery.

OBJECTIVE: To determine whether nocturnal respiratory abnormality (cyclic oxygen desaturation and tachycardia) is associated with nocturnal myocardial ischemia in older individuals with ischemic heart disease. DESIGN: Non-invasive monitoring on a single occasion. SETTING: Tertiary care referral hospital. PATIENTS: Thirty four consecutive older (68.5 +/- 6 yrs) patients referred for elective abdominal or carotid reconstructive vascular surgery. RESULTS: Seven patients (21%) had moderately severe nocturnal respiratory abnormality, defined by more than 50 dips in arterial oxygen saturation and increases in heart rate during the night. Two of these seven had clinical risk factors for ischemic heart disease and had nocturnal myocardial ischemia. Ten patients (29%) developed ischemia at some time during the study, of whom seven hand known ischemic heart disease, hypertension, and/or angina. Those with increased nocturnal ischemia showed very low frequency (1-2 cycles per minute) cyclic heart rate oscillations and repetitive nocturnal episodes of arterial oxygen desaturation, similar to patients with sleep apnea. CONCLUSION: Repetitive nocturnal cyclic arterial desaturation and cyclic increases in heart rate are associated with nocturnal myocardial ischemia in individuals with clinical risk factors for ischemic heart disease. Further investigation in a large patient sample utilizing non-invasive monitoring of saturation, heart rate, and blood pressure may provide definitive evidence regarding causation of some of the nocturnal myocardial ischemia occurring in older individuals with vascular disease.

Postoperative obstructive sleep apnoea. Haemodynamic effects of treatment with nasal CPAP.

A 74-year-old man presenting for aortic reconstructive surgery showed severe, previously undiagnosed obstructive sleep apnoea during overnight oximetry monitoring before operation. Postoperatively, in the first 4 hours following extubation, he suffered 238 episodes of respiratory obstruction. These events were associated with frequent arousals, large fluctuations in systolic and diastolic blood pressure. Administration of nasal continuous positive airways pressure abolished the obstructions and allowed an uninterrupted night's sleep, with a significantly reduced blood pressure. Subsequent dips in oxygen saturation as a result of respiratory obstruction recurred on the fifth postoperative night. We conclude that pre-operative overnight oximetry may be useful in identifying those patients at risk of postoperative upper airway obstruction. Use of nasal continuous positive airway pressure may prevent the occurrence of early postoperative obstruction and the associated haemodynamic changes.

Further characterization of IgG receptors from human placenta.

A Cell membrane fraction from term human placenta was prepared by homogenization and ultracentrifugation. The fraction was found to bind both human IgG and human serum albumin. Maximal specific binding occurred at pH 5.2, and the amount of binding was dependent upon incubation time, temperature, buffer, and ionic strength. The binding of human serum albumin was inhibited by preincubation with H-IgG but the reverse did not happen.

Localizing of C-reactive protein in synovium of patients with rheumatoid arthritis.

Synovial biopsies from 8 patients with rheumatoid arthritis, 2 patients with degenerative osteoarthritis, and 4 patients with nonarthritic disease were studied for localization of C-reactive protein (CRP) using immunofluorescence microscopy. The nuclei of many synoviocytes and histiocytes in rheumatoid synovial membrane were found to bind CRP. Cultures of rheumatoid synovium in 14C-labeled amino acids produced radioactive IgG, IgM, IgA, and C3; but not CRP, indicating the synovial-bound CRP was not of local origin. A few CRP-binding nuclei were present in one osteoarthritis synovium, but none was found in the other and none in synovium from the 4 nonarthritis patients. The nature of the nuclear CRP ligand in rheumatoid synovium was not determined.

Larva-specific antibodies in patients with visceral larva migrans.

Seven of 10 patients with visceral larva migrans (VLM) had serum precipitating antibodies specific for larval antigens of Toxocara canis as determined by double diffusion in agar. Such antibodies were absent in 114 normal adults and 25 patients with collagen disease. Precipitation of ascarid components by C-reactive protein resulted in false-positive reactions, but this precipitation was readily prevented by appropriate absorption of sera before testing. A more sensitive assay, the enzyme-linked immunosorbent assay, revealed high titers of antibodies to larvae of Toxocara in all patients with VLM; the log2 titer ranged from 9 to 14. Five of eight household relatives of these patients and four children who had had VLM two to four years before testing had titers of 6-12. Of the 114 normal adults, 105 had titers of 0-2; nine had titers of 3-8. Of the 25 patients with collagen disease, 23 had titers of 0, and two had titers of 4 and 6, respectively. Additional studies of those patients indicated that infection with Toxocara can be distinguished serologically from ascariasis, filariasis, and trichinellosis.

Selective transfer of plasma proteins across mammary gland in lactating mouse.

Specific plasma proteins were labeled with 131I, and their half-lives in lactating and nonlactating mice were determined. The proteins included mouse IgF and IgM, mouse, bovine, rabbit, and human IgG, human serum and salivary IgA, human transferrin and albumin, and mouse and human immunoglobin light chains. The rates at which these proteins are transferred across the mammary gland in mice suckling their young were calculated: transmammary protein transfer was found to be highly selective. The G-class immunoglobulins readily traversed the mammary gland, the rate being dependent on the IgG load presented to the transport system. Immunoglobulin lambda-chains and human serum IgA crossed the mammary gland even more rapidly than did the G immunoglobulins. Human IgA without secretory piece was transported into milk more rapidly than IgA with secretory piece attached. Protein transport across the mouse mammary gland was found to be similar to and yet different from protein transport across either the suckling mouse intestine or the mouse placenta as to which proteins crossed and at what relative rates.

Protein binding by specific receptors on human placenta, murine placenta, and suckling murine intestine in relation to protein transport across these tissues.

Human, rat, and mouse placentas and rat and mouse intestines were homogenized in buffered saline, and fraction consisting primarily of cell membranes was separated from each of the homogenates by differential centrifugation. Human, bovine, and guinea pig IgG, and human IgE, Bence-Jones protein, serum albumin, insulin, and growth hormone were labeled with (131)I or (125)I, and the binding of these proteins by the cell membrane fractions was investigated. Rat and mouse sucklings were given labeled proteins intragastrically, and the amount of each protein absorbed after a given interval of time was determined. It was found that the degree and specificity of protein binding by the cell membrane fractions from human and murine placentas strikingly paralleled the relative rate and specificity of protein transport from mother to fetus in the respective species at or near term. Similarly, the degree and specificity of protein binding by the cell membrane fractions from suckling rat and mouse intestines tended to parallel the rate and specificity of protein absorption from the gastrointestinal tract in these animals. However, some discordance between protein binding and protein transport was also observed. The data suggest that: (a) the binding of a protein by specific receptors on cell membranes may be a necessary first step in the transcellular transport of the protein; (b) specific protein binding by cell receptors does not ensure the transport of that protein across the tissue barrier; and (c) specific transport mechanisms other than or in addition to specific cell membrane receptors are involved in the active transport of proteins across the human or murine placenta or the suckling murine intestine.

Ontogeny of fetal plasma proteins.

PIP: Ontogeny of fetal plasma proteins was investigated. By 4.5 weeks' gestation, the yolk sac synthesizes prealbumin, albumin, alpha 1-antitrypsin, alpha fetoprotein (AFP), and transferrin. Synthesis of immunoglobulin M (IgM), IgG, IgE, and IgD begins around 10-11 weeks' gestation. By 17-18 weeks' gestation, lymphoid cells are distinguishable in the spleen, and the spleen then becomes the major single organ for IgM and IgG production. It rises rapidly to a maximum of 300 mg% at 10-13 weeks which is due entirely to endogenous synthesis. Serum AFP then falls exponentially with a 1/2 life of about 32 days. After 32 weeks' gestation, the AFP level falls rapidly, indicating a sharp reduction in total AFP production. Synthesis of AFP is still evident at term in at least some normal fetuses. Cortisone acetate administered to pregnant rats just prior to parturition resulted in fetal suppression of AFP synthesis. Evidence indicates that cortisone acts only indirectly on the synthesizing pathway.^ieng