Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion.

OBJECTIVE: To determine the impact of an inpatient, emergency department (ED)-managed acute care unit (ACU) on ED overcrowding and use of ambulance diversion. METHODS: Descriptive observational study with prospectively collected data from a 14-bed ACU recently opened remote from the main ED. Rates of patients who left without being seen (LWBS) and ambulance diversion frequency and duration were adjusted for ED patient volumes and compared with those for the period immediately before the ACU was opened and with those for a matching time period during the previous year. RESULTS: There were 1,589 patients seen in the ACU during the first ten weeks of operation, representing about 14.5% of the ED volume (10,871). About 33% could be classified as post-ED management, 20% as admission processing, and the rest as primary evaluation. The number of patients who LWBS decreased from 10.1% of the ED census two weeks prior to opening of the ACU, and from 9.4% during the previous year, to 5.0% (range 4.2%-6.2%) during the ensuing ten weeks post opening. Ambulance diversion was a mean of 6.7 hours per 100 patients before the unit opened and 5.6 hours per 100 patients during the same time in the previous year, and decreased to 2.8 hours per 100 patients after the unit opened (p < 0.05, respectively). A six-month pre- and two-month post-examination revealed that the mean monthly hours of ambulance diversion for the ED decreased by 40% (202 hours vs 123 hours) (p < 0.05) in contrast to a mean increase of 44% (186 hours vs 266 hours) (p < 0.05) experienced by four proximate hospitals. CONCLUSIONS: An ED-managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED.

Possible asphyxiation from carbon dioxide of a cross-country skier in eastern California: a deadly volcanic hazard.

This report describes an incident in which exceedingly high levels of carbon dioxide may have contributed to the death of a skier in eastern California. A cross-country skier was found dead inside a large, mostly covered snow cave, 1 day after he was reported missing. The autopsy report suggests that the skier died of acute pulmonary edema consistent with asphyxiation; carbon dioxide measurements inside the hole in which he was found reached 70%. This area is known for having a high carbon dioxide flux attributed to degassing of a large body of magma (molten rock) 10 to 20 km beneath the ski area. The literature describes many incidents of fatal carbon dioxide exposures associated with volcanic systems in other parts of the world. We believe this case represents the first reported death associated with volcanically produced carbon dioxide in the United States. Disaster and wilderness medicine specialists should be aware of and plan for this potential health hazard associated with active volcanoes.

Scalp topography of the short-latency components of the respiratory-related evoked potential in children.

Respiratory-related evoked potentials (RREPs) have been elicited by inspiratory occlusion and recorded at electroencephalographic (EEG) sites overlying the somatosensory cortex in adults. The present study was the first to be conducted in normal children and was designed to identify the scalp distribution of the early RREP components. EEG responses to occlusion were recorded from CZ-C3, CZ-C4, and 17 sites referenced to the linked earlobes. The RREP was observed in all subjects in the CZ-C3 and CZ-C4 electrode pairs. The earlobe-referenced recordings revealed two RREP patterns. The P1 and N1 peaks were found in C3, C4, P3, P4, T3, and T4. The RREPs recorded from the F3, F4, F7, and F8 electrodes did not exhibit either the P1 or N1 peaks. A negative peak (NF) occurred approximately 13 ms after the P1 peak. The results show that the RREPs to inspiratory occlusions were present bilaterally but diminished greatly over midline sites. Furthermore, consistent with mechanically and electrically elicited somatosensory evoked potentials, the RREP displayed a polarity inversion over the central sulcus in the early component latency range.

Antibodies to the E4, E6, and E7 proteins of human papillomavirus (HPV) type 16 in patients with HPV-associated diseases and in the normal population.

In a cross-sectional study, titers of antibodies to the E4 and E7 proteins of human papillomavirus (HPV) type 16 were measured by peptide-based enzyme-linked immunosorbent assay in 1707 sera. Sera were obtained from healthy individuals (ages 1 to 95 years), from patients with HPV-associated infection (cervical intraepithelial neoplasia and cervical cancer), and from patients who were at high risk for HPV infection (attending a sexually transmitted disease clinic or referred to a colposcopist because of an abnormal Papanicolaou smear). The prevalence of anti-E7 antibodies increased with age, although the overall prevalence in the adult population was low (10.36%) compared to the frequent detection of HPV 16 DNA in the population. This suggests that only a fraction of patients infected with HPV 16 develop an anti-E7 response. The age distribution of anti-E4 antibodies showed a different pattern, i.e., the prevalence was low in the adult population (1.14%) but exceeded 20% in children and teenagers. As the specificity of the anti-E4 reaction was supported by a highly significant association with anti-E6 positivity in children's sera (p = 0.002), it was assumed that infection with HPV 16 can occur frequently early in life. As compared to healthy controls, patients at high risk for HPV infection had a significantly higher frequency (p < 0.001) of antibodies to the HPV 16 E4 protein (but not to the E6 or the E7 protein) in their sera. Therefore, we conclude that in adults E4-specific antibodies may be a marker for virus replication.

Effects of a physical conditioning programme on asthmatic patients.

AIMS: to determine whether moderate/severe asthmatics can improve their physical fitness using standard commercial gymnasium fitness programmes and to examine the effect on their asthma. METHODS: eight moderate to severe asthmatics and seven nonasthmatic controls were tested before and after 12 weeks indoor circuit training at a commercial gymnasium. The aerobic fitness of both groups was assessed before, during and after the conditioning period. Measures of asthma severity, habitual activity levels and psychological status were also assessed. RESULTS: peak oxygen uptakes increased significantly in both asthmatics and controls, mean and 95% confidence interval (95% CI) values rising from 27.5 (21.9-33.0) to 31.3 (23.5-39.1) and 29.2 (25.9-32.5) to 32.2 (28.5-35.9) mL.min-1.kg-1 respectively. Following training, minute ventilation at high workloads was significantly reduced in the asthmatic subjects. In all participants subjective ratings of the ability to perform physical tasks was significantly increased as was the amount of habitual physical activity reported. Although the asthmatics' bronchial responsiveness to histamine, medication usage and symptom scores did not change, the daily recorded peak expiratory flow (PEFR) increased slightly, and its variability declined. CONCLUSIONS: these findings demonstrate that with proper management severe asthmatics can engage in vigorous circuit training and enjoy the health benefits of regular exercise.

Antibodies to HPV-16 E6 and E7 proteins as markers for HPV-16-associated invasive cervical cancer.

Transforming proteins E6 and E7 of human papillomaviruses (HPVs) are consistently expressed in HPV-associated cervical cancers. In ELISA with four HPV-16 E6-E7 peptides, patients with HPV-16-associated invasive cervical cancer (group 1) had a greater seroreactivity than all other groups, which included patients with HPV-16-associated cervical intraepithelial neoplasia, invasive cervical cancer patients without HPVs, and unaffected controls. A larger proportion of group 1 sera, as compared to sera of all other groups, was reactive with at least one peptide (49% vs 17-27%), and with two or more peptides (22% vs 0-6%). A clear difference between group 1 and all other groups was also found for high ELISA absorbance values to at least one peptide (22% vs 0-8%). This high seroreactivity of group 1 sera was confirmed by a radioimmunoprecipitation assay with in vitro transcribed and translated HPV-16 E7 protein. Sera from 50% of group 1 but only 3% of controls were reactive in this test. Antibodies to HPV-16 E6 and E7 proteins appear to be virus-specific and disease state-specific markers of HPV-associated cervical cancer.

The domiciliary consultation service: time to take stock.

OBJECTIVE: To review the use of the domiciliary consultation service in modern clinical practice in the Northern region. DESIGN: Retrospective study of data on domiciliary consultations from claim forms for payment submitted to the regional health authority by consultants during 1984-5 and prospective study during 1985-9. Peer review of patterns of practice by consultants. SETTING: 15 Of the 16 health districts in the Northern region, comprising a mixed urban and rural population of about 2.8 million. PARTICIPANTS: 760 Consultants in 28 specialties and 1666 general practitioners who were eligible to perform or request domiciliary consultations. MAIN OUTCOME MEASURES: Numbers of domiciliary consultations, general practitioners' requests for consultations, and consultants performing consultations and expenditure on the service by the region. RESULTS: Use of the domiciliary consultation service in the Northern region declined by 53% between 1984-5 and 1988-9, considerably in excess of the national rate of decline of 27%, and expenditure on the service was reduced, after allowing for inflation, by 604,000 pounds, or 38%, in real terms. Most consultants and general practitioners used the service sparingly whereas a small proportion used it heavily; a few specific consultants and general practitioners were responsible for a relatively high rate of domiciliary consultations. Contrary to the original definition of domiciliary consultation, the general practitioner accompanied the consultant on only one occasion in 17 and, in one specialty examined (paediatrics) patients who received domiciliary consultations seemed to have minor medical problems. CONCLUSIONS: Peer review examination of the pattern of practice in the domiciliary consultation service proved effective in rationalising use of the service, although a substantial minority of consultants and general practitioners continued to use the service heavily. The place of the service in modern clinical practice would benefit from a national review.

Diagnosis and differentiation of HTLV-I and HTLV-II infection by enzyme immunoassays using synthetic peptides.

Synthetic peptides from the major envelope protein of HTLV-I (ENV-I, amino acid 177-213) and HTLV-II (ENV-II, amino acid 173-209) and a conserved region of the transmembrane protein (TM, amino acid 378-402) were used as antigens in microtiter plate enzyme immunoassays (EIA) to detect and discriminate antibodies to HTLV-I and II. The ENV-I and ENV-II peptide EIAs were able to correctly discriminate HTLV-I and II infections in 17 of 18 subjects whose infections were determined by a gene amplification method. Sera from 100 of 107 subjects with serologically confirmed infection with HTLV-I/II and 0 of 218 seronegative controls reacted with one or more of the peptides (sensitivity, 93.5%; specificity, 100%). Ninety-six of the 100 peptide positive sera reacted exclusively with either the ENV-I or the ENV-II peptide, thereby differentiating the two viral infections. The pattern of reactivity to the ENV peptides was distinct in different populations. Patients attending an Emergency Department, who had a history of drug abuse, and male inmate entering a correctional facility only had antibody reactivity to the ENV-II peptide. Subjects from Haiti and patients with HTLV-associated neurological disease only had antibody reactivity to the ENV-I peptide. Peptide-based enzyme immunoassays that distinguish antibodies to HTLV-I and HTLV-II will facilitate studies of the epidemiology of HTLV.

Predicting concerns for the mouth among institutionalized elders.

There is a widespread belief that old people do not have healthy mouths, although the reason for this neglect is not clear. A random sample of 41 long-term care facilities in Vancouver was selected--653 residents were examined and about three-quarters of them were interviewed--to find associations between variables that might influence a concern for oral health and to assess the effectiveness of multivariate models for predicting this concern. A bivariate analysis of the data, using chi-square tests, assessed any significant associations between the variables, and three classification techniques--discriminant analysis, logistic regression, and CART (classification and regression trees)--were used to assess the usefulness of the multivariate models. Complaints of oral problems were heard from half (53%) of the sample. Most (85%) of the participants expressed a desire for treatment, while fewer than half (44%) of the participants had used a dental service since entering the facility or in the previous year. The complaints were associated significantly with the subjects who had been to a dentist recently, with those dissatisfied with the cost or quality of previous treatment, and with women. The desire for treatment was associated significantly with the recent use of dental services, and with a lack of concern for the cost of dental treatment, while the use of services was associated significantly with subjects who were younger, dentate, or from the higher socioeconomic groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung volumes in Polynesian children.

Polynesian (Maori and Pacific Island) children account for approximately one quarter of the children in New Zealand, but good data for lung function in this group are not available. In this review, we report lung volume measurements in 571 healthy children 5 to 13 yr of age: 270 Polynesians (139 boys and 131 girls) and 301 Europeans (177 boys and 124 girls). All measurements were made in a body plethysmograph. Polynesian boys had significantly larger VC, FVC, FRC, TLC, and expiratory reserve volume than did Polynesian girls. Polynesian and European children generally showed different slope and intercept relationships for the prediction of lung volume from height. Racial differences are not adequately explained by differences in body proportions or social factors including parental smoking. Possible explanations include racial differences in lung growth and maturation.

Filterability of L-forms.

We investigated the recovery of L-forms through micropore filtration. The findings indicate that L-form recovery and viability are a function of filter size and preparation technique. Current methods in use for L-form isolation appear to give erroneously low results, underestimating the potential role of L-forms in human disease.

Removal of observer variability from the determination of the volume of isoflow.

The initial attractiveness of the volume of isoflow (VisoV) as an index of early small airways dysfunction has faded, perhaps because of VisoV's high variability, a significant part of which is contributed by the observer. We suggest here that the observer variability can be removed by filtering the flow data in the reciprocal volume domain, by using a modified foreign gas mixture in which some of the helium is replaced by neon, and by reading VisoV from a plot of density dependence vs. lung inflation. Support for these suggestions is drawn from both model simulations and experiments. Model simulations suggested that VisoV would be increased by the substitution of neon for some of the helium in the usual helium-oxygen (Helox) mixture. This was confirmed in tests on matched groups of normal and asymptomatic asthmatic children. The inclusion of 20% neon (Heneox20) was found to reduce the coefficient of variation in the mean value of VisoV in both groups of subjects. An interesting result of this test was that VisoV using Heneox20 was significantly higher in the asthmatic group than in the normal group, whereas VisoV using Helox was not. The results for density dependence (DD) between the 2 groups were not significantly different using Heneox20 but were using Helox. Plots of DD (derived from heavily filtered flow curves) vs. lung inflation showed an unambiguous value for VisoV.

Physical fitness of blind and sighted children.

Twenty-seven children (age 7-17 years) with varying degrees of blindness but with no other known disorder were assessed for physical fitness. Twenty-seven randomly selected children with normal eyesight were also assessed. Maximum oxygen uptake (VO2max) was measured directly during a progressive exercise test on a treadmill. There was a significant and substantial reduction in VO2max in totally blind children (mean +/- standard deviation 35.0 +/- 7.5 ml X min-1 X kg-1) compared with normal children (45.9 +/- 6.6 ml X min-1 X kg-1). Partially sighted children had a significant but smaller reduction in VO2max. Fitness assessed by a step-test was significantly reduced in the visually impaired children, and skin-fold thickness was also significantly greater in totally blind children. The level of habitual physical activity for each child, as assessed by a questionnaire, correlated with VO2max (r = 0.53, p less than 0.0001). Blind children were significantly less active than normal children, and the difference between mean VO2max for blind and normal children became non-significant when their different activity levels were taken into account. It is concluded that totally blind children are less fit than other children at least partly because of their lower level of habitual activity.

Student expectations and personal perceptions as an approach to course evaluation.

Evaluation of courses tends to emphasize individual teacher behaviour and/or student reaction to the course. To avoid this approach a technique to determine student expectations and the degree to which the expectations were or were not met by the course was used. In addition, student perceptions of laboratory teaching/learning objectives of teachers were obtained.

The impact of successful laboratory system on the teaching of nursing skills.

The laboratory guided practice approach has been found an effective strategy for teaching nursing skills to large numbers of students. It provides flexibility in meeting individualized needs and serves to decrease stress levels of both students and faculty. At the School of Nursing, University of N.C. at Chapel Hill, it has served to establish more uniform clinical expectations of students and greater correlation between skills level and clinical site placement, as well as integration of skill components into clinical courses. These outcomes and the positive evaluations discussed above help to validate this strategy as a practical and effective way to approach the teaching of clinical nursing skills.

Taylor laminar dispersion in human airways.

Healthy subjects took breaths of approximately 200 ml or approximately 600 ml, from functional residual capacity, of a mixture of He, Ar, SF6 (approximately 7% each), 21% O2, balance N2. Without breath-holding they expired steadily to residual volume. Concentrations of He, Ar and SF6 were measured continuously near the lips and expressed in each case as a fraction of the inspired concentration. After the bigger breaths the order in phase 2 was SF6 greater than Ar greater than He and at the end of phase 3 He greater than SF6, in agreement with other workers. After small breaths, and especially with low inspiratory flows, the early part of phase 2 showed, in a highly significant number of experiments, the order He greater than Ar greater than SF6; in these cases phase 3 still showed He greater than SF6. These results are fully consistent with the occurrence, during inspiration, of Taylor laminar dispersion (TLD) in airways situated within about 200 ml from the lips. They show that the end of phase 3 cannot be used to infer the presence or absence of TLD, and that correction for the response of the mass spectrometer is of crucial importance in the interpretation of phase 2.

Pretend play and patterns of cognition in Down's syndrome children.

This study was designed to examine the relationship between cognitive functioning of Down's syndrome subjects as measured by the Bayley Scales of Infant Development and their symbolic play level. Subjects ranged in chronological age from 20 to 53 months and in mental age from 12 to 26 months. Each child was seen at home with the mother or primary caretaker present. A 1/2-hour play session was videotaped, followed by administration of the Bayley Mental Scale and Infant Behavior Record. Analysis of play behavior supported a 4-level scale. Symbolic play level was more highly correlated with mental age than with chronological age. Performance on the Infant Behavior Record was also highly correlated with symbolic play level.