The effects of an aviation-style computerised pre-induction anaesthesia checklist on pre-anaesthetic set-up and non-routine events.

This prospective, observational study compared the proportion of cases with missing critical pre-induction items before and after the implementation of an aviation-style computerised pre-induction anaesthesia checklist. Trained observers recorded the availability of critical pre-induction items and evaluated the characteristics of the pre-induction anaesthesia checklist performance including provider participation and distraction level, resistance to the use of the checklist and the time required for completion. Surgical cases that met the criteria for inclusion in the National Surgical Quality Improvement Program at a single academic hospital were selected for observation. A total of 853 cases were observed before and 717 after implementation of the checklist. The proportion of cases with failure to perform all pre-induction steps decreased from 10.0% to 6.4% (p = 0.012). There was also a significant decrease in the proportion of cases with non-routine events from 1.2% cases before to none after checklist implementation (p = 0.003). In 17 cases, the checklist alerted the anaesthesia provider to correct a mistake in pre-induction preparation.

Outcomes of gynecologic oncology patients admitted to the intensive care unit following surgery: A university teaching hospital experience.

The objective of this study was to determine the outcomes of gynecological oncology patients requiring intensive care unit (ICU) admission following surgery. A computerized database identified postsurgical ICU admissions from January 1, 1999 to December 31, 2004 at a university hospital. Abstracted data included: demographics, preoperative diagnosis, reason(s) for ICU admission, consultations, interventions, length of stay (LOS), Acute Physiology and Chronic Health Evaluation (APACHE) II score, and 30-day mortality. Statistical analysis was performed with the Student's t-test. A total of 185 surgical gynecological oncology ICU patients was identified. Median age was 60 years (range, 21-92 years), and 63% of patients were white. Only 72% of patients had ovarian, endometrial, or cervical cancer. The most common indications for ICU admission were volume resuscitation (108 patients) and respiratory insufficiency (80 patients). Median ICU LOS was 1 day (range, 1-55 days). Patients surviving their hospital admission had a mean APACHE II score of 11.5 (range, 2-37) compared to a mean of 21.2 (range, 13-44) for patients who died prior to hospital discharge (P < 0.001). The overall mortality rate was 12%. A substantial number of gynecological oncology patients will be admitted to the ICU following surgery. Patient outcomes are favorable if APACHE II scores are low and ICU LOS is short.

Pain in the intensive care unit: recognition, measurement, management.

There has been a resurgence in interest in the in-hospital management of pain, largely related to results of investigations into the role of analgesia in outcome and cost-efficiency. The traditional aim of analgesia as simply an altruistic goal has been supplanted by the goal of impacting on the altered physiology accompanying critical illness and trauma. Elucidation of the effect of pain and the accompanying stress response on pulmonary dysfunction in particular, but also on myocardial ischemia and coagulation, has suggested that the provision of adequate analgesia by time-honored methods may not in itself effect a reduction in morbidity without attention to the method of analgesic delivery and choice of agent.

Hypercapnia induces injury to alveolar epithelial cells via a nitric oxide-dependent pathway.

Ventilator strategies allowing for increases in carbon dioxide (CO(2)) tensions (hypercapnia) are being emphasized to ameliorate the consequences of inflammatory-mediated lung injury. Inflammatory responses lead to the generation of reactive species including superoxide (O(2)(-)), nitric oxide (.NO), and their product peroxynitrite (ONOO(-)). The reaction of CO(2) and ONOO(-) can yield the nitrosoperoxocarbonate adduct ONOOCO(2)(-), a more potent nitrating species than ONOO(-). Based on these premises, monolayers of fetal rat alveolar epithelial cells were utilized to investigate whether hypercapnia would modify pathways of.NO production and reactivity that impact pulmonary metabolism and function. Stimulated cells exposed to 15% CO(2) (hypercapnia) revealed a significant increase in.NO production and nitric oxide synthase (NOS) activity. Cell 3-nitrotyrosine content as measured by both HPLC and immunofluorescence staining also increased when exposed to these same conditions. Hypercapnia significantly enhanced cell injury as evidenced by impairment of monolayer barrier function and increased induction of apoptosis. These results were attenuated by the NOS inhibitor N-monomethyl-L-arginine. Our studies reveal that hypercapnia modifies.NO-dependent pathways to amplify cell injury. These results affirm the underlying role of.NO in tissue inflammatory reactions and reveal the impact of hypercapnia on inflammatory reactions and its potential detrimental influences.

Ixodid ticks (Acari, Ixodidae) found in San Diego County, California.

In San Diego County, California, 11 species of ixodid ticks were collected from vegetation and/or from small and large mammals, and/or found parasitizing humans. Adults of the Pacific Coast tick, Dermacentor occidentalis, were the most abundant tick collected from vegetation, with peak numbers occurring during March and April. Adults of the Western black-legged tick, Ixodes pacificus, were the second most abundant, with peaks occurring during February and March. Eight species of ticks were found on mammals, with D. occidentalis being the most abundant. Adults of this tick were found primarily on black-tailed deer, Odocoileus hemionus columbianus. Nymphs occurred mostly on larger rodents, particularly the dusky-footed wood rat, Neotoma fuscipes, while larvae preferred mice. Ixodes pacificus was the second most abundant on hosts. Adults of this tick were found mostly on larger mammals, such as carnivores and deer. Nymphs preferred larger rodents, and larvae primarily mice. Five tick species were found on humans. Adults of I. pacificus, mostly females, were the most prevalent and occurred mostly (80.1%) on individuals during October-March, followed by those of Dermacentor variabilis which were found primarily (95.0%) during April-September. Adults of D. occidentalis were the third most prevalent, being found mostly (96.0%) on humans during January-June. Of the ten species of ticks endemic to California found during the survey, two (Ixodes sculptus and Ixodes woodi), have not been previously recorded from San Diego County.

A novel approach to monitor tissue perfusion: bladder mucosal PCO2, PO2, and pHi during ischemia and reperfusion.

PURPOSE: The purpose of this study is to determine if monitoring urinary bladder PCO2, PO2, and calculated intramucosal pH would be a reliable index of tissue perfusion. MATERIALS AND METHODS: This nonrandomized controlled study was conducted in a laboratory at a university medical center. Eight immature female Yorkshire pigs were studied with T-9 aortic cross-clamping for 30 minutes followed by a 60-minute period of reperfusion. Cystotomy was performed for placement of a Foley catheter and Paratrend 7 O2/CO2 sensor. RESULTS: Baseline hemodynamic and metabolic measurements were obtained along with measurements of bladder mucosal PO2 and PCO2 (mean+/-SEM). Blood flow measured with microspheres confirmed absence of blood flow during occlusion and hyperemia during reperfusion. Bladder mucosal PO2 decreased from 42+/-14.0 mm Hg (5.6 kPa) to 1.3+/-1.3 mm Hg (1.4 kPa) during the 30-minute interval of ischemia. This was followed by an increase of bladder PO2 to greater than baseline values at the end of the reperfusion period. Bladder mucosal Pco2 increased from 57+/-4.7 mm Hg (7.6 kPa) to 117+/-7.1 mm Hg (15.6 kPa) (P < .05) during ischemia. During reperfusion the Pco2 returned to baseline levels (55+/-4.0 mm Hg [7.3 kPa]). Calculated bladder mucosal pHi declined from 7.31+/-0.04 to 7.08+/-0.05 (P < .05) during the ischemic period and after reperfusion pHi was 7.17+/-0.03. CONCLUSIONS: Monitoring urinary bladder PO2, PCO2, or calculating pHi may provide a simple and reliable means of monitoring tissue perfusion.

Pain. A prelude.

Although pain is a common fear to most, our overall ability to recognize pain, and assess and intervene with appropriate therapies is mediocre at best. However, if made a priority, substantial gains can be made in improving patient satisfaction with pain control and in rectifying deficits in the knowledge of health-care professionals. This goal is not easily obtained and generally requires time, patience, and a multidisciplinary team approach. Pain can induce numerous metabolic and neuroendocrine responses. While seemingly homeostatic, these changes can have significant physiologic and sometimes adverse consequences. Anesthesia and analgesia, especially by way of neural blockade, can alleviate some of the changes and sometimes improve unwanted consequences. While at times these techniques have not significantly altered outcome, at other times significant benefits have been observed. More sophisticated techniques and pharmacotherapies are being developed and introduced with increased frequency, but alone they will probably have only minimal impact on overall morbidity and mortality. The integration of a multimodal approach seems logical in the critical care setting, with analgesia as the cornerstone.

PentaLyte decreases lung injury after aortic occlusion-reperfusion.

Lung injury often occurs after hepatoenteric ischemia, with xanthine oxidase (XO, an oxidant-generating enzyme), released from reperfusing liver and intestines, mediating a significant component of this injury. Since pentastarch administration decreases intestinal reperfusion injury, we determined whether resuscitation with PentaLyte (a pentastarch-containing solution) would decrease hepatoenteric reperfusion injury, xanthine oxidase release, and concomitant lung injury after aortic occlusion- reperfusion. Aortic occlusion was established in rabbits for 40 min, and was followed by 3 h of reperfusion, during which either PentaLyte or lactated Ringer's solution-based resuscitation was administered. Sham-operated animals served as controls. Hepatoenteric reperfusion injury, as manifested by release of the enzyme aspartate aminotransferase and decreased gastric intramucosal pH, was significantly (p < 0.0167) attenuated by PentaLyte administration after aortic occlusion-reperfusion, as compared with its occurrence in animals given lactated Ringer's solution. The release of XO after aortic occlusion-reperfusion was 4-fold smaller after PentaLyte administration than after resuscitation with lactated Ringer's solution (p < 0.05). Pulmonary injury, as defined by an increase in bronchoalveolar lavage fluid (BALF) protein content and lactate dehydrogenase (LDH) activity, was 4-fold less after PentaLyte administration following aortic occlusion-reperfusion than after administration of lactated Ringer's solution (p < 0.05). We conclude that remote pulmonary injury is significantly decreased by concomitant PentaLyte-mediated reduction of hepatoenteric reperfusion injury and XO release.

Factors affecting the seasonal abundance of ground squirrel and wood rat fleas (Siphonaptera) in San Diego County, California.

Abiotic and biotic factors affecting the seasonal abundance of 3 species of sylvatic fleas on their hosts were examined at 7 sites in San Diego County, California. Indices for Oropsylla (Diamanus) montana (Baker) were usually highest on Spermophilus beecheyi nudipes (Huey) when < 18.4 degrees C (October-December), whereas those for Hoplopsyllus anomalus (Baker) were highest when > 18.4 degrees C (July-September). O. montana was affected most by ambient temperature (inversely for the coastal site [134 m] and directly for most mountain sites [> 1,183 m]). O. montana was affected most (directly) by relative humidity at the inland valley site, which concurs with this flea being most abundant in other areas during periods yielding higher relative humidties and moderate ambient temperatures. H. anomalus was influenced most (directly) by ambient temperature at lower sites (< 1,183 m) and by host activity at higher ones (> 1,456 m). Usually nonrandom distribution findings, when indices for each squirrel flea were higher on some hosts, indicate that flea numbers are correspondingly higher in some nests and burrows because of more favorable microconditions. Data also indicated that plague may persist at higher sites in southern California or in other areas where climatic conditions permit increased and prolonged interactions between more abundant O. montana and its host during spring through summer. Whereas, plague may have less chance of persisting at lower sites because these interactions are decreased and shortened during the warmer months. Squirrels may become infected with plague following hibernation and again when reoccupying colonial burrows. The flea Orchopeas sexdentatus was affected most (inversely) by relative humidity at a coastal site, with higher indices occurring on fewer Neotoma lepida Thomas and on more abundant Neotoma fuscipes macrotis Thomas during colder months. Such increased flea/Neotoma fuscipes Baird activity at lower sites may favor plague amplification during the winter which may involve ground squirrels and other rodents in the spring.

SHORT INTEGUMENT (SIN1), a gene required for ovule development in Arabidopsis, also controls flowering time.

The short integument (sin1) mutation causes a female-specific infertility, and a defect in the control of time to flowering in Arabidopsis. Female sterility of Sin- plants is due to abnormal ovule integument development and aberrant differentiation of the megagametophyte in a subset of ovules. An additional defect of sin1 mutants is the production of an increased number of vegetative leaf and inflorescence primordia leading to delayed flowering. The delayed flowering phenotype of sin1-1 is not due to a defect in the perception of day length periodicity or in gibberellic acid metabolism. Phenotypes of double mutant combinations of sin1 with terminalflower (tfl1) indicate that SIN1 activity is required for precocious floral induction typical in a tfl1 mutant. Unexpectedly, sin1-1 tfl1-1 plants do not make pollen, thus revealing a novel role for TFL1 in the anther. Early flowers of sin1-1 ap1-1 double mutants are transformed to long inflorescence-like shoots. A genetic model for the role of SIN1 in flowering time control is proposed.

Effects of dietary calcium supplementation on blood pressure. A meta-analysis of randomized controlled trials.

OBJECTIVE: To review the effect of supplemental calcium on blood pressure. DATA SOURCE: We searched MEDLINE and EMBASE for 1996 to May 1994. We contacted authors of eligible trials to ensure accuracy and completeness of data and to identify unpublished trials. STUDY SELECTION: We included any study in which investigators randomized people to calcium supplementation or placebo and measured blood pressure for at least 2 weeks. Fifty-six articles met the inclusion criteria, and 33 were eligible for analysis, involving a total of 2412 patients. DATA EXTRACTION: Two pairs of independent reviewers abstracted data and assessed validity according to six quality criteria. DATA SYNTHESIS: We calculated the differences in blood pressure change between the calcium supplementation group and the control group and pooled the estimates, with each trial weighted with the inverse of the variance using a random-effects model. Predictors of blood pressure reduction that we examined included method of supplementation, baseline blood pressure, and the methodological quality of the studies. The pooled analysis showed a reduction in systolic blood pressure of -1.27 mm Hg (95% confidence interval [CI], -2.25 to -0.29 mm Hg; P=.01) and in diastolic blood pressure of -0.24 mm Hg (95% CI, -0.92 to 0.44 mm Hg; P=.49). None of the possible mediators of blood pressure reduction explained differences in treatment effects. CONCLUSIONS: Calcium supplementation may lead to a small reduction in systolic but not diastolic blood pressure. The results do not exclude a larger, important effect of calcium on blood pressure in subpopulations. In particular, further studies should address the hypothesis that inadequate calcium intake is associated with increased blood pressure that can be corrected with calcium supplementation.

Effect of calcium supplementation on pregnancy-induced hypertension and preeclampsia: a meta-analysis of randomized controlled trials.

OBJECTIVE: To review the effect of calcium supplementation during pregnancy on blood pressure, preeclampsia, and adverse outcomes of pregnancy. DATA SOURCE: We searched MEDLINE and EMBASE for 1966 to May 1994. We contacted authors of eligible trials to ensure accuracy and completeness of data and to identify unpublished trials. STUDY SELECTION: Fourteen randomized trials involving 2459 women were eligible. DATA EXTRACTION: Reviewers working independently in pairs abstracted data and assessed validity according to six quality criteria. DATA SYNTHESIS: Each trial yielded differences in blood pressure change between calcium supplementation and control groups that we weighted by the inverse of the variance. The pooled analysis showed a reduction in systolic blood pressure of -5.40 mm Hg (95% confidence interval [CI], -7.81 to -3.00 mm Hg; P<.001) and in diastolic blood pressure of -3.44 mm Hg (95% CI, -5.20 to -1.68 mm Hg; P<.001). The odds ratio for preeclampsia in women with calcium supplementation compared with placebo was 0.38 (95% CI, 0.22 to 0.65). CONCLUSIONS: Calcium supplementation during pregnancy leads to an important reduction in systolic and diastolic blood pressure and preeclampsia. While pregnant women at risk of preeclampsia should consider taking calcium, many more patient events are needed to confirm calcium's impact on maternal and fetal morbidity.

sin 1, a mutation affecting female fertility in Arabidopsis, interacts with mod 1, its recessive modifier.

In Arabidopsis thaliana, a mutation in the SIN 1 gene causes aberrant ovule development and female-specific sterility. The effect of the sin 1 mutation is polymorphic and pleiotropic in different genetic backgrounds. The polymorphism concerns morphology of the mutant ovules. The pleiotropism involves internodal distance and inflorescence initiation time. The particular ovule phenotype and the length of internodes are dependent on an interaction of sin 1 with a second recessive gene, which we term mod 1. The recessive mod 1 allele in a homozygous sin 1 mutant plant reduces internode length and ovule integument size. The mutation sin 1, but not mod 1, has a demonstrable effect on ovule morphology when acting independently. In our crosses mod 1 was inseparably linked to the well known mutation erecta that is known to cause a reduction in internode and pedicle lengths.

Arabidopsis floral homeotic gene BELL (BEL1) controls ovule development through negative regulation of AGAMOUS gene (AG).

Ovules are the developmental precursors of seeds. In angiosperms the ovules are enclosed within the central floral organs, the carpels. We have identified a homeotic mutation in Arabidopsis, "bell" (bel1), which causes transformation of ovule integuments into carpels. In situ hybridization analysis shows that this mutation leads to increased expression of the carpel-determining homeotic gene AGAMOUS (AG) in the mutant ovules. Introduction of a constitutively expressed AG transgene into wild-type plants causes the ovules to resemble those of bel1 mutants. We propose that the BEL1 gene product directs normal integument development, in part by suppressing AG expression in this structure. Our results allow expansion of the current model of floral organ identity to include regulation of ovule integument identity.

Prescribed versus unrestricted carbohydrate diets in children with type 1 diabetes.

The diets of 53 children over 8 years of age with diabetes mellitus were examined by 24 h recall. Thirty-seven had been on prescribed carbohydrate diets while 16 had been on an unrestricted carbohydrate diet since diagnosis. The mean intakes of energy (prescribed 9.1 MJ, unrestricted 9.0 MJ, p = 0.66), carbohydrate (prescribed 259 g, unrestricted 251 g, p = 0.64), fat (prescribed 99.8 g, unrestricted 98.2 g, p = 0.84) and fibre (prescribed 29.2 g, unrestricted 31.0 g, p = 0.42) were not significantly different between the two groups. Both groups showed similar distribution of carbohydrate through the day and considerable day to day variation in their carbohydrate intake (coefficient of variation, prescribed 14.5%, unrestricted 14.1%, p = 0.87). Those on prescribed diet had a mean carbohydrate intake which exceeded their prescription by 36%. Both groups had above average fibre intake suggesting that qualitative advice was being followed. There were no significant differences between the two groups in metabolic control (HbA1 prescribed 12.4%, unrestricted 11.9%, p = 0.23), body mass index (prescribed 19.8 kg m-2, unrestricted 20.4 kg m-2) or insulin dosage (prescribed 1 unit kg-1 day-1, unrestricted 0.9 units kg-1 day-1). This study has shown no differences between prescribed and unrestricted carbohydrate diets. Qualitative, rather than quantitative advice may be more appropriate in the management of Type 1 diabetic children.

Promoter recognition by the RNA polymerase from vegetative cells of the cyanobacterium Anabaena 7120.

The transcription start points (tsp) of seven genes of Anabaena 7120 were previously identified by S1 nuclease protection and primer extension experiments using RNA extracted from cells. In the present work, these tsp were confirmed, with one exception, by in vitro transcription using purified RNA polymerases of Anabaena 7120 and Escherichia coli, and crude extracts of Anabaena 7120 active in transcription. In all cases, the template for transcription consisted of closed circular plasmid DNA in which the putative promoter-containing fragment was cloned in front of a strong terminator, which resulted in defined 'pseudo-runoff' transcripts whose sizes correspond (with one exception) to those expected on the basis of the tsp determined for in vivo RNA. These results, together with others obtained with templates containing bacteriophage T4 or cyanophage N1 promoters, led to the conclusion that the principal Anabaena 7120 RNA polymerase prefers promoters whose sequence and spacing approximate that of the E. coli consensus promoter, and that the Anabaena 7120 genes expressed in vegetative cells, characterized to date, have relatively weak promoters.

A vector for analysis of promoters in the cyanobacterium Anabaena sp. strain PCC 7120.

A plasmid vector containing a multiple-cloning site followed by a promoterless chloramphenicol acetyltransferase (cat) gene, protected by transcription terminators and mobilizable by conjugation from Escherichia coli into Anabaena sp. strain PCC 7120, was constructed. The utility of the vector was shown by deletion analysis of the promoter region of the Anabaena psbB gene.