In situ diagnostic methods for catheter related bloodstream infection in burns patients: A pilot study.

BACKGROUND: One of the most common and potentially fatal complications in critically ill burns patients is catheter related bloodstream infection (CR-BSI). Lack of in situ diagnostic techniques requires device removal if CR-BSI is suspected with 75-85% of catheters withdrawn unnecessarily. AIMS: To assess the sensitivity, specificity and accuracy of two in situ diagnostic methods for CR-BSI in an adult ICU burns population: Differential Time to Positivity (DTP) and Semi-Quantitative Superficial Cultures (SQSC). METHODS: Both arterial (AC) and central venous (CVC) catheters were studied. On clinicians' suspicion of CR-BSI, the CVC and AC were removed. Superficial semi-quantitative cultures were taken by removing the dressings and swabbing within a 3cm radius of the CVC and AC insertion sites, as well as inside each hub of the CVC and AC. Peripheral blood was taken for qualitative culture and the catheter tip sent for semi-quantitative culture. DTP was considered positive if culture of lumen blood became positive at least 120min before peripheral blood with an identical pathogen. Superficial and tip cultures were identified as positive if ≥15 CFUs were grown. CR-BSI was confirmed when both catheter tip culture and peripheral blood culture were positive with the same micro-organism. RESULTS: Sixteen patients (88% male) with an APACHE II score of 22.0 (7.3) were enrolled. The mean age was 45.7 (16.9) years with mean total burn surface area 32.9 (19.4)%. Fifty percent had airway burns. ICU stay was 19.9 (11.1) days. All 16 survived ICU discharge with a hospital survival of 93%. There were 20 episodes of CR-BSI in these 16 patients. For these 20 episodes the exposure time (line days) was 113.15. The CR-BSI rate was 15.6 per 1000 catheter days (95% CI 1.9-56.4). For diagnosis of CR-BSI in either AC and CVC, SQSC had a sensitivity of 50% [95% CI 3-97], specificity 83.3% [95% CI 67-93], PPV 14.3 [95% CI 1-58], NPV 96.8 [95% CI 81-100], accuracy of 81.6% [95%CI 65-92] and diagnostic odds ratio 5.0 [95% CI 0.3-91.5]. To diagnose tip colonisation (>15CFU), sensitivity of SQSC was 75% [95% CI 22-99], specificity 88.2% [95%CI 72-96], PPV 42.7 [95% CI 12-80], NPV96.8% [95% CI 81-100], accuracy 86.8% [95% CI 71-95] and diagnostic odds ratio 22.5 [95% CI 1.9-271.9]. For combined DTP blood cultures, sensitivity for CR-BSI was 50% [95% CI 3-97], with specificity 97% [95% CI 82-100], PPV 50% [5% CI 3-97%], NPV 97% [95% CI 82-100], accuracy 94.3% 95% CI 79-99] and diagnostic odds ratio 32 [95% CI 1.1-970.8]. CONCLUSION: Both DTP and SQSC displayed high specificity, NPV and accuracy in a population of adult burns patients. These features may make these tests useful for ruling out CR-BSI in this patient group. This study was limited by a low number of events and further research is required.

Rural Organization of Australian Stroke Teams: Emergency Department project.

BACKGROUND: Many junior doctors have poor stroke assessment skills. Although major efforts have gone in to changing the attitudes of clinicians to stroke through the development of guidelines and implementation strategies, the most important step may be to make sure that medical schools include appropriate teaching of this important topic in their curricula. The Rural Organization of Australian Stroke Teams Emergency Department (ROASTED) project sought to determine the effectiveness of a practical intervention to improve the assessment and education of stroke knowledge among our junior emergency department doctors. METHODS: We used a prospective before and after study of two separate cohorts (intervention vs no intervention) to assess the stroke knowledge of our junior emergency department doctors and to test the effectiveness of an educational intervention. The project took place at five sites in rural Victoria in November 2006. Both cohorts undertook the same two validated quizzes 1 month apart. At the intervention sites two 1-h tutorials were conducted between the quizzes and participants were encouraged to use a web-based educational tool. RESULTS: Pre-project stroke knowledge was shown to be poor at all of the participating sites. At the sites where no intervention took place no improvement in knowledge was shown (z = 0.83, P = 0.41, two-sided Mann-Whitney U-test). The median score for quiz 1 was 8.1 (41%, interquartile range (IQR) 6.5-9.4) and for quiz 2, 7.2 (36%, IQR 5.1-9.3). At the intervention sites, participants significantly improved their stroke knowledge between quiz 1 and quiz 2 (z = 4.75, P < 0.001). The median score for quiz 1 in this cohort was 8.3 (42%, IQR 6.5-10.0) and for quiz 2, 12.8 (64%, IQR 12.0-14.8). CONCLUSION: This project showed that junior doctors have an inadequate knowledge of stroke and that among our junior emergency department doctors there is a need for the ROASTED intervention and other innovative educational measures.

A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty.

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 microg clonidine and 9 ml 0.9% saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P < 0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.

The planning of rural health research: rurality and rural population issues.

Rurality and rural population issues require special consideration when planning both qualitative and quantitative health research in rural areas. The objective of this article was to explore the issues that require attention when planning the research. This is the first of two articles and focus on issues that require consideration when undertaking rural health research. The diversity of study populations, the feasibility of a research topic, the selection of a research team, and the cultural traditions of Indigenous communities, are all aspects of rural health research planning that require attention. Procedures such as identifying the characteristics of the population, the selection of measures of rurality appropriate for the research topic, the use of local liaison persons, decisions on the use of 'insider' or 'outsider' researchers, and the identification of skills resources available, increase the quality of the research outcomes. These issues are relevant to both qualitative and quantitative research. Procedures are available to address issues of particular concern in developing appropriate methods for rural health research. While we have concentrated on Australian issues and solutions, rural localities in other countries may face similar issues. Attention to rurality and rural situations when planning rural health research, results in studies that support the continued improvement of health in rural communities.

The conducting and reporting of rural health research: rurality and rural population issues.

Rurality and rural population issues require consideration when conducting and reporting on rural health research. A first article focused on the planning stage of the research. The objective of this article is to explore conducting and reporting issues that require attention when undertaking rural health research. The privacy of participants, the collection of data, the cultural traditions of Indigenous communities, the dissemination of results, and giving something back to the community, are all aspects of conducting and reporting rural health research that require attention. Procedures such as identifying the characteristics of the population, attention to safety issues when collecting data, the use of local liaison persons and acknowledging the ownership of intellectual property, increase the quality of the research outcomes. They are issues that are relevant to both qualitative and quantitative research methods. Procedures are available to address issues of particular concern in developing appropriate methods for rural health research. While we have concentrated on Australian issues, and possible solutions, rural localities in many other countries may face similar issues. In any rural setting, paying attention to issues that may affect the conducting and reporting of rural health research will hopefully result in studies that support the continued improvement of health in rural communities.

Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies.

BACKGROUND: Many people use complementary or alternative medicine (CAM). It is estimated that over 50% of patients that require health care use CAM either in conjunction with, or separate from, conventional health care. Despite the popular use of CAM, patients do not always inform their conventional medicine health carers of their CAM use. The medical practitioner is in most cases the first health care professional a person contacts concerning a health care matter, and needs to have a full history of a health problem to understand and provide optimum care. This literature review aims to provide an understanding of the degree to which patients disclose their use of CAM to their medical practitioners, and their reasons for not doing so. METHOD: A comprehensive literature search identified 12 studies published between 1993 and 2002 that examined what percentage of consumers did not disclose to their medical practitioners their use of CAM, and their reasons for not doing so. RESULTS: The rate of non-disclosure of those using CAM is as high as 77% in some studies. The main reasons patients provided for not disclosing their use of CAM to their medical practitioners were concerns about a negative response by the practitioners, the belief that the practitioner did not need to know about their CAM use, and the fact that the practitioner did not ask. DISCUSSION: The pre-conceptions patients have that influence their non-disclosure may be based on three issues. First, beliefs and concerns that influence their decision-making, second personal experiences in their consultations with medical practitioners, and third, the desire for more control over their health care. Medical practitioners need to acknowledge the concerns and beliefs of patients in making their health care decisions, and work with patients so that the use of CAM is acknowledged and the patients' needs, beliefs and concerns respected.

Echidna: a Web-based community information database to assist students undertaking rural clinical placements.

The number of health-sciences students who spend time training in rural areas is increasing. Students undertaking rural placements have identified the need to be fully informed about the rural areas in which they are to be placed. To address this need, Echidna, a Web-based database containing rural-community information has been developed. The website brings fragmented information together in one easily navigable location for quick and accurate searching. Information provided in the website includes demographic data, health and community services information and relevant links. This paper examines the history of Echidna's development, data inclusion and data maintenance issues and discusses how students from medicine, nursing and other health disciplines, as well as other health professionals and organisations benefit from the resource.

Rural health resource databases: a little nurturing goes a long way.

Access to rural health research information together with the type and availability of educational resources in rural areas, are important to rural health care providers, community members, researchers, students, planners and policy makers. The Rural Health Research Register (RHRR) focuses on current and recent research activity being undertaken in Australia in the field of rural health, while the Health Education Rural Remote Resources Database (HERRD) focuses on education courses and resources relevant to the practice and professional development of rural and remote health professionals throughout Australia. Early versions of these databases were established between 1992 and 1997, and in the period 1998-2001 both information resources were systematically updated through targeted promotion, registrations and the creation of web-accessible search facilities. They continue to be maintained and updated. Detailed information is available by searching the RHRR and HERRD databases via the web or by contacting the relevant coordinator. This article examines some of the issues in developing and maintaining these resources and demonstrates the usefulness of their contents to rural healthcare workers.

Relationship of disability prevention to patient health status and satisfaction with primary care provider.

A sample of 625 patients aged 18 to 65 with primary care visits was used to explore the relationship of disability prevention to patient health status and satisfaction with health care provider. Disability prevention and the patient-provider relationship, the latter a potential mediating factor, were measured using reliable and valid scales. The joint effects of disability prevention and a strong patient-provider relationship were associated with decreased risks for poor physical health, as measured by the Medical Outcomes Study 12-item short-form health survey, decreased restricted activity days, and overall satisfaction with their primary care provider. Patient-provider relationship was independently associated with increased patient satisfaction with the provider overall and endorsement of the provider to family or friends. The evidence questions the conventional wisdom among some primary care providers that incorporating disability prevention principles into their daily practice jeopardizes patient satisfaction. These results suggest that primary care providers with strong patient-provider relationships can successfully add disability prevention to their practice.

Disability prevention principles in the primary care office.

The simple request for a sick note can disguise important medical, psychologic or social issues. Disability may be influenced by social and cultural factors as well as by patient expectations. Assessment of impairment and subsequent disability is best made on the basis of objective data by use of a biopsychosocial model to ensure that the expression of disability does not mask other unaddressed psychologic or social issues. Enabling prolonged disability in such a situation can be a dysfunctional physician response to a maladaptive process. The physician's role is to treat the condition, to fulfill the appropriate role of patient advocate, to facilitate health (including resumption of activity), to offer proactive advice on the basis of prognosis, to be familiar with the patient's social obligations and resources and to provide education about the therapeutic benefits of returning to optimal function. This factual, medical-based approach offers an effective preventive strategy that will save many patients from unnecessary disability and morbidity.

Kinesin-dependent axonal transport is mediated by the sunday driver (SYD) protein.

A broadly conserved membrane-associated protein required for the functional interaction of kinesin-I with axonal cargo was identified. Mutations in sunday driver (syd) and the axonal transport motor kinesin-I cause similar phenotypes in Drosophila, including aberrant accumulations of axonal cargoes. GFP-tagged mammalian SYD localizes to tubulovesicular structures that costain for kinesin-I and a marker of the secretory pathway. Coimmunoprecipitation analysis indicates that mouse SYD forms a complex with kinesin-I in vivo. Yeast two-hybrid analysis and in vitro interaction studies reveal that SYD directly binds kinesin-I via the tetratricopeptide repeat (TPR) domain of kinesin light chain (KLC) with K(d) congruent with 200 nM. We propose that SYD mediates the axonal transport of at least one class of vesicles by interacting directly with KLC.

Cytoplasmic dynein is required for the nuclear attachment and migration of centrosomes during mitosis in Drosophila.

Cytoplasmic dynein is a multisubunit minus-end-directed microtubule motor that serves multiple cellular functions. Genetic studies in Drosophila and mouse have demonstrated that dynein function is essential in metazoan organisms. However, whether the essential function of dynein reflects a mitotic requirement, and what specific mitotic tasks require dynein remains controversial. Drosophila is an excellent genetic system in which to analyze dynein function in mitosis, providing excellent cytology in embryonic and somatic cells. We have used previously characterized recessive lethal mutations in the dynein heavy chain gene, Dhc64C, to reveal the contributions of the dynein motor to mitotic centrosome behavior in the syncytial embryo. Embryos lacking wild-type cytoplasmic dynein heavy chain were analyzed by in vivo analysis of rhodamine-labeled microtubules, as well as by immunofluorescence in situ methods. Comparisons between wild-type and Dhc64C mutant embryos reveal that dynein function is required for the attachment and migration of centrosomes along the nuclear envelope during interphase/prophase, and to maintain the attachment of centrosomes to mitotic spindle poles. The disruption of these centrosome attachments in mutant embryos reveals a critical role for dynein function and centrosome positioning in the spatial organization of the syncytial cytoplasm of the developing embryo.

Common peroneal nerve palsy in a UH-60 aviator.

A case of common peroneal nerve palsy in a UH-60 Blackhawk U.S. Army helicopter pilot is reported. A review of the literature revealed several reports of common peroneal nerve palsy, although there were no published reports of this injury secondary to performing flight duties in the UH-60 cockpit. A common practice among Blackhawk pilots is to brace the "collective" with their left knee, subjecting the common peroneal nerve to possible injury. This action should be considered as a possible cause of common peroneal nerve palsy in this select group of aviators.

The microtubule motor cytoplasmic dynein is required for spindle orientation during germline cell divisions and oocyte differentiation in Drosophila.

During animal development cellular differentiation is often preceded by an asymmetric cell division whose polarity is determined by the orientation of the mitotic spindle. In the fruit fly, Drosophila melanogaster, the oocyte differentiates in a 16-cell syncytium that arises from a cystoblast which undergoes 4 synchronous divisions with incomplete cytokinesis. During these divisions, spindle orientation is highly ordered and is thought to impart a polarity to the cyst that is necessary for the subsequent differentiation of the oocyte. Using mutations in the Drosophila cytoplasmic dynein heavy chain gene, Dhc64C, we show that cytoplasmic dynein is required at two stages of oogenesis. Early in oogenesis, dynein mutations disrupt spindle orientation in dividing cysts and block oocyte determination. The localization of dynein in mitotic cysts suggests spindle orientation is mediated by the microtubule motor cytoplasmic dynein. Later in oogenesis, dynein function is necessary for proper differentiation, but does not appear to participate in morphogen localization within the oocyte. These results provide evidence for a novel developmental role for the cytoplasmic dynein motor in cellular determination and differentiation.

Cytoplasmic dynein function is essential in Drosophila melanogaster.

The microtubule motor cytoplasmic dynein has been implicated in a variety of intracellular transport processes. We previously identified and characterized the Drosophila gene Dhc64C, which encodes a cytoplasmic dynein heavy chain. To investigate the function of the cytoplasmic dynein motor, we initiated a mutational analysis of the Dhc64C dynein gene. A small deletion that removes the chromosomal region containing the heavy chain gene was used to isolate EMS-induced lethal mutations that define at least eight essential genes in the region. Germline transformation with a Dhc64C transgene rescued 16 mutant alleles in the single complementation group that identifies the dynein heavy chain gene. All 16 alleles were hemizygous lethal, which demonstrates that the cytoplasmic dynein heavy chain gene Dhc64C is essential for Drosophila development. Furthermore, our failure to recover somatic clones of cells homozygous for a Dhc64C mutation indicates that cytoplasmic dynein function is required for cell viability in several Drosophila tissues. The intragenic complementation of dynein alleles reveals multiple mutant phenotypes including male and/or female sterility, bristle defects, and defects in eye development.

A comprehensive initiative to manage the incidence and cost of occupational injury and illness. Report of an outcomes analysis.

A comprehensive initiative utilizing an in-house preferred provider organization, medical case management, and application of ergonomic techniques was implemented in an effort to control the incidence and cost of workplace injuries. The program was evaluated utilizing OSHA 200 Logs to compare the incidence and lost time due to compensable injury and illnesses before and after beginning the program. After the introduction, there was a significant decrease in injuries and illnesses (53/1000 vs 27/1000, P<.01) and average days lost per event (10.4 vs 6.6 days, P<.01). A significant increase in restricted-duty days (.2 vs 1.5 days, P<.01) and an 18% reduction in medical and indemnity costs of the institution's workers' compensation expenditures were observed. This study demonstrates the initial effectiveness of an aggressive ergonomic and managed care approach to reducing the incidence, severity, and cost of occupationally related injury and illness. It also highlights the effectiveness of an outcomes analysis approach, using lost time as an end point, to measure the effectiveness of preventive and management strategies in the workers' compensation setting.

Predictors of blood lead levels in organolead manufacturing workers.

The relations between recent and cumulative exposure to organic and inorganic lead and blood lead levels were examined in 222 organolead manufacturing workers. Personal monitoring data grouped by 29 exposure zones were used to derive estimates of recent and cumulative occupational exposure. Recent exposure to organic lead and recent combined exposure to organic and inorganic lead were significantly and positively associated with blood lead levels. Exposure duration was found to modify the relation between recent inorganic lead exposure and blood lead levels. Age and cigarette smoking were positively associated with blood lead levels, whereas alcohol use was associated with lower blood lead levels. This is in notable contrast to the influence of alcohol consumption on blood lead levels among inorganic lead workers or the general population. Furthermore, the data suggested that current alcohol use modified the relation between recent organic lead exposure and blood lead levels (P = .08): current alcohol users evidenced less of an increase in blood lead levels with increasing recent organic lead exposures than did workers who did not currently use alcoholic beverages. The data suggest that organic lead exposure affects blood lead levels, probably after dealkylation to inorganic lead. The associations with alcohol consumption may be evidence for differences in enzyme-mediated metabolism of organolead compounds. Finally, the data suggest that recent external lead exposure and internal lead stores both influenced blood lead levels in these workers.

Regulation of cytoplasmic dynein function in vivo by the Drosophila Glued complex.

The Drosophila Glued gene product shares sequence homology with the p150 component of vertebrate dynactin. Dynactin is a multiprotein complex that stimulates cytoplasmic dynein-mediated vesicle motility in vitro. In this report, we present biochemical, cytological, and genetic evidence that demonstrates a functional similarity between the Drosophila Glued complex and vertebrate dynactin. We show that, similar to the vertebrate homologues in dynactin, the Glued polypeptides are components of a 20S complex. Our biochemical studies further reveal differential expression of the Glued polypeptides, all of which copurify as microtubule-associated proteins. In our analysis of the Glued polypeptides encoded by the dominant mutation, Glued, we identify a truncated polypeptide that fails to assemble into the wild-type 20S complex, but retains the ability to copurify with microtubules. The spatial and temporal distribution of the Glued complex during oogenesis is shown by immunocytochemistry methods to be identical to the pattern previously described for cytoplasmic dynein. Significantly, the pattern of Glued distribution in oogenesis is dependent on dynein function, as well as several other gene products known to be required for proper dynein localization. In genetic complementation studies, we find that certain mutations in the cytoplasmic dynein heavy chain gene Dhc64C act as dominant suppressors or enhancers of the rough eye phenotype of the dominant Glued mutation. Furthermore, we show that a mutation that was previously isolated as a suppressor of the Glued mutation is an allele of Dhc64C. Together with the observed dependency of Glued localization on dynein function, these genetic interactions demonstrate a functional association between the Drosophila dynein motor and Glued complexes.

Comparison of measures of lead exposure, dose, and chelatable lead burden after provocative chelation in organolead workers.

OBJECTIVES: To describe 6 h urinary lead excretion (6 h PbU) after 1 g intravenous ethylene diamine tetraacetic acid (EDTA) in organolead manufacturing workers with mixed exposure to organic and inorganic lead; to determine the predictors of lead excretion (PbU); and to determine the extent to which internal lead stores and ongoing external exposure govern blood concentrations of lead (PbB). METHODS: A case series of 21 active workers were studied. Personal industrial hygiene data, grouped by 29 exposure zones, in combination with personal interviews about work location and times were used to derive several measures of recent and cumulative exposure to organic and inorganic lead. The average exposure intensities assigned to the 29 zones ranged from 4 to 119 micrograms/m3 (0.02-0.57 mumol/m3 as lead) for organic lead and from 1 to 56 micrograms/m3 (0.004-0.27 mumol/m3) for inorganic lead. RESULTS: After controlling for age, 6 h PbU was significantly and positively correlated with summary measures of PbB--for example, lifetime peak PbB, time weighted PbB--and zinc protoporphyrin concentrations--for example, lifetime peak zinc protoporphyrin, time weighted zinc protoporphyrin--but not with measures of estimated external exposure--for example, duration of exposure and cumulative exposure to inorganic or organic lead. Among workers with higher chelatable lead burdens (6 h PbU > or = 212.4 micrograms (1.03 mumol) divided at the median), there was no apparent relation between recent inorganic lead exposure and PbB at the time of chelation. Among workers with lower chelatable lead burdens (6 h PbU < 212.4 micrograms (1.03 mumol) however, there was a significant relation between exposure and effect between recent exposure to inorganic lead and PbBs. CONCLUSION: These findings are consistent with the concept of physiological dampening. The high chelatable lead burden, a source of internal exposure, dampens the effect of external exposure on PbBs. The data suggest that in organolead workers with high chelatable lead burdens, PbBs may be more influenced by internal lead stores than by variations in airborne exposure to organic and inorganic lead.

Drosophila cytoplasmic dynein, a microtubule motor that is asymmetrically localized in the oocyte.

The unidirectional movements of the microtubule-associated motors, dyneins, and kinesins, provide an important mechanism for the positioning of cellular organelles and molecules. An intriguing possibility is that this mechanism may underlie the directed transport and asymmetric positioning of morphogens that influence the development of multicellular embryos. In this report, we characterize the Drosophila gene, Dhc64C, that encodes a cytoplasmic dynein heavy chain polypeptide. The primary structure of the Drosophila cytoplasmic dynein heavy chain polypeptide has been determined by the isolation and sequence analysis of overlapping cDNA clones. Drosophila cytoplasmic dynein is highly similar in sequence and structure to cytoplasmic dynein isoforms reported for other organisms. The Dhc64C dynein transcript is differentially expressed during development with the highest levels being detected in the ovaries of adult females. Within the developing egg chambers of the ovary, the dynein gene is predominantly transcribed in the nurse cell complex. In contrast, the encoded dynein motor protein displays a striking accumulation in the single cell that will develop as the oocyte. The temporal and spatial pattern of dynein accumulation in the oocyte is remarkably similar to that of several maternal effect gene products that are essential for oocyte differentiation and axis specification. This distribution and its disruption by specific maternal effect mutations lends support to recent models suggesting that microtubule motors participate in the transport of these morphogens from the nurse cell cytoplasm to the oocyte.