Milk urea nitrogen concentration: heritability and genetic correlations with reproductive performance and disease.

The objectives of this study were to estimate the heritability of milk urea nitrogen (MUN) concentration and describe the genetic relationship between MUN and reproductive performance and between MUN and diseases in Holsteins. Dairy Records Management Systems (Raleigh, NC) provided lactation data. The Danish Agricultural Advisory Center provided breeding value estimates for diseases. Infrared (IR) and wet chemistry (WC) data were analyzed separately. Heritabilities and genetic correlations for 2 different measures of MUN and reproductive performance were estimated with an animal model using ASREML. Heritabilities for MUN were estimated using all lactations combined (lactations 1 through 5) and separately for first lactation and second lactation. Genetic correlations with reproduction and health were estimated separately for parities 1 and 2. Herd-test-day or herd-year-season along with age at calving and days in milk were included as fixed effects in all models. Heritability estimates for all lactations combined were 0.15 for WC MUN and 0.22 for IR MUN. Genetic correlations between WC MUN and 2 measures of reproductive performance, days to first service, and first service conception were not different from zero. In contrast, the genetic correlation between WC MUN and days open of 0.21 in first lactation and 0.41 in second lactation indicated that higher WC MUN values were associated with increased days open. Correlations among estimated breeding values for MUN and estimated breeding values for Danish diseases identified no significant relationships. Although the results of this study indicate that heritable variation for MUN exists, the inability to identify significant genetic relationships with several measures of disease or reproductive performance appears to limit the value of MUN in selection for disease resistance and improved reproduction.

Paramedic activities, drug administration and survival from out of hospital cardiac arrest.

OBJECTIVE: To examine the impact of administration of cardioactive drugs on the outcome from out of hospital cardiac arrest. DESIGN: Longitudinal observational cohort study with historical controls before and after the introduction of drug use in cardiac arrest by paramedics. SUBJECTS: Adult patients who had sustained an out of hospital cardiac arrest of cardiac aetiology and were treated by paramedics. SETTING: Edinburgh, Scotland. OUTCOME MEASURES: Return of spontaneous circulation, admission to and discharge from hospital. RESULTS: There was no significant difference in the demographics between Period 1 (prior to drug administration) and Period 2 (after). There was no difference in outcome between Period 1 and Period 2 for all three parameters, return of spontaneous output 30.1 versus 35%, admission to hospital 18.9 versus 24.5% and discharge 5.8 versus 6.5%. If the presenting rhythm of VF/pulseless VT alone was considered survival to hospital discharge was 12.1% in Period 1 and 10.3% in Period 2. CONCLUSION: The addition of cardioactive drug administration to the treatment of out of hospital cardiac arrest does not improve survival.

Excessive morphine requirements after pre-hospital nalbuphine analgesia.

Nalbuphine hydrochloride is an opioid agonist-antagonist that has gained acceptance as a pre-hospital analgesic agent. Nalbuphine has equal analgesic properties to morphine, has a low addiction potential, and can be stored and administered without restrictions, unlike morphine. To date no clinical evidence has been published to support the theoretical difficulty that the action of opioids administered after nalbuphine could be altered or negated. The following case reports highlight 10 patients who received nalbuphine pre-hospital and subsequently required higher doses of opioid analgesia than expected. The discussion summarises the properties of nalbuphine and identifies potential reasons why excessive amounts of opioid analgesia were required.

Advanced life support for out-of-hospital cardiac arrest--the changing role of a hospital-based flying squad.

The success of hospital-based flying squads in the management of out-of-hospital cardiac arrest has been well documented, but since the introduction of ambulance paramedics the need for such teams to deal with cardiac arrests has been questioned. We performed a 3-year retrospective study of non-traumatic arrests attended by Medic 1, the flying squad based at the Royal Infirmary of Edinburgh. There were 99 males and 46 females, mean age 57.6 years (range 17-86 years). Seventy-eight (53.9%) patients were pronounced dead at scene, 47 patients (32.4%) were admitted to hospital and 20 (13.7%) survived to hospital discharge. All but two of the survivors had return of spontaneous circulation prior to the arrival of Medic 1. Accident flying squads operating as a secondary response unit to victims of non-traumatic cardiac arrest are unlikely to have a significant effect upon overall survival.

Can the full range of paramedic skills improve survival from out of hospital cardiac arrests?

OBJECTIVE: To examine the effect of full implementation of advanced skills by ambulance personnel on the outcome from out of hospital cardiac arrest. SETTING: Patients with cardiac arrest treated at the accident and emergency department of the Royal Infirmary of Edinburgh. METHODS: All cardiorespiratory arrests occurring in the community were studied over a one year period. For patients arresting before the arrival of an ambulance crew, outcome of 92 patients treated by emergency medical technicians equipped with defibrillators was compared with that of 155 treated by paramedic crews. The proportions of patients whose arrest was witnessed by lay persons and those that had bystander cardiopulmonary resuscitation (CPR) were similar in both groups. RESULTS: There was no difference in the presenting rhythm between the two groups. Eight of the 92 patients (8.7%) treated by technicians survived to discharge compared with eight of 155 (5.2%) treated by paramedics (NS). Of those in ventricular fibrillation or pulseless ventricular tachycardia, eight of 43 (18.6%) in the technician group and seven of 80 (8.8%) in the paramedic group survived to hospital discharge (NS). For patients arresting in the presence of an ambulance crew, four of 13 patients treated by technicians compared with seven of 15 by paramedics survived to hospital discharge. Only two patients surviving to hospital discharge received drug treatment before the return of spontaneous circulation. CONCLUSIONS: No improvement in survival was demonstrated with more advanced prehospital care.

Inhalational anaesthesia in emergency medicine using a new volatile--sevoflurane.

Two cases are described in which an inhalation anaesthetic was performed in order to secure an airway in patients with upper airway compromise. The agent used, sevoflurane, is relatively new and its properties are described. This is an important technique in which accident and emergency staff should obtain the appropriate supervised training.

Comparison of two emergency response systems and their effect on survival from out of hospital cardiac arrest.

The pre-hospital care provided by emergency response systems will have an effect on the outcome of patients who have sustained an out of hospital cardiac arrest. This study compares the results of resuscitation in two centres, one in the UK (Edinburgh) and the other in the USA (Milwaukee), and examines the demographics in both centres. An overall greater proportion of patients survived to hospital discharge in Edinburgh, 12.4%, compared with 7.2% in Milwaukee (P < 0.01). However patients were more likely to have a witnessed collapse in Edinburgh 65.7%, compared with 25% (P < 0.001) and significantly more of those patients received bystander cardiopulmonary resuscitation (CPR) 42.3%, compared with 27.1% (P < 0.005). When these two effects are accounted for there is no difference in outcome. The importance of early alerting of emergency services and early bystander CPR should not be underestimated.

Increased prevalence of Listeria monocytogenes in the faeces of patients receiving long-term H2-antagonists.

BACKGROUND: Human listeriosis is an uncommon infection caused by the Gram-positive organism Listeria monocytogenes. OBJECTIVE: To investigate the effects of therapeutic gastric acid suppression on faecal isolation of L. monocytogenes and the incidence of human listeriosis. METHODS: Five stool specimens from each of 20 patients on continuous H2-antagonist therapy and two faecal samples from each of 47 healthy controls were investigated for the presence of Listeria spp. RESULTS: A higher faecal isolation rate of L. monocytogenes was detected amongst the patients (20%) compared with the controls (2.1%) (P < 0.025). All subjects with stools positive for Listeria spp. were female, this sex difference being significant in the patient group (P < 0.0036) compared with controls. No patient, however, developed listeriosis. CONCLUSION: Patients on long-term gastric acid suppressive therapy may be at increased risk of faecal carriage of L. monocytogenes.

Survival after laceration of the superior vena cava from blunt chest trauma.

Laceration of the superior vena cava is an unusual result of blunt trauma and is almost invariably lethal. A case caused by a high speed road traffic accident is presented; the factors relating to survival are discussed.

Paramedics and technicians are equally successful at managing cardiac arrest outside hospital.

OBJECTIVE: To examine the effect on survival of treatment by ambulance paramedics and ambulance technicians after cardiac arrest outside hospital. DESIGN: Prospective study over two years from 1 April 1992 to 31 March 1994. SETTING: Accident and emergency department of university teaching hospital. SUBJECTS: 502 consecutive adult patients with out of hospital cardiopulmonary arrest of cardiac origin. INTERVENTIONS: Treatment by ambulance technicians or paramedics both equipped with semiautomatic defibrillators. MAIN OUTCOME MEASURES: Rate of return of spontaneous circulation, hospital admission, and survival to hospital discharge. RESULTS: Rates of return of spontaneous circulation, hospital admission, and survival to hospital discharge were not significantly different for patients treated by paramedics as opposed to ambulance technicians. Paramedics spent significantly longer at the scene of the arrest than technicians (P < 0.0001). CONCLUSIONS: The response of ambulance paramedics to patients with cardiopulmonary arrest outside hospital does not provide improved outcome when compared with ambulance technicians using basic techniques and equipped with semi-automatic defibrillators.

Achalasia. A new modality for treatment.

This lesion of the esophagus, first described in 1682 by Thomas Willis, been subject to many forms of therapy. We feel botulinum toxin injection to be an acceptable alternative treatment modality for select patients with primary esophageal achalasia. Traditional methods of treating achalasia consist of medical therapy for short-term relief, balloon dilation and myotomy. Botulinum toxin injection is an alternative method of treatment, suggested by Pasricha et al and used successfully in our patient, which does not seem to cause the significant complications of perforation or gastroesophageal reflux and which may be more attractive to patients less able to undergo dilation or myotomy. This method of injecting botulinum toxin directly into the LES appears to be a relatively safe modality of treatment. Reports suggest symptoms of achalasia may recur (in up to a year's time) and repeated injections may be needed. Even so, this would seem to be acceptable in the overall management of achalasia. We agree that long-term follow-up of these patients is indicated. Data to date, plus our personal experiences, have been encouraging. We feel this represents an option for non-surgical patients and may even be considered prior to the endoscopic balloon surgery approach. It is certainly more cost effective. We are currently evaluating a second patient for botulinum toxin therapy.

Therapeutic ERCP: spectrum of procedures performed in 60 consecutive patients.

Therapeutic applications of endoscopic retrograde cholangiopancreatography (ERCP) have increased dramatically, and endoscopic sphincterotomy (ES) is the cornerstone of these techniques. Indications include treatment of retained biliary duct stones, papillary stenosis, benign and malignant strictures, and acute cholangitis and pancreatitis. We reviewed our recent experience to assess the spectrum of procedures done and their results. Medical records and radiographic examinations in 60 consecutive patients undergoing therapeutic ERCP were studied. Patients were placed into one of three treatment groups; Group 1, ES alone (N = 21); Group 2, ES plus stone retrieval (N = 15); and Group 3, ES plus stent placement (N = 24). In Group 1, all of eight patients with ductal stones had spontaneous passage. In 11 patients with papillary stenosis, nine had relief of symptoms following ES. Two patients with pancreatitis improved after ES. In Group 2, all 15 patients with ductal stones had successful retrieval. In Group 3, patients were treated for biliary stricture alone (4), retained stones (7), pancreatitis (5), neoplasms (6) and papillary stenosis (2). In these 24 patient, 21 (88%) were treated successfully or had palliation of their symptoms. In our series, a wide variety of therapeutic applications of ERCP was used to manage simple and complex biliary disease. ES alone or in combination with other techniques was done in all patients. Overall, 55 (92%) of 60 interventional procedures were successful as defined by removal of stones and relief or palliation of symptoms.

Bacteriocin (monocin) interactions among Listeria monocytogenes strains.

Monocin interactions of 97 strains of Listeria monocytogenes were assessed using an improved production method and standardisation of the monocins against the type strain of L. ivanovii. Monocins were resistant to trypsin, sensitive to heating at 56 degrees C for 30 min and stable at 4 degrees C. Only serovar 4 strains acted as indicators. A typing system using 8 producer and 11 indicator strains showed poor discrimination.

High mortality among patients with the leukemoid reaction and alcoholic hepatitis.

We describe a patient with severe alcoholic hepatitis, markedly elevated white blood cell count, and high fever. After review of the English literature, we discovered reports of other cases similar to our case. The striking feature in all of these cases was a high short-term mortality rate, despite predictions of a favorable outcome. We therefore believe these patients represent a subgroup of patients with alcoholic hepatitis and that the leukemoid reaction is a poor prognostic sign in this disease.

Electro-convulsive therapy: informing patient and nurse.

Although there is still considerable controversy surrounding electro-convulsive therapy (ECT), it is widely used in psychiatric hospitals. Good nursing care is central to its successful administration, and nurses must be able to explain the procedure to patients and why it can help them.

Mycobacterial infections after renal transplantation.

Mycobacterial infections occurred in 11 of 633 (1.7 per cent) recipients of successful renal transplants. There were no cases of tuberculosis in patients receiving chemoprophylaxis, but amongst those who did not receive prophylaxis disease occurred in six of the 27 (22 per cent) high-risk patients. The major cause of morbidity during treatment was renal allograft rejection, largely due to reduction in immunosuppressive drug therapy.

The long-term outcome following "special clearance" after vasectomy.

Between 1980 and 1985, 6067 out-patient vasectomies were performed under local anaesthesia at the Elliot Smith Clinic in Oxford. During this period 151 men (2.5%) were given a "special clearance". This sanctioned the discontinuation of other forms of contraception despite the persistence of scanty (less than 10,000/ml) sperm in 2 consecutively examined semen samples at least 7 months after vasectomy. These men have been reviewed and further specimens of semen requested after a minimum follow-up of 3 years (range 3-8); 50 patients supplied a specimen and all except 1 were azoospermic. No pregnancies attributable to failure of the vasectomy have been identified.