Results of the California Healthy Homes Indoor Air Quality Study of 2011-2013: impact of natural gas appliances on air pollutant concentrations.

This study was conducted to assess the current impact of natural gas appliances on air quality in California homes. Data were collected via telephone interviews and measurements inside and outside of 352 homes. Passive samplers measured time-resolved CO and time-integrated NOX , NO2 , formaldehyde, and acetaldehyde over ~6-day periods in November 2011 - April 2012 and October 2012 - March 2013. The fraction of indoor NOX and NO2 attributable to indoor sources was estimated. NOX , NO2 , and highest 1-h CO were higher in homes that cooked with gas and increased with amount of gas cooking. NOX and NO2 were higher in homes with cooktop pilot burners, relative to gas cooking without pilots. Homes with a pilot burner on a floor or wall furnace had higher kitchen and bedroom NOX and NO2 compared to homes without a furnace pilot. When scaled to account for varying home size and mixing volume, indoor-attributed bedroom and kitchen NOX and kitchen NO2 were not higher in homes with wall or floor furnace pilot burners, although bedroom NO2 was higher. In homes that cooked 4 h or more with gas, self-reported use of kitchen exhaust was associated with lower NOX , NO2 , and highest 1-h CO. Gas appliances were not associated with higher concentrations of formaldehyde or acetaldehyde.

Paediatric community-acquired septic shock: results from the REPEM network study.

UNLABELLED: INTRODUCTION AND PURPOSE OF THE STUDY: With this study we aimed to describe a "true world" picture of severe paediatric 'community-acquired' septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included. RESULTS: A 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). 'Severe' outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept). CONCLUSION: The outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

Clinical research nursing: a critical resource in the national research enterprise.

Translational clinical research has emerged as an important priority for the national research enterprise, with a clearly stated mandate to more quickly deliver prevention strategies, treatments and cures based on scientific innovations to the public. Within this national effort, a lack of consensus persists concerning the need for clinical nurses with expertise and specialized training in study implementation and the delivery of care to research participants. This paper reviews efforts to define and document the role of practicing nurses in implementing studies and coordinating clinical research in a variety of clinical settings, and differentiates this clinical role from the role of nurses as scientists and principal investigators. We propose an agenda for building evidence that having nurses provide and coordinate study treatments and procedures can potentially improve research efficiency, participant safety, and the quality of research data. We also provide recommendations for the development of the emerging specialty of clinical research nursing.

Ultrafine particle concentrations and exposures in seven residences in northern California.

UNLABELLED: Human exposures to ultrafine particles (UFP) are poorly characterized given the potential associated health risks. Residences are important sites of exposure. To characterize residential exposures to UFP in some circumstances and to investigate governing factors, seven single-family houses in California were studied during 2007-2009. During multiday periods, time-resolved particle number concentrations were monitored indoors and outdoors and information was acquired concerning occupancy, source-related activities, and building operation. On average, occupants were home for 70% of their time. The geometric mean time-average residential exposure concentration for 21 study subjects was 14,500 particles per cm(3) (GSD = 1.8; arithmetic mean ± standard deviation = 17,000 ± 10,300 particles per cm(3)). The average contribution to residential exposures from indoor episodic sources was 150% of the contribution from particles of outdoor origin. Unvented natural-gas pilot lights contributed up to 19% to exposure for the two households where present. Episodic indoor source activities, most notably cooking, caused the highest peak exposures and most of the variation in exposure among houses. Owing to the importance of indoor sources and variations in the infiltration factor, residential exposure to UFP cannot be characterized by ambient measurements alone. PRACTICAL IMPLICATIONS: Indoor and outdoor sources each contribute to residential ultrafine particle (UFP) concentrations and exposures. Under the conditions investigated, peak exposure concentrations indoors were associated with cooking, using candles, or the use of a furnace. Active particle removal systems can mitigate exposure by reducing the persistence of particles indoors. Eliminating the use of unvented gas pilot lights on cooking appliances could also be beneficial. The study results indicate that characterization of human exposure to UFP, an air pollutant of emerging public health concern, cannot be accomplished without a good understanding of conditions inside residences.

Ultrafine particle concentrations and exposures in six elementary school classrooms in northern California.

UNLABELLED: Potential health risks may result from environmental exposure to ultrafine particles (UFP), i.e., those smaller than 0.1 µm in diameter. One important exposure setting that has received relatively little attention is school classrooms. We made time-resolved, continuous measurements of particle number (PN) concentrations for 2-4 school days per site (18 days total) inside and outside of six classrooms in northern California during normal occupancy and use. Additional time-resolved information was gathered on ventilation conditions, occupancy, and classroom activity. Across the six classrooms, average indoor PN concentrations when students were present were 5200-16,500/cm(3) (overall average 10,800/cm(3)); corresponding outdoor concentrations were 9000-26,000/cm(3) (overall average 18,100/cm(3)). Average indoor levels were higher when classrooms were occupied than when they were unoccupied because of higher outdoor concentrations and higher ventilation rates during occupancy. In these classrooms, PN exposures appear to be primarily attributable to outdoor sources. Indoor emission sources (candle use, cooking on an electric griddle, use of a heater, use of terpene-containing cleaning products) were seen to affect indoor PN concentrations only in a few instances. The daily-integrated exposure of students in these six classrooms averaged 52,000/cm(3) h/day for the 18 days monitored. PRACTICAL IMPLICATIONS: This study provides data and insight concerning the UFP exposure levels children may encounter within classrooms and the factors that most significantly affect these levels in an urban area in northern California. This information can serve as a basis to guide further study of children's UFP exposure and the potential associated health risks.

Lack of utility of (111)In-pentetreotide scintigraphy in localizing ectopic ACTH producing tumors: follow-up of 18 patients.

Octreotide scintigraphy has been advocated as the principal imaging modality for localizing ectopic ACTH-secreting tumors in Cushing's syndrome. To assess its usefulness we reviewed the course of 18 consecutive patients with ectopic ACTH-producing tumor. Imaging included (111)In-pentetreotide scintigraphy, computed tomography (CT), and/or magnetic resonance imaging (MRI). Tumor was detected initially in 7/18 patients, and in 3/18 during follow-up. No ACTH-secreting tumor was detected by octreotide scintigraphy when CT/ MRI were negative. Seventeen of forty octreotide scintigrams were abnormal. CT and/or MRI confirmed tumors in 10, but demonstrated nonendocrine lesions in association with 6 false positive octreotide scintigrams. Hepatic venous sampling for ACTH refuted one lesion detected by octreotide and CT scans. Twenty-three of forty octreotide scintigrams were normal. Of these, 8 were false negative, as CT and/or MRI detected tumor; 10 agreed with negative CT and MRI, and 5 correctly refuted false positive CT and/or MRI scans. Repeated CT/ MR, but not octreotide scintigraphy, led to tumor resection in 2 patients. We conclude that octreotide scintigraphy does not offer greater sensitivity than CT/MRI and that false positive scans are common. Although octreotide scintigraphy may be helpful in selected cases, it is not a significant advance over conventional imaging for ectopic ACTH-secreting tumors.

Carbohydrate and lipid metabolism in endogenous hypercortisolism: shared features with metabolic syndrome X and NIDDM.

Carbohydrate and lipid metabolism was cross-sectionally assessed in 16 patients with endogenous hypercortisolism (endogenous Cushing syndrome). Five patients (31%) had fasting glucose levels over 6.6 mmol/l and a HbA1C over 7.5%. Six patients (38%) had diabetes mellitus based on an abnormal 75 g oral glucose tolerance test (OGTT) and two additional patients (13%) had impaired glucose tolerance based on an OGTT. Compared to obese individuals, patients with Cushing syndrome had an elevated glucose but no elevated insulin response to the OGTT. Regression analysis showed positive correlations between 24-h urinary free cortisol (UFC) and fasting blood glucose (P < 0.0005), UFC and OGTT glucose area under the curve (AUC) (P < 0.01), and UFC and HbA1C (P < 0.005). UFC levels were negatively correlated (P < 0.05) with OGTT insulin AUC and insulin/glucose ratios. Eleven (69%) patients required anti-hypertensive therapy for blood pressure control. Total cholesterol and triglycerides were elevated in patients with Cushing syndrome compared to obese controls, while LDL and HDL cholesterol, and Lp(a) were similar in the two groups. We conclude that impaired glucose tolerance and/or diabetes in patients with endogenous Cushing syndrome is due to the hyperglycemic effects of cortisol with relative insulinopenia. Thus, Cushing syndrome shares features with both the Metabolic Syndrome X and NIDDM, including impaired glucose uptake, hyperlipidemia and hypertension. However, in Cushing syndrome, a relative insulinopenia occurs, while in Metabolic Syndrome X and NIDDM, insulin excess is observed. In Cushing syndrome, as the hypercortisolemia exacerbates, insulinopenia becomes more paramount, suggesting that cortisol exerts a direct or indirect "toxic" effect on the beta-cell.

Cranial computed tomography scans in children after minimal head injury with loss of consciousness.

STUDY OBJECTIVE: To assess the need for cranial computed tomography (CT) in the emergency department evaluation of children with Glasgow Coma Scale (GCS) score of 15 after mild head injury with loss of consciousness. DESIGN: Retrospective case series of children aged 2 to 17 years with documented loss of consciousness after head injury from January 1, 1988, to July 31, 1992. All had a GCS score of 15 on initial ED evaluation and were further categorized according to physical examination findings, neurologic status, and whether the head injury was isolated or nonisolated. Recursive partitioning was used to identify variables predictive of the presence and absence of intracranial hemorrhage. SETTING: ED in two settings: a regional tertiary care trauma center and a community children's hospital. RESULTS: Of the 185 patients who met study criteria, 17 had evidence of depressed or basilar skull fractures on physical examination or had a ventriculoperitoneal shunt in place before head injury. In the remaining 168 patients, recursive partitioning identified two variables (neurologic status and head injury type) associated with intracranial hemorrhage. Overall, 12 of 168 patients (7%) had intracranial bleeding. However, none of the 49 neurologically normal children with isolated head injury had intracranial hemorrhage (95% confidence interval, 0.0 to 6.0). CONCLUSION: The prevalence of intracranial hemorrhage in children with mild closed-head injury appears to vary with the presence of neurologic abnormalities and other noncranial injuries. After isolated head injury with loss of consciousness, children older than 2 years who are neurologically normal and without signs of depressed or basilar skull fracture may be discharged home from the ED without a cranial CT scan after careful physical examination alone.

Oral gossypol in the treatment of metastatic adrenal cancer.

Medical treatment of metastatic adrenal cancer is largely unsuccessful and has considerable toxicity. We previously demonstrated the activity of the plant toxin gossypol against human adrenal cancers in nude mice. We therefore examined the efficacy and toxicity of oral gossypol as a treatment for adrenal cancer in humans. Twenty-one patients with metastatic adrenal cancer received oral gossypol at doses of 30-70 mg/day. Patients were monitored for side effects of gossypol, changes in hormone secretion, and tumor response. Eighteen patients completed at least 6 weeks of gossypol treatment. Three of these patients, whose tumors were refractory to other chemotherapeutic agents, had partial tumor responses (> or = 50% decrease in tumor volume) that lasted from several months to over 1 yr. One patient had a minor response followed by resection of her remaining disease, 1 patient had stable disease, and 13 patients had disease progression. Three patients died of their disease without receiving sufficient gossypol to achieve detectable drug levels, and were eliminated from the final analysis. The side effects of gossypol were generally well tolerated; the only serious side effect was abdominal ileus that resolved when the drug was temporarily withheld and restarted at a lower dose. We conclude that oral gossypol can be used relatively safely on an outpatient basis for the treatment of metastatic adrenal cancer. The response rate is similar to the other agents currently available for adrenal cancer, and responses were seen in patients who had failed other chemotherapeutic regimens. This study provides the first indication that gossypol may have activity against cancer in humans, suggesting the need for further investigation of gossypol as an antitumor agent.

The use of nebulized albuterol in wheezing infants.

Using a double-blind, placebo-controlled protocol, we evaluated the efficacy of nebulized albuterol in the treatment of infants aged 0 to 24 months who presented to the emergency department with wheezing. Twenty-five infants were randomly assigned to receive two identical treatments of either nebulized albuterol (0.15 mg/kg) or placebo (saline). Assessment after each treatment included a wheeze and retraction score, respiratory and heart rates, and pulse oximetry. After two treatments, there was a significant improvement in the wheeze scores (P less than 0.05) and total scores (P less than 0.05) of the albuterol group compared with the placebo group. After one treatment, there was an initial decrease in oxygen saturation in the albuterol group, which improved after the second treatment. There were no significant differences between the two groups in heart rate or respiratory rate. This study supports the use of nebulized albuterol in the treatment of wheezing infants in the emergency department.

Hip fracture mortality. A prospective, multifactorial study to predict and minimize death risk.

Four hundred consecutive hip fractures were studied prospectively. Two hundred forty-seven patients were classified as unhealthy (poor cardiac status, pneumonia, cancer history, bowel obstruction history, malnutrition, dehydration, stroke history, renal failure history, cirrhosis). Twenty-two percent of this unhealthy group died, while only 6% of the remaining healthy group died. Death rates varied with admission activity level and mental status but not when patient health status was factored out. After factoring out health status, age was associated with higher death rates only in patients older than age 85. Confusion, a change of mental status in the hospital, occurred in 25% of patients. Confusion was associated with a medical complication in 94% of cases, was the presenting symptom of a medical complication in 79% of cases, and was associated with a 39% death rate. Major medical complications occurred in 9% of the healthy group (29% of them died) and 21% of the unhealthy group (64% of them died). Major medical complications in unhealthy, shut-in patients were associated with an 80% death rate. Vigorous urinary tract monitoring and early treatment of bacteriuria decreased death rate. Postfracture malnutrition was associated with higher complication rates. Hip surgery performed within 72 hours on patients with acute medical illnesses in addition to their fracture was associated with a higher death rate. Whether a patient walked postfracture seemed not to be correlated with the death rate. Patients who were not walking prefracture but treated by internal fixation had a 34% failure rate.