Temporal changes in hematologic markers after splenectomy, splenic embolization, and observation for trauma.

INTRODUCTION: The spleen is one of the most commonly injured abdominal solid organs during blunt trauma. Modern management of splenic trauma has evolved to include non-operative therapies, including observation and angioembolization to preclude splenectomy in most cases of blunt splenic injury. Despite the shift in management strategies, relatively little is known about the hematologic changes associated with these various modalities. The aim of this study was to determine if there are significant differences in hematologic characteristics over time based on the treatment modality employed following splenic trauma. We hypothesized that alterations seen in hematologic parameters would vary between observation (OBS), embolization (EMB), and splenectomy (SPL) in the setting of splenic injury. METHODS: An institutional review board-approved, retrospective study of routine hematologic indices examined data between March 2000 and December 2014 at three academic trauma centers. A convenience sample of patients with splenic trauma and admission lengths of stay >96 h was selected for inclusion, resulting in a representative sample of each sub-group (OBS, EMB, and SPL). Basic demographics and injury severity data (ISS) were abstracted. Platelet count, red blood cell (RBC) count and RBC indices, and white blood cell (WBC) count with differential were analyzed between the time of admission and a maximum of 1080 h (45 days) post-injury. Comparisons between OBS, EMB, and SPL groups were then performed using non-parametric statistical testing, with statistical significance set at p < 0.05. RESULTS: Data from 130 patients (40 SPL, 40 EMB, and 50 OBS) were analyzed. The median age was 40 years, with 67 % males. Median ISS was 21.5 (21 for SPL, 19 for EMB, and 22 for OBS, p = n/s) and median Glasgow Coma Scale (GCS) was 15. Median splenic injury grade varied by interventional modality (grade 4 for SPL, 3 for EMB, and 2 for OBS, p < 0.05). Inter-group comparisons demonstrated no significant differences in RBC counts. However, mean corpuscular volume (MCV) and RBC distribution width (RDW) were elevated in the SPL and EMB groups (p < 0.01). Similarly, EMB and SPL groups had higher platelet counts than the OBS group (p < 0.01). In aggregate, WBC counts were highest following SPL, followed by EMB and OBS (p < 0.01). Similar trends were noted in neutrophil and monocyte counts (p < 0.01), but not in lymphocyte counts (p = n/s). CONCLUSION: This study describes important trends and patterns among fundamental hematologic parameters following traumatic splenic injuries managed with SPL, EMB, or OBS. As expected, observed WBC counts were highest following SPL, then EMB, and finally OBS. No differences were noted in RBC count between the three groups, but RDW was significantly greater following SPL compared to EMB and OBS. We also found that MCV was highest following OBS, when compared to EMB or SPL. Finally, our data indicate that platelet counts are similarly elevated for both SPL and EMB, when compared to the OBS group. These results provide an important foundation for further research in this still relatively unexplored area.

Emergency department visits by demented patients with malfunctioning feeding tubes.

BACKGROUND: Objective data indicate that feeding tubes in demented patients may not be efficacious and can have serious complications, but no study characterizes emergency department resource utilization for these patients. This study aimed to evaluate the incidence and resource utilization related to feeding tube malfunction in demented patients visiting the emergency department. METHODS: A retrospective chart review for all demented patients visiting the emergency department with malfunctioning feeding tubes from September 1999 to May 2001 was conducted. Demographic data, diagnoses, type of tube, length of emergency department stay, method of transportation to the emergency department, consultations, laboratory evaluation, x-ray data, and total hospital and ambulance charges were determined. RESULTS: A total of 138 emergency department visits by 33 patients occurred during this period (range of visits per patients, 1-21; mean, 4.1 +/- 4.3). Malfunctions occurred in 61 percutaneous endoscopically placed gastric tubes, 37 jejunostomy tubes, 34 gastric tubes, 4 endoscopically placed gastrostomy and jejunostomy tubes, and 2 percutaneous endoscopically placed jejunostomy tubes. This required 108 ambulance round-trips to and from the emergency department. The most frequent complication was unintentional dislodgement (n = 125). The average length of stay was 2.6 +/- 1.6 h. All the patients were seen by an emergency department physician. In addition, there were 99 surgical and 26 gastroenterology consultations about these patients. The total hospital charges, not including physician fees, were 86,234.48 dollars, and the total reimbursement (actual) from Medicare for ambulance charges was 57,664.00 dollars. During the same 21-month period, 42 feeding tubes were placed for dementia. CONCLUSIONS: The expense of emergency department visits for tube dislodgment or malfunction is a previously unreported issue involved in the tube feeding of demented patients. Extrapolation of our data yields an estimated health care charge of almost $11 million for the country per year.

Postoperative staphylococcal toxic shock syndrome due to pre-existing staphylococcal infection: case report and review of the literature.

Staphylococcal postoperative toxic shock syndrome (PTSS) has been associated with a variety of surgical procedures. It is generally believed that the source of infection is acquired at or near the time of surgery. PTSS has been specifically associated with nasal packing, insertion of hardware, surgical drains, retained foreign materials, and breaks in sterile technique. Although PTSS has been associated with postoperative abscesses, development of PTSS after surgery of a pre-existing source of infection has not been described. We report a case of PTSS that developed after vertebral abscess drainage, and we review the literature to determine the incidence of PTSS due to preexisting staphylococcal infection.

Requirement for a negative charge at threonine 60 of the FcRgamma for complete activation of Syk.

Aggregation of FcepsilonRI on mast cells results in the phosphorylation of the FcepsilonRIgamma chain on tyrosine and threonine residues within the immunoreceptor tyrosine-based activation motif. In the present study we sought to identify the site of threonine phosphorylation in FcepsilonRIgamma and investigate its functional importance. We found that threonine 60 was phosphorylated in vitro and in vivo. Expression of a mutated FcepsilonRIgamma (T60A), in either FcepsilonRIgamma-deficient or gamma-null mast cells, resulted in a delay of FcepsilonRI endocytosis, inhibition of TNF-alpha mRNA production, and inhibition of degranulation but did not affect FcepsilonRI-induced cell adhesion. Tyrosine phosphorylation of the T60A mutant gamma chain was normal, but Syk phosphorylation was dramatically reduced in these transfectants. This correlated with reduced co-immunoprecipitation of FcepsilonRIgamma with Syk. Substitution of an aspartic residue for threonine 60 of the FcepsilonRIgamma reconstituted complete activation of Syk and co-immunoprecipitation of FcepsilonRIgamma with Syk. We conclude that the negative charge provided by phosphorylation of threonine 60 of the FcepsilonRIgamma is required for the appropriate interaction and activation of Syk. This is a likely requirement for immunoreceptor tyrosine-based activation motifs involved in Syk activation.

ER-27319, an acridone-related compound, inhibits release of antigen-induced allergic mediators from mast cells by selective inhibition of fcepsilon receptor I-mediated activation of Syk.

Engagement of the mast cell high-affinity receptor for immunoglobulin E (IgE), FcepsilonRI, induces tyrosine phosphorylation of Syk, a non-receptor tyrosine kinase, that has been demonstrated as critical for degranulation. Herein we describe a synthetic compound, ER-27319, as a potent and selective inhibitor of antigen or anti-IgE-mediated degranulation of rodent and human mast cells. ER-27319 affected neither Lyn kinase activity nor the antigen-induced phosphorylation of the FcepsilonRI but did effectively inhibit the tyrosine phosphorylation of Syk and thus its activity. As a consequence, tyrosine phosphorylation of phospholipase C-gamma1, generation of inositol phosphates, release of arachidonic acid, and secretion of histamine and tumor necrosis factor alpha were also inhibited. ER-27319 did not inhibit the anti-CD3-induced tyrosine phosphorylation of phospholipase C-gamma1 in Jurkat T cells, demonstrating a specificity for Syk-induced signals. In contrast the tyrosine phosphorylation and activation of Syk, induced by in vitro incubation with the phosphorylated immunoreceptor tyrosine-based activation motif (ITAM) of FcepsilonRI gamma subunit or by antigen activation of RBL-2H3 cells, was specifically inhibited by ER-27319. However, when ER-27319 was added to immunoprecipitated Syk, derived from activated cells, no effect was seen on Syk activity. ER-27319 did not inhibit the tyrosine phosphorylation of Syk induced by activation in the presence of Igbeta ITAM or the anti-IgM-induced phosphorylation of Syk in human peripheral B cells. Therefore, ER-27319 selectively interferes with the FcepsilonRI gamma phospho-ITAM activation of Syk in vitro and in intact cells. These results confirm the importance of Syk in FcepsilonRI-mediated responses in mast cells and demonstrate the mast cell selectivity and therapeutic potential of ER-27319 in the treatment of allergic disease.

Effects of an educational intervention on mothers of male children with attention deficit hyperactivity disorder.

An experimental research study was done to determine whether an educational intervention about attention deficit hyperactivity disorder (ADHD) would improve a mother's knowledge about ADHD and her feelings of competence as a parent. 20 low socioeconomic status mothers who had a male child between the ages of 5 and 11 diagnosed with ADHD and placed on methylphenidate were randomly selected for the study. An experimental group of 10 mothers was given a 5-week educational intervention on ADHD; the remaining 10 mothers served as a control group. Differences between the experimental and non-experimental mothers in knowledge and opinions about ADHD and parental sense of competency were measured. Scores improved in parental satisfaction and parental sense of competency in mothers who participated in the educational intervention. The research findings support the idea that nurses can assist a family in learning and dealing with their child's ADHD, a chronic condition.

Developing a critical pathway for orientation.

A direct correlation exists between job satisfaction and employee retention with an organized and compassionate orientation process for new employees on a nursing unit. It is generally recognized that preceptorship/mentoring is the most desirable orientation modality; however, situations occasionally require orientees to work with several preceptors with varying levels of proficiency. A program based upon a framework designated "critical pathway" was established in a coronary care unit and a cardiac progressive care unit to organize orientation information into weekly segments, with each week's content building upon the previous week's information. Because the critical pathway clearly delineates the orientation content, all necessary information is imparted to the orientee in an organized fashion without omitting pertinent details. Problems with orientation are documented as variances on the critical pathway, and are discussed between the preceptor and orientee during weekly evaluation sessions. This article reports the procedure for developing a critical pathway for orientation using the critical pathway concept, which is adapted from the nursing case management practice model.

Strategies and tactics for promoting generalization and maintenance of young children's social behavior.

Employing a conceptual framework of generalization strategies proposed by Stokes and Osnes (1986), the authors selectively reviewed the research literature concerning interventions to improve young children's social behavior and strategies for promoting generalization and maintenance of young children's social responding. Three basic strategies are discussed: (a) taking advantage of natural communities of reinforcement, (b) training diversely, and (c) incorporating functional mediators, along with several accompanying tactics, to improve children's social interactions. Pragmatic recommendations for proactive programming of generalization and maintenance of young children's social behavior are included. In addition, the authors argue for the continued development of a technology (or technologies) of generalization and maintenance for young children's social competence interventions.

Informed consent and the geriatric dental patient.

Dental professionals are increasingly aware of their ethical responsibility to permit patients to participate in treatment decisions through the informed consent process. At the same time, growing numbers of geriatric patients present special challenges that can jeopardize the use of informed consent. Consequently, the use of informed consent with geriatric patients warrants special analysis due to complicating factors such as patient passivity and questionable competency. This article establishes the relationship between the ethical principle of autonomy and informed consent while examining factors that must be present in order for a valid informed consent to be obtained. Additionally, the article addresses informed consent issues regarding competent patients, geriatric patients with fluctuating or uncertain competency, and patients who are clearly incompetent.

Fading teacher prompts from peer-initiation interventions for young children with disabilities.

This study examined a system for fading teacher prompts to children who served as peers in peer-initiation interventions for young children with disabilities. A teacher taught peers to direct social initiations to children with disabilities, provided verbal prompts for those initiations, and introduced a system that provided peers with visual feedback about the social interactions of the children with disabilities. She then systematically withdrew the verbal prompts to peers, and subsequently faded the visual feedback system. Peer initiations increased when the intervention began and resulted in increases in social interaction for the children with disabilities. As the teacher systematically faded the prompts and visual feedback to the peers, social interaction continued at the levels found during intervention and was maintained during a short maintenance period.

Efficiency and expense of time-shared mass spectrometer systems.

The two main experimental issues dealt with in this brief summary allow the following conclusions. Time-efficiency: The overwhelming majority of cycle times for a well-designed and altruistically utilized (approximately equal sharing) TSMS system are adequate for safe monitoring. However, there may remain a number of instances where cycle times are too long. Inefficient valve scheduling algorithms and carless use of a TSMS system can easily increase the number of instances of sample times in the unacceptable range. In the present period of transition (to dedicated systems?), one of the best solutions is to combine a TSMS system with judicious use of dedicated capnometry, either independent or integrated (for example, systems such as the Perkin-Elmer/Marquette Life Watch system). Cost-efficiency: Amortized costs of monitoring systems that were apparently initially very expensive can be very low, especially in comparison with other capital outlays and the costs of disposable plastics and supplies used during anesthesia. It will take several years to compare the cost of TSMS systems that have +5,000-10,000 per room installation costs (depending on date purchased and total number of rooms) with the costs associated with dedicated multi-gas analyzers, which initially cost +17,000-19,000 per room. Of course, it would be unfair to compare such TSMS systems, which have comprehensive gas monitoring (including nitrogen and automatic discrimination of anesthetic gases) with simple capnometry or multi-gas analyzers, which do not include nitrogen and do not reliably discriminate between anesthetic agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of social integration on preschool children with handicaps.

This study examined the effects of (a) integrating handicapped and nonhandicapped children in preschools and (b) a condition designed to promote social integration. Fifty-six children with mild and moderate handicaps were randomly assigned to four experimental conditions: integrated/social interaction, integrated/child-directed, segregated/social interaction, and segregated/child-directed. Observation revealed a higher proportion of interactive play, as well as higher language development, in the social interaction conditions; and children in the integrated/social interaction condition received significantly higher ratings of social competence. These data suggest that structuring social interaction between higher and lower performing children can result in benefits to the lower performing students.

A comparison of peer-initiation and teacher-antecedent interventions for promoting reciprocal social interaction of autistic preschoolers.

We compared two procedures for improving the social interactions of three autistic children. In a peer-initiation condition, confederates were taught to initiate interaction with the autistic children. In a teacher-antecedent condition, teachers prompted the autistic children to initiate with confederates, who had been taught to reciprocate. Using an alternating treatment design, differential effects were found. The peer-initiation procedure reliably increased the social responses of the autistic children, whereas the teacher-antecedent condition increased the initiations and responses of the autistic children. In addition, longer chains of social interaction occurred during the teacher-antecedent condition.

Increasing handicapped preschoolers' peer social interactions: cross-setting and component analysis.

The purposes of our study were: (a) to train a set of observationally determined social behaviors via peer initiation; (b) to determine if effects generalized across classroom settings and to directly intervene if generalization did not occur; and (c) to analyze components of the peer-initiation intervention. After baseline, nonhandicapped preschool children (confederates) were taught to direct social initiations to the three handicapped preschool-aged students. Teachers prompted the confederates to engage the students in social interaction when necessary and rewarded the confederates with tokens. Confederates' initiations to the students resulted in increased frequencies of positive social interaction. There was no generalization to other classroom settings, and the intervention was subsequently implemented in a second and third classroom. Next, the confederates' token reinforcement system was withdrawn, with no apparent deleterious effects on the confederates' or students' social interactions. When teachers substantially reduced their prompts to the confederates, students' social interactions decreased. Finally, reinstatement of teacher prompts resulted in increases in the confederates' social initiations and, consequently, the positive social interactions of the students.