Estrogenic and CYP1A response of mummichogs and sunshine bass to sewage effluent.

Recent studies demonstrating feminization of effluent-exposed wild-caught male fish in the UK have prompted much research regarding the estrogenic activity of effluent from municipal sewage treatment plants (MSTPs). To investigate the estrogenicity and cytochrome P450 1A (CYP1A) induction potency of MSTP effluent, two species of fish, adult male mummichogs, Fundulus heteroclitus, and juvenile sunshine bass, Morone saxatilis x Morone chrysops, were exposed to un-chlorinated effluent (75% effluent, 25% seawater) from a large MSTP in Yonkers, NY, USA. After a 21-day static-daily (75%) renewal exposure, significant elevations over controls were observed in levels of vitellogenin (VtG) in plasma (1730%) and liver (131%) in effluent-exposed sunshine bass. In contrast, hepatic VtG was not elevated in mummichogs; plasma VtG was not measured in this species. Effluent exposure elevated hepatic CYP1A protein (140-145%) and ethoxyresorufin-O-deethylase (EROD) activity (408-598%) in both species. These findings suggest ontogenetic and/or species differences in response to estrogenic compounds in MSTP effluent. Furthermore, the elevation of CYP1A in response to sewage effluent exposure indicates the presence of additional compounds that may alter xenobiotic and/or steroid biotransformation in fish.

Media and dilution procedures tested to minimize handling effects on human, rabbit, and bull sperm for computer-assisted sperm analysis (CASA).

Proper handling of semen prior to computer-assisted sperm analysis (CASA) is critical if the analysis is to be representative of the fresh sample. The effects of diluting medium or dilution and holding time before CASA on multiple sperm characteristics were studied. Four replicates of unselected semen samples from each of eight human donors were diluted with phosphate-buffered saline (PBS)-glucose plus bovine serum albumin (BSA), with Tyrode's albumen lactate pyruvate (TALP), and with high-potassium TALP (K-TALP) to a concentration of approximately 25 x 10(6) sperm/ml. The diluted semen was held for 0, 1, and 2 hours at approximately 30 degrees C before CASA, with little difference between the three diluents in all 12 variables measured. There was a decline of 3-6% in the proportion of motile sperm over a 2-hour period (P < 0.05). Donors were the largest source of differences (P < 0.05). Rabbit sperm (five bucks, four ejaculates per buck) were processed in a manner similar to that of the human sperm. There was a major effect of media. The average percentages of motile sperm over 2 hours in TALP, K-TALP, and PBS were 76, 42, and 29%, respectively (P < 0.05), with a decline of only 3% in TALP during the 2 hours. Hyperactivity and other characteristics were affected by treatment. Donors were a large source of variation. Bull semen (10 bulls, two ejaculates per bull) either was not diluted or diluted with TALP 2x or 4x and held for 0, 1, and 2 hours at 30 degrees C. It was then diluted to 25 x 10(6) sperm/ml with TALP. There was little change in most sperm characteristics in any treatment during the first hour, although many of the changes were statistically significant. The percentage of motile sperm in undiluted semen declined from 87% to 82% over 2 hours. Modified TALP was a suitable medium for sperm from all three species, and a simple PBS-glucose-BSA medium can be used for human sperm.

Ethylene glycol monomethyl ether effects on health and reproduction in male rabbits.

Male Dutch rabbits were weighed and randomly assigned within each weight group to five groups of six animals each (plus one more in the highest dose group). They received 0, 12.5, 25.0, 37.5, or 50.0 mg of ethylene glycol monomethyl ether (EGME) per kg of body weight in the drinking water 5 d/week for 12 weeks. Feed and water consumption were monitored daily and body weight weekly. All animals consumed the water and feed, maintained body weight, and were in good health throughout the experiment. Semen was collected twice weekly for 12 weeks, and 96% of the ejaculates were obtained. By weeks 6 and 9, most males in groups receiving 50.0 or 37.5 mg of EGME per kg were oligospermic. Only minor changes in other characteristics of sperm obtained from treated animals were found, as measured by computer-assisted sperm analysis. Fertility of the males still producing sufficient sperm during week 12 to use for insemination was tested with 96 does producing 2839 oocytes, and fertility of treated males (41%) was not lower (P > 0.05) than 47% in controls. At necropsy, all vital organs were grossly normal, with no notable histopathology. However, the groups of animals receiving 37.5 and 50 mg of EGME per kg of body weight produced fewer sperm and had smaller testes than controls (P < 0.05). Although all rabbits appeared grossly normal, there was a marked disruption of spermatogenesis as ingestion of EGME increased above 25 mg/kg of body weight. Rabbit testes appear to be more sensitive to EGME than testes of rats or mice.

Co-trimoxazole induced aseptic meningitis.

A 15 year old boy presented with two episodes of aseptic meningitis-like reactions after ingestion of co-trimoxazole. The diagnosis of co-trimoxazole induced aseptic meningitis was made. This syndrome should be considered in the differential diagnosis of aseptic meningitis.

An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement.

The purpose of auditing trauma care is to maintain quality assurance and to guide quality improvement. This study was conducted to identify the incidence, type, and setting of errors leading to morbidity and mortality in trauma patients. Determinations of the Medical Audit Committee of San Diego County were reviewed and classified by the authors for identification of preventable errors leading to morbidity or mortality. Errors were classified by type and categorized by phase of care. Errors were identified in the cases of 4% of all patients admitted for trauma care over a 4-year period. Of all trauma patient deaths, 5.9% were considered preventable or potentially preventable. The most common single error across all phases of care was failure to appropriately evaluate the abdomen. Although errors in the resuscitative and operative phases were more common, critical care errors had the greatest impact on preventable death. The detected error rate of 4% may represent the baseline error rate in a trauma system. While regionalized trauma care has dramatically reduced the incidence of preventable death after injury, efforts to further reduce preventable morbidity and mortality may be guided by an identification of common errors in a trauma system and their relationship to outcome.

The significance of critical care errors in causing preventable death in trauma patients in a trauma system.

The regionalization of trauma care has led to a decrease in preventable death after injury. This decrease has been attributed to earlier resuscitation and surgical intervention. Little emphasis, however, has focused on the critical care phase of trauma patient management. This study was undertaken to determine the significance of critical care errors (CCEs) on preventable mortality and morbidity in a regionalized system of trauma care. The records of 12,910 trauma patients admitted to six trauma centers over a three-year period were reviewed. The cause and preventability of death was determined by a panel of trauma experts. Critical care errors occurred in 151 (23%) of all patients with errors occurring during any phase of care. The CCEs were identified in 38 of 125 (30%) deaths of patients with errors in some phase of care. The CCEs were implicated as the cause of death in 30 (48%) of the 62 preventable deaths. The proportion of preventable deaths attributable to CCEs was higher than the proportion of preventable death attributable to errors in the resuscitative and operative phases of care (p less than 0.001, chi-square). These data indicate that CCEs significantly contribute to preventable mortality and morbidity in trauma patients. It is imperative that physicians caring for trauma patients possess expertise in the critical care management of injured patients.

Complications in evaluating abdominal trauma: diagnostic peritoneal lavage versus computerized axial tomography.

We reviewed our experience with 2,809 DPL's and 1,331 CT's obtained in the resuscitative phase over a 3-year period in our trauma system to determine the significant complications associated with each modality. There were 25 DPL complications: eight false negatives, three false positives, and 14 technical errors. There were 46 CT complications including 25 false negative scans, three false positive scans, and 18 delays to the operating room from obtaining abdominal CT evaluation, with two of these delays resulting in preventable deaths. Although both modalities had low complication rates (0.9% DPL vs. 3.4% CT), DPL was associated with less preventable mortality and morbidity than CT in the evaluation of abdominal trauma.

Assuring quality in a trauma system--the Medical Audit Committee: composition, cost, and results.

A multidisciplinary concurrent audit of the quality of medical care within a trauma system was carried out by a committee of physicians, nurses, and health officials representing trauma centers, nontrauma hospitals, and the public agency administrating the trauma system. Care was audited with regard to timeliness and appropriateness of diagnosis and therapy. Complications were classified as being due to an error in diagnosis, judgment, or technique. Deaths were classified as nonpreventable, potentially salvageable, or frankly preventable. During the first 22 months of operation (1 August 1984-30 May 1986), 7,936 cases were audited. Of the 224 deaths occurring at nontrauma hospitals, 17 (7.6%) were felt to be frankly preventable. Of 541 deaths occurring at trauma centers, 11 (2.0%) were felt to be frankly preventable (p less than 0.001). The most common problem implicated in preventable deaths at nontrauma center hospitals was an error in diagnosis. Preventable deaths at trauma centers were most commonly due to an error in technique. Complications or protocol violations occurred in 595 of 6,564 surviving trauma patients (9.1%). During the first 12 months of system operation, 7,200 person-hours were required to perform the audit. Personnel costs alone for audit in the first year were $300,420.

Role of the trauma nurse coordinator.

Trauma center designation paved the way for an exciting, expanded nursing role, the Trauma Nurse Coordinator. This position has evolved to include, not only the in-hospital role, but also a role in government. This article focuses on the role of the trauma nurse coordinator in the health care system.