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Objective: Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium. Design: Cross-sectional study nested in the 2017 "Delirium Day" project. Setting and participants: Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy. Methods: Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters). Results: A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63). Conclusions and implications: Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.

The purpose of this study was to obtain a better understanding of polychlorinated biphenyl (PCB) immunotoxicity in the developing mouse. Adult female mice were dosed with three subcutaneous injections per week of 50 mg/kg Aroclor 1242 (A1242), Aroclor 1254 (A1254), or corn oil for 2 weeks and then mated with nondosed males. First-litter pups were sacrificed at 7 or 28 days of age. At both ages, the tissue concentration of PCB was significantly higher in both the A1242 and A1254 pups than in oil-treated controls. Seven-day-old pups exposed to A1242 or A1254 had significantly decreased splenic IL-2 production. Alterations in the percentages of T cell subsets compared to controls were observed in A1242-exposed pups; an increased spleen somatic index was noted only in A1254-exposed pups. Twenty-eight-day-old pups exposed to A1254 demonstrated a significant decrease in thymus somatic index, an increase in liver somatic index, a 25% decrease in total circulating T(4), and decreased B cell percentages relative to their controls. Alteration in the percentages of CD3(int) T cells was observed in A1254-exposed 28-day-old pups. A significant increase in 7-ethoxyresorufin- O-deethylase (EROD) and 7-benzoxyresorufin-O-dearylase (BROD) activity was measured at both ages in A1254-exposed pups and in A1242-exposed 28-day-old pups. These data confirm that during gestation and lactation A1242 and A1254 are transferred from dams to pups and that such exposure results in immune-related effects in neonatal (7-day-old) and juvenile (28-day-old) mice. Furthermore, A1254 exposure produces more frequent and pronounced effects than exposure to A1242.

Preremediation studies at Crab Orchard National Wildlife Refuge (CONWR) revealed statistically significant accumulations of polychlorinated biphenyls (PCBs) and effects in starling chicks (Sturnus vulgaris) from contaminated sites, including decreased nest attentiveness, decreased fledging success, and an increase in chick mortality. Although the expected route of exposure for starling chicks is thought to be via diet, this has not previously been documented at CONWR. The purpose of this study was to develop an equation to predict starling chick carcass PCB concentrations from PCB concentrations in ingested animal matter. During 1995 and 1996, stomach contents from 14 and 22 starling chicks collected from contaminated and reference sites, respectively, were evaluated. Animal, plant, and mineral matter in the stomach contents were separated and animal matter from stomachs of individuals from the same nest were combined, dried, and percent dry weight calculated. Composite samples of animal matter were then analyzed for the presence of PCBs (Aroclor 1254). Stomach contents were primarily composed of animal matter (76%), and the percent animal matter in the stomachs did not differ significantly among locations (range = 38.4% to 100%). The mean PCB concentration in composite samples of animal matter from stomachs of chicks collected from contaminated sites (1.82 +/- 1.17 mg/kg) was significantly greater than the concentrations in composite samples from two reference locations (

Methods of implementing the clinical nurse specialist (CNS) role can be approached in many ways. Providing the clinical specialist with concrete strategies to use during role implementation or expansion can aid in expediting the acceptance process for the CNS. Some authors have discussed phases the CNS encounters during role development. Time span of these phases vary greatly, dependent not only on the individual specialist, but also on the system for which they are employed. Kramer's four phases detailing the adjustment period of the newly practicing nurse may be used when discussing CNS role implementation. These four phases are: honeymoon, shock/rejection, recovery, and resolution. Practical suggestions to expedite role implementation can make progression through these phases easier and less overwhelming. Although obstacles will often be present, the CNS must then become a catalyst by using creative ideas and effective coping mechanisms to effect change and advance the role.

Polychlorinated biphenyls (PCBs) are environmental contaminants known to cause adverse health effects to biological systems. Limited data are available on their effects on the immune system of wildlife species. Previously, we found that 4 and 6-week-old white-footed mice (Peromyscus leucopus) born from dams injected with a single dose (300 mg/kg) of Aroclor 1254, had altered immunological, hematological, and biochemical responses. Here, we examined the effect of transplacental, lactational and postnatal exposure to Aroclor 1254, at a concentration similar to that found at contaminated sites, on various physiological parameters of 22-week-old white-footed mice. Liver weight and liver somatic index of PCB treated animals were significantly higher, the combined weights of the adrenal glands were significantly lower and EROD and BROD enzyme activity was significantly higher compared to control values. The number of thymocytes of the treated mice was significantly lower than that of the controls; however, thymocytes of treated mice had a higher proliferative response to the mitogen Con A. These alterations were correlated with the PCBs body burdens. Some toxic effects of chronic exposure to PCBs, at levels comparable to exposure found in contaminated sites in the USA, are still evident in adult P. leucopus.

The clinical nurse specialist (CNS) and nurse practitioner (NP) have been distinct and separate advanced nursing practice roles since the 1960s. The forces of economics and health care reform have fostered an interest in merging these two advanced practice roles. Economic and regulatory advantages have been noted in the literature for both roles. What is not so evident are the possible disadvantages. Several aspects of the merger issue are explored as is the recent background of the creation of the CNS and NP roles. Problems and questions are asked to stimulate future discussions in nursing's professional associations and in education and service settings.

To evaluate whether, in the forearm of hypertensive patients with different circulating renin profiles, local beta-adrenergic receptor-induced production of active renin, plasma renin activity, angiotensin I (Ang I), and angiotensin II (Ang II) was or was not related to the renin profile, we studied four groups of patients: 1) hypertensive patients with primary aldosteronism and suppressed circulating plasma renin activity values (0.15 +/- 0.1 ng Ang I/mL per hour; n = 7), 2) essential hypertensive patients with low (0.47 +/- 0.1 ng Ang I/mL per hour; n = 8) circulating plasma renin activity values, 3) essential hypertensive patients with normal (2.48 +/- 0.52 ng Ang I/mL per hour; n = 8) circulating plasma renin activity value, and 4) renovascular hypertensive patients with high circulating plasma renin activity values (4.16 +/- 2.1 ng Ang I/mL per hour; n = 10). Isoproterenol was infused into the brachial artery, and active renin, plasma renin activity, and Ang I and Ang II forearm balance (venous-arterial differences corrected for forearm blood flow by strain-gauge plethysmography) were measured. Despite a comparable vasodilation, beta-adrenergic stimulation failed to release active renin, plasma renin activity, and Ang I and Ang II in primary aldosteronism. It slightly increased them (except for Ang I) in low renin patients but determined a local production in normal renin and renovascular hypertensive patients. The individual increments in plasma renin activity and Ang II release induced by isoproterenol showed a correlation with the renin profile.(ABSTRACT TRUNCATED AT 250 WORDS)

e15561 Background: Many reports have correlated 1) hypoxia with attenuated responses to radiotherapy and 2) a good oxygenation as function of high HGB level in the peripheral blood. There is agreem...

for atherosclerotic cardiovascular disease (ASCVD). No such WC cut-offs have been identified in adolescents, despite the consensus that risk factors for ASCVD are present in adolescents. The current study aims to identify WC cut-offs that will distinguish AfricanAmerican males ages 12 to 19 years with central adiposity who are at risk for ASCVD as defined by meeting metabolic syndrome (MetS) criteria. Methods: This study is a secondary data analysis using data from the CDC Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). A subpopulation of African-American males, ages 12 to 19 years with records containing data on WC and at least three of the following variables, were included in this study: fasting glucose, high density lipoprotein (HDL), serum triglyceride (TG), systolic blood pressure (SBP) and diastolic blood pressure (DBP). This resulted in 428 participants, with a weighted sample size of 1,688,814 African-American males. Participants were scored and grouped based on ASCVD risk factors as defined by the American Heart Association, National Cholesterol Education Program (NCEP) Adult Treatment Panel III as modified by Cook, et al. These include: fasting glucose 110 mg/ dL, HDL 40 mg/ dL, TG 110 mg/ dL, SBP and DBP 95% for age and gender. Individuals were categorized as low risk ( 3 risk factors) or high risk ( 3 risk factors) for ASCVD. Using WC as the independent variable, receiver-operating characteristics curve (ROC) analysis was used for each year of age to identify the optimal WC measurements that identify high-risk individuals. Results: Initial linear regression models confirm that WC predicts abnormal values in all dependent variables except fasting glucose. Results of ROC analysis are pending. Conclusions: It is expected that waist circumference values that identify three or more risk factors (thus defining MetS) will be considered the optimal cut-off point at which a clinical provider should begin screening for MetS. Sources of Support: None.

This fifth edition is a timely and welcome one because of recent management changes in the treatment of acute poisoning. The routine use of syrup of ipecac as the primary household emetic has been supplanted by immediately calling the Poison Control Center, which may then recommend ipecac or, more likely, other measures and actions. General management of poisoning and overdoses is more important than the use of specific antidotes. Nevertheless, important antidotes or antagonists are still useful and recommended for special situations. Each chapter ends with an in-depth discussion of the relevant antidotes for the particular type of poison. I particularly enjoyed the historical account of the "birth" of the Poison Control Center concept and movement, since I was a member of the first Accident Prevention Committee of the American Academy of Pediatrics when it made the survey of its 3000 members in 1952 seeking the most prevalent childhood accident.

This paper identifies the major food safety concerns and separates fact from fiction in weighing any scientific evidence bearing on these concerns. Relevent information on federal laws and regulations governing food safety certification are interwoven.

An unusual case of hypervitaminosis A with severe craniotabes in a 6½ month old infant is presented. This is the youngest infant reported with this condition and the first to present craniotabes. Symptoms of hypervitaminosis A are compared with those of hypervitaminosis D and with those of infantile cortical hyperostosis. In the case presented prompt and complete disappearance of craniotabes and other symptoms followed withdrawal of administration of vitamin A.

Chairman Wheatley: Our theme is a discussion of prevention. We want to discuss the question: How can we help prevent accidents in children? The meeting will be divided into 2 parts. Dr. Arena and I will outline the accident problem for the first part. For the second part, we will discuss the preventive aspects and what pediatricians can do about preventing accidents. We want you to do most of the talking in this part. I would like to give you a brief picture of the dimensions of the accident problem. 1. It is the leading cause of deaths ages 1-14; kills about 14,000 at these ages annually—more than the next 6 combined (pneumonia, congenital anomalies, cancer, tuberculosis, leukemia, heart disease). 2. Every year between ages 1-5 kills twice as many children as rubeola, scarlet fever, pertussis, diphtheria, dysentery, tuberculosis and poliomyelitis combined. 3. For every fatal accident, it is estimated there are 90-150 severe injuries. No comprehensive studies are available to show the magnitude in terms of injury, cost of treatment, permanent disability in the United States child population. English hospital admission study showed 22% of the accidents requiring hospital treatment happened to children under the age of 5 years, though this age group constituted only 8% of the population. 4. About a third of all fatal accidents to children (1-14) occur in the home; for those under 5 years of age, nearly half the fatal accidents are home accidents. The home is a much more important site than this for injury to children, if we include nonfatal accidents because deaths caused by motor vehicles influences the fatal accident picture.

Dr. Wilburt C. Davison, first Dean and Pediatric Chairman of the Duke University School of Medicine, was once described by Sir William Osler as "a new American colt who is wrecking a medical school tradition." Since that memorable day at Oxford University in 1913 and until his retirement in 1960, Dean Davison continued to wreck traditions. Dr. Davison came to Duke in 1927 when both the hospital and medical school were still only in the idea stage. He shouldered the responsibility of planning, organizing, and directing the medical school and hospital literally from the ground up. As construction progressed he was never without his tape measure or yardstick and on occasion would don overalls and join the labor crew to give a hand as well as direct. Dean Davison realized from the outset that an efficient faculty would have to be more than a collection of brilliant individuals who might

BECAUSE they are such necessary and familiar household items, cleaners are not usually regarded as hazardous substances. However, in 1962, 1,727 incidents involving ingestion of detergents, as well as soaps and cleaners, in children under 5 years of age were reported to the National Clearinghouse for Poison Control Centers. This represented 4.2% of all the reported accidental ingestions in this age group. Although severe toxic effects occur infrequently and fatalities are rare, these are still rather significant statistics for a potential cause of injury that is largely preventable by handling and storing these products properly to keep them out of reach of children.Unfortunately, the terms soap and detergent are synonymous to many laymen, and I know of an incident, for example, in which significant injury occurred from the misuse of a detergent instead of a soapsuds enema. To prevent this type of erroneous substitution, the physician should give very

A RECENT study by Dr. I. G. Greer of five large white orphanages in North Carolina (Presbyterian Orphans' Home, Methodist Children's Home, Methodist Orphanage, Oxford Masonic Orphanage, and Baptist Orphanage) showed that 1,138 men and women who grew up in these institutions were accepted by the armed services and only sixteen or 1.4 per cent were rejected. 1 The national percentage of rejection for white men who had not previously been examined was 36.1. For the same group in North Carolina as a whole the percourage was 44.6. It is possible that the high North Carolina rejection ratio was due to the fact that the State had the highest rate of volunteers--many youths who believed that they could pass the physical examination did not wait for the draft. As a result, many of the Selective Service registrants in North Carolina were physically unfit. It also is possible that the low pe~'eentage of orphanage rejections was partially due to the fact that some orphans with irremediable defects were not accepted by the orphanages and were sent to special hospitals. However, even with this correction the conclusion is inescapable that the good pediatric care, periodic examinations, the correction of remediable defects, and the balanced diets which the orphans received were responsible for their health. The reports from the National Headquarters of the Selective Service System 2, a have therefore been analyzed, in order to determine the conditions and defects which could have been corrected by competent pediatric and surgical care during infancy and childhood so that the incidence of Selective Service rejections could have been reduced. Museuloske]etal abnormalities were the leading cause of rejection in white registrants, accounting for 8 per cent, and ranked second in Negroes, representing 4.3 per cent. Deformities resulting from rickets are preventable in infants by adequate diets and early administration of cod liver oil. Such deformities as genu varum, valgnm, and recurvatum can be corrected by orthopedic surgery. Abnormalities of the spine, which include seoliosis, lordosis, and kyphosis, are often corrected early in life by exercises. Arthritis, ankylosis, and atrophy may be arrested before disabling deformities can result by early definitive treatment. Tortieollis and the residuals of osteomyelitis can be corrected by specific orthopedic surgery. The incidence of hernias was found to be the second cause of rejection in whites (6.3 per cent) and third in Negroes (3.2 per cent). I t . is welI known that some inguinal and femoral hernias in Mfants disappear spontaneously and may be reduced easily. Surgical treatment results in a good prognosis if the

As one who always found Dr Goldfrank's articles in the Hospital Physician journal informative and useful, I especially welcomed this expanded second edition of his handbook with eight contributors. The editors have compiled ten major sections and 46 case presentations, twice as many as in the first edition, which not only cover the primary toxicological problems of interest and concern, but also many of the current controversies in the management of acute and chronic poisoning.Major headings include "General Management of the Poisoned and Overdosed Patient," "Alcohol," "Analgesics," "Botanicals," "Toxic and Hallucinogenic Mushrooms," "Food and Plant Poisoning," "Cyanide," "Heavy Metals," "Insecticides," and "Mixed Problems." Also included are many other specific and general toxic drugs and chemicals. At the end of each chapter there is a list of suggested readings and ample references.A new segment of this second edition is the self-assessment section with 460 questions (ten per case study)

THERE are not many effective, useful, specific antidotes for poisoning, and their overuse often complicates the initial injury by producing other forms of poisoning. As I mentioned in part I (232:1272,1975), sensible selection and use of drugs and other therapy for symptomatic and supportive treatment of poisoning are more likely to save lives than ill-considered and heroically applied therapy. Tables 1 and 2 list most of the general and all of the specific antidotes now available to the physician for emergency use, and these can be combined with the symptomatic and supportive drugs and measures on hand. The "universal antidote" of burnt toast (charcoal), milk of magnesia (magnesium hydroxide), and strong tea solution (tannic acid) is ineffective and obsolete. It can do more harm than good, mainly because it often gives a false sense of security, and because preparing and administering it takes up valuable time. Antibiotics Antibiotics are often

ACUTE poisoning, unfortunately, is often mismanaged. It is impossible at times to determine whether recovery occurred because of or in spite of the treatment used. Although poisoning is a common pediatric problem, many other specialists are involved (obstetrician, neonatologist, internist, family physician, surgeon, etc), and it has an interface with many disciplines (environmentalism, sociology, and others). The basic treatment for acute poisoning, whether drug or chemical, is mainly symptomatic and supportive. Overtreatment of the poisoned patient with large doses of non-specific and questionably effective antidotes, stimulants, sedatives, and other therapeutic agents often does far more harm and damage than the poison itself. A calm attitude, with the judicious use of drugs, parenteral fluids, and electrolytes for homeostasis, and the maintenance of an adequate airway is far more effective than heroic measures, which usually are unnecessary. The four cardinal principles of good management are (1) identification of the drug or chemical

In this small monograph on general toxicology, with consideration for its molecular and biochemical principles, the goal is to provide briefly the three main phases of toxic action as it relates to various compounds: (1) the exposure phase, which includes factors that determine the uptake of the toxic agent from the environment, (2) the pharmacokinetic or toxokinetic phase, which includes processes such as adsorption, distribution, metabolism, and excretion factors that determine the biologic availability of the toxic substance, and (3) the pharmacodynamic or toxodynamic phase, which covers the various mechanisms involved in the induction of the toxic effect on specific organs or systems. Included in the publication are the dose-response and time-response relationships necessary for a full understanding of toxicological mechanisms, interaction among various compounds, a focus on the systemic site of action by toxic agents, which relates to the specific kind of injury produced, toxicological risks of dangerous substances

When Oliver Wendell Holmes wrote "To guard is better than to heal, the shield is nobler than the spear!" he must have had in mind the origin, many years later, of the poison control center movement. In 1952, the American Academy of Pediatrics (AAP), through a survey by its newly appointed Committee on Accident Prevention, found that the most common medical emergency in children was poisoning. The study brought forth many requests for up-to-date information on toxic ingredients in household products, as well as for improved therapeutic measures. This gave impetus to the development and implementation of poison control centers in the United States, an endeavor practically all-pediatric oriented. Then, the development of safety closures and packaging and the Poison Prevention Packaging Act in 1970 rapidly followed. This is a historical account of the AAP's role and the combined efforts of practicing and academic pediatricians in a mid-20th century movement that has saved countless children's lives.

Since demands are increasing for toxicological information on every aspect of environmental hazards, the toxicological sciences must have a broad, multidisciplinary, and active role in providing a safer environment than now exists. This is a difficult task, indeed, and will become even more difficult in the future. The essentially negative attitude of the past—"What will kill?"—must be replaced with a positive position for the future, "What is safe?" Toxicology: The Basic Science of Poisons is a publication sorely needed to supplement the few available textbooks of toxicology for the increasing number of individuals entering training programs in this field. The book has four comprehensive sections or units. The first describes the method and approach that identify the science of toxicology, including those principles, such as dose-response, necessary for a full understanding of toxicological mechanisms. Unit II, which focuses on the systemic site of action of toxins, provides answers to two

In Reply.— The JAMA articles on poisoning were, of necessity, brief, and not all therapeutic and preventive measures could be included. I am very familiar with the Sobel and Margolis study and report, and I certainly agree that Dr Copan's eighth preventive measure is important and should be included. Family evaluation by the poisoned victim's physician should be part and parcel of the treatment, but, unfortunately, most practicing pediatricians are far too busy for any lengthy investigation, and early appointments with a child psychiatrist, if one can be found, are difficult to obtain. The millenium in poison prevention has never been reached—and probably never will.