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Indicators of weaning success have been tested primarily in patients who have been ventilated for short periods of time, and they may not be as accurate in cases where support has been required for longer than a few days. In patients requiring longer periods of support it is difficult to estimate the likelihood of successful liberation. Therefore we evaluated established weaning indices for their accuracy in surgical patients who required > or = 72 hours of mechanical ventilation. Surgical patients who required mechanical ventilation for > or = 72 hours were prospectively followed (over 6 months). We obtained standard indices of ventilatory function daily once patients were ready to wean. These indices included the respiratory rate/tidal volume ratio (RSBI), the maximal inspiratory pressure, and the minute ventilation. The duration of weaning and explicitly defined episodes of fatigue were the outcomes of interest. Statistical analyses evaluated the multiple factors that might influence the duration of weaning. Ninety-five patients (66% trauma; 34% surgery) survived to begin weaning, and 93% were liberated. The median duration of mechanical ventilation prior to weaning was 4 days (range 3-16 days), and the median duration of weaning was 3 days (range 0-56 days). Fatigue occurred in 36 patients and was not reliably predicted by any of the weaning measurements. However, a RSBI of > 105 on the first day of weaning was associated with prolonged weaning. By multivariate analysis, an RSBI of > 105 on the first day of weaning predicted prolonged weaning (hazard ratio 1.9; p = 0.03). After 72 hours of mechanical ventilation, clinical fatigue and successful liberation are not reliably predicted by standard indices of respiratory muscle strength and reserve. However, an RSBI of >105 observed once the patient is ready to wean is associated with prolonged weaning.

Diagnostic criteria that define ventilator-associated pneumonia (VAP) remain controversial. The purpose of this study was to evaluate common definitions of VAP and determine their relationship to each other and clinical treatment. This study prospectively evaluated several diagnostic criteria that define VAP in a cohort of 255 consecutive SICU patients ventilated for < 48 h. Definitions evaluated include the CDC definitions, the Johanson definitions which do not rely on culture data, the Physician's Probable diagnosis which relies on positive quantitative cultures, and the antibiotic treatment group. Forty-four patients (17%) received antibiotic treatment for VAP. Depending on the definition evaluated, criteria were met for a diagnosis of VAP from as low as 4% of patients by the Johanson definition to as high as 48% of patients by the CDC definition. There was poor agreement among the definitions in their ability to select the same patient as having VAP. Besides duration of mechanical ventilation and tube feeding, which were risk factors that predicted meeting the criteria for all groups, risk factors predicting VAP varied among the definitions. This study demonstrates that in a surgical ICU, the candidate definitions of pneumonia evaluated show little agreement. The particular case definition chosen to diagnose VAP will determine the incidence rate of pneumonia, the time to onset of pneumonia, and the risk factors of the type of patient treated.

Changes in activity or expression of transporters may account for alterations in cell behavior in diabetes. We sought to ascertain if mesangial cells (MC) grown in different glucose concentrations exhibit changes in activity and expression of acid-extruding transporters, the Na(+)/H(+) and Na(+)-dependent Cl(-)/HCO(-)(3) exchanger. pH(i) was determined by the use of the fluorescent pH-sensitive dye BCECF. In MCs grown in 5 mM glucose (control), the Na(+)/H(+) exchanger was responsible for 31.8 +/- 5.1% of steady-state pH(i), whereas Na(+)-dependent Cl(-)/HCO(-)(3) contributed 62.9 +/- 4.0% (n = 11). In MCs grown in high glucose for 2 wk, Na(+)/H(+) exchange contribution to acid-extrusion increased as follows: 42.3 +/- 4.6% [n = 8, 10 mM, not significant (NS)], 51.1 +/- 5.1% (n = 8, 20 mM, P < 0.01), and 64.8 +/- 5.5% (n = 7, 30 mM, P < 0.001). The Na(+)-dependent Cl(-)/HCO(-)(3) exchanger contributed less [47.0 +/- 4.6, 38.6 +/- 5.8, and 21.1 +/- 3.8%, for 10, 20, and 30 mM glucose, respectively (n > 7)]. We sought to ascertain if the magnitude of the acute stimulated response to ANG II by the Na(+)/H(+) and Na(+)-dependent Cl(-)/HCO(-)(3) exchanger is changed. Na(+)/H(+) exchanger (1.89-fold increase in 30 vs. 5 mM, P < 0.002), but not Na(+)-dependent Cl(-)/HCO(-)(3) exchange (0. 17-fold, NS), exhibited an enhanced response to ANG II (1 microM). Na(+)/H(+) exchange (NHE1) expression was significantly different (1. 72-fold) after prolonged exposure to high glucose. These results suggest that the Na(+)/H(+) exchanger, but not Na(+)-dependent Cl(-)/HCO(-)(3) exchanger, may play an early role in the response to hyperglycemia in the diabetic state.

Cigarette smoking is a major preventable cause of serious chronic disease. The majority of smokers begin smoking during their adolescent years. Print cigarette advertising plays an influential role in encouraging young people to smoke. Eight hundred and forty-three middle/junior high-school-aged students from a large midwestern metropolitan area participated in this study of adolescents' recognition of and belief in messages associated with print cigarette advertising. Results indicated no significant difference between smokers and nonsmokers in their recognition of messages associated with print cigarette advertising. However, smokers and nonsmokers differed significantly in the degree to which they believed the messages communicated by print cigarette advertising. Consistent with social cognitive theory, students who smoke at least occasionally were more likely to believe messages conveyed by print cigarette ads than were students who had never smoked. Implications of these findings for research and practice are discussed, including specification of guidelines for effective counteradvertising.

Inhibition of matrix metalloproteinases (MMPs) is an attractive approach to adjuvant therapy in the treatment of cancer. Marimastat is the first orally administered, synthetic MMP inhibitor to be evaluated, in this capacity, in the clinic. Measurement of the rate of change of circulating tumour antigens was used for evaluating biological activity and defining optimum dosage in the early clinical trials of marimastat. Although tumour antigen levels have been used in the clinical management of cancer for many years, they have not been validated as markers of disease progression. In order to investigate the relationship between the effects of marimastat on tumour growth and circulating tumour antigen levels, mice bearing the human gastric tumour, MGLVA1, were treated with marimastat. The MMP inhibitor exerted a significant therapeutic effect, reducing tumour growth rate by 48% (P = 0.0005), and increasing median survival from 19 to 30 days (P = 0.0001). In addition, carcinoembryonic antigen (CEA) levels were measured in serum samples from animals sacrificed at regular intervals, and correlated with excised tumour weight. It was shown that the natural log of the CEA concentration was linearly related to the natural log of the tumour weight and that treatment was not a significant factor in this relationship (P = 0.7). In conclusion, circulating CEA levels were not directly affected by marimastat, but did reflect tumour size. These results support the use of cancer antigens as markers of biological activity in early phase trials of non-cytotoxic anticancer agents.

We have previously demonstrated that performance on a brief and conceptually simple laboratory task (the Sustained Attention to Response Test: SART) was predictive of everyday attentional failures and action slips in brain injured patients and normal control participants. The SART is a go-no-go paradigm in which the no-go target appears rarely and unpredictably. Performance on this measure was previously interpreted as requiring sustained attention to response rather than a putative 'response inhibition' capacity. Three further studies are presented which support this claim. They demonstrate that performance is crucially determined by the duration of time over which attention must be maintained on one's own actions that this demand underpins the task's relationship to everyday attentional lapses. In keeping with a number of recent studies it suggests that inefficiencies in the maintenance of attentional control may be apparent over much briefer periods than is traditionally considered using vigilance measures and analysis.

Unlabelled: In this study the effectiveness of 4.5% human albumin was compared with 4.2% sodium bicarbonate for neonatal metabolic acidosis, using a randomised controlled trial. The change in median pH following bicarbonate was more than twice that in the albumin group. This was statistically significant., Conclusion: In normotensive infants, use of bicarbonate to correct metabolic acidosis may be more effective than use of albumin.

The Association for Professionals in Infection Control and Epidemiology, Inc (APIC) is a multidisciplinary, voluntary, international organization of professionals who practice infection control and the application of epidemiology in all health settings. APIC is an international leader in prevention and control of infection transmission.

The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) is a multidisciplinary organization of more than 11,000 health care professionals who practice infection control and epidemiology within a variety of health care settings. As an authority in infection control, APIC endorses the Advisory Committee on Immunization Practices (ACIP) recommendations that are published by the Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. APIC supports the immunization initiative of the Healthy People 2000: National Health Promotion and Disease Prevention Objectives, which contains a national strategy for significantly improving the health of the nation, including preventing infectious diseases through immunization.

The Association for Professionals in Infection Control and Epidemiology, Inc (APIC), is a multidisciplinary, voluntary, international organization of professionals who practice infection control and the application of epidemiology in all health settings. APIC is an international leader in prevention and control of infection transmission.

Objective: The study examined the effect of clozapine treatment on the health care costs and health status of people with schizophrenia who are supported by public funds., Methods: Thirty-three patients with schizophrenia hospitalized in a state facility were interviewed within one week of starting clozapine and six months later. Health status was assessed with four clinical rating scales measuring severity of psychopathology, negative symptoms, depression, and quality of life. Cost and health care utilization data were collected for the six months before and after initiation of clozapine., Results: Only 52 percent of the subjects stayed on clozapine for six months. Subjects who continued on clozapine were more likely to be discharged within six months than those who did not continue. Six months after clozapine was started, health care costs showed a sayings of $11,464 per person, even after adjustment for pretreatment costs, and health status was improved., Conclusions: For subjects who continued on clozapine for six months, clozapine treatment was associated with reduced days of psychiatric hospital care, reduced overall costs despite increased outpatient treatment and residential costs, and improved health status.

Macrophage inflammatory protein-1alpha (MIP-1alpha) is a chemokine that can inhibit the cell cycle progression of both primitive haemopoietic and epidermal progenitor cells. This property could potentially be exploited to attenuate both the myelosuppressive effects of chemotherapy as well as mucositis. We evaluated both the biological and clinical effects of BB-10010, a genetically engineered variant of MIP-1alpha, in patients with malignant lymphoma or breast cancer receiving high-dose etoposide (VP 3.6 g/m2) and cyclophosphamide (Cy 200 mg/kg). 52 patients were randomized to one of three cohorts. Cohort A received no BB-10010; cohorts B and C received 10 microg/kg and 100 microg/kg of BB-10010, respectively. All patients received post-chemotherapy G-CSE BB-10010 was well tolerated. There were no significant differences between groups in recovery to an ANC > 0.5 x 10(9)/l, 1 x 10(9)/l or 1.5 x 10(9)/l, the number of days with an ANC < 0.5 x 10(9)/l, days to a platelet count > 50 x 10(9)/l or 100 x 10(9)/l, or the incidence and severity of mucositis. There was no evidence of any effect of BB-10010 on colony-forming cell (CFC) or long-term culture-initiating cell (LTC-IC) mobilization, cycling activity in the marrow or on chemotherapy-induced changes in CFC or LTC-IC number both of which were in the normal range by 22 d after completion of the chemotherapy. To our knowledge this is the first report of a myelointensive regimen having no apparent long-term effect on the LTC-IC compartment. In summary, BB-10010 is safe when used in patients receiving high-dose therapy but has no effect on reducing the toxicity of such therapy.

Background: The peripherally inserted central catheter (PICC) is increasingly used in protracted intravenous therapy. The device has several advantages for family practice, but its use has been chiefly described in nursing and interventional radiology literature. We investigated the use of the PICC in a family practice teaching hospital., Methods: Forty PICCs were inserted from 1993 to 1995 in 29 patients. Available records and radiographs were reviewed for indication, nature of placement attempts, indwelling time, PICC role in therapy, and attendant complications., Results: Successful placement was achieved in 95 percent of instances requiring PICC use. Fluoroscopically guided placement, usually without venography, was found to be preferable to unguided bedside placement. In a few cases in which PICCs were placed, no other access was subsequently required to complete therapy. Few clinically serious complications were encountered. Most complications were related to placement at bedside., Conclusions: Our experience supports the PICC as a minimally invasive, economical alternative for protracted intravenous therapy. Fluoroscopically guided placement was found preferable to unguided bedside placement. Physicians ordering or placing PICCs should understand fully how to assess placement.

In vitro and in vivo data suggest a remarkable plasticity in the differentiated phenotype of intrinsic glomerular cells, which after injury express new structures and functions. We have shown that a protein kinase C (PKC) isoform, beta II, is expressed in diseased but not normal glomeruli. Since intrarenal cytokine synthesis has been implicated in the pathogenesis of progressive glomerular injury, we have hypothesized that these mediators induce a change in isoform profile. To test this hypothesis in vitro, we have determined whether platelet-derived growth factor (PDGF) and interleukin-1 (IL-1) alter the expression or activation of PKC isoforms in cultured mesangial cells (MCs). By immunoblot and ribonuclease (RNase) protection assays, both PDGF and IL-1 induce as early as 2 h de novo synthesis of PKC-beta II. Since MCs constitutively express PKC-alpha, -beta I, and -zeta, we also determined whether IL-1 or PDGF alter the activity of these isoforms. PDGF maximally induced translocation of PKC-alpha (10 min), -beta I (90 min), -epsilon (120 min), and -zeta (120 min) from the cytosolic to the membrane fraction. IL-1, in contrast, did not alter the distribution of alpha, beta I, or epsilon at any time measured but did induce PKC-zeta translocation. These data suggest inflammatory mediators regulate PKC isoform activity in diseased glomeruli both by de novo synthesis of unexpressed isoforms and by activation of constitutively expressed PKC isoforms.

Sustained, low level muscarinic activity was induced in rats by feeding the muscarinic agonist and experimental drug candidate CI-969 at 50, 100 and 200 mg/kg body weight/day for 4 wk. Except for urine staining, clinical signs typical of acute high-dose exposure to muscarinic agonists were not observed. A dose-related suppression of body weight gain approached 60% at the high dose, but no significant effects on haematology or clinical chemical parameters were observed after 4 wk of exposure. Corneal opacities with histopathological features including neovascularization, acanthosis and stromal proliferation were observed in a dose-related fashion in both sexes at 100 and 200 mg/kg/day. Hypertrophy of the Harderian and lacrimal glands also occurred, probably as an adaptive response to sustained muscarinic activity. Lacrimal gland concentrations of the muscarinic agonist were in the range of pmol/mg tissue and therefore significant direct exposure of cornea to the compound through the tears was discounted. The presence of corneal muscarinic receptors was investigated to determine whether opacities could be related to direct, receptor-mediated events in the cornea; however, no specific binding of the muscarinic receptor radioligand [3H]quinuclidylbenzilate was detected. Because muscarinic agonist-induced opacities can be inhibited by scopolamine, the apparent lack of muscarinic receptors in the cornea indicates that the opacities are not a direct effect, but are instead secondary to muscarinic events at another site. To our knowledge, this is the first report of corneal opacities induced by a muscarinic agonist.

Background: The chromogranin/secretogranin (Cg/Sg) acidic proteins are widely distributed in vertebrate species. They are thought to play a role in hormone packaging within secretory granules, in hormone secretion, and serve as prohormones for various proteolytic cleavage products. The genes for most members of the Cg/Sg family have been cloned, so hybridization analysis can be used to analyze the distribution and regulation of Cg/Sg mRNAs in various vertebrate species., Experimental Design: The method of in situ hybridization was used to localize chromogranin A, chromogranin B, and secretogranin II in adrenal and pituitary tissues from laboratory animals and from humans in order to analyze the distribution of various Cg/Sg mRNAs in these tissues. To gain some insight into the regulation and possible functions of specific Cg/Sg members, female rats were ovariectomized for different periods with and without estrogen replacement and the pituitaries were subsequently analyzed by in situ hybridization and Northern hybridization analyses. Combined ISH and immunohistochemistry were used to localize the specific cell types in normal rat pituitary that expressed the mRNA for chromogranin A, chromogranin B, and secretogranin II., Results: All three Cg/Sg mRNAs were detected in pituitary and adrenal tissues of rats, mice, dogs, monkeys, and humans. Combined in situ hybridization and immunohistochemistry using rat pituitary revealed that the glycoprotein hormone-secreting cells expressed all three Cg/Sg mRNAs in approximately equal amounts. Ovariectomy followed by estrogen replacement resulted in decreased levels of CgA and SgII mRNAs. In contrast, the level of CgB mRNA, that was not changed by ovariectomy, was increased after estrogen treatment, probably secondary to prolactin cell hyperplasia., Conclusions: The three principal Cg/Sg mRNAs are present in the adrenal and pituitary of various vertebrates. Estrogen plays a significant role in regulating the mRNA levels of different Cgs/Sgs suggesting functional and regulatory differences in Cg/Sg proteins.

We describe three infants (aged 9 weeks to 4 months) with the classic features of hemorrhagic shock and encephalopathy syndrome, including sudden onset of shock, neurologic disturbance, bleeding, disseminated intravascular coagulation, and impaired hepatic and renal function. Unlike the cases previously described, all three children recovered rapidly without evidence of long-term neurologic damage. These findings may modify the perception that this disorder has a uniformly bad outcome.

Peptide E is a mu-selective opioid peptide derived from proenkephalin A which contains [Met5]-enkephalin at the amino end and [Leu5]-enkephalin at the carboxyl end. Peptide E is further processed both centrally and peripherally to a [Leu5]-enkephalin-containing fragment which was investigated to determine if processing leads to alterations in receptor selectivity. Peptide E-(15-25) inhibited electrically stimulated contractions in both the mouse vas deferens, longitudinal muscle, myenteric (IC50 = 459 nmol/L), and guinea pig ileum (IC50 = 2630 nmol/L), indicating a sixfold delta-receptor selectivity. When administered intracerebroventricularly to mice, peptide E-(15-25) also produced potent analgesia which was completely antagonized by naloxone pretreatment, but the peptide had no effect on intestinal transit as measured by the radiochromium geometric center method. This is consistent with earlier findings that intracerebroventricular delta-opioid-selective agents are analgesic but do not inhibit intestinal transit. In vitro radioligand binding assays were performed using male Sprague-Dawley rat whole brain homogenates. The IC50 for peptide E against [3H]naloxone was 1.8 nmol/L compared with the delta-opioid ligand, [3H] [D-Pen2, D-Pen5]-enkephalin of 38.8 nmol/L. The IC50 for peptide E-(15-25) against [3H]naloxone was 497 nmol/L, but for [3H] [D-Pen2, D-Pen5]-enkephalin it was 50.6 nmol/L. Therefore, peptide E loses mu-opioid receptor affinity (1.8-497 nmol/L) after proteolytic processing and the loss of the amino terminal tyrosine but maintains a high delta-opioid affinity (38.8-50.6 nmol/L). These studies demonstrate that enzymatic peptide processing of peptide E to peptide E-(15-25) leads to a shift from mu- to delta-receptor selectivity and a different spectrum of biological effects on gut motility.

Redness and scaling of the feet in prepubertal children is likely to represent a skin disease other than tinea pedis. If the dermatitis involves the dorsum of the feet, allergic contact dermatitis is a likely cause. In this study, 8/19 (42%) children with involvement of the dorsum of the feet had clinically relevant positive patch tests related to shoe allergens. All who avoided the allergens remained free of disease on a 2-year follow-up examination. Those children with dermatitis on the weight-bearing surface of the foot (juvenile plantar dermatosis) did not have positive patch tests (P = .15).

The interactions of hormones with plasma membranes in the human placenta were characterized for specific fetal and maternal components. The microvillus brush border membrane, which is exposed to maternal blood in the intervillous space, was markedly enriched in specific insulin receptors but contained no hormone-sensitive adenylate cyclase. On the other hand, a basal plasma membrane fraction, which is presumably exposed more directly to fetal hormones, contained adenylate cyclase which was sensitive to prostaglandins, epinephrine, and fluoride but was not enriched in insulin receptors or other brush border markers. This study demonstrates separate fetal and maternal aspects of placental-hormone interactions. This separation and the relative impermeability of the placenta to hormones may allow for independent maternal and fetal components of the interaction of hormones with the placenta.

A patient with multiple sclerosis and bilateral retrochiasmal visual field defects is reported. Homonymous field defects are rare in multiple sclerosis despite the frequency of pathological involvement of the retrochiasmal visual pathways. A higher incidence might be found with a higher index of suspicion and careful visual field testing with qualitative confrontation technique. Other reasons for the infrequent clinical detection of retrochiasmal lesions are considered. Such lesions may exist without demonstrable defect. This may be explained by anatomical factors, for example, fibre arrangement, or physiological factors, such as, geniculate or retrogeniculate integration. Lesions producing demonstrable defects may be asymptomatic because they: affect only the peripheral field, are small scotomas that do not impair visual acuity, affect only one eye, or occur late in the course of disease when masked by optic nerve involvement.

A heat-stable humoral substance (coagulopoietin-X) is present in rabbits partially depleted of Factor X, which is capable of raising Factor X levels when injected into recipient rabbits. Rabbits were partially depleted of Factor X by slow infusion of a globulin fraction of goat anti-rabbit Factor X antibody. This resulted in the reduction of Factor X to 40--50% of normal at 1 h and 60--70% of normal at 6 h. No effect was noted on levels of Factors II, V, or VII. Plasma from these animals, when injected into 10 recipients, specifically raised Factor X levels when measured by four different assay: one-stage assay with bovine VII- and X-deficient plasma and Russell's viper venom; one-stage assay with human X-deficient plasma and thromboplastin; chromogenic substrate assay with Russell's viper venom; and an immunologic assay (Laurell technique). No rise was noted in two control experiments in which normal plasma was injected into recipient rabbits from 2 rabbits injected with a globulin fraction of normal goat serum, nor in 12 rabbits injected with plasma from normal rabbits, nor in 5 rabbits injected with boiled plasma from normal rabbits. The rise in biologic activity of 120--150% of base line was significantly greater than the rise in immunologic activity of 114--117% of base line (P less than 0.05) on 3 different days, suggesting the production of a molecule with greater specific activity rather than increased protein synthesis.