Management of Cardiac Arrest: A Discussion of Cardiorespiratory Resuscitation

In cases of sudden cardiac arrest the time limit during which anoxic brain damage can be reversed is about four minutes. Therefore, cardiorespiratory resuscitation must be instituted immediately. A simple plan requiring no complicated maneuvers or equipment should be memorized and employed in such cases. The following program is recommended: (1) Institute artificial ventilation. (2) Thump the chest once or twice. (3) Employ closed chest compression. (4) Transfer the patient to hospital if survival appears possible. (5) Obtain an electrocardiogram immediately. (6) Apply specific treatment for cardiac standstill or ventricular fibrillation. (7) Reassess after 30 minutes. Discontinue treatment if there has been no response; if the pupils have remained dilated, fixed and unresponsive to light for over 10 minutes; or if it has been ascertained that the patient has definite serious illness incompatible with continuing life. Such a plan as outlined above should be instituted at once, before attempting to determine the cause of cardiac arrest or planning further special treatment.     

New mechanical aid to physiotherapy in cystic fibrosis.

The force of impact and frequency of percussion by physiotherapists and parents of children with cystic fibrosis were analysed on a special test rig and incorporated in a prototype percussor. In adult volunteers and cadavers a maximum intrathoracic pressure could be achieved by a critical frequency of mechanical percussion which was higher than that reached by physiotherapists and parents. Consequently the percussor was redesigned to operate at this optimum frequency. It was then discovered that if the percussor was pressed firmly enough against the chest, this maximum intrathoracic pressure could be indicated by quivering of the voice. In a continuing study of intrathoracic pressures obtained mechanically and manually the Salford percussor''s produced higher pressures than the physiotherapists'' and maintained them constantly, while the physiotherapists'' efforts and results varied from one to another. Hospital and domiciliary use of the percussor have shown it to help in the first stage of the physiotherapy routine for patients with cystic fibrosis. The percussor should enable adolescents and adults to treat themselves and encourage twice-daily and more effective chest treatments. It is easy to apply and its speed and efficiency should enable parents to improve the quality of their chest therapy for younger children at home. Its long-term benefits are difficult to assess because of the nature of the disease.     

Unsuspected Pneumocystis carinii pneumonia and vertically acquired HIV infection in infants requiring intensive care.

When an infant develops acute respiratory failure of sufficient severity to necessitate supportive mechanical ventilation a cause should always be sought. A chest radiograph showing predominantly interstitial lung disease and an infant''s failure to respond to standard antibiotic treatment are indications for non-bronchoscopic bronchoalveolar lavage. If P carinii pneumonia is diagnosed a congenital immunodeficiency should be sought and the parents counselled about HIV infection. Earlier investigation may be indicated by features of immunodeficiency when taking a history, performing a general examination, or analysing the results of basic haematological testing.     

Application of airline pilots' hours to junior doctors.

OBJECTIVE--To determine the staff required if the rules for airline pilots'' hours of work are applied to junior doctors. DESIGN--Junior anaesthetists recorded their workload from 1 March 1988 to May 31 1988. SETTING--District general hospital. SUBJECTS--Two groups of three junior anaesthetists sharing a one in three rota to provide continuous emergency cover. INTERVENTIONS--By using the guidelines published by the Civil Aviation Authority in The Avoidance of Excessive Fatigue in Aircrews schedules were drawn up to cover the hours that junior doctors had been on duty. RESULTS--Each anaesthetist provided emergency and routine cover for 48-112 (mean 75) hours each week. To cover the work of six junior anaesthetists on an annual basis would require 26 doctors if they were working within the Civil Aviation Authority''s guidelines. CONCLUSIONS--Junior anaesthetists'' hours are much longer than those of airline pilots. Both professions entail considerable periods of monitoring interspersed with episodes of high demands on physical and cognitive skills. Errors induced by fatigue made by anaesthetists and pilots could result in death. The medical profession should define rules similar to those of the aviation authority to prevent junior doctors having to work unsafe numbers of hours.     

Soil Organic Matter and Management of Plant-Parasitic Nematodes

Organic matter and its replenishment has become a major component of soil health management programs. Many of the soil''s physical, chemical, and biological properties are a function of organic matter content and quality. Adding organic matter to soil influences diverse and important biological activities. The diversity and number of free-living and plant-parasitic nematodes are altered by rotational crops, cover crops, green manures, and other sources of organic matter. Soil management programs should include the use of the proper organic materials to improve soil chemical, physical, and biological parameters and to suppress plant-parasitic nematodes and soilborne pathogens. It is critical to monitor the effects of organic matter additions on activities of major and minor plant-parasitic nematodes in the production system. This paper presents a general review of information in the literature on the effects of crop rotation, cover crops, and green manures on nematodes and their damage to economic crops.     

RIGHT DIAPHRAGMATIC HERNIA SECONDARY TO TRAUMA—With Report of Two Cases

With automobile accidents at high speed on the increase, some previously rare injuries are becoming more common. Rupture of the left diaphragm is fairly common. On the right, it has been believed rare. The diagnosis has often been missed for many years after the causative injury.Any suspicious x-ray film shadow at the base of the right lung field after injury such as those that occur in accidents of great impact should arouse the physician''s suspicions. A mushroom-shaped mass on the lateral x-ray view is characteristic.Introduction of pneumoperitoneum may help in diagnosis. Only if the peritoneal and pleural cavities communicate will this procedure produce a pneumothorax.Surgical correction is indicated in all cases. This is best done through the chest. The right lobe of the liver usually must be reduced. In general the results are excellent.     

Management of airway complications of burns in children.

Children who have been exposed to smoke in a confined space or who have soot or burns, however minimal, on the face should be admitted to hospital. Respiratory distress may be delayed, but if it is progressive the patient should be curarised, intubated, and mechanically ventilated. Unless ventilation continues for 48 hours, followed by 24 hours'' spontaneous respiration against a positive airway pressure, stridor and pulmonary oedema may recur. An endotracheal tube small enough to allow a leak between it and the oedematous mucosa must be passed to prevent laryngeal damage and subsequent subglottic stenosis. High humidity of inspired gases keeps secretions fluid and the endotracheal tube patent. A high oxygen concentration compensates for deficient oxygen uptake and transport caused by pulmonary lesions and the presence of poisonous compounds interfering with oxygen transport. Dexamethasone to minimise cerebral oedema and antibiotics to reduce the incidence of chest infections should be given.     

Pneumocystis Carinii Pneumonia in Children

From a retrospective study at the University of California, San Francisco, Medical Center, it is evident that pneumocystic carinii pneumonia is being seen more frequently as a secondary complication to the use of immunosuppressive drugs. This disease presents with nonspecific respiratory symptoms, therefore a high degree of suspicion and knowledge of the population at risk are necessary for an early diagnosis. Except for x-ray films of the chest, physical and laboratory studies are of minimal diagnostic value. In a patient with compromised immune defenses and respiratory distress, bilateral diffuse reticular infiltrates seen on a film of the chest are highly suggestive of pneumocystis carinii pneumonia. The diagnosis should be confirmed histologically because a variety of pathogens can cause these findings and each requires a specific treatment. At our institution, open thoracotomy is the method of choice for obtaining a lung biopsy specimen. Pentamidine isothionate is moderately effective against this usually fatal disease, but its effectiveness depends on beginning treatment early in the illness.     

Are coronary artery spasm and progressive damage to the heart associated with the hyperventilation syndrome?

A case of coronary artery vasospasm was studied in a man with a four year history of angina. He had evidence of symptomatic hyperventilation during a spontaneous episode of chest pain. When asked to hyperventilate the pain in his chest and ST elevation were reproduced in the same leads as occurred during the spontaneous attack. This may be the first reported case of spontaneous hyperventilation producing vasoconstriction, and the patient''s previous admissions to the coronary care unit may have been associated with coronary vasospasm induced by hyperventilation. When patients with variant angina report pains in the chest in association with dizziness and breathlessness hyperventilation should be considered to be a possible cause of the symptoms. As coronary vasospasm is increasingly implicated in angina after myocardial infarction the role of hyperventilation should be considered more often.     

How Microbial Community Composition Regulates Coral Disease Development

Reef coral cover is in rapid decline worldwide, in part due to bleaching (expulsion of photosynthetic symbionts) and outbreaks of infectious disease. One important factor associated with bleaching and in disease transmission is a shift in the composition of the microbial community in the mucus layer surrounding the coral: the resident microbial community—which is critical to the healthy functioning of the coral holobiont—is replaced by pathogenic microbes, often species of Vibrio. In this paper we develop computational models for microbial community dynamics in the mucus layer in order to understand how the surface microbial community responds to changes in environmental conditions, and under what circumstances it becomes vulnerable to overgrowth by pathogens. Some of our model''s assumptions and parameter values are based on Vibrio spp. as a model system for other established and emerging coral pathogens. We find that the pattern of interactions in the surface microbial community facilitates the existence of alternate stable states, one dominated by antibiotic-producing beneficial microbes and the other pathogen-dominated. A shift to pathogen dominance under transient stressful conditions, such as a brief warming spell, may persist long after environmental conditions have returned to normal. This prediction is consistent with experimental findings that antibiotic properties of Acropora palmata mucus did not return to normal long after temperatures had fallen. Long-term loss of antibiotic activity eliminates a critical component in coral defense against disease, giving pathogens an extended opportunity to infect and spread within the host, elevating the risk of coral bleaching, disease, and mortality.     

Microbial rights?

Our ability to disrupt habitats and manipulate living organisms requires a discussion of the ethics of microbiology, even if we argue that microbes themselves have no rights.Synthetic biology and the increasing complexity of molecular biology have brought us to the stage at which we can synthesize new microorganisms. This has generated pressing questions about whether these new organisms have any place in our system of ethics and how we should treat them.The idea that microbes might have some moral claims on us beyond their practical uses or instrumental value is not a new question. Microbiologist Bernard Dixon (1976) presciently asked whether it was ethical to take the smallpox virus to extinction at the height of the attempts of the World Health Organization in the 1970s to eradicate it. There is no unambiguous answer. Today, we might still ask this question, but we might extend it to ask whether the destruction or extinction of a synthetic microbe that was made by humans is also ethically questionable or is such an entity—in that it is designed—more like a machine, which we have no compunction in terminating? Would two lethal pathogens, one of them synthetic and one of them natural, but otherwise identical, command the same moral claims?In a colloquial way, we might ask whether microbes have rights. In previous papers (Cockell, 2004) I have discussed the ‘rights'' of microbes and further explored some issues about the ethics we apply to them (Cockell, 2008). Julian Davies, in a recent opinion article in EMBO reports (Davies, 2010) described my assertion that they should have constitutional rights as ‘ridiculous''. Although I did suggest that environmental law could be changed to recognize the protection of microbial ecosystems—which would imply statutory rights or protection—nowhere have I claimed that microbes should have ‘constitutional'' rights. Nevertheless, this misattribution provides a useful demonstration of the confusion that exists about exactly how we should treat microbes.Few people are in any doubt that microbes should be conserved for their direct uses to humans, for example, in food and drug production, and their indirect uses such as the crucial role they have in the health of ecosystems. Indeed, these motivations can be used to prioritize microbial conservation and protection efforts (Cockell & Jones, 2009). The crucial question is whether microbes have ‘intrinsic value'' beyond their practical uses. If the answer is ‘no'', then we should have no guilt about deliberately driving microbes to extinction for our benefit. However, there are people who feel uneasy with this conclusion, a feeling that calls forth more complex ethical questions.The question is whether microbes have some sort of ‘interests'' that make demands on our treatment of them that go beyond a mere utilitarian calculation. These arguments themselves question what we define as ‘interests'' and whether interests make demands on us. A microbe has no future plans or thought processes; the sorts of interests that are accepted as being of sufficient scope to place demands on our treatment of other human beings, for instance. However, microbes do have biological interests. A halophilic microbe might eventually die if it is dropped into freshwater. Does our knowledge of what is in the biological interests of a microbe mean that we must show it any consideration beyond practical uses? The answer is not obviously negative (Taylor, 1981), but even if we decide that it is, this does not let us off the hook quite yet.There are other intrinsic value arguments that are more obscure, particularly those around the notion of ‘respect''; the idea that we should show empathy towards the trajectory, however deterministic, of other life forms. These unquantifiable and controversial arguments might, nevertheless, partly explain any unease that we have in watching a group of people smash up and destroy some exquisite microbial mats, just because they were bored.Clearly, human instrumental needs do trump microbes at some level. If they did not, we could not use bleach in our houses, an absurd end-point raised in a 1970s science fiction story that explored the futuristic ramifications of full microbial rights, in which household bleaches and deodorants are banned (Patrouch, 1977).However, we should not be so quick to ridicule ideas about microbial ethics and rights. Although it might be true that phages kill a large percentage of the bacterial population of the world every few days, as Julian Davies points out, human society has achieved an unprecedented capacity for destruction and creation. Our ability to poison and disrupt habitats has been unquantified, with respect to the loss of microbial species. Both synthetic biology and bioterrorism raise the spectre of creating new organisms, including pathogens, which we might need to control or deliberately pursue to extinction. Dixon''s dilemma about the smallpox virus, raised more than 30 years ago, has become an urgent point of discussion in the ethics of molecular biology and microbiology.     

WELLBEING,SCHIZOPHRENIA AND EXPERIENCE MACHINES

In the USA and England and Wales, involuntary treatment for mental illness is subject to the constraint that it must be necessary for the health or safety of the patient, if he poses no danger to others. I will argue against this necessary condition of administering treatment and propose that the category of individuals eligible for involuntary treatment should be extended. I begin by focusing on the common disorder of schizophrenia and proceed to demonstrate that it can be a considerable harm to a person's life without causing the person to be a danger to himself. I illuminate this claim by constructing a thought experiment concerning a person who slips on a banana peel and falls into a malfunctioning version of Robert Nozick's experience machine. I propose that the reasons why we should remove the person from the machine are the same reasons why we should administer involuntary treatment to individuals with schizophrenia. I rebut three objections to the analogy and conclude that if we believe that we have a duty to provide treatment for reasons relating to a person's wellbeing, it follows that we should reject the health or safety requirement and instead broaden the category of individuals who are eligible for involuntary treatment.     

Herbicide and Tillage Effects on Volunteer Vegetation Composition and Diversity During Reforestation

Fraxinus pennsylvanica (green ash) is commonly used for reforestation of agricultural lowlands in the midwestern and eastern United States. We evaluated the effects of herbicide (untreated, glyphosate, and sulfometuron methyl) and tillage (tilled and no‐till) on F. pennsylvanica success and composition of associated volunteer vegetation 3 years after the treatment applications and reforestation of a formerly cultivated field in southern Illinois. Tillage had no effect on F. pennsylvanica growth, whereas both herbicides increased all measures of tree performance. The response of associated native and non‐native species cover was affected by an interaction between the herbicide and tillage treatments. In the presence of herbicide, cover of native species was greater in the no‐till treatment, whereas non‐native cover was higher in the tillage treatment. Both native and non‐native cover were unaffected by tillage in the absence of herbicide, and there were no differences in cover among the herbicide treatments in the presence of tillage. Total diversity was higher in the tillage treatment than the no‐till treatment, and diversity was lower in the sulfometuron methyl herbicide treatment than the control and glyphosate herbicide treatment. Lower diversity in the sulfometuron methyl treatment was attributed to greater cover of a native perennial grass, Andropogon virginicus (Broomsedge), which was inversely related to total diversity. We conclude that a single glyphosate herbicide application can enhance F. pennsylvanica growth and conserve associated species diversity in this system. Furthermore, species‐specific responses of the associated vegetation should be included in management considerations, particularly if silvicultural treatments influence dominance and diversity in the establishing understory community during reforestation.     

The probability of treatment induced drug resistance

We propose a discrete time branching process to model the appearance of drug resistance under treatment. Under our assumptions at every discrete time a pathogen may die with probability 1−p or divide in two with probability p. Each newborn pathogen is drug resistant with probability μ. We start with N drug sensitive pathogens and with no drug resistant pathogens. We declare the treatment successful if all pathogens are eradicated before drug resistance appears. The model predicts that success is possible only if p<1/2. Even in this case the probability of success decreases exponentially with the parameter m=μN. In particular, even with a very potent drug (i.e. p very small) drug resistance is likely if m is large.     

Cervicopectoral flap in head and neck cancer surgery

Background  

Reconstruction of the head and neck after adequate resection of primary tumor and neck dissection is a challenge. It should be performed at one sitting in advanced tumors. Defects caused by the resection should be closed with flaps which match in color, texture and hair bearing characteristics with the face. Cervicopectoral flap is a one such flap from chest and neck skin mainly used to cover the cheek defects.     

Habilitation of Patients with Congenital Malformations Associated with Thalidomide: Psychiatric and Psychological Aspects

Nearly 100 cases of congenital malformations associated with thalidomide ingestion by the mother have been reported in Canada to the Department of National Health and Welfare. Depression and selfcastigation have been the specific psychiatric reactions noted, particularly in the mother. In most cases it is preferable psychologically for the parents and the child if the child is kept at home rather than placed in an institution. Parents should be fully informed concerning the child''s prognosis for future development. Most of the children followed up for about two years showed no intelligence defects. A prosthesis, if required, should be applied early (at three to six months) so that it may become a part of the child''s body-image, but it should not interfere with play activities. Assessment by a psychiatrist and a psychologist is indicated at about six months.     

Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child''s refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children''s consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.     

Density and habitat associations of Henslow's Sparrows wintering in saline soil barrens in southern Arkansas

ABSTRACT Although the habitat requirements of breeding populations of Henslow's Sparrow (Ammodramus henslowii) have been examined, less is known about their habitat requirements and ecology during the nonbreeding season. We estimated population densities and quantified habitat associations of Henslow's Sparrows wintering in saline soil barrens in southern Arkansas. Densities of Henslow's Sparrows in the saline soil barrens were similar to those in the Longleaf Pine (Pinus palustris) Ecosystem of the southeastern United States, considered by many to be their primary wintering habitat. Henslow's Sparrows were closely associated with open areas with greater cover of Aristida spp. and globe beaksedge (Rhynchospora globularis), greater stem density at 11–20 cm above ground, more lichens, more herbaceous cover, more bare ground, greater occurrence of little bluestem (Schizacyrium scoparium) as the tallest vegetation, less moss, and less shrub cover than randomly selected sites. In contrast to the results of studies conducted in the Longleaf Pine Ecosystem, the presence of Henslow's Sparrows in our study was not correlated with the height of the tallest vegetation. Our results indicate that saline soil barrens of southern Arkansas support a high density of wintering Henslow's Sparrows and do so for longer postdisturbance periods than longleaf pine savanna. We also found that stem density near the ground was similar to that reported from longleaf pine savanna, but only about half that observed on their breeding grounds. Areas used by Henslow's Sparrows had more lichen and less moss cover, suggesting that those areas were drier than random sites within the barrens. Further research is needed to determine if large populations of Henslow's Sparrows winter in other saline soil barrens and if fire influences habitat associations and densities in the barrens.