Elafin (elastase-specific inhibitor) has anti-microbial activity against gram-positive and gram-negative respiratory pathogens.

Elafin (elastase-specific inhibitor) is a low molecular weight inhibitor of neutrophil elastase which is secreted in the lung. Using synthetic peptides corresponding to full-length elafin (H2N-1AVT.....95Q-OH), the NH2-terminal domain (H2N-1AVT.....50K-OH) and the COOH-terminal domain (H2N-51PGS.....95Q-OH), we demonstrate that elafin's anti-elastase activity resides exclusively in the COOH-terminus. Several characteristics of elafin suggest potential anti-microbial activity. The anti-microbial activity of elafin, and of its two structural domains, was tested against the respiratory pathogens Pseudomonas aeruginosa and Staphylococcus aureus. Elafin killed both bacteria efficiently, with 93% killing of P. aeruginosa by 2.5 microM elafin and 48% killing of S. aureus by 25 microM elafin. For both organisms, full-length elafin was required to optimise bacterial killing. These findings represent the first demonstration of co-existent anti-proteolytic and anti-microbial functions for elafin.     

Use of a Static Progressive Stretch Orthosis to Treat Post-Traumatic Ankle Stiffness

ABSTRACT: BACKGROUND: Chronic ankle stiffness can develop for numerous reasons after traumatic injury, and may adversely affect patient gait, mobility, and function. Although standard physical therapeutic techniques typically resolve this stiffness, some cases may be recalcitrant to these measures, making it difficult to restore range-of-motion. The purpose of this study was to evaluate a static progressive stretch orthosis for the treatment of persistent ankle stiffness. METHODS: Twenty-six patients (26 ankles) who had persistent post-traumatic ankle stiffness were studied. The patients began treatment at a mean of 47 weeks (range, 6 to 272 weeks) following their initial injury using a static progressive stretch orthosis. A patient-directed protocol was used for 30 minutes per day, 1 to 3 times per day, until the range-of-motion was considered to have plateaued. Mean treatment time was 10 weeks (range, 3 to 19 weeks). Treatment duration, range-of-motion, and complications with the device were assessed. RESULTS: The overall mean improvement in motion (combined dorsiflexion and plantar flexion) was 17 degrees (range, 2 to 44 degrees). There was a mean improvement in dorsiflexion of 9 degrees (range, -2 to 20 degrees), and a mean improvement of 8 degrees of plantar flexion (range, -10 to 35 degrees). There were no reports of numbness or skin problems. CONCLUSIONS: The outcomes of this study suggest that a patient-directed treatment protocol using a static progressive stretch orthosis was an effective ancillary method for the treatment of persistent post-traumatic ankle stiffness that was refractory to standard physical therapy techniques. Key Words: ankle; stiffness; orthosis; progressive stress relaxation; rehabilitation.     

Participation of California Physicians in Emergency Medical Care Panels, Report of Bureau of Research and Planning

Over 40 per cent of all California physicians belonged to some type of emergency medical care panel during 1961. Of these physicians, almost 60 per cent were affiliated with hospital panels and 27 per cent with County Society panels. Other findings indicate the following facts about physician participation in emergency care panels:...84 per cent of physicians who participate do so on a voluntary basis, with 16 per cent belonging to panels on a compulsory basis....higher than average per cents of physicians belong to such panels in rural areas....compulsory membership is more prevalent in hospital panels than in County Society panels.     

Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study

Background

Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this “weekend effect” is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke.

Methods and Findings

We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91–1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose–response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07–1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77–0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services.

Conclusions

Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care. Please see later in the article for the Editors'' Summary     

Comparison of community based service with hospital based service for people with acute,severe psychiatric illness.

OBJECTIVE--To compare the burden on relatives and outcome of people treated for severe acute psychiatric illness by a community service and a traditional hospital based service. DESIGN--Follow up of patients aged 16-65 who required admission to hospital or home treatment for psychiatric illness during January 1990 to February 1991. SETTING--Two Birmingham electoral wards, Sparkbrook and Small Heath; Sparkbrook has a community based service and Small Heath a traditional hospital based service. SUBJECTS--69 patients from Sparkbrook and 55 from Small Health. MAIN OUTCOME MEASURES--Scores on present state examination, social behaviour assessment schedule, and general health questionnaire. RESULTS--24 (35%) of Sparkbrook patients received some treatment in hospital during the initial episodes. Relatives of Sparkbrook patients were less distressed by their burden at the initial assessment than relatives of Small Health patients (mean score 0.11 v 0.29, p < 0.01). Relatives were also more satisfied with the support they received and the treatment received by patients. More patients from Sparkbrook than Small Health were in contact with a psychiatrist (81% (95% confidence interval 71% to 91%) v 62% (44% to 68%)) and community nurse (56% (44% to 68%) v 14% (13% to 24%)) one year after the initial episode. Sparkbrook patients spent significantly fewer days in hospital during the initial episode (8 days v 59 days) and the first year (20.6 v 67.9 days). CONCLUSION--The community based service is as effective as the hospital based service and is preferred by relatives. It is more effective in keeping people in long term contact with psychiatrists.     

Insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial

BACKGROUND: Diabetic patients taking insulin often have suboptimal glucose control, and standard methods of health care delivery are ineffective in improving such control. This study was undertaken to determine if insulin adjustment according to advice provided by telephone by a diabetes nurse educator could lead to better glucose control, as indicated by level of glycated hemoglobin (HbA1c). METHODS: The authors conducted a prospective randomized trial involving 46 insulin-requiring diabetic patients who had poor glucose control (HbA1c of 0.085 or more). Eligible patients were those already taking insulin and receiving endocrinologist-directed care through a diabetes centre and whose most recent HbA1c level was 0.085 or higher. The patients were randomly assigned to receive standard care or to have regular telephone contact with a diabetes nurse educator for advice about adjustment of insulin therapy. RESULTS: At baseline there was no statistically significant difference between the 2 groups in terms of HbA1c level (mean [and standard deviation] for standard-care group 0.094 [0.008] and for intervention group 0.096 [0.010]), age, sex, type or duration of diabetes, duration of insulin therapy or complications. After 6 months, the mean HbA1c level in the standard-care group was 0.089 (0.010), which was not significantly different from the mean level at baseline. However, the mean HbA1c level in the intervention group had fallen to 0.078 (0.008), which was significantly lower than both the level at baseline for that group (p < 0.001) and the level for the standard-care group at 6 months (p < 0.01). INTERPRETATION: Insulin adjustment according to advice from a diabetes nurse educator is an effective method of improving glucose control in insulin-requiring diabetic patients.     

Eradication of Helicobacter pylori for the prevention of peptic ulcer rebleeding

AIM: To evaluate the effect of Helicobacter pylori eradication on ulcer bleeding recurrence in a prospective, long-term study including more than 400 patients. METHODS: Patients with peptic ulcer bleeding were prospectively included. H. pylori infection was confirmed by rapid urease test, histology or (13)C-urea breath test. Several eradication regimens were used. Ranitidine 150 mg was administered daily until eradication was confirmed by breath test 8 weeks after completing eradication therapy. Patients with therapy failure received a second or third course of therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy, and were controlled yearly with a repeated breath test. RESULTS: Four hundred and twenty-two patients were followed up for at least 12 months, with a total of 906 patient-years of follow up. Mean age was 59 years, and 35% were previous nonsteroidal anti-inflammatory drug (NSAID) users. Sixty-nine percent had duodenal, 24% gastric, and 7% pyloric ulcer. Recurrence of bleeding was demonstrated in two patients at 1 year (incidence: 0.22% per patient-year of follow up), which occurred after NSAID use in both cases. CONCLUSION: Peptic ulcer rebleeding does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved.     

Impact on the quality of life of lymphoedema patients following introduction of a hygiene and skin care regimen in a Guyanese community endemic for lymphatic filariasis: A preliminary clinical intervention study

BACKGROUND: Hygiene and skin care are effective and important interventions in the management of lymphoedema secondary to lymphatic filariasis. We analyzed the impact on the quality of life that education and introduction of a designated nurse had on lymphoedema patients in a community that was endemic for lymphatic filariasis. METHODS: Patients' life quality was assessed using a Dermatology Life Quality Index (DLQI) questionnaire. At the same time they received education on appropriate hygiene, skin care techniques and simple exercises that encourage lymph drainage. A designated nurse was provided with educational materials and treatments. The DLQI life quality measure was repeated one year later. RESULTS: The DLQI improved for all patients and reported acute attacks were reduced. A paired t-test showed the improvement in DLQI to be highly significant (P = < 0.0001). CONCLUSIONS: A nurse-led service combined with patient education in communities endemic for lymphatic filariasis is an effective intervention in improving the quality of life of patients with lymphoedema.     

ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase,oral aspirin,both, or neither

Objective: To assess effects of intravenous streptokinase, one month of oral aspirin, or both, on long term survival after suspected acute myocardial infarction. Design: Randomised, “2×2 factorial,” placebo controlled trial. Setting: 417 hospitals in 16 countries. Subjects: 17 187 patients with suspected acute myocardial infarction randomised between March 1985 and December 1987. Follow up of vital status complete to at least 1 January 1990 for 95% of all patients and to mid-1997 for the 6213 patients in United Kingdom. Interventions: Intravenous streptokinase (1.5 MU in 1 hour) and oral aspirin (162 mg daily for 1 month) versus matching placebos. Main outcome measures: Mortality from all causes during up to 10 years’ follow up, with subgroup analyses based on 4 year follow up. Results: After randomisation, 1841 deaths were recorded in days 0-35, 991 from day 36 to end of year 1, 1478 in years 2-4, and 1230 in years 5-10. Allocation to streptokinase was associated with 29 (95% confidence interval 20 to 38) fewer deaths per 1000 patients during days 0-35. This early benefit persisted (death rate ratio 0.98 (0.92 to 1.04) for additional deaths between day 36 and end of year 10), so that there were 28 (14 to 42) and 23 (2 to 44) fewer deaths per 1000 patients treated with streptokinase after 4 years and 10 years respectively. There was no evidence that absolute survival benefit increased with prolonged follow up among any category of patient, including those presenting early after symptoms started or with anterior ST elevation. Nor did the early benefits seem to be lost in any category (including those aged over 70). Allocation to one month of aspirin was associated with 26 (16 to 35) fewer deaths per 1000 during first 35 days, with little further benefit or loss during subsequent years (death rate ratio 0.99 (0.93 to 1.06) between day 36 and end of year 10). The early benefit obtained with combination of streptokinase and one month of aspirin also seemed to persist long term. Conclusions: The early survival advantages produced by fibrinolytic therapy and one month of aspirin started in acute myocardial infarction seem to be maintained for at least 10 years.

Key messages

• Large randomised trials have shown that the survival benefits of intravenous fibrinolytic therapy for patients with acute myocardial infarction persist for at least one year, but there is relatively little information about longer term effects
• By contrast, this report from the ISIS-2 trial of intravenous streptokinase and of one month of oral aspirin includes nearly 4000 deaths between the start of year 2 and the end of year 10
• The early survival benefits of fibrinolytic therapy persist for at least 10 years after treatment and do not seem to increase or decrease with prolonged follow up in any category of patients, including elderly subjects
• The survival benefits of short term aspirin treatment in acute myocardial infarction also persist long term and are additional to those of fibrinolytic therapy, and other studies show that these benefits can be increased by continuing aspirin treatment for some years after myocardial infarction

     

The Elimination of Lymphatic Filariasis: A Strategy for Poverty Alleviation and Sustainable Development – Perspectives from the Philippines

BACKGROUND: Hygiene and skin care are effective and important interventions in the management of lymphoedema secondary to lymphatic filariasis. We analyzed the impact on the quality of life that education and introduction of a designated nurse had on lymphoedema patients in a community that was endemic for lymphatic filariasis. METHODS: Patients' life quality was assessed using a Dermatology Life Quality Index (DLQI) questionnaire. At the same time they received education on appropriate hygiene, skin care techniques and simple exercises that encourage lymph drainage. A designated nurse was provided with educational materials and treatments. The DLQI life quality measure was repeated one year later. RESULTS: The DLQI improved for all patients and reported acute attacks were reduced. A paired t-test showed the improvement in DLQI to be highly significant (P = < 0.0001). CONCLUSIONS: A nurse-led service combined with patient education in communities endemic for lymphatic filariasis is an effective intervention in improving the quality of life of patients with lymphoedema.     

Alteration of protein constituents induced by low-energy (<35 eV) electrons: II. Dissociative electron attachment to amino acids containing cyclic groups

We report measurements of the desorption of anions from thin condensed films of tryptophan (Trp), histidine (His) and proline (Pro) stimulated by 5-35 eV electron impact. H-, O-, OH- and CN- desorb from Trp, His and Pro, whereas CH2- is observed only from Pro fragmentation. Below 12 eV, the anion yield functions exhibit resonant structures indicative of dissociative electron attachment. For all three amino acids, this process is likely to be initiated by the resonant capture of the incident electron at the NH3(+)-CH-.....-COO- and/or NH2-CH-.....-COOH group of the molecule. Temporary electron attachment to the ring leads to anion desorption only for tryptophan and proline. The energy-averaged yields measured at the detector of the mass spectrometer are (4.9, 0.3 and 54.0) x 10(-8) H-/incident electron and (3.4, 2.9, 1.8) x 10(-11) O-/incident electron, respectively, from Trp, His and Pro dissociation. Fragmentation of amino acids is found to be as intense as that of the nucleic acid bases. These results are discussed within the context of radiobiological damage induced by secondary electrons.     

Nurse led versus lay educators support for those with asthma in primary care: a costing study

ABSTRACT: BACKGROUND: Regular review and support for asthma self-management is promoted in guidelines. A randomised controlled trial suggested that unscheduled health care usage was similar when patients were offered self management support by a lay-trainer or practice nurses. METHODS: Following the RCT, a costing study was undertaken using the trial data to account for the cost of delivery of the service under both strategies and the resulting impact on unscheduled healthcare (measure of effectiveness) in this trial. RESULTS: One year data (n = 418) showed that 29% (61/205) of the nurse group required unscheduled healthcare (177 events) compared with 30.5% (65/213) for lay-trainers (178 events).The training costs for the lay-trainers were greater than nurses ([pound sign]36 versus [pound sign]18 respectively per patient, p<0.001), however, the consultation cost for lay-trainers were lower than nurses ([pound sign]6 per patient versus [pound sign]24, p<0.001). If the cost of unscheduled healthcare are accounted for then the costs of nurses is [pound sign]161, and [pound sign]135 for lay-trainers (mean difference [pound sign]25, [95% CI = -[pound sign]97, [pound sign]149, p = 0.681]). The total costs (delivery and unscheduled healthcare) were [pound sign]202 per patient for nurses versus [pound sign]178 for lay-trainers, (mean difference [pound sign]24, [95%CI = -[pound sign]100, [pound sign]147, p = 0.707]). CONCLUSIONS: There were no significant differences in the cost of training and healthcare delivery between nurse and lay trainers, and no significant difference in the cost of unscheduled health care use.     

Clinical effects of anticoagulant therapy in suspected acute myocardial infarction: systematic overview of randomised trials.

OBJECTIVES: Most randomised trials of anticoagulant therapy for suspected acute myocardial infarction have been small and, in some, aspirin and fibrinolytic therapy were not used routinely. A systematic overview (meta-analysis) of their results is needed, in particular to assess the clinical effects of adding heparin to aspirin. DESIGN: Computer aided searches, scrutiny of reference lists, and inquiry of investigators and companies were used to identify potentially eligible studies. On central review, 26 studies were found to involve unconfounded randomised comparisons of anticoagulant therapy versus control in suspected acute myocardial infarction. Additional information on study design and outcome was sought by correspondence with study investigators. SUBJECTS: Patients with suspected acute myocardial infarction. INTERVENTIONS: No routine aspirin was used among about 5000 patients in 21 trials (including half of one small trial) that assessed heparin alone or heparin plus oral anticoagulants, and aspirin was used routinely among 68,000 patients in six trials (including the other half of one small trial) that assessed the addition of intravenous or high dose subcutaneous heparin. MAIN OUTCOME MEASUREMENTS: Death, reinfarction, stroke, pulmonary embolism, and major bleeds (average follow up of about 10 days). RESULTS: In the absence of aspirin, anticoagulant therapy reduced mortality by 25% (SD 8%; 95% confidence interval 10% to 38%; 2P = 0.002), representing 35 (11) fewer deaths per 1000. There were also 10 (4) fewer strokes per 1000 (2P = 0.01), 19 (5) fewer pulmonary emboli per 1000 (2P < 0.001), and non-significantly fewer reinfarctions, with about 13 (5) extra major bleeds per 1000 (2P = 0.01). Similar sized effects were seen with the different anticoagulant regimens studied. In the presence of aspirin, however, heparin reduced mortality by only 6% (SD 3%; 0% to 10%; 2P = 0.03), representing just 5 (2) fewer deaths per 1000. There were 3 (1.3) fewer reinfarctions per 1000 (2P = 0.04) and 1 (0.5) fewer pulmonary emboli per 1000 (2P = 0.01), but there was a small non-significant excess of stroke and a definite excess of 3 (1) major bleeds per 1000 (2P < 0.0001). CONCLUSIONS: The clinical evidence from randomised trials dose not justify the routine addition of either intravenous or subcutaneous heparin to aspirin in the treatment of acute myocardial infarction (irrespective of whether any type of fibrinolytic therapy is used).     

Prevention of respiratory complications after abdominal surgery: a randomised clinical trial.

OBJECTIVE--To evaluate the prevention of respiratory complications after abdominal surgery by a comparison of a global policy of incentive spirometry with a regimen consisting of deep breathing exercises for low risk patients and incentive spirometry plus physiotherapy for high risk patients. DESIGN--Stratified randomised trial. SETTING--General surgical service of an urban teaching hospital. PATIENTS--456 patients undergoing abdominal surgery. Patients less than 60 years of age with an American Society of Anesthesia classification of 1 were considered to be at low risk. OUTCOME MEASURES--Respiratory complications were defined as clinical features consistent with collapse or consolidation, a temperature above 38 degrees C, plus either confirmatory chest radiology or positive results on sputum microbiology. We also recorded the time that staff devoted to prophylactic respiratory therapy. RESULTS--There was good baseline equivalence between the groups. The incidence of respiratory complications was 15% (35/231) for patients in the incentive spirometry group and 12% (28/225) for patients in the mixed therapy group (P = 0.40; 95% confidence interval -3.6% to 9.0%). It required similar amounts of staff time to provide incentive spirometry and deep breathing exercises for low risk patients. The inclusion of physiotherapy for high risk patients, however, resulted in the utilisation of an extra 30 minutes of staff time per patient. CONCLUSIONS--When the use of resources is taken into account, the most efficient regimen of prophylaxis against respiratory complications after abdominal surgery is deep breathing exercises for low risk patients and incentive spirometry for high risk patients.     

Is telephone counselling a useful addition to physician advice and nicotine replacement therapy in helping patients to stop smoking? A randomized controlled trial

BACKGROUND: The authors evaluated the incremental efficacy of telephone counselling by a nurse in addition to physician advice and nicotine replacement therapy in helping patients to stop smoking. METHODS: The trial was conducted at the University of Ottawa Heart Institute. A total of 396 volunteers who smoked 15 or more cigarettes daily were randomly assigned to either of 2 groups: usual care (control group) and usual care plus telephone counselling (intervention group); the groups were stratified by sex and degree of nicotine dependence. Usual care involved the receipt of physician advice on 3 occasions, self-help materials and 12 weeks of nicotine replacement therapy. Telephone counselling was provided by a nurse at 2, 6 and 13 weeks after the target quit date. Point-prevalent quit rates were determined at 52 weeks after the target quit date. RESULTS: The point-prevalent quit rates at 52 weeks did not differ significantly between the control and intervention groups (24.1% v. 23.4% respectively). The quit rates did not differ significantly at the secondary measurement points of 4, 12 and 26 weeks. INTERPRETATION: Brief physician assistance, along with nicotine replacement therapy, can help well-motivated smokers to quit. Three additional sessions of telephone counselling by a nurse were ineffective in increasing quit rates. This form of assistance may be useful in the absence of physician advice or when self-selected by patients.     

METHYL-BIS (BETA-CHLOROETHYL) AMINE IN LARGE DOSES IN THE TREATMENT OF NEOPLASTIC DISEASES

Sixty-seven patients with neoplastic diseases were treated with 151 courses of methylbis (beta-chloroethyl)amine hydrochloride (HN₂). Seventy-seven of the courses consisted of single injections of 0.2 to 0.4 mg. per kilogram of body weight, and 35 courses were given as single injections of 0.6 mg. per kilogram of body weight.Twenty-three patients with Hodgkin''s disease were treated. Remissions averaged approximately three months in 13 patients who were in good or fair general physical condition, and 1.5 months in 11 patients who were in poor or moribund condition; one of the 11 did not respond to the therapy.Fifteen patients with lymphosarcoma were treated. Remissions averaged between one and two months in four patients who were in good or fair general physical condition. Of the remaining 11 patients, two showed no response, and the longest remission among the remaining nine was approximately 40 days.Satisfactory remissions of one to three months were obtained in four patients with mycosis fungoides treated with single courses of 0.3 mg. per kilogram of body weight.Serious toxic reactions were observed in six patients, four of whom died. In five of the six instances the reactions consisted of pancytopenia and hemorrhagic diathesis. All these patients were in poor general or hematologic status before therapy.In general, large single doses of HN₂ were neither more nor less effective than the four-to six-day course usually employed with this agent. Combination of the administration of HN₂ with artificial hyperpyrexia, or with concurrent courses of pteroylglutamic conjugates, did not enhance the therapeutic effects of the agent.     

Urinary Tract Infection/Vaginitis Protocol: Use in a Walk-in Clinic

A process, outcome and salary-cost analysis was made of the use of a urinary tract infection/vaginitis protocol. Three nurse practitioners, in a university-based, walk-in clinic, cared for 128 women presenting with complaints of dysuria or vaginal discharge, or both. There were no significant differences among the nurse practitioners in data collection, diagnostic accuracy or patient outcome. The diagnoses were correct in 92 percent, incorrect in 6 percent and indeterminate in 2 percent of the patients. Incorrect diagnoses were due to presumption of urinary tract infection in patients with the urethral syndrome or vaginitis. Of the patients, 78 percent were actually sent home without seeing a physician. Concordance with the nurse practitioners'' physical examination was 100 percent in those patients examined by a physician. In 82 percent of the patients there was alleviation of symptoms. Patient satisfaction with this method of care was extraordinary, with 98 percent of the patients giving favorable reports. True physician extension was achieved with a reduction in physician time per patient from 20 minutes to 6 minutes. In contrast to previously reported data, only a modest reduction in salary cost savings (10 percent) could be shown. The author concludes that nurse practitioners working in an acute care clinic or emergency department can see the patients defined in the study and provide high-quality care at a reasonable cost.     

Low areal bone mineral density values in adolescents and young adult turner syndrome patients increase after long-term transdermal estradiol therapy

OBJECTIVE: To study the effects of long-term estradiol therapy on areal bone mineral density (aBMD) values in young adult Turner syndrome patients. METHODS: The effects of 2-year transdermal estradiol administration on lumbar, L2-L4, aBMD values were evaluated in 12 Turner syndrome patients, 15.41-21.85 years old, who had reached adult height and had low aBMD values. Puberty was induced in all at a chronological age above 12 years and menarche appeared between 13.82 and 15.40 years. The patients were on oral estrogen/gestagen therapy from then until the start of the study. Adhesive patches of 17-beta-estradiol designed to be worn for 72 h and deliver 100 microg of estradiol per day, which results in a steady mean serum estradiol level of 75 pg/ml, were used for 21 days. From day 11 to day 21, 10 mg of oral didrogesterone were also added. Nutritional and physical activity habits were evaluated at the beginning, after 1 year and at the end of the study. RESULTS: aBMD values significantly increased from 0.910 +/- 0.065 to 1.005 +/- 0.086 g/cm2 (10.06 +/- 3.37%) and the z-score from -2.38 +/- 0.63 to -1.54 +/- 0.71 (0.81 +/- 0.30 z-score). No significant differences were observed in body mass index, calcium intake and physical activity habits at the start, during and at the end of the study. CONCLUSION: In summary, our results underline the importance of estrogens for bone mass peaking and suggest that this therapeutic protocol may be useful in the therapy of Turner syndrome patients with low bone mass.     

Preventive health care, 1999 update: 2. Echocardiography for the detection of a cardiac source of embolus in patients with stroke

OBJECTIVE: To develop guidelines for the use of echocardiography in the investigation of patients with stroke. OPTIONS: (1) Routine transthoracic echocardiography (TTE); (2) routine transesophageal echocardiography (TEE); (3) routine TTE followed by TEE if the TTE findings are noncontributory; (4) selective TTE or TEE in patients with cardiac disease who would not otherwise receive anticoagulant therapy. OUTCOMES: This article reviews the available evidence on the yield of TTE and TEE in detecting cardiac sources of cerebral emboli in patients with stroke, the effectiveness of treatment for cardiac sources of emboli and the effectiveness of screening echocardiography for secondary stroke prevention. EVIDENCE: MEDLINE was searched for relevant articles published from January 1966 to April 1998; also reviewed were additional articles identified from the bibliographies and citations obtained from experts. BENEFITS, HARMS AND COSTS: Echocardiography can detect intracardiac masses (thrombus, vegetation or tumour) in about 4% (with TTE) to 11% (with TEE) of stroke patients. The yield is lower among patients without clinical evidence of cardiac disease by history, physical examination, electrocardiography or chest radiography (less than 2%) than among patients with clinical evidence of cardiac disease (less than 19%). The risks of echocardiography to patients are small. TTE has virtually no risks, and TEE is associated with cardiac, pulmonary and bleeding complications in 0.18%. Patients with an identified intracardiac thrombus are at increased risk for embolic events (absolute risk uncertain, range 0%-38%), and this appears to be reduced with anticoagulant therapy (absolute risk reduction uncertain). Anticoagulant therapy carries a risk of major hemorrhage of 1% to 3% per year. The overall effectiveness of echocardiography in the prevention of recurrent stroke is unknown. VALUES: The strength of evidence was evaluated using the methods of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS: There is fair evidence to recommend echocardiography in patients with stroke and clinical evidence of cardiac disease by history, physical examination, electrocardiography or chest radiography (grade B recommendation). There is insufficient evidence to recommend for or against TEE in patients with normal results of TTE (grade C recommendation). There is insufficient evidence to recommend for or against routine echocardiography in patients (including young patients) without clinical cardiac disease (grade C recommendation). Routine echocardiography is not recommended for patients with clinical cardiac disease who have independent indications for or contraindications to anticoagulant therapy (grade D recommendation). There is fair evidence to recommend anticoagulant therapy in patients with stroke and intracardiac thrombus (grade B recommendation). There is insufficient (no) evidence to recommend for or against any specific therapy for patent foramen ovale (grade C recommendation). VALIDATION: The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care.