JAMA

doi: 10.1001/jama.279.20.1668pmid: N/A

It is probable that man was originally a tropical animal, perfectly adapted to his environment in a physical point of view, the natural product of evolution under the conditions in which he lived. Since he has emerged from his primal state and extended his habitat throughout nearly all latitudes and climates and has become a garment-wearing animal a host of unnatural and insanitary possibilities has arisen. The question of clothing, what to wear and how to wear it, has an importance altogether aside from the social and esthetic, and even from some of the ordinarily recognized considerations of comfort that commonly govern our selection. The hygienic choice of clothing, when it is not interfered with by conventional or economic or other factors, is usually a rule of thumb procedure, that takes little or no account of the chances or consequences of error. This is more especially true in our so-called temperate climates, where every extreme of temperature is experienced, often within the compass of a few days or weeks or in some localities even a day. The result is a sacrifice of human comfort, health and even of human life that is none the less formidable and real because it is unappreciated even by the victims themselves. The average layman's idea of hygiene is ordinarily that it is a matter that concerns diet, water-supply, drainage, etc., and the subject of clothing is one of the very last that occurs to him under this head. The relative importance attributed to these other matters by sanitarians encourages this error, and it may be asked whether, as physicians, we are not guilty of forgetting or condoning some of the commoner sins against good health in this regard; our familiarity with them has led to their neglect. We change our summer and winter costumes, for example, according to the calendar or our individual whims and feelings, and the result is often a crop of lung and bronchial affections and the aggravation of those already existing. According to RUBNER, the most recent writer who has treated the subject systematically, the average man is, as a rule, too warmly clothed in summer, and this, even with good ventilation, is an evil that should be avoided, and tends to increased perspiration and abnormal activity of the skin, which in many ways may lead to evil consequences. With ill ventilated clothing confining the perspiration and its excretions, we have a condition that interprets itself, often to our unaided senses, as hardly more compatible in principle with perfect sanitation than is an undrained cellar sending its exhalations into the living rooms above. . . . The question of winter clothing is, according to RUBNER, a simple one, the chief demand is for sufficient warmth; the excretory function of the skin is not so actively in evidence and the difference of external and bodily temperature in itself is sufficient to effect or materially aid in such ventilation as is required. The external conditions themselves more directly indicate the needs than is the case in summer, and errors are less likely to be made. It is in the variable climates of our Northern States that the hygiene of clothing needs most particular attention, and more especially in the changeable weather of the transitions from winter to summer and summer to winter. In the tropics one readily learns how to adapt himself to his surroundings, and as a rule the white race in those regions does not attempt occupations that are unsuited to his conventional costume, at least, for any length of time. In the arctic regions also, the clothing is rationally adapted to the climate, and the freedom from colds and lung disease experienced there is not altogether due to the absence of germs. It is in the middle latitudes, in temperate regions, with their wide ranges of temperature and changing seasons, that the choice of clothing becomes a serious sanitary problem too often neglected, but none the less important and worthy the earnest attention of the medical profession. The public is at present left too largely to its own devices as regards this matter, and while the result is not altogether as bad as it might be, it is certainly not an ideal one in a sanitary point of view. JAMA. 1898;30:1179-1180

Tatarunis, Paula

doi: 10.1001/jama.279.20.1590pmid: N/A

Splenic translations and variations (after Baudelaire) I am like the king of a rainy country, rich, but impotent, young and nevertheless ancient, who, contemptuous of his brown-nosing tutors, bores himself with his dogs and his other beasts. Nothing amuses him, neither gamebird nor falcon, not even the subjects dying beneath his balcony. The poet laureate's most grotesque ditty doesn't animate the features of this cruel invalid. His fleur-de-lised bed has become his tomb, and even the courtesans, to whom every prince is fair, can no longer find lingerie exotic enough to pull a leer from this young skeleton. The wise man who fashioned him from gold never could refine out all the impurities, and not even an old-fashioned Roman blood bath, the sort about which all potentates, in their dotage, reminisce, could rewarm that dazed cadaver in whom, instead of blood, the green water of Lethe flows. I'm like the god with features bright as gold (well-paid, powerless, infantile and old) who scorns his white-coat colleagues' obsequies, preferring to consort with poetries. Nothing amuses him, not gout or flu, not wards of patients requiring a Code Blue. The wildest case report, replete with gore and exotic bacteria: quel bore. His diploma'ed office has become a tomb, Cartoon nurses couldn't pierce his gloom with white starched bosoms, adulating sighs, and nylon skirts ascending sleek, white thighs. Mentors plucked him squalling from pre-med. He should have stuck with English Lit instead. No brilliant diagnosis or great case can animate his masked and stony face— Leptospirosis cannot wake the dead. (He quaffs from River Lethe, takes to bed.)

doi: 10.1001/jama.279.20.1593pmid: N/A

Lipid Lowering for Primary Prevention of Heart Disease Optimal pharmacologic strategiesArticle for preventing coronary heart disease continue to evolve rapidly, as illustrated by AFCAPS/TexCAPS. This randomized controlled trial demonstrates that lipid-lowering therapy reduces acute major coronary events in low-risk patients with average to mildly elevated total and low-density lipoprotein cholesterol levels. See related commentary Article Changing Pattern of Prenatal Care Utilization Despite changes in the organization and delivery of medical care, 2 traditional indices find that prenatal care utilization has remained relatively stable. However, 2 new indices, based on American College of Obstetricians and Gynecologists' recommendations, include a more-than-recommended-care category. Applying these measures to US births between 1981 and 1995, Dr Kogan and colleagues foundArticle an increase in prenatal care utilization, especially intensive use. See related editorial Article Outpatient Treatment of Croup Dr Klassen and colleagues studied which of 3 glucocorticoid regimens was most effective in children aged 3 months to 5 years with mild-to-moderate croup. In this randomized controlled trial, they found no difference in change in croup score among oral dexamethasone, nebulized budesonide, or oral dexamethasone with nebulized budesonide. They suggest that oral dexamethasone alone is the preferred regimen because it is less expensive and easier to administer. See Article Smoke Detectors Save Lives—Even Among Vulnerable Populations People are less likely to die in fires if their residences have working smoke detectors. However, these devices have been presumed to be less effective for people who are too young, too incapacitated, or too intoxicated to respond appropriately to the alarm. Dr Marshall and colleagues found the risk of death in a residential fire is reduced even among these groups and show that smoke detectors are most effective when a rescuer is available to assist vulnerable people. See Article Do Patients Use Performance Reports? Clinical performance and outcome reports cards are popular among health care managers and public policy experts, but patients seem to pay scant attention. Drs Schneider and Epstein found that in 1996 in Pennsylvania, a state that issues comparative reports on mortality for coronary artery bypass grafts, just 12% of patients undergoing the procedure even knew of the existence of such information before surgery. And fewer than 1% knew how their surgeon and hospital ranked and said it affected their selection process. See Article A 40-Year-Old Woman Considering Contraception Unwanted pregnancy is a common concern among women aged 40 to 45 years. The patient in this Clinical Crossroads, Mrs B, has had 3 healthy children and is faced with deciding the best way to prevent future pregnancies. Dr Peterson discusses preventing unwanted pregnancy and patients' options for contraception. See Article The Cover "Undulating hills of an almost tropical green and great, puffy clouds sailing across a blue sky . . ." Hayley Lever, Midday in the Harbor, c 1917, American. See Article Medical News & Perspectives Will "cosmeceuticals" keep baby boomers blooming? The safety and efficacy of cosmetics said to have druglike effects—but unregulated by the FDA—concern dermatologists. See Article Contempo 1998 Critically ill patients at risk—a systematic review of 10 years of studies on risk factors for ICU-acquired pneumonia. See Article A Piece of My Mind "I think the decline in gift giving by patients results from a feeling of distance from their physicians, which paradoxically has been bred by familiarity." From "The Ungifted Physician." See Article JAMA Patient Page This week's topic: prenatal care. See Article

Southgate, M. Therese

doi: 10.1001/jama.279.20.1594pmid: N/A

When the 82-year-old Australian-born artist Hayley Lever (1876-1958) died at his Mount Vernon (NY) home, the news for most was not the fact of his death, but that he had still been alive; once enormously popular and critically acclaimed, Hayley Lever had all but disappeared from public view more than two decades earlier. But the biggest surprise was that, for all those years, Hayley Lever had been painting. His former dealers especially were confounded by the cache of unsold and largely unseen paintings in his Mount Vernon barn. On the other hand, such astonishment was not entirely warranted. To Lever painting and living were nearly synonymous actions: to paint was to live, to live was to paint. When, in his last years, his right hand became crippled, he learned to paint with the left. And when, in the hospital during his final illness, painting materials were not readily available, he improvised canvases from window shades and the cardboard taken from shirt boxes. Born in Adelaide, South Australia, Lever had his early education there. Subsidized by his well-to-do tanner grandfather, Lever studied painting in Paris and London, settling finally in the artists' colony of St Ives in Cornwall in the mid 1890s. It was here, along the Devon and Cornwall coasts, that Lever developed his familiar and enduring motifs: harbors, sandy beaches, wind-tossed boats. It was here also that Lever became inspired by the work of Cézanne, but even more so by van Gogh's high-key color. The remainder of Lever's career bears examples of his experiments with color. In 1911, at the urging of the Canadian expatriate painter Ernest Lawson (JAMA cover, April 17, 1991), Lever emigrated to the United States, where he was a near overnight success. A lifelong friend of Lawson, Lever also was associated with other members of "The Eight," including Robert Henri, John Sloan, William Glackens, as well as George Bellows. Like Bellows, Lever never affiliated formally with the group, preferring instead the self-chosen role of "eclectic." Though he would spend the remaining 47 years of his painting career in the United States, dividing his time between Gloucester, Mass, whose coast reminded him of Cornwall, and New York City, where there were teaching and exhibiting opportunities, Lever never abandoned his Cornwall and St Ives motifs. True to his belief that "art is the re-creation of mood in line, form and color," Lever also painted in all seasons and all weathers and at all times of the day and night: summer, winter, snow, wind, tide in, tide out, sunrise, sunset, moonlight, midday. The only requirement was that, even at midday, there be motion: boats pulling at anchor, smoke spiraling from domestic chimneys, steam dragging behind a locomotive, clouds scudding across a sky. Human forms figure little, but even in their miniature state they walk, strain into the wind, trim a sail, row, haul up fish. Many of these features can be seen in Midday in the Harbor (cover ), which Lever painted in 1917 when he was at his fullest maturity. The high-color key prompts a recollection of one critic's description of Lawson's "palette of crushed jewels," applicable here as well. The loose brush work, especially the agitated water strokes, recall van Gogh. At the left, midground, is a sandy beach, for which St Ives is noted, and just above it is the thin line of a train on a trestle, always a Lever favorite (JAMA cover, January 9, 1981). Nestled between the hill and the beach is a pastel confection of houses, each with a straight-up squiggle of smoke. Undulating hills of an almost tropical green and great, puffy clouds sailing across a blue sky complete the canvas. The time is midday, the shadowless time of the noonday devil. Fishermen have returned with their catch of pilchard; dinner is being prepared. Lever catches a lifetime in a moment, yet, as was commonly the case, one that took him months of patient observation and experimentation to capture. Though he was the winner of many important prizes and awards, after 1931 Lever was seldom seen or heard from. Various reasons are given, among them his almost whimsical changing of galleries and dealers and certain difficulties of temperament. His work is in numerous important museums, and even at one time hung in the White House, when he painted the official portrait of the presidential yacht Mayflower for Calvin Coolidge. Many critics consider Lever more charming than original, yet the cumulative effect of more than 50 years of work is substantial. His greatest influence lay perhaps not in each individual work considered in itself, though each is pleasant, but in what he was able to pass on to the generation of students who studied with him at the Art Students League from 1919 to 1931. Still, his passion was for painting, for putting crushed jewels on canvas, and that he lived to the end, long after he apparently thought people cared. Hayley Lever(1876-1958),Midday in the Harbor, c 1917, American. Oil on canvas. 127×125 cm. Courtesy of The Saint Louis Art Museum, St Louis, Mo (http://www.slam.org); Eliza McMillan Fund.

Lamberg, Lynne

doi: 10.1001/jama.279.20.1595pmid: 9613893

COSMETICS alleged to achieve druglike effects, such as the repair of sun damage and reversal of aging, add a new wrinkle to skin care, according to presentations at the annual meeting of the American Academy of Dermatology (AAD) in Orlando, Fla, in March, and interviews with government and industry experts. Debate continues on how well these products work, whether substances that behave like drugs should be marketed as cosmetics, and whether they are safe for long-term use. These new cosmetics have been dubbed "cosmeceuticals," a term the Food and Drug Administration (FDA) does not recognize, John Bailey, PhD, director of the FDA's Office of Cosmetics and Colors, said in an interview. Cosmetics are defined by law as products not intended to affect the body's structure or functions, and drugs are defined as products that do so. While several dermatologists noted in their presentations at the AAD meeting that even water affects the skin's structure and function, the legal distinction between a cosmetic and a drug hinges not on the ingredients in a product but on the claims made for it. A product said to make skin look younger is a cosmetic, Bailey said, while the identical product, if alleged to reverse aging, would be regulated as a drug. Manufacturers of cosmetics, unlike those of drugs, are not required to demonstrate safety and efficacy, or to obtain premarket approval. A key concern to regulators, Bailey said, is whether the effects of a product are temporary or sustained, subtle or more profound. Dividing lines, he acknowledged, often are not clear. The so-called treatment cosmetics fall into this gray area. Following are some of the most frequently encountered. Hydroxy Acid Products These include cleansers, moisturizers, toners, masks, age-spot removers, and other preparations, and exemplify the issues raised above. Hydroxy acids are botanical substances that induce mild inflammation and accelerate exfoliation with little or no burning or stinging, said Paul Lazar, MD, emeritus clinical professor of dermatology at Northwestern University Medical School, Chicago, Ill. "A little inflammation isn't bad. It improves skin coloring and evens skin tone," said Lazar, who served for many years as director of the American Medical Association's Committee on Cosmetics and Cutaneous Health. "A little edema," he noted, "puffs out fine wrinkles." But concerns remain, he said, about whether chronic low-grade irritation has adverse lasting effects, such as increasing blood vessel dilation, whether the acids harm the skin's barrier functions, and how much they increase sun sensitivity. The most widely used of these chemicals are the alpha-hydroxy acids (AHAs). Beta-hydroxy acid, better known as salicylic acid, long a part of the dermatologist's acne-treatment armamentarium, is a newer addition to cosmetic products, as are combination-hydroxy acids and poly-hydroxy acids. The concentration of hydroxy acids in a product is directly related to its potential to cause peeling and irritation, said Zoe Draelos, MD, clinical associate professor of dermatology at Bowman Gray School of Medicine, Winston-Salem, NC, and chair of an AAD symposium on innovations in cosmetic dermatology. But concentration is not the only factor, she said, as preparations can be changed by buffering or through neutralization. Low concentrations, such as 1% AHAs, have been shown to alter the pH of the outer 3 layers of the stratum corneum, she said, while the higher concentrations available in some cosmetic products, such as 10% AHAs, have been shown to affect the pH of the stratum corneum 10 to 20 layers deep. Application of a glycolic acid preparation to the skin, she said, has been reported to yield a 2.4% concentration in the stratum corneum, an 11.6% concentration in the epidermis, and an 8.6% concentration in the dermis. "This degree of biological activity," she said, "does not fit with the current definition of cosmetics" (Skin Aging. 1998;6:45-47). The safety of glycolic acid and other AHA ingredients has been investigated by the Cosmetic Ingredient Review Board, an independent panel of physicians and other scientists with no financial ties to the cosmetic industry, for the Cosmetic, Toiletry, and Fragrance Association (CTFA), the industry's trade organization in Washington, DC. The review board concluded that AHAs were safe for use by consumers at a concentration less than 10% and at a pH of 3.5 or greater, and also for brief, discontinuous use in salons when applied by trained professionals in a concentration no greater than 30% and at a pH of no less than 3.0, followed by thorough rinsing of the skin. The reviewers did not examine the medical uses of AHAs at higher concentrations. The review board also found that use of AHAs increased sun sensitivity by 13% overall but in some persons by as much as 50%, a finding that raises concern about accelerated photoaging and elevated risk of skin cancer. The reviewers, said Gerald McEwen, PhD, CTFA vice president for science, concluded that formulating some products differently—adding a sunscreen with a sun protection factor of 2, for example—could eliminate the added sun sensitivity. They also recommended that people who use these preparations be advised to use daily sun protection, including sunscreens and protective clothing (Int J Toxicol. In press). The FDA, according to Bailey, "is not as convinced as the industry that the problem can be solved this easily." The FDA has referred AHAs to the National Toxicology Program for a study of phototoxicity, a process that will take several years. The same concerns about possible long-term effects apply to beta-hydroxy and other hydroxy acid products. In the meantime, Bailey said, the FDA may provide guidelines to the industry or regulations for safe use but has not yet made a decision on this matter. Along with hydroxy acids, other new cosmetic ingredients alleged to provide therapeutic benefits include the following. Vitamins C and E Ascorbic acid (vitamin C) and vitamin E function as antioxidants when consumed orally. Some manufacturers have added them to moisturizers and other products, saying they serve as scavengers of sunlight-induced free radicals even when applied topically. "This is a bit of a jump," cautioned Bailey. Whether vitamins C and E serve as active ingredients or simply as marketing ingredients, Bailey said, is not yet clear. "Vitamins may not cause any harm when used topically," he noted, "but their benefit, if any, is not well established." Botanical Additives These include such substances as extracts of aloe vera and green tea. While so-called natural ingredients have high consumer appeal and are promoted as having low potential for adverse reactions, they also vary considerably from batch to batch, by site of origin, and in manner of processing. Few safety data exist for most of these substances. High on the FDA's list of current concerns is wild yam extract, purported to have estrogenic activity and, when applied topically, to increase skin thickness and decrease fine wrinkling, much as topical estrogens are said to do. According to McEwen, the Cosmetic Ingredient Review Board is embarking on a study of wild yam extract. Retinol (Vitamin A Alcohol) This substance, added to moisturizers, serves as a humectant, attracting water to plump up the epidermis. Topical retinol also is alleged to convert in the skin to retinoic acid, a biologically active agent that shrinks sebaceous glands and unclogs follicles, and is used to treat acne, fine wrinkling, and mottled hyperpigmentation. If used regularly, cosmetic retinol products may help prevent actinic keratoses and other age-related skin damage, said Nia Terezakis, MD, clinical professor of dermatology, Tulane University School of Medicine, New Orleans, La, at the AAD symposium on innovations in cosmetic dermatology. But prescription retinoic acid (tretinoin), she said, is more effective. Retinoids rebuild the skin's collagen infrastructure, Terezakis said, and thus may provide improvements that persist after they are discontinued. This effect contrasts with that of the hydroxy acids, which, she said, benefit skin only as long as they are used. Serial photographs of some of her patients who have used topical retinoids for 5 to 10 years, she said, suggest that the benefit may be cumulative. The appearance of skin in most persons would be improved, Terezakis asserted, if they were to use retinoids consistently from their teen years onward. $30 Billion Annually Americans spend $30 billion on cosmetics annually. The average American adult, Bailey said, uses 10 to 12 cosmetic products daily, including soaps. Some 85 manufacturers of cosmetics staffed commercial exhibits at the AAD meeting, deluging dermatologists with samples and literature on product formulation and efficacy. Some exhibitors wore white coats, promoting their products by linking them with familiar, positive medical imagery. Exhibitors included private-label brands that some dermatologists, and others, such as facial plastic surgeons, dispense in their offices, with their own name on the package. Lazar, who heads the AAD's ethics committee, said AAD guidelines require dermatologists who dispense cosmetics in their offices to tell patients if they own stock in the company that makes the products they are selling, not to charge inflated prices, and, if products are prescription items, to give patients copies of the prescriptions so that they may fill them elsewhere if desired. Given the widespread use of all types of cosmetics, adverse reactions are few. "As now formulated and when used according to directions," Bailey said, "these products are by and large very safe." He termed the likelihood of an acute serious reaction"very remote." But most studies of cosmetics, he stressed, have only short-term safety end points. More than 5000 ingredients are used in cosmetics, and for most of them, no long-term safety data exist, alone or in combination. Physicians will find a list of cosmetics associated with adverse reactions on the FDA Web page on the Internet at http://www.fda.gov and may report adverse reactions to their local FDA office, listed in the blue pages of their local phone directory. If there is a need for follow-up, Bailey said, it will be at the local level. Recent budget reductions have cut the FDA's cosmetics program about 50%. Consequently, research to find or anticipate problems will suffer, Bailey said, asserting that his office "is working hard to preserve consumer safety and public health aspects." Skin treatment products, Terezakis said in an interview, already have changed the way women use cosmetics. "Their skin looks so good," she asserted, "that they don't need to hide it." Changes in recreational activities also favor a more natural look, she said, adding, "Women can't go into an exercise class wearing lots of cosmetics."

Phillips, Pat

doi: 10.1001/jama.279.20.1596-JMN0527-2-1pmid: N/A

A RESTRICTIVE blood transfusion strategy significantly reduces 30-day all-cause mortality in critically ill patients compared with a liberal blood transfusion strategy, according to new data from the first prospective, randomized trial to examine the use of both strategies in intensive care units. The multicenter Canadian trial known as TRICC, for Transfusion Requirements in Critical Care, found that mortality was 24% in the liberal transfusion group compared with 18% in the restrictive transfusion group, an absolute difference of 6%. In the liberal group, 101 patients died, and in the restrictive group, 77 patients died. The trial was conducted in 25 critical care units throughout Canada, with 420 patients randomized to the liberal transfusion group and 428 patients allocated to the restrictive group. "That means, on average, 1 life was saved for every 17 patients transfused with the restrictive strategy," said Paul C. Hebert, MD, principal investigator of the trial and associate professor of medicine and epidemiology at the University of Ottawa in Ontario. Hebert said 52% fewer transfusions were given in the restrictive group compared with the liberal group. "Transfusion was avoided in 33% of the patients in the restrictive group," he emphasized. The bottom line is "less transfusion is better than more transfusion," he said, noting that "no patient in the trial ever did better when transfused more." Hebert made the first presentation of the study findings in March at the 18th International Symposium on Intensive Care and Emergency Medicine, held in Brussels, Belgium. The meeting drew more than 3000 intensive care physicians from throughout Europe and North America. A full analysis of the trial, including subgroup analysis, is being completed. Immediate Practice Change "These data are sufficiently compelling that we will have to revise our transfusion strategy," said symposium chair Jean-Louis Vincent, MD, clinical director of the department of intensive care at Erasme Hospital, Free University of Brussels, in Belgium. "We will decrease the amount of blood being transfused in our critically ill patients, and we are planning to change the practice in our hospital immediately," he said. Vincent said, "This is the first time we have had a prospective evaluation of blood transfusion and a well-conducted and scientific study." He noted that some articles in the literature have proposed that transfusion may have deleterious effects, but it has been difficult to separate the effects of the severity of the disease process and the amount of the transfusion. Enrollment in the Canadian study, funded by the Medical Research Council of Canada, began in 1994 and was completed in 1997. During this period, 6285 patients in 25 critical care units were screened. Of those who met the criteria and gave informed consent, 838 were randomized into 2 groups with comparable patient characteristics. The patients' average age was 58 years, with slightly more men than women in both groups. The Acute Physiology and Chronic Health Evaluation (APACHE) II score at baseline was about 21. The length of hospital stay was 35 days, and the stay in the intensive care unit was 11 days in both groups. The hemoglobin levels of patients randomized to the restrictive arm of the trial were maintained at between 70 g/L and 90 g/L, with a transfusion trigger at 70 g/L. Hemoglobin levels of patients allocated to the liberal transfusion strategy were maintained at between 100 g/L and 120 g/L, with a transfusion trigger at 100 g/L. Physicians participating in the trial used allogeneic red blood cell transfusion and were asked to transfuse red blood cells 1 unit at a time and to measure hemoglobin concentrations after administration of each unit. "We managed to significantly reduce exposure to blood in the patients without harm," Hebert said. "The restrictive strategy is superior to the liberal strategy." Based on the study findings to date, Hebert's recommendation to critical care physicians is "consider transfusing less." He advised adopting a transfusion policy with a trigger at 70 g/L and maintaining patients who are seriously ill at hemoglobin levels between 70 g/L and 90 g/L. However, he stopped short of recommending this strategy for the subgoup of patients with ischemic heart disease. Red Cells in ICUs In a conference round table report entitled "Tissue Oxygenation in Acute Medicine," William Sibbald, MD, assistant dean, academic network and clinical evaluations, at the University of Western Ontario, London, Ontario, raised a number of issues about red blood cell transfusion in intensive care departments. "We're concerned about the effects of storage on the efficacy of blood," Sibbald said. "We're concerned that the longer blood has been stored, the less efficacious it is." He suggested that free hemoglobin in stored blood may aggravate the sepsis syndrome and said, "We are aware there is free hemoglobin in old blood that we transfuse into our patients." He also suggested that there may be a problem with leukocytes in stored blood, which may aggravate an inflammatory response syndrome. Sibbald questioned the safety profile of stored blood and challenged the medical community to determine whether the red blood cells in stored blood effectively deliver oxygen to tissue. Hebert hypothesized that one of the major determinants of outcome in transfusion is the shelf life of the blood stored in hospitals. He pointed out that many countries, including Canada and the United States, originally established policies on the shelf life of blood based on cell survival studies that "have nothing to do with whether the blood product is efficacious." He said the efficacy of the product can be based only on oxygen delivery. Currently, the shelf life of blood in Canadian hospitals is about 35 days, said Hebert. From a health policy perspective, a change in the shelf life of blood would raise overwhelming issues and a radical change in how the product is used, he said. Restricting the shelf life of blood to 15 days would challenge the Canadian, US, and European blood systems, leading to major changes in collecting, processing, and delivering blood. "For my critically ill patients, when a transfusion is required I want units of fresh blood," Hebert maintained. In the TRICC study, data were collected on the age of every unit of blood transfused. Hebert is now planning to do a separate analysis comparing the effect of old blood vs new blood, a topic he considers a "hot new issue."

Lamberg, Lynne;Goldsmith, Marsha F.

doi: 10.1001/jama.279.20.1597-JMN0527-3-1pmid: N/A

BOSTON, Mass, with many of the best and best-known hospitals in the United States, has taken steps to make sure its citizens become aware of them early. At a special event in March called Children and Hospitals Day, the Children's Museum of Boston and a local affiliate of the Association for the Care of Children's Health (based in Mt Royal, NJ), aided by dozens of volunteer local health care professionals, gave young visitors and their parents a chance to learn about medical equipment and procedures and general health practices. View LargeDownload Arin Greene, MD, a surgical resident at Beth Israel Deaconess Medical Center in Boston, performs a careful check-up at the Teddy Bear Clinic at the museum event. Children saw x-rays of bears who had "swallowed" Lego pieces and learned from the x-rays that all bears have their hearts in the right place. (Photo credit: Lynne Lamberg) Even the smallest could watch the favorite stuffed animals that accompanied them—or ones "adopted" for the day from a museum menagerie—get "check-ups" from cooperative physicians in the Teddy Bear Clinic, while their more sanguine older siblings used unique ingredients to make "blood soup," thereby learning about the composition of that vital substance. View LargeDownload Ronald Minter, MD, director of pediatric anesthesiology at the Massachusetts Eye and Ear Infirmary (MEEI), Boston, demonstrates operating room procedures at the Children's Museum of Boston on Children and Hospitals Day. Assisting him is Milagros Lopez-Ramirez, MEEI's director of Child Life. At MEEI, parents are invited to be in the operating room while their child falls asleep and are encouraged to be present when the child wakes up. (Photo credit: Lynne Lamberg) Musical productions entitled "Let's Get Moving" (on fitness and well-being) and "Blue Plate Special" (featuring food and healthy eating) entertained museumgoers, while wannabe physicians could try on caps, gloves, masks, and shoe covers—without having to scrub! Other events included making casts for fingers, constructing collages of such materials as Band-Aids, cotton balls, and tongue depressors, learning about good oral hygiene, and exploring an ambulance. An annual spring event for the past 10 years, Children and Hospitals Day is designed, according to Darlene Salvatore, a Child Life specialist at Children's Hospital in Boston, "to help children learn about hospitals in a nonthreatening way," as well as to promote good attitudes about health and nutrition. Salvatore was cocoordinator of this year's event with Milagros Lopez-Ramirez, director of Child Life at Massachusetts Eye and Ear Infirmary. While the museum venue may be unique, Salvatore said, the event is one of many celebrations of an annual Children and Health Care Week sponsored throughout the United States by the Association for the Care of Children's Health. The association is an international, multidisciplinary group of parents and professionals in diverse fields "promoting family-centered care, policies, and practices that are responsive to the unique developmental and psychosocial needs of children and youth and their families." In other areas of the country where, as Salvatore put it, "physicians are beginning to appreciate the importance of children's psychosocial understanding of going to the hospital," recognition has taken various forms. Usually, she said, hospitals hold some sort of festive event within the institution, such as the Pancake Breakfast and Teddy Bear Clinic featured at St Francis Hospital Medical Center in Hartford, Conn, or a tea party or the like. What is exciting about the Boston approach, she added, is to have so many dedicated people working together entirely on a volunteer basis to try to make going to the hospital a far less frightening experience than they themselves may remember.

Voelker, Rebecca

doi: 10.1001/jama.279.20.1599pmid: N/A

A new "risk index" could help physicians predict which adult patients with asthma will have attacks during the next year. In a study presented last month at the American Lung Association/American Thoracic Society International Conference in Chicago, Ill, researchers from The Johns Hopkins University School of Medicine and School of Public Health offered several predictors of poor outcomes. The most accurate predictors, they reported, are visiting the emergency department in the past 2 years and canceling activities in the past month. Other important predictors of poor outcomes include nonwhite race, asthma symptoms experienced between attacks, and using more than 8 puffs a day of an inhaled beta agonist. The predictors were derived from surveys of 4742 managed care plan members treated for moderate to severe asthma. From the surveys, the researchers developed 13 questions physicians can use to identify patients who are at risk for several types of poor outcomes, including hospital use, emergency department use, and lost workdays. "We need to confirm the applicability of our findings, but it may be possible to use these models to help doctors target high-risk patients for more education about such things as medication compliance," said postdoctoral fellow Robin Yurk, MD.

Voelker, Rebecca

doi: 10.1001/jama.279.20.1599-JQU80002-3-1pmid: N/A

Researchers at Vanderbilt University Medical Center in Nashville, Tenn, are studying whether a new nasal spray may be an effective method of vaccinating children against influenza. In a study of 19 children, researchers obtained nasal washes from those who received the vaccine or a placebo. The majority who received the vaccine had developed IgA antibodies to 3 strains of influenza virus, while most of those who received the placebo did not develop antibodies to the virus strains. "The nasal spray vaccine appears to stimulate the production of local antibodies in the nose, where influenza enters the body," said Thomas Boyce, MD, fellow in pediatric infectious diseases. "We hope these antibodies will stop the virus in its tracks, before it has a chance to spread to the rest of the respiratory system." Boyce presented the study earlier this month in New Orleans, La, at the annual meeting of the Society for Pediatric Research.

Voelker, Rebecca

doi: 10.1001/jama.279.20.1599-JQU80002-5-1pmid: N/A

American women are shelving their high-heeled shoes in favor of wearing healthier, low-heeled ones to work, according to a new survey. Results from the poll of 500 women showed that only one fourth wear shoes with a heel higher than 1 inch to work. Fewer than 3% of the women polled said they wear shoes with heels higher than 214 inches. Younger women are leading the way. "Only 16% of women 20 to 30 years old indicated they wore heels higher than 1 inch to work, while 28% of women 40 to 50 years old said they did," said Cherise Dyal, MD, a member of the American Orthopedic Foot and Ankle Society (AOFAS) Council on Women's Footwear. She presented the AOFAS-sponsored survey at the society's recent meeting in New Orleans. A 1990 survey showed that 37% of women polled wore shoes with a heel higher than 1 inch to work.