The filmless radiology reading room: a survey of established picture archiving and communication system sites

The purpose of this study was to survey radiologists experienced in soft-copy diagnosis using computer workstations about their current reading room environment, their impressions of the efficacy of their reading room design, and their recommendations based on their experience for improvement of the soft-copy reading environment. Surveys were obtained from radiologists at seven sites representing three major picture archiving and communication system (PACS) vendors throughout the world that have had extensive experience with soft-copy interpretation of radiology studies. The radiologists filled out a detailed survey, which was designed to assess their current reading room environment and to provide them with the opportunity to make suggestions about improvement of the PACS reading rooms. The survey data were entered into a database and results were correlated with multiple parameters, including experience with PACS, types of modalities interpreted on the system, and number of years of experience in radiology. The factors judged to be most important in promoting radiologist productivity were room lighting, monitor number, and monitor brightness. Almost all of the radiologists indicated that their lighting source was from overhead rather than indirect or portable light sources. Approximately half indicated they had the capability of dimming the brightness of the overhead lighting. Most radiologists indicated that they were able to adjust room temperature but that they did not have individual temperature controls at their workstations. The radiologists indicated that the most troublesome sources of noise included background noise, other radiologists, and clinicians much more than noise from computer monitors, technologists, or patients. Most radiologists did not have chairs that could recline or arm rests. Most did have wheels and the capability to swivel, both of which were judged important. The majority of chairs also had lumbar support, which was also seen to be important. Radiologists commonly adjusted room lighting and their reading chair, but rarely adjusted room temperature or monitor brightness. The median number of hours spent at the workstation before taken a "break" was 1.5. Common recommendations to improve the room layout included compartmentalization of the reading room and availability of the hospital/radiology information system at each workstation. The survey data suggest several areas of potential improvement based on radiologists' experience. Optimization of soft-copy reading room design is likely to result in decreased fatigue and increased productivity.

ENVIRONMENTAL AUDITING: An Integrated Approach to Reservoir Management: The Williston Reservoir Case Study

/ The management of industrial reservoirs for hydroelectric energy can cause severe impacts to surrounding communities. This study examines the generation of dust along the northern foreshore zones of Williston Reservoir in northern British Columbia. The dust is generated in the spring when the reservoir levels are low and impacts a relocated First Nations' village (Tsay Keh) at the north end of the reservoir. Data were gathered to provide an overview of the physical conditions that contribute to the dust problem, including a social survey, soil analysis, and vegetation inventory. The study provides a scoping method to assess a large-scale and complex problem with respect to dust management along a large reservoir. Methods for dust control include short- and long-term solutions that integrate the use of native vegetation along the foreshore zones of the reservoir.

Analysis of genetic and phenotypic heterogeneity in juvenile polyposis

BACKGROUND

Juvenile polyposis syndrome (JPS) is characterised by gastrointestinal (GI) hamartomatous polyposis and an increased risk of GI malignancy. Juvenile polyps also occur in the Cowden (CS), Bannayan-Ruvalcaba-Riley (BRRS) and Gorlin (GS) syndromes. Diagnosing JPS can be problematic because it relies on exclusion of CS, BRRS, and GS. Germline mutations in the PTCH, PTEN and DPC4 (SMAD4) genes can cause GS, CS/BRRS, and JPS, respectively.

AIMS

To examine the contribution of mutations in PTCH, PTEN, and DPC4 (SMAD4) to JPS.

METHODS

Forty seven individuals from 15 families and nine apparently sporadic cases with JPS were screened for germline mutations in DPC4, PTEN, and PTCH.

RESULTS

No patient had a mutation in PTEN or PTCH. Five different germline mutations were detected in DPC4; three of these were deletions, one a single base substitution creating a stop codon, and one a missense change. None of these patients had distinguishing clinical features.

CONCLUSIONS

Mutations in PTEN and PTCH are unlikely to cause juvenile polyposis in the absence of clinical features indicative of CS, BRRS, or GS. A proportion of JPS patients harbour DPC4 mutations (21% in this study) but there remains uncharacterized genetic heterogeneity in JPS.

Mucin core protein expression in colorectal cancers with high levels of microsatellite instability indicates a novel pathway of morphogenesis

Particular mucinous phenotypes have been associated with serrated epithelial polyps of the colon. These polyps also show a high frequency of DNA instability. The aim of this study was to examine the expression of mucins in colorectal cancers that arise through the suppressor and mutator pathways. The immunohistochemical distribution of the human apomucins MUC1, MUC2, MUC4, and MUC5AC was determined in 93 sporadic colorectal cancers classified previously (J. R. Jass et al., J. Clin. Pathol., 52: 455-460, 1999) according to levels of DNA microsatellite instability (MSI) as 22 MSI-high (MSI-H), 24 MSI-low (MSI-L), and 47 MS stable (MSS). MUC2 expression was observed in 19 (86%) MSI-H, 10 (42%) MSI-L, and 15 (32%) MSS cancers (P = 0.0001); and MUC5AC expression was observed in 17 (77%) MSI-H, 8 (33%) MSI-L, and 13 (28%) MSS cancers (P = 0.0003). There was no association between MUC1 or MUC4 expression and MSI status. The mucinous phenotype described in serrated polyps (MUC2+/MUC5AC+) was seen in 15 (68%) of 22 MSI-H and only 10 (14%) of 71 MSI-L/MSS cancers (P < 0.0001). Increased expression of the secretory mucins MUC2 and MUC5AC was observed in sporadic MSI-H cancers. Identical mucin changes and DNA MSI occurred in serrated polyps of the colorectum, which suggests that these lesions may represent precursors of MSI-H cancers.

Artificial insemination outcomes in beef females using bovine sperm with a detectable fertility-associated antigen

In this study, semen samples from 25 bulls that had passed a breeding soundness evaluation were analyzed for the presence or absence of a 31-kDa protein, known as fertility-associated antigen (FAA), on spermatozoal membranes. Eighteen bulls had FAA on sperm (FAA-positive) and seven were devoid of FAA on sperm (FAA-negative). A single ejaculate from each bull was extended and frozen with 25 to 30 x 10(6) sperm in .5-mL straws. Crossbred replacement heifers (n = 865) were estrus-synchronized and artificially inseminated either at timed AI or 12 h after they were detected in estrus. Mature cows (n = 285) were inseminated 12 h after they were detected in estrus during a 45-d AI period. Pregnancy rates (pooled) to first AI service for females (n = 764) inseminated with FAA-positive sperm were 65.6% and were 49.7% for females (n = 386) inseminated with FAA-negative sperm (P < .005). Among the estrus-synchronized replacement heifers, pregnancy rates to synchronized AI service for heifers (n = 550) inseminated with FAA-positive sperm were 62% and were 45.7% for heifers (n = 315) inseminated with FAA-negative sperm (P < .005). These data indicate that pregnancy rates to first AI service at spontaneous and synchronized estrus are higher when using semen from bulls with detectable FAA on spermatozoal membranes compared to semen from bulls devoid of FAA on membranes. Fertility-associated antigen is an important determinant for fertility potential of sperm from bulls to be used in AI breeding programs.

Randomized trial of candesartan cilexetil in the treatment of patients with congestive heart failure and a history of intolerance to angiotensin-converting enzyme inhibitors

BACKGROUND

Many patients with congestive heart failure do not receive the benefits of angiotensin-converting enzyme (ACE) inhibitors because of intolerance. We sought to determine the tolerability of an angiotensin II receptor blocker, candesartan cilexetil, among patients considered intolerant of ACE inhibitors.

METHODS

Patients with CHF, left ventricular ejection fraction less than 35%, and history of discontinuing an ACE inhibitor because of intolerance underwent double-blind randomization in a 2:1 ratio to receive candesartan (n = 179) or a placebo (n = 91). The initial dosage of candesartan was 4 mg/d; the dosage was increased to 16 mg/d if the drug was tolerated. A history of intolerance of ACE inhibitor was attributed to cough (67% of patients), hypotension (15%), or renal dysfunction (11%).

RESULTS

The study drug was continued for 12 weeks by 82.7% of patients who received candesartan versus 86.8% of patients who received the placebo. This 4.1% greater discontinuation rate with active therapy was not significant; the 95% confidence interval ranged from 4.8% more discontinuation with placebo to 13% more with candesartan. Titration to the 16-mg target dose was possible for 69% of patients who received candesartan versus 84% of those who received the placebo. Frequencies of death and morbidity were not significantly different between the candesartan and placebo groups (death 3.4% and 3.3%, worsening heart failure 8.4% and 13.2%, myocardial infarction 2.8% and 5.5%, all-cause hospitalization 12.8% and 18.7%, and death or hospitalization for heart failure 11.7% and 14.3%).

CONCLUSIONS

Candesartan was well tolerated by this population. The effect of candesartan on major clinical end points, including death, remains to be determined.

Unpacking the 'black box' of a nurse-led stroke support service

OBJECTIVES

To describe in detail the nature of the specialist nurse interventions; to increase understanding of the principal problems facing stroke patients and their care-givers in the first year following stroke and to demonstrate how these problems may change over time; and to investigate the value of qualitative research methodologies within the context of a randomized trial.

METHODS

Specialist nurses providing support in the year following stroke were asked to maintain comprehensive written records of their involvement with all patients and care-givers participating in a randomized controlled trial. Qualitative methods were used to examine the problems faced by stroke patients and their care-givers, and the actions taken by nurses in response.

RESULTS

Specialist nurses commenced 120 records. As 19 patients died or left the area during the year-long interventions, we obtained 101 complete records. The problems encountered by stroke patients and their care-givers were numerous, diverse, complex and changed over time. Initially, practical difficulties were noted; over time, these were accompanied by growing numbers of psychological needs. The nurses responded by providing information, advice, support and monitoring using a flexible, individualized approach. The nurses also collaborated or liaised with 17 other professional groups and provided direct support to care-givers.

CONCLUSION

The need for many stroke patients and their care-givers to be professionally supported during the stages of stroke adjustment, for at least the first year and probably beyond, was emphasized by this study.

Prevalence and determinants of microalbuminuria in high-risk diabetic and nondiabetic patients in the Heart Outcomes Prevention Evaluation Study. The HOPE Study Investigators

OBJECTIVE

To describe the characteristics of diabetic and nondiabetic participants in the Heart Outcomes Prevention Evaluation (HOPE) Study who are at high risk of developing cardiovascular (CV) disease and who have microalbuminuria (MA), and to identify the key determinants of MA in these two groups.

RESEARCH DESIGN AND METHODS

Albuminuria was measured in 97% of patients enrolled in the HOPE Study as part of the MICRO-HOPE (MA, CV, and Renal Outcomes in HOPE) substudy. Baseline clinical characteristics of diabetic and nondiabetic participants with MA were recorded, and the univariate and multivariate relationship between these characteristics and the presence of MA was estimated for both groups.

RESULTS

Baseline urinary albumin determinations were available in 3,574 (97.8%) diabetic participants and 5,708 (97.0%) nondiabetic participants. MA was detected in 1,151 (32.2%) diabetic participants and 837 (14.7%) nondiabetic participants. Age, waist-to-hip ratio, diabetes, smoking, hypertension, vascular disease, and left ventricular hypertrophy were independent determinants of MA in all participants. In diabetic participants, the odds of MA increased 16% for every 10.4 years of diabetes duration, and increased 8% for every 0.9% increase in glycated hemoglobin (assuming a GHb assay with an upper limit of 6% in the nondiabetic range).

CONCLUSIONS

MA is independently associated with several risk factors for CV and renal disease in both diabetic and nondiabetic individuals at high risk for CV disease.

On the evolution of misunderstandings about evolutionary psychology

Some of the controversy surrounding evolutionary explanations of human behavior may be due to cognitive information-processing patterns that are themselves the result of evolutionary processes. Two such patterns are (1) the tendency to oversimplify information so as to reduce demand on cognitive resources and (2) our strong desire to generate predictability and stability from perceptions of the external world. For example, research on social stereotyping has found that people tend to focus automatically on simplified social-categorical information, to use such information when deciding how to behave, and to rely on such information even in the face of contradictory evidence. Similarly, an undying debate over nature vs. nurture is shaped by various data-reduction strategies that frequently oversimplify, and thus distort, the intent of the supporting arguments. This debate is also often marked by an assumption that either the nature or the nurture domain may be justifiably excluded at an explanatory level because one domain appears to operate in a sufficiently stable and predictable way for a particular argument. As a result, critiques in-veighed against evolutionary explanations of behavior often incorporate simplified--and erroneous--assumptions about either the mechanics of how evolution operates or the inevitable implications of evolution for understanding human behavior. The influences of these tendencies are applied to a discussion of the heritability of behavioral characteristics. It is suggested that the common view that Mendelian genetics can explain the heritability of complex behaviors, with a one-gene-one-trait process, is misguided. Complex behaviors are undoubtedly a product of a more complex interaction between genes and environment, ensuring that both nature and nurture must be accommodated in a yet-to-be-developed post-Mendelian model of genetic influence. As a result, current public perceptions of evolutionary explanations of behavior are handicapped by the lack of clear articulation of the relationship between inherited genes and manifest behavior.

Dietary and/or nutritional risk factors and breast carcinoma: consumer response

The author is a former state legislator and feminist activist. Having traveled extensively in Asia, she questions the comparison of U.S. statistics regarding dietary/nutritional risk factors with those from countries whose public health standards are below that of the U.S. The author also notes that only recently has the U.S. had a critical mass of women in Congress that led to the funding of the first Women's Health Initiative. Countries in Asia have few women in positions of political power to advocate for public policies regarding women's health issues, especially concerning the gathering of data regarding breast carcinoma, which is considered a culturally sensitive topic. Although soy is considered a healthy staple of the majority of Asian diets because of its phytoestrogens, there is a mixed message to American consumers because cancer, rather than heart disease, is the leading cause of death among Asian females.

p73 is up-regulated in a subset of hepatocellular carcinomas

Loss of heterozygosity (LOH) at 1p36 occurs in a number of solid tumors including hepatocellular carcinoma (HCC). Recently, a novel gene, p73, has been identified at 1p36.33. p73 is structurally and functionally related to p53 located at 17p13.1, which is a target for inactivation in HCCs. p73 produces at least two splicing variants, p73alpha and beta, and a polymorphism in exon 2 results in two alleles, GC or AT. Initially, only the AT allele and p73alpha transcripts were identified in malignant cell lines, suggesting a role for these in the malignant phenotype. The aims of this study were to determine the extent of LOH at 1p36 and 17p13.1 in HCCs from Australia and South Africa, and to identify patterns of p73 mRNA and p73 and p53 protein expression. LOH at 1p36 was found in 8 of 25 Australian and 6 of 10 South African cases. p73 mRNA expression occurred in 8 HCCs, but not in nonmalignant liver tissue. Two of these 8 HCCs had LOH of 1p36. Both alpha and beta transcripts were observed in GC/GC homozygotes and GC/AT heterozygotes. No p73 protein expression was observed by immunohistochemistry in nonmalignant liver tissue or in HCC. p53 inactivation appeared to be associated with up-regulation of p73 expression, suggesting a compensatory role for p73 in this situation. The LOH at 1p36 implies a liver-specific tumor suppressor gene is in this region. However, the up-regulation of p73 mRNA suggests p73 is not the target of this loss.

Sequence variants of DLC1 in colorectal and ovarian tumours

Loss of heterozygosity occurs frequently on the short arm of chromosome 8 in many neoplasms, including colorectal and ovarian cancer. Monochromosome transfer experiments into colorectal tumour cell lines have provided functional evidence for a tumour suppressor gene located at 8p22-23. One of the genes from this region that is expressed by our suppressed hybrids is a candidate tumour suppressor gene, DLC1 (deleted in liver cancer), which has homology to rat RhoGAP. We have delineated the structure of the DLC1 gene and used single-stranded conformation polymorphism analysis (SSCP) to look for sequence variants in 126 colorectal and 33 ovarian primary tumours and cell lines. One exonic missense mutation and three intronic insertions/deletions were identified in primary colorectal tumours, as well as many polymorphisms present in germline DNAs. The rarity of exonic missense mutations, and the absence of protein-truncating mutations, indicates that DLC1 is not the target of 8p LOH in colorectal or ovarian tumours. The delineation of the gene structure allows mutation analysis of DLC1 in other tumour types for which it remains a candidate tumour suppressor gene based on its location and homology to rhoGAP.

The forensic analysis of soil organic by FTIR

In order to elucidate the discriminating power of various soil analytical techniques, over 100 soils samples were analyzed using conventional analysis (i.e., color, percent organic and density gradient) and a novel FTIR technique. The FTIR technique involves collecting a spectrum of a soil sample that has been oxidatively pyrolysed, and therefore all organic have been degraded. This spectrum is subtracted from the spectrum of the same sample that contained the organic prior to pyrolysis. This resultant IR spectrum represents the organic portion of the sample. The use of organic components increases the discrimination in soils that are otherwise similar. We have illustrated the usefulness of this technique by selecting four soil samples, which have identical Munsel color values but can be discriminated by subtractive ETIR. We propose that the ETIR spectra of the organic portion of soil serves a useful purpose in forensic investigations.

Epigenetic aspects of cellular senescence

The limited proliferative potential of normal cells in culture has been proposed as a model for cellular aging in vivo. It is clear that cellular aging has a genetic component but epigenetic processes could also be involved. Insight gained during years of intensive study suggests cellular aging is a multi-step process and that cells possess a counting mechanism that determines the number of doublings the cells can complete. In this paper, we review evidence suggesting a role for epigenetic processes in cell senescence and discuss the possible insights that might be provided by experiments designed to induce a premature senescent like state.

Adenocarcinoma of colon differentiating as dome epithelium of gut-associated lymphoid tissue

AIMS

An early adenocarcinoma of the ascending colon was confined to a mass of gut-associated lymphoid tissue (GALT). The first description of an adenocarcinoma of colon differentiating as dome epithelium is presented.

METHODS AND RESULTS

A plaque-like carcinoma was identified opposite the ileocaecal valve in an asymptomatic 56-year-old man with a family history of colorectal cancer. Malignant epithelium was confined to a mass of GALT filling but limited to the submucosa. Characterization of the neoplasm was undertaken by means of mucin histochemistry, immunohistochemistry, electron microscopy and assessment of DNA microsatellite instability status. The malignant epithelium comprised well differentiated columnar cells with a microvillous brush border and expressing MUC1, but no goblet cells or expression of MUC2. The demonstration of focal clusters of intraepithelial B-lymphocytes supported the presence of functioning M-cells within the malignant neoplasm. The cancer was DNA microsatellite stable despite the finding of tumour infiltrating lymphocytes.

CONCLUSIONS

There is evidence for the origin of colorectal neoplasia from dome epithelium in both experimental models and microreconstruction studies of early adenomas in nonpolypotic human colorectal mucosa. It is suggested that the lymphocyte-rich subset of colorectal cancer that expresses MUC1 but not MUC2 may be differentiating as dome epithelium of gut-associated lymphoid tissue.

Heart failure: highlights from new consensus guidelines

New guidelines for managing heart failure urge physicians to identify patients likely to benefit from therapy, obtain an echocardiogram to measure the ejection fraction, and, in patients with systolic dysfunction (i.e., an ejection fraction < or = 40%), institute therapy with an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker if at all possible. Digoxin and diuretics can relieve symptoms but do not affect the mortality rate. Spironolactone in low nondiuretic doses may reduce mortality when added to baseline drug regimens. The proper role of angiotensin II receptor blocking agents has yet to be determined.

Is dipalmitoylphosphatidylcholine a substrate for convertase?

Convertase has homology with carboxylesterases, but its substrate(s) is not known. Accordingly, we determined whether dipalmitoylphosphatidylcholine (DPPC), the major phospholipid in surfactant, was a substrate for convertase. We measured [(3)H]choline release during cycling of the heavy subtype containing [(3)H]choline-labeled DPPC with convertase, phospholipases A(2), B, C, and D, liver esterase, and elastase. Cycling with liver esterase or peanut or cabbage phospholipase D produced the characteristic profile of heavy and light peaks observed on cycling with convertase. In contrast, phospholipases A(2), B, and C and yeast phospholipase D produced a broad band of radioactivity across the gradient without distinct peaks. [(3)H]choline was released when natural surfactant containing [(3)H]choline-labeled DPPC was cycled with yeast phospholipase D but not with convertase or peanut and cabbage phospholipases D. Similarly, yeast phospholipase D hydrolyzed [(3)H]choline from [(3)H]choline-labeled DPPC after incubation in vitro, whereas convertase, liver esterase, or peanut and cabbage phospholipases D did not. Thus convertase, liver esterase, and plant phospholipases D did not hydrolyze choline from DPPC either on cycling or during incubation with enzyme in vitro. In conclusion, conversion of heavy to light subtype of surfactant by convertase may require a phospholipase D type hydrolysis of phospholipids, but the substrate in this reaction is not DPPC.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

Geriatric day hospitals provide multi-disciplinary rehabilitation in an outpatient setting. Concern has been expressed that evidence for effectiveness is equivocal and that day hospital care is expensive.

OBJECTIVES

To assess the effects of medical day hospitals for elderly people.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, Sigle, Bids, and Cinahl up to January 1997, and reference lists of articles. We also searched Index Medicus and International Dissertation Abstracts up to January 1997. We contacted authors of previous studies of day hospital care.

SELECTION CRITERIA

Randomised trials comparing geriatric medical day hospitals with alternative forms of care. The participants were elderly medical patients. The outcomes were death, place of residence, dependency, global 'poor' outcome (death, institutionalisation or dependency), activities of daily (ADL) score, subjective health status, patient satisfaction, and resource use.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twelve studies were included involving 22 day hospitals and 2867 patients. Five studies compared day hospital with comprehensive elderly care, four compared day hospital with domiciliary care and three compared day hospital with no comprehensive elderly care. There were no significant differences between day hospital attendance and comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio 0.73; 95% confidence interval 0.53-1.00; P < 0.05). Dependency was measured in 11 studies using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remainder there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed reduced odds of deterioration compared with those receiving no comprehensive elderly care (0.60; 0.38-0.97; P <0.05). When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care. Nine studies comparing treatment costs indicated that day hospital attendance was a more expensive option, although only two analyses took into account long-term care costs.

REVIEWER'S CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

The treatment of neurogenic orthostatic hypotension with 3,4-DL-threo-dihydroxyphenylserine: a randomized, placebo-controlled, crossover trial

OBJECTIVE

To study the therapeutic effect and mechanism of action of 3,4-DL-threodihydroxyphenylserine (DL-DOPS) in neurogenic orthostatic hypotension.

METHODS

The blood pressure (BP) response to an orthostatic challenge on DL-DOPS was compared with that of placebo in a randomized, double-blind, placebo-controlled, crossover trial in 10 patients. The mechanism of action of DOPS was studied by measuring forearm vascular resistance and changes in supine and upright plasma DL-DOPS and norepinephrine levels. The effect of DL-DOPS on the quality of life was determined by questionnaire.

RESULTS

DL-DOPS increased the supine (p<0.001) and upright (p<0.05) systolic blood pressure (SBP) and diastolic blood pressure (DBP) (both p<0.01). The peak SBP on DL-DOPS in the supine position occurred 300 minutes after ingestion of the medication. The increase in BP was accompanied by an increase in plasma levels of norepinephrine and DL-DOPS in both the supine and upright positions after DL-DOPS ingestion (p<0.0001). There was a trend toward improvement in symptoms of orthostatic intolerance.

CONCLUSION

DL-DOPS improved features of neurogenic orthostatic hypotension in patients with central and peripheral autonomic nervous system disease. There was an increase in plasma norepinephrine. No major side effects occurred.