Reducing Intraoperative Hypothermia in Infants from the Neonatal Intensive Care Unit

Infants from the neonatal intensive care unit (NICU) undergoing surgery in the operating room (OR) are at greater risk for hypothermia during surgery than afterward due to environmental heat loss, anesthesia, and inconsistent temperature monitoring. A multidisciplinary team aimed to reduce hypothermia (<36.1 °C) for infants at a level IV NICU at the beginning of the operation (first OR temperature) or at any time during the operation (lowest OR temperature) by 25%.

Methods

The team followed preoperative, intraoperative (first, lowest, and last OR), and postoperative temperatures. It sought to reduce intraoperative hypothermia using the "Model for Improvement" by standardizing temperature monitoring, transport, and OR warming, including raising ambient OR temperatures to 74°F. Temperature monitoring was continuous, secure, and automated. The balancing metric was postoperative hyperthermia (>38 °C).

Results

Over 4 years, there were 1235 operations: 455 in the baseline and 780 in the intervention period. The percentage of infants experiencing hypothermia upon OR arrival and at any point during the operation decreased from 48.7% to 6.4% and 67.5% to 37.4%, respectively. Upon return to the NICU, the percentage of infants experiencing postoperative hypothermia decreased from 5.8% to 2.1%, while postoperative hyperthermia increased from 0.8% to 2.6%.

Conclusions

Intraoperative hypothermia is more prevalent than postoperative hypothermia. Standardizing temperature monitoring, transport, and OR warming reduces both; however, further reduction requires a better understanding of how and when risk factors contribute to hypothermia to avoid further increasing hyperthermia. Continuous, secure, and automated data collection improved temperature management by enhancing situational awareness and facilitating data analysis.

First Constraints on Heavy QCD Axions with a Liquid Argon Time Projection Chamber Using the ArgoNeuT Experiment

We present the results of a search for heavy QCD axions performed by the ArgoNeuT experiment at Fermilab. We search for heavy axions produced in the NuMI neutrino beam target and absorber decaying into dimuon pairs, which can be identified using the unique capabilities of ArgoNeuT and the MINOS near detector. This decay channel is motivated by a broad class of heavy QCD axion models that address the strong CP and axion quality problems with axion masses above the dimuon threshold. We obtain new constraints at a 95% confidence level for heavy axions in the previously unexplored mass range of 0.2-0.9 GeV, for axion decay constants around tens of TeV.

Laser tongue base mucosectomy is a useful diagnostic tool in the management of unknown primary cancers of the head and neck region

OBJECTIVE

Tongue base mucosectomy identified cancer in 78 per cent of cancers of unknown primary in a recent meta-analysis. The carbon dioxide laser is an alternative technique if there is no access to a robot. This study aimed to describe the steps for undertaking tongue base mucosectomy using the carbon dioxide laser and its diagnostic utility in cancers of unknown primary.

METHOD

This was a prospective feasibility study utilising carbon dioxide laser for tongue base mucosectomy in cancers of unknown primary. Data collected included demographic data and p16 status.

RESULTS

There were 14 cancers of unknown primary with 86 per cent p16 positivity on immunohistochemistry. Laser tongue base mucosectomy alone identified the cancer primary in 7 of 12 (58 per cent) cancers of unknown primary among p16 positive tumours and 0 of 2 (0 per cent) among p16 negative tumours. Combining bilateral tonsillectomy with laser tongue base mucosectomy resulted in identification of the primary cancer in 8 of 12 (67 per cent) p16 positive tumours.

CONCLUSION

In centres without a robot, tongue base mucosectomy using the carbon dioxide laser is a viable alternative, especially in combination with bilateral tonsillectomy in p16 positive cases.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

New Constraints on Tau-Coupled Heavy Neutral Leptons with Masses m_{N}=280-970 MeV

A search for heavy neutral leptons has been performed with the ArgoNeuT detector exposed to the NuMI neutrino beam at Fermilab. We search for the decay signature N→νμ^{+}μ^{-}, considering decays occurring both inside ArgoNeuT and in the upstream cavern. In the data, corresponding to an exposure to 1.25×10^{20}  POT, zero passing events are observed consistent with the expected background. This measurement leads to a new constraint at 90% confidence level on the mixing angle |U_{τN}|^{2} of tau-coupled Dirac heavy neutral leptons with masses m_{N}=280-970  MeV, assuming |U_{eN}|^{2}=|U_{μN}|^{2}=0.

Recommendations for photoprotection of parenteral nutrition for premature infants: An ASPEN position paper

Although crucial in improving health outcomes in the preterm infants, parenteral nutrition (PN) is not without risk, especially if handled improperly. A growing body of evidence suggests that components of PN admixtures, including lipid injectable emulsions (ILEs), are susceptible to degradation, including oxidation when exposed to light (ie, photo-oxidation), resulting in the production of reactive oxygen species. Infants, especially those born preterm, are considered more susceptible to consequences of oxidative stress than children and adults. Oxidative stress is associated with bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and intestinal failure-associated liver disease. The American Society for Parenteral and Enteral Nutrition (ASPEN) assembled a working group to provide recommendations on clinical practice surrounding photoprotection of PN.This Position Paper reviews the scientific literature on the formation of quantifiable peroxides and other degradation products when PN admixtures and ILEs are exposed to light and reports adverse clinical outcomes in premature infants exposed to PN. Recommendations for photoprotection of PN admixtures and ILEs are provided, as well as the challenges in achieving complete photoprotection with the equipment, supplies, and materials currently available in the US. ASPEN and the authors understand that the full implementation of complete photoprotection may not currently be feasible given current product availability; recommendations provided in this paper serve to represent the goal to which to strive as well as to highlight the importance of product availability to achieve these practices. This paper has been approved by the ASPEN Board of Directors.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Improved Limits on Millicharged Particles Using the ArgoNeuT Experiment at Fermilab

A search for millicharged particles, a simple extension of the standard model, has been performed with the ArgoNeuT detector exposed to the Neutrinos at the Main Injector beam at Fermilab. The ArgoNeuT liquid argon time projection chamber detector enables a search for millicharged particles through the detection of visible electron recoils. We search for an event signature with two soft hits (MeV-scale energy depositions) aligned with the upstream target. For an exposure of the detector of 1.0×10^{20} protons on target, one candidate event has been observed, compatible with the expected background. This search is sensitive to millicharged particles with charges between 10^{-3}e and 10^{-1}e and with masses in the range from 0.1 to 3 GeV. This measurement provides leading constraints on millicharged particles in this large unexplored parameter space region.

First measurement of neutrino and antineutrino coherent charged pion production on argon

We report on the first cross section measurements for charged current coherent pion production by neutrinos and antineutrinos on argon. These measurements are performed using the ArgoNeuT detector exposed to the NuMI beam at Fermilab. The cross sections are measured to be 2.6(-1.0)(+1.2)(stat)(-0.4)(+0.3)(syst)×10(-38)  cm(2)/Ar for neutrinos at a mean energy of 9.6 GeV and 5.5(-2.1)(+2.6)(stat)(-0.7)(+0.6)(syst)×10(-39)  cm(2)/Ar for antineutrinos at a mean energy of 3.6 GeV.

First measurements of inclusive muon neutrino charged current differential cross sections on argon

The ArgoNeuT Collaboration presents the first measurements of inclusive muon neutrino charged current differential cross sections on argon. Obtained in the NuMI neutrino beam line at Fermilab, the flux-integrated results are reported in terms of outgoing muon angle and momentum. The data are consistent with the Monte Carlo expectation across the full range of kinematics sampled, 0°<θ(μ)<36° and 0<P(μ)<25 GeV/c. Along with confirming the viability of liquid argon time projection chamber technology for neutrino detection, the measurements allow tests of low-energy neutrino scattering models important for interpreting results from long baseline neutrino oscillation experiments designed to investigate CP violation and the orientation of the neutrino mass hierarchy.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System

BACKGROUND

Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining.

METHODS

We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files.

RESULTS

Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08).

CONCLUSION

Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Site-specific effects of PECAM-1 on atherosclerosis in LDL receptor-deficient mice

OBJECTIVE

Atherosclerosis is a vascular disease that involves lesion formation at sites of disturbed flow under the influence of genetic and environmental factors. Endothelial expression of adhesion molecules that enable infiltration of immune cells is important for lesion development. Platelet/endothelial cell adhesion molecule-1 (PECAM-1; CD31) is an adhesion and signaling receptor expressed by many cells involved in atherosclerotic lesion development. PECAM-1 transduces signals required for proinflammatory adhesion molecule expression at atherosusceptible sites; thus, it is predicted to be proatherosclerotic. PECAM-1 also inhibits inflammatory responses, on which basis it is predicted to be atheroprotective.

METHODS AND RESULTS

We evaluated herein the effect of PECAM-1 deficiency on development of atherosclerosis in LDL receptor-deficient mice. We found that PECAM-1 has both proatherosclerotic and atheroprotective effects, but that the former dominate in the inner curvature of the aortic arch whereas the latter dominate in the aortic sinus, branching arteries, and descending aorta. Endothelial cell expression of PECAM-1 was sufficient for its atheroprotective effects in the aortic sinus but not in the descending aorta, where the atheroprotective effects of PECAM-1 also required its expression on bone marrow-derived cells.

CONCLUSIONS

We conclude that PECAM-1 influences initiation and progression of atherosclerosis both positively and negatively, and that it does so in a site-specific manner.

Making performance indicators work: experiences of US Veterans Health Administration

Eve Kerr and Barbara Fleming explain how measuring performance helped transform a failing healthcare system

The prevalence and outcomes of in-hospital acute myocardial infarction in the Department of Veterans Affairs Health System

BACKGROUND

Most studies of the epidemiology and treatment of acute myocardial infarction (AMI) have focused on patients who experienced onset of their symptoms in the community and then presented to the hospital. There are, however, patients whose symptoms of AMI begin after hospitalization for other medical conditions. The purposes of this study were to determine the prevalence of in-hospital AMI in the Veterans Health Administration (VHA) and to compare baseline characteristics, treatments, and outcomes according to whether individuals presented with AMI or had an in-hospital AMI.

METHODS

This was a retrospective cohort study of 7054 veterans who were hospitalized for AMI in 127 VHA medical centers between July 2003 and August 2004. The main outcome measure was 30-day mortality. Key covariates included age, body mass index, admission systolic blood pressure, heart rate, previous use of lipid-lowering drugs, elevated admission troponin value, prolonged and/or atypical chest pain on admission, and ST-segment elevation on the initial electrocardiogram.

RESULTS

There were 792 patients (11.2%) who had AMI while hospitalized for other medical conditions. These patients differed substantially from those who presented to the hospital with AMI. The odds of 30-day mortality were greater in the in-hospital group (odds ratio, 3.6; 95% confidence interval, 3.1-4.3; P<.001) and remained higher after statistical adjustment (odds ratio, 2.0; 95% confidence interval, 1.7-2.4; P<.001).

CONCLUSION

Although most attention has been paid to patients with AMI admitted via the community emergency medical system or through the emergency department, AMI occurring during hospitalization for other medical problems is an important clinical problem.

Trabeculectomy: a training dilemma

AIM/PURPOSE

The incidence of trabeculectomy is falling due to more effective medical therapies, resulting in fewer trabeculectomy operations carried out by Ophthalmology trainees. This study audits all primary trabeculectomy procedures performed publicly at the two major teaching hospitals in Brisbane, Australia.

METHOD

A retrospective consecutive case review analysing the rates and outcomes of Ophthalmology trainee versus consultant trabeculectomies that were performed during the period May 1996-May 2002.

RESULTS

In all, 290 primary trabeculectomies were undertaken during the study period. Ophthalmology trainees performed 95 (33%) of the procedures. This represents a rate of 1.6 trabeculectomy procedures per year per trainee (10 trainees train at the two hospitals per year). Rates of complications postoperatively were similar between the trainee and consultant groups. The percentage of patients achieving an IOP < or =15 mmHg on no medication at their last follow-up was low at 30%.

CONCLUSIONS

The results of this study suggests that improvement in trabeculectomy technique is required. In order to acquire skills, wetlab training on artificial or animal eyes may become mandatory within the training programmes, otherwise trabeculectomy will become the realm of sub-specialists with glaucoma fellowship training.

A national progress report on diabetes: successes and challenges

Over the last few decades, numerous public health agencies and other private and public organizations have sought to prevent and delay the disabling complications of diabetes by increasing the use of preventive care practices and reducing risk factors for complications among people with diabetes. Now, federal diabetes surveillance activities are yielding encouraging reports that progress is being made in increasing the use of preventive care practices, reducing risk factors for complications, and preventing or delaying diabetes complications. However, although several gains have been noted, levels of preventive care practices remain suboptimal, risk factors for diabetes complications are too prevalent, and diabetes complications are too pervasive. Furthermore, with compelling evidence that the onset of diabetes can be prevented or delayed among adults at high risk, prevention of diabetes has become a major new challenge. Additional efforts are needed to address the growing problems of obesity and physical inactivity, to identify the most efficacious and cost-effective prevention strategies and interventions, and to implement surveillance activities that allow us to gauge our success. Although progress has been made against diabetes complications, the current epidemic of diabetes increases the urgency of primary prevention efforts.

The relationship between organizational systems and clinical quality in diabetes care

OBJECTIVE

To assess the clinical quality of diabetes care and the systems of care in place in Medicare managed care organizations (MCOs) to determine which systems are associated with the quality of care.

STUDY DESIGN

Cross-sectional, observational study that included a retrospective review of 2001 diabetes Health Plan Employer and Data Information Set (HEDIS) measures and a mailed survey to MCOs.

METHODS

One hundred and thirty-four plans received systems surveys. Data on clinical quality were obtained from HEDIS reports of diabetes measures.

RESULTS

Ninety plans returned the survey. Composite diabetes quality scores (CDSs) were based on averaging scores for the 6 HEDIS diabetes measures. For the upper quartile of responding plans, the average score was 77.6. The average score for the bottom quartile was 53.9 (P < .001). The mean number of systems or interventions for the upper-quartile group and the bottom-quartile group was 17.5 and 12.5 (P < .01), respectively. There were significant differences in the 2 groups in the following areas: computer-generated reminders, physician champions, practitioner quality-improvement work groups, clinical guidelines, academic detailing, self-management education, availability of laboratory results, and registry use. After adjusting for structural and geographic variables, practitioner input and use of clinical-guidelines software remained as independent predictors of CDS. Structural variables that were independent predictors were nonprofit status and increasing number of Medicare beneficiaries in the MCO.

CONCLUSIONS

MCO structure and greater use of systems/interventions are associated with higher-quality diabetes care. These relationships require further exploration.

Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels

CONTEXT

Despite condition-specific and managed care-specific reports, no systematic program has been developed for monitoring the quality of medical care provided to Medicare beneficiaries.

OBJECTIVE

To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, reliable estimates at the national and state levels for fee-for-service (FFS) Medicare beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

National study of repeated, cross-sectional observational data collected in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample of beneficiaries with a particular condition. Data were collected using medical record abstraction for inpatient care, analysis of Medicare claims for some ambulatory services, and surveys for immunization rates. Separate samples were drawn for each topic for each state.

MAIN OUTCOME MEASURES

Beneficiary patients' receipt of 24 process-of-care measures related to primary prevention, secondary prevention, or treatment of 6 medical conditions (acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care either directly improves outcomes or is a necessary step in a chain of care that does so.

RESULTS

Across all states for all measures, the percentage of patients receiving appropriate care in the median state ranged from a high of 95% (avoidance of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). The median performance on an indicator is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the Northeast) consistently ranked high in relative performance while others (particularly more populous states and those in the Southeast) consistently ranked low.

CONCLUSIONS

It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement. JAMA. 2000;284:1670-1676.

Conceptualizing battered women as a vulnerable population: a case study report

Battered women are a vulnerable population in the United States. Using a case study report, resource availability and relative risk are identified and examined as critical components that influence morbidity and mortality in battered women. The case study supports the conceptualization that battered women have few societal and environmental resources, which results in a high number of risk factors. Decreased health status, especially morbidity and premature mortality, are associated with gender, sociocultural, and economic factors which define battered women as a vulnerable population group.

Effect of pre-emptive NMDA antagonist treatment on long-term Fos expression and hyperalgesia in a model of chronic neuropathic pain

The unilateral sciatic nerve chronic constriction injury (CCI) model of Bennett and Xie [G.J. Bennett, Y.-K. Xie, A peripheral neuropathy in rat that produces disorders of pain sensation like those seen in man, Pain, 33 (1988) 87-108] shows features of a neuropathic pain state. We examined mechanical hyperalgesia and Fos protein staining in the lumbar spinal cord 1, 7, 14 and 28 days after unilateral CCI to the sciatic nerve or sham operation. In addition, we examined the effect of the NMDA antagonist MK-801 (0.3 mg/kg s.c. administered 30 min prior to and 6 h following operation) on Fos expression and hyperalgesia at 28 days. CCI animals were hyperalgesic compared to the sham operated animals at 14 and 28 days post injury. MK-801 reduced hyperalgesia by 68% in CCI animals on day 28 (p=0.0001). In the spinal cord, Fos positive cells were present bilaterally in deeper laminae in both sham and CCI animals at all time points examined. Relatively few Fos positive cells were present in laminae 1-2 at any time point examined. At days 1 and 7, there were increased numbers of Fos positive cells ipsilaterally in the deeper laminae of the spinal cord in CCI animals compared to sham animals, but by 14 and 28 days Fos counts were similar in sham and CCI despite the obvious behavioural differences between the two groups. Fos counts ipsilateral to the injury in laminae 3-10 correlated with hyperalgesia scores in the CCI but not sham animals. Analysis at the 28-day time point showed that MK-801 differentially affected Fos expression: MK-801 significantly reduced the Fos count bilaterally in laminae 3-10 in the CCI but not in the sham group animals. These results indicate that Fos expression is initiated by different peripheral and central mechanisms following nerve injury or sham operation.

Diabetes care for Medicare beneficiaries. Attitudes and behaviors of primary care physicians

OBJECTIVE

To obtain information related to primary care physician (PCP) attitudes, knowledge, and practice patterns, as well as perceptions about barriers to care and the use of materials to assist in the delivery of diabetes care for elderly patients in the office setting.

RESEARCH DESIGN AND METHODS

A survey was mailed to a random sample (n = 900) of PCPs (internal medicine, family practice, and general practice physicians and endocrinologists) from the states of Alabama, Iowa, and Maryland who met selection criteria and provided diabetes care to > or = 25 Medicare beneficiaries during calendar year 1993.

RESULTS

Respondents provided self-reported information regarding diabetes care for elderly patients. PCP respondents (n = 370) considered blood glucose control to be the most important treatment goal. Most respondents (92%) considered acceptable GHb values to be those < 8%. Blood pressure measurement and foot inspections for the detection of ulcers and infection were the most commonly reported routine procedures performed as part of an office visit. Laboratory tests reported to be frequently ordered included GHb, serum creatinine, and proteinuria tests. Patient nonadherence to the treatment regimen was reported to be the most common barrier to care. The majority of respondents reported using two treatment aids in caring for patients with diabetes.

CONCLUSIONS

The results of this study provide some evidence that PCP self-reported attitudes, knowledge, and practice patterns in delivering diabetes care for elderly patients in the office setting more closely reflect current recommended practice than reported in previous physician surveys. Opportunities for improvement still exist.

Adherence to Agency for Health Care Policy and Research guidelines for benign prostatic hyperplasia

PURPOSE

We determined adherence rates to guideline recommendations for the diagnosis and treatment of benign prostatic hyperplasia published and distributed by the Agency for Health Care Policy and Research in 1994.

MATERIALS AND METHODS

Measures of care were developed based upon Agency for Health Care Policy and Research guideline recommendations approved by the Health Care Financing Administration and the American Urological Association (AUA). A random 4-state sample of 2,000 inpatient records with a principal diagnosis of hyperplasia of the prostate (ICD-9-CM code 600) and principal procedure code of 60.2 was selected by the Health Care Financing Administration and abstractions were performed. We assessed reliability and validity and determined results for each of the following measures of care: 1) documentation of indications for a transurethral resection of the prostate; 2) documentation of appropriate preoperative assessment; 3) documentation of indications for an inpatient excretory urogram (IVP) and/or sonogram when the procedures were performed and 4) documentation of surgical time and grams of tissue removed. Adherence rates for all measures of care were determined.

RESULTS

Of the 4-state sample of inpatient cases 1,828 cases met entry criteria for the study. Of the cases 93% had at least 1 symptom and/or score, and/or an anatomical abnormality documented before surgery. An AUA score was documented in the inpatient medical record in 7.5% of the cases. Recommendations for preoperative evaluation included urinalysis, a digital rectal exam and determination of preoperative creatinine. All of these were documented in 475 (26%) cases. Of the 1,828 cases 216 (12%) had an IVP or sonogram performed in the inpatient setting. In 36% indications were documented when sonograms were performed; 74% had documented indications when IVPs were performed. Excluding laser transurethral resections of the prostate, surgical time and tissue amounts were documented and recorded in 1,424 transurethral resections of the prostate cases (91%).

CONCLUSIONS

Adherence to selected Agency for Health Care Policy and Research guideline recommendations is documented infrequently in the medical record.

Plasma morphine and glucuronide (M3G and M6G) concentrations in hospice inpatients

Plasma morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) concentrations were quantified by high performance liquid chromatography (HPLC) in 36 hospice inpatients receiving morphine orally or subcutaneously. The data were analyzed in relation to dose, serum creatinine, serum gamma glutamyl transferase, and presence or absence of opioid-induced adverse effects. There were significant associations (P < 0.05) between plasma morphine, M3G (subcutaneous route only), and M6G concentrations and dose for both routes of administration. The mean dose-corrected plasma morphine concentration for the subcutaneous group was three times that of the oral group, confirming present oral to subcutaneous dose conversion practices. Nineteen patients experienced symptoms attributed to morphine: nausea and vomiting in ten and acute delirium in nine. Serum creatinine was elevated in patients with adverse effects (P = 0.031), as were the dose-corrected plasma M3G (P = 0.029) and M6G (P = 0.043) concentrations. All seven patients with serum creatinine concentrations above the normal range had symptoms attributed to opioid-induced adverse effects. Plasma M3G, M6G, and dose-corrected plasma M3G and M6G concentrations were significantly (P < 0.001) higher in these patients than in those with normal serum creatinine concentrations. The data indicate that accumulation of M3G and M6G may be a causal or aggravating factor in the nausea and vomiting and cognitive function profile of palliative and terminal care patients with significant renal function impairment.

A sagittal plane model of the knee and cruciate ligaments with application of a sensitivity analysis

In this investigation the complex multi-bundle structure of the cruciate ligaments and their interaction with the tibiofemoral joint was modeled analytically by representing the different regions of the cruciates with ligament elements. A sensitivity analysis was then performed to describe the effect that variations of the model input parameters had on the model variables (outputs). The effect that the cruciate ligament bundles had in controlling joint kinematics was dependent on knee flexion angle, and the load applied to the tibiofemoral joint. For passive range of knee motion with the thigh in the horizontal plane (a common rehabilitation activity), all cruciate ligament bundles were strained with the joint positioned between 0 and 10 deg of knee flexion, between 10 and 50 deg only the anterior bundle of the posterior cruciate ligament A-PCL was strained, and from 50 to 90 deg both the anteromedial portion of the anterior cruciate ligament A-ACL and the A-PCL were strained. This finding indicates that a strain distribution about a transverse cross section of the cruciates exists, and demonstrates the importance of differentiating between the strained and unstrained (unloaded) states of these ligaments. The strain value of a cruciate ligament bundle was an indication of how the bundle controls joint kinematics, while the unstrained values describe how much the ligament bundle must deform before it becomes strained and a restraint to tibiofemoral joint motion. In response to anterior and posterior directed loads, applied parallel to the tibial plateau, the respective, ACL and PCL load values were larger in magnitude. The sensitivity of the model outputs to the input parameters was highly dependent on knee flexion angle. The geometrical input parameters of the model (including the ligament insertion site locations and articular surface geometry) had the most pronounced effect on the model output quantities, while the stiffness and initial strain conditions of the ligament bundles had less of an effect on the model outputs. When loaded, the strain values of the ligament bundles were sensitive to the ligament insertion site position. The greatest sensitivity of the model outputs was the femoral insertion of the ACL; supporting clinical impressions and previous experimental findings. Changes in the anterior-posterior dimension of the femoral articular surface did not produce a substantial effect on the model outputs, while changes in the proximal-distal dimension created a large effect; similar results were found for the tibial surface dimensions. These findings indicate that rigid body contact between the articular surfaces may not be a realistic assumption particularly with application to the prediction of tibiofemoral compressive loading and the force/strain values of the cruciate ligament elements. This also has important implications for the design and clinical application of total knee replacements (that function as rigid bodies), particularly those that spare the PCL.

Psychological sequelae to assassination attempts

The experiences of nine subjects who were the victims of assassination attempts are described. All but one were the victims of shootings or attempted shootings. Post Traumatic Stress Disorder (PTSD) was an almost invariable response. Brief alcohol abuse was quite common. Most subjects displayed considerable feelings of anger. Only a minority expressed anger against their assailants while much anger was displaced towards the medical profession and institutions of the state. This displacement of anger is discussed as are the implications for treatment of such displacement.

Isometric versus tension measurements. A comparison for the reconstruction of the anterior cruciate ligament

This study was designed to compare the displacement patterns of an isometer, used to determine graft placement during reconstruction, with the actual tensions on an anterior cruciate ligament substitute. In cadaveric specimens, a Kevlar anterior cruciate ligament substitute was implanted in three separate femoral sites, each of which was subsequently fixed to two different tibial sites. The initial tension of the Kevlar substitute was set to 22 or 33 N at 20 degrees of knee flexion. The displacement patterns for each position were recorded during passive flexion-extension using the isometer. Using a custom-designed tensiometer, the tensile forces on the substitute after rigid fixation at the tibia and femur were measured. During passive flexion-extension, the maximum change in tension of the anterior cruciate ligament substitute, measured by the tensiometer, was correlated with the maximum change in displacement between attachment sites, measured by the isometer. The coefficient of determination was equal to 0.15, indicating that the isometer may not accurately predict the tensions developed in the substitute.

Test-retest variation in lifting capacity and indices of subject effort

Tests of lifting capacity ideally produce consistent outcomes from one test to the next. Physiological indices of effort, such as heart rates, coefficients of force variation, and isokinetic force-distance curve variability, should also remain constant. This study examined the test-retest reliability of isometric, isokinetic and isoinertial maximal lifting tests in pain-free, well-motivated subjects. First, isokinetic and isoinertial maximum lifting forces and weights were quite consistent between test sessions, while isometric forces increased slightly in the second session. Second, heart rates did not vary significantly between test sessions of isokinetic and isoinertial modes. However, other indices of effort, including force variances, force-weight differences and ratios, and force-weight curve variability, varied significantly between test sessions. Test-retest variations in these non-cardiac effort indices imply that these indices may not reliably distinguish maximal from submaximal lifting efforts even in normal subjects.

RELEVANCE

Efforts to reduce occupational low-back injuries and disability have focused recently on measurements of lifting capacity. Accurate and reliable estimation of subject effort is critical to the validity of such measurements. This study demonstrates a need for reconsideration of previously reported indices of lifting effort.

Clinical practice guidelines. The Agency for Health Care Policy and Research fosters the development of evidence-based guidelines

As medical technology increases rapidly and becomes more complex, clinical practice guidelines can help healthcare providers assess current practices and integrate technological advances. Through the Agency for Health Care Policy and Research (AHCPR), the federal government has begun to facilitate the development of clinical practice guidelines. Expert or contract panels, authorized by the AHCPR, develop guidelines on specific clinical conditions. The AHCPR guideline methodology is designed to produce evidence-based guidelines that are valid, clinically applicable, and clinically flexible. Each panel spends a year or more developing the guideline, beginning with an extensive literature search and review. The panel prepares evidence tables, statistically analyzes aggregate data (where appropriate), conducts harm and benefit analyses, and prepares health policy analyses (or cost-impact studies). During this process, the panel holds an open forum to solicit comments on the guideline topic. After this public discussion, the panel prepares a final draft of the guideline. Several hundred individuals review the guideline. Some policymakers believe clinical practice guidelines can lead to better healthcare outcomes. Guidelines can provide information in a useful format for clinicians to use at the bedside or the point of decision making in patient care. Guidelines also provide information that can be used in continuing education and professional education programs.

External fixator pin design

The integrity of the bone-pin interface is the critical link in the stability of external fixation systems. External fixation pins placed in cancellous metaphyseal bone frequently loosen over time, resulting in fixation failure and an increased risk of infection. To design an external fixation pin with optimal bone-metal interface strength in cancellous bone, a systematic study of various thread design features was performed. Combinations of pitch, tooth profile, and minor diameter in 5 mm self-tapping half pins were evaluated in coaxial pullout testing using a fresh bovine cancellous bone. A significant increase in pullout strength was found with a decrease in minor diameter. No statistical differences were found in pullout strength attributable to thread profile and pitch. There were no significant interactions between minor diameter and tooth profile or minor diameter and pitch. The data obtained suggest significantly greater holding power in cancellous bone can be achieved by using an external fixation pin with a smaller minor diameter or a larger interference. Additional pullout testing of five commercially available external fixator pins was performed. Of these, the two pins with the largest interference demonstrated greater pullout strength. Therefore, within a range of acceptable major diameters and adequate minor diameters for the torsional strength requirements, an optimal interference for cancellous pin application may exist and it may well be larger than that present in currently available external fixation pins.

Effect of tension and placement of a prosthetic anterior cruciate ligament on the anteroposterior laxity of the knee

We wished to determine the optimal tension required to restore normal joint laxity to anterior cruciate ligament (ACL)-deficient knees using a braided polyethylene ACL prosthesis (PACL). In 10 cadaveric specimens, we measured the anteroposterior (AP) laxity of the intact knee at 10 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion. The ACL was then removed and replaced with the PACL using tunnel-tunnel (T-T) and "over-the-top" (OTT) placement techniques. In both positions, the PACL was initially tensioned to 0, 9, 18, and 27 N with the knee flexed to 30 degrees. AP joint laxity was then measured at each flexion angle. With an increase in initial tension, there was a corresponding decrease in AP laxity. At 30 degrees and 90 degrees of flexion, AP laxity was not significantly different from normal using T-T placement and an initial tension of 0 N. At 90 degrees of flexion, AP laxity was not significantly different from normal using OTT placement at 0 or 9 N of initial tension. For both positions, all other tension levels and flexion angles constrained AP laxity. No laxity differences were detected between the OTT and T-T positions at any flexion angle. The variability in AP laxity of the T-T position was significantly greater than OTT. With a 150-N anterior shear force applied to the proximal tibia, the maximum tensions developed in the PACL were not significantly different between the two positions except at 90 degrees. The results suggest that implantation of the PACL is best performed using OTT positioning with an initial tension of 0 N applied at 30 degrees of knee flexion.

Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II. A specific sport review

Eighty-three patients, from a 10 year follow-up study, who underwent ACL reconstruction with a quadriceps patellar tendon graft were reviewed. A questionnaire qualifying their sports performance in 20 possible sports compared their preinjury status to postinjury and postreconstructive surgery. Successful and unsuccessful patients, as determined by our previous investigation, were likewise compared. Sports performance, regardless of the sport or level of competition, decreased substantially postinjury and then rose significantly to near but not equal to patient preinjury status. The most strenuous sports dipped to the lowest performance level after injury and returned with a correspondingly more modest gain after the reconstruction. Not surprisingly, successful patients had a more impressive return in performance than unsuccessful patients, mirroring their clinical grading. Of those deemed unsatisfactory (N = 20), graft failures were no worse off in performance rating than those that were classified as unsatisfactory because of persistent symptoms.

Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term followup

Eighty-three patients with ACL reconstructions using the quadriceps patellar tendon graft were evaluated in a 10 year (mean, 5.5 years) follow-up study. A five-part analysis, consisting of physical examination, questionnaire, Genucom analysis, operative note review, and radiographs, was performed. Seventy-six percent were categorized as satisfactory. Ninety-two percent were content with their results, while only 4% were unsatisfied. Ninety-three percent of the patients had no significant pain and 95% had no giving way postreconstruction. Ninety-two percent had no more than a mild functional deficit. Eighty-seven percent and 90% of the patients had no significant Lachman or pivot shift by examination, respectively. Our results showed no increase in failure over time (1 to 10 years), although those operated on during the initial 5 years showed more radiographic degenerative changes. Plotting our results in classification systems of other authors yielded success rates as good as or better than those using our own criteria. An objective means by which to quantify laxity did not reliably correlate with the quantifying of laxity made by physical examination. Only the lack of a formal rehabilitation program greater than 4 months postoperatively and repaired tears of the medial or lateral collateral ligaments proved to be significant risk factors for poor recovery.

Marital Attitude Survey: A Measure of Dysfunctional Attributions and Expectancies

The Marital Attitude Survey (MAS) was designed to assess potentially dysfunctional attributions and expectancies regarding relationship problems. The eight MAS subscales measure attributions regarding one’s partner’s malicious intent and lack of love, attribution of causality to one’s own behavior and personality, attribution of causality to the partner’s behavior and personality, perceived ability of the couple to change, and expectancy of change in the relationship. All subscales except the subscale assessing attribution of causality to own behavior exhibited adequate internal consistency and showed evidence of construct validity in relation to measures of marital dysfunction. Multivariate analyses indicated that considering subscales in combination increases the measure’s ability to discriminate between clinical and nonclinical samples. The results demonstrate the utility of the MAS as a measure of dysfunctional cognitions associated with marital distress.

Antagonists of bombesin/gastrin releasing peptide based on [D-Ala24]GRP(20-26)-heptapeptide. Modifications leading to potent analogues with prolonged duration of action

Analogues of gastrin releasing peptide (GRP) and bombesin based on His-Trp-Ala-Val-D-Ala-His-Leu, the 20-26 heptapeptide sequence of [D-Ala24]GRP, have been synthesized and tested in vitro for their ability to inhibit GRP (18-27)-induced mitogenesis in Swiss 3T3 cells. Compounds identified as potent antagonists in this test system were also tested in vivo for their ability to inhibit bombesin-induced amylase secretion in rats. The Trp-Ala-Val sequence was found to be a very important feature of the antagonist activity; most substitutions in this region led either to much less potent or inactive analogues. In contrast, amino acid replacements in other parts of the molecule were more tolerated and sometimes led to marked increases in the in vitro and in vivo activity. The most potent analogues were obtained by replacing Leu26 by MeLeu and His25 by Lys(X) where X = Z, PhCO, PhCH2CO or Ph(CH2)2CO. Thus 4-pyridylcarbonyl-His-Trp-Ala-Val-D-Ala-Lys(CO-CH2-CH2-Ph)-Leu- NHMe (86) and 4-pyridylcarbonyl-His-Trp-Ala-Val-D-Ala-Lys(Z)-MeLeu-OMe (87) had IC50 values of less than 20 micrograms/kg s.c. in vivo, and their effects lasted for more than 3 hr.