Patient-Centric Quality Standards

To ensure the quality, safety and efficacy of medicinal products, it is necessary to develop and execute appropriate manufacturing process and product control strategies. Traditionally, product control strategies have focused on testing known quality attributes with limits derived from levels administered in preclinical and clinical studies with an associated statistical analysis to account for variability. However, not all quality attributes have impact to the patient and those with the potential to impact safety and efficacy may not be significant when dosed at patient-centric levels. Therefore, achieving patient-centricity is understanding patient relevance, which is defined as the level of impact that a quality attribute could have on safety and efficacy within the potential exposure range. A patient-centric quality standard (PCQS) is therefore a set of patient relevant attributes and their associated acceptance ranges to which a drug product should conform within the expected patient exposure range. This manuscript describes historical perspectives details the way to create and leverage a PCQS in a variety of pharmaceutical product modalities.

CBETA: First Multipass Superconducting Linear Accelerator with Energy Recovery

Energy recovery has been achieved in a multipass linear accelerator, demonstrating a technology for more compact particle accelerators operating at higher currents and reduced energy consumption. Energy delivered to the beam during the first four passes through the accelerating structure was recovered during four subsequent decelerating passes. High-energy efficiency was achieved by the use of superconducting accelerating cavities and permanent magnets. The fixed-field alternating-gradient optical system used for the return loop successfully transported electron bunches of 42, 78, 114, and 150 MeV in a common vacuum chamber. This new kind of accelerator, an eight-pass energy recovery linac, has the potential to accelerate much higher current than existing linear accelerators while maintaining small beam dimensions and consuming much less energy per electron.

Image Quality in Chest Radiography: Abstract

Image quality in chest radiography is an important, but complex, subject. The complicated anatomy of the chest, as well as the various ways that chest disease may manifest itself, require careful consideration of radiographic technique. The manner in which human observers deal with the complexity of chest images adds further dimensions to image analysis that are not found in other radiography examinations. This report describes many issues that are related to the quality of chest radiographic images. In so doing, it relies upon the very extensive literature on this topic, a topic that has been one of the most thoroughly studied in all of radiography. Strategies that are generally agreed to improve the quality of chest radiographs are described, as are approaches to the assessment of image quality.

Food Insecurity and Health-Related Quality of Life: A Cross-Sectional Analysis of Older Adults in Florida, U.S

Individuals 65 years or older will comprise an estimated 20.0% of the U.S. population by 2030. This study investigated the association between food insecurity and health-related quality of life (HRQoL) among an older adult population (n = 234). HRQoL was measured using Healthy Days, a validated survey tool developed by the Centers of Disease Control and Prevention. Food-insecure individuals were more likely to report ≥14 physically unhealthy days (OR = 1.49, 95% CI 0.47-4.78) and ≥14 days with activity limitations (OR = 4.07, 95% CI 0.68-24.1). Although nonsignificant, the findings highlight food insecurity as a potentially important social determinant of health throughout the life course, including at an older age.

Design, conditioning, and performance of a high voltage, high brightness dc photoelectron gun with variable gap

A new high voltage photoemission gun has been constructed at Cornell University which features a segmented insulator and a movable anode, allowing the cathode-anode gap to be adjusted. In this work, we describe the gun's overall mechanical and high voltage design, the surface preparation of components, as well as the clean construction methods. We present high voltage conditioning data using a 50 mm cathode-anode gap, in which the conditioning voltage exceeds 500 kV, as well as at smaller gaps. Finally, we present simulated emittance results obtained from a genetic optimization scheme using voltage values based on the conditioning data. These results indicate that for charges up to 100 pC, a 30 mm gap at 400 kV has equal or smaller 100% emittance than a 50 mm gap at 450 kV, and also a smaller core emittance, when placed as the source for the Cornell energy recovery linac photoinjector with bunch length constrained to be <3 ps rms. For 100 pC up to 0.5 nC charges, the 50 mm gap has larger core emittance than the 30 mm gap, but conversely smaller 100% emittance.

The VALUE national hysterectomy study: description of the patients and their surgery

OBJECTIVES

To describe hysterectomies practised in 1994 and 1995: the patients, their surgery and short term outcomes.

DESIGN

One of two large cohorts, with prospective follow up, recruited to compare the outcomes of endometrial destruction with those of hysterectomy.

SETTING

England, Wales and Northern Ireland.

POPULATION

All women who had hysterectomies for non-malignant indications carried out during a 12-month period.

METHODS

Gynaecologists in NHS and independent hospitals were asked to report cases. Follow up data were obtained at outpatient follow up approximately six weeks post-surgery.

MAIN OUTCOME MEASURES

Indication for surgery, method of hysterectomy, ovarian status post-surgery, surgical complications.

RESULTS

37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95% CI 0.25-0.64).

CONCLUSIONS

This large study describes women who undergo hysterectomy in the UK, and presents results on early complications associated with the surgery. Operative complications occurred in one in 30 women, and post-operative complications in at least one in 10. Laparoscopic techniques tend to be associated with higher complication rates than other methods.

Service learning: integrating student learning and community service

Health professions education is directly effected by changes in health care service delivery and financing systems. In the United States, as the health care industry increasingly shifts to a market economy, service delivery venues are moving away from acute care facilities and into community-based settings. Additionally, there is increased emphasis on primary prevention programs, often provided in public health settings. For health professions programs that traditionally provide clinical training in hospitals and long-term care facilities, there are unique challenges associated with identifying new venues in order to insure that students are exposed to a wide variety of patients with a range of chronic to acute disease conditions. One set of tools that has demonstrated usefulness during these kinds of transitions is service learning. This teaching methodology emphasizes increased partnership with clinical training sites, extensive orientation to patient populations and community resources, structured reflection and instilling the ethic of service in future health care providers. Although this article describes utilization of service learning in the context of current conditions in the United States, we hope that the principles presented here can be readily adapted in any setting.

Gas in the sternoclavicular joints of patients with blunt chest trauma: significance and frequency of CT findings

OBJECTIVE

In trauma patients, gas (vacuum phenomenon) in the sternoclavicular joints could represent sequelae of significant distraction forces and thus serve as a potential marker for severe intrathoracic injury. We evaluated the significance and frequency of the finding of gas in the sternoclavicular joints on chest CT of patients with blunt trauma.

SUBJECTS AND METHODS

We prospectively studied all chest CT examinations performed at our institution over a 14-week period for the finding of gas in the sternoclavicular joints. Chest CT examinations (n = 267) were performed in 234 patients. We excluded data from follow-up CT examinations (n = 33), limiting our evaluation to the initial CT examination for each patient. Of the study population, 103 patients (83 men and 20 women) who ranged in age from 14 to 79 years (mean, 40 years) had sustained blunt chest trauma. For all trauma patients, we recorded the mechanism of injury and the associated thoracic injuries.

RESULTS

CT revealed gas in the sternoclavicular joints in 47 patients (21%). Gas was unilateral in 27 patients and bilateral in 20 patients. Sternoclavicular joint gas was seen in 39 (38%) of the 103 trauma patients but was found in only eight (6%) of the 131 nontrauma patients (p < .0001). In the 39 trauma patients with sternoclavicular joint gas, associated thoracic injuries were seen in 17 patients (44%); either a sternal fracture or a retrosternal hematoma was seen in three patients. Radiographically evident thoracic injury was revealed in 20 (31%) of the 64 trauma patients who had no gas in the sternoclavicular joint; however, 10 of these 20 patients had either a sternal fracture or a mediastinal hematoma.

CONCLUSION

Although gas in the sternoclavicular joints is more frequently seen in patients with blunt chest trauma than in patients undergoing chest CT for other indications, this finding does not indicate a greater risk of significant mediastinal or thoracic injury.

Clinical pathway for pneumonia: development, implementation, and initial experience

BACKGROUND

As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented.

METHODS

After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994.

RESULTS

For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769).

CONCLUSIONS

The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development.

Pancreas divisum in a family with hereditary pancreatitis

Hereditary pancreatitis is characterized by an autosomal-dominant mode of inheritance with incomplete penetrance, onset of symptoms in childhood or early adolescence (mean age of onset approximately 13 years), and an approximately equal sex incidence. Pancreas divisum is a congenital variant of pancreatic ductal anatomy in which the ventral and dorsal pancreatic ductal systems fail to fuse, so that two functional papillae drain the exocrine secretions of the pancreas. In recent years, several reports of pancreatitis associated with pancreas divisum in children have appeared. We now report a family in which the mother, son, and daughter all had presented with recurrent pancreatitis from an early age. Both the mother and son have endoscopic retrograde cholangiopancreatography-documented pancreas divisum, whereas the daughter has a stricture in her distal pancreatic duct. To our knowledge, this is the first such report of "familial" pancreas divisum. The implications of these findings in the setting of hereditary pancreatitis highlight the controversial issues of the clinical significance of pancreas divisum and the appropriateness of surgical therapy.

Metachronous small-bowel adenocarcinoma in celiac sprue

Celiac sprue, or nontropical sprue, is associated with an increased incidence of digestive tract malignancy. We report a patient with celiac sprue who developed two primary adenocarcinomas of the jejunum > 2 years apart. The second cancer was asymptomatic and detected by surveillance computed tomography. Small-bowel cancers are unusual, and frequency of follow-up has not been established, so that it is important to have a high index of suspicion for these malignancies in celiac patients with vague gastrointestinal symptoms.

The effect of extent of resection on recurrence in patients with low grade cerebral hemisphere gliomas

BACKGROUND

To evaluate the role of radical resection for low grade cerebral hemisphere gliomas, the authors analyzed the preoperative and postoperative radiographic tumor volumes (computed tomography hypodensity, magnetic resonance imaging-T2 signal hyperintensity) in 53 patients.

METHODS

Using a previously described method of computerized image analysis, the authors evaluated whether the percent of resection and volume of residual disease, postoperatively, influenced the incidence of recurrence, time to tumor progression, and histology of the recurrent tumor. Survival was not analyzed in this study.

RESULTS

No recurrence was detected, regardless of percent of resection and volume of residual disease, in patients with preoperative tumor volumes less than 10 cm2 (mean follow-up, 41.7 months). Patients with tumors measuring 10-30 cm3 had an incidence of recurrence and time to tumor progression of 13.6% and 58 months, respectively, compared with tumors measuring greater than 30 cm3, which had an incidence of recurrence and time to tumor progression of 41.2% and 30 months, respectively (P = 0.016). All patients (n = 13) who underwent a 100% resection had a recurrence-free follow-up period (mean, 54 months). In the remaining patients (n = 40), as the percent of resection decreased, the incidence of recurrence increased along with a shorter time to tumor progression (P = 0.03). Patients with a volume of residual disease of greater than 10 cm3 had a higher incidence of recurrence (46.2%) and a shorter time to tumor progression (30 months) compared with patients with a tumor volume of residual disease of less than 10 cm3 (incidence of recurrence, 14.8% and time to tumor progression, 50 months) (P = 0.002). Forty-six percent of patients with a tumor volume of residual disease of more than 10 cm3 had a recurrence of higher histologic grade, and this was significantly more frequent than patients with a volume of residual disease less than 10 cm3 (3.7%) (P = 0.0009). Age, radiotherapy, and histologic subtype had no influence on recurrence patterns.

CONCLUSION

For tumors greater than 10 cm3, the authors' data suggest that a greater percent of resection and a smaller volume of residual disease conveys a significant advantage, that is, terms of incidence of recurrence and the recurrent tumor phenotype, for patients with low grade cerebral hemisphere gliomas, compared with those who have a less aggressive resection or biopsy. While this may also be the case with tumors less than 10 cm3, further follow-up is necessary to determine the effect of surgery on recurrence patterns for this subset of patients.

Low-grade gliomas associated with intractable epilepsy: seizure outcome utilizing electrocorticography during tumor resection

Adults and children with low-grade gliomas often present with medically refractory epilepsy. Currently, controversy exists regarding the need for intraoperative electrocorticography (ECoG) to identify and, separately, resect seizure foci versus tumor removal alone to yield maximum seizure control in this patient population. Forty-five patients with low-grade gliomas and intractable epilepsy were retrospectively analyzed with respect to preoperative seizure frequency and duration, number of antiepileptic drugs, intraoperative ECoG data (single versus multiple foci), histology of resected seizure foci, and postoperative control of seizures with or without antiepileptic drugs. Multiple versus single seizure foci were more likely to be associated with a longer preoperative duration of epilepsy. Of the 45 patients studied, 24 were no longer taking antiepileptic drugs and were seizure-free (mean follow-up interval 54 months). Seventeen patients, who all had complete control of their seizures, remained on antiepileptic drugs at lower doses (mean follow-up interval 44 months); seven of these patients were seizure-free postoperatively, yet the referring physician was reluctant to taper the antiepileptic drugs. Four patients continued to have seizures while receiving antiepileptic drugs, although at a reduced frequency and severity. In this series 41% of the adults versus 85% of the children were seizure-free while no longer receiving antiepileptic drugs, with mean postoperative follow-up periods of 50 and 56 months, respectively. This difference was statistically significant (p = 0.016). Therefore, based on this experience and in comparison with numerous retrospective studies involving similar patients, ECoG is advocated, especially in children and in any patient with a long-standing seizure disorder, to maximize seizure control while minimizing or abolishing the need for postoperative antiepileptic drugs.

Factors in pin tract infections

To determine the factors pertinent to the etiology of pin tract infections, 214 pins in 42 patients were examined prospectively at the time of pin removal. Eighty-nine (41.6%) pin tracts were inflamed, 49 (22.9%) pins had loose anchorages, and 160 (74.8%) pin tips cultured positive for bacteria. The predominant organism cultured was Staphylococcus epidermidis (90.6%), considered nonvirulent, followed by virulent Staphylococcus aureus (37.5%), and Escherichia coli (9.4%). There were 32 loose, inflamed pin tracts. This correlation was statistically significant (P less than .005). There were 40 loose pins whose pin tips had positive cultures. Loose pins correlated for infection with virulent species of bacteria at a highly significant level (P less than .005). Results demonstrate that most pins possess bacterial colonization. Clinically, this means that either inflamed pin tracts or pins with cultures positive for invasive organisms are probably loose and should be removed. Also, mechanical factors are the critical variable in determining the flora of external fixation pins.

Techniques for the determination of left ventricular mass by signal-averaged electrocardiography

The standard ECG correlates poorly with LV mass. The SAECG precisely measures myocardial energy and may allow more exact noninvasive assessment of LV mass. A commercially available system (Corazonix Predictor I) was tested for its ability to reproduce and measure known input energy in square wave and QRS waveforms, using frequency bandwidths different from those used for late potential analysis. A test group of 15 patients was studied to determine optimum filter type and bandwidth for comparison of SAECG energy measurement versus LV mass as determined by echocardiography (Penn conversion) and LV hypertrophy via standard ECG criteria. The best means of energy measurement were maximum and total RMS voltage and the integral of the area under the QRS curve. Optimum correlation with echocardiography was seen with a bidirectional band-pass filter of 5 to 250 Hz applied either to the vector sum of the three orthogonal leads or to the Z lead alone (r values 0.61 to 0.73), which was equal to or superior to standard ECG LV hypertrophy determinants. A second group of 20 patients was studied prospectively to confirm these findings, which yielded similar results.

CONCLUSION

(1) the SAECG when appropriately modified serves as a rapid noninvasive assessment of LV mass. (2) These modifications must examine the entire duration and energy spectrum of the surface ECG and not just the region of late potentials. (3) Very low frequencies (below 5 Hz) must be excluded to eliminate the energy present due to DC offset voltage.

Postcholecystectomy syndrome: evaluation using biliary scintigraphy and endoscopic retrograde cholangiopancreatography

We prospectively studied 30 patients with postcholecystectomy syndrome to determine the efficacy of biliary scintigraphy in the detection of stenosis of the sphincter of Oddi. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP). Biliary scintigraphy disclosed stenosis of the sphincter by agreement with the ERCP or surgical findings in nine (90%) of ten patients and in eight (100%) of eight patients with biliary obstruction from other causes. Retention of activity at 2 hours in visually prominent ducts was the best predictor of abnormal biliary drainage. Biliary scintigraphy is a useful, noninvasive screening test for the detection of postcholecystectomy biliary obstruction.

Strategy for the use of biliary scintigraphy in non-iatrogenic biliary trauma

Biliary scintigraphy was used to examine 21 patients who had suspected non-iatrogenic biliary trauma. Seven patients (33%) had scintigraphic evidence of biliary leakage. Ultimately, surgical biliary repair was required for only three of these patients. Visualization of the gallbladder did not occur in eight trauma patients, but only one patient was shown to have cholecystitis. In this series, 16 patients had Tc-99m sulfur colloid scans that offered no significant advantage over cholescintigraphy in the detection of hepatic parenchymal defects. Biliary scintigraphy provides clinically useful information in cases both of blunt and penetrating trauma.

Effect of D-alanine methionine enkephalin amide on ion transport in rabbit ileum

The presence of enkephalins in the intestine and the use of opiates to treat diarrheal diseases suggests that enkephalins may affect intestinal ion transport. Using isolated rabbit ileal mucosa, we found that leucine enkephalin, methionine enkephalin, and D Ala2-methionine enkephalin amide (D Ala2-Met E) decreased the short circuit current (Isc) and potential difference although the effect of D Ala2-Met E was more pronounced and prolonged. D Ala2-Met E increased net sodium (+1.27 +/- 0.5 mu eq/cm2h), and chloride absorption (+2.33 +/- 0.4), and increased tissue conductance by 37%. Although the effect of enkaphalin on ion transport is opposite that of cyclic AMP, D-Ala2-Met had no effect on basal or vasoactive intestinal polypeptide-stimulated cyclic AMP levels. The effect of D-Ala2-Met E on Isc was blocked by naloxone, suggesting the involvement of specific opiate receptors. Tetrodotoxin completely blocked the decrease in Isc induced by D-Ala2-Met E but not by epinephrine, inferring that enkephalins are preganglionic neurotransmitters. The effect of D-Ala2-Met E on Isc was not blocked by phentolamine, haloperidol, or pretreatment of animals with 6-hydroxydopamine, suggesting that enkephalin does not affect the Isc by stimulating the release of alpha-adrenergic or dopaminergic agonists. D-Ala2-Met E also decreased the Isc in the presence of carbachol and bethanechol, indicating that enkephalin does not inhibit the release of acetylcholine. Further, up to 10 mu M atropine had no effect on the Isc. These studies demonstrate that enkephalins stimulate intestinal ion transport and may do so by stimulating (or inhibiting) the release of a nonadrenergic, noncholinergic neurotransmitter.

Liquefactive necrosis of the pancreas: the pancreatic sac

The authors describe an unusual form of pancreatic necrosis in which the excavated necrotic core is surrounded by a shell of tissue and forms a sac which generally conforms to the axis and contour of the pancreas. This debris-containing sac could be misinterpreted on ultrasound and CT and is best defined by direct injection into the pancreatic duct.

Diagnosis of annular pancreas with endoscopic retrograde cholangiopancreatography

Two patients with annular pancreas are described. The diagnosis was established unequivocally with endoscopic retrograde cholangiopancreatography before operation. In both patients there was pancreatitis of the annular pancreas. The first patient also had congenital absence of the ventral pancreas and pancreatic insufficiency. The second patient subsequently developed gastric outlet obstruction. The literature is reviewed.

Role of plasma lecithin:cholesterol acyltransferase in the metabolism of high density lipoproteins

The role of the plasma lecithin:cholesterol acyltransferase reaction in the esterification of the cholesterol of human and baboon plasma high density lipoproteins has been studied. Human plasma was incubated in vitro, and the initial rate of cholesterol esterification in lipoprotein fractions obtained by chromatography on hydroxylapatite was determined. The rate of esterification was greater in the high density lipoprotein fraction than in the low density lipoprotein fraction. High density lipoproteins from human and baboon plasma were filtered through columns of Sephadex G 200, and the relative concentrations in the effluent of key lipids involved in the acyltransferase reaction were determined. The ratio of esterified to unesterified cholesterol varied across the lipoprotein peak obtained from either type of plasma. The relative concentration of lecithin compared to sphingomyelin also varied across the peaks obtained with human high density lipoproteins. When human or baboon plasma was incubated with cholesterol-(14)C and the high density lipoproteins were filtered through Sephadex, the specific activity of the esterified cholesterol varied across the lipoprotein peak. Similar results were obtained when plasma esterified cholesterol was labeled in vivo by the injection of labeled mevalonate into baboons. The data suggest that the acyltransferase reaction is the major source of the esterified cholesterol of the high density lipoproteins.