Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study

INTRODUCTION

Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults.

AIMS

i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma.

METHODS

A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019.

RESULTS

After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days.

CONCLUSION

Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.

Models of acute care for injured older patients-Australia and New Zealand practice

INTRODUCTION

The epidemiology of injured patients has changed, with an increasing predominance of severe injury and deaths in older (65 years and above) patients after low falls. There is little evidence of the models of care that optimise outcomes for injured older patients. This study aims to describe clinician perspectives of existing models of acute care for injured older patients in Australia and New Zealand.

METHODS

This cross-sectional online survey of healthcare professionals (HCP) managing injured older patients in Australia or New Zealand hospitals was conducted between November 2nd and December 12th, 2020. Recruitment was via survey link and snowball sampling to professional organisations and special interest groups via email and social media. HCP were asked, using a Likert scale, how likely four typical case vignettes were to be admitted to one of twelve options for ongoing care. Additional questions explored usual care components.

RESULTS

Participants (n=157) were predominantly Australian medical professionals in a major trauma service (MTS) or metropolitan hospital. The most common age defining "geriatric" was aged 65 years and older (43%). HCP described variability in the models and components of acute care for older injured patients in Australia and New Zealand. As a component of care, cognitive, delirium and frailty screening are occurring (60%, 61%, 46%) with HCP from non-major trauma services (non-MTS) reporting frailty and cognitive impairment screening more likely to occur in the emergency department (ED). Access to an acute pain service was more likely in a MTS. Participants described poor likelihood of a geriatrician (highest 16%) or physician (highest 12%) review in ED CONCLUSION: Despite a low response rate, HCP in Australia and New Zealand describe variability in acute care pathways for injured older patients. Given the change in epidemiology of injury towards older patients with low force mechanisms, models of acute injury care should be evaluated to define a cost-effective model and components of care that optimise patient-centred outcomes relevant to injured older patients. HCP described some factors they perceive to determine care, and outcomes of variability, offering guidance for future research and resource allocation in the Australia and New Zealand trauma system.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Impact of comorbidities on survival following major injury across different types of road users

BACKGROUND

While comorbidities and types of road users are known to influence survival in people hospitalised with injury, few studies have examined the association between comorbidities and survival in people injured in road traffic crashes. Further, few studies have examined outcomes across different types of road users with different types of pre-existing comorbidities. This study aims to examine differences in survival within 30 days of admission among different road user types with and without different pre-existing comorbidities.

METHOD

Retrospective cohort study using data for all major road trauma cases were extracted from the NSW Trauma Registry Minimum Dataset (1 January 2013 - 31 July 2019) and linked to the NSW Admitted Patient Data Collection, and the NSW Registry of Births, Deaths and Marriages - death dataset. Pre-existing comorbidities and road user types were identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and Charlson Comorbidity Index in the Trauma Registry, hospital admission, and death datasets. Logistic regression was used to assess the associations between six types of road users (pedestrian, pedal cycle, two- and three-wheel motorcycle, car and pick-up truck, heavy vehicle and bus, and other types of vehicle) and death within 30 days of hospital admission while controlling for comorbidities. All models used 'car and pick-up truck driver/passenger' as the road user reference group and adjusted for demographic variables, injury severity, and level of impaired consciousness.

RESULTS

Within 6253 traffic injury person-records (all aged ≥15 years old, ISS>12), and in final models, injured road users with major trauma who had a history of cardiovascular diseases (including stroke), diabetes mellitus, and higher Charlson Comorbidity Index score, were more likely to die, than those without pre-existing comorbidities. Furthermore, in final models, pedestrians were more likely to die than car occupants (OR: 1.68 - 1.77, 95CI%: 1.26 - 2.29 depending on comorbidity type).

CONCLUSIONS

This study highlights the need to prioritize enhanced management of trauma patients with comorbidities, given the increasing prevalence of chronic medical conditions globally, together with actions to prevent pedestrian crashes in strategies to reach Vision Zero.

Evaluation of a Hyperbaric Oxygen Therapy Intervention in Individuals with Fibromyalgia

OBJECTIVE

To evaluate the feasibility and safety of hyperbaric oxygen therapy (HBOT) in patients with fibromyalgia (FM).

DESIGN

A cohort study with a delayed treatment arm used as a comparator.

SETTING

Hyperbaric Medicine Unit, Toronto General Hospital, Ontario, Canada.

SUBJECTS

Eighteen patients diagnosed with FM according to the American College of Rheumatology and a score ≥60 on the Revised Fibromyalgia Impact Questionnaire.

METHODS

Participants were randomized to receive immediate HBOT intervention (n = 9) or HBOT after a 12-week waiting period (n = 9). HBOT was delivered at 100% oxygen at 2.0 atmospheres per session, 5 days per week, for 8 weeks. Safety was evaluated by the frequency and severity of adverse effects reported by patients. Feasibility was assessed by recruitment, retention, and HBOT compliance rates. Both groups were assessed at baseline, after HBOT intervention, and at 3 months' follow-up. Validated assessment tools were used to evaluate pain, psychological variables, fatigue, and sleep quality.

RESULTS

A total of 17 patients completed the study. One patient withdrew after randomization. HBOT-related adverse events included mild middle-ear barotrauma in three patients and new-onset myopia in four patients. The efficacy of HBOT was evident in most of the outcomes in both groups. This improvement was sustained at 3-month follow-up assessment.

CONCLUSION

HBOT appears to be feasible and safe for individuals with FM. It is also associated with improved global functioning, reduced symptoms of anxiety and depression, and improved quality of sleep that was sustained at 3-month follow-up assessment.

Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Morbidity and mortality meetings at Australian major trauma centres: A proof of concept study

Background

Morbidity and mortality meetings are held at all Australian major trauma centres and provide a forum to identify problems and improve practices. Meetings should focus on addressing factors in the system to prevent similar errors occurring, rather than individual culpability. This paper describes current meeting practices and assesses the use of a systems approach.

Methods

This proof of concept study used a convenience sample of four Australian major trauma centres. Trauma leaders at each centre were surveyed regarding morbidity and mortality meeting practices. The use of a systems approach was measured by assessing practices against the London Protocol for Systems Analysis of Clinical Incidents. Meeting participants were also surveyed regarding perceptions of the objectives and effectiveness of meetings.

Results

This study found variable utilisation of a systems approach. Cases are not routinely analysed for contributing system factors and effective processes are not always used to correct problems that are identified. Meeting practices also vary between centres in terms of frequency, case selection criteria and use of audit filters. Participants generally view quality improvement as the most important objective of meetings.

Conclusion

Morbidity and mortality meeting practices vary between Australian major trauma centres and a systems approach has not been fully adopted.

Uveal Melanoma UK National Guidelines

The United Kingdom (UK) uveal melanoma guideline development group used an evidence based systematic approach (Scottish Intercollegiate Guidelines Network (SIGN)) to make recommendations in key areas of uncertainty in the field including: the use and effectiveness of new technologies for prognostication, the appropriate pathway for the surveillance of patients following treatment for primary uveal melanoma, the use and effectiveness of new technologies in the treatment of hepatic recurrence and the use of systemic treatments. The guidelines were sent for international peer review and have been accredited by NICE. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website.

Risk factors associated with the severity of injury outcome for paediatric road trauma

Road trauma is one of the most common causes of injury for children. Yet risk factors associated with different levels of injury severity for childhood road trauma have not been examined in-depth. This study identifies crash and injury risk factors associated with the severity of non-fatal injury outcome for paediatric road trauma. A retrospective analysis was conducted of paediatric road trauma identified in linked police-reported and hospitalisation records during 1 January 2001 to 31 December 2011 in New South Wales (NSW), Australia. The linkage rate was 54%. Injury severity was calculated from diagnosis classifications in hospital records using the International Classification of Disease Injury Severity Score. Univariate and multi-variable logistic regression was conducted. There were 2412 car occupants, 1701 pedestrians and 612 pedal cyclists hospitalised where their hospital record linked to a police report. For car occupants, unauthorised vehicle drivers had twice the odds (OR: 2.21, 95%CI 1.47-3.34) and learner/provisional drivers had one and a half times higher odds (OR: 1.54, 95%CI 1.15-2.07) of a child car occupant sustaining a serious injury compared to a minor injury. For pedal cyclists and pedestrians, there were lower odds of a crash occurring during school commuting time and higher odds of a crash occurring during the weekend or on a dry road for children who sustained a serious versus a minor injury. Injury prevention initiatives, such as restraint and helmet use, that should reduce injury and/or crash severity are advocated.

Vaccine-associated Leptospira antibodies in client-owned dogs

Background

Long‐term microscopic agglutination test (MAT) results after vaccination with 4‐serovar Leptospira vaccines are not available for all vaccines used in client‐owned dogs.

Hypothesis/Objectives

To determine antibody responses of client‐owned dogs given 1 of 4 commercially available Leptospira vaccines.

Animals

Healthy client‐owned dogs (n = 32) with no history of Leptospira vaccination for at least the previous year.

Methods

Dogs were given 1 of 4 Leptospira vaccines on week 0 and then approximately on week 3 and week 52. Sera were collected before vaccine administration on week 0 and then within 3 days of week 3, within 2 days of week 4, and approximately on weeks 7, 15, 29, 52, and 56. Antibody titers against Leptospira serovars bratislava, canicola, grippotyphosa, hardjo, icterohemorrhagiae, and pomona and were determined by MAT.

Results

When compared among vaccines, MAT results varied in maximal titers, the serovars inducing maximal titers, and the time required to reach maximal titers. Each vaccine induced at least some MAT titers ≥1 : 800. Most dogs were negative for antibodies against all serovars 1 year after vaccination, and anamnestic responses were variable.

Conclusions and Clinical Importance

Dogs vaccinated with Leptospira vaccines have variable MAT titers over time, and antibodies should not be used to predict resistance to Leptospira infection. MAT titers ≥1 : 800 can develop after Leptospira spp. vaccination, which can complicate the clinical diagnosis of leptospirosis.

A validity study of the Working Group's Orientation Test for individuals with moderate to severe intellectual disability

BACKGROUND

Decline in orientation skill has been reported as an early indicator of Dementia of Alzheimer's Type (DAT). Orientation subtest of the Working Group's Test Battery was examined whether this test is useful to identify DAT patients among adults with moderate to severe ID.

METHODS

Sixteen DAT patients and 35 non-demented normal controls with moderate to severe ID were followed for a year using Orientation Test. The scores on the baseline evaluation and the longitudinal changes over a 1-year period among the DAT patients and the normal controls were compared. The effects of age and etiologies of ID on the performance of Orientation were also examined.

RESULTS

The DAT group's score was significantly poorer than that of the normal control group on the baseline evaluation. The score changes over the 1-year period were not significantly different between the groups. However, there was a considerable overlap between the score distributions of the two groups. The effects of age and etiologies of ID on the performance of Orientation were not significant.

CONCLUSIONS

Screening DAT patients based only on the score of the Orientation Test of the Working Group's Test Battery may produce a large number of diagnostic errors.

A preliminary study of the validity of memory tests recommended by the Working Group for individuals with moderate to severe intellectual disability

BACKGROUND

Normal aging and Dementia of Alzheimer's Type (DAT) among higher functioning individuals with intellectual disability (ID) have been relatively well studied using a variety of cognitive tests. However, cognitive studies for lower functioning individuals with ID are scarce in the literature. The Working Group recommended the Test Battery for the Diagnosis of Dementia in Individuals with various level of ID. Few studies have investigated whether the Test Battery is useful to study dementia among individuals with moderate to severe ID. The purpose of this study is to investigate whether the memory subtests of the Test Battery are useful for measuring memory function and studying DAT in individuals with moderate to severe ID.

METHODS

We compared performances on the memory subtests in the Test Battery between 31 normal controls and 13 DAT patients with moderate to severe ID. Performance on the Picture Recognition Test was also compared between five normal controls and five DAT patients. This test was designed by our team to measure memory functions of individuals with moderate to severe ID.

RESULTS

Among the memory subtests of the Test Battery, the Autobiographical Memory and the Orientation were found to be useful for studying normal and abnormal aging among individuals with moderate to severe ID. Preliminary data for the Picture Recognition Test demonstrated that these individuals properly responded to this test and the majority of DAT patients could be differentiated from the normal controls based on their performance.

CONCLUSIONS

Further studies are necessary to improve usefulness of the memory subtests of the Test Battery for lower functioning individuals with ID. While the results suggest that the Picture Recognition Test may be more effective in discriminating individuals with DAT, given the very small sample sizes, a study with larger sample sizes should be undertaken to validate these findings.

Children as partners with adults in their medical care

AIMS

To investigate the seldom published views of children with type 1 diabetes about their condition and ways in which they share in managing their medical and health care with adults.

METHODS

Semi-structured, tape recorded interviews, during 2003, with a purposive sample of 24 children aged 3-12 years who have type I diabetes and who attend two inner London hospitals and one hospital in a commuter town.

RESULTS

The children reported high levels of understanding, knowledge, and skill gained from their experience of living with diabetes and constantly having to take account of the condition and their paediatrician's guidance. Their key goals were to be "normal" and "just get on with their lives".

DISCUSSION

The interviews showed that children's experiences of diabetes tended to enable them to make informed, "wise" decisions in their own best interests, even at a young age. They achieved a complicated balance between the sometimes competing goals of social health "being normal" and physiological health in controlling glycaemia. Their competence supports approaches in children's rights and in policy makers' aims that people with diabetes--including children--gain more knowledge, skills, and responsibility for their own care in partnership with healthcare professionals. Consent is usually considered in relation to surgery; however the children showed how they constantly dealt with decisions about consent or refusal, compliance with, or resistance to their prescribed treatment. Their health depends on their informed commitment to medical guidance; more research is needed about the daily realities of children's committed and responsible co-management of their chronic illness.

Putting public health evidence into practice: increasing the prevalence of working smoke alarms in disadvantaged inner city housing

STUDY OBJECTIVES

The UK government recommends that local authorities install battery operated smoke alarms to prevent fire related injury. However, a randomised controlled trial of smoke alarm installation in local authority housing found a low level of working alarms at follow up. Qualitative work, which accompanied the trial explored barriers and levers to the use of this public health intervention.

DESIGN

Semi-structured group and individual interviews were conducted with a sample of the adult participants in a randomised controlled trial of free smoke alarm installation. Group interviews and "draw and write" exercises were conducted with children at a local primary school.

PARTICIPANTS

A sample of trial participants and primary school children in the trial neighbourhood.

SETTING

An inner city housing estate in central London.

MAIN RESULTS

The main barrier to smoke alarm use was the distress caused by false alarms. Although trial participants considered themselves to be at high risk for fires and would recommend smoke alarms to others, respondents' reports on the distress caused by false alarms suggest that people balance immediate and longer term risks to their health and wellbeing when they disable alarms.

CONCLUSIONS

This study identified some of the reasons for the low level of functioning smoke alarms, and problems experienced with alarms. The results have implications for the implementation of this public health intervention. The effectiveness of smoke alarm installation could be improved if alarm manufacturers and those responsible for implementation programmes considered ways of tackling the issues raised in this study.

Operational psychology countermeasures during the Lunar-Mars Life Support Test Project

The Crew and Thermal Systems Division at the NASA Johnson Space Center conducted a series of human-rated tests, termed the Lunar-Mars Life Support Test Project (LMLSTP), designed to advance technology in closed life support systems. As the duration of these tests lengthened, the psychological factors associated with placing humans in these environments became increasingly salient to successful mission completion. A number of psychological activities were conducted to ensure successful operations and protect crew member well-being, including individual crew member selection, crew composition, training and preparation, family inclusion, educational briefings, in-mission tracking, operational interventions, and postmission repatriation. This article describes these activities, the rationale behind their design, the similarities and differences to techniques utilized for spaceflight, and considerations related to designing psychological countermeasures for confined environments. In addition to testing physical and engineering systems, the LMLSTP series functioned as an effective testbed for developing operational concepts and countermeasures for extended space missions.

Nurses' experiences of working with trauma patients

AIM

To identify the issues relating to nursing care of trauma patients at St George Hospital in Sydney, Australia.

METHOD

A series of nursing focus groups were conducted with nurses from the emergency department, high dependency surgical ward and several general surgical wards. The nurses were asked seven questions relating to their experience of working with trauma patients.

RESULTS

The resulting data identified recurring themes, such as communication, education, documentation, pain management, workload and resources.

CONCLUSION

It is hoped that the information from the focus groups will lead to an improvement in the communication between healthcare professionals as well as better co-ordination of patient care.

Do community-based support services benefit bereaved children? A review of empirical evidence

AIMS

To consider the evidence of effect from English language, empirically based quantitative evaluations of community-based interventions for bereaved children; community-based interventions being understood as those taking place outside a clinical setting.

METHODS

MedLine, PsychInfo, Applied Social Sciences Index and Sociological Abstracts were searched for documents containing the words 'child', 'bereavement' and 'program', 'group', 'intervention', 'support' or 'evaluation'. The criterion for inclusion was that studies use a control group or pre- and post-test measurements using a standardized instrument.

RESULTS

Nine relevant studies were identified. However, empirical evidence of positive outcomes for children was limited and compromised by methodological weaknesses in the design of the studies. Small sample sizes, irregular attendance, high levels of attrition, short time scales between pre- and post-testing and difficulty in developing appropriate instrumentation, including assessment of adherence to the agreed intervention programme, all created problems.

CONCLUSIONS

The case for universal inclusion of this group of children in such support programmes remains unproven, and further exploration of the outcomes of a range of different community interventions is required, with a specific focus on long-term and/or unwanted effects and evaluation of the basis for referral.

Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center

BACKGROUND

Antibiotic misuse is common and costly and may promote antibiotic resistance. We tested the efficacy of a targeted one-on-one educational program ("academic detailing") designed to improve the appropriateness of broad-spectrum antibiotic use.

METHODS

A randomized controlled trial was conducted in a large US teaching hospital. During an 18-week study period, 17 general medical, oncology, and cardiology services either received academic detailing or did not. The intervention was prompted by an order for either levofloxacin or ceftazidime that led to a computer-based review of data for that patient. Orders for the 2 target antibiotics deemed unnecessary by a priori criteria were included in the study. The primary outcome examined was the number of days that unnecessary levofloxacin or ceftazidime was administered in intervention and control groups.

RESULTS

Before the trial, intervention and control services had similar prescribing patterns for the target antibiotics; the drugs were used for similar indications throughout the study period. During the intervention, there was a reduction of 37% in days of unnecessary levofloxacin or ceftazidime use per 2-week interval on services randomized to the educational intervention vs control services (P< .001). In multivariable analyses controlling for baseline prescribing and study interval, the rate of unnecessary use of the 2 target antibiotics was reduced by 41% on the intervention services compared with controls (95% confidence interval, 44%-78%; P< .001). Length of stay, intensive care unit transfers, readmission rates, and in-hospital death rates were similar in both groups (P> or =.10 for all).

CONCLUSION

Targeted one-on-one education is a practical, effective, and safe method for reducing excessive broad-spectrum antibiotic use.

Refractory hypotension in trauma: a case study

In the patient with blunt trauma, diagnosis of the cause of ongoing hypotension may be difficult. A number of causes may contribute to refractory hypotension, either alone or in combination. However, by following standard algorithms for the management of these patients, causes can be excluded or identified, then managed appropriately. The following case study highlights one of the diagnoses of exclusion for refractory hypotension in the blunt trauma victim. Ongoing considerations and implications for the nursing care of spinal injured patients are also discussed.

Holographic storage of multiple high-capacity digital data pages in thick photopolymer systems

Multiple digital data pages (480 kbits per page) were holographically recorded and retrieved with low bit-error rates in thick (~250- and ~500-mum) photopolymer media. The photopolymer systems were fabricated with the optical quality and low level of scatter required for digital data storage. We believe that these results represent the first demonstration of holographic storage of high-capacity digital data pages in photopolymer media with the thickness that will be required for such storage densities.

Holographic storage using shift multiplexing

We demonstrate theoretically and experimentally a new multiplexing method for volume holographic storage using a single reference beam that is composed of multiple plane waves or is a spherical wave. We multiplex the holograms by shifting the recording material or the recording/readout head. The volume properties of the recording medium allow selective readout of holograms stored in successive overlapping locations. High storage densities can be achieved with a relatively simple implementation by use of the new method.

Cross talk for angle- and wavelength-multiplexed image plane holograms

The cross talk for image plane holograms is calculated and compared with previously derived results for Fourier plane holograms. Image plane storage is found to have significantly smaller cross talk.

Characterization of the DuPont photopolymer for three-dimensional holographic storage

DuPont's HRF-150 photopolymer film is investigated for use in three-dimensional holographic memories. Measurements of sensitivity, hologram persistence, the lateral spread of the photoinitiated reaction, and the variation of diffraction efficiency with modulation depth, spatial frequency and tilt angle, and intensity are reported. We observed that the diffraction efficiency of the HRF-150 photopolymer for a given exposure decreases with increases in intensity and grating tilt angle. The holograms were nondestructively reconstructed for long periods of time at room temperature. The photoinitiated reaction spread less than 100 µm over a period of 16 h.

Method for holographic storage using peristrophic multiplexing

A method of multiplexing holograms by rotating the material or, equivalently, the recording beams is described. Peristropic (Greek for rotation) multiplexing can be combined with other multiplexing methods to increase the storage density of holographic storage systems. Peristrophic multiplexing is experimentally demonstrated with Du Pont's HRF-150 photopolymer film. We multiplexed a total of 295 holograms in a 38-microm-thick photopolymer film by combining peristrophic multiplexing with angle multiplexing.

Total quality improvement according to hospital nursing executives

Total quality management (TQM) is certainly a hot topic in health care today. The Department of Veterans Affairs is not alone in launching the quality movement in their hospitals. The question is, can it succeed. The success of total quality lies in the commitment of the organizations' leaders. Nursing leadership has yet to be studied regarding TQM implementation. Nursing performs a vital role in hospitals, and if nursing leaders are opposed to total quality, then it is highly unlikely that the philosophy will succeed. This study is designed to measure the attitudes and perceptions of VA nursing chiefs regarding the total quality improvement (TQI) process.

Perceptions of VA chiefs of staff on total quality management implementation

A national survey of United States Veterans Affairs (VA) Medical Centers (n = 167) chiefs of staff was conducted. The survey solicited feedback of the attitudes and perceptions of respondents toward planning, implementation, and monitoring of the Total Quality Management (TQM) process in their facilities. A Likert scale type of responses were collected and analyzed to measure the degree of agreement or disagreement of the respondents to survey statements on TQM. The survey included responses to three sections of the questionnaire: 25 statements on TQM, information on the TQM process status in the facility, and demographics of respondents and their facilities. The results of the survey indicate a considerable involvement of responding chiefs of staff in the TQM process and indicated their willingness to support it. Respondents agreed that TQM requires time and commitment of top management, and, again, they indicated their willingness to devote the time necessary for the process to succeed. They were, however, cautious in endorsing the statement that TQM will decrease health care costs (fiscal and human). The survey provides information that should prove valuable to administration in planning TQM and Continuous Quality Improvement efforts.

Cross talk in wavelength-multiplexed holographic memories

The cross talk between wavelength-multiplexed holograms is analyzed. The signal-to-noise ratio (SNR) is calculated for a recording schedule that places the center of each image at the null (in wavelength space) of the adjacent hologram. An asymptotic closed-form expression for the minimum SNR is derived in a general reflection geometry. The reflection geometry with counterpropagating signal and reference beams is shown to have the best SNR.

Hippocampal damage does not impair instrumental appetitive conditioning with delayed reinforcement

The present study evaluated the effects of bilateral hippocampal lesions on appetitive instrumental conditioning with delayed (5-s interval) reinforcement in rats. Acquisition of a bar press response was considerably slower than rates observed with immediate reinforcement; however, no significant differences between hippocampally lesioned and control groups were noted regarding training to criteria or ratio of responses to reinforcements. These results suggest that the hippocampus is not essential for the association of temporally discontinuous stimuli, and that deficits in other forms of associative learning, such as spatial cognition, must be mediated by the loss of other functions. Putative functions and underlying substrates are discussed for response modulation and sensory (cue relations) associations.

Recording of multiple holograms in photopolymer films

Multiple images were recorded in DuPont HRF-150 photopolymer as transmission holograms by using angle multiplexing. Agreement with Kogelnik's two-wave diffraction theory for phase gratings, the time considerations and its effect on dynamic range, the necessity of a pre-illumination pulse, and good image quality at readout are reported.