Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals

BACKGROUND

An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework.

METHODS

We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework.

RESULTS

Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling.

CONCLUSIONS

We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.

Towards an integrated blood pressure self-monitoring solution for stroke/TIA in Ireland: a mixed methods feasibility study for the TASMIN5S IRL randomised controlled trial

BACKGROUND

Optimising blood pressure (BP) control is one of the most important modifiable risk factors in preventing subsequent stroke where the risk increases by one-third for every 10 mmHg rise in systolic BP. This study evaluated the feasibility and potential effectiveness of blood pressure self-monitoring with planned medication titration, to inform a definitive trial of the intervention, in patients with a previous stroke or transient ischaemic attack (TIA).

METHODS

Patients with a history of stroke/TIA and sub-optimal BP control were invited to take part in a mixed methods feasibility study for a randomised controlled trial. Those meeting the inclusion criteria with systolic BP >130 mmHg were randomised to a self-monitoring intervention group or usual care group. The intervention involved self-monitoring BP twice a day for 3 days within a 7-day period, every month, following text message reminders. Treatment escalation, based on a pre-agreed plan by the general practitioner (GP) and patient, was initiated according to the results of these readings. Semi-structured interviews were carried out with patients and clinicians and analysed thematically.

RESULTS

Of those identified, 47% (32/68) attended for assessment. Of those assessed, 15 were eligible for recruitment and were consented and randomised to the intervention or control group on a 2:1 basis. Of those randomised, 93% (14/15) completed the study and there were no adverse events. Systolic BP was lower in the intervention group at 3 months. Participants found the intervention acceptable and easy to use. GPs found it easy to incorporate into their practice activity without increasing workload.

CONCLUSIONS

TASMIN5S, an integrated blood pressure self-monitoring intervention in patients with a previous stroke/TIA, is feasible and safe to deliver in primary care. A pre-agreed three-step medication titration plan was easily implemented, increased patient involvement in their care, and had no adverse effects. This feasibility study provides important information to inform a definitive trial to determine the potential effectiveness of the intervention in patients post-stroke or TIA.

TRIAL REGISTRATION

ISRCTN57946500 . Registered on 12/08/2019.

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

OBJECTIVES

Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds.

RESULTS

The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized.

CONCLUSIONS

In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

Peptide nutrient-energy dense enteral feeding in critically ill infants: an observational study

BACKGROUND

Enteral feeding is challenging in critically ill infants. Target intakes are often not achieved as a result of fluid restriction, procedural interruptions and perceived enteral feeding intolerance. In those infants perceived to have poor feeding tolerance, the use of a peptide nutrient-energy dense enteral feed (PEF) may improve nutritional intake and minimise feeding interruptions as a result of gastrointestinal symptoms. The aim of this observational study was to characterise the use of a PEF amongst critically ill infants in two paediatric intensive care units (PICUs).

METHODS

Records from critically ill infants aged <12 months admitted to two PICUs were retrospectively reviewed with a PICU length of stay (LOS) ≥ 7 days. Achievement of nutritional targets for the duration of PEF was reviewed. Gastrointestinal symptoms, including gastric residual volume, constipation and vomiting, were evaluated as tolerance parameters.

RESULTS

In total, 53 infants were included, with a median age on admission of 2.6 months. Median admission weight was 3.9 kg in PICU-1 and 4.7 kg in PICU-2. Median (interquatile range) energy intake in PICU-1 and PICU-2 was 68 (47-92) and 90 (63-124) kcal kg^-1 , respectively, and median (interquatile range) protein intake 1.7 (1.1-2.4) g kg^-1 and 2.5 (1.6-3.2) g kg^-1 , respectively. Feeding was withheld because of feeding intolerance in one infant (4%) on two occasions in PICU-1 for 2.5 h and in two infants (7%) on two occasions in PICU-2 for 19.5 h. Gastric residual mean (SD) volumes were 3.5 (5.4) mL kg^-1 in PICU-1 and 16.9 (15.6) mL kg^-1 in PICU-2.

CONCLUSIONS

Peptide nutrient-energy dense feeding in infants admitted to the PICU is feasible, well tolerated and nutritional targets are met. However, with this study design, it is not possible to draw any conclusions regarding the benefit of PEF over standard PE feed in critically ill children and future work is required to clarify this further.

A Prospective Randomized, Double-Blind, Two-Period Crossover Pharmacokinetic Trial Comparing Green Coffee Bean Extract-A Botanically Sourced Caffeine-With a Synthetic USP Control

Coffee is a primary dietary source of the chlorogenic acids (CGAs) of phenolic compounds. Coffee contains caffeine and other phytonutrients, including CGAs. Caffeine on its own has been well characterized and descried pharmacokinetically in the literature, less so for CGAs. The purpose of this double‐blind crossover study was to determine the comparative pharmacokinetics of CGAs with caffeine (natural extract) with synthetic caffeine (US Pharmacopeia [USP] standard). Sixteen healthy male subjects were randomly assigned to take 1 dose of product 1, 60 mg of botanically sourced caffeine from 480 mg of green coffee bean extract, or product 2, 60 mg of synthetic USP caffeine, with 5 days between. Blood analysis was done to determine the levels of CGA compounds, more specifically 3‐, 4‐, and 5‐caffeoylquinic acid (CQA), and serum caffeine. The natural caffeine extract exhibited mean peak concentrations (C_max) of 3‐CQA (11.4 ng/mL), 4‐CQA (6.84 ng/mL), and 5‐CQA (7.20 ng/mL). The mean systemic 4‐hour exposure (AUC_0–4 h) was 3‐CQA (27.3 ng·h/mL), 4‐CQA (16.1 ng·h/mL), and 5‐CQA (15.7 ng·h/mL). The median t_max was 3‐CQA (1.00 hour), 4‐CQA (1.00 hour), and 5‐CQA (1.50 hours). The t_max of caffeine was 0.75 hours (natural extract) and 0.63 hours (synthetic caffeine). C_max and AUC_0–4 h of serum caffeine were statistically equivalent between products. The geometric least‐squares mean ratios (GMRs) of C_max and AUC_{0–4 h} of caffeine were 97.77% (natural extract) and 98.33% (synthetic caffeine). It would appear that CGA compounds from the natural caffeine extract are bioavailable, and 3‐CGA may be the compound most absorbed. In addition, caffeine sourced from natural extract versus synthetic were statistically similar for pharmacokinetic parameters. There were no adverse events or safety concerns.

Exploring equity in uptake of the NHS Health Check and a nested physical activity intervention trial

BACKGROUND

Socio-demographic factors characterizing disadvantage may influence uptake of preventative health interventions such as the NHS Health Check and research trials informing their content.

METHODS

A cross-sectional study examining socio-demographic characteristics of participants and non-participants to the NHS Health Check and a nested trial of very brief physical activity interventions within this context. Age, gender, Index of Multiple Deprivation (IMD) and ethnicity were extracted from patient records of four General Practices (GP) in England.

RESULTS

In multivariate analyses controlling for GP surgery, the odds of participation in the Health Check were higher for older patients (OR 1.05, 95% CI 1.04-1.07) and lower from areas of greater deprivation (IMD Quintiles 4 versus 1, OR 0.37, 95% CI 0.18-0.76, 5 versus 1 OR 0.42, 95% CI 0.20-0.88). Older patients were more likely to participate in the physical activity trial (OR 1.04, 95% CI 1.02-1.06).

CONCLUSIONS

Younger patients and those living in areas of greater deprivation may be at risk of non-participation in the NHS Health Check, while younger age also predicted non-participation in a nested research trial. The role that GP-surgery-specific factors play in influencing participation across different socio-demographic groups requires further exploration.

Human hydration level monitoring using embedded piezoresistive microcantilever sensors

Embedded piezoresistive microcantilever (EPM) sensors were used to measure osmolality changes in both saliva mimic solutions and true human saliva. Osmolality changes in human saliva or urine may prove to be reliable, simple, and easy to measure markers for tracking human hydration levels. EPM sensors used in these experiments show good response to osmolality changes in both NaCl-based saliva mimic solutions and to human saliva. The addition of zero-point offset correction to EPM sensors allows for tracking of saliva osmolality changes with high accuracy. Also, the same EPM sensors exhibit a large enough range of osmolality response to make them potentially suitable for urine or blood serum osmolality monitoring.

Thirty-four patients with carcinoma of the cervical esophagus treated with chemoradiation therapy

OBJECTIVE

To review the experience of 2 institutions in the management of localized carcinoma of the cervical esophagus with chemoradiation therapy.

DESIGN

A series of 34 patients received chemoradiation therapy for a 5-year period. All patients were treated with curative intent. Three different regimens were used, all involving concomitant chemotherapy and high-dose radiation therapy. Data relating to toxic effects, local control of disease, and disease-free and overall survival were prospectively collected.

SETTING

Two combined clinics at separate major hospitals where multidisciplinary care is the standard practice for this disease.

PATIENTS

Patients with biopsy-proved carcinoma of the cervical esophagus.

INTERVENTIONS

Patients received 3 different chemotherapy regimens. Two of the regimens used a combination of cisplatin and fluorouracil. The high-dose cisplatin regimen was a large dose of cisplatin (80 mg/m2) given on days 1 and 22 followed by a 96-hour infusion of fluorouracil (800 mg/m2) from days 2 to 5 and from days 23 to 26. The low-dose cisplatin regimen was cisplatin, 20 mg/m2, from days 1 to 5 and from days 22 to 26 and the same 96-hour infusion of fluorouracil. The third regimen used fluorouracil alone. The mean radiation dose administered was 61.2 Gy in 29.6 fractions during 41.8 days using 4- or 6-mV photons and a shrinking field technique.

RESULTS

The results of treatment have shown a high rate of local control, although some patients developed metastases. The local complete response rate following treatment was 91%, and the rate of local control of disease was 88%. The projected actuarial 5-year survival rate was 55%. Death from other causes was common. The acute toxic effects of the treatment were acceptable, with only 5 patients requiring nasogastric feeding or gavage. Two patients died of complications related to strictures.

CONCLUSION

Concomitant chemoradiation therapy, should be the treatment of choice for carcinoma of the cervical esophagus.

Chemoradiation for inoperable non small cell lung cancer: a phase II study using a regimen with acceptable toxicity

Over the past few years there have been numerous schedules of combined modality therapy proposed as being useful in the management of inoperable non-small cell lung cancer (NSCLC). These have generally involved the use of high dose radiation therapy to doses of the order of 60 Gy combined with chemotherapy given prior to or concurrently with the radiation. Concurrent chemotherapy has been given with the intention of being both active in NSCLC and with the role of being a possible radiosensitiser. The most commonly employed drugs have been cisplatin, etoposide, 5-fluorouracil, vindesine and mitomycin. Although response rates of the primary tumour to the combined therapy have been optimistic, there has not been a great survival benefit with the median survival in most series remaining at just over 12 months. In this study we have prospectively treated a group of patients with non-metastatic inoperable NSCLC with a regimen of known acceptable toxicity. These patients were inoperable because they were unfit for surgery or had locally advanced disease. The local radiological response rate was 86% and the median survival for the whole group was 13 months. Adenocarcinomas appeared to do significantly worse than squamous cell carcinomas. Toxicity was acceptable and lower than reported in other similar series. There was one treatment related death. We feel that this combination of radiation therapy and chemotherapy is a reasonable compromise for a disease which still has a very poor outlook.

Multicenter trial validation of a camera-based method to measure Tc-99m mercaptoacetyltriglycine, or Tc-99m MAG3, clearance

PURPOSE

To evaluate an improved camera-based method for calculating the clearance of technetium-99m mercaptoacetyltriglycine (MAG3) in a multicenter trial.

MATERIALS AND METHODS

Tc-99m MAG3 scintigraphy was performed in 49 patients at three sites in the United States and Canada. The percentage of the injected dose of Tc-99m MAG3 in the kidney at 1-2, 1.0-2.5, and 2-3 minutes after injection was correlated with the plasma-based Tc-99m MAG3 clearances. The data were combined with the results obtained in 20 additional patients in a previously published pilot study.

RESULTS

Regression models correlating the plasma-based Tc-99m MAG3 clearance with the percentage uptake in the kidney for each time interval were developed; there was no statistically significant difference among sites in the regression equations. Correction for body surface area statistically significantly (P < .005) improved the correlation coefficient for each time interval. For the 1.0-2.5-minute interval, the body surface area-corrected correlation coefficient for the four combined sites was .87, and it improved to .93 when one outlier was omitted from the analysis. Similar results were obtained with the other time intervals. Independent processing by two observers showed no clinically important differences in the percentage dose in the kidney or in relative function.

CONCLUSION

An improved camera-based method to calculate the clearance of Tc-99m MAG3 was validated in a multicenter trial.

Use of PCR for prenatal and postnatal diagnosis of congenital rubella

A reverse transcription-nested PCR assay (RT-PCR) was evaluated for diagnosis of congenitally acquired rubella in utero and during infancy. RT-PCR was compared with virus isolation for retrospective detection of rubella virus in placental and fetal tissues obtained after termination of pregnancy following primary rubella or rubella virus reinfection. Concordant results were obtained for 85% of samples; rubella virus RNA was detected by RT-PCR alone in four samples, and rubella virus was detected by isolation alone in two samples. Samples were also obtained for prenatal diagnosis of congenital infection; rubella virus RNA was detected in three of seven chorionic villus samples and one of three amniotic fluid samples by RT-PCR, while rubella virus was isolated in only one chorionic villus sample. To demonstrate that the RNA extracted from chorionic villus samples contained amplifiable RNA, a nested RT-PCR was used to detect keratin mRNA. Rubella virus was detected in placenta in two cases in which the fetus was uninfected, and there was no evidence of rubella virus in the placenta from one case in which the fetus was infected. Thus, detection of rubella virus in chorionic villus samples by RT-PCR may not always correctly predict fetal rubella virus infection. RT-PCR was successfully used for the diagnosis of congenitally acquired rubella in infancy. Rubella virus RNA was detected in cyropreserved or formalin-fixed lens aspirates obtained from infants in India with serologically confirmed congenital rubella but not in samples from controls with inherited cataract.

A comparison of two intravenous insulin regimens among surgical patients with insulin-dependent diabetes mellitus

We compared two intravenous insulin regimens among 58 consecutive surgical patients who required perioperative insulin infusions. Patients were randomized to either a standard glucose-insulin-potassium (GIK) infusion or a more complex, tailored two-pump protocol. Both methods provided similar overall glycemic control. However, the two-pump regimen resulted in a significantly greater proportion of finger-prick results in the target range both preoperatively (47.4% vs 60.1%) and postoperatively (52.0% vs 66.4%). The length of stay (15 vs 16 days), duration of infusion (15 vs 16 hours), and number of medical and nursing incidents (18% vs 20%) were similar. Although the two-pump protocol required more changes to the administration rate (2 vs 10), this method was preferred by the nursing staff over the GIK regimen, resulted in more stable glucose control, and is likely to be associated with fewer clinical errors.

Reasons for Rubella Susceptibility among Pregnant Women in West Lambeth

One hundred and thirty-three pregnant women who delivered at St Thomas' Hospital, in 1990 were noted to require rubella vaccination post partum. Fifty-three (39%) had completed a telephone questionnaire in order to determine reasons for susceptibility to rubella. Laboratory reports confirmed that 92 women were rubella seronegative and 27 had low levels of antibody. Of the 53 women interviewed, 25 gave a history of one or more rubella immunizations, 20 had no history of immunization and vaccination history was unknown for eight. Eleven of the 20 unvaccinated women had not been at school in the UK between 11 and 14 years of age. Eighty-seven per cent of the patients' general practitioners had no knowledge of their patients' rubella antibody status. Ninety-four per cent of the 133 women received rubella vaccine post partum. The Department of Health guidelines should be more vigorously implemented in order to identify and immunize remaining rubella susceptible women of child-bearing age. Susceptibility among women with a history of rubella immunization suggests that the seroconversion rate following rubella immunization in clinical practice may be lower than in vaccine trials.

Psychological functioning of children with craniofacial anomalies and their mothers: follow-up from late infancy to school entry

Twenty-three mothers and their 5- to 7-year-old children with craniofacial anomalies (CFA) who were assessed during the child's infancy were followed. Three types of CFA were included: cleft lip and palate (CLP), isolated cleft palate (CP), and sagittal synostosis. Measures of child status focused on behavior-problem frequency and self-concept. Mothers completed self-report measures of emotional well-being, marital satisfaction, and social support. Results indicated that (1) a sizable minority (18%) of the children with CFA had clinically significant behavior-problem scores shown in concordant reports by parent and teacher of behavior problems; (2) individual differences in child functioning within the CFA group were predicted by observational measures of earlier mother-infant interaction during play and teaching situations; (3) mothers of children with CLP reported less favorable social support than mothers of children with CP or sagittal synostosis.

The changing phenotypic appearance of a malignant vulval neoplasm containing both carcinomatous and sarcomatous elements

We describe the changing phenotypic appearance over a 7-year period of a malignant neoplasm of the vulva. This lesion was studied by light and electronmicroscopy and immunohistochemical techniques. The tumour contained both carcinomatous and sarcomatous elements including osteosarcomatous differentiation. To our knowledge osteosarcomatous differentiation has not been reported previously at this site. We submit that the best term for this type of neoplasm, based on tumour differentiation rather than reputed histogenesis, is carcinosarcoma. Tumours such as these occurring in the female genital tract should be distinguished from metastatic mixed Müllerian tumours.

A further look at infection at the time of therapeutic abortion

Microbiological investigations and clinical follow-up were performed on 516 patients undergoing first-trimester termination of pregnancy, over a 2-year period. Chlamydia trachomatis was isolated by pre-operative microbiological screening in 6.7% of patients, gonococcus in 0.4% and Trichomonas vaginalis in 2%. Candida spp and Gardnerella vaginalis were isolated from 16% and 28% of the women, respectively. Patients who had positive cervical chlamydial isolation were significantly younger (less than 22 years) than those who did not. Doctor's clinical diagnosis of genital tract infection was found to be associated with a positive screening result but not with the likelihood of postabortal pelvic infection. Among the 175 patients followed up in the outpatient clinic, 4 of the 15 patients with a positive result for N. gonorrhoeae, C. trachomatis and/or T. vaginalis developed postoperative pelvic infection, which is significantly more than the group who did not harbour any of these three organisms (9/114).

Expression of CD15 antigen in urinary bladder transitional cell carcinoma

The biopsy specimens of 91 patients between the ages of 38 and 94 with transitional cell carcinoma of the bladder were retrospectively reviewed to determine if the expression of CD15 antigen detected by a monoclonal antibody MC2 was correlated with prognosis. Expression was variable, ranging from strong expression of the antigen by only the superficial cells in well differentiated papillary lesions to weak expression by most cells in solid or invasive tumours. In the invasive component there was a correlation between MC2 expression and tumour type, suggesting that the cell surface carbohydrate detected by MC2 may have a role in cell adhesion. There was no correlation between staining and survival. It is concluded that tumour type, grade, and stage remain the best prognostic indicators of urothelial tumours.

Colocalization of fibroblast growth factor binding sites with extracellular matrix components in normal and keratoconus corneas

Basic and acidic fibroblast growth factor (bFGF, aFGF) binding sites were determined in frozen sections of normal and keratoconus corneas. After incubation with I-125 radiolabelled growth factors, corneal binding sites were revealed by autoradiography. The growth factors were localized mainly to Descemet's membrane and to the epithelial basement membrane. FGF binding sites were generally similar in normal and keratoconus corneas. The binding specificity was demonstrated by competitive inhibition experiments with an excess of unlabelled growth factors. The binding sites were sensitive to pretreatment of the corneal sections with heparitinase. We have attributed FGF's basement membrane affinity to one of its constituents, proteoheparan sulfate. Proteoheparan sulfate, laminin, collagen type IV, and fibronectin were all revealed by immunofluorescent techniques. While keratoconus cornea stroma had less laminin but more fibronectin than normal corneas the main difference lied in type IV collagen which was overexpressed in keratoconus epithelium.

Corneal stromal wound healing in rabbits after 193-nm excimer laser surface ablation

An argon fluoride excimer laser (193 nm) with a moving slit delivery system was used to perform anterior myopic keratomileusis in both eyes of 24 New Zealand white rabbits. Rabbits were killed immediately after ablation and at intervals up to 100 days. By slit-lamp microscopy, four rabbits at day 100 exhibited four clear corneas and four corneas had central, spotty, subepithelial haze. Light and electron microscopy documented corneal healing. In the early stages a transient acellular zone in the anterior stroma appeared over a period of three weeks, followed by an increased number of fibrocytes. In the corneas with opacification, focal areas of 20-microns-thick subepithelial scarring were present. An unexpected finding was transient damage to posterior stromal keratocytes and endothelial cells. The endothelium produced a layer of granular material that migrated anteriorly across Descemet's membrane. Immunochemistry at day 6 showed a marked staining for collagen IV, proteoglycans, fibronectin, and laminin.

In vivo binding of topically applied human bFGF on rabbit corneal epithelial wound

We present the results of the first evaluation of human placenta extracted basic fibroblast growth factor (bFGF) in a rabbit corneal epithelium wound-healing model. Healing dose-response experiments after selective epithelial wounding with iodine vapors demonstrated that bFGF accelerated the repair process in a saturable manner. Corneal binding of topically applied 125I-labeled bFGF was investigated using radioassay and autoradiographic techniques. Basic FGF was shown to bind specifically to denuded epithelial basement membrane in a very stable fashion and not to the intact epithelium. No transfer of the topical bFGF to the aqueous humor or any intraocular structure could be observed. The stability of this interaction was further demonstrated by reextracting and characterizing the labeled factor from treated corneas. The specificity of the fixation was documented by in vivo topical competition with unlabeled bFGF or heparin. We propose that bFGF-basement membrane interactions play a role in corneal wound healing.

Angiolymphoid hyperplasia with eosinophilia: report of a case arising from the radial artery

A case of angiolymphoid hyperplasia with eosinophilia arising from the radial artery is presented. Histologically, there was proliferation of atypical endothelial cells forming vascular spaces and solid cords, with a background infiltrate of inflammatory cells and prominent tissue eosinophilia. Immunohistochemical studies demonstrated vimentin and factor VIII related antigen in the endothelial cells. The lymphoid infiltrate was polyclonal. These lesions, which typically occur in the dermis and subcutaneous tissue of the head and neck, are known by a variety of different names reflecting disagreement regarding their pathogenesis. The probable nature of the process is discussed.

Assessment of skin ulcer healing capability by technetium-99m phosphate angiogram and blood-pool images

The accuracy of radionuclide angiography and blood-pool imaging using [99mTc]-phosphate to assess skin ulcer perfusion as an indicator of healing capacity was determined in 50 studies performed on 45 patients with nonhealing ulcers of the lower extremities. Two nuclear medicine physicians without clinical bias, graded the perfusion of the ulcer on the images as normal, increased or reduced with respect to the opposite limb. Patients were followed closely with aggressive local wound care for at least 14 days. Of the 31 ulcers which healed, the radionuclide study correctly predicted 30; of the 19 ulcers which did not heal, 14 were correctly predicted. Eight patients had osteomyelitis; four of those healed and four did not. The radionuclide study predicted healing in seven. Excluding those patients with osteomyelitis, the sensitivity for the radionuclide angiogram and blood-pool image in predicting healing was 96%, specificity was 87%, and accuracy was 93%. This technique is a simple, reliable way to predict the microcirculatory adequacy for ulcer healing. Specificity is diminished in the presence of osteomyelitis.

Two forms of poliovirus VPg result from amino acid modification of a single viral protein

The protein (VPg) covalently attached to the 5' terminus of poliovirus RNA has been reported to resolve into two forms, separable by electrofocusing, yet the viral gene sequence predicts only one apparent gene for VPg. The two VPg species were separated and analyzed for structural differences. The protein contains no phosphorylated amino acid residues other than the junction tyrosine linked to the nucleic acid moiety. After isolation, the acidic form of VPg remains stable, but the more basic form again generates a distribution of both species. This suggests some lability or modification of at least one amino acid residue postsynthesis. The position of the alteration in the protein was localized to the amino-terminal tryptic peptide, containing nine amino acids.

Some electromyogaphy data towards a model of speech poduction

An experiment in electromyography is described ; data on action potentials obtained from m. orbicularis oris is presented. There is every indication that the EMG signal is statistically insignificantly different in duration and amplitude for initial and final /p/ and /b/ in context with several vowels in monosyllabic words. The data is linked to a provisional theory of production.