Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database

INTRODUCTION

Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay.

METHODS

The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05.

RESULTS

A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001).

CONCLUSION

National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.

The Utility of Smartphone-Based Thermal Imaging in the Management and Monitoring of Microvascular Flap Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Smartphone-based thermal imaging (SBTI) has been reported in the literature to be an easy-to-use, contactless, cost-friendly alternative to standard imaging modalities in identifying flap perforators, monitoring flap perfusion, and detecting flap failure. Our systematic review and meta-analysis aimed to evaluate SBTI's accuracy in perforator identification and secondarily evaluate SBTI's utility in flap perfusion monitoring as well as ability to predict flap compromise, failure, and survival.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was performed using PubMed from inception to 2021. Articles were uploaded into Covidence and, following duplicate deletion, were initially screened for use of SBTI in flap procedures through title and abstract screening followed by full-text review. The following data points, if provided, were extracted from each included study: study design, number of patients, patient demographics, perforator number and location, flap number and location, room temperature, cooling method, imaging distance, time from cloth removal, primary (SBTI's accuracy in perforator identification), and secondary outcomes (prediction of flap compromise/failure/survival and cost analysis). Meta-analysis was performed using RevMan v.5.

RESULTS

The initial search yielded 153 articles. Eleven applicable studies with a total of 430 flaps from 416 patients were ultimately included. The SBTI device assessed in all included studies was FLIR ONE. Four studies assessed the SBTI's perforated detection ability and were included in meta-analysis. Smartphone-based thermal imaging correctly identified 378 (93.3%; n = 405) perforators, and computed tomography angiography (CTA) correctly identified 402 (99.2%; n = 402), although in one study SBTI found additional perforators not detected on CTA. A random-effects model was used (I2 = 65%), and no significant difference in perforator detection ability was found between SBTI and CTA (P = 0.27).

CONCLUSIONS

This systematic review and meta-analysis supports SBTI as user- and cost-friendly ($229.99), contactless imaging modality with perforator detection ability comparable to current criterion-standard CTA. Postoperatively, SBTI outperformed Doppler ultrasound in early detection of microvascular changes causing flap compromise, allowing for prompt tissue salvage. With a minimal learning curve, SBTI seems to be a promising method of postoperative flap perfusion monitoring able to be used by all hospital ranks. Smartphone-based thermal imaging could thus increase flap monitoring frequency and lower complication rates, although further study is warranted.

Accuracy of clinical versus oculographic detection of pathological saccadic slowing

Saccadic slowing as a component of supranuclear saccadic gaze palsy is an important diagnostic sign in multiple neurologic conditions, including degenerative, inflammatory, genetic, or ischemic lesions affecting brainstem structures responsible for saccadic generation. Little attention has been given to the accuracy with which clinicians correctly identify saccadic slowing. We compared clinician (n = 19) judgements of horizontal and vertical saccade speed on video recordings of saccades (from 9 patients with slow saccades, 3 healthy controls) to objective saccade peak velocity measurements from infrared oculographic recordings. Clinician groups included neurology residents, general neurologists, and fellowship-trained neuro-ophthalmologists. Saccades with normal peak velocities on infrared recordings were correctly identified as normal in 57% (91/171; 171 = 9 videos × 19 clinicians) of clinician decisions; saccades determined to be slow on infrared recordings were correctly identified as slow in 84% (224/266; 266 = 14 videos × 19 clinicians) of clinician decisions. Vertical saccades were correctly identified as slow more often than horizontal saccades (94% versus 74% of decisions). No significant differences were identified between clinician training levels. Reliable differentiation between normal and slow saccades is clinically challenging; clinical performance is most accurate for detection of vertical saccade slowing. Quantitative analysis of saccade peak velocities enhances accurate detection and is likely to be especially useful for detection of mild saccadic slowing.

MICK (Mobile Integrated Cognitive Kit) app: Feasibility of an accessible tablet-based rapid picture and number naming task for concussion assessment in a division 1 college football cohort

Although visual symptoms are common following concussion, quantitative measures of visual function are missing from concussion evaluation protocols on the athletic sideline. For the past half century, rapid automatized naming (RAN) tasks have demonstrated promise as quantitative neuro-visual assessment tools in the setting of head trauma and other disorders but have been previously limited in accessibility and scalability. The Mobile Interactive Cognitive Kit (MICK) App is a digital RAN test that can be downloaded on most mobile devices and can therefore provide a quantitative measure of visual function anywhere, including the athletic sideline. This investigation examined the feasibility of MICK App administration in a cohort of Division 1 college football players. Participants (n = 82) from a National Collegiate Athletic Association (NCAA) Division 1 football team underwent baseline testing on the MICK app. Total completion times of RAN tests on the MICK app were recorded; magnitudes of best time scores and between-trial learning effects were determined by paired t-test. Consistent with most timed performance measures, there were significant learning effects between the two baseline trials for both RAN tasks on the MICK app: Mobile Universal Lexicon Evaluation System (MULES) (p < 0.001, paired t-test, mean improvement 13.3 s) and the Staggered Uneven Number (SUN) (p < 0.001, mean improvement 3.3 s). This study demonstrated that the MICK App can be feasibly administered in the setting of pre-season baseline testing in a Division I environment. These data provide a foundation for post-injury sideline testing that will include comparison to baseline in the setting of concussion.

Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis

BACKGROUND

Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP).

METHODS

ACS-NSQIP database was accessed to identify patients treated for LE sarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index (BMI) of 57 and 27.4 kg/m,² respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes (3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications.

CONCLUSIONS

Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.

Detection of normal and slow saccades using implicit piecewise polynomial approximation

The quantitative analysis of saccades in eye movement data unveils information associated with intention, cognition, and health status. Abnormally slow saccades are indicative of neurological disorders and often imply a specific pathological disturbance. However, conventional saccade detection algorithms are not designed to detect slow saccades, and are correspondingly unreliable when saccades are unusually slow. In this article, we propose an algorithm that is effective for the detection of both normal and slow saccades. The proposed algorithm is partly based on modeling saccadic waveforms as piecewise-quadratic signals. The algorithm first decreases noise in acquired eye-tracking data using optimization to minimize a prescribed objective function, then uses velocity thresholding to detect saccades. Using both simulated saccades and real saccades generated by healthy subjects and patients, we evaluate the performance of the proposed algorithm and 10 other detection algorithms. We show the proposed algorithm is more accurate in detecting both normal and slow saccades than other algorithms.

New concept: "TARN friendly trauma reporting" (what radiologists say really does matter)

AIM

To establish if detailed review of trauma reports with reference to coding manual improved accuracy of ISS and to establish if demonstrated changes in coding affected performance and tariff payment.

MATERIALS AND METHODS

A study was undertaken which gathered data from 6 months across the five trusts with information on imaging undertaken, mechanism of injury (MOI), Injury Severity Score (ISS), and injury descriptors was included. Patients with ISS near to a best practice tariff boundary of 9 and 16 (5-8 and 11-15) then had their imaging reviewed by the Radiology Department with direct reference to the ISS coding manual. Injuries were then re-coded and ISS recalculated.

RESULTS

Over the 6-month period, 1,693 patients were admitted to the database from the five hospitals. One hundred and sixty-nine (9.9%) patients met the inclusion criteria for review. Thirty-five (20.7%) had a change in abbreviated (region specific) injury code, with 30 a change in the resultant ISS. Three had a decrease in ISS and 27 increased ISS with all 27 moving across an ISS best practice tariff and three moving across two payment tariff boundaries. With re-coding, there was a potential £15,000 of lost revenue from the major trauma centre (MTC) alone.

CONCLUSION

Reporting with reference to ISS description improves the accuracy of ISS significantly. Radiologists improving the descriptions of specific injury patterns and adopting 'Trauma Audit and Research Network friendly' reporting strategies may improve data accuracy, performance, and payment of best practice tariffs to hospitals.

Validity of low-resolution eye-tracking to assess eye movements during a rapid number naming task: performance of the eyetribe eye tracker

OBJECTIVE

To evaluate the performance of the EyeTribe compared to the EyeLink for eye movement recordings during a rapid number naming test in healthy control participants.

BACKGROUND

With the increasing accessibility of portable, economical, video-based eye trackers such as the EyeTribe, there is growing interest in these devices for eye movement recordings, particularly in the domain of sports-related concussion. However, prior to implementation there is a primary need to establish the validity of these devices. One current limitation of portable eye trackers is their sampling rate (30-60 samples per second, or Hz), which is typically well below the benchmarks achieved by their research-grade counterparts (e.g., the EyeLink, which samples at 500-2000 Hz).

METHODS

We compared video-oculographic measurements made using the EyeTribe with those of the EyeLink during a digitized rapid number naming task (the King-Devick test) in a convenience sample of 30 controls.

RESULTS

EyeTribe had loss of signal during recording, and failed to reproduce the typical shape of saccadic main sequence relationships. In addition, EyeTribe data yielded significantly fewer detectable saccades and displayed greater variance of inter-saccadic intervals than the EyeLink system.

CONCLUSION

Caution is advised prior to implementation of low-resolution eye trackers for objective saccade assessment and sideline concussion screening.

A nonlinear generalization of the Savitzky-Golay filter and the quantitative analysis of saccades

The Savitzky-Golay (SG) filter is widely used to smooth and differentiate time series, especially biomedical data. However, time series that exhibit abrupt departures from their typical trends, such as sharp waves or steps, which are of physiological interest, tend to be oversmoothed by the SG filter. Hence, the SG filter tends to systematically underestimate physiological parameters in certain situations. This article proposes a generalization of the SG filter to more accurately track abrupt deviations in time series, leading to more accurate parameter estimates (e.g., peak velocity of saccadic eye movements). The proposed filtering methodology models a time series as the sum of two component time series: a low-frequency time series for which the conventional SG filter is well suited, and a second time series that exhibits instantaneous deviations (e.g., sharp waves, steps, or more generally, discontinuities in a higher order derivative). The generalized SG filter is then applied to the quantitative analysis of saccadic eye movements. It is demonstrated that (a) the conventional SG filter underestimates the peak velocity of saccades, especially those of small amplitude, and (b) the generalized SG filter estimates peak saccadic velocity more accurately than the conventional filter.

Abstract W P140: Post-stroke Oculomotor Abnormalities evident during Objective Eye Tracking but Not under Clinical Assessment

Introduction: Visual abnormalities and manual motor control have been studied extensively after stroke, but an understanding of oculomotor control post-stroke has not.

Recent studies have revealed that in visually guided reaches arm movements are planned during eye movement execution, which may contribute to increased task complexity. In fact, in healthy controls during visually guided reaches, the onset of eye movement is delayed, its velocity reduced, and endpoint errors are larger relative to isolated eye movements.

Our objective in this experiment was to examine the temporal properties of eye movement execution for stroke patients with no diagnosed visual impairment. The goal is to improve understanding of oculomotor control in stroke relative to normal function, and ultimately further understand its coordination with manual motor control during joint eye and hand movements.

We hypothesized that stroke patients would show abnormal initiation or onset latency for saccades made in an eye movement task, as compared to healthy controls.

Methods: We measured the kinematics of eye movements during point-to-point saccades; there was an initial static, fixation point and the stimulus was a flashed target on a computer monitor. We used a video-based eye tracker for objective recording of the eye at a sampling frequency of 2000 Hz (SR Research, Eyelink). 10 stroke subjects, over 4 months from injury and with no diagnosed visual impairment, and 10 healthy controls completed 432 saccades in a serial fashion.

Results: Stroke patients had significantly faster onset latencies as compared to healthy controls during saccades (99.5ms vs. 245.2ms, p=0.00058).

Conclusion: A better understanding of the variations in oculomotor control post-stroke, which may go unnoticed during clinical assessment, may improve understanding of how eye control synchronizes with arm or manual motor control. This knowledge could assist in tailoring rehabilitative strategies to amplify motor recovery. For next steps, we will perform objective eye and hand recordings during visually guided reaches post-stroke to better understand the harmonization or lack thereof after neurologic insult.

Ureteroscopy with laser lithotripsy for urolithiasis in the spinal cord injury population

STUDY DESIGN

Retrospective study.

OBJECTIVES

The purpose of this investigation was to review the outcomes and safety of retrograde ureteroscopic laser lithotripsy (URS) for the treatment of urolithiasis in the spinal cord injury (SCI) population.

SETTING

Virginia, USA.

METHODS

All patients with SCI who underwent URS with holmium:YAG laser lithotripsy for urolithiasis over a 15-year period were identified. Stone size, location and number at presentation were recorded. Information regarding patient characteristics, intra-operative complications, surgical efficacy, stone clearance, peri-operative complications, and follow-up stone events was collected and analyzed.

RESULTS

A total of 67 URS procedures were performed on 29 SCI patients during the study period with an average follow-up of 3.4 years. Patients had an average of 2.3 ipsilateral ureteroscopies. The majority (85.1%) used indwelling catheters for long-term bladder management, and complete stone clearance after the first procedure was 34.3%. Of the 44 cases with residual stones >4 mm, 20 (45.5%) were secondary to technical or procedural limitations. The intra-operative complication rate was comparable to non-SCI studies at 1.5%, but peri-operative complications were significantly higher at 29.9% with the majority due to urosepsis. Factors associated with peri-operative complications include chronic obstructive pulmonary disease, motor incomplete injuries and lack of a pre-operative ureteral stent.

CONCLUSION

URS in the SCI population is an effective treatment for ureteral or renal stones but may be associated with greater risks and reduced efficacy.

COGENT (COlorectal cancer GENeTics): an international consortium to study the role of polymorphic variation on the risk of colorectal cancer

It is now recognised that a part of the inherited risk of colorectal cancer (CRC) can be explained by the co-inheritance of low-penetrance genetic variants. The accumulated experience to date in identifying these variants has served to highlight difficulties in conducting statistically and methodologically rigorous studies and follow-up analyses. The COGENT (COlorectal cancer GENeTics) consortium includes 20 research groups in Europe, Australia, the Americas, China and Japan. The overarching goal of COGENT is to identify and characterise low-penetrance susceptibility variants for CRC through association-based analyses. In this study, we review the rationale for identifying low-penetrance variants for CRC and our proposed strategy for establishing COGENT.

Phase II trial of irinotecan (Ir) plus cisplatin (CDDP) in patients with recurrent or metastatic squamous carcinoma of the head and neck (SCCHN)

6041

Background: Prognosis for recurrent or metastatic SCCHN patients remains poor with median survivals of 6–9 months. Therapies targeting this group are needed. We conducted a single arm Phase II trial of Ir plus CDDP in patients with recurrent or metastatic SCCHN. The goal of this trial was to evaluate the efficacy and toxicity of this combination in advanced SCCHN. Methods: Eligible patients had incurable SCCHN, an ECOG PS of 0–2 and were chemonaive (no prior chemotherapy or chemotherapy for primary disease at least 6 months prior to study entry). A two-stage accrual design (Simon) was used. Irinotecan 65 mg/m2 and CDDP 30 mg/m2 were administered weekly for 4 weeks, followed by a 2 week rest for a 6 week cycle. Due to GI toxicity and neutropenia, the Ir was decreased to 50 mg/m2 with CDDP 30 mg/m2. Response assessment was made after every cycle using WHO criteria. The primary endpoint was response rate. Results: Forty patients were enrolled (male: 33, female:7). Median age was 58 (33–79). Forty and 32 patients were evaluable for toxicity and response, respectively. Reasons for unevaluable: 7 without at least 1 full cycle of therapy; 1 patient with incomplete records. Overall response rate was 34% (11/32 PR) with 18% SD (6/32). Median progression free survival was 2.6 months. The median overall survival was 8.2 months. Toxicity was substantial at Ir 65 mg/m2 with a rate of Grade (G) 3 or 4 toxicity of 82% compared to 56% at Ir 50 mg/m2. For both dose levels, G 3 or 4 nausea and vomiting (23%), diarrhea (15%) and neutropenia (35%) were the most common toxicities. Conclusions: The combination of irinotecan and cisplatin is active in a poor prognosis group of patients. Toxicity of irinotecan at 65 mg/m2 with CDDP 30 mg/m2 is substantial. Irinotecan 50 mg/m2 and CDDP 30 mg/m2 is tolerable and provides a 34% response rate.

No significant financial relationships to disclose.

Point mutations in the pfcrt and pfmdr-1 genes of Plasmodium falciparum and clinical response to chloroquine, among malaria patients from Nigeria

Chloroquine (CQ) resistance in Plasmodium falciparum has been associated with specific point mutations in the pfcrt and pfmdr-1 genes. In the present study, 30 children aged 1-12 years, who were all suffering from acute, uncomplicated, P. falciparum malaria in Ibadan, Nigeria, were evaluated to assess the association between these mutations and clinical outcome following treatment with CQ. The parasites, in blood samples collected pre-treatment and, in those who failed treatment, on the day symptoms re-occurred post-treatment, were genotyped using the polymorphic MSP1, MSP2 and GLURP loci and PCR-RFLP. The results showed that, pre-treatment, all 30 patients had polyclonal infections, the mean numbers of P. falciparum clones detected per infection being 2.6 with MSP1, 4.2 with MSP2 and 2.8 with GLURP. The T76 allele of pfcrt and the Y86 allele of pfmdr-1 were found in 53% and 40%, respectively, of the pre-treatment samples from the 15 patients who failed CQ treatment, but the Y1246 mutation in pfmdr-1 was never detected. Although the parasites from the two patients with high-grade (RIII) resistance to CQ had both of these point mutations, the presence of the T76 allele of pfcrt or the Y86 allele of pfmdr-1 (considered individually) could not be used to predict treatment outcome. However, a high frequency of clonal multiplicity may confound attempts to associate the point mutations in pfcrt or pfmdr-1 with clinical response to CQ. It remains unclear whether the present results represent the characteristics of the predominant parasite populations in the study area. Further studies are needed before the strength of the association between the point mutations identified as markers of drug resistance and clinical outcome can be accurately evaluated, in this and other regions of intense transmission.

Genetic and nongenetic factors associated with variation of plasma levels of insulin-like growth factor-I and insulin-like growth factor-binding protein-3 in healthy premenopausal women

Circulating levels of insulin-like growth factor-I (IGF-I) and insulin-like growth factor-binding protein 3 (IGFBP-3) vary considerably between normal individuals. Recent epidemiological studies have provided evidence that these levels are predictive of risk of several common cancers. To evaluate possible sources of variation of the levels of circulating IGF-I and IGFBP-3 in females, we studied specific candidate genetic and nongenetic factors in 311 nulliparous, premenopausal Caucasian women, 17-35 years of age. Women who used oral contraceptives (OC) had reduced levels of IGF-I (269 versus 301 ng/ml; P = 0.001 adjusted for age) and increased levels of IGFBP-3 (4213 versus 4009 ng/ml; P = 0.002, adjusted for age) compared with nonusers. The ratio of IGF-I:IGFBP-3 was associated with the dose of estrogen contained in the OC (P(trend) = 0.006, adjusted for age). We identified a novel single bp polymorphism in the promoter region of the gene encoding IGFBP-3. This polymorphism was related to the level of IGFBP-3 in the circulation. Mean IGFBP-3 levels were 4390, 4130, and 3840 ng/ml for the AA, AC, and CC genotypes, respectively (P(trend) = 0.006, adjusted for age and OC use). We observed no effect of a recently described polymorphism in the promoter region of the gene encoding IGF-I on the plasma IGF-I level, but there was evidence for a modifying effect of this locus on the influence of OC on the IGF-I level. Our results support the view that circulating IGF-I levels and IGFBP-3 levels are complex traits and are influenced by a number of interacting genetic and nongenetic factors.

Novel promoter polymorphism in insulin-like growth factor-binding protein-3: correlation with serum levels and interaction with known regulators

Insulin-like growth factor (IGF)-binding protein-3 (IGFBP-3) is a major determinant of circulating levels of the IGFs and is clinically useful for the evaluation of GH deficiency and for predicting the response to GH treatment. Recent studies provide evidence that the circulating level of IGFBP-3 is inversely related to the risk of several common cancers, and that antiproliferative agents such as antiestrogens and retinoids act in part by up-regulating IGFBP-3 gene (IGFBP3) expression. Although approximately 50% of the substantial interindividual variability in circulating IGFBP-3 levels is known to have a genetic basis, the specific loci involved are unknown. Direct sequencing of genomic DNA specimens from a multiethnic population identified several single nucleotide polymorphisms in the promoter region of IGFBP3. For the most common single nucleotide polymorphism (nucleotide -202) found to be in Hardy-Weinberg equilibrium, genotype was highly correlated to circulating level of IGFBP-3 in 478 men from the Physicians' Health Study. In vitro, we documented significantly higher promoter activity of the A allele at the -202 locus compared with the C allele, consistent with the relationship observed between genotype and circulating IGFBP-3 (AA > AC > CC). A positive correlation was observed between circulating retinol levels and circulating IGFBP-3 levels; subset analysis by genotype showed that this relationship was only present among individuals carrying an A allele at -202 (AA > AC > CC). Tall individuals or individuals with a body mass index of 27 or greater had levels of circulating IGFBP-3 that were significantly higher when they possessed at least one A allele (AA > AC > CC). The IGFBP3 promoter region deserves investigation as a locus where polymorphic variation occurs frequently and may influence GH responsiveness, somatic growth, and possibly cancer risk.

Edge enhancement and edge-enhanced correlation with photorefractive polymers

We demonstrate a simple all-optical realization of programmable edge enhancement and edge-enhanced correlation using novel photorefractive polymers. We show that the higher non-Bragg order in a two-beam coupling scheme contains the edge enhancement of the object when placed in the path of one of the incident beams. Also, this arrangement provides a scheme for writing joint transform correlation dynamic holograms, which can be read by a third beam. The correlation is edge enhanced, and the correlation peak increases with the applied bias voltage. Numerical results without and with beam fanning are presented. Theoretical predictions are reconciled with experimental results.

Glycerol as a correlate of impaired glucose tolerance: dissection of a complex system by use of a simple genetic trait

Glycerol kinase (GK) represents the primary entry of glycerol into glucose and triglyceride metabolism. Impaired glucose tolerance (IGT) and hypertriglyceridemia are associated with an increased risk of diabetes mellitus and cardiovascular disease. The relationship between glycerol and the risk of IGT, however, is poorly understood. We therefore undertook the study of fasting plasma glycerol levels in a cohort of 1,056 unrelated men and women of French-Canadian descent. Family screening in the initial cohort identified 18 men from five families with severe hyperglycerolemia (values above 2.0 mmol/liter) and demonstrated an X-linked pattern of inheritance. Linkage analysis of the data from 12 microsatellite markers surrounding the Xp21.3 GK gene resulted in a peak LOD score of 3.46, centered around marker DXS8039. In addition, since all of the families originated in a population with a proven founder effect-the Saguenay Lac-St.-Jean region of Quebec-a common disease haplotype was sought. Indeed, a six-marker haplotype extending over a region of 5.5 cM was observed in all families. Resequencing of the GK gene in family members led to the discovery of a N288D missense mutation in exon 10, which resulted in the substitution of a highly conserved asparagine residue by a negatively charged aspartic acid. Although patients with the N288D mutation suffered from severe hyperglycerolemia, they were apparently otherwise healthy. The phenotypic analysis of the family members, however, showed that glycerol levels correlated with impaired glucose metabolism and body-fat distribution. We subsequently noted a substantial variation in glycerolemia in subjects of the initial cohort with normal plasma glycerol levels and demonstrated that this variance showed significant family resemblance. These results suggest a potentially important genetic connection between fasting glycerolemia and glucose homeostasis, not only in this X-linked deficiency but, potentially, in individuals within the "normal" range of plasma glycerol concentrations.

Leadership: the elusive search for fit

When filling important jobs, a good fit now works both ways. "Recruiting is an attitude," says one executive search pro. "And it's marketing." It's also equal parts horse sense, careful interviewing, and soul-searching. No matter how down-pat your organization's recruiting process, a refresher will keep you on your toes and a bad fit from disrupting your strategy--or your sleep.

Caring About Women and Cancer (CAWAC): a European survey of the perspectives and experiences of women with female cancers

This paper reports on the findings of the largest ever European survey of female patients' perceptions of their cancer treatment. It has provided clarification of what women consider important in relation to their management and has identified several areas where more research is needed. It has shown that women's knowledge about cancer before diagnosis is poor and the number undergoing regular screening could be improved. Women are not being adequately prepared and educated about what to expect from treatment and steps should be taken as a matter of urgency to redress this shortcoming. It was revealed that whilst families were the primary source of support to female cancer patients, women also derive considerable support from healthcare professionals, particularly senior doctors; more attention should be paid by specialists and nurses to developing psychological skills to cope with this. In this context, further research is needed into how support groups may best meet patient needs.

Retooling the basics

Spending on staff training in health care lags behind other fields, but several hospitals are getting ahead of the curve with innovative programs. They're offering classes to department managers, clinicians, even housekeeping staff. "Before, we were considered managers without brains," says the education coordinator at one hospital. "Now you have ownership, responsibility, and authority. The morale at the hospital is the best it's ever been."

A sharper point on using safer needles

National legislation is just one sign of changing attitudes about safety needles. Fifteen states are considering similar bills; five already have passed such laws. OSHA also says it will put needlestick injuries on its agenda this fall. Yet if needlesticks and efforts to prevent them are nothing new, what's causing this change of heart? Two things: improved technology and media attention.

Evidence for host-specific clades of tetraphyllidean tapeworms (Platyhelminthes: Eucestoda) revealed by analysis of 18S ssrDNA

Sequence data from the V4 and V7-V9 variable regions of the 18S small subunit ribosomal DNA (ssrDNA) gene were used to examine relationships among 26 tetraphyllidean and two lecanicephalidean taxa. Newly collected specimens of 21 of the tetraphyllidean species were used to generate ssrDNA sequences that were combined with sequences previously available, including those of two diphyllidean taxa used for outgroup rooting. The sequences were aligned by eye according to secondary structural motifs of the conserved core of the molecule. Of the 1520 sites in the alignment, 874 (58%) were excluded from analysis due to alignment gaps and lack of positional homology as inferred by manual inspection. Genetic variability of the ssrDNA gene regions compared was greater than would be expected, based on the present taxonomy of the ingroup species, and the genetic divergences among tetraphyllidean 'families' and genera were comparable to that among tapeworm orders. Phylogenetic hypotheses were generated by the methods of maximum parsimony and maximum likelihood (GTR + I + Gamma nucleotide substitution model). Four most parsimonious trees resulted from analysis by maximum parsimony. Strict consensus of the four trees supported the monophyly of the Tetraphyllidea, with the lecanicephalidean taxa forming a sister lineage. Among the tetraphyllidean taxa included in the analysis were three major clades: a basal clade including species of the phyllobothriid genera Anthocephalum, Echeneibothrium, Rhinebothrium, Rhodobothrium and Spongiobothrium; a clade uniting the phyllobothriids of the genus Duplicibothrium with the dioecotaeniid genus Dioecotaenia; and a larger sister clade to the Duplicibothrium + Dioecotaenia clade that included the phyllobothriid genera Caulohothrium, Ceratobothrium, Clistobothrium, Paraoryigmatobothrium and Prosobothrium, the litobothriid genus Litobothrium and the onchobothriid genera Acanthobothrium, Calliobothrium, Phoreiobothrium and Platybothrium. Maximum likelihood analysis resulted in a topology that was congruent where nodes were strongly supported by parsimony analysis, but differed in the relative positions of the well-supported clades. In addition,maximum likelihood analysis grouped the lecanicephalidean taxa among the tetraphyllidean taxa, indicating paraphyly of the order Tetraphyllidea as currently defined. Relationships suggested by both methods of analysis reflected common host associations of the taxa better than their current classification, suggesting that coevolution has had a significant role in the evolution of the group.

Selling brand MD

Health care is more than local, of course: It's personal. Recognizing the connections between doctors and patients as a potent form of brand loyalty, health systems are looking for ways to leverage those bonds--and encourage new ones--with special marketing campaigns.

Chartbook. Quality checkup

With hospital quality programs, the reach is broad, not deep. So says the National Hospital Quality Improvement Survey, conducted by health care researcher Stephen Shortell for Arthur Andersen and the American Hospital Association. Though 93 percent of responding hospitals and health systems use CQI and TQM methods is some fashion, they've taught them to only 35 percent of employees and a scant 22 percent of doctors on their medical staffs. Those poor showings leave health care lagging behind most other industries.

Buy vs. bye

At first, the retreat of practice management companies looked like a great opening for hospitals. What better way to acquire prime medical groups from motivated sellers? Trouble is, you still need a motivated buyer. That's why some observers contend hospitals will purchase only a fraction of medical groups being divested by MedPartners and other retrenching firms.

Budget battlers ... profiles

If managed care discounts give you a headache, you'll get a migraine figuring your losses from the 1997 Balanced Budget Act--they're an 8 on the Richter scale, says one hospital policy pro. The savvy aren't waiting to act: Around the country, hospitals are fighting the cuts on the national front and battling back at home. H&HN profiles five.

Marketing nets out. Spending--and expecting--more than ever, hospitals and systems take their message to the Web

Live on the Web, it's open-heart surgery--a showroom window on sweeping new marketing plans. Along with perennial promos like radio and TV ads, health systems have tapped the power of the Internet to hard-wire their organizations for growth. But marketing must be linked to operations as never before.

Procedure to protect confidentiality of familial data in community genetics and genomic research

The collection of familial data is an essential step for community genetics programs or genetic research. Ethical issues concerning privacy and confidentiality present a major challenge in such programs. In order to keep familial data confidential, we have developed a family-based numerical coding procedure which allows the use of confidential data and the determination of familial relationships without risk of disclosure. This procedure is composed of two parts: the physical separation of identifying information and individual data; and the use of a code containing all the information required to build family trees. This procedure has been used in Eastern Quebec since 1995, mainly for screening, genetic counseling, research on familial dyslipidemias, public health intervention, and research projects on the genetics of complex traits, such as arterial hypertension and coronary artery disease.

Be on the lookout

The cost coil tightens. The Net widens. Alternative care booms. And higher tech means more trade-offs. These and other trends play out in a new health care environmental assessment created by VHA and Deloitte & Touche--an Executive Chartbook exclusive to H&HN.

Off target

Leave it to the market. It's our collective corrective, the American way of problem-solving. So it's no surprise that we looked to the market to stop runaway health care costs. For awhile, it seemed to work. Medicare HMOs, physician practice management, risk contracting, and other innovations boomed. Then came the setbacks, exposing health care's complexities and contradictions--and reminding us that nothing escapes market discipline.