Preinduction activities: a closed malpractice claims perspective

The American Association of Nurse Anesthetists Foundation conducts an ongoing study of closed malpractice claims that involve nurse anesthetists. A team of 8 CRNA researchers has to date investigated 223 closed claim files from the St Paul Fire and Marine Insurance Company. Research findings have demonstrated that failure to provide appropriate anesthesia care relative to the Scope and Standards for Nurse Anesthesia Practice was significantly associated with adverse anesthetic outcomes. Claims that involved inadequate preinduction activities (n = 22) were analyzed in the context of their compliance with published standards of care. The largest group of claims in this analysis (59%) involved damaging respiratory events, 28% entailed damaging cardiovascular events, and the principal issue in 13% of these claims involved failure to seek available information such as laboratory studies on the medical record. The most prevalent occurrence with damaging respiratory events was undocumented airway assessment in 27% of the claims. In 55% of these claims, the medical history was not completely documented. The surgical procedure categories were general surgical (32%), obstetrical (27%), otolaryngogical (23%), orthopedic (14%), and gynecologic (5%). The involved standards of care are reviewed, and recommendations are made regarding consistent completion of preinduction activities.

Phylogenetic relationships of Loasaceae subfamily Gronovioideae inferred from matK and ITS sequence data

Members of subfamily Gronovioideae are distinctive among Loasaceae in their androecial and gynoecial simplicity. The four genera of the subfamily differ, however, in chromosome number, floral novelties, and pollen exine sculpturing, which led to suggestions that the Gronovioideae were polyphyletic. Phylogenetic analyses based on sequences of the chloroplast gene matK and the internal transcribed spacer region (ITS) of nuclear rDNA have been conducted using parsimony and maximum likelihood methods to assess the monophyly of Gronovioideae and to determine the sister group relationships of gronovioid genera. The results show Gronovioideae are monophyletic and placed as the sister to Mentzelia. Within Gronovioideae, Petalonyx is sister to a clade consisting of Cevallia, Gronovia, and Fuertesia. Among the remaining Loasaceae, subfamily Mentzelioideae, as originally circumscribed, is paraphyletic. Subfamily Loasoideae is placed as the sister to the Gronovioideae-Mentzelia clade.

Phylogenetic relationships among Acanthaceae: evidence from noncoding trnL-trnF chloroplast DNA sequences

We used sequence data from the intron and spacer of the trnL-trnF chloroplast region to study phylogenetic relationships among Acanthaceae. This region is more variable than other chloroplast loci that have been sequenced for members of Acanthaceae (rbcL and ndhF), is more prone to length mutations, and is less homoplasious than these genes. Our results indicate that this region is likely to be useful in addressing phylogenetic questions among but not within genera in these and related plants. In terms of phylogenetic relationships, Elytraria (representing Nelsonioideae) is more distantly related to Acanthaceae sensu stricto (s.s.) than Thunbergia and Mendoncia. These last two genera are strongly supported as sister taxa. Molecular evidence does not support monophyly of Acanthaceae s.s., although there is strong morphological evidence for this relationship. There is strong support for monophyly of four major lineages within Acanthaceae s.s.: the Acanthus, Barleria, Ruellia, and Justicia lineages as here defined. The last three of these comprise a strongly supported monophyletic group, and there is weaker evidence linking the Ruellia and Justicia lineages as closest relatives. Within the Acanthus lineage, our results confirm the existence of monophyletic lineages representing Aphelandreae and Acantheae. Lastly, within the Justicia lineage, we develop initial hypotheses regarding the definition of sublineages; some of these correspond to earlier ideas, whereas others do not. All of these hypotheses need to be tested against more data.

Drug therapy for nocturnal enuresis. Current treatment recommendations

It is estimated that enuresis occurs in 5 to 7 million children in the United States. The treatment approach for enuresis is controversial, in large part due to a lack of consensus as to the exact cause of enuresis. Several factors either alone or together may contribute to this syndrome. In addition, there is strong evidence of a genetic component to enuresis. Pharmacotherapy continues to be the preferred treatment for both physicians and families. The most widely used drugs include antidepressants, anticholinergics, and desmopressin. The tricyclic antidepressant imipramine has been used extensively since the 1960s. The exact mechanism of action in enuresis is unknown although it appears to be related to the anticholinergic and antispasmodic effects of the drug. The most common adverse effects reported with imipramine include personality changes, insomnia, anorexia and anxiety. There has been renewed interest in antidiuretic treatment of enuresis. Researchers have found that enuretic children do not have the ability to reduce urine volume at night or concentrate the urine they produce during the night. Clinical trials with desmopressin administered by nasal inhalation report a marked reduction in enuretic episodes. Adverse effects were limited to nasal complaints, rhinitis, or epistaxis. Additional long term studies are needed to delineate desmopressin's role in therapy. Although the number of options for treatment of enuresis is expanding, criteria to predict patient response need to be defined.

The effects of fibular and talar displacement on joint contact areas about the ankle

The purpose of this study was to advance prior techniques and studies regarding the effects of fibular and talar displacement of contact areas of the tibio-talar joint. Type IV supination external rotation injuries were experimentally created on five fresh cadaveric specimens. Tibio-talar contact and peak pressures were measured using Fuji pressure-sensitive film with the talus in a neutral position and then displaced 1, 3, 4, 5, and 8 mm laterally as well as a repeat measurement following reduction and plate fixation. Results demonstrated a 50% reduction in contact area with only 1 mm of talar displacement along with a linear increase in average peak pressures. Reapproximation of the fibular osteotomy with a plate and rereduction of the talus allowed for return to normal pretesting contact areas. This study confirms prior studies demonstrating the significance of 1 mm of talar displacement in regards to marked reduction in contact area of the tibio-talar joints. In addition, restoration of the normal anatomy and fixation of the osteotomy allows for return of normal contact areas.

Revising a drug information center quality assurance program to conform to Joint Commission standards

Revisions in the quality assurance (QA) program for a drug information center (DIC) at a large community teaching hospital are described. The initial QA program, implemented in 1984, was based on 25 specific criteria and on the periodic evaluation process that was stressed by the Joint Commission on Accreditation of Hospitals at that time. In 1985 the hospital was surveyed for reaccreditation, and the Joint Commission stressed a new approach to QA that replaced periodic evaluation with an ongoing, planned process. Accordingly, the 25 specific QA criteria were replaced with 10 general indicators. Since 1985 the Joint Commission has shifted its focus to patient outcomes. The 10 general criteria have now been reduced to two specific criteria: the total number of questions received by the DIC staff and the percentage of responses that are appropriate. Drug information responses given by the DIC pharmacist as well as by the frontline pharmacists are monitored. As Joint Commission requirements for QA programs evolve, the QA program for this DIC is revised to ensure that it always meets the current standards.