Evaluation of the accuracy of 3-dimensional ultrasonography of the kidney using an in vitro renal model

OBJECTIVE

Three-dimensional ultrasonography (3DUS) has recently become a reality because of advances in ultrasound probes and machine processing ability. We have developed an anthropomorphic phantom of the human loin to assess both the accuracy of 3DUS of the kidney and its potential usefulness for training in ultrasonographically guided percutaneous renal intervention.

METHODS

The model was built with easily available and inexpensive materials such as agar and latex with known ultrasonographic properties. The accuracy of 2-dimensional ultrasonography (2DUS) and 3DUS was assessed by measuring the dimensions of the pelvicalyceal system (PCS) ultrasonographically (pelvis width and calyx diameters) and then comparing these with measurements obtained at the time of construction. Radiology interventional trainees then punctured the PCS with 2DUS and 4-dimensional ultrasonographic (real-time/time-resolved 3DUS) guidance and reported the phantom's performance.

RESULTS

The 3-dimensional nature of the model's PCS could be clearly visualized on 2DUS and 3DUS, and the scan characteristics were very similar to those in real life. Measurements using 3DUS proved to be closer to the true dimensions of the model's PCS than those using 2DUS. The mean error percentage for 2DUS measurements was -10.2%, and that for 3DUS was -2.2% (P < 0.0001). Interventional trainees were satisfied with the "tissue feel" and level of difficulty posed on puncturing the phantom.

CONCLUSIONS

Three-dimensional ultrasonography proved to be more accurate than 2DUS for intrarenal measurements using this in vitro renal model. Three-dimensional ultrasonography has the potential to ease diagnostic renal scanning with the ability to further scrutinize and postprocess the scanned volumes. The model was realistic in its anthropomorphic properties and simulated human tissue during puncture.

Multi-modality imaging of N-methyl-N-nitrosourea-induced mammary tumors by MRI and small animal PET

Abstract #6008

Background: We evaluated the use of high resolution Magnetic Resonance Imaging (MRI) and small animal Positron Emission Tomography (PET) imaging in assessing tumor proliferation and response to therapy in N-methyl-N-nitrosourea (MNU)-induced mammary tumors.&#x2028; Materials and Methods: The study comprised of 30 untreated MNU rats, 6 Targretin-treated MNU rats, and 6 Vorozole-treated MNU rats. Rats received a baseline imaging session when they developed their first palpable mammary tumor and were subsequently randomized into a control group or a treatment group with either Targretin (220mg/kg in the diet) or Vorozole (1.25mg/kg body weight by gavage). Treatment lasted for 8 weeks following the baseline imaging session. Each rat was imaged for 10-weeks at 2-week intervals with a) FDG to assess the metabolic state of tumors, b) MRI to monitor tumor volume, and c) [18F]ISO-1, a Sigma-2 radiolabeled ligand, to assess the proliferative status of MNU-induced tumors. Static images (10-minute) were obtained 60-minutes post-injection of FDG and [18F]ISO-1. In untreated tumors, a minimum of 40 PET outcome measures were assessed for their ability to predict changes in MRI-derived volume measurements between consecutive imaging sessions. In addition, regression analysis was performed to assess the correlation (R) between the measures. In treated tumors, the time-course of changes in PET outcome measures relative to baseline was evaluated to assess the efficacy of Targretin and Vorozole, in particular in characterizing short-term response (initial 2-weeks) and response to treatment withdrawal (weeks 8-10).&#x2028; Results: An index characterizing a MRI-normalized [18F]ISO-1 uptake significantly correlated (R=0.7, P&lt;0.0003) with changes in tumor volume between consecutive imaging sessions in untreated tumors. In contrast, there was no correlation between FDG outcome measures and changes in tumor volume. Targretin had the strongest short-term efficacy with a reduction in tumor load, on average, by as much as 60% compared with Vorozole's 20% reduction in tumor load. We observed higher rate of tumor resurgence in rats treated with Vorozole compared with Targretin, suggesting a residual effect of Targretin. In general, PET outcome measures of both FDG and [18F]ISO-1 delineated short-term response to treatment and non-responding tumors. [18F]ISO-1 was more sensitive than FDG in capturing tumor growth following treatment withdrawal at week 8.&#x2028; Conclusion: MRI and small animal PET provide a platform to assess MNU-induced tumor proliferation and the efficacy of therapeutic interventions non-invasively, as demonstrated in this work.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6008.

Percutaneous renal intervention: comparison of 2-D and time-resolved 3-D (4-D) ultrasound for minimal calyceal dilation using an ultrasound phantom and fluoroscopic control

The rapid advances made by ultrasound in recent years have increasingly taken 3-D ultrasound (3DUS) and 4-D ultrasound (4DUS) from the research setting to the patient's bedside. There are still unexplored areas like renal percutaneous intervention, where 4DUS has yet to be proven an effective tool. Ultrasound-only guidance in renal percutaneous access is used in selected well-dilated pelvi-calyceal systems (PCS), and fluoroscopy is often utilized as an adjunct. Our aim was to compare 2-D and 4-D guidance for punctures, with fluoroscopy as control, using an in vitro ultrasound phantom. Agar and latex were the tissue-mimicking materials used for the construction of the phantom. The latex targets were designed to simulate multidirection-facing minimally dilated renal calyces. Two interventional fellows punctured the "calyces" using first 2DUS and then 4DUS guidance, making use of a different set of targets each time. The time to puncture, time to introduction of wire, quality of puncture (judged on fluoroscopy) and global rating of both modalities were documented. There was no significant difference between the times to puncture using 2DUS (1.8 min) and 4DUS (2 min). Nor was there a significant difference in the quality of puncture. 4DUS had a higher median difficulty rating. The multiplanar reformatted (MPR) longitudinal and transverse images were found to be the most useful for needle guidance. Cross hairs in all MPR images were not just useful in aligning the images on target but also as surrogate targets. The phantom was found to be robust, with only one instance of air introduction after 30 punctures. We have found that 4DUS is at least as good as 2DUS in terms of quality of punctures in vitro. The technology still has some way to go as frame rates, transducer size and resolution improve.

An evidence-based definition of lifelong premature ejaculation: report of the International Society for Sexual Medicine Ad Hoc Committee for the Definition of Premature Ejaculation

OBJECTIVE

To develop a contemporary, evidence-based definition of premature ejaculation (PE).

METHODS

There are several definitions of PE; the most commonly quoted, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - 4th Edition - Text Revision, and other definitions of PE, are all authority-based rather than evidence-based, and have no support from controlled clinical and/or epidemiological studies. Thus in August 2007, the International Society for Sexual Medicine (ISSM) appointed several international experts in PE to an Ad Hoc Committee for the Definition of PE. The committee met in Amsterdam in October 2007 to evaluate the strengths and weaknesses of current definitions of PE, to critically assess the evidence in support of the constructs of ejaculatory latency, ejaculatory control, sexual satisfaction and personal/interpersonal distress, and to propose a new evidence-based definition of PE.

RESULTS

The Committee unanimously agreed that the constructs which are necessary to define PE are rapidity of ejaculation, perceived self-efficacy, and control and negative personal consequences from PE. The Committee proposed that lifelong PE be defined as a male sexual dysfunction characterized by ejaculation which always or nearly always occurs before or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. This definition is limited to men with lifelong PE who engage in vaginal intercourse. The panel concluded that there are insufficient published objective data to propose an evidence-based definition of acquired PE.

CONCLUSION

The ISSM definition of lifelong PE represents the first evidence-based definition of PE. This definition will hopefully lead to the development of new tools and patient-reported outcome measures for diagnosing and assessing the efficacy of treatment interventions, and encourage ongoing research into the true prevalence of this disorder, and the efficacy of new pharmacological and psychological treatments.

Portable ultrasonography and bladder volume accuracy--a comparative study using three-dimensional ultrasonography

OBJECTIVES

To compare the ultrasound bladder volume accuracy and level of agreement between two portable bladder scanners (Bladderscan and Bardscan) and a three-dimensional ultrasound (3D-US) system.

METHODS

A total of 50 healthy volunteers were scanned using the Bladderscan BVI 3000, Bardscan, and 3D-US system (HDI 4000), in random sequence. The BVI3000 is a dedicated bladder volume calculator, and the Bardscan combines real-time ultrasonography with bladder volume calculation. The ultrasound bladder volumes were compared with the voided volume measurements. The volunteers underwent repeat scanning after voiding, and those with a measurable residual volume were excluded from the final analysis.

RESULTS

A residual volume was detected in 16 subjects (32%). In the remaining 34 subjects, the mean voided volume +/- standard deviation was 252.9 +/- 167.4 mL (range 33 to 709). A significant correlation (P <0.001) was found between the voided and ultrasound volumes with all three methods (Bardscan, r = 0.97; Bladderscan, r = 0.98; and 3D-US system, r = 0.99). No significant differences were found between the voided volumes and the Bladderscan or 3D-US volumes; however, the Bardscan significantly underestimated the voided volume by a mean of 21.4 mL (t = 2.84, P = 0.0076). The Bland-Altman 95% limit of agreement between the voided and calculated volumes was -64.5 to 107.2 mL, -73.7 to 88.4 mL, and -28.9 to 40.0 mL for the Bardscan, Bladderscan, and 3D-US systems, respectively.

CONCLUSIONS

The results of our study have shown that although the Bardscan has the advantages of real-time scanning with portability and instantaneous volume calculation, it is not as accurate as the Bladderscan. The accuracy and level of clinical agreement was greatest when using the 3D-US system to calculate the bladder volume.

ORIGINAL RESEARCH—EJACULATORY DISORDERS: Trends in Research on Premature Ejaculation Over the Past 25 Years

INTRODUCTION

The authors posit that, among other things, the increasing popularity of pharmacological remedies has reinvigorated research interest in premature ejaculation (PE). However, the authors also posit that the emphasis has shifted from psychological-behavioral studies to biological-pharmacological studies, thereby distracting researchers from potent psychological/relationship factors known to play important roles in the recovery of overall sexual satisfaction.

AIM

To explore actual patterns of research on PE, the authors determined trends in the overall quantity and focus of PE research over the past 25 years.

METHODS

The two major databases, PsychINFO and MEDLINE, were searched from 1979 to 2006 using several key words to identify all PE-related publications.

MAIN OUTCOME MEASURES

Referenced articles on PE were cataloged by year and assigned to broad hypothetically and empirically based categories representing different approaches to the study of this dysfunction.

RESULTS

MEDLINE, but not PsychINFO, exhibited a large increase in publications on PE over the past decade. Although the number of publications on PE increased only in MEDLINE, the 25-year trend showed a decline in the proportion of psychological behavior articles in both databases and a concomitant rise in biological and pharmacological articles.

CONCLUSIONS

Although several explanations might account for these research trends, the authors worry that researchers are missing the opportunity to investigate important biobehavioral interactions underlying ejaculatory response and dysfunction, and to augment the current biopharmacological paradigm by integrating cognitive-behavioral and sex therapy programs into pharmacological PE treatment.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision as an Appropriate Diagnostic for Premature Ejaculation

INTRODUCTION

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria for premature ejaculation (PE) are multifactorial, and include concepts of latency, perceived control over ejaculation, and personal distress and interpersonal difficulty related to the condition. Recent publications have suggested that these criteria are not supported by empirical evidence, leading to the proposal that a PE diagnosis should be based solely on intravaginal ejaculatory latency time (IELT), while the presence of other factors (such as perceived lack of control over ejaculation) may be used to guide treatment decisions.

AIM

To examine the evidence supporting the elements of the DSM-IV-TR criteria for PE.

MAIN OUTCOME MEASURES

Literature searches on IELT, perceived control over ejaculation, and personal distress and interpersonal difficulty related to ejaculation.

RESULTS

From a historical perspective, there has been a lack of large observational studies that evaluated the contributions of the DSM-IV-TR components in men with PE. However, recently performed large observational studies have generated data supporting the inclusion of perceived control over ejaculation and personal distress related to ejaculation in the definition of PE. Furthermore, emerging evidence indicates that a perceived lack of control over ejaculation is directly associated with elevated personal distress related to ejaculation and decreased satisfaction with sexual intercourse, while the effects of IELT on these parameters are indirect, and mediated by perceived control over ejaculation. A key advantage of the DSM-IV-TR approach to the diagnosis of PE is that it firmly links PE to a negative outcome for the patient, which is an element common to diagnostic criteria for other conditions, including depression, hypertension, and osteoporosis.

CONCLUSIONS

This new evidence strongly suggests that the DSM-IV-TR criteria for PE encompass aspects of the condition that patients describe as important.

Pharmaceutical companies could serve their own interests by supporting research on the efficacy of psychotherapy on premature ejaculation

For many men, the treatment of sexual dysfunctions such as premature ejaculation may well be most effective when pharmacotherapy is combined with psychotherapy. Yet the essential elements of psychotherapy that might best be combined with pharmacological-based therapy are currently unknown. Support for evidence-based studies that identify key components of psychotherapy that might improve positive long-term outcomes, including patient satisfaction, are needed. Pharmaceutical companies having a vested interest in achieving both treatment adherence and improved patient outcomes could benefit from such information.

Interrelationships among measures of premature ejaculation: the central role of perceived control

INTRODUCTION

Domains of premature ejaculation (PE) include short intravaginal ejaculatory latency time (IELT), poor perceived control over ejaculation, decreased satisfaction with sexual intercourse, and personal distress and interpersonal difficulty related to ejaculation. How these measures interrelate is unknown.

AIM

Here, we evaluated the interrelationships between these PE-specific variables, applying cross-sectional data from a large U.S. observational study of men with PE.

METHODS

We analyzed data from men with PE identified in a previously reported observational study. PE was diagnosed by experienced clinicians using the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision.

MAIN OUTCOME MEASURES

Subjects reported their stopwatch-measured IELT, perceived control over ejaculation, satisfaction with sexual intercourse, personal distress related to ejaculation, and interpersonal difficulty related to ejaculation. Relationships between variables were assessed using bivariate correlations, and the strength and significance of direct or indirect effects between variables were evaluated using a form of regression analysis known as path analysis.

RESULTS

Bivariate Pearson correlation coefficients for all relationships were significant at the P <or= 0.05 level, with the exception of IELT and interpersonal difficulty related to ejaculation. When all variables were included in the model, IELT showed a significant direct effect on perceived control over ejaculation but did not show a significant direct effect on ejaculation-related personal distress or satisfaction with sexual intercourse. Perceived control over ejaculation showed a significant direct effect on both ejaculation-related personal distress and satisfaction with sexual intercourse, which each showed direct effects on interpersonal difficulty related to ejaculation.

CONCLUSIONS

The patient's perception of control over ejaculation is central to understanding how PE is associated with satisfaction with sexual intercourse and ejaculation-related distress. In contrast, the association of IELT with satisfaction with sexual intercourse and distress related to ejaculation is mediated by perceived control over ejaculation.

Disorders of orgasm and ejaculation in men

INTRODUCTION

Ejaculatory/orgasmic disorders, common male sexual dysfunctions, include premature ejaculation, inhibited ejaculation, anejaculation, retrograde ejaculation and anorgasmia.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men.

METHODS

An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Disorders of Ejaculation/Orgasm in Men Committee, there were nine experts from six countries.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate.

RESULTS

Premature ejaculation management is dependent upon etiology. When secondary to ED, etiology-specific treatment is employed. When lifelong, initial pharmacotherapy (SSRI, topical anesthesia, PDE5 inhibitors) is appropriate. When associated with psychogenic/relationship factors, behavioral therapy is indicated. When acquired, pharmacotherapy and/or behavioral therapies are preferred. Retrograde ejaculation, diagnosed with spermatozoa and fructose in centrifuged post-ejaculatory voided urine, is managed by education, patient reassurance, pharmacotherapy or bladder neck reconstruction. Men with anejaculation or anorgasmia have a biologic failure of emission and/or psychogenic inhibited ejaculation. Men with age-related penile hypoanesthesia should be educated, reassured and be instructed in revised sexual techniques which maximize arousal.

CONCLUSIONS

More research is needed in understanding management of men with ejaculation/orgasmic dysfunction.

Psychosexual factors that differentiate men with inhibited ejaculation from men with no dysfunction or another sexual dysfunction

AIM

Inhibited or retarded ejaculation (IE) is an uncommon male sexual dysfunction that may result in a lack of sexual fulfillment for both the man and his partner. In this study, we attempted to identify factors that differentiate men with IE from sexually functional controls or from men with other sexual dysfunctions and to specify whether such factors predict self-reported sexual arousal during psychophysiological assessment.

METHODS

Each patient underwent psychophysiological assessment and a structured clinical interview based on a standardized questionnaire that included demographic information, psychosexual and medical history, and assessment of current sexual, erectile, and ejaculatory function, including relationship quality and characteristics.

RESULTS

Men with IE resemble men with other dysfunctions but are differentiated from controls, in their lower level of relationship satisfaction, greater level of distress, and higher level of health-related problems. Men with IE were further characterized by lower levels of self-reported subjective sexual arousal, despite exhibiting strong penile response during psychophysiological testing and reporting high quality erections across a variety of situations. Also notable, however, were the many factors on which men with IE did not differ from controls.

CONCLUSIONS

Taken together, this research helps specify directions for future investigations of men with IE.

Self-reported premature ejaculation and aspects of sexual functioning and satisfaction

BACKGROUND

Although premature ejaculation (PE) is a common male sexual dysfunction, its relevant parameters have not been adequately studied in large community-based samples.

OBJECTIVE

To examine the diagnostic utility of two self-report questions based on the DSM-IV-TR definition of PE and to investigate the relationship between self-identified PE, sexual functioning, and sexual satisfaction in men.

METHODS

An Internet survey of general health and aspects of sexual functioning and satisfaction was conducted in 2,056 males. Subjects were classified as having "probable" or "possible" PE, or as "non-PE" by survey responses.

RESULTS

A total of 1158 men met the selection criteria (sexually active in a stable heterosexual relationship), and 189 (16.3%) were classified as having probable PE by reporting they ejaculated before they wished and indicating it was "very much" or "somewhat" a problem. Another 188 (16.2%) men reported ejaculating before they wished but rated their distress lower and were classified as having possible PE. Compared to non-PE men, those with probable and possible PE reported significantly worse sexual functioning in 6 of 8 study measures. Concern about partner satisfaction was high in all groups. The importance of ejaculatory control and the ability to have intercourse for the desired time was significantly higher in men with PE as compared to non-PE men (P < 0.01).

CONCLUSIONS

PE was a common problem, was characterized by a lack of ejaculatory control, and was associated with significant effects on sexual functioning and satisfaction. Additional research on the sensitivity and specificity of these self-report questions should be pursued.

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.

Randomised controlled trial of site specific advice on school travel patterns

AIMS

To evaluate the effect of site specific advice from a school travel coordinator on school travel patterns.

METHODS

Cluster randomised controlled trial of children attending 21 primary schools in the London boroughs of Camden and Islington. A post-intervention survey measured the proportion of children walking, cycling, or using public transport for travel to school, and the proportion of parents/carers very or quite worried about traffic and abduction. The proportion of schools that developed and implemented travel plans was assessed.

RESULTS

One year post-intervention, nine of 11 intervention schools and none of 10 control schools had travel plans. Proportions of children walking, cycling, or using public transport on the school journey were similar in intervention and control schools. The proportion of parents who were very or quite worried about traffic danger was similar in the intervention (85%) and control groups (87%). However, after adjusting for baseline and other potential confounding factors we could not exclude the possibility of a modest reduction in parental concern about traffic danger as a result of the intervention.

CONCLUSIONS

Having a school travel coordinator increased the production of school travel plans but there was no evidence that this changed travel patterns or reduced parental fears. Given the uncertainty about effectiveness, the policy of providing school travel coordinators should only be implemented within the context of a randomised controlled trial.

Potential public health importance of the oven ready chip

BACKGROUND

Chip pan fires are responsible for 25% of fire related injury in the UK, despite government strategies to encourage safer frying. To establish the feasibility of promoting oven ready chips (fries), the residents in a materially deprived ward of London were surveyed. Sample frame: 1073 of 2145 households participating in a randomised controlled trial.

RESULTS

Approximately half of those surveyed deep fry, mostly chips, fish, and meat. Ownership of ovens and microwaves was high (99% and 80% respectively). Reasons for deep frying included taste (50%), speed (32%), and tradition (25%).

CONCLUSIONS

Improving the quality of oven baked alternatives may encourage consumers to change to safer and healthier cooking methods, with potentially important repercussions for public health.

The British Labour government's reform of the National Health Service

The recent general election in Britain saw healthcare as the dominant issue amongst voters. The victorious Labour Party responded to this concern with a set of reforms designed to introduce greater private-sector involvement in the delivery of healthcare. These reforms are ill-thought-out. The standard of care in British private hospitals is below that found in public hospitals, whilst new contracting arrangements are likely to increase the administration costs within the system. Faith in private-sector management techniques is misplaced at a time when the real problem facing the NHS is that of capacity. The Labour Party is also committed to redefining some aspects of healthcare as a personal responsibility and not a right, moving Britain towards a more market-based healthcare system.

Job-based health insurance in 2001: inflation hits double digits, managed care retreats

Drawing on the results of a national survey of 1,907 firms with three or more workers, this paper reports on several facets of job-based health insurance, including the cost to employers and workers; plan offerings and enrollments; patient cost sharing and benefits; eligibility, coverage, and take-up rates; and results from questions about employers' knowledge of market trends and health policy initiatives. Premiums increased 11 percent from spring 2000 to spring 2001, and the percentage of Americans in health maintenance organizations (HMOs) fell six percentage points to its lowest level since 1993, while preferred provider organization (PPO) enrollment rose to 48 percent. Despite premium increases, the percentage of firms offering coverage remained statistically unchanged, and a relatively strong labor market has continued to shield workers from the higher cost of coverage.

Gaps in health coverage among working-age Americans and the consequences

This paper examines health coverage and access to care among working-age adults using the Kaiser/Commonwealth 1997 National Survey of Health Insurance. One in three (52 million) working-age adults were either uninsured at the time of the survey or had a recent gap in their health coverage in the past two years. Having even a temporary gap in health coverage made a significant difference in access to care. Compared to the elderly, who are continuously covered by Medicare, working-age adults have greater problems paying their medical bills and gaining access to care and are less satisfied with their health insurance coverage.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

BACKGROUND

Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care.

METHODS

Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care.

RESULTS

Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25).

CONCLUSIONS

Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system

BACKGROUND

Injury mortality in rural regions remains high with little evidence that trauma system implementation has benefited rural populations.

OBJECTIVE

To evaluate risk-adjusted mortality in remote regions of Oregon before and after implementation of a statewide trauma system.

RESEARCH DESIGN

A retrospective cohort study assessing injury mortality through 30 days after hospital discharge.

SETTING

Nine rural Oregon hospitals serving counties with populations <18 persons per square mile.

SUBJECTS

Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation.

MEASURES

Interhospital transfer, hospital death, and demise within 30 days following hospital discharge.

RESULTS

A total of 940 patients were analyzed. After trauma system implementation, patients presenting to level-4 hospitals were more likely transferred to level-2 facilities (P <0.001). Interhospital transfer times from level-3 hospitals lengthened significantly after system implementation (P <0.001). Overall mortality rates were higher in the postsystem period (8.3%) than the presystem period (6.7%), but not significantly. Controlling for covariates, no additional benefit to risk-adjusted mortality was associated with trauma system implementation. Additional deaths, occurring after trauma system implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals.

CONCLUSIONS

Increased injury survival after Oregon trauma system implementation, demonstrated in urban and statewide analyses, was not confirmed in remote regions of the state. Efforts to improve trauma systems in rural areas should focus on the processes of care for head-injured patients transferred to higher designation trauma centers.

Early diagnosis of scrub typhus with a rapid flow assay using recombinant major outer membrane protein antigen (r56) of Orientia tsutsugamushi

The variable 56-kDa major outer membrane protein of Orientia tsutsugamushi is the immunodominant antigen in human scrub typhus infections. We developed a rapid immunochromatographic flow assay (RFA) for the detection of immunoglobulin M (IgM) and IgG antibodies to O. tsutsugamushi. The RFA employs a truncated recombinant 56-kDa protein from the Karp strain as the antigen. The performance of the RFA was evaluated with a panel of 321 sera (serial bleedings of 85 individuals suspected of scrub typhus) which were collected in the Pescadore Islands, Taiwan, from 1976 to 1977. Among these 85 individuals, IgM tests were negative for 7 cases by both RFA and indirect fluorescence assay (IFA) using Karp whole-cell antigen. In 29 cases specific responses were detected by the RFA earlier than by IFA, 44 cases had the same detection time, and 5 cases were detected earlier by IFA than by RFA. For IgG responses, 4 individuals were negative with both methods, 37 cases exhibited earlier detection by RFA than IFA, 42 cases were detected at the same time, and 2 cases were detected earlier by IFA than by RFA. The sensitivities of RFA detection of antibody in sera from confirmed cases were 74 and 86% for IgM and IgG, respectively. When IgM and IgG results were combined, the sensitivity was 89%. A panel of 78 individual sera collected from patients with no evidence of scrub typhus was used to evaluate the specificity of the RFA. The specificities of the RFA were 99% for IgM and 97% for IgG. The sensitivities of IFA were 53 and 73% for IgM and IgG, respectively, and were 78% when the results of IgM and IgG were combined. The RFA test was significantly better than the IFA test for the early detection of antibody to scrub typhus in primary infections, while both tests were equally sensitive with reinfected individuals.

Race, ethnicity, and the health care system: public perceptions and experiences

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.