[Gastrointestinal bleeding in the elderly]

Peptic ulcer disease is a common cause of gastrointestinal bleeding, independent of the patient's age. With advancing age, an increase of lower gastrointestinal bleeding (diverticula, angiodysplasia) has been observed. The administration of non-steroidal anti-inflammatory drugs and aspirin is an important risk factor for upper and lower gastrointestinal bleeding, thus in patients aged 65 years and more a concomitant therapy with proton pump inhibitors is recommended in order to prevent ulcer bleeding. Even in very old individuals endoscopy should be used for the diagnosis of gastrointestinal bleeding, providing the opportunity for definite endoscopic bleeding therapy. In elderly patients with comorbidities and recurrent bleeding after endoscopic therapy or continuous blood loss, surgery or transarterial embolisation should be considered in good time.

Laparoscopic repair of a large interstitially incarcerated inguinal hernia

A 68 year old female presented for elective repair of an abdominal wall hernia. Preoperative CT imaging revealed a right inguinal hernia defect with hernia contents coursing cephalad between the external and internal abdominal oblique muscles. This was consistent with an interstitial inguinal hernia, a rare entity outside of post- traumatic hernias. At operation the hernia contents were reduced laparoscopically. The hernia was then repaired by transitioning to the totally extraperitoneal (TEP) approach using a 15cm X 15cm piece of polyester mesh. The patient had an uneventful recovery. Interstitial hernias are rare, difficult to diagnose and potentially dangerous if left untreated. There is no consensus on the ideal repair of these unique hernias. This represents a minimally invasive repair of an unusual hernia, with a novel approach to diagnose and manage the hernia and its redundant sac.

Tube width fluctuations in F-actin solutions

We determine the statistics of the local tube width in F-actin solutions, beyond the usually reported mean value. Our experimental observations are explained by a segment fluid theory based on the binary collision approximation. In this systematic generalization of the standard mean-field approach, effective polymer segments interact via a potential representing the topological constraints. The analytically predicted universal tube width distribution with a stretched tail is in good agreement with the data.

Dynamic structure factor of a stiff polymer in a glassy solution

We provide a comprehensive overview of the current theoretical understanding of the dynamic structure factor of stiff polymers in semidilute solution based on the wormlike chain (WLC) model. We extend previous work by computing exact numerical coefficients and an expression for the dynamic mean square displacement (MSD) of a free polymer and compare various common approximations for the hydrodynamic interactions, which need to be treated accurately if one wants to extract quantitative estimates for model parameters from experimental data. A recent controversy about the initial slope of the dynamic structure factor is thereby resolved. To account for the interactions of the polymer with a surrounding (sticky) polymer solution, we analyze an extension of the WLC model, the glassy wormlike chain (GWLC), which predicts near power law and logarithmic long-time tails in the dynamic structure factor.

Affect in electoral politics

Recent U.S. history provides vivid illustrations of the importance of politicians' emotional displays in subsequent judgments of them. Yet, a review of empirical research on the role of affect (emotion, mood, and evaluation) in electoral politics reveals little work that has focused on the impact of candidates' emotional expression on voters' preferences for them. A theoretical framework is proposed to identify psychological mechanisms by which a target's displays of emotion influence judgments of that target. Findings from the emerging literature on emotions and politics challenge the traditional assumption of political science that voters make decisions based solely on the cold consideration of nonaffectively charged information. The affect and politics literature, although somewhat unfocused and broad, represents an interdisciplinary domain of study that contributes to the understanding of both electoral politics and social interaction more generally.

Phase transformation of ammonium monomolybdate. The structure of the low temperature modification, (NH4)2[MoO4] (mP60, P21/a)

(NH4)2[MoO4] (mS60) undergoes on cooling a phase transition at 190 K. The investigation of this phase transition by means of time and temperature resolved X-ray powder diffraction showed that the phase transition appears on heating at a temperature of 250 K. From this hysteresis and the abrupt changes in the peak positions of the diffractograms it is assumed that this is a first order transition. A diffractogram of the low temperature modification was recorded between 10° and 100° in 2θ. The structure was determined using direct methods and was refined by Rietveld methods. The low temperature modification of (NH4)2[MoO4] (mP60, P21/a) crystallizes in space group P21/a (No. 14) and lattice constants a = 767.57(5) pm, b = 1120.53(7) pm, c = 712.64(4) pm and β = 115.727(2)°.

Structure of the dimethyl sulfoxide solvated thallium(III) ion in solution and in the solid state

The structure and vibrational spectra of the dimethyl sulfoxide solvated thallium(III) ion have been studied in a dimethyl sulfoxide solution and in the solid state. X-ray crystallography shows a trigonal unit cell, space group R(-)3 (No. 148), for the [Tl(dmso)(6)](ClO(4))(3) compound with Z = 3, a = b = 11.9764(13) [11.8995(9)] A, c = 20.802(2) [20.467(2)] A, and V = 2584.0(5) [2509.9(4)] A(3) at 295 [150] K. The crystal structure comprises a highly symmetric hexakis(dimethyl sulfoxide)thallium(III) ion, with thallium in a (-)3 symmetry site and a Tl-O bond distance of 2.224(3) A at 295 K. The octahedral TlO(6) kernel is compressed along the threefold axis with an O-Tl-O bond angle of 96.20(11) degrees. The Tl-O-S bond angle of 120.7(2) degrees corresponds to a Tl.S distance of 3.292(2) A. One perchlorate ion centered on the (-)3 axis was described by a statistically disordered model. A low-temperature EXAFS study (10 K) resulted in the Tl-O and Tl.S distances of 2.221(4) and 3.282(6) A, respectively, consistent with a Tl-O-S bond angle of 120(1) degrees. The low Debye-Waller factors confirm a regular coordination without the disorder of the dimethyl sulfoxide ligands, which would have resulted from the alternative choice of space group R3 for the crystal structure. Raman and infrared spectra have been recorded and assigned, with the bands at 435 and 447 cm(-)(1) corresponding to the vibrational frequency of the symmetric and asymmetric Tl-O stretching modes, respectively. EXAFS data of a 0.5 mol dm(-3)thallium(III) trifluoromethanesulfonate in a dimethyl sulfoxide solution were consistent with that of a hexasolvated ion with mean Tl-O and Tl.S distances of 2.22(1) and 3.33(2) A, respectively, which correspond to a mean Tl-O-S bond angle of 124(2) degrees. The anomalously large disorder parameter for the Tl-O distances is consistent with a weak pseudo-Jahn-Teller effect. The (205)Tl, (13)C, and (1)H NMR spectra of the complex in solution show single signals at 1886, 39.5, and 2.3 ppm, respectively.

[Team and patient orientation in nursing as a part of quality management--status and needs for research]

The paper introduces a holistic concept of quality management in hospitals--the approach of employee and patient orientation ("MPO-Mitarbeiter- und Patientenorientierung"). It is shown that quality in health care does not primarily depend on the regulation of quantitative input and output of the health care system but is largely determined by improvements of processes within the system. TQM models like the European Quality Award are showing the way towards improving processes by focusing on employee and client orientation and satisfaction. Patient satisfaction has become a more and more popular indicator for quality in health care. However, reviews of the vast amount of literature on patient satisfaction reveal that present research suffers from the same problems and shortcomings that have already been criticised about 20 years ago. Only few studies choose innovative approaches by integrating the perspectives of patients and employees and by refraining from the insufficient measurement of satisfaction. Three of these studies are presented and compared. Against this background the MPO-approach is described; the approach integrates results from work psychology as well as from nursing research within the concept of complete activity. In contrast to other models of quality management the MPO-approach provides suitable methods for analysis and assessment of employee and patient orientation. These methods are described and are finally discussed with respect to strategies of total quality management in hospitals.

New class of oligonuclear platinum-thallium compounds with a direct metal-metal bond. 5. Structure determination of heterodimetallic cyano complexes in aqueous solution by EXAFS and vibrational spectroscopy

The structures of three closely related heterodimetallic cyano complexes, [(NC)(5)Pt-Tl(CN)(n)()](n)()(-) (n = 1-3), formed in reactions between [Pt(II)(CN)(4)](2)(-) and Tl(III) cyano complexes, have been studied in aqueous solution. Multinuclear NMR data ((205)Tl, (195)Pt, and (13)C) were used for identification and quantitative analysis. X-ray absorption spectra were recorded at the Pt and Tl L(III) edges. The EXAFS data show, after developing a model describing the extensive multiple scattering within the linearly coordinated cyano ligands, short Pt-Tl bond distances in the [(NC)(5)Pt-Tl(CN)(n)()](n)()(-) complexes: 2.60(1), 2.62(1), and 2.64(1) A for n = 1-3, respectively. Thus, the Pt-Tl bond distance increases with increasing number of cyano ligands on the thallium atom. In all three complexes the thallium atom and five cyano ligands, with a mean Pt-C distance of 2.00-2.01 A, octahedrally coordinate the platinum atom. In the hydrated [(NC)(5)Pt-Tl(CN)(H(2)O)(4)](-) species the thallium atom coordinates one cyano ligand, probably as a linear Pt-Tl-CN entity with a Tl-C bond distance of 2.13(1) A, and possibly four loosely bound water molecules with a mean Tl-O bond distance of about 2.51 A. In the [(NC)(5)Pt-Tl(CN)(2)](2)(-) species, the thallium atom probably coordinates the cyano ligands trigonally with two Tl-C bond distances at 2.20(2) A, and in [(NC)(5)Pt-Tl(CN)(3)](3)(-) Tl coordinates tetrahedrally with three Tl-C distances at 2.22(2) A. EXAFS data were reevaluated for previously studied mononuclear thallium(III)-cyano complexes in aqueous solution, [Tl(CN)(2)(H(2)O)(4)](+), [Tl(CN)(3)(H(2)O)], and [Tl(CN)(4)](-), and also for the solid K[Tl(CN)(4)] compound. A comparison shows that the Tl-C bond distances are longer in the dinuclear complexes [(NC)(5)Pt-Tl(CN)(n)()](n)()(-) (n = 1-3) for the same coordination number. Relative oxidation states of the metal atoms were estimated from their (195)Pt and (205)Tl chemical shifts, confirming that the [(NC)(5)Pt-Tl(CN)(n)()](n)()(-) complexes can be considered as metastable intermediates in a two-electron-transfer redox reaction from platinum(II) to thallium(III). Vibrational spectra were recorded and force constants from normal-coordinate analyses are used for discussing the delocalized bonding in these species.

Tl-Pt(CN)5 in the solid state--A multimethod study of an unusual compound containing inorganic wires

The crystal and molecular structure of a polycrystalline powder with a metal-metal bond and the composition TlPt(CN)5 has been determined by combining results from X-ray powder diffraction (XRD), extended X-ray absorption fine structure (EXAFS) and vibrational spectroscopic studies. The XRD data gave the tetragonal space group P4/nmm (No. 129), with a= 7.647(3), c=8.049(3) A, Z=2, and well-determined positions of the heavy metal atoms. The Pt-TI bond length in the compound is 2.627(2) A. The platinum atom coordinates four equivalent equatorial cyano ligands, with a fifth axial CN ligand and a thallium atom completing a distorted octahedral coordination geometry. The Tl-Pt(CN)5 entities are linked together in linear -NC-Pt-Tl-NC-Pt-Tl chains through the axial cyano ligand. These linear "wires" are the essential structural features and influence the properties of the compound. A three-dimensional network is formed by the four equatorial cyano ligands of the platinum atom that form bridges to the thallium atoms of neighbouring antiparallel chains. The platinum atom and the five nitrogen atoms from the bridging cyano groups form a distorted octahedron around the thallium atom. EXAFS data were recorded at the Pt and Tl L(III) edges for a more complete description of the local structure around the Pt and Tl atoms. The excessive multiple scattering was evaluated by means of the FEFF program. Raman and infrared absorption spectroscopy reveal strong coupling of the vibrational modes of the TlPt(CN)5 entities, in particular the metal-metal stretching mode, which is split into four Raman and two IR bands. Factor group theory shows that a structural unit larger than the crystallographic unit cell must be used to assign vibrational bands. Intra- and intermolecular force constants have also been calculated. The compound exhibits red luminescence at 700 +/- 3 nm in glycerol and has a corresponding excitation maximum at 240 nm. X-ray photoelectron spectra (XPS) show that the metal atoms have intermediate oxidation states, Pt3.2+ and Tl1.6-, between those in the parent Pt(II) and Tl(III) species and the decomposition products, Pt(IV) and Tl(I). The solid compound TlPt(CN)5 is stable to 520 degrees C. However in presence of water, a two-electron transfer between the metal atoms results in the cleavage of the metal-metal bond at 80 degrees C, forming a Pt(IV) pentacyanohydrate complex and a monovalent thallium ion.

Partners Community HealthCare Extranet (PCHInet): a business plan

This article presents an edited version of the business plan for PCHInet, an extranet designed to further Partners HealthCare System's strategic objectives of integrating its physician community, reducing costs, improving the quality of care, and raising the level of service delivery to its medical staff.

Horseshoe kidney injury during laparoscopic inguinal herniorrhaphy

A 23-year-old man was admitted to our department following laparoscopic right-side inguinal herniorrhaphy at a community-based hospital. Gross hematuria led to the diagnosis of renal pelvis injury that was first suspected on sonography. A computerized tomography (CT) scan revealed perforation of a horseshoe kidney with blood clots in the renal pelvis. Retrograde pyelography showed extravasation into perirenal tissue. The renal pelvis injury was managed conservatively by drainage of the upper urinary tract by transurethral placement of a mono-J stent. Serial sonography tests and a repeated retrograde pyelography revealed complete resolution of blood clots and perirenal urinoma. The clinical course was uneventful, with the double-J stent left in place for 4 weeks. To our knowledge, this is the first case report of a renal pelvis perforation in a horseshoe kidney during laparoscopic inguinal herniorrhaphy. In the present case, preoperative abdominal sonography would have been helpful to demonstrate the anatomical aberration. In general, but even more so in the case of anatomic abnormalities, the execution of a mini-laparotomy is recommended to allow a safe insertion of the optical trocar. This precaution would ensure that such injuries are avoided.

Prevalence of HTLV-I-associated T-cell lymphoma

In order to assess the prevalence rate of HTLV-1-associated T-cell lymphomas and human retrovirus infection in general, approximately 21,000 individuals representing various patient populations, retroviral risk groups, and blood donors were examined for HTLV-I, HTLV-II, HIV-1, or HIV-2 infection using serologic and PCR assays. The prevalence rates among volunteer blood donors were 0.02% and 0% for HTLV and HIV, respectively. Significantly increased HTLV prevalence rates were observed among paid blood donors, African American health care clinic patients, Amerindians, recipients of HTLV-positive cellular blood products, intravenous drug users, sexual contacts and family members of HTLV-positive people, and patients with primary thrombocytosis and other-than-low-grade non-Hodgkin's lymphoma (NHL). Among some of these groups there were significant differences in the prevalence of HTLV-I versus HTLV-II. The eight HTLV-positive NHL patients all had mature, high-grade, CD4+ T-cell lymphomas with clonally integrated HTLV-I, for a prevalence of 4% among other-than-low-grade NHL patients. Seven of the eight died from their disease within 2 years despite treatment. Interestingly, two groups at risk for HTLV infection, namely needle stick victims and recipients of HTLV-infected and/or pooled plasma products, showed no evidence for infection. Significantly increased HIV-1 prevalence was observed among paid blood donors, African Americans, homosexuals, female prostitutes, hemophiliacs, and other-than-low-grade NHL patients. Only one patient was infected with HIV-2. Of the nine HIV-positive, other-than-low-grade NHL patients, seven HIV-1 positives had B-cell lymphomas, one HIV-1 positive had an HTLV-I-positive CD4+ T-cell lymphoma, and one infected with HIV-2 had a CD4+ T-cell lymphoma that was HTLV negative. The data indicate that HTLV-I lymphoma, while uncommon, is not necessarily rare among other-than-low-grade NHL cases in the United States and, given its poor prognosis, should probably be studied separately in clinical trials.

Comparative performances of an HTLV-I/II EIA and other serologic and PCR assays on samples from persons at risk for HTLV-II infection

BACKGROUND

HTLV-I and HTLV-II are related exogenous pathogenic human retroviruses. Until recently, ELISAs based on HTLV-I antigens have been used to screen for the presence of HTLV-I or -II antibodies. The HTLV-I-based assays have not been as sensitive in detecting antibodies to HTLV-II as in detecting antibodies to HTLV-I. The Abbott HTLV-I/HTLV-II ELISA uses a combination of HTLV-I and HTLV-II antigens to detect antibodies to the whole HTLV group. The performance of this ELISA was compared to that of several HTLV-I-based serologic assays and an HTLV-II PCR assay in cohorts of South American Indians and New York City IV drug users (IVDUs) in whom HTLV-II is endemic.

STUDY DESIGN AND METHODS

Sera from 429 South American Indians and New York City IVDUs were evaluated for HTLV antibodies by the use of three ELISAs (rgp21-enhanced HTLV-I/II, Cambridge Biotech; Vironostika HTLV-I/II, Organon Teknika; and HTLV-I/HTLV-II, Abbott), and a Western blot (WB) assay. Peripheral blood leukocyte DNA from each person was analyzed for HTLV-I and HTLV-II pol DNA via PCR. The HTLV-II PCR-positive samples were further subtyped via cloning and sequencing and/or oligomer restriction.

RESULTS

Two hundred four samples (48%) were positive for HTLV-II by serologic and/or PCR assays. All of the positive samples from the Indians and approximately one-third of the positive samples from the IVDUs were of the HTLV-IIB subtype. Comparative analyses indicate that the sensitivity and specificity of the various assays were: PCR, 98 and 100 percent; Abbott HTLV-I/HTLV-II, 78 and 95 percent; Cambridge Biotech HTLV-I/II, 76 and 96 percent; Vironostika HTLV-I/II, 71 and 98 percent; and WB, 73 and 100 percent, respectively.

CONCLUSION

There were no significant differences among the sensitivities and specificities of the HTLV-I/II ELISAs (p values, 0.056-0.438). The WB and PCR assays were much more specific than the other serologic assays (p</=0.03). However, the PCR assay is significantly (p<0.001) more sensitive than any of the serologic assays in the detection of HTLV-II infection. Thus, optimal detection of HTLV-II infection would seem to require both serologic and DNA PCR assays.

Pancreas and aging: a study using ultrasonography

BACKGROUND

The pancreas undergoes a continuous aging process leading to alterations such as atrophy, fatty infiltration and fibrosis.

OBJECTIVE

The aim of this study was to determine the normal ultrasonic aspect of the pancreas and any relationship to age with special regard to pancreatic echogenicity and pancreatic duct diameter.

METHODS

In the study on pancreatic echogenicity 131 patients (56 male, 75 female), aged 18-92 (median 52) years, with normal weight were examined prospectively. The echogenicity of the pancreas was compared with the normal liver and divided into four different categories. The prospective investigation into any age relationship of pancreatic duct diameter was performed on 101 patients (44 male, 57 female), ages 18-91 (median 53) years, with normal weight. In both studies, the patients were split into seven age groups. For statistical analysis the chi-square test for independence was used.

RESULTS

With advancing age, ultrasonography demonstrated an increasing echogenicity of the pancreas, beginning in the 4th decade of life. Most patients over 50 years, and all patients over 80 had a marked echogenicity, distinctly higher than that found in the liver. The mean pancreatic duct diameter of all patients in the second study was 1.9 mm. Younger subjects had a smaller diameter - average 1.5 mm in the group 18-29 years - but with advancing age a distinct duct enlargement was observed: mean 1. 9 mm in the group 40-49 years, mean 2.3 mm in patients over 80 years, but not exceeding 3 mm.

CONCLUSION

On ultrasonography, the aging process of the pancreas leads to an increase of echogenicity. In the aged, a very high echogenicity is a normal ultrasonic finding. The pancreatic duct diameter also increases with advancing age. Even in advanced age, a diameter of more than 3 mm, however, should be regarded as a pathological finding.

A clinical information systems strategy for a large integrated delivery network

Integrated delivery networks (IDNs) are an emerging class of health care institutions. IDNs are formed from the affiliation of individual health care institutions and are intended to be more efficient in the current fiscal health care environment. To realize efficiencies and support their strategic visions, IDNs rely critically on excellent information technology (IT). Because of its importance to the mission of the IDN, strategic decisions about IT are made by the top leadership of the IDN. At Partners HealthCare System, a large IDN in Boston, MA, a clinical information systems strategy has been created to support the Partners clinical vision. In this paper, we discuss the Partners' structure, clinical vision, and current IT initiatives in place to address the clinical vision. The initiatives are: a clinical data repository, inpatient process support, electronic medical records, a portal strategy, referral applications, knowledge resources, support for product lines, patient computing, confidentiality, and clinical decision support. We address several of the issues encountered in trying to bring excellent information technology to a large IDN.

Does aging influence pancreatic response in the ultrasound secretin test by impairing hydrokinetic exocrine function or sphincter of Oddi motor function?

BACKGROUND

Secretin administration induces a brief distinct dilatation of the main pancreatic duct in healthy persons, visible at ultrasonography. Several investigations have indicated that sonographic duct measurements before and after secretin injections are a useful tool in the diagnostic screening for pancreatic disease.

AIMS

Aim of this study was to evaluate the influence of aging on the test results.

METHODS

We examined prospectively two groups of patients with distinctly different mean age, measuring the pancreatic duct diameter sonographically before, 2, 4, 6 and 10 minutes after intravenous injection of 1 CU secretin per kilogram body weight. The examination was performed in all patients on account of abdominal complaints, and pancreatic disease could be excluded by further diagnostic procedures. Group 1 consisted of 22 patients, median age 30.5 years, Group 2: 21 patients, median age 68 years.

RESULTS

The younger patients (Group 1) had a mean basal pancreatic duct diameter of 1.6 mm. After secretin injection they showed dilatation reading 3. 1 mm, corresponding to 94% of the basal duct diameter. The older patients (Group 2), with a basal diameter of 1.9 mm, showed a duct enlargement of about 84% to 3.5 mm. There was no statistically significant difference between the two groups concerning extent and temporal development of secretin-induced pancreatic duct dilatation.

CONCLUSIONS

The underlying mechanisms of response to secretin stimulation - hydrokinetic pancreatic function, sphincter of Oddi motor function, and extensibility of Wirsung's duct--do not seem to be impaired by aging. Thus, the ultrasound secretin test should be suitable for application in older patients.

When fair is foul and foul is fair: reverse priming in automatic evaluation

Responses to information were facilitated by the rapid prior presentation of evaluatively congruent material. This fundamental discovery (R. H. Fazio, D. M. Sanbonmatsu, M. C. Powell, & F. R. Kardes, 1986) marked a breakthrough in research on automatic information processing by demonstrating that evaluative meaning is grasped without conscious control. Experiments employing a word naming task provided stringent tests of the automaticity of evaluation and found support for it. More strikingly, a previously unobserved reversal of these effects (i.e., slower responses to evaluatively matched rather than mismatched items) was found when primes were evaluatively extreme. Procedural variances across 6 experiments revealed that the reverse priming effect was highly robust. This discovery is analogous to demonstrations of contrast effects in controlled judgments. It is theorized that the reverse priming effect reflects an automatic correction for the biasing influence of the prime.

[Primary sclerosing cholangitis, ulcerative colitis and type 1 diabetes mellitus]

Primary sclerosing cholangitis is a cholestatic disease of unknown origin. Occasionally, this disease is combined with different of probable autoimmune genesis, particularly with ulcerative colitis (> 50%). The reported case describes the rare subsequent development of primary sclerosing cholangitis, ulcerative colitis and insulin-dependent diabetes mellitus (IDDM) in a 22-year-old male patient. The coincidence of primary sclerosing cholangitis and IDDM supports the assumption of common factors in the etiopathogenesis of both diseases.