Educating students with TBI: themes and recommendations

Ten educational consultants and researchers, each with extensive experience working with children with traumatic brain injury (TBI) in school settings, identified seven themes related to serving this population in public schools. These themes are discussed under the headings (1) incidence of TBI and prevalence of persistent educational disability, (2) diversity and central tendencies within the population, (3) assessment, (4) intervention and support in school settings, (5) training and support for educators, (6) intervention and support for families, and (7) systems change and flexibility. For each theme, a set of recommendations is provided, forming an educational research and policy agenda for pediatric TBI.

Identifying medical school learning needs: a survey of Australian interns

OBJECTIVES

To survey interns regarding their opinion of medical school learning needs for a range of core skills.

METHODS

A random sample of interns practising in New South Wales, Australia, who graduated from the state's three medical schools were surveyed two-thirds of the way through their first hospital year. They were asked whether there was a need for further medical school education for each of 226 core skills. Skills were grouped into five themes: management of clinical conditions; clinical investigations; clinical procedures; core practice; and professional development.

RESULTS

Frequency distributions weighted for age, gender and medical school background were calculated for each item. The 20 most frequently identified needs related to examinations of the eye and ear, nose and throat; managing uncooperative patients and difficult patient interactions; prescribing; writing not for resuscitation orders and death certificates. Also included were procedural needs related to ear, nose and throat; plastering and wound management; and needs for more education in the management of clinical conditions related predominantly to "acute" cases such as anaphylaxis and diabetic ketoacidosis.

CONCLUSION

Interns were able to discriminate between their needs for different skills and identified many core skills for which they perceived there was a need for more medical school education. The implications for medical education are discussed.

A transient assay for regulatory gene function in haemopoietic progenitor cells

This work aimed to provide a means of assaying directly the effects of transient expression of introduced genes on the survival, proliferation, lineage commitment and differentiation of haemopoietic progenitor cells. For this purpose, we have developed a system that allows isolation of productively transfected, mulitipotent haemopoietic cells within a few hours of the introduction of test genes. We have shown that FDCP-mix cells productively transfected with expression plasmids encoding green fluorescent protein (GFP) differentiate normally and retain colony-forming potential. We constructed an expression vector consisting of a bicistronic cassette in which a GFP marker gene and a test gene are driven from the same promoter. The vector design has been optimized for co-expression and the test gene was shown to be biologically active. The expression profile from a transiently transfected template under different growth conditions reveals that active expression continues for at least 2 d after transfection. The transient transfection of FDCP-mix cells with the vectors described provides a powerful tool for analysis of the immediate early effects of test gene overexpression during haemopoietic differentiation.

Ultrasound criteria in the diagnosis of polycystic ovary syndrome (PCOS)

Not all women with the polycystic ovary syndrome (PCOS) on ultrasound (US) will have the syndrome, and clinical and biochemical features of PCOS may be present without US features. The sensitivity of US in detecting PCOS was, therefore, prospectively determined in 72 women (32 PCOS and 40 controls). The most sensitive features were the presence of 10 or more follicles (82% and 69% in the left and right ovary) and a peripheral distribution of follicles (81.8% and 71.9% in the left and right ovary). Although ovarian enlargement and stromal brightness were not as sensitive as the previous criteria, stromal brightness was most specific. Combining all the criteria predicted a diagnosis of PCOS or control correctly in 86.4% of cases. This study shows that established US criteria of polycystic ovaries remain of value in the diagnosis of PCOS; however, the discrepancy between the left and right ovaries is an interesting but unexplained finding.

Herpes B-virus specific-pathogen-free breeding colonies of macaques (Macaca mulatta): diagnostic testing before and after elimination of the infection

BACKGROUND AND PURPOSE

The National Institutes of Health's (NIH) National Center for Research Resources' (NCRR) Division of Comparative Medicine has funded the establishment of specific pathogen-free (SPF) captive macaque colonies. Herpes B-virus (Herpesvirus simiae, Cercopithecine herpesvirus type 1) has been targeted for elimination. Late seroconversion presents the greatest threat to the integrity of SPF colonies. The purpose of the study reported here was to evaluate that threat through detailed investigation of the patterns of seroreactivity and housing histories in one colony.

METHODS

From 1990 through 1997, the B-virus Resource Laboratory screened macaques for B-virus, using ELISA or western immunoblot analysis. In 1993, we combined test results and housing histories to verify the seronegative status of one colony.

RESULTS

Two groups of latently infected macaques were identified as to time and place of transmission. The infection was eradicated within 3 years (1990-1992), as judged by the absence of true positive seroreactivity in any screened macaques. New infections were not identified in four years of follow-up evaluation.

CONCLUSION

With rigorous surveillance, the SPF status of the colony was achieved and maintained.

Clinical pathway management of total knee arthroplasty: a retrospective comparative study

BACKGROUND

Clinical pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The aim of the present study was to evaluate the effectiveness of a clinical pathway in improving a range of selected outcome measures in patients who have undergone total knee arthroplasty (TKA).

METHODS

The present study was conducted at Queen Elizabeth Hospital, Adelaide. Using a retrospective comparative study design, 119 TKA patients who were managed on a clinical pathway from July 1997 to January 1998 (group 2) were compared with a retrospective group of 58 patients who underwent the same procedure from July 1996 to January 1997 (group 1) prior to the pathway's implementation. The following outcomes were measured: length of hospital stay; postoperative complications; readmissions and emergency service visits within 6 months of discharge; day of transfer to the convalescent unit; convalescent unit utilization and admission and discharge times.

RESULTS

There was a significant reduction in the median length of stay in group 2 patients (9 vs 7 days; P < 0.0001). In addition there was a 66% increase in the proportion of patients in group 2 who were admitted on the day of surgery (P < 0.0001) and a 19.6% increase in the number of patients discharged within 8 postoperative days (P < 0.01). There were no significant differences between the groups with respect to the occurrence of postoperative complications. Although there was a trend toward a reduction in emergency service utilization and readmissions within 6 months of discharge for patients managed on the pathway, this was not significant.

CONCLUSIONS

The development and implementation of a TKA clinical pathway resulted in a significant reduction in length of stay and improved streamlining of admission, discharge and transfer processes without adversely affecting patient outcomes.

Characterization of recombinant, ureolytic Streptococcus mutans demonstrates an inverse relationship between dental plaque ureolytic capacity and cariogenicity

Dental caries results from prolonged plaque acidification that leads to the establishment of a cariogenic microflora and demineralization of the tooth. Urease enzymes of oral bacteria hydrolyze urea to ammonia, which can neutralize plaque acids. To begin to examine the relationship between plaque ureolytic activity and the incidence of dental caries, recombinant, ureolytic strains of Streptococcus mutans were constructed. Specifically, the ureABCEFGD operon from Streptococcus salivarius 57.I was integrated into the S. mutans chromosome in such a way that the operon was transcribed from a weak, cognate promoter in S. mutans ACUS4 or a stronger promoter in S. mutans ACUS6. Both strains expressed NiCl(2)-dependent urease activity, but the maximal urease levels in ACUS6 were threefold higher than those in ACUS4. In vitro pH drop experiments demonstrated that the ability of the recombinant S. mutans strains to moderate a decrease in pH during the simultaneous metabolism of glucose and urea increased proportionately with the level of urease activity expressed. Specific-pathogen-free rats that were infected with ACUS6 and fed a cariogenic diet with drinking water containing 25 mM urea and 50 microM NiCl(2) had relatively high levels of oral urease activity, as well as dramatic decreases in the prevalence of smooth-surface caries and the severity of sulcal caries, relative to controls. Urease activity appears to influence plaque biochemistry and metabolism in a manner that reduces cariogenicity, suggesting that recombinant, ureolytic bacteria may be useful to promote dental health.

Crystal structure of the IMP-1 metallo beta-lactamase from Pseudomonas aeruginosa and its complex with a mercaptocarboxylate inhibitor: binding determinants of a potent, broad-spectrum inhibitor

Metallo beta-lactamase enzymes confer antibiotic resistance to bacteria by catalyzing the hydrolysis of beta-lactam antibiotics. This relatively new form of resistance is spreading unchallenged as there is a current lack of potent and selective inhibitors of metallo beta-lactamases. Reported here are the crystal structures of the native IMP-1 metallo beta-lactamase from Pseudomonas aeruginosa and its complex with a mercaptocarboxylate inhibitor, 2-[5-(1-tetrazolylmethyl)thien-3-yl]-N-[2-(mercaptomethyl)-4 -(phenylb utyrylglycine)]. The structures were determined by molecular replacement, and refined to 3.1 A (native) and 2.0 A (complex) resolution. Binding of the inhibitor in the active site induces a conformational change that results in closing of the flap and transforms the active site groove into a tunnel-shaped cavity enclosing 83% of the solvent accessible surface area of the inhibitor. The inhibitor binds in the active site through interactions with residues that are conserved among metallo beta-lactamases; the inhibitor's carboxylate group interacts with Lys161, and the main chain amide nitrogen of Asn167. In the "oxyanion hole", the amide carbonyl oxygen of the inhibitor interacts through a water molecule with the side chain of Asn167, the inhibitor's thiolate bridges the two Zn(II) ions in the active site displacing the bridging water, and the phenylbutyryl side chain binds in a hydrophobic pocket (S1) at the base of the flap. The flap is displaced 2.9 A compared to the unbound structure, allowing Trp28 to interact edge-to-face with the inhibitor's thiophene ring. The similarities between this inhibitor and the beta-lactam substrates suggest a mode of substrate binding and the role of the conserved residues in the active site. It appears that the metallo beta-lactamases bind their substrates by establishing a subset of binding interactions near the catalytic center with conserved characteristic chemical groups of the beta-lactam substrates. These interactions are complemented by additional nonspecific binding between the more variable groups in the substrates and the flexible flap. This unique mode of binding of the mercaptocarboxylate inhibitor in the enzyme active site provides a binding model for metallo beta-lactamase inhibition with utility for future drug design.

Pressurised liquid extraction of pentachlorophenol from dyestuffs and cotton

Pressurised liquid extraction (PLE) was used to extract pentachlorophenol from cotton and dyestuffs. Five dyes and one dyed cotton were investigated for pentachlorophenol. The dyed cotton was found to have between 5.3 and 5.9 microg g(-1) pentachlorophenol, while the dyes were found to have between 42 and 2569 microg g(-1) pentachlorophenol present. The latter were found to be dye and manufacturing site dependant. Recovery experiments, in all cases, were found to be quantitative indicating appropriate sample work-up and manipulations.

Intern Prescribing for Common Clinical Conditions

To examine the ability of interns to prescribe appropriately for common clinical conditions at the commencement and completion of the intern year. Interns' perceptions of their ability to prescribe and the perceived influences on their practices were also assessed. The study was conducted at a teaching hospital in urban New South Wales, Australia. A self-complete questionnaire was administered to 56 interns at the beginning and end of internship. At the beginning of the year respondents were asked to identify how equipped they felt they were to perform specific functions related to prescribing practice. Interns were also asked to write hospital prescriptions for four common clinical cases scenarios: post-operative pain, urinary tract infection, asthma, and community-acquired pneumonia. At the end of the year interns were asked to prescribe for the same clinical scenarios and also asked to identify the main influences on their practice. At the beginning of the year 54% of interns felt equipped to choose an appropriate drug for common clinical conditions, however, few felt they were able to determine the appropriate dose (23% of respondents) or dose frequency (25%). A previously validated four-point rating scale was used by two assessors to judge appropriateness of prescribing [Kappa = 0.6]. At the beginning of the year at least two-thirds of interns were prescribing 'inappropriately' for all clinical conditions. By the end of the year 75% were prescribing 'appropriately' for all conditions. The main perceived influences on prescribing practices were registrars, consultants, books and pharmacists.The use of hypothetical clinical cases to explore prescribing ability has shown that doctors are ill-equipped to perform various aspects of prescribing on graduating from medical school. Although our findings may not translate into practice directly they highlight the existence of a potential problem that warrants further study, especially in the areas of actual practice and the influences on it in the early postgraduate years.

Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial

BACKGROUND

The provision of information before medical or surgical procedures should improve knowledge and allay anxiety about the pending procedure. This trial aimed to assess the value of an information video in this process.

METHODS

Patients scheduled to undergo colonoscopy were approached about 1 week before the procedure. All patients were given an information leaflet about colonoscopy, and completed a Spielberger state anxiety inventory (STAI) questionnaire to assess baseline anxiety. The patients were then randomly assigned to watch or not watch the information video. Immediately before colonoscopy, all patients completed a second anxiety questionnaire and a knowledge questionnaire.

FINDINGS

198 patients were screened. 31 declined to participate and 17 were unable to complete the forms. Of the remaining 150 patients, 72 were assigned the video, and 78 no video. The groups were similar with regard to age, sex, educational attainment, and initial anxiety score. Female patients had higher baseline anxiety than male patients (mean STAI 46.3 [95% CI 44.9-47.7] vs 36.9 [35.5-38.3]; difference 9.4 [7.8-12.2], p=0.0008). Patients who had not had a previous colonoscopy had higher baseline anxiety scores than those who had prior experience of the procedure (46.9 [45.4-48.5] vs 36.3 [34.7-37.9]; difference 10.6 [7.5-13.8], p=0.0008). Patients who watched the video were significantly less anxious before colonoscopy than those who did not. The former also scored more highly in the knowledge questionnaire than the latter with regard to the purpose of the procedure, procedural details, and potential complications of colonoscopy.

INTERPRETATION

An information video increases knowledge and decreases anxiety in patients preparing for colonoscopy.

Is health-related quality of life among older, chronically ill patients associated with unplanned readmission to hospital?

BACKGROUND

Assessment of health-related quality of life (HRQL) is being used increasingly to assess the impact of treatment.

AIMS

To determine if HRQL, assessed shortly after acute hospitalisation, is associated with readmission to hospital.

METHODS

In a prospective, longitudinal study, 163 chronically ill, medical and surgical patients (mean age 67.0+/-16.3 years) discharged to home following acute hospitalisation were studied. HRQL was assessed at one month post-hospital discharge using the MOS 36-Item Short-Form Health Survey (SF-36). Patients were followed-up for six months thereafter to determine subsequent incidence of unplanned readmission.

RESULTS

HRQL as measured by the eight health dimensions of the SF-36, for the entire cohort, was lower relative to age and gender matched norms for the local population (p<0.01). During study follow-up, 47 (35%) patients had an unplanned readmission and one patient died. Patients who had an unplanned readmission demonstrated both significantly lower physical (32.2+/-9.8 vs 38.6+/-10.1: p<0.001) and mental (45.1+/-12.7 vs 49.9+/-12.3: p=0.03) health component scores in comparison to the remainder of the cohort. On multivariate analysis, independent correlates of unplanned readmission were: 1) presence of formal home assistance (OR 6.4: p<0.01), 2) > or =five prescribed medications (OR 2.4: p=0.04), 3) > or =two admissions in the six months before follow-up (OR 4.3: p<0.01) and 4) an SF-36 physical component score of < or =40 (OR 2.2: p=0.05).

CONCLUSIONS

In this cohort of predominantly older and chronically ill patients recently discharged from acute hospital care, relatively lower SF-36 physical health component scores were independently associated with an increased risk of subsequent unplanned readmission.

Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs fee-for-service insurance

BACKGROUND

A commonly voiced concern is that health maintenance organizations (HMOs) may withhold or delay the provision of urgent, essential care, especially for vulnerable patients like the elderly.

OBJECTIVE

To compare the quality of emergency care provided in Minnesota to elderly patients with acute myocardial infarction (AMI) who are covered by HMO vs fee-for-service (FFS) insurance.

METHODS

We reviewed the medical records of 2304 elderly Medicare patients who were admitted with AMI to 20 urban community hospitals in Minnesota (representing 91% of beds in areas served by HMOs) from October 1992 through July 1993 and from July 1995 through April 1996.

MAIN OUTCOME MEASURES

Use of emergency transportation and treatment delay (>6 hours from symptom onset); time to electrocardiogram; use of aspirin, thrombolytics, and beta-blockers among eligible patients; and time from hospital arrival to thrombolytic administration (door-to-needle time).

RESULTS

Demographic characteristics, severity of symptoms, and comorbidity characteristics were almost identical among HMO (n = 612) and FFS (n = 1692) patients. A cardiologist was involved as a consultant or the attending physician in the care of 80% of HMO patients and 82% of FFS patients (P = .12). The treatment delay, time to electrocardiogram, use of thrombolytic agents, and door-to-needle times were almost identical. However, 56% of HMO patients and 51% of FFS patients used emergency transportation (P = .02); most of this difference was observed for patients with AMIs that occurred at night (60% vs 52%; P = .02). Health maintenance organization patients were somewhat more likely than FFS patients to receive aspirin therapy (88% vs 83%; P = .03) and beta-blocker therapy (73% vs 62%; P = .04); these differences were partly explained by a significantly larger proportion of younger physicians in HMOs who were more likely to order these drug therapies. All differences were consistent across the 3 largest HMOs (1 staff-group model and 2 network model HMOs). Logistic regression analyses controlling for demographic and clinical variables produced similar results, except that the differences in the use of beta-blockers became insignificant.

CONCLUSIONS

No indicators of timeliness and quality of care for elderly patients with AMIs were lower under HMO vs FFS insurance coverage in Minnesota. However, two indicators of quality care were slightly but significantly higher in the HMO setting (use of emergency transportation and aspirin therapy). Further research is needed in other states, in different populations, and for different medical conditions.

Non-veridical size perception of expanding and contracting objects

Observers were presented with various types of stimulus expansion and contraction which resulted in marked misperceptions of size. Firstly, the perceived size of an object which is changing in size is shown to be biased in the direction of the size change. Secondly, expansion or contraction of the internal texture of objects is found to influence their perceived size. Finally, an illusory texture manipulation in the form of a movement after-effect is shown to produce the same type of size misperception as a real expansion or contraction of internal texture. The spatio-temporal characteristics of these illusory size changes are investigated.

Uncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill

BACKGROUND

Sub-optimal use of prescribed medication is often associated with unplanned hospitalisation among the chronically ill.

AIMS

To examine the extent of sub-optimal use of prescribed medication in a 'high risk' patient cohort recently discharged from acute hospital care.

METHODS

Chronically ill patients discharged from acute hospital care (n = 342) were studied. At one week post discharge a home visit was performed by a nurse and a pharmacist during which medication management (including compliance and medication-related knowledge) was assessed.

RESULTS

During the majority of home visits at least one medication-related problem was detected: approximately half of the cohort subject to a 'reliable' pill-count were found to be mal-compliant and almost all demonstrated inadequate medication-related knowledge. Mal-compliance was correlated with > or = five prescribed medications (Odds ratio [OR] 2.6: p < 0.002). Comparatively, lower medication-related knowledge was correlated with age > 75 years (OR 2.2: p < 0.001), exacerbation of a pre-existing chronic illness (OR 2.7: p = 0.044) and < or = six years formal education (OR 1.9: p = 0.004). Neither were modulated by extent of in-hospital counselling. Other previously unknown problems detected during the home visit included hoarding of previously prescribed medication (35%) and reducing medication intake to minimise costs (21%).

CONCLUSIONS

Management of prescribed medications among chronically ill patients recently discharged from acute hospital care is often sub-optimal. Assessment of medication management in the home provides an invaluable opportunity to detect and address problems likely to result in poorer health outcomes.

Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure

BACKGROUND

A single home-based intervention (HBI) applied immediately after hospital discharge in a cohort of "high-risk" patients with congestive heart failure has been shown to decrease numbers of unplanned readmissions plus out-of-hospital deaths during a period of 6 months. The duration of this beneficial effect remains uncertain.

METHODS

Hospitalized patients with congestive heart failure who had been randomly assigned to receive either usual care (n=48) or HBI 1 week after discharge (n=49) were subject to an extended follow-up of 18 months. The primary end point of the study was frequency of unplanned readmissions plus out-of-hospital deaths. Secondary end points included total hospital stay, frequency of multiple readmissions, cost of hospital-based care, and total mortality.

RESULTS

During 18-month follow-up, HBI patients had fewer unplanned readmissions (64 vs 125; P=.02) and out-of-hospital deaths (2 vs 9; P=.02), representing 1.4+/-1.3 vs 2.7+/-2.8 events per HBI and usual-care patient, respectively (P=.03). The HBI patients also had fewer days of hospitalization (2.5+/-2.7 vs 4.5+/-4.8 per patient; P=.004) and, once readmitted, were less likely to experience 4 or more readmissions (3/31 vs 12/38; P=.03). Hospital-based costs were significantly lower among HBI patients (Aust $5100 vs Aust $10600 per patient; P=.02). Unplanned readmission was positively correlated with 14 days or more of unplanned readmission in the 6 months before study entry (odds ratio [OR], 5.4; P=.006). Positive correlates of death were (1) non-English speaking (OR, 4.9; P=.008), (2) 14 days or more of unplanned readmission in the 6 months before study entry (OR, 4.9; P=.008), and (3) left ventricular ejection fraction of 40% or less (OR, 3.0; P=.03); conversely, assignment to HBI was a negative correlate (OR, 0.3; P=.02).

CONCLUSIONS

In this controlled study, among a cohort of high-risk patients with congestive heart failure, beneficial effects of a postdischarge HBI were sustained for at least 18 months, with a significant reduction in unplanned readmissions, total hospital stay, hospital-based costs, and mortality.

Ebola (subtype Reston) virus among quarantined nonhuman primates recently imported from the Philippines to the United States

In April 1996, laboratory testing of imported nonhuman primates (as mandated by quarantine regulations) identified 2 cynomolgus macaques (Macaca fascicularis) infected with Ebola (subtype Reston) virus in a US-registered quarantine facility. The animals were part of a shipment of 100 nonhuman primates recently imported from the Philippines. Two additional infected animals, who were thought to be in the incubation phase, were identified among the remaining 48 animals in the affected quarantine room. The other 50 macaques, who had been held in a separate isolation room, remained asymptomatic, and none of these animals seroconverted during an extended quarantine period. Due to the rigorous routine safety precautions, the facility personnel had no unprotected exposures and remained asymptomatic, and no one seroconverted. The mandatory quarantine and laboratory testing requirements, put in place after the original Reston outbreak in 1989-1990, were effective for detecting and containing Ebola virus infection in newly imported nonhuman primates and minimizing potential human transmission.

Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care

BACKGROUND

The rapid expansion of managed care in the United States has increased debate regarding the appropriate mix of generalist and specialist involvement in medical care.

OBJECTIVE

To compare the quality of medical care when generalists and cardiologists work separately or together in the management of patients with acute myocardial infarction (AMI).

METHODS

We reviewed the charts of 1716 patients with AMI treated at 22 Minnesota hospitals between 1992 and 1993. Patients eligible for thrombolytic aspirin, beta-blockers, and lidocaine therapy were identified using criteria from the 1991 American College of Cardiology guidelines for the management of AMI. We compared the use of these drugs among eligible patients whose attending physician was a generalist with no cardiologist input, a generalist with a cardiologist consultation, and a cardiologist alone.

RESULTS

Patients cared for by a cardiologist alone were younger, presented earlier to the hospital, were more likely to be male, had less severe comorbidity, and were more likely to have an ST elevation of 1 mm or more than generalists' patients. Controlling for these differences, there was no variation in the use of effective agents between patients cared for by a cardiologist attending physician and a generalist with a consultation by a cardiologist. However, there was a consistent trend toward increased use of aspirin, thrombolytics, and beta-blockers in these patients compared with those with a generalist attending physician only (P<.05 for beta-blockers only). Differences between groups in the use of lidocaine were not statistically significant. The adjusted probabilities of use of thrombolytics for consultative care and cardiologist attending physicians were 0.73 for both. Corresponding probabilities were 0.86 and 0.85 for aspirin and 0.59 and 0.57 for beta-blockers, respectively.

CONCLUSIONS

For patients with AMI, consultation between generalists and specialists may improve the quality of care. Recent policy debates that have focused solely on access to specialists have ignored the important issue of coordination of care between generalist and specialist physicians. In hospitals where cardiology services are available, generalists may be caring for patients with AMI who are older and more frail. Future research and policy analyses should examine whether this pattern of selective referral is true for other medical conditions.

Images in clinical medicine. Endobronchial Kaposi's sarcoma

Images