Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees

PURPOSE

Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees.

METHOD

The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied.

RESULTS

Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment (P = 0.27 - 0.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training, however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices.

CONCLUSIONS

Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.

Surgical Residents' Awareness of the Costs of Common Operating Room Supplies

BACKGROUND

The Accreditation Council for Graduate Medical Education mandates that residency programs incorporate cost awareness into patient care. This presents a challenge for surgical residents because they must understand operating room costs in addition to other expenses. Trainees' understanding of operating room supply costs is not well understood.

METHODS

A survey was distributed to surgical residents (N = 73) at an urban, university-based residency program. Residents estimated the costs of 21 single-use operating room items. Descriptive statistics and a regression analysis were calculated.

RESULTS

The response rate was 62%. Respondents accurately estimated costs for a median of 7/21 items, with error ranging from 26% to 5438%. They substantially underestimated the three highest-cost items. Increasing post-graduate year did not improve estimation accuracy (β = .233, P = .138).

DISCUSSION

Residents have a poor understanding of single-use item costs, and this does not improve with post-graduate training, suggesting inefficiencies. There is opportunity to educate residents and ultimately decrease surgical health care costs.

Update on the Financial Well-Being of Surgical Residents in New England

BACKGROUND

Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being.

STUDY DESIGN

A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort.

RESULTS

Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans.

CONCLUSIONS

Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education

OBJECTIVE

To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among.

SETTING

Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals.

PARTICIPANTS

Clinical faculty within the Department of Surgery.

RESULTS

A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care.

CONCLUSIONS

Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.

Learning Environment is the Prevailing Factor in Surgical Residents' Favorite Rotations

OBJECTIVE

Understand the characteristics of residents' favorite rotations to improve the ability of educators to maximize positive learning experiences.

DESIGN

Novel cross-sectional survey developed through thematic analysis of focus groups with residents using 4-point Likert scales ranked from "Not at all important" to "Extremely important."

SETTING

Single university-affiliated urban hospital PARTICIPANTS: Clinical surgical residents BACKGROUND: Resident assessments of learning experiences vary between rotations leading to the development of "favorite" rotations.

MATERIALS AND METHODS

A novel survey instrument containing 31 characteristics divided into 4 thematic categories was developed following analysis of surgical resident focus groups. Clinical surgical residents were asked how important each characteristic was for determining their favorite rotation on a 4-point Likert Scale from "not at all important" to "extremely important." Two-sided independent sample T-tests were used.

RESULTS

The response rate was 59% (33/56) with proportional representation of postgraduate levels. Overall, 67% (22/33) of residents reported their favorite rotation was in their preferred specialty, 70% (23/33) reported their favorite rotation required >70 hours per week in the hospital, and 97% (32/33) of residents reported their favorite rotation required <2 days of clinic. Overall, the average ranking of the categories from most to least important was content (mean = 2.84, SD = 0.48), learning environment (mean = 2.67, SD = 0.57), working environment (mean = 2.38, SD = 0.56), and accomplishment (mean = 2.31, SD = 0.57). The only category with a statistically significant difference between junior and senior resident was content with seniors ranking it most important (mean = 3.35, SD = 0.93) compared to junior residents who ranked it least important (mean = 2.21, SD = 1.25), p = 0.01. Personal characteristics such as "Attendings cared about my learning" (mean = 3.56, SD = 0.50) and "I felt good at my job" (mean = 3.45, SD = 0.67), tended to be more important than structural characteristics such as "call schedule" (mean = 2.71, SD = 0.86), "formal didactics" (mean = 2.67, SD = 1.04), and "work-life balance" (mean = 2.70, SD = 0.99).

CONCLUSIONS

This study demonstrates a novel understanding of the factors that contribute to resident preferences for certain rotations. Junior and senior residents attribute importance differently, which may provide the basis for level-appropriate improvements. Personal factors tended to be more contributory than structural factors, highlighting additional dimensions to examine when considering how to optimize certain rotations.

Effect of Surgical Team Communication on Adherence to Opioid Discharge Guidelines in Post-Operative Inpatients

OBJECTIVE

Current opioid prescribing guidelines state that post-operative inpatients who do not receive opioids in the 24 hours preceding discharge do not require an opioid prescription on discharge. This study was designed to assess providers' understanding of opioid discharge guidelines and explore drivers of adherence.

DESIGN

An electronic survey was released which assessed knowledge of opioid discharge guidelines and probed surgical team communication. Kruskal-Wallis tests were used to determine differences between provider types. Spearman's correlation evaluated relationships between estimated and observed adherence to guidelines.

SETTING

Yale New-Haven Hospital, (tertiary, university-based) PARTICIPANTS: Surgical residents, advanced practice providers (APPs) and attendings who discharged inpatients with opioids between November 2017-August 2019 RESULTS: The response rate was 36% (90/253), including 36% (49/136) of residents, 23% (13/56) of APPs, and 46% (28/61) of attendings. Seventy eight percent of participants believed patients who met the guideline should "never" or "sometimes" receive opioids on discharge. There was a significant difference between attending preferences and what residents (H²₂ = 202.7, p = 0.0001) and APPs (H²₂ = 24.6, p = 0.003) believed were the attending's preferences. Eleven percent of attendings preferred their patients to "most of the time" or "always" receive opioids on discharge, while 45% of residents and 54% of APPs reported the same. Overall, 57% of attendings reported they "most of the time" or "always" communicated their discharge preferences while 12% of residents (H²₂ = -20.4, p = 0.0003) and 8% of APPs (H²₂ = -23.5, p = 0.003) reported the same. There was no correlation between all groups' estimated adherence to the guidelines and observed adherence (r_s = 0.135, p = 0.206).

CONCLUSIONS

This study demonstrates that surgical residents, APPs, and attendings are aware of the guideline but breakdowns in communication between the attending and the surgical team may contribute to deviation from this guideline. Improving communication may lead to improved adherence to post-operative opioid discharge prescribing guidelines.

Video Coaching in Surgical Education: Utility, Opportunities, and Barriers to Implementation

OBJECTIVE

This review discusses the literature on Video-Based Coaching (VBC) and explores the barriers to widespread implementation.

DESIGN

A search was performed on Scopus and PubMed for the terms "operation," "operating room," "surgery," "resident," "house staff," "graduate medical education," "teaching," "coaching," "assessment," "reflection," "camera," and "video" on July 27, 2021, in English. This yielded 828 results. A single author reviewed the titles and abstracts and eliminated any results that did not pertain to operative VBC or assessment. All bibliographies were reviewed, and appropriate manuscripts were included in this study. This resulted in a total of 52 manuscripts included in this review.

SETTING/PARTICIPANTS

Original, peer-reviewed studies focused on VBC or assessment.

RESULTS

VBC has been both subjectively and objectively found to be a valuable educational tool. Nearly every study of video recording in the operating room found that subjects, including surgical residents and seasoned surgeons alike, overwhelmingly considered it a useful, non-redundant adjunct to their training. Most studies that evaluated skill acquisition via standardized assessment tools found that surgical residents who underwent a VBC program had significant improvements compared to their counterparts who did not undergo video review. Despite this evidence of effectiveness, fewer than 5% of residency programs employ video recording in the operating room. Barriers to implementation include significant time commitments for proposed coaching curricula and difficulty with integration of video cameras into the operating room.

CONCLUSIONS

VBC has significant educational benefits, but a scalable curriculum has not been developed. An optimal solution would ensure technical ease and expediency, simple, high-quality cameras, immediate review, and overcoming entrenched surgical norms and culture.

The Reporting of Race and Ethnicity in Surgery Literature

Importance

The reporting of race provides transparency to the representativeness of data and helps inform health care disparities. The International Committee of Medical Journal Editors (ICMJE) developed recommendations to promote quality reporting of race; however, the frequency of reporting continues to be low among most medical journals.

Objective

To assess the frequency as well as quality of race reporting among publications from high-ranking broad-focused surgical research journals.

Design, Setting, and Participants

A literature review and bibliometric analysis was performed examining all human-based primary research articles published in 2019 from 7 surgical journals: JAMA Surgery, Journal of the American College of Surgeons, Annals of Surgery, Surgery, American Journal of Surgery, Journal of Surgical Research, and Journal of Surgical Education. The 5 journals that stated they follow the ICMJE recommendations were analyzed against the 2 journals that did not explicitly claim adherence.

Main Outcomes and Measures

Measured study outcomes included race reporting frequency and use of the ICMJE recommendations for quality reporting of race.

Results

A total of 2485 publications were included in the study. The mean (SD) frequency of reporting of race and ethnicity in publications of ICMJE vs non-ICMJE journals was 32.8% (8.4) and 32.0% (20.9), respectively (P = .72). Adherence to ICMJE recommendations for reporting race was more frequent in ICMJE journals than non-ICMJE journals (mean [SD] of 73.1% [17.8] vs 37.0% [10.2]; P < .001).

Conclusions and Relevance

The frequency of race and ethnicity reporting among surgical journals is low. A journal's statement of adherence to ICMJE recommendations did not affect the frequency of race and ethnicity reporting; however, there was an increase in the use of ICMJE quality metrics. These findings suggest the need for increased and more standardized reporting of racial and ethnic demographic data among surgical journals.

Residency Program Use of Social Media in the COVID-19 Era: An Applicant's Perspective

General surgery residency programs' use of social media has exploded since early spring 2020, as it became clear that the COVID-19 pandemic would prevent away rotations and in-person interviews. Faced with the prospect of ranking programs they cannot visit, applicants are becoming reliant on programs' use of social media to showcase program culture, now a key recruitment tool. However, proper etiquette for applicant engagement with programs' social media accounts is unclear. Who administers these accounts - residents, program directors, program coordinators, or marketing staff? The subjectivity of criteria for "potentially unprofessional" content may pose disproportionate risks to female applicants and applicants of color. From this applicant's perspective, programs' recent use of social media has been informative and humanizing. It is our hope that departments, programs, and residents continue to post on social media throughout the application cycle. However, we applicants would benefit from clear guidance and expectations as to how to engage with residency programs via social media.

Characterizing the social media footprint of general surgery residency programs

Background

The medical community has increasingly embraced social media for a variety of purposes, including trainee education, research dissemination, professional networking, and recruitment of trainees and faculty. Platform choice and usage patterns appear to vary by specialty and purpose, but few studies comprehensively assess programs’ social media presence. Prior studies assessed general surgery departments’ Twitter use but omitted additional social media platforms and residency-specific accounts.

Objective

This study sought to broadly characterize the social media footprint of U.S. general surgery residency programs.

Methods

Using a protocolized search of program websites, social media platforms (Twitter, Facebook, Instagram, LinkedIn), and internet search, cross-sectional data on social media usage in March 2020 were collected for programs, their affiliated departments, their program directors (PDs), and their assistant/associate PDs (APDs).

Results

318 general surgery residency programs, 313 PDs, and 296 APDs were identified. 47.2% of programs had surgery-specific accounts on ≥1 platform. 40.2% of PDs and APDs had ≥1 account on Twitter and/or LinkedIn. Program type was associated with social media adoption and Twitter utilization, with lower usage among university-affiliated and independent programs (p<0.01).

Conclusions

Most general surgery residencies, especially non-university-based programs, lacked any department or residency accounts across Twitter, Facebook, and Instagram by March 2020. These findings highlight opportunities for increased social media engagement and act as a pre-pandemic baseline for future investigations of how the shift to virtual trainee education, recruitment, conferences, and clinical care affect social media use.

Driving Safety Among Surgical Residents in the Era of Duty Hour Restrictions

OBJECTIVE

Fatigued driving is a known contributor to adverse motor vehicle events (AMVEs), defined as crashes and near misses. Surgical trainees work long and irregular hours; the safety of work-related driving since the introduction of work hour regulations has not yet been studied in this population. We aimed to assess the impact of fatigue on driving safety and explore perceptions of a funded rideshare program.

DESIGN

An electronic survey was delivered and inquired in retrospective fashion about fatigue and sleepiness while driving, occurrences of AMVEs, and projected use of a funded rideshare program as a potential solution to unsafe driving. Chi-square testing determined categorical differences between response choices.

SETTING

Yale University School of Medicine, Department of Surgery, New Haven, CT-a general surgery program with 4 urban clinical sites positioned along a roughly twenty mile stretch of interstate highway in Southeastern Connecticut.

PARTICIPANTS

General Surgery residents at the Yale University School of Medicine.

RESULTS

Of 58 respondents (81% response rate), 97% reported that fatigue compromised their safety while driving to or from work. Eighty-three percent reported falling nearly or completely asleep, and 22% reported AMVEs during work-related driving. Junior residents were more likely than Seniors to drive fatigued on a daily-to-weekly basis (69% vs 47%, p = 0.02) and twice as likely to fall asleep on a weekly-to-monthly basis (67% vs 33%, p = 0.02). Despite this, only 7% of residents had ever hired a ride service when fatigued, though 88%, would use a free rideshare service if provided.

CONCLUSIONS

Work-related fatigue impairs the driving safety of nearly all residents, contributing to frequent AMVEs. Currently, few residents hire rideshare services. Eliminating the cost barrier by funding a rideshare and encouraging its routine use may protect surgical trainees and other drivers.

Surgical Education in the Time of COVID: Understanding the Early Response of Surgical Training Programs to the Novel Coronavirus Pandemic

OBJECTIVE

Describe the early impact of the COVID-19 pandemic on general surgery residency training nationwide.

DESIGN

A 31-question electronic survey was distributed to general surgery program directors. Qualitative data underwent iterative coding analysis. Quantitative data were evaluated with summary statistics and bivariate analyses.

PARTICIPANTS

Eighty-four residency programs (33.6% response rate) with representation across US geographic regions, program affiliations, and sizes.

RESULTS

Widespread changes were observed in the surgical training environment. One hundred percent of programs reduced the number of residents on rounds and 95.2% reduced the size of their in-hospital resident workforce; on average, daytime staffing decreased by nearly half. With telehealth clinics (90.5%) and remote inpatient consults (26.2%), both clinical care and resident didactics (86.9%) were increasingly virtual, with similar impact across all program demographics. Conversely, availability of some wellness initiatives was significantly higher among university programs than independent programs, including childcare (51.2% vs 6.7%), housing (41.9% vs 13.3%), and virtual mental health services (83.7% vs 53.3%).

CONCLUSIONS

Changes in clinical care delivery dramatically reduced in face-to-face learning opportunities for surgical trainees during the COVID-19 pandemic. While this effect had equal impact across all program types, sizes, and geographies, the same cannot be said for wellness initiatives. Though all programs initiated some strategies to protect resident health, the disparity between university programs and independent programs may be cause for action.

What's it Worth?: The Costs and Benefits of an Initiative to Decrease Post-Call Fatigued Driving Among Surgery Residents

BACKGROUND

In 2017 the ACGME enacted new regulations requiring sponsoring institutions to ensure "safe transportation options for residents who may be too fatigued to safely return home." We investigate here the impact of a pilot "Safe Ride" program designed to mitigate the risks of fatigued driving.

METHODS

During a 2-month pilot period at a single university-affiliated general surgery residency with four urban clinical sites, all residents (n = 72) were encouraged to hire a rideshare (e.g., Uber, Lyft) to and from 24-h clinical shifts if they felt too fatigued to drive safely. The cost of the rideshare was fully reimbursed to the resident. The impact of this intervention was evaluated using utilization data and a post-intervention resident survey.

RESULTS

A total of 16.6% of trainees utilized a rideshare at least one time. Sixty-three post-call rides were taken, predominantly by junior residents (92.4%) and for commutes greater than 15 miles (91%). The cost for the 60-day pilot was $3030. Comparing pre-intervention to post-intervention data, there was a significant improvement in the reported frequency of falling asleep or nearly asleep while driving (P < 0.001). Trainees nearly unanimously (98%) supported efforts to make the program permanent.

DISCUSSION

Driving while fatigued is common among surgical residents, with increased risk among junior residents, during longer commutes and following longer shifts. A reimbursed rideshare program effectively targets these risk factors and was associated with a significant decrease in rates of self-reported fatigued driving. Future efforts should focus on strategies to promote use of reimbursed rideshare programs while remaining cost efficient.

Creating an Opioid Recommendation Card for Trainees: Methods, Use, and Impact

BACKGROUND

In academic hospitals, surgical residents write most of the postoperative prescriptions; yet, few residents are trained on postoperative analgesia. This leads to wide variability in practices and often excess opioid prescribing. We sought to create an opioid guideline pocket card for surgical residents to access when prescribing opioids postoperatively and to evaluate the impact of this initiative.

METHODS

A comprehensive literature review was conducted to generate evidence-based procedure-specific opioid recommendations; additional recommendations were formulated via consensus opinion from surgical divisions at an academic institution. A pocket-sized guideline card was developed to include these procedure-specific recommendations as well as opioid guidelines for discharges after inpatient stays, non-opioid analgesic recommendations, access to opioid safety and disposal instructions for patients discharge, an equianalgesic dosing chart, and instructions for naloxone use. The card was distributed to all General Surgery house staff at a university-affiliated hospital in the spring of 2018. Following the distribution, trainees were surveyed on their use of the card. Descriptive statistics were used to analyze the survey.

RESULTS

Of 85 trainees, 62 (72.9%) responded to the survey in full; 58% use the card regularly. Of the 27 junior resident respondents, 70.4% use the card at least monthly including 48.1% who use the card daily-to-weekly. Overall, 81.6% of residents changed their opioid-prescribing practices because of this initiative and 89.8% believe the card should continue to be distributed and used.

DISCUSSION

An evidence-based guideline card for postoperative analgesia is highly valued and utilized by surgical trainees, especially those most junior in their training.

"Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent

OBJECTIVE

Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations.

DESIGN

This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature.

CONCLUSIONS

We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.

Can hybridization cause local extinction: a case for demographic swamping of the Australian native Senecio pinnatifolius by the invasive Senecio madagascariensis?

Hybridization between native and invasive species can have several outcomes, including enhanced weediness in hybrid progeny, evolution of new hybrid lineages and decline of hybridizing species. Whether there is a decline of hybridizing species largely depends on the relative frequencies of parental taxa and the viability of hybrid progeny. Here, the individual- and population-level consequences of hybridization between the Australian native Senecio pinnatifolius and the exotic Senecio madagascariensis were investigated with amplified fragment length polymorphism (AFLP) markers, and this information was used to estimate the annual loss of viable seeds to hybridization. A high frequency (range 8.3-75.6%) of hybrids was detected in open pollinated seeds of both species, but mature hybrids were absent from sympatric populations. A hybridization advantage was observed for S. madagascariensis, where significantly more progeny than expected were sired based on proportional representation of the two species in sympatric populations. Calculations indicated that S. pinnatifolius would produce less viable seed than S. madagascariensis, if hybridization was frequency dependent and S. madagascariensis reached a frequency of between 10 and 60%. For this native-exotic species pair, prezygotic isolating barriers are weak, but low hybrid viability maintains a strong postzygotic barrier to introgression. As a result of asymmetric hybridization, S. pinnatifolius would appear to be under threat if S. madagascariensis increases numerically in areas of contact.

The effect of elevated hydrostatic pressure on the spectral absorption of deep-sea fish visual pigments

The effect of hydrostatic pressure (0.1-54 MPa, equivalent to pressures experienced by fish from the ocean's surface to depths of ca. 5,400 m) on visual pigment absorption spectra was investigated for rod visual pigments extracted from the retinae of 12 species of deep-sea fish of diverse phylogeny and habitat. The wavelength of peak absorption (lambda(max)) was shifted to longer wavelengths by an average of 1.35 nm at 40 MPa (a pressure approximately equivalent to average ocean depth) relative to measurements made at one atmosphere (ca. 0.1 MPa), but with little evidence of a change in absorbance at the lambda(max). We conclude that previous lambda(max) measurements of deep-sea fish visual pigments, made at a pressure close to 0.1 MPa, provide a good indication of lambda(max) values at higher pressures when considering the ecology of vision in the deep-sea. Although not affecting the spectral sensitivity of the animal to any important degree, the observed shift in lambda(max) may be of interest in the context of understanding opsin-chromophore interaction and spectral tuning of visual pigments.

Effects of various treatments on the quantitative recovery of endotoxin from water-soluble metalworking fluids

Three extraction methods were compared for their effectiveness in the quantitative removal of endotoxin from unused and used bulk water-soluble metalworking fluid (MWF) samples. Soluble, synthetic, and semisynthetic fluids were studied. The three modes of extraction consisted of (1) pyrogen-free water (PFW); (2) PFW and Tween 20 (polyoxyethylene sorbitan monolaurate); and (3) PFW, Tween 20, and sonication. Results suggest that vigorous recovery methods yield higher amounts of endotoxin from MWF samples than mild recovery methods in PFW alone. Additional studies are required to aid in the understanding of the factors that significantly affect endotoxin extraction yields from these fluids.

Preliminary report on the results of the second phase of a round- robin endotoxin assay study using cotton dust

In an on-going endotoxin assay study, a two-part interlaboratory endotoxin assay study has been completed. The purpose of the study was to compare the variation in assay results between different laboratories, and, if the variation was high, to see if a common protocol would reduce the variation. In both parts of the study, membrane filters laden with the same approximate amount and type of cotton dust were sent for analysis to laboratories that "routinely" perform endotoxin analyses. First, each of these laboratories performed the analysis using the methodology common to its laboratory. In the second part of the study, membrane filters with cotton dust were again sent to the same laboratories where the analyses were performed as before but with a common extraction protocol. The preliminary results from the first phase of the study have been collected and showed that intra-laboratory variations were small, but large and significant interlaboratory variation was observed. The results were reported elsewhere. The preliminary results from the second part of the study consisting of the data currently collected are presented here. Again, intra-laboratory variations were small, but, also again, large and significant inter-laboratory variation was observed. However, in this part of the study, the range between the highest and lowest average results was narrower than in the first part of the study. Influence of the assay kit type was examined. The variation within assay kit type was small but significant differences in results were observed between assay kit types. The findings suggest that endotoxin concentration in samples can be ranked within laboratories, but not necessarily between laboratories. However, some of the variation between laboratories has been reduced by a common extraction protocol which suggests the possibility of further standardization that may lead to better comparability between laboratories.

Validation of retroviral detection for rodent cell-derived products and gene therapy applications

The availability of sensitive assays for detecting infectious murine retroviruses has become critical for the development and acceptance of a number of biopharmaceuticals, including monoclonal antibody-derived products and gene therapy vectors. Comparative studies demonstrated that the PG4 S+L- retrovirus infectivity test routinely yields higher titres than the mink cell test for xenotropic, amphotrophic and MCF murine retroviruses. A validation study for the PG4 S+L- assay demonstrated very good linearity (r2 of 0.95 to 0.99), reproducibility within a study (+/-0.35 log10 units), and precision between tests (+/-0.45 log10 units). Interference (or selectivity) in the presence of a non-specific antibody was insignificant (less than 0.2 log10 units). Sensitivity levels established from measurements as virus titres approach zero demonstrated a threshold value of 2-3 focus forming units (FFU)/ml. Two methods for increasing assay sensitivity were used including: (i) increased product samplings combined with a Poisson distribution analysis, and (ii) a 14-day co-cultivation with Mus dunni cells. Each of these methods was shown to increase sensitivity by at least one log10 unit. Murine retroviruses may also be detected by a less sensitive immunofluorescence assay (IFA) using specific monoclonal antibodies; this assay is essential for detecting certain recombinant ecotropic MuLVs. In summary, murine retroviral detection ranked by sensitivity is mink S+L- < IFA with monoclonal antibodies < PG4 S+L- < Mus dunni co-cultivation followed by PG4 S+L-.

Allograft safety: viral inactivation with bone demineralization

A study was performed to validate the effectiveness of a bone demineralization process with respect to its inactivation of viruses. The viruses selected for study included human immunodeficiency virus (HIV), duck hepatitis B virus (a model for human hepatitis B), bovine viral diarrheal virus (a model for human hepatitis C), human cytomegalovirus, and human poliovirus (a model for small nonenveloped viruses, e.g., hepatitis A). This study was performed in compliance with Good Laboratory Practice regulations using validation methodology similar to that used to ensure the safety of blood derivatives and other products. Use of the bone demineralization process described in this report resulted in a reduction in infectivity of greater than one million (10(6)) for all viruses and as much as one trillion (10(12)) for the poliovirus.

Cross sectional stature and weight reference curves for the UK, 1990

The current reference curves of stature and weight for the UK were first published in 1966 and have been used ever since despite increasing concern that they may not adequately describe the growth of present day British children. Using current data from seven sources new reference curves have been estimated from birth to 20 years for children in 1990. The great majority of the data are nationally representative. The analysis used Cole's LMS method and has produced efficient estimates of the conventional centiles and gives a good fit to the data. These curves differ from the currently used curves at key ages for both stature and weight. In view of the concerns expressed about the current curves and the differences between them and the new curves, it is proposed that the curves presented here should be adopted as the new UK reference curves.

Body mass index centile charts to assess fatness of British children

Body mass index (BMI) relates weight to height and reflects the shape of a child, but because of age dependency it has not been used conventionally for the estimation of fatness in children. From measurements of Tayside children (n = 34,533) centile charts were constructed for BMI (wt/ht2) from the raw data of height and weight, using Cole's LMS method for normalised growth standards. These data were compared with the only available European BMI charts published from data of French children obtained over a period of 24 years from 1956-79. British children appear to be 'fatter'. Within a subgroup (n = 445) the BMI values were correlated with estimations of body fat, for boys and girls, from skinfold thickness (r = 0.8 and 0.81) and bioelectrical impedance (r = 0.65 and 0.7). The limits of acceptable BMI have yet to be defined.

Magnetic resonance imaging in synovial disorders and arthropathy of the knee

The ability of MR imaging to demonstrate articular cartilage, the synovium, and the adjacent bone greatly assists in the diagnosis and treatment of synovial disorders and a variety of arthropathies of the knee. The use of specific pulse sequences and intravenous contrast material can improve the performance of MR imaging of the knee in patients with synovitis, arthritis, or synovial-based neoplasms.

Passive hepatic congestion: cross-sectional imaging features

Passive hepatic congestion is caused by stasis of blood within the liver parenchyma due to compromise of hepatic venous drainage. It is a common complication of congestive heart failure and constrictive pericarditis, wherein elevated central venous pressure is directly transmitted from the right atrium to the hepatic veins because of their close anatomic relationship (Fig. 1). The liver becomes tensely swollen as the hepatic sinusoids dilate and engorge to accommodate the backflow of blood. A variety of structural and functional hepatic derangements develop that have distinctive appearances on sonograms, CT scans, and MR images.

Carcinoma arising in urinary bladder diverticula: imaging findings in six patients

OBJECTIVE

Carcinoma arising within urinary bladder diverticula has a poorer prognosis than do neoplasms that originate within the main bladder lumen as a result of early transmural tumor infiltration. Imaging plays an important role in diagnosing and staging the disease. We describe the radiologic findings in six patients with pathologically proved diverticular carcinomas.

MATERIALS AND METHODS

We reviewed the records of six patients who had radiologic examinations and surgically confirmed vesical diverticular carcinomas. The examinations included excretory urography in three patients, cystography in three patients, CT in five patients, and MR imaging in one patient. All patients had hematuria. Five patients had transitional cell carcinoma, and one patient had squamous cell carcinoma.

RESULTS

Three of the tumors manifested as an intraluminal filling defect within a bladder diverticulum on excretory urograms or cystograms. In one patient, CT scans showed a concentric soft-tissue tumor in a diverticular neck. Correlative cystograms showed only smooth narrowing in this area. CT and MR imaging showed a tumor within a large diverticulum, which was not visualized on cystograms because of obstruction at the diverticular orifice.

CONCLUSION

Imaging plays an important role in identifying bladder diverticula as a potential site of occult neoplasm.

Imaging manifestations of pleural tumors

Although radiologic assessment of pleural tumors may be accomplished with several imaging modalities, the standard noninvasive techniques include chest radiography and computed tomography (CT). These examinations may be supplemented with magnetic resonance imaging and occasionally with ultrasound. Depending on the location, size, and underlying histologic features, pleural tumors may produce a spectrum of findings. CT is particularly useful in defining the location and extent of these masses. The authors present a review of basic pleural anatomy and imaging features of both benign and malignant pleural neoplasms. The pleural may be involved by one of several primary or metastatic tumors. Specific cell types are diffuse malignant mesothelioma (the most common plain radiographic findings are unilateral pleural effusion and pleural thickening), localized fibrous tumor (circumscribed, spherical or ovoid, noncalcified lesions arising in the pleural surface), metastatic disease (radiographic findings may mimic those of malignant mesothelioma), and uncommon neoplasms including thymoma and lymphoma. Among these various pleural tumors, metastatic disease represents the most common neoplasm.

Practical screening priorities for hearing impairment among children in developing countries

Routine screening for hearing impairment in childhood is now widespread in industrial countries, although there is considerable controversy over the most efficient techniques and procedures. In most developing countries, however, routine screening programmes for hearing impairment do not currently exist. The problems involved in implementing screening programmes in developing and industrial countries are very different, and in selecting screening procedures for a particular population the following factors have to be taken into consideration: the environmental test conditions; the availability of resources for equipment and the training of testers; the local attitudes towards disability; the level of hearing impairment that may cause handicaps; and the major types of pathology causing hearing impairment. We suggest that in developing countries children should be screened at school entry using a simple field audiometer and that the external ear be inspected for the presence of a discharge. There is an urgent need to develop reliable and simple screening procedures for infants and young children; where possible, all children should be screened for severe or significant hearing impairment before the age of 2 years. No screening should, however, be implemented until appropriate follow-up services are available.

Appendices epiploicae of the colon: radiologic and pathologic features

Appendices epiploicae are adipose structures protruding from the serosal surface of the colon. They can be seen with abdominal radiography and cross-sectional imaging if the colonic wall is surrounded by intraperitoneal contrast material, ascites, or blood. Normal appendices epiploicae appear as lobulated masses of pericolic fat, usually 2-5 cm long and 1-2 cm thick. Their enlargement, deformity, or altered radiopacity may result from various pathologic processes that can originate locally or extend from adjacent viscera. In a series of 22 cases, appendices epiploicae were affected by spontaneous torsion and hemorrhagic infarct, calcification due to aseptic fat necrosis, primary or secondary inflammation, enlargement by lipomas or metastases, and incarceration in hernias. Disorders of appendices epiploicae are often manifested by nonspecific clinical signs and symptoms (eg, torsion is often mistaken for appendicitis or diverticulitis). These entities should be included in the differential diagnosis of any unexplained abdominal pain or pericolic lesions in adults.

Linkage analysis in a large family with nonspecific X-linked mental retardation

We report on a large 5-generation family with "nonspecific" X-linked mental retardation. Nine living affected males have an IQ between 50 and 70 but have normal stature, facial appearance, and testicular volumes and no other abnormalities. Two obligate carrier females had borderline intellectual abilities and visual-psychomotor difficulties similar to those seen in affected males. Results of chromosome studies, including fragile X, were normal in males and females. Linkage analysis was undertaken, with 19 X-specific chromosomal restriction fragment length polymorphisms (RFLPs), giving a maximal LOD score of 1.60 at a 0.10 recombination fraction for F9, suggesting a localization to distal Xq for the mutant gene in this family.

Linkage analysis in the fragile X syndrome using multiple distal Xq polymorphic DNA markers

Linkage data using the polymorphic loci F9, DXS105, DXS98, DXS52, DXS15, and F8 and the DNA probe 1A1 are presented from 14 families segregating for fragile X [fra(X)] syndrome. Recombination fractions corresponding to the maximum LOD scores obtained by two-point linkage analysis suggest that DXS98 (Zmax = 3.23, theta = 0.0) and DXS105 (Zmax = 2.09, theta = 0.0) are the closest markers proximal to FRAXA and that DXS52 is the closest distal marker (Zmax = 3.55, theta = 0.16). FRAXA is located within a 25 cM interval between F9 and DXS52, coincident with DXS98, on multipoint linkage analysis. Phase-known three way crossover information places F8 outside the cluster (DXS52, DXS15, 1A1). Confidence limits for the markers DXS98 and DXS52 are relatively wide (0.0-0.15 and 0.06-0.31, respectively), but when used in combination with cytogenetic examination offer improved carrier detection in comparison with cytogenetic analysis alone.

Conservation of intron position indicates separation of major and variant H2As is an early event in the evolution of eukaryotes

Genomic clones of Drosophila and Tetrahymena histone H2A variants were isolated using the corresponding cDNA clones (van Daal et al. 1988; White et al. 1988). The site corresponding to the initiation of transcription was defined by primer extension for both Drosophila and Tetrahymena genomic sequences. The sequences of the genomic clones revealed the presence of introns in each of the genes. The Drosophila gene has three introns: one immediately following the initiation codon, one between amino acids 26 and 27 (gln and phe), and one between amino acids 64 and 65 (glu and val). The Tetrahymena gene has two introns, the positions of which are identical to the first two introns of the Drosophila gene. The chicken H2A.F variant gene has been recently sequenced and it contains four introns (Dalton et al. 1989). The first three of these are in the same positions as the introns in the Drosophila gene. The fourth intron interrupts amino acid 108 (gly). In all cases the sizes and the sequences of the introns are divergent. However, the fact that they are in conserved positions suggests that at least two of the introns were present in the ancestral gene. A phylogenetic tree constructed from the sequences of the variant and major cell cycle-regulated histone H2A proteins from several species indicates that the H2A variant proteins are evolutionarily separate and distinct from the major cell cycle-regulated histone H2A proteins. The ancestral H2A gene must have duplicated and diverged before fungi and ciliates diverged from the rest of the eukaryote lineage. In addition, it appears that the variant histone H2A proteins analyzed here are more conserved than the major histone H2A proteins.

Infected abdominal tumors: percutaneous catheter drainage

Sixteen patients underwent percutaneous catheter drainage of infected primary (n = 9) or metastatic (n = 7) abdominal tumors. Twelve of the patients improved clinically, as evidenced by defervescence and decrease or normalization of leukocytosis. Four patients did not respond to catheter drainage and required surgery. Three of the twelve who improved underwent operations for attempts at surgical cure or debulking of tumor volume despite an initial "good" response to percutaneous drainage. Of the nine patients who did not undergo surgery after percutaneous drainage, four underwent catheter removal after 5 weeks of drainage and had no recurrence of infection, two remained alive with the catheter in place up to 8 months and 1 year after drainage, and two died with the catheter in place. One patient had the catheter removed inadvertently after 3 weeks of drainage and had recurrences that required replacement of the catheter until his death. The major differences between drainage of necrotic tumors and drainage of standard abscesses were the need for surgery in the majority of the cases and the fact that patients needed the catheters for continued palliation until their death.

Nucleus-specific and temporally restricted localization of proteins in Tetrahymena macronuclei and micronuclei

Labeled nuclear proteins were microinjected into the cytoplasm of Tetrahymena thermophila. Macronuclear H1, calf thymus H1, and the SV40 large T antigen nuclear localization signal linked to BSA accumulated specifically in macronuclei, even if cells were in micronuclear S phase or were nonreplicating. The way in which histone H4 localized to either the macronucleus or the micronucleus suggested that it accumulates in whichever nucleus is replicating. The inability of the micronucleus to accumulate Tetrahymena H1 or heterologous nuclear proteins, even at a period in the cell cycle when it is accumulating H4, suggests that it has a specialized transport system. These studies demonstrate that although the mechanism for localizing proteins to nuclei is highly conserved among eukaryotes, it can differ between two porecontaining nuclei lying in the same cytoplasm.

Adapting milieu approaches to acute inpatient care for schizophrenic patients

Classic therapeutic community or milieu therapy techniques are not applicable in many contemporary acute-treatment settings, which emphasize crisis intervention, short stays, psychotropic medication, and cost containment. However, milieu techniques can be integrated with an understanding of biological and psychosocial factors to provide a framework for the acute, short-term treatment of schizophrenic patients. After reviewing recent biological and psychosocial research, the authors outline three principles for incorporating such research with milieu techniques: creating a holding environment, developing a graduated therapeutic program, and focusing on common patient needs. Application of these principles in a short-stay setting will provide an intensely supportive treatment environment that allows the use of many different therapies and modulates stresses on staff.

Pancreatic pseudotumors associated with multifocal idiopathic fibrosclerosis

Two patients with multifocal idiopathic fibrosclerosis and sclerosing cholangitis developed biliary obstruction due to a fibrotic pancreatic pseudotumor. The masslike fibrosis mimicked pancreatic carcinoma on sonography and cholangio-pancreatography. In one patient sonography was successfully used to assess the response of the pseudotumor to corticosteroid therapy.

Localization and expression of mRNA for a macronuclear-specific histone H2A variant (hv1) during the cell cycle and conjugation of Tetrahymena thermophila

hv1 is a histone H2A variant found in the transcriptionally active Tetrahymena macronucleus but not in the transcriptionally inert micronucleus. This, along with a number of other lines of evidence, suggests that hv1 is associated with active genes. We have used a cDNA clone as a probe to study hv1 mRNA accumulation throughout the cell cycle and during conjugation. In situ hybridization to glutaraldehyde-fixed growing cells, whose position in the cell cycle was determined by size and morphology, showed that hv1 message is present throughout the cell cycle. The message was uniformly distributed in these vegetative cells. Compared with four other Tetrahymena histone genes studied to date (S. -M. Yu, S. Horowitz, and M. A. Gorovsky, Genes Dev., 1:683, 1987; M. Wu, C. D. Allis, and M. A. Gorovsky, Proc. Natl. Acad. Sci. USA 85:2205, 1988), hv1 mRNA is the only one that does not show a pattern of accumulation during the cell cycle that could explain the nuclear localization of its encoded protein. Thus, either hv1 or some molecule with which it associates contains a macronuclear-specific targeting sequence or there exists a cell cycle-regulated event that restricts its translation to the macronuclear S phase. In situ hybridization to conjugating cells revealed that hv1 message amounts increase just prior to macronuclear development and decline precipitously after the cells separate. The hv1 message showed no marked subcellular localization and is, therefore, unlikely to play a role in the cytoplasmic determination known to occur during macronuclear development.

Drosophila has a single copy of the gene encoding a highly conserved histone H2A variant of the H2A.F/Z type

The Tetrahymena histone H2A variant designated hv1 is localized exclusively in the transcriptionally active macronucleus and is absent from the quiescent micronucleus (1). A cDNA clone of the hv1 gene (2) was used to screen a Drosophila cDNA library. A cross-hybridizing clone was recovered and shown by sequence analysis to code for a protein homologous to hv1 as well as to the chicken H2A variant, H2A.F (3), the sea urchin H2A variant, H2A.F/Z (4) and the mammalian H2A variant H2A.Z (5). Southern analysis of Drosophila genomic DNA indicates that the H2AvD (H2A variant Drosophila) gene is present in one copy. In situ hybridization places the locus at 97CD on chromosome 3, while the S-phase regulated histone genes are on chromosome 2 (6). Thus the Drosophila H2A variant should be accessible to genetic analysis, which will enable its function to be determined.

Sequence and properties of the message encoding Tetrahymena hv1, a highly evolutionarily conserved histone H2A variant that is associated with active genes

hv1 is a histone H2A variant found in the transcriptionally active Tetrahymena macronucleus, but not in the transcriptionally inert micronucleus. hv1 also contains antigenic determinants conserved in the histone complements of representatives of all four eukaryotic kingdoms. A cDNA clone encoding hv1 has been isolated and sequenced. Comparison of the derived protein sequence of hv1 with that of the chicken variant H2A.F and the sea urchin variant H2A.F/Z reveals remarkable homology in all but the extreme amino- and carboxy-termini and a small region in the conserved core. Putative regions of conserved antigenicity are discussed. Evidence is presented that suggests that hv1 is a single-copy, intron-containing gene that encodes a polyadenylated message. Unusual features in the 3' flanking sequence and in codon usage are also described. Evidence is also presented showing that hv1 message amounts are ten-fold greater in growing cells than in starved cells.

Low-level echogenicity in intraventricular hemorrhage versus ventriculitis

Serial cranial sonograms of 55 neonates with large perinatal intraventricular/intraparenchymal hemorrhages and moderate-to-severe posthemorrhagic hydrocephalus were reviewed. In all 55 patients, the ventricles were initially enlarged and filled with anechoic cerebrospinal fluid, which contained discrete hyperechoic fragments of hematoma. Between 7 and 25 days after the initial hemorrhagic episode, however, diffuse, low-level echogenicity appeared in the ventricles of 34 patients. The low-level echogenicity was transient and persisted for 7-59 days (average, 18 days). In 32 patients, low-level echogenicity was a benign finding associated with prior intraventricular hemorrhage. In two patients, the low-level echogenicity was associated with ventriculitis. Low-level echogenicity appeared, increased, then cleared, but reappeared with the onset of ventriculitis in these two patients. Thickening of the ependyma and abnormal periventricular echogenicity, signs of inflammation, were also present. Although low-level echogenicity may commonly be a benign finding, the possibility of ventriculitis should not be ignored.

Cranial duplex sonography of the infant

Duplex sonography was used to evaluate the cranial contents of 75 infants. The first 35 were scanned to establish technique and evaluate basic flow patterns. All cranial vessels scanned in healthy term infants produced diphasic (low-resistance) waveforms, although certain cerebral vessels had characteristic Doppler signatures. The pericallosal, callosomarginal, anterior cerebral, basilar, middle cerebral, and internal carotid arteries and the vein of Galen were isolated and evaluated in almost every subject. In the second part of the study duplex characteristics of healthy term infants, healthy preterm infants, preterm infants with intracranial hemorrhages, and hydrocephalic infants were evaluated. Relative flow velocity at peak systole and end diastole and pulsatility index were investigated. The most significant variable was gestational age. Preterm infants frequently had no forward flow during diastole. Duplex sonography does not appear to add significant diagnostic information to routine real-time cranial studies. It does, however, permit more exact evaluation of cerebral blood flow than does non-pulse-gated, nondirected Doppler scanning.

Renal metastases: clinicopathologic and radiologic correlation

The clinical and radiologic features of 27 patients with renal metastases arising from eight different types of nonlymphomatous primary malignancies are presented. Renal metastases were generally detected late in the course of the malignancy. In 23 patients there were no symptoms referable to the kidney. Urinalysis was normal in nine patients and showed microscopic hematuria in nine, gross hematuria in four, and proteinuria in four. Radiologically, metastases were usually multifocal; however, metastases arising from colon, lung, and breast carcinoma were sometimes large, solitary, and otherwise indistinguishable from primary renal cell carcinoma. Three of four melanoma metastases and three of seven lung metastases infiltrated the perinephric space. Computed tomography was the most sensitive modality, depicting renal metastases in all 24 cases in which it was employed, followed by ultrasound and intravenous urography. In patients with a history of malignancy, renal metastases outnumbered renal cell carcinomas by approximately 4:1. This study indicates that a new renal lesion in a patient with advanced, noncurable cancer is more likely metastatic than primary and that biopsy in this setting is unlikely to be of aid.