Fluoroscopic image-based behavior analysis can objectively explain subjective expert assessment of wire navigation skill

Psychomotor skill and decision-making efficiency in surgical wire navigation can be objectively evaluated by analysis of intraoperative fluoroscopic image sequences. Prior work suggests that such image-based behavior analysis of operating room (OR) performance can predict performer experience level (R2  = 0.62) and agree with expert opinion (the current standard) on the quality of a final implant construct (R2  = 0.59). However, it is unclear how objective image-based evaluation compares with expert assessments for entire technical OR performances. This study examines the relationships between three key variables: (1) objective image-based criteria, (2) expert opinions, and (3) performing surgeon experience level. A paired-comparison survey of seven experts, based upon eight OR fluoroscopic wire navigation image sequences, shows that the experts' preferences are best explained by objective metrics that reflect psychomotor and decision-making behaviors which are counter-productive to successful implant placement, like image count (R2  = 0.83) and behavior tally (R2  = 0.74). One such behavior, adjustments away from goal, uniquely correlated well with all three key variables: a fluoroscopic image-based analysis composite score (R2  = 0.40), expert consensus (R2  = 0.76), and performer experience (R2  = 0.41). These results confirm that experts view less efficient technical behavior as indicative of lesser technical proficiency. While expert assessments of technical skill were reliable and consistent, neither individual nor consensus expert opinion appears to correlate with performer experience (R2  = 0.11).

Establishing Construct Validity of a Novel Simulator for Guide Wire Navigation in Antegrade Femoral Intramedullary Nailing

Background

Antegrade femoral intramedullary nailing (IMN) is a common orthopedic procedure that residents are exposed to early in their training. A key component to this procedure is placing the initial guide wire with fluoroscopic guidance. A simulator was developed to train residents on this key skill, building off an existing simulation platform originally developed for wire navigation during a compression hip screw placement. The objective of this study was to assess the construct validity of the IMN simulator.

Methods

Thirty orthopedic surgeons participated in the study: 12 had participated in fewer than 10 hip fracture or IMN related procedures and were categorized as novices; 18 were faculty, categorized as experts. Both cohorts were instructed on the goal of the task, placing a guide wire for an IM nail, and the ideal wire position reference that their wire placement would be graded against. Participants completed 2 assessments with the simulator. Performance was graded on the distance from the ideal starting point, distance from the ideal end point, wire trajectory, duration, fluoroscopy image count, and other elements of surgical decision making. A two-way ANOVA analysis was used to analyze the data looking at experience level and trial number.

Results

The expert cohort performed significantly better than the novice cohort on all metrics but one (overuse of fluoroscopy). The expert cohort had a more accurate starting point and completed the task while using fewer images and less overall time.

Conclusion

This initial study shows that the IMN application of a wire navigation simulator demonstrates good construct validity. With such a large cohort of expert participants, we can be confident that this study captures the performance of active surgeons today. Implementing a training curriculum on this simulator has the potential to increase the performance of the novice level residents prior to their operating on a vulnerable patient. Level of Evidence: III.

Minimally Trained Analysts Can Perform Fast, Objective Assessment of Orthopedic Technical Skill from Fluoroscopic Images

Skill assessment in orthopedics has traditionally relied on subjective impressions from a supervising surgeon. The feedback derived from these tools may be limited by bias and other practical issues. Objective analysis of intraoperative fluoroscopic images offers an inexpensive, repeatable, and precise assessment strategy without bias. Assessors generally refrain from using the scores of images obtained throughout the operation to evaluate skill for practical reasons. A new system was designed to facilitate rapid analysis of this fluoroscopy via minimally trained analysts. Four expert and four novice analysts independently measured one objective metric for skill using both a custom analysis software and a commercial alternative. Analysts were able to measure the objective metric three times faster when using the custom software, and without a practical difference in accuracy in comparison to the expert analysts using the commercial software. These results suggest that a well-designed fluoroscopy analysis system can facilitate inexpensive, reliable, and objective assessment of surgical skills.

Surgical Skill Can be Objectively Measured From Fluoroscopic Images Using a Novel Image-based Decision Error Analysis (IDEA) Score

BACKGROUND

To advance orthopaedic surgical skills training and assessment, more rigorous and objective performance measures are needed. In hip fracture repair, the tip-apex distance is a commonly used summative performance metric with clear clinical relevance, but it does not capture the skill exercised during the process of achieving the final implant position. This study introduces and evaluates a novel Image-based Decision Error Analysis (IDEA) score that better captures performance during fluoroscopically-assisted wire navigation.

QUESTIONS/PURPOSES

(1) Can wire navigation skill be objectively measured from a sequence of fluoroscopic images? (2) Are skill behaviors observed in a simulated environment also exhibited in the operating room? Additionally, we sought to define an objective skill metric that demonstrates improvement associated with accumulated surgical experience.

METHODS

Performance was evaluated both on a hip fracture wire navigation simulator and in the operating room during actual fracture surgery. After examining fluoroscopic image sequences from 176 consecutive simulator trials (performed by 58 first-year orthopaedic residents) and 21 consecutive surgical procedures (performed by 19 different orthopaedic residents and one attending orthopaedic surgeon), three main categories of erroneous skill behavior were identified: off-target wire adjustments, out-of-plane wire adjustments, and off-target drilling. Skill behaviors were measured by comparing wire adjustments made between consecutive images against the goal of targeting the apex of the femoral head as part of our new IDEA scoring methodology. Decision error metrics (frequency, magnitude) were correlated with other measures (image count and tip-apex distance) to characterize factors related to surgical performance on both the simulator and in the operating room. An IDEA composite score integrating decision errors (off-target wire adjustments, out-of-plane wire adjustments, and off-target drilling) and the final tip-apex distance to produce a single metric of overall performance was created and compared with the number of hip wire navigation cases previously completed (such as surgeon experience levels).

RESULTS

The IDEA methodology objectively analyzed 37,000 images from the simulator and 688 images from the operating room. The number of decision errors (7 ± 5 in the operating room and 4 ± 3 on the simulator) correlated with fluoroscopic image count (33 ± 14 in the operating room and 20 ± 11 on the simulator) in both the simulator and operating room environments (R2 = 0.76; p < 0.001 and R2 = 0.71; p < 0.001, respectively). Decision error counts did not correlate with the tip-apex distance (16 ± 4 mm in the operating room and 12 ± 5 mm on the simulator) for either the simulator or the operating room (R2 = 0.08; p = 0.15 and R2 = 0.03; p = 0.47, respectively), indicating that the tip-apex distance is independent of decision errors. The IDEA composite score correlated with surgical experience (R2 = 0.66; p < 0.001).

CONCLUSION

The fluoroscopic images obtained in the course of placing a guide wire contain a rich amount of information related to surgical skill. This points the way to an objective measure of skill that also has potential as an educational tool for residents. Future studies should expand this analysis to the wide variety of procedures that rely on fluoroscopic images.

CLINICAL RELEVANCE

This study has shown how resident skill development can be objectively assessed from fluoroscopic image sequences. The IDEA scoring provides a basis for evaluating the competence of a resident. The score can be used to assess skill at key timepoints throughout residency, such as when rotating onto/off of a new surgical service and before performing certain procedures in the operating room, or as a tool for debriefing/providing feedback after a procedure is completed.

A Vision for Using Simulation & Virtual Coaching to Improve the Community Practice of Orthopedic Trauma Surgery

BACKGROUND

Many orthopedic surgeries involve the challenging integration of fluoroscopic image interpretation with skillful tool manipulation to enable procedures to be performed through less invasive approaches. Simulation has proved beneficial for teaching and improving these skills for residents, but similar benefits have not yet been realized for practicing orthopedic surgeons. A vision is presented to elevate community orthopedic practice and improve patient safety by advancing the use of simulators for training and assessing surgical skills.

METHODS

Key elements of this vision that are established include 1) methods for the objective and rigorous assessment of the performance of practicing surgeons now exist, 2) simulators are sufficiently mature and sophisticated that practicing surgeons will use them, and 3) practicing surgeons can improve their performance with appropriate feedback and coaching.

RESULTS

Data presented indicate that surgical performance can be adequately and comparably measured using structured observations made by experts or non-expert crowds, with the crowdsourcing approach being more expedient and less expensive. Rigorous measures of the surgical result and intermediate objectives obtained semi-automatically from intra-operative fluoroscopic image sequences can distinguish performances of experts from novices. Experience suggests that practicing orthopedic surgeons are open to and can be constructively engaged by a family of mature simulators as a means to evaluate and improve their surgical skills.

CONCLUSIONS

The results presented support our contention that new objective assessment measures are sufficient for evaluating the performance of working surgeons. The novel class of orthopedic surgical simulators available were tested and approved by practicing physicians. There exists a clear opportunity to combine purpose-designed simulator exercises with virtual coaching to help practicing physicians retain, retrain, and improve their technical skills. This will ultimately reduce cost, increase the quality of care, and decrease complication rates.

CLINICAL RELEVANCE

This vision articulates a means to boost the confidence of practitioners and ease their anxiety so that they perform impactful procedures more often in community hospitals, which promises to improve treatment and reduce the cost of care while keeping patients closer to their homes and families.

An Extensible Orthopaedic Wire Navigation Simulation Platform

The demand for simulation-based skills training in orthopaedics is steadily growing. Wire navigation, or the ability to use 2D images to place an implant through a specified path in bone, is an area of training that has been difficult to simulate given its reliance on radiation based fluoroscopy. Our group previously presented on the development of a wire navigation simulator for a hip fracture module. In this paper, we present a new methodology for extending the simulator to other surgical applications of wire navigation. As an example, this paper focuses on the development of an iliosacral wire navigation simulator. We define three criteria that must be met to adapt the underlying technology to new areas of wire navigation; surgical working volume, system precision, and tactile feedback. The hypothesis being that techniques which fall within the surgical working volume of the simulator, demand a precision less than or equal to what the simulator can provide, and that require the tactile feedback offered through simulated bone can be adopted into the wire navigation module and accepted as a valid simulator for the surgeons using it. Using these design parameters, the simulator was successfully configured to simulate the task of drilling a wire for an iliosacral screw. Residents at the University of Iowa successfully used this new module with minimal technical errors during use.

Estimating Time Physicians and Other Health Care Workers Spend with Patients in an Intensive Care Unit Using a Sensor Network

BACKGROUND

Time and motion studies have been used to investigate how much time various health care professionals spend with patients as opposed to performing other tasks. However, the majority of such studies are done in outpatient settings, and rely on surveys (which are subject to recall bias) or human observers (which are subject to observation bias). Our goal was to accurately measure the time physicians, nurses, and critical support staff in a medical intensive care unit spend in direct patient contact, using a novel method that does not rely on self-report or human observers.

METHODS

We used a network of stationary and wearable mote-based sensors to electronically record location and contacts among health care workers and patients under their care in a 20-bed intensive care unit for a 10-day period covering both day and night shifts. Location and contact data were used to classify the type of task being performed by health care workers.

RESULTS

For physicians, 14.73% (17.96%) of their time in the unit during the day shift (night shift) was spent in patient rooms, compared with 40.63% (30.09%) spent in the physician work room; the remaining 44.64% (51.95%) of their time was spent elsewhere. For nurses, 32.97% (32.85%) of their time on unit was spent in patient rooms, with an additional 11.34% (11.79%) spent just outside patient rooms. They spent 11.58% (13.16%) of their time at the nurses' station and 23.89% (24.34%) elsewhere in the unit. From a patient's perspective, we found that care times, defined as time with at least one health care worker of a designated type in their intensive care unit room, were distributed as follows: 13.11% (9.90%) with physicians, 86.14% (88.15%) with nurses, and 8.14% (7.52%) with critical support staff (eg, respiratory therapists, pharmacists).

CONCLUSIONS

Physicians, nurses, and critical support staff spend very little of their time in direct patient contact in an intensive care unit setting, similar to reported observations in both outpatient and inpatient settings. Not surprisingly, nurses spend far more time with patients than physicians. Additionally, physicians spend more than twice as much time in the physician work room (where electronic medical record review and documentation occurs) than the time they spend with all of their patients combined.

Low-Cost, Distributed Environmental Monitors for Factory Worker Health

An integrated network of environmental monitors was developed to continuously measure several airborne hazards in a manufacturing facility. The monitors integrated low-cost sensors to measure particulate matter, carbon monoxide, ozone and nitrogen dioxide, noise, temperature and humidity. The monitors were developed and tested in situ for three months in several overlapping deployments, before a full cohort of 40 was deployed in a heavy vehicle manufacturing facility for a year of data collection. The monitors collect data from each sensor and report them to a central database every 5 min. The work includes an experimental validation of the particle, gas and noise monitors. The R² for the particle sensor ranges between 0.98 and 0.99 for particle mass densities up to 300 μg/m³. The R² for the carbon monoxide sensor is 0.99 for concentrations up to 15 ppm. The R² for the oxidizing gas sensor is 0.98 over the sensitive range from 20 to 180 ppb. The noise monitor is precise within 1% between 65 and 95 dBA. This work demonstrates the capability of distributed monitoring as a means to examine exposure variability in both space and time, building an important preliminary step towards a new approach for workplace hazard monitoring.

Development of a Portable Aerosol Collector and Spectrometer (PACS)

This article presents the development of a Portable Aerosol Collector and Spectrometer (PACS), an instrument designed to measure particle number, surface area, and mass concentrations continuously and time-weighted mass concentration by composition from 10 nm to 10 μm. The PACS consists of a six-stage particle size selector, a valve system, a water condensation particle counter to detect number concentrations, and a photometer to detect mass concentrations. The stages of the selector include three impactor and two diffusion stages, which resolve particles by size and collect particles for later chemical analysis. Particle penetration by size was measured through each stage to determine actual collection performance and account for particle losses. The data inversion algorithm uses an adaptive grid-search process with a constrained linear least-square solver to fit a tri-modal (ultrafine, fine, and coarse), log-normal distribution to the input data (number and mass concentration exiting each stage). The measured 50% cutoff diameter of each stage was similar to the design. The pressure drop of each stage was sufficiently low to permit its operation with portable air pumps. Sensitivity studies were conducted to explore the influence of unknown particle density (range from 500 to 3,000 kg/m3) and shape factor (range from 1.0 to 3.0) on algorithm output. Assuming standard density spheres, the aerosol size distributions fit well with a normalized mean bias of -4.9% to 3.5%, normalized mean error of 3.3% to 27.6%, and R 2 values of 0.90 to 1.00. The fitted number and mass concentration biases were within ±10% regardless of uncertainties in density and shape. However, fitted surface area concentrations were more likely to be underestimated/overestimated due to the variation in particle density and shape. The PACS represents a novel way to simultaneously assess airborne aerosol composition and concentration by number, surface area, and mass over a wide size range.

DESIGN OF A PERCUTANEOUS ARTICULAR FRACTURE REDUCTION SIMULATOR

The American Board of Orthopaedic Surgery has mandated dedicated skills training for first-year orthopedic surgical residents.1 Most residency programs address this requirement with training exercises with cadavers and plastic foam bones. Some programs incorporate one or more simulators in their skills training, including several sophisticated virtual reality simulators and a variety of low-tech simulators. Simulators are helpful because they can provide repeatable educational experiences and quantitative performance assessment. Unfortunately, few simulators have been developed for orthopedic trauma skills training. Even fewer simulators have been developed and validated with more advanced students, such as residents in their 3rd or 4th year of training, and for more complex surgeries. In contrast to the completely virtual surgical simulation using haptic feedback devices and sophisticated renderings of soft tissue deformation, our group has chosen to use physical models, real surgical instruments and position tracking in conjunction with virtual reality.2–4 The physical models provide experience with the surgical tools, and enable more realistic hand movements and haptic cue feedback.

Developing an objective assessment of surgical performance from operating room video and surgical imagery

An unbiased, repeatable process for assessing operating room performance is an important step toward quantifying the relationship between surgical training and performance. Hip fracture surgeries offer a promising first target in orthopedic trauma because they are common and they offer quantitative performance metrics that can be assessed from video recordings and intraoperative fluoroscopic images. Hip fracture repair surgeries were recorded using a head-mounted point-of-view camera. Intraoperative fluoroscopic images were also saved. The following performance metrics were analyzed: duration of wire navigation, number of fluoroscopic images collected, degree of intervention by the surgeon's supervisor, and the tip-apex distance (TAD). Two orthopedic traumatologists graded surgical performance in each video independently using an Objective Structured Assessment of Technical Skill (OSATS). Wire navigation duration correlated with weeks into residency and prior cases logged. TAD correlated with cases logged. There was no significant correlation between the OSATS total score and experience metrics. Total OSATS score correlated with duration and number of fluoroscopic images. Our results indicate that two metrics of hip fracture wire navigation performance, duration and TAD, significantly differentiate surgical experience. The methods presented have the potential to provide truly objective assessment of resident technical performance in the OR.

How bedside feedback improves head-of-bed angle compliance for intubated patients

One clinical defense against ventilator-associated pneumonia is maintaining the head-of-bed angle of ventilated patients above 30°. Most previous studies of head-of-bed angles using electronic monitoring have recorded compliance rates of less than 50%. The purpose of this study was to determine how bedside feedback of the head-of-bed angle affects bed angles set by healthcare workers. Electronic inclinometers were installed on 22 beds in an intensive care for a period of 38 days. Intubated patients were randomly assigned into two cohorts. One cohort received a graphical display of the bed angle adjacent to the in-room computer display. The head-of-bed angle of each intubated patient was continuously recorded, yielding 1,528 h of observation. The mean head-of-bed angle was 28.78° for beds with displays and 25.50° for those without, a significant difference. The most significant effects were for angles near 30°. Beds in the display cohort were three times as likely to be in a compliant position as beds in the no-display cohort. The results suggest that electronic bedside feedback improves head-of-bed angle compliance by raising angles slightly below the compliance threshold into compliance. This result may support studies of how compliant bed-angle protocols affect health outcomes.

Assessing Wire Navigation Performance in the Operating Room

OBJECTIVE

There are no widely accepted, objective, and reliable tools for measuring surgical skill in the operating room (OR). Ubiquitous video and imaging technology provide opportunities to develop metrics that meet this need. Hip fracture surgery is a promising area in which to develop these measures because hip fractures are common, the surgery is used as a milestone for residents, and it demands technical skill. The study objective is to develop meaningful, objective measures of wire navigation performance in the OR.

DESIGN

Resident surgeons wore a head-mounted video camera while performing surgical open reduction and internal fixation using a dynamic hip screw. Data collected from video included: duration of wire navigation, number of fluoroscopic images, and the degree of intervention by the surgeon׳s supervisor. To determine reliability of these measurements, 4 independent raters performed them for 2 cases. Raters independently measured the tip-apex distance (TAD), which reflects the accuracy of the surgical placement of the wire, on all the 7 cases.

SETTING

University of Iowa Hospitals and Clinics in Iowa City, IA-a public tertiary academic center.

PARTICIPANTS

In total 7 surgeries were performed by 7 different orthopedic residents. All 10 raters were biomedical engineering graduate students.

RESULTS

The standard deviations for anteroposterior, lateral, and combined TAD measurements of the 10 raters were 2.7, 1.9, and 3.7mm, respectively, and interrater reliability produced a Cronbach α of 0.97. The interrater reliability analysis for all 9 video-based measures produced a Cronbach α of 0.99.

CONCLUSIONS

Several video-based metrics were consistent across the 4 video reviewers and are likely to be useful for performance assessment. The TAD measurement was less reliable than previous reports have suggested, but remains a valuable metric of performance. Nonexperts can reliably measure these values and they offer an objective assessment of OR performance.

Objective Structured Assessments of Technical Skills (OSATS) Does Not Assess the Quality of the Surgical Result Effectively

BACKGROUND

Performance assessment in skills training is ideally based on objective, reliable, and clinically relevant indicators of success. The Objective Structured Assessment of Technical Skill (OSATS) is a reliable and valid tool that has been increasingly used in orthopaedic skills training. It uses a global rating approach to structure expert evaluation of technical skills with the experts working from a list of operative competencies that are each rated on a 5-point Likert scale anchored by behavioral descriptors. Given the observational nature of its scoring, the OSATS might not effectively assess the quality of surgical results.

QUESTIONS/PURPOSES

(1) Does OSATS scoring in an intraarticular fracture reduction training exercise correlate with the quality of the reduction? (2) Does OSATS scoring in a cadaveric extraarticular fracture fixation exercise correlate with the mechanical integrity of the fixation?

METHODS

Orthopaedic residents at the University of Iowa (six postgraduate year [PGY]-1s) and at the University of Minnesota (seven PGY-1s and eight PGY-2s) undertook a skills training exercise that involved reducing a simulated intraarticular fracture under fluoroscopic guidance. Iowa residents participated three times during 1 month, and Minnesota residents participated twice with 1 month between their two sessions. A fellowship-trained orthopaedic traumatologist rated each performance using a modified OSATS scoring scheme. The quality of the articular reduction obtained was then directly measured. Regression analysis was performed between OSATS scores and two metrics of articular reduction quality: articular surface deviation and estimated contact stress. Another skills training exercise involved fixing a simulated distal radius fracture in a cadaveric specimen. Thirty residents, distributed across four PGY classes (PGY-2 and PGY-3, n = 8 each; PGY-4 and PGY-5, n = 7 each), simultaneously completed the exercise at individual stations. One of three faculty hand surgeons independently scored each performance using a validated OSATS scoring system. The mechanical integrity of each fixation construct was then assessed in a materials testing machine. Regression analysis was performed between OSATS scores and two metrics of fixation integrity: stiffness and failure load.

RESULTS

In the intraarticular fracture model, OSATS scores did not correlate with articular reduction quality (maximum surface deviations: R = 0.17, p = 0.25; maximum contact stress: R = 0.22, p = 0.13). Similarly in the cadaveric extraarticular fracture model, OSATS scores did not correlate with the integrity of the mechanical fixation (stiffness: R = 0.10, p = 0.60; failure load: R = 0.30, p = 0.10).

CONCLUSIONS

OSATS scoring methods do not effectively assess the quality of the surgical result. Efforts must be made to incorporate assessment metrics that reflect the quality of the surgical result.

CLINICAL RELEVANCE

New objective, reliable, and clinically relevant measures of the quality of the surgical result obtained by a trainee are urgently needed. For intraarticular fracture reduction and extraarticular fracture fixation, direct physical measurement of reduction quality and of mechanical integrity of fixation, respectively, meet this need.

Skill Assessment in the Interpretation of 3D Fracture Patterns from Radiographs

BACKGROUND

Interpreting two-dimensional radiographs to ascertain the three-dimensional (3D) position and orientation of fracture planes and bone fragments is an important component of orthopedic diagnosis and clinical management. This skill, however, has not been thoroughly explored and measured. Our primary research question is to determine if 3D radiographic image interpretation can be reliably assessed, and whether this assessment varies by level of training. A test designed to measure this skill among orthopedic surgeons would provide a quantitative benchmark for skill assessment and training research.

METHODS

Two tests consisting of a series of online exercises were developed to measure this skill. Each exercise displayed a pair of musculoskeletal radiographs. Participants selected one of three CT slices of the same or similar fracture patterns that best matched the radiographs. In experiment 1, 10 orthopedic residents and staff responded to nine questions. In experiment 2, 52 residents from both orthopedics and radiology responded to 12 questions.

RESULTS

Experiment 1 yielded a Cronbach alpha of 0.47. Performance correlated with experience; r(8) = 0.87, p<0.01, suggesting that the test could be both valid and reliable with a slight increase in test length. In experiment 2, after removing three non-discriminating items, the Cronbach coefficient alpha was 0.28 and performance correlated with experience; r(50) = 0.25, p<0.10.

CONCLUSIONS

Although evidence for reliability and validity was more compelling with the first experiment, the analyses suggest motivation and test duration are important determinants of test efficacy. The interpretation of radiographs to discern 3D information is a promising and a relatively unexplored area for surgical skill education and assessment. The online test was useful and reliable. Further test development is likely to increase test effectiveness.

CLINICAL RELEVANCE

Accurately interpreting radiographic images is an essential clinical skill. Quantitative, repeatable techniques to measure this skill can improve resident training and improve patient safety.

Value Added: the Case for Point-of-View Camera use in Orthopedic Surgical Education

BACKGROUND

Orthopedic surgical education is evolving as educators search for new ways to enhance surgical skills training. Orthopedic educators should seek new methods and technologies to augment and add value to real-time orthopedic surgical experience. This paper describes a protocol whereby we have started to capture and evaluate specific orthopedic milestone procedures with a GoPro® point-of-view video camera and a dedicated video reviewing website as a way of supplementing the current paradigm in surgical skills training. We report our experience regarding the details and feasibility of this protocol.

METHODS

Upon identification of a patient undergoing surgical fixation of a hip or ankle fracture, an orthopedic resident places a GoPro® point-of-view camera on his or her forehead. All fluoroscopic images acquired during the case are saved and later incorporated into a video on the reviewing website. Surgical videos are uploaded to a secure server and are accessible for later review and assessment via a custom-built website. An electronic survey of resident participants was performed utilizing Qualtrics software. Results are reported using descriptive statistics.

RESULTS

A total of 51 surgical videos involving 23 different residents have been captured to date. This includes 20 intertrochanteric hip fracture cases and 31 ankle fracture cases. The average duration of each surgical video was 1 hour and 16 minutes (range 40 minutes to 2 hours and 19 minutes). Of 24 orthopedic resident surgeons surveyed, 88% thought capturing a video portfolio of orthopedic milestones would benefit their education.

CONCLUSIONS

There is a growing demand in orthopedic surgical education to extract more value from each surgical experience. While further work in development and refinement of such assessments is necessary, we feel that intraoperative video, particularly when captured and presented in a non-threatening, user friendly manner, can add significant value to the present and future paradigm of orthopedic surgical skill training.

Do peer effects improve hand hygiene adherence among healthcare workers?

OBJECTIVE

To determine whether hand hygiene adherence is influenced by peer effects and, specifically, whether the presence and proximity of other healthcare workers has a positive effect on hand hygiene adherence.

DESIGN

An observational study using a sensor network.

SETTING

A 20-bed medical intensive care unit at a large university hospital.

PARTICIPANTS

Hospital staff assigned to the medical intensive care unit.

METHODS

We deployed a custom-built, automated, hand hygiene monitoring system that can (1) detect whether a healthcare worker has practiced hand hygiene on entering and exiting a patient's room and (2) estimate the location of other healthcare workers with respect to each healthcare worker exiting or entering a room.

RESULTS

We identified a total of 47,694 in-room and out-of-room hand hygiene opportunities during the 10-day study period. When a worker was alone (no recent healthcare worker contacts), the observed adherence rate was 20.85% (95% confidence interval [CI], 19.78%-21.92%). In contrast, when other healthcare workers were present, observed adherence was 27.90% (95% CI, 27.48%-28.33%). This absolute increase was statistically significant (P < .01). We also found that adherence increased with the number of nearby healthcare workers but at a decreasing rate. These results were consistent at different times of day, for different measures of social context, and after controlling for possible confounding factors.

CONCLUSIONS

The presence and proximity of other healthcare workers is associated with higher hand hygiene rates. Furthermore, our results also indicate that rates increase as the social environment becomes more crowded, but with diminishing marginal returns.

Surgical Coaching from Head-Mounted Video in the Training of Fluoroscopically Guided Articular Fracture Surgery

BACKGROUND

The evolving surgical skills education paradigm in orthopaedics has generated a strong demand for validated educational tools and methodologies. This study aimed to confirm that a one-on-one faculty coaching review of the head-mounted video recording of a resident's surgical performance on a validated articular fracture simulation trainer would substantially improve subsequent performance.

METHODS

Fifteen first-year or second-year orthopaedic surgery residents reduced and fixed a standardized intra-articular tibial plafond fracture model under fluoroscopic guidance. Their performances were recorded by a head-mounted video camera. Prior to repeating the procedure six weeks later, eight subjects (the intervention group) reviewed the video of their performance with an orthopaedic traumatologist, and seven subjects (the control group) did not. Cohort performance was compared with respect to task duration, number of fluoroscopic images, and scores on the Objective Structured Assessment of Technical Skills (OSATS) as evaluated by fellowship-trained orthopaedic traumatologists blinded to the residents' year in training and prior surgical experience.

RESULTS

The initial performance OSATS scores were not significantly different (p ≥ 0.05) between the control and intervention groups. Assessments of their repeat performance showed a significant net interval improvement (p < 0.05) in OSATS scores in the intervention group (mean [and standard deviation], 21 ± 8 points) compared with the control group (6 ± 3 points). The mean fluoroscopy utilization had a significant net decrease (p < 0.05) in the intervention group (-5.4 ± 11.7 points) compared with the control group (5.3 ± 7.0 points). Task duration in the repeat performance was similar between both groups.

CONCLUSIONS

Personalized video-based feedback improved performance on a standardized articular fracture trainer for first-year and second-year residents. The described technique may further enhance resident surgical skills education.

How lapse and slip errors influence head-of-bed angle compliance rates as measured by a portable, wireless data collection system

The recommended protocols to prevent ventilator-associated pneumonia include keeping ventilated patients' head and upper body elevated to an angle between 30 and 45 degrees. These recommendations are largely based on a study that has been difficult to replicate, because studies that have attempted to replicate the original conditions have failed to achieve the necessary bed angles consistently. This work suggests the possibility that two specific types of human error, slips and lapses, contribute to non-compliant bed angles. A novel device provided 83,655 samples of bed angles over a period of 1579 hours. The bed angle was out of compliance 64.2% of the time analyzed. Slips, the accident of raising the bed to an angle slightly less than the desired angle, accounted for most of the out-of-compliance measurements, or 55.9% of the time analyzed. It appears that stochastic variation in the bed adjustments results in the bed being out of compliance. Interventions should be investigated such as increasing the target angle and providing feedback at the moment the bed is raised to close to, but less than, the target angle.

Internal fit of pressed and computer-aided design/computer-aided manufacturing ceramic crowns made from digital and conventional impressions

STATEMENT OF PROBLEM

No studies have evaluated the internal adaptation of pressed and milled ceramic crowns made from digital impressions.

PURPOSE

The purpose of this in vitro study was to evaluate the internal fit of pressed and milled ceramic crowns made from digital and conventional impressions.

MATERIAL AND METHODS

Thirty polyvinyl siloxane (PVS) impressions and 30 Lava COS impressions made of a prepared dentoform tooth (master die) were fabricated. Thirty crowns were pressed in lithium disilicate (IPS e.max Press), and 30 crowns were milled from lithium disilicate blocks (IPS e.max CAD) (15/impression technique) with the E4D scanner and milling engine. The master die and the intaglio of the crowns were digitized with a 3-dimensional laser coordinate measurement machine. The digital master die and intaglio of each crown were merged. The distance between the die and the intaglio surface of the crown was measured at 3 standardized points. One-way ANOVA was used for statistical analysis (α=.05).

RESULTS

One-way ANOVA revealed that the internal gap obtained from the Lava/press group (0.211 mm, ±SD 0.041) was significantly greater than that obtained from the other groups (P<.001), while no significant differences were found among PVS/press (0.111 mm ±SD 0.047), PVS/CAD/CAM (0.116 mm ±SD 0.02), and Lava/CAD/CAM (0.145 mm ±SD 0.024).

CONCLUSIONS

The combination of the digital impression and pressed crown produced the least accurate internal fit.

A review of the role of simulation in developing and assessing orthopaedic surgical skills

Orthopaedic surgical skill is traditionally acquired during training in an apprenticeship model that has been largely unchanged for nearly 100 years. However, increased pressure for operating room efficiency, a focus on patient safety, work hour restrictions, and a movement towards competency-based education are changing the traditional paradigm. Surgical simulation has the potential to help address these changes. This manuscript reviews the scientific background on skill acquisition and surgical simulation as it applies to orthopaedic surgery. It argues that simulation in orthopaedics lags behind other disciplines and focuses too little on simulator validation. The case is made that orthopaedic training is more efficient with simulators that facilitate deliberate practice throughout resident training and more research should be focused on simulator validation and the refinement of skill definition.

Pre-slaughter mortality and post-slaughter wastage in bobby veal calves at a slaughter premises in New Zealand

AIMS

To determine the reasons for pre-slaughter mortality and post-slaughter wastage in New Zealand bobby veal calves, and to assess compliance with the national animal welfare codes at a slaughter premises in New Zealand.

METHODS

The study was conducted at a single slaughter premises in Southland, New Zealand, during the 2011 bobby veal processing season. Calves that died during the pre-slaughter period underwent post-mortem examination to identify the reasons for death and notable secondary findings. Data from calves condemned at official post-mortem meat inspection were also analysed.

RESULTS

The mortality risk in the pre-slaughter period was 0.7% (288/42,494) and post-slaughter condemnation losses were 0.4% (180/42,206), resulting in a total loss to food production of 1.1%. Of the calves that were examined after dying in the pre-slaughter period (n=247), digestive tract disorders (41%) and omphalitis (23%) were the most common primary diagnoses. Secondary findings in these calves included absence of curd in the abomasum (25%), immaturity (21%) and emaciation (9%). Omphalitis (54%) and septicaemia (37%) were the most common causes of post-mortem wastage.

CONCLUSIONS AND CLINICAL RELEVANCE

Digestive tract disorders, omphalitis and septicaemia were the most common reasons for pre-slaughter mortality and post-mortem wastage. Further investigation of pre-transportation husbandry and feeding practices is indicated to determine compliance with animal welfare codes by farmers that supplied calves that had no curd in the abomasum, or were immature or emaciated on arrival at the slaughter premises.

The precision of human-generated hand-hygiene observations: a comparison of human observation with an automated monitoring system

We compared the observations of nearly 1,400 hand-hygiene-related events recorded by an automated system and by human observers. Observation details differed for 38% of these events. Two likely explanations for these inconsistencies were the distance between the observer and the event and the busyness of the clinic.

Healthcare personnel perceptions of hand hygiene monitoring technology

OBJECTIVE

To assess healthcare personnel (HCP) perceptions regarding implementation of sensor-based electronic systems for automated hand hygiene adherence monitoring.

DESIGN

Using a mixed-methods approach, structured focus groups were designed to elicit quantitative and qualitative responses on familiarity, comfort level, and perceived impact of sensor-based hand hygiene adherence monitoring.

SETTING

A university hospital, a Veterans Affairs hospital, and a community hospital in the Midwest.

PARTICIPANTS

Focus groups were homogenous by HCP type, with separate groups held for leadership, midlevel management, and frontline personnel at each hospital.

RESULTS

Overall, 89 HCP participated in 10 focus groups. Levels of familiarity and comfort with electronic oversight technology varied by HCP type; when compared with frontline HCP, those in leadership positions were significantly more familiar with ([Formula: see text]) and more comfortable with ([Formula: see text]) the technology. The most common concerns cited by participants across groups included lack of accuracy in the data produced, such as the inability of the technology to assess the situational context of hand hygiene opportunities, and the potential punitive use of data produced. Across groups, HCP had decreased tolerance for electronic collection of spatial-temporal data, describing such oversight as Big Brother.

CONCLUSIONS

While substantial concerns were expressed by all types of HCP, participants' recommendations for effective implementation of electronic oversight technologies for hand hygiene monitoring included addressing accuracy issues before implementation and transparent communication with frontline HCP about the intended use of the data.

Fingerprint lines may not directly affect SA-I mechanoreceptor response

Understanding how skin microstructure affects slowly adapting type I (SA-I) mechanoreceptors in encoding edge discontinuities is fundamental to understanding our sense of touch. Skin microstructure, in particular papillary ridges, has been thought to contribute to edge and gap sensation. Cauna's 1954 model of touch sensibility describes a functional relationship between papillary ridges and edge sensation. His lever arm model proposes that the papillary ridge (exterior fingerprint line) and underlying intermediate ridge operate as a single unit, with the intermediate ridge acting as a lever which magnifies indentation imposed at the papillary ridge. This paper contests the validity of the lever arm model. While correctly representing the anatomy, this mechanism inaccurately characterizes the function of the papillary ridges. Finite element analysis and assessment of the critical anatomy indicate that papillary ridges have little direct effect on how SA-I receptors respond to the indentation of static edges. Our analysis supports a revised (stiff shell-elastic bending support) interpretation where the epidermis is split into two major layers with a stiff, deformable shell over an elastic bending support. Recent physiological, electrophysiological, and psychophysical findings support our conclusion that the function of the intermediate ridge is distinct from the function of the papillary ridge.

Immunoglobulin and peripheral B-lymphocyte concentrations in Fell pony foal syndrome

REASONS FOR PERFORMING STUDY

Fell pony foals are affected by a congenital fatal disease that leads to profound anaemia and immunodeficiency. Previous studies comparing healthy and affected foals have shown normal T-cell populations, but a severe B-lymphopenia.

OBJECTIVES

To measure the levels of individual immunoglobulin subisotypes in normal and affected Fell ponies and correlate these levels with the number of peripheral B-lymphocytes.

METHODS

Serum levels of individual immunoglobulin subisotypes were measured by ELISA and correlated with the number of peripheral B-lymphocytes (measured by flow cytometry).

RESULTS

Affected foals had significantly reduced serum levels of IgM, IgGa, IgGb and IgG(T) that coincided with the normal reduction in maternally derived immunoglobulin in foals and, with the exception of IgGb, correlated strongly with the B-lymphopenia.

CONCLUSIONS

These data suggest that affected foals are unable to produce their own immunoglobulins. Therefore, once maternal immunity has waned, it may be the lack of specific foal-derived immunoglobulin that gives rise to the clinical signs of immunodeficiency.

POTENTIAL RELEVANCE

Measurement of IgM after age 4 weeks may provide a more accessible means of confirming the status of future affected Fell pony foals than the measurement of B-lymphocytes (a technique limited to a few specialist laboratories).

Augmented, pulsating tactile feedback facilitates simulator training of clinical breast examinations

Haptic training devices can facilitate tactile skill development by providing repeatable exposures to rare stimuli. Extant haptic training simulator research primarily emphasizes realistic stimuli representation; however, the experiments reported herein suggest that providing augmented feedback can improve training effectiveness, even when the feedback is not natural. A novel clinical breast examination training device uses inflated balloons embedded in silicone to simulate breast lumps. Oscillating the balloon water pressure makes the lumps pulsate. The pulsating lumps are easier to detect than the static lumps used in current simulators, and this manipulation seems to effectively introduce trainees to small, deep lumps that are initially difficult to perceive. A study of 48 medical students indicates that training with the dynamic breast model increased the number of lumps detected, F(1, 47) = 9.34, p = .004, decreased the number of false positives, F(1, 47) = 5.78, p = .020, and improved intersimulator skill transfer, F(1, 47) = 26.56, p < .001. The results suggest that at least in this case, augmented, tactile feedback increases training effectiveness, despite the fact that the feedback does not attempt to mimic any physical phenomenon present in the natural stimulus. Applications of this research include training techniques and tools for improved detection of palpable cancers.

Aid to the antemortem diagnosis of Fell pony foal syndrome by the analysis of B lymphocytes

Fell pony foals are affected by a congenital fatal immunodeficiency that commonly leads to anaemia and lymphopenia. Previous work has shown that the foals' circulating subpopulations of CD4 and CD8 T lymphocytes are unaffected. In this study it was shown that the mean population of B lymphocytes in 10 affected foals was less than 10 per cent of that in normal foals.

Effectiveness of a dynamic breast examination training model to improve clinical breast examination (CBE) skills

Despite the potential utility of clinical breast examination (CBE), doctors' palpation skills are often inadequate and difficult to train. CBE sensitivity ranges from 39-59%, in part because current training does not effectively teach tactile skills. To address CBE training limitations, we developed a breast examination training model with 15 dynamically controlled lumps, set to desired hardness within underlying rib and muscle structures, in a silicone breast. In an experiment of 48 medical students, training with the dynamic model increased lump detection by 1.35 lumps compared to 0.60 lumps for a traditional breast model (P=0.008), reduced false positives by -0.70 lumps compared to +0.42 lumps (P=0.0277), and demonstrated skill transfer with a 1.17 lump detection improvement on the traditional device compared to only a 0.17 lump detection improvement by traditional device trainees on the dynamic device (P<0.001). Findings demonstrate the advantage of the dynamic model over conventional models in training CBE tactile skills.

Clinical role of F-18 fluorodeoxyglucose positron emission tomography for detection and management of renal cell carcinoma

PURPOSE

We evaluate the accuracy of F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) for staging and management of renal cell carcinoma.

MATERIALS AND METHODS

FDG-PET was performed in 25 patients with known or suspected primary renal tumors and/or metastatic disease and compared with conventional imaging techniques, including computerized tomography (CT). Histopathological confirmation was obtained in 18 patients and confirmation of the disease was by followup in the remainder. The impact of FDG-PET on disease management was also assessed.

RESULTS

Of the 17 patients with known or suspected primary tumors FDG-PET was true positive in 15, true negative in 1 and false-negative in 1. Comparative CT was true positive in 16 patients and false-positive in 1. The accuracy of FDG-PET and CT was similar (94%). All patients would have undergone radical nephrectomy after conventional imaging findings but FDG-PET results altered treatment decisions for 6 (35%), of whom 3 underwent partial nephrectomy and 3 avoided surgery due to confirmation of benign pathology or detection of unsuspected metastatic disease. Of the 8 cases referred for evaluation of local recurrence and/or metastatic disease FDG-PET changed treatment decisions in 4 (50%), with disease up staged in 3 and recurrence excluded in 1. Compared with CT, FDG-PET was able to detect local recurrence and distant metastases more accurately and differentiated recurrence from radiation necrosis.

CONCLUSIONS

FDG-PET accurately detected local disease spread and metastatic disease in patients with renal cell carcinoma and altered treatment in 40%. FDG-PET may have a role in the diagnostic evaluation of patients with renal cell carcinoma preoperatively and staging of metastatic disease.

An analog of the human albumin N-terminus (Asp-Ala-His-Lys) prevents formation of copper-induced reactive oxygen species

Copper mobilization and redox activity form damaging reactive oxygen species (ROS) and are implicated in the pathogenesis of ischemia-reperfusion injury, chronic inflammation, Alzheimer's disease, aging, and cancer. Protein sequestration of Cu(II) ions has been shown to prevent ROS-generating reactions. The first four amino acids of the N-terminus of human albumin, Asp-Ala-His-Lys (DAHK), form a tight binding site for Cu(II) ions. We synthesized several analogs, including the enantiomer d-DAHK, to study their effects on copper-induced hydroxyl radical and superoxide formation in the presence of ascorbate. d-DAHK prevented thiobarbituric acid-reactive species (TBARS) formation within physiological and acidic pH ranges (7.5-6.5) and inhibited low-density lipoprotein lipid peroxidation. A d-DAHK/Cu complex exhibited superoxide dismutase-like activity by significantly inhibiting superoxide formation. These in vitro results suggest that d-DAHK may shift the Cu(II)-binding equilibrium from the exchangeable Cu(II) pool to the tightly-bound, nonexchangeable pool, prevent ROS formation, and potentially provide therapeutic benefit for ROS-related diseases.

Isoforms of Jun kinase are differentially expressed and activated in human monocyte/macrophage (THP-1) cells

Ten isoforms of c-jun N-terminal kinase (JNK) have been described that arise by differential mRNA splicing of three genes. In that the relative expression and function of these different JNK proteins in human monocytic cells is not known, we have examined the JNK isoforms in THP-1 monocyte/macrophage cells. Differentiation of THP-1 cells by exposure to 10(-8) M PMA for 42-48 h enhances cellular responses to LPS, including enhanced activation of total JNK activity and increased phosphorylation of p54 JNK as well as p46 JNK. Examination of JNK proteins on Western blots reveals a predominance of p46 JNK1 and p54 JNK2 proteins. Clearing of lysates by immunoprecipitation of JNK1(99% effective) removes 46% of the JNK enzymatic activity (p < 0.01), whereas clearing of JNK1 plus JNK2 (70% effective) depletes the sample of 72% of the JNK activity (p < 0.01). Further analysis, undertaken with real-time RT-PCR, revealed that 98% of the JNK messages code for three isoforms: JNK1beta1, JNK2alpha1, and JNK2alpha2. The p54 JNK that is phosphorylated in LPS-stimulated, PMA-differentiated THP-1 cells is most likely JNK2alpha2 because 97% of the p54 JNK-encoding messages code for JNK2alpha2. By analogous reasoning, the p46 JNKs that are not heavily phosphorylated, but account for approximately half of the N-terminal c-jun kinase enzymatic activity, are most likely either JNK1beta1 or JNK2alpha1 because they account for 98% of the messages that can code for 46kDa JNKS:

Asp-Ala-His-Lys (DAHK) inhibits copper-induced oxidative DNA double strand breaks and telomere shortening

Both DNA and the telomeric sequence are susceptible to copper-mediated reactive oxygen species (ROS) damage, particularly damage attributed to hydroxyl radicals. In this study, ROS-induced DNA double strand breaks and telomere shortening were produced by exposure to copper and ascorbic acid. Asp-Ala-His-Lys (DAHK), a specific copper chelating tetrapeptide d-analog of the N-terminus of human albumin, attenuated DNA strand breaks in a dose dependent manner. d-DAHK, at a ratio of 4:1 (d-DAHKCu), provided complete protection of isolated DNA from double strand breaks and, at a ratio of 2:1 (d-DAHKCu), completely protected DNA in Raji cells exposed to copper/ascorbate. Southern blots of DNA treated with copper/ascorbate showed severe depletion and shortening of telomeres and Raji cell treated samples showed some conservation of telomere sequences. d-DAHK provided complete telomere length protection at a ratio of 2:1 (d-DAHKCu). The human albumin N-terminus analog, d-DAHK, protects DNA and telomeres against copper-mediated ROS damage and may be a useful therapeutic adjunct in ROS disease processes.

NMR phase noise in bitter magnets

We have studied the temporal instability of a high field resistive Bitter magnet through nuclear magnetic resonance (NMR). This instability leads to transverse spin decoherence in repeated and accumulated NMR experiments as is normally performed during signal averaging. We demonstrate this effect via Hahn echo and Carr--Purcell--Meiboom--Gill (CPMG) transverse relaxation experiments in a 23-T resistive magnet. Quantitative analysis was found to be consistent with separate measurements of the magnetic field frequency fluctuation spectrum, as well as with independent NMR experiments performed in a magnetic field with a controlled instability. Finally, the CPMG sequence with short pulse delays is shown to be successful in recovering the intrinsic spin--spin relaxation even in the presence of magnetic field temporal instability.

Granulomatous glomerulonephritis in intravenous drug users: a report of three cases in oxycodone addicts

Various well-documented renal lesions are associated with intravenous drug use; however, intraglomerular mesangial granulomas have not been previously described. We report three patients who developed an unusual granulomatous glomerulonephritis and interstitial nephritis after intravenous injection of oxycodone, derived from suppositories. Granulomas were seen in an intraglomerular mesangial and also interstitial location. In both sites, the granulomas were associated with filamentous material, presumably derived from a component of the suppositories. This material was periodic acid-Schiff-positive, but negative with Congo red and silver stains. Ultrastructurally, the filamentous material was seen within the mesangial granulomas and also in a subendothelial location, suggesting derivation from the circulation with subsequent transport across the basement membrane and accumulation in the mesangium, where a granulomatous reaction was elicited. All patients developed a degree of renal failure; two of the patients require hemodialysis 20 and 30 months after presentation.

Dysembryoplastic neuroepithelial tumour: the Western Australian experience

Dysembryoplastic neuroepithelial tumour (DNET) is a rare tumour that is usually seen in the context of epilepsy surgery. The purpose of this study was to provide a profile of DNET in an unbiased population. The 2020 brain tumours diagnosed in Western Australia in the 10-year period 1982-1991 were reviewed; 5 cases of DNET were identified. All patients were neurologically intact and presented with complex partial seizures from a young age. Surgery was performed for tumour resection or biopsy in all cases; no patient underwent surgery specifically for epilepsy control. The lesions were intracortical, multinodular and were composed of astrocytes, oligodendrocytes and neurons. Three patients underwent total or subtotal resection and their seizures were either abolished or reduced in frequency. Two patients had biopsies only and were clinically unchanged. There has been no evidence of recurrence in up to 8 years' follow-up. The diagnosis of DNET is important because it is a surgically treatable benign tumour.

Stereotactic biopsy of 100 intracerebral lesions at Sir Charles Gairdner Hospital

The pathological findings in a retrospective review of 100 consecutive intracranial stereotactic biopsies are presented. Definite diagnosis could be established in the majority (89) of cases and included 85 neoplasms (69 primary cerebral tumors, 10 non-Hodgkin's lymphomas and 6 metastases) and 4 non-neoplastic processes. In the remaining 11 samples the findings were non-diagnostic; 2 consisted of normal glial tissue, while the remainder variously showed changes of necrosis, hematoma, histiocytic reaction or astrocytic proliferations of uncertain nature. Verification of the stereotactic diagnosis by examination of lesional tissue obtained at subsequent craniotomy or postmortem was possible in 7 of 10 cases. Two broad categories of diagnostic difficulty were identified in interpreting stereotactic biopsies: (1) accurate tumor typing and grading, and (2) the distinction between reactive and neoplastic astrocytic proliferations. Two essential components in the diagnostic process are: (1) careful correlation with the clinical and radiological findings; and (2) use of intraoperative smear and/or frozen section preparations to confirm specimen adequacy. By adhering to these principles accurate intraoperative diagnosis can usually be established, particularly for high grade astrocytoma, lymphoma and metastasis. Tumor typing is aided by the use of immunohistochemistry and ultrastructural examination and the examination of serial sections is of value in grading.

Retaining Army nurses: a longitudinal model

A longitudinal sample of active duty Army nurses working in a broad range of nursing specialties and settings was analyzed for retention behavior. A turnover model of actual retention behavior, estimated using logistic regression, included external market, personal/demographic, and work-related variables as explanatory factors. Satisfaction with work and military life, satisfaction with location/assignment stability, race--ethnic group, and family status had significant effects on the retention of Army junior nurse-officers.

Vincristine with high-dose etoposide in advanced breast cancer: a phase II trial of the Piedmont Oncology Association

Vincristine (VCR) and etoposide (VP-16) have been shown to be synergistic in a murine model, and this combination was studied in a phase II trial. Eligibility required measurable disease, a performance status of 0-2, a life expectancy of > or = 2 months, an interval of at least 3 weeks since the receipt of previous radiation therapy or chemotherapy and recovery from related toxicity, no prior treatment with VCR or VP-16, and no more than two prior chemotherapy regimens (only one for treatment of metastatic disease). Treatment consisted of 0.5 mg i.v. (bolus) VCR followed by 200 mg/m2 VP-16 given over 2 h. Both drugs were given daily for 3 consecutive days every 3 weeks (total dose: VCR, 1.5 mg; VP-16, 600 mg/m2). A total of 18 patients with metastatic breast cancer were accured; 14 had adjuvant chemotherapy and 8 had chemotherapy for advanced disease. As judged by International Union Against Cancer (UICC) criteria, one complete response (CR) and three partial responses (PR) were obtained, for a CR + PR rate of 22% (95% confidence interval, 6%-48%). All responders had soft-tissue involvement only. Six patients had stable disease and 8 showed progression. The median time to treatment failure was 3.5 months, and the median survival from study entry was 8.3 months. The major toxicity was myelosuppression, with 9 patients (50%) experiencing a total WBC of < 1,000/mm3. Grade 2-3 neurologic toxicity was noted in 6 patients (33%) and grade 3 nausea and vomiting was noted in 5 (28%). The combination of VCR and VP-16 is active in advanced breast cancer but is not convincingly superior to either of these agents used alone.

Comparison of two management systems of dairy farmlets based on conservation of either hay or silage

Two management systems for dairy farms, early (silage farmlet) and late (hay farmlet) conservation, were compared for milk production in 4 consecutive years, at 2 cowsha. Half of the total silage farmlet area was made to wilted silage in each year. The remaining area was conserved as direct-cut silage in the first year and hay in the fourth year. About 40-50% of the hay farmlet area was made to hay. Over the 4 years, the silage farmlet produced an average of 8.2% more milk and 11.9% more (P<0.01) milk fat per year than the hay farmlet. The improvement in milk and milk fat production averaged 2.7 and 5% (P<0.01) in the spring and 27.4 and 30% (P<0.01) in the period from commencement of supplementary feeding in the summer. On average, the silage farmlet conserved a greater area, but because of high storage losses and greater consumption, it required more brought-in feed than the hay farmlet.

Pancreatitis in northern Newfoundland and Labrador: a 20-year review of the Grenfell Regional Health Services experience

A retrospective review of the Grenfell Regional Health Services experience with pancreatitis over a 20-year period (1968-1987) has been presented. The small number of cases in this series precludes meaningful statistical analysis, however, in general, one can state that native peoples are represented in this study in roughly the same proportion as they are represented in the population served. We have demonstrated that pancreatitis in its chronic form does occur in the Inuit of Northern Labrador. Given the prominent role that alcohol abuse plays in the social and behavioral ills of Labrador's native peoples as reflected in the high incidence of family violence, accidental deaths, and suicides, one might anticipate a disproportionately high incidence of pancreatitis and its chronic sequelae among the Inuit. The answer to this seeming paradox may be found through future study of the nature of the alcohol consumed, its pattern of consumption or of genetically-determined differences in the metabolism of alcohol and its toxic effects within the body, of differences in the composition of pancreatic secretions, or of environmental and dietary factors.