Analysis of Telestroke Usage in Rural Critical Access Emergency Departments

Introduction: Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods: This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results: The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion: This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this.

mHealth impact on secondary stroke prevention: a scoping review of randomized controlled trials among stroke survivors between 2010-2020

BACKGROUND

A fundamental gap between clinical prevention and self-management awareness heightens the risk for stroke recurrence in approximately one-fourth of the highest risk stroke survivors annually. Secondary stroke prevention has the potential to be promoted by mobile health (mHealth) applications for effective real-world adoption of vascular risk factor mitigation. This scoping review aims to evaluate the impact of mHealth interventions and their effectiveness to reduce recurrent stroke rates among stroke survivors in randomized controlled trials (RCTs).

METHODS

Scoping review in Ovid Medline, Cochrane Library, CINAHL, and Scopus for RCT literature employing mHealth among stroke populations published in English from 2010 to November 19, 2020. Small or pilot studies that included randomized design were included.

RESULTS

A total of 352 abstracts met inclusion criteria; 31 full-text articles were assessed and 18 unique RCTs involving 1,453 patients ultimately fulfilled criteria. Twelve of 18 met the pre-defined primary outcome measure, including 2 studies evaluating feasibility. Eight of 18 only addressed recovery from index stroke deficits. Most outcomes focused on self-reported functional status, mood, quality of life or compliance with intervention; primary outcome was an objective metric in 4/18 (blood pressure readings, step number, obstructive sleep apnea support compliance). Intervention duration 2-12 months, with a median 9 weeks.

CONCLUSIONS

No high-quality evidence supporting mHealth applications to reduce recurrent stroke was found in this scoping review. Overall, most studies were relatively small, heterogenous, and employed subjective primary outcome measures. mHealth's potential as an effective tool for stroke stakeholders to reduce recurrent stroke rates has not been sufficiently demonstrated in this review. Future randomized studies are needed that explicitly evaluate stroke recurrence rate.

Hand perfusion following radial or ulnar forearm free flap harvest for oral cavity reconstruction: A prospective study

The radial forearm free flap (RFFF) and ulnar forearm free flap (UFFF) are used in head and neck reconstruction because they provide a thin and pliable skin paddle as well as a long vascular pedicle. However, in spite of several studies showing the safety of the UFFF, the RFFF is more popular among reconstructive surgeons based on concerns about hand ischaemia. A prospective study was designed in which 10 UFFF and 11 RFFF surgeries were performed in 20 patients undergoing oral cavity reconstruction between January 2017 and July 2018. Hand vascular parameters were evaluated preoperatively and postoperatively using Doppler ultrasound and plethysmography. The preoperative and postoperative diameters of the radial and ulnar arteries, and the flow velocities through the remainder of the forearm artery were measured preoperatively and at 3 months postoperative. Additionally, a comparison was performed between the preoperative and postoperative fingertip perfusion values according to impedance plethysmography. The preoperative mean diameter of the radial artery (2.89±0.47mm) was significantly greater than that of the ulnar artery (2.35±0.48mm) at the level of the wrist; however, 3 months after the surgery, the mean diameters of the two arteries did not differ significantly. There were no differences in digital perfusion when a UFFF was used compared with an RFFF.

Impact of a shift work-like lighting schedule on the functioning of the circadian system in the short-lived fish Nothobranchius furzeri

Adult Nothobranchius furzeri of the MZM-04/10 strain were individually kept and subjected to a "5 + 2" shifting lighting schedule (SHIFT) for 8 weeks in order to evaluate the desynchronizing effects of a simulated human-like shift-work schedule on the functioning of the circadian system (CS). With this aim, sixteen 21-week-old N. furzeri were placed into a Morning, Night and Evening schedule (lights on from 08:00 to 16:00, 00:00 to 08:00 and 16:00 to 00:00 h, respectively) and fed once a day in the middle of the corresponding photophase (12:00, 04:00 and 20:00 h, respectively). Then, in the weekends (2 days), fish were always returned to the Morning shift. As controls, 16 fish were maintained under a non-shifting LD cycle condition (CONTROL) throughout the whole experiment, with lights on from 08:00 to 16:00 h. Rest-activity rhythm (RAR) of fish subjected to SHIFT showed several symptoms of chronodisruption, such as a decrease in the percentage of diurnal activity and a reduction of the relative amplitude and the circadian function index with time. When a periodogram analysis was performed, RAR of N. furzeri under SHIFT conditions showed up to three separate circadian components: one longer than 24 h (26.5 h) that followed the weekly 8 h delays; a short-period component (~23 h) that was related to the weekend's phase advances, and finally, a 24 h component. The shifting LD schedule also affected fish CS at a molecular level, with several significant differences in the expression of core genes of the molecular clock (bmal1, clock, rorα, rev-erbα) between SHIFT and CONTROL animals. RAR impairment along with changes in clock gene expression could be associated with high stress and accelerated aging in these fish.

Blazar spectral variability as explained by a twisted inhomogeneous jet

Blazars are active galactic nuclei, which are powerful sources of radiation whose central engine is located in the core of the host galaxy. Blazar emission is dominated by non-thermal radiation from a jet that moves relativistically towards us, and therefore undergoes Doppler beaming. This beaming causes flux enhancement and contraction of the variability timescales, so that most blazars appear as luminous sources characterized by noticeable and fast changes in brightness at all frequencies. The mechanism that produces this unpredictable variability is under debate, but proposed mechanisms include injection, acceleration and cooling of particles, with possible intervention of shock waves or turbulence. Changes in the viewing angle of the observed emitting knots or jet regions have also been suggested as an explanation of flaring events and can also explain specific properties of blazar emission, such as intra-day variability, quasi-periodicity and the delay of radio flux variations relative to optical changes. Such a geometric interpretation, however, is not universally accepted because alternative explanations based on changes in physical conditions-such as the size and speed of the emitting zone, the magnetic field, the number of emitting particles and their energy distribution-can explain snapshots of the spectral behaviour of blazars in many cases. Here we report the results of optical-to-radio-wavelength monitoring of the blazar CTA 102 and show that the observed long-term trends of the flux and spectral variability are best explained by an inhomogeneous, curved jet that undergoes changes in orientation over time. We propose that magnetohydrodynamic instabilities or rotation of the twisted jet cause different jet regions to change their orientation and hence their relative Doppler factors. In particular, the extreme optical outburst of 2016-2017 (brightness increase of six magnitudes) occurred when the corresponding emitting region had a small viewing angle. The agreement between observations and theoretical predictions can be seen as further validation of the relativistic beaming theory.

The International Mood Network (IMN) Nosology Project: differentiating borderline personality from bipolar illness

OBJECTIVE

The differential diagnosis of bipolar illness vs. borderline personality is controversial. Both conditions manifest impulsive behavior, unstable interpersonal relationships, and mood symptoms. This study examines whether and which mood clinical features can differentiate between both conditions.

METHOD

A total of 260 patients (mean ± standard deviation age 41 ± 13 years, 68% female) attending to a mood clinic were examined for diagnosis of bipolar illness and borderline personality disorder using SCID-I, SCID-II, and clinical mood criteria extracted from Mood Disorder Questionnaire (MDQ). They were analyzed using diagnoses as dependent variables. Predictors of bipolar and borderline diagnoses were identified by multivariable logistic regressions, and predictive validity of models was assessed using ROC curve analysis.

RESULTS

Bipolar illness was strongly predicted by elevated mood (OR = 4.02, 95% CI: 1.80-9.15), increased goal-directed activities (OR = 3.90, 95% CI: 1.73-8.96), and episodicity of mood symptoms (OR = 3.48, 95% CI 1.49-8.39). This triad model predicted bipolar illness with 88.7% sensitivity, 81.4% specificity, and obtained an auROC of 0.91 (95% CI: 0.76-0.96) and a positive predictive value of 85.1%. For borderline personality disorder, only female gender was a statistically significant predictor (OR = 3.41, 95% CI: 1.29-13.7), and the predictive model obtained an auROC of 0.67 (95% CI: 0.53-0.74).

CONCLUSION

In a mood disorder clinic setting, manic criteria and episodic mood course distinguished bipolar illness from borderline personality disorder.

Mercury Accumulation, Structural Damages, and Antioxidant and Immune Status Changes in the Gilthead Seabream (Sparus aurata L.) Exposed to Methylmercury

In aquatic systems, mercury (Hg) is an environmental contaminant that causes acute and chronic damage to multiple organs. In fish, practically all of the organic Hg found is in the form of methylmercury (MeHg), which has been associated with animal and human health problems. This study evaluates the impact of waterborne-exposure to sublethal concentrations of MeHg (10 μg L(-1)) in gilthead seabream (Sparus aurata). Hg was seen to accumulate in liver and muscle, and histopathological damage to skin and liver was detected. Fish exposed to MeHg showed a decreased biological antioxidant potential and increased levels of the reactive oxygen molecules compared with the values found in control fish (nonexposed). Increased liver antioxidant enzyme activities (superoxide dismutase and catalase) were detected in 2 day-exposed fish with respect to the values of control fish. However, fish exposed to MeHg for 10 days showed liver antioxidant enzyme levels similar to those of the control fish but had increased hepato-somatic index and histopathological alterations in liver and skin. Serum complement levels were higher in fish exposed to MeHg for 30 days than in control fish. Moreover, head-kidney leukocyte activities increased, although only phagocytosis and peroxidase activities showed a significant increase after 10 and 30 days, respectively. The data show that 30 days of exposure to waterborne MeHg provokes more significant changes in fish than a short-term exposure of 2 or 10 days.

Molecular mechanisms by which white tea prevents oxidative stress

The flavonoid content of tea (Camellia sinensis) has beneficial properties in the prevention of diseases. However, the mechanisms by which white tea can protect against oxidative stress remain unclear. To shed light on this issue, rats were given distilled water (controls), 0.15 mg/day (dose 1) or 0.45 mg/day (dose 2) of solid tea extract/kg body weight for 12 months. All the animals received an injection of adriamycin (ADR; 10 mg/kg body weight), except half of the control group, which were given an injection of saline solution. The expression of the nuclear factor, E2-related factor 2 (Nrf2), NAD(P)H:quinone oxidoreductase 1 (Nqo1), glutathione S-transferase (Gst), haem oxygenase-1 (Ho1), catalase (Cat), superoxide dismutase (Sod) and glutathione reductase (Gr) in liver was analysed by real-time PCR, and the activity of catalase (CAT), superoxide dismutase (SOD) and glutathione reductase (GR) was measured spectrophotometrically. ADR significantly increased the expression of Nrf2, Gst, Nqo1, Ho1, Cat, Sod and Gr with respect to the control levels and also increased the activity of CAT, SOD and GR. The intake of white tea increased in a higher degree the expression of Nrf2, Gst, Nqo1 and Ho1 in the tea + ADR group compared with the control group and C + ADR group. In addition, tea + ADR groups decreased the expression and activity of CAT, SOD and GR in a dose-dependent manner.

[Nosocomial candidemia: new challenges of an emergent problem]

Candida spp. are currently one of the most common causes of bloodstream infections in hospitals. Over the last two decades there has been a shift towards a greater involvement of non-Candida albicans as the cause of candidemia. Several of these non-albicans spp. (e.g., C. glabrata and C. krusei) exhibit resistance to traditional triazole antifungals (fluconazole), and cross-resistance with newer triazoles (voriconazole), focusing attention on the first-line use of antifungals such as the echinocandins, which possess improved activity against fluconazole-resistant strains. Early and adequate empirical treatment as well as early removing of the central catheters are the main factors related to mortality; thus it is necessary to implement guidelines of empirical treatment (including these aspects) in patients with risk factors and possible candidemia. Recent treatment guidelines from the Infectious Diseases Society of America (IDSA) recommend an echinocandin as primary therapy for non neutropenic or neutropenic patients with moderately severe to severe candidiasis and for patients at risk for infection with a triazole-resistant strain; the increasing MIC of echinocandins in case of C. parapsilosisis also an emerging concern. Clinicians should remain vigilant to prescribe early empiric treatment of patients at risk of having candidemia.

Avian influenza surveillance in backyard poultry of Argentina

Avian influenza (AI) is an exotic disease in Argentina. A surveillance program for AI was conducted in backyard poultry during 1998-2005 in two regions: 1) region A, which included the avian population in the provinces that border Brazil, Bolivia, and Paraguay, and 2) region B, which included the rest of the provinces of the country. More than 8000 serum samples were tested for antibodies by enzyme-linked immunosorbent assay and/or agar gel immunodiffusion tests, and more than 18,000 tracheal and cloacal swabs were tested for virus by isolation in embryonated specific-pathogen-free eggs. This study was part of the AI prevention program in Argentina, which includes other avian populations such as commercial poultry and all the controls for importation and exportation of live birds. The results from backyard poultry were negative for AI.

[Association between blood lead and sociodemographic parameters among children]

OBJECTIVE

To determine the relationship between blood lead concentration (Pb-S), and sociodemographic parameters among children.

METHODS

Blood lead concentration (Pb-S) was determined in 243 children (aged 5.94 +/- 2.78 years) in the district of Valencia. The required analysis was performed at the Center for Toxicological Investigations of University of Carabobo (CITUC), Venezuela, between January 1st, 1998 to December 31st, 2000. Geographical Information Systems (GIS) technology was used for data mapping.

RESULTS

Average Pb-S (11.62 ug/dl) was significantly higher than the allowed levels. One hundred and fifty (61.7%) children had Pb-S levels above the allowed concentration (VSLP) and this amount was significantly high in relation to the total number of subjects studied. The logistic regression analysis showed a significant association of sectors 12 (status A) and 16 and 28 (status C) with VSLP (R=0.1189; p<0,01; R=0.1202, p<0,01 and R=0.1189; p<0.01, respectively). Odds ratio showed that children from status C are 7,286 times more likely to have Pb-S VSLP than those from A or B.

CONCLUSIONS

This study confirms that SGI and epidemiological-statistical methods widen the possibilities of preventing contaminants' adverse health effects. It also shows that correlating geographical and health data has allowed to identifying "high risk" areas, leading to a pro-active public health action

Effect of anaerobic pretreatment on environmental and physicochemical characteristics of duckweed based stabilization ponds

Duckweed based stabilization ponds, an alternative for wastewater treatment, are attracting a growing interest from researchers because they are basically a low cost technology, easy to built and operate, and produce tertiary quality effluents. Besides, this technology offers the possibility of resource recovery by producing high quality duckweed protein, which can be of further use. Since the technology is rather new, there are many aspects to be studied before its full-scale implementation. It is necessary to gain sound knowledge of the basic principles of the complex processes occurring in the system, as well as of the practical aspects of design and operation. The presence of a layer of duckweed on the surface is expected to produce different environmental and physicochemical conditions in the water from those found in conventional stabilization ponds. These environmental and physicochemical conditions affect both plant growth and biological treatment processes in the system, therefore it is important to determine their behavior in a duckweed system and how they can be affected by an anaerobic pretreatment. Continuous flow pilot plants composed of seven ponds in series were operated with artificial substrate under two different conditions: with anaerobic pretreatment and without anaerobic pretreatment. The flow was kept constant during the operation. Conditions such as pH, temperature, dissolved oxygen, alkalinity, conductivity, chemical oxygen demand, biochemical oxygen demand, total and ammonium nitrogen, nitrites and nitrates, and phosphorus were evaluated in the system under steady state conditions. The main conclusions from the study include the following: pH, temperature and oxygen profiles are more stable in duckweed ponds than in conventional stabilization ponds; anaerobic pretreatment has a significant effect on the oxygen concentration in the system and on the organic matter removal but not on the nutrient removal.

Study of GH sensitivity in chilean patients with idiopathic short stature

We hypothesized that some children with idiopathic short stature in Chile might bear heterozygous mutations of the GH receptor. We selected 26 patients (3 females, 23 males) from 112 patients who consulted for idiopathic short stature at the University of Chile. Their chronological age was 8.3 +/- 1.9, and bone age was 6.1 +/- 1.0 yr. Their height was -3.0 +/- 0.7 SDS; IGF-I, -1.2 +/- 1.1 SD; IGF binding protein 3, -0.7 +/- 2.0 SDS; and GH binding protein, 0.4 +/- 0.8 SDS. Patients were admitted, and blood samples were obtained every 20 min to determine GH concentrations overnight. Coding sequences and intron-exon boundaries of exons 2-10 of GH receptor gene were amplified by PCR and subsequently analyzed through single-strand conformational analysis. Mean serum GH concentration, over 12-h, was 0.20 +/- 0.08 nM; pulse amplitude, 0.40 +/- 0.15 nM; number of peaks, 5.8 +/-1.5 peaks/12 h; peak value of GH during the 12-h sampling, 1.03 +/- 0.53 nM; and area under the curve, 151.4 +/- 56.1 nM/12 h. There were positive correlations between mean GH vs. area under the curve (P < 0.001) and GH peak (P < 0.01). The single-strand conformational analysis of the GH receptor gene showed abnormal migration for exon 6 in 9 patients and for exon 10 in 9 patients, which (by sequence analysis) corresponded to 2 polymorphisms of the GH receptor gene: an A-to-G transition in third position of codon 168 in exon 6 and a C-to-A transversion in the first position of codon 526 in exon 10. We further sequenced all coding exons and intron-exon boundaries in the most affected patients (nos. 6, 9, 11, 14, 15, 16, and 23). This analysis revealed a C-to-T transition in codon 161 of exon 6 in patient 23, which results in an amino acid change (Arg to Cys) in an heterozygous form in the patient and his father. In conclusion, the results of our study suggest that, in Chilean patients with idiopathic short stature, GH receptor gene mutations are uncommon, although we cannot exclude mutations that were missed by single-strand conformational analysis or mutations within introns or in the promoter regions of the GH receptor gene.

[Costs of health care resources of ambulatory-care patients diagnosed with Alzheimer's disease in Spain]

BACKGROUND

The annual consumption and costs of the health care resources used by ambulatory Alzheimer's disease patients were estimated. Patients were classified according to the degree of severity of the disease using Folstein's Mini Mental State Examination scale. The sociodemographic characteristics of both patients and their careers were described.

PATIENTS AND METHODS

Patients with an established diagnosis of Alzheimer's disease according to NINCDS/ADRDA criteria were included in the study. Information on the use of health and non-health care resources consumed during the last 12 months was recorded. The following scales were administered: MMSE, Global Deterioration Scale, Rapid Disability Rating Scale and Hachinski's scale modified by Rosen. Finally, the time dedicated by careers to look after the Alzheimer's disease patients was recorded.

RESULTS

A total of 337 patients were considered to be valid for the analysis with an average of 72 (8.4) years and with an average duration of the disease of 48.3 (35.7) months. The average annual cost per patient was 3,194,664 ptas. The average cost per patient in the group with MMSE > 18 was 2,119,889 ptas; 2,723,159 ptas. in those with MMSE 12-18 and 3,676,707 ptas. in the MMSE < 12 group.

CONCLUSIONS

In patients with Alzheimer's disease an increase in cost directly related to functional cognition state was observed. The most important cost component was that imputed to value time dedicated by principal career.

Relationship between bacterial flora in sputum and functional impairment in patients with acute exacerbations of COPD. Study Group of Bacterial Infection in COPD

STUDY OBJECTIVES

To investigate the possible relationship between functional respiratory impairment measured by FEV1 and isolation of diverse pathogens in the sputum of patients with exacerbations of COPD.

DESIGN

Multicenter, cross-sectional, epidemiologic study.

SETTING

Pneumology units in six secondary or tertiary hospitals in Spain.

PATIENTS

Ninety-one patients with acute exacerbation of COPD were included.

INTERVENTIONS

A quantitative sputum culture was performed, and bacterial growth was considered significant only when the germ was isolated at concentrations > 10(6) cfu (> 10(5) for Streptococcus pneumoniae) in samples with < 10 epithelial cells and > 25 leukocytes per low magnification field (x 100).

RESULTS

Germs isolated were the following: Haemophilus influenzae (20 cases; 22%), Pseudomonas aeruginosa (14 cases; 15%), S. pneumoniae (9 cases; 10%), Moraxella catarrhalis (8 cases; 9%), other gram-negative bacteria (7 cases; 7%), and non-potentially pathogenic microorganisms (non-PPMs; 33 cases; 36%). P. aeruginosa and H. influenzae were isolated more frequently among the patients with FEV1 < 50% than among those with FEV1 > 50% (p < 0.05). All patients with P. aeruginosa in sputum had FEV1 < 1,700 mL. FEV1 < 50% was associated with a very high risk of P. aeruginosa or H. influenzae isolation: the odds ratios (ORs) are 6.62 (95% confidence interval [CI], 1.2 to 123.6) and 6.85 (95% CI, 1.6 to 52.6), respectively. Furthermore, active tobacco smoking was associated with a high risk of H. influenzae isolation (OR, 8.1; 95% CI, 1.9 to 43.0).

CONCLUSIONS

Patients with the greatest degree of functional impairment, as measured by their FEV1, presented a higher probability of having an isolation of P. aeruginosa or H. influenzae in significant concentrations in sputum during an exacerbation. The diagnostic yield of sputum in patients with an FEV1 > 50% was low, with a predominance of non-PPMs. Low FEV1 and active tobacco smoking are data that should be considered when establishing an empiric antibiotic treatment for exacerbated COPD.

[Costs of known diabetes mellitus in Spain]

BACKGROUND

Diabetes mellitus is an important cause of mortality and morbidity in western nations with high costs for both patients and health care systems.

MATERIAL AND METHODS

Based on the latest epidemiological studies and in combination with Spanish demographic data the direct health care costs of known diabetes mellitus were estimated for the following areas: hospitalisation directly due to the disease, hospitalisation due to certain chronic complications such as acute myocardial infarction, amputations and renal disease (dialysis and transplant), outpatient visits, consumption of anti-diabetic medication, self-control, analyses, additional explorations and camps for diabetic children.

RESULTS

In 1994, the total direct costs of diabetes mellitus in Spain were estimated to be more than 90,000 millions pesetas in a population of more than 1,400,000 known diabetic persons. This implies an average annual costs of approximately 63,000 pesetas per patient. If this cost is divided into categories, hospitalisation represents approximately 58% of the global cost, outpatient visits 14%, antidiabetic drugs 13%, self-control 4.7%, analyses 10% and camps a mere 0.04%.

CONCLUSIONS

The most important component of the costs of diabetes mellitus in Spain in 1994 was hospitalisation due to the disease itself and its chronic complications which would seem to logically imply that resources ought to be targeted at reducing or postponing the development of such complications.

A simulation model of the cost of the incidence of IDDM in Spain

This study estimates the direct health care costs of the incidence of insulin-dependent diabetes mellitus (IDDM) in Spain. A discrete event simulation model was developed to approximate the natural history of a cohort of newly diagnosed patients in a given year and used to calculate the average costs which would accumulate during the lifetime of the group of patients. The model takes into account both the underlying costs of control and maintenance of the disease plus the additional costs of long-term complications that are likely to develop as the disease progresses. The model is based on national and international epidemiological and demographic information combined with local cost data. The number of newly diagnosed cases of IDDM each year, based on Spanish epidemiological data, was calculated to be approximately 1791 cases in 1994. The baseline results from the model indicate that the average life expectancy of an IDDM patient is approximately 59.6 years with an average lifetime cost of 12.7 million pesetas per individual (1994 undiscounted values), 5.1 million pesetas per individual when discounted at a rate of 6% and 8060 million pesetas for the entire newly diagnosed cohort discounted at a rate of 6%. Sensitivity analysis was undertaken in order to observe the effect on the result of changes in the values of key variables.

[The assessment of functional status in hospitalized elderly patients: the Plutchik scale]

BACKGROUND

To study the usefulness of the Plutchik Scale to measure functional capacity in daily activities of hospitalized elderly patients.

PATIENTS AND METHODS

A sample of 300 patients stratified by age and sex (111 male and 189 female), mean age 81 years, hospitalized in the Geriatric Unit, was selected from all the patients admitted to our Unit along the year 1994 (n = 974, mean length of stay in acute beds 15 days, in convalescent beds 57 days, total 19 days). Scores of patients in the Plutchik Scale, Katz Activities of Daily Living and Barthel ADL Index were obtained. Ninety seven of the subjects were rated by two independent observers.

RESULTS

The kappa statistic of interrater reliability in Plutchik Scale scoring was high (0.807). There was a good correlation between the three instruments at cut-points for autonomy/dependence: 0.824 for cut-points 4/5 in Plutchik Scale and 2/3 in Katz Activities of Daily Living; 0.846 for cutpoints 4/5 in Plutchik Scale and 55/60 in Barthel ADL Index (p < 0.01). The coefficient alpha (Cronbach) in Plutchik Scale was 0.876 and the standardized alpha 0.868, which reflect that the Plutchik Scale is internally consistent. By factor analysis one factor was obtained explaining 58% of the variance. The factor showed the highest correlation with "washing/dressing" (0.861) and lowest with "vision" (0.349).

CONCLUSIONS

The Plutchik Scale is a good instrument for measuring functional capacity in hospitalized elderly patients.

A lumbar chordoma treated with a wide resection

Chordomas are rare skeletal tumors arising from the embryonic remains of the notochord [18, 30]. These tumors tend to appear in midline regions, particularly at the upper and lower extremities of the spinal column. We report the case of a 74-year-old woman with radicular compression associated with an L3 chordoma that was treated with a wide resection.

Redefinition of cutaneous lymphatic drainage with the use of lymphoscintigraphy for malignant melanoma

Lymphoscintigraphy was performed on 82 patients with melanoma registered at the University Melanoma Clinic. From these data, precise lymphatic drainage basins could be drawn for the head, neck, shoulder, and trunk. These drawings differed significantly from the classic anatomic studies, providing a functional look at the cutaneous lymphatic drainage. This new method correlates much better with clinical experiences and demonstrates much larger areas of ambiguous drainage than previously reported. Data from the lymphoscintigrams also emphasize the individuality of cutaneous lymphatic flow. The implications of these data in planning elective node dissections for intermediate thickness melanomas are obvious, since it is estimated that up to 59% of the dissections for trunk and head and neck primary melanomas may be misdirected if based on classic anatomic studies. The data indicate that all patients with head, neck, and shoulder lesions should undergo lymphoscintigraphy to define possible drainage basins at risk for metastatic disease. Similarly, truncal lesions require scintigrams except when they are within four well-defined areas with an extremely low probability of ambiguous drainage. Lesions in these areas show very reliable and predictable drainage to a single nodal group.

Localization of malignant melanoma using monoclonal antibodies

Finding a screening test to evaluate patients with cancer for occult metastatic disease, as well as imaging all known disease, is a goal of research efforts. Twenty-nine evaluable patients with deeply invasive (stage I), regional nodal (stage II), or systemic (stage III) melanoma underwent imaging by administration of a preparation of the antimelanoma antibody labeled with technetium 99m. Scan results indicated that 28 of 32 confirmed metastatic sites were imaged with this technique (88% sensitivity). Analysis of the individual positive sites revealed that nodal basins and visceral metastases accounted for the highest percentage of metastatic sites imaged, with 14 (88%) of 16 nodal basin metastases and all four visceral metastases being detected through imaging. Occult nodal disease was detected in the iliac nodal chain in two of the 29 patients. The imaging of benign tumors and nodal basins not containing disease accounted for a confirmed false-positive rate of 21%. Three (10%) of the 29 scan results were confirmed to be false-negative. In vivo tumor localization with monoclonal antibodies showed a sensitivity similar to that of other roentgenographic procedures for identifying metastatic disease and was useful in two of three patients in identifying occult iliac nodal disease, a region that is difficult to evaluate with physical examination and other imaging modalities.

The expanding role of lymphoscintigraphy in the management of cutaneous melanoma. First Place Winner: Conrad Jobst award

Accepted therapy for intermediate-thickness melanomas is wide local excision and regional lymphadenectomy for nodes known to be in the lymph drainage basin. Lymphoscintigraphy has been shown to be of great help in predicting the drainage pattern of truncal, shoulder, proximal extremity, and head and neck melanomas. Lymphoscintigraphy using Technetium-99 antimony sulfur colloid was performed on 17 patients with cutaneous melanomas at H. Lee Moffitt Cancer Center at the University of South Florida. Of 13 patients with primary truncal and shoulder lesions, drainage patterns were discordant 54 per cent of the time and resulted in dissection of nodal groups different than would otherwise have been planned. This resulted in several lymph nodes positive for metastatic disease removed from operative sites not expected to show metastatic spread by clinical experience alone. The discordant rate for head and neck drainage was also high with 2 of 3 forehead studies showing drainage to both anterior and posterior cervical chains when only anterior chain drainage was expected, while only one of these drained to the preauricular nodes. Again, this led to elective lymph-node dissections of nodal basins not anticipated on clinical grounds alone. After a mean follow-up of 2 years, in which 60 to 75 per cent of all recurrences from melanoma are expected to occur, there has been no lymph-node metastasis development in basins that were not predicted by the scan. It is clear from our data that well-known historical patterns of lymph drainage in addition to the clinical impression of experienced surgeons cannot reliably predict the lymphatic drainage of many truncal, shoulder, and head and neck melanomas.(ABSTRACT TRUNCATED AT 250 WORDS)