Medical Information Delivering Improved Customer Experience: A Guide

Customer experience (CX) is essential in any business. In the pharmaceutical industry, the Medical Information Contact Center is a customer-facing unit that provides evidence-based, scientifically balanced information to healthcare professionals and patients in response to unsolicited inquiries. The purpose of this paper is to provide analysis and guidance for designing and measuring interactions in the Medical Information Contact Center to facilitate the delivery of a superior and continuously improving CX. Surveys were conducted to establish current trends in CX among a diverse group of CX professionals and members of phactMI, a non-profit collaboration of Medical Information leaders from the pharmaceutical industry. The top three observations from the CX professionals survey centered on establishing a clear CX strategy, use of technology, and frequency of sharing results. Three potential areas for improvement focus on CX strategy, measurements of CX, and sharing of results. An analysis of quality monitoring results of customer interactions in the pharmaceutical industry from Centerfirst, a contact center quality monitoring service provider, was also reviewed. This analysis found a positive correlation between CX and three agent skills: taking the lead, empathy, and strong compliance skills. Based on these results, a CX guide was developed and specifically tailored for the pharmaceutical industry. This tool may be used to help identify, assess, and possibly improve CX.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

734 Evaluation of A Webinar Based Surgical Teaching Course (EDUCATE) - A Prospective Cohort Study

Aim

Anecdotal evidence suggests Foundation Year (FY) doctors start surgical rotations with less confidence than medical rotations. The study aimed to determine the effect of a national webinar-based surgical teaching course on participants’ confidence, and to assess attitudes surrounding undergraduate surgical education.

Method

This prospective cohort study is reported with reference to STROBE guidelines and received ethical approval. A series of 15 free-access webinars was developed based on the Royal College of Surgeons Undergraduate Curriculum. An expert-validated questionnaire was used to collect data before and after the course. Inclusion criteria were UK-based medical students and FY doctors who attended at least one webinar. The primary outcome was confidence in completing common tasks during surgical rotations.

Results

Completed pre-course (484) and post-course (352) questionnaires yielded 92 paired samples (63% female). 85% were medical students, representing 29 UK universities, and 15% FY doctors. Mean confidence in assessing, investigating, and implementing initial management of surgical conditions was greater after the intervention (p ≤ 0.001). Mean confidence in managing on-call tasks and starting a surgical FY job was also higher post-course greater (p ≤ 0.001). These improvements correlated with webinar attendance (p ≤ 0.05). 27.1% of participants were satisfied with the quality of undergraduate surgical education. 22.9% agreed that surgical placements prepared them well to manage surgical tasks.

Conclusions

Medical students and FY doctors report low confidence and feel unprepared in managing surgical tasks. Additionally, they report poor satisfaction with undergraduate surgical education. This shortfall may be improved through delivery of a national, accessible, targeted online webinar series and curriculum.

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

429 National Evaluation of Confidence and Preparedness for Surgical Rotations in Medical Students and Foundation Year Doctors

Introduction

Limited published and anecdotal evidence suggests foundation year (FY) doctors start their surgical rotations with lower confidence than medical rotations. This may be due to insufficient undergraduate practical teaching related to common surgical rotations. This study aimed to evaluate the confidence and preparedness for surgical rotations of medical students and FY doctors.

Method

An expert-validated questionnaire was distributed nationally to UK medical students and FY doctors. The primary outcome was confidence in completing common tasks during surgical rotations.

Results

491 participants (84% medical students, 16% FYs) were recruited from 36 UK medical schools. 80% were likely to pursue a career in surgery however only 7% felt confident about starting a surgical FY job. 66% felt neutral or unsatisfied about the quality of medical school surgical teaching, and 80% indicated that placements did not prepare them well to manage common FY surgical tasks. The internal reliability of the questionnaire was high (=0.939).

Conclusions

Medical students and FY doctors lack confidence and preparation for surgical jobs. High-quality, practically grounded educational courses such as the National Surgical Teaching Society (NSTS) webinar curriculum could improve confidence and preparedness for surgical rotations. Further research evaluating the benefits of such courses is warranted.

Model reduction techniques for the computation of extended Markov parameterizations for generalized Langevin equations

The generalized Langevin equation is a model for the motion of coarse-grained particles where dissipative forces are represented by a memory term. The numerical realization of such a model requires the implementation of a stochastic delay-differential equation and the estimation of a corresponding memory kernel. Here we develop a new approach for computing a data-driven Markov model for the motion of the particles, given equidistant samples of their velocity autocorrelation function. Our method bypasses the determination of the underlying memory kernel by representing it via up to about twenty auxiliary variables. The algorithm is based on a sophisticated variant of the Prony method for exponential interpolation and employs the positive real lemma from model reduction theory to extract the associated Markov model. We demonstrate the potential of this approach for the test case of anomalous diffusion, where data are given analytically, and then apply our method to velocity autocorrelation data of molecular dynamics simulations of a colloid in a Lennard-Jones fluid. In both cases, the velocity autocorrelation function and the memory kernel can be reproduced very accurately. Moreover, we show that the algorithm can also handle input data with large statistical noise. We anticipate that it will be a very useful tool in future studies that involve dynamic coarse-graining of complex soft matter systems.

Transcriptional Assessment of Striatal mRNAs as Valid Biomarkers of Disease Progression in Three Mouse Models of Huntington's Disease

BACKGROUND

Huntington's disease (HD) is a progressive neurodegenerative disorder that prominently affects the basal ganglia, leading to affective, cognitive, behavioral, and motor decline. The primary site of neuron loss in HD is the striatal part of the basal ganglia, with GABAergic medium size spiny neurons (MSNs) being nearly completely lost in advanced HD.

OBJECTIVE

Based on the hypothesis that mutant huntingtin (mHTT) protein injures neurons via transcriptional dysregulation, we set out to establish a transcriptional profile of HD disease progression in the well characterized transgenic mouse model, R6/2, and two Knock-in models (KI); zQ175KI (expressing mutant mouse/human chimeric Htt protein) and HdhQ200 HET KI (carrying one allele of expanded mouse CAG repeats).

METHODS

In this study, we used quantitative PCR (qPCR) to evaluate striatal mRNA levels of markers of neurotransmission, neuroinflammation, and energy metabolism.

RESULTS

After analyzing and comparing transcripts from pre-symptomatic and symptomatic stages, markers expressed in the basal ganglia MSNs, which are typically involved in maintaining normal neurotransmission, showed a genotype-specific decrease in mRNA expression in a pattern consistent with human studies. In contrast, transcripts associated with neuroinflammation and energy metabolism were mostly unaffected in these animal models of HD.

CONCLUSION

Our results show that transcripts linked to neurotransmission are significantly reduced and are consistent with disease progression in both zQ175KI and R6/2 transgenic mouse models.

How Older Adults Cope with Cognitive Complexity and Environmental Constraints during Dual-Task Walking: The Role of Executive Function Involvement

This cross-sectional study investigated the interactive dual-task (DT) effects of executive function demands and environmental constraints on older adults' walking and the moderating role of habitual physical activity (PA). Locomotor performance under different environmental constraints (flat versus obstructed walking) and cognitive performance with different executive function involvement (backward counting versus random number generation) were assessed under single-task (ST) and DT conditions in 135 participants (mean age 68.1 ± 8.4). The weekly number of daily steps was measured. Reciprocal DT effects of walking on cognitive performance and of the cognitive task on gait performance were computed and submitted to analyses of covariance with age, PA level, and cognitive functioning as covariates, followed by linear regressions with PA level as predictor. Cognitive task demands and environmental constraints individually and jointly affected gait variability (p = 0.033, ηp2 = 0.08) and executive function performance (p = 0.009, ηp2 = 0.09). Physical activity level predicted a low but significant percentage of variance of DT effects on gait only in flat walking (R2 = 0.04, p = 0.027). Results suggest that older individuals may adopt variable task prioritization in dual tasking depending on the type of executive function involvement and the environmental constraints on walking. Their DT ability was slightly affected by habitual PA.

Biomarker Analysis of Orally Dosed, Dual Active, Matrix Metalloproteinase (MMP)-2 and MMP-9 Inhibitor, AQU-118, in the Spinal Nerve Ligation (SNL) Rat Model of Neuropathic Pain

There is an unmet medical need for the development of non-addicting pain therapeutics with enhanced efficacy and tolerability. The current study examined the effects of AQU-118, an orally active inhibitor of metalloproteinase-2 (MMP-2) and MMP-9, in the spinal nerve ligation (SNL) rat model of neuropathic pain. Mechanical allodynia and the levels of various biomarkers were examined within the dorsal root ganglion (DRG) before and after oral dosing with AQU-118. The rats that received the SNL surgery exhibited significant mechanical allodynia as compared to sham controls. Animals received either vehicle, positive control (gabapentin), or AQU-118. After SNL surgery, the dorsal root ganglion (DRG) of those rats dosed with vehicle had elevated messenger RNA (mRNA) expression levels for MMP-2, IL1-β & IL-6 and elevated protein levels for caspase-3 while exhibiting decreased protein levels for myelin basic protein (MBP) & active IL-β as compared to sham controls. Rats orally dosed with AQU-118 exhibited significantly reduced mechanical allodynia and decreased levels of caspase-3 in the DRG as compared to vehicle controls. Results demonstrate that oral dosing with the dual active, MMP-2/-9 inhibitor, AQU-118, attenuated mechanical allodynia while at the same time significantly reduced the levels of caspase-3 in the DRG.

Conservatism Measures in Papua New Guinea

A modification of a previously used "catch-phrase" approach in measuring conservatism was used in Papua New Guinea. Results were compared with data collected earlier in New Zealand. Problems of equating New Zealand and Papua New Guinea political affiliation in an effort to gauge subjects' conservatism led to the use of church attendance and divergent thinking abilities as external criteria. Degree of European contact, rapid social change, and homogeneity of religious experience may help account for the unexpected high, but nonlinear, relationship between high divergent thinking and high conservatism.

Presence of Autoantibodies in the Sera of Meniere's Disease

We examined the sera of patients with Meniere's disease for the presence of antibodies against 8 inner ear antigens by enzyme-linked immunosorbent assay (ELISA). One hundred eight patients with Meniere's disease and 28 control subjects were studied. The antibodies against chicken type II collagen, bovine type II collagen, the cyanogen bromide cleaved peptide 11 (CB11) of each, type IX and XI collagens, C-Raf, and tubulin were measured by ELISA. The sensitivity of each antigen was between 37% and 60% individually, and was 91% when all 8 inner ear antigens were combined. These results showed that 91% of Meniere's disease sera have antibody activities to 1 or more of these inner ear antigens. The results suggest that performing ELISA for these 8 inner ear antigens was useful as a diagnostic tool for Meniere's disease. Further study is required for elucidating the role of these antigens in the pathogenesis of Meniere's disease, which might eventually result in better therapy.

Seasonal Activity, Density, and Collection Efficiency of the Blacklegged Tick (Ixodes scapularis) (Acari: Ixodidae) in Mid-Western Pennsylvania

Although Pennsylvania has recently reported the greatest number of Lyme disease cases in the United States, with the largest increase for PA occurring in its western region, the population biology of the blacklegged tick (Ixodes scapularis Say) has not been adequately characterized in western PA. We studied the seasonal activity of host-seeking I. scapularis larvae, nymphs, and adults in mid-western PA over the course of a year, including a severe winter, and determined their absolute densities and collection efficiencies using replicated mark-release-recapture or removal methods. Our results are compared to those from similar studies conducted in the highly Lyme disease endemic Hudson Valley region of southeastern New York State. The seasonal activity of I. scapularis was intermediate between patterns observed in the coastal northeastern and upper Midwestern United States. Only one peak of larval activity was observed, which was later than the major peak in the Midwest, but earlier than in the northeast. Seasonal synchrony of larvae and nymphs was similar to the northeast, but the activity peaks were much closer together, although not completely overlapping as in the Midwest. Pre- and postwinter relative densities of questing adult I. scapularis were not significantly different from one another. The absolute densities and collection efficiencies of larvae, nymphs, and adults were comparable to results from classic research conducted at the Louis Calder Center in Westchester County, NY. We conclude that the population biology of I. scapularis in mid-western PA is similar to southeastern NYS contributing to a high acarological Lyme disease risk.

Development and evaluation of a standardized questionnaire for identifying adverse events in vaccine clinical trials

In vaccine trials, diary questionnaires or vaccination report cards (VRCs) are used extensively to collect complaints reported by subjects or guardians following vaccination. These have not been evaluated for accuracy or standardized to facilitate tolerability comparisons among vaccines.Objectives -(1) Develop standardized, age-specific VRCs for collecting self-reported adverse events (AEs) in trials; (2) Evaluate whether complaints elicited by nurse examinations or telephone interviews were missed by VRCs.Methods -Vaccine-trial databases, focus groups, experts and experienced nurses were used to develop paediatric and adolescent/adult VRCs. VRCs were evaluated at four sites. The primary outcome was subjects with AEs missed on the VRC and reported in nurse examinations (for injection-site reactions) or telephone interviews (for systemic complaints).Results -Of 855 subjects, 96.5% completed VRCs. For systemic complaints, 1.5% (12/812) reported both no complaint on VRCs and at least one complaint in telephone interviews. For injection-site reactions, 5.1% (53/1030) of injection sites had both no reaction reported on VRCs and had reactions noted by nurse examination. No missed AEs were rated as severe.Conclusion -The data suggest VRCs provide a practical and reasonably complete method of eliciting complaints following vaccination. Copyright (c) 2000 John Wiley & Sons, Ltd.

HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi

OBJECTIVE

To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services.

DESIGN

Descriptive analysis.

SETTING

Thyolo District, with a population of 600,000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004.

POPULATION

Women attending reproductive health services care in 2005 and 2010.

METHODS

Review of facility records and databases for routine monitoring.

MAIN OUTCOME MEASURES

Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care.

RESULTS

There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52).

CONCLUSIONS

During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.

A quantitative analysis of variability in brachial plexus anatomy

The aim of this study was to quantify the lengths of nerve segments within the brachial plexus. Twenty cadavers were dissected bilaterally, giving a total of 40 brachial plexuses for measurement. Individual lengths of plexus segments were measured and recorded, and means and standard deviations were calculated for all data. Differences between the means were statistically evaluated using the Student's t-test. Only 3 of 16 segments were found to be longer in women on average, which included the anterior division of the superior trunk, the anterior division of the middle trunk and the posterior division of the inferior trunk. All three cords (medial, lateral, and posterior) were found to be significantly different between genders, the longer segments being in males. Significant bilateral differences were also observed when right and left brachial plexuses from each cadaver were compared. Extra lateral heads (ELHs) to the median nerve were found in 50% of brachial plexuses, the anatomy of which varied bilaterally as well as between genders. Awareness of this variability is important both to anatomists and to clinicians who operate on and around the brachial plexus.

Mathematical modeling of pathogenicity of Cryptococcus neoformans

Cryptococcus neoformans (Cn) is the most common cause of fungal meningitis worldwide. In infected patients, growth of the fungus can occur within the phagolysosome of phagocytic cells, especially in non-activated macrophages of immunocompromised subjects. Since this environment is characteristically acidic, Cn must adapt to low pH to survive and efficiently cause disease. In the present work, we designed, tested, and experimentally validated a theoretical model of the sphingolipid biochemical pathway in Cn under acidic conditions. Simulations of metabolic fluxes and enzyme deletions or downregulation led to predictions that show good agreement with experimental results generated post hoc and reconcile intuitively puzzling results. This study demonstrates how biochemical modeling can yield testable predictions and aid our understanding of fungal pathogenesis through the design and computational simulation of hypothetical experiments.

Depletion of alveolar macrophages decreases the dissemination of a glucosylceramide-deficient mutant of Cryptococcus neoformans in immunodeficient mice

In previous studies we showed that a Cryptococcus neoformans mutant lacking glucosylceramide (Deltagcs1) is avirulent and unable to reach the brain when it is administered intranasally into an immunocompetent mouse and is contained in a lung granuloma. To determine whether granuloma formation is key for containment of C. neoformans Deltagcs1, we studied the role of C. neoformans glucosylceramide in a T- and NK-cell-immunodeficient mouse model (Tgepsilon26) in which alveolar macrophages (AMs) are not activated and granuloma formation is not expected. The results show that Tgepsilon26 mice infected with Deltagcs1 do not produce a lung granuloma and that the Deltagcs1 mutant proliferates in the lungs and does disseminate to the brain, although its virulence phenotype is dramatically reduced. Since Deltagcs1 can grow only in acidic niches, such as the phagolysosome of AMs, and not in neutral or alkaline environments, such as the extracellular spaces, we hypothesize that in immunodeficient mice Deltagcs1 proliferates inside AMs. Indeed, we found that depletion of AMs significantly improved Tgepsilon26 mouse survival and decreased the dissemination of Deltagcs1 cells to the central nervous system. Thus, these results suggest that the growth of Deltagcs1 in immunodeficient mice is maintained within AMs. This study highlights the hypothesis that AMs may exacerbate C. neoformans infection in conditions in which there is severe host immunodeficiency.

The Boston Safe Shops Project--preliminary findings of a case study in applying the 10 essential services of public health to building environmental health capacity

Boston's more than 500 automotive shops, located primarily in low-income communities of color, are a source both of well-paying jobs and of potential hazardous exposures to employees and residents. The Safe Shops Project works to reduce occupational and environmental health hazards without having to close these businesses. Combining inspections, in-shop trainings, outreach, and technical/financial assistance, it brings shops into compliance with laws and promotes use of safer practices and alternative products. After 18 months, 254 workers at 61 of 124 participating shops had received training. Surveys showed improved worker knowledge: Pre-training, 24.2 percent of the worker survey respondents stated that they knew what an MSDS was, and post-training, 75 percent stated that they knew. The surveys also found improvement in work practices: Pre-training, 48 percent of workers indicated that they used safety goggles in their work, while post-training, 70 percent indicated proper use of safety goggles. The results also showed shops investing in capital improvements such as replacement of PCE-based brake cleaners with aqueous cleaners. The Safe Shops Project has a successfully modeled application of the 10-essential-services framework to the building of public health capacity and community collaboration, and this model can be adapted to other locations and industries.

Optics and mechanisms for the Extreme-Ultraviolet Imaging Spectrometer on the Solar-B satellite

The Extreme-Ultraviolet Imaging Spectrometer (EIS) is the first of a new generation of normal-incidence, two-optical-element spectroscopic instruments developed for space solar extreme-ultraviolet astronomy. The instrument is currently mounted on the Solar-B satellite for a planned launch in late 2006. The instrument observes in two spectral bands, 170-210 A and 250-290 A. The spectrograph geometry and grating prescription were optimized to obtain excellent imaging while still maintaining readily achievable physical and fabrication tolerances. A refined technique using low ruling density surrogate gratings and optical metrology was developed to align the instrument with visible light. Slit rasters of the solar surface are obtained by mechanically tilting the mirror. A slit exchange mechanism allows selection among four slits at the telescope focal plane. Each slit is precisely located at the focal plane. The spectrograph imaging performance was optically characterized in the laboratory. The resolution was measured using the Mg iii and Ne iii lines in the range of 171-200 A. The He ii line at 256 A and Ne iii lines were used in the range of 251-284 A. The measurements demonstrate an equivalent resolution of ~2 arc sec? on the solar surface, in good agreement with the predicted performance. We describe the EIS optics, mechanisms, and measured performance.

Effect of prone positioning systems on hemodynamic and cardiac function during lumbar spine surgery: an echocardiographic study

STUDY DESIGN

Prospective randomized study of patients undergoing spine surgery.

OBJECTIVE

To compare changes in hemodynamic and cardiac function after prone positioning using different prone positioners.

SUMMARY OF BACKGROUND DATA

Prone positioning decreases blood pressure and cardiac function. Several studies have evaluated changes in cardiac function after prone positioning, and linked them to reduced venous return and ventricular compliance. This study compares different prone positioners using transesophageal echocardiography, and determines their effect on cardiac function and hemodynamics.

METHODS

After correction of fluid deficits with the patient under stable anesthesia, hemodynamic and cardiac performance was measured using transesophageal echocardiography. After prone positioning, repeat measurements were performed, and comparisons were made between prone and supine positions.

RESULTS

No intergroup differences in demographics, fluid deficit, baseline hemodynamics, or differences from supine to prone position were noted. Cardiac output decreased with the Wilson (Union City, CA) and Siemens AG (Munich, Germany) frames, while cardiac index and stroke volume decreased with the Andrews (Hollywood, CA), Wilson, and Siemens systems. Cardiac preload decreased using the Andrews frame. The Jackson spine table (Hollywood, CA) and bolsters had the least effect on cardiac performance.

CONCLUSION

Adequate fluid replacement reduced hypotension and hemodynamic instability after prone positioning. The Jackson spine table and longitudinal bolsters had minimal effects on cardiac function, and should be considered in patients with limited cardiac reserve.

A prospective randomized comparison of the Zadik procedure and chemical ablation in the treatment of ingrown toenails

BACKGROUND

We present the results of a prospective randomized trial of the Zadik procedure versus chemical ablation by sodium hydroxide for the treatment of ingrowing toenails.

METHODS

Thirty-eight patients had the Zadik procedure, and 45 patients had chemical ablation by sodium hydroxide. Mean followup was 12.45 months for the Zadik group and 11.69 months for the chemical ablation group.

RESULTS

In the Zadik group, the average return to normal shoe-wear was 2.13 weeks and in the chemical ablation group 3.73 weeks. Average return to normal activity was 2.18 weeks for the Zadik group and 3.89 weeks for the chemical ablation group. The median number of dressings were 3 and 8 for the Zadik and chemical ablation groups, respectively. The pain score, using the visual analogue scale were not statistically significant between the two groups. The recurrence rates were 23 recurrences in the Zadik group (60.5%) and seven recurrences in the chemical ablation group (15.6%).

CONCLUSION

The use of chemical ablation by sodium hydroxide in the treatment of ingrowing toenails shows statistically significant (p < 0.05) reduction in recurrence rates of ingrowing toenails compared to the Zadik procedure.

The effect of spinal bupivacaine in combination with either epidural clonidine and/or 0.5% bupivacaine administered at the incision site on postoperative outcome in patients undergoing lumbar laminectomy

Spinal anesthesia has numerous advantages over general anesthesia for patients undergoing lumbar laminectomy and microdisk surgery. In this study, we evaluated the addition of epidural clonidine and/or bupivacaine, injected at the incision site, on postoperative outcome variables in patients undergoing lower spine procedures using spinal anesthesia. One hundred twenty patients having lumbar spine surgery received bupivacaine spinal anesthesia supplemented by 150 microg of epidural clonidine with or without incisional bupivacaine, epidural placebo plus incisional bupivacaine, or placebo with incisional saline. Demographic data, intraoperative hemodynamics, blood loss, pain, nausea, urinary retention, hospital discharge, and other variables were compared by using either analysis of variance or chi(2) analysis. Demographics were similar. IV fluids, blood loss, incidence of intraoperative bradycardia, and hypotension were not different among groups. Postanesthesia care unit pain scores were lower and demand for analgesics was less in patients who received both the clonidine and subcutaneous bupivacaine. Patients who received epidural clonidine also had improved postoperative hemodynamics. Hospital discharge, urinary retention, and other variables were not different. We conclude that epidural clonidine as a supplement to spinal anesthesia produced no perioperative complications and improved postoperative pain and hemodynamic stability in patients undergoing lower spine procedures.

IMPLICATIONS

Spinal anesthesia with supplemental epidural clonidine in combination with incision site subcutaneous bupivacaine was evaluated both intra- and postoperatively and compared with spinal anesthesia alone for lower lumbar spine procedures. Both epidural clonidine and subcutaneous incisional bupivacaine, added to spinal anesthesia for lumbar spine surgery, improves pain relief and reduces the need for postoperative opioids with their associated side effects.

Increased mortality of elderly female peritoneal dialysis patients with diabetes--a descriptive analysis

Three recent studies using registry data from the United States, in comparing the mortality risks between peritoneal dialysis (PD) and hemodialysis (HD), have consistently found that elderly diabetic women on PD have a higher mortality risk as compared with their counterparts on HD. Though the cause for this observation is not clear, the phenomenon may be unique to the United States. Alternatively, a selection bias impossible to decipher may be at work in these studies, as none of them have data on comorbidity, nutrition, or adequacy of dialysis. Finally, the possibility that elderly diabetic women are, for some reason, more vulnerable to the ill effects of peritoneal dialysis should be considered. We report here a retrospective analysis of 47 diabetic women, above 55 years of age, with end-stage renal disease, who were started on PD and who later died on dialysis. The primary outcome of interest was cause of death. Demographic details about the patients, comorbid conditions, dialysis adequacy, and biochemical parameters at the start of PD were noted. Death in these patients was attributed mainly to vascular causes, and there appeared to be a high prevalence of peripheral vascular disease. Infection was the next major cause of death, being the primary cause in 14 patients. Of these, only 5 patients had peritonitis. On a Cox regression analysis, only patient age and duration of diabetes at onset of dialysis were found to be predictive of vascular death. No factor was found to be predictive of death from infection. It appears that elderly diabetic women on PD die mainly of the long-term complications of diabetes.

Late renal transplant failure: an adverse prognostic factor at initiation of peritoneal dialysis

BACKGROUND

Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis.

OBJECTIVE

To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant.

SETTING

Peritoneal dialysis (PD) unit in a teaching hospital.

PATIENTS AND DESIGN

All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998.

RESULTS

There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group (p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease.

CONCLUSIONS

We conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.

Charged-particle multiplicity near midrapidity in central Au+Au collisions at sqrt[SNN]=56 and 130 GeV

We present the first measurement of pseudorapidity densities of primary charged particles near midrapidity in Au+Au collisions at sqrt[s(NN)] = 56 and 130 GeV. For the most central collisions, we find the charged-particle pseudorapidity density to be dN/deta|(|eta|<1) = 408+/-12(stat)+/-30(syst) at 56 GeV and 555+/-12(stat)+/-35(syst) at 130 GeV, values that are higher than any previously observed in nuclear collisions. Compared to proton-antiproton collisions, our data show an increase in the pseudorapidity density per participant by more than 40% at the higher energy.

Photoelastic analysis of stresses produced by different acetabular cups

Porous-coated acetabular components can provide long-term biologic fixation to bone. However, the periacetabular stress patterns and mechanisms by which different types of cementless acetabular cups obtain initial stability is not clear. In the current study, periacetabular stresses produced by different cementless acetabular cup geometries were quantitated using a three-dimensional photoelastic model. The cup geometries consisted of trispiked, finned, hemispherical, and nonhemispherical (wider than a hemisphere at the periphery) geometries. The cup models were loaded incrementally in the photoelastic material to simulate periacetabular stress distributions at the time of implantation during surgery rather than under physiologic weightbearing loads. The peripheral stress distributions and their magnitudes induced by the trispiked and oversized hemispherical cups were similar, but the trispiked cup induced localized high stress regions where the spikes penetrate the bone model. The fins separated the periacetabular material into quadrants, which was associated with decreased peripheral stresses. A nonhemispherical geometry with a wider diameter at the rim than a hemisphere increased peripheral stresses more than an oversized hemispherical geometry and required less force to seat the implant. Although various cementless acetabular cups can perform well clinically, they produce different periacetabular stresses and appear to obtain initial fixation by different mechanisms.

Evaluation of Salmonella typhimurium mutants in a model of experimental gastroenteritis

Salmonella typhimurium strains harboring independent, defined mutations in aroA, invA, ssrA, or msbB were assessed for their ability to induce fluid accumulation, tissue damage, and local inflammation in rabbit ileal loops. Three wild-type strains of S. typhimurium, TML, HWSH, and SL1344, and two mutant strains, S. typhimurium SL1344 ssrA and S. typhimurium SL1344 msbB, consistently induced fluid accumulation in the lumen of loops and inflammation of loop-associated tissues. In contrast, three different S. typhimurium aroA strains and an invA mutant of SL1344 did not induce significant fluid accumulation in the rabbit ileal loops. However, the S. typhimurium aroA strains did induce an inflammatory infiltrate and some local villus-associated damage, but the invA mutant did not. Histologically, wild-type S. typhimurium, S. typhimurium SL1344 ssrA, and S. typhimurium SL1344 msbB demonstrated more severe effects on villus architecture than S. typhimurium aroA strains, whereas S. typhimurium invA-infected loops showed no detectable damage. This suggests that villus damage most likely contributes to fluid accumulation within the loop.

How preliminary data affect people's stated willingness to enter a hypothetical randomized controlled trial

PURPOSE

To explore how preliminary trial data affect the general public's stated willingness to enter a randomized clinical trial.

METHODS

We asked 165 prospective jurors to imagine that their physicians wanted them to enroll in a clinical trial. We then presented them with scenarios portraying preliminary trial results--for example, 9 out of 10 patients get better with drug A and 5 out of 10 get better with drug B--and asked after each scenario, whether they would choose to be part of the trial. We designed the scenarios to test how stated willingness to enter the trial would be influenced by: 1) the difference in effectiveness of the 2 treatments based on the patients enrolled thus far; and 2) by the chance that the difference in effectiveness was random (i.e., the P value). The subjects' willingness to enter the trial at various decision points was analyzed using logistic regression.

RESULTS

Fewer subjects were willing to enter the trial as preliminary data indicated either an increasing difference in the effectiveness of the two treatments or an increasing statistical significance of that difference. For example 75% of subjects were willing to enter the research trial before any preliminary data were presented, but this number fell to 49% when subjects were presented with preliminary data showing that 9 out of 10 patients improved with one treatment and 5 out of 10 with the other. Multivariable logistic regression revealed that higher P values (odds ratio = 4.29; P < 0.001; 95% CI: 2.22-8.28) and smaller differences in effectiveness (odds ratio = 0.02; P < 0.001; 95% CI: 0.00-0.07) implicit in preliminary data presented to subjects made subjects less likely to agree to enter clinical trials. After adjustment for other relevant variables, male gender was associated with increased willingness to enter the trial.

CONCLUSION

A subjects' willingness to enter the hypothetical trial was influenced by preliminary data. Fewer subjects were willing to enter the trial as the differences in benefit between 2 treatment groups increased. However, the majority of subjects were willing to enter the hypothetical trial even when preliminary evidence strongly favored one treatment over another. Given the importance of informed consent in entering patients in clinical trials, these results should be confirmed in actual trial settings.

Effect of cementless acetabular cup geometry on strain distribution and press-fit stability

Use of cementless acetabular cups, which are slightly larger than the reamed acetabulum, can provide press-fit stability without screws; however, the ideal cup geometry to maximize stability is not clear. Acetabular strain distribution, deformation, and implant stability were studied using an axisymmetric finite-element model, and mechanical stability was assessed by testing lever-out and extraction forces required to displace different cup geometries from foam bones. The implants tested included four nonhemispheric cup geometries and 1- and 2-mm oversized hemispheric geometries. A nonhemispheric cup that provides a gradual transition from a hemisphere at the dome to a larger peripheral dimension appears to maximize peripheral strains and implant stability without increasing overall acetabular deformation as much as a larger oversized hemispheric cup.

Endoscopic closure of postsurgical anterior cranial fossa cerebrospinal fluid leaks

OBJECTIVE

The primary objective of this study is to present an alternative technique to closure of anterior cranial fossa cerebrospinal fluid (CSF) leaks. This study also serves to review our experience with our technique and presents some technical "tricks" we have learned through experience.

METHODS

The design of this study is a clinical chart review. The setting is an academic medical center.

RESULTS

Eight patients were referred for closure of postsurgical CSF leaks. Seven of eight patients underwent closure with one attempt and closure was achieved after a second attempt in one patient. Follow-up ranged from 1.5 to 4.0 years. There were no complications. No patient developed an acute or delayed episode of meningitis.

CONCLUSION

The technique of endoscopic closure of a CSF leak is a safe and effective means for closure of a postsurgical anterior cranial fossa CSF fistula when performed by an experienced operator.

A prospective randomized study comparing short- and intermediate-term perioperative outcome variables after spinal or general anesthesia for lumbar disk and laminectomy surgery

General or regional anesthesia may be used for lumbar laminectomy. To determine whether one method is superior, 122 patients were randomly assigned to receive either a standard general anesthetic (GA) or spinal anesthesia (SA) supplemented with intravenous (IV) propofol sedation. Data from the intraoperative period through hospital discharge were collected and compared. Demographically, both groups were similar. Total anesthesia (131.0 +/- 4.3 vs 106.6 +/- 3.2 min) and surgical times (81.5 +/- 3.6 vs 67.1 +/- 2.8 min) were longer in the GA group. Intraoperative hemodynamics were similar between groups except that the incidence of increased blood pressure was more frequent with GA (26.2% vs 3.3%). Blood loss was less during SA (133 +/- 18 mL vs 221 +/- 32 mL). Postanesthesia care unit (PACU) heart rates and mean arterial pressures were higher in the GA group. Peak pain scores in the PACU were higher after GA compared with SA (58 +/- 4 vs 22 +/- 3) as were the number of patients who required analgesics. Severe nausea was more common in the GA group both in the PACU and during the 24 h after surgery. Analgesic requirements after discharge from the PACU, urinary retention, and days in the hospital did not differ between groups. This study suggests that SA may be superior to GA both intraoperatively and postoperatively for lumbar spine procedures lasting less than 2 h.

SF-20 score and item distributions in a human immunodeficiency virus-seropositive sample

The question of whether the full range of possible health states is measured by the Medical Outcomes Study (MOS) 20-Item Short-Form Health Survey (SF-20) in human immunodeficiency virus (HIV)-seropositive individuals is examined in this article. Ninety-five HIV-seropositive men (37 with asymptomatic infection, 58 with symptomatic infection) from two primary care practices were enrolled. Patients completed the SF-20 evaluating six dimensions of health status. Asymptomatic patients reveal substantial skew in score distributions for the dimensions of physical (-1.60), role (-1.19), and social (-1.13) functioning; no substantial skew is exhibited by symptomatic patients. Both subgroups reveal ceiling effects for physical, role, and social functioning, and pain dimensions; asymptomatic patients' ceiling effects are higher (physical functioning: 65% versus 31%; role functioning: 73% versus 41%; social functioning: 54% versus 43%; and pain: 41% versus 24%). Patients from both subgroups reveal floor effects for the role functioning dimension (asymptomatic patients, 22%; symptomatic patients, 34%). When looking at items rather than scales, asymptomatic patients' item distributions for the physical, role, and social functioning, and pain dimensions reveal clustering toward positive health states in most items; distributions of symptomatic patients are similar. Because this HIV-seropositive sample exhibits substantial ceiling effects in four of six SF-20 dimensions, effects that particularly are notable for asymptomatic patients, these dimensions should be revised for use in HIV-seropositive individuals or a disease-specific quality of life instrument should be constructed.