Factors influencing teamwork in healthcare applicable to interventional and diagnostic radiology

Teamwork in healthcare has been analysed extensively in the literature, mainly in acute healthcare settings such as the operating room, emergency room, and intensive care unit, with limited evidence related to diagnostic and interventional radiology. Multiple factors that affect teamwork in different domains have been described, such as communication, hierarchy, and distractions. Teamwork is an important patient safety, job satisfaction and patient outcome determinant, with interprofessional and interdisciplinary healthcare education playing a relevant role in the different domains affecting team performance. The aim of this article is to review the literature to describe domains and specific factors that influence teamwork in diagnostic and interventional radiology practice. This is of particular interest for radiologist involved in quality improvement and/or patient safety initiatives development and implementation. The review will conclude with a summary table highlighting the most important factors that, according to the authors, appear relevant to the radiology practice.

Safety, feasibility, and acceptability of patient-controlled anxiolysis with dexmedetomidine for burn-care dressing changes: an open-label, single-arm, pilot study

Anxiety is common among patients with burn injury, occurring frequently surrounding wound care. Few pharmacologic interventions targeting anxiety in burn injury have been evaluated. This study aimed to evaluate patient-controlled anxiolysis using dexmedetomidine (PCA-DEX) in patients undergoing burn dressing changes. This was a prospective, open-label, single-arm pilot study to determine the feasibility, safety, and acceptability of PCA-DEX. PCA-DEX included a loading dose, continuous infusion, and patient-administered boluses during dressing changes for up to 5 days. Vital signs were monitored throughout PCA-DEX. Procedural pain and anxiety were evaluated before and after each dressing change. Nursing and patient satisfaction were evaluated after each dressing change. Twenty patients were included; 9 (45%) males and 11 females (55%) with a mean age of 45.1 ± 16.9 years and median total body surface area burn injury of 7 [IQR 4-9.5]%. Median heart rate and systolic blood pressure prior to PCA-DEX on day 1 were 82 [75-97] bpm and 147 [128-170] mmHg. Overall PCA-DEX was tolerated well with a median heart rate of 72 [66-82] bpm and systolic blood pressure 115 [99-141] mmHg after PCA-DEX. One patient was withdrawn due to severe bradycardia (heart rate < 45 bpm) not attributed to PCA-DEX; 4 patients experienced mild hypotension (systolic blood pressure 85-89/diastolic blood pressure 45-49 mmHg), all of which resolved without intervention. The majority of both nurses and patients were either satisfied or highly satisfied with PCA-DEX overall (78.1% for nursing, 86.5% for patients). PCA-DEX is a novel, safe and feasible method of anxiolysis during burn dressing changes with high patient and nurse satisfaction rates. A randomized, controlled trial is warranted to confirm the efficacy of PCA-DEX.

Incidence of Unplanned 30-Day Readmissions in Adult Burn Patients in the United States

This study characterizes adult burn readmissions in the United States using a nationally representative hospital inpatient sample. Readmission rates, diagnoses, and risk factors are discussed. We analyzed the 2013 and 2014 Nationwide Readmission Database for adult burn patients. The data were weighted to estimate national 30-day readmission rates. Principal readmission diagnoses were sorted into burn-specific or other readmission categories. We used multivariable logistic regression to assess the effects of patient and hospital stay risk factors on readmissions. An estimated 42,957 U.S. adult burn patients were discharged between January and November of 2013 and 2014. Of these patients, an estimated 3203 had unscheduled readmissions within 30 days (all-cause readmission rate: 7.5%, 95% CI: 6.7-8.2). An estimated 55.4 per cent of unplanned readmissions were for burn-specific principal readmission diagnoses. Burn-specific readmission was associated with burn severity and increased with both patient age and the number of comorbidities. Patients whose length of stay was less than 1 day per % total body surface area (%TBSA) burned had higher readmission risk (Adjusted odds ratio = 2.10, 95% CI = 1.48-2.99). The results of logistic regression models were similar for burn-specific readmissions and all-cause readmissions. In a nationally representative sample of adult burn patients, 4.1 per cent had unplanned 30-day readmissions for burn-specific reasons; 7.5 per cent were readmitted for any reason. Patient comorbidities and discharge before 1 day per %TBSA from the hospital impact readmission risk. Healthcare providers can use this information to identify at-risk patients, modify their treatment plans, and prevent readmissions.

Angioleiomyoma of the inferior turbinate: a rare cause of isolated facial pain

We present the case of a 33-year-old man with right-sided facial pain. Clinical examination revealed an isolated mass attached to the right inferior turbinate. This was confirmed with computed tomography. Excision was achieved endoscopically and histology revealed an angioleiomyoma. Full symptomatic relief was achieved after surgical excision. Less than 1% of angioleiomyoma lesions are found within the sinonasal cavity. We describe the first documented presentation of angioleiomyoma as a cause of isolated, unilateral facial pain; a very common presentation to the otorhinolaryngology clinic. We promote consideration of angioleiomyoma as a different diagnosis in the presence of facial pain and a unilateral sinonasal lesion. Endoscopic resection provides complete symptomatic resolution.

Pregabalin in the reduction of pain and opioid consumption after burn injuries: A preliminary, randomized, double-blind, placebo-controlled study

BACKGROUND

The primary objective of the study was to evaluate the efficacy of 300 milligrams (mg) and 600 mg of pregabalin compared to placebo in the reduction of pain in patients with noncritical partial and full thickness burn injuries.

METHODS

A prospective, randomized, double-blinded, single center, placebo-controlled trial was conducted. Simple randomization method was used in this trial. After subjects met all the inclusion and none of the exclusion criteria, they were randomized and assigned to 1 of the 3 18-day treatments groups: Pregabalin 300 group, Pregabalin 600 group, or Placebo group. Demographics and clinical characteristics were recorded. The severity of pain was assessed by using the visual analog scale for pain intensity at baseline on day 3, day 9 ± 3, day 25 ± 7, day 90 ± 6, and day 180 ± 12.

RESULTS

A total of 54 subjects were randomly assigned, and 51 were included in the data analysis. Demographics and clinical characteristics did not differ significantly between the 3 groups. There was a statistically significant difference in pain between the Pregabalin 300 and Pregabalin 600 groups (P-value = .0260). The Pregabalin 300 group had 17.93 units (95% confidence interval: 1.83-34.04) higher pain scores on average than the Pregabalin 600 group, regardless of time. The adjusted P-value comparing 0 to 300 was .1618, while the adjusted P-value for 0 versus 600 was .5304. There was an overall difference in pain across time regardless of study group (P-value = <.0001). An overall difference in opioid consumption (P-value = .0003) and BSHS (P-value = .0013) across time regardless of study group was noted.

CONCLUSIONS

Pregabalin could be part of a promising multimodal analgesic regimen in noncritical burn population. Future placebo-controlled studies assessing the use of pregabalin in burn victim patients may further endorse our findings.

Survey of national and local practice of compression therapy timing for burn patients in the United States

OBJECTIVE

Compression therapy (CT) has been an important, but debated, treatment for burn scars. To better understand one source of variation in observed outcomes after CT, an evaluation of CT timing of application is needed.

MATERIALS AND METHODS

Following IRB approval, 126 burn centers were contacted to complete a 17-question survey regarding the center's practice pattern for compression garment therapy. Locally, study subjects were identified between March 1, 2014 and December 31, 2015 and medical records examined for timing of garment ordering, delivery and fitting.

RESULTS

The majority believed that compression therapy is beneficial. Most centers reported using custom-fit and pre-fabricated garments, and a goal time of application between 2-4 weeks (42%) and 4-6 weeks (36%). After the garments are ordered, 61% of centers estimate that it takes 2-4 weeks for them to arrive. No significant differences in practices were found among centers treating pediatric patients only, adults only or both. Locally, the mean number of weeks between the date of original injury and garment order placement was 9.1 weeks with an additional 8.7 weeks between the date of order and date of delivery.

CONCLUSIONS

The current study identified that although the national reporting of time to garment application is estimated to be between 2-6 weeks at the majority of burn centers including our own, we found our center to be well in excess of 17 weeks. The findings offer an opportunity for local improvement, and raise the possibility of similar incongruity between goals and practice at other centers.

Incidence of oxandrolone induced hepatic transaminitis in patients with burn injury

The benefits of oxandrolone in burn patients has led to its accepted use in the burn care community, however details regarding the most common adverse effect, transaminitis, remains unclear. The purpose of this study was to determine the incidence of transaminitis in patients with burn injury and identify risk factors associated with the development of transaminitis. This single-center, retrospective risk factor analysis compared burn patients on oxandrolone with and without the development of transaminitis, defined as any aspartate aminotransferase or alanine aminotransferase value >100mg/dL. Patient demographics, past medical history, lab values, and burn characteristics were recorded. Overall 28 out of 66 (42%) patients developed transaminitis. The transaminitis group had a significantly higher proportion of other concomitant medications with a transaminitis risk (p=0.045). No significant difference in liver dysfunction or length of stay was observed between the two groups. Oxandrolone induced transaminitis is occurring in patients significantly more frequently than previously reported warranting further research to guide monitoring requirements, use of concomitant medications, and to determine if rechallenging after resolution should be considered.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: A Multicenter Retrospective Study of 377 Adult Patients from the United States

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe mucocutaneous reaction with few large cohorts reported. This multicenter retrospective study included patients with SJS/TEN seen by inpatient consultative dermatologists at 18 academic medical centers in the United States. A total of 377 adult patients with SJS/TEN between January 1, 2000 and June 1, 2015 were entered, including 260 of 377 (69%) from 2010 onward. The most frequent cause of SJS/TEN was medication reaction in 338 of 377 (89.7%), most often to trimethoprim/sulfamethoxazole (89/338; 26.3%). Most patients were managed in an intensive care (100/368; 27.2%) or burn unit (151/368; 41.0%). Most received pharmacologic therapy (266/376; 70.7%) versus supportive care alone (110/376; 29.3%)-typically corticosteroids (113/266; 42.5%), intravenous immunoglobulin (94/266; 35.3%), or both therapies (54/266; 20.3%). Based on day 1 SCORTEN predicted mortality, approximately 78 in-hospital deaths were expected (77.7/368; 21%), but the observed mortality of 54 patients (54/368; 14.7%) was significantly lower (standardized mortality ratio = 0.70; 95% confidence interval = 0.58-0.79). Stratified by therapy received, the standardized mortality ratio was lowest among those receiving both steroids and intravenous immunoglobulin (standardized mortality ratio = 0.52; 95% confidence interval 0.21-0.79). This large cohort provides contemporary information regarding US patients with SJS/TEN. Mortality, although substantial, was significantly lower than predicted. Although the precise role of pharmacotherapy remains unclear, co-administration of corticosteroids and intravenous immunoglobulin, among other therapies, may warrant further study.

What the child "SAID" to the dentist: A UK randomized controlled trial

BACKGROUND

The electronic Survey of Anxiety and Information for Dentists (eSAID) allows children to tell dentists about their feelings and coping preferences. It is a computer "quiz" with 26 questions and free-text responses that produces a report for the children that they can then hand to their dentist. This is the first study to report the use of eSAID in a hospital paediatric dental clinic.

METHODS

This was a randomized controlled trial to evaluate whether children thought that eSAID benefitted them, made them less anxious, and improved cooperation and their treatment satisfaction. Fifty-one children aged 8-13 years were randomized to complete either eSAID or a control version in the waiting room before their scheduled dental appointment. The study group had a 26-item questionnaire; the control had only two items. Both groups scored their anxiety on a 7-point anxiety scale at the start and again at the end of the quiz. All subjects handed the resultant eSAID report as a printout to their dentist. Dental treatment proceeded as planned. After treatment, each child reported how they thought the eSAID quiz had benefitted them by scoring on a 10 cm Visual Analogue Scale and their satisfaction on the Modified Treatment Evaluation Inventory. The operating dentists scored the children's cooperation using a 10 cm Visual Analogue Scale.

RESULTS

Overall, the baseline anxiety levels were low (study: mean 1.2; control: mean 1.5). The study group's post-survey anxiety reduced by 0.4, whereas controls' increased by 0.2; this difference is statistically significant (p = .04). However, it made no difference to the children's self-reported benefit (p = .30), satisfaction (p > .05), or cooperation (p = .34).

CONCLUSIONS

eSAID reduced pre-treatment anxiety but made no difference to children's perceived benefit, satisfaction, or cooperation. Future study should include known anxious children.

The use of intravenous tPA for the treatment of severe frostbite

OBJECTIVE

tPA and anticoagulation for treatment of severe frostbite have been reported suggesting differences in imaging techniques, route of tPA administration and management of patients after tPA infusion. This is a report of our results following a protocol of Tc-99m scanning, intravenous tPA administration, followed by either systemic anticoagulation or antiplatelet therapy.

METHODS

Patients admitted to our burn center between February 13, 2015 and February 13, 2016 for frostbite who met inclusion criteria were treated with Tc-99m scan and intravenous tPA followed by systemic anticoagulation or antiplatelet therapy. Inclusion criteria included rewarming had not started more than 24h prior to the scan and no contraindications to the use of tPA.

RESULTS

Fifteen patients met inclusion criteria and 12 were treated according to the protocol. Nine received scans with 2 showing normal perfusion. Seven displayed perfusion defects and received intravenous tPA. Five recovered fully after tPA. Two who showed improved but abnormal scans after tPA experienced bleeding complications necessitating stopping heparin/Coumadin. Those two went on to partial amputation of digits.

CONCLUSION

The use of intra-arterial or intravenous tPA along with angiography or Tc-99m scanning followed by systemic anticoagulation or antiplatelet therapy may be beneficial to patients suffering frostbite.

TRALI following fresh frozen plasma resuscitation from burn shock

INTRODUCTION

Resuscitation from burn shock using fresh frozen plasma (FFP) has been described. Critics of FFP resuscitation cite the development of transfusion related acute lung injury (TRALI) as a deterrent to its use. This study examines the occurrence of TRALI with FFP resuscitation of critically ill burned patients.

METHODS

A retrospective chart review was conducted of severely burned patients who received FFP resuscitation. Data points included age, TBSA, TBSA full thickness, presence of alternate etiologies of acute lung injury, total FFP administered, and signs and symptoms of TRALI as defined per the Canadian Blood Services Consensus Conference.

RESULTS

Eighty-three patients met the definition of severe burn and received FFP resuscitation. Of those, 65 met exclusion criteria. Eighteen patients were left for analysis with only one found to have signs and symptoms of TRALI. That patient suffered a 53.5% TBSA burn, received a total of 6228ml FFP, had no competing etiologies of ALI, and was diagnosed with TRALI within 6h of completing the FFP transfusion.

CONCLUSION

The possible occurrence of TRALI in burn patients receiving FFP resuscitation should be weighed against the reported benefits of such a resuscitation strategy.

A review of occupationally-linked suicide for dentists

BACKGROUND AND OBJECTIVES

Suicide rates among dentists and a perceived elevated risk for suicide have been debated in the academic literature. It has filtered into the public psyche that dentists have the highest suicide rate of any occupation. The present review seeks support for both protagonist and antagonist positions from multidisciplinary perspectives. Contemporary risk factors and strategies for intervention and the prevention of suicide in dentistry are explored.

METHODS

An online database search for articles and reports, with selected target words, was conducted for peer reviewed publications on suicide in the dental profession, and for factors contributing to dentist suicide. Review guidelines from the American Psychological Association were used to clarify concepts, identify where most work was focussed, and to explore the superiority of any approach to the emotive topic over another.

RESULTS

Findings suggest the dominant belief that dentists have an elevated risk of suicide may be historically, but not currently, accurate. Although dentists' suicide is trending down, diversity in methodology means no current consensus is possible. Factors found to be influencing dentists' suicide ranged from known occupational stressors, to toxins and substance abuse, and untreated mental health problems.

CONCLUSION

The contemporary position in New Zealand shows dentists per sé are not more likely than other health professionals to commit suicide although they may have been in the past. Dentists should be aware of individual susceptibility to burnout and mental health problems. Future directions are outlined to address this including peer intervention, and programmes available for dentists to cope better with risks leading to suicide.

Empathy in the dentist-patient relationship: review and application

BACKGROUND AND OBJECTIVES

A review of psychology, dental, and medical literature aimed to identify key variables for an ideal dentist-patient relationship. When empathy surfaced as the key positive variable, a further aim, which became the aim of this paper, was to explore how empathy could be intentionally applied.

METHODS

An online database search, limited to judgementally selected target-words, was conducted for peer-reviewed papers on the dentist-patient relationship. Review guidelines from the American Psychological Association were used to clarify concepts, identify where most work was focussed, and to explore the superiority of any approach to the topic, over another.

RESULTS

The distinction between instrumental (information) and affective (emotional) communication was important with empathy being the key variable. Empathy was seen clearly to facilitate improved communication and the experience of dentistry for patient and practitioner alike. Empathy was positively associated with negotiated treatment plans, treatment adherence, increased patient satisfaction, and reduced dental anxiety. However, the concept of empathy was rarely operationally defined, or empirically measured. At best it was a scale score or a theme in qualitative data analysis. As such, applied empathy is discussed as a perceived concept. Dental school curricula and patient request forms were found to have the greatest potential to train dentists to convey empathy, and for patients to perceive empathy.

CONCLUSION

Future directions are proposed, to apply empathy in the dentist-patient relationship through an integrated model of patient-centred communication.

The rationale and pilot study of a new paediatric dental patient request form to improve communication and outcomes of dental appointments

BACKGROUND

Children's unhappy visits to the dentist can negatively impact lifelong oral health. A possible intervention is to enhance empathy in the child patient-dental practitioner relationship through communication. The present paper presents a new instrument, the Survey of Anxiety and Information for Dentists (SAID), which targets children's dental anxiety, coping preferences and dental neglect, and offers children a change to request information and engage in treatment planning.

METHOD

Five children's focus groups pilot tested the content, wording and response format of a prototype patient request form, the SAID. Participants were 34 10- to 13-year-old children who individually completed the form then discussed it item by item in their small groups.

RESULTS

Children had no difficulty completing most items. They identified ambiguities, and items that were meaningless to them, and proposed a new item asking the dentist about their job. Children were polarized over the response format, but they were emphatic about passing the form directly to the dentist, and not to a receptionist or assistant, stressing the importance of having a conversation with their dentist.

CONCLUSIONS

Before the pilot, dentists had expressed concerns about the potential for words in the SAID-provoking negative feelings. Children, however, wanted and needed facts, so requested that dentists use plain language, not euphemisms, to describe problems and treatment options. We report their selected practical suggestions. SAID-informed negotiated care may promote more patient cooperation and satisfaction at appointments, and more attention to oral hygiene between appointments.

Corticosteroid-binding globulin, cortisol, free cortisol, and sex hormone-binding globulin responses following oral glucose challenge in spinal cord-injured and able-bodied men

Circulating cortisol, corticosteroid-binding globulin, and sex hormone-binding globulin were measured retrospectively in plasma samples following the oral glucose tolerance test in 20 spinal cord-injured men and 20 able-bodied controls. Plasma-free cortisol responses attenuated more rapidly in the able-bodied men, compared to spinal cord-injured subjects, due to significant rise in circulating corticosteroid-binding globulin whereas changes in total plasma cortisol were similar in both groups. The changes in plasma-free cortisol in both groups paralleled changes in insulin and glucose and show that spinal cord-injured men had heightened exposure to free cortisol during this dynamic test. This raises the possibility that the mechanism of abdominal obesity and the propensity towards insulin resistance in spinal cord-injured men could be subtly mediated by perturbations in free cortisol. There were no significant changes in plasma sex hormone-binding globulin in either group.

Stem cell spinal cord regeneration: first do no harm

The prospect of "curing" spinal cord injury using stem cell therapy is one of the significant goals of many stem cell researchers. In this communication we consider some of the physiological implications of successful in vivo spinal cord repair and the ethical issues this potential revolutionary therapy will raise.

CHARACTERISTICS OF BRUCELLAPHAGE

McDuff, C. R. (University of Wisconsin, Madison), Lois M. Jones, and J. B. Wilson. Characteristics of brucellaphage. J. Bacteriol. 83:324-329. 1962.-Methods of characterizing phage have been applied to a brucellaphage of Russian origin grown on its propagating strain, Brucella abortus R 19. Phage can be propagated by single plaque transfer. Phage titers of about 10(10) particles per ml can be obtained by propagation on a young culture of R 19 in Albimi broth on a shaker at 37 C. After lyophilization, phage retains its activity during storage for at least 20 months at 4 C. Phage is stable in broth at pH values from 6 to 8 for 24 hr at 37 C. Some loss in activity results from heating for 1 hr at 60 C. All activity is lost in the presence of 10% chloroform. It has a slow adsorption rate (K = 3.6 x 10(-11) ml/min), a latent period of 100 min, and a burst size of 121 particles. Electron micrographs indicate that the phage is approximately 65 mmu in diameter, polygonal in shape, with a short tail.

Intensive exercise may preserve bone mass of the upper limbs in spinal cord injured males but does not retard demineralisation of the lower body

STUDY DESIGN

Cross-sectional study comparing a group of active spinal cord injured (SCI) males carefully matched for age, height, and weight with active able-bodied male controls.

OBJECTIVES

To compare bone mass of the total body, upper and lower limbs, hip, and spine regions in active SCI and able-bodied individuals.

SETTING

Outpatient study undertaken in two centres in New Zealand.

METHODS

Dual energy X-ray absorptiometry (DEXA) scanning was used to determine bone mass. Questionnaires were used to ascertain total time spent in weekly physical activity for each individual. The criterion for entry into the study was regular participation in physical activity of more than 60 min per week, over and above that required for rehabilitation.

RESULTS

Seventeen SCI and their able-bodied controls met our required activity criterion. Bone mineral density (BMD) values of the total body and hip regions were significantly lower in the SCI group than in their controls (P=0.0001). Leg BMD and bone mineral content (BMC) were also significantly lower in the SCI group (P=0.0001). By contrast, lumbar spine BMD and arm BMD and BMC did not differ between the SCI and control groups. Arm BMD and BMC were greater (not significant) than the reference norms (LUNAR database) for both groups.

CONCLUSION

Intensive exercise regimens may contribute to preservation of arm bone mass in SCI males, but does not prevent demineralisation in the lower body.

Successful digoxin therapy of fetal supraventricular tachycardia in a triplet pregnancy

BACKGROUND

Fetal supraventricular tachycardia is a rare complication of pregnancy associated with cardiac failure, hydrops, and fetal death. If no underlying cardiac defects are present, medical management with digoxin has been successful.

CASE

A young woman with a triplet pregnancy presented at 23 17 weeks' gestation for routine Doppler auscultation which suggested fetal supraventricular tachycardia, confirmed by M-mode echocardiography. She was treated with oral digoxin for the remainder of her pregnancy with subsequent conversion of the tachycardic triplet to normal sinus rhythm with occasional premature atrial beats. After delivery, the triplet previously demonstrating supraventricular tachycardia had a normal sinus rhythm.

CONCLUSION

Digoxin might be used safely and successfully to treat fetal supraventricular tachycardia in multifetal pregnancies.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma

BACKGROUND

The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults.

METHODS

Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively.

RESULTS

Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05).

CONCLUSION

Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Comparative genomics of Listeria species

Listeria monocytogenes is a food-borne pathogen with a high mortality rate that has also emerged as a paradigm for intracellular parasitism. We present and compare the genome sequences of L. monocytogenes (2,944,528 base pairs) and a nonpathogenic species, L. innocua (3,011,209 base pairs). We found a large number of predicted genes encoding surface and secreted proteins, transporters, and transcriptional regulators, consistent with the ability of both species to adapt to diverse environments. The presence of 270 L. monocytogenes and 149 L. innocua strain-specific genes (clustered in 100 and 63 islets, respectively) suggests that virulence in Listeria results from multiple gene acquisition and deletion events.

Why is sexual abuse declining? A survey of state child protection administrators

OBJECTIVES

Cases of substantiated sexual abuse have declined approximately 39% nationwide from 1992 to 1999, according to estimates from the National Child Abuse and Neglect Data System (NCANDS). Despite the dramatic nature of the decline, little discussion of the trend has occurred at either the national or the state level. Aims of the research were to: (1) gather state-level information about possible sources of the sexual abuse decline, (2) identify child protection trends that might be contributing to the decline, and (3) assess the level of awareness of the decline in state child protection offices.

METHODS

Telephone interviews were conducted with child protection administrators in 43 states.

RESULTS

More than half of the officials in states with large declines were unaware of any discussion of the declines within their agency or in the public at large within their state. State officials cited a diverse array of possible causes for the decline, including: (1) increased evidentiary requirements to substantiate cases, (2) increased caseworker caution due to new legal rights for caregivers, and (3) increasing limitations on the types of cases that agencies accept for investigation. More than half also mentioned the effectiveness of prevention programs, increased prosecution, and public awareness campaigns, implying that a portion of the decline may result from a real decline in occurrence.

CONCLUSIONS

Responses from child protection officials have inherent biases, but they are useful in generating hypotheses for further study in trying to account for the decline. The results suggest that further discussion and increased analysis of child maltreatment system data are important next steps.

Should Level I trauma centers be rated NC-17?

BACKGROUND

Previous studies have reached contradictory conclusions regarding where injured children are best treated. Our hypothesis was that no differences in survival outcome exist among trauma centers caring for pediatric patients.

METHODS

For 16,108 injured children, we created a dependant variable, As-Ps (actual survival--predicted survival), which represents variation from TRISS-predicted outcome for each individual. We then used that variable to compare trauma centers' survival results overall and results for liver, spleen, and head injuries, statistically adjusting for age and injury severity.

RESULTS

When adjusted for age and injury severity, centers with added qualifications in pediatrics and Level I centers had improved survival performance overall and in the subcategory of head injured children. No differences existed in other organ-specific injury categories.

CONCLUSION

The improved unexpected outcome results at Level I centers and centers with Added Qualifications in Pediatrics suggest that a team of qualified professionals working in an institution willing to commit the required resources can sufficiently offer injured children the survival advantage expected of a trauma center.

Effects of the incorporation of CHAPS into SDS micelles on neuropeptide-micelle binding: separation of the role of electrostatic interactions from hydrophobic interactions

It is well known that neuropeptides interact with lipid vesicles in a manner similar to biological membranes, with electrostatic interactions between the two providing a mechanism for concentrating the peptide at the vesicle's surface, followed by hydrophobic interactions between the peptide and the core of the vesicle that induce and stabilize secondary structure motifs. In an effort to understand these interactions to a greater extent, our group has developed a series of anionic micelles (SDS) containing various concentrations of the bile salt CHAPS, which is used as a model for cholesterol. The incorporation of CHAPS into the hydrophobic core of these micelles should alter the degree to which the neuropeptide can insert itself, affecting structure. These interactions were investigated using two-dimensional NMR, pulse-field gradient (PFG) NMR, and molecular modeling experiments. The results of this study clearly indicate that electrostatic and hydrophobic interactions between the micelle and neuropeptide are completely independent of one another. Increasing the concentration of CHAPS to 15 mM in the micelles blocks the insertion of the hydrophobic side chains of the neuropeptide into the hydrophobic core of the micelles. The electrostatic interactions as determined by diffusion measurements are not affected by the presence of increasing CHAPS concentration. Our observations are consistent with the predictions of Seelig (A. Seelig and J. Seelig, "Interaction of Drugs and Peptides with the Lipid Membrane," in Structure and Function of 7TM Receptors, T. W. Schwartz, S. A. Hjorth, and T. S. Kastrup, Eds., Munksgaard: Location, 1996).

Multidisciplinary airway stent team: a comprehensive approach and protocol for tracheobronchial stent treatment

Tracheobronchial stents are being used with increasing frequency to treat major airway obstruction from both malignant and benign processes. Traditionally, stents have been placed via rigid bronchoscopy, flexible bronchoscopy, or fluoroscopy by members of various individual disciplines. We describe a novel multidisciplinary airway stent team (MAST) protocol for tracheobronchial stent placement and endoscopic management of major airway obstruction. A patient with symptoms of airway obstruction is generally first evaluated with a computed tomography scan and a videotaped flexible bronchoscopy. These studies are reviewed by the team otolaryngologist, pulmonologist, and interventional radiologist. A treatment plan, including the type and location of stents and the need for adjuvant therapies, is formulated. Stent placement is performed in the operating room under general anesthesia. Rigid bronchoscopy, with flexible bronchoscopy and fluoroscopy as needed, allows precise stent placement and the best use of various therapeutic methods. The MAST protocol combines the skills, knowledge, and unique therapeutic options of specialists from otolaryngology, pulmonology, and interventional radiology. This approach allows optimal stent placement and the use of other endobronchial therapies, including laser ablation, balloon dilation, photodynamic therapy, cryotherapy, and brachytherapy. A protocol with representative case reports is presented, along with a review and comparison of several of our most commonly used stents. Otolaryngologists who practice bronchoesophagoscopy, by virtue of their operative skill and knowledge of airway management, are well equipped to become leaders of MASTs and are encouraged to initiate MASTs at their institutions.

Membrane protein glycosylation and CD44 content in the adhesion of human ovarian cancer cells to hyaluronan

The adhesion of tumour cells to the hyaluronan (HA) pericellular coat of mesothelial cells is an important step in the peritoneal spread of ovarian cancer. Previously, we have shown that the cell surface molecule CD44 is involved in this process. Paradoxically, the degree of adhesion does not appear to be related to the amount of CD44 expressed. In order to explain this observation we have examined the in vitro adhesion to HA of four high CD44-expressing ovarian cancer lines in relation to their CD44 spliced variant content and the CD44 glycosylation. Adhesion was measured in multiwell plates coated with different concentrations of HA in order to determine both the avidity and the maximum adhesion. Two lines had high adhesion and two lines had low adhesion. The avidity for HA was different for each line, but in all cases this could be totally blocked by treatment with an anti-CD44 antibody. The standard form of CD44 was the major species detected by RT/PCR in all lines and spliced variants were present in low amounts. Neuraminidase treatment increased the adhesion of the 'low-adhesion' lines at all HA coating concentrations; but only substantially increased the adhesion of the 'high-adhesion' lines at the lower HA coating concentrations. Tunicamycin treatment decreased the adhesion of the 'high-adhesion lines' at all HA coating concentrations and only substantially decreased the adhesion of one of the 'low-adhesion' lines when the plates were coated with a low concentration of HA. The adhesion of the remaining 'low-adhesion' line was slightly increased after tunicamycin treatment. It is concluded that glycosylation and not spliced variant content of CD44 affects the adhesive properties of ovarian tumour cells. This conclusion may have important consequences for developing new therapies in ovarian cancer.

Outlining the prostate boundary using the harmonics method

In a computerised ultrasound image guidance for automated prostatectomy system, it is necessary to identify a smooth, continuous contour for the prostate (boundary) from the ultrasound image. The radial bas-relief (RBR) method, which has been reported previously, can extract a skeletonised image from an ultrasound image automatically. After this process the prostate boundary is clearly revealed. However, analysis of the image is far from complete, as there are many spurious branches that create too much ambiguity for the system to define the actual boundary. There are also sections missing from the prostate boundary. Therefore further post-processing is required to describe and define the prostate boundary. In the paper, the harmonics method is used to describe the prostate boundary. The harmonics method uses Fourier information for noise removal and encodes a smooth boundary. The results of using the harmonics method after application of the RBR method on ultrasound images are presented. Factors that affect the performance are also highlighted and discussed.

DEXA: a practical and accurate tool to demonstrate total and regional bone loss, lean tissue loss and fat mass gain in paraplegia

Persons with spinal cord injury lose lean tissue mass and bone but gain body fat. There is a need to quantify the magnitude of these changes in body composition because there are associated skeletal and cardiovascular health risks. We have compared total body and regional (lower limb) differences in body composition in a group of males with paraplegia and in healthy able-bodied males matched for age, and height using dual energy X-ray absorptiometry. Although patients and controls had similar body mass indices, significant reductions in lean tissue mass (16% less) and bone (12% less) were observed in those with spinal cord injury. Group differences were even more pronounced in the lower limb. DEXA also revealed large increases in fat mass in subjects who did not look obese, total fat mass being 47% higher in the paraplegic group. We suggest that DEXA provides a simple and practical means to quantify both whole body and regional changes in body composition associated with spinal cord injury.

The Biobrane stent

For a successful take, skin grafts must be immobilized when applying dressings. Surgical beds requiring a stent to maintain contact between the graft and wound bed can be treated with Biobrane (Dow B. Hickam, Inc., Sugarland, Texas), which is held in place with skin staples at the periphery. Moistened gauze is placed over the grafted area, the redundant Biobrane stretched over the gauze, and this top layer again stapled at the periphery. When the stent is no longer needed, the top layer of Biobrane and gauze are removed, leaving a graft adherent to the bed and covered with Biobrane. This allows the surgeon to quickly construct an effective stent.

Binding of ovarian cancer cells to immobilized hyaluronic acid

Ovarian cancer has the highest mortality rate of any gynaecological malignancy. This is caused by metastatic deposits obstructing the intestinal tract. Very little is known about the molecules involved in the initial attachment of the metastatic tumour cells to the peritoneal mesothelial lining. Previously, we showed that many ovarian tumour lines express the adhesion molecule, CD44, on their cell surface. The major ligand for CD44 is the extracellular matrix glycosaminoglycan, hyaluronic acid (HA). Because mesothelial cells have a pericellular cost that contains large amounts of HA, it was postulated that the CD44/HA interaction is an important stage in ovarian cancer spread. However, it was difficult to demonstrate this interaction in an in vitro adhesion assay with mesothelial cells as most of the HA, and presumably the bound tumour cells, were lost from the mesothelial cells during the washing steps of the assay. In order to try and clarify the situation, the adhesion of six ovarian tumour lines to immobilized HA was measured. Four lines expressed high levels of CD44 and two lines expressed negligible amounts. Preliminary experiments were carried out with one of the CD44-expressing lines. After coating a plate overnight with 3 mg ml(-1) HA, the 5 min adhesion of this line varied between 2% and 73% according to the type of plate that was used. Falcon Micro Test III flexible plates gave the highest adhesion and was used for further experiments. Plates were coated with concentrations of HA between 0.001 mg ml(-1) and 3 mg ml(-1). All CD44 expressing lines adhered to HA, but the maximum adhesion and the adhesion strength varied with the line studied and was not closely related to the total CD44 expression. These results suggest that CD44 on ovarian tumour cells binds to HA on mesothelial cells. As much of the HA can be very easily lost from the mesothelial cell surface, additional factors such as the strength of the CD44/HA interaction, and the formation of bonds by the tumour cells with other membrane adhesion molecules, such as integrins, are also important in promoting tumour spread.

Binding of ovarian cancer cells to immobilized hyaluronic acid

Ovarian cancer has the highest mortality rate of any gynaecological malignancy. This is caused by metastatic deposits obstructing the intestinal tract. Very little is known about the molecules involved in the initial attachment of the metastatic tumour cells to the peritoneal mesothelial lining. Previously, we showed that many ovarian tumour lines express the adhesion molecule, CD44, on their cell surface. The major ligand for CD44 is the extracellular matrix glycosaminoglycan, hyaluronic acid (HA). Because mesothelial cells have a pericellular cost that contains large amounts of HA, it was postulated that the CD44/HA interaction is an important stage in ovarian cancer spread. However, it was difficult to demonstrate this interaction in an in vitro adhesion assay with mesothelial cells as most of the HA, and presumably the bound tumour cells, were lost from the mesothelial cells during the washing steps of the assay. In order to try and clarify the situation, the adhesion of six ovarian tumour lines to immobilized HA was measured. Four lines expressed high levels of CD44 and two lines expressed negligible amounts. Preliminary experiments were carried out with one of the CD44-expressing lines. After coating a plate overnight with 3 mg ml(-1) HA, the 5 min adhesion of this line varied between 2% and 73% according to the type of plate that was used. Falcon Micro Test III flexible plates gave the highest adhesion and was used for further experiments. Plates were coated with concentrations of HA between 0.001 mg ml(-1) and 3 mg ml(-1). All CD44 expressing lines adhered to HA, but the maximum adhesion and the adhesion strength varied with the line studied and was not closely related to the total CD44 expression. These results suggest that CD44 on ovarian tumour cells binds to HA on mesothelial cells. As much of the HA can be very easily lost from the mesothelial cell surface, additional factors such as the strength of the CD44/HA interaction, and the formation of bonds by the tumour cells with other membrane adhesion molecules, such as integrins, are also important in promoting tumour spread.

The use of a permanent dermal allograft in full-thickness burns of the hand and foot: a report of three cases

The standard method of grafting deep, thermal hand-and-foot burns with either full-thickness sheet grafts or narrowly meshed, thick, split-thickness skin grafts not only leaves a deep donor site, but also becomes complicated by infection, hypertrophic scarring, blistering, and hyper- or hypopigmentation. The availability now of an acellular, immunologically inert dermal transplant (AlloDerm; LifeCell Corp., The Woodlands, Texas) allows the successful use of ultrathin autografts while maximizing the amount of dermis delivered to the wound site. These autografts leave thin donor sites that heal faster and with fewer complications. This case report describes the use of AlloDerm dermal grafts on three patients with full-thickness burns of the distal extremities. Grafts were applied to the hand in two cases and the dorsum of the foot in the third. Range of motion, grip strength, fine motor coordination, and functional performance were quantitatively evaluated. As demonstrated by these patients, cosmetic and functional results were considered good to excellent after the use of AlloDerm grafts with thin autografts.

The synthesis and characterization of analogs of the antimicrobial compound squalamine: 6 beta-hydroxy-3-aminosterols synthesized from hyodeoxycholic acid

Analogs of the aminosterol antimicrobial agent squalamine have been synthesized beginning from hyodeoxycholic acid. After carboxylic acid esterification and oxidation of both alcohol functions to ketones, the A/B ring junction was converted from cis to trans by acid-catalyzed isomerization. Different polyamines were added to the 3-keto group by reductive amination, yielding both the 3 alpha and 3 beta addition products. The synthetic products exhibited potent, broad-spectrum antimicrobial activity similar to that of the parent compound. Changing the identity of the polyamine or the stereochemistry of addition has little effect upon antimicrobial activity but appears to change the selectivity of the agents. The analogs are synthesized with high yield from inexpensive starting materials and are promising alternatives to squalamine as potential antibiotics.

Human ovarian tumour cells can bind hyaluronic acid via membrane CD44: a possible step in peritoneal metastasis

Our previous studies have suggested that the interaction between hyaluronic acid (HA) on peritoneal mesothelial cells and the membrane adhesion molecule, CD44, on ovarian tumour cells could be important in ovarian cancer metastasis. In order to study this further, adhesion of six ovarian tumour lines to HA coated on to a plastic surface was investigated. Four lines bound to the HA coat and two lines did not. The adhesive lines were those that expressed high amounts of CD44, but the degree of adhesion was not closely correlated with CD44 expression. The results suggested that different tumour lines had different affinities for HA. Treatment of the HA coat with hyaluronidase substantially reduced adhesion. Adhesion was also partially reduced if the tumour cells were preincubated with either soluble HA, or anti-CD44 antibodies directed against the HA binding region. An antibody against a non-HA binding region only slightly blocked adhesion at high antibody concentrations. Only the CD44H isoform was detected by immunoprecipitation on the tumour cells. These results suggest that ovarian tumour cells can attach to immobilised HA via CD44H on the cell membrane.

Earthquake prediction: the interaction of public policy and science

Earthquake prediction research has searched for both informational phenomena, those that provide information about earthquake hazards useful to the public, and causal phenomena, causally related to the physical processes governing failure on a fault, to improve our understanding of those processes. Neither informational nor causal phenomena are a subset of the other. I propose a classification of potential earthquake predictors of informational, causal, and predictive phenomena, where predictors are causal phenomena that provide more accurate assessments of the earthquake hazard than can be gotten from assuming a random distribution. Achieving higher, more accurate probabilities than a random distribution requires much more information about the precursor than just that it is causally related to the earthquake.

Allosteric interactions at L-type calcium channels between FPL 64176 and the enantiomers of the dihydropyridine Bay K 8644

Functional interactions between the enantiomers of the dihydropyridine 1,4-dihydro-2,6-dimethyl-5-nitro-4-[2-(trifluoromethyl)-phenyl]-3-pyridi ne carboxylic acid methyl ester (Bay K 8644) and the benzoylpyrrole methyl 2,5-dimethyl-4-[2(phenylmethyl)benzoyl]-H-pyrrole-3-carboxylate (FPL 64176) were investigated on L-type Ca++ channels in guinea pig ileal longitudinal smooth muscle. The effects of these drugs, when applied individually, were as described in earlier studies. For instance, both (-)-(S)-Bay K 8644 and FPL 64176 caused concentration-dependent contraction, which is consistent with Ca++ channel activation, whereas (+)-(R)-Bay K 8644 gave concentration-dependent relaxation, which is consistent with Ca++ channel inhibition. The activities of the different drugs were dependent on the extracellular levels of KCI. When applied in combination, however, the responses evoked were not those predicted from the effects of the drugs applied individually. Contractions produced by FPL 64176 (25 nM to 1 microM) were abolished in the presence of 100 nM (-)-(S)-Bay K 8644 but were potentiated by 10 to 150 nM (+)-(R)-Bay K 8644 and inhibited by 1 microM (+)-(R)-Bay K 8644. Conversely, contractile responses to (-)-(S)-Bay K 8644 were abolished by 100 nM FPL 64176. In the presence of 1 microM FPL 64176, however, (-)-(S)-Bay K 8644 gave concentration-dependent relaxation of the muscle, which is consistent with Ca++ channel inhibition.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyaluronic acid secreted by mesothelial cells: a natural barrier to ovarian cancer cell adhesion

The adhesion to mesothelial monolayers of eight cultured ovarian tumour cell lines was studied in multiwell plates as a model for some of the interactions of ovarian cancer in the peritoneal cavity. When only the upper half of the conditioned medium (CM) from a confluent mesothelial cell culture was aspirated, the adhesion of the tumour cells was low (3.5%-36%). When the medium was removed completely the adhesion increased. The tumour cell lines showing the greatest enhancement of adhesion were those which had previously been shown to express the highest amounts of CD44. By adding erythrocyte suspensions to mesothelial cells it was shown that there was a pericellular coat around the mesothelial cells that could be destroyed by aspirating the medium, or by treating the medium with hyaluronidase (Hase). Treatment of the CM with Hase also considerably increased tumour cell adhesion. Furthermore, CM was shown to contain high amounts of hyaluronic acid (HA). HA blocked adhesion in the absence of CM, but the effect was not as large as that produced by the pericellular coat. It is proposed that pericellular HA produced by mesothelial cells has an important role in the invasion of ovarian tumour cells in the peritoneal cavity.

Serious silver sulphadiazine and mafenide acetate dermatitis

Infrequently reported, serious allergic reactions to topical antimicrobial agents used in the treatment of burn injuries are a potential source of confusion. To avoid misdirected therapy, an understanding of the manifestations of such reactions is important. Two recent cases of serious allergic reactions, one to silver sulphadiazine, one to mafenide acetate, are presented and the literature is reviewed.

Expression of cell adhesion molecules on ovarian tumour cell lines and mesothelial cells, in relation to ovarian cancer metastasis

A major route for the spread of ovarian cancer is by the attachment of tumour cells to the mesothelium lining in the peritoneal cavity. The expression of various adhesion molecules has been measured on freshly-prepared mesothelial cells, two mesothelial cells lines and 13 established ovarian tumour cell lines. The integrins beta 1 and beta 3, ICAM-1, and CD44 were detected on all mesothelial preparations and on many or all of the tumour lines. VCAM-I was expressed exclusively on the mesothelial cells and Lewis x was expressed on half of the tumour lines. There was low or no expression of sialyl Le(x), sialyl Le(a), integrins alpha 4, beta 1, beta 4, or E and P selectins. Only CD44 expression was significantly affected by trypsin treatment. From the known interactions of adhesion molecules, the results suggest that CD44, and beta 1 and beta 3 integrins may be important in tumour/mesothelial interactions.