Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care

INTRODUCTION

Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety.

METHODS

A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed. Domains included demographics, medical error experience, patient safety opinions and concerns.

RESULTS

184 patients and 116 doctors completed the survey. Of the doctors, 41.4% felt patient safety had deteriorated over the previous five years and 54.3% felt patient safety measures were inadequate compared to 13.0% and 27.7% of patients respectively. Of the 30 patients who experienced medical errors/negligence claims, 18 reported permanent or long-term physical and emotional effects. Forty-two of 48 (87.5%) doctors who experienced medical errors/negligence claims reported emotional health impacts. Almost half of doctors involved in negligence claims considered early retirement. Forty-four patients and 154 doctors didn't experience errors but reported their patient safety concerns. Doctors were more concerned about communication and administrative errors, staffing and organisational factors compared to patients. Multiple barriers to error reporting were highlighted.

CONCLUSION

This is the first study to assess patients' and doctors' patient safety views and medical error/negligence claims experiences in breast cancer care in Ireland. Experience of medical error/negligence claims had long-lasting implications for both groups. Doctors were concerned about a multitude of errors and causative factors. Failure to embed these findings is a missed opportunity to improve safety.

Dealing with digital paralysis: Surviving a cyberattack in a National Cancer center

INTRODUCTION

Cyberattacks represent a growing threat for healthcare delivery globally. We assess the impact and implications of a cyberattack on a cancer center in Ireland.

METHODS

On May 14th 2021 (day 0) Cork University Hospital (CUH) Cancer Center was involved in the first national healthcare ransomware attack in Ireland. Contingency plans were only present in laboratory services who had previously experienced information technology (IT) failures. No hospital cyberattack emergency plan was in place. Departmental logs of activity for 120 days after the attack were reviewed and compared with historical activity records. Daily sample deficits (routine daily number of samples analyzed - number of samples analyzed during cyberattack) were calculated. Categorical variables are reported as median and range. Qualitative data were collected via reflective essays and interviews with key stakeholders from affected departments in CUH.

RESULTS

On day 0, all IT systems were shut down. Radiotherapy (RT) treatment and cancer surgeries stopped, outpatient activity fell by 50%. hematology, biochemistry and radiology capacity fell by 90% (daily sample deficit (DSD) 2700 samples), 75% (DSD 2250 samples), and 90% (100% mammography/PET scan) respectively. Histopathology reporting times doubled (7 to 15 days). Radiotherapy (RT) was interrupted for 113 patients in CUH. The median treatment gap duration was six days for category 1 patients and 10 for the remaining patients. Partner organizations paused all IT links with CUH. Outsourcing of radiology and radiotherapy commenced, alternative communication networks and national conference calls in RT and Clinical Trials were established. By day 28 Email communication was restored. By day 210 reporting and data storage backlogs were cleared and over 2000 computers were checked/replaced.

CONCLUSION

Cyberattacks have rapid, profound and protracted impacts. While laboratory and diagnostic deficits were readily quantified, the impact of disrupted/delayed care on patient outcomes is less readily quantifiable. Cyberawareness and cyberattack plans need to be embedded in healthcare.

POLICY SUMMARY

Cyberattacks pose significant challenges for healthcare systems, impacting patient care, clinical outcomes, and staff wellbeing. This study provides a comprehensive review of the impact of the Conti ransomware attack on cancer services in Cork University Hospital (CUH), the first cyberattack on a national health service. Our study highlights the widespread disruption caused by a cyberattack including shutdown of information technology (IT) services, marked reduction in outpatient activity, temporary cessation of essential services such as radiation therapy. We provide a framework for other institutions for mitigating the impact of a cyberattack, underscoring the need for a cyberpreparedness plan similar to those made for natural disasters and the profound legacy of a cyberattack on patient care.

Room to Improve: An Audit of In-Hospital End-of-Life Care for Oncology Patients in a Tertiary Cancer Centre in Ireland During the COVID-19 Pandemic

The COVID-19 pandemic compounded isolation for patients through social distancing measures and staff shortages. We were concerned about the impact of COVID-19 on the quality of care provided at end-of-life in 2021 in a national cancer centre, and instigated the first ever review of the care of the dying. Quality of care was assessed retrospectively using a validated instrument developed by the United Kingdom's National Quality Board. Sixty-six patient deaths occurred in our cancer centre in 2021. The 'risk of dying' was documented in 65.2% of records. Palliative care services were involved in 77%, and pastoral care in 10.6%. What was important to the patient was documented in 24.2%. The 'quality-of-death' score was satisfactory for most but poor in 21.2%. Our study prompted change, including appointment of an end-of-life coordinator, development of a checklist to ensure comprehensive communication, expansion of the end-of-life committee to include junior doctors, and regular audit.

Attitudes and knowledge of emergency doctors towards end-of-life care in the emergency department: a national survey

BACKGROUND

Emergency departments (EDs) are seeing an increase in patients requiring end-of-life (EOL) care. There is paucity of data of attitudes and knowledge of physicians providing EOL care in the ED both internationally and in Ireland.

OBJECTIVE

The aim of this project was to assess the attitudes and knowledge of ED physicians towards EOL care.

METHODS

This was a cross-sectional electronic survey of ED physicians working in Irish EDs and was facilitated through the Irish Trainee Emergency Research Network over a 6-week period. The questionnaire covered the following domains: demographic data, awareness of EOL Care, views and attitudes towards EOL care.

RESULTS

Of a potential 679 respondents, 441 responses were received, of which 311 (response rate of 44.8%) had fully completed the survey across 23 participant sites. Majority of the respondents were under the age of 35 (62%), were male (58%) and at Senior House Officer level (36%). In terms of awareness, 32% (98) of respondents were not aware of palliative care services in their hospitals while only 29% (91) were aware of national EOL guidance. Fifty-five percent (172) reported commencing EOL care in the ED, however 75.5% (234) respondents reported their knowledge of EOL care to be limited or non-existent. Only 30.2% respondents felt comfortable commencing EOL care in the ED without speciality team input. There appears to be a lack of clarity on the roles and responsibilities of emergency medicine nurses and doctors in the care of the dying patient in ED with only 31.2% (95) being clear on this role. Significant differences were observed associated with clinical experience and physician grade.

CONCLUSION

This study has highlighted a lack of awareness and knowledge of EOL care particularly amongst less experienced emergency medicine doctors. Formalized training and education programs in the provision of EOL care in the ED will improve comfort levels and knowledge amongst the emergency medicine doctors and improve the quality of care provided.

Impact of the COVID-19 pandemic on cancer care in Ireland - Perspectives from a COVID-19 and Cancer Working Group

Upon the COVID-19 pandemic onset in Ireland, cancer service disruptions occurred due to prioritisation of COVID-19 related care, redeployment of staff, initial pausing of screening, diagnostic, medical and surgical oncology procedures, staff shortages due to COVID-19 infection and impacts on the physical and mental health of cancer healthcare workers. This was coupled with reluctance among people with symptoms suspicious for cancer to attend for clinical evaluation, due to concerns of contracting the virus. This was further compounded by a cyber-attack on national health service IT systems on May 14th 2021. The Irish Cancer Society, a national cancer charity with a role in advocacy, research and patient supports, convened a multi-disciplinary stakeholder group (COVID-19 and Cancer Working Group) to reflect on and understand the impact of the pandemic on cancer patients and services in Ireland, and discuss potential mitigation strategies. Perspectives on experiences were gathered across domains including timeliness of data acquisition and its conversion into intelligence, and the resourcing of cancer care to address cancer service impacts. The group highlighted aspects for future research to understand the long-term pandemic impact on cancer outcomes, while also highlighting potential strategies to support cancer services, build resilience and address delayed diagnosis. Additional measures include the need for cancer workforce recruitment and retention, increased mental health supports for both patients and oncology professionals, improvements to public health messaging, a near real-time multimodal national cancer database, and robust digital and physical infrastructure to mitigate impacts of the current pandemic and future challenges to cancer care systems.

An Overview of the Impact of the Covid-19 Pandemic on the Provision of Palliative Care

The Sars-Cov-2 pandemic had an immeasurable impact on the provision of palliative care in Ireland, and continues to do so. Patients and families were affected by stringent infectious disease measures. Healthcare professionals were also impacted, with recent research demonstrating the psychological impact that the pandemic had on some of those working in palliative care during the pandemic. The services provided by palliative care services also shifted. Many patients opted to stay at home to receive end-of-life care or symptom management from their GP and community palliative homecare teams where possible. Palliative care services in the acute hospital setting were increasingly utilised to support teams to provide end-of-life care in a developing and challenging clinical environment. Communication technology was used to for multidisciplinary team meetings, to communicate with families and by community home care teams for some patient assessments. Our article outlines some of the major ways in which palliative care was impacted by the Sars-Cov-2 pandemic.

Immune Checkpoint Inhibitors and Palliative Care at the End of Life: An Irish Multicentre Retrospective Study

Background and Objectives: Immune checkpoint inhibitors (ICIs) have less toxicity than standard chemotherapy and are now standard of care for many patients with advanced cancer. A manageable side effect profile and potential for durable responses may lead to aggressive care of the palliative patient. We sought to evaluate palliative care input and ICI use at the end of life at two Irish cancer centres. Methods: We identified deceased patients who received at least one dose of an ICI between first of January 2013 to 31st of December 2018. A retrospective electronic chart review was performed. Results: The electronic records of 102 patients were analysed. Fifty eight percent were male and the median age of diagnosis of advanced disease was 60 years (range 17-78). Median time from last dose of ICI to death was 57 days (range 8-574) and 20% of patients died within 30 days of last dose of ICI. Most patients, 92%, were referred to palliative care. The median time from palliative care referral to death was 64 days (range 1- 1010). In the last 30 days of life, 39% of patients attended the emergency department (ED) and 46% had at least one hospital admission. Late palliative care referrals, ≤3 months before death, were associated with hospitalisations in the last month of life (64% vs. 36%, P = .02). Timing of palliative care referral did not affect ICI prescribing at the end of life (P = 0.38). ICI use in the last 30 days of life was not associated with increased ED presentations or hospitalisations at the end of life. Patients who received ICI in the last month had a higher likelihood of in-hospital death (43% vs. 16%, P = 0.02). Conclusions: ICI within 30 days of death was associated with dying in hospital but did not lead to more hospitalisations and emergency department presentations. Early palliative care did not affect ICI use but reduced hospitalisations at the end of life.

Place of care: from referral to specialist palliative care until death

BACKGROUND

While there are many poorly standardised studies focusing on place of death, there are limited data on place(s) of care during the final stages of disease.

AIM

This study aims to identify where patients are cared for in the interval from referral to specialist palliative care until death.

METHODS

All patients who died while under the care of a specialist palliative care service over a 6-month period were considered.

RESULTS

Of the 507 patients included, 255 (50.3%) were men and 428 (84.4%) had a malignant diagnosis. The mean referral-to-death interval was 70 days (SD 113, Range 1-838). The majority (n=281, 55.4%) received care in a single care setting-hospital (28.4%), home (21.5%), nursing home/community hospital (4.1%), hospice (1.4%)-and had a shorter mean referral-to-death interval. Most patients with more than one care setting spent three-quarters of their time in their normal place of residence. A total of 199 (39.3%) died in hospital, 131 (25.8%) in hospice, 131 (25.8%) at home (25.8%) and 46 (9.1%) in a nursing home/community hospital. Patients referred by a general practitioner (n=80 patients, 15.8%) were more likely to be cared for at home (p<0.001), and die at home (p<0.001).

CONCLUSIONS

A significant number of patients received specialist palliative care across multiple care settings. Late referral is associated with a single domain of care. General practitioner involvement supports patient care and death at home. Place of care and ease of transfer between care settings may be better indicators of the quality of care we provide.

Distribution of blood groups and secretor status in schistosomiasis

Urine and stool specimens from 425 school children in Swaziland were examined for evidence of Schistosoma mansoni or Schistosoma haematobium infection. Concurrently, saliva collections were analysed for ABH secretory ability and blood samples were typed for ABO, Rh and Lewis groups. Among individuals infected with S. mansoni, the frequency of blood group B was significantly increased (P < 0.001), and there was a greater prevalence of positive secretor status (P < 0.05). In contrast, the presence and severity of S. haematobium infection did not correlate with any of the variables tested.

Pathogenesis and recovery of tetraplegia after electrical injury

The site of neurological damage causing paralysis after electrical trauma remains to be clarified. A patient is described who developed a flaccid tetraplegia after a high voltage electrical injury. The findings on initial examination and neurophysiological investigation showed a very severe generalised sensory-motor polyneuropathy. His subsequent follow up over 60 months showed a remarkable degree of reinnervation and the unmasking of a myelopathy. The degree of reinnervation noted suggests an axonopathy that left the other elements of the peripheral nerves relatively spared. These findings provide the most convincing evidence to date that a generalised polyneuropathy can follow electrical injury and that it results from non-thermal mechanisms such as electroporation.

Sequential changes in in vivo muscle and liver protein synthesis and plasma and tissue glutamine levels in sepsis in the rat

We have investigated sequential changes in skeletal muscle and hepatic protein synthesis following sepsis, and their relationship to changes in circulating and tissue glutamine concentrations. Male Wistar rats underwent caecal ligation and puncture (CLP) or sham operation, with starvation, and were killed 24, 72 or 96 h later. A group of non-operated animals were killed at the time of surgery. Protein synthesis was determined using a flooding dose of L-[4-(3)H] phenylalanine, and glutamine concentrations were measured by an enzymic fluorimetric assay. Protein synthesis in gastrocnemius muscle fell in all groups. Gastrocnemius total protein content was reduced after CLP and at 72 and 96 h after sham operation. After CLP, protein synthesis was lower at 24 h, and total protein content was lower at 72 and 96 h, than in sham-operated animals. CLP was associated with increased liver protein synthesis at all time points, whereas there was no change after sham operation. Liver protein content did not change after CLP, but was lower at 72 and 96 h after sham operation than in non-operated animals. Plasma glutamine concentrations were reduced at 24 h after sham operation, and at 72 and 96 h after CLP. Muscle glutamine concentrations were reduced in all groups, with the decrease being greater following CLP than after sham operation. In the liver, glutamine concentrations were unchanged after CLP, but increased after sham operation. In rats with sepsis, decreases in muscle protein synthesis and content are associated with markedly reduced muscle glutamine concentrations. Plasma glutamine concentrations are initially maintained, but fall later. In liver, protein synthesis is increased, while glutamine concentrations are preserved. These results support a peripheral-to-splanchnic glutamine flux in sepsis.

Human chorionic gonadotrophin inhibition of pregnant human myometrial contractility

OBJECTIVE

To evaluate the effect of human chorionic gonadotrophin (hCG) on pregnant human myometrial contractility in vitro and to determine whether the hCG-elicited effect was oestrogen dependant.

METHODS

Isometric tension recording was performed under physiological conditions in isolated myometrial strips from biopsies obtained at elective caesarean section. The effect of cumulative additions of hCG (0.001, 0.01, 0.1, 1.0 and 10 iu/mL) on myometrial contractility was evaluated. Secondarily, the contractile activity of pregnant myometrium following hCG exposure was investigated in tissue pre-treated with beta-oestradiol.

RESULTS

hCG exerted a statistically significant relaxant effect on pregnant human myometrial tissue. The relaxant effect increased with increasing concentrations of hCG from 8.96% (SEM 2.06) (0.001 iu/mL hCG: P < 0.01 ) to a net cumulative total of 58.50% (SEM 3.74) (10 iu/mL hCG; P < 0.01). The relaxant effect was also time-dependant, increasing in magnitude throughout the duration of experiments. Beta-oestradiol did not significantly affect the response of myometrial tissue to hCG.

CONCLUSIONS

These results clearly demonstrate that hCG exerts a significant concentration-dependant relaxant effect on human myometrial tissue obtained rate in pregnancy. These findings outline an inhibitory physiological role of hCG on human myometrial contractility and raise the possibility of its potential use as a tocolytic.

Targeted topical steroid therapy in sudden sensorineural hearing loss

OBJECTIVE

To treat patients with sudden sensorineural hearing loss (SSNL) who failed oral prednisone therapy by using a round window membrane (RWM) microcatheter. This topical delivery strategy sought to improve effectiveness of steroid treatment to the inner ear by targeting drug delivery to the RWM.

STUDY DESIGN

Nonrandomized prospective design.

SETTING

Tertiary care facility.

PATIENTS

Six patients with severe unilateral SSHL, five of whom were refractory to a course of oral steroid therapy treated within 6 weeks of SSHL and three additional patients treated more than 6 weeks after SSHL.

INTERVENTION

Therapeutic use of RWM catheter.

MAIN OUTCOME MEASURES

Pure-tone averages (PTAs) and word identification scores (WIS).

RESULTS

Five of the six patients treated within 6 weeks of SSHL improved their WIS. Of the six, four returned to baseline hearing, one recovered hearing that could benefit by hearing amplification, and one regained moderate improvement in PTA but not WIS.

CONCLUSION

Targeted topical steroid administration avoids the significant systemic side effects of oral steroids and may offer more effective dosing than simple transtympanic injection of medicine. Although these findings are preliminary, it is possible that after further study, targeted drug delivery may be a useful technique to consider in patients with severe to profound hearing loss that have failed all other management options.

In rats with sepsis, the acute fall in IGF-I is associated with an increase in circulating growth hormone-binding protein levels

OBJECTIVE

Growth hormone (GH) given to reverse muscle catabolism in critical illness increased mortality, illustrating the need for better understanding of the pathophysiology of the GH axis. We describe the relationship between changes in plasma insulin-like growth factor-I (IGF-I) and growth hormone-binding protein (GHBP) levels and hepatic growth hormone-binding in rats with sepsis.

DESIGN

Randomised, controlled study.

SETTING

University research laboratory.

SUBJECTS

One hundred and eleven male Wistar rats.

INTERVENTION

Three groups of rats underwent caecal ligation and puncture (CLP) and three groups laparotomy only (LAP). Survivors were killed at 24, 72, and 96 h. All animals were starved during the study. Twelve rats were killed at the start of the experiment (baseline) and twelve (allowed food) at 96 h.

MEASUREMENTS AND RESULTS

Plasma levels of IGF-I and GHBP and binding of 125I-labelled human GH in liver homogenates were measured. IGF-I fell significantly following both CLP and LAP; at 24 h, IGF-I levels were lower after CLP than LAP (950 +/- 74 vs 1,522 +/- 60 microg/l, P = < 0.001). GHBP increased at 24 h following both CLP and LAP (45.6 +/- 1.87 and 47.7 +/- 3.01 vs 38.7 +/- 1.98 ng/ml at baseline, P = < 0.05). In LAP animals GHBP fell to below baseline by 72 h, and significantly so by 96 h (33.5 +/- 1.43, P = < 0.05), whereas GHBP remained elevated 72 h following CLP, returning to baseline by 96 h. The density of GH-binding sites in liver tended to increase, following both CLP and LAP at both 24 and 96 h, but these changes failed to achieve statistical significance.

CONCLUSION

Reduced IGF-I levels in sepsis in the rat are associated with elevations in GHBP and a trend to increased hepatic GH binding. This suggests that in sepsis 'GH resistance' is not associated with reduced GH receptor numbers.

A method for active surveillance of selected communicable diseases

In 1991, an initiative was launched in the Western Pacific Region of WHO to eradicate poliomyelitis by the year 2000. Confirmation of eradication requires a certification process, in which specific criteria must be met. A hospital-based surveillance system was developed. It was sensitive enough to detect, at least one case of acute flaccid paralysis (AFP) per 100,000 children under age 15 per year, which is considered the "background rate" of AFP. This system was instituted in 1997 in most countries in the Pacific, and included measles and neonatal tetanus as well as AFP. By mid-1998, 53 hospitals in the Pacific were submitting monthly forms indicating whether or not AFP, suspect measles, or neonatal tetanus had been seen in the preceding month. Compliance was excellent, with over 80% of forms submitted to WHO in 1998, thus meeting the certification standard. In 1999 a proposal was made to expand this method, in selected countries, to encompass most conditions presenting with acute fever plus rash, thus including, for example, cases of rubella and dengue. Important aspects of such surveillance include the capacity to confirm diagnoses in the laboratory, and to take effective public health action. A coordinated laboratory network had been established previously for virological analysis of stool specimens for conditions causing AFP, but laboratory support for other conditions is currently the responsibility of individual hospitals to arrange.

Oxygenator exhaust capnography as an index of arterial carbon dioxide tension during cardiopulmonary bypass using a membrane oxygenator

We have studied the relationship between the partial pressure of carbon dioxide in oxygenator exhaust gas (PECO2) and arterial carbon dioxide tension (PaCO2) during hypothermic cardiopulmonary bypass with non-pulsatile flow and a membrane oxygenator. A total of 172 paired measurements were made in 32 patients, 5 min after starting cardiopulmonary bypass and then at 15-min intervals. Additional measurements were made at 34 degrees C during rewarming. The degree of agreement between paired measurements (PaCO2 and PECO2) at each time was calculated. Mean difference (d) was 0.9 kPa (SD 0.99 kPa). Results were analysed further during stable hypothermia (n = 30, d = 1.88, SD = 0.69), rewarming at 34 degrees C (n = 22, d = 0, SD = 0.84), rewarming at normothermia (n = 48, d = 0.15, SD = 0.69) and with (n = 78, d = 0.62, SD = 0.99) or without (n = 91, d = 1.07, SD = 0.9) carbon dioxide being added to the oxygenator gas. The difference between the two measurements varied in relation to nasopharyngeal temperature if PaCO2 was not corrected for temperature (r2 = 0.343, P = < 0.001). However, if PaCO2 was corrected for temperature, the difference between PaCO2 and PECO2 was not related to temperature, and there was no relationship with either pump blood flow or oxygenator gas flow. We found that measurement of carbon dioxide partial pressure in exhaust gases from a membrane oxygenator during cardiopulmonary bypass was not a useful method for estimating PaCO2.

Morphologic changes in the inner ear of Chinchilla laniger after middle ear administration of gentamicin in a sustained-release vehicle

The use of transtympanic gentamicin has become a popular method of treating Meniere's disease; nevertheless, many questions still remain regarding this therapy. Until investigators can control the exact amount of medicine that is administered to the ear and have an understanding of the kinetics of gentamicin, therapy will continue to rely on empirical data. Previously we described the use of a fibrin-based sustained-release vehicle impregnated with gentamicin in the middle ears of chinchillas. With this model a kinetics curve of gentamicin was defined. The inner ears of these animals were submitted for immunohistochemical and histologic analysis. We discuss the ultrastructural changes seen and correlate this to our kinetics data. We also examine measurement of hair cell damage with heat shock protein levels. By better understanding the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population.

Attentional localization prior to simple and directed manual responses

The relationship between attention and the programming of motor responses was investigated, using a paradigm in which the onsets of targets for movements were preceded by peripheral attentional cues. Simple (button release) and reaching manual responses were compared under conditions in which the subjects either made saccades toward the target location or refrained from making eye movements. The timing of the movement onset was used as the dependent measure for both simple and reaching manual responses. Eye movement latencies were also measured. A follow-up experiment measured the effect of the same peripheral cuing procedure on purely visual processes, using signal detection measures of visual sensitivity and response bias. The results of the first experiment showed that reaction time (RT) increased with the distance between the cued and the target locations. Stronger distance effects were observed when goal-directed responses were required, which suggests enhanced attentional localization of target positions under these conditions. The requirement to generate an eye movement response was found to delay simple manual RTs. However, mean reaching RTs were unaffected by the eye movement condition. Distance gradients on eye movement latencies were relatively shallow, as compared with those on goal-directed manual responses. The second experiment showed that the peripheral cue had only a very small effect on visual detection sensitivity in the absence of directed motor responses. It is concluded that cue-target distance effects with peripheral cues are modulated by the motor-programming requirements of the task. The effect of the peripheral cue on eye movement latencies was qualitatively different from that observed on manual RTs, indicating the existence of separate neural representations underlying both response types. At the same time, the interactions between response modalities are consistent with a supramodal representation of attentional space, within which different motor programs may interact.

Dissociation of pituitary-adrenal and catecholamine activation after induced cardiac arrest and defibrillation

To avoid factors which confound attempts to characterize the neuroendocrine response to cardiac arrest, we studied the pituitary-adrenocortical and catecholamine responses to induced ventricular fibrillation (VF) and direct current cardioversion in 10 patients undergoing testing of 'implanted cardioverter defibrillator' devices under sedation. Plasma concentrations of epinephrine were increased 5 min after VF (from a mean basal of 0.39 (S.E.M. 0.09) to a peak of 0.632 (0.212) nmol litre-1; P < 0.05) but were unchanged at other times. Plasma concentrations of norepinephrine did not change at any time. Plasma concentrations of cortisol increased significantly at 10 min (from a mean of 367 (SEM 62) to 539 (64) nmol litre-1; P < 0.001) and remained increased 30 min after VF (470 (74) nmol litre-1; P < 0.05) but had returned towards baseline at 60 min, whereas plasma prolactin concentrations were increased at 5 min (from a mean of 224 (SEM 54) to 320 (63) mu. litre-1; P < 0.01) and remained increased until the end of the sampling period at 60 min (288 (65) mu. litre-1; P < 0.05). Concentrations of adrenocorticotrophic hormone (ACTH) (n = 5) tended to increase but this was not statistically significant. We conclude that a short period of cardiac arrest in lightly sedated humans activated the pituitary-adrenocortical axis but did not appear to stimulate catecholamine secretion. These findings raise questions about the nature and mechanisms of the neuroendocrine response to cardiac arrest.

Kinetics of gentamicin uptake in the inner ear of Chinchilla langier after middle-ear administration in a sustained-release vehicle

The search for a safe, effective treatment for the vertigo associated with Meniere's disease has long been an important topic in otolaryngology. In recent years many groups have begun using intratympanic gentamicin to treat this vertigo. Although reported cure rates are as high as 90%, many questions remain regarding this type of treatment. Current limitations are the necessity for repeated treatments and a lack of clear dosing guidelines. In addition, the gentamicin must be delivered in a manner that allows maximal vestibulotoxic effect without injury to hearing. Until investigators can control the exact amount of medicine that is placed in the ear and have an understanding of the kinetics of gentamicin absorption, adequate dosing guidelines will be difficult to establish, and therapy will continue to rely on empiric data. We describe the use of a fibrin-based sustained-release vehicle, impregnated with gentamicin, injected into the middle ear of chinchillas. This allows for a prolonged effect without repeated dosing. Using this model, we studied the absorption kinetics of gentamicin at time points ranging from 8 hours to 1 week after injection. We used our findings to create a kinetics curve of gentamicin absorption. We discuss the shape and characteristics of this kinetics curve and examine the effects of the fibrin-based sustained-release vehicle and gentamicin on the middle ear. We noted no absorption in the contralateral (untreated ear) or blood. Through better understanding of the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population and initiate programs for the use of this sustained-release vehicle in human beings.

Use of sustained release vehicles in the treatment of Meniere's disease

Over the years, a variety of empirical regimens have evolved using intratympanic gentamicin to treat the vertigo associated with Meniere's disease. Although these regimens have been effective, their application is not without risk. Many of the problems associated with intratympanic medications could be overcome with the use of a sustained release vehicle. This article examines the role of such vehicles in the treatment of Meniere's disease and how sustained release vehicles might impact future treatment for this disabling disease.

Venous Channels of the Petrous Apex: Their Presence and Clinical Importance

A methyl methacrylate casting technique was used to make detailed casts of the intracerebral venous system of four human cadaver specimens. Seven of the eight petrous apices studied were diploeic (n = 5), or pneumatic (n = 2) and had venules coursing in the anterior petrous apex. These venules form conduits connecting the cavernous to the inferior petrosal sinus or the jugular bulb and have not been previously described. In addition to the air cell system of the petrous apex, these venules may represent pathways for the spread of infection and the development of petrous apicitis, Gradenigo's syndrome, and the rare otogenic cavernous sinus thrombophlebitis. Their presence also may help explain the location of cholesterol granulomas, which afflict this area of the skull base.

Venous channels of the petrous apex: their presence and clinical importance

A methyl methacrylate casting technique was used to make detailed casts of the intracerebral venous system of four human cadaver specimens. Seven of the eight petrous apices studied were diploeic (n = 5), or pneumatic (n = 2) and had venules coursing in the anterior petrous apex. These venules form conduits connecting the cavernous to the inferior petrosal sinus or the jugular bulb and have not been previously described. In addition to the air cell system of the petrous apex, these venules may represent pathways for the spread of infection and the development of petrous apicitis, Gradenigo's syndrome, and the rare otogenic cavernous sinus thrombophlebitis. Their presence also may help explain the location of cholesterol granulomas, which afflict this area of the skull base.

Free tissue transfer in oromandibular reconstruction. Necessity or extravagance?

The challenges of oromandibular reconstruction have spawned tremendous progress and controversy in recent years. Foremost has been the development of free-tissue transfer. The selection of autogenous composite grafts whose volume and features closely approximate those of the ablative defect seems attractive, but are free flaps for everybody? This article defines the goals of the elusive "ideal" oromandibular restorative technique and compares the numerous options available to today's surgeon.

The neurocutaneous free fibula flap in mandibular reconstruction

Despite the delayed application of the free fibula flap to mandibular reconstruction, its recognition as a reliable, sensate skin paddle combined with enough bone to repair any mandibular defect and offer bicortical fixation of osseointegrated implants has proved the free fibula flap to be a "workhorse" in the repair of composite mandibular defects. The low donor site morbidity slightly eases the wait for the molecular reconstructive "cocktails" from the shelf of the next millennium.

Stimulus congruence and the Simon effect

A standard experimental procedure was implemented with novel response requirements to assess the hypothesis that the Simon effect is attributable not to the irrelevant stimulus-response relationship, but to the congruence between stimulus attributes. The stimulus ensemble consisted of the words LEFT and RIGHT, one of which was presented on each trial to the left or right of a central fixation point. The distinctive feature of the task is that subjects were asked to respond, by laterally placed keys, whether or not the stimulus word was in accord (i. e., congruent) with its location on the display. Asking subjects to judge stimulus congruence directly enables the effect of congruence to be assessed, as well as independent estimates of the two irrelevant S-R relationships that apply in the task--that is, between the response location and (1) the stimulus location (the Simon effect) and (2) the stimulus word (the reverse Simon effect). Marked effects were obtained in all three cases. Stimulus congruence remains in contention as a factor in the explanation of the Simon effect, but the strong effects of irrelevant S-R factors suggest that a more comprehensive account of the Simon effect is needed. An explanation in terms of stimulus salience, based on an interactive activational model, is briefly discussed.

Does stimulus correspondence account for the Simon effect? Comments on Hasbroucq and Guiard (1991)

In a recent paper analysing the Simon effect, Hasbroucq and Guiard (1991) concluded that stimulus congruence, a correspondence relationship between stimulus components, accounts for the Simon effect and explains its reversal in the Hedge and Marsh experiment (1975). We contend that their definition of stimulus congruence is applied inconsistently, which invalidates their conclusion. It is argued here that the effect of display-control arrangement correspondence (Simon, Sly, & Vilapakkam, 1981) is an alternative account that fits the presented data better. In a second experiment, Hasbroucq and Guiard (1991) claimed to have invalidated the suggestion that display-control arrangement correspondence could be considered to be an alternative account of the findings in their Experiment 1. However, we assert that the type of display-control arrangement employed in their second experiment was so unpredictable that no effect of display-control arrangement correspondence could occur.

Interference effects in the Stroop and Simon paradigms

The possibility that Stroop and Simon effects reflect the same cognitive processes was tested in 3 experiments with 62 adult Ss. The words LEFT and RIGHT were shown left and right of screen center. Similar levels of interference were found for a Simon task (keypress to meaning of word) and a spatial Stroop task (name its location). A reverse Simon task (keypress to word location) showed minimal interference from the irrelevant word, but in a reverse spatial Stroop task (read the word aloud) interference from the irrelevant location was sizable. This poses difficulty for translational accounts of Stroop interference. Presenting LEFT and RIGHT laterally balanced by a color-name foil yielded a Simon effect inconsistent with an orienting response hypothesis. With bilateral stimuli in a reverse Simon task, interference was marked, supporting an integrative account of Stroop and Simon effects in terms of cognitive activation and the salience of irrelevant stimuli.

HIV serosurveillance in Papua New Guinea

To determine human immunodeficiency virus-1 (HIV-1) prevalence in low- and high-risk populations in Papua New Guinea (PNG), anonymous unlinked serosurveillance was conducted in government-administered antenatal and sexually transmitted disease (STD) clinics at six sites beginning in June 1989. Although 3 of 1233 samples were HIV positive in a pilot study, none of 7948 samples was HIV positive during the first full year of serosurveillance (June 1989--May 1990). HIV-infected people are also identified in PNG through clinical diagnostic testing. Although underreporting is probably substantial, 45 HIV-infected people had been identified in PNG (population 3.6 million) through diagnostic testing between 1987 and the end of the first serosurveillance year (May 1990). In view of the steadily emerging clinical problem of acquired immune deficiency syndrome (AIDS) in PNG, the negative results of serosurveillance required explanation. Three possibilities are proposed: 1) the sample size chosen could fail to detect a case 5% (or more) of the time under the likely conditions of this survey; 2) the populations chosen for surveillance may not, yet, be those in which HIV is circulating at this early stage of the epidemic in PNG; and 3) laboratory error could account for some false negative results. The first two of these, alone or in combination, are most likely. Limited surveillance continued in PNG in 1991 and 1992. By June of 1992, 5 of an additional 6035 serosurveillance samples had tested positive. All 5 were among 2000 samples from a single site, the Port Moresby STD Clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

Interference effects in the Stroop and Simon paradigms

The possibility that Stroop and Simon effects reflect the same cognitive processes was tested in 3 experiments with 62 adult Ss. The words LEFT and RIGHT were shown left and right of screen center. Similar levels of interference were found for a Simon task (keypress to meaning of word) and a spatial Stroop task (name its location). A reverse Simon task (keypress to word location) showed minimal interference from the irrelevant word, but in a reverse spatial Stroop task (read the word aloud) interference from the irrelevant location was sizable. This poses difficulty for translational accounts of Stroop interference. Presenting LEFT and RIGHT laterally balanced by a color-name foil yielded a Simon effect inconsistent with an orienting response hypothesis. With bilateral stimuli in a reverse Simon task, interference was marked, supporting an integrative account of Stroop and Simon effects in terms of cognitive activation and the salience of irrelevant stimuli.

Arterial supply of the human endolymphatic duct and sac

The arterial anatomy of the endolymphatic duct and sac was studied in vascular casts of methyl methacrylate of six human heads. The chief source of arterial blood supply to the endolymphatic duct and sac appeared to be the occipital artery. Arterioles entered the bone of the mastoid process. Arterioles in bone, the walls of the sigmoid sinus, and the posterior fossa dura coursed medially to supply the endolymphatic sac. The orientation of arterioles tended to be along the long axis of the endolymphatic duct and sac, whereas venules were more likely to be circumferentially oriented. Arterioles arising from dural vessels divided into deeper branches, which supplied periductal connective tissue, and superficial branches, which entered canaliculi of the vestibular aqueduct. Gross anatomic findings were confirmed by histologic examination of temporal bones.

Cochleosacculotomy revisited. Long-term results poorer than expected

Cochleosacculotomy has been described as a simple, efficacious treatment for relief of vertigo in patients with Meniere's disease in whom medical therapy has failed. We reviewed records of 11 elderly patients with good vestibular function who were thought to be ideal candidates for this procedure. Average follow-up was 17 months. Contrary to previous reports, long-term control of vertigo was poor, and more than 80% of the patients suffered a significant hearing loss from this procedure. Four of 11 patients required a second surgical procedure to control their vertigo. Audiometric measures revealed statistically significant postoperative increases in puretone thresholds at all frequencies and speech reception threshold, and a decrease in discrimination scores. Based on the results of this study, we no longer plan to use cochleosacculotomy for the treatment of elderly patients with Meniere's disease.

Glomus tympanicum tumors: a clinical perspective

Since Guild first discovered glomus bodies in the middle ear, the diagnostic evaluation and therapy of glomus tympanicum tumors have remained challenging. This study describes 73 cases diagnosed as glomus tympanicum tumors over the past 30 years. During this period, imaging techniques have markedly improved, and surgical approaches have evolved and been refined. These 73 cases were reviewed from a clinical perspective involving presentation, diagnostic evaluation, and therapeutic management. Pulsatile tinnitus was the primary symptom in over half the patients, followed by hearing loss in one third. The physical exam rarely revealed a circumferential view of the lesion, emphasizing the necessity of further diagnostic evaluation. High-resolution computerized tomography (CT) is currently the radiographic study of choice. A transmastoid surgical approach with extended facial recess was most commonly employed. Extension to the jugular bulb or internal carotid was rare, and no intraoperative complications of catecholamine secretion were noted. Postoperative complications were few, and the overall residual/recurrence rate was less than 5%. Additional clinical insights may assist in the management of these rare but fascinating tumors.

Electrode insertion trauma in cochlear implantation

Residual hearing conservation may be important in cochlear implantation of children and of adults with disabling tinnitus responsive to extracochlear stimulation. Damage to the neural elements of the cochlea during electrode insertion may have a negative impact on residual hearing conservation. Histologic analysis of eight temporal bones with cochlear implants reveals trauma at essentially two locations: the round window insertion site and along the basal turn of the cochlea. In four of the bones, insertion at the round window resulted in damage to the osseous spiral lamina and the electrode was inserted through the scala media into the scala vestibuli. Evidence of secondary reactive osseous formation was also noted in these bones. This paper relates the surgical anatomy of the round window to histologic findings and microanatomical dissections. Recommendations for implantation surgery include creation of a cochleostomy by removal of the floor of the round window niche and a superior-to-inferior angle of electrode insertion.