Advanced wound healing in a patient with transmetatarsal amputation caused by severe diabetic foot infection: A case report

Introduction and importance: Diabetic foot accounts for 50% to 95 % of non-traumatic amputations. The healing process of a surgical wound resulting from amputation in the diabetic foot is complex, and it is difficult to achieve an optimal outcome, which should include obtaining a functional stump for the patient. Healing is mainly hindered by infection, vascular disease, and wound size. In turn, biofilm formation significantly delays the healing process, increasing morbidity and impairing the amputee's quality of life. Case presentation: This study analyzes the case of an 80-year-old male patient with diabetes who had failed to respond to previous treatment on an infected wound from a transmetatarsal amputation. The new treatment involved spraying the wound with silver sulfadiazine, lidocaine, and vitamin A aerosol and covering it with gauze dressings soaked in silver sulfadiazine, lidocaine, and vitamin A. The case evolution indicators used were total wound area, percentage of granulation tissue, wound perimeter, and maximum distance between the wound edges. A 3D simulation was also used to assess the wound bed. Clinical Discussion: Biofilm is linked to slower wound healing and wound chronicity, as this community of microorganisms in the wound slows down healing even when there are no apparent signs of infection. Therefore, treatment should be geared toward preventing contamination from leading to biofilm formation. Conclusion: Our results show that silver sulfadiazine, lidocaine, vitamin A gauze dressings, and aerosol have promoted fast and effective healing in a diabetic patient with a wound at high risk of greater amputation.

Technical Aspects of Using a Second Magnetic Grasper to Improve the Surgical Field in Single Port Revisional Bariatric Surgery

BACKGROUND

The future of minimally invasive surgery in revisional surgery is experiencing changes with new equipment such as the magnetic assistance that can be used with single port devices in order to perform an incisionless surgery (Luengas R, Galindo J, Castro M, et al. Surg Obes Relat Dis. 2021;17(1):147-152). Magnetic assistance through an auxiliary grasper with two internal magnets serves beyond liver retraction in different steps of the surgery improving the surgical field by obtaining a better visualization and triangulation.

PURPOSE

Expose the feasibility of using two internal magnetic graspers by single port performing a conversion surgery of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB).

METHODS

A 36-year-old female patient underwent a SG in 2015 and consults in 2021 because of severe GERD with a 33-point GERD-HRQL score. She has preoperative evaluation for a conversion surgery from SG to RYGB. Using a single port device through the umbilicus, an additional 5 mm trocar was placed in the left side of the abdomen. Two internal magnets were introduced through the umbilicus, and they were controlled by two external magnets placed over the abdomen with an articulated arm. The first magnet was used for liver retraction and the second one to perform both anastomoses, close the intermesenteric and Petersen defect, acting as an auxiliary grasper. The ethical committee approval was obtained through an informed consent from the participant included in the study.

Impaired Fibrinolytic Capacity in Patients with Inflammatory Bowel Disease

The venous occlusion test was applied to 17 patients with inflammatory bowel disease (IBD; 7 cases of Crohn’s disease, 10 cases of ulcerative colitis). Results were compared to those obtained in 20 healthy matched control subjects. Patients with IBD had significantly decreased t-PA Ag release (p <0.001) and had no significant vWF Ag release. Residual PAI activity was evidenced after venous stasis in the IBD group but not in the control group. Hypofibrinolysis was more important in patients with an evolutive IBD than in patients with IBD in remission. Impaired systemic fibrinolytic capacity might contribute to an increased risk for thromboembolic complications and to the pathogenesis of inflammatory bowel disease.

Development of an AAV9 coding for a 3XFLAG-TALEfrat#8-VP64 able to increase in vivo the human frataxin in YG8R mice

Artificially designed transcription activator-like effector (TALE) proteins fused to a transcription activation domain (TAD), such as VP64, are able to activate specific eukaryotic promoters. They thus provide a good tool for targeted gene regulation as a therapy. However, the efficacy of such an agent in vivo remains to be demonstrated as the majority of studies have been carried out in cell culture. We produced an adeno-associated virus 9 (AAV9) coding for a TALEfrat#8 containing 13 repeat variable diresidues able to bind to the proximal promoter of human frataxin (FXN) gene. This TALEfrat#8 was fused with a 3XFLAG at its N terminal and a VP64 TAD at its C terminal, and driven by a CAG promoter. This AAV9_3XFLAG-TALEfrat#8-VP64 was injected intraperitoneally to 9-day-old and 4-month-old YG8R mice. After 1 month, the heart, muscle and liver were removed and their FXN mRNA and FXN protein were analyzed. The results show that the AAV9_3XFLAG-TALEfrat#8-VP64 increased the FXN mRNA and FXN protein in the three organs studied. These results corroborate our previous in vitro studies in the FRDA human fibroblasts. Our study indicates that an AAV coding for a TALE protein coupled with a TAD may be used to increase gene expression in vivo as a possible treatment not only for FRDA but also for other haploinsufficiency diseases.

The bifoil photodyne: a photonic crystal oscillator

Optical tweezers is an example how to use light to generate a physical force. They have been used to levitate viruses, bacteria, cells, and sub cellular organisms. Nonetheless it would be beneficial to use such force to develop a new kind of applications. However the radiation pressure usually is small to think in moving larger objects. Currently, there is some research investigating novel photonic working principles to generate a higher force. Here, we studied theoretically and experimentally the induction of electromagnetic forces in one-dimensional photonic crystals when light impinges on the off-axis direction. The photonic structure consists of a micro-cavity like structure formed of two one-dimensional photonic crystals made of free-standing porous silicon, separated by a variable air gap and the working wavelength is 633 nm. We show experimental evidence of this force when the photonic structure is capable of making auto-oscillations and forced-oscillations. We measured peak displacements and velocities ranging from 2 up to 35 microns and 0.4 up to 2.1 mm/s with a power of 13 mW. Recent evidence showed that giant resonant light forces could induce average velocity values of 0.45 mm/s in microspheres embedded in water with 43 mW light power.

Elongated unique DNA strand deposition on microstructured substrate by receding meniscus assembly and capillary force

Ordered deposition of elongated DNA molecules was achieved by the forced dewetting of a DNA solution droplet over a microstructured substrate. This technique allows trapping, uncoiling, and deposition of DNA fragments without the need of a physicochemical anchoring of the molecule and results in the combing of double stranded DNA from the edge of microwells on a polydimethylsiloxane (PDMS) substrate. The technique involves scanning a droplet of DNA solution caught between a movable blade and a PDMS substrate containing an array of microwells. The deposition and elongation appears when the receding meniscus dewets microwells, the latter acting here as a perturbation in the dewetting line forcing the water film to break locally. Thus, DNA molecules can be deposited in an ordered manner and elongated conformation based solely on a physical phenomenon, allowing uncoiled DNA molecules to be observed in all their length. However, the exact mechanism that governs the deposition of DNA strands is not well understood. This paper is an analysis of the physical phenomenon occurring in the deposition process and is based on observations made with the use of high frame/second rate video microscopy.

Excess congenital non-synonymous variation in leukemia-associated genes in MLL- infant leukemia: a Children's Oncology Group report

Infant leukemia (IL) is a rare sporadic cancer with a grim prognosis. Although most cases are accompanied by MLL rearrangements and harbor very few somatic mutations, less is known about the genetics of the cases without MLL translocations. We performed the largest exome-sequencing study to date on matched non-cancer DNA from pairs of mothers and IL patients to characterize congenital variation that may contribute to early leukemogenesis. Using the COSMIC database to define acute leukemia-associated candidate genes, we find a significant enrichment of rare, potentially functional congenital variation in IL patients compared with randomly selected genes within the same patients and unaffected pediatric controls. IL acute myeloid leukemia (AML) patients had more overall variation than IL acute lymphocytic leukemia (ALL) patients, but less of that variation was inherited from mothers. Of our candidate genes, we found that MLL3 was a compound heterozygote in every infant who developed AML and 50% of infants who developed ALL. These data suggest a model by which known genetic mechanisms for leukemogenesis could be disrupted without an abundance of somatic mutation or chromosomal rearrangements. This model would be consistent with existing models for the establishment of leukemia clones in utero and the high rate of IL concordance in monozygotic twins.

Genome-wide association analysis identifies 13 new risk loci for schizophrenia

Schizophrenia is a heritable disorder with substantial public health impact. We conducted a multi-stage genome-wide association study (GWAS) for schizophrenia beginning with a Swedish national sample (5,001 cases, 6,243 controls) followed by meta-analysis with prior schizophrenia GWAS (8,832 cases, 12,067 controls) and finally by replication of SNPs in 168 genomic regions in independent samples (7,413 cases, 19,762 controls, and 581 trios). In total, 22 regions met genome-wide significance (14 novel and one previously implicated in bipolar disorder). The results strongly implicate calcium signaling in the etiology of schizophrenia, and include genome-wide significant results for CACNA1C and CACNB2 whose protein products interact. We estimate that ∼8,300 independent and predominantly common SNPs contribute to risk for schizophrenia and that these collectively account for most of its heritability. Common genetic variation plays an important role in the etiology of schizophrenia, and larger studies will allow more detailed understanding of this devastating disorder.

Risk assessment analysis of the future technical unit dedicated to the evaluation and treatment of motor disabilities

OBJECTIVES

The National Hospital of Saint Maurice (HNSM) for Physical Medicine and Rehabilitation aims at strengthening its position as a pivot rehabilitation and physical therapy center. The opening in 2011 of a new unit for the evaluation and treatment of motor disabilities meets this objective. This project includes several parts: clinical, financial, architectural, organizational, applied clinical research as well as dealing with medical equipments and information system. This study focuses on the risk assessment of this future technical unit.

METHODS

This study was conducted by a group of professionals working for the hospital. It started with the design of a functional model to better comprehend the system to be analyzed. Risk assessment consists in confronting this functional model to a list of dangers in order to determine the vulnerable areas of the system. Then the team designed some scenarios to identify the causes, securities barriers and consequences in order to rank the risks.

RESULTS

The analysis targeted various dangers, e.g. political, strategic, financial, economical, marketing, clinical and operational. The team identified more than 70 risky scenarios. For 75% of them the criticality level was deemed initially tolerable and under control or unacceptable. The implementation of an action plan for reducing the level of risks before opening this technical unit brought the system down to an acceptable level at 66%.

CONCLUSION

A year prior to opening this technical unit for the evaluation and treatment of motor disabilities, conducting this preliminary risk assessment, with its exhaustive and rigorous methodology, enabled the concerned professionals to work together around an action plan for reducing the risks.

Sustained efficacy and immunogenicity of the HPV-16/18 AS04-adjuvanted vaccine up to 7.3 years in young adult women

We report efficacy and immunogenicity of the HPV-16/18 AS04-adjuvanted vaccine up to 7.3 years post-vaccination. The study was conducted in a population (N=433) of women enrolled in Brazilian centres from an initial placebo-controlled study. Women were aged 15-25 years at first vaccination. During the most recent year of follow-up, approximately 7 years after initial vaccination, no cases of infection or cytohistological lesions associated with HPV-16/18 were observed in the vaccinees. Vaccine efficacy (95% confidence interval) up to 7.3 years was 94.5% (82.9, 98.9) for incident infection, 100% (55.7, 100) for 12-month persistent infection and 100% (-129.8, 100) for cervical intraepithelial neoplasia grade 2+. Antibody titres for total IgG and neutralising antibodies remained several folds above natural infection levels and >or=96% of women were seropositive. Vaccine safety was similar to placebo. This is the longest follow-up study for a licensed cervical cancer vaccine.

Impact of glyphosate on the development, fertility and demography of Chrysoperla externa (Neuroptera: Chrysopidae): ecological approach

Few ecotoxicological studies have used life table analysis to evaluate the toxicity of pesticides on beneficial organisms. This study is the first report of the effect of the herbicide glyphosate on a predator insect, Chrysoperla externa, using a demographic approach. This predator is associated to soybean pests and has a potential role as a biological control agent in the Neotropical Region. The objective of this work was to evaluate the side-effects of glyphosate on the development, fertility and demography of C. externa, treated orally by ingestion of glyphosate-dipped eggs of Sitotroga cerealella in laboratory conditions. The data were analyzed using the age-stage, two-sex life table. Development from third larval instar to pupae and adult longevity were shorter in glyphosate-treatment than in the control. Adult pre-reproductive period was longer in glyphosate-treatment than in the control. Fecundity and fertility were deeply reduced, as well, being fertility greater affected. A high important reduction was registered in all population parameters. Most eggs from glyphosate-treated cohort looked abnormal, smaller than control, dehydrated and became black 2d after oviposition. In addition, adults developed tumours in the abdomen region at 20d after emergence, being the effect more drastic in females than males. It is beyond the scope of our study to speculate on the effects of this herbicide on C. externa field populations. However, it seems likely that populations under continuous use of glyphosate would be exposed at greater detrimental effects in the long term.

Magnetic states at the oxygen surfaces of ZnO and Co-doped ZnO

First principles calculations of the O surfaces of Co-ZnO show that substitutional Co ions develop large magnetic moments which long-range order depends on their mutual distance. The local spin polarization induced at the O atoms is 3 times larger at the surface than in the bulk, and the surface stability is considerably reinforced by Co. Moreover, a robust ferromagnetic state is predicted at the O (0001) surface even in the absence of magnetic atoms, correlated with the number of p holes in the valence band of the oxide, and with a highly anisotropic distribution of the magnetic charge even in the absence of spin-orbit coupling.

Laser Microdissection Separation of Pure Spermatozoa from Epithelial Cells for Short Tandem Repeat Analysis*

Short tandem repeat (STR) analysis is a valuable tool in identifying the source of biological stains, particularly from the investigation of sexual assault crimes. Difficulties in analysis arise primarily in the interpretation of mixed genotypes when cell separation of the sexual assailant's sperm from the victim's cells is incomplete. The forensic community continues to seek improvements in cell separation methods from mixtures for DNA typing. The feasibility of applying laser microdissection (LMD) technology to precisely separate sexual assault cell mixtures by visual inspection coupled with laser dissection was assessed through three experiments. First, various histological stains were evaluated for use with LMD and DNA analysis. Second, different DNA isolation methods were evaluated on LMD-collected cells. Finally, STR analysis was performed on LMD-separated sperm cells from mixtures of semen and female buccal epithelial cells. The results indicated (a) hematoxylin/eosin staining performed best in its ability to differentiate sperm and epithelial cells while exhibiting the least negative effect on further downstream analysis; (b) both QIAamp and Lyse-N-Go methods were useful for recovery of DNA from LMD-collected sperm cells; and (c) LMD separation provided clear STR profiles of the male donor with the absence of any additional alleles from the female donor. This report describes an efficient, low-manipulation LMD method for the efficient separation of spermatozoa from two-donor sperm/epithelial cell mixtures.

Endoscopic Release of Limb Constriction Rings in utero

Amniotic band syndrome is a sporadic condition that may result in constriction bands, amputation and multiple craniofacial, visceral and body wall defects. It occurs in 1/1,200 to 1/15,000 live births. Most cases present with multiple congenital anomalies that are incompatible with life. A small group of fetuses shows isolated limb constrictions that may cause severe limb dysfunction or limb amputation if left untreated. Successful in utero surgical lyses of constriction rings have been reported. We report a case of constriction amniotic bands involving both legs and compromising blood flow to the distal extremity. The constriction ring was successfully released by a minimally invasive endoscopic surgical technique avoiding severe limb dysfunction or foot amputation.

Auditory sensory gating deficit and cortical thickness in schizophrenia

Both an EEG P50 sensory gating deficit and abnormalities of the temporal lobe structure are considered characteristic of schizophrenia. The standard P50 sensory gating measure does not foster differential assessment of left- and right-hemisphere contributions, but its analogous MEG M50 component may be used to measure gating of distinct auditory source dipoles localizing to left- and right-hemisphere primary auditory cortex. The present study sought to determine how sensory gating ratio may relate to cortical thickness at the site of the auditory dipole localization. A standard auditory paired-click paradigm was used during MEG for patients (n=22) and normal controls (n=11). Sensory gating ratios were determined by measuring the strength of the 50 ms response to the second click divided by that of the first click (S2/S1). Cortical thickness was assessed by two reliable raters using 3D sMRI. Results showed that: (1) patients had a P50 and left M50 sensory gating deficit relative to controls; (2) cortex in both hemispheres was thicker in the control group; (3) in schizophrenia, poorer left-hemisphere M50 sensory gating correlated with thinner left-hemisphere auditory cortical thickness; and (4) poorer right-hemisphere M50 auditory sensory gating ratio correlated with thinner right-hemisphere auditory cortical thickness in patients. The MEG-assessed hemisphere-specific auditory sensory gating ratio may be driven by this structural abnormality in auditory cortex.

Essential role for RGS9 in opiate action

Regulators of G protein signaling (RGS) are a family of proteins known to accelerate termination of effector stimulation after G protein receptor activation. RGS9-2, a brain-specific splice variant of the RGS9 gene, is highly enriched in striatum and also expressed at much lower levels in periaqueductal gray and spinal cord, structures known to mediate various actions of morphine and other opiates. Morphine exerts its acute rewarding and analgesic effects by activation of inhibitory guanine nucleotide-binding regulatory protein-coupled opioid receptors, whereas chronic morphine causes addiction, tolerance to its acute analgesic effects, and profound physical dependence by sustained activation of these receptors. We show here that acute morphine administration increases expression of RGS9-2 in NAc and the other CNS regions, whereas chronic exposure decreases RGS9-2 levels. Mice lacking RGS9 show enhanced behavioral responses to acute and chronic morphine, including a dramatic increase in morphine reward, increased morphine analgesia with delayed tolerance, and exacerbated morphine physical dependence and withdrawal. These findings establish RGS9 as a potent negative modulator of opiate action in vivo, and suggest that opiate-induced changes in RGS9 levels contribute to the behavioral and neural plasticity associated with chronic opiate administration.

Silent infarction as a risk factor for overt stroke in children with sickle cell anemia: a report from the Cooperative Study of Sickle Cell Disease

OBJECTIVE

To determine whether children with homozygous sickle cell anemia (SCD) who have silent infarcts on magnetic resonance imaging (MRI) of the brain are at increased risk for overt stroke.

METHODS

We selected patients with homozygous SCD who (1) enrolled in the Cooperative Study of Sickle Cell Disease (CSSCD) before age 6 months, (2) had at least 1 study-mandated brain MRI at age 6 years or older, and (3) had no overt stroke before a first MRI. MRI results and clinical and laboratory parameters were tested as predictors of stroke.

RESULTS

Among 248 eligible patients, mean age at first MRI was 8.3 +/- 1.9 years, and mean follow-up after baseline MRI was 5.2 +/- 2.2 years. Five (8.1%) of 62 patients with silent infarct had strokes compared with 1 (0.5%) of 186 patients without prior silent infarct; incidence per 100 patient-years of follow-up was increased 14-fold (1.45 per 100 patient-years vs 0.11 per 100 patient-years, P =.006). Of several clinical and laboratory parameters examined, silent infarct was the strongest independent predictor of stroke (hazard ratio = 7.2, P =.027).

CONCLUSIONS

Silent infarct identified at age 6 years or older is associated with increased stroke risk.

Detection of epileptogenic focal cortical dysplasia by depth, not subdural electrodes

Centers that perform presurgical epilepsy evaluations disagree on whether depth or subdural electrodes represent the optimal technique for invasive recording, especially in seizures originating outside the temporal lobe. A 13-year-old girl with a normal magnetic resonance imaging scan had unlocalized partial onset seizures, despite scalp and subdural grid ictal video/EEG recordings. Repeat video/EEG with depth electrodes showed a discrete site of continuous interictal spiking and seizure onset that was located 2-2.5 cm beneath the surface of the sensory cortex. The resected region showed focal cortical dysplasia and the patient had greater than 95% seizure frequency reduction at 3-year follow-up. We conclude that although subdural electrodes have many advantages when recording seizures outside the temporal lobes, depth electrodes may provide superior recordings when the epileptogenic region is beneath the cortical surface.

The effects of perceived stigma and psychological over-control on the behavioural problems of children with epilepsy

This pilot study finds that parents who think that their child will be stigmatized and who perceive that epilepsy limits their child, report higher levels of four child behavioural problems than reported by other parents of children with epilepsy. Those children with epilepsy who report that their parents use an over-controlling psychological approach to parenting report higher levels of four behavioural problems than those children with epilepsy who do not report over-controlling behaviour from their parents. The effects of simple partial seizures and of seizure severity on children's behavioural problems are completely mediated by perceived stigma, perceived limitations, and perceived parenting. Seizure frequency, absence seizures, and treatment with ethosuximide have direct effects on three children's behavioural problems; the effects of these medical variables are generally unaffected by control for parent's and children's perceptions.

Evaluation of two competing methods for calculating Charlson's comorbidity index when analyzing short-term mortality using administrative data

The performance and predictive power of the Deyo-Charlson and the Romano-Charlson comorbidity indices were compared when short-term mortality after hospitalization was the outcome of interest. These indices are commonly used to adjust for the effect of comorbidities when using administrative data in comparative studies. In hospital Medicare clam data for patients admitted to one of six medical categories (back pain, stroke, pneumonia, hip replacement, transurethral radical prostatectomy, or lysis of peritoneal adhesion), were selected for analyses. Logistic regression models were employed to evaluate the relative importance and the explanatory power of these indices for predicting mortality 30, 90, and 180 days after admission. The contribution of each index to mortality was assessed via the likelihood ratio chi-square statistic (G2), and the area under the receiver operator characteristic (ROC) curve was used to assess predictive power. Indices were evaluated using weights suggested by Charlson et al. and using empirically derived weights. Both indices improved the base model equally, although the predictive power of both indices was poor with values of the C statistic ranging from 0.60 to 0.78. Our results suggest limited applicability of these approaches when examining short-term mortality. A slight increase in predictive power was observed when indices were calculated using empirical weights derived from our data.

Gaucher disease: enzyme therapy in the acute neuronopathic variant

The responses to regular intravenous enzyme infusions were compared in two sibs with Gaucher disease type 2, the acute neuronopathic variant. Enzyme administration was begun at 7 months in patient 1 who had severe progressive visceral and neuronopathic disease. No significant effect of enzyme infusions was noted. Death occurred at 9 months. Patient 2 was prenatally diagnosed and enzyme infusions were initiated at age 4 days. Overall development progressed at a rate similar to her unaffected full sib until her death at 15.1 months. Slowly progressive esotropia, ocular paresis and dysphagia began at 8 months as did infiltrative pulmonary disease. Comparison of these clinical courses show significant visceral and neurologic effects of anticipatory enzyme therapy, but with unaltered outcome, for Gaucher disease type 2.

The effect of accommodative hysteresis on apparent stationarity

The potential contribution of accommodation to the ability to perceive whether an object is moving in space during lateral movement of the head was examined in 16 visually-normal young adults. The target, which provided a highly effective accommodation stimulus, was viewed monocularly in an otherwise completely darkened room. Self-generated head movements of controlled amplitude and frequency were used to produce lateral target motion of continuously variable amplitude either in-phase or counter-phase to the lateral translation of the head. Tonic accommodation and the target/head displacement ratio needed for apparent target stationarity were measured before and after sustained focus at either the nearpoint or farpoint. Tonic accommodation shifted inward under the nearpoint condition and outward under the farpoint condition. The tonic aftereffects induced under the nearpoint and farpoint conditions were accompanied by increases and decreases, respectively, in the degree of positive (same direction as the head) concomitant motion required for apparent target stationarity. These results suggest that the altered accommodative effort required to compensate for the tonic aftereffects influenced the magnitude of the absolute visual parallax ascribed to self-motion. The accommodative system therefore appears to contribute to position constancy, at least in a relatively impoverished visual environment.

Cooperative stroke management project by a peer-review organization

To improve the care of patients in Mississippi through increased adherence to nationally accepted ischemic stroke management guidelines, patterns for ischemic stroke services were determined from hospital chart review. Hospital-specific education and data feedback were performed to encourage international systems improvements. The Mississippi Foundation for Medical Care, Inc, reviewed records of Medicare beneficiaries discharged with the principal diagnosis of acute ischemic stroke from four hospitals over a 1-year period. Records were analyzed for compliance with stroke management guidelines. Hospital-specific and aggregate data were presented to the staffs of each hospital and the hospitals were encouraged to develop internal quality improvement projects. The Foundation reviewed 427 records of acute stroke patients, of whom 375 (87.8%) had ischemic stroke. Among the 427 stroke patients, there were 76 (17.8%) in-hospital deaths. Notable variances from the ischemic stroke management guidelines included those for emergent hypertension management, deep vein thrombosis prophylaxis, evaluation for cause of ischemic stroke, and use of antithrombotic therapy on discharge of ischemic stroke patients. Thus, the management of acute stroke patients in these four regional hospitals in Mississippi often differed from nationally accepted guidelines. We hope to improve the care of stroke patients by using the expertise of academic stroke physicians and hospital-specific analyses that are personally meaningful but not personally threatening to treating physicians.

The cooperative cardiovascular project an AFMC special report

Patients who suffer myocardial infarction can have improved outcomes if the following elements are part of their treatment plans: 1. Rapid diagnosis of the condition. 2. Use of thrombolytics or angioplasty early in the presentation, if appropriate. 3. Use of aspirin early in the course of care. 4. Discharge medications of aspirin and beta blockade, in appropriately selected patients. 5. Documentation of efforts to counsel the patient to quit smoking. The above material outlines the key indicators in the national project to improve care for heart attack victims. Hospitals should assess the diagnosis, immediate care, and long-term management of patients with this condition. Patients have a variety of comorbidities and do not always fit into a simplified therapeutic scheme. Nevertheless, the care of myocardial infarction victims in the pilot CCP states demonstrated that a sizable number of these patients could benefit from a more focused approach to the above therapeutic interventions.

The relationship of episiotomy to third and fourth degree lacerations

Third and fourth degree lacerations can produce significant long term morbidity to women undergoing childbirth. The incidence of third and fourth degree lacerations is variable depending on the institution and the obstetrical provider. While episiotomy remains a valuable intervention in selected cases, an improvement program directed at lowering the use of episiotomy can reduce the incidence of this clinical event. Hospitals and physicians with higher rates of third and fourth degree tears should examine the use of episiotomy, and midline episiotomy in particular, which is associated with an increased incidence of third and fourth degree tears.

Gallbladder surgery for Medicare patients in Mississippi

Mississippi Foundation for Medical Care (MFMC) conducted a review of gallbladder surgery performed on Mississippi Medicare Patients using hospital claims files and limited record review for verification of claims file data. Significant error rates in the surgeon identification number were found in the claims files. It should also be noted that the current ICD-9-CM coding system does not allow for identification of laparoscopic cholecystectomies converted to open procedures. Past studies have attempted to use claims data alone for these types of analyses. These findings demonstrate the importance of using caution by those attempting to use claims data (without verification) to define patterns of hospital utilization, clinical outcomes and/or physician profiling. Claims data must be tested for validity for reliable pattern analysis. In addition, considerable variation was found among providers in elements such as conversion rates, complication and readmission rates. A few surgeons showed patterns for critical variables that were quite different from the universe. There was however, no statistically significant differences associated between volume of cases performed and outcomes. Time frame comparisons over several years show significant (> 80%) increase in gallbladder surgery since the introduction of the laparoscopic procedure.

Chromatic aberration and ocular focus: Fincham revisited

Longitudinal chromatic aberration of the eye (LCA) produces "color fringes" at edges that specify focus. Fincham [(1951) British Journal of Ophthalmology, 35, 381-393] concluded that these chromatic effects were important for accommodation, but most investigators disagree. We monitored accommodation in 25 subjects while they viewed a sinusoidally moving target (1.5-2.5 D at 0.2 Hz) in a Badal optometer. The target was monochromatic (590 nm with 10 nm bandwidth), or white (3000 K) with LCA normal, neutralized or reversed. Sensitivity to the effects of LCA is profound and widespread. Gain decreases substantially and phase-lag increases when LCA is eliminated, and reversing the aberration severely disrupts accommodation. The ordered arrangement of spectral foci produced by LCA seems to be a fundamental aspect of the stimulus for "reflex" accommodation.