Search

Objective: The Enduring Consensus Cervical Cancer Screening and Management Guidelines Committee developed recommendations for the use of extended genotyping results in cervical cancer prevention programs., Methods: Risks of cervical intraepithelial neoplasia grade 3 or worse were calculated using data obtained with the Onclarity HPV Assay from large cohorts. Management recommendations were based on clinical action thresholds developed for the 2019 American Society for Colposcopy and Cervical Pathology Risk-Based Management Consensus Guidelines. Risk estimates were reviewed in relation to clinical action thresholds and used as the basis for draft recommendations. After an open comment period, recommendations were finalized and ratified through a vote by the Consensus Stakeholder Group., Results: Colposcopy is recommended after positive tests for human papillomavirus (HPV) types 16 and 18. For those positive for HPV 45, 33/58, 31, 52, 35/39/68, or 51 but negative for 16 or 18, triage with cytology or dual stain testing is recommended. When screening with primary HPV testing, for patients who test positive for HPV types 56/59/66 and no other carcinogenic types, repeat HPV testing in 1 year is recommended. When screening with cotesting, for those who test positive for HPV types 56/59/66 and no other carcinogenic types, 1-year return is recommended for negative for intraepithelial lesion or malignancy, atypical squamous cells of undetermined significance, and low-grade squamous intraepithelial lesion, and colposcopy is recommended for atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H), atypical glandular cells, high-grade squamous intraepithelial lesion, or carcinoma. When patients without prior high-grade cytology (atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion, atypical glandular cells, high-grade squamous intraepithelial lesion, or carcinoma) or histology (cervical intraepithelial neoplasia [CIN]2, CIN3, or adenocarcinoma in situ) are being followed, use of extended genotyping results is acceptable. When high-grade cytology or histology results are present, or when patients are being followed after treatment of CIN2+, management using the 2019 guidelines is recommended., Conclusions: Human papillomavirus extended genotyping can guide clinical management in the setting of a positive HPV test result., Competing Interests: L.S.M. participated in an HPV vaccine call with Merck. N.B. has served on an advisory board for Merck. D.C. is a member of the United States Preventive Services Task Force (USPSTF); this article does not necessarily represent the views and policies of the USPSTF. D.C. was recused from development of recommendations related to screening and fully participated in recommendations related to diagnosis and management. M.E. has served as a consultant for Papivax, Merck, BD, PDS. R.G. has served as a consultant for Inovio. D.H. has served as a consultant for Roche. W.H. has served as a consultant for Roche, SeeGene, and AstraZeneca. R.N. has participated in an educational meeting supported by Roche. M.C. reports legal work for Merck. The other authors have declared they have no conflicts of interest., (Copyright © 2025, ASCCP.)

This article is the fourth in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This article is the third in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This article is the second in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This article is the first in a new series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this new series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by the John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Guide to the 4Ms of an Age-Friendly Health System for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The American Society of Plastic Surgeons commissioned the Autologous Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing autologous breast reconstruction and other breast reconstruction surgery. Four outcome measures and one process measure were identified. Outcomes include patient satisfaction with information for all breast reconstruction, a subscale of the BREAST-Q, and the length of stay, operative time, and rate of blood transfusion for autologous blood transfusion. The process measure looks at coordination of care around managing the breast reconstruction patient's care, with the physician coordinating the ongoing care, be it an oncologist, radiologist, other specialist, or primary care physician. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, continuing medical education, maintenance of certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality-reporting programs.

Objective: The aim of this study was to conduct a cross-sectional assessment of the adoption of Total Worker Health (TWH) policies and practices by business size and evaluate extent and alignment of their safety and health., Methods: We conducted an analysis of 382 businesses that completed the Health Links Assessment. We measured organizational adoption of TWH across six benchmarks: organizational supports, workplace assessments, health policies and programs, safety, engagement, and evaluation., Results: Benchmark scores were significantly associated with business size. Larger businesses were more likely to score higher across each benchmark., Conclusion: Small businesses are implementing TWH in a variety of ways and the level of implementation differs by business size. Practical interventions as well as dissemination and implementation research should take business size into account to ensure that TWH is both effective and sustainable in meeting the needs of employees.

Objectives: To determine the risk and risk factors for mental illness among colorectal cancer (CRC) survivors across short-term and long-term follow-up periods., Methods: We used the Utah Cancer Registry to identify CRC survivors diagnosed between 1997 and 2013. Mental health diagnoses were available in electronic medical records and statewide facilities data that were linked by the Utah Population Database. CRC survivors were matched to individuals from a general population cohort. The risk of developing a mental illness was compared between cohorts. The association between mental illness and mortality was also analyzed., Results: In total, 8961 CRC survivors and 35,897 individuals in a general population cohort were identified. CRC survivors were at increased risk for any mental health diagnosis at 0 to 2 years (hazard ratio [HR], 3.70; 95% confidence interval [CI], 3.47-3.95), >2 to 5 years (HR, 1.23; 95% CI, 1.09-1.38), and >5 years (HR, 1.20; 95% CI, 1.07-1.36) after cancer diagnosis. CRC survivors were also at increased risk of depressive disorders specifically during the same time periods. At >5 years, CRC survivors still had an increased risk of developing many mental health diagnoses. Factors associated with increased risk of any mental health disorder among CRC survivors included colostomy and Charlson Comorbidity Index of 1+. There was an increased risk of death for CRC survivors diagnosed with any mental health disorder (HR, 2.18; 95% CI, 2.02-2.35) and depression (HR, 2.10; 95% CI, 1.92-2.28)., Conclusions: CRC survivors are at increased risk for mental health disorders in the short-term and long-term. Survivors who develop mental health disorders also experience decreased survival.

In a previous study, individuals from a single Traumatic Brain Injury Model Systems and trauma center were matched using a novel probabilistic matching algorithm. The Traumatic Brain Injury Model Systems is a multicenter prospective cohort study containing more than 14,000 participants with traumatic brain injury, following them from inpatient rehabilitation to the community over the remainder of their lifetime. The National Trauma Databank is the largest aggregation of trauma data in the United States, including more than 6 million records. Linking these two databases offers a broad range of opportunities to explore research questions not otherwise possible. Our objective was to refine and validate the previous protocol at another independent center. An algorithm generation and validation data set were created, and potential matches were blocked by age, sex, and year of injury; total probabilistic weight was calculated based on of 12 common data fields. Validity metrics were calculated using a minimum probabilistic weight of 3. The positive predictive value was 98.2% and 97.4% and sensitivity was 74.1% and 76.3%, in the algorithm generation and validation set, respectively. These metrics were similar to the previous study. Future work will apply the refined probabilistic matching algorithm to the Traumatic Brain Injury Model Systems and the National Trauma Databank to generate a merged data set for clinical traumatic brain injury research use.

In 2014 the Papanicolaou Society of Cytopathology (PSC) published a system of standardised terminology and nomenclature for pancreaticobiliary cytology (STNPC). In the present study, 232 previously reported pancreaticobiliary cytology specimens were categorised according to this set of guidelines in order to identify potential challenges to implementation of the PSC system into routine practice. Overall, 207 (89%) of the cases were found to comply with the PSC scheme in their original form. Twenty-five cases (11%) demonstrated that the application of the PSC system would result in a change of category. In the majority of these cases, the change was related to the method of categorising low grade and premalignant neoplasms, using the categories of 'Neoplastic: other' (a new category unique to STNPC classification scheme) and 'Atypical', for specimens deemed to be diagnostic of or suspicious for these lesions, respectively. The study also highlighted the emphasis on the inclusion of imaging context and cyst fluid analysis in the interpretation of endoscopic ultrasound guided fine needle aspiration specimens in the guidelines. The STNPC offers an approach to pancreaticobiliary cytology that reflects the considerable variation in the nature and treatment of the entities that may be encountered in these specimens. Challenges in utilisation of the scheme include awareness of the unique approach to the categorisation of premalignant and low grade neoplasms, and the amount and quality of available clinical and imaging information., (Crown Copyright © 2016. Published by Elsevier B.V. All rights reserved.)

The aim of this study was to establish a scoring method for ploidy analysis using silver in situ hybridisation (SISH) with a chromosome 17 centromere probe. SISH was performed using the Ventana chromosome 17 centromere probe on sections from formalin fixed, paraffin embedded archival cases of complete hydatidiform moles, partial hydatidiform moles and hydropic products of conception with previously established ploidy status (determined by flow cytometry or karyotyping). In order to determine ploidy status, a scoring method was developed based on both the average number of signals per nucleus (ASN) and the percentage of nuclei with three signals (N3S), enumerated in 50 villous cytotrophoblastic and/or stromal cells. The results of four independent observers were compared individually and collectively with previously established ploidy status. There was a highly statistically significant difference between diploid and triploid gestations for ASN (1.86 ± 0.13 and 2.70 ± 0.16 respectively, Student t-test, p < 0.0001) and for N3S (1.14 ± 1.65 and 71.59 ± 14.25 respectively, Student t-test, p < 0.0001). The sensitivity and specificity of the SISH-based assay was 99.1% and 100% respectively for ASN, and 100% and 100% respectively for N3S. A chromosome 17 centromere probe SISH-based assay can reliably distinguish between diploid and triploid gestations. This test has diagnostic utility in distinguishing partial hydatidiform moles from histological mimics.

Objective: To measure the impact of a national propofol shortage on the duration of mechanical ventilation., Design: Before-after study., Setting: Three, noncardiac surgery, adult intensive care units at a 320-bed academic medical center., Patients: Consecutive patients requiring mechanical ventilation ≥48 hrs, administered a continuously infused sedative ≥24 hrs, extubated, and successfully discharged from the intensive care unit were compared between before (December 1, 2008 to May 31, 2009) and after (December 1, 2009, to May 31, 2010) a propofol shortage., Intervention: None., Measurements and Main Results: Sedation drug use and common factors affecting time on mechanical ventilation were collected and if found either to differ significantly (p ≤ .10) between the two groups or to have an unadjusted significant association (p ≤ .10) with time on mechanical ventilation were included in a multivariable model. The unadjusted analyses revealed that the median (interquartile range) duration of mechanical ventilation increased from 6.7 (9.8; n = 153) to 9.6 (9.5; n = 128) days (p = .02). Fewer after-group patients received ≥24 hrs of continuously infused propofol (94% vs. 15%, p < .0001); more received ≥24 hrs of continuously infused lorazepam (7% vs. 15%, p = .037) and midazolam (30% vs. 81%, p < .0001). Compared with the before group, the after group was younger, had a higher admission Acute Physiology and Chronic Health Evaluation II score, was more likely to be admitted by a surgical service, have acute alcohol withdrawal, and be managed with pressure-controlled ventilation as the primary mode of mechanical ventilation. Of these five factors, only the Acute Physiology and Chronic Health Evaluation II score, admission service, and use of a pressure-controlled ventilation affected duration of mechanical ventilation across both groups. Although a regression model revealed that Acute Physiology and Chronic Health Evaluation II score (p < .0001), admission by a medical service (p = .009), and use of pressure-controlled ventilation (p = .02) each affected duration of mechanical ventilation in both groups, inclusion in either the before- or after-propofol shortage groups (i.e., high vs. low use of propofol) did not affect duration of mechanical ventilation (p = .35)., Conclusions: An 84% decrease in propofol use in the adult intensive care units at our academic institution as a result of a national shortage did not affect duration of mechanical ventilation.

Background: Few data support an association between blood pressure variability and clinical outcomes during cardiac surgery. We tested the hypothesis that intraoperative systolic blood pressure variability outside a targeted blood pressure range predicts 30-day mortality in patients undergoing cardiac surgery., Methods: Electronically captured blood pressure data from 7,504 consecutive coronary bypass surgery procedures between September 1, 1996, and December 31, 2005, were divided into development and validation cohorts. Systolic blood pressure variability episodes outside a blood pressure range (e.g., higher than 135 or lower than 95 mmHg) were characterized by number of episodes, magnitude of episode, duration of episode, and magnitude x duration of excursion (i.e., area under the curve). Multiple logistic regression analysis was used to assess 30-day mortality association. The most predictive mortality risk characteristic and blood pressure range was tested in the validation cohort., Results: A total of 3.1 million intraoperative blood pressure evaluations were analyzed. Systolic blood pressure variability was derived in 5,038 patients and validated in 2,466 patients (8% without cardiopulmonary bypass and 6% with valve procedure). Among all tested indices of blood pressure variability, mean duration of systolic excursion (outside a range of 105-130 mmHg) was most predictive of 30-day mortality (odds ratio = 1.03 per minute, 95% CI 1.02-1.39, P < 0.0001)., Conclusions: Intraoperative blood pressure variability is associated with 30-day postoperative mortality in patients undergoing aortocoronary bypass surgery.

Background: Symmastia is a rare but challenging problem to correct. A number of techniques have been proposed, but each has drawbacks in terms of reliability, accuracy, and difficulty. A recently described technique to treat subpectoral symmastia is reported whereby a new pocket is created between the deep surface of the pectoralis major muscle and the anterior surface of the periprosthetic capsule, the boundaries of which are limited by the adherence between the capsule and overlying tissue. The "neosubpectoral" pocket is therefore not a "repair" of the excessively medialized symmastia pocket, but is a new pocket, limited at its perimeter by the patient's own tissues rather than by sutures or a patch., Methods: A precise neosubpectoral plane is developed between the pectoralis major and the anterior implant capsule wall, with dissection limited to creating only the space necessary for proper placement of the implant. The technical details of this procedure are described. A chart review was conducted of all patients who underwent symmastia correction using this technique since December of 2003 at Georgetown University Hospital in the practices of Steven Teitelbaum, M.D., and G. Patrick Maxwell, M.D., Results: A total of 23 patients underwent symmastia correction using the neosubpectoral technique. Several of these patients presented for recurrence after failed capsulorrhaphy. There has been no recurrence of symmastia to date in this study. The average follow-up was 22 months. One postoperative hematoma and one seroma occurred. One patient had uncorrected, underdiagnosed inferior malposition from an earlier procedure requiring revision., Conclusions: The neosubpectoral technique is a method for the correction of symmastia that may offer a more efficient, accurate, and effective solution in a single stage. It is an appealing concept that allows for a site change while maintaining the subpectoral position. This procedure is technically straightforward and may offer a reliable means of correcting many other forms of implant malposition and difficult reconstructions.

Administrators at 5 schools of nursing who implemented a progression policy based on HESI Exit Examtrade mark scores were interviewed regarding their NCLEX-RN pass rates before and after initiating the policy and methods used for remediation. Even though the methods used for remediation were quite different among the participating schools, data obtained from these interviews indicated that the schools' NCLEX-RN pass rates improved 9-41% within 2 years after implementing the progression policies.

This follow-up study compares the accuracy of the HESI Exit Exam (E) in predicting NCLEX success for the academic years 1996-97 (N = 2,809) and 1997-98 (N = 3,752) and is designed to replicate the study of Lauchner et al and to implement recommendations suggested by the authors for further research. The E was again found to be highly predictive of licensure success, regardless of the type of program tested: associate degree, baccalaureate degree, diploma, or practical nurse programs. The predictive accuracy of the E was 98.27% for the RN group and 99.34% for the PN group. The E was again found to be significantly more accurate when administration of the exam was monitored than when it was not monitored (P = 0.05). In the 1997-98 academic year, NCLEX success of low-scoring E students was examined. Significantly more (P = 0.001) of the low-scoring E students failed the licensure exam than high-scoring E students. However, significantly fewer (p = 0.05) of these low-scoring E students failed the licensing exam when the E was used as a benchmark or guide for remediation.

This study was designed to determine the accuracy of computerized comprehensive nursing exams, HESI Exit Exams (Es), in predicting registered nurse and practical nurse students' success on the licensing exam. Schools of nursing that administered Es during the academic year 1996-97 were surveyed to determine how many students (n = 2809) predicted by the E to pass the licensure exam had failed, and if the exam administration was monitored or proctored. Based on the findings of this study, the E was determined to be an accurate predictor of students' success on the licensing exam. However, it was significantly more accurate (P = .05) when the exam was monitored (99.49%) than unmonitored (96.82%). The E was determined to be highly predictive of students' success on the licensing exam for all groups tested: associate degree, baccalaureate, diploma, and practical nursing students.

Objective: To characterize the magnitude and course of alterations in total and free lamotrigine (LTG) clearance (Cl) during pregnancy and the postpartum period, to assess the impact of therapeutic drug monitoring (TDM) on seizure frequency, to determine the ratio to individual target LTG concentration that is associated with increased seizure risk, and to evaluate maternal postpartum toxicity., Methods: A cohort of women were enrolled before conception or during pregnancy in this prospective, observational study. Visits occurred every 1 to 3 months with review of seizure and medication diaries, examination, and blood sampling. Total and free LTG Cls were calculated. Individualized target concentrations were used for TDM. The ratio to target concentration (RTC) was compared between patients with and without increased seizures. A receiver operating characteristic curve determined the threshold RTC that best predicts increased seizure frequency., Results: Analysis of 305 samples in 53 pregnancies demonstrated increased total and free LTG Cl in all trimesters above nonpregnant baseline (p < 0.001), with peak increases of 94% and 89% in the third trimester. Free LTG Cl was higher in white compared with black women (p < 0.05). Increased seizure frequency (n = 36 women with epilepsy) in the second trimester was associated with a lower RTC (p < 0.001), and RTC < 0.65 was a significant predictor of seizure worsening. An empiric postpartum taper reduced the likelihood of maternal LTG toxicity (p < 0.05) (n = 27). Newborn outcomes were similar to the general population (n = 52)., Conclusions: These novel data contribute to a rational treatment plan and dosing paradigm for lamotrigine use during pregnancy, parturition, and the postpartum period.

This follow-up study compares the accuracy of the HESI Exit Exam (E2) in predicting NCLEX success for the academic years 1996-97 (N = 2,809) and 1997-98 (N = 3,752) and is designed to replicate the study of Lauchner et a1l and to implement recommendations suggested by the authors for further research. The E2 was again found to be highly predictive of licensure success, regardless of the type of program tested: associate degree, baccalaureate degree, diploma, or practical nurse programs. The predictive accuracy of the E2-was 98.27% for the RN group and 99.34% for the PN group. The E2 was again found to be significantly more accurate when administration of the exam was monitored than when it was not monitored (P = 0.05). In the 1997-98 academic year, NCLEX success of low-scoring E2 students was examined. Significantly more (P = 0.001) of the low-scoring E2 students failed the licensure exam than high-scoring E2 students. However, significantly fewer (p = 0.05) of these low-scoring E2 students failed the licensing exam when the E2 was used as a benchmark or guide for remediation.

This study was designed to determine the accuracy of computerized comprehensive nursing exams, HESI Exit Exams (E2s), in predicting registered nurse and practical nurse students' success on the licensing exam. Schools of nursing that administered Els during the academic year 1996-97 were surveyed to determine how many students (n = 2809) predicted by the E2 to pass the licensure exam had failed, and if the exam administration was monitored or proctored. Based on the findings of this study, the E2 was determined to be an accurate-predictor of students' success on the licensing exam. However, it was significantly more accurate (P = .05) when the exam was monitored (99.49%) than unmonitored (96.82%}. The E2 was determined to be highly predictive of students' success on the licensing exam for all groups tested: associate degree, baccalaureate, diploma, and practical nursing students.

Administrators at 5 schools of nursing who implemented a progression policy based on HESI Exit Exam scores were interviewed regarding their NCLEX-RN pass rates before and after initiating the policy and methods used for remediation. Even though the methods used for remediation were quite different among the participating schools, data obtained from these interviews indicated that the schools' NCLEX-RN pass rates improved 9-41% within 2 years after implementing the progression policies.

Administrators at 5 schools of nursing who implemented a progression policy based on HESI Exit Exam scores were interviewed regarding their NCLEX-RN pass rates before and after initiating the policy and methods used for remediation. Even though the methods used for remediation were quite different among the participating schools, data obtained from these interviews indicated that the schools' NCLEX-RN pass rates improved 9-41% within 2 years after implementing the progression policies.

This follow-up study compares the accuracy of the HESI Exit Exam (E2) in predicting NCLEX success for the academic years 1996-97 (N = 2,809) and 1997-98 (N = 3,752) and is designed to replicate the study of Lauchner et al. and to implement recommendations suggested by the authors for further research. The E2 was again found to be highly predictive of licensure success, regardless of the type of program tested: associate degree, baccalaureate degree, diploma, or practical nurse programs. The predictive accuracy of the E2 was 98.27% for the RN group and 99.34% for the PN group. The E2 was again found to be significantly more accurate when administration of the exam was monitored than when it was not monitored (P = 0.05). In the 1997-98 academic year, NCLEX success of low-scoring E2 students was examined. Significantly more (P = 0.001) of the low-scoring E2 students failed the licensure exam than high-scoring E2 students. However, significantly fewer (p = 0.05) of these low-scoring E2 students failed the licensing exam when the E2 was used as a benchmark or guide for remediation.

This study was designed to determine the accuracy of computerized comprehensive nursing exams, HESI Exit Exams (E2s), in predicting registered nurse and practical nurse students success on the licensing exam. Schools of nursing that administered E2s during the academic year 1996-97 were surveyed to determine how many students (n = 2809) predicted by the E2 to pass the licensure exam had failed, and if the exam administration was monitored or proctored. Based on the findings of this study, the E2 was determined to be an accurate predictor of students' success on the licensing exam. However, it was significantly more accurate (P = .05) when the exam was monitored (99.49%) than unmonitored (96.82%). The E2 was determined to be highly predictive of students' success on the licensing exam for all groups tested: associate degree, baccalaureate, diploma, and practical nursing students.

This article reviews the outcome of 23 consecutive patients who developed pseudarthrosis after anterior cervical fusion surgery. Sixteen of the 23 patients failed to achieve significant relief of their symptoms (69.6%). These 16 had a second fusion procedure. Thirteen of this same 16 obtained a fusion, and 9 of these (69.2%) converted to an excellent or good result. These findings support the thesis that solid arthrodesis is important to a successful outcome of anterior cervical fusion procedures.

Although much has been learned about cerebral physiology during CPB in the past decade, the role of alterations in CBF and CMRO2 during CPB and the unfortunately common occurrence of neuropsychologic injury still is understood incompletely. It is apparent that during CPB temperature, anesthetic depth, CMRO2, and PaCO2 are the major factors that effect CBF. The systemic pressure, pump flow, and flow character (pulsatile versus nonpulsatile) have little influence on CBF within the bounds of usual clinical practice. Although cerebral autoregulation is characteristically preserved during CPB, untreated hypertension, profound hypothermia, pH-stat blood gas management, diabetes, and certain neurologic disorders may impair this important link between cerebral blood flow nutrient supply and metabolic demand (Figure 5). During stable moderate hypothermic CPB with alpha-stat management of arterial blood gases, hypothermia is the most important factor altering cerebral metabolic parameters. Autoregulation is intact and CBF follows cerebral metabolism. Despite wide variations in perfusion flow and systemic arterial pressure, CBF is unchanged. Populations of patients have been identified with altered cerebral autoregulation. To what degree the impairment of cerebral autoregulation contributes to postoperative neuropsychologic dysfunction is unknown. It must be emphasized that not the absolute level of CBF, but the appropriateness of oxygen delivery to demand is paramount. However, the assumption that the control of cerebral oxygen and nutrient supply and demand will prevent neurologic injury during CPB is simplistic. A better understanding of CBF, CMRO2, autoregulation and mechanism(s) of cerebral injury during CPB has lead to a scientific basis for many of the decisions made regarding extracorporeal perfusion.

We tested the hypothesis that insulin-dependent diabetic patients with coronary artery bypass graft surgery experience altered coupling of cerebral blood flow and oxygen consumption. In a study of 23 patients (11 diabetics and 12 age-matched controls), cerebral blood flow was measured using 133Xe clearance during nonpulsatile, alpha-stat blood gas managed cardiopulmonary bypass at the conditions of hypothermia and normothermia. In diabetic patients, the cerebral blood flow at 26.6 +/- 2.42 degrees C was 25.3 +/- 14.34 ml/100 g/min and at 36.9 +/- 0.58 degrees C it was 27.3 +/- 7.40 ml/100 g/min (p = NS). The control patients increased cerebral blood flow from 20.7 +/- 6.78 ml/100 g/min at 28.4 +/- 2.81 degrees C to 37.6 +/- 8.81 ml/100 g/min at 36.5 +/- 0.45 degrees C (p less than or equal to 0.005). The oxygen consumption was calculated from jugular bulb effluent and increased from hypothermic values of 0.52 +/- 0.20 ml/100 g/min in diabetics to 1.26 +/- 0.28 ml/100 g/min (p = 0.001) at normothermia and rose from 0.60 +/- 0.27 to 1.49 +/- 0.35 ml/100 g/min (p = 0.0005) in the controls. Thus, despite temperature-mediated changes in oxygen consumption, diabetic patients did not increase cerebral blood flow as metabolism increased. Arteriovenous oxygen saturation gradients and oxygen extraction across the brain were calculated from arterial and jugular bulb blood samples. The increase in arteriovenous oxygen difference between temperature conditions in diabetic patients and controls was significantly different (p = 0.01). These data reveal that diabetic patients lose cerebral autoregulation during cardiopulmonary bypass and compensate for an imbalance in adequate oxygen delivery by increasing oxygen extraction.