Search

Background The dural puncture epidural technique may improve analgesia quality by confirming midline placement and increasing intrathecal translocation of epidural medications. This would be advantageous in obese parturients with increased risk of block failure. This study hypothesizes that quality of labor analgesia will be improved with dural puncture epidural compared to standard epidural technique in obese parturients. Methods Term parturients with body mass index greater than or equal to 35 kg · m–2, cervical dilation of 2 to 7 cm, and pain score of greater than 4 (where 0 indicates no pain and 10 indicates the worst pain imaginable) were randomized to dural puncture epidural (using 25-gauge Whitacre needle) or standard epidural techniques. Analgesia was initiated with 15 ml of 0.1% ropivacaine with 2 µg · ml–1 fentanyl, followed by programed intermittent boluses (6 ml every 45 min), with patient-controlled epidural analgesia. Parturients were blinded to group allocation. The data were collected by blinded investigators every 3 min for 30 min and then every 2 h until delivery. The primary outcome was a composite of (1) asymmetrical block, (2) epidural top-ups, (3) catheter adjustments, (4) catheter replacement, and (5) failed conversion to regional anesthesia for cesarean delivery. Secondary outcomes included time to a pain score of 1 or less, sensory levels at 30 min, motor block, maximum pain score, patient-controlled epidural analgesia use, epidural medication consumption, duration of second stage of labor, delivery mode, fetal heart tones changes, Apgar scores, maternal adverse events, and satisfaction with analgesia. Results Of 141 parturients randomized, 66 per group were included in the analysis. There were no statistically or clinically significant differences between the dural puncture epidural and standard epidural groups in the primary composite outcome (34 of 66, 52% vs. 32 of 66, 49%; odds ratio, 1.1 [0.5 to 2.4]; P = 0.766), its individual components, or any of the secondary outcomes. Conclusions A lack of differences in quality of labor analgesia between the two techniques in this study does not support routine use of the dural puncture epidural technique in obese parturients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Optimizing analgesia after cesarean delivery is a priority and requires balancing adequate pain relief with the risk of analgesics-associated adverse effects. Current recommendations are for use of a multimodal, opioid-sparing analgesic regimen that includes neuraxial morphine combined with scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) and scheduled acetaminophen. Furthermore, recent studies recommend scheduled acetaminophen with as-needed opioids in lieu of acetaminophen-opioid combination drugs to reduce opioid consumption and optimize analgesia. However, the extent of utilization of this recommended regimen in the United States is unclear. We therefore performed this retrospective study to evaluate postoperative analgesic regimens utilized after cesarean delivery under neuraxial anesthesia, examine variability across institutions, evaluate changes over time in postoperative analgesic practice, and examine factors associated with the use of neuraxial morphine and of multimodal analgesia. Methods This retrospective cohort study was approved by the Duke University Institutional Review Board. Parturients who underwent cesarean delivery under neuraxial anesthesia from 2008 to 2018 were included. Data were extracted from a nationwide inpatient administrative-financial database (Premier Inc, Charlotte, NC) and included parturient characteristics, comorbidities, hospital characteristics, and charges for administered medications. The primary outcome was the postoperative analgesic regimen utilized during hospitalization, including utilization of neuraxial morphine and of multimodal analgesia for postoperative pain control. We also examined the factors associated with the use of neuraxial morphine and of the multimodal regimen incorporating neuraxial morphine, NSAIDs, and acetaminophen. Results Data from 804,752 parturients were analyzed. Of this cohort, 75.8% received neuraxial morphine, 93.2% received NSAIDs, 28.4% received acetaminophen, and 81.3% received acetaminophen-opioid combination drugs. Only 6.1% received the currently recommended regimen of neuraxial morphine with NSAIDs and acetaminophen, with this percentage increasing from 1.3% in 2008 to 15.0% in 2018. On the other hand, 58.9% received neuraxial morphine, NSAIDs, and an acetaminophen-opioid combination drug, with this regimen being utilized in 57.0% of cases in 2008 and 58.1% in 2018. The hospital in which the patient was treated accounted for 54.7% of the variation in receipt of neuraxial morphine and 41.2% in the variation in receipt of multimodal analgesia with neuraxial morphine, NSAIDs, and acetaminophen, with this variability in receipt of neuraxial morphine and of multimodal analgesia being largely independent of patient characteristics. Conclusions Relatively few parturients received the currently recommended multimodal analgesic regimen of neuraxial morphine with NSAIDs and acetaminophen after cesarean delivery. Additionally, the majority received acetaminophen-opioid combination drugs rather than plain acetaminophen. Further studies should investigate the implications for patient outcomes.

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA‐ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA‐ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48‐month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7‐day objective cardiac testing). Secondary outcomes were 30‐day objective cardiac testing, 60‐day major adverse cardiac events (MACE), and 60‐day MACE‐CR (MACE excluding coronary revascularization). Difference‐in‐differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30‐day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60‐day MACE risk (−2.5%, 95% CI −3.7 to −1.2%, P 2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P =0.014), without significant overall change (−1.0%, 95% CI −2.1 to 0.1%, P =0.079). There were no statistically significant differences in index visit resource utilization, 60‐day MACE or 60‐day MACE‐CR. Conclusions Implementation of RISTRA‐ACS was associated with better allocation of 30‐day objective cardiac testing and no change in index visit resource utilization or 60‐day MACE. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03286179.

Chaikhot, D, Reed, K, Petroongrad, W, Athanasiou, F, van Kooten, D, and Hettinga, FJ. Effects of an upper-body training program involving resistance exercise and high-intensity arm cranking on peak handcycling performance and wheelchair propulsion efficiency in able-bodied men. J Strength Cond Res 34(8): 2267-2275, 2020-The aim of this study was to determine the training effects of an upper-body training program involving resistance exercise and high-intensity arm cranking on peak handcycling performance, propulsion efficiency, and biomechanical characteristics of wheelchair propulsion in able-bodied men. The training group (n = 10) received a 4-week upper-body resistance training (RT), 70% of 1 repetition maximum, 3 sets of 10 repetitions, 8 exercise stations, 2 times per week, combined with high-intensity interval training (HIIT) 2 times per week. High-intensity interval training consisted of arm-crank exercise, 7 intervals of 2 minutes at 80-90% of peak heart rate (HRpeak) with 2-minute active rest at 50-60% of HRpeak. The control group (n = 10) received no training. Both groups performed a preincremental and postincremental handcycling test until volitional exhaustion to evaluate fitness and a 4-minute submaximal wheelchair propulsion test at comfortable speed (CS), 125 and 145% of CS, to evaluate gross mechanical efficiency (GE), fraction of effective force (FEF), percentage of peak oxygen consumption (% V[Combining Dot Above]O2peak), and propulsion characteristics. Repeated-measures analysis of variance was performed (p < 0.05). Training resulted in a 28.2 ± 16.5% increase in peak power output, 13.3 ± 7.5% increase in V[Combining Dot Above]O2peak, 5.6 ± 0.9% increase in HRpeak, and 3.8 ± 1.5% decrease in HRrest. No training effects on FEF, GE, % V[Combining Dot Above]O2peak, and push characteristics were identified. In conclusion, the combined RT and arm-cranking HIIT improved fitness. However, it seems that this training did not result in improvements in propulsion efficiency and push characteristics. Additional wheelchair skill training may be needed to fully benefit from this advantage in daily life propulsion.

Schoenmakers, PPJM, Crisell, JJ, and Reed, KE. Physiological and perceptual demands of running on a curved nonmotorized treadmill compared with running on a motorized treadmill set at different grades. J Strength Cond Res 34(5): 1197-1200, 2020-The current study compared the physiological and perceptual demands of running on a commercially available curved nonmotorized treadmill (cNMT) with different incline grades on a motorized treadmill (MT). Ten male team-sport athletes completed, after a familiarization session, a 6-minute run at a target velocity of 2.78 m·s on the cNMT (cNMTrun). The mean individual running velocity of cNMTrun was then used as warm-up and experimental running velocity in 3 subsequent visits, in which subjects ran for 6 minutes on the MT set at different grades (4, 6, or 8%). In all experimental trials (cNMTrun, 4MTrun, 6MTrun, and 8MTrun) and in the warm-up of the subjects' third visit (1MTrun), oxygen consumption (V[Combining Dot Above]O2) and heart rate (HR) were monitored, and ratings of perceived exertion (RPE) were obtained. The HR in cNMTrun was significantly higher compared with all MT trials. V[Combining Dot Above]O2 and RPE were significantly higher in cNMTrun compared with 1MTrun and 4MTrun, but not different from 6MTrun and 8MTrun. The relationship between V[Combining Dot Above]O2 and MT grades was highly linear (V[Combining Dot Above]O2 = 34.36 + 1.7 MT grade; r = 0.99), and using linear interpolation, the concave curved design of the cNMT was estimated to mimic a 6.9 ± 3% MT grade. On matched running velocities, V[Combining Dot Above]O2 and RPE responses while running on the cNMT are similar to a 6-8% MT grade. These findings can be used as a reference value by athletes and coaches in the planning of cNMT training sessions and amend running velocities accordingly. Future studies are needed to determine whether this estimate is similar for female runners, or those of a lower body mass.

Idiopathic guttate hypomelanosis (IGH) is a commonly acquired benign leukoderma characterized by multiple discrete, hypo- or depigmented macules often on extremities that can be aesthetically undesirable for patients. This is the first study using excimer laser for treatment.To determine the effectiveness of excimer laser for repigmentation of idiopathic guttate hypomelanosis.In this longitudinal, split-body controlled, single-blinded pilot study, 6 patients were treated with excimer laser for 12 weeks using the vitiligo protocol. Effectiveness was graded by the blinded observer scale through photographic comparisons at the end of the study. Participants also graded their progress at intervals during the study. A descriptive trend analysis and an ANOVA model were used to determine outcomes.Lesions that received the excimer treatment had significantly higher repigmentation by the end of the study compared with baseline and untreated lesions.Excimer laser treatments are already considered to be a safe modality for a variety of skin conditions. This study suggests that excimer is an effective treatment option with acceptable cosmetic outcomes for IGH.

Summary Background Raised blood pressure is an important risk factor for cardiovascular diseases and chronic kidney disease. We estimated worldwide trends in mean systolic and mean diastolic blood pressure, and the prevalence of, and number of people with, raised blood pressure, defined as systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher. Methods For this analysis, we pooled national, subnational, or community population-based studies that had measured blood pressure in adults aged 18 years and older. We used a Bayesian hierarchical model to estimate trends from 1975 to 2015 in mean systolic and mean diastolic blood pressure, and the prevalence of raised blood pressure for 200 countries. We calculated the contributions of changes in prevalence versus population growth and ageing to the increase in the number of adults with raised blood pressure. Findings We pooled 1479 studies that had measured the blood pressures of 19·1 million adults. Global age-standardised mean systolic blood pressure in 2015 was 127·0 mm Hg (95% credible interval 125·7–128·3) in men and 122·3 mm Hg (121·0–123·6) in women; age-standardised mean diastolic blood pressure was 78·7 mm Hg (77·9–79·5) for men and 76·7 mm Hg (75·9–77·6) for women. Global age-standardised prevalence of raised blood pressure was 24·1% (21·4–27·1) in men and 20·1% (17·8–22·5) in women in 2015. Mean systolic and mean diastolic blood pressure decreased substantially from 1975 to 2015 in high-income western and Asia Pacific countries, moving these countries from having some of the highest worldwide blood pressure in 1975 to the lowest in 2015. Mean blood pressure also decreased in women in central and eastern Europe, Latin America and the Caribbean, and, more recently, central Asia, Middle East, and north Africa, but the estimated trends in these super-regions had larger uncertainty than in high-income super-regions. By contrast, mean blood pressure might have increased in east and southeast Asia, south Asia, Oceania, and sub-Saharan Africa. In 2015, central and eastern Europe, sub-Saharan Africa, and south Asia had the highest blood pressure levels. Prevalence of raised blood pressure decreased in high-income and some middle-income countries; it remained unchanged elsewhere. The number of adults with raised blood pressure increased from 594 million in 1975 to 1·13 billion in 2015, with the increase largely in low-income and middle-income countries. The global increase in the number of adults with raised blood pressure is a net effect of increase due to population growth and ageing, and decrease due to declining age-specific prevalence. Interpretation During the past four decades, the highest worldwide blood pressure levels have shifted from high-income countries to low-income countries in south Asia and sub-Saharan Africa due to opposite trends, while blood pressure has been persistently high in central and eastern Europe. Funding Wellcome Trust.

Background Care for patients with chronic conditions often requires coordination between multiple physicians and delivery sites. Electronic Health Record (EHR) use could improve care quality and efficiency in part by facilitating care coordination. Objective We examined the association between EHR use and clinician perceptions of care coordination for patients transferred across clinicians and delivery sites. Research design Repeated surveys of primary care clinicians during the staggered implementation of an outpatient EHR (2005-2008), followed by an integrated inpatient EHR (2006-2010). We measured the association between EHR use stages (no use, outpatient EHR only, and integrated inpatient-outpatient EHR) and care coordination using logistic regression, adjusting for clinician characteristics, study year, and medical center. Subjects Adult primary care clinicians in a large Integrated Delivery System. Measures Three measures of clinician-reported care coordination for patient care transferred across clinicians (eg, from specialist to primary care team) and across delivery sites (eg, from the hospital to outpatient care). Results Outpatient EHR use was associated with higher reports of access to complete and timely clinical information and higher agreement on clinician roles and responsibilities for patients transferred across clinicians, but not for patients transferred across delivery sites. Use of the integrated outpatient-inpatient EHR was associated with higher reports of access to timely and complete clinical information, clinician agreement on the patient's treatment plan for patients transferred across delivery sites, and with all coordination measures for patients transferred across clinicians. Conclusion Use of an integrated EHR with health information exchange across delivery settings improved patient care coordination.

Employers are increasingly offering high-deductible health insurance plans with associated health savings accounts (HSAs), but there is limited information on account contributions or effects on patient care seeking.We examined HSA contributions and their source, patient-reported effects of costs on care seeking, and reports of financial burden.We conducted telephone interviews with 488 adult members of small group of employer-sponsored HSA-eligible plans within an integrated delivery system.HSA contribution sources and amounts varied with 32% receiving an employer contribution and also making their own employee contribution, 35% only receiving an employer contribution (no employee contribution), 19% only making their own contribution (no employer contribution), and 14% with no HSA contribution from either source. After adjustment for respondent characteristics, those who made their own HSA contributions in addition to their employer's contribution were significantly more likely to report that costs affected their care-seeking behavior, compared with those with only employer contributions (39% vs. 31% for emergency department and 60% vs. 49% for office visits, all P0.05). Respondents who contributed to their HSA or who paid out-of-pocket for care were significantly more likely to report financial burdens than those with only employer contributions (P0.05).The majority of consumers receive employer contributions to their HSA, but few have fully funded accounts. Those with only an employer contribution reported fewer changes in their care-seeking behavior and were less likely to report experiencing financial burdens.

To compare toxicities, disease control, and survival outcomes for patients treated with either cisplatin/irinotecan versus carboplatin/paclitaxel concurrent chemoradiotherapy for locally advanced esophageal cancer.Single-institution retrospective comparison between treatment groups: the cisplatin/irinotecan group was treated with 2 cycles of induction chemotherapy followed by concurrent chemoradiotherapy, whereas the carboplatin/paclitaxel group began with chemoradiotherapy followed by 2 additional cycles of chemotherapy. Acute toxicities, response rates, disease control, survival outcomes, and patterns of failure were compared between the groups.Between January 2000 and December 2007, 57 patients were identified for inclusion in the present study (38 cisplatin/irinotecan and 19 carboplatin/paclitaxel). Groups were well-balanced by clinical-, pathologic-, staging-, and treatment-related factors. Thirty-five patients (92%) in the cisplatin/irinotecan group and 18 patients (95%) in the carboplatin/paclitaxel group completed the concurrent phase of chemoradiotherapy. There were no significant differences in hematologic or nonhematologic toxicities between the groups. At a median survivor follow-up of 37.6 months (range: 7.3-59.3 months) for the entire population, 22 patients were alive (16 without evidence of disease). The 3-year overall survival estimates was 19.7% for the cisplatin/irinotecan group versus 56.1% for the carboplatin/paclitaxel group (P = 0.022). Estimated 3-year cancer-specific survivals were 24.6% for the cisplatin/irinotecan group versus 59.3% for the carboplatin/paclitaxel group (P = 0.033).Concurrent chemoradiotherapy with carboplatin/paclitaxel is well-tolerated and provided superior overall and disease-specific survival compared with cisplatin/irinotecan chemoradiotherapy in the present study population. Further investigation is warranted.

Background There has been much focus on factors influencing medical students' career choice, prompted by such concerns as a sufficient future surgical workforce, declining applicant pool, changing gender composition, and a cultural shift in values and priorities. Once in a surgical residency, there are little data on factors influencing general surgery (GS) residents' final specialty choice. Study Design A survey instrument was developed and content validated in conjunction with the Association of American Medical Colleges Center for Workforce Studies. The final instrument was distributed electronically between March 24 and May 2, 2008, through 251 GS program directors to all ACGME-accredited GS residents (n = 7,508). Results Response rate was 29% (2,153 residents; 89% programs). Half of GS residents remained undecided about specialty choice through the 2nd year, declining to 2% by year 5. Of the two-thirds who decided on a specialty, 16.5% chose to remain in GS, 14.6% chose plastics, 9.3% cardiothoracic, and 8.5% vascular. The specialty choice factors most likely to be very important were type of procedures and techniques, exposure to positive role model, and ability to balance work and personal life. Relative importance of factors in specialty choice varied by gender and chosen specialty. Mentors play a key role in specialty choice (66% decided had mentors versus 47% undecided). Work schedule was the most frequently selected shortcoming in every specialty except plastics. Cardiothoracic surgery followed by GS had the highest shortcomings. Conclusions The majority of GS residents plan to subspecialize. Three factors dominate specialty choice. Faculty need to understand their impact potential to modify or change perceptions of their specialty.

Using Worldwide Esophageal Cancer Collaboration data, we sought to (1) characterize the relationship between survival and extent of lymphadenectomy, and (2) from this, define optimum lymphadenectomy.What constitutes optimum lymphadenectomy to maximize survival is controversial because of variable goals, analytic methodology, and generalizability of the underpinning data.A total of 4627 patients who had esophagectomy alone for esophageal cancer were identified from the Worldwide Esophageal Cancer Collaboration database. Patient-specific risk-adjusted survival was estimated using random survival forests. Risk-adjusted 5-year survival was averaged for each number of lymph nodes resected and its relation to cancer characteristics explored. Optimum number of nodes that should be resected to maximize 5-year survival was determined by random forest multivariable regression.For pN0M0 moderately and poorly differentiated cancers, and all node-positive (pN+) cancers, 5-year survival improved with increasing extent of lymphadenectomy. In pN0M0 cancers, no optimum lymphadenectomy was defined for pTis; optimum lymphadenectomy was 10 to 12 nodes for pT1, 15 to 22 for pT2, and 31 to 42 for pT3/T4, depending on histopathologic cell type. In pN+M0 cancers and 1 to 6 nodes positive, optimum lymphadenectomy was 10 for pT1, 15 for pT2, and 29 to 50 for pT3/T4.Greater extent of lymphadenectomy was associated with increased survival for all patients with esophageal cancer except at the extremes (TisN0M0 andor=7 regional lymph nodes positive for cancer) and well-differentiated pN0M0 cancer. Maximum 5-year survival is modulated by T classification: resecting 10 nodes for pT1, 20 for pT2, andor=30 for pT3/T4 is recommended.

Objective— We hypothesize that controversial effects of angiotensin II (Ang II) are attributable to its regulation of reactive oxygen species (ROS) and ROS-dependent signaling. Methods and Results— Coronary collateral growth (CCG) was stimulated in normal (WKY) and syndrome X (JCR) rats by transient/repetitive ischemia (RI). Blood flow was measured in the normal (NZ) and the collateral-dependent (CZ) zone. In WKY, RI increased CZ flow (0.84 mL/min/g), but RI+subpressor Ang II increased it more (1.24 mL/min/g). This was associated with transient p38 and sustained Akt activation. A hypertensive dose of Ang II decreased CZ flow (0.69 mL/min/g), which was associated with sustained p38 and transient Akt activation. AT1R blockade by candesartan abrogated CZ flow in WKY (0.58 mL/min/g), reduced myocardial superoxide, and blocked p38 and Akt activation. RI-induced CZ flow in JCR was significantly decreased compared with WKY (0.12 mL/min/g), associated with a large increase in superoxide and lack of p38 and Akt activation. CZ flow in JCR was partially restored by candesartan (0.45 mL/min/g), accompanied by reduction in superoxide and partial restoration of p38 and Akt activation. Conclusion— Ang II/AT1R blockade, at least in part, regulates CCG via generating optimal ROS amounts and activating redox-sensitive signaling.

Faculty members who enter academe from the ranks of practicing health professionals, unlike those in some other disciplines, always have the option of leaving education and returning to professional practice in their individual disciplines. However, in order to facilitate a continuous supply of practitioners for society, a certain number of health professionals must choose careers in academe to teach new generations of health care providers. Satisfaction with educational careers translates into faculty retention and stability in academic programs. The purpose of this literature review was to examine what has been studied relating to faculty job satisfaction in higher education and, particularly, in academic medicine. It was hoped that this review would provide insight into the critical factors contributing to job satisfaction and faculty retention in physician assistant (PA) programs, as well as provide information that would assist PA program leadership in assessing those factors to preserve the often scarce but valuable resource of satisfied PA program faculty.

Patients are increasingly paying for more of their medical care through cost-sharing, yet little is known about how patients change the ways that they seek care in response.We sought to assess how patients change their care-seeking behavior in response to emergency department (ED) copayments.Telephone interviews with a stratified random sample of adult members of a large integrated delivery system.There were 932 respondents (72% response rate).We examined participants' knowledge of their copayment level for ED services, and measures of how the cost-sharing affected their decisions about where or when to seek care.Overall, 82% of participants faced a copayment for ED services (ranging between 5 US dollars and 100 US dollars), and 41% correctly reported the amount of this copayment. In response to the perceived copayment amount, 19% reported changing their care-seeking behavior within the previous 12 months: 12% sought care from an alternate delivery site, 12% contacted a provider by telephone or the Internet, 9% delayed going to the ED, and 2% avoided medical care altogether. In multivariate models, the ED cost-sharing amount was significantly associated with reporting changes in care-seeking behavior.When faced with an ED copayment, patients in the health system most commonly shifted toward seeking care from other available alternatives, and rarely avoid medical care altogether.

Background The use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients' knowledge of cost-sharing or its influence on behavior. Objective The objective of this study was to evaluate what patients know about their individual levels of cost-sharing and how it influences decisions to seek care. Study design We conducted a cross-sectional telephone survey with a 69% response rate. Subjects We studied a stratified random sample of 695 adult patients in an integrated delivery system: 266 subjects > or =65 years, 218 low-income subjects, and 211 subjects from the overall membership. Measures We used perceived and actual levels of copayments for emergency department (ED) visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes. Results One third of subjects correctly reported their ED copayment, whereas three fourths correctly reported their prescription drug and office visit copayments. Over half of the subjects (57%) underestimated their ED copayment by $20 or more. Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, ie, delayed or avoided emergency care. The perceived copayment level was strongly associated with behavior change (odds ratio, 3.9). Other significant factors included having more ED visits in the past 12 months and having a low health status. Conclusions Patients have less knowledge of their ED cost-sharing levels than for other services. The perceived copayment amount was strongly associated with avoidance of or delays in emergency care. Further research is needed to determine whether these responses reflect greater efficiency or harmful decisions.

This is a report of three cases of complete dislocation of both the radius and ulna at the elbow in infants born with obstetric palsy. All three patients had painless elbow-flexion contractures. The pathologic anatomy included (a) medial and posterior displacement of the radius and ulna on the humerus, (b) laxity of the lateral capsule and collateral ligaments, (c) contracted medial capsule and collateral ligaments, (d) contracted biceps and triceps muscles, and (e) hypoplasia of the capitellum, trochlea, coronoid process, and olecranon fossa. Open reduction was attempted in all three of these patients and was successful in two.

Zopolrestat is an aldose reductase inhibitor that may be useful in the treatment of diabetic complications by reducing flux through the polyol pathway. The plasma half-life of zopolrestat in man is approximately 30 h, and approximately 45% of an orally administered 1000-mg dose is eliminated in the urine as unchanged drug. Because active secretion accounts for much of the renal clearance for zopolrestat, a carboxylic acid with a pK(a) of 5.46, the effect of urinary pH and flow rate on renal clearance of drug was investigated in a series of studies. Renal clearance of zopolrestat following oral administration of 200 mg was determined in normal male volunteers under basal conditions and after treatment with NH(4)Cl and NaHCO(3) to alter urinary pH. Plasma concentrations of zopolrestat were similar under basal and NaHCO(3) treatment but were approximately twofold higher under NH(4)Cl treatment. However, the half-life of zopolrestat under NH(4)Cl treatment (29.5 h) was similar to the half-life of zopolrestat in untreated subjects. Renal clearance decreased by a factor of 2.54 for each unit decrease in urinary pH. In a second study, there was no effect of urine flow rate on renal clearance following an oral dose of 400 mg. Renal elimination of zopolrestat and zopolrestat glucuronide was also examined in volunteers with normal urine flow dosed at either 600 or 1000 mg/day. Whereas renal clearance of zopolrestat decreased with decreasing urinary pH, renal elimination of zopolrestat glucuronide was not affected by pH.

RATIONALE AND OBJECTIVES Detection of endocardial and epicardial borders of the left ventricle (LV) using various imaging modalities is time-consuming and prone to interpretive error. An automatic border detection algorithm is presented that is used with ultrafast computed tomographic images of the heart to compute cavity volumes. METHODS The basal-level slice is identified, and the algorithm automatically detects the endocardial and epicardial borders of images from the basal to the apical levels. From these, the ventricular areas and chamber volumes are computed. The algorithm uses the Fuzzy Hough Transform, region-growing schemes, and optimal border-detection techniques. The cross-sectional areas and the chamber volumes computed with this technique were compared with those from manually traced images using canine hearts in vitro (n = 8) and studies in clinical patients (n = 27). RESULTS Though the correlation was good (r = .88), the algorithm overestimated the LV epicardial area by 4.8 +/- 6.4 cm2, though this error was not statistically different from zero (P > .05). There was no difference in endocardial areas (r = .95, P > .05). The algorithm tended to underestimate the end-diastolic volume (r = .94) and the end-systolic volume (r = .94), although these errors were not statistically different from zero (P > .05). The algorithm tended to underestimate the ejection fraction (r = .80), although this error was not statistically different from zero (P > .05). CONCLUSIONS Automatic detection of myocardial borders provides the clinician with a useful tool for calculating chamber volumes and ejection fractions. The algorithm, with the corrections suggested, provides an accurate estimation of areas and volumes. This algorithm may be useful for contour border identification with ultrasound, positron-emission tomography, magnetic resonance imaging, and other imaging modalities in the heart, as well as other structures.

To promote clinical scholarship, critical thinking, problem-solving ability, and effective writing and research skills in their students, faculty replaced their major care plan with a capstone scholarly paper. The authors discuss how faculty, who serve as mentors, guide their students through the development of the scholarly paper.

Background:Hypertension is the leading preventable cause of premature death worldwide.Objective:We estimated the prevalence, awareness, treatment and control of hypertension worldwide in 2010 and compared the global burden of hypertension in 2000 and 2010.Method:We searched MEDLINE for published rep

BACKGROUND Our laboratory reported a greater increase in bone mineral at the femoral neck (4.6%) and at the lumbar spine (3.7%) following a 20 month intervention (10 min, 3x/week) in intervention girls compared with controls. Whether this increase is maintained following withdrawal of the targeted exercise stimulus is uncertain. PURPOSE To determine whether the bone mineral accrual advantage is maintained one year after cessation of the program. METHODS A subset of girls (11.8 p 0.49yrs, n = 23 intervention (Int), 30 control (Con)) from the original Healthy Bones II Study (n = 191), were re-assessed one year after withdrawal of the high impact, circuit intervention. All children performed regular activities and PE following withdrawal of the program. We evaluated bone mineral content (g) at the femoral neck (FN) and lumbar spine (LS) with DXA (Hologic QDR 4500). We assessed height (cm), weight (kg) and Tanner staging with standard techniques. Physical activity and calcium intake were assessed by questionnaire. The primary outcome measures were 12 month adjusted change in BMC (g) and percent change. Data were analysed using ANCOVA, adjusting for '20 month' (end of intervention) bone mineral and height, height change, final Tanner stage and physical activity. RESULTS Girls previously in Int and Con groups were similar for height (152.9 p 7.9 cm), weight (46.7 p 10.4kg) and maturity (81% in Tanner stage 2/3) and were performing similar amounts of physical activity at 20 months. Change in these variables over the follow-up period were similar between groups. Results of ANCOVA showed no difference between groups for adjusted change in BMC (g) during the follow up year at either the LS (Int = 6.7, Con = 6.1 NS) or the FN (Int = 19.1 Con = 17.7 NS). There was also no difference between groups in percent change BMC at the LS (Int = 0.21 Con = 0.14 NS) or FN (Int = 6.1 Con = 4.5 NS). CONCLUSION The benefits of a 20 month intervention are not maintained one year after removal of the stimulus in this cohort. Exercise must be maintained if bone mineral accural benefits are to remain.n

The growing interest in coronary calcium quantification by electron-beam CT (EBCT) has led to the development of various software systems for the analysis of EBCT raw data, but it is unknown whether these software systems yield comparable results.Two sets of EBCT scans were obtained in 73 asymptomatic patients less than 15 minutes apart. Both scans of each patient were analyzed using two different software systems, the Mayo Clinic software and the AccuImage Scoring System. The authors compared the calcium quantities yielded by the two different software systems, analyzed the interscan variability, and calculated the interobserver variability. Finally, they investigated the influence of the CT density factor inherent in the widely used Agatston score for the quantification of coronary calcium on reproducibility.The mean score determined by the Mayo Clinic software was 14% greater than that determined by the AccuImage system. The mean difference between the two systems was 14% +/- 25%, and the median difference was 3%. The relative mean and the median difference between the two scans of one patient were 15.3% and 6% determined by the AccuImage system and 17% and 6.5% determined by the Mayo Clinic software. The interobserver reliability calculated by the Mayo Clinic software was better than that of the AccuImage system. There was a trend for better reproducibility using calcium area rather than the Agatson score.Two different scoring systems do not necessarily yield the same result. Calcium quantities were systematically determined to be greater by one system than the other, and there were significant differences with regard to interobserver reliability. Hence, software should be tested with regard to reproducibility data, and the interpretation of calcium quantities should acknowledge which type of software was used.

The effects of mannitol on the spinal cord blood flow patterns in experimental traumatic paraplegia were correlated with microangiographic and electrophysiologic studies. At 1 hour following a therapeutic dose of mannitol (3 g/kg), an improved fluorescent intramedullary vascular pattern was detected among the mannitol-treated animals relative to those that were not treated. Within 4 hours, perfusion of many areas of the lateral white matter of the spinal cord often approximated normal in the mannitol-treated group. This pattern of perfusion was in striking contrast to that seen in the spinal cord of untreated animals, which displayed an almost total lack of fluorescing vessels at this later time. These findings correlated with an increased vascular caliber as revealed by microangiography and were postulated to be the result of a decrease in vasospasm and an expanded intramedullary blood volume following the administration of mannitol. Although mannitol therapy did not reverse the loss of the cortical evoked response observed during the 4-hour interval studied, the observation of improved blood flow patterns in the white matter is encouraging and warrants further study.