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Objective: To assess whether bioimpedance spectroscopy analysis (BIA) can be used as a tool to guide postoperative fluid management in patients undergoing cardiac surgery., Design: An observational study., Setting: A single tertiary hospital., Participants: Patients who underwent cardiac surgery with cardiopulmonary bypass between June and November 2023 who were able to undergo BIA measurements., Interventions: None., Measurements and Main Results: Correlations between BIA measurements of extracellular fluid (ECF) and total body water (TBW) volumes and daily changes in weight and 24-hour net intake and output (I/O) of fluids were assessed. Correlations between predischarge ECF volume as a percentage of TBW volume (ECF%TBW) and predischarge pro-B-type natriuretic peptide (Pro-BNP) levels and readmissions were analyzed. Changes in daily ECF volume significantly correlated with daily weight changes (p < 0.01) and 24-hour I/O (p < 0 .01). TBW volume significantly correlated with daily weight changes (p < 0.01) and with 24-hour I/O (p = 0.04). Daily weight changes did not correlate with 24-hour I/O (p = 0.06). The patients with predischarge ECF%TBW(%) greater than or equal to 51 had significantly higher predischarge Pro-BNP than those with ECF%TBW(%) less than 51 (p < 0.01). Patients who had heart failure revisits or admissions after discharge had a higher predischarge ECF%TBW(%) on index admission compared with patients who did not have heart failure readmissions (p = 0.01)., Conclusions: BIA measurements in postoperative cardiac surgery patients may be a valuable tool to quantitatively determine fluid status to help guide fluid management in this patient population. Further studies validating the use of BIA for postoperative care in this population are warranted., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Rationale & Objective: Animal models of kidney disease suggest a protective role for female sex hormones but in humans, some authorities assert that female sex is a risk factor for acute kidney injury (AKI). To better understand the risk of AKI, we studied the strength of association between sex and AKI incidence in hormonally distinct age groups across the life span., Study Design: Prospective cohort study., Settings & Participants: All patients hospitalized in the Montefiore Health System between 10/15/2015 and 1/1/2019, excluding those with kidney failure or obstetrics diagnoses., Exposure: Male versus female sex., Outcomes: Acute kidney injury (AKI) occurring during hospitalization based on KDIGO definitions., Analytical Approach: Generalized Estimating Equation logistic regression adjusted for comorbidities, socio-demographic factors, and severity of illness. Analyses were stratified into 3 age categories, 6 months to ≤16 years, age >16 years - <55 years, and age ≥55 years., Results: A total of 132,667 individuals were hospitalized a total of 235,629 times. The mean age was 55.2 (SD 23.8) years. The counts (%) of hospitalizations for women were 129,912 (55%). Hospitalization counts (%) among Black and Hispanic patients were 71,834 (30.5%) and 24,199 (10.3%), respectively. AKI occurred in 53,926 (22.9%) hospitalizations. In adjusted models, there was a significant interaction between age and sex (p<0.001). Boys and men had higher risk of AKI across all age groups, an association more pronounced in the age group >16 years to <55 years in which the OR for men was 1.7 (95% CI, 1.6-1.8). This age-based pattern remained consistent across prespecified types of hospitalizations. In a sensitivity analysis, women older than 55 years who received prescriptions for estrogen had lower odds of AKI than those without prescriptions., Limitations: Residual confounding., Conclusion: The greatest relative risk of AKI for males occurred during ages >16 to <55 years. The lower risk among post-menopausal women receiving supplemental estrogen supports a protective role for female sex hormones., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: To compare the outcomes of factor eight inhibitor bypassing activity (FEIBA) versus fresh frozen plasma (FFP) as the primary treatment for postoperative coagulopathy in patients undergoing cardiac surgery., Design: A retrospective, propensity-matched study., Setting: A single, tertiary hospital., Participants: Patients who underwent noncoronary cardiac surgery with cardiopulmonary bypass between 2015 and 2023., Interventions: None., Measurements and Main Results: We stratified patients into 2 groups based on whether they received intraoperative FFP or FEIBA; cases using both were excluded. We analyzed 434 cases, with 197 receiving FFP and 237 receiving FEIBA. After propensity matching, there was no significant difference in the proportion of the patients who required packed red blood cell transfusions (p = 0.08). However, of those who required packed red blood cell transfusions, patients in the FEIBA group required significantly fewer units of packed red blood cells (p < 0.001). Significantly fewer patients in the FEIBA group required platelet (p < 0.001) and cryoprecipitate (p < 0.001) transfusions. The FEIBA group showed decreased prolonged postoperative intubation (p = 0.05), decreased intensive care unit length of stay (p = 0.04), and lower 30-day readmission rates (p = 0.03). There were no differences in the rates of thrombotic complications between the 2 cohorts., Conclusions: In the initial treatment of postcardiopulmonary bypass coagulopathy, FEIBA may be more effective than FFP in decreasing blood product transfusions and readmission rates. Further studies are needed to explore the potential routine use of FEIBA as first-line agent in this patient population., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: To understand if red blood cell (RBC) transfusions are independently associated with a risk of mortality, prolonged intubation, or infectious, cardiac, or renal morbid outcomes., Design: A retrospective review., Setting: A single-institution university hospital., Participants: A total of 2,458 patients undergoing coronary bypass artery graft and/or valvular surgery from July 2014 through January 2018., Interventions: No interventions were done., Measurements and Main Results: The primary outcome was the occurrence of an adverse event or prolonged intubation. Infectious, cardiac, and renal composite outcomes were also defined. These composites, along with mortality, were analyzed individually and then combined to form the "any adverse events" composite. Preoperative demographic and intraoperative parameters were analyzed as univariate risk factors for adverse outcomes. Logistic regression was used to screen variables, with a p value criterion of p < 0.05 for entry into the model selection procedure. A backward selection algorithm was used with variable entry and retention criteria of p < 0.05 to select the final multivariate model. Multivariate logistic regression models were used to determine whether there was an association between the volume of RBC transfusion and the defined adverse event after adjusting for covariates. A p value < 0.01 was considered statistically significant in the final model of each aim to adjust for multiple comparisons. The final logistic models for each of the following outcomes indicate an increased risk of that outcome per each additional unit of RBC transfused. For prolonged intubation, the odds ratio (OR) was 1.493 (p < 0.0001), OR = 1.358 (p < 0.0001) for infectious composite outcomes, OR = 1.247 (p < 0.0001) for adverse renal outcomes, and OR = 1.467 (p < 0.0001) for any adverse event., Conclusions: The authors demonstrated a strong independent association between RBC transfusion volume and adverse outcomes after cardiac surgery. Efforts should be undertaken, such as preoperative anemia management and control of coagulopathy, in order to minimize the need for RBC transfusion., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The growing number of prevalent arteriovenous (AV) accesses has been associated with an increase in the incidence of procedures being performed to maintain patency. To reduce the rate of unnecessary procedures, the 2019 Kidney Disease Outcome Quality Initiative guidelines addended the AV access surveillance recommendations, which includes clinical monitoring and assessment of dialysis adequacy alone. Abnormal clinical findings would necessitate follow-up angiography with or without confirmatory duplex ultrasound. Due to poor patency, increased surveillance schedules have been proposed to identify stenosis early and potentially prevent acute thrombotic events and AV access failure. In this review, we outlined current AV access monitoring and maintenance procedure recommendations, as described by the Centers for Medicare and Medicaid Services and 2019 Kidney Disease Outcome Quality Initiative guidelines. In addition, we highlight the findings of recently published randomized controlled trials that have examined increased surveillance schedules., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Long-term anticoagulant therapy is generally recommended for thrombotic antiphospholipid syndrome (TAPS) patients, however it may be withdrawn or not introduced in routine practice., Objectives: To prospectively evaluate the risk of thrombosis recurrence and major bleeding in non-anticoagulated TAPS patients, compared to anticoagulated TAPS, and secondly, to identify different features between those two groups., Patients/methods: Using an international registry, we identified non-anticoagulated TAPS patients at baseline, and matched them with anticoagulated TAPS patients based on gender, age, type of previous thrombosis, and associated autoimmune disease. Thrombosis recurrence and major bleeding were prospectively analyzed using Kaplan-Meier method and compared using a marginal Cox's regression model., Results: As of June 2022, 94 (14 %) of the 662 TAPS patients were not anticoagulated; and 93 of them were matched with 181 anticoagulated TAPS patients (median follow-up 5 years [interquartile range 3 to 8]). The 5-year thrombosis recurrence and major bleeding rates were 12 % versus 10 %, and 6 % versus 7 %, respectively (hazard ratio [HR] 1.38, 95 % confidence interval [CI] 0.53 to 3.56, p = 0.50 and HR 0.53; 95 % CI 0.15 to 1.86; p = 0.32, respectively). Non-anticoagulated patients were more likely to receive antiplatelet therapy (p < 0.001), and less likely to have more than one previous thrombosis (p < 0.001) and lupus anticoagulant positivity (p = 0.01)., Conclusion: Fourteen percent of the TAPS patients were not anticoagulated at recruitment. Their recurrent thrombosis risk did not differ compared to matched anticoagulated TAPS patients, supporting the pressing need for risk-stratified secondary thrombosis prevention trials in APS investigating strategies other than anticoagulation., Competing Interests: Declaration of competing interest Authors had no conflict of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Insertable cardiac monitors (ICMs) have been used more frequently and in a wider variety of circumstances in recent years. ICMs are used for symptom-rhythm correlation when patients have potentially arrhythmogenic syncope and for less traditional reasons such as rhythm surveillance in patients with genetic arrhythmia syndromes or other diseases with high arrhythmia risk. ICMs have good diagnostic yield in pediatric patients and in adults with congenital heart disease and have a low rate of complications. Implantation techniques should take patient-specific factors into account to optimize diagnostic yield and minimize risk., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The rising number of total knee arthroplasties (TKA's) in the United States increases demand for perioperative pain modalities, which can promote early mobilization and discharge. Over the decades, a focus has shifted from opioid-dominant regimens to motor-sparing multimodal protocols, which have not only improved pain scores and reduced opioid consumption but also improved overall patient outcomes. In this article, we briefly review the evolution of post-operative pain management in patients undergoing TKA and summarize the literature on the most popular modalities currently used including periarticular injections, adductor canal blocks, distal selective nerve blocks, as well as liposomal bupivacaine as part of a multimodal approach., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Children with renal masses require surgical management to provide accurate surgical staging and skilled resection of the tumor. This document includes evidence-based recommendations for pediatric surgeons regarding the resection, staging, and proper nodal basin evaluation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To develop a practical thromboelastograph guided (TEG) anticoagulation protocol to guide the management of COVID-19 critically ill patients., Design: An inter disciplinary team reviewed the current literature on hypercoagulability in critically ill COVID-19 patients, clinical management practices and challenges with high rates of thrombotic events despite anticoagulant therapies., Setting: The largest tertiary care hospital within the Northwell Health System in New York., Patients: COVID-19 invasively mechanically ventilated patients in Medical Intensive Care Unit Settings., Methods: TEG was monitored in critically ill COVID-19 patients. Patterns were reviewed to guide the development of a treatment protocol leveraging TEG parameters to select anticoagulant therapy. Three patients are reported to highlight TEG profiles that led to the development of the algorithm. Clinical trajectory and treatment decisions were extracted retrospectively from the Electronic Health Record, with input from the intensivists. Anticoagulant use, laboratory and TEG values, and venous/arterial lower extremity (LE) ultrasound results were recorded., Main Results: These patients demonstrated hypercoagulable TEG results despite prophylactic or therapeutic dosages of unfractionated heparin or low-molecular-weight heparin (LMHW). TEG surveillance identified functional fibrinogen and maximum amplitude in high-risk patients with hyper inflammatory markers. Anticoagulation assessment, TEG parameters, and LE ultrasound monitoring for venous and arterial thrombus were used to construct an algorithm to guide and escalate anticoagulant therapy., Conclusions: TEG provides patient-specific evidence for a hypercoagulable state in patients receiving all types of anticoagulant therapy. The proposed TEG algorithm guides anticoagulation management decisions to maintain or escalate anticoagulant dose and/or change choice of anticoagulant. A TEG algorithm may help negotiate the potential harm/benefit balance of full-dose anticoagulation in critically ill COVID-19 patients, by allowing for a more individualized approach that goes beyond the review of activated partial thromboplastin time (aPTT) levels., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Rationale & Objective: Outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) and acute kidney injury (AKI) are not well understood. The goal of this study was to investigate the survival and kidney outcomes of these patients., Study Design: Retrospective cohort study., Setting & Participants: Patients (aged≥18 years) hospitalized with COVID-19 at 13 hospitals in metropolitan New York between March 1, 2020, and April 27, 2020, followed up until hospital discharge., Exposure: AKI., Outcomes: Primary outcome: in-hospital death., Secondary Outcomes: requiring dialysis at discharge, recovery of kidney function., Analytical Approach: Univariable and multivariable time-to-event analysis and logistic regression., Results: Among 9,657 patients admitted with COVID-19, the AKI incidence rate was 38.4/1,000 patient-days. Incidence rates of in-hospital death among patients without AKI, with AKI not requiring dialysis (AKI stages 1-3), and with AKI receiving dialysis (AKI 3D) were 10.8, 31.1, and 37.5/1,000 patient-days, respectively. Taking those without AKI as the reference group, we observed greater risks for in-hospital death for patients with AKI 1-3 and AKI 3D (HRs of 5.6 [95% CI, 5.0-6.3] and 11.3 [95% CI, 9.6-13.1], respectively). After adjusting for demographics, comorbid conditions, and illness severity, the risk for death remained higher among those with AKI 1-3 (adjusted HR, 3.4 [95% CI, 3.0-3.9]) and AKI 3D (adjusted HR, 6.4 [95% CI, 5.5-7.6]) compared with those without AKI. Among patients with AKI 1-3 who survived, 74.1% achieved kidney recovery by the time of discharge. Among those with AKI 3D who survived, 30.6% remained on dialysis at discharge, and prehospitalization chronic kidney disease was the only independent risk factor associated with needing dialysis at discharge (adjusted OR, 9.3 [95% CI, 2.3-37.8])., Limitations: Observational retrospective study, limited to the NY metropolitan area during the peak of the COVID-19 pandemic., Conclusions: AKI in hospitalized patients with COVID-19 was associated with significant risk for death., (Copyright © 2020 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Persons who have disorders of consciousness (DoC) require care from multidisciplinary teams with specialized training and expertise in management of the complex needs of this clinical population. The recent promulgation of practice guidelines for patients with prolonged DoC by the American Academy of Neurology, American Congress of Rehabilitation Medicine (ACRM), and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) represents a major advance in the development of care standards in this area of brain injury rehabilitation. Implementation of these practice guidelines requires explication of the minimum competencies of clinical programs providing services to persons who have DoC. The Brain Injury Interdisciplinary Special Interest Group of the ACRM, in collaboration with the Disorders of Consciousness Special Interest Group of the NIDILRR-Traumatic Brain Injury Model Systems convened a multidisciplinary panel of experts to address this need through the present position statement. Content area-specific workgroups reviewed relevant peer-reviewed literature and drafted recommendations which were then evaluated by the expert panel using a modified Delphi voting process. The process yielded 21 recommendations on the structure and process of essential services required for effective DoC-focused rehabilitation, organized into 4 categories: diagnostic and prognostic assessment (4 recommendations), treatment (11 recommendations), transitioning care/long-term care needs (5 recommendations), and management of ethical issues (1 recommendation). With few exceptions, these recommendations focus on infrastructure requirements and operating procedures for the provision of DoC-focused neurorehabilitation services across subacute and postacute settings., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This article reviews the industrial underpinnings of the quality improvement (QI) movement and describes how QI became integrated within the larger health care landscape, including hospital medicine. QI methodologies and a framework for using them are described. Key components that make up a successful QI clinical project are outlined, with a focus on the essential role of pediatric hospitalists and practical professional tips to be successful. QI training opportunities are reviewed with opportunities for hospitalists to get involved in QI on a national level. National QI networks are showcased, with multiple examples of advanced improvement projects that have significantly improved patient outcomes highlighted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Parkinson disease (PD) is the second most common neurodegenerative disorder and affects more than 1 million individuals in the United States. Deep brain stimulation (DBS) is one form of treatment of PD. DBS treatment is still evolving due to technological innovations that shape how this therapy is used., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Cardiovascular disease is a major cause of death in individuals diagnosed with kidney disease during childhood. Children with kidney disease often incur a significant cardiovascular burden that leads to increased risk for cardiovascular disease. Evidence has shown that children with kidney disease, including chronic kidney disease, dialysis, kidney transplantation, and nephrotic syndrome, develop abnormalities in cardiovascular markers such as hypertension, dyslipidemia, left ventricular hypertrophy, left ventricular dysfunction, atherosclerosis, and aortic stiffness. Early identification of modifiable risk factors and treatment may lead to a decrease of long-term cardiovascular morbidity and mortality, but evidence in this population is lacking., (Copyright © 2018 Elsevier Inc. All rights reserved.)

A schwannoma or neurilemmoma is a benign, isolated, noninvasive, and encapsulated tumor originating from Schwann cells of the peripheral nerve sheath. The incidence of a schwannoma occurring in the foot and ankle is rare, with prevalence rate of 1% to 10%. Schwannomas have no sex predilection, and they commonly occur in patients in their fourth decade. Malignant transformation of benign schwannoma is unusual; however, it is important to note that malignant variants of schwannomas do exist and account for about 5% to 10% of all soft tissue sarcomas. We present 3 cases of benign schwannoma in the lower extremity. All 3 patients presented with varying clinical symptoms, including pain, paresthesia, weakness, and a palpable mass. A schwannoma was eventually diagnosed in all 3 patients. We discuss and review the known entities of peripheral nerve schwannoma and describe the clinical and imaging findings and therapeutic strategies for treating and diagnosing peripheral nerve schwannoma., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Human milk is the preferred diet for preterm infants as it protects against a multitude of NICU challenges, specifically necrotizing enterocolitis. Infants who receive greater than 50% of mother's own milk (MOM) in the 2 weeks after birth have a significantly decreased risk of NEC. An additional factor in the recent declining rates of NEC is the increased utilization of donor human milk (DHM). This creates a bridge until MOM is readily available, thus decreasing the exposure to cow milk protein. Preterm infants are susceptible to NEC due to the immaturity of their gastrointestinal and immune systems. An exclusive human milk diet compensates for these immature systems in many ways such as lowering gastric pH, enhancing intestinal motility, decreasing epithelial permeability, and altering the composition of bacterial flora. Ideally, preterm infants should be fed human milk and avoid bovine protein. A diet consisting of human milk-based human milk fortifier is one way to provide the additional nutritional supplements necessary for adequate growth while receiving the protective benefits of a human milk diet., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To determine if implementing a protocol maintaining an air leak when using cuffed endotracheal tubes (ETT) throughout the course of mechanical ventilation (MV) in children would decrease the rate of postextubation stridor (PES)., Methods: All children requiring MV through a cuffed ETT were included, except those with (1) upper airway anomaly, (2) died while on MV, (3) received tracheostomy before extubation, and (4) transferred before extubation. We implemented a protocol limiting the volume of air instilled into the cuff, allowing an air leak by 25 cm H 2 O pressure or by peak inspiratory pressure, whichever was higher. Monitoring occurred every 6 hours, adjusting cuff volumes if necessary. Patients receiving nebulized racemic epinephrine within 24 hours of extubation for upper airway obstruction were defined as having PES., Results: At baseline, 110 patients received cuffed ETTs. The proportion of patients who had an air leak at the time of extubation was 47.3%, and that who developed PES was 21.8%. During the intervention, 101 patients received cuffed ETTs. Most (72.3%) had an air leak at the time of extubation (P< .01), and 9.9% developed PES, a 54.6% relative decrease (relative risk, 0.45; 95% confidence interval, 0.22-0.90; P= .018)., Conclusions: Maintaining an appropriate air leak throughout the course of MV using cuffed ETT decreases the rate of PES in children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Peripartum hemorrhage is one of the most preventable causes of maternal mortality worldwide. Much effort has been directed toward creating programs that address deficits in maternity care responsible for preventable hemorrhage-related morbidity and mortality. To have a significant impact on outcomes, such programs must address both providers and processes involved in the delivery of maternity care. At the core of a successful program, are standardized care bundles integrating medical and surgical techniques for managing hemorrhage with principles of transfusion medicine and critical care. In this article, we review the components of the safety bundle for obstetric hemorrhage developed by ACOG District II Safe Motherhood Initiative., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU)., Design: A prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center., Interventions: A team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes. Measurements and Main Results The team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P<.001). Hospital length of stay decreased from 9.9±9 to 8.3±7 days (P<.03)., Conclusion: A team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Rationale: Critical care consults requested shortly after admission could represent a triage error. This consult process has not been adequately assessed, and data are retrospective relying on discharge diagnoses., Objectives: The aims of this study were to identify reasons for medical Intensive care unit (MICU) consultations within 48 hours of admission and to detect differences between those accepted and those denied MICU admission., Methods: Data were prospectively collected including demographics, reason for consultation, Acute Physiology and Chronic Health Evaluation II score, Elixhauser comorbidity measure, functional status, need for assisted ventilation or vasopressor, presence of do-not-resuscitate (DNR) order, and whether a DNR order was obtained after MICU consultation., Results: Ninety-four percent of patients consulted were not initially evaluated in the emergency department, half of whom were accepted. Respiratory failure, sepsis, and alcohol withdrawal were the most frequent reasons for MICU transfers. Factors predicting MICU admission included respiratory illness, better baseline functional status, and less comorbidity, whereas DNR predicted rejection. We did not find differences in hospital mortality; but hospital length of stay was longer., Conclusions: Prospective examination of the consult process suggests that disease progression rather than triage error accounted for most unplanned transfers. Functional status and comorbidity predicted MICU admission rather than illness severity. Goals of care were not being discussed adequately. We did not detect differences in mortality although hospital length of stay was increased., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated, viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points., Design: A prospective, observational clinical study., Setting: A teaching hospital, single center., Participants: Consecutive patients undergoing cardiac surgery (N = 300)., Interventions: Besides routine laboratory coagulation studies and heparin management with standard (kaolin) activated clotting time, additional native blood samples were analyzed on a Sonoclot using glass bead-activated tests. Glass bead-activated clotting time, clot rate, and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure., Measurements and Main Results: Primary outcome was postoperative blood loss (chest tube drainage at 4, 8, and 12 hours postoperatively). Secondary outcome parameters were transfusion requirements, need for surgical re-exploration, time of mechanical ventilation, length of intensive care unit and hospital stay, and hospital morbidity and mortality. Patients were categorized into "bleeders" and "nonbleeders." Patient characteristics, operations, preoperative standard laboratory parameters, and procedural times were comparable between bleeders and nonbleeders except for sex and age. Bleeders had higher rates of transfusions, surgical re-explorations, and complications. Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding., Conclusions: Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Radionuclide procedures frequently are performed as part of the diagnostic workup of osteomyelitis. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. Degenerative joint disease, fracture, and orthopedic hardware decrease the specificity of the bone scan, making it less useful in these situations. Gallium-67 scintigraphy was often used as an adjunct to bone scintigraphy for diagnosing osteomyelitis. However, now it is used primarily for spinal infections when (18)F-FDG imaging cannot be performed. Except for the spine, in vitro-labeled leukocyte imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Leukocytes accumulate in bone marrow as well as in infection. Performing complementary bone marrow imaging with (99m)Tc-sulfur colloid facilitates the differentiation between osteomyelitis and normal marrow and improves test overall accuracy. Antigranulocyte antibodies and antibody fragments, such as (99m)Tc-besilesomab and (99m)Tc-sulesomab, were developed to eliminate the disadvantages associated with in vitro-labeled leukocytes. These agents, however, have their own shortcomings and are not widely available. As biotin is used as a growth factor by certain bacteria, (111)In-biotin is useful to diagnose spinal infections. Radiolabeled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, can differentiate infection from sterile inflammation and may be useful to monitor response to treatment. (18)F-FDG is extremely useful in the diagnostic workup of osteomyelitis. Sensitivity in excess of 95% and specificity ranging from 75%-99% have been reported. (18)F-FDG is the radionuclide test of choice for spinal infection. The test is sensitive, with a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of (18)F-FDG for diagnosing diabetic pedal osteomyelitis are contradictory, and its role for this indication remains to be determined. Initial investigations suggested that (18)F-FDG accurately diagnoses prosthetic joint infection; more recent data indicate that it cannot differentiate infection from other causes of prosthetic failure. Preliminary data on the PET agents gallium-68 and iodine-124 fialuridine indicate that these agents may have a role in diagnosing osteomyelitis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Fracture of the posteromedial tubercle of the talus is an uncommon injury that is often missed on plain radiographs. In the present report, we describe the case of an adult male with a chronic nonunited fracture of the medial tubercle of the posterior process of the talus after having undergone clinical and radiographic evaluation in a community hospital emergency department. A review of the computed tomographic, magnetic resonance imaging, and plain film radiographic findings associated with nonunion of the posteromedial tubercle of the talus is also presented., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to evaluate the ability of Thromboelastograph with Platelet Mapping (TEG-PM(TM)) to predict postoperative bleeding tendency in patients with a history of recent anti-platelet therapy undergoing coronary artery bypass grafting (CABG)., Design: A retrospective analysis. Association between predictor variables (MAADP [maximum amplitude produced by adenosine diphosphate], MAAA [maximum amplitude produced by arachidonic acid], percent of platelets inhibited by clopidogrel, percent of platelets inhibited by aspirin) and the outcomes as elevated chest tube drainage (CTD) and blood transfusion were investigated by logistic regression model. CTD was considered elevated if it was ≥ 600 mL within 12 hours after surgery., Setting: A university hospital., Participants: Patients on antiplatelet therapy scheduled to undergo CABG that had TEG-PM(TM) done as a point-of-care test., Interventions: None., Results: A total of 78 patients had preoperative TEG-PM(TM) test and on-pump CABG surgeries performed on the same day. Among them, 20 patients (25.6%) had elevated CTD. Decreased MAADP (odds ratio [OR] 0.94), increased percent inhibition of platelets by clopidogrel (OR 1.03), and lower body mass index (BMI) (OR 0.78) were significantly associated with elevated CTD. The same parameters were also associated with platelets transfusion: MAADP (OR 0.94), percent of inhibition of platelets by clopidogrel (OR 1.03) and BMI (OR 0.77)., Conclusions: TEG-PM(TM) parameters and BMI are predictive of elevated CTD and platelets transfusion. A 1 mm decrease in MAADP increases the likelihood of elevated CTD and the likelihood of platelets transfusion by 6% whereas 1 unit decrease in BMI is associated with an increased likelihood of elevated CTD and platelets transfusion by 22% and 23% respectively., (Copyright © 2014 Elsevier Inc. All rights reserved.)

All pediatric intensivists need a primer on ICU finance. The author describes potential alternate revenue sources for the division. Differentiating units by size or academic affiliation, the author describes drivers of expense. Strategies to manage the bottom line including negotiations for hospital services are covered. Some of the current trends in physician productivity and its described metrics, with particular focus on clinical FTE management is detailed. Methods of using this data to enhance revenue are discussed. Some of the other current trends in the ICU business related to changes at the federal and state level as well as in the insurance sector, moving away from fee-for-service are covered., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The pediatrician plays a major role in advocating, promoting, and managing breastfeeding, beginning in the prenatal period by providing facts and discussing questions and concerns regarding breastfeeding with the expectant mother and continuing after delivery in the hospital and during infant health supervision visits. The early weeks after birth require education, support, and encouragement. The pediatrician sets the standard that breastfeeding is norm. The pediatrician is in the optimal place to advocate and formulate hospital policies conducive to lactation and the provision of human milk and must be knowledgeable about the breastfeeding support provided by the office and community., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The repair of articular cartilage defects in patients' knees presents a particular challenge to the orthopedic surgeon because cartilage lacks the ability to repair or regenerate itself. Various cartilage repair techniques have not produced a superior or uniform outcome, which has led to a new generation of cartilage repair based on tissue-engineering strategies and the use of biological scaffolds. Clinical advances have been made regarding the regeneration of articular cartilage, and continue to be made toward the achievement of a suitable treatment method for resurfacing osteochondral defects, through cartilage tissue engineering and the use of pluripotent cells seeded on bio-scaffolds., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In April 2009, media reports indicated an outbreak of swine flu (H1N1) resulting from several students from a local high school having been in Mexico. Over the next 6 weeks, the demand for the services of the children's hospital strained available resources, requiring innovative measures to care for more than 3,200 pediatric patients and their families with influenza-like illness. The purpose of this analysis is to provide an overview of the established emergency response to disasters for hospitals, describe the chronology of events of this disaster and the planning improvisations needed for management, and discuss the lessons learned and challenges for the future., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Synovial sarcoma arising in the foot is a rare finding. We report a 64-year-old female with synovial sarcoma involving the calcaneus and central plantar compartment. The patient presented with a 2-year history of painful heel with soft tissue mass presentation 21 months after initial pain. We performed an incisional biopsy with frozen section; histopathology was consistent with synovial sarcoma., (Copyright 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center., Methods: Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score., Results: The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality., Conclusion: The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.

Nearly 700,000 hip and knee arthroplasties are performed annually in the United States. Although the results in most cases are excellent, implants do fail. Complications like heterotopic ossification, fracture, and dislocation are now relatively rare and easily diagnosed. Differentiating aseptic loosening, the most common cause of prosthetic joint failure, from infection, is important because their treatments are very different. Unfortunately, differentiating between these 2 entities can be challenging. Clinical signs of infection often are absent. Increased peripheral blood leukocytes, erythrocyte sedimentation rate, and C-reactive protein levels are neither sensitive nor specific for infection. Joint aspiration with Gram stain and culture is the definitive diagnostic test. Its specificity is in excess of 90%; its sensitivity is variable, however, ranging from 28% to 92%. Plain radiographs are neither sensitive nor specific and cross-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, can be limited by hardware-induced artifacts. Radionuclide imaging is not affected by orthopedic hardware and is the current imaging modality of choice for suspected joint replacement infection. Bone scintigraphy is sensitive for identifying the failed joint replacement, but cannot be used to determine the cause of failure. Neither periprosthetic uptake patterns nor performing the test as a 3-phase study significantly improve accuracy, which is only about 50-70%. Thus, bone scintigraphy typically is used as a screening test or in conjunction with other radionuclide studies. Combined bone gallium imaging, with an accuracy of 65-80%, offers only modest improvement over bone scintigraphy alone. Presently, combined leukocyte/marrow imaging, with approximately 90% accuracy, is the radionuclide imaging procedure of choice for diagnosing prosthetic joint infection. In vivo leukocyte labeling techniques have shown promise for diagnosing musculoskeletal infection; their role in prosthetic joint infection has not been established. (111)In-labeled polyclonal immunoglobulin lacks specificity. (99m)Tc-ciprofloaxicin does not consistently differentiate infection from aseptic inflammation. (18)F-fluorodeoxyglucose positron emission tomography has been extensively investigated; its value in the diagnosis of prosthetic joint infection is debatable.

Because of their proven efficacy, intravenous bisphosphonates play an important role in reducing the risk of skeletal-related events including pathologic fractures, spinal cord compression, and palliative radiotherapy to bone in patients with malignant bone lesions. Overall, intravenous bisphosphonates have an acceptable safety profile and are commonly associated with transient and manageable flu-like symptoms after initial infusions. In addition, bisphosphonates have dose- and infusion rate-dependent effects on renal function that can be proactively managed in patients with reduced creatinine clearance rates by following recommended dosing guidelines. Recently, there have been reports of osteonecrosis of the jaw (ONJ) in patients with advanced cancer receiving complex chemotherapeutic treatment regimens and supportive care with bisphosphonates. ONJ prevention and management recommendations have been developed that may reduce the risk of ONJ and the impact of ONJ on quality of life. Moreover, bisphosphonate therapy has resulted in considerable clinical benefits in patients with malignant bone disease; therefore, the potential for adverse events such as ONJ must be placed into context with these meaningful benefits.

Diamond Blackfan anemia (DBA) is a genetically and clinically heterogeneous disorder characterized by erythroid failure, congenital anomalies, and a predisposition to cancer. Faulty ribosome biogenesis is hypothesized to be the underlying defect, leading to erythroid failure due to accelerated apoptosis in affected erythroid progenitors/precursors. Since first observed in DBA, pro-apoptotic hematopoiesis has been recognized as a common mechanism for hematopoietic failure in virtually all of the inherited bone marrow failure syndromes. Inherited as an autosomal dominant trait, one of what appears to be multiple DBA genes, coding for ribosomal protein RPS19, has been cloned. The discovery of additional genes will no doubt clarify the molecular pathophysiology of this disorder. Even within families, individuals may vary dramatically as to the degree of anemia, treatment response, and the presence of congenital anomalies. The study of DBA has been facilitated by the creation of international patient registries that provide more reliable information regarding clinical presentation, genetics, and outcome, as well as descriptions of congenital malformations and cancer predisposition, than can be culled from the literature. Analysis of registry data has led to improvements in clinical care and provides patients and research specimens for clinical and laboratory investigations.

In the last 10 years purine analogs have become the chemotherapy of choice for the first-line treatment of chronic lymphocytic leukemia, principally because of their superior efficacy compared with alkylating agents. However, many patients experience a relapse after an initial response or become refractory to these agents. The introduction of immunotherapeutic agents has provided renewed hope for fludarabine-refractory patients. Several clinical trials have shown the efficacy of alemtuzumab in patients with fludarabine-refractory chronic lymphocytic leukemia, including those with poor prognostic factors. Current studies indicate that treatment with alemtuzumab can achieve remissions with undetectable residual disease, as assessed by highly sensitive methods such as quantitative polymerase chain reaction or 4-color flow cytometry. These results suggest new applications for alemtuzumab such as combination treatment with chemotherapeutics or immunotherapeutics, maintenance therapy, and in vivo bone marrow purging prior to transplantation. A number of clinical trials are under way assessing the role of alemtuzumab in these settings.

Juvenile idiopathic arthritis (JIA), a term referring to a group of disorders characterized by chronic arthritis, is the most common chronic rheumatic illness in children and is a significant cause of short- and long-term disability. This article discusses the classification, differential diagnosis, and treatment of JIA.

Background: A circulating factor that increases in vitro glomerular permeability to albumin (P alb ) has been isolated from patients with recurrence of focal segmental glomerulosclerosis in their renal allografts. The prevalence and prognostic significance of permeability activity has not been examined in children with idiopathic nephrotic syndrome (INS)., Methods: P alb activity level was determined in sera from 26 children with new-onset INS before the initiation of therapy by using an in vitro assay. Permeability factor was considered present if P alb was greater than 0.5. The following clinical and laboratory data for patients were tabulated: demographic information, serum albumin and cholesterol concentrations, calculated glomerular filtration rate, age at disease onset, response to corticosteroid treatment, and long-term outcome., Results: Patients ranged in age from 2 to 18 years, and 19 patients (73%) were male. Mean P alb was 0.45 +/- 0.04 (SEM). P alb in patients with a steroid-responsive course (n = 17) did not differ from that of patients with steroid-resistant disease (n = 9). Percentages with P alb greater than 0.5 did not differ between patients with steroid-responsive and steroid-resistant disease (47% and 33%, respectively). P alb was determined after 41 +/- 5 months in 6 patients with steroid-responsive INS. These patients had normal serum creatinine concentrations, and 4 of 6 patients were in prolonged remission. P alb at the onset of INS before therapy was 0.51 +/- 0.09 (P alb > 0.5 in 2 patients) and was not changed at follow-up (P alb = 0.40 +/- 0.12; P alb > 0.5 in 2 patients)., Conclusion: Permeability activity, defined as P alb greater than 0.5, is present in pretreatment serum samples from nearly half the children with INS. The presence of permeability activity does not predict clinical response to steroid treatment, renal histopathologic characteristics, or clinical outcome at up to 5 years of follow-up.

Diabetes remains the most commonly encountered endocrinopathy with the incidence of type 2 doubling in the past decade. The prevalence of diabetes is projected to continue to increase dramatically over the next several decades unless major public health initiatives are successful in stemming this growth. Both type I and 2 diabetics more frequently require surgical and critical care than their non-diabetic counterparts. Type 1 and 2 diabetics also sustain greater peri-operative morbidity and mortality. Careful preoperative assessment and appropriate perioperative intervention may limit this. There is increasing evidence that maintenance of normal blood glucose in the perioperative period and during critical illness is beneficial for diabetic and non-diabetic patients. More data will hopefully be forthcoming to substantiate recent reports and identify the mechanisms of improved outcome. Thyroid disease remains a commonly encountered pathology that is more readily identified and controlled in the modern era of radioimmune assays of thyroid hormone and successful medical and surgical therapies. Severe hypothyroidism and thyroid storm are associated with significant increases in perioperative morbidity and mortality. Recognition of these entities or those at risk for developing them post operatively is crucial in initiating timely and effective therapy. Primary Al is uncommon, but results in glucocorticoid and mineralocorticoid deficiency. Tertiary Al is far more common, most often secondary to iatrogenic therapy with exogenous glucocorticoids for the management of chronic diseases such as connective tissue disorders, anti-rejection regimes, and severe asthma. Glucocorticoid replacement or supplementation is needed on a case-by-case basis and should be individualized based on chronic steroid dose, duration, and stress of the surgical procedure. Perioperative steroid dosing regimes now recommend lower doses for shorter periods than previously suggested. More recently Al has been recognized in two populations, elderly patients undergoing major surgery and a subgroup of patients with septic shock. Timely diagnosis using synthetic ACTH stimulation testing and stress glucocorticoid, and possibly mineralocorticoid therapy, seems to reverse these processes and improve recovery. Although uncommon, patients with pheochromocytoma who undergo open or laparoscopic resections remain diagnostic and therapeutic challenges. Perioperative outcome seems to have improved, in part, related to newer therapies and less invasive surgeries when indicated. The appropriate preoperative assessment and management of patients with various endocrinopathies is important to optimize outcome and limit avoidable complications. Hopefully additional evidence based guidelines will be forth-coming particularly in caring for the ever increasingly encountered perioperative diabetic.

Monoclonal antibodies directed at the lymphoid antigens have become established treatments for hematological malignancies either alone or in combination with chemotherapy. However, their incorporation in the transplant setting remains investigational. This review focuses on the currently available data for in vitro and in vivo purging with these antibodies as well as their role in modulating graft-versus-host disease (GVHD).

Pneumonia is a very common admission diagnosis of critically ill patients. Patients with severe episodes of pneumonia are at risk for development of the systemic inflammatory response syndrome, which is known to induce the production of proinflammatory cytokines, such as interleukins (ILs) and tumor necrosis factor alpha (TNF-alpha). This response subsequently triggers activation of anti-inflammatory cytokine production and specific soluble cytokine receptors. Lung cell apoptosis can be stimulated or inhibited by different cytokines and/or cell signals. Some of these mediators can be proapoptotic or antiapoptotic. This article discusses the clinical implications of the systemic response to pneumonia in the critically ill patient.

Complications occur during the repair of anorectal malformations relatively frequently. Unfortunately, these complications are often preventable. Furthermore, the consequences of these complications are significant. Not only do patients experience unnecessary pain and suffering, but a secondary operation always renders less optimal functional results. A 20-year experience in the care of children with anorectal malformations was retrospectively analyzed. Patients who previously underwent surgical repair at other institutions, and subsequently required secondary surgery by the primary author were evaluated; 334 patients were identified. Reasons for reoperation included fecal incontinence in 77 patients; dehiscence and retraction in 96; recto-genito-urinary fistulae in 55; persistent urogenital sinus in 31 cloaca patients; acquired vaginal atresia in 21; acquired urethral atresia in 9; posterior urethral diverticulum in 20; and overflow pseudo incontinence in 25 patients. Except for fecal incontinence, all other complications are considered preventable. The source of the complications in almost all other settings are technical errors at the time of the primary repair. Recommendations are presented to help prevent these complications, and suggestions are made on how to treat them when they occur., (Copyright 2003 Elsevier Inc. All rights reserved.)

An in vivo method of labeling white cells that diagnoses diabetic pedal osteomyelitis safely, rapidly, and accurately is desirable. The objectives of this investigation were to evaluate a technetium-99m-labeled monoclonal antigranulocyte antibody for diagnosing diabetic pedal osteomyelitis, compared with indium-111-labeled leukocyte and 3-phase bone imaging for this purpose. Twenty-five diabetic patients with pedal ulcers, 22 in the forefoot and 3 in the midfoot, underwent antibody, indium-111-labeled leukocyte, and technetium-99m methylene diphosphonate 3-phase bone imaging. The 1-hour antibody, 24-hour labeled leukocyte, and 3-phase bone images were interpreted separately for the presence of osteomyelitis. The antibody and labeled leukocyte images also were interpreted together with the bone images to determine if the combined study was more accurate than each individual study. There were 10 cases of osteomyelitis among the 25 patients. The sensitivity, specificity, and accuracy of the antibody were.90,.67, and.76, respectively. These results were not significantly different from those obtained with labeled leukocyte imaging:.80,.67, and.72, respectively. The antibody was significantly more specific (P =.004) than 3-phase bone imaging (.27). Interpreting the antibody together with the bone scan did not alter the results. When interpreted with the bone images, the accuracy of labeled leukocyte imaging improved from.72 to.80. This was not significantly more accurate than either the antibody or labeled leukocyte imaging alone. The data suggest that the monoclonal antigranulocyte antibody is comparable with in vitro labeled leukocyte imaging for diagnosing pedal osteomyelitis in diabetic patients, and warrants further investigation in a larger population.

Technologic advances have contributed to numerous diverse approaches to the management of hemorrhoid disease over the past centuries. Better understanding of the pathophysiology and anatomy of the anal canal has also added to the increased success in the treatment of hemorrhoids. This article reviews the clinical and pathological aspects of hemorrhoid disease, emphasizing new therapeutic modalities.

Objectives: To describe inpatient rehabilitation outcome in persons with nontraumatic subarachnoid hemorrhage (SAH) and to explore the predictive capacity of acute measures of SAH severity and demographic and disease variables., Design: Retrospective with descriptive and relational analyses., Setting: Free-standing, acute, inpatient brain injury rehabilitation unit., Participants: Forty-two consecutive persons with nontraumatic SAH and for whom complete data were available were studied. Mean age of the group was 56.5 years, mean acute hospital stay was 26.2 days, and 60% were women. Over 40% experienced rupture of an anterior communicating artery aneurysm. The time from injury to rehabilitation admission varied from 11 to 227 days (mean, 43.8d)., Interventions: Not applicable., Main Outcome Measure: Change in FIMtrade mark instrument scores, home discharge rate, and rehabilitation length of stay (LOS.), Results: The mean admission and discharge FIM scores were 57.7 and 85.5 points, respectively. There was a 27.8-point mean change in FIM score over a 24.1-day mean rehabilitation LOS for a FIM efficiency (points/day) of 1.15. Over 80% of the sample was discharged home. No demographic or disease characteristic variables, including acute severity measures, were statistically significant predictors of outcome., Conclusions: Functional gains during inpatient rehabilitation made in this group of 42 persons with SAH are in line with earlier studies. Our rehabilitation LOS is the shortest reported among 4 studies to date and is probably a reflection of managed care in the United States. A small sample, uneven cell sizes, and variability of patients might have contributed to a lack of significant findings. Future study should explore the prediction of rehabilitation outcome using larger sample sizes and longer follow-up periods., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: To examine intermanual differences in performing a clinical, visuoconstructional task. While many examiners have their hemiparetic patients complete visuospatial tasks with their nondominant hand, normative data have only been available based on dominant hand performance. This study sought to determine normal differences in intermanual visuoconstructional performance., Design: A group of individuals with no history of neurologic disorder completed a visuoconstruction task with their dominant and nondominant hands. Intermanual differences were compared., Setting: General metropolitan community., Participants: Forty-four individuals with no history of psychiatric, neurologic, visual, or motor impairment. Mean age was 29 years. Mean education level was 16 years., Main Outcome Measure: Free-drawn clock drawings., Results: The intermanual difference was not significant (t(43) = 1.95, p = .06). Ninety-three percent scored within normal limits with their nondominant hand., Conclusions: Use of the nondominant hand for clock drawing appears to be a reasonable alternative for those who are unable to use their dominant hand.

This article discusses use of the Developmental-Interactional Model of family therapy by a Psychiatric Clinical Nurse Specialist (CNS) for selected patients receiving psychiatric home care services. This form of family therapy is an integrative approach to working with individuals, couples, and families that combines elements of structural-strategic family therapy with life cycle and intergenerational approaches. Applied to patients and families in a home care setting, this model permits the CNS to assess relational dynamics over time, determining how these transitions relate to a family's problem-solving capability. Case studies are provided to show the application of this model for desired outcomes.

Although chronic lymphocytic leukemia (CLL) cells provide an excellent target for antibody therapy, to date this approach has met with limited success in patients with CLL. Promising data are emerging with a new generation of antibodies, such as Campath-1H, which may offer effective therapeutic options not only as single agents but also in combination with such drugs as fludarabine. Other new antibodies, including rituximab and several new radioimmunoconjugates, have provided impressive results in the indolent non-Hodgkin's lymphomas and warrant further investigation.