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Background Endoscopic retrograde cholangiopancreatography (ERCP) patients typically receive either tubeless anesthesia or general endotracheal anesthesia (GETA). Patients receiving propofol-based total intravenous anesthesia (TIVA) are at higher risk of sedation-related adverse events (SRAEs) than patients receiving GETA, primarily due to the need for additional airway maneuvers. The increasing use of non-operating room (OR) anesthesia and the perception of a higher incidence of adverse outcomes in non-OR areas has led to the development of devices to improve safety while maintaining efficiency. The purpose of this study was to evaluate if the LMA Gastro™ could be used as a safe alternative to tubeless anesthesia for successfully completing ERCPs. Methods Eligible subjects were identified within the patient population at MD Anderson Cancer Center. Inclusion criteria consisted of adult patients (≥18 years old) scheduled for elective ERCP with TIVA. This was a prospective observational study in which the following data were collected: number of attempts and time to successful supraglottic airway (SGA) placement, vital signs, peripheral oxygen saturation (SpO2), median end-tidal CO2, practitioner satisfaction, and any complications. Results A total of 30 patients were included in this study. The overall rate of successful SGA placement within 3 attempts was 96.7% (95% confidence interval [CI], 82.8-99.9) or 29/30. The rate of successful ERCP with SGA placement within 3 attempts was 93.3% (95% CI, 77.9-99.2) or 28/30. Both the gastroenterologist and anesthesiologist reported satisfaction with the device in 90% of the cases (in 66.7% of the cases both anesthesiologist and gastroenterologist scored the device a 7/7 for satisfaction). Patients maintained an SpO2 of 95%-100% from induction to discharge, with the exception of 1 patient who had an SpO2 of 93%. The median end-tidal CO2 during the procedure for all patients was 35 mm Hg. Observed aspiration did not occur in any patient. Symptoms of hoarseness (13.3%), mouth soreness (6.7%), sore throat (6.6%), and minor bleeding/cuts/redness/change in taste to the tongue (3.3%) were determined through patient questioning before postanesthesia care unit (PACU) discharge. Conclusions Our study suggests that the LMA Gastro might be a safe alternative for ERCP procedures. There was a high level of practitioner satisfaction. Only minor complications, such as hoarseness, mouth or throat soreness, or minor trauma to the tongue were experienced by patients. Similar incidences of complications may occur with GETA and tubeless anesthesia. The procedure was well tolerated by all patients; all patients maintained adequate oxygenation and required only minimal blood pressure support.

Purpose We integrated a brachytherapy procedural workflow within an existing diagnostic 3.0-T (3T) MRI suite. This setup facilitates intraoperative MRI guidance for optimal applicator positioning, particularly for interstitial needle placements in gynecologic cases with extensive parametrial involvement. Methods and Materials Here we summarize the multidisciplinary collaboration, equipment, and supplies necessary to implement an intraoperative MRI-guided brachytherapy program; outline the operational workflow via process maps; and address safety precautions. We evaluate internal resource utilization associated with this progressive approach via time-driven activity-based costing methodology, comparing institutional costs to that of a traditional workflow (within a CT suite, followed by separate postprocedure MRI) over a single brachytherapy procedural episode. Results Resource utilization was only 15% higher for the intraoperative MRI-based workflow, attributable to use of the MRI suite and increased radiologist effort. Personnel expenses were the greatest cost drivers for either workflow, accounting for 76–77% of total resource utilization. However, use of the MRI suite allows for potential cost-shifting opportunities from other resources, such as CT, during the procedural episode. Improvements in process speed can also decrease costs: for each 10% decrease in case duration from baseline procedure time, total costs could decrease by roughly 8%. Conclusions This analysis supports the feasibility of an intraoperative MRI-guided brachytherapy program within a diagnostic MRI suite and defines many of the resources required for this procedural workflow. Longer followup will define the full utility of this approach in optimizing the therapeutic ratio for gynecologic cancers, which may translate into lower costs and higher value with time, over a full cycle of care.

Introduction About one-third of critically ill patients with acute kidney injury (AKI) develop persistently decreased kidney function, known as acute kidney disease (AKD), which may progress to chronic kidney disease (CKD). Although sepsis is the most common cause of AKI, little is known about sepsis-associated AKD. Methods Using data from a large randomized trial including 1341 patients with septic shock, we studied patients with stage 2 or 3 AKI on day 1 of hospitalization. We defined AKD as a persistently reduced glomerular filtration rate for >7 days. In addition to clinical data, we measured several urinary biomarkers (tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 [TIMP-2∗IGFBP7], neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule-1 [KIM-1], liver-type fatty acid binding protein, and type 4 collagen) at 0, 6, and 24 hours, to predict AKD. Results Of 598 patients, 119 (19.9%) died within 7 days, 318 (53.2%) had early reversal of AKI within the first 7 days, whereas 161 (26.9%) developed AKD. In patients with early reversal, 45 (14.2%) had relapsed AKI after early reversal, and only about one-third of these recovered. Among patients developing AKD, only 15 (9.3%) recovered renal function prior to discharge. Male sex, African American race, and underlying CKD were more predominant in patients developing AKD. None of the biomarkers tested performed well for prediction of AKD, although NGAL modestly increased the performance of a clinical model. Conclusions AKD is common in patients with septic shock, especially among African American males and those with underlying CKD. Existing AKI biomarkers have limited utility for predicting AKD but might be useful together with clinical variables. Novel predictive biomarkers for renal recovery are needed., Graphical abstract

“Papyrius Geminus Eleates,” ostensive author of an imaginative, reconditely humanist-stylish anti-scholastic polemic, Hermathena, seu de Eloquentiae victoria, narrating the allegorical triumph of E...

Background and study aims Endoscopic mucosal resection (EMR) is increasingly used for the treatment of large colonic polyps (≥ 20 mm). A drawback of EMR is local adenoma recurrence. Therefore, we studied the impact of argon plasma coagulation (APC) of the EMR edge on local adenoma recurrence. Patients and methods This was a retrospective study of patients with laterally spreading tumors (LST) ≥ 20 mm, who underwent EMR from January 2009 to August 2018 and follow-up endoscopic assessment. A cap-fitted endoscope was used to assess completeness of resection by systematically inspecting the EMR defect for any macroscopic disease. This was followed by forced APC of the resection edge followed by clip closure of the defect. Surveillance colonoscopy was performed at 6 months after resection to detect recurrence. Results Two hundred forty-six patients met the inclusion criteria. Most were female (53 %) and white (80 %), with a Median age of 64 years. Median polyp size was 35 mm (interquartile range, 30–45 mm). Most polyps were located in the right colon (77 %) and were removed by piecemeal EMR (70 %). Eleven patients (5 %) had residual tumor at the resection site. Conclusions We observed low adenoma recurrence after argon plasma coagulation of the EMR edge with a cap fitted colonoscope in patients with LST ≥ 20 mm of the colon, which requires further validation in a randomized controlled study.

This article discusses empirical evidence regarding the theoretical claims that Incentive Rate regulation for electricity distribution creates greater consumer value than Cost of Service in terms o...

William Feriby was an historic actor: Richard II's secretary between the “Revenge Parliament” of 1397–98 and the deposition of the king in September 1399; subsequently, a contributor to the deposition proceedings; and, finally, a rebel against Henry IV in January 1400. Feriby was also a literary figure, the author of an historical “Lament for Richard II,” amongst other things, written in a highly mannered style of a sort to indicate an interest on Feriby's part in the purely literary: imagination and form. Though Feriby's prose style is distinctive, he was not the only historic-historiographical figure who manifested an interest in the strictly literary at the same moment, ca. 1400. The writings of Adam Usk, Thomas Favent, the Historia vitae author, and Thomas Brinton—even the deposition proceedings and the documentary record of them (the “Record and Process”)—are comparably (though differently) literary. The relations between Ricardian history and literature can be reconceived, dialectically, by light of such evidence: the literature is historical and historic, but, also, the history itself and historiography are literary.

Background Several studies have examined the impact of anesthetics on cancer recurrence. Isoflurane but not desflurane has protumoral effects. We hypothesize the use of isoflurane but not desflurane during surgery for primary GBM is an independent predictor of disease progression and mortality. Methods 378 adult patients were included in the study. The progression free survival (PFS) and overall survival (OS) rates at 1 and 5 years were compared in patients who had either desflurane or isoflurane alone or in combination with propofol infusion. Multivariate analyses were conducted to test the association between preoperative, intraoperative and postoperative hyperglycemia with PFS and OS. Results Kaplan–Meier curves demonstrated similar survival in patients who had either desflurane or isoflurane. The use of a propofol infusion during surgery did not affect survival. Univariate analysis demonstrated that age, body mass index and the adjusted Charlson comorbidity score were associated with reduced survival. The multivariate analysis confirmed that age and BMI but not the type volatile anesthetic use were independent prognostic factors for PFS (HR, 95%CI: 1.07, 0.85–1.37, 9 = 0.531) and OS (HR, 95%CI: 1.13, 0.86–1.48, p = 0.531). Conclusion The use of isoflurane or desflurane during GBM surgery is not associated with reduced PFS or OS.

Background Several studies have examined the association between hyperglycemia in the first 10 to 12 weeks following surgery and postoperative survival in glioblastoma multiforme (GBM) patients. We hypothesize that episodes of hyperglycemia before, during and/or following surgery for primary GBM are independent predictors of disease progression and mortality. Materials and methods A total of 162 adult patients were included in the analysis. All patients received adjuvant temozolamide. The progression free survival (PFS) and overall survival (OS) rates at 1 and 5 years were analyzed using different glycemic cutoff values. Multivariate analyses were conducted to test the association between preoperative, intraoperative and postoperative hyperglycemia with PFS and OS. Results Kaplan-Meier curves revealed a trend toward increased PFS and OS with lower glucose concentrations with the exception of glucose concentrations >180 mg/dL in the intraoperative/postoperative day 0 time period. Univariate analysis of blood glucose levels did not demonstrate a statistically significant effect on PFS in any time period, however hyperglycemia was statistically significant for OS in the preoperative time period. Although, multivariate analysis showed no statistically significant association with hyperglycemia on PFS, a statistically significant decrease in OS was seen for plasma glucose concentrations >112 mg/dL (P=0.01) and >180 mg/dL (P=0.01) in the preoperative period. There was a decreasing effect on OS with blood glucose concentrations greater than the median in multiple time periods (P=0.02). Conclusions Preoperative hyperglycemia is associated with poor OS after GBM surgery.

Cohort studies have suggested that the use of statins is associated with decreased risk of glioma formation and mortality. Here, a cohort of patients with glioblastoma multiforme (GBM) was analyzed to further investigate associations between preoperative use of statins and recurrence, and progression free and overall survival. Patients who had surgery for GBM (N = 284) were followed up for a median of 18.1 months. Seventy-eight patients were taking statins preoperatively while the rest were not. Cox proportional hazards models adjusted for several covariates of interest were applied before and after propensity score matching. Compared with statin users, those not taking the lipid-lowering drugs had similar progression free survival before (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.70–1.26; p = 0.68) and after propensity score matching (HR 0.95, 95% CI 0.67–1.35; p = 0.68). Mortality was similar between both groups of patients before (HR 0.94, 95% CI 0.70–1.22; p = 0.73) and after propensity score matching (HR 1.13, 95% CI 0.78–1.64; p = 0.49). Age and dexamethasone use were independent prognostic factors of survival. Contrary to previously published evidence, this study could not find an association between preoperative statin use and longer survival in GBM patients. Due to the small number of patients and retrospective nature of the study, further work is needed to understand the role of perioperative statins in GBM patients.

When at the conclusion of the Confessio amantis of John Gower (c. 1330–1408) the protagonist Amans is revealed to be old and hoar, Gower’s representation of Amans’s impotence depends on the now little-known elegies of Maximianus (fl. c. 525). A contemporary and critic of Boethius (c. 480–524), Maximianus uses his poems for recounting his sexual activities and erectile dysfunction. Although (or possibly because) Maximianus was pornographic, his writing became a standard school-text in late medieval Western Europe, and his influence can be traced in a number of Middle English poets, including Geoffrey Chaucer (c. 1343–1400) and now Gower. At a crucial concluding point of the Confessio, Gower quotes Maximianus.

Bacterial resistance to antibiotics continues to be a grave threat to human health. Because antibiotics are no longer a lucrative market for pharmaceutical companies, the development of new antibiotics has slowed to a crawl. The World Health Organization reported that the 8 new bacterial agents approved since July 2017 had limited clinical benefits. While a cohort of biopharmaceutical companies recently announced plans to develop 2-4 new antibiotics by 2030, we needn’t wait a decade to find innovative antibiotic candidates. Essential oils (EOs) have long been known as antibacterial agents with wide-ranging arsenals. Many are able to penetrate the bacterial membrane and may also be effective against bacterial defenses such as biofilms, efflux pumps, and quorum sensing. EOs have been documented to fight drug-resistant bacteria alone and/or combined with antibiotics. This review will summarize research showing the significant role of EOs as nonconventional regimens against the worldwide spread of antibiotic-resistant pathogens. The authors conducted a 4-year search of the US National Library of Medicine (PubMed) for relevant EO studies against methicillin-resistant Staphylococcus aureus, multidrug-resistant (MDR) Escherichia coli, EO combinations/synergy with antibiotics, against MDR fungal infections, showing the ability to permeate bacterial membranes, and against the bacterial defenses listed above. EOs are readily available and are a needed addition to the arsenal against resistant pathogens.

Background We sought to determine the effects of alternative resuscitation strategies on microcirculatory perfusion and examine any association between microcirculatory perfusion and mortality in sepsis. Methods This was a prospective, formally designed substudy of participants in the Protocolized Care in Early Septic Shock (ProCESS) trial. We recruited from six sites with the equipment and training to perform these study procedures. All subjects were adults with septic shock, and each was assigned to alternative resuscitation strategies. The two main analyses assessed (1) the impact of resuscitation strategies on microcirculatory perfusion parameters and (2) the association of microcirculatory perfusion with 60-day in-hospital mortality. We measured sublingual microcirculatory perfusion using sidestream dark field in vivo video microscopy at the completion of the 6-h ProCESS resuscitation protocol and then again at 24 and 72 h. Results We enrolled 207 subjects (demographics were similar to the overall ProCESS cohort) and observed 40 (19.3%) deaths. There were no differences in average perfusion characteristics between treatment arms. Analyzing the relationship between microcirculatory perfusion and mortality, we found an association between vascular density parameters and mortality. Total vascular density (beta = 0.006, p

To test the association between the use of scalp blocks for malignant brain tumor craniotomy and survival. This is a retrospective study conducted in a tertiary academic center. Demographic, intraoperative and survival data from 808 adult patients with malignant brain tumors was included in the analysis. Patients were divided in those who received an Intraoperative use of scalp block or not. The progression free survival (PFS) and overall survival (OS) rates were compared in patients who had and had not scalp blocks. Kaplan-Meier method was used for time-to-event analysis including recurrence free survival and overall survival. Multivariate analyses before and after propensity score matching were conducted to test the association between different covariates including scalp blocks with PFS and OS. Five hundred and ninety (73%) of the patients had a scalp block. Before PSM, patients with a scalp block were more likely to have an ASA physical status of 3–4, recurrent tumors and receive adjuvant radiation. Patients with scalp block showed no significant reduction in intraoperative opioids. After adjusting for significant covariates, the administration of a scalp block was not associated with an increase in PFS (HR, 95%CI = 0.98, 0.8–1.2, p = 0.892) or OS (HR, 95%CI = 1.02, 0.82–1.26, p = 0.847) survival. This retrospective study suggests that the use of scalp blocks during brain tumor surgery is not associated with patients’ longer survival.

Uncertainties surrounding the continued operation of older coal generation units, the increased penetration of renewable resources, and the aging or retirement of certain nuclear units have exposed vulnerabilities in the natural gas supply chain. The increased availability and low price of natural gas for electric generation in many parts of the United States compounds them by increasing the economic pressure on various non-gas-fired base-load generation plants. Our growing dependence on natural gas as a primary fuel for electricity generation offers environmental and efficiency benefits, but it also presents operational challenges for independent system operators (ISOs) and regional transmission organizations (RTOs) that depend on the natural gas pipeline and storage network to facilitate reliability objectives. During the peak heating season, pipeline congestion can result in interruptions of gas deliveries to those gas-fired generators lacking primary firm entitlements. Scheduling restrictions associated with the provision of nonfirm transportation for gas-fired generators stress the capability of the electric system to meet demand and maintain operating reserves, as RTOs must quickly replace output from more efficient natural gas-fueled combined-cycle plants and quick-start peakers to maintain electric reliability. In this article, we address the gas-electric interdependencies across the Eastern Interconnection that are the subject of a multitarget research project sponsored by the U.S. Department of Energy (DOE) with the participation of PJM Interconnection, Midcontinent Independent System Operator (MISO), New York Independent System Operator (NYISO), ISO New England (ISO-NE), TVA, and the Independent Electricity System Operator of Ontario (IESO), collectively known as the participating planning authorities (PPAs).

Background Cancer cells can produce lactate in high concentrations. Two previous studies examined the clinical relevance of serum lactate as a biomarker in patients with brain tumors. Patients with high-grade tumors have higher serum concentrations of lactate than those with low-grade tumors. We hypothesized that serum lactic could be used of biomarker to predictor of survival in patients with glioblastoma (GB). Methods This was a retrospective study. Demographic, lactate concentrations and imaging data from 275 adult patients with primary GB was included in the analysis. The progression free survival (PFS) and overall survival (OS) rates were compared in patients who had above and below the median concentrations of lactate. We also investigated the correlation between lactate concentrations and tumor volume. Multivariate analyses were conducted to test the association lactate, tumor volume and demographic variables with PFS and OS. Results The median serum concentration of lactate was 2.3 mmol/L. A weak correlation was found between lactate concentrations and tumor volume. Kaplan–Meier curves demonstrated similar survival in patients with higher or lower than 2.3 mmol/L of lactate. The multivariate analysis indicated that the intraoperative levels of lactate were not independently associated with changes in survival. On another hand, a preoperative T1 volume was an independent predictor PFS (HR 95%CI: 1.41, 1.02–1.82, p = 0.006) and OS (HR 95%CI: 1.47, 1.11–1.96, p = 0.006). Conclusion This retrospective study suggests that the serum concentrations of lactate cannot be used as a biomarker to predict survival after GB surgery. To date, there are no clinically available serum biomarkers to determine prognosis in patients with high-grade gliomas. These tumors may produce high levels of lactic acid. We hypothesized that serum lactic could be used of biomarker to predictor of survival in patients with glioblastoma (GB). In this study, we collected perioperative and survival data from 275 adult patients with primary high-grade gliomas to determine whether intraoperative serum acid lactic concentrations can serve as a marker of prognosis. The median serum concentration of lactate was 2.3 mmol/L. Our analysis indicated the intraoperative levels of lactate were not independently associated with changes in survival. This retrospective study suggests that the serum concentrations of lactate cannot be used as a biomarker to predict survival after GB surgery.

Article-at-a-Glance Background A study was conducted to test whether patient reports of medical errors via surveys could produce sufficiently accurate information to be used as a measure of patient safety. Methods A survey mailed regularly by a large multispecialty medical group to recent patients to assess their satisfaction and error experiences was expanded to collect more details about the patient-perceived errors. Following an initial mailing to 3,109 patients and parents of child patients soon after they had office visits in June 2005, usable mailed or phone follow-up responses were obtained from 1,998 respondents (65.1% adjusted). Responses were reviewed through a two-stage process that included chart audits and implicit physician reviewer judgments. The analysis categorized the review results and compared patient-reported errors with satisfaction. Results Of the 1,998 respondents, 219 (11.0%) reported 247 separate incidents, for a rate of 12.4 errors per 100 patients. After complete review, only 5 (2.0%) of these incidents were judged to be real clinician errors. Most appeared to represent misunderstandings or behavior/communication problems, but 15.4% lacked sufficient information to categorize. Women, Hispanics, and those aged 41–60 years were most likely to report errors. Those respondents making error reports were much more likely to report visit dissatisfaction than those not reporting them (odds ratio [OR] = 13.8, p Discussion Although patient reports of perceived errors might be useful to improve the patient experience of care, they cannot be used to measure technical medical errors and patient safety reliably without added evaluation. This study's findings need to be replicated elsewhere before generalizing from one metropolitan region and a patient population that is about two-thirds members of one health plan.

Mitochondrial (m) adenosine triphosphate sensitive potassium (K(ATP)) channel opening has been reported to trigger and/or mediate cardioprotection by volatile anesthetics. However, the effects of volatile anesthetics on mitochondrial function are not well understood. Prevention of mitochondrial matrix volume (MMV) contraction during ischemia may contribute to cardioprotection against ischemia/reperfusion injury. We investigated whether sevoflurane increases MMV and if this increase is mediated by mK(ATP) channel opening.Mitochondria from fresh guinea pig hearts were isolated and diluted in buffer that included oligomycin and ATP to inhibit ATP synthesis. Changes in MMV by diazoxide, a known mK(ATP) channel opener, and by different sevoflurane concentrations, were measured by light absorption at 520 nm in the absence or presence of the mK(ATP) channel blocker, 5-hydroxydecanoate.Compared with control, 30-300 microM sevoflurane (approximately 0.2-2.1 vol %) increased MMV by 30%-55%, which was similar to the effect of diazoxide. These increases were blocked by 5-hydroxydecanoate. Higher sevoflurane concentration (1000 microM; 7.1 vol %), however, had no effect on MMV.In clinically relevant concentrations, sevoflurane increases MMV via mK(ATP) channel opening. Preservation of mitochondrial integrity may contribute to the cardioprotective effects of sevoflurane against ischemia/reperfusion injury. Impaired mitochondrial function at supraclinical anesthetic concentrations may explain the observed biphasic response. These findings add to our understanding of the intracellular mechanisms of volatile anesthetics as cardioprotective drugs.

AIM To determine the effect of sedation with propofol on adenoma detection rate (ADR) and cecal intubation rates (CIR) in average risk screening colonoscopies compared to moderate sedation. METHODS We conducted a retrospective chart review of 2604 first-time average risk screening colonoscopies performed at MD Anderson Cancer Center from 2010-2013. ADR and CIR were calculated in each sedation group. Multivariable regression analysis was performed to adjust for potential confounders of age and body mass index (BMI). RESULTS One-third of the exams were done with propofol (n = 874). Overall ADR in the propofol group was significantly higher than moderate sedation (46.3% vs 41.2%, P = 0.01). After adjustment for age and BMI differences, ADR was similar between the groups. CIR was 99% for all exams. The mean cecal insertion time was shorter among propofol patients (6.9 min vs 8.2 min; P < 0.0001). CONCLUSION Deep sedation with propofol for screening colonoscopy did not significantly improve ADR or CIR in our population of average risk patients. While propofol may allow for safer sedation in certain patients (e.g., with sleep apnea), the overall effect on colonoscopy quality metrics is not significant. Given its increased cost, propofol should be used judiciously and without the implicit expectation of a higher quality screening exam.

Emissions changes for a 2005 International tractor operating on low-sulfur diesel and biodiesel in Santa Monica were measured to demonstrate performance and impacts of selective catalytic reduction.

The Untied States Department of Energy is engaged in the research, development and deployment of PHEV technology through the “Advanced Vehicle Testing Activity.” In this program, data has been collected from a Prius PHEV converted by HymotionTM using industry standard dynamometer testing procedures and from in-use operation of fleets. Differences in fuel-only consumption rates observed in the on-road data compared to the dynamometer results were fairly dramatic. Correlations of the driving style and conditions of dynamometer testing and on-road conditions were made possible by comprehensive onroad loggers. A model was developed to infer driving intensity from the on-road dataset from data load measurement during dynamometer testing. The reasons for the shortfall are detailed in the paper. They range from driver aggressiveness, accessory loads, ambient temperature (weather), and the high sensitivity the control system exhibits with increased acceleration pedal demand and higher average cruising speeds.

The Geological Sciences Department at California State University, Fullerton is providing a comprehensive three-year institute for fifty-two 6–12th grade earth science teachers. The National Science Foundation, local industries and school districts are providing the major support for this program which is entitled “Project Catalyst.” The purpose of Project Catalyst is to enhance teacher competencies in earth-science instruction through academic year workshops and two content-intensive summer institutes. The first summer institute included class activities and field study in the eastern Sierra Nevada Mountains. The second will include five weeks of classroom presentations along with visits to local field sites. Half of the participants are also conducting two years of academic-year workshops within their school districts. All of the teachers are writing earth-science activities which will be aligned with state and national guidelines for contemporary earth-science instruction. Activity and resource guides ...

In recent years, the use of remote or home computer terminals has made a significant impact on the IS department and its clients ( users). In response to IS and user needs, including a desire to decentralize the workplace (i.e., IS department) and a belief that home terminals would have a positive effect on productivity and employee morale, IBM decided to implement several such home terminals as a means of determining their effectiveness. This article describes an experiment that measured the effects of implementing a home terminal program.

IEEE 802.3 Ethernet networks, a standard LAN environment, provide a way to auto-negotiate the settings of capacity (10, 100, or 1000 Mb/s) and duplex (full- or half-). Under certain conditions described below, the auto-negotiation protocol fails to work properly. The resultant configuration problem, duplex mismatch, appears to be common; when this problem occurs, the connectivity is impaired, but not completely removed. This can result in performance problems that are hard to locate. This paper describes a work in progress aimed at (i) studying the condition of duplex mismatch in IEEE 802.3 Ethernet networks, (ii) producing an analytical model of duplex mismatch, (iii) validating the model, (iv) studying the effects of duplex mismatch on TCP throughput, (v) designing an algorithm for duplex mismatch detection using data from active testing, and (vi) incorporating the detection algorithm into an existing open-source network troubleshooting tool (NDT).

Identification and treatment of routine tobacco use in medical practice is an effective intervention but is not used consistently. A study was conducted at HealthPartners, a large network-model health plan in Minnesota, to determine the effect of an outcomes recognition strategy that involved bonus funds and the rates at which network physicians document that tobacco users are identified and advised to quit.Audits of 14,489 ambulatory patient records from 19-20 medical groups were conducted to determine the proportion of charts from each medical group that demonstrated identification of smoking status and counseling to encourage quitting at the most recent office visit in each year.Overall mean tobacco use identification increased from 49% +/- 7% (95% confidence interval [CI]) in 1996 to 73% +/- 7% in 1999 (p.001), while advice to quit increased from 32% +/- 10% in 1996 to 53% +/- 10% CI in 1999 (p.005). The number of medical groups with tobacco status identified at80% of visits and80% of tobacco users advised to quit increased from 0 in 1996 to 8 in 1999.Data feedback combined with a financial incentive appear to be an effective way for a health plan to improve physician compliance with the tobacco treatment guideline. Other health plans might consider similar reporting and incentive approaches to effectively engage medical group leadership and to improve the health of their members who use tobacco.

The objective of this study was to evaluate the impact of a multifaceted improvement strategy on diabetes quality of care in a defined population of patients.A multifaceted improvement strategy to enhance diabetes care was deployed to 18 primary care clinics serving 170,000 adults. Interventions empowered patient self-management, supported care team decision making, redesigned office systems, and maximized use of available information technology. Specific goals were to improve glycemic control and reduce cardiovascular risk in all adult diabetes patients. DATA SOURCE AND COLLECTION: Diabetes was identified through pharmacy and diagnostic data (estimated sensitivity 0.91, positive predictive value 0.94), and the target population ranged from 6,542 to 7,037 members over time. Trends in glycosylated hemoglobin (HbA1c) and low-density lipid LDL-cholesterol were analyzed monthly throughout 1999 in both cohorts and serial cross-sections.During 12 months, mean HbA1c improved from 7.86% to 7.47%, and the proportion of patients with HbA1c levels8% rose from 60.5% to 68.3%, and the proportion with HbA1c10% fell from 10.3% to 7.2%. The LDL test rate rose from 47.4% to 57.4%, and mean LDL fell from 120 mg/dl to 116 mg/dl. The proportion with acceptable lipid control (LDL130 mg/dl, or100 mg/dl with coronary artery disease) rose from 48.9% to 57.7%. All changes were significant at p0.01 or less.Clinically significant population-based improvements in diabetes care were observed during a 1-year period using a multifaceted "enhanced primary care" strategy.

The UC Davis FutureCar Team has redesigned a 1996 Ford Taurus as a parallel hybrid electric vehicle with the goals of tripling the fuel economy, achieving California ultra low emissions levels (ULEV), and qualifying for partial zero emissions vehicle (ZEV) credits in California. These goals were approached using a highly efficient powertrain, reducing component weight, and improving stock aerodynamics. A charge depletion driving strategy was chosen to maximize energy economy and provide substantial all-electric operating capabilities. The UC Davis FutureCar couples a Honda 660 cc gasoline engine and a UNIQ Mobility 48 kW-peak brushless permanent magnet motor within a compact, lightweight, and reliable powertrain. The motor is powered by a 15.4 kWh Ovonic Nickel Metal Hydride battery pack. The body of the vehicle has been reshaped using carbon fiber composite panels to improve airflow characteristics and reduce weight. At the 1997 FutureCar Challenge, the vehicle achieved an equivalent fuel consumption of 5.64 L/100 km (41.7 mpg) on the federal urban driving schedule and 3.74 L/100 km (62.8 mpg) on the federal highway driving schedule for a combined fuel consumption of 4.79 L/100 km (49.1 mpg). This represents a doubling of the stock vehicle’s fuel economy. Driving range exceeded 400 km on the combined driving schedules. The vehicle accelerates from 0 to 100 kph in 14.4 seconds and has an all-electric range of 105 km.

Article-at-a-Glance Background In August 1992 the medical director of the 19 Group Health medical clinics (now part of HealthPartners) in Minnesota chartered a continuous quality improvement (CQI) team to improve the pediatric (two-year-old) immunization rates. The team’s work The team created a process flow for the current immunization process, collected data on the process, determined the causes of late or missed immunizations, collected data on children not up-to-date with immunization, analyzed the data, acted on recommendations, and obtained buy-in. The chief reasons for the child's not being up-to-date on immunizations included missed opportunities (when the child is in the clinic receiving care, perhaps for an acute illness, and could have safely received the immunization but did not), no previous visits or chart, and parents instructed to have their child return at two years. Intervention Recommendations pertained to missed opportunities, record keeping, and enhanced patient and provider responsibility. For example, providers were given algorithms for catch-up of patients not on schedule or with incomplete immunizations. Another CQI team was launched to address and simplify the myriad locations in a medical record for recording information on immunizations. An automated vaccine administration record is now being piloted at two clinics. Results Immunizations have increased from a mean of 53.5% before the team started to meet to a mean of 86.5% for the most recent four quarters for which data are available. Conclusions A problem is best addressed by the very people who will have to bring about the necessary changes for the desired improvements.