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To provide empirical evidence comparing pressure ulcer healing rates between different support surfaces, data were analyzed from eligible residents with pressure ulcers (N = 664) enrolled in the National Pressure Ulcer Long-Term Care Study, a retrospective pressure ulcer prevention and treatment study. Support surfaces were categorized as: Group 1 (static overlays and replacement mattresses), Group 2 (low-air-loss beds, alternating pressure, and powered/non-powered overlays/mattresses), and Group 3 (air-fluidized beds). Calculation of healing rates, using the largest ulcer from each resident, found mean healing rates greatest for air-fluidized therapy (Group 3) (mean = 5.2 cm(2)/week) versus Group 1 (mean =1.5 cm(2)/week) and Group 2 (mean = 1.8 cm(2)/week) surfaces (P = 0.007). Healing rates also were assessed using 7- to 10-day "episodes"; each ulcer generated separate episode(s) that included all ulcers when residents had multiple ulcers. Mean healing rates were significantly greater for Stage III/IV ulcers on Group 3 surfaces (mean = 3.1 cm(2)/week) versus Group 1 (mean = 0.6 cm(2)/week) and Group 2 (mean = 0.7 cm(2)/week) surfaces (Group 2 versus Group 3: P = 0.0211). This finding persisted for ulcers with comparable initial baseline areas (20 cm(2) to 75 cm(2)) on Group 2 and Group 3 surfaces; healing improved on Group 3 surfaces (+2.3 cm(2)/week) versus Group 2 surfaces (-2.1 cm(2)/week, P = 0.0399). Residents on Group 3 (6 out of 82; 7.3%) and Group 1 (47 out of 461; 10.2%) surfaces had fewer hospitalizations and emergency room visits than those on Group 2 surfaces (23 out of 121; 19.0%, P = 0.01) despite significantly greater illness in residents on Group 2 and 3 versus Group 1 surfaces (P is less than 0.0001). Despite limitations inherent in retrospective studies, ulcers on Group 3 surfaces versus Groups 1 and Group 2 surfaces had statistically significant faster healing rates (particularly for Stage III/IV ulcers) with significantly fewer hospitalizations and emergency room visits (Group 3 versus Group 2), despite significantly more illness in residents on Group 2 or Group 3 versus Group 1 surfaces. Episode analyses -- providing greater power, uniform treatment duration, and comparable baseline sizes -- confirmed these findings. Air-fluidized support surfaces represent great healing potential that justifies further exploration.

Hospice has become a major component of end-of-life care, but little scientific information is available to guide clinicians in knowing when the use of hospice is appropriate, in knowing how to measure the impact of its care, and in knowing which hospice interventions lead to the best outcomes. The National Hospice Outcomes Project (NHOP) arose from the need to identify patient factors and hospice interventions that are associated with better end-of-life outcomes. Clinical Practice Improvement (CPI) methodology allowed us to generate a large comprehensive database that could identify scientifically hospice interventions associated with better outcomes for specific patient populations. The complex interplay of patients, medical and complementary treatments, and families can be evaluated. This paper describes an overview of the research methods used for the NHOP, describes the project's 13 clinical sites and study population of 1,306 patients, and presents some basic findings from the study.

We present detailed electron-spin resonance investigations on single crystals of the one-dimensional vanadium-oxide bronze beta-Na(1/3)V2O5. From the angular dependence of the g value it can be concluded that the electrons are primarily located on the V1 zigzag chains. The anisotropy of the linewidth, which is determined by the intrachain symmetric anisotropic exchange interaction, favors statistic electron distribution in the metallic and blockwise charge-order in the insulating phase. The temperature dependence of the linewidth indicates the opening of a charge gap at the metal-to-insulator transition at T(MI)=132 K.

We present atomic scale images of a V 2 O 3 single crystal (0001) surface. Depending on preparation two structural modifications of the surface are observed: (i) a reconstructed surface due to dimerization of vanadium ionsand (ii) a defect rich vanadium terminated bulklike surface. From scanning tunneling spectroscopy measurements a gap in the electronic density of states at the Fermi energy is inferred for the reconstructed surface, while the bulklike surface shows metallic behavior. The spectral weight of the quasiparticle peak originating from electronic correlations was measured by photoelectron emission and found to be dramatically different for the two surface modifications, in accordance with the scanning tunneling spectroscopy data. The results proof the sensitivity of V 2 O 3 to surface reconstruction. The fact that different surface modifications can be prepared emphasizes the necessity of a thorough surface characterization for photoelectron emission spectroscopy.

To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long-term care residents.Retrospective cohort study with convenience sampling.Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States.A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry.Data collected for each resident over a 12-week period included resident characteristics (e.g., demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs).Seventy-one percent of subjects (n=1,081) did not develop a PU during the 12-week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses' aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU.A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors.

Restricted access to health care services and medication is associated with overall higher utilization and higher health care costs. Although randomized controlled trials (RCTs) are regarded as the best method of determining whether a treatment strategy does more good than harm, clinical practice improvement (CPI) methods may be a more effective way of achieving superior medical outcomes for the least cost over the course of a patient's care. The Managed Care Outcomes Project, a large-scale CPI study, tracked detailed factors regarding medical care, patients, and outcomes from different managed care settings. Results showed that cost-containment strategies employed by various health maintenance organizations were associated with poor treatment outcomes for patients and in fact increased total health care costs. Psychiatric illnesses were underdiagnosed, and care ranged from patients receiving psychiatric medications without a psychiatric diagnosis to patients with a psychiatric diagnosis receiving no psychiatric treatment at all. Cost-containment strategies appeared to limit psychiatric referrals, frequency of psychiatric visits, and use of certain antidepressants (i.e., selective serotonin reuptake inhibitors). Further, the severity of the primary physical illness in the study population was associated with greater psychiatric illness. The fact that treatment was inconsistent and frequently inappropriate shows the need for better diagnostic and management protocols.

To characterize complications among infants hospitalized for bronchiolitis or respiratory syncytial virus (RSV).Retrospective data from 684 infants with bronchiolitis or RSV pneumonia,or =1 year old, admitted to 10 children's hospitals from April 1995 to September 1996. Outcomes included complication rates and effects on hospital and pediatric intensive care unit (PICU) length of stay (LOS) and hospital costs.Most infants (79%) had one or more complication, with serious complications in 24%. Even minor complications were associated with significantly longer PICU and hospital LOS and higher costs (P.001). Respiratory complications were most frequent (60%), but infectious (41%), cardiovascular (9%), electrolyte imbalance (19%), and other complications (9%) were common. Complication rates were higher in former premature infants (87%), infants with congenital heart disease (93%), and infants with other congenital abnormalities (90%) relative to infants without risk factors (76%). Infants 33 to 35 weeks gestational age (GA) had the highest complication rates (93%), longer hospital LOS, and higher costs (P.004) than other former premature infants.Complications were common in infants hospitalized for bronchiolitis or RSV pneumonia and were associated with longer LOS and higher costs. Former premature infants and infants with congenital abnormalities are at significantly greater risk for complications. Broader use of RSV prevention should be considered for these higher-risk infants.

Magnetization, ferromagnetic resonance (FMR), heat capacity, and electrical conductivity of ${\mathrm{MnCr}}_{2}{\mathrm{S}}_{4}$ spinel single crystals were investigated as a function of temperature and magnetic field. Two \ensuremath{\lambda} anomalies observed in the heat capacity correlate with magnetic phase transformations and their field dependence found in magnetization measurements. The upper \ensuremath{\lambda} anomaly at a temperature of $\ensuremath{\sim}65\mathrm{K}$ marks the onset of ferrimagnetic ordering, while the lower one at $\ensuremath{\sim}4.8\mathrm{K}$ indicates an additional antiferromagnetic ordering of the $A(\mathrm{Mn})$ sublattice. Below the Curie temperature, magnetization, and FMR measurements revealed a positive magnetocrystalline anisotropy. The dominating role of the $B(\mathrm{Cr})$ sublattice in generating this anisotropy is shown.

Background. Portions of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program were used to develop and validate a perioperative risk index to predict abdominal wound dehiscence after laparotomy. Methods. Perioperative data from 17,044 laparotomies resulting in 587 (3.4%) wound dehiscences performed at 132 Veterans Affairs Medical Centers between October 1, 1996, and September 30, 1998, were used to develop the model. Data from 17,763 laparotomies performed between October 1, 1998, and September 30, 2000, resulting in 562 (3.2%) dehiscences were used to validate the model. Models were developed using multivariable stepwise logistic regression with preoperative, intraoperative, and postoperative variables entered sequentially as independent predictors of wound dehiscence. The model was used to create a scoring system, designated the abdominal wound dehiscence risk index. Results. Factors contributing significantly to the model and their point values (in parentheses) for the risk index include CVA with no residual deficit (4), history of COPD (4), current pneumonia (4), emergency procedure (6), operative time greater than 2.5 h (2), PGY 4 level resident as surgeon (3), clean wound classification (−3), superficial (5), or deep (17) wound infection, failure to wean from the ventilator (6), one or more complications other than dehiscence (7), and return to OR during admission (−11). Scores of 11–14 are predictive of 5% risk of dehiscence while scores of >14 predict 10% risk. Conclusions. This abdominal wound dehiscence risk index identifies patients at risk for dehiscence and may be useful in guiding perioperative management.

The authors describe characteristics, treatment, and acute service use associated with agitation and depression in dementia.Authors used retrospective chart review of symptoms, physician-level prescribing, and acute service use over 3 months for 2,487 physically frail older residents, including 1,836 with dementia, (mean age: 79.8 years) in 109 long-term care facilities, describing differences between uncomplicated dementia and three mutually exclusive subgroups of complicated dementia, including dementia with agitation-only, dementia with depression-only, and dementia with mixed agitation and depression.Compared with the other subgroups, frail elderly patients with dementia complicated by mixed agitation and depression have the highest rate of hospitalization, the greatest number of medical diagnoses, and the greatest medical severity, and they receive the greatest number of psychiatric medications. Depression in dementia (either alone or mixed with agitation) was associated with greater prevalence of pain.Dementia complicated by mixed agitation and depression accounts for over one-third of complicated dementia and is associated with multiple psychiatric and medical needs, intensive pharmacological treatment, and use of high-cost services. Research should target this complex, high-risk group to develop appropriate diagnostic criteria and effective treatment interventions.

Patient-controlled analgesia (PCA) pumps are widely used after surgery, but their association with various outcomes is not completely understood. Is PCA pump use related to the incidence of postoperative surgical site infections among patients undergoing open intestinal surgery?We undertook a comprehensive retrospective chart review of 515 randomly selected patients over age 18 who had major rectal or intestinal surgery (Diagnosis Related Groups [DRGs] 146-149) between January 1994 and March 1997 from eight community or teaching hospitals along the U.S. west coast. Of these patients, 214 used PCA pumps. Outcome measures were in-hospital postoperative surgical site infections, respiratory complications, ileus/abdominal distention, urinary tract infection/urinary retention, and length of stay.Use of a PCA pump was significantly associated with increased in-hospital postoperative surgical site infections (10.7% for PCA, 4.0% for no PCA). The odds ratio for PCA use was about 4.0 after controlling for many variables, including severity of illness at admission, body mass index, preadmission use of corticosteroids, perforated viscus, number of previous abdominal operations, wound classification category, hypothermia, malnutrition on admission, preoperative antibiotic use within 2 h before incision, time from hospital admission to surgery, skin prep to incision time, anesthesia start to incision time, surgical skin to skin time, wound closure type, time from incision closure to the start of PCA, use of drains, blood product use, central line use, line infection, mobility assistance required, hospital, DRG, and surgeon.No confounding variables explained the significant association between PCA pump use and in-hospital surgical site infection. These results stand firmly on data that merit additional study to further elucidate possible immunologic effects of PCA pumps.

To adapt the adult Comprehensive Severity Index (CSI) for hospitalized pediatric patients and evaluate the ability of the CSI to predict common outcomes.Adult CSI was modified by a panel of pediatric subspecialists from 10 children's hospitals. Predictive power was evaluated by using retrospective data collected from 16,495 randomly selected children admitted to these hospitals from April 1995 through September 1996. Outcomes were mortality, length of stay (LOS), and cost.Admission CSI score predicted mortality well (Hosmer-Lemeshow tests: P =.41-.98) and discriminated well (area under receiver operating characteristic [ROC] curve range = 0.80-0.99) within 9 case-mix groups withor =10 deaths (P.0001). Maximum CSI score explained the variation in LOS (r2 = 0.13-0.67) and cost (r2 = 0.08-0.73) within 32 case-mix groups (P.005). Significant differences existed in admission and maximum average CSI scores across sites in 26 and 29 of 32 case-mix groups, respectively (P.05). CSI had better predictability than Pediatric Risk of Mortality.The age- and disease-specific pediatric CSI score correlates highly with LOS, cost, and mortality in hospitalized children and can help determine the best clinical practices for specific diseases and adjust for differences in severity of illness across providers.

The pressure dependence of phase transitions in the quasi-one-dimensional vanadium oxide $\ensuremath{\beta}\ensuremath{-}{\mathrm{Na}}_{1/3}{\mathrm{V}}_{2}{\mathrm{O}}_{5}$ has been studied by magnetic susceptibility and electrical resistivity measurements. The pressure dependence of the various transition temperatures is quite different. The transition at $T=240 \mathrm{K},$ previously reported and attributed to ordering on Na sites, and a second transition at $T\ensuremath{\approx}222 \mathrm{K},$ reported here and attributed to a further increase of order on Na sites, are almost independent of pressure. On the other hand, the metal-insulator (MI) transition at ${T}_{\mathrm{MI}}=130 \mathrm{K}$ shifts to lower temperatures, while the magnetic transition at ${T}_{N}=24 \mathrm{K}$ shifts to higher temperatures with increasing pressure. We discuss the different pressure dependencies of ${T}_{\mathrm{MI}}$ and ${T}_{N}$ in terms of increasing interchain coupling and the MI transition to be of Peierls type.

According to the crystal structure of MgB2 and band structure calculations, quasi-two-dimensional (2D) boron planes are responsible for the superconductivity. We report on critical-field and resistance measurements of 5.6-μm-thick MgB2 films grown on a sapphire single-crystal substrate. Resistivity measurements yield a temperature dependence of the fluctuation conductivity above the critical temperature, which agrees with the Aslamazov-Larkin and Maki-Thompson theory of fluctuations in layered superconductors, indicating a quasi-two-dimensional nucleation of superconductivity in MgB2.

Analysis of the leading nonlinear term of the susceptibility χ3(T) of the singlet‐ground‐state heavy‐fermion superconductor UPd2Al3 shows evidence for a jump at TN and a ‘‘third‐order’’ Curie–Weiss type behavior at higher temperatures, inferring quadrupolar or magnetoelastic interactions. These effects are closely related to quadrupolar correlations observed in measurements of the nonlinear susceptibility and calculated in a crystal‐electric‐field approach for the singlet‐ground‐state systems URu2Si2 and PrNi5 .

We have observed two spin-density wave phases in hole-doped metallic ${\mathrm{V}}_{2\ensuremath{-}y}{\mathrm{O}}_{3},$ one evolves from the other as a function of doping, pressure, or temperature. They differ in their response to an external magnetic field, which can also induce a transition between them. The phase boundary between these two states in the temperature-, doping-, and pressure-dependent phase diagram has been determined by magnetization and magnetotransport measurements. One phase exists at high doping level and has already been described in the literature. The second phase is found in a small parameter range close to the boundary to the antiferromagnetic insulating phase. The quantum-phase transitions between these states as a function of pressure and doping and the respective metamagnetic behavior observed in these phases are discussed in the light of structurally induced changes of the band structure.

Objective. Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, and its relationship to severity and impact on outcome is unclear. Using the Pediatric Comprehensive Severity Index, we analyzed the correlation of institutional practice variation with severity and resource utilization in 10 children's medical centers. Methods. Demographics, clinical information, laboratory results, interventions, and outcomes were extracted from the charts of consecutive infants with VLRI from 10 children's medical centers. Pediatric Component of the Comprehensive Severity Index scoring was performed at admission and at maximum during hospitalization. The correlation of patient variables, interventions, and resource utilization at the patient level was compared with their correlation at the aggregate institutional level. Results. Of 601 patients, 1 died, 6 were discharged to home health care, 4 were discharged to rehabilitative care, and 2 were discharged to chronic nursing care. Individual patient admission severity score correlated positively with patient hospital costs (r = 0.48), but institutional average patient severity was negatively correlated with average institutional costs (r = -0.26). Maximal severity score correlated well with costs (r = 0.66) and length of stay (LOS; r = 0.64) at the patient level but poorly at the institutional level (r = 0.07 costs; r = 0.40 LOS). The institutional intensity of therapy was negatively correlated with admission severity (r = -0.03) but strongly correlated with costs (r = 0.84) and LOS (r = 0.83). Conclusions. Institutional differences in care practices for children with VLRI were not explained by differences in patient severity and did not affect the children's recovery but correlated significantly with hospital costs and LOS. Pediatrics 2001;108:851-855; respiratory syncytial virus, bronchiolitis, lower respiratory illness, practice variation, pediatric intensive care, intravascular catheters, Comprehensive Severity Index, severity scoring. of Diseases-Ninth Revision; RSV, respiratory syncytial virus; ISIS, International Severity Information Systems; CSI, Comprehensive Severity Index; ACSIC, Admission Comprehensive Severity Index; MCSIC, Maximum Comprehensive Severity Index; ICD-9-CM, International Classification of Diseases-Ninth Revision-Clinical Modification.

The ferroelectric insulator ${\mathrm{BaTiO}}_{3}$ can be electron-doped by substitution of divalent ${\mathrm{Ba}}^{2+}$ with trivalent ${\mathrm{La}}^{3+},$ creating d states at the transition-metal sites. The successive filling of the $3d$ Ti band initiates a sequence of electronic transitions. First, the system undergoes an Anderson-type insulator-to-metal-transition into a paramagnetic and metallic state, and second, a correlation-induced antiferromagnetic and insulating phase is established for La-rich concentrations. Ceramic ${\mathrm{La}}_{1\ensuremath{-}x}{\mathrm{Ba}}_{x}{\mathrm{TiO}}_{3}$ samples covering the whole concentration range were systematically examined utilizing measurements of resistivity, specific heat, and magnetic susceptibility in the temperature range $1.8lTl300\mathrm{K}.$ The concentration dependence of the Sommerfeld coefficient $\ensuremath{\gamma}$ and the Pauli spin susceptibility was systematically investigated. The temperature dependence of the resistivity was studied in detail. In addition a $(T,x)$ phase diagram of ${\mathrm{La}}_{1\ensuremath{-}x}{\mathrm{Ba}}_{x}{\mathrm{TiO}}_{3}$ was constructed.

We have studied the electronic properties of the ladder compound ${\ensuremath{\alpha}}^{\ensuremath{'}}\ensuremath{-}{\mathrm{NaV}}_{2}{\mathrm{O}}_{5},$ adopting a joint experimental and theoretical approach. The momentum-dependent loss function was measured using electron energy-loss spectroscopy in transmission. The optical conductivity derived from the loss function by a Kramers-Kronig analysis agrees well with our results from local spin density approximation (LSDA) +U band-structure calculations upon application of an antiferromagnetic alignment of the V ${3d}_{\mathrm{xy}}$ spins along the legs and an on-site Coulomb interaction U between 2 and 3 eV. The decomposition of the calculated optical conductivity into contributions from transitions between selected energy regions of the density of states reveals the origin of the observed anisotropy of the optical conductivity. In addition, we have investigated the plasmon excitations related to transitions between the vanadium states within an effective 16-site vanadium cluster model. Good agreement between the theoretical and experimental loss functions was obtained using the hopping parameters derived from the tight-binding fit to the band-structure and moderate Coulomb interactions between the electrons within the $\mathrm{ab}$ plane.

Electron-spin-resonance (ESR) measurements have been performed on ${\mathrm{FeCr}}_{2}{\mathrm{S}}_{4}$ single crystals in the temperature range 4.2--200 K. On decreasing temperature, the resonance lines strongly shift to low fields for the easy magnetization direction, 〈100〉, and to high fields for the hard directions, 〈110〉 and 〈111〉. In the hard directions additional resonance modes appear below 125 K. The nonmonotonic behaviors of the ESR linewidth and intensity indicate substantial changes of the relaxation processes below 125 K, which correlates with the macroscopic dc magnetization and ac susceptibility data.

The inositol polyphosphate 5-phosphatase SHIP plays an important role in negative signalling in B cells and mast cells and in the down-regulation of cytokine receptor-mediated signals in myeloid cells. SHIP is expressed as a 145 kDa full-length protein and an isoform of 135 kDa due to alternative splicing. Additional smaller forms of SHIP which are truncated at the carboxy terminus have been described in bone marrow and peripheral blood mononuclear cells (PBMC). Our data demonstrate that human bone marrow cells and PBMC from healthy donors and patients with acute myeloid leukemia express the 145 kDa form of SHIP and low amounts of a 135 kDa form of SHIP in vivo whereas C-terminal-truncated SHIP proteins are generated by a PMSF-sensitive protease during the preparation of cell lysates in vitro. We have further characterized this protease and identified a proteolytic cleavage site in the human SHIP protein C-terminal to tryptophan residue 941. These data support a physiological role for the 145 and 135 kDa forms of SHIP in bone marrow and peripheral blood cells from normal donors and patients with acute myeloid leukemia.

This chapter focuses on the need for assessment of quality in healthcare as well as the advantages and pitfalls of various approaches to that assessment. Good health services research is the foundation of sound health policy. Although the current best methods may seem cumbersome because they are typically abstracted by hand from existing paper medical records, this situation is likely to change. In the future, most hospitals will use computerized clinical information systems (CISs). Then, rather than relying on labor intensive manual data abstraction, the needed patient, process, and outcome data can be found electronically in the hospitals' CIS. The efficiency and logistics of this new data acquisition modality will make it easier and less costly to conduct iterative clinical practice improvement studies to determine best practices. Also, the resulting research-based dynamic protocols can be programmed into the hospitals' CIS to flag for clinicians the appropriate protocol steps for a specific combination of patient signs and symptoms. This should result in more consistent implementation of protocol steps.

An inelastic neutron scattering (INS) study was performed on the heavy fermion system CePtSi. A Kondo temperature of 16 K can be inferred from the quasielastic line width. There are two inelastic lines corresponding to CF-transitions from the ground to the first and second excited state at 6.3 and 17.8meV, respectively.

Background. The role of perioperative nutrition in surgical patients remains controversial. We performed a Clinical Practice Improvement (CPI) study that, while controlling for severity of illness, explored the relationship between the timing and amount of parenteral or enteral nutrition, with two outcomes: length of stay (LOS) and total charges in patients undergoing open intestinal operations. Materials and methods. A CPI study was conducted at eight hospitals to determine which process steps were associated with shorter LOS and lower charges. Hospital charts were abstracted for over 800 components of detailed patient, process, and outcome measures. Severity of illness was measured multiple times during the stay using the Comprehensive Severity Index, a disease-specific physiologic severity measurement instrument. Data on 1007 patients undergoing intestinal operations, 183 of whom received nutritional support, were then analyzed using multiple regression procedures. Early (within 48 h of surgery) and sufficient (60% of protein and calorie goals) nutrition, patient variables, and a severity of illness measure were included as independent variables and LOS and hospital charges were used as dependent variables. Results. Mean patient age was 58 years. After controlling for severity of illness, patients who received early and sufficient nutrition had significantly shorter LOS (11.9 days) and lower charges ($34,602) than patients who received early (13.3; $36,452), sufficient (14.6, $39,883), or neither early nor sufficient (14.8, $38,578) (P ≤ 0.0001 for early and sufficient versus all other groups). Conclusions. CPI methodology provides a detailed view of the actual relationship between the timing and the amount of nutrition with LOS and hospital charge outcomes.

The heavy fermion compound CePtSi has been studied employing neutron scattering, specific heat, magnetic susceptibility and Hall effect measurements. Only the magnetic susceptibility indicates a magnetic anomaly at low temperatures consistent with previous measurements. It is suggested that the sample dependent properties result from disorder effects.

Magnetization measurements performed on UCu2Si2 and UNi2Si2 are reported. The compound UCu2Si2 appears to undergo both an antiferromagnetic (AFM) transition at T≊107 K and a ferromagnetic (FM) transition at Tc≊103 K. While the second transition at Tc has already been reported, the AFM phase was apparently overlooked in earlier studies. The compound UNi2Si2 undergoes a transition at T≊97 K, which was previously shown to be AFM by neutron scattering; we present evidence for the occurrence of a FM state below the AFM transition.

Pressure‐dependent electrical resistivity measurements on CePtGe and CePt2, which belong to the class of magnetically ordering Kondo lattice systems, reveal that the antiferromagnetic transition temperature TN, as determined from the position of the maximum of the derivative dρ/dT, depends only weakly on the applied external pressure. At higher temperatures the shape of the ρ(T) curve indicates the presence of crystal‐field effects. Application of pressure does not affect the high‐temperature behavior significantly. In view of these results, which suggest a characteristic temperature smaller than TN for these systems, we discuss a steep decrease of the resistivity at T≊10 K in CePtGe and CePt2 in terms of magnetic short‐range order between local moments rather than in terms of formation of a coherent Kondo ground state.

Lyme disease is well known for affecting the myocardium in the form of carditis and dilated cardiomyopathy. Pericardial effusion associated with Lyme disease has not been described as yet. This article demonstrates a case of a female patient, 54 years of age, with Borrelia burgdorferi infection and associated pericardial effusion. Recurrent pericardiocenteses as well as conventional treatment of the condition were without success. Diagnosis of Borrelia infection and subsequent treatment with ceftriaxone led to permanent restitution of the pericardial effusion.

We have measured the V 2p3/2 and O 1s X-ray absorption spectra of singlecrystal V2O5 and compared them with linear-combination-of-atomic-orbitals density-of-states (DOS) calculations. The spectra change dramatically with incident angle and the use of polarized light and a single crystal limits the number of transitions possible, revealing spectral features that cannot be resolved using polycrystals (angle integrated). The measured O 1s and V 2p3/2 spectra agree with the projected unoccupied O 2p and V 3d DOSs respectively, indicating that atomic effects alone cannot adequately describe the absorption spectrum, but that solid-state effects, including V-O hybridization, must be included.

Objective : To report lessons learned from evaluation of an automated interface between a hospital clinical information system and a severity of illness index. Design : A system was developed to convert coded electronic patient findings from the HELP System at LDS Hospital into the attributes used by the Computerized Severity Index (CSI) to calculate a severity of illness score. Performance was assessed by comparing the automated CSI score with the manual CSI score (from paper chart review) and by evaluating changes introduced by augmenting the manual CSI score with verified patient data discovered by the automated CSI method. Measurements : The strengths and weaknesses of each method are presented. Results : The automated CSI score matched the manual CSI score in 61% of the cases. Sources of errors were analyzed. When the automated score was in error, two-thirds of the time it was due to the lack of codes in the HELP system representing CSI concepts; one-third of the time it was due to nurses not using established HELP system codes. Surprisingly, significant problems were also discovered in the manual system, making it difficult to define a “gold standard.” Conclusions : Automated computerized severity indices have great potential for future applicability once their performance exceeds that of the time-consuming manual chart review method. Neither automated nor manual methods are adequate at the present time. This area remains a fertile ground for future research.

Many American healthcare facilities have come to understand that quality controls cost. Clinical practice improvement (CPI) is a methodology that creates a clinical laboratory, built into the everyday practice setting, to find and test best practices. A CPI study is an analysis of the content and timing of individual steps in a medical care process aimed at producing better clinical outcomes for the least necessary cost over the continuum of a patient's care. Statistical regression analyses are used to determine whether and how much a particular step actually improves medical outcomes. Systematic determination of individual process steps that improve medical outcomes is the best way to develop demonstrably better care and practice. Combining CPI methodology and a data monitor creates a dynamic environment in which all patient encounters potentially contribute to improving the process of care. We describe a recent multisite study: the Managed Care Outcomes Project (MCOP). The MCOP study design permits us to compare the effects of various pharmaceutical treatments on resource utilisation in actual practice in managed-care organisations. The MCOP database is an important resource for developing information required to design systems-based disease management programmes.

The advent of several signal-averaged electrocardiogram (SAECG) systems for late potential (LP) assessment warrants comparisons to assess intersystem reproducibility and variability. Simultaneous SAECGs on two systems, Arrhythmia Research Technology (ART) and Marquette (MEI), were performed on 104 normal volunteers (53 males, age 44 +/- 14 years), and analyzed filtered QRS duration (TFQRS), root mean square voltage (RMS40), and low amplitude signal duration (LAS40), filtered at 40-250 Hz. The Gomes criteria (TfQRS114 msec, RMS4020 microV and LAS4038 msec) were used as criteria for LP. The data was also analyzed using the recently proposed system specific criteria for MEI (TFQRS120 msec, RMS4020 microV and LAS4038 msec). Where appropriate, statistical analysis was performed using simple linear and Spearman's rank correlation, analysis of variance, Finn's R and McNemar's test.The means +/- SD for ART and MEI were: TFQRS: 97.2 +/- 8.9 vs 108.2 +/- 7.2 msec (R = 0.76), RMS40: 31.8 +/- 17.8 vs 45.3 +/- 19.9 microV (R = 0.53), and LAS40: 32.2 +/- 8.4 vs 30 +/- 7.4 (R = 0.54). When the Gomes criteria were applied, the number of subjects identified by each system as abnormal were: TFQRS = 3 vs 22 (P0.001), RMS40 = 20 vs 8 (P = 0.004), LAS40 = 21 vs 9 (P = 0.004), TFQRS/RMS40 = 3 vs 6 (P = 0.38), TFQRS/LAS40 = 3 vs 7 (P = 0.22), RMS40/LAS40 40 = 17 vs 8 (P = 0.02), and all three criteria = 3 vs 6 (P = 0.38) for ART vs MEI, respectively. Percent agreement was 81.7% for TFQRS and 84.6% for RMS40 and LAS40 when single criteria were applied. Agreement improved when combined criteria were utilized (87.5%-95.2% for any two criteria and 95.2% for all three criteria). The intersystem agreement that was not due to chance was 0.63-0.69 for single criteria and 0.75-0.90 for combined criteria. Disagreement was highly significant for the three criteria when used singly and for RMS40 and LAS40 combined. Disagreement was not significant when TFQRS was used in combination withor = one other criteria. When the MEI criteria were applied, there was a decrease in the number of subjects identified by the MEI system as abnormal, using the TFQRS criteria singly or in combination. Percent agreement for system specific TFQRS measurements was 94.2% for single criteria and 97.1% for combined criteria. The intersystem agreement that was not due to chance improved (88-0.94). Disagreement between system specific criteria for TFQRS was not significant (P0.05).Our data indicate that although there is a general correlation between ART and MEI measurements, variability is substantial, leading to significant differences when the criteria for LP are applied, especially for single parameter determinations. Thus, there is a need to establish system specific normal ranges and more accurate criteria for LP parameters.

Many autoantibodies have been described in HIV-infected individuals. We have examined the incidence, associations and prognostic significance of anti-nuclear antibodies (ANA), anti-neutrophil cytoplasmic antibodies (ANCA) and anti-glomerular basement membrane (GBM) antibodies in individuals with HIV infections. One hundred and five patients, with asymptomatic infections (n = 37), AIDS-related complex (n = 32) or AIDS (n = 36) were studied. Plasma from 24 of these (23%) were positive for ANA: most demonstrated speckled fluorescence (n = 21) and were of low titre (1+ in 18). ANCA were demonstrated by IIF in 18 individuals (17%) and all fluorescent patterns were seen; 6 of these plasma were also positive in the ELISAs for antibodies to proteinase 3, myeloperoxidase or elastase. Thirteen plasma were positive for ANCA in the neutrophil cytoplasm ELISA; 10 of these were also positive in the specific ELISAs. A total of 30 plasma bound to proteinase 3, myeloperoxidase or elastase in specific ELISAs, in 6 cases with 2 specificities. Finally, 18 plasma (17%) contained anti-GBM antibodies by ELISA, but none of 4 plasma tested in inhibition assays was specific. ANA, ANCA and anti-GBM antibodies were not uncommon in HIV-infected individuals but the presence of these antibodies was not associated with the clinical manifestations of the corresponding autoimmune diseases. In addition, there was no correlation between the demonstration of these antibodies and the immunological status of the individual (apart from a correlation between CD4 counts less than 400/microliters with anti-GBM antibodies), the presence of an opportunistic infection, the development of malignancy or reduced survival. Some of these antibodies may arise from polyclonal activation, or be due to "sticky" serum since we have shown that the presence of anti-GBM antibodies correlated with the demonstration of ANCA by ELISA. These antibodies are not more common in hypergammaglobulinemic plasma but some may be due to heat-treatment of the plasma. The clinician caring for HIV-infected individuals needs to be aware of these "false-positive" antibody results.

We were disappointed with the conclusions of Harris (1) and the accompanying editorial (2) on self-monitoring of blood glucose (SMBG). The article is based on outdated data and reflects an era with much less SMBG capability and convenience, reimbursement, therapeutic modalities, and evidence for the benefits of improved glycemic control. Moreover, the study itself was uncontrolled, self-reported, and did not indicate whether the patients were taught about data usage. It would be unfortunate if this article and editorial were used to justify denial of appropriate reimbursement for SMBG in type 2 diabetes. Optimal modern therapy of type 2 diabetes uses a “treat-to-target” approach, expeditiously moving patients along a …

The theoretical description of the Fulde-Ferrell-Larkin-Ovchinnikov like state establishing in nanostructered bilayers of ferromagnetic (F) and superconducting (S) material leads to critical temperature oscillations and reentrant superconductivity as the F-layer thickness gradually increases. The experimental realization of these phenomena is an important prerequisite for the fabrication of the Ferromagnet/Superconductor/Ferromagnet core structure of the superconducting spin-valve. A switching of the spin-valve is only expected if such non-monotonic critical temperature behavior is observed in F/S bilayers as well as in the S/F bilayers, a combination of which the spin-valve core structure can be regarded to consist of. In our former investigations we could demonstrate the required non-monotonic behavior of the critical temperature in S/F bilayers. In this study we succeeded in the preparation of F/S bilayers, where the superconducting material is now grown on top of the ferromagnetic metal, which show deep critical temperature oscillations as a function of the ferromagnetic layer thickness as well as an extinction and recovery, i.e. a reentrant behavior, of superconductivity. Especially, the latter is necessary to obtain a spin-valve with a large critical temperature shift between the parallel and antiparallel configurations of magnetizations in the F layers., Comment: 18 pages, 5 figures

Multiple overlapping thin-slab acquisition (MOTSA) is a hybrid time-of-flight MR angiography technique that combines the advantages of two- and three-dimensional methods. A venetian blind-like artifact, resulting from variations in signal intensity at slab boundaries, is a potentially significant disadvantage. The objective of this study was to determine the accuracy of MOTSA MR angiography for the measurement of stenosis and to evaluate the effectiveness of modifications to reduce the venetian blind artifact.Fifty-one consecutive patients undergoing conventional and MR angiography of the carotid arteries for suspected atherosclerotic disease were studied. Methods established in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) were used to measure stenosis. Measurements from the conventional angiograms were compared with those from the MR angiograms. Modifications of the MR angiographic technique that were instituted after the initial 26 patients to reduce the venetian blind artifact included new acquisition parameters and the use of a postprocessing algorithm.After modification, highly significant improvements in Spearman ranked correlation coefficients were observed for MR angiography interobserver comparison (.573 to .974, p.001) and comparison of conventional and MR angiography (.774 to .949, p.001). A corresponding reduction was observed in the standard deviation of the difference measurement for percent stenosis for both interobserver (34.5% to 11.7%, p.001) and intertechnique (22.6% to 12.6%, p.001) comparisons. In the postmodification group, the interobserver correlation coefficients for conventional and MR angiography were not significantly different (.969 vs .974). The areas under the receiver-operating-characteristic curves used to predict surgically significant disease for the premodification and postmodification groups were 0.79 and 0.98, respectively, for observer A and 0.85 and 0.95, respectively, for observer B.Improved acquisition parameters and postprocessing significantly reduce the severity of the venetian blind artifact and increase the accuracy of MOTSA MR angiography in the measurement of percent stenosis. With these improvements, MOTSA MR angiography shows promise for noninvasive evaluation of stenosis of the carotid arteries.

Artery wall calcification associated with atherosclerosis frequently contains fully formed bone tissue including marrow. The cellular origin is not known. In this study, bone morphogenetic protein-2a, a potent factor for osteoblastic differentiation, was found to be expressed in calcified human atherosclerotic plaque. In addition, cells cultured from the aortic wall formed calcified nodules similar to those found in bone cell cultures and expressed bone morphogenetic protein-2a with prolonged culture. The predominant cells in these nodules had immunocytochemical features characteristic of microvascular pericytes that are capable of osteoblastic differentiation. Pericyte-like cells were also found by immunohistochemistry in the intima of bovine and human aorta. These findings suggest that arterial calcification is a regulated process similar to bone formation, possibly mediated by pericyte-like cells.

An investigation was carried out on the effect of lecithin (phosphatidylcholine, 90%) on the plasma choline concentrations during continuous strain in 10 top level triathletes (4 women and 6 men), trial I, and 13 excellent adolescent runners (3 girls and 10 boys), trial II. Venous blood, collected before and immediately after the race, was separated and plasma was assayed by an improved high performance liquid chromatography method for choline. Each study comprised three experiments. In trial I the triathletes performed two periods of bicycle exercise each lasting 2 h at an average speed of 35 km · h−1, and in the second study (trial II) the subjects were subjected to severe physical stress on two occasions during cross-country races of durations between 30–60 min according to their ages. The participants received either a placebo or 0.2 g lecithin · kg body mass−1, 1 h before each exercise. As a control the same dose of lecithin was administered without any exercise (both trials I and II). Bicycle exercise without lecithin supply decreased plasma choline concentrations in all the triathletes, on average by 16.9% (P≤0.01). When lecithin was given before exercise, average plasma choline concentrations remained at the same level as the initial values. The supply of lecithin without exercise led to a significant increase of the plasma choline concentrations, on average by 26.9% (P≤0.01). In trial II, when running without a supply of lecithin, the mean plasma choline concentrations in the adolescent runners remained stable which may have been due to the duration of the physical stress. When lecithin was given before exercise, plasma choline concentrations increased, on average by 18.9% (P≤0.01). The administration of lecithin without exercise led in these participants to an increase in plasma choline concentrations, on average by 54% (P≤0.001). It was found from the present study that a combination of both lecithin intake and hard physical stress prevented in most subjects a decrease in plasma choline and this could affect performance.

The case of a 19-year-old male who sustained a severe brain injury is described. This patient was initially given a very gloomy prognosis, leading to poor expectations for recovery. Additionally, like many such patients in the United Kingdom, he was cared for by a ward team who were without specialized training in head injury rehabilitation. Despite these factors the patient went on to make a good recovery. The issues of specialized care and the need for more appropriate patient assessment procedures are raised. The MRC Head Injury Assessment Project is described.

We have studied the magnetic relaxation rate of Li 1− x Zn x V 2 O 4 by means of quasielastic neutron scattering. At low temperatures, LiV 2 O 4 shows the typical features of a canonical heavy fermion state, namely a residual quasielastic line width of 0.5 meV and a square root temperature dependence. However, at elevated temperatures, LiV 2 O 4 behaves like a weak ferromagnetic d-metal. Zn doping leads to a lattice expansion and drives the system via a spin glass state to an antiferromagnetically ordered state in pure ZnV 2 O 4 . For low Zn concentrations, a similar behavior of the magnetic relaxation rate is observed as in pure LiV 2 O 4 . A slight increase of the residual line width and a strong decrease of the intensity is observed upon increasing Zn concentration. The results may indicate the presence of magnetic inter-site fluctuations at low temperatures.