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This report describes restructuring on four critical care units at an acute, tertiary care hospital in South-east Pennsylvania. Utilizing a Patient Centered Care conceptual framework that had been successfully applied in the medical-surgical areas, restructuring involved three main areas: revamping of work processes, inclusive of redesigned staff roles; environmental and facility changes; and enhancement of telecommunication and information systems. Preliminary analyses six months post redesign revealed improvements and maintenance in four outcomes areas--satisfaction, quality and efficiency, and costs of care.

Increasingly, hospital restructuring is viewed with skepticism because of a lack of systematic and rigorous evaluation of its impact on quality of care. This first article in a two-part series describes comprehensive evaluation of the effects of hospital restructuring on patient satisfaction, nurse satisfaction, costs of care, and clinical quality on four medical-surgical units at a large tertiary hospital. In addition, early application of the model to critical care is described. A quasiexperimental pre- and post-design combined with concurrent control units for selected measures was the overall strategy. The authors conclude that comprehensive restructuring of hospital-based care can take place in a manner that preserves multiple dimensions of quality while decreasing costs. This only can be ascertained, however, through rigorous and systematic measurement and evaluation. Part 2 will detail application and evaluation of the restructuring model in the critical care environment.

The molecular structure of nido-1,2-C(2)B(3)H(7), 1, the principal volatile carborane generated in the quenched gas-phase reaction of B(4)H(10) and ethyne at 70 degrees C, has been determined by a combined analysis of gas-phase electron-diffraction data and rotation constants restrained by ab initio computations at the CCSD(T)/TZP' level. The structure is consistent with a geometry having C(s)() symmetry, similar to that of pentaborane(9). The apical position is occupied by a carbon atom, displaced toward B(4) from a position directly above the B(5).B(3) vector, and hydrogen atoms asymmetrically bridge the B-B bonds. The basal atoms are almost coplanar, C(2) lying ca. 2 degrees below the B(3)-B(4)-B(5) plane. Important experimental structural parameters (r(alpha) degrees /pm, angle(alpha)/ degrees ) are r[C(1)-C(2)] = 162.6(6); r[C(1)-B(3)] = 161.4(3); r[C(2)-B(3)] = 154.3(2); r[C(1)-B(4)] = 157.4(5); r[B(3)-B(4)] = 185.7(3);

This article reports on study evaluating the effects of hospital restructuring on patient satisfaction, nurse satisfaction, cost of care, and clinical quality. The restructuring involved facility redesign, telecommunications enhancement, and implementation of patient care processes incorporating multiskilled personnel and case facilitation systems. The results indicate improved patient and nurse satisfaction, decreased length of stay and variable cost per patient day, and good clinical outcomes.

The technique of early extubation after coronary artery bypass grafting is increasing in popularity, but its safety and effect on myocardial ischaemia remain to be established. In a randomized, prospective study, patients undergoing routine elective coronary artery bypass grafting were managed with either early or late tracheal extubation. The incidence and severity of electrocardiographic myocardial ischaemia were compared. Data were analysed from 85 patients (43 early extubation; 42 late extubation). Median time to extubation was 110 min in the early extubation patients and 757 min in the late extubation patients. After correction for randomization bias, there were no significant differences between groups in ischaemic burden, maximal ST-segment deviation, incidence of ischaemia and area under the ST deviation-time curve (integral of ST deviation and time). Similarly, there were no differences between groups in postoperative creatine kinase MB-isoenzyme concentrations and duration of stay in the ICU or hospital. Therefore, this study provides evidence for the safety of early extubation after routine coronary artery bypass grafting.

Organizations have expended enormous resources to restructure care delivery Despite the growing literature describing these organizational innovations there is a paucity of credible data that reflects systematic measurement and evaluation of such changes. This report not only describes a comprehensive research based restructuring effort in a 720 bed acute care hospital, but it also describes an outcomes evaluation strategy and associated findings that may serve as a model and a guide for other healthcare institutions.

As the most common lethal autosomal recessive disorder in North America, cystic fibrosis (CF) is an obvious candidate for general population carrier screening. Although the identification of the causative gene has made detection of asymptomatic carriers possible, the extreme heterogeneity of its mutations has limited the sensitivity of the available DNA screening tests and has called into question their utility when they are applied to patients with no family history of the disease. The purpose of this study was to determine the technical feasibility, patient acceptance and understanding, and psychosocial impact of large-scale CF carrier screening in an ethnically diverse pregnant population. A total of 4,739 pregnant women attending prenatal clinics located in both an academic medical center and a large HMO were invited in person to participate. Of this group, 3,543 received CF instruction and assessments of knowledge and mood, and 3,192 underwent DNA testing for the six most common CF mutations, by means of a noninvasive PCR-based reverse-dot-blot method. Overall participation rates (ranging from 53% at the HMO to 77% at the academic center) and consent rates for DNA testing after CF instruction (>98%) exceeded those of most other American studies. The PCR-based screening method worked efficiently on large numbers of samples, and 55 carriers and one at-risk couple were identified. Understanding of residual risk, anxiety levels, and overall satisfaction with the program were acceptable across all ethnic groups. Our strategy of approaching a motivated pregnant population in person with a rapid and noninvasive testing method may provide a practical model for developing a larger CF screening program targeting appropriate high-risk groups at the national level, and may also serve as a paradigm for population-based screening of other genetically heterogeneous disorders in the future.

The molecular structure of trifluorophosphine tetraborane(8), B(4)H(8)PF(3), has been studied in the gas phase by electron diffraction. The experimental data can be fitted using a model which represents the gas as consisting solely of the endo conformer with C(s)() symmetry, the PF(3) group staggered with respect to the B(1)-H(1) bond. Important experimental structural parameters (r(alpha) degrees ) are r[B(1)-B(2)] (hinge-wing) = 184.7(9) pm, r[B(1)-B(3)] (hinge-hinge) = 172.2(12) pm, r[B(2)-B(3)] = 179.9(10) pm,r[B(1)-P] = 179.8(9) pm, and r(P-F) (mean) = 152.8(1) pm; B(3)B(1)P = 131.6(11) degrees, and the dihedral ("butterfly") angle between the planes B(1)B(2)B(3) and B(1)B(4)B(3) is 133.9(23) degrees. These values agree well with the ab initio (MP2/TZP level) optimized molecular geometry for the endo conformer; at the MP2/TZP//MP2/TZP + ZPE(HF/6-31G) level, the exo conformer is predicted to represent ca. 2% of the compound vapor, consistent with the experimental (11)B NMR solution spectrum. The experimental and theoretical geometries are supported by comparison of the calculated (IGLO) (11)B NMR chemical shifts with the experimental NMR data.

In this study we examined the relations among psychosocial factors associated with pregnant women's attitudes toward genetic carrier testing for cystic fibrosis (CF). A sample of 511 pregnant women attending various health clinics for general prenatal care were educated about CF. Women's health beliefs, coping styles, and attitudes toward CF carrier screening were assessed. Results from structural equation modeling analyses indicated that women who perceived themselves as more likely to be carriers of the CF gene and who perceived greater benefits of screening were positively inclined toward genetic screening. Perceived barriers to screening were negatively associated with women's attitudes toward CF genetic testing. In addition, the findings suggest that some types of avoidant coping styles may indirectly influence one's decision to undergo genetic screening through perceptions of risk, benefits, and barriers. Given the advent of genetic screening options for many diseases, in this study we address some issue in women's attitudes toward prenatal screening that are relevant to a variety of genetic screening programs.

Patients sometimes notice an onion or garlic taste before losing consciousness with thiopentone. An assessment of 113 patients revealed that 42% of patients noticed this taste. The effect was observed less in older patients. There was no statistically significant difference in the incidence between men and women. Premedicated patients had a lower incidence, but this was explained by the greater proportion of older patients receiving a premedication. If the taste effect of thiopentone is genetically determined then it is a different gene to thiocarbamate which has about 75% tasters.

Nasogastric (NG) tubes are routinely used in patients undergoing cardiac surgery. This randomized study was designed to assess gastroesophageal reflux (GER) without a NG tube (control) compared with a NG tube managed either by gravity drainage (gravity) or continuous low-grade suction (suction). Antimony pH probes were placed in the lower esophagus and trachea after induction of anesthesia in 51 patients, and pH was recorded every 5 s until the time of tracheal extubation. GER was defined as reversible decrease in esophageal pH to less than 4.0. No significant difference was found between groups in age, weight, gender, duration of postoperative ventilation, morphine use, or antiemetic use. All indicators of GER were seen more frequently in the gravity group compared with the two other groups (P < 0.001). One episode of sudden decrease in tracheal pH was observed in a patient in the gravity group, indicating tracheal aspiration, which was associated with delayed extubation and postoperative pneumonia. The absence of a NG tube is not associated with reflux, probably since the gastroesophageal sphincter remains competent. NG tubes are not routinely necessary for cardiac surgery in patients without risk factors for GER, and increase reflux risk if managed without low-grade suction.

Several families of peptides composed of alternating L-alanine (Ala) and alpha-aminoisobutyric acid (Aib) residues with an appended N,N-dimethylanilino and/or 2-naphthalenyl group exist in MeOH and CDCl(3) as alpha-helices. Steady state and time-resolved fluorescence measurements show that the distance and dihedral angle between the appended donor and acceptor and the alignment of the vectors for intramolecular charge transfer interaction (from donor to acceptor) with or against that of the helical dipole moment significantly influence the efficiency of photoinduced electronic coupling and, hence, of intramolecular fluorescence quenching.

Objective: The purposes of this study were to describe and compare the prevalence of disease features in subjects with Mycobacterium avium complex (MAC) disease with those of Mycobacterium tuberculosis infection (MTB), to compare the abilities of CT and chest radiography to identify the features of MAC disease, and to determine if sputum positivity is related to any of the CT features of MAC disease., Methods: Computed tomographic scans of 15 subjects with MTB and 55 subjects with MAC were reviewed by 2 observers. Sputum culture results (obtained within 1.9 +/- 2.8 days of scanning) were available in 50 of the 55 subjects with MAC., Results: Bronchiectasis involving four or more lobes (often associated with centrilobular nodules) was seen only in subjects with MAC. The combination of right middle lobe and lingular bronchiectasis was seen only in MAC (p = 0.015). Thirty-one of the 34 subjects (91%) with MAC who had cavities on CT had a positive sputum culture within 3 weeks of CT, compared with 7 of 12 subjects (58%) without cavities (p = 0.001). Similarly, 36 of 42 subjects (85%) with airspace disease, but only 2 of 8 subjects (25%) without airspace disease grew mycobacteria from their sputa (p < 0.001). Sputum positivity was not associated with the presence of bronchiectasis (p = 0.156) or nodules (p = 0.377)., Conclusion: A subgroup of patients with MAC may be distinguished from those with MTB by the presence of widespread bronchiectasis, particularly if it involves the right middle lobe and lingula. Cavities and airspace opacification on CT are associated with positive sputum cultures for MAC.

Population-based screening for cystic fibrosis carrier mutations presents a number of challenges for genetic counselors, owing primarily to the inability of current DNA testing technology to identify all possible mutations and the difficulty involved in conveying the concept of residual risk to those patients who test negative. To address these issues, we are conducting a pilot study, as part of a consortium established by the National Center for Human Genome Research, to explore the efficacy, acceptance, and psychosocial impact of various approaches to carrier screening in an ethnically diverse Southern California population. This article reports the patient instructional and screening strategies we developed in the initial phase of the project in order to optimize our chances of answering these questions and delivering this service on a large scale.

We studied three groups of patients without previous renal impairment, undergoing elective coronary artery bypass surgery. Group H (n = 7) underwent open heart surgery using moderate hypothermia (28 degrees C); Groups N and M (n = 8, each) were managed at normothermia. The extracorporeal circuit was primed with Hartmann's solution 2.5 L with the addition of mannitol 0.5 g/kg in Group M. Serum concentrations of sodium and creatinine, and the urinary concentrations of microalbumin and N-acetyl-beta-D-glucosaminidase (NAG) were measured in each patient at six different time intervals: T0, 6 h prior to surgery; T1, between sternotomy and 45 min into cardiopulmonary bypass (CPB); T2, in the interval from 45 min into, to prior to weaning off CPB; T3, from coming off CPB to skin closure; T4, in the first 6 h in the intensive care unit; and T5, at 6 days postoperatively. Creatinine clearance (CCR) and fractional sodium excretion (FENA) were calculated at each time point. Urine output during CPB at Interval T2 was significantly higher in Group H compared to Group N (P = 0.03) but not Group M. We found no significant differences in CCR, FENA, microalbuminuria, and urinary NAG among the three groups at any time. However, there were overall significant changes in measured variables over time compared to baseline. We conclude that CPB is associated with a significant alteration in renal function as shown by increased FENA, microalbuminuria, and urinary NAG. The use of hypothermic or normothermic CPB and the use of prophylactic mannitol did not produce any significant modification of these changes.

Objective: To evaluate which Doppler transmitral velocity indices of left ventricular diastolic function change with alteration of left ventricular filling pressure., Methods: Twenty-two patients undergoing coronary artery bypass surgery. The effect of fluid loading on indices derived from the transmitral Doppler waveform, recorded by a trans-oesophageal echocardiography, was evaluated using a generalised linear statistical model., Results: E-wave maximum velocity, E-wave acceleration time and slope, E-wave deceleration slope, A-wave maximum velocity and E/A wave maximum velocity ratio showed significant changes after alterations in left ventricular filling pressure. E-wave deceleration time and E-wave maximum velocity/time velocity integral showed no significant change after fluid loading., Conclusion: Several commonly used Doppler derived indices of left ventricular diastolic function are significantly affected by changes in filling pressure of the left ventricle. This may limit the usefulness of the Doppler method for serial assessment of diastolic function when the left ventricular filling pressure has changed between assessments. Only the E-wave deceleration time did not show significant changes and might be a useful Doppler index for the serial measurement of left ventricular compliance but this needs to be confirmed with haemodynamic measurements.

There were 160 incidents associated with regional anaesthesia amongst the first 2000 incidents reported to the Australian Incident Monitoring Study. They were categorised into 6 groups; epidural anaesthesia (83), spinal anaesthesia (42), brachial plexus blocks (14), intravenous local anaesthesia (4), ocular blocks (3), and local infiltration (14). The largest single cause of incidents involved circulatory problems; these occurred in all the groups except brachial plexus block (30 cases of hypotension, 7 of arrhythmias, 3 of cardiac arrest, 2 of hypertension and 1 of myocardial ischaemia). There were 24 drug errors, of which 10 involved the "wrong drug" and 4 "inappropriate use". With the exception of these, all the remainder involved problems specific to regional anaesthesia: 26 inadvertent dural punctures; 19 failed or inadequate blocks; 14 dural puncture headaches (all cured by blood patches); 10 inadvertent total or high spinal blocks (of which 7 required artificial ventilation); 5 blocks on the wrong side or in the wrong patient; 3 late hypoxic incidents and a variety of miscellaneous problems. Three-quarters of all incidents occurred in the presence of an anaesthetist and over 90% in patients of ASA Groups I-III. Rapid recognition by the anaesthetist prevented many potentially life threatening events, and the only death was as a result of surgical bleeding.

The first 2000 incidents reported to the Australian Incident Monitoring study (AIMS) were examined to identify those incidents which occurred preoperatively (defined as occurring prior to the commencement of general or regional anaesthesia). The 35 incidents, representing 1.7% of the total, which occurred in this time period were analysed with a view to identifying areas in which current practice could be improved. Almost all incidents led to significant delays in operating lists, and 9 resulted in cancellation of surgery. A number of areas of concern specific to the preoperative period were identified. Inadequate coordination between surgical and anaesthetic staff in patient preparation was a frequent cause of preoperative incidents. Improvement in this area may reduce surgical delays and patient morbidity. Problems with premedication drugs resulted in 8 of the 35 incidents, and care must be taken in the prescription and administration of these drugs to minimise adverse effects on patients. Only 2 cases of incorrect patient identification were reported. However, in view of its disastrous consequences, vigilance in patient identification by all members of the operating team, including the anaesthetist, is essential.

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 56 (3%) involved environmental hazards or injuries to patients or staff. There were 17 cases of oral trauma (14 of tooth loss or damage, in 7 of which poor dentition played a role), 10 incidents involving problems with the operating table, 6 cases of skin or eye damage and 6 cases in which an electrical hazard was identified. Five incidents occurred during transport, and there were 4 cases of monitor induced trauma, 4 "needlestick" injuries and 4 miscellaneous incidents. Recommendations are made for trying to avoid or reduce the incidence of some of these problems.

There were 65 incidents involving access to the vascular system amongst the first 2000 reported to the Australian Incident Monitoring Study. Thirty-three involved peripheral venous access (14 cases of extravascular extravasation, 8 of unintended arterial cannulation, 6 of disruptions to intravenous lines, and 5 of problems with infusion lines, taps, pumps and connectors). Eighteen cases involved central venous access (9 cases of arterial puncture with haematomas, 5 with morbidity and/or prolonged admission), 5 of catheter misplacement and pneumo- or hydro-thorax and 4 of problems arising from operator inexperience. Thirteen cases involved peripheral arterial access (5 involved equipment problems (3 with possible air embolism), 3 of mistaking an arterial for a venous line (drugs were injected in 2), 3 of losing arterial lines or signals, and 2 in which the presence of an arterial line placed the patient at risk). The anaesthetist should always question the continued integrity of any vascular access system, even when it has recently been shown to be functioning, and the possibility of later "migration" and misplacement should always be borne in mind. Whenever possible, correct placement of the tip should be checked (e.g. by visual inspection of the site, use of test doses, aspiration of blood, pressure measurement, X-rays). When there is more than one line, all lines and sites of access (e.g. 3-way taps) should be clearly labelled and checked before anything is injected or infused.

An electrooptical memory effect is observed with solid thin films of the photoconductor zinc-octakis(beta-decoxyethyl) porphyrin (ZnODEP) sandwiched between two optically transparent electrodes. Upon irradiation with the simultaneous application of an electric field, electron-hole pairs are generated and separated within the photoconductive layer. These electron-hole pairs become "frozen" within the films when the irradiation is interrupted. These trapped charges can be released by irradiation of the cell, resulting in a transient short-circuit photocurrent. No cross talk between adjacent memory elements separated by approximately 0.2 micrometer (a density of 3 gigabits per square centimeter) was detected. The charge storage system is robust and nonvolatile. The response time for the write-read beam is in the subnanosecond range, and no refreshing is required for long-term retention of trapped charges.

Re-infusion of shed blood carries the risk of re-infusing cellular debris. All re-infusion devices have some sort of integral filtration which is variably supplemented with a second intravenous filter. Using electron microscopy we have observed what debris is collected by secondary filtration. In 12 patients studied, nine out of 12 filters had significant amounts of cellular debris present, but not clearly related to increased rates of postoperative bleeding. Noncellular debris, silicon and strands of cellulose were also observed. Although we have not detected any clinically significant embolic phenomena from re-infusion of shed mediastinal blood, it seems prudent to include a second filter prior to re-infusion.

Objective: To test the hypothesis that selective decontamination of the digestive tract improves outcome in cardiac surgical patients., Design: Prospective, consecutive, controlled trial over two 4-month periods., Setting: Eight-bed, open-plan postcardiac surgery ICU., Patients: All patients undergoing cardiac bypass surgery were eligible. Patients requiring endotracheal intubation for greater than 4 days were included in the analysis. In the initial 4 months, 12 (8.5%) of 141 patients required greater than 4 days of intubation. These 12 patients were not treated with selective decontamination of the digestive tract. We therefore used these patients as the control group. In the second 4-month period, 12 (6.6%) of 180 patients were treated with selective decontamination of the digestive tract and formed the study group., Main Outcome Measures: The primary measure was mortality. Secondary measures included oropharyngeal decontamination and the presence of lower airway infection., Interventions: Cephradine prophylaxis. The study group received every 6 hrs 4 mL orally and 20 mL intragastrically a suspension of antimicrobial agents (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg), starting on postoperative day 1. The control group did not receive any oral antimicrobial agents., Results: Mortality rate was significantly (p less than .05) reduced from eight (66%) of 12 patients in the control group to two (16.7%) of 12 patients in the selective decontamination of the digestive tract group. No differences in oropharyngeal decontamination or lower airway infection rates between the two groups were found., Conclusions: There is a reduced mortality rate in patients receiving selective decontamination of the digestive tract. However, the reader should recognize the small sample size studied. A simple suspension of the antimicrobial agents failed to rid the oropharynx of bacteria.

This study of the accident scene focuses on the effects of vehicular deformity and restraint devices on occupant injury. In 500 patients evaluated in a Level I trauma center, seatbelts significantly reduced the likelihood of individuals' requiring the trauma center (P less than 0.0001). Seatbelts also significantly reduced the mortality rate of those who were transported to the trauma center (P less than 0.04). Dashboard intrusion correlated with pelvic (P less than 0.001) and femur (P less than 0.03) fractures, closed head injuries (P less than 0.001), and intraabdominal injuries (P less than 0.02). Steering wheel deformity correlated with pelvic fractures (P less than 0.001) and closed head injuries (P less than 0.005). Windshield violation correlated with closed head injuries (P less than 0.014) and spinal fractures (P less than 0.03). Irreparable vehicles correlated with pelvic (P less than 0.0001) and femur fractures (P less than 0.01), closed head injuries (P less than 0.0001) and intra-abdominal injuries (P less than 0.0001). The authors conclude that a careful examination of the accident scene for specific mechanisms of injury can lead to better prehospital care, more rapid and consistent diagnosis of injury, and improved patient outcome. Further prospective studies should accumulate data that will improve prehospital care, alert physicians to possible injury, increase community awareness of injury prevention, and improve vehicle construction.

Purpose: To investigate the nature of diabetes (health deviation) self-care in youths with IDDM and to relate diabetes self-care to metabolic control, perceived health status, and general (universal) self-care., Method: Thirty seven youths with IDDM between the ages of 11-19 completed the Diabetes Self-Care Practices Instrument, Denyes Self-Care Practice Instrument, and Denyes Health Status Instrument. Metabolic control was measured by glycosylated hemoglobin. Data were analyzed by correlational analysis., Results: Diabetes self-care was positively related to general (universal) self-care, health status, and metabolic control., Conclusions: Results of the study provide clear direction for ongoing assessment and teaching of diabetes self-care in youths with IDDM.

Debridement, fecal diversion, and rectal washout have been proposed as the primary therapy for complex perineal lacerations, but, in most series, survivors have a pelvic sepsis rate of 40-80%. In a retrospective study, six of 18 patients sustaining severe perineal lacerations died within the first few hours of injury due to exsanguination from pelvic injuries. The remaining 12 patients underwent sigmoidoscopy, diversion of the fecal stream with irrigation of the distal rectal stump, and radical initial debridement of necrotic soft tissue. Enteral access was obtained in two patients. In the patients with mandatory daily debridement and pulsatile irrigation, no pelvic sepsis occurred. In three patients without daily debridement, pelvic sepsis complicated recovery. The ability of patients to resume oral nutrition was significantly delayed, necessitating total parenteral nutrition in three patients. We conclude that sigmoidoscopy, total diversion of the fecal stream with irrigation of the distal rectal stump, enteral access for feeding, radical initial debridement of necrotic soft tissue, and mandatory daily debridement with pulsatile irrigation optimize recovery from this devastating injury.

Using an established prehospital regional triage protocol, 175 patients sustaining fractures of the pelvis were managed in a level one trauma center during a 38-month interval. The majority of injuries (51.7%) were caused by motor vehicle accidents and involved an average trauma score (TS) of 13 and an average injury severity score (ISS) of 24. The overall mortality was 16%; 43.5% had open fractures, 13.2% had closed fractures, and 30.6% had been in pedestrian accidents. Significant risk factors for mortality were age, blood pressure on admission, associated injuries, and the presence of an open pelvic fracture. It appears that TS alone is not reliable in prehospital triage of patients with pelvic fractures. Age and mechanism of injury may better identify the patient at risk for morbidity and mortality.

Eighty-six femoropopliteal bypass operations were performed for ischemic ulceration, gangrene or rest pain in 77 patients whose mean preoperative ABI was 0.35. In this homogeneous patient sample, we compared prospectively a trial of saphenous vein versus PTFE grafts. During the follow-up period amputations were required in 30 per cent of the patients with a vein graft and in 31 per cent of patients with a PTFE graft. However, the presence of gangrene significantly decreased the interval to first occlusion (p less than 0.001). Over-all, autogenous saphenous vein grafts had longer patency than PTFE grafts in both the femoropopliteal and distal bypass positions. This advantage prevailed when 45 of the patients were randomized, although not at statistically significant levels. In patients without gangrene who underwent limb salvage, bypassing the diseased femoropopliteal segment with either of the graft materials increased graft patency and limb salvage compared with patients who had ischemic tissue necrosis.

Seven cases of endodermal sinus tumor (yolk sac tumor) primary in the anterior mediastinum are added to the literature bringing to 21 the number of reported cases. This germ cell tumor should be included in the differential diagnosis of anterior mediastinal tumors. It has occurred in males 13--49 years old who are often systemically ill. Since this tumor almost always produces elevated levels of serum alpha-fetoprotein, a strong presumptive diagnosis is possible prior to biopsy. The prognosis is poor. The two disease-free survivors of the 21 reported cases were both treated with a combination of excision and chemotherapy.

A topical anesthetic emulsion consisting of a mixture of lidocaine and prilocaine (EMLA) was used in an attempt to reduce the pain associated with radial artery cannulation. Three groups were compared: (1) EMLA applied at least 90 minutes prior to cannulation (EMLA 90); (2) EMLA applied 60 minutes prior to cannulation (EMLA 60); and (3) lidocaine 2% infiltration performed immediately prior to the procedure (infiltration). Pain was registered using visual analog and verbal ranking scales by both the patient and an independent observer. The EMLA 90 group experienced significantly less pain (P < .001) than either the EMLA 60 or lidocaine infiltration groups. There was no statistically significant difference in pain scores between the EMLA 60 and infiltration groups. Local side-effects of EMLA were negligible.

We conducted a prospective, randomized, controlled trial comparing homologous blood consumption between groups of patients receiving conventional mediastinal drainage (group 1) or reinfusion of shed mediastinal blood (group 2) using hard-shell cardiotomy reservoir. One hundred consecutive patients who had elective coronary artery or valvular operations were studied. The two groups were comparable with regard to age, sex, weight, preoperative and postoperative hemoglobin levels, and surgical procedure. Group 2 patients had their shed mediastinal blood reinfused for up to 18 hours postoperatively; otherwise, the two groups were treated identically. For groups 1 and 2, average mediastinal blood losses were 705 +/- 522 and 822 +/- 445 mL and homologous blood consumption was 3.83 +/- 2.58 and 3.15 +/- 2.05 U, respectively (neither measure was significantly different). However, if blood losses exceeded 500 mL, there was a statistically significant reduction in homologous blood requirements in group 2 as compared with matched controls in group 1. This difference was most significant in patients with the greatest mediastinal losses.

Anthracene that has been dispersed into atmospheric particulate matter is photooxidized to an array of products reminiscent of oxidation by singlet oxygen in the solution phase. Photooxidation is a more important degradative pathway under ambient conditions than ozonation. Significant disappearance of anthracene also occurs by pathways not involving oxygenation.