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Introduction This study aimed to compare patients' Salzmann Index scores for those who applied for Medicaid orthodontic coverage in Pennsylvania with their corresponding American Board of Orthodontics discrepancy index (DI) scores to assess if there is a correlation between Salzmann and DI scores. In addition, a threshold DI score was calculated that would correspond to Medicaid coverage approval. The study intended to answer the following questions: is there a correlation of 0.7 or greater between a patient's Salzmann Index and their DI? If so, is there a particular DI score that can be used as the minimum score for approving Medicaid orthodontic coverage in the state of Pennsylvania? Methods Salzmann Index scores, DI scores, and approval and disapproval results for Medicaid orthodontic coverage were obtained from 104 subjects aged between 10 and 17 years. A linear regression model was generated to assess if there was a correlation between the Salzmann scores and DI scores. If a correlation coefficient of 0.7 or greater were found, a threshold Salzmann Index score would be determined for subjects who were approved for Medicaid orthodontic coverage. The threshold Salzmann score would be used in the linear regression formula to find the corresponding DI score, which would be designated as the threshold DI score for approval for Medicaid orthodontic coverage in the state of Pennsylvania. Results A Pearson correlation of 0.453 was calculated between the 104 Salzmann scores and DI scores, demonstrating a moderate correlation. With the correlation coefficient being lower than 0.7, binary logistic regressions were calculated to assess the predictability between a given Salzmann score and approval and disapproval for Medicaid orthodontic coverage. The Salzmann score had an overall 68.3% success in predicting Medicaid orthodontic coverage approval/disapproval. Of the 58 subjects that were approved for Medicaid orthodontic coverage, 46.6% had Salzmann scores equal to or greater than 25. Of the 46 subjects that were disapproved for Medicaid orthodontic coverage, 78.3% had Salzmann scores equal to or less than 24. Conclusions With the lack of high prediction rates seen from the results of the regression models, the current system of Medicaid does not appear to show consistency for assessing the need for orthodontic treatment coverage. Multiple insurance companies that participate under Medicaid require a Salzmann score of 25 or greater for approval; however, the results show the Salzmann score is arbitrary in terms of approval and disapproval. There appear to be underlying factors apart from the Salzmann score that the Pennsylvania Medicaid system uses to justify whether a patient was approved or denied for coverage.

Summary Objective The objective of this trial was to compare the plaque removal ability of a triple-headed toothbrush to a conventional manual toothbrush in adolescents with fixed orthodontic appliances. Materials and methods Sixty adolescent patients undergoing orthodontic treatment were randomly assigned to brush one time with either a conventional manual toothbrush or a triple-headed toothbrush. The main outcome was the post-brushing plaque index as measured by the Silness-Loe plaque index. Results Sixty patients (mean age, 14.2; standard deviation, 1.65) were randomized in a 1:1 ratio to either a manual toothbrush group or a triple-headed toothbrush group. Baseline characteristics were similar between the two groups. There were no dropouts. The mean post-brushing plaque index was 0.84 (95% CI, 0.67–1.02; SD, 0.60) for the conventional manual toothbrush group, and 0.31 (95% CI, 0.13–0.49; SD, 0.48) for the triple-headed toothbrush group. There was a statistically significant difference in the mean plaque index of 0.53 (95% CI, 0.28–0.78; P Conclusion The results of this study indicate strong evidence that the triple-headed toothbrush leads to a significantly lower plaque index compared to the conventional manual toothbrush post-brushing.

Summary Objective This systematic review aimed to clarify whether there are any significant long-term sequelae to wearing mandibular advancement devices focusing on dental and skeletal effects in adults with OSA. Materials and methods Databases, including PubMed, Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and SAGE Journals. Hand searches and grey literature were also used. A piloted data collection form was used to extract the appropriate data. Results Twenty-three reports of 19 studies were included. Five had serious risk of bias while 18 had moderate risk of bias. Meta-analysis revealed a significant change in overbite and overjet. I-squared analysis showed a high level of statistical heterogeneity. A moderate correlation was found between wear time and amount of change. Conclusion Mandibular advancement devices will cause a small but statistically significant change in the dentition of long-term wearers. Skeletal changes are generally secondary to dental changes.

OBJECTIVE This study aimed to analyze the impact of different maxillary lateral incisor width ratios on the perception of smile esthetics among orthodontists and laypersons. METHODS A smile photograph of a male subject showing the lips and gingival margins was selected. The smile was standardized for maxillary central incisor width proportions and ideally perceived smile esthetics. The maxillary lateral incisor width was symmetrically modified in increments of ratios of the central incisor from a ratio of 4:10 to a ratio of 8:10. The images were analyzed by 283 laypersons and 83 orthodontists who ranked the level of attractiveness using a visual analog scale. RESULTS There were significant differences between the esthetic perception of the five different width ratios, and between the orthodontists and laypersons in their evaluations of esthetics (P

Resume Objectif Nous avons etudie la perception d’individus non cliniciens face a des sujets presentant des dents et un nez bien alignes, une modification legere a moderee du nez ou une modification legere a moderee des dents. Nos objectifs etaient de determiner : (1) l’impact de la modification du nez ou des dents chez des sujets cibles sur la perception par autrui de leur attractivite faciale ; (2) l’influence du sexe des sujets cibles et des evaluateurs sur ces evaluations ; (3) l’impact des vues frontale et de trois quarts sur les evaluations. Materiaux et methodes Les donnees du sondage ont ete recueillies aupres de 266 etudiants a l’universite de Seton Hill (49 % hommes, 51 % femmes ; âge : 18 a 25 ans) qui ont evalue sur un VAS 100 mm des photographies de sujets ayant une denture et un nez bien alignes (controles), une modification legere a moderee du nez ou une modification legere a moderee de leur denture en vues frontale et de trois quarts. Resultats Les vues de l’homme et de la femme cibles ayant subi une modification de leur denture etaient considerees comme les moins attrayantes. Les vues de l’homme et de la femme cibles ont montre que les evaluateurs de sexe feminin ont evalue aussi bien les controles et les modifications dentaires legeres a moderees de facon plus positive que leurs equivalents masculins. En ce qui concerne les images de l’homme et de la femme cibles, la vue frontale montrant les modifications dentaires etaient considerees comme l’element le moins esthetique. Conclusion Les evaluateurs hommes et femmes ont estime les modifications dentaires moins attrayantes que les modifications nasales. Pour les candidats a une rhinoplastie presentant aussi une denture mal alignee, il serait peut-etre dans l’interet des chirurgiens esthetiques d’etablir une approche interdisciplinaire en collaboration avec un orthodontiste.

This pilot study evaluated effects of a video-guided T'ai Chi group intervention on center of balance (COB) and falls efficacy, using a one arm, pre/post design. Thirty-two participants began the study, 17 completed pre- and post-testing and 15 were lost to follow-up. Outcomes were compared for the 17 participants who completed pre- and post-testing and subgroups based on session attendance. Irrespective of session attendance, participant COB scores improved. There was a significant negative correlation between number of sessions attended and pre and post scores on the fall efficacy (fear of falling) measure, indicating those with higher fear of falling were less likely to complete the study. Older participants were also less likely to continue participation. Findings indicate potential benefits of T'ai Chi in improving COB (a fall risk factor) among community-dwelling older adults. However, those with greater potential benefit (higher fear scores, older participants) were less likely to continue participation.

Introduction The correction of a deviated midline can involve complicated mechanics and a protracted treatment. The threshold below which midline deviations are considered acceptable might depend on multiple factors. The objective of this study was to evaluate the effect of facial type on laypersons' perceptions of various degrees of midline deviation. Methods Smiling photographs of male and female subjects were altered to create 3 facial type variations (euryprosopic, mesoprosopic, and leptoprosopic) and deviations in the midline ranging from 0.0 to 4.0 mm. Evaluators rated the overall attractiveness and acceptability of each photograph. Results Data were collected from 160 raters. The overall threshold for the acceptability of a midline deviation was 2.92 ± 1.10 mm, with the threshold for the male subject significantly lower than that for the female subject. The euryprosopic facial type showed no decrease in mean attractiveness until the deviations were 2 mm or more. All other facial types were rated as decreasingly attractive from 1 mm onward. Among all facial types, the attractiveness of the male subject was only affected at deviations of 2 mm or greater; for the female subject, the attractiveness scores were significantly decreased at 1 mm. The mesoprosopic facial type was most attractive for the male subject but was the least attractive for the female subject. Conclusions Facial type and sex may affect the thresholds at which a midline deviation is detected and above which a midline deviation is considered unacceptable. Both the euryprosopic facial type and male sex were associated with higher levels of attractiveness at relatively small levels of deviations.

Objectives/hypothesis To develop and validate a cough severity index (CSI) which quantifies patients' symptoms associated with upper airway chronic cough and to provide a tool for treatment outcome measures. Methods Two hundred patients who had a complaint of chronic cough and/or dyspnea were given a 49- item questionnaire developed through a clinical consensus of the most common symptoms of chronic cough of upper airway origin. The instrument was reduced to 10 questions using statistical methodology. Fifty subsequent patients were given the CSI to measure test-retest reliability at two different moments in time. Twenty healthy controls (HC) were given the instrument to obtain validity. An additional 95 participants provided pre- and posttreatment outcomes using the CSI. Results Principle Component Analysis (PCA) revealed a single factor with the original 49 questions. A combination of PCA, rank-ordering item-total correlation and communality, as well as clinical consensus further reduced the questionnaire to 10 items. Internal consistency of the CSI was 0.97. Test-retest reliability was r = 0.83. An r = 0.60 for divergent validity between the CSI and the Cough-Specific Quality-of-Life Questionnaire (CQLQ) demonstrated two fairly separate instruments, although both measured cough. Mann-Whitney test was significant between symptomatic patients and healthy controls (P Conclusion The CSI is a short, simple instrument that can be used in the clinical setting to quantify a patient's symptoms of chronic cough of upper airway origin. It represents a statistically reliable, valid, and clinically relevant instrument that can be used to measure treatment outcomes for chronic cough.

Voice therapy changes how people use and care for their voices. Speech-language pathologists (SLPs) have a multitude of choices from which to modify patient's vocal behaviors. Six SLPs performed 1461 voice therapy sessions and quantified the percentage of time spent in eight component parts of indirect and four component parts of direct voice therapy across five common voice disorders. Voice therapy data collection forms were prospectively completed immediately following each therapy visit. The SLPs were free to choose the component parts of voice therapy best suited for their respective patients. Results showed that direct voice therapy represented more than 75% of the treatment time across all voice therapy sessions. In the components of direct voice therapy, there was no statistical difference between percentages of time spent in resonant voice and flow phonation across all voice disorders. However, a significant difference was found for the time spent addressing transfer to conversational speech for muscle tension dysphonia, lesions, and scar than for vocal immobility and atrophy. Interestingly, while SLPs used a more common approach to direct voice therapy across voice disorders, they tended to vary the use of indirect components of therapy across voice disorders with certain components being addressed in greater length for specific voice disorders. Collectively, these results indicate that although SLPs may individualize their approach to indirect voice therapy, when it comes to direct voice therapy, SLPs have a common approach to voice therapy regardless of voice disorder.

It is estimated that 50 million people in the United States provide care for a chronically ill, disabled, or aged family member or friend.1 For caregivers of persons with cancer and dementia, extensive evidence shows that negative psychological and behavioral consequences are common and may be linked to a decline in caregivers’ overall health.2,3 Caregivers of critically ill patients also experience high levels of stress. Recovery from critical illness may occur quickly or gradually over an extended period. The term chronically critically ill (CCI) is commonly used to describe persons who require an extended duration of mechanical ventilation and hospitalization after recovery from critical illness.4 Evidence from a variety of sources suggests that growing numbers of caregivers will face the need to support CCI patients after hospital discharge. Demand for critical care, including mechanical ventilation, is anticipated to increase sharply as the generation of “baby boomers” grows to 20% of the total US population by 2030.5 Currently, 5% to 20% of patients in intensive care units (ICUs) require mechanical ventilation for periods that can extend to weeks or months,6 and those percentages are expected to increase.7,8 It has been estimated that by 2020 more than 600 000 patients per year will require extended critical care support.9 Such patients encounter enormous difficulties, including psychoemotional stress, reduced physical and neurocognitive function, symptom burden, and frequent hospital readmissions.7,10,11 Concurrently, family caregivers must cope with financial, emotional, and physical stressors.12 In several prior studies,12–18 caregivers of CCI patients were surveyed about their psychological responses. Despite heterogeneous characteristics of patients (eg, severity of illness, days of mechanical ventilation) and follow-up intervals (2 to 23 months), findings uniformly included a high incidence of depression12–18 that was comparable to the incidence of depression in caregivers of the frail elderly and twice the incidence of depression in the general population. Douglas and Daly12 reported decreased physical health and increased risk of depression in caregivers of CCI patients that exceeded reports for other populations of patients who require long-term caregiving, such as patients with Alzheimer’s disease and patients with spinal cord injury. When patients remained institutionalized, family caregivers reported a higher incidence of depression and burden, more disruption in daily schedules, more health problems, and less family support.14,16 Depressive symptoms decreased over time,13,18 but remained higher than in the general population. Notably, in an analysis of a national data set comprising almost 300 000 cases, a significantly higher risk of death was reported in spouses of persons who received mechanical ventilation for 4 days or longer.19 Reports of prior studies13,16–18 have described the challenges encountered by caregivers of CCI patients. However, most did not identify the specific lifestyle restrictions, distress, or problem behaviors of patients that were of most concern. In an effort to identify ways to support caregivers of CCI patients, it may be helpful to explore longitudinal changes in caregiver response as influenced by changes in the characteristics of patients. It is also important to identify specific areas that cause caregivers to experience greater lifestyle restriction and distress. Therefore, the purpose of this study was to describe perceived lifestyle restrictions and distress among caregivers of CCI patients at 1 and 6 months after ICU discharge. We also explored how caregivers’ lifestyle restrictions and distress differed according to the characteristics of the patients and the caregivers.

fero l.j., o’donnell j.m., zullo t.g., dabbs a.d., kitutu j., samosky j.t. & hoffman l.a. (2010) Critical thinking skills in nursing students: comparison of simulation-based performance with metrics. Journal of Advanced Nursing 66(10), 2182–2193. Abstract Aim This paper is a report of an examination of the relationship between metrics of critical thinking skills and performance in simulated clinical scenarios. Background Paper and pencil assessments are commonly used to assess critical thinking but may not reflect simulated performance. Methods In 2007, a convenience sample of 36 nursing students participated in measurement of critical thinking skills and simulation-based performance using videotaped vignettes, high-fidelity human simulation, the California Critical Thinking Disposition Inventory and California Critical Thinking Skills Test. Simulation-based performance was rated as ‘meeting’ or ‘not meeting’ overall expectations. Test scores were categorized as strong, average, or weak. Results Most (75·0%) students did not meet overall performance expectations using videotaped vignettes or high-fidelity human simulation; most difficulty related to problem recognition and reporting findings to the physician. There was no difference between overall performance based on method of assessment (P = 0·277). More students met subcategory expectations for initiating nursing interventions (P ≤ 0·001) using high-fidelity human simulation. The relationship between videotaped vignette performance and critical thinking disposition or skills scores was not statistically significant, except for problem recognition and overall critical thinking skills scores (Cramer’s V = 0·444, P = 0·029). There was a statistically significant relationship between overall high-fidelity human simulation performance and overall critical thinking disposition scores (Cramer’s V = 0·413, P = 0·047). Conclusion Students’ performance reflected difficulty meeting expectations in simulated clinical scenarios. High-fidelity human simulation performance appeared to approximate scores on metrics of critical thinking best. Further research is needed to determine if simulation-based performance correlates with critical thinking skills in the clinical setting.

Objectives: Laryngeal framework surgery, including medialization laryngoplasty (ML) and arytenoid adduction (AA), are common treatments for vocal fold paralysis and glottal incompetence. Little information is known about the incidence of ML/AA surgery nationwide, in particular the success and complication rates. Methods: A 25-item questionnaire was mailed to 6,644 Board-certified otolaryngologists. Results: The response rate was 25.7% (n = 1,707). Sixty-three percent perform ML and/or AA, representing 29,748 procedures. Experience with Silastic medialization implants has decreased over time, while utilization of other materials has increased. The overall complication rate was 15%, including 0.8% implant extrusion and 6% revision rates. The most common revision was placement of a larger implant (37% of all revisions). Airway compromise requiring intervention was observed in 2.2%, and suboptimal voice outcome in 4%. Although not statistically significant, a trend was observed of decreasing complication rate with increasing experience. Conclusions: Laryngeal framework surgeries are being performed with increasing frequency in the United States. The overall complication rate is slightly increased in the present study, but airway compromise and poor vocal outcome are decreased, and the need for revision surgery is unchanged. These findings suggest a continued high level of efficacy of these procedures. Laryngoscope, 2010

Background Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled “Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management,” which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden. Methods Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management. Results After the intervention, experimental group patients rated their HRQoL less positively ( P = .038) and tended to report more anxiety ( P = .077) compared with controls. Care partners rated their stress at a lower level ( P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others. Conclusion Further exploration of the impact of disease-management interventions in patients with advanced lung disease and their care partners is needed using both qualitative and quantitative methodology. Disease-management interventions have the potential to positively affect patients with advanced lung disease and their care partners.

Objectives/Hypothesis: To develop a shortened version of the validated health status instrument for singers, the Singing Voice Handicap Index (SVHI). Study Design: Prospective item analysis of the SVHI in patients with singing voice problems and creation and validation of an abbreviated SVHI, the SVHI-10. Methods: Patients presenting to two tertiary care voice clinics prospectively completed the SVHI. Principal component analysis was performed. Individual item to total correlations were calculated, and individual items were also evaluated for bipolar response patterns. A clinical consensus conference prioritized each individual item. Items were then eliminated, and the internal consistency was evaluated. A second cohort of patients with singing voice problems completed the Voice Handicap Index-10 (VHI-10) and SVHI-10 at two time points. Singers without voice problems also completed the SVHI-10. SVHI-10 scores were compared between the groups, correlations between the SVHI-10 and VHI-10 were performed, and test-retest reliability of the SVHI-10 assessed. Results: Singers with voice problems had worse SVHI-10 scores than normal singers (P < .0001, t test). Test-retest reliability was high (Spearman correlation = 0.86, P < .001). Internal consistency of the SVHI-10 demonstrated a Cronbach α of .94, and the correlation between the SVHI-10 and VHI-10 was 0.7 (P < .001, Spearman correlation). Conclusions: The SVHI-10 is a valuable instrument to assess self-perceived handicap associated with singing voice problems with reduced patient burden. Laryngoscope, 2009

The hemodynamic response to hypoxia may be influenced by exposure pattern and inducible biological signals, such as nitric oxide synthase (iNOS) expression. The systemic blood pressure (BP) and heart rate (HR) response to intermittent and continuous hypoxia (IH and CH) were examined as was the relationship between these responses and iNOS expression in 10 normal subjects. BP and HR were recorded during exposure to IH or CH (total hypoxic time=60 min/dayx3 days for each exposure profile), whereas arterial oxygen saturation (SpO2) was maintained at 80-90%. Total RNA was isolated from peripheral blood lymphocytes before exposure on Day 1 and 2 hours after the last exposure on Day 3, and it was assayed for iNOS messenger RNA (mRNA) expression using quantitative polymerase chain reaction (PCR). HR, systolic BP (SBP), and diastolic BP (DBP) increased during both experimental conditions (P

Summary Objective We investigated how laypeople perceive persons with straight teeth and nose, mild to moderate modification of the nose, and mild to moderate modification of the teeth. The objectives were to determine: (1) how modification of the nose or teeth affects others’ perceptions of target persons’ facial attractiveness, (2) whether these evaluations are affected by the target persons’ or raters’ gender, (3) whether the frontal view or three-quarter view has any effect on the ratings. Materials and methods Survey data were collected from 226 college students at Seton Hill University (49% male, 51% female; age range, 18–25 years) who rated, on a 100 mm VAS, photos of subjects with straight teeth and nose (control), mild to moderate modification of the nose, and mild to moderate modification of the teeth from the frontal and three-quarter views. Results Male and female target photos with teeth modification were considered the least attractive. Both male and female target photos showed that female raters evaluated both control and nose modification conditions more positively than did male raters. For male and female target photos, the frontal view was less esthetically pleasing under teeth modification. Conclusions Both male and female evaluators judged teeth modification as the least attractive compared to nose modification. It is recommended for rhinoplasty patients with malaligned teeth that it may be beneficial for cosmetic surgeons to establish an interdisciplinary approach working with orthodontists.

Postthoracotomy pain syndrome (PTPS) is a common complication following thoracic surgery. Most studies examining the influence of PTPS on patient-reported symptoms include few patients managed using a minimally invasive approach. Associated sensory changes, potentially neuropathic in origin, are not well described. We therefore examined the symptoms and quality of life (QOL) of patients with and without PTPS who underwent a standard thoracotomy (n = 43) or minimally invasive surgery (n = 54). Patients in this prospective, cross-sectional study completed questionnaires to assess pain (McGill Pain Questionnaire), neuropathic symptoms (Neuropathic Symptom Questionnaire), symptom distress (Symptom Distress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and QOL (Functional Assessment Cancer Therapy–Lung). Excepting younger age (p = .009), no demographic or surgical characteristic differentiated patients with and without PTPS. Patients with PTPS described discomfort as pain only (15.1%), neuropathic symptoms only (30.2%) or pain and neuropathic symptoms (54.7%). Scores differed between patients with and without PTPS for symptom distress (p < .001), anxiety and depression (p < .001), and QOL (p = .009), with higher distress associated with PTPS. Despite new surgical techniques, PTPS remains common and results in considerable distress. A focused assessment is needed to identify all experiencing this condition, with referral to pain management specialists if symptoms persist.

• Background Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.• Objective To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.• Methods During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes.• Results Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02).• Conclusions In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

• Background Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results.• Objectives To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors.• Methods Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons.• Results The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative β-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs.• Conclusion Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.

• Background Most lung transplant recipients experience improvement in their underlying pulmonary condition but are faced with the threat of allograft rejection, the primary determinant of long-term survival. Several studies examined predictors of rejection, but few focused on the early period after transplantation.• Objectives To describe the pattern and predictors of early rejection during the first year after transplantation to guide the development of interventions to facilitate earlier detection and treatment of rejection.• Methods Data for donor, recipient, and posttransplant variables were retrieved retrospectively for 250 recipients of single or double lung transplants.• Results Most recipients (85%) had at least 1 episode of acute rejection; 33% had a single episode; 23% had recurrent rejection; 3% had persistent rejection; 13% had refractory rejection; and 14% had clinicopathological evidence of chronic rejection. Serious rejection (refractory acute rejection or chronic rejection) developed in 27% of recipients. Compared with other recipients, recipients who had serious rejection had more episodes of acute rejection (P = .004), and the first acute episodes occurred sooner after transplantation (P = .01) and were of a higher grade (P = .002).• Conclusions Recipients who experienced higher grades for their first episode of acute rejection (P=.03) and higher cumulative rejection scores (P = .004) were significantly more likely than other recipients to have serious rejection during the first year after transplantation.

• Background Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients’ outcomes.• Objective To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients’ care in a step-down medical intensive care unit.• Methods Work sampling techniques were used to collect data when the nurse practitioner had 6 months’ or less experience in the role (T1), after the nurse practitioner had 12 months’ experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.• Results Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001).• Conclusion The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients’ families and collaborating with health team members.

Munin MC, Rosen CA, Zullo T. Utility of laryngeal electromyography in predicting recovery after vocal fold paralysis. Arch Phys Med Rehabil 2003;84:1150–3. Objectives: To determine the value of laryngeal electromyography in predicting recovery after vocal fold paralysis and to determine what elements of laryngeal electromyography are most predictive of outcome. Design: Cohort study with retrospective data review. Setting: University voice center. Participants: Consecutive sample of 31 patients with vocal fold paralysis diagnosed by indirect laryngoscopy, using either nasal insertion with a flexible nasopharyngoscope or peroral with a 70° Hopkins rod. Inclusion criteria were that laryngeal electromyography had to have been performed between 21 days and 6 months from the onset of symptoms and patients must have been followed a minimum of 6 months. Interventions: Not applicable. Main Outcome Measure: Vocal fold motion at 6 months from onset of symptoms. Results: Nine subjects (29%) had resolved vocal fold motion, whereas 22 (71%) had persistent vocal fold paralysis. By using our laryngeal electromyography paradigm, 4 of 6 patients with a laryngeal electromyography prognosis of excellent resolved. The predictive value for a negative test was 66.7%. For patients with a fair or poor prognosis, 5 of 25 resolved. The predictive value for a positive test was 80%. Only 8 of 22 patients with persistent vocal fold paralysis had fibrillations, and spontaneous activity was not significantly related to outcome. Patients with absent or greatly decreased motor unit recruitment had a significantly higher proportion of permanent vocal fold paralysis ( P P Conclusions: This study confirms the utility of laryngeal electromyography in assessing prognosis for recovery of vocal fold motion after laryngeal nerve injury. The results support our hypothesis that preset decision rules based on laryngeal electromyography data can be effectively used to determine a prognosis for recovery of vocal fold motion.

• Background Tracheal gas insufflation reduces inspired tidal volume and minute ventilation in spontaneously breathing patients and may facilitate weaning from mechanical ventilation.• Objective To determine if tracheal gas insufflation can reduce ventilatory demand during weaning trials in patients who require prolonged mechanical ventilation.• Methods A reduction in ventilatory demand was defined as a relative decrease in tidal volume, minute ventilation, and mean inspiratory flow during trials with tracheal gas insufflation compared with the values during trials without this therapy. A total of 14 subjects underwent T-piece trials with and without insufflation (flow rate 6 L/min) on 2 consecutive days; the order of insufflation was randomized. Tidal volume, minute ventilation, and mean inspiratory flow were measured at baseline (without insufflation) and 2 hours later.• Results Differences in ventilatory demand were not significant when comparisons were made for condition (tracheal gas insufflation vs no flow) or time (baseline vs 2 hours) for the total group (P = .48). Subjects were classified post hoc as responders (n = 9) or nonresponders (n = 5). Comparisons between responders and nonresponders indicated a significant (P = .02) 3-way multivariate interaction for group (responder vs nonresponder), condition (tracheal gas insufflation vs no flow), and time (baseline vs 2 hours) for ventilatory demand variables.• Conclusion Tracheal gas insufflation can reduce ventilatory demand during weaning trials in some patients who require mechanical ventilation.

Context The Questionnaire for Lung Transplant Patients was designed for clinical use by the pulmonary transplant team in the routine evaluation of lung transplant recipients. Using the self-administered questionnaire, recipients check symptoms that they have had since their last evaluation and rate their shortness of breath, cough, and activity tolerance. Objective To determine whether the questionnaire meets reliability and validity standards for empirical measurement. Methods Demographics and disease-severity characteristics were examined in a cross-sectional survey of 37 recipients. Test-retest and intraclass correlation methods were used to estimate stability, and the Cronbach α was used to estimate internal consistency. Criterion validity was examined by using The Modified Symptom Frequency/Symptom Distress Scale, Functional Performance Inventory, and visual analog scales for cough and shortness of breath as criterion measures. Construct validity was examined to assess the predicted negative correlation between symptoms and functional performance. Results The questionnaire and its subscales were internally consistent (Cronbach α = 0.82, 0.76, 0.80, and 0.96), and the questionnaire was stable ( r = 0.70) and reliable (intraclass correlations = 0.80 and 0.90). Significant correlations were found between the questionnaire and all criterion measures ( r = 0.50–0.93). Significant correlations in the predicted negative direction were found between the respiratory subscale and functional performance ( r = −0.51) and between cough ( r = −0.51) and shortness of breath ( r = −0.68) ratings and functional performance. Conclusions The Questionnaire for Lung Transplant Patients is reliable and valid, and it provides scientifically sound information for clinical and empirical evaluation of symptoms and their effects on activity tolerance after lung transplantation.

Study objective To determine if distractive auditory stimuli (DAS) in the form of music would promote adherence to a walking regimen following completion of a pulmonary rehabilitation program (PRP) and, thereby, maintenance of gains achieved during the program. Design Experimental, randomized, two-group design with testing at baseline, 4 weeks, and 8 weeks. Setting Outpatient. Patients Twenty-four patients (4 men and 20 women) with moderate-to-severe COPD (FEV 1 41.3 ± 13% predicted [mean ± SD]). Intervention Experimental group subjects (n = 12) were instructed to walk at their own pace for 20 to 45 min, two to five times a week, using DAS with a portable audiocassette player. The control group (n = 12) received the same instructions, but no DAS. Measurements and results Primary outcome measures were perceived dyspnea during activities of daily living (ADL) and 6-min walk (6MW) distance. Secondary outcome measures were anxiety, depressive symptoms, health-related quality of life (QoL), global QoL, and breathlessness and fatigue at completion of the 6MW. In addition, all subjects recorded the distance and time walked using self-report (pedometers and daily logs). There was a significant decrease in perceived dyspnea during ADL (p = 0.0004) and a significant increase in 6MW distance (p = 0.0004) over time in the DAS group compared to the control group. DAS subjects increased 6MW distance 445 ± 264 feet (mean ± SD) from baseline to 8 weeks, whereas control subjects decreased 6MW distance to 169 ± 154 feet. No significant differences were noted for the remaining variables. The cumulative distance walked by the DAS group was 19.1 ± 16.7 miles compared to 15.4 ± 8.0 miles for the control group, a 24% difference (p = 0.49). Despite this difference, self-report exercise log data were similar for the two groups. Conclusion Subjects who used DAS while walking had improved functional performance and decreased perceptions of dyspnea, whereas control subjects could not maintain post-PRP gains. DAS is a simple, cost-effective strategy that may have the potential to augment the effectiveness of post-PRP maintenance training.

Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB.Retrospective, comparative survey.University-affiliated tertiary care hospital.Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository.None.The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p =.0004), number of vessels bypassed (p =.013), vessel location (diagonal [p.003] or posterior descending artery [p.001]), and net fluid balance on the operative day (p =.015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p =.0004), more intensive care unit readmissions (p =.0004), and required more assistance at hospital discharge (p =.017).Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.

• Background Many benefits and adverse effects of positioning are related to changes in ventilation and perfusion. A number of unique factors related to the allograft make the effects of positioning difficult to determine in single-lung transplant recipients.• Objectives To determine the effect of 3 body positions (supine, lateral with allograft lung down, and lateral with native lung down) on oxygenation and blood flow in single-lung transplant recipients in the 24 hours immediately after surgery.• Methods A quasi-experimental repeated-measures design with stratified assignment to 1 of 3 different sequencing patterns for turning group was used to study 15 transplant recipients, 9 with emphysema and 6 with fibrosis. Oxygenation, ventilation, and blood flow measures (heart rate, blood pressure) were assessed after each turn. The effect of ischemic reperfusion injury was also explored.• Results The oxygenation, ventilation, and blood flow variables did not differ significantly across group, diagnosis, or time. Oxygenation variables measured when the allograft lung was dependent did not differ significantly from such measurements obtained when the native lung was dependent.• Conclusions No single position maximizes oxygenation in the immediate postoperative period in single-lung transplant recipients. Although a single standard protocol for positioning cannot be supported, the study does support the idea that transplant recipients can be safely turned in the immediate postoperative period without compromising oxygenation or hemodynamic status.

Objective: To investigate whether text message reminders regarding oral hygiene have an effect on plaque removal in orthodontic patients. Materials and Methods: In this randomized, controlled clinical trial, 50 orthodontic patients were assigned to either a text message or control group. Patients in the text message group received 12 text messages over the course of 4 weeks and one text message for 8 weeks thereafter. Photos were taken at baseline (T0), at 4 weeks after baseline (T1), and at 12 weeks after baseline (T2). For each subject, photos of eight teeth were taken and then the area of the tooth and amount of plaque were measured using planimetry. Results: There was a statistically significant difference in plaque coverage between baseline and both T1 and T2 in the text message group as measured using planimetry. This was demonstrated by comparing the average measurements of the control group and the treatment group. Conclusion: This study demonstrated that the use of automated text message reminders sent from an orthodontic office was effective in improving oral hygiene compliance in orthodontic patients.

Purpose: To compare health-related quality of life outcomes in a cohort of abdominal aortic aneurysm (AAA) patients treated concurrently with either a conventional or endoluminal intervention. Methods: Between December 1997 and April 1999, 51 AAA patients treated by either open or endovascular techniques were enrolled in this prospective study. Conventional therapy was performed in 26 patients (19 men; mean age 70.4 ± 6.0 years) with anatomical features unsuitable for the endovascular approach. Twenty-five patients (23 men; mean age 70.7 ± 7.2 years) underwent endoluminal AAA exclusion using either the Ancure or bifurcated Enduring stent-grafts. The Medical Outcomes Study Short-Form 36-item health survey was administered preoperatively and at 1, 4, 8, and ≥52 weeks after discharge. Results: At 1 week, both groups showed significant reductions (p < 0.001) in mean scores compared to baseline in 4 dimensions (physical function, social function, role-physical, and vitality), but the decline was more pronounced in patients having open repair. Endoluminal patients returned to their baseline scores by the 4th postoperative week, whereas complete recovery to baseline in the conventional patients was delayed to the 8th week. Conclusions: Patients treated endoluminally exhibit better physical and functional scores as early as 1 week after discharge; they also return to baseline status significantly earlier than the conventional group. These findings document the perceived advantage of endovascular therapy over conventional AAA treatment.

Objective: The major benefit of tracheal gas insufflation (TGI) is an increase in CO 2 elimination efficiency by removal of CO 2 from the anatomical deadspace. In conjunction with mechanical ventilation, TGI may also alter variables that affect CO 2 elimination, such as minute ventilation and peak airway pressure (peak Paw) and cause the development of auto-positive end-expiratory pressure (auto-PEEP). We tested the hypothesis that TGI-induced auto-PEEP alters ventilatory variables. We predicted that TGI-induced auto-PEEP offsets the beneficial effects of TGI on CO 2 elimination and that keeping total PEEP (ventilator PEEP + auto-PEEP) constant enhances the CO 2 elimination efficiency afforded by TGI. Design: Prospective study of two series of patients with acute respiratory distress syndrome receiving mechanical ventilation. Setting: Intensive care units at a university medical center. Patients: Each series consisted of eight sequential hypercapnic patients. Interventions: In series 1, we examined the effect of continuous TGI at 0 and 10 L/min on Paco 2 , without compensating for the development of auto-PEEP. In series 2, we examined this same effect of continuous TGI while reducing ventilator PEEP to keep total PEEP constant. TGI-induced auto-PEEP was calculated based on dynamic compliance measurements during zero TGI flow conditions (ΔV/ΔP) after averaging the two baseline values for peak Paw and tidal volume and assuming compliance did not change between the zero TGI and TGI flow conditions (ΔV TGI /ΔP TGI ). Measurements and Main Results: In series 1, total PEEP increased from 13.2 ± 3.2 cm H 2 O to 17.8 ± 3.5 cm H 2 O without compensation for auto-PEEP (P =.01). Paco 2 decreased (P =.03) from 56.2 ± 10.6 mm Hg (zero TGI) to 52.9 ± 9.3 mm Hg (TGI at 10 Umin), a 6% decrement. In series 2, total PEEP was unchanged (p = NS). Paco 2 decreased (p =.03) from 59.5 ± 10.4 mm Hg (zero TGI) to 52.2 ± 8.3 mm Hg (TGI at 10 L/min), a 12% decrement. There was no significant change in Pao 2 there were no untoward hemodynamic effects in either series, Conclusions: These data are consistent with the hypothesis that mechanical ventilation + TGI causes an increase in auto-PEEP that can blunt CO 2 elimination. In addition to the ventilator modifications necessary to keep ventilatory variables constant when TGI is used, it is also necessary to reduce ventilator PEEP to keep total PEEP constant and further enhance CO 2 elimination efficiency.

The purpose of this pilot study was to describe short and long-term changes in cognitive function and quality of life in patients with melanoma receiving interferon (IFN) -2b. This study used a three-group, repeated measures design in which cognitive function and quality of life were evaluated prior to initiation of treatment at 3-month intervals during treatment and 3 months following the completion of treatment. The sample consisted of 16 adults with Stage II or III melanoma, randomized to one of three treatment groups. Participants in Arm A received high-dose IFN -2b, those in Arm B received low-dose IFN• -2b, and those in Arm C received no therapy (control). No significant changes in cognitive function were detected. In participants in ArmA, there was a significant deterioration in the physical well-being dimension of quality of life from baseline to 3 months after beginning therapy.

In mechanically ventilated adults with acute respiratory distress syndrome (ARDS), peak airway pressures (Paw(peak)) above 35 cm H(2)O may increase the risk of barotrauma or volutrauma. Tracheal gas insufflation (TGI), an adjunctive ventilatory technique, may facilitate a reduction in set inspiratory pressure in these patients, and thereby in the tidal volume (VT) and Paw(peak) used in their ventilation, without a consequent increase in arterial carbon dioxide tension (PaCO(2)). The purpose of this study was to: (1) assess the limits of efficacy of continuous TGI at two levels of decreased mechanical ventilatory support; and (2) determine an appropriate time interval after initiation of TGI at which to evaluate response. We prospectively studied eight adults with ARDS and increased airway pressures (40.2 +/- 2.7 cm H(2)O) who were managed with pressure-control ventilation (PCV). After obtaining baseline ventilatory and hemodynamic measures, we initiated TGI at 10 L/min, adjusting ventilator positive-end expiratory pressure (PEEP) to maintain baseline VT, and decreased the set inspiratory pressure by 5 cm H(2)O. Data were obtained after 30 and 60 min. Set inspiratory pressure was then decreased by an additional 5 cm H(2)O (total: 10 cm H(2)O), and data were again obtained after 30 min. Baseline (zero TGI) measures were then again recorded. Thirty minutes after decreasing the set inspiratory pressure by 5 cm H(2)O with TGI at 10 L/min, there was a 15% decrease in Paw(peak) and a 16% decrease in VT as compared with their baseline values. However, Pa(CO(2)) remained constant (59 +/- 10 mm Hg versus 57 +/- 6 mm Hg) (p = NS). There was no change in Pa(O(2)) or in hemodynamic variables, and no differences between variables, at 30 min versus 60 min in seven subjects. The remaining subject did not tolerate the reduction in set inspiratory pressure for 60 min. Thirty minutes after the set inspiratory pressure was decreased by 10 cm H(2)O with TGI at 10 L/min, there was a 26% decrease in Paw(peak) and a 26% decrease in VT. However, Pa(CO(2)) increased by 19% and Pa(O(2)) decreased by 13%. Six subjects completed this phase of the protocol for 30 min, and one subject completed it for 60 min. TGI can be used to rapidly facilitate a 5 cm H(2)O reduction in set inspiratory pressure without an increase in Pa(CO(2)). The ability to achieve a 5 cm H(2)O reduction in set inspiratory pressure without adverse physiologic effects was evident within 30 min. Attempts to further reduce set inspiratory pressure were not successful.

Four orthodontic faculty at one dental school classified 25 dental casts according to the classification systems of Angle, Katz, and the British Incisor Classification. The dental casts were selected from a pool of 350 pretreatment graduate orthodontic cases and were those deemed the most atypical. The results demonstrated that Katz's classification was more reliable than both Angle and the British. Angle's classification was the least reliable of the three methods.

It has been theorized that adenosine is a leading candidate for the metabolite responsible for ischemic muscle pain. The purpose of this study was to determine the effect of the non-selective adenosine receptor antagonist, caffeine, on ischemic skeletal muscle contraction pain. Seven healthy adult volunteers with no history of pain disorders, systemic disease, or habitual caffeine use, were chosen for the two-session, cross-over, double-blind study. Every subject received either 200 mg of caffeine (NoDoz, Bristol-Myers) or identical placebo 1 hour before each of the two trials. Ischemia of the forearm was achieved by inflation of a blood pressure cuff to 250 mm Hg. Forearm muscle activity was generated by performance of wrist curis using a 5-gram bar at a rate of 40 cycles per minute. Pain was rated at 15-second intervals for 1 minute using a visual analog scale (0 to 10) with verbal descriptors. Significance was determined by univariate and multivariate analyses of variance and covariance including repeated measures. Pain ratings at 15 seconds in the caffeine trial were significantly lower (P < 0.02) than those in the placebo trial. This effect continued at 30 seconds (P < 0.05). However, by 45 seconds, pain in the caffeine trial was not significantly lower (P = 0.4) than that in the placebo trial. These results show that high-dose caffeine exhibits considerable analgesic efficacy in experimental muscle pain, adding support for a role of adenosine in producing ischemic muscle contraction pain.

Objectives To (1) develop and validate the Dyspnea Index (DI); (2) quantify severity of symptoms in upper airway dyspnea; and (3) validate the DI as an outcome measure. Study Design Survey development and validation. Methods Three hundred sixty-nine participants were recruited for different phases of the study. Two hundred participants with chief complaints of dyspnea were given a 41-item questionnaire addressing common symptoms of dyspnea related to the upper airway. The questions were then reduced based on principal component analysis (PCA) and internal consistency resulting in a 10-item questionnaire. Cognitive interviews were conducted with 15 participants. Test-retest reliability and discriminant validity were measured from 51 participants. The DI was further validated by administering the index to 57 healthy controls (HC). Validation of the DI as a treatment outcome tool occurred with 46 participants' pre- and post-treatment scores. Results PCA revealed that only a single factor was being measured in both the original 41- and 10-item questionnaires. Additional cognitive interviewing suggested that no modification was needed to the DI. Test-retest reliability was r = 0.83. Discriminant validity was r = 0.62. The Mann-Whitney test demonstrated significant differences between healthy/symptomatic participants. Scores from the HC cohort resulted in a mean of 3.12 (SEM = 0.484; SD = 3.65) for the normative values. Conclusions The DI is an effective and efficient instrument to quantify patients' symptoms of upper airway dyspnea. It is a statistically robust index, with significant reliability and validity, and can be dependably used as a treatment outcome measure.

Prior studies demonstrate the ability of upper extremity training to increase arm strength and endurance when incorporated into a pulmonary rehabilitation program. However, patients with severe chronic obstructive pulmonary disease (COPD) may have transportation or mobility problems that make it difficult to travel to a rehabilitation site to obtain this training. This pilot study was designed to determine whether a home-based, upper-arm exercise program could increase arm strength and endurance, and decrease perceptions of breathlessness and fatigue during five activities of daily living. Twenty patients with severe COPD (FEV1 0.80 +/- 0.42) were randomized to an experimental (n = 10) or control group (n = 10). The experimental-group training included three upper arm exercises five times a week for 8 weeks, with training level incremented during weekly home visits. Control-group subjects were contacted weekly to equalize attention from health care providers. During the upper-extremity endurance test for number of rings moved, no significant differences between groups were seen for interaction or treatment. However, there was a significant interaction between treatment and time for perceived fatigue (p = 0.0012), with the experimental group perceiving less fatigue during upper arm work than did the control group. No change was seen in perceived breathlessness. Findings of this study suggest that a home-based, upper-arm exercise program can reduce perceptions of fatigue for patients with severe COPD during activities involving upper arm work. Testing in a larger sample is indicated to determine whether this training can also improve ability to perform unsupported arm work.

With a prevalence of 34% (55/162 at-risk recipients) and a mortality of 25% (14/55 affected recipients), obliterative bronchiolitis is the most significant long-term complication after pulmonary transplantation. Because of its importance, we examined donor-recipient characteristics and antecedent clinical events to identify factors associated with development of obliterative bronchiolitis, which might be eliminated or modified to decrease its prevalence. We also compared treatment outcome between recipients whose diagnosis was made early by surveillance transbronchial lung biopsy before symptoms or decline in pulmonary function were present versus recipients whose diagnosis was made later when symptoms or declines in pulmonary function were present. Postoperative airway ischemia, an episode of moderate or severe acute rejection (grade III/IV), three or more episodes of histologic grade II (or greater) acute rejection, and cytomegalovirus disease were risk factors for development of obliterative bronchiolitis. Recipients with obliterative bronchiolitis detected in the preclinical stage were significantly more likely to be in remission than recipients who had clinical disease at the time of diagnosis: 81% (13/15) versus 33% (13/40); p

Objectives: To determine whether a text message reduces the severity of patient self-reported levels of pain and anxiety following initial placement of orthodontic appliances. Materials and Methods: Thirty-nine orthodontic patients were randomly assigned to one of two groups and matched for age, gender, and bracket type (self-ligating vs conventional). The subjects completed baseline questionnaires to ascertain their levels of pain and anxiety before initiating orthodontic treatment. Following the initial appointment, subjects completed the pain questionnaire and anxiety inventory at the same time daily for 1 week. One group received a structured text message showing concern and reassurance, while the second group served as a control and received no postprocedural communication. Results: There was a statistically significant difference in pain in relation to time between the text message group and the control group as it was demonstrated that demonstrated that compared with the text message group, mean pain intensity increased and selfreported discomfort was longer in the control group. Anxiety was determined to be at its peak the day following initial orthodontic appliance placement and gradually tapered off from that time point. No intergroup difference was noted when analyzing anxiety. Conclusions: This study demonstrated that a text message sent from an orthodontic office following initial appliance placement resulted in a lower level of patient's self-reported pain. Additionally, patient anxiety is at its peak the day following the initial appointment and decreases from that point forward.

To develop and validate a cough severity index (CSI) which quantifies patients' symptoms associated with upper airway chronic cough and to provide a tool for treatment outcome measures.Two hundred patients who had a complaint of chronic cough and/or dyspnea were given a 49- item questionnaire developed through a clinical consensus of the most common symptoms of chronic cough of upper airway origin. The instrument was reduced to 10 questions using statistical methodology. Fifty subsequent patients were given the CSI to measure test-retest reliability at two different moments in time. Twenty healthy controls (HC) were given the instrument to obtain validity. An additional 95 participants provided pre- and posttreatment outcomes using the CSI.Principle Component Analysis (PCA) revealed a single factor with the original 49 questions. A combination of PCA, rank-ordering item-total correlation and communality, as well as clinical consensus further reduced the questionnaire to 10 items. Internal consistency of the CSI was 0.97. Test-retest reliability was r = 0.83. An r = 0.60 for divergent validity between the CSI and the Cough-Specific Quality-of-Life Questionnaire (CQLQ) demonstrated two fairly separate instruments, although both measured cough. Mann-Whitney test was significant between symptomatic patients and healthy controls (P0.0004). The results of 20 HC showed a mean of 0.45 (standard deviation = 1.39). Results for treatment outcomes revealed significance with the Wilcoxon test (P0.0001) and paired samples t test showed significantly different correlations between pre- and postmeasures.The CSI is a short, simple instrument that can be used in the clinical setting to quantify a patient's symptoms of chronic cough of upper airway origin. It represents a statistically reliable, valid, and clinically relevant instrument that can be used to measure treatment outcomes for chronic cough.

Transcranial radiographs of the temporomandibular joint with and without simulated pathology were compared with digital subtracted and histogram equalized images of the same joints. Subtracted images had specificity and sensitivity values of 0.83 and 0.76 respectively, compared with values of 0.42 and 0.54 for conventional radiographs. It was concluded that digital subtraction radiography has the potential to increase the diagnostic yield of transcranial temporomandibular radiography for bony changes to the condylar head.

Laryngeal framework surgery, including medialization laryngoplasty (ML) and arytenoid adduction (AA), are common treatments for vocal fold paralysis and glottal incompetence. Little information is known about the incidence of ML/AA surgery nationwide, in particular the success and complication rates.A 25-item questionnaire was mailed to 6,644 Board-certified otolaryngologists.The response rate was 25.7% (n = 1,707). Sixty-three percent perform ML and/or AA, representing 29,748 procedures. Experience with Silastic medialization implants has decreased over time, while utilization of other materials has increased. The overall complication rate was 15%, including 0.8% implant extrusion and 6% revision rates. The most common revision was placement of a larger implant (37% of all revisions). Airway compromise requiring intervention was observed in 2.2%, and suboptimal voice outcome in 4%. Although not statistically significant, a trend was observed of decreasing complication rate with increasing experience.Laryngeal framework surgeries are being performed with increasing frequency in the United States. The overall complication rate is slightly increased in the present study, but airway compromise and poor vocal outcome are decreased, and the need for revision surgery is unchanged. These findings suggest a continued high level of efficacy of these procedures.

The purpose of this study was to compare the efficacy of transtracheal (TT) oxygen delivery to that of nasal cannula delivery in subjects with chronic obstructive pulmonary disease (COPD). Twenty subjects (14 men, 6 women) were followed for 6 months during nasal cannula delivery. A TT catheter was then inserted, and measurements were repeated during TT use. With TT delivery, subjects required 45% less oxygen at rest and 39% less during exercise (p less than 0.0001). Oxygen use, measured by pounds of oxygen delivered to the home, also decreased, but the magnitude of change was less than anticipated (mean, 14%; range, +4% to -32%). Hospital days decreased from 12 +/- 10 during nasal cannula use to 4 +/- 6 during TT use (p less than 0.002). Exercise tolerance, as measured by a 12-min walk distance, was greater during TT use (p less than 0.0001). No change was seen in spirometry or acid-base balance. Also, no change was seen in Profile of Mood States, Sickness Impact Profile or Katz Adjustment Scale scores. Some problems were encountered relating to use of the catheter (displacement, mucus balls), but they were minor, and most were confined to the initial 2 months of TT use when the tract was immature. Our experience suggests that, in addition to decreasing oxygen flow rate, use of TT delivery may confer benefits that result in improved exercise tolerance and decreased hospitalization in patients with COPD.

Preliminary evidence suggests local brain tissue oxygenation (PbtO(2)) values ofor=15 mm Hg following severe traumatic brain injury (TBI) represent brain tissue hypoxia. Accordingly, many neurotrauma units attempt to maintain PbtO(2)or=20 mm Hg to avoid hypoxia. This study tested the impact of a short (2 h) trial of normobaric hyperoxia on measures of oxidative stress. We hypothesized this treatment would positively affect cerebral oxygenation but negatively affect the cellular environment via oxidative stress mechanisms. Cerebrospinal fluid (CSF) was serially assessed in 11 adults (9 male, 2 female), aged 26 +/- 1.8 years with severe TBI (Glasgow Coma Scale score, 6 +/- 1.4) before, during, and after a FiO(2) = 1.0 challenge for markers of oxidative stress, including lipid peroxidation (F(2)-isoprostane [ELISA]), protein oxidation (protein sulfhydryl [fluorescence]), and antioxidant defenses (total antioxidant reserve (AOR) [chemiluminescence] and glutathione [fluorescence]). Physiological parameters [PbtO(2), arterial oxygen content (PaO(2)), intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP)] were assessed at the same time points. Mean (+/-SD) PbtO(2) and PaO(2) levels significantly changed for each time point. Oxidative stress markers, antioxidant reserve defenses, and ICP, MAP, and CPP did not significantly change for any time period. These preliminary findings suggest that brief periods of normobaric hyperoxia do not produce oxidative stress and/or change antioxidant reserves in CSF. Additional studies are required to examine extended periods of normobaric hyperoxia in a larger sample.

The aim of this study was to determine if nurses, using patient-centered care (PCC), affect patient satisfaction, perceptions of nursing care, and quality outcomes.The Institute of Medicine proposed PCC as 1 of 6 national quality aims, whereas the Centers for Medicare and Medicaid Services highlighted integration of PCC as 1 of 12 actions for quality improvement.A total of 116 patients were randomized into an intervention (PCC) or control group. Patients who were to receive PCC were called before admission and cared for by nurses who trained to administer/practice PCC. Control patients received usual care. Both groups completed questionnaires and received postdischarge calls. Length of stay, falls, infections, and adverse events were measured to assess quality of care.No significant differences were found between groups for length of stay, infection, falls, postoperative complications, quality of care, satisfaction level, or perceptions of nursing care.Patient-centered care did not affect patient's level of satisfaction or quality of care. However, findings yielded clinically relevant results regarding patient/staff responses.

This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses.Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize.In 2004-2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six subcategories.Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate (P=0.007) and baccalaureate (P0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses (P=0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses withor=10 years experience (P=0.046).Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.

A clinical randomized study (posttest design) was conducted to examine whether patient-centered care (PCC) impacts patient satisfaction, perception of nursing care, and quality of care. Differences were seen in 2 of 3 subscales within the Baker and Taylor Measurement Scale. The PCC group rated satisfaction (P = .04) and quality of services (P = .03) higher than controls. PCC may impact patients' perception of the level of satisfaction and quality of care received.

To compare 2 models for managing patients admitted to a subacute medical intensive care unit (MICU) who required prolonged mechanical ventilation (or = 7 d).The subjects were 192 consecutive patients (mean +/- SD age 61.5 +/- 16.1 y, 52% male, 86% white) managed during alternating 7-month blocks of time by an attending physician in collaboration with an acute care nurse practitioner (ACNP) (n = 98 patients) or by an attending physician in collaboration with critical care/pulmonary fellows (n = 94 patients). The total observation time was 28 months (14 mo per team).At unit entry, there were no significant differences in age, sex, race, comorbidity, Acute Physiology and Chronic Health Evaluation III score, or time of tracheostomy between the patients managed by the 2 teams. Patients managed by the ACNP team were more likely to have required mechanical ventilation due to an acute pulmonary problem (p = 0.005). At subacute MICU discharge, the groups were not significantly different in regard to subacute MICU length of stay, days on mechanical ventilation, or discharge weaning status (p0.05). The number of readmissions to the MICU was similar for the ACNP team (n = 7) and fellows team (n = 8), as were readmissions to the subacute MICUor = 72 h after discharge (ACNP = 2, fellows = 1). Each team had 2 deaths without treatment limitation.As hypothesized, management of patients who required prolonged mechanical ventilation with tracheostomy had equivalent outcomes with the ACNP team or the fellows team.

Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes.Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02).In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

Prompt treatment of acute rejection and pulmonary infection reduces morbidity and mortality in lung transplant recipients. Symptoms, spirometry, and bronchoscopy are used to detect these complications. Of these, symptom reporting is the least invasive, yet has received little critical examination.To examine the potential for using reports of symptoms, such as cough and shortness of breath, to recognize clinically significant acute rejection and pulmonary infection after lung transplantation.Symptoms reported during routine follow-up visits were compared between lung transplant recipients (LTR) with clinically significant acute rejection (gradeor= A2) and those without (grade A0 or A1) and between LTR with rejection (gradeor= A2) and those with pulmonary infection.LTR with rejection (gradeor= A2) reported more symptoms (P.01) than did those without (grade A0, A1); however, the magnitude of difference was minimal. LTR with clinically significant acute rejection (gradeor= A2) reported symptoms at a rate comparable with those having pulmonary infection.Although symptoms may alert LTR to changes in their condition, no symptoms (respiratory, general, or activities of daily living [ADL]) differentiate between grades of rejection or pulmonary infection.