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PubMed1997

A framework for capturing clinical data sets from computerized sources.

The pressure to improve health care and provide better care at a lower cost has generated the need for efficient capture of clinical data. Many data sets are now being defined to analyze health care. Historically, review and research organizations have simply determined what data they wanted to collect, developed forms, and then gathered the information through chart review without regard to what is already available institutionally in computerized databases. Today, much electronic patient information is available in operational data systems (for example, laboratory systems, pharmacy systems, and surgical scheduling systems) and is accessible by agencies and organizations through standards for messages, codes, and encrypted electronic mail. Such agencies and organizations should define the elements of their data sets in terms of standardized operational data, and data producers should fully adopt these code and message standards. The Health Plan Employer Data and Information Set and the Council of State and Territorial Epidemiologists in collaboration with the Centers for Disease Control and Prevention and the Association of State and Territorial Public Health Laboratory Directors provide examples of how this can be done.

Abstracting and Indexing↗

PubMed1998

Infection control of hepatitis C in Dutch dialysis centres.

BACKGROUND: In dialysis patients, blood transfusions and long-term dialysis are well-known risk factors for transmission of hepatitis C virus (HCV). Transmission of HCV by transfusions has become extremely rare since the introduction of antibody screening. However, nosocomial transmission of HCV within dialysis units still occurs. We performed a survey of current infection control measures against HCV in Dutch dialysis centres that had participated in a national HCV prevalence study. METHODS: All twenty-seven Dutch dialysis centres where HCV-positive patients had been identified (HCV prevalence 1-8%), participated. With the use of a questionnaire we evaluated screening procedures for resident patients and guest patients, routine hygienic measures in HCV-positive and -negative patients, and cleaning procedures of dialysis equipment. RESULTS: All centres except one screened new patients for HCV antibodies, but the frequency of periodic follow-up screening varied. Most centres requested HCV antibody screening of guest patients in advance, but in daily practice 55% of the centres dialysed guest patients even when HCV antibody status was not available. The majority of centres had not implemented special precautions for patients with unknown HCV antibody status. In most centres the use of protective glasses, masks and aprons depended on the HCV antibody status of the patients. Surprisingly, 85% of the centres allowed their nurses to operate dialysis machines with gloves possibly blood contaminated. All centres sterilized their machines at the end of the day, but only 77% sterilized their machines between all dialysis sessions. Traces of blood were removed with alcohol in 63% of the centres. CONCLUSION: Dutch dialysis centres have not yet implemented an optimal policy for prevention of HCV. Especially, operating dialysis machines with gloves might be a potential source for nosocomial transmission of HCV, not yet covered by the issued guidelines. Because dialysis patients probably have a prolonged serological window phase after a recent HCV infection, it does not suffice to implement a preventive strategy against nosocomial transmission based on the results of HCV antibody screening. Universal, rigorous implementation of adequate infection control measures irrespective of HCV antibody status should be the cornerstone for prevention of nosocomial transmission of HCV and other blood borne pathogens.

Ambulatory Care Facilities↗

PubMed2002

The relationship of post-acute home care use to Medicaid utilization and expenditures.

RESEARCH OBJECTIVES: To describe the use of post-acute home care (PAHC) and total Medicaid expenditures among hospitalized nonelderly adult Medicaid eligibles and to test whether health services utilization rates or total Medicaid expenditures were lower among Medicaid eligibles who used PAHC compared to those who did not. STUDY POPULATION: 5,299 Medicaid patients aged 18-64 discharged in 1992-1996 from 29 hospitals in the Cleveland Health Quality Choice (CHQC) project. DATA SOURCES: Linked Ohio Medicaid claims and CHQC medical record abstract data. DATA EXTRACTION: One stay per patient was randomly selected. DESIGN: Observational study. To control for treatment selection bias, we developed a model predicting the probability (propensity) a patient would be referred to PAHC, as a proxy for the patient's need for PAHC. We matched 430 patients who used Medicaid-covered PAHC ("USE") to patients who did not ("NO USE") by their propensity scores. Study outcomes were inpatient re-admission rates and days of stay (DOS), nursing home admission rates and DOS, and mean total Medicaid expenditures 90 and 180 days after discharge. PRINCIPAL FINDINGS: Of 3,788 medical patients, 12.1 percent were referred to PAHC; 64 percent of those referred used PAHC. Of 1,511 surgical patients, 10.9 percent were referred; 99 percent of those referred used PAHC. In 430 pairs of patients matched by propensity score, mean total Medicaid expenditures within 90 days after discharge were $7,649 in the USE group and $5,761 in the NO USE group. Total Medicaid expenditures were significantly higher in the USE group compared to the NO USE group for medical patients after 180 days (p < .05) and surgical patients after 90 and 180 days (p < .001). There were no significant differences for any other outcome. Sensitivity analysis indicates the results may be influenced by unmeasured variables, most likely functional status and/or care-giver support. CONCLUSIONS: Thirty-six percent of the medical patients referred to PAHC did not receive Medicaid-covered services. This suggests potential underuse among medical patients. The high post-discharge expenditures suggest opportunities for reducing costs through coordinating utilization or diverting it to lower-cost settings. Controlling for patients' need for services, PAHC utilization was not associated with lower utilization rates or lower total Medicaid expenditures. Medicaid programs are advised to proceed cautiously before expanding PAHC utilization and to monitor its use carefully. Further study, incorporating non-economic outcomes and additional factors influencing PAHC use, is warranted.

Acute Disease↗

PubMed2006

[Effects of additional pulmonary blood flow after bidirectional Glenn procedure].

Thirteen cases of functional single ventricle who had undergone bidirectional Glenn procedure were divided into 2 groups according to presence (5) or absence (8) of additional pulmonary blood flow. Additional flow was preserved in cases with relatively small pulmonary artery index (PA index), and their sources were antegrade pulmonary blood flow (2), and Blalock-Taussig (BT) shunt (3). In the control group, PA index was reduced to about 70% of the preoperative value, while in the additional group, pulmonary artery growth was recognized without significant elevation of mean pulmonary artery pressure. However, atrioventricular valve regurgitation progressed and systemic ventricular volume did not decrease after Glenn in the additional group. Therefore special consideration for the timing of Fontan procedure is mandatory.

Anastomosis, Surgical↗

PubMed1976

Sources of the slow-growing pigmented water bacteria.

The group of organisms often labelled as "slow-growing pigmented water bacteria" may include various species of the Xanthomonas, Cytophoga, Pseudomonas, Aeromonas and Flavobacterium genera. Due to their slow growth, this group is usually overlooked in the average clinical laboratory since the pigmented colonies are most easily noted on membrane filter pads or on surface streaked agar plates, but only after 5-15 days of incubation at room temperature. Although present at low levels in free-flowing domestic water supplies (less than 1 per ml), they can be easily isolated by swabbing sink faucets, drinking fountain heads, surgical scrub sink heads and aerators, dental chair spray units, and from the air water interface in humidifiers, nebulizers, water baths, and reservoirs where the water may remain static for weeks. Although not considered primary pathogens, several strains have been implicated in infections in nurseries and among patients in intensive care units. Contamination control in critical research and patient care areas demands scrupulous sanitation practices, regular cleaning and decontamination of all equipment, and the use of bacteria-free water whenever possible.

Bacteria↗

PubMed1986

Randomized clinical trial of intra-operative antimicrobial prophylaxis of infection after neurosurgical procedures.

A randomized, placebo-controlled, double-blind and sequentially analysed clinical trial to determine the efficacy of intra-operative parenteral gentamicin and vancomycin (with streptomycin in the irrigating solution) in preventing infection at the operative site following neurosurgical procedures is described. Patients receiving prophylaxis had a significantly (P = 0.046) lower operative site infection rate (2/71 = 2.8%) than those receiving placebo (9/77 = 11.7%). This difference was most apparent during an epidemic, the source of which was not evident. Moreover, a total of 13 infections (two operative site, five pneumonia and six urinary tract) occurred among 12 patients receiving prophylaxis, whereas there was a total of 31 infections (nine operative site, nine pneumonia, 10 urinary tract and three septicaemia) among 24 patients receiving placebo. A smaller quantity of antimicrobial drugs was administered postoperatively to patients receiving prophylaxis (3.96 'antibiotic-days' per patient) than to those receiving placebo (6.87 'antibiotic-days' per patient).

Anti-Bacterial Agents↗

PubMed1997

In situ detection of matrix metalloproteinase-2 (MMP2) and the metalloproteinase inhibitor TIMP2 transcripts in human primary hepatocellular carcinoma and in liver metastasis.

BACKGROUND/AIMS: Metalloproteinase (MMP)-2 and the metalloproteinase inhibitor TIMP2, play a critical role in tumor invasion. We have investigated the cellular sources of MMP2 and TIMP2 in primary and secondary human liver cancers. METHODS: Using in situ hybridization and zymography, we analyzed surgical biopsies from matching pairs of tumoral and non-tumoral liver from six hepatocellular carcinomas and seven liver metastases and from four liver donors. The cellular sources of MMP2 and TIMP2 were further characterized using an anti-alpha-smooth muscle actin antibody on contiguous sections. RESULTS: In hepatocellular carcinoma and liver metastases, in situ hybridization showed that MMP2 and TIMP2 mRNA were expressed by anti-alpha-smooth muscle actin-positive cells at the invasive front. Slender fibroblasts embedded in a denser matrix were MMP2(+)/TIMP2(+)/anti-alpha-smooth muscle actin(+). Intratumor microvessels showed a strong labeling for MMP2 but weak for TIMP2 mRNA. In contrast, the endothelial lining of the central veins was MMP2(+)/TIMP2(+) in non-tumoral areas with signs of blood-flow obstruction. In control livers, MMP2 and TIMP2 mRNA distribution was restricted to fibroblasts and endothelial cells within portal tracts and scattered sinusoidal cells. Direct zymography of samples comprising the invasive front revealed variable amounts of both proMMP2 and its active form in hepatocellular carcinoma, whereas strong bands corresponding to both active and latent forms of MMP2 were detected in liver metastases. CONCLUSIONS: The striking density of MMP2(+)/TIMP2(+)/anti-alphaSM(+) stellate-shaped cells in the perisinusoidal space adjacent to liver tumors suggests that hepatic stellate cells, upon differentiation to myofibroblasts, may contribute to the dissemination of liver metastases through the sinusoidal network.

Actins↗

PubMed1998

Paediatric trauma and resuscitation.

Severe paediatric trauma differs from adult trauma in that blunt trauma, and especially head trauma, represents 98% of cases. In these instances, early control of the airways, prompt haemodynamic stabilization, emergency explorations and further conservative management of bleeding abdominal lesions are the most challenging issues. On-scene resuscitation, primary stabilization before transportation and transfer to a specialized centre are mandatory. The pre-hospital management of injured children, however, is frequently neglected. The need for emergency intubation and rapid intravenous access insertion is difficult to meet, in spite of many attempts to ameliorate this situation. The option of conservative surgical management of spleen and liver lesions has been extensively developed, and is now applied in many paediatric institutions with a high rate of success. A better application of on-scene resuscitation and of the selective management of bleeding lesions is the key to the prevention of secondary lesions, representing a major source of avoidable death and long-term sequelae.

Journal Article↗

PubMed2001

Acute gastrointestinal bleeding: Part II.

OBJECTIVE: To review the management of acute gastrointestinal bleeding in the critically ill patient in a two part presentation. DATA SOURCES: Articles and a review of studies reported from 1991 to 2001 and identified through a MEDLINE search of the English language literature on acute gastrointestinal bleeding. SUMMARY OF REVIEW: Oesophageal varices are a common source of upper gastrointestinal bleeding in patients who have portal hypertension. Management requires resuscitation and treatment of associated coagulation disturbances along with intravenous octreotide (50 microg followed by 50 microg/hr for 48 hr) before endoscopy is performed. Octreotide is more effective than vasopressin in controlling acute variceal suppressant and has fewer side effects compared with glypressin. To provide haemostasis, endoscopic variceal sclerosis has largely been replaced by variceal ligation using an overtube and small elastic 'o' rings to band the bleeding variceal channels. If bleeding continues then Balloon tamponade and intravenous fibrinolytic inhibitors (e.g. tranexamic acid 3-6 g i.v. daily) are used for 24 hr before endoscopy (with variceal ligation) is repeated. If the variceal bleeding is resistant to repeated banding, portal decompression using transjugular intrahepatic portosystemic shunt or surgical shunt should be considered. While beta adrenergic blockers (e.g. propranalol) are indicated to reduce the incidence of rebleeding, they are contraindicated in a patient with actively bleeding oesophageal varices. CONCLUSIONS: Acute oesophageal variceal bleeding can often be managed successfully using octreotide and variceal ligation. If bleeding continues then transjugular intrahepatic portosystemic shunt or surgical shunt should be considered.

Journal Article↗

PubMedDate not supplied

Routes of infection. A study of using "tracer particles" in the orthopedic operating room.

Wound irrigates and tissue samples were cultured from clean orthopedic wounds at the conclusion of 280 orthopedic operations. The surgeons used a laminar flow unit and took extra precautions against wound contamination although personnel exhaust systems were not used. It was possible to culture residual organisms but difficult to trace the source of these by bacteriological methods. Artificial or "tracer" particles which could be applied to patient or surgeon were retrieved from the wound and suitably stained. Using albumin microspheres it was possible to identify and differentiate "patient-derived particles" from "surgeon-derived particles" in the majority of all wounds. Contamination from the surgeon was significant even under near optimum operating room conditions. These techniques are useful for development of control measures for residual wound contamination in orthopedic operating rooms.

Bacterial Infections↗

PubMed1984

The effect of prostacyclin infusion on platelet hemostatic function in patients undergoing cardiopulmonary bypass.

Prostacyclin (PGI2) infusion was studied in patients during cardiopulmonary bypass for coronary artery bypass grafting to assess its capacity to protect platelet hemostatic function. Twelve patients received PGI2 at doses ranging from 20 to 70 ng/kg/min by continuous infusion directly into the bubble oxygenator. Nine control patients were also studied. Platelet counts were not different in the two groups; the platelet count at the completion of the operation was decreased by a mean of 29% in treated patients and 40% in control patients (p greater than 0.15). Bleeding times were uniformly greater than 30 minutes following 30 minutes on bypass in both groups (p greater than 0.5). Also there was no difference in the bleeding times between the treated and untreated groups in the immediate postbypass period (p greater than 0.05). In addition, no difference in transfusion requirements was observed between the treated and control groups. However, plasma levels of platelet factor 4 were lower in the treated patients (p less than 0.05), and, more significantly, blood pressure was lower at all time points in the treated patients (p less than 0.001) despite the greater use of vasopressors. We conclude that PGI2 infusion in this study was of no hemostatic benefit but produced significant hypotension, a potential source of morbidity.

Adult↗

PubMed2000

Robotics in child neurosurgery.

We felt there was a need for a new device with "minimal invasive" tracking hardware, to be used in image-guided neurosurgery, and the system we designed to fill this need is now presented. It combines precision of movement, stability and self-positioning capabilities together with optically tracked registration and procedural control within the structure of a surgical microscope. The results are reduced setup time and minimal "distraction" from the procedure itself, factors of special relevance in child neurosurgery. The system is composed of a six-axis industrial robot suitable for use in the operating room, carrying a surgical microscope. Three progressive scan-synchronized infrared cameras mounted around the lenses of the scope are used to register the patient's position and track surgical instruments with reference to the registered space. Orientation of the microscope during surgery is obtained with a six-axis joystick used as a microscope handle. The system has been clinically used in 14 cases, and it has proven itself to be reliable, providing the expected performance advantages. The implementation of a tracked ultrasound or endoscope intraoperative imaging source is also described.

Brain Diseases↗

PubMedDate not supplied

Immunoblot evaluation of the 100 and 130 kDa antigens in camel hydatid cyst fluid for the serodiagnosis of human cystic echinococcosis in Libya.

Two high molecular weight antigens with molecular masses approximately 100 kDa and 130 kDa were identified by immunoblotting camel hydatid cyst fluid, with 94% sensitivity in sera from surgically confirmed Libyan cystic echinococcosis cases. 40% of sera from surgically confirmed alveolar echinococcosis cases cross-reacted with the 100 and 130 kDa antigens, as did 5.3% of sera from human Taenia solium cysticercosis patients. No cross-reaction occurred with sera from human schistosomiasis mansoni or onchocerciasis patients. In addition, all sera from patients with non-hydatid space-occupying lesions (i.e. simple liver cysts, kidney cysts, lung tuberculosis, pulmonary carcinoma, pulmonary empyema, and lung abscess) were seronegative against the same antigens, as were control serum samples from healthy individuals. The 100 and 130 kDa antigens were strongly recognized by sera from cystic echinococcosis patients when camel or horse hydatid cyst fluid was used in immunoblotting but were only weakly recognized if sheep or human hydatid cyst fluid was used. Camel hydatid cyst fluid could be an important source of diagnostic antigens for human cystic echinococcosis in the Middle East endemic region.

Animals↗

PubMed1995

Interstitial high-dose rate brachytherapy with iridium-192 in patients with oral squamous cell carcinoma.

Thirty-four patients with recurrent oral and oropharyngeal carcinomas were treated over a period of 4 years, by interstitial high-dose rate (HDR) brachytherapy (BT) using an iridium-192 source (Gammamed 2i and 12i equipment, Sauerwein, Germany) and fractionated application (1 up to 3 times, weekly recovery phases, single maximum dose 10 Gy). Pretreatment characteristics of patients in terms of irradiation (RT) and surgery differed (22 had external RT alone, with a total dose between 60.0 and 75.6 Gy; RT and surgery: 7; surgery alone: 1). The initial TNM-stages (UICC, Hermanek et al., 1987) of patients were: I = 2, II =3, III = 7, IV = 22. In the majority of cases, clinical indications for HDR-BT included tumour recurrence or progression following external RT, and second primary tumours of the oral cavity. Therapy was successful in most cases, i.e. complete remission: 11, partial remission: 16, no change: 2, progression: 5. Local control and overall survival rates, including patients surgically treated after BT, were at 6 months 58% and 62%, and 44% and 53% at 12 months, respectively. This type of treatment is recommended in patients with local recurrence or second primary tumours after previous external RT in the head and neck region. However, the benefit of interstitial HDR-BT remains questionable, particularly in patients with large tumours and lymph node metastases.

Adult↗

PubMedDate not supplied

Pertinent issues related to laparoscopic radical prostatectomy.

PURPOSE: We describe the critical steps of the laparoscopic radical prostatectomy (LRP) technique and discuss how they impact upon the pertinent issues regarding prostate cancer surgery: blood loss, potency and continence. RESULTS: A major advantage of LRP is the reduced operative blood loss. The precise placement of the dorsal vein complex stitch associated with the tamponading effect of the CO(2) pneumoperitoneum significantly decrease venous bleeding, which is the main source of blood loss during radical prostatectomy. At the Cleveland Clinic, the average blood loss of our first 100 patients was 322.5 ml, resulting in low transfusion rates. The continuous venous bleeding narrowed pelvic surgical field and poor visibility can adversely impact on nerve preservation during open radical prostatectomy. Laparoscopy, with its enhanced and magnified vision in a relatively bloodless field allows for excellent identification and handling of the neurovascular bundles. During open retropubic radical prostatectomy, the pubic bone may impair visibility and access to the urethral stump, and the surgeon must tie the knots relying on tactile sensation alone. Consequently, open prostatectomy is associated with a prolonged catheterization period of 2 - 3 weeks. Comparatively, during laparoscopic radical prostatectomy all sutures are meticulously placed and each is tied under complete visual control, resulting in a precise mucosa-to-mucosa approximation. CONCLUSION: The laparoscopic approach may represent a reliable less invasive alternative to the conventional open approach. Despite the encouraging preliminary anatomical and functional outcomes, prospective randomized comparative trials are required to critically evaluate the role of laparoscopy for this sophisticated and delicate operation.

Journal Article↗

PubMed2005

Biceps femoris perforator free flap for upper extremity reconstruction: anatomical study and clinical series.

BACKGROUND: Perforator flaps are an important development in reconstructive surgery. The description of new perforator flaps is an open field in anatomical and surgical research. METHODS: The anatomy of the musculocutaneous perforating vessels of the short head of the biceps femoris muscle was investigated as a possible source for free tissue transfer in 10 fresh specimens. A series of 10 free biceps femoris perforator flaps for upper extremity reconstruction is described. RESULTS: There were three constant sizable perforators, located at 6 cm (range, 5 to 6.5 cm), 11.6 cm (range, 10 to 14 cm), and 15.3 cm (range, 14 to 17 cm), respectively, from the knee joint line. The distalmost perforator was a branch off the superior lateral genicular artery in all anatomical specimens. The middle perforator was a direct branch off the popliteal artery in 60 percent of the cases and off the profunda femoris in the remaining 40 percent. The uppermost perforator was usually a branch off the middle perforator. The flaps of the clinical series were based on the middle perforator (11.6 cm). All 10 free flaps were used for upper extremity trauma coverage, with a 100 percent success rate, although one flap required pedicle revision because of arterial thrombosis and developed partial necrosis. Donor-site delayed wound healing occurred in two patients. CONCLUSIONS: The vascular anatomy is relatively constant. Flap dissection is straightforward under tourniquet control, donor morbidity is low provided a primary closure is possible, and pedicle size is appropriate for repair. When a moderate-size free flap with moderate thickness and a medium-sized pedicle is needed, the biceps femoris perforator flap should be considered in the first-choice group of donor areas.

Adolescent↗

PubMed1991

Effect of desmopressin acetate on hemorrhage without identifiable cause in coronary bypass patients.

After early hopeful reports, the ability of desmopressin acetate (DDAVP) to substantially reduce post surgical hemorrhage has been questioned. A total of 74 elective coronary bypass patients (Group A) receiving DDAVP (0.3 micrograms/kg) who, in the opinion of the operating surgeon, did not achieve adequate hemostasis after protamine neutralization of heparin were studied. They were compared with 91 age- and sex-matched controls (Group B). Before surgery there was no difference in hematocrit (40.8% vs. 40.3%); bleeding time (5.3 vs. 4.9 sec); platelet count (267 +/- 8 vs. 309 +/- 13 X 10(3)/mm3); fibrinogen (363 vs. 361 mg/dl); or activated clotting time (ACT) (168 +/- 4 vs. 163 +/- 3 sec). Both groups had the same number of grafts (3.3/pt), use of the mammary artery (72%), and average bypass time (124 min). There were also no differences in postbypass ACT (142 +/- 3 vs. 135 +/- 2 sec); platelet count (97 +/- 10 vs. 120 +/- 24 X 10(3)/mm3); and fibrinogen (157 +/- 35 vs. 207 +/- 40 mg/dl). However, postoperative hemorrhage was strikingly different: 1306 +/- 89 vs. 896 +/- 33 ml (P less than .0001). Fifteen patients in Group A bled more than 1.5 liters compared with 4 in Group B. Red cell transfusion rates were 1.23 +/- 0.26 for Group A and 0.35 +/- 0.8 for Group B (P less than 0.005). Sixteen Group A patients received additional blood products (plasma and platelets). The hemorrhage difference remained significant even when these patients were excluded (1098 +/- 57 vs. 896 +/- 34, P less than 0.003). Three Group A patients were re-explored without a bleeding source located.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2000

Use of intensive care-specific interventions in major teaching and other hospitals: a regional comparison.

OBJECTIVE: To compare the use of 40 specific medical interventions in intensive care units (ICUs) of major teaching and other hospitals DESIGN: Retrospective cohort study. SETTING: Thirty-eight ICUs in 28 hospitals in a large metropolitan region. PATIENTS: A total of 12,929 consecutive eligible admissions to medical, surgical, neurologic, or mixed medical/surgical ICUs between January 1, and June 30, 1994. MEASUREMENTS: The use of 40 diagnostic and therapeutic interventions during the first 24 hrs of ICU admission were obtained from patient medical records and a weighted intervention score was determined for each patient. Admission severity of illness was measured by using the Acute Physiology and Chronic Health Evaluation III methodology. MAIN RESULTS: Patients at the five teaching hospitals had a greater severity of illness (mean predicted risk of in-hospital death, 15.1%+/-21.9% vs. 11.2%+/-19.0%; p < .01) than patients at the 23 other hospitals. Patients at major teaching hospitals also had higher mean intervention scores (3.5+/-4.9 vs. 2.3+/-3.7; p < .01). Differences in intervention scores persisted after controlling for severity of illness, admission diagnosis, and admission source. However, scores varied among the major teaching hospitals. When examined individually, only three of the five major teaching hospitals had higher (p < .05) interventions scores, compared with other hospitals, whereas one had a lower (p < .05) intervention score. CONCLUSIONS: Patients in ICUs at major teaching hospitals were, in aggregate, more likely to receive diagnostic and therapeutic interventions than patients at other hospitals. Variation among major teaching hospitals suggests that factors other than teaching status also affect the use of these interventions.

APACHE↗