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At least 1,027 records · Page 57Linked to original sources

PubMed1993

Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification.

From January 1987 to September 1990, 132 displaced intraarticular calcaneal fractures were treated operatively using a lateral approach, lag screws, and side plate without bone graft. To evaluate the results, a classification for intraarticular calcaneal fractures was developed, based on standardized coronal and transverse computed tomography (CT) scans of both feet. Type 1 fractures were nondisplaced (and received nonoperative treatment); Type II were two-part or split fractures; Type III were three-part or split depression fractures; and Type IV were four-part or highly comminuted articular fractures. Results were evaluated using the Maryland Foot Score and repeat CT scans. One hundred twenty cases were available for a minimum of one year follow-up evaluation (range, 12-56 months; mean, 29.3 months). Roentgenographic evaluation of calcaneal body dimensions showed restoration of heel height (98%), width (110%), and length (100%) to virtually normal in all cases, regardless of preoperative displacement. Roentgenographically, articular reduction was anatomic in 68 of 79 (86%) Type II fractures, 18 of 30 (60%) Type III fractures, and 0 of 11 (0%) Type IV fractures. Excellent or good clinical results occurred in 58 of 79 (73%) Type II fractures, 21 of 30 (70%) Type III fractures, and one of 11 (9%) Type IV fractures. When excellent and good clinical results were compared by year, a distinct learning curve appeared (1987, 27%; 1988, 54%; 1989, 74%; 1990, 84%). Despite an improved outcome for Type II and III fractures with increasing surgical experience, the results of operative intervention in Type IV fractures were no better, even after four years.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcaneus↗

PubMed2006

Paying physicians for quality: evidence and themes from the field.

BACKGROUND: Health plans, self-insured employers, health plans, and provider organizations are currently introducing financial incentives that reward physicians for delivering high-quality medical care. Yet a review of existing research reveals virtually no empirical studies of the effect of direct, internal quality incentives on physician performance. Key-informant interviews with leaders of provider organizations should shed new light on evolving quality incentives within organizations. METHODS: Structured key-informant interviews with administrators and medical directors in 22 medical groups and 9 hospitals affiliated with 10 large, integrated health systems were conducted from July 2003 through January 2004. FINDINGS: Views on the role of financial incentives varied widely and were related to a number of other factors, including institutional culture, community context, organizational strategy and structure, organizational stability, quality measurement, nature and size of incentives, and the sustainability of interventions. DISCUSSION: These findings have implications for the acceptability and structure of financial incentives for quality directed to health care provider organizations. A set of considerations for the design and implementation of quality incentives relate to the incentives' scope, controllability, transparency, size, and orientation (individual or team), as well as the relationship between the extrinsic financial incentives and professionals' intrinsic motivation.

Hospital Administrators↗

PubMed2001

Seeing mum drinking a 'light' product: is social learning a stronger determinant of taste preference acquisition than caloric conditioning?

OBJECTIVE: It was examined whether caloric conditioning or social learning strategies dominate in taste preference acquisition in children. The caloric learning paradigm predicts that eating or drinking artificially sweetened products, which deliver virtually no energy, will not lead to a taste preference whereas the social learning paradigm predicts that seeing important others modelling the eating and drinking of these 'light' products will induce a preference for the taste of light products in the child. DESIGN: In a 2 x 2 between subjects factorial design, the amount of energy and social modelling was varied. SETTING: The study was undertaken at primary schools in Maastricht, The Netherlands. SUBJECTS: Forty-five children participated and six children dropped out. The 39 children who completed the study (14 boys and 25 girls) had a mean age of 67 months (range 51--81, s.d. 5.6). INTERVENTIONS: Each subject took part in nine conditioning trials with an individually selected tasting yoghurt which was not preferred very much at the pre-test. RESULTS: The children in the combined caloric and social condition showed an increase in their preference for the conditioned taste which was larger than a regression-to-the-mean effect (P=0.007), whereas children in the other groups did not. CONCLUSION: Caloric and social learning combined, ie modelling the consumption of energy-rich foods or drinks, is the best way to establish taste preferences. Children more easily learn a preference for energy-rich food that is eaten by significant others than for food that is low in energy and eaten by significant others.

Child↗

PubMed1996

Stereoscopic visualization system for clinical angiography.

Four dimensional visualization (FDV) project for clinical angiography has started at National Cancer-Center since 1995 in cooperation with medical virtual reality projects in our center. All stereo pair of x-ray angiographic images, both digital images and film based conventional x-ray images, are available in this system. FDV system software was developed on a Silicon Graphics platform. Every stereo pair angiographic images can be viewed stereoscopically using a stereoscopic visualization interface. Series of image data sets provide three dimensional blood flow dynamics that is very useful to diagnose vascular encasement by the tumor and to determine vessel of purpose which locates in front or in back from superimposed angiographic images. FDV system is expected to improve the accuracy and efficiency of diagnostic radiology and interventional radiology (IVR) procedures. In future, angiography system will equipped with a stereoscopic visualization interface that will provide a more flexible and more effective guidance tool for diagnostic radiology, especially for IVR that requires image-guided procedure.

Angiography↗

PubMed1999

[The knowledge and application of regulations on smoking in secondary teaching centers].

OBJECTIVES: Despite the growing body of legal and normative regulations regarding promotion, sales and consumption of cigarettes, a few studies have already pointed to a low enforcement and commitment of these restrictions. This study explores the degree of awareness and compliance of these norms in the secondary school. DESIGN: Cross-sectional, observational study. A telephone survey was carried out. PARTICIPANTS: A simple of school principals or deputy principal was surveyed. MEASUREMENTS: A questionnaire was designed to obtain respondents knowledge of the current policies regarding smoking, as well as on the existence of visible signals in the school wards. Besides, opinion on tolerance towards smoking behavior among the school teachers was ascertained. RESULTS: Virtually at the respondents (98.8%) declared to know the existence of the regulations, although only 74.4% declared to have specific regulations at the school level. Smoking by teachers was allowed in their own offices in 61.6% of the centers. In open grounds, only 4.7% of the centers authorized adults to smoke while 18.6% permitted to smoke to the students. Public centers were less restrictive than private centers. DISCUSSION: Principals of secondary schools are aware of the existing, policy, and in most cases largely restrict public consumption. However, there are still some important gaps regarding signals, consumption in outdoor public spaces and teachers consumption in their own offices. Specific interventions seem to be necessary to overcome this situation.

Adolescent↗

PubMedDate not supplied

[Use of average-acting nondepolarizing myorelaxants in abdominal surgery].

The efficiency and safety of use of average-acting nondepolarizing myorelaxants, such as atracurium, vecuronuim, rocuronium, and cisatracurum, during abdominal surgical interventions under general anesthesia (combined or total intravenous anesthesia) were investigated in 162 patients. There is evidence that the use of the above agents ensures a qualitative myorelaxation during different types of operations (laparoscopic and laparotomic) and no impact on hemodynamics (according to the data of continuous non-invasive monitoring) allows these myorelaxants to be used in patients with concomitant cardiovascular diseases. Rocuronium is the myorelaxant of choice for rapid tracheal intubation. The high degree of predictability of the duration of an effect produced by atracurium and cisatracurium enables these myorelaxants to be used without monitoring neuromuscular conduction. With the equally good quality of myoplegia and with virtually comparable consumed diseases, the infusion procedure of relaxation maintenance is preferable for early activation of patients. Insignificant effects on histamine release make it possible to use vecuronium, rocuronium, and cisatracurium in patients with the compromised immune system.

Abdomen↗

PubMedDate not supplied

Males as sexual assault victims: multiple levels of trauma.

The definite and persistent phenomenon of sexual assault upon males is virtually ignored in the literature, although incidence data reported here suggest the greater scope of the problem. The avoidance of the subject of sexual assault on males creates a negative environment for victims. While the motivation of assailants is briefly discussed, the article focuses on the psychological aftermath for sexual assault victims. A paradigm is offered, consisting of "Set-up," "Attack," and "Aftermath" phases. Male victims suffer "Rape Trauma Syndrome" as described for females, as well as various forms of stigmatization and secondary trauma. Differences and similarities between male and female victims are identified. Victim responses are discussed as they proceed through several stages, with implications for appropriate interventions on both the clinical and community levels. The article concludes with an extensive bibliography.

Adolescent↗

PubMed1998

[HIV infection: relevant pediatric aspects].

After 15 years of intense AIDS research several fascinating new findings have recently produced real hope for people infected with HIV and new optimism among scientists. A second group of powerful antiretroviral drugs (proteinase inhibitors) has been introduced. These drugs can virtually stop viral replication when used in combination with other drugs (nucleoside or non-nucleoside reverse transcriptase inhibitors), which also almost totally eliminates the emergence of HIV-resistance. New moleculargenetic methods (plasma HIV-RNA assays) made a new marker to quantify and survey therapeutic effects and to accurately predict individual progression of HIV infection available. These new instruments also provided us with a more realistic imagination about pathogenesis and viral dynamics in HIV infection. In neonates prophylactic antiretroviral treatment of pregnant women already prevents two thirds of vertically acquired infections, and the vertical transmission rate may well continue to decline with new prophylactic regimens and/or other interventions (e.g. cesarean section). Given these splendid innovations, a huge impact on prognosis can well be anticipated in the near future.

Adolescent↗

PubMed1999

Y-appendicoplasty: a technique to minimize stomal complications in antegrade continence enema.

PURPOSE: The antegrade continence enema (ACE) is an effective method of treatment of fecal incontinence and constipation. However, the original procedure described is not easy to perform and is associated with a high complication rate, especially stomal stenosis-necrosis (55%). Even with introduction of orthotopic appendicostomy, composite series still report an incidence of 30% with stomal problems. The authors report a virtually complication-free simple modification, the Y-appendicoplasty. METHODS: The base of the appendix is imbricated into cecum by 2 successive rows of interrupted seromuscular stitches. A small Y-shaped incision is made on the abdominal wall at McBurney's point, and 3 triangular skin flaps are raised. The appendix is brought out of the skin incision. The tip is excised, and 3 vertical cuts are made 120 degrees apart. The 3 appendiceal flaps thus created are interdigitated with the skin flaps using interrupted sutures. RESULTS: Twelve children underwent Y-appendicoplasty and orthotopic appendicostomy. Mean operating time was 1 hour. None experienced stomal complications that required intervention. Control of fecal continence with ACE ranged from excellent to good. CONCLUSION: Y-appendicoplasty and orthotopic appendicostomy minimizes complications for ACE and is easy to perform.

Appendix↗

PubMed1998

Systemic T cell adoptive immunotherapy of malignant gliomas.

OBJECT: To determine the feasibility, toxicity, and potential therapeutic benefits of systemic adoptive immunotherapy, 10 patients with progressive primary or recurrent malignant glioma received this treatment. Adoptive immunotherapy, the transfer of immune T lymphocytes, is capable of mediating the regression of experimental brain tumors in animal models. In animal models, lymph nodes (LNs) that drain the tumor vaccine site are a rich source of tumor-immune T cells. METHODS: In this clinical study, patients were inoculated intradermally with irradiated autologous tumor cells and granulocyte macrophage-colony stimulating factor as an adjuvant. Cells from draining inguinal LNs, surgically resected 7 days after vaccination, were stimulated sequentially with staphylococcal enterotoxin A and anti-CD3, and a low dose of interleukin-2 (60 IU/ml) was used to expand the stimulated cells. The maximum cell proliferation was 350-fold over 10 days of culture. The activated cells were virtually all T cells consisting of various proportions of CD4 and CD8 cells. These cells were given to patients by intravenous infusion at doses ranging from 9 x 10(8) to 1.5 x 10(11). There were no Grade 3 or 4 toxicities associated with the treatment. Following T-cell transfer therapy, radiographic regression that lasted at least 6 months was demonstrated in two patients with recurrent tumors. One patient demonstrated stable disease that has lasted for more than 17 months. The remaining patients had progressive disease; however, four of the eight patients with recurrent tumor remain alive more than 1 year after surgery for recurrence. Three patients required intervention with corticosteroid agents or additional surgery approximately 1 month following cell transfer. CONCLUSIONS: These intriguing clinical observations warrant further trials to determine whether this approach can provide therapeutic benefits and improve survival.

Adjuvants, Immunologic↗

PubMed1993

Inhibition of experimental neointimal hyperplasia and thrombosis depends on the type of vascular injury and the site of drug administration.

BACKGROUND: Heparin inhibits vascular smooth muscle cell proliferation in tissue culture and limits neointimal hyperplasia after experimental arterial injury but has been ineffective in reducing clinical restenosis. We examined how this discrepancy might reflect suboptimal drug-tissue interactions and/or differences in the vascular response to injury. METHODS AND RESULTS: Intravenous infusion was compared with local administration of heparin to injured rabbit iliac arteries either from drug-impregnated polymeric controlled release matrices in the perivascular space or from drug-releasing endovascular stents. Occlusive thrombosis, seen in 42% of control stent-bearing arteries, and partial thrombosis were virtually eliminated by heparin delivery from any route. Intimal area 14 days after balloon withdrawal denudation alone was reduced to an equal extent by continuous systemic heparin or by perivascular heparin for the first 3 days. In contrast, endovascular stents produced more exuberant neointimal hyperplasia, the inhibition of which required continuous rather than only early heparin administration. Neither perivascular delivery limited to the first 3 days nor stent-based delivery reduced neointimal hyperplasia as effectively. CONCLUSIONS: The antiproliferative and antithrombotic effects of heparin differ markedly, depending on the type of arterial injury and the mode of drug administration. Different forms of injury may require different therapies, and complications of arterial intervention such as excessive neointimal hyperplasia and thrombosis may demand alternate therapeutic regimens. Duration, dose, and site of delivery rather than frank resistance to therapy may explain why experimentally effective antiproliferative and antithrombotic agents fail clinically.

Administration, Topical↗

PubMed2006

Mental health care in juvenile detention facilities: a review.

Juvenile detention facilities have come under increasing legal pressure to provide mental health services to detainees, and mental health clinicians may be asked to design and implement programs in detention facilities. However, there is little consensus on what types of services should be provided, and virtually no data on the effectiveness of such services in a detention setting. The objective of this article is to provide an overview of the existing literature on mental health services in juvenile detention and to make suggestions about future research needs. Specifically, it highlights the tension surrounding the provision of mental health care in juvenile detention, presents data on the prevalence of psychiatric problems in detention settings and what types of services are currently provided, and draws on the larger child and adolescent mental health literature to suggest what types of services might be most appropriate for juvenile detention settings. We conclude that, although there are some suggestions of promising interventions that may be appropriate, much more research, specifically in detention settings, is needed to determine their effectiveness.

Adolescent↗

PubMed1995

The hemolytic uremic syndrome.

HUS is the most common cause of acute renal failure in infants and young children and follows a diarrheal prodrome about 90% of the time. Persuasive evidence shows that virtually all of postdiarrheal cases are caused by EHEC infections, and that the great majority of cases in the United States are caused by the EHEC serotype O157:H7. Mortality is approximately 5%, and approximately 10% of survivors are left with severe sequelae. A much larger number (30%-50%) experience mild chronic renal damage. Public health strategies, including zero tolerance for fecal contamination in slaughter houses and additional public education on proper food handling and cooking, does much to decrease the prevalence of the syndrome. Efforts to further dissect the postdiarrheal pathogenic cascade should continue, and an animal model needs to be developed. Only then will researchers be positioned to develop effective intervention strategies. Preventing life-threatening extrarenal complications, especially of the CNS, is a major challenge. Idiopathic nondiarrheal HUS accounts for approximately 10% of cases and comprises a poorly understood composite of HUS subsets. Research directed toward a better understanding of these mysterious variants also is a priority for the years ahead.

Child↗

PubMed1994

Effects of nitric oxide synthesis inhibition in hyperdynamic endotoxemia.

OBJECTIVE: To investigate the effects of N omega-nitro-L-arginine methyl ester, an inhibitor of nitric oxide synthesis, on hemodynamics, gas exchange and oxygen transport in an ovine model of hyperdynamic sepsis. DESIGN: Prospective, nonrandomized, controlled study, with repeated measurements. SETTING: University research laboratory. SUBJECTS: Twenty healthy adult sheep (weighing 20 to 45 kg) were divided into two groups of 12 treated sheep and eight control sheep and studied. INTERVENTIONS: Twenty awake, chronically instrumented sheep received a continuous infusion of endotoxin (10 ng/kg/min) over 48 hrs. Twenty-four hours after the start of the endotoxin infusion, 12 sheep (treatment group) received a bolus of the nitric oxide synthesis inhibitor N omega-nitro-L-arginine methyl ester (25 mg/kg), while the other eight animals (control group) received the carrier (0.9% NaCl). MEASUREMENTS AND MAIN RESULTS: Twenty-four hours after the start of the endotoxin infusion, both groups exhibited a hyperdynamic state with increased cardiac indices, decreased systemic vascular resistance indices, impaired oxygenation, and increased pulmonary shunt fractions. In both groups, oxygen delivery was significantly increased, while oxygen consumption remained virtually unchanged, resulting in a decreased oxygen extraction ratio. In the control group, the significant alterations in systemic hemodynamics, lung function and oxygen transport persisted for the remainder of the study. Administration of N omega-nitro-L-arginine methyl ester normalized cardiac index and systemic vascular resistance index, increased mean arterial blood pressure, and decreased heart rate. Although oxygen delivery significantly decreased after administration of N omega-nitro-L-arginine methyl ester, oxygen consumption did not change, resulting in a normalization of oxygen extraction ratio. Despite a significant reduction of pulmonary shunt fraction, oxygenation did not improve. Pulmonary arterial pressure and pulmonary vascular resistance index showed a peak 2 hrs after administration of the nitric oxide synthesis inhibitor and then tended to decrease. In contrast, the effects of N omega-nitro-L-arginine methyl ester on the systemic circulation persisted for the remainder of the study. CONCLUSIONS: The data support the assumption that augmented nitric oxide production is a major cause of the hemodynamic alterations seen in hyperdynamic endotoxemia. Administration of the nitric oxide synthesis inhibitor N omega-nitro-L-arginine methyl ester normalized the endotoxin-induced hyperdynamic state, but did not impair oxygen consumption, indicating adequate tissue perfusion of metabolically active organs. Inhibition of nitric oxide synthesis may be a therapeutic option in the treatment of hyperdynamic septic patients when conventional therapy fails to maintain a minimum of cardiovascular performance.

Animals↗

PubMed1994

Functional characteristics of pediatric veno-venous hemofiltration.

OBJECTIVE: To evaluate the functional characteristics of continuous veno-venous hemofiltration in a pediatric size animal model. DESIGN: Prospective trial. SETTING: Animal laboratory at a large university-affiliated medical center. SUBJECTS: Four-week old lambs (weight 12.2 +/- 1.3 kg). INTERVENTIONS: Veno-venous hemofiltration was performed in anesthetized lambs (n = 5, 12.2 +/- 1.3 kg) using a standard pediatric hemofilter and pumped blood and ultrafiltrate. We compared postdilution, predilution, and hemofiltration with counterflow dialysis. MEASUREMENTS AND MAIN RESULTS: At net ultrafiltrate flows of 200, 400, and 600 mL/hr, we measured system pressures and urea clearance. Stable blood flow could reproducibly be achieved up to 140 mL/min (10 mL/kg/min); at higher flow demand, tubing collapse occurred. At blood flow rates of 5 to 10 mL/kg/min, ultrafiltrate flow of 1 mL/kg/min would create negative filter compartment pressure but consistently less negative than -500 mm Hg. During postdilution, predilution, and counterflow dialysis, urea clearance was virtually equal to ultrafiltrate flow. There was no increase in urea clearance when adding predilution or dialysis to basic postdilution. CONCLUSIONS: Veno-venous hemofiltration, using small filters and circuits in a pediatric size animal, can achieve stable blood flow up to 10 mL/kg/min. At this flow, ultrafiltrate flow of 1 mL/kg/min can produce a urea clearance of 1 mL/kg/min while keeping filter compartment pressure above maximal recommended negative pressures. Addition of dialysis in this nonuremic model did not increase urea clearance.

Animals↗

PubMedDate not supplied

A model for computer-controlled delivery of 3-D conformal treatments.

Three-dimensional conformal radiation treatments are highly complex and may comprise a large number of coplanar and noncoplanar beams, virtually all of which are shaped and may also employ arbitrary intensity modulation. The delivery of such treatments with conventional means is highly labor intensive and limited to a relatively small number of fields. A generalized model for a system that can deliver 3-D conformal treatments rapidly and safely using a computer-controlled treatment machine equipped with a multileaf collimator is presented. The model emphasizes the separation of tasks between an external computer programmed by the user institution and a control computer proprietary to the treatment machine manufacturer. The treatment scheme that is employed consists of a sequence of fixed fields, called segments, which are delivered in succession without human intervention. Settings for all segments, derived from a 3-D conformal treatment planning system, are downloaded by the external computer into the control computer of the treatment machine. During patient setup, the control computer enables the operator to step through computer-controlled setup of the segments without radiation to ensure the absence of collisions, and to allow the adjustment of setup parameters if necessary. The external computer verifies the treatment setup and permits the control computer to carry out the treatment segment by segment. Safety aspects of the model and anomalous situations which may arise are discussed.

Computer Simulation↗

PubMed1995

ECT as a therapeutic option in severe brain injury.

Electroconvulsive therapy (ECT) is a safe, highly effective, and rapidly acting treatment for certain major psychiatric illnesses, most notably severe mood disorders. Disturbances in mood and behavior as symptoms of delirium may complicate recovery from traumatic brain injury, but virtually no data exist on the role of ECT as a treatment modality in such clinical situations. We describe a patient with severe, unremitting, agitated behavior following a severe closed head injury from a motor vehicle accident. The initial Glasgow Coma Scale score was 3, with computed tomographic evidence of bilateral frontal and left thalamic contusions. After awakening from a 21-day coma, the patient failed to improve beyond a Ranchos Los Amigos level 4 recovery stage. He exhibited persistent severe agitation with vocal outbursts and failed to assist in performing activities of daily living. His difficulties proved unresponsive to combined behavioral therapy and multiple trials of various psychopharmacologic agents. As an intervention of "last resort," he then received six brief-pulse, bilateral ECT treatments that resulted in marked lessening of his agitation and improvement in his ability to express his needs and participate in his self-care. Also, following the ECT, he showed a markedly enhanced response to psychopharmacologic agents. These findings may have important clinical implications for treatment of prolonged delirium after traumatic brain injury.

Activities of Daily Living↗

PubMed2004

Plasma precursors of brain catecholaminergic and serotonergic neurotransmitters in rehabilitation patients with ischemic stroke.

OBJECTIVE: To determine levels of plasma amino acid tyrosine and tryptophan, precursors of brain catecholamine and serotonin neurotransmitters, respectively, in rehabilitative patients with ischemic stroke. DESIGN: Controlled, pre-post analysis, consecutive sample. SETTING: Rehabilitation center. PARTICIPANTS: Twenty men with ischemic stroke (age, 68+/-11.3y) consecutively admitted into rehabilitation 15+/-10 days (range, 7-28d) after an acute cerebrovascular insult; 15 healthy sedentary subjects (controls 1); and 13 healthy hypoactive individuals who had recently had knee arthroplasty (controls 2). Both control groups were matched to stroke subjects for age, gender, and body weight. INTERVENTIONS: At 8:00 am, after overnight fasting, venous blood samples were drawn from patients to determine plasma tyrosine and tryptophan levels. A nutritional evaluation, including nitrogen balance, was made. The same procedures were repeated after 45 days of rehabilitation. Amino acid data were compared with those obtained from the controls. MAIN OUTCOME MEASURE: Plasma concentrations of amino acids. RESULTS: Patients with ischemic stroke, on admission, had lower plasma tyrosine concentration than did both controls 1 (P<.0005) and controls 2 (P<.001), but a similar tryptophan level. The plasma content of tyrosine was similar between the 2 control groups. After 45 days of rehabilitation, the stroke patients' tyrosine and tryptophan levels remained virtually unchanged, as did nutritional parameters. Nutritional intakes were adequate to meet body needs but insufficient to correct plasma tyrosine. CONCLUSIONS: Patients experiencing a recent stroke may have low plasma tyrosine levels and, therefore, reduced brain catecholamine formation. It is possible that an imbalance of brain neurotransmitters may occur.

Aged↗