Acute pain management services have progressed, albeit insufficiently in Canadian academic hospitals

PURPOSE: Acute pain management services (APMS) evolved in response to the desire for improved management of postoperative pain. The management of postoperative pain received formal support from international organizations over the past decade and by 1993 half of the Canadian university-affiliated teaching hospitals had implemented an APMS. The purpose of this survey was to describe APMSs in Canadian academic institutions, with specific emphasis on postoperative analgesics, new analgesic methods, training and research. METHODS: Between June 2000 and January 2001, 62 Canadian hospitals affiliated with the 16 Canadian university anesthesiology departments were sent a postal questionnaire. RESULTS: Fifty of the 62 respondents returned a completed questionnaire representing a response rate of 81%. Eighty percent of the hospitals surveyed had at least 200 beds, 90% (45) had implemented an APMS. Anesthesiology was primarily responsible in all 45 hospitals with an APMS. The results presented are based on the 45 centres with an APMS. CONCLUSION: Since the early 1990s the percent of Canadian academic hospitals with an APMS has increased from 53% to 92%. These figures are comparable to the United States. Greater collaboration from nursing and pharmacy, mandatory training for medical and nursing students and residents, and a standardized approach to continuous quality improvement remain necessary.     

Performance characteristics and image fidelity of gray-scale monitors.

Gray-scale monitors are an essential element of electronic radiology, and their ability to provide images that are perceived to be identical to those available on conventional or laser-printed film is crucial to success of electronic radiology. Image fidelity is measured in physical characteristics (luminance, dynamic range, distortion, resolution, and noise) and with psychophysical techniques, including receiver operator characteristics analysis with clinical images and testing with contrast-detail patterns to determine threshold contrast. Currently, laser-printed images facilitate greater information transfer than does a gray-scale monitor because of their higher absolute luminance (500 ft-L vs 60 ft-L), greater perceived dynamic range, and better spatial resolution. In the near future, the developments of gray-scale monitors with 150-200 ft-L luminance, a display standard based on just noticeable differences, and algorithms to improve similarities between gray-scale display images and laser-printed images will help increase the acceptability of monitors as a means to make primary diagnoses.     

Neanderthal reconstructed

A century and a half of controversy concerning the differences between Neanderthals (or Neandertals) and modern humans has left us with many questions and no sign of abatement. One of these remaining questions concerns the articulated structure of the Neanderthal skeleton and how it compares to that of a modern human. Although this question has been tackled many times by more artistic avenues, never has a complete, fully articulated Neanderthal skeleton been constructed systematically using castings from real Neanderthal bones. In an attempt to provide a more objective understanding of Neanderthal stature and biomechanics, a complete Neanderthal skeleton was reconstructed and articulated. This reconstruction was primarily based on the La Ferrassie 1 specimen, with missing or incomplete elements filled in from other Neanderthal cast collections.     

Intrahepatic absorbable fine mesh packing of hepatic injuries: Preliminary clinical report

A previous report from the authors' institution reported the effectiveness of hepatic packing with absorbable fine mesh (AFMP) for the control of hemorrhage in an animal model with an otherwise lethal hepatic injury. The technique has subsequently been applied to 12 abdominal trauma patients with hemodynamic instability and actively hemorrhaging hepatic injuries. Two patients expired in the operating room owing to uncontrolled hemorrhage from hepatic and associated injuries for a mortality of 16.7%. AFMP was successful in controlling hemorrhage in the remaining 10 patients. Hepatic injuries ranged from grade II to grade V, and all were actively hemorrhaging at the time of exploration. None of the surviving 10 patients experienced early or late recurrent bleeding attributable to the hepatic injuries, and there were no intraabdominal abscesses or late deaths. Liver function studies returned to normal prior to discharge in all surviving patients. Follow-up included serial computed tomographic scans, which demonstrated fibrosis incorporating the mesh packing. Complete resolution of injury and mesh appears to proceed over approximately a 6-month period. AFMP is a safe, effective method for controlling hepatic hemorrhage. It is easy to perform in the operating room, offers an excellent matrix for hemostasis, provides tamponade of bleeding sites, and does not require reoperation for removal of packing material, as is necessary with conventional, nonabsorbable packing techniques.

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Resumen En una publicación previa se informó la eficacia del empaquetamiento hepático con una fina malla absorbible en el control de la hemorragia en un modelo animal experimental sometido a lesión hepática letal. Desde entonces la técnica ha sido aplicada en 12 pacientes con trauma abdominal e inestabilidad hemodinámica y lesiones hepáticas sangrantes. Dos pacientes expiraron en la mesa de operaciones por hemorragia no controlada proveniente de la arteria hepática y de otras lesiones asociadas, con una tasa de mortalidad de 16.7%. La malla fue eficaz en cuanto a controlar la hemorragia en el resto de los pacientes. Las lesiones hepáticas variaron en cuanto a severidad entre los Grados II a V y todas exhibían hemorragia activa en el momento de la exploración. Ninguno de los 10 sobrevivientes desarrolló sangrado recurrente temprano o tardío que pudiera ser atribuible a las lesiones hepáticas y no se observaron abscesos intraabdominales o muertes tardías. Las pruebas de función hepática retornaron a valores normales con anterioridad al egreso, en la totalidad de los sobrevivientes. El seguimiento incluyó tomografías computadorizadas seriadas, que demostraron fibrosis del área de empaquetamiento con la malla; la resolución completa de la lesión y de la malla parece tener lugar en el curso de seis meses, aproximadamente. La malla representa un método seguro y eficaz de control de la hemorragia hepática, es fácil de aplicar en el quirófano, ofrece una excelente matriz para la hemostasia, produce taponamiento de los sitos sangrantes y no requiere reoperación para remover el material de empaquetamiento, como sí lo requieren las técnicas convencionales de empaquetamiento con materiales no absorbibles.

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Résumé Nous avons déjà rapporté l'efficacité du packing périhépatique par un filet fin résorbable (FFA) pour contrôler l'hémorragic autrement mortelle provenant d'une lésion hépatique chez l'animal. Cette même technique a été utilisée utilisée chez 12 patients ayant un traumatisme sévère du foie avec une hémodynamique instable. Deux patients sont décédés en salle d'opération des lésions hépatiques et des structures avoisinantes soit une mortalité de 16.7%. La technique de FFA a été couronnée de succès chez les 10 autres patients. Les lésions ont été classées selon leur sévérité du grade II au grade V et toutes saignaient activement au moment de l'opération. Aueun des patients survivants n'a eu de récidive hémorragique attribuable à la lésion hépatique et il n'y a eu aucun abcès intra-abdominal ni de mortalité tardive. La fonction hépatique est redevenue normale avant la sortie chez tous les autres patients. La surveillance du suivi a comporté une tomodensitométrie montrant une fibrose autour du filet. La résolution complète de la lésion et la résorption du filet évoluent en général sur six mois. La technique de FFA est sûre et efficace dans le contrôle de l'hémoragie provenant des traumatismes du foie. La méthode est facile à appliquer en salle d'opération, procure une hémostase excellent par tamponnade et ne nécessite pas de réintervention pour enlever le packing comme quand on utilise le matériel traditionnel non résorbable.

     

A distributed approach to integrated inquiry and display for radiology

Picture archive and communications (PACS) systems should be flexible and modular in design so that new advances in storage, computation, and display technology can be introduced into the system without a significant redesign of existing software. The acquisition, storage, and management of radiologic images must be carefully integrated with a radiology information system. Our architecture is based on a four-level data model: (1) patient information, (2) examination information and reports, (3) image information, and (4) instances of images. The PACS being developed at the Mallinckrodt Institute of Radiology within the Electronic Radiology Laboratory consists of three primary components: application clients, database servers and image servers. One type of application client is an image-capable workstation that supports a radiology image viewing application. The application client queries the database server for information regarding patient and examination data in response to user-level requests. The database server responds to the request by retrieving the appropriate patient demographics and examination information, along with a pointer to the image/instance data from a central database. The client then uses the image data pointer to query the image server for the actual pixel data. The image server responds by transmitting the pixel data to the requesting application client or a designated auxiliary display device. Other clients act as image data acquisition nodes. Queries to the database servers are made via a library of callable subroutines. Software integrity is maintained throughout the system by dynamically loading software from a code-control database. Inquiry and display transactions, supported on a local-area network (Ethernet), have been measured and analyzed. Results and observations are presented.     

Survival and developmental disability in infants with birth weights of 501 to 800 grams, born between 1979 and 1994

OBJECTIVE: Because the survival rate has increased for extremely low birth weight neonates, many have raised the concern that the rate of developmental disability among survivors will also increase. To address this concern, we analyzed changes over time in survival and major neurosensory impairment in a sample of extremely low birth weight infants born between July 1, 1979, and June 30, 1994. METHODS: The study sample included 513 infants with birth weights of 501 to 800 g who were cared for in either of the two neonatal intensive care units that serve a 17-county region in northwest North Carolina and who were born to mothers residing in that region. At 1 year of age (corrected for gestation), survivors were examined by a pediatrician and were tested using the Bayley Scales of Infant Development. Major neurosensory impairment was defined as cerebral palsy, a Bayley Mental Developmental Index <68, or blindness. A total of 209/216 (97%) of survivors were examined at 1 year of age. Epoch of birth was defined as follows: epoch 1, July 1, 1979 to June 30, 1984; epoch 2, July 1, 1984 to June 30, 1989; and epoch 3, July 1, 1989 to June 30, 1994. RESULTS: Survival rates for epochs 1, 2, and 3 were, respectively, 24/120 (20%), 63/175 (36%), and 129/218 (59%). In contrast, the proportions with a major neurosensory impairment did not increase over time; rates for successive epochs were 6/24 (25%), 17/61 (28%), and 26/124 (21%). Rates of cerebral palsy were 3/24 (13%), 12/61 (20%), and 9/124 (7%); rates of delayed mental development were 4/24 (17%), 12/61 (20%), and 17/124 (14%); and rates of blindness were 2/24 (8%), 0/62, and 5/124 (4%), respectively. CONCLUSIONS: This analysis suggests that the increasing survival of extremely low birth weight neonates since the late 1970s has not resulted in an increased rate of major developmental problems identifiable at 1 year of age.