9:30-9:45. Preliminary Evaluation of F-18 Fluorocholine (FCH) as a PET Tumor Imaging Agent

The purpose of this study was to develop and evaluate an F-18 labeled choline tumor imaging agent.FCH was synthesized through the intermediate F-18 fluorobromomethane that was used to alkylate dimethylethanolamine. The isolated FCH was evaluated in PC-3 human prostate cancer cells, PC-3 human prostate cancer xenograft studies, and human prostate and brain tumor patients.FCH was accumulated at a slightly lower rate than FDG in the cultures of PC-3 cells. Inhibition of choline transport and phosphorylation by hemicholinium-3 resulted in a 90% decrease in FCH uptake without altering FDG uptake. FCH had a similar biodistribution as C-14 choline in mice, with the liver and kidneys being the primary sites of uptake. Tumor uptake of FCH and FDG were comparable at 45-60 mins after injections. The tumor:blood ratio was higher for FCH (5.3 +/- 2.4) than for FDG (3.2 +/- 0.3). Brain uptake of FCH was 10% that of FDG. FCH-PET studies were compared to FDG-PET studies. In the prostate cancer patients, more lesions have been seen on the FCH studies than on the FDG studies, and the standardized uptake values (SUV) have been higher with the FCH. Decreases in FCH-PET SUV have been noted in patients treated by androgen deprivation. Patients with suspected recurrent brain tumors have had more clearly defined abnormal accumulation on the FCH-PET scans than on the FDG-PET scans. The FCH is not accumulated by normal cortex.FCH is a promising imaging agent for the evaluation of metastatic prostate cancer and recurrent brain tumor.     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Surgical management of primary aortoesophageal fistula secondary to thoracic aneurysm

Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal fistula, secondary to thoracic aortic aneurysm, but techniques used have varied. We report a successful repair of primary aortoesophageal fistula, secondary to descending thoracic aortic aneurysm, and review the evolution of management since the three previously reported successful repairs at our institution.     

Professionalism and professional values in orthopaedics

During a consensus conference in Fall, 1998, the Academic Orthopaedic Society identified the values and qualities of professionalism as defined by its members. One hundred eighty-six respondents rated 20 characteristics and values describing professionalism, based on the extent to which they believed each item was appropriate. The five items receiving highest average ratings were: integrity, trustworthiness, responsibility, reliability, and accountability. Principal components analysis yielded five factors that captured 62% of the total variability. These factors were labeled respect and relationships, altruism, accountability and reliability, integrity, and excellence. The authors anticipate that the Academic Orthopaedic Society will find these data useful, and incorporate this information into their decisions concerning evaluation of current residents and applicants to their programs. An additional challenge will be to develop a values curriculum (formal curriculum) and a learning environment (informal curriculum) that will encourage residents and faculty to aspire to the highest in professional values and professional conduct.     

The virtuous orthopaedist has fewer malpractice suits

It generally is believed that physicians who have poor relationships with their patients are more likely to be sued. We studied certain physician characteristics and related them to their number of malpractice suits and the amount paid to settle those claims. Physicians with better rapport with their patients, who took more time to explain, and who were available had fewer malpractice suits. The most significant correlation was found in time spent with the patient. As the time spent increased, the number of suits decreased.     

A retrospective study of physiotherapy management for patients with pneumonia requiring invasive ventilation in a single-center Australian ICU

Background:Pneumonia is a frequent diagnosis for patients admitted to Australian intensive care units (ICUs) for invasive ventilation. Physiotherapists in ICU provide interventions to enhance respiratory function and physical recovery.Objective:This retrospective cohort study aimed to describe physiotherapy management of adults with pneumonia who require invasive mechanical ventilation in a single Level 3 ICU in a quaternary teaching hospital.Methods:All adults admitted with a medical diagnosis of pneumonia requiring invasive mechanical ventilation over a two-year period were included. Demographic and clinical data, including APACHE II score, ventilator-free days (VFDs) to day 28, ICU length of stay (LOS), and type and frequency of physiotherapy episodes of care delivered in ICU, were collected from electronic medical records. Correlations between VFDs to day 28 and the frequency of physiotherapy interventions delivered per subject were examined using Spearman’s rho analysis.Results:From 208 records screened, 66 subjects with an ICU admission diagnosis of pneumonia, who required invasive mechanical ventilation, were included. Median (IQR) ICU LOS was 10 (5–17) days, and mortality rate was 15.2% (n=10). The cohort had a median of 20.5 (IQR 2–25) VFDs to day 28. Community-acquired pneumonia (66.7%, n=44) was the most frequent type of pneumonia diagnosis. There were 1110 episodes of physiotherapy care, with patients receiving a median of 13.5 (IQR 6.8–21.3) episodes during their ICU stay, with a median rate of 1.2 (IQR 1.0–1.6) episodes per day. Over 96.7% of patients with pneumonia received physiotherapy treatment during their ICU stay. Overall, physiotherapy treatments consisting only of respiratory techniques were most commonly provided (55.1%, n=612). Airway suctioning (92.4%, n=61), patient positioning (72.7%, n=48) or positioning advice to nurses (77.3%, n=51), and hyperinflation techniques (63.6%, n=42) were among the respiratory techniques most delivered.Conclusion:This study described the current intensive care physiotherapy management in a single center for adults with pneumonia who required invasive mechanical ventilation, demonstrating that respiratory physiotherapy interventions are often provided for this ICU patient cohort. Further research is warranted to determine the efficacy of respiratory physiotherapy interventions to justify their use for ICU patients with pneumonia receiving invasive mechanical ventilation.     

A Randomized Controlled Trial of the Community-Friendly Health Recovery Program (CHRP) Among High-Risk Drug Users in Treatment

Existing evidence-based HIV risk reduction interventions have not been designed for implementation within clinical settings, such as methadone maintenance programs, where many high-risk drug users seek treatment services. We therefore systematically developed an adapted, significantly shortened, version of a comprehensive evidence-based intervention called the Community-friendly Health Recovery Program (CHRP) which has demonstrated preliminary evidence of efficacy in a feasibility/acceptability study already published. In a randomized controlled trial reported here, we tested the efficacy of the CHRP intervention among high-risk drug users newly enrolled in drug treatment at an inner-city methadone maintenance program. The CHRP intervention produced improvements in drug risk reduction knowledge as well as demonstrated sex- and drug-risk reduction skills. Support was found for the IMB model of health behavior change. Implications for future intervention research and practice are considered.     

Effects of Aerosol-Vapor JP-8 Jet Fuel on the Functional Observational Battery,and Learning and Memory in the Rat

To determine whether JP-8 jet fuel affects parameters of the Functional Observational Battery (FOB), visual discrimination, or spatial learning and memory, the authors exposed groups of male Fischer Brown Norway hybrid rats for 28 d to aerosol/vapor-delivered JP-8, or to JP-8 followed by 15 min of aerosolized substance P analogue, or to sham-confined fresh room air. Behavioral testing was accomplished with the U.S. Environmental Protection Agency's Functional Observational Battery. The authors used the Morris swim task to test visual and spatial learning and memory testing. The spatial test included examination of memory for the original target location following 15 d of JP-8 exposure, as well as a 3-d new target location learning paradigm implemented the day that followed the final day of exposure. Only JP-8 exposed animals had significant weight loss by the 2nd week of exposure compared with JP-8 with substance P and control rats; this finding compares with those of prior studies of JP-8 jet fuel. Rats exposed to JP-8 with or without substance P exhibited significantly greater rearing and less grooming behavior over time than did controls during Functional Observational Battery open-field testing. Exposed rats also swam significantly faster than controls during the new target location training and testing, thus supporting the increased activity noted during Functional Observational Battery testing. There were no significant differences between the exposed and control groups' performances during acquisition, retention, or learning of the new platform location in either the visual discrimination or spatial version of the Morris swim task. The data suggest that although visual discrimination and spatial learning and memory were not disrupted by JP-8 exposure, arousal indices and activity measures were distinctly different in these animals.     

Guidelines for Evaluating the Educational Performance of Medical School Faculty: Priming a National Conversation

Background: The academic community needs a sound framework for the promotion and advancement of educators. The Group on Educational Affairs of the Association of American Medical Colleges organized a consensus conference that affirmed the use of five domains for documenting the quantity and quality of scholarly engagement in educational activities: teaching, curriculum, advising/mentoring, educational leadership/administration, and learner assessment. Summary: In this article, we offer detailed guidelines to evaluate these five domains of educator performance and the essential elements of scholarly activity. The guidelines are adapted from our developmental educator portfolio template and educator portfolio analysis tool, previously published in MedEdPORTAL. A short tool for educator performance evaluation that summarizes items in the guidelines is proposed for discussion. Conclusions: Our goal in this article is to itemize criteria for systematic faculty evaluation that can be applied in any institutional setting to assist promotion decision makers in their task of evaluating medical school faculty.