The position of the spine in the recovery position--an experimental comparison between the lateral recovery position and the modified HAINES position

The lateral recovery position is widely used for the positioning of unconscious patients. Ideally, in the setting of trauma it is avoided because of concerns about spinal cord injury. However, unconscious individuals with unsuspected trauma or trauma victims attended by partially trained first-aiders may be placed in the recovery position, potentially endangering the cord. Excessive movement of the spine in the recovery position may increase the risk of spinal cord injury in these situations. A new recovery position, termed the modified HAINES position, is described and the position of the spine in this position is compared with the lateral recovery position. HYPOTHESIS: That the modified HAINES position results in less distortion of the position of the spine than the lateral recovery position. METHODS: Thirty-eight healthy volunteers were imaged in the two different positions. Measurements of rotation, flexion and lateral flexion of the cervical and thoraco-lumbar spine were made. Two tailed paired t-tests were employed to compare measurements of the two positions and a McNemar test was used to compare the subjects' subjective experiences. RESULTS: The modified HAINES position resulted in 13.0 degrees (99% CI: 7.5-18.5) less lateral flexion and 12.6 degrees (99% CI: 9.4-15.9) less extension of the cervical spine while the position of the thoraco-lumbar spine was similar in both positions. Nineteen of 28 subjects found the modified HAINES position more comfortable (not significant). CONCLUSION: The modified HAINES position results in a more neutral position of the spine making it preferable to the lateral recovery position in the management of patients when trauma may have occurred. Further research is required to ensure that the recovery positions in use today are the best possible.     

Clinical blood flow quantification with segmented k-space magnetic resonance phase velocity mapping

PURPOSE: To evaluate the accuracy of segmented k-space magnetic resonance phase velocity mapping (PVM) in quantifying aortic blood flow from through-plane velocity measurements. MATERIALS AND METHODS: Two segmented PVM schemes were evaluated, one with seven lines per segment (seg-7) and one with nine lines per segment (seg-9), in twenty patients with cardiovascular disease. A non-segmented (non-seg) PVM acquisition was also performed to provide the reference data. RESULTS: There was agreement between the aortic flow curves acquired with segmented and non-segmented PVM. The calculated systolic and total flow volume per cycle from the seg-7 and the seg-9 scans correlated and agreed with the flow volumes from the non-seg scans (differences < 5%). Sign tests showed that there were no statistically significant differences (P-values > 0.05) between the segmented and the non-segmented PVM measurements [corrected]. Seg-9, which was the fastest among the three sequences, provided adequate spatial and temporal resolution (> 10 phases per cycle). CONCLUSION: Segmented k-space PVM shows great clinical potential in blood flow quantification.     

Quantitative assessment of myocardial scar in delayed enhancement magnetic resonance imaging

PURPOSE: To characterize the extent and distribution of left ventricular myocardial scar in delayed enhancement magnetic resonance imaging (MRI). MATERIALS AND METHODS: Delayed enhancement images from 18 patients were categorized into three groups based on myocardial scar appearance: discrete myocardial infarction (N = 10), diffuse fibrosis (N = 4), and circumferential endocardial scarring (N = 4). Images were segmented manually by two observers (twice by one observer) to identify nonviable myocardium. Scar was characterized by the following morphologic parameters: the relative area of nonviable myocardium (Percent Scar); a measure of scar cohesion (Patchiness); and the extent to which scar traversed the ventricle wall (Trans>50). RESULTS: The three scar parameters successfully discriminated between patient groups, although no one parameter was able to differentiate between all groups. The average bias between readers was approximately 3% for each parameter, and the average bias between repeated measurements was 1%. In addition, five patients exhibited regions of nonhyperenhanced nonviable myocardium that were expected to show hyperenhancement based upon their location within the infarct zone and appearance on cine images. CONCLUSION: Quantitative characterization of myocardial scar showed good interobserver and intraobserver agreement. However, the appearance of nonhyperenhanced scar in chronic ischemia is problematic for segmentation of delayed enhancement images.     

Decreasing nosocomial urinary tract infection in a large academic community hospital

Urinary Tract Infection (UTI) is the second most prevalent complication at Lehigh Valley Hospital and Health Network, occurring in 3% of all patients admitted over a 12-month period and contributing to a significant increase in costs. Utilizing data from CareScience's Care Management System, an online decision support tool, in conjunction with hospital laboratory data, and without manual chart review, approximately 20% of all UTIs diagnosed were found to be potentially nosocomial, and were often treated with an expensive broad-spectrum antibiotic. A multidisciplinary hospital committee developed interventions to study and address these findings. The National Nosocomial Infection Surveillance program was initiated on selected units of the hospital; strict catheter placement guidelines and a postoperative urinary retention protocol were developed to minimize catheter use and dwell time, a cost-benefit analysis was conducted, antibiotic use for UTIs was evaluated, and system-wide education was conducted for physicians, residents, and nurses.     

Carotid MR angiography: phase II study of safety and efficacy for MS-325

PURPOSE: To evaluate the safety and efficacy of MS-325 in patients suspected of having carotid arterial disease. MATERIALS AND METHODS: Fifty carotid arteries in 26 patients were imaged with three-dimensional spoiled gradient-recalled-echo magnetic resonance (MR) angiography at 5 and 50 minutes after injection of MS-325. MS-325 was administered intravenously as a single dose of 0.01, 0.03, or 0.05 mmol per kilogram of body weight as determined with a dose randomization scheme for four, nine, and 13 patients, respectively. Safety, including clinical laboratory changes and electrocardiographic monitoring, was assessed until approximately 3 days after injection. Conventional contrast agent-enhanced angiography was used as the standard of reference. Independent readers blinded to the dose interpreted the MR angiographic and conventional images. Images were assessed for location and extent of carotid arterial stenosis. RESULTS: There were no severe or serious adverse events. For the determination of clinically significant stenosis (>70%) on the 5-minute images, sensitivity, specificity, and accuracy (P =.07, three-way comparison) were 100%, 100%, and 100%; 63%, 100%, and 88%; and 40%, 75%, and 55% at 0.01, 0.03, and 0.05 mmol/kg, respectively. Sensitivity and specificity for images at 50 minutes after MS-325 administration showed the same trends as the 5-minute images. CONCLUSION: Overall accuracy for MS-325-enhanced carotid MR angiography performed during steady-state conditions of circulating contrast agent approximately 5 minutes after injection was high (88%-100%) at 0.03 and 0.01 mmol/kg. MS-325 was well tolerated at all evaluated doses.     

Reliability of electrogustometry for the estimation of taste thresholds

Electrogustometry has been used as a clinical tool for diagnosis and assessment of a variety of conditions. Several studies which have estimated electrogustometric taste threshold have reported good test-retest reliability but there is some evidence that thresholds measured this way may decrease with practice. In this study, repeated testing of the right and left sides of the tongue of two subjects over 80 sessions resulted in considerable session-to-session variability for both subjects, and three of the four sets of threshold estimates decreased systematically with continued testing. Two of the four data sets continued to show systematic decreases when the first 10 sessions were omitted from analysis to allow for any initial unfamiliarity with the testing procedure. This suggests that estimates based on few tests should be interpreted with caution, particularly when used for evaluation or monitoring of interventions.     

Dietary fat, body weight, and cancer: contributions of studies in rodents to understanding these cancer risk factors in humans

Understanding diet and energy balance as risk factors for breast, colon, and other cancers requires information on the contribution of each factor and of interactions among factors to cancer risk. Rodent models for breast cancer provide extensive data on effects of dietary fat and calories, energy balance, body weight gain, and physical activity on tumor development. Analyses of the combined data from many studies have shown clearly that quality and quantity of dietary fat and energy balance contribute independently to increased mammary gland tumorigenesis. These findings were seen in female rats fed diets high in fat (35-40% of calories) compared to rats fed control diets, with approximately 10% of calories as fat (Fay and Freedman, 1997, Breast Cancer Res. Treat. 46, 215-223). The methods used permit comparison of experimental and epidemiological data, and they may be useful in extrapolating between species and developing public health recommendations. In addition to the contributions of lifetime-diet composition, intake, energy balance, and physical activity to cancer risk, there are questions about the timing and duration of alterations in these factors and about the "dose-response" characteristics of cancer risk to the factors. Endocrine mechanisms may be significant in mammary gland tumor risk, but experimental and epidemiological data indicate that cancers at other sites, such as colon and liver, also are influenced by the factors listed. Other diet and lifestyle factors that influence energy, or specifically fat, metabolism may also affect risk for cancers that are promoted by increased intake of fat and calories. Studies of separate and interactive effects of dietary fat, black tea, weight gain, and mammary gland tumorigenesis (Rogers, et al, 1998, Carcinogenesis 19, 1269-1273) have been analyzed. Using adjustment of carcinogenesis endpoints for body weight, tumor burden, and latency, they were found to be related to weight gain within treatment groups in 2 of 3 experiments.      

Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial.

PURPOSE: Pain and symptom management is an integral part of the clinical practice of oncology. A number of guidelines have been developed to assist the clinician in optimizing comfort care. We implemented clinical guidelines for cancer pain management in the community setting and evaluated whether these guidelines improved care. PATIENTS AND METHODS: Eighty-one cancer patients, aged 37 to 76 years, were enrolled onto a prospective, longitudinal, randomized controlled study from the outpatient clinic settings of 26 western Washington-area medical oncologists. A multilevel treatment algorithm based on the Agency for Health Care Policy and Research Guidelines for Cancer Pain Management was compared with standard-practice (control) pain and symptom management therapies used by community oncologists. The primary outcome of interest was pain (Brief Pain Inventory); secondary outcomes of interest were all other symptoms (Memorial Symptom Assessment Scale) and quality of life (Functional Assessment of Cancer Therapy Scale). RESULTS: Patients randomized to the pain algorithm group achieved a statistically significant reduction in usual pain intensity, measured as slope scores, when compared with standard community practice (P < .02). Concurrent chemotherapy and patient adherence to treatment were significant mediators of worst pain. There were no significant differences in other symptoms or quality of life between the two treatment groups. CONCLUSION: This guideline implementation study supports the use of algorithmic decision making in the management of cancer pain. These findings suggest that comprehensive pain assessment and evidence-based analgesic decision-making processes do enhance usual pain outcomes.     

Successful pregnancy in transfusion-dependent thalassaemia

Successful pregnancy in a transfusion-dependent thalassaemic patient receiving subcutaneous desferrixaomine is reported. This is the first such case to be described.