Impact of orthopedic trauma consolidation on resident education

Background

In July 2005, the Saskatoon Health Region, in conjunction with its orthopedic surgeons, consolidated its management of orthopedic emergencies from 3 sites to 1, resulting in trauma patients being directed to the university hospital site (Royal University Hospital; RUH) where orthopedic residents were the first responders. We sought to measure resident workload in the emergency department, operating room and ward before and after consolidation and to measure the perceptions of residents and faculty on the newly established orthopedic trauma service.

Methods

We compared orthopedic volumes at RUH in the emergency department (ED) and trauma-related operating rooms over 2 periods of 3 months’ duration before and after trauma consolidation. We developed and disseminated questionnaires evaluating issues relating to patient care; resident education, including all CanMEDS domains; resident well-being; and the orthopedic trauma service to all orthopedic residents and faculty members.

Results

The number of patients seen by orthopedic residents in the ED increased by 67%, the number admitted through the ED to the ward increased by 66%, and the total number of inpatients and consultations increased by 43% after the consolidation. The number of patients processed through the orthopedic emergency operating room increased by 90%. In general, response to the change was positive and appreciated by residents and faculty members.

Conclusion

Sudden substantial increases in the volume of patients seen by orthopedic residents may not prompt negative resident responses when the overall gains offset, if not exceed, the perceived losses.     

A framework for a streamline-based probabilistic index of connectivity (PICo) using a structural interpretation of MRI diffusion measurements

PURPOSE: To establish a general methodology for quantifying streamline-based diffusion fiber tracking methods in terms of probability of connection between points and/or regions. MATERIALS AND METHODS: The commonly used streamline approach is adapted to exploit the uncertainty in the orientation of the principal direction of diffusion defined for each image voxel. Running the streamline process repeatedly using Monte Carlo methods to exploit this inherent uncertainty generates maps of connection probability. Uncertainty is defined by interpreting the shape of the diffusion orientation profile provided by the diffusion tensor in terms of the underlying microstructure. RESULTS: Two candidates for describing the uncertainty in the diffusion tensor are proposed and maps of probability of connection to chosen start points or regions are generated in a number of major tracts. CONCLUSION: The methods presented provide a generic framework for utilizing streamline methods to generate probabilistic maps of connectivity.     

New approaches to spatially analyse primary health care usage patterns in rural South Africa

OBJECTIVE: To develop indices to quantitatively assess and understand the spatial usage patterns of health facilities in the Hlabisa district of South Africa. METHODOLOGY: We mapped and interviewed more than 23 000 homesteads (approximately 200 000 people) in Hlabisa district, South Africa and spatially analysed their modal primary health usage patterns using a geographical information system. We generated contour maps of health service use and quantified the relationship between clinic catchments and distance-defined catchments using inclusion and exclusion error. We propose the distance usage index (DUI) as an overall spatial measure of clinic usage. This index is the sum of the distances from clinic to all client homesteads divided by the sum of the distances from clinic to all homesteads within its distance-defined catchment. The index encompasses inclusion, exclusion, and strength of patient attraction for each clinic. RESULTS: Eighty-seven per cent of homesteads use the nearest clinic. Residents of homesteads travel an average Euclidean distance of 4.72 km to attend clinics. There is a significant logarithmic relationship between distance from clinic and their use by homesteads (r(2)=0.774, P < 0.0001). The DUI values range between 31 and 198% (mean=110%, SD=43.7) for 12 clinics and highlight clinic usage patterns across the district. CONCLUSIONS: The DUI is a powerful and informative composite measure of clinic usage. The results of the study have important implications for health care provision in developing countries.     

Localization of P2X3 receptors and coexpression with P2X2 receptors during rat embryonic neurogenesis.

It is well known that extracellular ATP mediates rapid excitatory signaling by means of the ionotropic P2X receptors. One of its subunits, the P2X(3) receptor, is well documented to be associated with sensory innervation in adult animals. It is speculated that the P2X(3) receptor may have already been present in the early sensory system. The aim of this study was to investigate the distribution of the P2X(3) receptor during neurogenesis by using immunohistochemistry on rat embryos from embryonic day (E)9.5-18.5. The P2X(3) receptor was first identified in the hindbrain neural tube and the sensory ganglia in E11-11.5 embryos. At E14.5, the optic tract and retina, nucleus tractus solitarius, mesencephalic trigeminal nucleus, and sensory nerves in both respiratory and digestive tract showed positive staining. The facial nucleus, the prepositus hypoglossal nucleus, and the sympathetic ganglia also showed P2X(3) immunoreactivity, even though these are not sensory associated. P2X(3) immunoreactivity was detected in the vestibular nucleus, the nerves in mesentery, bladder, and kidney in E16.5 and in nerves in vibrissae in E18.5. P2X(3) immunoreactivity in the facial nucleus, spinal trigeminal tract, the mesencephalic trigeminal nucleus, and the vestibular nucleus were undetectable in postnatal day 16 rat brainstem. The P2X(3) receptor was coexpressed with the P2X(2) receptor in nucleus tractus solitarius, dorsal root ganglion, nodose ganglion, and the taste bud in E16.5 embryo, which was 5 days later than the first appearance of the native P2X(3) receptor. In summary, we present a detailed expression pattern of the P2X(3) receptor during neurogenesis and report that P2X(3) immunoreactivity is down-regulated in early postnatal brainstems.     

Functional implications of kappa opioid receptor-mediated modulation of glutamate transmission in the output regions of the basal ganglia in rodent and primate models of Parkinson's disease

Parkinson's disease is characterized by an increased excitatory amino acid transmission in the internal segment of the globus pallidus and the substantia nigra pars reticulata. The effects of the kappa receptor agonist enadoline (CI-977) on glutamate transmission were investigated in vitro. Enadoline reduced the K⁺-evoked release of glutamate from slices of substantia nigra in a concentration-dependent manner (maximum effect: 78% inhibition at 200 μM). This effect was blocked by the selective kappa receptor antagonist nor-binaltorphimine. The endogenousm ligand for kappa receptors i sthought to be dynorphin. Dynorphin released from terminals of striato-pallidal and striato-nigral pathways might thus act as an endogenous modulatory agent on glutamatergic transmission in the basal ganglia. In vivo experiments were carried out in rodent and primate models of Parkinson's disease to assess the potential of manipulating kappa receptors as a potential treatment for Parkinson's disease. Enadoline reduced reserpine-induced akinesia when injected in the entopeduncular nucleus of the rat. Similarly, injections of CI-977 in the internal segment of globus pallidus (GPi) of the MPTP-treated marmoset alleviated parkinsonian symptoms and allowed the animal to recover its locomotor activity. This suggest that reducing the overactive glutamatergic transmission in the output regions of the basal ganglia by activating kappa receptors might potentially form the basis of a novel anti-parkinsonian therapy.     

Genetic defects of human brain development

This review focuses on malformations of the central nervous system that have a genetic etiology. One can view each malformation as giving us unique details on a map entitled "how to make a human brain." The gene(s) that cause each malformation are being identified, allowing discovery of their specific role in neurodevelopment, and defining a "road" on the map. The malformation is then the developmental consequence of "taking a wrong turn." Assimilation of complementary data from other species with human malformation phenotype and genotype is revealing just how wonderful and complex the neurodevelopment map is. Here we highlight recent research on brain malformations and how this is illuminating the map of normal human brain formation.     

Phase II evaluation of dibromodulcitol and actinomycin D,hydroxyurea, and cyclophosphamide in previously untreated patients with malignant melanoma

In this Eastern Cooperative Oncology Group (ECOG) phase II study, dibromodulcitol (DBD) and a combination of actinomycin D, hydroxyurea, and cyclophosphamide (AHC) were compared with methyl-CCNU, the current ECOG standard, in patients who had received no prior chemotherapy for disseminated malignant melanoma. The response rates were 6% (3/50) for AHC, 9% (3/34) for DBD, and 14% (7/49) for methyl-CCNU. Median survival times were 4, 5, and 6 months, respectively. Neither regimen appears to offer any advantage over methyl-CCNU as front-line therapy for patients with disseminated melanoma.