Using a Theory-Guided Learning Collaborative Model to Improve Implementation of EBPs in a State Children’s Mental Health System: A Pilot Study

Learning collaboratives (LCs) are used widely to promote implementation of evidence-based practices. However, there has been limited research on the effectiveness of LCs and models vary widely in their structure, focus and components. The goal of the present study was to develop and field test a theory-based LC model to augment a state-led, evidence-based training program for clinicians providing mental health services to children. Analysis of implementation outcomes contrasted LC sites to matched comparison sites that participated in the clinical training program alone. Results suggested that clinicians from sites participating in the LC were more highly engaged in the state-led clinical training program and were more likely to complete program requirements.     

Screening for vesicoureteral reflux and renal scars in siblings of children with known reflux

The incidence of vesicoureteral reflux (VUR) in the general population is less than 1%, but it is high in families with reflux. The reported prevalence of VUR among siblings of index patients with reflux has ranged from 4.7% to 51%. Reflux carries an increased risk of pyelonephritis and long-term renal impairment. The purpose of this study was to identify the age-related incidence and severity of reflux, and the frequency of associated renal parenchymal damage in siblings of children with reflux in order to assess the use of screening at different ages. Between October 1994 and February 2003, 40 siblings of 34 index patients were screened with direct voiding cystography. 99( m ) technetium (Tc)-dimercaptosuccinic acid (DMSA) nuclear renal scans were performed in siblings with VUR to detect renal scarring. The cystograms were interpreted as showing the presence or absence of VUR and the DMSA scan as symmetrical or asymmetrical differential function, with or without renal scarring. Of 40 siblings, 17 had VUR, representing an incidence of 42.5%. The mean age at study entry of the 15 boys and 25 girls was 63 months (range 6 months to 12 years). The majority of siblings with abnormal DMSA scans were asymptomatic. Reflux was unilateral in 12 siblings and bilateral in 5. Of the 17 refluxing siblings (22 refluxing ureters), 7 (41.17%) had a history of symptomatic urinary tract infection (UTI). The frequency of VUR was nearly equal in siblings over 6 years and those younger than 6 years. Of the 17 siblings with VUR, 16 had DMSA scintigraphy. Of these, 5 were normal and 11 (68.75%) showed abnormalities (7 asymmetrical differential function and 4 parenchymal defect), which was bilateral in 7 and unilateral in 4. In conclusion, this study confirms a significant overall incidence of VUR and renal parenchymal damage in the siblings of patients with known reflux. The prevalence of reflux in older siblings is similar to that in younger siblings. Our review suggests that all siblings over 6 years should undergo a screening cystogram, even in the absence of urinary tract infection. DMSA scintigraphy of asymptomatic siblings appears to be beneficial in preventing renal injury.     

Versatile use of the muscle and nerve sparing latissimus dorsi flap

In this report, we describe the technique of muscle and nerve sparing latissimus dorsi (LD) flap and evaluate the outcomes of reconstruction of various defects with 12 free and 2 pedicled muscle and nerve sparing LD flaps in 14 patients. The LD muscle functions at operated and nonoperated muscles were evaluated clinically and with electroneuromyography. All flaps survived completely but one which had a partial necrosis. The mean follow-up time was 12.3 months. Adduction and extention ranges of the shoulders were the same bilaterally in all patients. In electroneuromyography, no significant difference was available statistically between the sides. This muscle and nerve sparing latissimus dorsi flap has advantages of thinness, muscle preservation and reliability, and thus can be a good option to other fasciocutaneous flaps in reconstruction surgery.     

Comprehensive PKD1 and PKD2 Mutation Analysis in Prenatal Autosomal Dominant Polycystic Kidney Disease

Prenatal forms of autosomal dominant polycystic kidney disease (ADPKD) are rare but can be recurrent in some families, suggesting a common genetic modifying background. Few patients have been reported carrying, in addition to the familial mutation, variation(s) in polycystic kidney disease 1 (PKD1) or HNF1 homeobox B (HNF1B), inherited from the unaffected parent, or biallelic polycystic kidney and hepatic disease 1 (PKHD1) mutations. To assess the frequency of additional variations in PKD1, PKD2, HNF1B, and PKHD1 associated with the familial PKD mutation in early ADPKD, these four genes were screened in 42 patients with early ADPKD in 41 families. Two patients were associated with de novo PKD1 mutations. Forty patients occurred in 39 families with known ADPKD and were associated with PKD1 mutation in 36 families and with PKD2 mutation in two families (no mutation identified in one family). Additional PKD variation(s) (inherited from the unaffected parent when tested) were identified in 15 of 42 patients (37.2%), whereas these variations were observed in 25 of 174 (14.4%, P=0.001) patients with adult ADPKD. No HNF1B variations or PKHD1 biallelic mutations were identified. These results suggest that, at least in some patients, the severity of the cystic disease is inversely correlated with the level of polycystin 1 function.     

Off-pump coronary artery grafting in patients with left main coronary artery disease

BACKGROUND: Left main coronary artery disease (LMCD) is considered a relative contraindication to off-pump coronary artery bypass (OPCAB) grafting. This study evaluates the safety and feasibility of OPCAB in these patients compared to an on-pump group (cardiopulmonary bypass, CPB) with LMCD. METHODS: Between January 2000 and July 2002, 95 patients with left main coronary artery stenosis >50% underwent coronary revascularization. Seventy-three unselected patients underwent OPCAB and 22 underwent revascularization using CPB. The techniques used for OPCAB included the use of deep traction sutures in the posterior pericardium and stabilizers to expose the distal coronary targets. Intraluminal coronary shunts were routinely used during construction of the anastomoses. Variables were analyzed using a Student's paired t-test with statistical significance defined as p < 0.05. RESULTS: The mean age in the OPCAB group was 59.9 years and the CPB group 61.8 years (p = 0.54). There were 56 males (77%) in the OPCAB and 18 (82%) in the CPB groups. Mean preoperative left ventricular ejection fraction (LVEF) was 40.3% in OPCAB and 47.3% in CPB (p = 0.015). Average number of grafts was 3.1 in OPCAB and 4.1 in CPB (p = 0.0038). There were no conversions to CPB in those patients initially chosen to undergo OPCAB. There were no early deaths in OPCAB. There was one death in CPB. Mean hospital length of stay was 6.9 days for OPCAB and 9.1 for CPB (p = 0.0159). CONCLUSIONS: Patients with LMCD can undergo OPCAB grafting safely and effectively despite reduced LVEF. LMCD should no longer be seen as a contraindication to perform OPCAB grafting.     

Collecting system invasion in renal cell carcinoma: impact on prognosis and future staging strategies

PURPOSE: To define further the prognostic impact of urothelial invasion in renal cell carcinoma (RCC) we examined the outcome in patients presenting to our institution with kidney cancer treated with nephrectomy. MATERIALS AND METHODS: We reviewed the medical records of 895 patients with RCC who were treated with nephrectomy between 1989 and 1999. Median followup was 31 months. Kaplan-Meier survival curves were constructed with respect to 1997 TNM stage, Fuhrman grade and University of California-Los Angeles Integrated Staging System stage, comparing patients with and without collecting system invasion. Univariate and multivariate analyses were performed. Overall survival was defined as time from nephrectomy to time of death or last followup. RESULTS: Of the 895 patients 124 (14%) demonstrated collecting system invasion. Patients with collecting system invasion were more likely to be symptomatic and have associated metastases and/or positive nodes at diagnosis. Urothelial invasion was evident in 21 of 329 T1, 12 of 131 T2, 84 of 388 T3 and 7 of 47 T4 tumors. Three-year overall survival for patients with vs without collecting system invasion by stage was 67% vs 81% for T1, 60% vs 69% for T2, 31% vs 46% for T3 and 29% vs 12% for T4 disease. Patients with urothelial invasion incurred a significant increase in the likelihood of death and were at 1.4 times greater risk of death compared with patients without collecting system invasion. CONCLUSIONS: Our findings suggest that collecting system invasion in RCC cases is associated with specific clinical findings as well as poor prognostic variables and it has a profound impact on prognosis in low stage tumors.     

Long-term outcomes in patients with mucinous, medullary, tubular, and invasive ductal carcinomas after lumpectomy

BACKGROUND: Mucinous, medullary, and tubular carcinomas are uncommon types of breast cancer whose rarity does not permit large single-institution studies or randomized trials to define optimal treatments. In this study, we evaluated the long-term outcomes of breast-conserving therapy (BCT) for these subtypes of breast cancer and compared them with those for invasive ductal carcinoma. METHODS: In our institutional database of patients who received BCT from 1965 to 1999, 1,643 patients with stage I to II mucinous (61), medullary (37), tubular (60), and invasive ductal (1,485) histologies were identified. The clinical and pathologic features of the 4 groups were evaluated and compared with respect to local-regional recurrence rates, disease-free survival, and overall survival (OS). RESULTS: No statistically significant differences were found in the local-regional failure rate among the 4 groups (10.6-year median follow-up). Only patients with tubular carcinoma had better 5- and 10-year OS rates (P = .013). In multivariable analysis, factors associated with improved OS included age at or below 50 years, negative nodal status, use of chemotherapy or hormonal therapy, and tubular histology. CONCLUSIONS: BCT for mucinous, medullary, or tubular carcinoma resulted in similar local-regional failure rates to that for invasive ductal carcinoma. Tubular carcinoma patients had the most favorable OS. BCT is an appropriate treatment strategy for early-stage mucinous, medullary, and tubular carcinomas.     

Abdominal Surgery in Nonagenarians: Short-Term Results

PURPOSE: To determine the short-term results of abdominal surgery in nonagenarians. METHODS: Retrospective analyses of 193 patients aged 90 and older operated on for abdominal complaints during a 15-year period (1990-2004) in a 500-bed tertiary care institutional hospital and 100-bed rural institutional hospital in Spain. The factors analyzed included the following: perioperative risk, diagnosis, operative procedures, timing of operation (elective or emergency), morbidity, mortality, and length of hospital stay. RESULTS: The most common diagnoses were hernia in 69 cases, colorectal cancer in 39, and biliary lithiasis in 24. One hundred and thirty-seven patients (71%) were operated on on an emergency basis. Forty-seven patients died (24%), with mortality rates of 9% (5/56) and 31% (42/137) respectively, for elective and emergency surgery. None of the 15 patients classified as grade I according to the criteria of the American Society of Anesthesiologists (ASA) died and only 3 out of 63 (5%) died who were ASA grade II. Eighty patients (41%) had postoperative complications. Local morbidity was 16% (n = 30), and systemic morbidity was 30% (n = 58). CONCLUSIONS: Our results support the notion that elective and acute abdominal surgery in nonagenarians can be performed with acceptable rates of mortality and morbidity. Mortality for surgery in nonagenarians is strongly related to the perianesthetic risk (ASA grade), emergency operation, and seriousness of the disease in question.     

Post streptococcal acute glomerulonephritis secondary to sporadic <Emphasis Type="Italic">Streptococcus equi</Emphasis> infection

Streptococcus equi subspecies zooepidemicus infection is rare in humans, but a well-known cause of pyogenic disease in cows and horses. S. zooepidemicus uncommonly causes post-strep glomerulonephritis (PSGN) in humans via epidemic outbreaks. We present a sporadic case of post S. zooepidemicus glomerulonephritis in a child most probably contracted from a horse. The 14-year-old girl presented with the typical signs of PSGN, with S. equi zooepidemicus isolated from a blood culture, together with a low C3 and raised anti-DNAse B. This is the first known report of a sporadic case of PSGN in a child caused by this organism.     

Predictors of locoregional recurrence among patients with early-stage breast cancer treated with breast-conserving therapy

Background Our aim was to identify predictors of locoregional recurrence (LRR) in patients with early-stage breast cancer treated with breast-conserving therapy (BCT) and long-term follow-up. Methods From 1970 to 1994, 1153 patients with stage I to II breast cancer underwent BCT and radiotherapy at our institution. Patients with prior breast cancer or other primary malignancies were excluded. Clinical and pathologic characteristics evaluated were age, race, tumor size, stage, pathologic tumor margins, axillary nodal involvement, estrogen and progesterone receptor status, Black's nuclear grade, type of surgery, and use of adjuvant therapy. Results Of 1083 patients, 54% presented with stage I disease and 46% with stage II disease. Median age was 50 years, and median follow-up was 9 years. Axillary nodes were positive in 31% of the patients who underwent axillary dissection. LRR developed in 6%, LRR followed by systemic recurrence in 5%, and systemic recurrence alone in 13%, 76% had no evidence of recurrence at last follow-up. Age, tumor size, positive lymph nodes, and not receiving chemotherapy or hormonal therapy were independent predictors of LRR. Disease-specific survival among patients with LRR was similar to that among patients with no recurrence. Conclusions Multidisciplinary treatment strategies should be used to accomplish durable locoregional control after BCT. Presented at the 54th Annual Cancer Symposium of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.