Inter-Rater Reliability of the PIPES Tool: Validation of a Surgical Capacity Index for Use in Resource-Limited Settings

Introduction

In response to the need for simple, rapid means of quantifying surgical capacity in low resource settings, Surgeons OverSeas (SOS) developed the personnel, infrastructure, procedures, equipment and supplies (PIPES) tool. The present investigation assessed the inter-rater reliability of the PIPES tool.

Methods

As part of a government assessment of surgical services in Santa Cruz, Bolivia, the PIPES tool was translated into Spanish and applied in interviews with physicians at 31 public hospitals. An additional interview was conducted with nurses at a convenience sample of 25 of these hospitals. Physician and nurse responses were then compared to generate an estimate of reliability. For dichotomous survey items, inter-rater reliability between physicians and nurses was assessed using the Cohen’s kappa statistic and percent agreement. The Pearson correlation coefficient was used to assess agreement for continuous items.

Results

Cohen’s kappa was 0.46 for infrastructure, 0.43 for procedures, 0.26 for equipment, and 0 for supplies sections. The median correlation coefficient was 0.91 for continuous items. Correlation was 0.79 for the PIPES index, and ranged from 0.32 to 0.98 for continuous response items.

Conclusions

Reliability of the PIPES tool was moderate for the infrastructure and procedures sections, fair for the equipment section, and poor for supplies section when comparing surgeons’ responses to nurses’ responses—an extremely rigorous test of reliability. These results indicate that the PIPES tool is an effective measure of surgical capacity but that the equipment and supplies sections may need to be revised.     

Radiological studies on the best entry point and trajectory of anterior cervical pedicle screw in the lower cervical spine

Objective

To explore the best entry point and trajectory of anterior cervical transpedicular screws in the lower cervical spine by radiological studies, and provide reference for clinical application.

Methods

Fifty patients were scanned by computed tomography and confirmed no obvious defect of the cervical spine. On horizontal axis, camber angle (α) and axial length (AL) were measured from C₃ to C₇. On sagittal view, the cranial or caudal angle (β) and sagittal length (SL) were also measured from C₃ to C₇. On the sagittal and horizontal planes vertebrae were respectively divided into four areas, ordered 1–4, on the anterior side of the pedicle. The areas and angles of pedicle intersect into the vertebral body were recorded. We inserted six anterior pedicle screws into the lower cervical spine of three patients by this technique.

Results

On transverse plane, camber angle (α) of C₃–C₅ increased gradually, while it decreased from C₅ to C₇. On sagittal view, C₃ and C₄ pedicles showed cranial tilting, while C₅ to C₇ were caudally tilted. AL and SL values increased gradually from C₃ to C₇. The number of the intersections of C₃–C₇ in each area was also different. Six pedicle screws of three cases were inserted into the lower cervical spine with proper placement and no complications.

Conclusion

Anterior transpedicular screw (ATPS) is a theoretically feasible option for internal fixation. The technique described in this paper was subsequently used in three patients without complication. Future improvement of ATPS insertion remains necessary for this technically demanding procedure.     

Neurohormones in patients with ischemic left ventricular dysfunction

Measurements of plasma neurohormones in patients with left ventricular dysfunction are generally performed for research purpose rather than for diagnostic purpose or to guide therapy. These studies have shown that in patients with left ventricular dysfunction, several neurohormonal systems were activated, even in the absence of symptoms of congestive heart failure. This suggested that the cardiovascular system was not in a steady state and pointed out potential culprits for the progression of the disease. It has also been shown that the levels of several of these markers, particularly plasma norepinephrine, had an important prognostic value. Another value of neurohormonal studies obviously is the design of new therapeutic approaches aimed at improving symptoms and prognosis. In this respect, important therapeutic successes have been obtained with agents that interfere with the actions of some of these neurohormonal systems, such as with the use of the angiotensin-converting enzyme (ACE) inhibitors, particularly captopril and enalapril, and to a lesser extent, with beta-blockers. It can therefore be expected that, in the future, most patients with severe ischemic dysfunction will be treated with an ACE inhibitor. Nonetheless, neurohormonal control is not complete with these drugs; powerful vasoconstrictor forces, such as endothelin-1, remain activated, and an escape of angiotensin II from the control of ACE inhibition may exist. Thus, morbidity (e.g., progression towards congestive heart failure and angina pectoris) and mortality remain high despite treatment with ACE inhibitors. In the search for further improvements, the new generation of long-acting dihydropyridines is worth considering. Their afterload reducing action, coupled with powerful coronary vasodilation, might hypothetically delay the progression of ischemic LV dysfunction. In addition, the improved pharmacokinetic profile of these drugs avoiding wide peak and trough variations in plasma levels may avoid triggering some neurohormonal reflexes.     

Rickettsia parkeri and Rickettsia montanensis,Kentucky and Tennessee,USA

We found that 14.3% (15/105) of Amblyomma maculatum and 3.3% (10/299) of Dermacentor variabilis ticks collected at 3 high-use military training sites in west-central Kentucky and northern Tennessee, USA, were infected with Rickettsia parkeri and Rickettsia montanensis, respectively. These findings warrant regional increased public health awareness for rickettsial pathogens and disease.     

The Effect of Presenting Information about Invasive Follow-Up Testing on Individuals’ Noninvasive Colorectal Cancer Screening Participation Decision: Results from a Discrete Choice Experiment

ObjectivesMany national colorectal cancer screening campaigns have a similar structure. First, individuals are invited to take a noninvasive screening test, and, second, in the case of a positive screening test result, they are advised to undergo a more invasive follow-up test. The objective of this study was to investigate how much individuals’ participation decision in noninvasive screening is affected by the presence or absence of detailed information about invasive follow-up testing and how this effect varies over screening tests.MethodsWe used a labeled discrete choice experiment of three noninvasive colorectal cancer screening types with two versions that did or did not present respondents with detailed information about the possible invasive follow-up test (i.e., colonoscopy) and its procedure. We used data from 631 Dutch respondents aged 55 to 75 years. Each respondent received only one of the two versions (N = 310 for the invasive follow-up test information specification version, and N = 321 for the no-information specification version).ResultsMixed logit model results show that detailed information about the invasive follow-up test negatively affects screening participation decisions. This effect can be explained mainly by a decrease in choice shares for the most preferred screening test (a combined stool and blood sample test). Choice share simulations based on the discrete choice experiment indicated that presenting invasive follow-up test information decreases screening participation by 4.79%.ConclusionsDetailed information about the invasive follow-up test has a negative effect on individuals’ screening participation decisions in noninvasive colorectal cancer screening campaigns. This result poses new challenges for policymakers who aim not only to increase uptake but also to provide full disclosure to potential screening participants.     

Toxicity evaluation and nasal mucosal tissue deposition of dexamethasone-infused mucoadhesive in situ nasal gelling systems

To demonstrate safety of a developed intranasal dexamethasone-infused in situ gelling formulation, quantification of a validated clinical biomarker indicative of cytotoxic potential using a human sinonasal explant model was first confirmed. Systematic cytotoxicity studies using the lactate dehydrogenase (LDH) detection assay revealed no elevation from baseline, in LDH levels, with tissue integrity of explanted human nasal mucosa also maintained; this was further corroborated using tissue histopathological examination. Next, with safety confirmed ex vivo, freshly excised human nasal tissue was utilised to quantify dexamethasone release from the lead sol–gel systems; this being achieved through development and validation of a HPLC-UV analytical method, which reliably quantified controlled therapeutic release and deposition into mucosal tissue. Collectively, these findings indicate promise in the safety of each excipient within the concentrations employed in the functional sol–gel system, complemented by successful and reliable drug release and deposition into human nasal mucosal tissue. These findings pave the way for application of the dexamethasone-based sol–gel system to the extended delivery of corticosteroids to nasal mucosa in the management of localised inflammatory conditions of an acute and chronic nature, such as chronic rhinosinusitis, which can be expected to benefit from controlled and extended drug delivery characteristics imparted by appropriately engineered in situ gelling systems.     

Late-life alcohol consumption and cognitive function in elderly men

Moderate alcohol consumption (one to two drinks per day) has been associated with better cognitive function and lower risk of developing dementia in the elderly. In light of alcohol’s well-known neurotoxic properties, more evidence from well-controlled population-based studies is required. The objective of this study was to examine whether self-reported alcohol intake at age 70 is linked to cognitive function (assessed by trail making tests (TMTs) A and B, which are measures of attention, mental speed, and flexibility) in a population-based cohort consisting of 652 cognitively healthy elderly men. Linear regression models were used to assess both cross-sectional (i.e., age 70) and prospective (i.e., age 77) associations between alcohol intake and cognitive function. The analyses were adjusted for education, body mass index, energy intake, self-reported physical activity, smoking, a history of hypertension or diabetes, apolipoprotein E ε4 status, and cholesterol levels at the age of 70. Baseline data were obtained from 1990 to 1996. Self-reported alcohol intake (mean 6.9 ± 7.1 g/day) was associated with better performance on TMT-B at ages 70 and 77 (β = −0.87, p < 0.001). In contrast, alcohol intake was not predictive of the difference in performance on these tests between ages 70 and 77. Despite cross-sectional associations with performance in a test of executive functioning, moderate intake of alcohol was not linked to differences in cognitive performance between ages 70 and 77 in the present study. Thus, our findings do not support the view that daily moderate alcohol consumption is a recommendable strategy to slow cognitive aging in elderly populations.     

Mini-implant stability at the initial healing period: A clinical pilot study

Objective:To evaluate the changes of mini-implant stability over the initial healing period in humans.Material and Methods:A sample of 19 consecutively treated patients (mean age 15.5 ± 7.3 years) was examined. In each patient, a mini-implant of a size of 2 × 9 mm was inserted into the anterior palate. Implant stability was assessed using resonance frequency analysis (RFA) immediately after insertion (T0), 2 weeks later (T1), 4 weeks later (T2), and 6 weeks later (T3). Insertion depth (ID) and the maximum insertion torque (IT) were measured. Data were tested for correlations between RFA, ID, and IT. All RFA values were tested for statistically significant differences between the different times.Results:The mean ID was 7.5 ± 0.6 mm, and the mean IT was 16.8 ± 0.6 Ncm. A correlation was found between RFA and ID (r  =  .726, P < .0001), whereas no correlations between RFA and IT or between IT and ID were observed. From T0 to T1, the stability (36.1 ± 6.1 implant stability quotient [ISQ]) decreased nonsignificantly by 4.9 ± 6.1 ISQ values (P > .05). Between T1 and T2, the stability decreased highly significantly (P < .001) by 7.9 ± 5.9 ISQ values. From T2 on, RFA remained nearly unchanged (−1.7 ± 3.5 ISQ; P > .05).Conclusions:Mini-implant stability is subject to changes during the healing process. During weeks 3 and 4, a significant decrease of the stability was observed. After 4 weeks, the stability did not change significantly.     

Corporate law and corporate psychopaths

For more than three decades there has been a growing interest, and concern, in the role that psychopathy plays in corporate affairs. The literature in this field is essentially interdisciplinary, drawing heavily on advances in neuroscience, behavioural and organisational psychology and criminology. In this paper, the authors open a line of enquiry on the role that law can play in the regulation, and remedies, available to deal with dysfunctional and psychopathic management. In this paper we argue that the impact of corporate psychopaths – particularly the sub-clinical types – is sometimes potentially devastating for the organisation, its mission, its employees and, where they exist, shareholders. In this article we outline the nature of corporate psychopathy and its impact on corporate entities and outline a range of potential legal remedies.