Preterm Infants 30–36 Weeks' Gestation in Victoria — Where Should They Be Delivered?

Summary: There is little doubt that very preterm infants <30 weeks' gestation should be born in level-3 perinatal centres. For preterm infants 30–36 weeks' gestation, however, the optimum place of birth is not so clear-cut. The aims of this study of livebirths 30–36 weeks' gestational age born in Victoria were to determine: 1) the proportions delivered outside level-3 centres, and 2) for infants born outside level-3 centres, the proportions transferred after birth to a level-3 nursery in the first days after birth. Data on the number of livebirths 30–36 weeks' gestational age in Victoria in the 3 years 1994–1996, inclusive, were supplied by the Victorian Perinatal Data Collection Unit. Data were obtained from the Newborn Emergency Transport Service (NETS) on all transfers within the first 3 days after birth to a level-3 centre for infants born outside level-3 centres. For the 3 years 1994–1996 there were 11,375 livebirths 30–36 weeks' gestational age in Victoria. The proportion born outside a level-3 perinatal unit was 57.9% overall, and rose with increasing gestational age, from 10.9% at 30 weeks to 69.0% at 36 weeks. Of the 6,587 livebirths outside a level-3 centre, 808 (12.3%) were transferred within the first 3 days after birth by NETS to a level-3 centre, the proportions falling with increasing maturity, being 73.7%, 48.5%, 28.4%, 26.9%, 18.8%, 11.8%, and 7.0% at 30, 31, 32, 33, 34, 35, and 36 weeks, respectively. These data may help medical practitioners when determining the place of delivery for infants 30–36 weeks' gestation.     

The Art of Building Decision Trees

Decision support systems that help physicians are becoming a very important part of medical decision making. They are based on different models and the best of them are providing an explanation together with an accurate, reliable, and quick response. One of the most viable among models are decision trees, already successfully used for many medical decision-making purposes. Although effective and reliable, the traditional decision tree construction approach still contains several deficiencies. Therefore we decided to develop and compare several decision support models using four different approaches. We took statistical analysis, a MtDeciT, in our laboratory developed tool for building decision trees with a classical method, the well-known C5.0 tool and a self-adapting evolutionary decision support model that uses evolutionary principles for the induction of decision trees. Several solutions were evolved for the classification of metabolic and respiratory acidosis (MRA). A comparison between developed models and obtained results has shown that our approach can be considered as a good choice for different kinds of real-world medical decision making.Art (from Latin ars meaning skill) is the skill in doing or performing that is attained by study, practice, or observation     

Acetylcholine Transmission in Nucleus Accumbens and VTA on Heroin- Seeking Elicited by Contextual and Conditioned Cues

The involvement of cholinergic transmission in heroin self - administration and the reinstatement of heroin - seeking was examined in rats trained to nose - poke for intravenous heroin. Systemic treatment with physostigmine modestly reduced the acquisition and rate of heroin self-administration. Following 10 -14 days of self-administration, rats were left in the home environment for 14 days. Withdrawn animals were evaluated for context-induced nosepokes during the first hour after being returned to the self-administration apparatus. One hr later a conditioned stimulus （ house light, light in the nose-poke hole, sound of the infusion pump） was presented to initiate cue-induced reinstatement.     

Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial.

OBJECTIVE: To determine the impact of a hospital-coordinated discharge care plan, involving a multidisciplinary team of primary health care providers, on hospital length of stay, quality of life, and both patient and general practitioner inclusion in, and satisfaction with, discharge procedures. DESIGN: This investigation comprised a prospective, randomized, controlled, clinical trial. SETTING: This multicentre and cross-jurisdictional study focused on areas of tertiary and primary health care as well as community allied health in Western Australia. PARTICIPANTS: Patients (n = 189) with chronic cardiorespiratory diagnoses were recruited from respiratory, cardiovascular, and general medical wards at two tertiary hospitals. INTERVENTION: Subjects were randomly assigned to one of two groups. Intervention group patients received a discharge care plan in accordance with that outlined in the Australian Enhanced Primary Care Package, completed before discharge and sent to the patient's general practitioner and other community service providers for review. Control patients were discharged under existing hospital processes. Outcome measures. Patients and general practitioners were surveyed pre-discharge and 7 days post-discharge for quality of life and opinion of discharge procedures. Hospital length of stay was also determined. RESULTS: Significant improvements in discharge planning involvement, health service access, confidence with discharge procedures, and opinion of discharge based on previous experience were seen for patients who received the discharge care plan. Further, improved perceptions of mental quality of life were observed within the first week post-discharge for intervention patients. Length of stay showed no difference between groups. Extent and speed of hospital-general practitioner communication were significantly improved via the intervention. CONCLUSIONS: Our results indicate that a multidisciplinary discharge care plan, initiated before separation, improves quality of life, involvement, and satisfaction with discharge care, and hospital-general practitioner integration. As such, it possesses benefits over current Western Australian hospital discharge procedures for the care of chronically ill populations.     

Physician attitudes regarding cardiovascular risk reduction: the gaps between clinical importance, knowledge, and effectiveness.

Reducing risk factors for patients with vascular disease can reduce the subsequent incidence of cerebro-cardiovascular disease. While physicians have had extensive training in the importance of atherosclerotic vascular disease risk factor modification, evidence suggests that they systematically miss opportunities for clinical prevention during routine practice. The aim of this study was to identify whether physicians felt confident in their knowledge and effectiveness regarding counseling patients to reduce cardiovascular risk and to determine barriers to prevention interventions in the office setting. Surveys were mailed to 509 physicians affiliated with an academic community hospital. Nonrespondents were sent reminders and a second survey. Comparisons were made using chi-square analysis. Two hundred and five surveys were returned (40.3%). Thirty-six percent of physicians felt knowledgeable about weight management techniques, compared to 3% who were confident that they succeeded in their practice (p < 0.001). Similar patterns were found for Tobacco Cessation (62% versus 14%, p = 0.001), Alcohol Reduction (46% versus 7%, p < 0.001), Stress Management (35% versus 5%, p < 0.001), Exercise (53% versus 10%, p < 0.001), Nutrition (36% versus 8%, p < 0.001), Diabetes Management (48% versus 23%, p < 0.001), Blood Pressure Management (57% versus 43%, p < 0.001) and Lipid Management (59% versus 38%, p < 0.001). We identified a significant gap between physician confidence in their knowledge about risk factors and their effectiveness at providing counseling and obtaining results in their office. Most physicians felt that the routine office follow-up visit was an ineffective method for instituting vascular risk factor reduction. Alternate settings for risk factor reduction may be needed for improving atherosclerosis prevention.     

Effects of exogenous sphinganine, sphingosine, and sphingosine-1-phosphate on relaxation and contraction of porcine thoracic aortic and pulmonary arterial rings.

Fumonisin mycotoxicosis in pigs causes a decrease in mean aortic pressure, an increase in mean pulmonary arterial pressure, and increases in serum concentrations of sphinganine (3.2 microM) and sphingosine (1.4 microM). To determine a causal relationship between the hemodynamic changes and sphingolipid alterations, we examined the in vitro effects of sphinganine, sphingosine, and sphingosine-1-phosphate on porcine aortic and pulmonary arterial rings. Both sphinganine and sphingosine relaxed un-contracted and phenylephrine-contracted aortic rings at > or = 10 microM and > or = 1 microM, respectively. Sphingosine (> or = 10 microM) relaxed un-contracted and phenylephrine-contracted pulmonary arterial rings, whereas sphingosine-1-phosphate (10 microM) contracted pulmonary arterial rings. Sphingosine (3 microM) also impaired the contractile response of pulmonary artery rings to 60 mM KCl. The results suggested that the systemic hypotension caused by fumonisin is mediated, in part, by increases in serum sphinganine and sphingosine concentrations, and the pulmonary hypertension is mediated, in part, by increased sphingosine-1-phosphate concentrations.     

Effects of spinal cord X-irradiation on the recovery of paraplegic rats

Axonal regrowth is limited in the adult CNS, especially in the spinal cord, one of the major sites of traumatic lesions. Pathophysiological changes occurring after spinal cord injury include complex acute, subacute, and late processes. In this study, we assessed whether X-irradiation interferes with the acute/subacute phases, thereby improving the functional recovery of paraplegic animals. Two days after acute compression of adult rat spinal cords, various doses (0, 2, 5, 10, 20 Gy) of X-rays were administered as one single dose to the compression site. The animals were functionally evaluated over the course of 1 month after injury, using the Tarlov scale and the Rivlin and Tator scale. We also designed a "physiological" scale, including an assessment of urinary function and infection, appropriate for the evaluation of spinal-cord-lesioned animals. Behavioral analysis suggested that the high doses, 20 Gy and, to a lesser extent, 5 and 10 Gy, were toxic, as shown by morbidity rate and "physiological" score. The 2-Gy group showed better motor performances than the lesioned nonirradiated (LNI) animals and the 5- and 20-Gy groups. Motor performance in the 5-, 10-, and 20-Gy groups was poorer than that seen in the LNI group. Gliosis was reduced in the 2-Gy group compared to LNI animals, and there was high levels of gliosis in the highly (>/=5 Gy) irradiated animals. There was a 23% less lesion-induced syringomyelia in the 2-Gy group than in the other groups (LNI and 5-20 Gy). Thus, low doses of X-rays may interfere with the formation of syringomyelia and glial scar, thereby facilitating the recovery of paraplegic animals. These findings suggest that low-dose irradiation of the lesion site, in association with other therapies, is a potentially promising treatment for improving recovery after spinal cord injury.     

Physician leadership is essential to the survival of teaching hospitals

BACKGROUND: Academic medical centers (AMCs) face severe financial constraints because they must now compete directly with private providers that focus exclusively on cost-effective healthcare delivery. Educational and research capacities developed at AMCs have been supported by government and third party payers, but government support is diminishing. Physicians are ill-equipped to respond to market pressures. DATA SOURCES: Analyses of cultural change and restructuring in corporate giants such as Greyhound, IBM and FedEx are relevant to teaching hospitals. To succeed, organizations must flatten hierarchy, empower staff, train leaders, and mobilize intellectual capital. Effective leadership is essential. CONCLUSION: Physicians must educate themselves on forces impacting the AMC, understand changes needed in the structure and processes of AMC governance and acquire competencies for leadership and management if AMCs are to survive and thrive. Surgeons should acquire competencies that will enable them to become leaders in the process of AMC transformation.     

The evolution of surgical approaches for posterior fossa meningiomas.

OBJECTIVE: To evaluate surgical outcomes for the treatment of posterior fossa meningiomas at the House Ear Clinic from 1987 to 2001. We review our current treatment algorithm and present our postoperative outcomes with attention to facial and auditory neural preservation. STUDY DESIGN: Retrospective review. SETTING: Tertiary care center. PATIENTS: Medical records of 71 patients who underwent posterior fossa meningioma surgery at the House Ear Clinic were reviewed. INTERVENTION: All patients had surgical removal of their meningioma via translabyrinthine, transcochlear, retrosigmoid, extended middle fossa, or combined petrosal approaches by House Ear Clinic neurotologists and neurosurgeons. MAIN OUTCOME MEASURES: Preoperative and postoperative auditory and facial nerve function data were collected. Patient and tumor characteristics including presenting symptoms, completion of tumor resection, and complications secondary to surgery were also recorded. RESULTS: The most common presenting symptoms in this series were otologic, with hearing loss (61%), tinnitus (58%), and imbalance (58%) as the three most common. Gross total resection was achieved in 67 (94%) patients. Hearing-preservation surgery was attempted in 37 (52%) patients (68% via extended middle fossa or combined approach). Twenty-one patients with preoperative Class A hearing had follow-up audiometric data and 18 (86%) had serviceable hearing preserved. Excluding transcochlear craniotomies, 85% of patients had normal facial nerve function postoperatively. Cerebrospinal fluid leak (6%) was the most common complication. CONCLUSIONS: Advances in microsurgical techniques have greatly changed our management of patients with posterior fossa meningiomas. These changes have reduced postoperative morbidity. Specifically, use of the anterior and posterior petrosal approaches has facilitated facial and auditory neural preservation while not compromising the extent of tumor excision.