Acute pain management services have progressed, albeit insufficiently in Canadian academic hospitals

PURPOSE: Acute pain management services (APMS) evolved in response to the desire for improved management of postoperative pain. The management of postoperative pain received formal support from international organizations over the past decade and by 1993 half of the Canadian university-affiliated teaching hospitals had implemented an APMS. The purpose of this survey was to describe APMSs in Canadian academic institutions, with specific emphasis on postoperative analgesics, new analgesic methods, training and research. METHODS: Between June 2000 and January 2001, 62 Canadian hospitals affiliated with the 16 Canadian university anesthesiology departments were sent a postal questionnaire. RESULTS: Fifty of the 62 respondents returned a completed questionnaire representing a response rate of 81%. Eighty percent of the hospitals surveyed had at least 200 beds, 90% (45) had implemented an APMS. Anesthesiology was primarily responsible in all 45 hospitals with an APMS. The results presented are based on the 45 centres with an APMS. CONCLUSION: Since the early 1990s the percent of Canadian academic hospitals with an APMS has increased from 53% to 92%. These figures are comparable to the United States. Greater collaboration from nursing and pharmacy, mandatory training for medical and nursing students and residents, and a standardized approach to continuous quality improvement remain necessary.     

Performance characteristics and image fidelity of gray-scale monitors.

Gray-scale monitors are an essential element of electronic radiology, and their ability to provide images that are perceived to be identical to those available on conventional or laser-printed film is crucial to success of electronic radiology. Image fidelity is measured in physical characteristics (luminance, dynamic range, distortion, resolution, and noise) and with psychophysical techniques, including receiver operator characteristics analysis with clinical images and testing with contrast-detail patterns to determine threshold contrast. Currently, laser-printed images facilitate greater information transfer than does a gray-scale monitor because of their higher absolute luminance (500 ft-L vs 60 ft-L), greater perceived dynamic range, and better spatial resolution. In the near future, the developments of gray-scale monitors with 150-200 ft-L luminance, a display standard based on just noticeable differences, and algorithms to improve similarities between gray-scale display images and laser-printed images will help increase the acceptability of monitors as a means to make primary diagnoses.     

Analysis of orthologous gene expression between human pulmonary adenocarcinoma and a carcinogen-induced murine model

Human adenocarcinoma (AC) is the most frequently diagnosed human lung cancer, and its absolute incidence is increasing dramatically. Compared to human lung AC, the A/J mouse-urethane model exhibits similar histological appearance and molecular changes. We examined the gene expression profiles of human and murine lung tissues (normal or AC) and compared the two species' datasets after aligning approximately 7500 orthologous genes. A list of 409 gene classifiers (P value <0.0001), common to both species (joint classifiers), showed significant, positive correlation in expression levels between the two species. A number of previously reported expression changes were recapitulated in both species, such as changes in glycolytic enzymes and cell-cycle proteins. Unexpectedly, joint classifiers in angiogenesis were uniformly down-regulated in tumor tissues. The eicosanoid pathway enzymes prostacyclin synthase (PGIS) and inducible prostaglandin E(2) synthase (PGES) were joint classifiers that showed opposite effects in lung AC (PGIS down-regulated; PGES up-regulated). Finally, tissue microarrays identified the same protein expression pattern for PGIS and PGES in 108 different non-small cell lung cancer biopsies, and the detection of PGIS had statistically significant prognostic value in patient survival. Thus, the A/J mouse-urethane model reflects significant molecular details of human lung AC, and comparison of changes in orthologous gene expression may provide novel insights into lung carcinogenesis.     

Ex vivo detection and characterization of early dental caries by optical coherence tomography and Raman spectroscopy

Early dental caries detection will facilitate implementation of nonsurgical methods for arresting caries progression and promoting tooth remineralization. We present a method that combines optical coherence tomography (OCT) and Raman spectroscopy to provide morphological information and biochemical specificity for detecting and characterizing incipient carious lesions found in extracted human teeth. OCT imaging of tooth samples demonstrated increased light backscattering intensity at sites of carious lesions as compared to the sound enamel. The observed lesion depth on an OCT image was approximately 290 microm matching those previously documented for incipient caries. Using Raman microspectroscopy and fiber-optic-based Raman spectroscopy to characterize the caries further, spectral changes were observed in PO4 (3-) vibrations arising from hydroxyapatite of mineralized tooth tissue. Examination of various ratios of PO4 (3-) nu2, nu3, nu4 vibrations against the nu1 vibration showed consistent increases in carious lesions compared to sound enamel. The changes were attributed to demineralization-induced alterations of enamel crystallite morphology and/or orientation. OCT imaging is useful for screening carious sites and determining lesion depth, with Raman spectroscopy providing biochemical confirmation of caries. The combination has potential for development into a new fiber-optic diagnostic tool enabling dentists to identify early caries lesions with greater sensitivity and specificity.     

Neanderthal reconstructed

A century and a half of controversy concerning the differences between Neanderthals (or Neandertals) and modern humans has left us with many questions and no sign of abatement. One of these remaining questions concerns the articulated structure of the Neanderthal skeleton and how it compares to that of a modern human. Although this question has been tackled many times by more artistic avenues, never has a complete, fully articulated Neanderthal skeleton been constructed systematically using castings from real Neanderthal bones. In an attempt to provide a more objective understanding of Neanderthal stature and biomechanics, a complete Neanderthal skeleton was reconstructed and articulated. This reconstruction was primarily based on the La Ferrassie 1 specimen, with missing or incomplete elements filled in from other Neanderthal cast collections.     

Chaos control of cardiac arrhythmias

Chaos theory has shown that many disordered and erratic phenomena are in fact deterministic, and can be understood causally and controlled. The prospect that cardiac arrhythmias might be instances of deterministic chaos is therefore intriguing. We used a recently developed method of chaos control to stabilize a ouabain-induced arrhythmia in rabbit ventricular tissue in vitro. Extension of these results to clinically significant arrhythmias such as fibrillation will require overcoming the additional obstacles of spatiotemporal complexity.     

Intrahepatic absorbable fine mesh packing of hepatic injuries: Preliminary clinical report

A previous report from the authors' institution reported the effectiveness of hepatic packing with absorbable fine mesh (AFMP) for the control of hemorrhage in an animal model with an otherwise lethal hepatic injury. The technique has subsequently been applied to 12 abdominal trauma patients with hemodynamic instability and actively hemorrhaging hepatic injuries. Two patients expired in the operating room owing to uncontrolled hemorrhage from hepatic and associated injuries for a mortality of 16.7%. AFMP was successful in controlling hemorrhage in the remaining 10 patients. Hepatic injuries ranged from grade II to grade V, and all were actively hemorrhaging at the time of exploration. None of the surviving 10 patients experienced early or late recurrent bleeding attributable to the hepatic injuries, and there were no intraabdominal abscesses or late deaths. Liver function studies returned to normal prior to discharge in all surviving patients. Follow-up included serial computed tomographic scans, which demonstrated fibrosis incorporating the mesh packing. Complete resolution of injury and mesh appears to proceed over approximately a 6-month period. AFMP is a safe, effective method for controlling hepatic hemorrhage. It is easy to perform in the operating room, offers an excellent matrix for hemostasis, provides tamponade of bleeding sites, and does not require reoperation for removal of packing material, as is necessary with conventional, nonabsorbable packing techniques.

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Resumen En una publicación previa se informó la eficacia del empaquetamiento hepático con una fina malla absorbible en el control de la hemorragia en un modelo animal experimental sometido a lesión hepática letal. Desde entonces la técnica ha sido aplicada en 12 pacientes con trauma abdominal e inestabilidad hemodinámica y lesiones hepáticas sangrantes. Dos pacientes expiraron en la mesa de operaciones por hemorragia no controlada proveniente de la arteria hepática y de otras lesiones asociadas, con una tasa de mortalidad de 16.7%. La malla fue eficaz en cuanto a controlar la hemorragia en el resto de los pacientes. Las lesiones hepáticas variaron en cuanto a severidad entre los Grados II a V y todas exhibían hemorragia activa en el momento de la exploración. Ninguno de los 10 sobrevivientes desarrolló sangrado recurrente temprano o tardío que pudiera ser atribuible a las lesiones hepáticas y no se observaron abscesos intraabdominales o muertes tardías. Las pruebas de función hepática retornaron a valores normales con anterioridad al egreso, en la totalidad de los sobrevivientes. El seguimiento incluyó tomografías computadorizadas seriadas, que demostraron fibrosis del área de empaquetamiento con la malla; la resolución completa de la lesión y de la malla parece tener lugar en el curso de seis meses, aproximadamente. La malla representa un método seguro y eficaz de control de la hemorragia hepática, es fácil de aplicar en el quirófano, ofrece una excelente matriz para la hemostasia, produce taponamiento de los sitos sangrantes y no requiere reoperación para remover el material de empaquetamiento, como sí lo requieren las técnicas convencionales de empaquetamiento con materiales no absorbibles.

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Résumé Nous avons déjà rapporté l'efficacité du packing périhépatique par un filet fin résorbable (FFA) pour contrôler l'hémorragic autrement mortelle provenant d'une lésion hépatique chez l'animal. Cette même technique a été utilisée utilisée chez 12 patients ayant un traumatisme sévère du foie avec une hémodynamique instable. Deux patients sont décédés en salle d'opération des lésions hépatiques et des structures avoisinantes soit une mortalité de 16.7%. La technique de FFA a été couronnée de succès chez les 10 autres patients. Les lésions ont été classées selon leur sévérité du grade II au grade V et toutes saignaient activement au moment de l'opération. Aueun des patients survivants n'a eu de récidive hémorragique attribuable à la lésion hépatique et il n'y a eu aucun abcès intra-abdominal ni de mortalité tardive. La fonction hépatique est redevenue normale avant la sortie chez tous les autres patients. La surveillance du suivi a comporté une tomodensitométrie montrant une fibrose autour du filet. La résolution complète de la lésion et la résorption du filet évoluent en général sur six mois. La technique de FFA est sûre et efficace dans le contrôle de l'hémoragie provenant des traumatismes du foie. La méthode est facile à appliquer en salle d'opération, procure une hémostase excellent par tamponnade et ne nécessite pas de réintervention pour enlever le packing comme quand on utilise le matériel traditionnel non résorbable.

     

Swallowing,speech, and brainstem auditory-evoked potentials in spasmodic torticollis

To explore the controversial brainstem theory of spasmodic torticollis, eight consecutively referred patients were examined. Three independent examinations were conducted on the same day: a videofluoroscopic barium swallowing examination, an instrumental speech examination, and a brainstem auditory-evoked potential (BAEP) analysis. Swallowing was normal in two patients; speech physiology, in five; and BAEPs, in all. Normal BAEPs refute the brainstem theory, while abnormalities of speech and swallowing temper this conclusion. Several alternative explanations are proposed.The authors have no commercial or proprietary interest in any product mentioned in this article.     

A distributed approach to integrated inquiry and display for radiology

Picture archive and communications (PACS) systems should be flexible and modular in design so that new advances in storage, computation, and display technology can be introduced into the system without a significant redesign of existing software. The acquisition, storage, and management of radiologic images must be carefully integrated with a radiology information system. Our architecture is based on a four-level data model: (1) patient information, (2) examination information and reports, (3) image information, and (4) instances of images. The PACS being developed at the Mallinckrodt Institute of Radiology within the Electronic Radiology Laboratory consists of three primary components: application clients, database servers and image servers. One type of application client is an image-capable workstation that supports a radiology image viewing application. The application client queries the database server for information regarding patient and examination data in response to user-level requests. The database server responds to the request by retrieving the appropriate patient demographics and examination information, along with a pointer to the image/instance data from a central database. The client then uses the image data pointer to query the image server for the actual pixel data. The image server responds by transmitting the pixel data to the requesting application client or a designated auxiliary display device. Other clients act as image data acquisition nodes. Queries to the database servers are made via a library of callable subroutines. Software integrity is maintained throughout the system by dynamically loading software from a code-control database. Inquiry and display transactions, supported on a local-area network (Ethernet), have been measured and analyzed. Results and observations are presented.