The modified Evan's blue dye procedure fails to detect aspiration in the tracheostomized patient: Five case reports

The modified Evan's blue dye procedure (MEBD) is a method of performing tracheal suctioning of the patient through the tracheostomy tube after administration of color-contrasted food and liquid. The MEBD is done when radiographic or fiberoptic procedures are not available or practical. In 5 tracheostomized patients, the MEBD does not detect aspiration.     

The Veterans Affairs Learners' Perceptions Survey: the foundation for educational quality improvement.

PURPOSE: The U.S. Department of Veterans Affairs (VA) supports 8,700 resident positions nationally to enhance quality of care for veterans and to educate physicians. This study sought to establish a yearly quality indicator to identify and follow strengths and opportunities for improvement in VA clinical training programs. METHOD: In March 2001, the VA Learners' Perceptions Survey, a validated 57-item questionnaire, was mailed to 3,338 residents registered at 130 VA facilities. They were asked to rate their overall satisfaction with the VA clinical training experience and their satisfaction in four domains: faculty/preceptor, learning, working, and physical environments using a five-point Likert scale. Questionnaires were received from 1,775 residents (53.2%). A full analysis was conducted using 1,436 of these questionnaires, whose respondents were categorized in four training programs: medicine (n = 706), surgery (n = 291), subspecialty (n = 266), and psychiatry (n = 173). RESULTS: On a scale of 0 to 100, residents gave their clinical training experience an average score of 79. Eighty-four percent would have recommended VA training to peers, and 81% would have chosen VA training again. Overall, 87% were satisfied with their faculty/preceptors, 78% with the learning environment, and 67% with the working and physical environments. The survey was sensitive to differences in satisfaction among the trainee groups, with residents in internal medicine (IM) the least satisfied. CONCLUSION: The VA Learners' Perceptions Survey is the first validated survey to address comprehensive satisfaction issues in clinical training. The survey highlights strengths and opportunities for improvement in VA clinical training and is the first step toward improving education.     

Sex differences in spatial ability in children

There is considerable evidence that sex differences in spatial ability exist in adults, with males outperforming females at every age after puberty. It is difficult, however, to find sex differences in children younger than 13. This is due in part to the lack of adequate measures of spatial ability for use with children. We report the use of spatial tests for children that are similar to those that have shown large sex differences in adults and may be measuring ability comparable to adult spatial ability. Four tests of mental rotation and spatial visualization were given to two samples of children. The first sample consisted of 81 children (39 males and 42 females) aged 9 to 12 years. The second sample consisted of 42 children (21 males and 21 females) aged 9 to 13 years. Sex differences of .4–.6 standard deviations were found on three tests in both samples. These results indicate that sex differences in spatial ability can be found in preadolescents if appropriate tests are used. Measurement of these abilities in children facilitates the investigation of possible biological and sociocultural contributors to the sex differences in spatial ability.This study was supported by National Institutes of Health Grant HD19644 and NIH Biomedical Research Support Grant S07 RR05366-24.     

Atypical maternal behavior,maternal representations,and infant disorganized attachment

The data for 197 mother-infant pairs from two longitudinal studies were analyzed to assess relations between maternal attachment representations; atypical maternal behavior, coded with a new tool. Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE), and infant attachment. Both maternal and infant attachment were systematically related to atypical maternal behavior: mothers who were Unresolved on the Adult Attachment Interview and those whose infants were disorganized in the Strange Situation Procedure engaged in more atypical behaviors than those who were not Unresolved and whose infants showed organized patterns of attachment, respectively. Regression analyses indicated that when tested as a mediator, atypical maternal behavior as measured on the AMBIANCE did not reduce the association between maternal Unresolved status and infant disorganized attachment. This may, in part, reflect the fact that our low-risk sample did not include enough cases in the risk categories. These data provide preliminary empirical validation for the AMBIANCE and strengthen the evidence for links between atypical maternal behavior and disorganized attachment but indicate that in addition to maternal attachment representations, other factors must contribute to atypical maternal behavior.     

Preschool children with mild to moderate traumatic brain injury: an exploration of immediate and post-acute morbidity.

This study explored premorbid, neurocognitive, behavioral, and familial factors in preschoolers, ages 3-6, who experienced a mild to moderate traumatic brain injury (TBI). Twenty-nine children with TBI, 33 children with mild to moderate injuries to other body regions, and 34 non-injured children participated in the study. Neuropsychological assessments and behavioral measures were administered at the time of hospitalization and 6 months later. In comparison to the non-injury children, preschool-aged children with TBI had higher rates of premorbid behavior difficulties, lower premorbid cognitive functioning, and poorer development of pre-academic skills. In addition, parents of children with TBI reported greater situational issues and life stressors than parents of children in the non-injured group. Some neurocognitive recovery was evident in the TBI group, but no differences were recognized in behavioral and family measures at the 6-month follow-up. This study emphasizes the relative effects of premorbid characteristics in later practice of preschool children who sustain TBI.     

Microrheology and light transmission of blood

Employing both microscopic and photometric methods the rheology of pathological red cell aggregation was studied in model experiments. Suspensions of washed human red blood cells in dextran solutions containing rising concentrations of dextrans (M.W. 40000, 70000, 110000, 250000, 500000) were used. At low concentrations (less than 500 mg-%) of high molecular weight dextrans (greater than 70000) red cell suspensions formed aggregates similar to the ones found in normal human blood. At higher concentrations, the aggregates were similar to those observed in pathological human blood. The aggregates were studied under the condition of stasis, slow flow and at shear rate of their hydrodynamic dispersion. Besides, the flow behavior of the dispersed cells at high shear rates was studied. We found: 1. In all samples the rate of spontaneous aggregate re-formation in stasis (following hydrodynamic desaggregation) rose with rising dextran concentration up to 5.0 g-%. 2. The shear resistance of the aggregates, as measured by the shear stress necessary to keep them dispersed, rose up to concentrations of 2.5g-%, but fell at higher concentrations. 3. Only with dextran of a molecular weight above 110000 coarse agglomerates could be produced at high concentrations. Loose elastic meshes were rapidly produced at high concentrations of Dx 70. 4. When subjected to steady state low shear (m sec-1) only the agglomerates, but not the meshes rapidly grew in size. Most of the aggregation kinetics recorded by photometry and microscopy evaded detection by viscometry.     

A Web-based compendium of clinical questions and medical evidence to educate internal medicine residents.

The authors designed an electronic database of clinical questions (CQs) and medical evidence and implemented it in 2001-02 at Duke University Medical Center and the Veterans Administration Medical Center in Durham, North Carolina. This Web-based data collection system is called the Critical Appraisal Resource (CAR) and is still in operation. This report is of ten months of the system's operation. During their medicine ward rotations, residents entered CQs into the CAR; they also entered Medline reference links and validated article summaries. Residents' utilization of the CAR database, Medline, and other electronic resources was prospectively measured. In addition, residents were prospectively surveyed regarding the impact of each question and associated reference on medical decision making for individual patients. Over ten months, residents entered 625 patient-based CQs into the CAR and were able to obtain useful information from the medical literature on 82% of the CQs they searched. The two most prevalent CQ types were therapy and diagnosis questions (53% and 22%). Sixty percent of the therapy articles considered useful were reports of randomized controlled trials. Residents obtained 77% of their useful data from Medline. They reported that obtaining useful data altered patient management 47% of the time. Residents used the CAR as a resource, searching the database for information 1,035 times over the study period. In summary, the use of an evidence-based critical appraisal resource led residents to engage the medical literature on behalf of their patients and influenced approximately half of their patient-care decisions. Residents benefited from questions previously searched by other residents, allowing them to address a wider spectrum of CQs during ward rotations.     

Incidence and outcome of chronic graft-versus-host disease using National Institutes of Health consensus criteria.

Chronic graft-versus-host disease (cGVHD), a common complication after stem cell transplant (SCT), has an impact on morbidity and survival. Previous classification of cGVHD has not been reproducible or prognostic for nonrelapse mortality (NRM). Recently the National Institutes of Health (NIH) consensus criteria were proposed, but the ability of this classification to predict outcome of various subtypes of cGVHD is unknown. Patients (N = 110) undergoing an SCT for a hematologic malignancy and surviving until day 100 posttransplant from 2001 to 2003 were studied. The overall survival (OS) using a landmark analysis at day 100 was 44% versus 66% (no GVHD vs. GVHD, P = .026). The OS of patients with various types of GVHD as proposed by the NIH criteria were significantly different (P < .0001). In a univariate analyses, this was more apparent when patients with any acute features of GVHD were compared to classic cGVHD (3-year OS 46% vs. 68%, P = .033). The 3-year NRM for the entire cohort was 21%, and was not affected by presence or absence of GVHD or subtypes of GVHD. In a multivariable analysis, extensive cGVHD (hazard ratio [HR] 0.35, P = .015) and having any acute feature of GVHD after day 100 (HR 3.36, P = .0144) were significant independent predictors of survival. The OS with different NIH subtypes of GVHD after day 100 from SCT varies, and is superior for patients with classic cGVHD.