St. Peter's Hospital

BACKGROUND AND PURPOSE: The purpose of this study was to establish the interrater reliability of assessments made with the Fugl-Meyer evaluation of physical performance in a rehabilitation setting. SUBJECTS: Twelve patients (7 male, 5 female), aged 49 to 86 years (mean = 66), who had sustained a cerebrovascular accident participated in the study. All patients were admitted consecutively to a rehabilitation center and were between 6 days and 6 months poststroke. METHODS: Three physical therapists, each with more than 10 years of experience, assessed the patients in a randomized and balanced order using this assessment. The therapists standardized the assessment approach prior to the study but did not discuss the procedure once the study began. RESULTS: The overall reliability was high (overall intraclass correlation coefficient = .96), and the intraclass correlation coefficients for the subsections of the assessment varied from .61 for pain to .97 for the upper extremity. CONCLUSION AND DISCUSSION: The relative merits of using the Fugl-Meyer assessment as a research tool versus a clinical assessment for stroke are discussed.

PREVIOUS studies in this laboratory have shown that the concentration of copper in serum is considerably increased after acute myocardial infarction.1 This change is proportional to an increase in ceruloplasmin, the copper protein of human serum, and its capacity to oxidize paraphenylenediamine.2 In the pursuit of these studies, the concentration of zinc and the activity of zinc enzymes in human serum have been found to be altered markedly in myocardial necrosis.Lactic dehydrogenase has recently been shown to be a zinc enzyme,3 and malic dehydrogenase also appears to be a metalloenzyme.4 These enzymes require coenzyme 1 (diphosphopyridine nucleotide) for their . . .

THIS report is a summary of our experience with kidney homografts in 13 patients treated with drugs as the sole modality for the suppression of immunity (Table 1). Five recent cases are reported in detail: 1 patient with a cadaveric kidney is still alive after one year; 1 died from cerebral hemorrhage more than five months after transplantation from an unrelated infant; 1 is alive three months after transplant from his mother; the fourth is alive six weeks after receiving a kidney from his brother; and the fifth is living four weeks after a transplant from an unrelated adult volunteer. . . .

BACKGROUNDCohort studies in Bangladesh showed promising cure rates among patients with multidrug-resistant tuberculosis who received existing drugs in regimens shorter than that recommended by the World Health Organization (WHO) in 2011. METHODSWe conducted a phase 3 noninferiority trial in participants with rifampin-resistant tuberculosis that was susceptible to fluoroquinolones and aminoglycosides.Participants were randomly assigned, in a 2:1 ratio, to receive a short regimen (9 to 11 months) that included high-dose moxifloxacin or a long regimen (20 months) that followed the 2011 WHO guidelines.The primary efficacy outcome was a favorable status at 132 weeks, defined by cultures negative for Mycobacterium tuberculosis at 132 weeks and at a previous occasion, with no intervening positive culture or previous unfavorable outcome.An upper 95% confidence limit for the between-group difference in favorable status that was 10 percentage points or less was used to determine noninferiority. RESULTSOf 424 participants who underwent randomization, 383 were included in the modified intention-to-treat population.Favorable status was reported in 79.8% of participants in the long-regimen group and in 78.8% of those in the short-regimen group -a difference, with adjustment for human immunodeficiency virus status, of 1.0 percentage point (95% confidence interval [CI], -7.5 to 9.5) (P = 0.02 for noninferiority).The results with respect to noninferiority were consistent among the 321 participants in the per-protocol population (adjusted difference, -0.7 percentage points; 95% CI, -10.5 to 9.1).An adverse event of grade 3 or higher occurred in 45.4% of participants in the long-regimen group and in 48.2% in the short-regimen group.Prolongation of either the QT interval or the corrected QT interval (calculated with Fridericia's formula) to 500 msec occurred in 11.0% of participants in the short-regimen group, as compared with 6.4% in the long-regimen group (P = 0.14); because of the greater incidence in the short-regimen group, participants were closely monitored and some received medication adjustments.Death occurred in 8.5% of participants in the short-regimen group and in 6.4% in the long-regimen group, and acquired resistance to fluoroquinolones or aminoglycosides occurred in 3.3% and 2.3%, respectively. CONCLUSIONSIn persons with rifampin-resistant tuberculosis that was susceptible to fluoroquinolones and aminoglycosides, a short regimen was noninferior to a long regimen with respect to the primary efficacy outcome and was similar to the long regimen in terms of safety.(Funded by the U.S. Agency for International Development and others; Current Controlled Trials number, ISRCTN78372190; ClinicalTrials.govnumber, NCT02409290.

Strong primary care systems are often viewed as the bedrock of health care systems that provide high-quality care, but the evidence supporting this view is somewhat limited. We analyzed comparative primary care data collected in 2009-10 as part of a European Union-funded project, the Primary Health Care Activity Monitor for Europe. Our analysis showed that strong primary care was associated with better population health; lower rates of unnecessary hospitalizations; and relatively lower socioeconomic inequality, as measured by an indicator linking education levels to self-rated health. Overall health expenditures were higher in countries with stronger primary care structures, perhaps because maintaining strong primary care structures is costly and promotes developments such as decentralization of services delivery. Comprehensive primary care was also associated with slower growth in health care spending. More research is needed to explore these associations further, even as the evidence grows that strong primary care in Europe is conducive to reaching important health system goals.

NEARLY fifty years ago the possibility of relieving the obstruction to blood flow through a narrowed mitral valve was first suggested. Subsequent attempts have been made to accomplish this.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The surgical technics employed in these bold but disappointing adventures have been variously described as valvulotomy and valvulectomy. Much of the discussion of the theoretical value of this procedure has been concerned with the problem whether the patient would tolerate a surgically induced mitral insufficiency better than his existing stenosis. This, however, is an oversimplification of the situation. Many factors produce the symptoms and determine the course of the disease in . . .

UNLABELLED: Anesthesia groups may need to determine which clinical anesthesia outcomes to track as part of quality improvement efforts. The goal of this study was to poll a panel of expert anesthesiologists to determine which clinical anesthesia outcomes associated with routine outpatient surgery were judged to occur frequently and to be important to avoid. Outcomes scoring highly in both scales could then be prioritized for measurement and improvement in ambulatory clinical practice. A mailed survey instrument instructed panel members to rate 33 clinical anesthesia outcomes in two scales: how frequently they believe the outcomes occur and which outcomes they expect patients find important to avoid. A feedback process (Delphi process) was used to gain consensus rankings of the outcomes for each scale. Importance and frequency scores were then weighted equally to qualitatively rank order the outcomes. Of the 72 anesthesiologists, 56 (78%) completed the questionnaire. The five items with the highest combined score were (in order): incisional pain, nausea, vomiting, preoperative anxiety, and discomfort from IV insertion. To increase quality of care, reducing the incidence and severity of these outcomes should be prioritized. IMPLICATIONS: Expert anesthesiologists reached a consensus on which low-morbidity clinical outcomes are common and important to the patient. The outcomes identified may be reasonable choices to be monitored as part of ambulatory anesthesia clinical quality improvement efforts.

IN May, 1956, one of a pair of twenty-one-year-old identical twin females from Oklahoma was being studied as a potential recipient for a kidney transplant from her twin sister. Both were childless, having been married for less than a year. The ailing twin, with a three-year history of chronic glomerulonephritis, was in a dire preterminal state, with hypertension (blood pressure of 190 systolic, 120 diastolic), congestive heart failure only partially helped by digoxin and severe oral and gastrointestinal hemorrhage. Extra-corporeal hemodialyses were required on three occasions to sustain life until the necessary preliminary studies were completed.At that time there . . .

UNLABELLED: In this prospective study, we evaluated the etiology of operating room (OR) delays in an academic institution, examined the impact of multidisciplinary strategies to improve OR efficiency, and established OR timing benchmarks for use in future OR efficiency studies. OR times and delay etiologies were collected for 94 cases during the initial phase of the study. Timing data and delay etiologies were analyzed, and 2 wk of multidisciplinary OR efficiency awareness education was conducted for the nursing, surgical, and anesthesia staff. After the education period, timing data were collected from 1787 cases, and monthly reports listing individual case delays and timing data were sent to the Chiefs of Service. For the first case of the day, patient in room, anesthesia ready, surgical preparation start, and procedure start time were significantly earlier (P < 0.01) in the posteducation period compared with the preeducation period, and the procedure start time for the first case of the day occurred, on average, 22 min earlier than all other procedures. For all cases combined, turnover time decreased, on average, by 16 min. Unavailability of surgeons, anesthesiologists, and residents decreased significantly (P < 0.05) as causes of OR delays. Anesthesia induction times were consistently longer for the vascular and cardiothoracic services, whereas surgical preparation time was increased for the neurosurgical and orthopedic services (P < 0.05). Identification of the etiology of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OR efficiency. The time savings realized are probably most cost-effective when combined with more flexible OR staffing and improved OR scheduling. IMPLICATIONS: We achieved significant improvements in operating room efficiency by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary team work, and accurate data collection were all important contributors to improved efficiency.

Anesthesia groups may need to determine which clinical anesthesia outcomes to track as part of quality improvement efforts.The goal of this study was to poll a panel of expert anesthesiologists to determine which clinical anesthesia outcomes associated with routine outpatient surgery were judged to occur frequently and to be important to avoid. Outcomes scoring highly in both scales could then be prioritized for measurement and improvement in ambulatory clinical practice. A mailed survey instrument instructed panel members to rate 33 clinical anesthesia outcomes in two scales: how frequently they believe the outcomes occur and which outcomes they expect patients find important to avoid. A feedback process (Delphi process) was used to gain consensus rankings of the outcomes for each scale. Importance and frequency scores were then weighted equally to qualitatively rank order the outcomes. Of the 72 anesthesiologists, 56 (78%) completed the questionnaire. The five items with the highest combined score were (in order): incisional pain, nausea, vomiting, preoperative anxiety, and discomfort from IV insertion. To increase quality of care, reducing the incidence and severity of these outcomes should be prioritized. Implications: Expert anesthesiologists reached a consensus on which low-morbidity clinical outcomes are common and important to the patient. The outcomes identified may be reasonable choices to be monitored as part of ambulatory anesthesia clinical quality improvement efforts. (Anesth Analg 1999;88:1085-91)

Advancements in UHS research should be matched with new field development studies on natural hydrogen exploration and production.

IN 1955, we reported the successful transplantation of a kidney from a healthy twenty-three-year-old man to his monozygotic twin who was terminally ill with chronic renal failure. At that time we concluded: "Tissue transplantation including that of a functioning kidney appears to be a feasible procedure in identical twins but to date successful permanently functioning homografts appear to be limited to such individuals."1 It is the purpose of this paper to report the functional survival of a transplanted kidney whose donor was a fraternal, not an identical, twin.Since 1955 in this laboratory, kidneys have been successfully transplanted between 9 . . .

THE skin manifestations of scleroderma have long been recognized and adequately described. These features are usually identified readily, particularly in the later phases of the disease when the spectacular, hardened, bound-down, wrinkleless appearance of the skin is so characteristic as to supply a descriptive name for the illness. This term refers to the most apparent manifestation of scleroderma and may, in part, explain the lack of emphasis on involvement of other body systems in the course of the disease.As early as 1897, Hektoen1 indicated that the disease was not limited to the skin. In a single case, he reported . . .

Injections of triiodothyronine (T(3)) and thyroxine (T(4)) into chronically hypothyroid rats were used to evaluate the contribution of intracellular T(4) to T(3) conversion to nuclear T(3) in pituitary, liver, and kidney, and to correlate the occupancy of pituitary nuclear T(3) receptors with inhibition of thyroid-stimulating hormone (TSH) release. Injection of a combination of 70 ng T(3) and 400 ng T(4)/100 g body wt resulted in plasma T(3) concentrations of 45+/-7 ng/dl (mean+/-SD) and 3.0+/-0.4 mug/dl T(4) 3 h later. At that plasma T(3) level, the contribution of plasma T(3) to the nuclear receptor sites resulted in saturation of 34+/-7% for pituitary, 27+/-5% for liver, and 33+/-2% for kidney. In addition to the T(3) derived from plasma T(3), there was additional T(3) derived from intracellular monodeiodination of T(4) in all three tissues that resulted in total nuclear occupancy (as percent saturation) of 58+/-11% (pituitary), 36+/-8% (liver), and 41+/-11% (kidney), respectively. The percent contribution of T(3) derived from cellular T(4) added 41% of the total nuclear T(3) in the pituitary which was significantly higher than the contribution of this source in the liver (24%) or the kidney (19%). 3 h after intravenous injection of increasing doses of T(3), the plasma T(3) concentration correlated well with both the change in TSH and the nuclear occupancy, suggesting a linear relationship between the integrated nuclear occupancy by T(3) and TSH release rate. The contribution of intrapituitary T(4) to T(3) conversion to nuclear T(3) was accompanied by an appropriate decrease in TSH, supporting the biological relevance of nuclear T(3). Pretreatment of the animals with 6-n-propylthiouracil before T(4) injection decreased neither the nuclear T(3) derived from intrapituitary T(4) nor the subsequent decrease in TSH. These results indicate that intracellular monodeiodination of T(4) contributes substantially to the nuclear T(3) in the pituitary of the hypothyroid rat, and suggest a linear inverse relationship between nuclear receptor occupancy by T(3) in the pituitary and TSH release rate. The data further indicate that T(4) to T(3) monodeiodination is considerably more important as a source of nuclear T(3) in the pituitary than in the liver and kidney. This provides a mechanism whereby the TSH secretion could respond promptly to a decrease in thyroid secretion (predominantly T(4)) before a decrease in plasma T(3) would be expected to lead to significant metabolic hypothyroidism.

UNLABELLED: This two-armed study was designed to determine whether recovery after esophageal resection may be improved by introducing a new multimodal approach. For 8 mo after the new approach was introduced, all patients undergoing abdominothoracic esophageal resection were studied (Group 2; n = 42). For comparison, a retrospective analysis was also conducted using the data of all patients who had undergone this operation in the 8 mo before the introduction of the new regimen, when the traditional therapy was still in use (Group 1; n = 49). All patients received an epidural catheter at the level of T6-9 before the induction of general analgesia. Afterward, Group 1 patients were operated under general anesthesia. For postoperative pain relief, a mixture of bupivacaine 1.25 mg/mL and sufentanil 1 microg/mL was administered during 5 days without titration of the quality of analgesia. Patients in Group 2 received a preoperative bolus of 10-15 mL bupivacaine 2.5 mg/mL and 20-30 microg sufentanil. After sensory block up to T4 was confirmed, general anesthesia was introduced and intraoperatively combined with a continuous infusion of 5 mL/h of a solution containing bupivacaine 1.75 mg/mL and sufentanil 1 microg/mL. Postoperatively, the epidural infusion rate was adjusted to the need of the individual patients, who were able to administer themselves additional bolus doses of 2 mL with a lockout time of 20 min. Early tracheal extubation and forced mobilization were pursued to improve recovery. Demographic data of both groups were comparable. The pain relief of Group 2 patients was superior to that of patients in Group 1. The nitrogen balance of a subgroup of nine matched pairs of patients with comparable nutritional status was less negative in Group 2 patients on Postoperative Days 1 and 2. Patients in Group 2 were tracheally extubated earlier (mean 6.7 vs 25.1 h after admission to the intensive care unit [ICU]), mobilized earlier (mean 1.2 vs 2.0 days after surgery), discharged from the ICU earlier (mean 1.7 vs 4.0 days), and fulfilled criteria for discharge from the ICU (mean 1.8 vs 4.1 days) and from the intermediate care unit earlier (4.9 vs 6.4 days). We conclude that the multimodal approach may improve recovery and thus reduce costs after abdominothoracic esophageal resection. IMPLICATIONS: Analgesia and blockade of the perioperative stress response, combined with other aspects of postoperative therapy, may improve recovery after surgery. The intensive care unit stay after esophageal resection was reduced by a new regimen (thoracic epidural analgesia, early tracheal extubation, forced mobilization). This approach may influence the cost of major surgery.

SINCE Daniels's1 report (1949) on biopsy of scalene lymph nodes for the diagnosis of intrathoracic diseases, considerable interest has been manifested in the application of this technic. Others2 , 3 have substantiated its usefulness. For the past three years we have employed a procedure that supplements the advantages of scalene-node biopsy by the addition of an exploration of the superior mediastinum. This procedure has been performed in cases of pulmonary disease presenting diagnostic problems. It is also used in patients having suspected or proved carcinoma of the lung to determine operability. It is emphasized that, in none of the patients described here . . .

Rising Incidence of Digitalis Intoxication With the introduction of the purified glycosides it was expected that the incidence of intoxication would diminish. The patient on such maintenance therapy is assured a constant dosage because the uncontrollable variation in the potency of digitalis-leaf preparations is removed. The converse, however, has been true. Many recent reports indicate a mounting frequency of digitalis poisoning.46, 69 70 71 72 73 74 Digitalis is becoming a significant factor in cardiac death. The explanations given are that the glycosides are more toxic than leaf and that the premonitory symptoms are infrequent or absent. Both these contentions are without clinical substance. The pattern . . .

This two-armed study was designed to determine whether recovery after esophageal resection may be improved by introducing a new multimodal approach. For 8 mo after the new approach was introduced, all patients undergoing abdominothoracic esophageal resection were studied (Group 2; n = 42). For comparison, a retrospective analysis was also conducted using the data of all patients who had undergone this operation in the 8 mo before the introduction of the new regimen, when the traditional therapy was still in use (Group 1; n = 49). All patients received an epidural catheter at the level of T6-9 before the induction of general analgesia. Afterward, Group 1 patients were operated under general anesthesia. For postoperative pain relief, a mixture of bupivacaine 1.25 mg/mL and sufentanil 1 micro g/mL was administered during 5 days without titration of the quality of analgesia. Patients in Group 2 received a preoperative bolus of 10-15 mL bupivacaine 2.5 mg/mL and 20-30 micro g sufentanil. After sensory block up to T4 was confirmed, general anesthesia was introduced and intraoperatively combined with a continuous infusion of 5 mL/h of a solution containing bupivacaine 1.75 mg/mL and sufentanil 1 micro g/mL. Postoperatively, the epidural infusion rate was adjusted to the need of the individual patients, who were able to administer themselves additional bolus doses of 2 mL with a lockout time of 20 min. Early tracheal extubation and forced mobilization were pursued to improve recovery. Demographic data of both groups were comparable. The pain relief of Group 2 patients was superior to that of patients in Group 1. The nitrogen balance of a subgroup of nine matched pairs of patients with comparable nutritional status was less negative in Group 2 patients on Postoperative Days 1 and 2. Patients in Group 2 were tracheally extubated earlier (mean 6.7 vs 25.1 h after admission to the intensive care unit [ICU]), mobilized earlier (mean 1.2 vs 2.0 days after surgery), discharged from the ICU earlier (mean 1.7 vs 4.0 days), and fulfilled criteria for discharge from the ICU (mean 1.8 vs 4.1 days) and from the intermediate care unit earlier (4.9 vs 6.4 days). We conclude that the multimodal approach may improve recovery and thus reduce costs after abdominothoracic esophageal resection. Implications: Analgesia and blockade of the perioperative stress response, combined with other aspects of postoperative therapy, may improve recovery after surgery. The intensive care unit stay after esophageal resection was reduced by a new regimen (thoracic epidural analgesia, early tracheal extubation, forced mobilization). This approach may influence the cost of major surgery. (Anesth Analg 1998;86:228-34)

THE classification of the thrombocytopenias has been based on bone-marrow cytology,1 2 3 4 various technics to demonstrate circulating antiplatelet substances,5 6 7 8 9 10 11 12 response to therapeutic measures such as corticosteroids or splenectomy13 14 15 16 17 18 19 and measurement of the platelet life span, with or without the use of radioactive labeling procedures.20 21 22 23 24 25 This study is concerned with an attempt to classify the thrombocytopenias on the basis of life-span studies using the Cr51-labeling technic of Aas and Gardner.24 The report is a culmination of five years' experience involving the administration of some 300 Cr51-labeled transfusions in normal and thrombocytopenic subjects. The technic has been perfected sufficiently now to . . .

In this prospective study, we evaluated the etiology of operating room (OR) delays in an academic institution, examined the impact of multidisciplinary strategies to improve OR efficiency, and established OR timing benchmarks for use in future OR efficiency studies.OR times and delay etiologies were collected for 94 cases during the initial phase of the study. Timing data and delay etiologies were analyzed, and 2 wk of multidisciplinary OR efficiency awareness education was conducted for the nursing, surgical, and anesthesia staff. After the education period, timing data were collected from 1787 cases, and monthly reports listing individual case delays and timing data were sent to the Chiefs of Service. For the first case of the day, patient in room, anesthesia ready, surgical preparation start, and procedure start time were significantly earlier (P < 0.01) in the posteducation period compared with the preeducation period, and the procedure start time for the first case of the day occurred, on average, 22 min earlier than all other procedures. For all cases combined, turnover time decreased, on average, by 16 min. Unavailability of surgeons, anesthesiologists, and residents decreased significantly (P < 0.05) as causes of OR delays. Anesthesia induction times were consistently longer for the vascular and cardiothoracic services, whereas surgical preparation time was increased for the neurosurgical and orthopedic services (P < 0.05). Identification of the etiology of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OR efficiency. The time savings realized are probably most cost-effective when combined with more flexible OR staffing and improved OR scheduling. Implications: We achieved significant improvements in operating room efficiency by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary team work, and accurate data collection were all important contributors to improved efficiency. (Anesth Analg 1998;86:896-906)