Crittenton Hospital Medical Center

PURPOSE: To identify current evidence of factors influencing dementia-related caregiver burden (CB), describe patient and caregiver characteristics associated with CB, and describe evidence-based interventions designed to lessen the burden of caregiving. DATA SOURCES: Comprehensive literature review of Cumulative Index of Nursing and Allied Health Literature, MEDLINE, and Psych Info was performed for the years 1996-2006 of peer-reviewed journals using keywords CB and dementia. CONCLUSION: Dementia caregiving has been associated with negative effects on caregiver health and early nursing home placement for dementia patients. Many factors influence the impact of the caregiving experience such as gender, relationship to the patient, culture, and personal characteristics. Although various interventions have been developed with the goal of alleviating CB, evidence suggests that individually developed multicomponent interventions including a diversity of services will decrease burden, improve quality of life, and enable caregivers to provide at-home care for longer periods prior to institutionalization. IMPLICATIONS FOR PRACTICE: The ability to properly assess the dementia patient-caregiver dyad related to CB is critical to decreasing its negative physical and psychological health outcomes. Appropriately tailored interventions can improve the health and well-being of both caregiver and patient.

BACKGROUND: Different indexes that may enhance the early detection capability of prostate specific antigen (PSA) have been proposed. In addition to the indexes relating to the normal PSA level, there are data suggesting the usefulness of the PSA level relative to prostate gland volume (PSA density), age-referenced PSA level, and PSA change. Little research comparing the sensitivity and specificity of these measures in the same population has been reported. METHODS: All subjects were participants in the American Cancer Society National Prostate Cancer Detection Project. Specificity was studied in 2011 men without prostate cancer, and sensitivity was determined for 171 men with prostate cancer. RESULTS: Prostate specific antigen change showed the highest specificity (96.4%), and PSA density the lowest (85.3%). The most sensitive index was PSA density, which was positive for 74.7% of the 171 cases of known cancer. A PSA change of more than 0.75 ng/ml per year was the least sensitive index (54.8%). Sensitivity and specificity varied in a narrow range. Improved performance in specificity was achieved only with the loss of sensitivity. CONCLUSIONS: None of the alternative indexes commonly used in general early detection practice demonstrated particular advantage when compared with the normal PSA concentration, defined as no more than 4.0 ng/ml.

BACKGROUND: In hopes of limiting low-yield prostate biopsies, results of digital rectal examination (DRE), transrectal ultrasound (TRUS), prostate specific antigen (PSA) and age-related PSA values, gland-volume-adjusted PSA levels, and longitudinal PSA changes were analyzed to identify their cost-effectiveness as prognostic indicators in screening, biopsy, and follow-up of patients with prostate cancer. METHODS: Twenty-nine hundred men with complete data sets from an initial cohort of 2999 men with an annual follow-up for up to 5 years were examined. Intrapatient PSA and gland-volume variability, optimal PSA operating points (o.p.), and test performance scores were determined for each parameter. Decision analysis was then applied retrospectively to each parameter to determine the cancer detection yield, biopsy requirements, and costs for commonly used detection strategies. RESULTS: For the initial screening decision, the optimal PSA o.p. was 3.0 ng/ml but increased to 5.0 ng/ml in combination with DRE, whereas age-related PSA performed no better than did PSA. The mean intrapatient variability in TRUS gland volume (+5.5 cc) relative to mean volume (34 cc) was 16%, which was less than the 28% (0.64/2.3 ng/ml) relative variability for PSA. For biopsy decisions, using PSA density (PSAD) with a level of 0.12 ng/ml/cc there was no significant difference in accuracy compared with the systematic biopsy of all patients with elevated PSA or age-related PSA levels. Rather than perform systematic biopsy on all patients with PSA levels greater than 4 ng/ml, decision analysis showed that a 16-55% reduction in biopsies could be achieved with a respective cancer loss of 4-25% by limiting biopsy to patients with an increased PSAD level and/or abnormal results of DRE. Using age-related PSA criteria in combination with DRE reduced biopsies by 12% but resulted in minimal cost reductions. The greatest biopsy reduction relative to cancer yield and lowest cost per cancer detected occurred with PSAD-driven biopsy strategies. During follow-up, longitudinal changes in absolute PSA and PSAD levels were significantly better (P < 0.05) than the percentage change in PSA levels per year. CONCLUSIONS: Cost-effective prostate cancer detection with PSA as a parameter is better achieved if screening and biopsy decisions are not linked intimately. A tailored-biopsy approach for patients with disproportionately elevated PSA levels of suspicious DRE results in the greatest biopsy reduction by selecting lower risk groups for more conservative follow-up.

CONTEXT: Current perception dictates that glenohumeral internal rotation deficit (GIRD) is a chronic adaptation that leads to an increased risk of pathologic conditions in the dominant shoulder or elbow of overhead athletes. OBJECTIVE: To determine whether adaptations in glenohumeral range of motion in overhead athletes lead to injuries of the upper extremity, specifically in the shoulder or elbow. DATA SOURCES: An electronic database search was performed using Medline, Embase, and SportDiscus from 1950 to 2016. The following keywords were used: GIRD, glenohumeral internal rotation deficit, glenohumeral deficit, shoulder, sport, injury, shoulder joint, baseball, football, racquet sports, volleyball, javelin, cricket, athletic injuries, handball, lacrosse, water polo, hammer throw, and throwing injury. STUDY SELECTION: Seventeen studies met the inclusion criteria for this systematic review. Of those 17 studies, 10 included specific range of motion measurements required for inclusion in the meta-analysis. STUDY DESIGN: Systematic review and meta-analysis. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Data on demographics and methodology as well as shoulder range of motion in various planes were collected when possible. The primary outcome of interest was upper extremity injury, specifically shoulder or elbow injury. RESULTS: The systematic review included 2195 athletes (1889 males, 306 females) with a mean age of 20.8 years. Shoulders with GIRD favored an upper extremity injury, with a mean difference of 3.11° (95% CI, -0.13° to 6.36°; P = 0.06). Shoulder total range of motion suggested increased motion (mean difference, 2.97°) correlated with no injury ( P = 0.11), and less total motion (mean difference, 1.95°) favored injury ( P = 0.14). External rotational gain also favored injury, with a mean difference of 1.93° ( P = 0.07). CONCLUSION: The pooled results of this systematic review and meta-analysis did not reach statistical significance for any shoulder motion measurement and its correlation to shoulder or elbow injury. Results, though not reaching significance, favored injury in overhead athletes with GIRD, as well as rotational loss and external rotational gain.

Systems analysis of cerebrospinal fluid pulse wave forms (CSFPWs) was carried out in 19 cats during the inhalation of 5% CO2 + 95% O2, 10% CO2 + 90% O2, and 10% O2 + 90% N2. The results were compared to CSFPWs obtained during the inhalation of 100% O2 and during an intraventricular infusion to the same level of cerebrospinal fluid (CSF) pressure (CSFP) as produced by the test gas. The systemic arterial pressure pulse was utilized as the system input, and the CSFP pulse was used as the output. The harmonic amplitudes of the two pulses and the amplitude transfer function (XFRa) between the pulses were calculated. Hypercapnia and hypoxia produced an increase in CSF pulse pressure (ΔPesf), an increase in primarily the XFRa of the fundamental frequency, and, as a result, an increase in amplitude of the fundamental frequency of the CSFPW with rounding of the pulse wave. The changes are greater than those noted during an intraventricular infusion (IVI) to the same level of CSFP. In addition, the volume-pressure test was performed on the hypercapnic animals. The volume-pressure response was less during hypercapnia than during the IVI at the same mean level of CSFP. The results suggest that the increase in ΔPcsf is related to cerebral arteriolar vasodilation and not to a steepening of the volume-pressure curve and that rounding of the CSFPW is related to a decrease in cerebrovascular tone. (Neurosurgery 9:14-27, 1981)

A tailored approach to cryosurgery of prostate cancer is presented. The authors have performed 214 cryoprocedures to date with use of this protocol. The technique requires pretreatment with androgen ablation therapy, preoperative diagnosis and staging with ultrasound (US)-guided biopsies, and detailed knowledge of prostate and rectal anatomy. Five cryoprobes are placed in the prostate under US guidance in a configuration that depends on tumor location, sites of extracapsular extension, the size of the tumor, and gland geometry. Freezing starts anteriorly to keep from obstructing the ultrasound beam. Two freezes are performed at the known cancer site, and additional freezes are performed, if necessary, to include the remainder of the gland. Thermosensors enable monitoring of the cryosurgical ice ball and determination of the number of freezes. Cryosurgery is always performed by a urologist and a radiologist working together.

PURPOSE: To present early results of cryosurgical ablation of prostate cancer with an ultrasound-guided percutaneous technique. MATERIALS AND METHODS: Cryosurgery was performed in 210 patients; near complete 3- and 6-month follow-up data were available for 130. Androgen ablation therapy was used to decrease the size of the prostate gland for optimal freezing. Prostate-specific antigen (PSA) and prostatic biopsy studies were performed at 3, 6, and 12 months. RESULTS: Gland volume decreased from 29 cm3 +/- 14.1 to 20.4 cm3 +/- 8.4 (P < .0001) after androgen ablation. Rates of positive biopsy findings at 3, 6, and 12 months were 7.7%, 3.3%, and 2.3%, respectively. Serious complications were minimal and included no deaths, urethrorectal fistulas in five patients, and total incontinence in three. Mean PSA levels decreased from 12.6 +/- 16.1 preoperatively to 0.35 +/- 0.75 at 3 months, 0.54 +/- 1.1 at 6 months, and 0.43 +/- 0.78 at 12 months (persistent cancers excluded). CONCLUSION: These preliminary results demonstrate that cryosurgery can cause necrosis of prostate cancer. Long-term results and randomized trials are necessary to determine if this means longer disease-free intervals and increased patient survival compared with results of current therapeutic methods.

Acute superior vena caval obstruction is one of the true emergencies encountered in radiotherapy. If untreated, the obstruction not only renders the patient helpless, but heralds death by suffocation. The main aim of any therapeutic program is to obtain rapid relief of this syndrome and avoid its recurrence. The patient with this condition is inevitably hospitalized, and consultants of different disciplines are often sought in determining the ideal management. The clinical literature unfortunately is indecisive as to the best treatment, and conflicting points of view confuse rather than clarify the issue. In view of the moribund status of the patient, there is a tendency for radiation therapy schedules to be conservative, particularly since an untoward reaction, as “radiation edema,” may tip the balance and lead to sudden death. The results of our experimental studies (p. 406) indicated that progressive edema is due to uncontrolled tumor growth rather than to irradiation (“radiation edema”). Cautious slow-dose schedules were unsuccessful, whereas high rapid-dose schedules were not only well tolerated but led to rapid relief in the majority of the animals. In the light of these findings, we have modified our clinical approach to this problem. Our initial observations are offered in this report. Diagnostic Considerations 1. Initial Study: History and physical examination should permit a working diagnosis in the emergency room. The classical physical signs are edema of the face, arms, and chest, congestion of face and conjunctivae, prominent venous collateral circulations, with aggravation of findings on recumbency. A chest film, often demonstrating a mass in the superior mediastinum, completes the first phase of examination. Because of the emergency and progressive nature of this syndrome, radiation therapy is instituted immediately and the diagnostic work-up is begun simultaneously. This is a departure from our usual policy of not accepting patients without pathologic proof of malignancy. All too often a patient becomes moribund while the house staff awaits confirmation of tests and biopsies before referral for radiotherapy. 2. Routine Confirmatory Tests: (a) Infrared photography is simple and effective in detailing collateral circulation over the chest wall and is worth following as a parameter of response to treatment. (b) Venous pressures have received much attention, but simple pressure recordings with a spinal fluid manometer in an arm vein 10 cm. below the anterior chest wall are sufficient to establish elevations, which may vary from 150 to over 350 mm. saline. It may be of interest to test both arms to determine if the innominate vein is also obstructed. Femoral vein pressures have been recorded to determine if the pressure rises with inspiration, in which circumstance the obstruction is below the entrance of the azygos vein; otherwise, it is above.

There is a tendency to implicate irradiation as an etiologic feature in all complications subsequent to a course of therapy. Although this is justifiable in many instances, it is important to recognize those late complications which are due to tumor invasion and repair of an infiltrated tissue rather than the direct result of irradiation. In the first instance, it may be impossible to achieve a selective effect of irradiation, since the neoplasm has already in part destroyed the normal structure. In the second instance, the tolerance of the normal tissue included in the therapy beam may inadvertently have been exceeded and late radiation injury may result. The importance of distinguishing the cause of the late change lies in the fact that only thus are protective measures and considerations possible. An excellent illustration of this problem is the development of scoliosis in the long-term survivor who has received radiotherapy for certain childhood axial tumors, such as Wilms's tumor and neuroblastoma. The question has been raised whether the degree of scoliosis is too debilitating to warrant the routine use of irradiation in conjunction with surgery. To answer this, one must have an understanding of the production of the scoliosis, the disturbance in form and function, and the possible deterioration of the curvature during the mid-growth and adolescent growth spurts, as described in longitudinal studies in infantile idiopathic scoliosis (Fig. 1) (4). In addition, the degree of deformity must be weighed against the risk of recurrence of the tumor with loss of life if irradiation is denied. Case Material The three common childhood neoplasms in which the vertebral column is exposed to irradiation are: Wilms's tumor, neuroblastoma, and medulloblastoma. A. Wilms's Tumor: Owings and Radakovich (12) recently reported the experience at Strong Memorial Hospital (Rochester, N. Y.) in 18 cases, with a survival of 55 per cent based on doubling time-not the more usual five-year survival figure. Seven of the survivors in this group have been closely followed with special studies. All of these patients were eighteen months of age or younger at the time of the initial treatment (Tables I A, IB, 1C). Ortho-voltage irradiation (200-280 kv) was employed with an h.v.l. of 1.0 mm. Cu. In the cases treated before 1950, lateral fields, in addition to opposed anterior and posterior fields, were common practice. Since that time, opposed fields overlapping the midline have been the general rule, based on the suggestion by Neuhauser et al. (10). The total tumor dose and dose to the vertebrae are similar, ranging from 3,000 to 4,000 r in three to four weeks. The interval of follow-up studies after treatment ranged from four to twenty-three years. B. Neuroblastoma: As of 1960, 30 cases of neuroblastoma have been treated with 8 survivors for a 26 per cent figure, based on doubling time.

Two hundred twenty-five patients with endometrial carcinoma are reviewed representing 28.7% of gynecologic malignancies and 1% of gynecologic admission; 77% had Stage I disease and 55% were over 60 years old; 14.5% were premenopausal, and abnormal or postmenopausal bleeding prompted medical consultation in 78%. Cytologic smears were positive in only 25% of the patients. Estrogen therapy was not related to the development of the tumor and six patients had had previous oophorectomy; 7.5% had received previous pelvic irradiation. Primary malignancies of other organs were noted in 8%. Treatment was surgical with or without radiation therapy. The overall corrected 5-year survival was 69%. Isolated vaginal recurrences were rare. Survival was not related to suturing the cervix, parity, type of chief complaint, duration of symptoms or age at menopause. Survival was affected by age at diagnosis, stage of disease, depth of myometrial invasion and cellular differentiation of the tumor.

Job satisfaction among hospital pharmacists employed by a national hospital pharmacy management company was measured by using a mail questionnaire. A previously validated survey that measured pharmacists' job satisfaction was adapted for use in this study. Additional questions determined the pharmacist's clinical pharmacy training and participation in clinical pharmacy services. Questionnaires were mailed to all full-time hospital pharmacists employed by the pharmacy management company. Of the 606 mailed, deliverable questionnaires, 354 usable responses were returned, for a response rate of 58.4%. The respondent hospital pharmacists' level of job satisfaction showed a positive association with clinical pharmacy involvement. Of the nine items in the questionnaire that measured the pharmacists' involvement in clinical pharmacy services, seven items showed a positive relationship between involvement in that clinical activity and job satisfaction. Mean job satisfaction increased as the percentage of time spent performing clinical pharmacy activities increased. Job satisfaction decreased as time spent performing distributive functions increased. The percentage of time hospital pharmacists were engaged in clinical activities was significantly associated with job satisfaction.

Systemic arterial (Ps), cerebrospinal fluid (Pcsf), and sagittal sinus (Pss) pressures were measured in 39 dogs divided into eight groups in which Ps was altered pharmacologically or by bleeding. The pharmaceuticals used were norepinephrine (N-EP), dopamine (DOP), sodium nitroprusside (SNP), and nitroglycerin (NTG). SNP and NTG were examined with and without methohexital (MHX) anesthesia and during chronic infusion and bolus injection. The various pressures were subjected to systems analysis in accordance with a previously published model of myogenic autoregulation. Myogenic autoregulation seemed to be impaired only during infusions of N-EP, DOP, and SNP without MHX and during hypovolemic hypotension. The various observed changes in Pcsf are explained by using a hydraulic model of the cerebrovascular bed in which Pcsf represents the pressure drop across the outflow resistance of the bridging veins and lateral lacunae and myogenic autoregulation at the arteries and arterioles represents the major inflow resistance. Impaired myogenic autoregulation is associated with a rise in Pcsf. In addition, variation in pulse pressure is demonstrated to be related to the arterial pulse pressure and the degree of arterial and arteriolar vasodilation.

The flexor hallucis longus (FHL) tendon is susceptible to injury along its entire course from the posterior aspect of the ankle to its insertion into the base of the distal phalanx of the great toe. Various lacerations, ruptures, longitudinal splits, and stenosing tenosynovitis have been noted. This report documents three cases of longitudinal split of the FHL at the knot of Henry. The diagnosis of this entity is based solely on history and physical examination. Patients with this problem have experienced either an acute or chronic repetitive hyperextension of the hallux metatarsophalangeal joint. They complain of pain with prolonged walking and running and have tenderness with palpation of the knot of Henry (the anatomical crossover between the FHL and the flexor digitorum longus) about one thumb-breadth lateral to the tuberosity of the navicular. Noninvasive imaging studies, including ultrasound and magnetic resonance imaging, are not helpful in establishing this diagnosis. Surgical treatment includes release of the knot of Henry, debridement and repair of the longitudinal split in the FHL, and excision of the interconnecting tendon between the FHL and the flexor digitorum longus. All three patients presented in this report have obtained long-term satisfactory relief of their symptoms with surgical treatment.

A hydraulic model of the cerebrovascular bed is presented. The model consists of a Starling resistor in series with an upstream resistance. Volume-pressure tests were performed on the model by injecting fluid into the rigid shell of the Starling resistor. An exponential pressure response to the increase in fluid volume was observed, which supports the hypothesis that the origin of the in vivo exponential pressure response to a transient increase in cerebrospinal fluid (CSF) volume can be attributed to compression of the cerebral vessels, most probably the veins. Mathematical expressions for the dependence of pressure on volume change were derived from the model and applied to in vivo volume-pressure data. The correlation between the model and in vivo experiments suggests that the CSF pressure is coupled to cerebral venous pressure and that the volume-pressure test is an indirect measure of the cerebral venous volume and is not a measure of intracranial elastance. The physical basis for the volume-pressure test is clarified, and expressions are derived to improve the utility of the test.

ARECENT SURVEY showed that the incidence of neoplasia in a group of children who had been treated with x-rays in infancy for enlargement of the thymus gland was higher than that in either their untreated siblings or in children of the same age in the population at large (1, 2). In particular, the number of cases of leukemia and thyroid cancer in the irradiated children far exceeded the number expected in a normal group of comparable size and age distribution. Although the findings are consistent with reports of an increased incidence of malignant disease, especially leukemia, in other human populations exposed to ionizing radiation (3-7), certain features of this study are sufficiently unusual to deserve further investigation. First, the doses of radiation were smaller than those formerly believed to be carcinogenic. Second, whereas the thyroid neoplasia and other cancers were found only in children exposed to comparatively high doses of x-rays (more than 200 r), leukemia sometimes occurred in children receiving less than 200 r. Third, because almost all children were selected for treatment on the basis of a diagnosis of thymic enlargement, it is impossible to differentiate the role of this factor from that of irradiation in the development of leukemia and other malignant diseases. The purpose of the present study is to obtain further information concerning the incidence of malignant disease in children treated with x-rays. The irradiated children in the series to be reported are of particular interest in that most of them had thymus glands of normal size. In this 3 per cent of the entire group. Although these children were usually asymptomatic, 80 per cent were treated with 200 to 450 r to the anterior mediastinum. In the course of the study, it was noted that signs and symptoms attributed to thymic enlargement never occurred in treated children who had enlarged thymus glands at birth. Since upper respiratory infections also seemed to be less prevalent in the treated children, it was decided to give all children born between June 1944 and May 1946 small doses of x-rays to the manubrial region. Ninety-five per cent of the 1,340 children so treated were given 150 r and the remainder received 75 to 100 r (Table I). A survey of these children, conducted by mail in 1948, reaching about half the total number, showed no apparent increase in either morbidity or mortality. The radiation factors used in treatment were: 140 kvp; filtration, 3 mm. Al; skin-target distance, 8 to 9 in.; port size, 4X4 cm.; port position, over the manubrium. Increments of 75-150 r were usually given at one- to two-day intervals. All children were treated within seven days after birth; children with illnesses not usually ascribed to thymic enlargement were excluded from the series. The method of interviewing parents of the treated children was the same as that used by Simpson and Hempelmann (2) except that the telephone was used wherever possible.

Nurses continue to sustain musculoskeletal injuries even with increased emphasis on safe patient handling and mobility (SPHM) and organizational cultures of safety to protect health care workers. Analysis of data from 2011-2014 registered nurse graduates explored hospital safety culture, SPHM education/training, and incidence of new-nurse musculoskeletal injury. Results indicated hospitals provided some type of SPHM education and training, but 46% of study participants were not informed or aware of national SPHM standards or guidelines. Merely 13.9% of participants stated a written "no manual lifting policy" had been implemented; only 32.9% indicated staffing was adequate for SPHM tasks; and only 39.4% stated the hospital had all of the equipment needed to perform SPHM safely. Thirty-nine percent of participants had already sustained a musculoskeletal injury with an additional 35% sustaining but not reporting an injury. More actions are needed to ensure a decrease in musculoskeletal injuries for new nurses.

Background: As novel therapeutic interventions are being developed and tested in the amyotrophic lateral sclerosis (ALS) population, there is a need to better understand the symptoms and issues that have the greatest impact on the lives of individuals with ALS. We aimed to determine the frequency and relative importance of symptoms experienced by adults in a national ALS sample and to identify factors that are associated with the greatest disease burden in this population. Methods: We conducted 15 qualitative interviews of individuals with varied ALS phenotypes and analyzed 732 quotes regarding the symptomatic disease burden of ALS between August 2018 and March 2019. We subsequently conducted a national, cross-sectional study of 497 participants with ALS and ALS variants through the Centers for Disease Control and Prevention's (CDC) National ALS Registry between July 2019 and December 2019. Participants reported on the prevalence and relative importance of 189 symptomatic questions representing 17 symptomatic themes that were previously identified through qualitative interviews. Analysis was performed to determine how age, sex, education, employment, time since onset of symptoms, location of symptom onset, feeding tube status, breathing status and speech status relate to symptom and symptomatic theme prevalence. Findings: Symptomatic themes with the highest prevalence in our sample were an inability to do activities (93.8%), fatigue (92.6%), problems with hands or fingers (87.7%), limitations with mobility or walking (86.7%), and a decreased performance in social situations (85.7%). Participants identified inability to do activities and limitations with mobility or walking as having the greatest overall effect on their lives. Interpretation: Individuals with ALS experience a variety of symptoms that affect their lives. The prevalence and importance of these symptoms differ among the ALS population. The most prevalent and important symptoms offer potential targets for improvements in future therapeutic interventions. Funding: Research funding was provided by ALS Association.

PURPOSE: The purpose of this study was to identify Class III malocclusions within a pediatric practice that lend themselves to a more favorable treatment outcome at an earlier age (before 10 years) rather than initiating treatment at later adolescent growth stages and also to identify the degree of difficulty of the treatment of the Class III malocclusion. METHODS: Review of the current dental literature pertaining to the different clinical types of Class III malocclusions and their respective treatment protocols was performed. Various classification systems were studied and compared. A new treatment classification system of Class III malocclusions utilizing three dentoalveolar and three skeletal components combined with cephalometric information derived from commonly used cephalometric analyses was developed. RESULTS: Class III treatment types were conclusively identified: 1.) Early orthodontics only, 2.) Early combined orthodontics and orthopedics, 3.) Combined orthodontics and orthognathic surgery. CONCLUSIONS: The conclusion supports Edward H. Angle's finding: "In studying a case of malocclusion, give no thought to the methods of treatment or appliances until the case shall have been classified and all peculiarities and variations from the normal type, occlusion and facial lines have been thoroughly comprehended. Then the requirements and proper plan of treatment becomes apparent".

ABSTRACT Objectives: To assess whether outcome and first–monitored rhythm for patients who sustain a witnessed, nonmonitored, out–of–hospital cardiac arrest are associated with on–scene CPR provider group. Methods: A retrospective, cohort analysis was conducted in a suburban, heterogeneous EMS system. Patients studied were ± 19 years of age, had had an arrest of presumed cardiac origin between July 1989 and January 1993, had gone into cardiac arrest prior to ALS arrival, and had received CPR on collapse. First–monitored rhythms and survival rates were compared for two patient groups who on collapse either: 1) had received CPR by nonprofessional bystanders (BCPR) or 2) had received CPR by on–scene EMS system first responders (FRCPR). Results: Of 217 cardiac arrest victims, 153 (71%) had received BCPR and 64 (29%) had received FRCPR. The BCPR patients were slightly younger (62. 4 vs 68. 4 years, p = 0. 01) and had slightly shorter ALS response intervals (6. 4 vs 7. 7 minutes, p = 0. 02). There was no difference in BLS response time intervals or automatic external defibrillator (AED) use rates. The percentage of patients with a first–monitored rhythm of pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) and the percentage of patients grouped by CPR provider who survived to hospital admission or to hospital discharge were: Controlling for age, the odds ratio for VT/VF with BCPR was 5. 45 (95% CI 2. 8, 10. 3). Conclusion: Patients who receive BCPR more often have a first–monitored rhythm of VT/VF than do FRCPR patients, despite both CPR–provider groups' initiating CPR essentially immediately after patient collapse. Hence, BCPR and FRCPR groups have different first–monitored arrest rhythms, which may affect survival rate. These patient populations should not be considered to be homogeneous groups in CPR research.

OBJECTIVE: This article reviews the dental literature pertaining to dental root resorption and proposes a classification system designed to facilitate communication of precise information for each type. DESIGN: A systematic review of the literature using PubMed was performed and supplemented with manual reviews of bibliographies from textbooks. RESULTS: A classification system was developed using etiology and morphologic characteristics of dental root resorption. Various types of dental root resorption were identified. The different forms were organized into dental and non-dental origins and further divided between internal and external resorption along etiologic and morphologic characteristics. CONCLUSIONS: The classification of dental root resorption proposed may assist dentists in the formulation of a differential diagnosis and management of root resorption.