St. Clare Hospital in Lakewood

BACKGROUND: Thrombolytic therapy with intravenous alteplase within 4.5 hours of ischemic stroke onset increases the overall likelihood of an excellent outcome (no, or nondisabling, symptoms). Any improvement in functional outcome distribution has value, and herein we provide an assessment of the effect of alteplase on the distribution of the functional level by treatment delay, age, and stroke severity. METHODS: Prespecified pooled analysis of 6756 patients from 9 randomized trials comparing alteplase versus placebo/open control. Ordinal logistic regression models assessed treatment differences after adjustment for treatment delay, age, stroke severity, and relevant interaction term(s). RESULTS: Treatment with alteplase was beneficial for a delay in treatment extending to 4.5 hours after stroke onset, with a greater benefit with earlier treatment. Neither age nor stroke severity significantly influenced the slope of the relationship between benefit and time to treatment initiation. For the observed case mix of patients treated within 4.5 hours of stroke onset (mean 3 hours and 20 minutes), the net absolute benefit from alteplase (ie, the difference between those who would do better if given alteplase and those who would do worse) was 55 patients per 1000 treated (95% confidence interval, 13-91; P=0.004). CONCLUSIONS: Treatment with intravenous alteplase initiated within 4.5 hours of stroke onset increases the chance of achieving an improved level of function for all patients across the age spectrum, including the over 80s and across all severities of stroke studied (top versus bottom fifth means: 22 versus 4); the earlier that treatment is initiated, the greater the benefit.

OBJECTIVE: The aim of this study was to determine the efficacy and safety of dialectical behavior therapy plus olanzapine compared with dialectical behavior therapy plus placebo in patients with borderline personality disorder. METHOD: Sixty patients with borderline personality disorder were included in a 12-week, double-blind, placebo-controlled study. All patients received dialectical behavior therapy and were randomly assigned to receive either olanzapine or placebo following a 1-month baseline period. RESULTS: Seventy percent of the patients completed the 4-month trial. Combined treatment showed an overall improvement in most symptoms studied in both groups. Olanzapine was associated with a statistically significant improvement over placebo in depression, anxiety, and impulsivity/aggressive behavior. The mean dose of olanzapine was 8.83 mg/day. CONCLUSIONS: A combined psychotherapeutic plus pharmacological approach appears to lower dropout rates and constitutes an effective treatment for borderline personality disorder.

Of 146 consecutive closed and Grade I open tibia shaft fractures treated with cast immobilization, external fixation, or intramedullary rod fixation during a 4-year period, 44 of 76 (58%) tibias of patients who smoked and 59 of 70 (84%) tibias of patients who did not smoke had followup to union or followup beyond 1 year. The demographics, fracture patterns, and treatments of the two groups were similar. Two of the 44 patients who smoked had nonunions at the 1-year followup, whereas none of the patients who did not smoke had nonunions. Of the 103 tibias with complete followup to union, the median time to clinical healing for patients who smoked (269 days) was significantly greater than that of patients who did not smoke (136 days). Likewise, there was a 69% delay in radiographic union in the group that smoked as interpreted by a radiologist blinded to the two groups. Statistical differences in clinical and radiographic healing rates between those who smoked and those who did not smoke were observed for patients receiving intramedullary fixation or external fixation. Statistical differences were not seen in the clinical and radiographic healing of tibias treated with cast immobilization, although tibias of patients who smoked took 62% longer to heal. The current data suggest that tibias of patients who smoke who require treatment with intramedullary nailing or external fixation require more time to heal than do those of patients who do not smoke.

An esophageal perforation after anterior cervical surgery is an uncommon but well recognized complication. During the past 25 years, 44 patients have presented to Craig Hospital (Rocky Mountain Regional Spinal Injury Center) with esophageal perforations; this is the largest series reported to date. There were 34 patients whose esophageal injury was related to the operations performed for cervical fractures, of which 28 patients had plate and screw fixation. The most frequently occurring clinical symptoms were that of neck and throat pain, odynophagia, dysphagia, hoarseness, and aspiration. The most common clinical findings were an elevated temperature, localized induration and neck tenderness, crepitus or subcutaneous air in the neck and anterior chest wall, an unexplained tachycardia, and blood in the nasogastric tube. Imaging studies indicated an esophageal injury in only 32 (72.7%) patients. Twenty-two patients experienced cervical osteomyelitis or an abscess of the neck. Nonoperative treatment is fraught with a high mortality, and 42 patients required surgical repair of their esophageal injury. The length of hospital stay averaged 253 days. Successful management of esophageal perforations depends on the physicians' awareness of the causes, prompt recognition of the symptoms and clinical findings, and immediate institution of treatment.

Background. Investigations of outbreaks of multidrug-resistant tuberculosis have found low rates of treatment response and very high mortality, and they have mainly involved patients with advanced human immunodeficiency virus (HIV) infection. For patients without HIV infection, one study reported an overall rate of response to treatment of 56 percent, and the mortality from tuberculosis was 22 percent. We investigated treatment response and mortality rates in 26 HIV-negative patients in New York with multidrug-resistant tuberculosis.

Widespread disposal of landfill leachate to municipal sewer in the US calls for improved understanding of the relative organic-chemical contributions to the WWTP waste stream and associated surface-water discharge to receptors in the environment.

BACKGROUND: Breakthrough pain is a transient increase in pain intensity over background pain. It is a common and distinct component of cancer pain that can have a negative impact for both the patient and carers' quality of life. Breakthrough pain is usually related to background pain and is typically of rapid onset, severe in intensity, and generally self-limiting with an average duration of 30 minutes. At present the current approach to managing breakthrough pain is using supplemental analgesia (also known as rescue medication) at a dose proportional to the total around-the-clock (ATC) opioid dose. OBJECTIVES: This review explores and assesses the evidence for the use of opioids in the management of breakthrough pain in patients with cancer. SEARCH STRATEGY: MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CancerLit (1993 to 2005), CINAHL (1982 to 2005) and Cochrane databases were searched. Handsearching of medical journals and reference from key textbooks was undertaken and drug companies contacted for unpublished data. There was no language restriction. Date of most recent search: January 2005. SELECTION CRITERIA: Randomized controlled trials of opioids used as rescue medication against active or placebo comparator in patients with cancer pain were included. Outcome measures sought were reduction in pain intensity measured by an appropriate scale, adverse effects, attrition, patient satisfaction and quality of life. There were no language restrictions. DATA COLLECTION AND ANALYSIS: Eligible studies were selected and examined independently by the two reviewers. Full text was retrieved if any uncertainty about eligibility remained. Non-English texts were screened. Quality assessment and data extraction were conducted using standardised data forms. Drug and placebo dose, titration, route and formulation were compared and detail of all outcome measures (if available) recorded. MAIN RESULTS: Four studies (393 participants) met the inclusion criteria, all were concerned with the use of oral transmucosal fentanyl citrate (OTFC) in the management of breakthrough pain. Two studies examined the titration of OTFC, one study compared OTFC to normal release morphine and one study compared OTFC to placebo.OTFC was shown to be an effective treatment for breakthrough pain. When compared to placebo and morphine, participants gave lower pain intensity scores and higher pain relief scores for OTFC at all time points. Global assessment scores also favoured OTFC. AUTHORS' CONCLUSIONS: There is evidence that OTFC is an effective treatment in the management of breakthrough pain. The randomised trial literature for the management of breakthrough pain is small and no trials were found for other opioids. Given the importance of this subject, more trials need to be undertaken.

BACKGROUND: Several commercial products are currently available for clinical application as bone graft substitutes. These products can be broadly classified into two categories: synthetic and natural. Bovine bone is a popular source for several of the natural bone substitutes. The availability of bovine derived xenogenic bone substitutes has made it possible to avoid traumatic and expensive secondary surgery to obtain autogenous bone once thought essential for effective bone replacement. While autogenous bone still remains the undisputed "gold standard" in bone grafting, the realization that bone requirement in several clinical applications is as effectively met by xenografts has lead to their widespread use. But the convenience of using xenografts is tempered by the possibility of disease transmission from cattle to humans. The recent incidents of bovine spongiform encephalopathies (BSE) in humans have underscored this likelihood. In this paper, we report a risk analysis performed to assess the possibility of such disease transmission from a commercially available bone graft substitute (BGS) that is popularly used in clinical dentistry. METHODS: An extensive review of current literature on the status of risk assessment of BSE transmission was conducted, and two risk assessment models were identified as applicable to the present study. Risk assessment models developed by the German Federal Ministry of Health and by the Pharmaceutical Research and Manufacturers Association of America were applied to BGS. RESULTS: Results from the analyses conducted using both models showed that the risk of disease (BSE) transmission from BGS was negligible and could be attributed to the stringent protocols followed in sourcing and processing of the raw bovine bone used in the commercial product. CONCLUSIONS: Based on the risk analysis, it is evident that the risk of BSE infection from BGS is several orders of magnitude less than that posed by the risk of death related to, lightning, tornadoes, or similar remote events. However, this low risk can only be maintained as long as an effective and active risk management program is implemented in operations that involve processing xenogenic tissue for human use.

The first case of a villous lesion of the colon removed by laparoscopic-guided surgery is reported. Injection of methylene blue into the lesion facilitated its access and exposure via the laparoscope. A very small skin incision allowed delivery onto the abdominal wall for resection and anastomoses.

In theory the eighteenth-century criminal law was a rigid, fixed and bloody penal code laying down the penalty of death for a broad range of property crimes. In practice it was a flexible and highly selective system. The legal process had no effective police force to provide an organizational core and it was therefore a private and negotiable process involving personal confrontation rather than bureaucratic procedure. All the major published studies of the administration of the criminal law in this period have stressed its highly discretionary nature. They have also shown that the law was important as ideology. The widely held notions that every freeborn Englishman was protected by the rule of law and that all were equal before the law both constrained authority and legitimized and strengthened it.

Many writers have commented on what they conceive to be an apparent antipathy of Malays for money, commercial relations and even labour. This conception which has its roots in the colonial era has led to a long debate centering on the nature or causes of a supposed 'economic retardation' among Malays and refutations of this charge. While I do not wish to enter into the detail of this debate here, it is significant that much of it has centred around a perceived contrast between the Malay values and those of Chinese traders and middlemen with whom the former are in intense contact. (See, for example, Mahathir 1970, Freedman 1960.) The question of why it is that Chinese traders have managed to be highly successful in precisely the spheres which the Malays are conceived as having difficulty in penetrating has thus pushed the discussion towards a consideration of ethnic differences between Malays and Chinese.

This article argues that the development of teaching as a profession for women in England has often been written using an anachronistic and gendered conception of the term ‘profession’. A closer examination of the work of middle-class schoolmistresses in the first part of the nineteenth century reveals that the image of the amateurish governess was in part a fiction, which concealed the commitment and expertise of many women teachers. The mid-century reformers drew on this earlier tradition of feminine pedagogy and did not simply adopt the standards of boys’ education and their male peers. On the contrary, they contributed to the ongoing process by which teachers of both sexes sought to claim the status and authority of the ‘learned professions’. However, by the 1870s, the pressure to conform to the dominant model in boys’ education meant that this independent strand in education had largely been eclipsed.

MADDEN, JOHN L. M.D.; KANDALAFT, SOUHEIL M.D.; BOURQUE, ROCHE-ANDRE M.D. Author Information

A major issue in proof of concept studies and early clinical trials of novel therapeutic agents is that the active drugs can often have a relatively small additional effect compared with placebo. This is especially the case in psychiatry when we usually have no direct method of measuring the pathology underlying the disorder being studied but, rather, have to rely on the subjective assessment of psychiatric symptoms. The use of the electroencephalogram (EEG) offers two potential major means of addressing this problem. First it is able to provide direct data relating to neural activity that may be abnormal in certain disorders. As such there are opportunities for utilizing the EEG in a variety of ways as an objective outcome measure. Second there is growing evidence that in certain circumstances the EEG can be used to predict which patients are likely to respond to treatment, thus potentially increasing the power of studies by decreasing non-response rates and increasing mean changes in outcome measure. Both of these uses of the EEG are illustrated in reference to the study of mood disorders and in particular depression and its treatment with antidepressants.

The Urad and Henderson stockwork molybdenite orebodies at Red Mountain, Clear Creek County, Colorado, are related to a rhyolitic subvolcanic center of Oligocene age referred to as the Red Mountain Complex. The two orebodies are well separated in space and are specifically related to different intrusive rocks of the complex. The Urad orebody was deposited first and at shallow depth. The Henderson formed deeper within the complex and is much the larger of the two. The Oligocene rocks intrude a batholith of Precambrian Silver Plume Granite near the western edge of the Colorado mineral belt and are within a mile of the north-north-east-trending Berthoud Pass fault. This fault is the major structural element of the area and has been identified by Tweto and Sims (1963) as a Precambrian fault reactivated in Tertiary time.The part of the Red Mountain Complex crops out over an irregular area about 2,400 feet long and 800 to 1,200 feet wide. Dikes related to the complex surround it and are present as much as 1 mile from the igneous center. Known rocks of the complex represent more than 15 stages and substages of igneous activity. All rocks are chemically and mineralogically similar and consist of essential quartz, K-feldspar, albite, and minor biotite. Clastic and fragmental textures are common features of the rocks exposed at surface, porphyries predominate at intermediate depths, and a granitic rock is present at the greatest depths reached in exploratory drilling. The major rock types of the complex exposed at the surface are columns that either grade into, or are cut off by, an underlying composite stock, the apex of which lies about 2,500 feet below the peak of Red Mountain. The stock, although much larger than the shallower columns, appears to be a steep-walled intrusive to explored depths. The space now occupied by the stock is thought to have been a magma chamber throughout the time the rocks exposed at the surface were emplaced; the magma chamber was their immediate source. The sequence of rocks exposed at surface is as follows: Tungsten Slide and East Knob units (relative ages unknown), Square quartz porphyry, rhyolite porphyry radial dikes, and the Red Mountain porphyry unit. Each unit consists of several members. Rock types which constitute the buried stock are, from oldest to youngest, the Urad porphyry, the Primos porphyry, and the Henderson granite. The Square quartz porphyry is the youngest known igneous rock predating the Urad orebody and is considered to have been the source intrusive for the Urad mineralized zone of which the Urad orebody is a part. The Urad mineralized zone is envisioned as a cylindrical body of mineralized rock. The orebody was localized within part of this zone by a series of moderately dipping arcuate fractures referred to as the main fissure system. The fissures are interpreted as cone sheet fractures caused by the emplacement of the Square quartz porphyry. About half of the orebody was contained in rocks of the Red Mountain Complex; the rest was in the Silver Plume Granite. The Urad mine, now worked out, produced about 14 million tons of ore. Intrusion of the Red Mountain porphyry, the principal rock of the complex at surface, destroyed much of the Square quartz porphyry, a large part of the Urad mineralized zone, and part of the Urad orebody. The magma from which the Red Mountain porphyry crystallized probably vented; a potential orebody may have been lost to the atmosphere during this event.The Henderson orebody is an umbrella-shaped stockwork entirely within the intrusive complex and contains more than 300 million tons of ore. The difference in the shape of the Urad mineralized zone and the Henderson orebody is thought to reflect the difference in the depth of formation. The Henderson deposit is genetically related to one or more phases of the Primos porphyry and to the Henderson granite and is a compound orebody. A master reservoir is postulated at depth beneath Red Mountain to explain the repetition of igneous and hydrothermal events and to provide the quantity of metal necessary for the formation of the ores. We believe that this magma derived its ore metal from crustal rocks anomalously rich in molybdenum during its rise toward the surface. The deposits at Red Mountain are remarkably similar in many respects to those at Climax, Colorado, but there are some notable differences. The abundance of Precambrian metamorphic rocks, possibly available for reaction with, or incorporation by, Oligocene magma at Climax, and the scarcity of these rocks at Red Mountain may account for the large amount of tungsten in the Climax deposit compared to that in the Urad and Henderson orebodies.

The application of biochar technology for soil amendment is largely based on evidence about soil fertility and crop productivity gains made in the Amazonian Black Earth (terra preta). However, the uncertainty of production gains at realistic application rates of biochars and lack of knowledge about other benefits and other concerns may have resulted in poor uptake of biochar technology in Australia so far. In this review, we identify important opportunities as well as challenges in the adoption of biochar technology for broadacre farming and other sectors in Australia. The paper highlights that for biochar technology to be cost-effective and successful, we need to look beyond carbon sequestration and explore other opportunities to value-add to biochar. Therefore, some emerging and novel applications of biochar are identified. We also suggest some priority research areas that need immediate attention in order to realise the full potential of biochar technology in agriculture and other sectors in Australia.

Although the first power source for an implantable pacemaker was a rechargeable nickel-cadmium battery, it was rapidly replaced by an unreliable short-life zinc-mercury cell. This sustained the small pacemaker industry until the early 1970s, when the lithium-iodine cell became the dominant power source for low voltage, microampere current, single- and dual-chamber pacemakers. By the early 2000s, a number of significant advances were occurring with pacemaker technology which necessitated that the power source should now provide milliampere current for data logging, telemetric communication, and programming, as well as powering more complicated pacing devices such as biventricular pacemakers, treatment or prevention of atrial tachyarrhythmias, and the integration of innovative physiologic sensors. Because the current delivery of the lithium-iodine battery was inadequate for these functions, other lithium anode chemistries that can provide medium power were introduced. These include lithium-carbon monofluoride, lithium-manganese dioxide, and lithium-silver vanadium oxide/carbon mono-fluoride hybrids. In the early 1980s, the first implantable defibrillators for high voltage therapy used a lithium-vanadium pentoxide battery. With the introduction of the implantable cardioverter defibrillator, the reliable lithium-silver vanadium oxide became the power source. More recently, because of the demands of biventricular pacing, data logging, and telemetry, lithium-manganese dioxide and the hybrid lithium-silver vanadium oxide/carbon mono-fluoride laminate have also been used. Today all cardiac implantable electronic devices are powered by lithium anode batteries.

Until recently the Malayalam-speaking region of southern India—once known as the Malabar coast and now the state of Kerala—was portrayed as a bastion of orthodox high Hinduism. The region's caste system was famous for its intricacy and supposed rigidity; its temples were rich, numerous and heavily patronized by Malayali rulers; and there was a general sense of the area as a picturesque backwater hidden away behind the western Ghats, untouched by the turbulent forces at work elsewhere in south Indian society. According to this view Kerala was a static society, ‘pure’ in culture and religious tradition, and ripe for drastic modernization once British suzerainty was established during the nineteenth century.

Cardiac Rehab Center St. Troynu Clare's Hospital Department of Physical Therapy Russell Sage College Sckenectady, NY

OBJECTIVES: This study examined the stresses associated with hospice volunteering, ways of coping and perception of available support. METHODS: Two focus groups were conducted comprising 17 volunteers. The data obtained were transcribed and analysed using thematic analysis. RESULTS: Reported stressors included losing patients and dealing with disfigurement. However, informants generally reported the work as satisfying and generally stress-free. Coping strategies ranged from keeping a distance from clients, religious faith, to the realization that death was a merciful end and was not necessarily painful. Informants generally perceived support to be adequate. CONCLUSIONS: The implications of these findings for training volunteers are discussed, especially the need to educate volunteers about the symptoms and signs of cancer.