Wesley Medical Center

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738). INTERVENTIONS: NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g. RESULTS: Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997. CONCLUSION: We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.

Intrathecal baclofen infusion has demonstrated effectiveness in decreasing spasticity of spinal origin. Oral antispasticity medication is minimally effective or not well tolerated in cerebral palsy. This study assessed the effectiveness of intrathecal baclofen in reducing spasticity in cerebral palsy. Candidates were screened by randomized, double-blind, intrathecal injections of baclofen and placebo. Responders were defined as those who experienced an average reduction of 1.0 in the lower extremities on the Ashworth Scale for spasticity. Responders received intrathecal baclofen via the SynchroMed System and were followed for up to 43 months. Fifty-one patients completed screening and 44 entered open-label trials. Lower-extremity spasticity decreased from an average baseline score of 3.64 to 1.90 at 39 months. A decrease in upper extremity spasticity was evidenced over the same study period. Forty-two patients reported adverse events. Most common reports were hypotonia, seizures (no new onset), somnolence, and nausea or vomiting. Fifty-nine percent of the patients experienced procedural or system-related events. Spasticity in patients with cerebral palsy can be treated effectively by continuous intrathecal baclofen. Adverse events, although common, were manageable.

BACKGROUND: Evidence for the association between Clostridium difficile (C. difficile) and the use of proton pump inhibitor (PPI) is unclear. This study investigated the relationship between Clostridium difficile-associated diarrhea (CDAD) and exposure to acid suppressive therapy in hospitalized adult patients while controlling for the most common predisposing risk factors. METHODS: A retrospective case-control study was conducted at a local hospital of all hospitalized patients between October 1, 2005 and September 30, 2006 who developed CDAD during hospitalization. Subjects were determined to have CDAD if there was a positive C. difficile toxin and clinical correlation of diarrhea at the time of diagnosis. Subjects were pair-matched to controls on the following factors: admission date, antibiotic exposure, gender, age groups, patient location (medical or surgical unit), and room type at time of admission. Seven risk factors were assessed for association with onset of CDAD: exposure to PPIs or H(2)-blockers, renal failure, diabetes mellitus, immunosuppression, malignancy, and gastrointestinal disease. RESULTS: Ninety-four cases were successfully matched to controls. Cases were more likely than controls to receive acid suppressive therapy during hospitalization, 72 (76.6%) versus 40 (42.6%), respectively, P= 0.030. In a multivariate exact conditional logistic regression analysis, CDAD was associated with use of PPI (odds ratio [OR]= 3.6, 95% confidence interval [CI]= 1.7-8.3; P < 0.001), and with renal failure (OR = 5.7, CI = 1.3-39.1; P= 0.02). CONCLUSION: This study showed elevated risk of developing CDAD in hospitalized patients with acid suppressive therapy, especially when PPIs were used.

Journal Article Effectiveness of a pharmacist-acquired medication history in promoting patient safety Get access Tina M. Nester, Pharm.D., Tina M. Nester, Pharm.D. Internal Medicine Specialist Wesley Medical Center (WMC), Wichita, KS Search for other works by this author on: Oxford Academic Google Scholar LaDonna S. Hale, Pharm.D. LaDonna S. Hale, Pharm.D. Assistant Professor Department of Physician Assistant, College of Health Professions, Wichita State University, Wichita, KS, and Clinical Pharmacist, WMC Address correspondence to Dr. Hale at the Department of Physician Assistant, Wichita State University, 1845 Fairmount, Box 43, Wichita, KS 67260-0043 (ladonna.hale@wichita.edu) Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 59, Issue 22, 15 November 2002, Pages 2221–2225, https://doi.org/10.1093/ajhp/59.22.2221 Published: 15 November 2002

Previous studies have proposed the involvement of caspase-3, a downstream executioner enzyme common to many paradigms of programmed cell death (PCD), in mediating the apoptosis of both germ and somatic cells in the ovary. Herein we used caspase-3 gene knockout mice to directly test for the functional requirement of this protease in oocyte and/or granulosa cell demise. Using both in vivo and in vitro approaches, we determined that oocyte death initiated as a result of either developmental cues or pathological insults was unaffected by the absence of caspase-3. However, granulosa cells of degenerating antral follicles in both mouse and human ovaries showed a strong immunoreaction using an antibody raised against the cleaved (activated) form of caspase-3. Furthermore, caspase-3 mutant female mice possessed aberrant atretic follicles containing granulosa cells that failed to be eliminated by apoptosis, as confirmed by TUNEL (terminal deoxynucleotidyl transferase-mediated deoxy-UTP nick end labeling) analysis of DNA cleavage and 4',6-diamidino-2-phenylindole staining of nuclear morphology (pyknosis). These in vivo results were supported by findings from in vitro cultures of wild-type and caspase-3-deficient antral follicles or isolated granulosa cells. Contrasting the serum starvation-induced occurrence of apoptosis in wild-type granulosa cells, caspase-3-null granulosa cells deprived of hormonal support were TUNEL-negative, showed attenuated chromatin condensation by 4',6-diamidino-2-phenylindole staining and exhibited delayed internucleosomal DNA cleavage. Such ex vivo findings underscore the existence of a cell autonomous (granulosa cell intrinsic) defect in apoptosis execution resulting from caspase-3 deficiency. We conclude that caspase-3 is functionally required for granulosa cell apoptosis during follicular atresia, but that the enzyme is dispensable for germ cell apoptosis in the female.

STUDY OBJECTIVE: To evaluate the impact of various body weights and serum creatinine (S(c) (r) ) concentrations on the bias and accuracy of the Cockcroft-Gault creatinine clearance (C-G Cl(c) (r) ) equation compared with measured 24-hour Cl(c) (r) . DESIGN: Retrospective analysis. SETTING: Tertiary care hospital. PATIENTS: A total of 3678 patients with stable renal function and who underwent a 24-hour urine collection between July 1, 1996, and June 30, 2010. MEASUREMENTS AND MAIN RESULTS: For each patient, C-G Cl(c) (r) was calculated and compared with a measured 24-hour Cl(c) (r) . Body weight adjustments to the calculation were performed based on the following weight classifications: underweight, normal weight, overweight, obese, and morbidly obese. In addition, C-G Cl(c) (r) was calculated by using rounded S(c) (r) values based on two S(c) (r) thresholds-0.8 mg/dl and 1 mg/dl-for patients with measured S(c) (r) values below those thresholds. Those patients were then evaluated after stratification into two age groups: all ages and a subgroup of patients aged 65 years or older. The S(c) (r) -rounded C-G Cl(c) (r) values were compared with the C-G Cl(c) (r) values using actual S(c) (r) values. Mean differences were calculated, and accuracy was evaluated. Use of actual body weight in the calculations for underweight patients resulted in an unbiased Cl(c) (r) of -0.22 ml/minute (p=0.898). Use of ideal body weight in the calculations of patients of normal weight returned an unbiased Cl(c) (r) of -1.3 ml/minute (p=0.544). An unbiased C-G Cl(c) (r) could not be calculated for other weight categories. In those patients, adjusted body weight using a factor of 0.4 (ABW(0.4) ) was the least biased and most accurate. In patients aged 65 years or older with an S(c) (r) less than 0.8 mg/dl and less than 1 mg/dl, actual S(c) (r) was unbiased (-3 ml/min [p=1] and -9 ml/min [p=0.279], respectively) and more accurate than rounded S(c) (r) . In patients of all ages with an S(c) (r) less than 0.8 mg/dl and less than 1 mg/dl, actual S(c) (r) proved less biased (-4.5 ml/min [p=0.038] and -5.5 ml/min [p<0.001], respectively) and more accurate than rounded S(c) (r) . CONCLUSION: An unbiased C-G Cl(c) (r) can be calculated using actual body weight in underweight patients and ideal body weight in patients of normal weight. Using ABW(0.4) for overweight, obese, and morbidly obese patients appears to be the least biased and most accurate method for calculating their C-G Cl(c) (r) . Rounding S(c) (r) in patients with low S(c) (r) did not improve accuracy or bias of the Cl(cr) calculations.

OBJECTIVE: To compare the relative safety and efficacy of Infasurf (calf lung surfactant extract; ONY, Inc, Amherst, NY, IND #27169) versus Survanta (Beractant, Ross Laboratories, Columbus, OH) in reducing the acute severity of respiratory distress syndrome (RDS) when given at birth and to infants with established RDS. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Thirteen neonatal intensive care units participated in the treatment arm: seven of these concurrently participated in the prevention arm. PATIENTS: The treatment arm enrolled infants of </=2000 g birth weight with established RDS, and the prevention arm enrolled infants of </=29 weeks' gestation with birth weights <1250 g. INTERVENTION: Infants were randomly assigned to receive Infasurf (n = 303, treatment arm; n = 180, prevention arm) or Survanta (n = 305, treatment arm; n = 194, prevention arm) in accordance with the Survanta package insert instructions. OUTCOME MEASURES: We projected a 25% reduction between groups in the need for a third dose of surfactant for infants with established RDS, and a 25% reduction in the need for a second dose of surfactant for infants who received prophylactic surfactant. Secondary outcomes included the severity of RDS measured by inspired oxygen concentrations and mean airway pressure, air leaks, complications associated with surfactant administration, and survival to 36 weeks' postmenstrual age without the need for oxygen supplementation. RESULTS: In the treatment arm, there was no difference between groups in the number of infants requiring more than two doses of surfactant. The interval between doses was significantly longer for Infasurf, suggesting an increased duration of treatment effect. The inspired oxygen concentration and mean airway pressure were lower in the Infasurf infants during the first 48 hours in the treatment arm. In the prevention arm, there were no differences with respect to the number of surfactant doses. The dosing intervals were longer for Infasurf infants after the second dose. No difference in inspired oxygen or mean airway pressure was noted during the first 72 hours. There were no significant differences in the incidence of air leaks, complications associated with dosing, complications of prematurity, mortality, or survival without chronic lung disease in the prevention or treatment arm. CONCLUSIONS: Infants treated with Infasurf have a modest benefit in the acute phase of RDS. Infasurf seems to produce a longer duration of effect than Survanta.

Diagnosing acute scrotal pain and swelling in children and adolescents is urgent and often difficult. A review of 395 boys hospitalized with acute scrotal pain and/or swelling shows that a useful approach is to divide these patients into four groups--those with intermittent but recurrent episodes of pain, those with pathognomonic physical findings, those with definite epididymitis, and a remaining group with nonspecific swelling and tenderness. Five per cent of boys in this series presented with recurring episodes of scrotal pain; these boys should undergo a simple scrotal operation that yields excellent results. Eight per cent had pathognomonic physical findings; treatment in these boys is straightforward. Eighteen per cent had a definite diagnosis of acute epididymitis (i.e., three nonpathognomonic but suggestive findings of acute epididymitis or two suggestive findings plus a radionuclide scan showing bilateral perfusion); nonoperative therapy is indicated in this group. In the remaining boys, scrotal exploration is the diagnostic (and usually therapeutic) procedure of choice.

PURPOSE: The feasibility of implementing an electronic system for targeted pharmacist- and nurse-conducted admission and discharge medication reconciliation and its effects on patient safety, cost, and satisfaction among providers and nurses were studied. METHODS: This study was conducted in two phases: a preimplementation phase and a postimplementation phase. In the preimplementation phase, admission medication histories and discharge medication counseling followed standard care processes. During postimplementation, pharmacists and nurses collaborated to electronically complete admission and discharge medication reconciliation documentation. Four reports were developed for medication reconciliation documentation: (1) home medication profile report, (2) home medication reconciliation report, (3) discharge medication reconciliation report, and (4) patient discharge medication report. Patients were contacted after discharge to measure their satisfaction with the medication counseling and medication instructions received. Health care providers completed a survey indicating their satisfaction with the electronic medication reconciliation processes. RESULTS: A total of 283 patients were included in the study. Patients in the postimplementation group took significantly more prescription and nonprescription medications, and their total number of medications significantly exceeded the number taken by the preimplementation group. Pharmacists completed significantly more dosage changes in the postimplementation phase than in the preimplementation phase. In the preimplementation phase, nurses identified more incomplete medication orders, dosage changes, and allergies than they did in the postimplementation phase. Patients in the postimplementation group reported a higher level of agreement on all survey items regarding adequate discharge medication instructions. CONCLUSION: Patients who had their medications electronically reconciled reported a greater understanding of the medications they were to take after discharge from the hospital, including medication administration instructions and potential adverse effects.

INTRODUCTION AND OBJECTIVES: Non-alcoholic fatty liver disease (NAFLD) is a widespread chronic liver disease. It is considered a multifactorial disorder that can progress to liver fibrosis and cause a worldwide public health concern. Coffee consumption may have a protective impact on NAFLD and liver fibrosis. However, the evidence from the previous studies is inconsistent. This meta-analysis summarizes available literature. MATERIALS AND METHODS: This study comprises two meta-analyses. The first meta-analysis summarizes the effect of coffee consumption on NAFLD in those who did or did not drink coffee. The second analysis compares the risk of liver fibrosis development between NAFLD patients who did or did not drink coffee. Pooled risk ratios (RR) and confidence intervals (CI) of observational studies were estimated. RESULTS: Of the total collected 321 articles, 11 met our eligibility criteria to be included in the analysis. The risk of NAFLD among those who drank coffee compared to those who did not was significantly lower with a pooled RR value of 0.77 (95% CI 0.60-0.98). Moreover, we also found a significantly reduced risk of liver fibrosis in those who drink coffee than those who did not drink in the NAFLD patients with the relative risk (RR) of 0.68 (95% CI 0.68-0.79). CONCLUSIONS: Regular coffee consumption is significantly associated with a reduced risk of NAFLD. It is also significantly associated with decreased risk of liver fibrosis development in already diagnosed NAFLD patients. Although coffee consumption may be considered an essential preventive measure for NAFLD, this subject needs further epidemiological studies.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Data on treatment costs were collected for infants with birth weight 501 to 1500 g for the period of January 1, 1994 to December 31, 1997. Data on resources expended by hospitals to conduct this project were collected in a survey for the period January 1, 1995 to December 31, 1996. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Nine other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (N = 2993) and the 9 comparison NICUs (N = 2203); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (N = 663) and the 9 comparison NICUs (N = 1007). INTERVENTIONS: NICUs formed multidisciplinary teams which worked together to undertake a collaborative quality improvement effort between January 1995 and December 1996. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: Treatment cost per infant is the primary economic outcome measure. In addition, the resources spent by hospitals in undertaking the collaborative quality improvement effort were determined. RESULTS: Between 1994 and 1996, the median treatment cost per infant with birth weight 501 to 1500 g at the 6 project NICUs in the infection group decreased from $57 606 to $46 674 (a statistical decline); at the 4 chronic lung disease hospitals, for infants with birth weights 501 to 1000 g, it decreased from $85 959 to $77 250. Treatment costs at hospitals in the control group rose over the same period. There was heterogeneity in the effects among the NICUs in both project groups. Cost savings were maintained in the year following the intervention. On average, hospitals spent $68 206 in resources to undertake the collaborative quality improvement effort between 1995 and 1996. Two thirds of these costs were incurred in the first year, with the remaining third in the second year. The average savings per hospital in patient care costs for very low birth weight infants in the infection group was $2.3 million in the post-intervention year (1996). There was considerable heterogeneity in the cost savings across hospitals associated with participation in the collaborative quality improvement project. CONCLUSION: Cost savings may be achieved as a result of collaborative quality improvement efforts and when they occur, they appear to be sustainable, at least in the short run. In high-cost patient populations, such as infants with very low birth weights, cost savings can quickly offset institutional expenditures for quality improvement efforts.

A ten-year period, 1966 through 1975, provided 2842 prostate specimens at The Wesley Medical Center, These specimens were classified as (1) adenocarcinoma, (2) adenosis, or (3) hyperplasia. During a follow-up period of 5--15 years (average 7.7 years), prostate carcinoma developed in seven of 108 patients (6.5%) with adenosis. During the same follow-up period prostate carcinoma developed in at least 84 of 2263 patients (3.7%) with hyperplasia. Adenosis is considered to be a dysplastic lesion because patients with histologic lesions limited to adenosis have approximately the same likelihood of prostate carcinoma developing as patients with hyperplasia.

In the period from January, 1982, to March, 1983, eight infants in the neonatal intensive care unit at one hospital had blood cultures positive for Candida parapsilosis; six cases had occurred after December, 1982. Epidemiologic investigation included a case-control study comparing the 8 cases with 29 birth weight-matched controls. Logistic regression analysis indicated that the model that best fit the observed data included the following risk factors for fungemia: duration of umbilical artery catheterization; duration of receipt of parenteral nutrition; and estimated gestational age. Parenteral nutrition therapy was often administered through the umbilical artery catheters, which were also used for monitoring arterial pressure; transducer domes thus contained parenteral nutrition fluid. Transducers were usually disinfected with alcohol. Laboratory investigation showed that the heads of 6 of 11 in-use blood pressure transducers and 1 of 4 transducers in storage after cleaning were culture-positive for C. parapsilosis. After control measures were instituted no further cases occurred.

BACKGROUND: Dysembryoplastic neuroepithelial tumors (DNETs) are uncommon neural tumors presenting most often in children and young adults and associated with intractable seizures. Rare midline neoplasms with similar histological features to those found in DNETs have been described near the septum pellucidum and termed "DNET-like neoplasms of the septum pellucidum." Due to their rarity, these tumors have been described in just a few reports and their genetic alterations sought only in small series. METHODS: We collected 20 of these tumors for a comprehensive study of their clinical, radiological, and pathological features. RNA sequencing or targeted DNA sequencing was undertaken on 18 tumors, and genome-wide DNA methylation profiling was possible with 11 tumors. Published cases (n = 22) were also reviewed for comparative purposes. RESULTS: The commonest presenting symptoms and signs were related to raised intracranial pressure; 40% of cases required cerebrospinal fluid diversion. Epilepsy was seen in approximately one third of cases. All patients had an indolent disease course, despite metastasis within the neuraxis in a few cases. Radiologically, the septum verum/septal nuclei were involved in all cases and are the proposed site of origin for septal DNET (sDNET). Septal DNET showed a high frequency (~80%) of mutations of platelet derived growth factor receptor A (PDGFRA), and alterations in fibroblast growth factor receptor 1 (FGFR1) and neurofibromatosis type 1 (NF1) were also identified. In a genomic DNA methylation analysis alongside other neural tumors, sDNETs formed a separate molecular group. CONCLUSIONS: Genetic alterations that are different from those of cerebral DNETs and a distinct methylome profile support the proposal that sDNET is a distinct disease entity.

OBJECTIVE: To increase weight gain in the first 28 days after birth for very low birth weight (VLBW) infants by isolating and sharing meaningful process differences between high- and low-weight-gain centers within a neonatal network. DESIGN/METHODS: We identified weight gain as an important target for improvement in 1999 for our national group practice of neonatologists. Site-specific average weight gain during the first 28 days was the primary outcome measure. Our target population was defined as inborn infants who survived and remained in the hospital of birth, whose birth weights were between 401 and 1500 g (VLBW), and who were >22 weeks' estimated gestational age. A team of 6 neonatologists and 1 nurse met, reviewed processes that might influence growth, and developed a structured observation guide for site visits. Weight gain data were obtained from an existing administrative database for the period January 1, 1997, through June 30, 1999. Centers were ranked and divided into upper, middle, and lower thirds. Seven team members visited 1 high- and 1 low-weight-gain center without being informed of the center's performance. Following the site visits, the team isolated 16 meaningful differences between high- and low-weight-gain sites. Meaningful differences were defined as processes observed in all or virtually all (for this project, 6 or 7 of 7 centers) of the high and none or virtually none (for this project, 0 or 1 of 7) of the low centers. The meaningful differences were distributed to our medical directors in August 2000 along with their site-specific weight-gain performance. To document the impact of sharing this material, we compared weight gain in a baseline period of January 1 through December 31, 1999 and a posteducational intervention period of January 1 through September 30, 2001. RESULTS: Compared with neonates admitted to our national neonatal practice in 1999, neonates admitted in 2001 were similar in birth weight, gestational age at birth, exposure to antenatal steroids, and male gender. Average daily weight gain during the first 28 days increased from 10.4 +/- 6 g for neonates cared for in 1999 to 12.5 +/- 6 g for neonates cared for in 2001. Thirty-nine of 51 (76%) units noted improvements, 4 were unchanged and 8 noted a decrease in average weight gain. Despite similar average lengths of stay, the average discharge weight for neonates sent home increased from 2.15 +/- 0.5 kg for 1999 to 2.29 +/- 0.5 kg for 2001. There were no differences in frequencies of mortality or major morbidities, including severe intraventricular hemorrhage, retinopathy, or necrotizing enterocolitis, between the 2 time periods. An increase in the use of continuous positive airway pressure was noted in the post implementation period. CONCLUSIONS: Variation in common processes can alter clinical outcomes. Although temporal trends in weight gain may be, in part, responsible for this trend, it appears that isolation and implementation of meaningful differences in processes can augment our desire to rapidly improve clinical outcomes.

OBJECTIVE: The objective of our study was to describe the "waist" sign as a feature of hydrosalpinx and to calculate the likelihood ratio of sonographic findings for predicting that a cystic adnexal mass is a hydrosalpinx. MATERIALS AND METHODS: Consecutive institutional records were reviewed to identify patients with surgically excised cystic adnexal masses and preoperative sonograms that had been used to identify the mass. Two radiologists blinded to outcome reviewed the sonograms and recorded the presence of five specific sonographic findings: incomplete septation, short linear projection, small round projection, tubular shape, and presence of a waist. The likelihood ratios of these signs and combinations of signs for the diagnosis of hydrosalpinx were calculated. RESULTS: There were 55 patients with 67 cystic adnexal masses. Of the 67 cystic adnexal masses, there were 26 hydrosalpinges (39%), 36 cystic ovarian neoplasms (54%), and five paraovarian masses (7%). The likelihood ratios for the sonographic findings were as follows: incomplete septation, 2.1; short linear projection, 3.5; small round projection, 2.7; tubular shape, 10.5; and waist sign, 20.5. The waist sign in combination with tubular shape was found in 12 hydrosalpinges and no other masses (likelihood ratio of between 18.9 and infinity). Small round projection combined with tubular shape was found in 14 hydrosalpinges and one other mass (likelihood ratio of 22.1). CONCLUSION: Hydrosalpinx can be diagnosed with the highest likelihood when a tubular mass with the waist sign or a tubular mass with small round projections is encountered. Incomplete septations and short linear projections are less discriminating findings of hydrosalpinx.

One-hundred and four consecutive cases of invasive bladder carcinoma were studied. Twenty of the 104 cases had a history of papillary neoplasms of the bladder while the remaining 84 cases did not. Further, 22 of the 104 cases had cystoscopies, months to years prior to the diagnosis of invasive bladder carcinoma, which documented the absence of previous papillary neoplasms of the bladder. Therefore, this study suggests that papillary neoplasms of the bladder may not be the most common precursor of invasive bladder carcinoma. Consequently, vigorously attacking the highly visible papillary neoplasms of the bladder may not be as fruitful in preventing invasive bladder carcinoma as attempting to identify the presence of other less visible nonpapillary lesions which may be the most frequent precursors of invasive bladder carcinoma.

OBJECTIVE: The Vermont Oxford Network (VON) CARE Group was formed in response to the need to create organizational cultures supportive of change and quality improvement. METHODS: The CARE Group consisted of team members from 4 participating neonatal intensive care units (NICUs). All CARE Group members chose to work on multidisciplinary teamwork for the duration of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000. A questionnaire was developed by the CARE Group and administered to the 4 focus group NICUs. The survey focused on 6 domains of the organization: unit coordination, working in the NICU, leadership, management of disagreements, authority, and unit culture. Benchmarking visits were completed to supplement the information found in the survey and the literature. RESULTS: Seven potentially better practices (PBPs) were developed on the basis of the surveys, benchmark visits, and literature reviews. The PBPs include 1) a clear, shared NICU purpose, goals, and values; 2) effective communication among and between teams and team members; 3) leaders lead by example; 4) nurture a collaborative NICU environment with trust and respect; 5) live principled standards of conduct and standards of excellence; 6) nurture competent and committed teams and team members; and 7) commit to effective and positive conflict management. CONCLUSIONS: The CARE Group successfully used quality improvement methods and collaboration to delineate principles and practices of multidisciplinary teamwork.

Severe sepsis, systemic inflammatory response syndrome (SIRS), and traumatic brain injury are frequently associated with hyperglycemia in non-diabetic patients. In patients suffering from any of these conditions, hyperglycemia at admission to an intensive care unit (ICU) is directly correlated with increased mortality or morbidity. Although there was initial enthusiasm for insulin treatment to blood glucose levels below 110 mg/dL in these patients, recent understanding suggests that the potential for hypoglycemic complications make this approach potentially dangerous. More moderate glucose control seems to be more beneficial than the aggressive glucose lowering initially suggested. An important publication has shown that hyperlactatemia accompanying hyperglycemia could be the real culprit in bad outcomes. This suggests that coupling moderate glucose lowering with therapeutic agents which might treat the underlying metabolic disturbances in these conditions may be a better strategy. The key metabolic disturbance in these three conditions seems to be persistent glycolysis as an energy source even in the presence of adequate tissue oxygenation (the Warburg Effect). We look at recent advances in understanding aerobic glycolysis and possibly the action of DPP4 on incretins resulting in insulin dysregulation and suggest key metabolic pathways involved in hyperglycemia regulation.

Recent changes in reimbursement for tonsillectomy and adenoidectomy have resulted in a large number of these procedures being done on an outpatient basis. There is still considerable controversy, however, as to the safety of this concept. We reviewed the charts of 1000 consecutive patients who underwent these procedures. Three hundred ninety-six procedures were performed as inpatient surgery and 604 were performed as outpatient surgery. Patients were considered as candidates for outpatient surgery if they met specific criteria, such as good overall medical health, no central apnea, normal bleeding history and profile, and had adequate social considerations. The inpatient group included those patients who did not meet the criteria to be outpatients. We compared the complication rates of these two groups with regard to age, type of procedure performed (tonsillectomy, adenoidectomy, adenotonsillectomy), and indication for surgery in order to determine if there was any increased risk of outpatient surgery, despite strict selection criteria. The two groups were similar in their distribution with regards to age, sex, type of procedure, and indication for surgery. The overall complication rate for the entire group was 7.9%, with an 11.8% complication rate for inpatients and 4.1% complications for outpatients. The higher complication rate among the inpatient group is probably a direct result of the selection process because this group included the higher-risk patients. On the basis of these findings, we believe that surgery of the tonsils and adenoids can be performed safely as an outpatient procedure, regardless of age, indication, or procedure, if the candidates for ambulatory surgery are carefully selected by the surgeon.