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This study evaluated the effectiveness of an ancillary service assignment protocol to improve women's retention in HIV medical care. HIV-positive women with acknowledged difficulty in keeping regularly scheduled HIV clinic appointments were assigned to an intervention based on presenting characteristics: 6 months transportation plus nursing case management followed by 6 months transportation only for women currently using heroin and/or showing mental illness problems or transportation only for 12 months. Self-report and HIV clinic data provided measures of kept and missed appointments. Results were as hypothesized. The Transportation Only sample maintained number of kept appointments and significantly decreased number of missed appointments. The Transportation Plus sample significantly increased number of appointments kept and significantly decreased number of missed appointments. When intensive intervention was reduced to transportation only, charted HIV medical appointments significantly decreased. Positive influence on retention in HIV medical care requires level of intervention to be determined by current relevant client characteristics. [ABSTRACT FROM AUTHOR]

This article describes the evolution of Personalized Nursing, a comprehensive nursing practice model of care. Findings from several nursing research studies contributed to the development of Personalized Nursing. The model includes a practice model of the art of nursing care based on nursing theory and a specific nursing process that directs nursing care delivery. The process of care delivery includes location of hard-to-reach clients; linkage to health care providers; integration of care among providers for clients diagnosed with HIV, mental illness, and substance abuse; and strategies to promote retention in health care. Use of Personalized Nursing is designed to assist clients to improve their well-being and increase positive health-related behaviors. Personalized Nursing has been used in urban landscapes to serve multiply diagnosed clients at risk for HIV infection. The model is currently being used in a study targeting multiply diagnosed women who are lost to follow-up from medical care. [ABSTRACT FROM AUTHOR]

Background: Model for End-Stage Liver Disease (MELD) score-based liver transplant allocation was implemented as a fair and objective measure to prioritize patients based upon disease severity. Accuracy and reproducibility of MELD is an essential assumption to ensure fairness in organ access. We hypothesized that variability in laboratory methodology between centers could impact allocation scores for individuals on the transplant waiting list., Methods: Aliquots of 30 patient serum samples were analyzed for creatinine, bilirubin, and sodium in all transplant centers within United Network for Organ Sharing (UNOS) region 9. Descriptive statistics, intraclass correlation coefficients (ICCs), and linear mixed-effects regression were used to determine the relationship between center, bilirubin, and calculated MELD-sodium (MELD-Na) score., Results: The mean MELD-Na score per sample ranged from 14 to 38. The mean range in MELD-Na per sample was 3 points, but 30% of samples had a range of 4-6 points. Correlation plots and intraclass correlation coefficient analysis confirmed bilirubin interfered with creatinine, with worsening agreement in creatinine at high bilirubin levels. Center and bilirubin were independently associated with creatinine reported in mixed-effects models. Unbiased hierarchical clustering suggested that samples from specific centers have consistently higher creatinine and MELD-Na values., Conclusions: Despite implementation of creatinine standardization, centers within a single UNOS region report clinically significant differences in MELD-Na on an identical sample, with differences of up to 6 points in high MELD-Na patients. The bias in MELD-Na scores based upon center choice within a region should be addressed in the current efforts to eliminate disparities in liver transplant access.

Perinatal complications linked to maternal comorbidities contribute to increased healthcare utilization through an extended postpartum length of stay (LOS). Understanding factors influencing postpartum LOS may minimize the adverse effects associated with comorbidities and complications. The purpose of this study was to identify risk factors with the greatest odds of increasing postpartum LOS. Linked 2008-2009 hospital discharge and birth certificate data were used to examine comorbidities and complication codes in 1 015 424 births. The overall rate for an extended LOS (vaginal: >5 days/cesarean: >6 days) was 3.63 per 1000 live births. Complications were present in 17% of pregnancies; multiple complications were seen in 1%. Chronic hypertension was associated with an extended stay for both vaginal and cesarean births (odds ratio [OR] = 5.89 [95% CI, 4.39-7.88]; OR = 3.57 [95% CI, 3.05-4.17], respectively). Puerperal infections (OR = 6.86 [95% CI, 5.73-8.21]), eclampsia (OR = 17.07 [95% CI, 13.76-21.17]), and transfusions (OR = 11.66 [95% CI, 9.20-14.75]) occurred most frequently and conferred the highest odds of an extended stay for vaginal births. Cerebrovascular conditions (OR = 15.32 [95% CI, 11.90-19.60]) and infection (OR = 15.35 [95% CI, 10.11-23.32]) conferred the highest odds of an extended LOS for cesarean births. The earlier risk factors are recognized, the sooner processes can be initiated to optimize organizational preparation, thus decreasing adverse maternal outcomes and extended hospital stays.

Objectives: To compare the radiographic and functional outcome of patients with high-energy pilon fractures treated with locked versus nonlocked plates., Design: Randomized prospective trial., Setting: Academic level 1 trauma center., Patients: Between December 2006 and December 2008, 60 consecutive patients with 62 AO/OTA type A, B, and C tibial pilon fractures were enrolled in the study. Thirty-two of the fractures were treated using locked plates and 29 were treated with nonlocked plates. Follow-up data were available for 33 of the 60 patients., Intervention: Treatment with locked versus nonlocked plates., Main Outcome Measures: Short Musculoskeletal Function Assessment (SMFA) questionnaire and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHS). Radiographic measurements on anteroposterior and lateral views for the quality of reduction and maintenance of alignment immediately postoperatively compared with the latest follow-up., Results: There were no significant differences in the mechanism or injury pattern, average age of the patients, ratio of males to females, tourniquet time, operative time, interval to surgery, AHS, or SMFA scores. One of 15 fractures in the locked plate group lost reduction at the latest follow-up compared with 3 of 19 fractures in the nonlocked group., Conclusions: In this study, there seems to be no difference between the 2 constructs. Thus, one must question the routine use of locked plates in the treatment of high-energy pilon fractures., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The goal of this study was to compare functional outcomes of patients with patella fractures treated with open reduction and internal fixation (ORIF) with those treated with partial patellectomy (PP)., Design: Retrospective cohort study., Setting: Urban Level I Trauma Center., Patients: Seventy-three patients with isolated displaced patella fractures underwent operative treatment between January 1, 2002, and December 31, 2009, at our institution. Of these, 52 (71%) patients with isolated patella fractures with minimum 1-year follow-up agreed to participate and were enrolled in the study., Intervention: PP or ORIF., Main Outcome Measurements: Patients completed outcome questionnaires and participated in a physical examination. Outcome instruments included the Knee Outcome Survey-Activities of Daily Living Scale, Short Form (SF)-36 Health Survey, and SF Musculoskeletal Function Assessment Survey., Results: Twenty-six patients underwent PP and 26 underwent ORIF. There were no significant differences in any of the functional outcome instruments, including Knee Outcome Survey-Activities of Daily Living Scale (ORIF: 64.1 ± 11, PP: 62.1 ± 7.9, P = 0.76), SF-36 physical component score (ORIF: 40.8 ± 5.4, PP: 41.1 ± 5.2, P = 0.94), SF-36 mental component (ORIF: 47.7 ± 5.1, PP: 51.8 ± 4.9, P = 0.19), Short Musculoskeletal Function Assessment (SMFA) Function Index (ORIF: 28.6 ± 9.1, PP: 27.7 ± 6.7, P = 0.78), or SMFA Bother Index (ORIF: 26.0 ± 9.7, PP: 23.6 ± 8.8, P = 0.72). Complication rates did not differ significantly between the 2 groups., Conclusions: This study demonstrates that functional impairment persists after operative treatment of patella fractures. Both ORIF and PP demonstrated similar final range of motion, functional scores, and complication rates. Despite its purported benefits, in this study, ORIF did not result in superior outcomes compared with PP., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

We report a child who demonstrates near electrocerebral silence secondary to obstructive apnea during polysomnography. The mechanism of this suppression of cortical activity appears to be related to hypoxemia in the absence of a malignant arrhythmia.

Background: Dextromethorphan (DM), a widely used antitussive agent, has been shown to possess both anticonvulsant and neuroprotective properties functionally related to its inhibitory effects on glutamate-induced neurotoxicity. The current study was designed to determine whether DM administration prevents delayed neuronal degeneration in central nervous system areas after global forebrain ischemia and whether this correlates with inhibition of induction of the immediate early gene c-fos., Methods: Mongolian gerbils, anesthetized with 2% halothane in air at 37 degrees C, received either 0.9% sodium chloride (vehicle, n = 9) or 50 mg/kg DM in vehicle (n = 9) by intraperitoneal injection before bilateral carotid artery occlusion. After 1 h of reperfusion under anesthesia, the animals were killed and the brains removed. Immunohistochemistry was used to detect neurons expressing Fos protein. Computer-assisted image analysis quantified changes in the number of labeled neurons as a function of drug treatment. To determine the extent of delayed neuronal degeneration within the hippocampus, other animals were treated with either DM (n = 7) or vehicle (n = 6) before carotid artery occlusion and allowed to survive for 1 week., Results: Global forebrain ischemia produced consistent patterns of Fos-like immunoreactivity in the hippocampus and neocortex of vehicle-treated animals. DM inhibited the induction of c-fos from 65% to 91%. DM also protected against delayed neuronal degeneration in the CA1 region of the hippocampus (P < 0.001)., Conclusions: The induction of nuclear-associated Fos protein represents a sensitive marker of cellular responses to ischemia and a method to assay the effectiveness of pharmacologic interventions. DM markedly inhibited ischemia-induced Fos expression and prevented cell death in CA1. DM given before conditions of ischemia or decreased central nervous system perfusion may be highly beneficial.

A descriptive correlational study was conducted to test the efficacy of the Model of Self-Care in Chronic Illness. The model, an adaption and extension of the Health Belief Model, was developed to describe and relate the variables that influence effective self-care among ambulatory chronically ill adults. Participants (n = 181) were randomly selected from the waiting lists of an ambulatory care clinic of a major military medical center. The research examined general self-care, i.e., behaviors to promote health and prevent illness, and therapeutic self-care, i.e., education, diet, and other behaviors prescribed for a specific illness. Self-concept was correlated significantly with general as well as medication and dietary self-care. Psychological status and general health motivations influence general self-care. Stepwise multiple regression analyses demonstrated that costs of medication, patients' psychological status and perceptions of the seriousness of their illnesses, and vulnerability to complications were significantly related to medication self-care, while costs and perceptions of seriousness and vulnerability were significantly related to dietary self-care.

Left ventricular (LV) rupture potential was studied after transmural myocardial infarction (MI) in rabbits by measuring 1) the tensile strength of infarcted tissue strips, 2) the force required to initiate a tear (tear threshold) in the central infarcted region, and 3) the intracavitary pressure required to rupture the infarcted ventricle. During the first week after MI, infarcts resulting from a permanent coronary occlusion were compared with infarcts reperfused "late" (i.e., 3 hours) after coronary occlusion with a resultant hemorrhagic transmural infarct but no reduction in infarct size. The reperfused hemorrhagic infarcted strips had less tensile strength than strips from permanently occluded infarcts in the initial 24 hours after MI (16 +/- 1 versus 24 +/- 3 g/mm2, p less than 0.05), but the tear threshold and response to increased LV pressure were not influenced by infarct reperfusion at this time. By 3 days after MI, reperfused infarcts had equal tensile strength, had greater resistance to infarct tearing, and could withstand a greater LV distending pressure compared with permanently occluded infarcts. By 5 days after MI, reperfused infarcts maintained a greater tear threshold but had less tensile strength than permanently occluded infarcts, although all infarct values were equivalent or greater than normal LV values. By 7 days after MI, reperfused and permanently occluded infarcts were equally strong by all measurements. Thus, late reperfusion of transmural infarcts increased resistance to infarct tearing and LV rupture above that of nonreperfused permanently occluded infarcts by 3 days after MI and enhanced tissue strength after an initial 24-hour vulnerable period. These findings suggest that late reperfusion may accelerate myocardial healing after MI.

Background: Left ventricular aneurysm formation after myocardial infarction (MI) has been associated with elongation of infarcted tissue in response to wall stress. Such elongation most commonly occurs in acutely infarcted or partially healed regions during the early post-MI period; however, recent reports have indicated that mature (15-week-old) healed infarct regions also undergo elongation after stress., Methods and Results: To assess factors contributing to post-MI left ventricular aneurysm formation, we subjected isolated strips (n = 50) of rabbit myocardial tissue from acutely ischemic (noninfarcted left ventricular), acutely infarcted (24 hours after MI), and healed infarct (3 and 15 weeks after MI) regions to a range of loading conditions and measured the reversible and irreversible length changes that occurred. The isolated strips were repetitively stretched for 1 hour at 4 Hz to impose cyclical physiological peak and resting stresses of 2.0 and 0.2 g/mm2. During a second hour, either peak stress ("afterload") or resting stress ("preload") was tripled, and the increase in strip length (strain) was measured. During a third hour, peak and resting stresses were returned to the initial values to assess the reversibility of length changes occurring during increased load. Elongation was expressed as the increase in natural strain from the first hour. Increasing afterload caused similar irreversible length increases of 4-5%/hr in acutely infarcted and 3- and 15-week-old healed infarct strips; acutely ischemic tissue length increased by 7.4%/hr (p less than 0.05 versus acutely infarcted tissue and scars). Increasing preload in acutely ischemic and acutely infarcted tissue caused a reversible length increase of less than 1%/hr. (Scar strips were not tested for the effect of preload.), Conclusions: Since an irreversible length increase may represent an early event in aneurysm formation, our results suggest that 1) afterload increases are more likely to lead to aneurysm development than preload increases, 2) acutely ischemic tissue is the most vulnerable to increased afterload, and 3) for a given wall stress level, healing scar tissue is as susceptible to irreversible length changes as is acutely infarcted tissue. The observation that even mature post-MI scar elongated in response to increases in afterload implies that long-term pharmacological management of afterload in post-MI patients may be beneficial in preventing tissue elongation and aneurysm formation and that factors that increase wall stress (e.g., hypertension and exercise stress) have the potential to promote aneurysm formation in healed infarct scars.

Adequacy of healing after acute myocardial infarction may determine the incidence of postmyocardial infarction rupture and ventricular aneurysm. Accordingly, in 36 rabbits, from 1 to 8 days after coronary ligation, and in 18 shams, we measured collagen formation and mechanical resistance of the infarcted left ventricle to stretch and rupture. Prolyl hydroxylase, an intracellular enzyme of collagen synthesis, increased from control activity of 3970 +/- 431 to 9224 +/- 643 counts/min per mg (cpm/mg) extractable protein (P less than 0.01) at 48 hours and was nearly maximal at 3 days postmyocardial infarction (14,518 +/- 2,030 cpm/mg, P less than 0.01). Lysyl oxidase, an extracellular collagen cross-linkage enzyme, increased from control activity of 29.6 +/- 4.8 to 74.7 +/- 18.8 cpm/mg extractable protein (P less than 0.01) at 72 hours and peaked at 121.5 +/- 7.3 (P less than 0.01) 4-6 days postmyocardial infarction. Hydroxyproline, a measure of collagen content, increased from control of 2.8 +/- 0.2 to 5.3 +/- 0.6 mg/g dry weight (P less than 0.05) at 72 hours and continued to increase at 8 days postmyocardial infarction (14.5 +/- 1.7 mg/g dry weight; P less than 0.01). When enzyme activities and hydroxyproline content were expressed relative to other reference bases, including DNA, tissue protein, dry weight, and total left ventricle, similar results were obtained. The mechanical properties of the infarcted left ventricle were determined by filling a balloon in the excised left ventricle until rupture. The rupture threshold in the normal left ventricle, [664 +/- 43 mm Hg (n = 16)], was not significantly different from that of the infarcted left ventricle on days 1-8 postmyocardial infarction. However, left ventricular rupture occurred more often through the myocardial infarction on days 1-4 postmyocardial infarction (59%) than on days 6 and 8 (18%; P = 0.03) when collagen content had significantly increased. Wall stress at the point of rupture in left ventricles from shams and normals was 30 +/- 2 g/mm2; tensile strength in isolated left ventricle muscle strips was 25 +/- 4 g/mm2 and in isolated scar strips at 7 days postmyocardial infarction was 59 +/- 7 g/mm2. The passive stiffness of the infarcted left ventricle increased from control of 61 +/- 5 to 94 +/- 6 mm Hg/100 microliters (P less than 0.05) at 4 days and 100 +/- 7 mm Hg/100 microliters (P less than 0.01) at 6 days postmyocardial infarction. Stiffness correlated with hydroxyproline content over the 8 days postmyocardial infarction (r = 0.599; P less than 0.001). Thus, the acutely infarcted ventricle was highly resistant to rupture during the initial 48 hours postmyocardial infarction, before any increase in collagen occurred. This result suggests that the preinfarction collagen content has an important role in preventing rupture. After 72 hours postmyocardial infarction, collagen synthesis appeared to be a determinant of infarct stiffness and resistance of the infarcted ventricle to rupture.

In this report we describe a new technique for the measurement of region at risk after coronary artery ligation in the rabbit by NADH fluorophotography. We also describe the application of this technique to a study of nifedipine combined with reperfusion in experimental myocardial infarction. In 16 untreated rabbits the epicardial surface area of NADH fluorescence immediately after coronary ligation correlated with infarct size at 24 hr after coronary occlusion, as measured by nitro blue tetrazolium staining (r = .84, p less than .001). In 24 rabbits we studied the effect of nifedipine administered immediately after coronary ligation and combined with reperfusion at 1 hr after occlusion. Nifedipine had no significant effect on region at risk or infarct size.

Early reperfusion after a coronary occlusion may reduce myocardial infarct size, but late reperfusion into necrotic myocardium may alter post-infarction healing. In rabbits, we compared 1- or 3-week-old scars resulting from permanent coronary occlusion to those resulting from a 1- or 3-hour occlusion followed by reperfusion. Reperfusion at 1 hour post-occlusion did not affect scar mechanical properties assessed at 1 week post-infarction, but at 3 weeks post-infarction, these scars had a tensile strength significantly lower than those not reperfused (78 +/- 11 vs. 158 +/- 15 g/mm2, P less than 0.001). They also were composed of a mixture of fibrous tissue (58 +/- 8%) and myocytes (43 +/- 8%) with a hydroxyproline content of 23 +/- 2.5 mg/g dry weight. The nonreperfused scars had a higher proportion of fibrous tissue (73 +/- 3%) by histological evaluation and a 35% higher hydroxyproline content (31 +/- 2 mg/g dry weight, P less than 0.001) than the scars reperfused after 1 hour. In contrast, 3-week-old scars resulting from "late" reperfusion at 3 hours post-occlusion were similar to nonreperfused scars in fibrous tissue composition and hydroxyproline content. Nonetheless, the tensile strength of these scars reperfused 3 hours post-occlusion was significantly less than that of the nonreperfused scars (72 +/- 5 vs. 158 +/- 15 g/mm2, P less than 0.001). The lower tensile strength was associated with a lower collagen cross-link density in this reperfused group of scars. At physiological stress levels (approximately 3 g/mm2), all groups of reperfused and nonreperfused scars had similar mechanical properties in terms of natural strain, stiffness, creep, and stress relaxation. Thus, although the reperfused scars ruptured more easily at high stresses, when assessed at physiological stresses their mechanical properties were not significantly different from those of nonreperfused scars.

Renal artery stenosis was induced in dogs and collateral arterial formation assessed by serial angiography and histology. Endothelial cell turnover was estimated by radioautography in five normal and five collateral-forming kidneys 18-39 days following stenosis with tritiated thymidine. Normal arterial endothelial labeling was 0.1% with a highly significant (p less than 0.0005), 55-fold increase in endothelial labeling in arterial collateral vessels. A smaller but statistically significant increase in the labeling index was also found in endothelial cells of the renal vein, from a normal of 0.065% to 0.4% (p less than 0.005). An excellent correlation was found between endothelial cell labeling in small arteries and the renal veins (r = 0.97; p less than 0.01). A marked increase in epithelial cell labeling of the ureters draining the stenotic kidneys was also evident (p less than 0.005). Thus, collateral vessel development is characterized by active DNA synthesis in cellular elements, and a humoral factor is implicated in the vascular response.