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Median arcuate ligament syndrome (MALS) is an often discounted and vexing condition that may go unnoticed in a population of patients with complex comorbid conditions or those with poor psychiatric health. We report a unique case of a patient with anorexia nervosa in whom the successful operation for MALS was briefly complicated by a postoperative conversion disorder.

The combination of promethazine and opioids is known to have an opioid-sparing effect, thereby facilitating a reduction in total patient opioid consumption. In recent years, this practice has fallen out of favor in many healthcare facilities, except primarily in the post anesthesia care unit (PACU). The goal of this study was to highlight the potential of promethazine as a direct or indirect adjuvant medication in acute pain management. The present investigation was undertaken with a case series of adult female patients who underwent open total abdominal hysterectomies. Data from the PACU was reviewed with patients being separated into two groups. Group 1 received only intravenous opioids for acute pain management. Group 2 received a combination of intravenous opioids for acute pain management and intravenous promethazine for nausea and/or vomiting. Patients were discharged from the PACU with a modified Aldrete score of 9 or 10. The study showed that patients who received promethazine in addition to opioids were discharged from the PACU an average of 19.2 minutes earlier than those patients who received only opioids (p=0.003). The time to achieve modified Aldrete score of 9 or higher was more quickly achieved when open abdominal hysterectomy patients received promethazine in addition to opioids in the PACU. The study concluded that promethazine, in combination with opioids, could potentially decrease PACU stay postoperatively. Based on the present investigation, the prospect of using promethazine in other facets of pain management are intriguing and warrant future studies. Specifically, it may be worth investigating whether promethazine is truly an adjunct in combination with opioids and to determine if there are any other antihistamines or neuroleptics which may have similar clinical effects to promethazine.

We report a five year military experience with anterior retroperitoneal spine exposure combining vascular and neurosurgical spine teams. From August 2005 through April 2010 (56 months), hospital records from a single institution were retrospectively reviewed. Complications, estimated blood loss, transfusions, operative time and length of stay were documented. Eighty-four patients with lumbar spondylosis underwent primary (63, 75%) or secondary exposure (21, 25%) of a single- (66, 79%) or multilevel disc space (18, 21%). Median operative time and estimated blood loss were 127 minutes (range, 30–331 minutes) and 350 mL (range, 0–2940 mL). The overall complication rate was 23.8%. Postoperative complications included six blood transfusions (7%), three patients with retrograde ejaculation (3.57%) or surgical site infection; two with a prolonged ileus (2.38%) or ventral hernia and one each with a bowel obstruction (1, 1.19%), deep venous thrombosis or lymphocele. All-cause mortality was 1%. In conclusion, a team approach can minimize complications while offering the technical benefits and durability of an anterior approach to the lumbar spine.

Damage control surgery with the principles of expeditious control of hemorrhage and contamination, followed by predominant crystalloid resuscitation in the intensive care unit has saved the lives of many severely injured trauma patients. Unfortunately, crystalloid resuscitation has too often led to worsening of coagulopathy in the setting of vascular injury. The recent conflicts in Iraq and Afghanistan have created injured patients with severe vascular injury and massive soft tissue destruction creating early and profound coagulopathy associated with high rates of mortality. An alternative strategy, known as damage control resuscitation, with the principal resuscitation of a 1:1 ratio of packed red blood cells and fresh frozen plasma has been developed during these conflicts. This method is associated with decreased mortality and improved limb salvage in military and civilian trauma patients.

Background: High velocity fragments have resulted in a multitude of complex injuries in the military patients, placing them at increased risk of venous thromboembolism. Methods: A retrospective analysis was performed of all the intravascular ultrasound (IVUS)-guided bedside inferior vena cava (IVC) filters placed between August 2003 and October 2007. Results: Fourteen patients had bedside IVUS-guided retrievable filter placement. Thirteen males and one female and the mean (+SD) injury severity scores (ISS) was 37.2 (+9.9). The most common causes of injury were explosive devices (57%), gunshot wounds (28%), rocket-propelled grenades (7%), and motor vehicle crashes (7%). Indications for filter insertion were deep venous thrombosis in 36% of patients and pulmonary embolus in 28%. Thirty five percent had filters inserted prophylactically. Conclusions: Military trauma population ISS is considerably higher than what is reported in the civilian population. The bedside IVUS-guided IVC filter insertion is particularly useful in this population.

Recent combat casualties have stimulated a reassessment of the principles of management of high-risk extremity injuries with a normal vascular examination. Rapid evacuations have presented numerous U.S. soldiers to our service for evaluation in the early postinjury period. The objective of this single-institution report is to analyze the application of liberal arteriography in the delayed evaluation of modern wartime extremity injuries. Data from consecutive wartime evacuees evaluated for extremity injuries between March 2002 and November 2004 were prospectively entered into a database and retrospectively reviewed. Analysis was focused on arteriography and its role in our current diagnostic and therapeutic approach. Information including injury sites and mechanisms, associated trauma, battlefield repairs performed, arteriography technique, complications, findings, and need for further intervention were reviewed. Indications for imaging in this high-risk group included proximity to vascular structures, abnormal or equivocal physical examination, adjunctive operative planning, and evaluation of battlefield repair. Ninety-nine of 179 patients (55%) with extremity injuries underwent arteriography, with 142 total limbs studied. The majority of them were wounded by explosive devices (82%) or high-velocity rifle munitions (14%). Abnormalities were found in 75 of 142 (52.8%) imaged limbs in 46 of the 99 (46.5%) patients. Twenty-four of these patients (52.2%) required additional operative intervention. Occult vascular injury findings were associated with bony fracture in 68% and nerve injury in 16%. Median delay between injury and stateside evaluation was 6 days. Two thirds of these soldiers presented with a normal physical examination result. There were no access site complications or incidents of contrast-induced acute renal failure. The liberal application of arteriography is a low-risk method to provide high-yield data in the delayed vascular evaluation of extremities injured from modern military munitions. Physical examination findings remain the most useful indicator, but a normal examination can be misleading and should not guide the decision for invasive imaging. Lesions are found and require further intervention at a higher rate than expected from the typical civilian trauma experience.

Traumatic hemorrhage and vascular injury management have been concerns for both civilian and military physicians. During the 20th century, advances in technique allowed surgeons to focus on vascular repair, restoration of perfusion, limb salvage, and life preservation. Military surgeons such as Makins, DeBakey, Hughes, Rich, and others made significant contributions to the field of surgery in general and vascular surgery in particular. Casualties from combat in Afghanistan and Iraq confront physicians and surgeons with devastating injuries. The current generation of providers is challenged with applying contemporary care while expanding upon the lessons taught by our predecessors. The objective of this report is to review the historical experience with managing military upper extremity arterial injuries and compare that experience with current management.

The management of venous trauma continues to be debated. Historically, ligation of injured veins is the most common modality of surgical treatment. In the past half-century, additional techniques have been used, including primary repair, interposition graft, and occasionally endovascular techniques. Venous repair, whether in the acute or chronic setting, is believed to prevent or ameliorate the complications of pain, edema, and phlegmasia. Venous repair in civilian trauma and in wartime is commonplace; however, overall treatment strategies remain largely unchanged since the Vietnam War.

Early epistemology assumed that the observer (a) was independent of and distinct from the object being observed and (b) could validate objective reality in a language system called the laws of science. The authors offer something different. In arguing that knowledge is responsive to the culture in which it is embedded, they take a perspectival approach, gathering localized intentionality, context, social practices, and linguistic meaning (called ground) into the project of inquiry (called figure). Knowledge building, in other words, depends on the background and interests of the epistemic community that is generating knowledge.

Public policy discourse has entered an era of media-driven hyperreality, becoming detached from the lived experience of the polity. Bumper-sticker political symbols, such as “the war on drugs,” have displaced vibrant discussion of public issues. This depreciation of the public discourse can be apprehended if we conceptualize this problematic as a postmodern phenomenon. By borrowing vocabulary and concepts from postmodern thought, we can try to figure out what is going on. How is modernity different from postmodernity? How does reality become hyperreality? After a description of postmodern conditions—and the implications of this for public policy discourse—the “war on drugs” is deconstructed to supply a vivid example of the slippery slope from reality to hyperreality.

In the next decade, American productivity and the ability to compete in an international market will be adversely affected by labor shortages and an aging workforce. The anticipated labor shortages are explained by simple demographics. After the baby-boom, the mid-1970s were featured by having the lowest birthrate (14.6 newborns per 1,000 people) in U.S. history; the prelude to the labor shortage is represented with 1992 having the smallest high-school graduating class in the past three decades.(1) It is expected that the growth of the 1990s workforce will be about one-third of that of the 1970s, and it is feared that the new workforce may lack many basic skills needed for the future job market.(2,3) To compound the problem of projected labor shortages, the baby-boomers from the 1950s represent an aging workforce. By the year 2000, the average age of the American worker will be 39 years.(4) As individuals reach the mid-career stage of their life, several factors acting in concert tend to alter personal needs, values, and ultimately performance on the job.(5,6,7,8,9) For instance, obsolescence in the workforce is a major concern of individuals and organizations. As technology and knowledge proliferate, the "half-life" of one's effective career is significantly reduced.(10,11,12) For many mid-career workers, reaching a stage of no further (13,14,15) advancement, or plateauing is a serious concern. Finally, the social attitude toward older workers is reflected in the need for federal laws to prevent discrimination against individuals between the ages of 40 and 70 years (Age Discrimination in Employment Act, 1967 with 1978 Amendment). With these factors influencing the lives of mid-career workers, it is not unusual to observe performance evaluations dropping after the age of 40.(16) In spite of the dismal outlook for mid-career personnel in the job market, some authors(17,18) view the older members of the workforce to be a solution to the pending personnel management problem, instead of a major component of the problem itself. As anticipated labor shortages and the aging workforce become more evident, literature related to personnel management is inundated with studies and theories of how organizations can deal with these changes.(19) However, the issue of mid-career workers is very complex, involving a variety of interrelated issues (e.g., values, motivation, work and non-work satisfaction, retraining, and professionalism), resulting in the amount of information available on any single topic often being diluted. Furthermore, discrepancies between problem definition, sectors of the workforce examined (e.g., organizational hierarchy or professions), factors examined (e.g., attitude, performance, or job satisfaction), methods of analysis, and interpretation of results, leaves very little to extrapolate for situations "closer to home." Regardless of the limitations of the vast amount of literature, the personnel management problems presented above are real, and proactive approaches to these issues are overdue. For this reason, there is a need to be able to identify some of the working parameters that may have broad application. The following contribution attempts to identify some of the important aspects of the mid-career issue, so that a rationale for organizational approaches can be developed. A fundamental aspect of this study is to build an understanding of the characteristics of the mid-career worker, particularly with respect to career stage, motivation, and career development. With this understanding in place, it may be possible to appreciate the value of different organizational actions toward mid-career workers, as well as gain an insight to anticipated personnel trends of the next century. Characteristics of "Mid-Career" Workers Stages. - The meaning of "mid-career" is varied in the literature. The concept of "mid-career" has been used in terms of tenure in a position(20), duration in an occupation(21), as well as time in the workforce. …

This paper analyzes use of the term "professionalism" in public administration by language usage analysis—an interpretive methodology. It begins by arguing against static interpretation of professionalism implied by the sociological model. It then explores various meanings of professionalism by using a series of antinomies: professional-laity, professional-amateur, achievement-ascription, and professionals as a new class in opposition to other classes. Each antinomy reveals meanings of professionalism that public administrators should avoid or embrace in their quest to make public administration a widely recognized profession. Concluding remarks suggest a particular definition of professionalism appropriate to public administration.

This article identifies a "discretion school" or position within current public administration theory and the proximate historical causes for its articulation. The extent to which administrative discretion is thought to be permissible, and the justifications for it, are explored by way of comparing current views to Plato `s explication of the functions of the guardian class in the ideal Republic. Contemporary analogues to "knowledge of the good " (public interest and regime values) and the role of education are arrayed. The article concludes by posing problematics heretofore insufficiently resolved by discretionist points of view.