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On 30 September 2009 at 05:16 pm local time (10:16 am UTC), a major earthquake registering a magnitude M 7.6 occurred off the coast of Padang in West Sumatra. This paper presents the observations from a reconnaissance mission that investigated the performance of structures, infrastructure and geotechnical structures within the affected region. As well as presenting the detailed observations made on the mission, insights as to why structures failed and deficiencies in the construction practices of the region are also presented. Considering the high seismic risk of this area and that seismic gaps suggest another earthquake with a magnitude greater than 8.7 may occur, these observations are particularly significant. One of the vital features of this earthquake was a number of very large and devastating landslides that occurred in the district of Pariaman. These landslides were not only extensive, but had an extremely high lethality. Another key feature of the earthquake was the surprisingly high number of government buildings that collapsed. The paper concludes by presenting a number of recommendations for both the rebuilding of failed structures as well as for hazard assessments of existing structures and geotechnical features. [ABSTRACT FROM AUTHOR]

Background: Pulmonary embolism is a common, often fatal condition that requires timely recognition and rapid institution of therapy. Previous studies have documented worse outcomes for weekend admissions for a variety of time-sensitive medical conditions. This phenomenon has not been clearly demonstrated for pulmonary embolism.Methods: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for the years 2000 to 2008 to identify people with a principal discharge diagnosis of pulmonary embolism. We classified admissions as weekend if they occurred between midnight Friday and midnight Sunday. We compared all-cause in-hospital mortality between weekend and weekday admissions and investigated the timing of inferior vena cava (IVC) filter placement and thrombolytic infusion as potential explanations for differences in mortality.Results: Unadjusted mortality was higher for weekend admissions than weekday admissions (OR, 1.19; 95% CI, 1.13-1.24). This increase in mortality remained statistically significant after controlling for potential confounding variables (OR, 1.17; 95% CI, 1.11-1.22). Among patients who received an IVC filter, a larger proportion of those admitted on a weekday than on the weekend received it on their first hospital day (38% vs 29%, P < .001). The timing of thrombolytic therapy did not differ between weekday and weekend admissions.Conclusions: Weekend admissions for pulmonary embolism were associated with higher mortality than weekday admissions. Our finding that IVC filter placement occurred later in the hospital course for patients admitted on weekends with pulmonary embolism suggests differences in the timeliness of diagnosis and treatment between weekday and weekend admissions. Regardless of cause, physicians should be aware that weekend admissions for pulmonary embolism have a 20% increased risk of death and warrant closer attention than provided during the week. [ABSTRACT FROM AUTHOR]

Stratifying preoperative risk and guiding perioperative therapy objectively has acquired critical importance, given robust data demonstrating that morbidity following non-cardiac surgery confers substantially increased risk of death, even beyond hospital discharge. The development of useful perioperative biomarkers depends fundamentally on both prospective morbidity data that enable the identification of higher risk patients as well as the translational understanding of pathophysiological mechanisms underlying postoperative organ dysfunction, the development of which may be specific to the perioperative environment. The emergence of cardiac insufficiency, rather than cardiac ischaemia, as the dominant factor associated with excess risk of prolonged postoperative morbidity has promoted the application of biomarkers used commonly in cardiovascular medicine. Several novel, organ specific biomarkers offer potential perioperative application. Nevertheless, common tests/biomarkers that are widely available do provide valuable, objective information that is perhaps under-utilised perioperatively. Despite significant challenges, perioperative medicine presents exciting-arguably unique-opportunities for novel biomarker development. [ABSTRACT FROM AUTHOR]

Although keeping patients informed is a part of quality hospital care, inpatients often report they are not well informed. The authors placed whiteboards in each patient room on medicine wards in their hospital and asked nurses and physicians to use them to improve communication with inpatients. The authors then examined the effect of these whiteboards by comparing satisfaction with communication of patients discharged from medical wards before and after whiteboards were placed to satisfaction with communication of patients from surgical wards that did not have whiteboards. Patient satisfaction scores (0-100 scale) with communication improved significantly on medicine wards: nurse communication (+6.4, P < .001), physician communication (+4.0, P = .04), and involvement in decision making (+6.3, P = .002). Patient satisfaction scores did not change significantly on surgical wards. There was no secular trend, and the authors excluded a trend in overall patient satisfaction. Whiteboards could be a simple and effective tool to increase inpatient satisfaction with communication. [ABSTRACT FROM AUTHOR]

The objective of the ENIQ 2nd pilot study was to show how to fully exploit the potential of technical justifications (TJ) in the qualification of inspection procedures and thereby reduce the number of test-piece trials on full-scale components. As the subject of the study, a ferritic BWR-type nozzle to shell weld was selected. A TJ was produced, partly relying on modelling, to predict whether a designated ultrasonic inspection would be successful in detecting the specified defects. In parallel, a test-piece with deliberately introduced defects was fabricated and inspected with the inspection system specified in the TJ. Predictions and inspection results were compared. In addition, as a separate exercise, three different mathematical models were used to predict the responses of the defects in the test-piece to provide information on model applicability and accuracy of prediction. The ENIQ 2nd pilot study has been largely successful in showing that TJs have the potential to predict the outcome of specific inspections and so reduce or remove the need for large scale test-pieces in qualification. The project has shown that models are available which give largely conservative predictions of defect response when used within their regimes of validity. [ABSTRACT FROM AUTHOR]

Background: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice.Objective: To compare the effectiveness and safety of 3 guideline implementation strategies.Design: Cluster-randomized, controlled trial.Setting: 32 emergency departments in Pennsylvania and Connecticut.Patients: 3219 patients with a clinical and radiographic diagnosis of pneumonia.Interventions: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12).Measurements: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients.Results: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions.Limitations: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial.Conclusions: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients. [ABSTRACT FROM AUTHOR]

Context: There is agreement that warfarin decreases stroke risk in patients with atrial fibrillation (AF), but prior studies suggest that warfarin is markedly underused, for unclear reasons.Objective: To determine if warfarin is underused in the treatment of patients with atrial fibrillation.Design: Cross-sectional.Setting: Tertiary care VA hospital.Patients: All patients with a hospital or outpatient diagnosis of AF between 10/1/95 and 5/31/98.Data Collection: One or more physician investigators reviewed pertinent records for each patient. When any of the 3 investigators thought warfarin might be indicated, the patient's primary care provider completed a survey regarding why warfarin was not used.Results: Of 1,289 AF patients, 844 (65%) had filled at least 1 warfarin prescription. Of the 445 remaining, 19 had died, 5 had inadequate medical records, and 54 received warfarin elsewhere, leaving 367 patients. Of these, 160 had no documented AF, 53 had only a history of AF, and 49 had only transient AF. Of the remaining 105 patients, 17 refused warfarin therapy and 72 had documented contraindications to warfarin use including bleeding risk or history, fall risk, alcohol abuse, or other compliance problems. The reasons for not using warfarin among the 16 patients remaining included provider oversight (n = 4) and various reasons suggesting provider knowledge deficits.Conclusion: In contrast to prior studies that suggested that warfarin is markedly underused, we found that few patients with AF and no contraindication to anticoagulation were not receiving warfarin. We believe that differing study methodologies, including the use of physician review and provider survey, may explain our markedly different rate of warfarin underutilization, although local institutional factors cannot be excluded. The findings suggest that primary providers may be far more compliant with the standard of care for patients with atrial fibrillation than previously believed. [ABSTRACT FROM AUTHOR]

Findings from a survey of 796 high school children in four districts constituting a health administrative area were examined to ascertain the factors influencing their dental disease experience, treatment received and attendance pattern. In three of the four districts, over 60 % of the children were regular attenders, enjoying the benefit of less active caries than irregular attenders. However, in the remaining district, much of which consisted of depressed, inner city areas undergoing re-development, only one third were regular attenders. Several local factors, such as availability and accessibility of services, probably influenced the numbers seeking regular care, but one of the most important appeared to be the level of provision in the salaried Community Dental Service. The implications of the findings for planning improvements in local services are discussed. [ABSTRACT FROM AUTHOR]

Presents a study that explored the application of a catchment fecal-indicator budget approach to the examination of fecal-indicator sources impacting on coastal recreational water quality. Characterization of water quality in sewage effluent and riverine inputs; Measurement and estimation of input flows; Effect of sewage-treatment scenarios on budgets.

Xanthine dehydrogenase, a molybdenum, iron-sulfur flavoenzyme encoded in the fruit fly Drosophila melanogaste by the rosy gene has been characterised both from the withtype and mutant flies Enzyme assays. using a variety of different oxidising and reducing substrates were supplemented by limited molecular characterisation. Four rosy strains showed no detectable activity in any enzyme assay tried, whereas from four wild-type and three rosy mutant strains, those for the [E89K], [ L127F] and [L1 57P]xanthine dehydrogenases (in all of which the mutation is in the iron -sulfur domain), the enzyme molecules. although present at different levels, had extremely similar or identical properties. This was confirmed by purification of one wild-type and one mutant enzyme. [E8QK] xanthine dehydrogenase. These both had ultraviolet -visible absorption spectra similar to milk xanthine oxidase Both were found to be quite stable molecules showing very high catalytic centre activities and with little tendency to become degraded by proteoIysis or modified by conversion to oxidase or desulfo forms. In three further rosy strains, giving [G353D] xantine dehydrogenase and [S357F]xanthine dehydrogenase mutated in the flavin domain, and [G1011E] xanthine dehydrogenase mutated in the molybdenum domain, enzyme activities were selectively diminished in certain assays. For the G353D and S357F mutant enzymes activities to NAD+ as oxidising substrate were diminished, to zero for the latter In addition for [G53D] xanthine dehydrogenase. there was an increase in apparent Km, values both for NAD and NADH. These findings indicate involvement of this part of the sequence in the NAD -binding site. The G1011 E mutation has a profound effect on the enzyme As isolated and as present in crude extracts of the flies, this xanthine dehydrogenase variant lacks activity to xanthine or pterin as reducing substrate, indicating an impairment of the functioning of its molybdenum center. However, it remain full activity to NADH with dyes as oxidising substrate. Mild oxidation of the enzyme converts it apparently irreversibly to a form showing full activity to xantine and petrin. The nature of the group that is oxidised is discussed in the light of redox potential data. It is proposed that the process involves oxidation of the pterin of the molybedenum cofactor from the tetrahyro to a dihydro oxidation state. This conclusion is fully consistent with recent information [Rom&asim;o M. J., Archer , M., Moura, I., Moura, J.J.G., LeGall, J., Engh, R., Schneider, M., Hof, P. & Hubber, R. (1995) Science 270, 1170-1176] from X-ray crystallography on the structure of a closely related enzyme from Desulfovibrio giagas. It is poposed, that apparent irreversibility of the oxidative activating process for [G1011E] xantine dehydrogenase, is due to conversion of its pterin to the tricyclic derivative detected by these workers. The data thus provide the strongest evidence available, that the oxidation state of the pterin can have a controlling influence on the activity of a molybdenum cofactor enzyme. Implications regarding ptering incorporation into xanthine dehydrogenase and in relation to other molybdenum enzymes are discussed. [ABSTRACT FROM AUTHOR]

A survey of the dental health and need for treatment of 796 children, one in 10 of those in the 1st and 3rd years of high schools in a health administrative area, was carried out using a comprehensive, computerized, epidemiological information system. The system was designed to aid in planning and evaluating services and expressed treatment need on the Resource Related Index as well as utilizing conventional indices. A baseline profile of the dental condition of children in four districts was obtained. This was compared with findings from other surveys. The problem of inter examiner reliability was also discussed. [ABSTRACT FROM AUTHOR]

Objective: To determine, in a representative sample of patients drawn from a variety of hospitals, the degree of adherence to consensus recommendations for anticoagulation among patients with deep vein thrombosis or pulmonary embolism.Design: Cross-sectional review of a population-based random sample.Setting: Twenty-one randomly selected Pennsylvania hospitals.Patients: Of 357 randomly selected Medicare beneficiaries discharged from study hospitals with a diagnosis of deep venous thrombosis or pulmonary embolism during 1992, 43 charts were not reviewed for administrative reasons, 31 were miscoded or not treated with intravenous administration of heparin, and 13 were excluded for other reasons, leaving 270 in the final sample.Measurements and Main Results: Overall, 179 patients (66%, 95% confidence interval [CI] 59%, 72%) received therapeutic anticoagulation (two consecutive partial thromboplastin times more than 1.5 times control) within 24 hours of starting heparin. Platelet counts were checked at least once during the first week of heparin therapy in 66% (95% CI 58%, 74%). At least 5 days of heparin therapy was given to 84% (95% CI 79%, 87%). Among 266 (99%) of the patients receiving warfarin, 193 (72%; 95% CI 63%, 80%) received heparin until the prothrombin time ratio or International Normalized Ratio was therapeutic. Patients who were started on warfarin therapy within 2 days of heparin had decreased length of stay (geometric mean 8.2 vs 9.7 days, p = .003). Compliance varied among hospitals.Conclusions: In a wide variety of hospitals, we found fair, but variable, compliance with consensus recommendations for anticoagulation of patients with venous thromboembolic disease. Simple interventions to improve compliance with these recommendations might improve quality of care and reduce costs. [ABSTRACT FROM AUTHOR]

Objective: To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans.Design: Cross-sectional survey.Setting: Tertiary care Department of Veterans Affairs hospital.Patients: Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study.Measurements and Main Results: Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward the procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician.Conclusions: Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization. [ABSTRACT FROM AUTHOR]

Using a 5% nationally random sample of Medicare beneficiaries, we calculated the probability of dying, the probability of being readmitted, and the mean level of inpatient hospital expenditures within various time periods following discharge for those beneficiaries who were discharged alive from an acute-care hospital during 1983. We then examined the 674 most common principal discharge diagnoses and found significant variations by diagnosis code for all three outcomes. We believe that analyses of claims data by diagnosis code can provide useful information to clinicians and their patients regarding the clinical and economic prognosis of specific diseases, help managed-care programs identify patients likely to incur substantial costs over a several-year period, and inform insurers regarding the expected level of resources that will be used following discharge for patients with specific diseases. [ABSTRACT FROM AUTHOR]

The use of administrative data to study pneumonia is limited because International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM) diagnosis codes do not specify whether pneumonia is community-ac quired (CAP), a key clinical distinction. We classified 212 patients discharged with a diagnosis code for pneumonia as to whether or not they had CAP, using three adminis trative data-based systems (Diagnosis Related Groups (DRGs) alone, principal diagnosis alone, and a complex al gorithm). We examined agreement with classification by clinician chart review. We also compared the length of stay (LOS) and mortality among the CAP populations identi fied with different methods. Agreement between the clin ical review and the three administrative data methods ranged from 86 to 80%. Classification by DRG performed least well. Populations defined by claims data had similar mortality but shorter mean LOS (9.70, 9.40, and 7.91 days for the algorithm, principal diagnosis and DRG methods, respectively) than the clinically defined population (10.85 days). We conclude that studies of CAP using populations identified by claims may underestimate LOS. [ABSTRACT FROM PUBLISHER]