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Background Chronic disease is a significant burden on the global population. The Helping Everyone Achieve Long Term Health (HEALTH) Passport is a paper-based approach previously utilized to help adults modify clinical risk factors through lifestyle, which may be effective in improving the long-term health of school-age children. This study investigates the feasibility of in-school use by engaging trainee teachers in primary and secondary education. Methods Two hundred and fifty six unique responses were collated to evaluate current teaching of the main health risk factors and HEALTH Passports specifically adapted for schools. Trainees attended workshops with pre- and post-questionnaires used to measure training efficacy and evaluate the Passports’ suitability for in-school use. Narrative analysis of feedback was performed. Results Feedback received for both Passports was positive overall. Trainees highlighted the need for the Passports to be further age differentiated. Significantly increased confidence (P Conclusions The HEALTH Passport has potential as an intervention to improve health literacy in school-age children. Age adaptation is needed with references to weight measures removed. Emotional well-being should be focused on, and data management stringently assessed for child protection.

To study the scope of clinical activities and the postoperational attitudes of mental health professionals responding emergently to a mass urban evacuation.Eleven mental health care providers participating in a reception team for medical evacuees after Hurricane Katrina were asked to complete a survey seeking data regarding cases encountered, psychopharmacologic interventions, and mental health support for evacuated medical personnel. Participants rated their levels of agreement with statements characterizing various aspects of the clinical experience.Nine of 11 providers returned surveys, for a response rate of 82%. Among 35 evacuees requiring immediate psychiatric consultation, acute stress disorder and dementia, equally represented among these cases, accounted for half the diagnoses. Medication interventions were relatively uncommon. Consultants provided mental health support to 14 evacuated medical professionals. Although somewhat uncertain about their role, psychiatric consultants strongly agreed that they would be willing to serve in future disaster operations of this type.In major disasters, psychiatric consultants are likely to play a critical role in providing emergency mental health services for both medical evacuees and evacuated medical professionals.

The authors aimed to determine the functional improvement rate over a 5-year interval among patients who had undergone index finger pollicization for isolated thumb absence compared with age-matched controls. They also investigated suggestions in previous reports that tissue remodeling in reconstructed thumbs causes improvements in function outpacing normal development.Five patients (seven hands) evaluated 5 years earlier with grip, lateral pinch, and tripod pinch strength tests; the pegboard Functional Dexterity Test; the Jebsen Hand Function Test; standard radiographs; and parent questionnaires on appearance, social interactions, and functionality were reevaluated. Percentage changes were compared with expected changes from published norms.Regarding grip strength, patients showed a 148 percent increase compared with 102 percent in controls. Regarding lateral and tripod pinch, patients had 99 and 125 percent increases compared with 78 and 69 percent in controls, respectively; the differences were not significant between groups. Functional dexterity outcomes showed the same trend. Controls improved in the five administered subtests of the Jebsen tests. In three Jebsen subtests, patients accomplished the tasks in 40 to 45 percent less time than 5 years previously. Parent perspectives were comparable to 5 years previously. Previously, 60 percent of responses were in the best category and 4 percent were in the worst category. Those percentages were 58 and 6 percent, respectively, in this study.Although this was a small study group, it seems that children who have undergone index finger pollicization have changes in function comparable to normal development. Parents still have positive perspectives of the reconstructed thumb. There is no evidence that tissue remodeling causes improvement outpacing normal development.

Previous studies have shown that a high level of dietary lipid (corn oil) exacerbates UV-carcinogenic expression in hairless mice. Furthermore, it was demonstrated that this effect occurs at the postinitiation, or promotion, stage of UV-carcinogenesis--a stage believed to be modulated immunologically. Thus, we sought to examine the influence of dietary lipid on specific immune parameters at various times within a UV-carcinogenic protocol, with the purpose of detecting potential relationships to UV carcinogenesis. Hairless mice were fed either a high- (12%, wt/wt, corn oil) or low-fat (0.75%, wt/wt, corn oil) diet for 2 weeks prior to start of the UV or experimental protocols. Animals were sensitized to dinitrochlorobenzene (DNCB) hapten and delayed-type hypersensitivity (DTH) was assessed. Delayed-type hypersensitivity was significantly suppressed (P = 0.01) in the high-fat group, even before UV irradiation. Although both groups exhibited UV-induced suppression of this response, the high-fat group was totally suppressed after 3 weeks of UV, whereas the low-fat group exhibited reactivity through week 8. The splenic T-lymphocyte (Thy 1.2+) population had declined by about 50% at the time of UV termination (11 weeks). Dietary lipid exerted no apparent influence upon this T-cell population. However, after 6 weeks of UV, I-J+ cells (a marker shown to be acquired adaptively by suppressor T lymphocytes) began to increase. By week 15 (4 weeks post-UV) I-J+ cells had increased by about 65% in the high-fat group, twice the % increase that occurred in the low-fat group. When UV-induced tumors were transplanted to recipient animals receiving various periods (0, 6, 11 weeks) of UV irradiation, no significant differences in median tumor rejection times between the two dietary groups occurred at 0 or 6 weeks. After 11 weeks of UV, the low-fat group exhibited a tumor rejection time that was comparable to that of nonirradiated animals, i.e. 21 days. However, median tumor rejection time for the high-fat group was greater than 63 days, significantly (P = 0.01) longer than that of the low-fat group. Thus, suppression of tumor rejection by high fat occurred at a time when high fat had been shown to exacerbate carcinogenic expression and when I-J+ cells had markedly increased. These data demonstrate that level of dietary lipid modulates immunoresponsiveness in UV-irradiated animals and is compatible with the thesis that immune suppression may account for the exacerbation of carcinogenic expression elicited by high dietary fat.

Background. It is well documented that infective endocarditis (IE) is strongly associated with morbidity and mortality in haemodialysis (HD) patients. Less clear are the mortality risk factors for IE, particularly in an urban African-American dialysis population. Methods. IE patients were identified from the medical records for the period from January 1999 to February 2004 and confirmed by Duke criteria. The patients were classified as ‘survivors’ and ‘non-survivors’ depending on in-hospital mortality, and risk factors for IE mortality were determined by comparing the two cohorts. Survivors were followed as out-patients with death as the endpoint. Results. A total of 52 patients with 54 episodes of IE were identified. A catheter was the HD access in 40 patients (74%). Mitral valve (50%) was the commonest valve involved, and Gram-positive infections accounted for 87% of IE. In-hospital mortality was high (37%) and valve replacement was required for 13 IE episodes (24%). On logistic regression analyses, mitral valve disease [P ¼ 0.002; odds ratio (OR) ¼ 15.04; 95% confidence interval (CI) ¼ 2.70–83.61] and septic embolism (P ¼ 0.0099; OR ¼ 9.56; 95% CI ¼ 1.72–53.21) were significantly associated with in-hospital mortality. Using the Cox proportional hazards model, mitral valve involvement (P ¼ 0.0008; hazard ratio 4.05; 95% CI ¼ 1.78–9.21) and IE related to drug-resistant organisms such as methicillin-resistant Staphyloccus aureus and vancomycin-resistant Enterococcus sp. (P ¼ 0.016; hazard ratio 2.43; 95% CI ¼ 1.18–5.00) were associated with poor outcome after hospital discharge. Conclusions. IE was associated with high mortality in our predominantly African-American dialysis population, when the mitral valve was involved, or septic emboli occurred and if MRSA or VRE were the causal organisms.

Lymphedema, infection, and healing delay are among feared complications in patients undergoing upper extremity surgery after prior mastectomy and axillary dissection with or without radiation therapy. Most of these cancer patients are advised to avoid any procedure on their ipsilateral upper extremity including blood pressure monitoring, intravenous punctures, and surgery. As a result, many of these patients hesitate to undergo necessary upper extremity surgery such as arthritis surgery and even carpal tunnel release. Many hand and upper extremity surgeons believe that these precautions are unnecessarily stringent and believe that indicated upper extremity surgeries could be performed safely in these patients. We surveyed 1,200 members of The American Society for Surgery of the Hand and the 606 returned questionnaires were analyzed. More than 95% of the hand surgeons surveyed do not hesitate to perform surgery on an upper extremity in a patient after ipsilateral lymphadenectomy and/or irradiation, decreasing to 85% if there is pre-existing chronic lymphedema; 94% use a tourniquet in a routine fashion (74% use a tourniquet in the presence of existing lymphedema); 46% use a Bier block when clinically indicated (only 21% would use a Bier block in a patient with lymphedema); and 36% are comfortable using an axillary block (25% in the case of lymphedema). Thus, most of the polled surgeons would prefer to perform surgery on these patients under a general anesthetic, but still would use an extremity tourniquet for a bloodless surgical field in their routine manner. The rate of reported complications in these patients was 23% in patients with pre-existing chronic lymphedema and only 3% in patients with no lymphedema. After surgery, 46.2% of the surgeons do not undertake any additional precautions than in their routine practice with all upper extremity surgery patients. However, 53.8% would change their routine practice for such patients and these changes range from placing the surgical tourniquet on the forearm instead of the upper arm, use of perioperative prophylactic antibiotics in all patients irrespective of the type of surgery, use of postoperative compression garments, and specific postoperative hand therapy aimed at the prevention of postoperative edema.

Background We assessed the impact of restricting surgical resident work hours as required by the Accreditation Council for Graduate Medical Education (ACGME), on postoperative outcomes. Materials and methods The divisions of General and Vascular Surgery at the Michael E. DeBakey Houston Veteran Affairs Medical Center implemented a limited work hours schedule effective October 1, 2002. We compared the rate of postoperative morbidity and mortality before and after the new schedule. Clinical data were collected by the VA National Surgical Quality Improvement Program (NSQIP) for the periods of October 1, 2001 to September 30, 2002 (preintervention), and October 1, 2002 to September 30, 2003 (postintervention). We assessed risk-adjusted observed to expected (O/E) ratios of mortality and prespecified postoperative morbidity for each study period. Results In the preintervention period, there were 405 general surgery and 202 vascular surgery cases as compared to 382 and 208 cases, respectively in the postintervention period. There were no significant differences in mortality O/E ratios between the pre- and postintervention periods (0.63 versus 0.60 in general surgery; 0.78 versus 0.81 in vascular surgery; P = 0.90 and 0.94, respectively) or in morbidity O/E ratios (1.06 versus 1.27 in general surgery; 1.47 versus 1.50 in vascular surgery; P = 0.20 and 0.90, respectively). Conclusion The restricted resident work hour schedule in general and vascular surgery in our facility did not significantly affect postoperative outcomes.

Multidisciplinary treatment programs for chronic pain typically emphasize the importance of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Sup- port. A previous validation study with 210 patients in a Canadian academic hospital setting supported an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564 veterans with a more extended history of chronic pain. Patients completed the study questionnaires before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed with depression, pain interference, general activity level, disability, and pain severity as the criterion variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demo- graphic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and the regression analyses supported the predictive validity of the CPCI scales, as indicated by their association with measures of patient adjustment to chronic pain. Perspective: This article validated the 8-factor structure of the CPCI by using a confirmatory factor analysis and a series of linear regressions. The results support the applicability and utility of the CPCI in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral pain coping strategies that might have an impact on patient outcomes.

After surgery for trauma or correction of congenital anomaly, hand function is difficult to evaluate in children because there are no reference norms on children 3 to 5 years old. The purpose of this study was to determine whether reproducible normative values for hand dexterity and grip and pinch strength could be obtained in young children using simple tests that could be administered quickly within the attention span of a 3- to 5-year-old. The Functional Dexterity Test (FDT), a pegboard test validated for adults and older children, seemed to meet our requirements for dexterity. The FDT was administered to a convenience sample of normal children in a prekindergarten school who were grouped according to age: 3-year-olds (n = 17), 4-year-olds (n = 24), and 5-year-olds (n = 22). Hand dominance was determined. The task was demonstrated by 1 of the 2 testers. The child was asked to turn the pegs over in the pegboard without using the free hand or balancing the peg against the chest. Both hands were tested. Grip and pinch strengths were measured in both hands in a consistent manner. All the children were tested with the arm at the side and the elbow at 90 degrees. A dynamometer was used for grip strength and a pinch meter was used to measure key (lateral) and tripod pinch strengths. Means and SDs were calculated for each age group, and the dependent values of dexterity, strength, and dominance were correlated. Dexterity and strength scores were significantly different by age group. A good FDT score in the dominant hand was predictive of a good score in the nondominant hand. Grip and pinch strength correlated poorly with functional dexterity. The normative values established in this study for children in the 3- to 5-year-old range can be referenced for disability estimates and establishing goals for children after surgery or hand injury.

Research has established a positive association between appraisals of control over pain and indexes of adaptive psychologic and physical functioning among persons with chronic pain. A number of measures of control appraisals have been used in the research literature. The current study sought to determine the number of factors or dimensions embedded in these commonly used measures of pain control appraisal. The study also sought to determine the association between the control appraisal construct(s) and measures of patient functioning. Two hundred fifty-two persons with chronic pain completed a questionnaire packet that included multiple measures of control appraisals. A factor analysis resulted in 6 factors: 1 factor representing beliefs about control over life in general, 1 representing perceived control over the effects of pain on one's life, and remaining 4 factors that appear to be more closely tied to perceived control over pain itself. Consistent with previous research, control appraisals made a significant contribution to the prediction of functioning (depression, disability, and pain interference). Most importantly, perceived control over the effects of pain on one's life and perceived control over life in general were more strongly associated with functioning than perceptions of control over pain itself. © 2002 by the American Pain Society

Neurocysticercosis, a parasitic infection of the human central nervous system caused byTaenia solium, is a leading cause of seizures. Seizures associated with neurocysticercosis are caused mainly by the host inflammatory responses to dying parasites in the brain parenchyma. We previously demonstrated sequential expression of Th1 cytokines in early-stage granulomas, followed by expression of Th2 cytokines in later-stage granulomas in murine cysticercosis. However, the mechanism leading to this shift in cytokine response in the granulomas is unknown. Neuropeptides modulate cytokine responses and granuloma formation in murine schistosomiasis. Substance P (SP) induces Th1 cytokine expression and granuloma formation, whereas somatostatin inhibits the granulomatous response. We hypothesized that neuropeptides might play a role in regulation of the granulomatous response in cysticercosis. To test this hypothesis, we compared expression of SP and expression of somatostatin in murine cysticercal granulomas by using in situ hybridization and immunohistochemistry. We also compared expression with granuloma stage. Expression of SP mRNA was more frequent in the early-stage granulomas than in the late-stage granulomas (34 of 35 early-stage granulomas versus 1 of 13 late-stage granulomas). By contrast, somatostatin was expressed primarily in later-stage granulomas (13 of 14 late-stage granulomas versus 2 of 35 early-stage granulomas). The median light microscope grade of SP mRNA expression in the early-stage granulomas was significantly higher than that in the late-stage granulomas (P= 0.008, as determined by the Wilcoxon signed rank test). By contrast, somatostatin mRNA expression was higher at later stages (P= 0.008, as determined by the Wilcoxon signed rank test). SP and somatostatin are therefore temporally expressed in granulomas associated with murine cysticercosis, which may be related to differential expression of Th1 and Th2 cytokines.

Purpose: The capacity of a preexisting coating of Escherichia coli 83972 to reduce catheter colonization by Enterococcus faecalis 210 was investigated. Enterococcus was chosen for these trials since it is a common urinary pathogen in patients with an indwelling urinary catheter.Materials and Methods: Each experiment tested 3 growth conditions. Group 1 or E. coli plus Enterococcus catheters were exposed to E. coli 83972 for 24 hours and then to Enterococcus for 30 minutes. Group 2 or E. coli alone catheters were incubated in E. coli for 24 hours and then in sterile broth for 30 minutes. Group 3 or Enterococcus alone catheters did not undergo the initial incubation with E. coli before the 30-minute incubation with Enterococcus: All catheters were then incubated in sterile human urine for 24 hours. Catheters were washed with saline and cut into 5, 1 cm. segments. Each segment was sonicated and the sonication fluid was diluted and plated. The results of each of the 5 segments were averaged and the set of expe...

Objectives The present cross-sectional study analyzed the prevalence and severity of depressive symptoms among patients with Alzheimer's disease (DAT), vascular dementia (VAD), and among the cognitively normal elderly. Putative risk factors contributing to depression were likewise evaluated. Methods Seventy-six DAT patients, 51 VAD patients, and 121 cognitively normal subjects were admitted to the study. Questionnaires concerning demography and their vascular and familial risk factors together with results of neuropsychological testing by combined Mini-Mental Status Examinations (MMSE), Cognitive Capacity Screening Examinations (CCSE), and Hamilton Depression Rating Scales (HDRS) were obtained so that resulting data would be statistically analyzed. Results Prevalence of depressive symptoms among VAD, DAT, and cognitively normal elderly were 31.4%, 19.9%, and 13.2%, respectively. 25.5% of VAD and 13.2% of DAT patients had depression of mild to moderate degrees. Regression analysis revealed that diagnosis of VAD and DAT, heart disease, and past history of depression was significantly associated with high HDRS scores. There was no correlation between degree of depression and severity of cognitive impairments. Conclusion Mild to moderate depression is a common comorbidity with organic dementia, especially VAD, but associated depression is independent of severity of cognitive impairments. Copyright © 2001 John Wiley & Sons, Ltd

Vascular headaches, including migraine, cluster, and migrainous transformation to chronic daily headaches, are disabling. During and shortly after headache intervals, difficulties are reported in concentration, comprehension, and communication, not accounted for by nausea, photophobia, or sonophobia. These interfere with interpersonal relations and performance at work with economic loss. The hypothesis tested and reported here is that cognitive impairments comprise an important part of vascular headache diatheses. One hundred ninety-six otherwise normative subjects suffering from migraine or cluster, but not tension-type, headaches (136 women, 63 men; mean age, 46 years) participated in an outpatient prospective trial. One hundred thirty-three patients had migraine without aura, 39 migraine with aura, 11 periodic cluster (by IHS criteria), and 13 had migrainous transformation into chronic daily headaches. Neuropsychological testing was compared with and without headaches, by combined Mini-Mental Status Examination (MMSE), Cognitive Capacity Screening Examination (CCSE), and Hamilton Depression Rating Scale (HDRS). During headache intervals, significant decline was measured in both CCSE and MMSE scores (P

Objectives. To examine the efficacy of bladder catheters impregnated with minocycline and rifampin in reducing catheter-associated bacteriuria. Methods. A prospective, randomized clinical trial was conducted at five academic medical centers. Patients undergoing radical prostatectomy were randomized to receive intraoperatively either regular silicone bladder catheters (control catheters) or silicone bladder catheters impregnated with minocycline and rifampin (antimicrobial-impregnated catheters). Catheters remained in place for a mean of 2 weeks. Urine cultures were obtained at about 3, 7, and 14 days after catheter insertion. Bacteriuria was defined as the growth of organism(s) in urine at a concentration of 104 colony-forming units per milliliter or greater. Results. Kaplan-Meier analysis demonstrated that it took significantly longer for patients (n = 56) who received the antimicrobial-impregnated catheters to develop bacteriuria than those (n = 68) who received the control catheters (P = 0.006 by the log-rank test). Patients who received the antimicrobial-impregnated catheters had significantly lower rates of bacteriuria than those in the control group both at day 7 (15.2% versus 39.7%) and at day 14 (58.5% versus 83.5%) after catheter insertion. Patients who received the antimicrobial-impregnated catheters had significantly lower rates of gram-positive bacteriuria than the control group (7.1% versus 38.2%; P

Background: Anecdotal descriptions of the discovery of occult breast cancers in reduction mammaplasty patients during the perioperative period have appeared in the literature. Subsequently, recommendations for routine preoperative and postoperative mammographic screening for reduction mammaplasty patients have been published. Other authors have recommended that only patients at risk according to the American Cancer Society’s guidelines should have mammographic screening. Objective: The purpose of this study was to resolve some of the conflicting conclusions presented in the literature. Methods: Twenty reduction mammaplasty patients underwent preoperative and postoperative mammography. The mammograms were randomly mixed and evaluated in a blind study by 2 radiologists, who were asked to identify and describe any mammographic abnormalities, indicate which films were preoperative and which were postoperative, and make recommendations for the patient represented in each film. Results: None of the mammograms identified as preoperative by the radiologists demonstrated any confirmed breast malignancies. Both radiologists reported some abnormalities among the preoperative views and identified a number of characteristic postoperative radiologic changes. Recommendations for patients represented in the films included additional views, repeat interval films, and biopsy. One radiologist accurately identified preoperative and postoperative mammograms in 72% of the films and the other radiologist in 54% of the films, with an overall agreement between the radiologists of only 50%. Conclusions: The radiologists’ evaluations led the authors to recommend against routine preoperative mammography in all breast reduction patients; those breast reduction patients falling within American Cancer Society guidelines for mammographic screening because of high risk characteristics should undergo preoperative mammograms. Based on this study, the authors’ recommendations include the option of performing postoperative baseline and interval mammography on all breast reduction patients and the alternative approach of carrying out postoperative baseline mammography only on high-risk patients—ie, those for whom routine screening would be recommended anyway or those whose excised breast tissue has demonstrated risk-indicating histologic features.

Background The use of central venous catheters impregnated with either minocycline and rifampin or chlorhexidine and silver sulfadiazine reduces the rates of catheter colonization and catheter-related bloodstream infection as compared with the use of unimpregnated catheters. We compared the rates of catheter colonization and catheter-related bloodstream infection associated with these two kinds of antiinfective catheters. Methods We conducted a prospective, randomized clinical trial in 12 university-affiliated hospitals. High-risk adult patients in whom central venous catheters were expected to remain in place for three or more days were randomly assigned to undergo insertion of polyurethane, triple-lumen catheters impregnated with either minocycline and rifampin (on both the luminal and external surfaces) or chlorhexidine and silver sulfadiazine (on only the external surface). After their removal, the tips and subcutaneous segments of the catheters were cultured by both the roll-plate and the sonication ...

The objectives were to (1) prospectively evaluate fatigue utilizing validated instruments in patients with localized prostate cancer, and (2) examine the relationships between fatigue, depression, quality of life, and sleep disturbance. The instruments used included: Piper Fatigue Scale, Beck Depression Inventory, Epworth Sleepiness Scale, and Functional Assessment of Cancer Therapy for Prostate Scale. Data on cancer stage, prostate specific antigen levels, hematocrit, patient's body weight and radiation dosage were recorded. Patients were evaluated preradiotherapy, middle of radiotherapy, completion of radiotherapy, and at 4–5 weeks follow-up. Thirty-six veterans with localized prostate cancer were studied. Mean age was 66.9 years (range 55–79). Duration of treatment was 7–8 weeks. Univariate procedure and Wilcoxon Signed Rank-test were used to examine changes in pretreatment scores for each of the three subsequent study periods. To adjust for multiple comparisons Bonferroni test was used. Spearman Correlations were calculated among parameters. No significant changes were noted in mean scores of hematocrit and body weight during the study period. On the Piper Fatigue Scale, adjusted for multiple comparisons, the median scores were significantly higher at completion of radiotherapy as compared with preradiotherapy values. Three patients (8%) were experienced fatigue according to Piper Fatigue Scale before treatment as compared to nine patients (25%) at completion of radiotherapy. On Prostate Cancer Specific and Physical Well Being sub-scales of the Functional Assessment for Prostate Cancer Therapy, the scores were significantly lower at middle and completion of radiotherapy than at pretreatment. At preradiotherapy, middle of radiotherapy, completion of radiotherapy and follow-up evaluation, patients scoring higher on the Piper Fatigue Scale were more likely to report a poorer quality of Physical Well Being on Functional Assessment of Cancer Therapy for Prostates. No significant changes were noted in the Beck Depression Inventory and Epworth Sleepiness Scale scores during treatment. Eight patients scored 10 or more on the Beck Depression Inventory before starting radiotherapy, suggesting depressive symptomatology. Of these, only seven patients scored 10 or more at completion of treatment. The incidence of fatigue is lower in our study than in previously published data. A relationship exists between fatigue scores and physical well being subscale scores. Higher scores on the Piper Fatigue Scale at the completion of radiotherapy, as well as no changes on depression and sleepiness scales, suggest that fatigue may not be the result of depression or sleep disturbance. Based upon our previous work, we propose that the physical expression of fatigue may be secondary to a decline in neuromuscular efficiency and enhanced muscle fatigue. Radiat. Oncol. Invest. 7:178–185, 1999. Published 1999 Wiley-Liss, Inc.

We investigated whether insertion of urinary catheters that had been coated withEscherichia coliHU2117 could establish bladder colonization with this nonvirulent organism. Ten of 12 subjects were successfully colonized for 14 days or more. The rate of symptomatic UTI during colonization was 0.15 per 100 patient-days.

Because of the growing concern surrounding the integrity and life span of silicone gel breast implants and the reported variations in the diagnostic accuracy of various imaging techniques in identifying ruptured implants, the authors undertook a meta-analysis of articles in the scientific literature to examine these concerns. They were able to include reports from the literature that detailed the condition and removal of 1,099 breast implants during the past 7 years. The median life span of a silicone gel implant was estimated to be 16.4 years. Of the implants, 79.1% were intact at 10 years, falling to 48.7% by 15 years. The sensitivities and specificities of three imaging modalities used in the diagnosis of implant rupture (mammography, ultrasonography, and magnetic resonance imaging [MRI]) were also evaluated and compared statistically in an effort to discover which of the three techniques might serve as the most reliable screening tool in the diagnosis of gel implant rupture. The sensitivity of mammography for finding a ruptured implant is 28.4% with a specificity of 92.9%. Ultrasonography has a sensitivity and specificity of 59.0% and 76.8% respectively compared with MRI, which was 78.1% and 80.0% respectively. For implants in place for 10 years, one would need to image 3.3 implants by ultrasound to identify a single possible rupture. However, because of the 76.8% specificity, 8.1 implants would need to be imaged to find a confirmed intraoperative rupture. This was similar to MRI, in which 3.1 implants would need to be imaged to detect one suspected rupture, and 6.1 implants would need to be imaged to find one intraoperatively confirmed rupture. The authors do not recommend either ultrasound or MRI as a screening tool based on their meta-analysis.

Ten fresh cadaver tipper extremities from 10 different subjects were used in this study of the effect of both open and endoscopic carpal tunnel release on flexor tendon excursion. The amount of excursion necessary to bring each finger from the fully extended to the fully flexed position with the fingertip just touching the palm was measured with the extremity mounted in a device that moved the wrist from extension through flexion. Endoscopic carpal tunnel release, open release, and transverse carpal ligament reconstruction were performed with tendon excursion measurements made in each of four wrist positions after each procedure. Fingertip to palm distance was also measured. The measurements of flexor tendon excursion in neutral wrist position with intact transverse carpal ligament servec as the norm for each finger and as the denominator in the ratio of postoperative to preoperative excursion distances. The study confirmed the importance of the transverse carpal ligament as a flexor pulley; transection of the ligament increased the amount of flexor tendon excursion necessary to achieve finger flexion and fingertip-to-palm contact. Tendon excursion/ digital flexion improved after transposition flap repair. Neither open nor endoscopic carpal tunnel release conferred any particular benefit to flexor tendon excursion postoperatively. The proximal palmar aponeurosis does not seem to have the same pulley effect as the transverse fibers of the distal palm.

The relationship between hospital utilization and psychometric, demographic, and diagnostic data was examined among veterans with psychiatric problems.Data were obtained from the records of 500 psychiatric inpatients admitted to a Veterans Affairs medical center between 1984 and 1987 and followed for four years. All patients completed the Minnesota Multiphasic Personality Inventory, the California Personality Inventory, the Millon Clinical Multiaxial Inventory, and the Psychological Inventory of Personality and Symptoms. Stepwise linear regression analysis was used to predict the number and length of inpatient stays, and Cox and logistic regression analyses predicted rehospitalization.Higher rates of psychiatric hospital utilization were found among patients who were unmarried, who had disabilities connected with their military service, who had lower levels of adaptive functioning, and who were diagnosed as having posttraumatic stress disorder, drug or alcohol use disorder, or passive-aggressive or antisocial personality disorder. Higher utilization was also found among those whom psychometric data characterized as less responsible and more compulsive. The data also predicted the length of subsequent medical hospitalization and identified patients who stayed out of the hospital longer and who were not rehospitalized.Hospital utilization was found to be a function of psychiatric diagnosis, marital status, and various personality factors. Factors relating to social disadvantage also played a role. Axis I diagnoses, particularly substance use disorders, were as important as, if not more important than, axis II diagnoses in predicting utilization.

Symptoms of pain and weakness are nearly ubiquitous after carpal tunnel release. This study investigates the length of time before restoration of grip and pinch strength after open carpal tunnel release, in a population of patients without workers' compensation-related injuries. Two different forms of carpal ligament reconstruction were carried out in 2 groups of patients, and a third group underwent no ligament reconstruction. Grip and pinch strengths were measured for participants in each group both preoperatively and at set postoperative intervals. Mean changes in strength were calculated and analysis of variance used to determine statistical significance of the changes. Grip strength at 6 weeks after surgery in the group that underwent transposition flap repair exceeded preoperative grip strength values and all 3 groups surpassed preoperative grip strength measurements at 12 weeks. By 6 weeks after surgery, all pinch measurements for 3 groups equaled or exceeded preoperative pinch measurements. The transposition flap repair group recovered faster than did the other 2 groups and surpassed those groups in maximum grip and pinch strength at 12 weeks. These results suggest that transverse carpal ligament reconstruction, particularly the transposition flap technique, after open carpal tunnel release confers a mechanical advantage and that the transverse carpal ligament is an important pulley in flexor tendon excursion.

A three-part study is described that examines postoperative weakness after open carpal tunnel release and investigates the role of the transverse carpal ligament in the digital flexor pulley system. The effect of this ligament on flexor tendon excursion is evaluated in a cadaver study. Magnetic resonance imaging analysis is used to determine whether division of the transverse carpal ligament promotes volar migration of the median nerve and flexor tendons. Finally, the effects of ligament division and various methods of transverse carpal ligament reconstruction on the return of grip and pinch strengths after open carpal tunnel release are evaluated. The authors were able to determine that transverse carpal ligament reconstruction, particularly the transposition flap repair technique, after open carpal tunnel release confers a mechanical advantage and that the transverse carpal ligament is an important pulley for flexor tendon excursion. Based on the magnetic resonance imaging studies, volar displacement of carpal contents is reduced in patients undergoing transverse carpal ligament reconstruction by means of a transposition flap compared with those undergoing no ligament reconstruction and those undergoing reconstruction using the palmar aponeurosis. Postoperative grip and pinch strength values for the transposition flap repair group surpassed those of the other two groups at 12 weeks.

Background . Although conceptually sound, the use of multiple internal thoracic artery (ITA) bypass grafts to improve long-term clinical results remains controversial. This operation typically involves grafting the left ITA to the anterior descending artery and the right ITA to the right coronary artery. Past clinical studies of bilateral ITA operations have not examined comparative results associated with which coronary arteries received the ITA bypass grafts. Because grafting a superior conduit to an artery of lesser physiologic importance might reduce the clinical benefits, we compared the outcomes of patients receiving different configurations of bilateral ITA operations. Methods . The study group was 498 consecutive bilateral ITA operations, constituting the 10-year experience of a single surgeon. Follow-up averaged 7.1 years (mode 7.3 years), and was 94.2% complete. These patients were divided into two groups, 311 patients (group I) who underwent the traditional operation (left ITA to the left anterior descending artery, right ITA to the right coronary artery), and 187 patients (group II) who received revascularization of branches of the left coronary artery (left ITA to the circumflex system and right ITA to the left anterior descending artery). Results . The study groups were similar in age, severity of disease, number of bypassed arteries, ejection fraction, diabetes, hypertension, and duration of operation. There were more male patients in group II (91.4% versus 82.3%). A multivariate analysis showed that the location of ITA bypass grafts influenced survival independent of gender ( p = 0.0288). Operative morbidity and mortality were similar between groups. Ninety-three patients had repeat angiography with equivalent patency rates of the ITA conduits (91.7% versus 89.6%; p = 0.67). The Kaplan-Meier actuarial survival estimate demonstrated a significant improvement in survival of patients in group II who received both ITA bypass grafts to left-sided arteries ( p = 0.021), with the survival curves diverging at 6 years. More patients in group II were in New York Heart Association class I or II, but the difference was not statistically significant (94.6% versus 91.6%). Only 2 patients required reoperation. Conclusions . It appears that maximum long-term benefit from bilateral ITA operations is achieved by grafting the ITA conduits to coronary arteries that supply more left ventricular muscle.

Thyroid and adrenal functions were evaluated in 49 consecutive critically ill, mechanically ventilated patients admitted to the medical intensive care unit (MICU) at Ben Taub General Hospital in Houston, TX. On admission, severity of illness was assessed by Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) and Therapeutic Intervention Scoring System (TISS) scores. Thyrotropin Stimulating hormone (TSH) measured with a sensitive assay, thyroxine (T4), tri-iodothyronine (T3), T3 resin uptake, and Cortisol levels were measured on the first MICU day at 8 am, and results were assessed based on ability to predict mortality. It was shown that severe hypothyroxinemia (T4 < 3 μg/dL) was associated with a 75% mortality as opposed to a mortality rate of 19% in patients with a T4 level of 3 μg/dL or more ( p < 0.01), and a high 8 am Cortisol level (>30 μg/mL) was associated with a 56% mortality versus 0% in patients with Cortisol values less than 30 μg/dL ( p < 0.005), whereas a high APACHE II (>25) score and a high TISS (>25) score were only associated with a mortality of 47% ( p = 0.06) and 32% (NS), respectively, versus 21 and 20%, respectively, in patients with scores less than 25. Logistical regression analysis revealed that of all the variables, 8 am Cortisol level had the best predictive value of outcome, followed by T4 levels and T3 resin uptake levels. Although high Cortisol and low T4 levels used alone had a sensitivity of 56 and 75% and a specificity of 100 and 80.5%, respectively, combined low T4 and high Cortisol levels had a sensitivity of 100% and a specificity of 81.5% in predicting mortality. Very low T4 levels, due to severe illness, combined with high Cortisol levels (implying high physiological stress), are more sensitive predictors of mortality than APACHE II, TISS, Cortisol levels, or T4 levels alone, or any other combination of predictors.

Objective: To determine the relation between various components of spasticity evaluated clinically in persons with spinal cord injury (SCI). Design: Case series evaluating spasticity using clinical scales commonly referenced in contemporary literature, including the Penn Spasm Frequency Scale, the Ashworth Scale, and standard scales of tendon caps, clonus, and plantar stimulation. Setting: A Veterans Affairs Medical Center Spinal Cord Injury Center. Patients: Eighty-five spinal cord injured individuals with varying degrees of spasticity. Results: Correlations demonstrated weak relationships between Spasm Frequency Scale and self-report scales of interference with function (.407) and painful spasms (.312). No clinical examination scores correlated with self-report scores greather than 0.4. Three clinical examination scores correlated modestly (>0.5)—Ashworth score with patellar tendon taps (.553), ankle clonus with Achilles tendon tap (.663), and patellar tendon tap with adductor tendon tap (.512). Two other clinical scales correlated weakly (>0.4)—Achilles tendon tap with patellar tendon tap (.417) and plantar reflex with adductor tendon taps (.423). Conclusions: Clinical scales currently used to evaluate spasticity in SCI correlate poorly with each other, suggesting that they each assess different aspects of spasticity. The use of any single scale is likely to underrepresent the magnitude and severity of spasticity in the SCI population. In the absence of agreement among these various scales and with the absence of an appropriate criterion standard for evaluation of spasticity, assessments of spasticity, whether clinical or neurophysiological in nature, should be comprehensive in scope.

We performed a fresh cadaver dissection study of the superficial venous system (cephalic vein and its branches) and the deep venous system (venae comitantes) of the radial forearm to assess the suitability of each system for venous anastomosis during free tissue transfer. We used methyl methacrylate to evaluate vessel diameters and anatomic variability of both venous systems. Colored radiopaque injectate allowed us to combine anatomic dissection with tissue radiographs. We discovered the cephalic vein to invariably be of larger caliber than the venae comitantes. Ensuring capture of the cephalic vein in the flap necessitated additional dorsoradial subcutaneous dissection beyond the boundaries of the skin flap in four of ten specimens. The vessel diameters of the venae comitantes in four cadavers were less than 2 mm. Proximal confluence of the two venae comitantes, and communication between the deep and superficial venous systems were encountered in only four cases. In these cases, had an anastomotic site been chosen proximal to such a communication to ensure greater vessel caliber, pedicle length probably would have made free tissue transfer unwieldy. We recommend mapping the course of the cephalic vein before flap elevation and maintaining a wide proximal subcutaneous pedicle to capture the best possible superficial drainage system. If the superficial venous system has been damaged (as by previous intravenous catheterization), one may not necessarily be able to rely on the vessel caliber of the deep venae comitantes for microvenous anastomosis.

To determine sensitivity and specificity of magnetic resonance imaging (MRI) and ultrasonography (US) in the detection of breast implant rupture, and also to determine the relative merits of clinical examination and mammography, we studied 81 patients (160 implants). All patients had implants removed, thus allowing confirmation of the presence or absence of rupture. Clinical examination positively identified only one patient with implant rupture, and mammography detected only two implant ruptures (both extracapsular). The sensitivity for US was 70% and specificity was 90%, while for MRI it was 75.6% and 94%, respectively. These differences between MRI and US were not statistically significant. Combining the results of US and MRI did not seem to add to the diagnostic discrimination. The most cost-effective method of diagnosing implant rupture was US in our study.

In a number of publications the distal branches of both the ulnar artery and ulnar nerve have been identified as being positioned ulnar to the hook of the hamate. We undertook a magnetic resonance imaging project in patients who presented for carpal tunnel release to determine how far radially vital structures of Guyon's canal may be located and if they may overlap the carpal tunnel at the hook of the hamate. Cross-sectional magnetic resonance imaging scans of 20 patients were performed prior to carpal tunnel release with the wrist positioned in neutral, flexed, and extended positions. Linear measurements were made either radial or ulnar to the hook of the hamate taken as the reference point. In the neutral position, the ulnar nerve was found to be, on average, 3.6 mm ulnar to the hook of the hamate (range of 5.8 mm radial to 7.5 mm ulnar). The ulnar artery averaged 0.7 mm to the radial side of the hook of the hamate (range 7.8 mm radial to 2.8 mm ulnar). Guyon's canal extended 28% of the way across the carpal ligament (range 9 to 63%). With the wrist in flexion and extension, there was an ulnar displacement and a radial displacement, respectively, of these structures relative to the hook of the hamate.

Blood loss from split-thickness skin graft donor sites may be significant. Various topical agents have been used to decrease this blood loss, including thrombin and epinephrine solutions of varying concentrations. We describe a K-Y jelly/epinephrine mixture that serves both as a lubricant for the dermatome and as a hemostatic agent. This mixture, in comparison with other topical agents, produces rapid hemostasis and offers the advantages of easy use, ready availability, and low cost. The blood loss savings based on this hemostatic technique is quantifiable and significant.

Debate continues over the relative merits of transconjunctival and the more customary subciliary transcutaneous approaches for lower lid blepharoplasty. Ten consecutive patients presented for blepharoplasty, and in all patients the transcutaneous subciliary musculocutaneous flap approach was used on the left lower eyelid and the transconjunctival preseptal approach was used on the right. Patients served as their own controls. Follow-up was evaluated clinically by patient questionnaire and by standardized photographs preoperatively and at 5 days, 1 month, 3 months, and 6 months postoperatively. Photographs were graded independently by four blinded examiners. No statistical difference was identified in measured fornix depth between preoperative patients and postoperatively on each side. Average fat removed from each side was the same, and no patient had an identified "missed fat compartment." Three patients had mild bilateral scleral show postoperatively, and a fourth developed it on the left (transcutaneous) side. However, overall grading on both sides was universally very good with no significant difference on the two sides--0.68 on the right and 0.60 on the left (maximum worst grade could be 5.0 and best grade 0). The potential for external scarring was never a perceived problem in the transcutaneous technique.

Patients who smoke have higher complication rates than nonsmokers following many surgical procedures. It is not known if the adverse effects of smoking are caused by a nicotine effect or by some other potentially harmful agents that exist in tobacco smoke. It is also not known if these vasoactive effects are mediated through sympathetic nerve fibers (via nicotinic receptors in ganglia) or through elevated circulating levels of vasoactive hormones. We designed a 5-day protocol to measure relative blood flow both before and after a digital sympathetic block in the digits of subjects who were regular smokers following both smoking and wearing of a transdermal nicotine patch. Suitable pulse/wave tracings were recorded on 23 subjects. We also measured serum levels of nicotine, cotinine, vasopressin, norepinephrine, epinephrine, dopamine, and carboxyhemoglobin on each test day. Data for these serum levels were available in 30 test subjects. Digital sympathetic block had a significant beneficial effect in reversing the decreased digital blood flow that occurred after smoking (and also with use of the nicotine patch), despite the elevated circulating levels of vasopressin and norepinephrine seen with smoking. The vasoactive effects of smoking are probably due to the nicotinic effects on sympathetic fibers at the ganglionic levels.

Patients who smoke have higher complication rates than nonsmokers in the postoperative period. The authors designed an experimental protocol for habitual smokers (n = 30) to determine the specific hemodynamic and hematologic adverse effects possibly caused by nicotine and whether the method of nicotine delivery and systemic nicotine levels achieved might influence these adverse effects. During the 5-day study, subjects were asked to refrain from smoking, and testing sessions were conducted as follows: on day 1, the subjects smoked two cigarettes immediately before testing; on day 3 (control day), testing was done after not smoking for 48 hours and then the subjects were instructed to wear a transdermal nicotine patch (PROSTEP 22 mg/day) for 24 hours and replace it with another so that, on day 5, testing took place after the subjects had worn the patch for approximately 34 hours. At each testing session, digital artery pulse amplitude and a number of clinical and serum blood level parameters were measured. Relative digital blood flow after smoking (69.2 +/- 5.8%) and with the patch (80.4 +/- 7.6%) was lower than on the control day (100.0 +/- 0.0%). The nicotine patch, unlike smoking, had no effect on vasopressin or fibrinogen concentrations, hematocrit, or white cell or platelet counts; both smoking and the patch resulted in elevated norepinephrine levels.

The effect of a low-fat diet on occurrence of non-melanoma skin cancer was examined in a 2-year dietary intervention trial. A total of 101 skin-cancer patients were randomized either to a control group that consumed, on average, 38% of caloric intake as fat, and in which no changes in dietary habits were introduced, or to a low-fat dietary-intervention group, in which patients were instructed to limit their calories from fat to 20% of total caloric intake. Patients were examined at 4-month intervals by dermatologists blinded to their dietary assignments. Nutrient analyses, conducted at each of the 4-month follow-up visits, indicated that the % calories of fat consumed in the intervention group had been reduced to 21% at 4 months and remained below this level throughout the 2-year period. There were no significant differences in total calories consumed, or in mean body weights, between the control and the intervention groups. Nor were there significant group differences in P/S ratios until month 24. Numbers of new skin cancers treated at each examination were analyzed in 8-month periods of the 2-year study. Comparisons of skin-cancer occurrences revealed no significant changes in the control group from baseline values. However, cancer occurrence in the low-fat intervention group declined after the first 8-month period and reached statistical significance by the last 8-month period. Patients in this group had significantly fewer cancers in the last 8-month period than did patients in the control group. In addition, there was a significant reduction in the number of patients developing skin cancer in the last 8-month period, as compared with the first 8-month period, within the low-fat intervention group. There were no significant changes in the control group. These data indicate that a low-fat diet can significantly reduce occurrence of a highly prevalent form of cancer.

This study examined some predictor variables for positive outcome with a state vocational rehabilitation agency. Referrals to the agency from VA Counseling Psychology were analyzed to develop guidelines for identifying clients with good probability for positive outcome in their vocational rehabilitation planning. All subjects had a history of substance-abuse treatment at the Houston VA Medical Center. Analyses suggested a number of factors are relevant when assessing potential for successful vocational rehabilitation. Provision of drug-free housing, recent work history, and discharge status from a substance-abuse program were identified as relevant factors.

We prospectively evaluated 81 patients (with 160 implants) who subsequently had implants removed to determine sensitivity and specificity of both magnetic resonance imaging and ultrasonography. Positive and negative predictive values were also calculated to determine whether a statistically beneficial interaction existed when ultrasonography and magnetic resonance imaging were used in combination to examine an implant. Finally, the misdiagnoses were retrospectively evaluated to identify the pitfalls of the investigations. Positive diagnostic criteria were described. The sensitivity and specificity of ultrasonography were 47% and 83%, respectively, and of MRI, 46% and 88%, respectively. On retrospective review by the radiologist, the sensitivity and specificity of ultrasonography were 70% and 90%, respectively, and of magnetic resonance imaging, 75.6% and 94%, respectively. Although definite conclusions could not be obtained, there did not seem to be an additive benefit from using both ultrasonography and magnetic resonance imaging.

Education and occupation as sociodemographic risk factors for dementias of the Alzheimer (DAT) and ischemic vascular types (IVD) were evaluated by two case series studies. Cases were compared to well-evaluated individuals identified as healthy normals acting as controls. There were 150 patients with probable DAT, 102 patients with probable IVD, and 188 neurologically and cognitively normal subjects. Logistic regression indicated that for DAT, education with occupation was the best predictor (OR, 1.51; 95% CI, 1.23–1.87). For IVD, the two predictors were: education with occupation (OR, 1.84; 95% CI 1.38–4.50) and education with gender (OR, 3.40; 95% CI, 1.29–8.92). We conclude that risk of dementia is increased in those with limited educational background and occupational achievement.

To determine the attitudes of physicians toward social and sexual contact with patients, we mailed a self-report survey to a nationwide randomized sample including general practitioners, internists, obstetrician-gynecologists, and ophthalmologists. The 777 physicians who responded specified whether or not behavior such as hugging, dating, and sexual contact with their own patients may be appropriate. Less than 1% of all respondents thought that sexual contact with patients was appropriate during patient consultations. Three percent of internists and obstetrician-gynecologists considered sexual contact with patients appropriate when concurrent with treatment but outside of patient consultation, as compared with 9% of general practitioners and 12% of ophthalmologists (X2 = 17.8, df = 3, P < .001). Nearly 50% of general practitioners and more than 50% of all other physicians thought that sexual contact might be appropriate after termination of treatment of a patient. These findings may facilitate professional discussion on standards for social and sexual contact with patients.

To develop psychometric measures specific to the ambiguities encountered in medicine and determine their value in predicting medical students' attitudes towards patients and their choice of residency, we administered to senior and first-year medical students a 25-item Likert-type questionnaire to assess their intolerance of ambiguity (ITA). Factor analysis yielded two dimensions that were converted to scales: 'Aversion to uncertainties in clinical medicine' (ITA1) and 'Preference for highly structured training environs' (ITA2). First-year students scored higher on ITA1 and lower on ITA2 than seniors. An excessive reliance on high-technology medicine, a negative orientation toward psychological problems, and Machiavellianism predicted ITA1. ITA1 was the best predictor of senior medical students' negative attributional style toward hypochondriac, geriatric and chronic pain patients. The following rank order of seniors' career choice was predicted by ITA1 scores: internal medicine, psychiatry and family medicine (lowest); radiology, surgery and anaesthesiology (highest). And by ITA2 scores: surgery, obstetrics and gynaecology, and surgical subspecialties (lowest); radiology, psychiatry and anaesthesiology (highest). We concluded that personality traits and role characteristics which predict 'Aversion to uncertainties in clinical medicine' are maladaptive to managing many primary care patients, and this mismatch is reflected in seniors' residency choice.

Purpose To gain a comprehensive perspective on outcomes by performing an array of tests on patients who had undergone index pollicization for isolated thumb aplasia or severe hypoplasia in the absence of clinical radial dysplasia; this led us to create a graphical snapshot for future comparison. Another purpose was to compare the function of the contralateral hand and to compare parent and patient perspectives. Methods We evaluated 22 hands (18 patients) by grip as well as lateral and tripod pinch strength tests; the pegboard Functional Dexterity Test (FDT); the Jebsen Hand Function Test (JHFT); and a parent/patient questionnaire. We compared operated hands with both contralateral nonoperated hands and nondominant hands in published normal data. We also compared contralateral nonoperated hands with dominant hands in published normal data, and FDT results and JHFT outcomes in children greater than 6 years old with published normal data. We evaluated questionnaire results. Results Mean grip as well as lateral and tripod pinch strength in operated hands were 3.4, 1.2, and 1.2 kg, and in normal nondominant hands were 11.7, 4.4, and 3.9 kg, respectively. Patients' contralateral nonoperated hands were weaker than normal dominant hands. Mean timed FDT results in operated hands was 127 seconds, compared with 44 seconds in published normal data. In 2 of 5 JHFT subtests administered, no difference existed between operated hands and published normal data. A graphical snapshot took various outcome measures into consideration and showed a global assessment. Mean parent and patient questionnaire scores were 10 and 22, respectively (best = 12; worst=60). Conclusions Comprehensive subjective and objective outcome testing suggested that an optimistic view of function after index pollicization is warranted. A graphical snapshot followed function over time. The contralateral hand fared worse than published normal data. Parent and patient perspectives were favorable. Type of study/level of evidence Therapeutic III.

Chronic low back pain (CLBP) is a significant healthcare problem, and many individuals with CLBP remain unresponsive to available interventions. Previous research suggests that hypnosis is effective for many chronic pain conditions; however, data to support its efficacy for CLBP are outdated and have been limited primarily to case studies. This pilot study indicated that a brief, 4-session standardized self-hypnosis protocol, combined with psycho-education, significantly and substantially reduced pain intensity and pain interference. Significant session-to-session improvements were also noted on pain ratings and mood states; however, follow-up data suggest that these benefits may not have been maintained across time in this sample. These findings need to be replicated and confirmed in a larger clinical trial, which could also assess the long-term effects of this treatment.

Infection is a common complication of ventricular-assist devices (VADs) and is associated with rehospitalization, thromboembolic events, VAD malfunction, delay in heart transplantation, and a high mortality rate. The objectives of this study were to investigate the frequency of fungal VAD infections and assess various risk factors and their effects on mortality as compared with bacterial VAD infections.We conducted a retrospective chart review of patients with infected VADs at a single tertiary care center. The frequency, risk factors, and outcomes of fungal versus bacterial VAD infections were compared.Of the 300 patients who received a VAD, 108 (36%) developed VAD infection, including 85 bacterial and 23 fungal infections. Most common bacterial causes of infection were Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and Pseudomonas aeuruginosa. The most common fungal etiologic agent was Candida albicans. Only the use of total parenteral nutrition was associated with the development of a fungal VAD infection in multivariate analysis (odds ratio, 6.95; 95% confidence interval, 1.71-28.16; P=.007). Patients who experienced fungal VAD infection were less likely to be cured (17.4% vs 56.3%; P=.001) and had greater mortality (91% vs 61%; P=.006), compared with those who experienced bacterial VAD infection.Fungi were responsible for approximately one-fifth of VAD infections and were associated with a mortality rate of 91%. Restriction of total parenteral nutrition use is essential in decreasing the rate of fungal VAD infection. Trials are needed for investigating the use of echinocandins or lipid formulations of amphotericin B for prevention and/or treatment of fungal VAD infection.