Patient Safety in the Operating Room During Urologic Surgery: The OR Black Box Experience.

PURPOSE: To mitigate intraoperative adverse events, it is important to understand the context in which these errors occur. The purpose of this study is to characterize the IAEs and potential distractions that occur in minimally invasive urologic procedures. METHODS: We conducted a prospective cohort study in patients undergoing laparoscopic urologic surgery at an academic health center. The OR Black Box, a unique technology system which captures video and audio recordings of the operating room as well as the operative field, was used to collect data regarding procedure type, critical step, IAEs, and distractions. RESULTS: Of a total of 80 cases analyzed, the majority of these cases were partial nephrectomy (n = 36; 45%), radical nephrectomy (n = 20; 25%), and adrenalectomy (n = 4; 5%). Across all cases, there were a total of 138 clinically significant IAEs, 10 of which (14%) were of the highest severity (five on the SEVerity of intraoperative Events and Rectification Tool (SEVERE) matrix). Of these, 70 (51%) occurred during an a priori defined critical step of the operation. Distractions were common across all cases. The median rate of external communication per case was 16 events (IQR 11-22); and per critical step was 4 (IQR 2.75-8), while median room traffic per case was 65 entries/exits (IQR 42-76); and per critical step was 17 (IQR 10-65). CONCLUSION: Our data demonstrate that IAEs occur frequently during all phases of the operation at hand. Future study will be required to examine the role of distractions and IAE as well as IAE and their relationship to post-operative clinical outcomes.

Psychosocial Functioning of Children with and without Dyslexia: A Follow-up Study from Ages Four to Nine.

This longitudinal study compares developmental changes in psychosocial functioning during the transition into school of children with and without dyslexia. In addition, it examines the effects of gender and family risk for dyslexia in terms of the associations between dyslexia and psychosocial functioning. Children's psychosocial functioning (social skills, inattention and externalizing and internalizing problems) was evaluated by their parents at ages 4, 6 and 9, and diagnosis for dyslexia was made at age 8 (in grade 2). The findings indicated that children with dyslexia were already rated as having poorer social skills and being more inattentive than were typical readers before their entry into school. Significant interactions of gender and diagnosis of dyslexia emerged for social skills and inattention. The social skills of boys with dyslexia improved after school entry as compared to the level of girls without dyslexia, whereas the social skills of girls with dyslexia did not improve. Boys with dyslexia were rated as showing a high level of inattention both prior to and after school entry, whereas, for girls with dyslexia, inattention ratings increased after school entry, eventually matching the boys' levels.

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine.

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

An occupational health intervention programme for workers at high risk for sickness absence. Cost effectiveness analysis based on a randomised controlled trial.

OBJECTIVES: To determine whether, from a healthcare perspective, a specific occupational health intervention is cost effective in reducing sickness absence when compared with usual care in occupational health in workers with high risk of sickness absence. METHODS: Economic evaluation alongside a randomised controlled trial. 418 workers with high risk of sickness absence from one corporation were randomised to intervention (n = 209) or to usual care (n = 209). The subjects in the intervention group were invited to occupational health service for a consultation. The intervention included, if appropriate, a referral to specialist treatment. Register data of sickness absence were available for 384 subjects and questionnaire data on healthcare costs from 272 subjects. Missing direct total cost data were imputed using a two-part regression model. Primary outcome measures were sickness absence days and direct healthcare costs up to 12 months after randomisation. Cost effectiveness (CE) was expressed as an incremental CE ratio, CE plane and CE acceptability curve with both available direct total cost data and missing total cost data imputed. RESULTS: After one year, the mean of sickness absence was 30 days in the usual care group (n = 192) and 11 days less (95% CI 1 to 20 days) in the intervention group (n = 192). Among the employees with available cost data, the mean days of sickness absence were 22 and 24, and the mean total cost euro974 and euro1049 in the intervention group (n = 134) and in the usual care group (n = 138), respectively. The intervention turned out to be dominant-both cost saving and more effective than usual occupational health care. The saving was euro43 per sickness absence day avoided with available direct total cost data, and euro17 with missing total cost data imputed. CONCLUSIONS: One year follow-up data show that occupational health intervention for workers with high risk of sickness absence is a cost effective use of healthcare resources.

The effectiveness of two occupational health intervention programmes in reducing sickness absence among employees at risk. Two randomised controlled trials.

OBJECTIVES: To evaluate the effectiveness of two occupational health intervention programmes, both compared with usual care. METHODS: Based on a health survey, 1341 employees (88% males) in construction, service and maintenance work were classified into three groups: "low risk" (n = 386), "intermediate risk" (n = 537) and "high risk" (n = 418) of sickness absence. Two separate randomised trials were performed in the groups "high risk" and "intermediate risk", respectively. Those high risk subjects that were allocated to the intervention group (n = 209) were invited to occupational health service for a consultation. The intervention included, if appropriate, a referral to specialist treatment. Among the intermediate risk employees those in the intervention group (n = 268) were invited to call a phone advice centre. In both trials the control group received usual occupational health care. The primary outcome was sickness absence during a 12-month follow-up (register data). RESULTS: The high risk group, representing 31% of the cohort, accounted for 62% of sickness absence days. In the trial for the high risk group the mean sickness absence was 30 days in the usual care group and 19 days in the intervention group; the mean difference was 11 days (95% CI 1 to 20 days). In the trial for the intermediate risk group the mean sickness absence was 7 days in both arms (95% CI of the mean difference -2.3 to 2.4 days). CONCLUSIONS: The identification of high risk of work disability was successful. The occupational health intervention was effective in controlling work loss to a degree that is likely to be economically advantageous within the high risk group. The phone advice intervention for the intermediate risk group was not effective in controlling work loss primarily due to poor adherence.

Disability pension for major depression in Finland.

OBJECTIVE: The authors' goal was to investigate the treatment received before receipt of a disability pension for major depression in a representative sample of depressed patients. METHOD: The medical statements for a random sample of 277 subjects drawn from the Disability Pension Register of the Social Insurance Institution were examined. The subjects selected represented individuals in Finland who were granted a disability pension because of DSM-III-R major depression during a 12-month period in 1993-1994. RESULTS: For 254 (92%) of the subjects, the statements regarding pension eligibility were written either by a psychiatrist or a psychiatric resident for patients who were currently being treated in psychiatric settings. There was an additional diagnosis of a comorbid mental disorder or a somatic disease contributing to disability in two-thirds of the statements. Overall, the statements indicated that 242 (87%) of the subjects were prescribed antidepressant medication, but only 24 (9%) received weekly psychotherapy, and only 11 (4%) received ECT. CONCLUSIONS: Most subjects granted a disability pension for major depression in Finland have comorbid mental or physical disorders contributing to their disability. Before receiving their pension, most received antidepressant treatment, but few received the established nonpharmacological treatments.

A multivariate analysis of the risk indicators of reduction limb defects.

In order to evaluate associations of various selected risk indicators with reduction limb defects, data on 453 cases of reduction limb defects and their time-area matched pair controls from the Finnish Registry of Congenital Malformations was studied. A multivariate analysis of the earlier reported associations was performed. This analysis showed that the following risk indicators were associated with the defects: high birth order, threatened abortion, low placental weight, low birth weight, previous malformations in the family, influenza during early pregnancy, other infectious diseases, and mother's alcohol consumption during pregnancy.

Incidence and secular trends of congenital limb defects in Finland.

The total incidence rate of three selected congenital limb defects was 12.8 per 10 000 births in Finland from 1964 to 1977; 1235 cases were reported to the Registry of Congenital Malformations. The incidence rate of reduction limb deformities was 5.0 per 10 000 births (481 cases), of polydactyly 5.8 (559) and of syndactyly 3.1 (299), respectively. The total incidence rate and the rates for all the subgroups had a statistically significant increasing trend even after the incidence rates were compared to the reporting rate of all malformations (p less than 0.01). No significant variations in seasonal distributions were found. In 69% of the reduction deformities only one or both upper limbs were affected, 20% of the children had only lower limb defects, and 11% of the cases had defects in both upper and lower limbs. In 28% of the cases additional malformations were reported. For comparison, incidence rates of the selected limb defects from 13 other national surveillance systems are presented.

Risk indicators of reduction limb defects.

The birth of a child with a reduction limb defect (RLD) was evaluated in relation to vaginal bleeding, threatened abortion, and other complications of pregnancy, placental weight, birth weight, family history, parental age, and the outcome of previous pregnancies. The material consisted of 453 cases of reduction limb defect and an equal number of non-malformed controls matched for time and place. The children were born in Finland during 1964-77. The cases with reduction limb defect without additional malformations were analysed separately. Statistically significant associations were found between the occurrence of reduction limb defect and the following risk indicators: vaginal bleeding, threatened abortion, duration of gestation under 37 weeks, placental weight 400 g or less, birth weight 2500 g or less, and any type of malformation in the relatives. Vaginal bleeding indicated the risk of reduction limb defect to be increased about fourfold; short gestation indicated about twofold risk of reduction limb defect as an isolated malformation. Both low placental weight and low birth weight were associated to a threefold risk of an isolated reduction limb defect. These factors of an abnormal pregnancy indicated even higher risk of reduction limb defect with additional malformations. Preliminary genetic analysis suggests that hereditary factors play no major part in the aetiology of reduction limb defects.

The accident at Chernobyl and trisomy 21 in Finland.

Our objective was to explore whether the radiation fallout in Finland after the accident at the Chernobyl nuclear power plant in April 1986 led to an increased incidence of trisomy 21. In this geographic and temporal cohort study, the country was divided into three zones according to the amounts of radioactive fallout and internal radiation caused by two cesium isotopes. The 518 cytologically verified cases of trisomy 21 were divided into a control group (conceived before the accident), and a study group of children whose expected dates of birth were in the post-accident years 1987-1988, i.e., pregnancies commenced after May 1986. The cases were also divided into three subgroups according to the zones of radiation. There were no significant differences in prevalence of trisomy 21 between the control and study groups nor between the three zones in spite of the significant differences in the levels of radiation and in the body burden that prevailed throughout the study period. Power estimates showed that in the two zones of lower radiation, an increase of 0.5% in the prevalence would have been detected with a power of 0.85, and in the somewhat smaller zone of the highest radiation, with a power of 0.70. The study lends no further support to the view that the low radiation fallout in western Europe would have been causally associated with trisomy 21.

Maternal diseases, alcohol consumption and smoking during pregnancy associated with reduction limb defects.

To evaluate the association of acute and common chronic diseases, alcohol consumption and smoking during pregnancy with reduction limb defects (RLD) 453 cases of RLD from the Finnish Registry of Congenital Malformations were studied. RLD cases without additional malformations were analyzed separately. Statistical associations were observed with maternal influenza. Alcohol consumption, and smoking were likewise associated with the defects. Medication, fever and/or other factors may explain the association of RLD with influenza. The relation to smoking was not explained by alcohol consumption or mother's age, and these variables were independent of each other.

Effects of season and processing on oil content and fatty acids of baltic herring (Clupea harengus membras).

Fatty acid composition, oil content, free fatty acid content, and peroxide value of Baltic herring (Clupea harengus membras) and two processed products (fried fillets and fish burgers) were investigated. The highest oil content of the fillets was found in autumn (10%), at the time when the free fatty acids had their minimum (1.4%). The main fatty acids were oleic (18-23%), palmitic (17%), palmitoleic (8-12%), and docosahexaeneoic (8-10%) acids. The proportion of saturated fatty acids was a constant 23% all year around, whereas mono- and polyunsaturated acids varied from 34 to 39% and 33 to 37%, respectively. During processing the oil content doubled and the fatty acid composition changed to the pattern of the rapeseed oil used for frying. Oleic acid was a major fatty acid in the products comprising over 40% of the total fatty acids. The proportion of n-3 acids decreased during processing but the total amount of polyunsaturated acids remained fairly constant.

Clinical significance of test refusal among young children.

The present study describes the incidence of test refusal at neuropsychological assessment, investigates its correlates, and its stability. The participants were 124 children aged 3.5 years whose development has been followed from birth in the Jyväskylä Longitudinal Study of Dyslexia (JLD). The frequency of test refusal on the Finnish version of the NEPSY was analyzed with respect to the children's concurrent and earlier cognitive and language skills, assessed using tests and parental ratings. Refusal during test-taking was found to be relatively common at this age, and high frequency of refusal at an earlier age was associated with similar tendency at a later age. High test refusal was associated with compromised neuropsychological and linguistic test scores. Missing data due to refusal were more common in neuropsychological tasks requiring verbal production. It is concluded that test refusals reflect a child's poor underlying skills and an attempt to avoid failure, rather than noncompliant or oppositional behavior.

The development of phonological abilities and their relation to reading acquisition: case studies of six Finnish children.

The relation between phonological abilities and reading acquisition and the interindividual variation in the development of different phonological manipulation skills were assessed for six 7-year-old Finnish nonreaders. Intensive time series data were collected by following the children for 13 months. Assessments were conducted every 4 weeks with five phonological manipulation tests. The results indicated gradual progress at the group level. However, analysis of the individual profiles indicated large interindividual variation in the rate of improvement and in the relation between different manipulation skills and reading acquisition.

Suggestions for revised scoring of the Tower of Hanoi test.

Detailed time and error analyses of the Tower of Hanoi (TOH) test was performed using four repeated assessments of eight children (ages 9-12 years), who had perceptual and problem solving deficits. The time before each move was measured. In addition to the traditionally counted time scores, new, relative time scores were computed in order to separate the planning time from the general reaction speed. New error scores were defined and sum scores of serious errors (perserative moves, illegal moves, and wrong results) and mild errors (self-corrected moves, almost performed moves, and interrupted trials) were computed. The relative planning time correlated positively with the achieved score, and negatively with the serious errors. The serious errors correlated negatively with the achieved score. The relative planning time seems to measure the quality of planning better than does the raw planning time, and it is a recommended score for TOH analysis. The value of new error scores requires additional research.

Repeated assessment of the Tower of Hanoi test: reliability and age effects.

The purpose of this research was to analyze the effects of repeating an executive function test. Three versions of the Tower of Hanoi (TOH) test were repeated three times each, with test-retest intervals of 2 months. Two groups of children participated in the research (7.7 and 11.6 years, n = 22 and n = 28). Repeating the assessment improved the performance and decreased the total performance time in both of the groups. The older participants improved their performance faster than the younger ones. The reliability of all the scores, besides the error scores, seemed to be satisfactory after the first few assessments. The stability of the scores was maintained through all the assessments. The planning time did not explain the variations of the achieved score. The reasons for the initially low reliabilities are discussed, and modifications for the test administration and scoring are suggested.

The accident at Chernobyl and outcome of pregnancy in Finland.

OBJECTIVE: To evaluate the outcome of pregnancy in Finnish women after the accident at the Chernobyl nuclear power plant on 26 April 1986. DESIGN: Geographic and temporal cohort study. SETTING: Finland divided into three zones according to amount of radioactive fallout. SUBJECTS: All children who were exposed to radiation during their fetal development. Children born before any effects of the accident could be postulated--that is, between 1 January 1984 and 30 June 1986--served as controls. INTERVENTIONS: Children were divided into three temporal groups: controls, children who were expected to be born in August to December 1986, and children who were expected to be born in February to December 1987. They were also divided, separately, into three groups according to the three geographic zones. END POINT: Incidence of congenital malformations, preterm births, and perinatal deaths. MEASUREMENTS AND MAIN RESULTS: There were no significant differences in the incidence of malformations or perinatal deaths among the three temporal and three geographic groups. A significant increase in preterm births occurred among children who were exposed to radiation during the first trimester whose mothers lived in zones 2 and 3, where the external dose rate and estimated surface activity of caesium-137 were highest. CONCLUSIONS: The results suggest that the amount of radioactive fallout that Finnish people were exposed to after the accident at Chernobyl was not high enough to cause fetal damage in children born at term. The higher incidence of premature births among malformed children in the most heavily polluted areas, however, remains unexplained.

Practice effects on visuomotor and problem-solving tests by children.

Practice effects on a visuomotor test (the Developmental Test of Visuo-Motor Integration), a timed visual discrimination test (the Underlining Test), and two problem-solving tests (the Porteus Mazes Test and the Tower of Hanoi Test) were analyzed. Children of two age groups (Ms: 7.7 and 11.6 yr.) were chosen to study the effect of age on practice effects. The tests were repeated nine times with test-retest intervals of 2 mo. The Developmental Test of Visuo-Motor Integration showed no practice effects, while the Porteus Mazes Test, the Underlining Test, and the Tower of Hanoi Test showed significant practice effects. Practice effects were larger for the older age group on all the tests, except the Developmental Test of Visuo-Motor Integration. The Developmental Test of Visuo-Motor Integration and the Underlining Test showed good reliability, but those of the problem-solving tasks were less satisfactory. The stability of all the tests, except the Tower of Hanoi Test, was good.