Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children.

BACKGROUND: During ultrasound (US)-guided cannulation of the subclavian vein (SCV) via an infraclavicular route, the view of the needle behind the clavicle may be obscured. This study describes the US-guided supraclavicular cannulation of the brachiocephalic vein (BCV). METHODS: The 25 mm broadband linear array US probe was placed in the supraclavicular region to obtain a longitudinal view of the BCV beginning at the junction of the internal jugular vein and SCV. Using the in-plane technique, the needle was directed under US guidance into the BCV. RESULTS: Forty-two cannulations in 35 patients (aged 26 months-8 yr, weight range 0.96-21 kg) were included. Central venous catheter placement was successful in all children. In 31 patients (73.8%), the BCV was successfully punctured on the first attempt, in six patients (14.2%) after two attempts, and in five patients (11.9%) after three attempts. Significantly more puncture attempts were needed in the smaller weight and younger children, whereas the time course of the study had no significant impact on the success rate. CONCLUSIONS: This US-guided method offers a new possibility for central venous line placement in small children. It provides good needle guidance without any disturbing US shadow caused by bony structures.

[Tonsillotomy and adenotonsillectomy in childhood. Study on postoperative pain therapy]. / Tonsillotomien und Adenotomien im Kindesalter. Studie zu postoperativen Schmerztherapie.

BACKGROUND: The primary aim of this study was to determine whether the combination of i.v. ketoprofen and i.v. paracetamol provides superior postoperative analgesia in children undergoing adenoidectomy or tonsillotomy compared to either drug alone. The secondary goal was to assess the time until rescue analgesia was needed, propofol requirements and the incidence of vomiting and time of discharge from the postanaesthesia recovery unit (PARU). METHODS: This double-blinded study included 120 children (aged 3-13 years) scheduled for elective tonsillectomy, adenoidectomy or adenotonsillectomy. The children were randomly assigned to one of 3 groups of 40 children each, using the sealed envelope method. The children received i.v. ketoprofen 2 mg/kgBW (group 1) or paracetamol 15 mg/kgBW (group 2) or the combination of these 2 drugs (group 3) after induction of anaesthesia. Standardized general anaesthesia consisted of sevoflurane and fentanyl at a dose of 2-3 µg/kgBW. Pain was assessed using a 5-point scoring system based on the Smiley scale. The Smiley scale shows various faces from a laughing face which corresponds to the state of no pain to a very unhappy face which corresponds to the situation of worst pain (1: no pain, 2: mild pain, 3: moderate pain, 4: severe pain, 5: worst pain). Pain was assessed at 30 min, 1 h, 2 h, 3 h and 4 h after arriving in the PACU. If the pain score exceeded 2 an i.v. dose of 0.1 mg/kgBW morphine was administered as rescue analgesia. RESULTS: During the stay in the PACU the children in the combination group required significantly less supplementary rescue analgesia than children in the ketoprofen and paracetamol groups (17.5% versus 30.8% versus 45%, respectively, χ(2) analysis <0.05). Pain scoring was highest after paracetamol, however, this difference was only significant when compared to the group receiving the combination of paracetamol and ketoprofen (U-test p<0.05). Rescue analgesia was administered earliest in group 2 (paracetamol) reaching statistical significance, however, only when compared to group 3 (logrank test p<0.05). Propofol requirements and time to discharge from the PACU did not differ significantly between the 3 groups (χ(2) analysis; U-test; p>0.05). The overall incidence of vomiting was very low in this study with 6.4% (9/139). Significantly more children in the paracetamol group compared to ketoprofen group and combination group suffered from vomiting (17.5% versus 2.6% versus 2.5%; χ(2) analysis; p<0.05). The time to discharge from PACU did not differ significantly between the 3 groups (U-test: p>0.05). CONCLUSION: The combination of i.v. paracetamol and i.v. ketoprofen provides superior postoperative analgesia compared to the single use of paracetamol.

Size of internal jugular vs subclavian vein in small infants: an observational, anatomical evaluation with ultrasound.

BACKGROUND: The primary goal of this study was to compare the size and depth of the internal jugular vein (IJV) and the subclavian vein (SCV) in infants under general anaesthesia. A secondary goal was to determine the correlation of weight, height, head circumference, and age to the size and depth of these veins. METHODS: Sixty small infants weighing from 1.4 to 4.5 kg were included. Using ultrasound, the diameters via short-axis (SAX) and long-axis (LAX) views, cross-sectional area (CSA), and depth of the left and right IJV and SCV were measured. RESULTS: The diameter of the IJV was 7.9% larger on average than that of the SCV as measured via the SAX and LAX views (mean: 3.1 vs 2.9 mm; Wilcoxon's signed-rank test: P<0.01). The CSA of the IJV was 27% larger on average than that of the SCV (mean: 10.2 vs 8.0 mm(2); Wilcoxon's signed-rank test: P<0.01). Seventy-five per cent of the neonates showed a larger CSA of the IJV. The SCV was 8.4% deeper on average from the skin surface than the IJV (mean: 6.4 vs 5.9 mm; Wilcoxon's signed-rank test: P<0.01). There was a significant positive correlation between weight, height, head circumference, and age to the size and depth of the veins (Spearman's rank correlation: P<0.01). CONCLUSIONS: Because of its most likely larger size, the IJV can be recommended as the better choice for cannulation in comparison with the SCV. However, other factors should also be considered.

Foot health and prevalence of Dichelobacter nodosus in 11 ungulate species at Berne Animal Park.

INTRODUCTION: Dichelobacter nodosus (D. nodosus) is the etiological agent of ovine footrot affecting mainly sheep worldwide, but also free-ranging wild ungulates such as Alpine ibex (Capra ibex ibex) and mufflon (Ovis orientalis orientalis). A nationwide ovine footrot eradication program is planned for the years to come, based on polymerase chain reaction (PCR)-testing of interdigital swab samples and regular footbathing. In this cross-sectional study, we clinically evaluated the foot health and analysed presence of D. nodosus in 11 different even-toed ungulate species (mainly European species) during a 13 months (2018-2019) period in Berne Animal Park. The foot lesions were scored for any clinical signs of pathologies as described in cattle and simultaneously for clinical signs of footrot as described for sheep, using a scale from 0 to 5 (while 0 describes clinically healthy feet and 5 loss of the horn capsule). From a total of 53 animals, 4-feet swab samples were taken from the interdigital cleft and subjected to real-time PCR assays to detect D. nodosus at animal level. Foot lesions were detected in five different species. In 3/5 muskoxen (Ovibos moschatus wardi), 7/12 Cretan wild goats (Capra hircus cretica) and 2/3 dwarf goats (Capra hircus aegagrus), they mainly consisted of white line disease, whereas in 9/10 European bison, dermatitis of the interdigital cleft was diagnosed. 1/3 alpaca was diagnosed with chorioptic mange of the heel area. None of the examined animals showed clinical signs of footrot (score 0), and neither benign (aprB2-positive) nor virulent (aprV2-positive) D. nodosus were detected in any of the samples. This study provides additional information to facilitate an efficient ovine footrot control program in Switzerland and suggests that captive wild even-toed ungulates do not pose a risk to the planned footrot control program.

INTRODUCTION: Dichelobacter nodosus (D. nodosus) est l'agent étiologique du piétin chez les ruminants, qui affecte principalement les moutons dans le monde, mais aussi les ongulés sauvages en liberté tels que les bouquetins (Capra ibex ibex) et les mouflons (Ovis orientalis orientalis). Un programme d'éradication du piétin ovin à l'échelle Nationale, basé sur des tests PCR (réaction de polymérisation en chaîne) d'écouvillons de l'espace interdigité et des pédiluves réguliers, est prévu dans les années à venir en Suisse. Dans cette étude transversale, nous avons évalué cliniquement la santé des onglons et recherché la présence de D. nodosus chez 11 espèces différentes d'animaux biongulés (principalement des espèces européennes) pendant une période de 13 mois (2018­2019) au Parc animalier de Berne. Les lésions des onglons ont été notées pour tout signe clinique de pathologie et de présence de piétin, comme cela est décrit chez les bovins et les moutons et en utilisant une échelle de 0 à 5 (où 0 décrit des pieds cliniquement sains et 5 la perte de la boîte cornée). Des écouvillons ont été prélevés dans l'espace interdigité des 4 pieds sur un total de 53 animaux et soumis à des tests PCR en temps réel pour détecter D. nodosus. Des lésions aux onglons ont été détectées chez cinq espèces différentes. Chez 3 boeufs musqués (Ovibos moschatus wardi) sur 5, 7 chèvres sauvages crétoises (Capra hircus cretica) sur 12 et 2 chèvres naines (Capra hircus aegagrus) sur 3, il s'agissait principalement de lésions de la ligne blanche, alors que dans 9 bisons sur 10, le diagnostic était une dermatite interdigitale. Un alpaga sur 3 a été diagnostiqué avec une gale chorioptique de la zone du paturon. Aucun des animaux examinés n'a montré de signes cliniques de piétin (score 0) et aucun D. nodosus bénin (aprB2-positif) ou virulent (aprV2-positif ) n'a été mis en évidence dans les échantillons. Cette étude fournit des informations supplémentaires pour améliorer l'efficacité du programme d'éradication du piétin ovin et suggère que les biongulés sauvages détenus dans les parcs zoologiques ne présentent pas de risque pour le programme d'éradication prévu en Suisse.

Psychosocial outcome following genetic risk counselling for familial colorectal cancer. A comparison of affected patients and family members.

Few studies have reported prospective data on psychosocial outcomes after genetic counselling in families with suspected hereditary non-polyposis colorectal cancer (HNPCC). This prospective study examines the impact of multidisciplinary risk counselling on the psychosocial outcome of 139 affected cancer patients and 233 family members without cancer at risk for HNPCC. Participants completed questionnaires specific to HNPCC before and 8 weeks after attending the familial cancer clinic. Affected patients' levels of distress were closely related to their health status and exceeded that of unaffected individuals, as did worry regarding their relatives' risk. A significant reduction in general anxiety (Hospital Anxiety and Depression Scale), distress specific to familial CRC (Impact of Events Scale) and general cancer worry (Distress Hereditary Disorder) was demonstrated after counselling in both affected patients and unaffected individuals. Reduction in distress was more pronounced in affected patients given a high risk of HNPCC compared with those at intermediate risk. Among unaffected individuals, distress declined regardless of what clinical risk they were assigned. Their perceptions of risk and cancer-related threat declined, while confidence in effective surveillance increased. These results suggest the beneficial effects of multidisciplinary counselling even when high-risk information is conveyed. A patient's previous cancer experience is likely to contribute to clinically relevant distress (15% of those patients), indicating the need for appropriate counselling.

Sulfur-enhanced defence: effects of sulfur metabolism, nitrogen supply, and pathogen lifestyle.

Evidence from field experiments indicates differential roles of sulfur and nitrogen supply for plant resistance against pathogens. Dissection of these observations in defined pathosystems and controlled nutritional conditions indicates an activation of plant sulfur metabolism in several incompatible and compatible interactions. Contents of cysteine and glutathione as markers of primary sulfate assimilation and stress response show increases in ARABIDOPSIS THALIANA upon infection, coinciding with the synthesis of sulfur-containing defence compounds. Similar increases of thiols were observed with necrotrophic, biotrophic, and hemibiotrophic pathogens. Sulfate supply was found to be neutral or beneficial for tolerance against fungal but neutral for bacterial pathogens under IN VITRO conditions. According to various reports and own observations the effects of nitrogen supply appeared to be neutral or harmful, depending on the pathogen. The activation of sulfur metabolism was a consequence of activation of gene expression as revealed by macroarray analysis of an A. THALIANA/ALTERNARIA BRASSICICOLA pathosystem. This activation appeared to be largely independent from sufficient or optimal sulfate supply and from the established sulfate deficiency response. The data suggest that plant-pathogen interactions and sulfur metabolism are linked by jasmonic acid as signal.

Results of the 2004 survey of the American Association of Academic Chief Residents in Radiology.

RATIONALE AND OBJECTIVE: Every year, the American Association of Academic Chief Residents in Radiology (A3CR2) conducts a survey of the chief residents in accredited radiology programs in the United States and Canada. The purpose of the survey is to evaluate current residents' opinions regarding a number of different issues pertaining to their educational experience, work responsibilities, and benefits. This information is useful in monitoring patterns of change in resident attitudes toward their experiences within their residency training programs. MATERIALS AND METHODS: Online surveys were made available to the chief residents from 193 training programs in North America. For the most part, the questions were presented in a multiple-choice format, with additional space for elaboration or comments provided for many of the items. Some questions are repeated annually, addressing general topics such as salary and hospital size. However, new questions are incorporated each year. In particular, this year's survey included questions pertaining to Armed Forces Institute of Pathology course funding, and advanced cardiac life support (ACLS) /basic life support certification and changes in duty work hour and call requirements in the face of changing ACGME (Accreditation Council for Graduate Medical Education) regulations. RESULTS: The results of the survey were then tabulated, and responses to several of the repeated questions were compared with those from prior surveys dating back to 1996. This year's response rate was 55%, with 106 unique responses received. This represents an improvement since last year's survey, when the response rate was 41%. In some cases, more than one response was generated by a given residency program, in which case the questionnaire that was more thoroughly completed was used for statistical analysis. Responses were received from chief residents in 37 states and in Canada. The largest number of respondents was from New York, and 80% percent of respondents were from programs affiliated with a university. Forty-two percent were incoming chief residents with less than 3 months' experience, whereas 58% were outgoing chief residents with less than 9 months remaining in their tenure. CONCLUSION: The majority of respondents report that changes made by their respective programs as the result of new ACGME maximum duty hour standards have been viewed favorably by radiology residents. Many training programs have moved toward a night float based call system in order to maintain compliance. Nearly all programs have overnight in-house radiology resident coverage, but there has been a slight decline in the percentage of programs that provide in-house attending coverage at night. The majority of residents, however, have access to attendings after-hours by pager. Finally, resident salaries and benefits continue to increase, as has been the trend over the past several years.

Phosphorus nutrition in Proteaceae and beyond.

Proteaceae in southwestern Australia have evolved on some of the most phosphorus-impoverished soils in the world. They exhibit a range of traits that allow them to both acquire and utilize phosphorus highly efficiently. This is in stark contrast with many model plants such as Arabidopsis thaliana and crop species, which evolved on soils where nitrogen is the major limiting nutrient. When exposed to low phosphorus availability, these plants typically exhibit phosphorus-starvation responses, whereas Proteaceae do not. This Review explores the traits that account for the very high efficiency of acquisition and use of phosphorus in Proteaceae, and explores which of these traits are promising for improving the phosphorus efficiency of crop plants.

Genomic and functional characterization of the oas gene family encoding O-acetylserine (thiol) lyases, enzymes catalyzing the final step in cysteine biosynthesis in Arabidopsis thaliana.

The final step of cysteine biosynthesis in plants is catalyzed by O-acetylserine (thiol) lyase (OAS-TL), which occurs as several isoforms found in the cytosol, the plastids and the mitochondria. Genomic DNA blot hybridization and isolation of genomic clones indicate single copy genes (oasA1, oasA2, oasB and oasC) that encode the activities of OAS-TL A, B and C found in separate subcellular compartments in the model plant Arabidopsis thaliana. Sequence analysis reveals that the newly discovered oasA2 gene represents a pseudogene that is still transcribed, but is not functionally translated. The comparison of gene structures suggests that oasA1/oasA2 and oasB/oasC are closely related and may be derived from a common ancestor by subsequent duplications. OAS-TL A, B and C were overexpressed in an Escherichia coli mutant lacking cysteine synthesis and exhibited bifunctional OAS-TL and beta-cyanoalanine synthase (CAS) activities. However, all three proteins represent true OAS-TLs according to kinetic analysis and are unlikely to function in cyanide detoxification or secondary metabolism. In addition, it was demonstrated that the mitochondrial OAS-TL C exhibits in vivo protein-protein interaction capabilities with respect to cysteine synthase complex formation similar to cytosolic OAS-TL A and plastid OAS-TL B. Multiple database accessions for each of the A. thaliana OAS-TL isoforms can thus be attributed to a specified number of oas genes to which functionally defined gene products are assigned, and which are responsible for compartment-specific cysteine synthesis.

The clinical efficacy and cost analysis of cranial computed tomography and the radionuclide brain scan.

Cranial computed tomography (CCT) has already been demonstrated to provide significant diagnostic information in patients with neurologic disease and to reduce the need for special neuroradiologic procedures. The important question remaining is: Should CCT replace the radionuclide brain scan (RBS) as the first diagnostic study in most patients with suspected intracranial pathology? Data are now available to define the costs and benefits of this substitution. The technical costs of CCT have been determined by a national survey and have shown to be $130 per patient at a volume of 50 patients per week. The costs of RBS at the Mallinckrodt Institute have been estimated at $51 per patient. Data from the literature indicate that CCT is slightly more sensitive and considerably more accurate than RBS. Eighteen to twenty-eight percent of patients studied by CCT and RBS have abnormalities (e.g. cerebral atrophy and ventricular dilatation) that are only detected by CCT, and the overall accuracy of CCT is 95%, while the accuracy of RBS is approximately 70%. Substituting CCT for RBS is cost-beneficial. Although CCT is more costly, it increases overall accuracy by approximately 25%. The cost benefit is further increased by the reduction of complicated diagnostic procedures (and associated hospitalization and morbidity) and improvement in diagnostic information for the individual patient. Substituting CCT for RBS may not be more costly because a positive RBS will be followed by CCT (because of increased diagnostic information), and a negative RBS may be followed by CCT (because of increased accuracy), whereas a positive or negative CCT is unlikely to be followed by RBS.

Hospital-wide distribution of nuclear medicine studies through a broadband digital network.

Nuclear medicine provides a good environment for the evaluation of picture archiving and communication systems (PACS) because of the relatively small quantity of digital data that are generated, leading to reduced requirements for storage, display, and transmission compared with those found in radiology. The PACS in nuclear medicine is characterized by use of a single computer as a central storage, display, and analysis node. Images are acquired with use of small, low-cost computers attached to each camera. This network configuration offers advantages of convenience, but with great reliance on a single computer. A campus-wide picture network is under development at Washington University employing broadband cable television technology supplemented by baseband Ethernet (Digital Equipment Corp, Maynard, MA) components. All areas of diagnostic radiology and nuclear medicine are connected via a PACS testbed project. A radiology information system, supporting over 250 terminals, provides digital tracking of patients and report generation and retrieval. A new image workstation is under development in conjunction with Digital Equipment Corp. This system will permit display in multiple windows of report information and images from various modalities. A lung scan demonstration project is now beginning that is designed to test the value of a PACS in nuclear medicine. Digitally acquired chest radiographs will be displayed on an image workstation in nuclear medicine along with digital ventilation and perfusion lung scans. It is hoped that time-consuming logistic bottlenecks now encountered in lung scan interpretation will be reduced.

Difficulty in initiating and maintaining sleep associated with cow's milk allergy in infants.

To confirm that sleeplessness in infants can be related to an undiagnosed allergy to cow's milk proteins, 71 infants were studied. Group I consisted of 20 infants referred for chronic insomnia that had appeared in the early days of life. Group II was made up of 31 infants admitted for skin or digestive symptoms attributed to cow's milk intolerance; 13 of these infants were shown to sleep as poorly as the infants of group I. Group III consisted of 20 infants with no history of sleep disturbance or milk allergy. The three groups of infants were comparable for sex and age. Laboratory tests revealed immunologic reactions to milk in all the infants in groups I and II. The sleep of the insomniac infants (group I, and the 13 "poor sleepers" in group II) became normal after cow's milk was eliminated from the diet. Insomnia reappeared when the infants in group I were challenged with milk. We conclude that infants with clinically evident milk allergy may suffer from sleeplessness and that when no evident cause for a chronic insomnia can be found in an infant the possibility of milk allergy should be given serious consideration.

Failure of Beal mitral valve prosthesis. Clinical and radiographic features.

This report presents a case of severe dysfunction of an improved Model 104 Beall valve secondary to disc wear. This type of valve failure may be extremely difficult to detect by auscultation, echocardiography, or fluoroscopic examination. Prosthesis failure with resulting mitral insufficiency should be considered in any patient with a Teflon disc Beall mitral valve in whom there is unexplained clinical deterioration.

Student analysis of imaging studies. A radiology clerkship exercise.

Senior radiology clerkships often must cope with medical students whose overly optimistic course goals are quite different from the objectives of the radiology faculty. Conference formats that satisfy both the clerks and the teachers are therefore difficult to design. We use a conference based on student assessments of radiology examinations that attracts student interest while accomplishing staff objectives. This learning session relies on student-prepared analyses of radiologic examinations. The five-year experience with this teaching method has been quite positive from the perspectives of students and the staff.

The senior radiology clerkship. Disparate goals of students and faculty.

A survey of medical students taking our radiology elective over the past five years revealed that 51% were chiefly interested in learning "to read x-rays." Other motivations for taking the elective, such as learning "radiographic workups" were relatively low-priority goals. On the other hand, a survey of our staff revealed a low priority placed on teaching medical students to interpret radiographic images and a high value placed on imparting an understanding of the role of radiology in clinical diagnosis and management. This disparity between the goals of the students and teachers delineates one of the major challenges in designing a radiology curriculum for medical schools.

Reexamination of the force relationship of cortical cell discharge patterns with conditioned wrist movements.

Single unit recordings were obtained from 103 precentral cortical cells whose activity was related to an alternate wrist flexion-extension task in monkeys. Although the task was carried out under different loads only a weak relationship between cortical cell firing rates and static force levels was observed for force in one direction. A large change in firing rate occurred, however, when direction of force shifted as a result of a change in the predominant activity between extensor and flexor muscles. The firing patterns of the observed cortical cells suggest that the motor cortex is involved in specifying the muscles to be activated for a given movement and not the level of force to be produced by these muscles. During the dynamic phase of the movement little change in cortical cell firing pattern was observed for large changes in the rate of change of force. Motor cortex cell firing patterns appear to be unrelated to the large values of rate of change of force seen in this experiment.

Involvement of cyclic AMP in the regulations of lymphokine induced glia cell stimulation.

T and B lymphocytes of human or murine origin were found to secrete a factor which increases the DNA and RNA synthesis of cultured glia cells. This factor, termed glia cell stimulating factor (GSF), is released upon stimulation of such immune cells by mitogen or antigen qualifying it as a lymphokine. In this communication we report on the role of cyclic AMP (cAMP) in regulating the effect of GSF on glia cells. Prostaglandin E1 (PGE1), isoproterenol and theophylline were effective in suppressing the GSF-induced increase of the glia cell proliferation. No inhibition of DNA synthesis and no decrease in cell number was observed when testing these substances on glia cells not being activated by GSF. The drugs were found to induce an increase in cAMP concentrations of glia cells. A partial desensitization of the glia cells to these drug induced elevations of cAMP was detected after pretreatment of the glia cell cultures with GSF. It is suggested that stimulated lymphocytes not only release GSF but also low molecular weight proteins such as PGE1 which regulate the effects of GSF on glia cells by activating their adenylate cyclase.

Practical methods of electron depth-dose measurement compared to use of the NACP design chamber in water.

Central axis relative dose versus depth measurements were performed using two different small volume thimble ionization chambers and a p-type silicon diode in a water phantom and with two parallel-plate ionization chambers, thermoluminescent dosimeters, and radiographic film in a popular clear polystyrene phantom. Values obtained were compared to the results of similar measurements in a water phantom performed with a plane-parallel ionization chamber designed and optimized for use in electron beams by the Nordic Association of Clinical Physicists (NACP). The NACP chamber is expected to minimally perturb the electron fluence and be least prone to point of measurement uncertainties. Its use in a water phantom closely approximates the spirit of recent international protocols. Data were obtained for the foil scattered electron beams generated by two different accelerators for field sizes from 6 cm X 6 cm to 25 cm X 25 cm and energies between 6 and 20 MeV. Easily identifiable effective points of measurements were defined for each measurement device and standard corrections were applied to the raw data to obtain depth-dose curves. The degree of agreement between the various techniques and the NACP-water standard was quantitatively analyzed through comparison of the resulting depths of 50% dose and practical range. All methods were found to yield reasonable results when carefully implemented, with average differences of less than 1 mm being easily achievable. Measurements with p-type silicon diode detectors were found to be particularly useful, as they are pointlike and appear from all practical considerations to directly represent relative dose, thus requiring little or no correction to raw readings.

Radiology reporting.

Several different computer methods have been developed to assist in the production of radiology reports. Some systems require the radiologist to interact directly with the computer; in other departments, it is the transcriptionist who types the report into a computer terminal. Automated reporting systems, if they are well designed, offer a significant benefit to most departments, providing an efficient method to produce, store, and distribute radiology reports.

Monitoring department efficiency and quality.

Effective radiology management requires accurate, timely data about the ongoing operation of a department. Computers provide a method to assemble detailed information, and well-designed management reports can then provide the department administrator with summarized information that can be useful in identifying problems and initiating changes to reduce costs and improve the quality of patient care.