Utility of intraoperative digital scintigraphy in radioguided parathyroidectomy.

BACKGROUND: Intraoperative scintigraphy (IoS) has been proposed as a tool for real-time intraoperative decision-making regarding parathyroid adenoma localization and confirmation of excision. METHODS: Retrospective review of patients who underwent minimally invasive parathyroidectomies with scintigraphy performed intraoperatively. Preoperative neck ultrasound, 4D computed tomography, as well as intraoperative parathyroid hormone (IOPTH) and gamma probe measurements were conducted per standard practice. IoS images were obtained prior to and following parathyroid excision. Cases were reviewed to determine accuracy of IoS for localizing parathyroid pathology and confirming successful excision. RESULTS: Fifty-six cases met the inclusion criteria. Twenty-nine patients (51.8%) showed confirmation of excision of an abnormal gland on post-excision IoS. There were no significant differences in IOPTH reduction and postoperative laboratory values between patients with IoS-identified resolution and those without IoS-identified resolution. CONCLUSIONS: With low accuracy in correctly localizing abnormal glands and confirming their excision, there is no appreciable benefit of IoS at this time.

Anemia Prevalence after Iron Supplementation among Pregnant Women in Midwifes Practice of Primary Health Care Facilities in Eastern Indonesia.

BACKGROUND: Iron deficiency anemia (IDA) in pregnant women is common, and iron supplementation is given during pregnancy to reduce birth complication. This study aimed to explore the prevalence of anemia and type of anemia after iron supplementation among pregnant women in the eastern part of Indonesia. METHODS: A cross-sectional study design was conducted between January and March 2019 in three Primary Health Care (PHC) facilities at Kupang, West Timor. After consent, pregnant women who had taken their iron supplementation for at least 3 months were asked for iron pills intake by using a self-designed questionnaire and by counting the pills leftover. Complete blood count examination was performed, and the type of anemia was assessed using Shine and Lal index (SLI; MCV ∗ MCV ∗ MCH/100) to determine whether anemia was due to iron deficiency or ß-thalassemia trait (ß-TT). In a subset of iron tablets distributed in the PHCs, Fe-concentration was measured. RESULTS: Of 102 pregnant women included, only 25.5% had taken the pills with a pill count of >80%. Interestingly, Fe-concentration in the pills from three different PHC facilities varied between 75% and 100%. After iron supplementation, however, anemia was detected in 34.3%, and based on SLI, 14.7% was suspected because of iron deficiency and 19.6% was suspective of ß-TT. Of note, nonanemic pregnant women (17.6%) had also low SLI, suggesting ß-TT or other hemoglobinopathies. CONCLUSION: Assessment of Shine and Lal index as the first step to screen the type of anemia in pregnant women from a limited area is of potential value, especially because Indonesia is located in the thalassemia belt area. An integrative approach and counseling among pregnant women with ß-TT and their partners will increase thalassemia awareness and optimal birth management.

Effect of decabromodiphenyl ether and antimony trioxide on controlled pyrolysis of high-impact polystyrene mixed with polyolefins.

The controlled pyrolysis of polyethylene/polypropylene/polystyrene mixed with brominated high-impact polystyrene containing decabromodiphenyl ether as a brominated flame-retardant with antimony trioxide as a synergist was performed. The effect of decabromodiphenyl ether and antimony trioxide on the formation of its congeners and their effect on distribution of pyrolysis products were investigated. The controlled pyrolysis significantly affected the decomposition behavior and the formation of products. Analysis with gas chromatograph with electron capture detector confirmed that the bromine content was rich in step 1 (oil 1) liquid products leaving less bromine content in the step 2 (oil 2) liquid products. In the presence of antimony containing samples, the major portion of bromine was observed in the form of antimony bromide and no flame-retardant species were found in oil 1. In the presence of synergist, the step 1 and step 2 oils contain both light and heavy compounds. In the absence of synergist, the heavy compounds in step 1 oil and light compounds in step 2 oils were observed. The presence of antimony bromide was confirmed in the step 1 oils but not in step 2 oils.

Physician leadership for the 21st century.

This article examines how rapidly evolving health care delivery structures are radically altering the traditional clinical and organizational autonomy enjoyed by physicians. These changes may render maintenance of prior levels of physician autonomy virtually impossible. The author calls for the emergence of a new breed of physician leaders who will preserve the best of traditional medical practice culture but also effectively implement a nascent form of integrated health care practice.

The Department of Defense Civilian External Peer Review Program: an interim report.

During a 2-year period (December 1987-December 1989), 165 Department of Defense (DoD) military hospitals world-wide provided 71,800 cases with 83,197 reviews for quality of care evaluations by the Civilian External Peer Review Program (CEPRP). The majority (78,246 of 79,896) of completed peer review determinations (97.9%) generated agreement with care and documentation. It is concluded that health care in military treatment facilities is of high quality, meeting and generally exceeding accepted standards of care. It is also concluded that the DoD CEPRP offers conceptual and practical experience to guide the further evolution and integration of clinical peer review and quality improvement activities.

Myths and misconceptions of the medical staff organization.

Many of the problems that confront hospitals in a rapidly changing and increasingly hostile environment are of their own making. Chief among these self-destructive tendencies has been misjudgment of the characteristics and functions of the medical staff organization. This article explores some common misconceptions and provides a more plausible reality.

Physician leadership. The time is now.

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.

The past, present and future of health care quality. Urgent need for innovative, external review processes to protect patients.

There are three paths to quality health care standards: the regulatory route, the "learning science" route, and the futuristic "management science" route. The regulatory path leads to punishment and blame. The learning science path splits, with one road leading back to harsh regulations and the other to the halls of academic medicine. And the management science path, while short, will be the road to success as American health care struggles to improve quality and overcome well-publicized and deadly medical errors.

Health care applications of complexity science. Life at the edge of chaos.

The authors explore complexity science, a relatively new field of inquiry, which holds for both clinicians and health care leaders the real possibility of stimulating fresh insights and approaches to health and medical care-both its provision and its organization. Two case studies are presented to illustrate how complexity theory can provide health care leaders with a new perspective on how to address the myriad challenges they confront daily: (1) a patient with dissociative identity disorder; and (2) a physician task group charged to advise on hospital medical staff reorganization and governance. These case studies help clinicians and leaders of health care organizations understand how complexity: (1) may be relevant, even helpful, as they consider difficult challenges in both patient and organizational management; and (2) might emerge as a synthesizing force as they face the extraordinarily complicated task of jointly creating integrated health care systems. A resource section is provided for those who may wish to further pursue the topic.

Modern medical practice: a profession in transition.

Modern medical practice is in a state of transition. The solo practitioner is slowly giving way to the large organized groups of health care providers. Driving this force of change is a change in payment for health care services from cost plus to preestablished pricing. For the first time, medical practice patterns are having a direct impact on the financial viability of the health care institution. To maintain quality of patient care and contain costs, more and more physicians are becoming involved in the administrative side of running a hospital. This article describes the forces of change, the change itself, and the future of medicine.

Evidence for the regulatory role of lipocalin 2 in high-fat diet-induced adipose tissue remodeling in male mice.

Lipocalin 2 (Lcn2) has previously been characterized as an adipokine/cytokine playing a role in glucose and lipid homeostasis. In this study, we investigate the role of Lcn2 in adipose tissue remodeling during high-fat diet (HFD)-induced obesity. We find that Lcn2 protein is highly abundant selectively in inguinal adipose tissue. During 16 weeks of HFD feeding, the inguinal fat depot expanded continuously, whereas the expansion of the epididymal fat depot was reduced in both wild-type (WT) and Lcn2(-/-) mice. Interestingly, the depot-specific effect of HFD on fat mass was exacerbated and appeared more pronounced and faster in Lcn2(-/-) mice than in WT mice. In Lcn2(-/-) mice, adipocyte hypertrophy in both inguinal and epididymal adipose tissue was more profoundly induced by age and HFD when compared with WT mice. The expression of peroxisome proliferator-activated receptor-γ protein was significantly down-regulated, whereas the gene expression of extracellular matrix proteins was up-regulated selectively in epididymal adipocytes of Lcn2(-/-) mice. Consistent with these observations, collagen deposition was selectively higher in the epididymal, but not in the inguinal adipose depot of Lcn2(-/-) mice. Administration of the peroxisome proliferator-activated receptor-γ agonist rosiglitazone (Rosi) restored adipogenic gene expression. However, Lcn2 deficiency did not alter the responsiveness of adipose tissue to Rosi effects on the extracellular matrix expression. Rosi treatment led to the further enlargement of adipocytes with improved metabolic activity in Lcn2(-/-) mice, which may be associated with a more pronounced effect of Rosi treatment in reducing TGF-ß in Lcn2(-/-) adipose tissue. Consistent with these in vivo observations, Lcn2 deficiency reduces the adipocyte differentiation capacity of stromal-vascular cells isolated from HFD-fed mice in these cells. Herein Rosi treatment was again able to stimulate adipocyte differentiation to a similar extent in WT and Lcn2(-/-) inguinal and epididymal stromal-vascular cells. Thus, combined, our data indicate that Lcn2 has a depot-specific role in HFD-induced adipose tissue remodeling.

Shared leadership in health care organizations.

This chapter explores why the leaders of both the medical profession and provider organizations are often in conflict, and why they must ultimately come together to create new leadership models for future health care organizations. Modern management concepts of knowledge/learning organizations, total quality process, and reengineering call for an innovative form of shared, truly collaborative leadership between clinicians and "scientific" managers.

Quality improvement to guide the new health system.

While there are many areas, such as intensive care treatment and pain management, where great gains in quality improvement can be made, the greatest strides will come as the leaders and trustees in health care organizations begin to create "the industrial revolution" in their organizations by creating cultures of quality. Stephen Shortell recommends the following list of things board members can do to improve quality in their organizations.