An evaluation of conscious sedation using propofol and remifentanil for tension-free vaginal tape insertion.

Tension-free vaginal tape insertion is a recommended treatment for stress incontinence. There is evidence that intra-operative testing of continence by asking patients to cough may improve outcomes, but an optimal sedation regimen has not been determined. We prospectively evaluated the effectiveness of propofol and remifentanil infusions in 25 patients using pre- and post-sedation peak cough pressures and pain scores. Patient satisfaction was assessed using the Iowa Satisfaction with Anaesthesia Score (ISAS). Post-sedation cough pressures were improved compared to baseline, with a mean peak pressure increase of 24 mmHg (95% CI 15.5-32.5; p < 0.001). Pain scores (median, IQR [range]) were low for local anaesthetic infiltration (0, [0-1]) and first (0, [0-1]) and second (0, [0-3.5]) needle insertions. Of the 19 patients completing the ISAS, all felt safe and satisfied. Sedation using propofol and remifentanil provides acceptable analgesia, satisfaction and effective continence testing.

The incremental direct costs associated with behavioral symptoms in AD.

OBJECTIVE: To determine the incremental costs associated with behavioral symptoms in patients with AD. METHODS: A total of 128 patients with probable AD were enrolled into this study. Cognitive function and extrapyramidal features were assessed in patients with AD. Caregivers were interviewed to determine use of health care services, receipt of unpaid care, severity of behavioral symptoms (Neuropsychiatric Inventory [NPI]), and comorbid medical conditions in patients with AD. Healthcare utilization data were multiplied by unit costs to estimate direct formal costs. Unpaid caregiving hours were multiplied by an hourly wage to estimate direct informal costs. The annual incremental direct costs of additional behavioral symptoms were estimated with multiple regression equations. RESULTS: Annual, direct costs were significantly higher in patients with AD at or above the median score on the NPI (high NPI group), after adjusting for group differences in severity of cognitive impairment and comorbid conditions. Patients in the high NPI group had formal costs between US$3,162 and US$5,919 higher than the low NPI group and total direct costs between US$10,670 and US$16,141 higher, depending on the severity of cognitive impairments. Models for the entire sample estimated that a one-point increase in the NPI score would result in an annual increase of between US$247 and US$409 in total direct costs, depending on the value of unpaid caregiving. CONCLUSIONS: Behavioral symptoms in patients with AD significantly increase direct costs of care.

Keeping track of needs in communal and exchange relationships.

Keeping track of needs in communal and exchange relationships was investigated in two experiments. In both, subjects could check to see if another person needed help. The first experiment tested the hypotheses that When there is no opportunity for the other to reciprocate in kind, keeping track of the other's needs will be greater if the person desires a communal relationship with the other than if the person desires an exchange relationship with the other. If the person desires an exchange relationship with the other, keeping track of the other's needs will be greater when an opportunity for the other to reciprocate in kind exists than when it does not. If a communal relationship is desired, the existence of an opportunity for the other to reciprocate in kind will not influence keeping track of the other's needs. The results of the first experiment supported all three hypotheses. The second experiment tested and found support for the hypothesis that even when nothing can be done to help the other, keeping track of the other's needs will be greater if a communal relationship is desired with the other than if an exchange relationship is desired.

Recipient's mood, relationship type, and helping.

We conducted two studies to examine how a potential helper is affected by having a communal orientation toward a relationship with a potential recipient and by the potential recipient's sadness. We hypothesized that (a) having a communal orientation would increase helping and that (b) people high in communal orientation, but not others, would respond to a potential recipient's sadness by increasing helping. These hypotheses were tested in two studies. In Study 1, individual differences in communal orientation toward relationships were measured by using a new communal orientation scale reported for the first time in this article. In Study 2, manipulations were used to lead subjects to desire either a communal or an exchange relationship with another person. In both studies, subjects were exposed to a sad person or to a person in a neutral mood whom they were given a chance to help. As hypothesized, in both studies communally oriented subjects helped the other significantly more than did others. Also as hypothesized, in both studies communally oriented subjects but not others, increased helping in response to the other person's sadness although this effect reached statistical significance only in the second study.

On the automatic activation of attitudes.

We hypothesized that attitudes characterized by a strong association between the attitude object and an evaluation of that object are capable of being activated from memory automatically upon mere presentation of the attitude object. We used a priming procedure to examine the extent to which the mere presentation of an attitude object would facilitate the latency with which subjects could indicate whether a subsequently presented target adjective had a positive or a negative connotation. Across three experiments, facilitation was observed on trials involving evaluatively congruent primes (attitude objects) and targets, provided that the attitude object possessed a strong evaluative association. In Experiments 1 and 2, preexperimentally strong and weak associations were identified via a measurement procedure. In Experiment 3, the strength of the object-evaluation association was manipulated. The results indicated that attitudes can be automatically activated and that the strength of the object-evaluation association determines the likelihood of such automatic activation. The implications of these findings for a variety of issues regarding attitudes--including their functional value, stability, effects on later behavior, and measurement--are discussed.

Measuring and assuring the quality of home health care.

The growth in home health care in the United States since 1970, and the exponential increase in the provision of Medicare-covered home health services over the past 5 years, underscores the critical need to assess the effectiveness of home health care in our society. This article presents conceptual and applied topics and approaches involved in assessing effectiveness through measuring the outcomes of home health care. Definitions are provided for a number of terms that relate to quality of care, outcome measures, risk adjustment, and quality assurance (QA) in home health care. The goal is to provide an overview of a potential systemwide approach to outcome-based QA that has its basis in a partnership between the home health industry and payers or regulators.

Magnetic resonance imaging and hydatidiform mole.

Five women with complete and partial hydatidiform mole were examined by magnetic resonance imaging (MRI). Spin-echo pulse sequences (T2 weighted) were found to provide excellent resolution, while inversion-recovery pulse sequences (T1 weighted) gave better pathological detail. The myometrium was clearly seen on each patient and no invasion by the tumour detected. This corresponded to the histological findings. The potential uses of magnetic resonance in the diagnosis of primary and recurrent trophoblastic disease and its role in management are discussed.

Magnetic resonance imaging of benign ovarian masses.

Forty-one patients with 45 pelvic mass lesions were assessed by magnetic resonance imaging (MRI). All lesions were initially considered to be benign ovarian masses with this diagnosis confirmed in 36 lesions. The characteristics on MRI are analysed and features useful in predicting histological type identified. Our results indicate that a high, though not absolute, level of diagnostic specificity should be obtainable in identification of ovarian pathology.

The implications of patient antibody response for the clinical usefulness of immunoscintigraphy.

The evolving clinical role for tumour immunoscintigraphy appears to be in monitoring patients for metastatic spread and tumour recurrence. Such diagnostic strategies inevitably involve repeat imaging investigations, and therefore the probability of patient immunization against the administered radiopharmaceutical is increased. Patient antibody responses would appear to affect the quality and sensitivity of repeat imaging studies, and this also has implications for the therapeutic efficacy of subsequent therapy doses. A simple test for determining patient sensitization to antibody is required.

Yield and nutritive quality of sericea lespedeza (Lespedeza cuneata) and little bluestem (Schizachyrium scoparium) exposed to ground-level ozone.

Sericea lespedeza (Lespedeza cuneata cv. Interstate 76) and little bluestem (Schizachyrium scoparium cv. Aldous) were raised from seed in a glasshouse, transplanted into 5.7-l pots and placed into open-top chambers (OTC) on 6 June 1999. Following a 7-day adjustment period, each of six OTCs (duplicate OTCs per treatment) was ventilated with either air that had been carbon-filtered (CF) to remove ambient ozone (O3); non-filtered (NF), representative of ambient air; or enriched to twice-ambient O3 concentration (2X). Primary-growth forage was harvested on days 7, 32, 46, 59 and 72 following the start of fumigation, and regrowth forage from the first primary-growth harvest was harvested on days 36, 54 and 72 following the start of fumigation. Dry matter (DM) yield of either forage species did not differ among treatments except in the final regrowth period when yield of sericea lespedeza was greater for the NF than 2X O3 treatment. In vitro DM digestibility (IVDMD) and concentrations of crude protein (CP), soluble phenolics (SP) and condensed tannins (CT) in primary-growth sericea lespedeza did not differ between treatments, but NF primary-growth forage had higher concentration of protein-precipitating tannins (PPT) than did 2X primary-growth forage. Concentrations of neutral detergent fiber (NDF), acid detergent fiber (ADF) and acid detergent lignin (ADL) were higher in NF and 2X than in CF primary-growth sericea lespedeza. Similarly, concentrations of NDF and ADL were higher, and IVDMD was lower for NF and 2X than for CF regrowth sericea lespedeza. Concentrations of ADF and ADL were lower, whereas IVDMD, in vitro NDF digestibility (IVNDFD) and concentrations of CP and SP were greater, in CF than in NF and 2X primary-growth little bluestem. Percentages IVDMD and IVNDFD and concentrations of CP and SP in NF primary-growth little bluestem were greater than those in forage exposed to 2X O3 treatment. No significant differences were observed among treatments in percentages IVDMD and IVNDFD, or concentrations of cell wall constituents or SP in little bluestem regrowth. Nutritive quality of little bluestem was decreased by < 2%, and that of sericea lespedeza by approximately 7% as a result of increased concentrations of cell wall constituents and decreased in vitro digestibility of NF and 2X compared with CF forages. Results indicate that existing and projected O3 levels can drive alterations in forage quality of select warm-season forages sufficient to have nutritional and economic implications for their utilization by ruminant herbivores.

Bilateral megaureters presenting as an inguinal hernia.

A 4-week-old male presented with a swelling in the right groin. At herniotomy a megaureter was discovered and a subsequent IVU demonstrated bilateral megaureters.

Sensorimotor half-day cAMP.

This paper describes a half-day sensorimotor camp program for young children. The camp program initially was offered to 4 pre-kindergarten children and supervised by one registered occupational therapist and one technician. The therapeutic format of the camp was multimodal. Principles of sensory integration, neurodevelopmental treatment, and education were incorporated in a structured, but varied sensorimotor environment. The goals of the camp were to provide (1) successful group play experiences, and opportunities to participate in (2) developmental/age appropriate sensorimotor activities, (3) recreational activities and (4) activities of daily living. The half-day sensorimotor camp offered a positive and successful experience to developmentally delayed children, which is usually not possible in many community based summer programs.

The application of magnetic resonance imaging to gynaecology.

Magnetic resonance imaging is a significant new imaging modality currently undergoing assessment. Already it has an established role in evaluation of the central nervous and musculoskeletal systems. Its potential application in gynaecology is reviewed with a discussion of its advantages over other imaging techniques.

Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women.

302 women aged 16-80 without symptoms of spinal disease had their lumbar intervertebral discs examined by magnetic resonance. The prevalence of one or more degenerate discs increased linearly with age but disc degeneration was already present in over one-third of women aged 21-40; these young women may prove to be at special risk of disc prolapse later in life. The high prevalence of symptomless disc degeneration must be taken into account when magnetic resonance is used for assessment of spinal symptoms.

Magnetic resonance imaging and placenta previa.

Twenty-five women with diagnoses of placenta previa on ultrasound examination underwent magnetic resonance imaging examination. An assessment of placental position and the relationship of the lower placental edge to the internal os was made with both techniques and the results were compared. There was complete correlation of placental localization but significant differences were found in the determination of the degree of placenta previa. This occurred more often with posteriorly situated placentas. Magnetic resonance imaging directly affected management with regard to delivery in seven cases. Magnetic resonance imaging provides a technique capable of accurately assessing placental position and its relationship to the cervix, thereby leading to a reduction in hospitalization and inappropriate operations.

Magnetic resonance imaging (MRI) in obstetrics. I. Maternal anatomy.

We assessed the ability of magnetic resonance, a recently introduced imaging technique, to demonstrate the maternal anatomy in obstetrics. The signal intensity of different maternal tissues using T1 and T2 weighted sequences was examined. The bony pelvis is depicted with sufficient clarity to provide an alternative to conventional X-ray pelvimetry. The placenta and cervix have a distinctive appearance facilitating the diagnosis of placenta praevia. The unique demonstration of cervical morphology will offer the potential for investigation into the ill-understood conditions of cervical dystocia and cervical incompetence.

Magnetic resonance imaging (MRI) in obstetrics. II. Fetal anatomy.

Magnetic resonance imaging (MRI) was performed in 36 patients at between 10 and 38 weeks gestation to determine the fetal anatomy that could be identified at different gestations. Fetal motion significantly degraded the image quality in the first and second trimesters, but in the final trimester fetal anatomy was clearly demonstrated. T2 weighted sequences showed the fetal brain and lungs to have a high signal intensity. Shorter TR leading to a T1 weighting gave better resolution of the overall anatomy. MRI has revealed the potential for assessment of lung maturity and the growth-retarded fetus.

Pre-operative magnetic resonance imaging of stage 1 endometrial adenocarcinoma.

Twelve women with stage I endometrial adenocarcinoma were examined by magnetic resonance imaging before definitive surgery. Using this technique the depth of myometrical invasion, tumour site and cervical involvement were assessed and the results compared with the operative and pathological findings. Magnetic resonance imaging is a unique non-invasive method of assessing the early stages of endometrial adenocarcinoma before radiotherapy and surgery.

Home care: moving forward with continuous quality improvement.

The utility of examining the effectiveness of home care is illustrated by selected examples and applications. The growth rate of home care over the past decade, questions regarding the possibly substantial differences between the quality of home care in rural and urban America, and empirical evidence that suggests inferior quality of home care for health maintenance organization patients support the need for measuring and monitoring outcomes of home care. The conclusions of a research program targeted at developing a system of outcome measures for home care, and the resulting national demonstration program to implement and refine that system, are summarized.

Magnetic resonance imaging--its application to cervical carcinoma.

Twenty-five women with primary carcinoma of the cervix were examined with magnetic resonance imaging (MRI). A number of different pulse sequences with T1 and T2 weighting were employed to determine optimum tissue contrast, and the potential for staging cervical cancer was assessed and compared with the clinical findings. MRI is seen to give a unique view of cervical cancer in particular in stage I and II disease where other imaging techniques have known limitations. In addition, stages III and IV were well seen with demonstration of tumour comparable with that of computerized axial tomography (CT).