Spinal cord schistosomiasis: a pediatric case mimicking intrinsic cord neoplasm.

We present the clinical, myelographic, MRI, and histologic data on a 7-year-old girl with confirmed Schistosoma mansoni infection of the spinal cord. MRI of the granulomatous spinal lesion revealed extensive enlargement of the cord in the T11-12 area, with some intramedullary swelling extending to T-5 through T-7. The clinical manifestations of spinal schistosomiasis can be diverse, and there should be a high index of suspicion for all patients from endemic areas.

Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system.

OBJECTIVE: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers' evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care. DESIGN: Survey. MEASUREMENTS: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses. RESULTS: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P < 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency. CONCLUSION: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects.

Carcinomatous meningitis from transitional cell carcinoma of bladder.

The following case report presents a patient with transitional cell carcinoma of the bladder referred to this medical center after carcinomatous meningitis developed. Previously he had undergone surgical resection of the primary lesion and had received cis-platinum chemotherapy for lung metastasis. This unusual presentation of metastatic disease (carcinomatous meningitis) seems to alert the surgical and medical communities to new complications.

Intraoperative fluid management of living donor versus cadaveric liver transplant recipients.

Living donor liver transplantation has increasingly become an alternative to cadaveric donor liver transplants for select adult patients. Because these cases can be performed electively, living donor recipients may have better compensated liver disease at the time of surgery than cadaver donor recipients. However, it is unknown if this difference would have a significant effect on their intraoperative course. Therefore, we compared the intraoperative fluid management of patients receiving liver grafts from either living or cadaveric donors (n = 25, each group). Patient groups did not differ in demographics or baseline laboratory values. The duration of anesthesia and anhepatic phases were significantly longer in living donor cases (651 +/- 80 minutes vs 409 +/- 20 and 55 +/- 14 vs 45 +/- 6, P < .05). Adjusted for anesthesia time and patient weight, fluid administration (crystalloid and albumin) was not different between the two groups. Intraoperative transfusion requirements were also not significantly different in recipients from living donors versus cadaveric donors with regard to red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. However, arterial oxygenation was better preserved in recipients from living donors. The PaO2/FiO2 (P/F) ratio at the end of the procedure was significantly better in patients receiving livers from living rather than from cadaveric donors (P/F ratio 335 +/- 114 mm Hg vs 271 +/- 174, P < .05). Our results indicate that while intraoperative fluid and transfusion requirements are similar, the impact of transplantation on pulmonary gas exchange is more pronounced in patients receiving organs from cadaveric donors. This difference may arise from longer cold ischemia times present in the cadaveric donor group.

Intraoperative fluid and pharmacologic management and the anesthesiologist's supervisory role for nontraditional technologies during liver transplantation: a survey of US academic centers.

BACKGROUND: Volume resuscitation and use of vasoactive medications during liver transplantation has not been systematically assessed. Furthermore, the anesthesiologist's role for intraoperative oversight of technologies such as renal replacement therapy and procedures such as venovenous bypass is poorly defined, and it is unclear if the center's annual transplant frequency affects these practices. METHODS: We conducted a database analysis of the Liver Transplant Anesthesia Consortium survey 202 that addresses these questions. Data from US academic liver transplant anesthesia programs meeting inclusion criteria were included. Results were categorized by their annual transplant volume. RESULTS: A representative sample of 66% of all eligible centers contributed to the results. Normal saline among crystalloids and albumin among colloids were the most frequently chosen maintenance and non-blood product volume expansion fluids, with little variation by center size. A large variety of vasoactive agents is routinely utilized across programs, with vasopressors as a cornerstone of hemodynamic support. Large programs seem to use less of these agents compared with lower volume centers. CONCLUSION: Anesthesiologists are increasingly involved in oversight and management of intraoperative renal replacement therapies, venovenous bypass and cell saver devices with rising transplant frequency. This new insight may be indicative of skill sets needed by members of liver transplantation anesthesia teams and should be considered in curriculum design for hepatobiliary transplant anesthesia fellowships.

Liver cirrhosis in the medical critical care patient.

Critically ill cirrhotic patients are characterized by unique and complicated clinical scenarios related to some characteristic and clear-cut pathophysiological features of their chronic end-stage liver disease that challenge Intensive Care Unit (ICU) physicians with several management problems. This class of patients may require admission to the ICU because of decompensation of their pre-existing liver disease or due to medical problems independent of cirrhosis as pneumonia, trauma or surgery. Either way, it is acknowledged that, when feasible, without definitive treatment by way of liver transplantation, cirrhosis is an independent predictor of poor outcome in critically ill patients. In fact, cerebral, cardiopulmonary and kidney dysfunctions as well as portal vein hypertension, ascites and gastrointestinal bleeding can make the course of these patients very complicated and may further affect their outcome. Despite some improvement that was recently reported, patients with decompensated cirrhosis pose to ICU physicians several and, sometimes, dramatic dilemmas in terms of therapeutic strategies and efficacy of the treatments also due to the lack of large specific studies on this particular class of patients. This review will focus on kidney, cardiopulmonary and cerebral complications of severe cirrhosis as well as those related to portal hypertension and their management.

Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial.

OBJECTIVE: To test in a prospective randomized study the hypothesis that use of thromboelastography (TEG) decreases blood transfusion during major surgery. MATERIAL AND METHODS: Twenty-eight patients undergoing orthotopic liver transplantation were recruited over 2 years. Patients were randomized into 2 groups: those monitored during surgery using point-of-care TEG analysis, and those monitored using standard laboratory measures of blood coagulation. Specific trigger points for transfusion were established in each group. RESULTS: In patients monitored via TEG, significantly less fresh-frozen plasma was used (mean [SD], 12.8 [7.0] units vs 21.5 [12.7] units). There was a trend toward less blood loss in the TEG-monitored patients; however, the difference was not significant. There were no differences in total fluid administration and 3-year survival. CONCLUSION: Thromboelastography-guided transfusion decreases transfusion of fresh- frozen plasma in patients undergoing orthotopic liver transplantation, but does not affect 3-year survival.

Resistance to computerization. An examination of the relationship between resistance and the cognitive style of the clinician.

The introduction of computer technology into the health care environment has been fraught with difficulty. The literature has identified that while there are many applications that have been successfully implemented, there are many others that have met significant resistance. As such, the diffusion of computer technology has been scattered and uneven in the health care arena. Some scholars attribute the problems of resistance to structural variables such as value conflicts, power conflicts, and ones that involve the man-machine interface. Other view the resistance as process-oriented, citing such key factors as inadequate training, lack of user involvement, and discomfort due to organizational change. It is held here that the essence of resistance to computerization in clinical settings is based upon the difference between the cognitive style of the user and that required by the computer. It appears that since the decision-making methods of the user tend to favor intuitive processes, he or she becomes more resistant to using a system that forces qualitative information into quantitative niches. This study examines the cognitive style of two groups of health care providers within a hospital, and attempts to provide insight into how personal decision-making processes are related to resistance to computerization. It is suggested that a more thorough understanding of this relationship will enhance the ability of health care facilities to implement new systems in the future.

The request for proposal (RFP). The key document in successful systems acquisition.

The health care industry is complex and changing. Management in this environment requires significant quantities of accurate timely data for administrators and clinicians alike. In response to this demand, health care facilities have sought to upgrade or replace their computer systems with ones that have greater ability to enhance decision making in real time. The standard development process dictates a requirements analysis, with a Request for Proposal (RFP) as a likely product. This document, which delineates the institution's needs and provides a guide for appropriate vendor responses, has been given scant attention in the literature, particularly in the health care environment. This paper attempts to provide insight into what the goals and objectives of the RFP should be and explicates those elements that are necessary to produce an effective instrument. It details what information should be included about the institution, basic hardware and software issues that should be addressed, and proposes guidelines for response and evaluation. It is suggested that the proper development of an RFP will be a key factor in the successful acquisition of an appropriate health care information system.

Role of adjuvant radiotherapy following radical prostatectomy for microscopic residual disease.

Radical prostatectomy and lymphadenectomy remain common therapy for stages A or B prostatic cancer. If surgical margins are positive, adjunctive radiotherapy is sometimes given. There is no clear evidence that such therapy alters the natural history of the disease. In an attempt to answer this question, we reviewed all 40 radical prostatectomy specimens seen at New York University Medical Center and Bellevue Hospital from 1977 to 1984. Twelve cases with microscopic disease at the surgical margins were found. Six of these patients received postoperative radiation and 6 observation only. In theory, microscopic residual disease following prostatectomy confers a high risk of local recurrence. Our retrospective study did not confirm this and questions the beneficial role of postoperative radiotherapy in such patients.

Collagen metabolism in rat incisor predentine in vivo: synthesis and maturation of type I, alpha 1 (I) trimer, and type V collagens.

Collagen synthesis and deposition in the predentine of the continuously erupting rat incisor was analyzed in vivo following a single intraperitoneal injection of [14C]glycine. Newly synthesized collagen was extracted from the dissected predentine with a solution of 1.0 m sodium chloride containing proteolytic enzyme inhibitors. Mature, cross-linked collagen was solubilized by limited pepsin digestion following extractions with 0.5 M acetic acid or 0.1 M penicillamine. Analysis of the radiolabeled collagens by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and fluorography showed that over 97% of collagen synthesized migrated in the alpha 1 (I) and alpha 2 positions following pepsin digestion; the remaining 3% migrated in the positions of alpha 1 (V) and alpha 3 (V) collagens. However, from the ratio of the alpha 1 (I): alpha 2 it was estimated that approximately 30% of the salt-extractable collagen was alpha 1 (I) trimer. The presence of this collagen was confirmed by salt-fractionation and cyanogen bromide digestion patterns. Type I, alpha 1 (I) trimer, and type V collagens were also found in the salt-insoluble tissue residue. In this fraction the alpha 1 (I) trimer comprised 10-15% of the collagen measured as radioactivity but was difficult to discern colorimetrically. Type III collagen could not be detected in any of the fractions analyzed. From the profiles of isotope incorporation into collagens and collagen precursors, it was evident that collagen synthesis and processing was rapid. Processing of type I collagen and probably also alpha 1 (I) trimer proceeded almost entirely through procollagen intermediates. Rapid maturation of the types I and V collagens in the salt-insoluble fraction and the appearance of beta and gamma chains as early as 30 min after isotope administration. Radiolabeled procollagens were also extracted with acetic acid and penicillamine, indicating that cross-linking of collagen precursors may be involved in fiber formation.

The benefits and perils of system integration.

The current health care environment is complex, with no single systems solution dominating the marketplace. A new approach utilizes Networked Systems Integration to link disparate systems together. This paper discusses the Systems Integration approach and suggests that it encourages user commitment, provides greater modularity, is cost effective, and supports solutions that offer greater functionality. However, it is noted that this approach is not without problems that can dramatically effect the realization of benefits.

Advanced Multi-Attribute Scoring Technique (AMAST): a model scoring methodology for the request for proposal (RFP).

The continued demand for more efficient and functionally rich automated systems will force health care facilities into a changing and complex marketplace. As the Request for Proposal (RFP) will be the key document in the systems acquisition process, it is imperative that a systematic process must be established to evaluate the vast array of data collected. It is suggested in this paper that the effective application of the Advanced Multi-Attribute Scoring Technique (AMAST) will assist in this process, enhance the decision making process and reduce the risk associated with systems development and procurement.