Development of performance measures for acute ischemic stroke.

BACKGROUND AND PURPOSE: The purpose of the present study was to develop and rate performance measures for hospital-based acute ischemic stroke. METHODS: A national multidisciplinary panel of 16 individuals (2 stroke specialists, 2 general neurologists, 2 internists, 2 neuroscience nurses, 2 stroke advocacy organization representatives, 1 stroke rehabilitationist, 1 family practitioner, 1 emergency room physician, 1 neuroradiologist, 1 managed care organization director, and 1 hospital association representative) from 10 medical societies or lay organizations assisted in the development of 44 potential stroke performance measures. We developed evidence summaries for each of the performance measures and graded the level of evidence associated with each measure. The panel received a summary of the literature pertaining to each measure and rated the measures by use of a modified Delphi approach for 6 dimensions of quality, including validity of evidence, feasibility, impact on outcomes, room for improvement, plausibility, and an overall rating (little reason to do, could do, should do, and must do). RESULTS: Highly rated and agreed on performance measures for the overall rating include warfarin in atrial fibrillation, antithrombotics on hospital discharge, carotid imaging in appropriate patients, and use of stroke units. Additional measures notable for high agreement were heparins for deep-vein thrombosis prophylaxis and use of a stroke protocol. Panelists rated time-related thrombolytic measures such as head CT within 25 minutes highly on the room for improvement dimension but low on the overall dimension. Neurologists tended to rate measures lower than did nonneurologists (P<0.01) for all 9 measures pertaining to thrombolytic management. CONCLUSIONS: Highly rated and agreed on performance measures exist in all domains of hospital-based stroke care.

Training the future neurology workforce.

OBJECTIVE: To address training demands on future neurologists, the American Academy of Neurology (AAN) surveyed its US members as to their views about training the future neurology workforce. METHODS: The survey was mailed to 575 US neurologists and 425 residents/fellows. Respondents (54%) were asked about their perceptions of current and future educational programs and settings needed to improve practice competence; issues related to subspecialization; and the role of non-neurologists in providing neurologic care. Views of neurologists were compared with those of neurology residents/fellows. RESULTS: Most respondents support additional training in outpatient, community, and staff model health maintenance organization settings. The majority of respondents oppose a required fifth year of training or a yearly competency examination, but neurologists who have a subspecialty interest and residents/fellows favor elective certification and higher fees by subspecialists. General neurologists oppose these ideas. Most neurologists feel that primary care physicians, nurse practitioners, and physician assistants can manage uncomplicated neurologic problems, although residents/fellows are less willing to accept the role of nonphysician providers for neurologic services. CONCLUSIONS: Neurology educational programs should consider addressing deficiencies that today's practitioners perceive. Increasing subspecialization, although favored by most neurologists, creates a challenge for the neurologic community as neurologists without subspecialty training see this trend as a threat to their livelihood.

The human mast cell: functions in physiology and disease.

Mast cells are multifunctional, tissue-dwelling cells capable of secreting a wide variety of mediators. They develop from bone marrow-derived progenitor cells, primed with stem cell factor (SCF), which mediates its actions by interacting with the SCF receptor or c-kit on the cell surface. Mast cells continue their maturation and differentiation in peripheral tissue, developing into two well described subsets of cells, MCT and MCTC cells, varying in content of tryptase and chymase as well as in immunobiology. Mast cells are activated by numerous stimuli, including antigen (acting via the high affinity IgE receptor, Fc?RI), superoxides, complement proteins, neuropeptides and lipoproteins resulting in activation and degranulation. Following activation, these cells express mediators such as histamine, leukotrienes and prostanoids, as well as proteases, and many cytokines and chemokines, pivotal to the genesis of an inflammatory response. Recent data suggests that mast cells may play an active role in such diverse diseases as atherosclerosis, malignancy, asthma, pulmonary fibrosis and arthritis. Mast cells directly interact with bacteria and appear to play a vital role in host defense against pathogens. Drugs, such as glucocorticoids, cyclosporine and cromolyn have been demonstrated to have inhibitory effects on mast cell degranulation or mediator release.

Tuberculosis and opportunistic infections: relevance to biologic agents.

With the expanding use of biologic agents, in particular TNF inhibitors, tuberculosis and other opportunistic infections have become an important and growing concern in rheumatology. Clinicians using these therapies should have an understanding of the scope of the problem, the underlying scientific rationale, as well as the optimal approaches to screening, monitoring and treatment.

[Functional heterogeneity of liver metastases in 3-phase computerized tomograms]. / Funktionelle Heterogenität von Lebermetastasen im Dreiphasen-Computertomogramm.

Ninety patients with liver metastases (68 colorectal carcinomas, 22 breast carcinomas) were examined by triphasic angio-CT. This included demonstration of the entire liver after a bolus-like injection of contrast. Originally, the metastases were hypodense, but showed four patterns of contrast enhancement. Quantitative evaluation of the mammary carcinomas showed a marked increase in density during the bolus phase, with similar contrast values in the liver and at the centre and edge of the metastasis at ten minutes after the injection. Colorectal carcinomas showed only slight increase in density after contrast injection. The difference in density between the centre and the periphery of the metastasis was still present on later images. This finding indicates that there are differences in the vascularisation of these metastases.

Development of a Brief, Multidimensional, Self-Report Instrument for Treatment Outcomes Assessment in Psychiatric Settings: Preliminary Findings.

Preliminary reliability and validity data are reported on a new, brief measure of psychiatric symptomatology. The Symptom Assessment-45 Questionnaire (SA-45) is a 45-item, patient self-report symptom inventory derived from the original Symptom Checklist-90-R (SCL-90), using cluster analytic methods. The SA-45 consists of nine 5-item scales assessing each of the same symptom domains as its parent instrument with no item overlap across domains. The vast majority of the internal consistency reliabilities for the SA-45's nine scales were in the .70s and .80s across different age and patient status samples. As expected, both adolescent and adult patient samples generally differed significantly from nonpatient control samples, and patients at treatment follow-up differed significantly from patients at intake. Moreover, depressed patients with and without psychotic features differed significantly on three scales. A cluster analysis generally supported the nine-scale structure of the inventory, but it failed to consistently support the distinction between the Paranoid Ideation and Interpersonal Sensitivity scales. Limitations to the study are noted, but overall, the initial findings support the use of the SA-45 in clinical settings. Suggestions for needed future research are presented.

[Spectral domain OCT in eyes with retinal artery occlusion]. / Aspects évolutifs de la rétine en coupe OCT spectral domain lors des oblitérations artérielles rétiniennes.

INTRODUCTION: Retinal artery occlusions are a straightforward, essentially clinical diagnosis. The role of spectral domain ocular coherence tomography (SD-OCT) in this condition is not well described. PURPOSE: Anoxic retinal edema develops in the acute phase of retinal artery occlusion (RAO) followed by a regressive phase giving way to retinal atrophy. The purpose of the study was to determine dynamics of theses retinal changes in central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO) using spectral domain optical coherence tomography (SD-OCT). PATIENTS AND METHODS: A prospective study of patients hospitalized at Hôpital Edouard-Herriot de Lyon between June and September 2009 was performed after patient education and informed consent. Retinal thickness of patients with central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or cilio-retinal artery occlusion was measured centered on the macula or on the site of occlusion with spectral domain optical coherence tomography (SD-OCT) using Cirrus(®) (Carl Zeiss Meditec, Germany) upon admission, throughout hospitalization, at 1 month and at 3 months. Thickness and reflectivity of the various retinal layers were compared with the fellow eye. RESULTS: Fourteen patients were included (seven CRAO, six BRAO and one cilio-retinal artery occlusion). SD-OCT in the acute phase showed retinal thickening and increased reflectivity confined to the inner retinal layers supplied by the retinal circulation with decreased reflectivity from the photoreceptor and retinal pigment epithelial layers secondary to a shadowing effect in the affected area. These changes subsequently resolved at 1 month and gave way to a marked thinning of the inner retinal layers by 3 months. In one case of CRAO associated with an ophthalmic artery occlusion and consequent occlusion of the ciliary circulation as well, initial OCT revealed complete retinal thickening involving both the inner and outer layers. DISCUSSION: This study demonstrates that the anoxic intracellular edema resulting from retinal artery occlusions (RAO) observed histologically appears on OCT as a thickening of the inner retinal layers in the acute stage of the condition, giving way to atrophic areas starting at approximately 1 month ("pseudonormalization") and becoming clearly atrophic at 3 months. CONCLUSION: SD-OCT is useful in the diagnosis of RAO, especially if the patient is seen later in the disease process, when the ischemic retinal whitening is no longer present on fundus exam.

[Hypopharyngeal carcinoma and radical surgery--does such a therapeutic procedure make sense?]. / Hypopharynxkarzinome und Radikaloperation--ein sinnvolles therapeutisches Vorgehen?

From 1977 to 1983, 49 patients with carcinoma of the hypopharynx were treated, including follow-up, at the ENT clinic of the Zentralkrankenhaus St. Jürgen Strasse in Bremen. Two groups of patients with comparable tumor stage distributions were either treated with a combination of radical surgery and radiotherapy (19 patients), or not operated at all, receiving instead radiotherapy and/or chemotherapy (30 patients). The five-year survival rates (33% and 11% respectively) revealed, albeit at an altogether low level, the superiority of the radical procedure, including total extirpation of the larynx. The recommendation for radical removal of a hypopharyngeal carcinoma must therefore be made on an individual basis and with some reservation. Compromises, such as surgical management of the lymph node metastases without extirpation of the primary tumor, which is then irradiated, or the excision of the primary tumor in combination with partial resection of the larynx, ought to be made when choosing between possible therapeutic alternatives.

Studies on the substrate specificity of the DNA methylase activity from Escherichia coli K-12.

A partially purified extract of DNA methylases from E. coli K-12 containing DNA-adenine as well as DNA-cytosine methylase activities has been examined with respect to different DNA species as substrates. The results show that the natural content of 6-MAP) in the applied DNA represses the DNA-adenine methylase activity. On the other hand, 5-MC, already present in the substrate does not influence the activity of the DNA-cytosine methylase. DNA from Micrococcus radiodurans, which is completely free of methylated bases served as comparison. Since netropsin preferentially binds to AT-rich regions of DNA, the influence of this oligopeptide antibiotic on the methylation of DNA was investigated. As expected the antibiotic predominantly inhibits adenine methylation of DNA. The degree of inhibition depends on the molar ratio of netropsin to DNA phosphate.

Danger: T.R. at work.

State credential processes may require applicant groups to specify the dangers to the public and clients of unregulated practice. A model for the equitable display of therapeutic recreation concerns is proposed as well as a classification of negative worker behaviors. The self-study process described has implications for education, personnel justifications and the development of standards and ethics.

Diversity of retron elements in a population of rhizobia and other gram-negative bacteria.

Genetic elements called retrons reside on the chromosome of Escherichia coli and the myxobacteria and represent the first reverse transcriptase-encoding element to be found in a prokaryotic cell. All known retrons produce a functionally obscure RNA-DNA satellite molecule called multicopy single-stranded DNA (msDNA). We report here the presence of msDNA-producing retron elements in a number of new bacterial groups, including strains of the genera Proteus, Klebsiella, Salmonella, Nannocystis, Rhizobium, and Bradyrhizobium. Among a population of 63 rhizobia strains, only 16% contain a retron element. The rhizobia retrons appear to be heterogeneous in nucleotide sequence and show little similarity to previously studied retrons of E. coli and the myxobacteria.

Beta cell function in siblings of diabetic children and HLA type.

Beta cell function was tested in HLA-DR typed siblings of insulin dependent diabetic children. HLA identical siblings showed an increased insulin response compared with controls and HLA nonidentical siblings. This beta cell hyperactivity may be an early carbohydrate intolerance or a genetically determined increase in beta cell metabolism.

Plasma catecholamines in children.

Plasma catecholamine concentrations in 46 children of various ages were determined by a sensitive radioenzymatic assay. Noradrenaline levels were found to be in the same range as in adults, whereas adrenaline levels in a few of the children were abnormally high.