HIV infection is associated with an increased prevalence of coronary noncalcified plaque among participants with a coronary artery calcium score of zero: Multicenter AIDS Cohort Study (MACS).

OBJECTIVES: HIV-infected individuals bear increased cardiovascular risk even in the absence of traditional cardiovascular risk factors. In the general population, coronary artery calcium (CAC) scanning is of value for cardiovascular risk stratification, but whether a CAC score of zero implies a low noncalcified coronary plaque burden in HIV-infected persons is unknown. METHODS: We assessed the prevalence of noncalcified coronary plaque and compared noncalcified coronary plaque burden between HIV-infected and HIV-uninfected participants who had CAC scores of zero in the Multicenter AIDS Cohort Study (MACS) using coronary computed tomography (CT) angiography. RESULTS: HIV infection was associated with the presence of noncalcified coronary plaque among these men with CAC scores of zero. In a model adjusted only for age, race, centre, and pre- or post-2001 cohort, the prevalence ratio for the presence of noncalcified plaque was 1.27 (95% confidence interval 1.04-1.56; P = 0.02). After additionally adjusting for cardiovascular risk factors, HIV infection remained associated with the presence of noncalcified coronary plaque (prevalence ratio 1.31; 95% confidence interval 1.07-1.6; P = 0.01). CONCLUSIONS: Among men with CAC scores of zero, HIV infection is associated with an increased prevalence of noncalcified coronary plaque independent of traditional cardiovascular risk factors. This finding suggests that CAC scanning may underestimate plaque burden in HIV-infected men.

Identification of the midline by obese and non-obese women during late pregnancy.

During central neuraxial blockade, identifying the midline in parturients can be difficult, particularly if they are obese. We assessed the ability of women in late pregnancy, both obese and non-obese, to identify the midline of their own back by pointing and by pinprick discrimination with reference to the true midline identified by ultrasound. Thirteen out of 25 (52%) obese women were accurate to within 5 mm in identifying the midline of their back by pointing with their fingertip, compared with 21/25 (84%) non-obese women (p = 0.03). The median (IQR [range]) fingertip-midline distance was greater in obese women (5 (5-10 [0-10]) mm compared with non-obese women (2 (0-5 [0-12]) mm; p = 0.007). Identification of the midline using pinprick was poorer by obese women (median (IQR [range]) 33 (25-45 [3-85]) mm) than by non-obese women (18 (13-25 [8-40]) mm; p < 0.0001). However, women in both groups were correct > 99% of the time in identifying that a stimulus was either to the left or to the right side.

Pregnant women's views on informed consent for research in labour.

BACKGROUND: Studies of the optimal treatment of accidental dural puncture occurring during epidural insertion in labour are difficult for practical reasons and because of the ethical issues around seeking consent. In a recent study of accidental dural puncture, participants were assigned to one of two treatment groups and only informed about the study and consent sought, after treatment. We sought the views of parturients on the timing of consent for such a study. METHODS: After ethical approval and written consent, 100 nulliparous women in the third trimester of pregnancy completed a structured, facilitated questionnaire, rating the acceptability of the consent process occurring: (i) in antenatal clinic; (ii) after the epidural was requested in labour; (iii) after the accidental dural puncture had occurred but before treatment; (iv) after the allocated treatment; or (v) without consent (waived consent). Results were analysed with the Friedman and Wilcoxon signed-rank tests. RESULTS: Antenatal consent was considered the most acceptable option, whilst consent on request for epidural analgesia and after accidental dural puncture were least acceptable. Consent after treatment and waived consent were rated in-between these extremes. There was a statistically significant difference between these three groups (P<0.0001). There was a wide range of opinions on each option presented. CONCLUSIONS: Antenatal consent was the preferred option but if this is not possible and the need for the research is strong, consent for the use of women's data after intervention, or waived consent, is acceptable to many women. It is important to seek the views of the participants themselves before planning research with difficult ethical aspects.

Quantification of lumen stenoses with known dimensions by conventional angiography and computed tomography: implications of using conventional angiography as gold standard.

BACKGROUND: Quantitative coronary angiography (QCA) has inherent limitations for displaying complex vascular anatomy, yet it remains the gold standard for stenosis quantification. OBJECTIVE: To investigate the accuracy of stenosis assessment by multi-detector computed tomography (MDCT) and QCA compared to known dimensions. METHODS: Nineteen acrylic coronary vessel phantoms with precisely drilled stenoses of mild (25%), moderate (50%) and severe (75%) grade were studied with 64-slice MDCT and digital flat panel angiography. Fifty-seven stenoses of circular and non-circular shape were imaged with simulated cardiac motion (60 bpm). Image acquisition was optimised for both imaging modalities, and stenoses were quantified by blinded expert readers using electronic callipers (for MDCT) or lumen contour detection software (for QCA). RESULTS: Average difference between true and measured per cent diameter stenosis for QCA was similar compared to MDCT: 7 (+/-6)% vs 7 (+/-5)% (p=0.78). While QCA performed better than MDCT in stenoses with circular lumen (mean error 4 (+/-3)% vs 7 (+/-6)%, p<0.01), MDCT was superior to QCA for evaluating stenoses with non-circular geometry (mean error 10 (+/-7)% vs 7 (+/-5)%, p<0.05). In such lesions, QCA underestimated the true diameter stenosis by >20% in 9 of 27 (33%) vs 1 of 29 (3%) in lumen with circular geometry. CONCLUSIONS: QCA often underestimates diameter stenoses in lumen with non-circular geometry. Compared to QCA, MDCT yields mildly greater measurement errors in perfectly circular lumen but performs better in non-circular lesions. These findings have implications for using QCA as the gold standard for stenosis quantification by MDCT.

Education and certification influence the nutrition and management knowledge of long-term-care foodservice managers.

OBJECTIVES: To describe nutrition knowledge, attitude toward nutrition, and management knowledge of long-term-care foodservice managers and to determine the relationship between these variables and the foodservice managers' personal and facility characteristics. DESIGN: Nutrition knowledge, management knowledge, and attitudes toward nutrition were measured using survey methodology designed for this study by modifying an instrument developed by the Nutrition Education Training Program for the Texas Department of Human Services. SUBJECTS/SETTING: Surveys were mailed to a random sample of 300 long-term-care foodservice directors from the 1,092 directors listed in the 1996 Ohio Department of Health Directory of Nursing Homes. The participants were 123 of the 300 foodservice directors (41%). STATISTICAL ANALYSES PERFORMED: Descriptive statistics, Spearman rank correlations, 1-way analysis of variance, and post hoc variance were calculated. RESULTS: Mean scores of respondents were 21.2 out of a possible 29 (73%) for the nutrition knowledge assessment, and 18.2 out of 26 (70%) for management knowledge. Dietitians and dietetic technicians scored significantly better than others on these tests. The mean score of attitudes toward nutrition was 4 on a 5-point scale (where 1 = strongly disagree to 5 = strongly agree). All participants requested more training in computers, nutrition terminology, and preparing appealing foods. APPLICATIONS: Dietitians and dietetic technicians are prepared with a wide scope of knowledge in nutrition and management. Thus, they are in an ideal position to take advantage of job opportunities in the area of foodservice management.

The moral responsibility of the hospital.

The hospital has legal liability. Does it also have moral responsibility? Is it a moral agent, and if so in what sense? There are two issues involved, one conceptual and the other normative. The conceptual issue is whether a hospital can be morally responsible. If seen not only as a physical facility but as a formal organization, it can be said to act rationally, choose between alternatives, and affect human beings. It thus satisfies the criteria for moral responsibility, even though it is not a person. Though moral responsibility can be attributed intelligibly to a hospital, such responsibility can be assumed only by those within it who act for it. Such responsibility is agent responsibility and may be shared in a number of ways. Hospital responsibilities can be separated from the professional moral responsibility and the personal moral responsibility held by doctors, nurses, and others within a hospital. Assuming these three types of responsibility makes possible conflicts of responsibility for those who hold them. Normatively, the moral responsibility of the hospital is appropriately limited by its purpose and is primarily administrative. It has designatable moral responsibilities to its patients, doctors and nurses, and the public. These can be distinguished from the responsibilities of doctors and nurses to the public. The responsibility of a doctor on the hospital staff is different from the responsibility of a doctor who simply practices in the hospital; that of a staff nurse from that of a private nurse. The difference is in large part a function of the one sharing the responsibility of the hospital and the other not. An analysis of a hospital's moral responsibilities suggests structures appropriate to a hospital that wishes to meet its moral responsibilities.

KIE: A hospital, as an organization, chooses alternatives and acts rationally; therefore, like an individual, it is seen as having moral responsibility. This responsibility is primarily administrative, with duties owed to its patients, health professionals, and the community served. The hospital's primary obligations are to develop norms to which the hospital and staff must conform, to serve patients by providing the best care possible, to allocate resources so as most effectively to respond to the needs of the community, and to create policies which allow staff members to refrain from performing acts which they consider immoral.