Parent vs burn-injured child self-report: contributions to a better understanding of anxiety levels.

Anxiety disorders are the most commonly reported form of mental health problem among youth, but they often go undiagnosed and untreated. This study examined the relationship between burn-injured youths' self-reported anxiety levels, as compared with their parent's perceptions of their child's emotional well-being. Burn-injured children were invited to voluntarily complete the Child Version of the 41-item survey, Screen for Child Anxiety Related Disorders, which consists of five anxiety subscales as well as a Total Anxiety Score. Parents were invited to complete the Parent Version. Sixty-three parent-child dyads, with girls (57%) and boys (43%), completed surveys. Mothers (73%) fathers (16%), and other caregivers (11%) participated. Youth mean age was 12.63 years and 60% reported visible burn scars. Matched-pairs t-tests were used to compare parent and child reports. Significantly lower mean scores were found between Screen for Child Anxiety Related Disorders Total Anxiety Score--Parent mean score of 10.52 vs the Youth mean score 21.06 (P<.001), as well as on all subscales including; panic disorder/somatic symptoms (P<.001), generalized anxiety disorder (P=.004), social anxiety disorder (separation anxiety (P<.001), and school avoidance (P<0.001). Results indicate that parents may be severely underestimating the psychological well-being of burn-injured youth. Findings emphasize the importance of a comprehensive approach in assessment for anxiety, involving the collection of feedback from both child and parent. Asking children for input into their psychological well-being is important. This study reinforces the need for a course of ongoing patient and parent education.

Limits on diffuse fluxes of high energy extraterrestrial neutrinos with the AMANDA-B10 detector.

Data from the AMANDA-B10 detector taken during the austral winter of 1997 have been searched for a diffuse flux of high energy extraterrestrial muon neutrinos. This search yielded no excess events above those expected from background atmospheric neutrinos, leading to upper limits on the extraterrestrial neutrino flux measured at the earth. For an assumed E-2 spectrum, a 90% classical confidence level upper limit has been placed at a level E2Phi(E)=8.4 x 10(-7) cm(-2) s(-1) sr(-1) GeV (for a predominant neutrino energy range 6-1000 TeV), which is the most restrictive bound placed by any neutrino detector. Some specific predicted model spectra are excluded. Interpreting these limits in terms of the flux from a cosmological distributions of sources requires the incorporation of neutrino oscillations, typically weakening the limits by a factor of 2.

Observation of high-energy neutrinos using Cerenkov detectors embedded deep in Antarctic ice.

Neutrinos are elementary particles that carry no electric charge and have little mass. As they interact only weakly with other particles, they can penetrate enormous amounts of matter, and therefore have the potential to directly convey astrophysical information from the edge of the Universe and from deep inside the most cataclysmic high-energy regions. The neutrino's great penetrating power, however, also makes this particle difficult to detect. Underground detectors have observed low-energy neutrinos from the Sun and a nearby supernova, as well as neutrinos generated in the Earth's atmosphere. But the very low fluxes of high-energy neutrinos from cosmic sources can be observed only by much larger, expandable detectors in, for example, deep water or ice. Here we report the detection of upwardly propagating atmospheric neutrinos by the ice-based Antarctic muon and neutrino detector array (AMANDA). These results establish a technology with which to build a kilometre-scale neutrino observatory necessary for astrophysical observations.

Rapid optical method for logging dust concentration versus depth in glacial ice.

We describe the design and simulated response of a dust logger consisting of a downward-pointing phototube, ~2 m below side-directed light-emitting diodes (LEDs), attached to a cable that can lower the device down a 3-in. (7.5-cm) borehole filled with butyl acetate. LED photons that enter the ice are scattered or absorbed by dust grains, and those that reach the phototube provide a measure of dust or volcanic ash concentration at a given depth. An increased dust concentration associated with an ancient colder climate will usually result in an increase in collected light, but may decrease collected light if air bubbles are present. Centimeter-thick volcanic ash bands can also be detected. The concept is based on six years of experience with pulsed light sources used to measure optical properties of deep Antarctic ice.

Professionalism and professional values in orthopaedics.

During a consensus conference in Fall, 1998, the Academic Orthopaedic Society identified the values and qualities of professionalism as defined by its members. One hundred eighty-six respondents rated 20 characteristics and values describing professionalism, based on the extent to which they believed each item was appropriate. The five items receiving highest average ratings were: integrity, trustworthiness, responsibility, reliability, and accountability. Principal components analysis yielded five factors that captured 62% of the total variability. These factors were labeled respect and relationships, altruism, accountability and reliability, integrity, and excellence. The authors anticipate that the Academic Orthopaedic Society will find these data useful, and incorporate this information into their decisions concerning evaluation of current residents and applicants to their programs. An additional challenge will be to develop a values curriculum (formal curriculum) and a learning environment (informal curriculum) that will encourage residents and faculty to aspire to the highest in professional values and professional conduct.

Can professional values be taught? A look at residency training.

Although medicine has long valued and reinforced certain behaviors, collectively labeled "professionalism," among its members, it is not clear if or how these behaviors might be conveyed to physicians in training. Despite this, teachers are required to assess and at times to act on their perceptions of their charges' professionalism. Surgery residents at a large metropolitan hospital were tracked during a 50-month period. They were evaluated on objective criteria, such as clinical abilities and performance, and more subjective qualities, including ethical standards and interpersonal skills (professionalism). Analysis of the data indicated that residents who scored above the mean on professionalism also scored significantly higher than their classmates on every dimension of skills and knowledge performance evaluated. This convergence suggests that those qualities comprising professionalism are important elements in resident's training, and tend to produce better overall clinical performance. This finding, and previous research in this area, should encourage investigators to explore the relationship between professionalism and clinical competence.

Effects of protective knee bracing on speed and agility.

We evaluated the effects of prophylactic knee braces on athlete speed and agility, as well as brace tendency to migrate. Thirty college football players in full gear ran a 40-yard dash and a four-cone agility drill wearing braces on both knees or no brace (control). Braces included the DonJoy Legend, Breg Tradition, OMNI-AKS 101W, McDavid Knee Guard, and models 1 and 2 of the Air Armor Knee and Thigh Protection System. Brace migration and subjective measures were recorded after each trial. In the 40-yard dash, times using Air Armor 1 and OMNI did not differ significantly from control. Times with other braces were significantly slower. In the four-cone drill, only the Breg times were significantly slower than control. The Air Armor 1 and McDavid braces showed significantly less superior/inferior migration in the 40-yard dash than other braces. In the four-cone drill, the Air Armor 1 and 2 showed significantly less superior/inferior migration than other braces. These findings indicate that selected knee braces do not significantly reduce speed or agility. Braces showed a variable tendency to migrate, which could affect their protective function and athlete performance. This information will help athletes and coaches decide about knee-brace use during sports; studies are needed regarding whether braces protect against knee injury. This study does not constitute an endorsement of knee-brace use or efficacy.

The epidemiology of labor induction: Arizona, 1997.

OBJECTIVE: This study was undertaken to describe labor induction risk factors and consequences among women with term singleton gestations with vertex presentation. STUDY DESIGN: Arizona births in 1997 (N = 65,607) were studied by means of stratified analysis and logistic regression. RESULTS: Labor induction occurred in 20.3% (n = 13,288). Labor induction risk factors were as follows: race or ethnicity (white non-Hispanic 25.3%; Hispanic, 13.9%; foreign-born Hispanic, 10.3%; and US-born Hispanic, 18.5%), education (<12 years, 14.1%; >12 years, 24.6%), payor (private insurance, 24.5%; Medicaid, 16.7%), hospital type (government controlled, 13.7%; investor owned, 30.5%). Race or ethnicity and hospital type remained important determinants of labor induction in the multivariate analysis. Relative risks of cesarean delivery with labor induction were as follows: nulliparous, 1.38; parous with no previous cesarean delivery, 1.00; and parous with previous cesarean delivery, 0.50. CONCLUSION: Large variations in labor induction were noted across maternal ethnicity and hospital type categories. Labor induction increased cesarean delivery rates among nulliparous women, whereas no increase was seen among parous women with no previous cesarean delivery. Labor induction was used less often among those with previous cesarean delivery; when it was used in this group, however, it was associated with a lower cesarean delivery rate.

A randomized controlled study of brief interventions to teach residents about domestic violence.

PURPOSE: To test an educational intervention regarding domestic violence. METHOD: Residents beginning their training in 1995 or 1996 were randomly assigned to attend, at their hospital orientation, either a 20-minute session emphasizing the importance of screening for domestic violence or a session on an unrelated topic. RESULTS: Seventy-one percent of the residents in the experimental group diagnosed domestic violence; 52% in the control did so (RR, 1.35; 95% CI, 0.96-1.90; p = .07) in the nine to 12 months following the intervention. Rates of diagnosis differed by specialty (p < .01): 100% family practice, 90% emergency medicine, 80% obstetrics-gynecology, 63% pediatrics, 47% internal medicine, 0% surgery. Change in knowledge was assessed in 1996; significant improvement was noted (p = .002). CONCLUSION: An intervention about domestic violence conducted at orientation for residents improved the rate of diagnosis of domestic violence. While the improvement was not statistically significant in this case, the intervention was brief and harmless. Other institutions should consider this kind of brief intervention.

Barriers to cancer screening in Mexican-American women.

OBJECTIVE: To test the simultaneous effect of various established predictors of breast and cervical cancer screening (breast self-examination, clinical breast examination by a physician, Papanicolaou [Pap] smear, and pelvic examination) in a low-income, Mexican-American sample. MATERIAL AND METHODS: A total of 188 Mexican-American women participated in a face-to-face structured interview in their preferred language. We tested a model with four established predictors of breast and cervical cancer screening--communication skills, knowledge of cancer, access to health care (finances and availability of care), and anxiety about cancer. Simultaneous structural equations analysis was used to form latent variables and to control for the effect of all predictors concurrently. RESULTS: Screening behavior was inversely associated with anxiety about cancer when all other predictors were statistically controlled. In addition, anxiety substantially affected the relationship between communication skills and screening behavior. Unexpectedly, knowledge of cancer was positively, rather than negatively, associated with anxiety about cancer. Predictors in the model demonstrated an excellent fit of the proposed model to the data. CONCLUSION: Successful cancer screening programs for Mexican-American women must address not only access barriers but also communication skills, knowledge, and, perhaps most importantly, anxiety.

Choosing the best abdominal closure by meta-analysis.

BACKGROUND: Local custom, rather than evidence-based medicine, dictates how a surgeon closes abdominal wounds. Closures might be more secure if grounded on statistical data. MATERIALS AND METHODS: A meta-analysis of 12,249 patients with abdominal wound closures was made. Infections, hernias, and dehiscences were compared examining continuous versus interrupted closures, continuous (absorbable versus nonabsorbable), interrupted (absorbable versus nonabsorbable), and mass versus layered. RESULTS: Continuous absorbable closures showed more hernias (P = 0.0007). Dehiscences were significantly more with continuous nonabsorbable suture (P = 0.01). Interrupted nonabsorbable closures showed a higher incidence of hernias and dehiscences (P = 0.0002, P = 0.04). Mass closures produced significantly less hernias and dehiscences when compared with layered closures (P = 0.02, P = 0.0002). CONCLUSIONS: Continuous closures with nonabsorbable suture should be used to close most abdominal wounds. However, if infection or distention is anticipated, interrupted absorbable sutures are preferred. Mass closures are superior to layered closures.

Parents can dose liquid medication accurately.

OBJECTIVE: To determine whether parental errors in dosing liquid medication can be decreased through education. DESIGN: Randomized convenience sample stratified to three study groups. SETTING: General pediatric clinic, largely indigent and Latino. PATIENTS: A total of 45 English-speaking and 45 Spanish-speaking children diagnosed with otitis media and treated with an antibiotic suspension. INTERVENTION: Group 1 patients received the prescription and verbal instructions. Group 2 patients received the prescription and a syringe, then the correct dose was demonstrated. Group 3 patients received the prescription, a syringe with a line marked at the correct dose, and a demonstration. After returning from the pharmacy, parents administered the medication under observation. Parents in group 1 used a dispensing device similar to that planned for home use. The other groups used the syringe. After observation but before discharge, everyone received a syringe with a line marked at the correct dose. Patients were seen again at approximately 1 month, and parents demonstrated how much medication they had administered. MAIN OUTCOME MEASURE: Percent of parents who administered the correct dose. RESULTS: Patients in group 1 received between 32% and 147% of the correct dose, with only 11 of 30 (37%) receiving the correct dose (+/-0.2 mL). In group 2, 25 of 30 (83%) parents administered the correct dose, and in group 3, 30 of 30 (100%) gave the correct dose. Simultaneous logistic regression indicated that accuracy of dosage differed across instructional groups and language. At follow-up, 23 of 26 parents demonstrated the correct dose. CONCLUSION: Education can decrease medication dosing errors made by both Spanish-speaking and English-speaking parents. Effectiveness was also shown at follow-up.

Laser Doppler evaluation of burned hands predicts need for surgical grafting.

Management of deep dermal hand burns represents a difficult clinical problem for the burn team because bedside estimation of burn depth is unreliable. Early identification of full-thickness injury and prolonged healing times might result in the decision to perform surgical excision of eschar and skin grafting of the wounds. Such a strategy may improve overall functional and cosmetic results of hand burn treatment. This report concerns a 2-year study of 31 patients with 43 burned hands using the LD6000 helium-neon laser Doppler flowmeter. After obtaining informed consent, burned areas of the hand were evaluated on days 1, 3, and 5 after burn. Results were reported as flow (mV), representing the quantity of moving erythrocytes multiplied by erythrocyte velocity in the capillary tissue. The reported volume in percentage of Doppler-shifted light represented only the quantity of moving erythrocytes. Median flow values in nongrafted hands were 150 mV; in those requiring skin grafts, median flow values were 89 mV. Flow values were significantly greater in nongrafted compared with grafted hand burns on days 1 and 5. Volume values were not associated with whether or not grafting was performed. Median volume values, however, did allow determination of whether the burns would spontaneously heal within 15 days (high group) or if a mean of 42 days would be required (low group). Functional and cosmetic outcomes were determined by retrospective chart review, which revealed comparable results regardless of grafting and regardless of short or prolonged healing times. Laser Doppler flowmetry may serve as a valuable adjunct to the prediction of the need for grafting and time to wound closure. Standardization of flowmetry data and techniques of evaluation are desirable. Spontaneous healing should be the goal in the majority of deep dermal hand burns.

How managed care may choose hospitals for contracts for laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVES: Maricopa Medical Center (MMC) was found to have higher charges and length-of-stays than 16 other regional hospitals in an analysis of DRG categories for gallbladder disease. These comparative figures identified MMC as being inefficient and demanded review to determine the reasons for the inefficiencies. METHODS: In an attempt to determine the reason for inefficiency of charges and length-of-stay for the laparoscopic portion of laparoscopic cholecystectomy, matched pairs of open cholecystectomy and converted laparoscopic cholecystectomy from a data base of 633 patients with cholecystectomies were reviewed. Thirty-five matches for age, sex and similar diagnosis were successful. RESULTS: Matched pair evaluation disclosed a $6,880 difference in charges, which was attributed solely to the charge for laparoscopy. Subsequent chart analysis showed a high charge for instrumentation, prolonged anesthesia and operative times and longer preoperative delays before surgery. Moreover, no matter what the conversion rate is, open cholecystectomy was more cost effective. However, if there is a conversion rate of 5%, total hospital charges for laparoscopic cholecystectomy would have to be reduced to $12,679 (a reduction of $3,332 from $16,011) to make laparoscopic cholecystectomy cost-effective. CONCLUSIONS: Cost-effective decision tree analysis of matched pair comparisons and sensitivity analysis proves to be an effective technique in evaluating the cost-effectiveness of laparoscopic cholecystectomy in a hospital population.

Using delta/DRG diagrams and decision tree analysis to select a cost-effective surgery for cholecystitis.

BACKGROUND AND OBJECTIVES: Many studies have attempted cost analysis of laparoscopic cholecystectomy as compared to open cholecystectomy. However, these analyses have included costs, charges, expenses, etc., and at times they have been used interchangeably. This paper demonstrates how DRG diagrams containing charges and length-of-stay, preoperative prediction of conversion rates, decision-tree construction and sensitivity analysis can be used to select the most cost-efficient operation for a given patient with cholecystitis. METHODS: A Delta DRG analysis for complicated cholecystectomy (DRG 195) showed the hospital to be an extreme outlier in both charges and length of stay. Record review indicated that 55% of the cases were converted laparoscopic cholecystectomies and the remainder were aged or younger patients with advanced disease. Chart and literature review determined the causes and the probability of conversion. Data were then placed into decision-tree and sensitivity analyses. The most cost-effective operation for a given probability of conversion was demonstrated. RESULTS: Three preoperative findings and combinations of each predicted conversion rates and analysis showed that the charge of laparoscopic cholecystectomy must be held below the range of $5,361-$13,084 to make routine laparoscopic cholecystectomy cost-effective. CONCLUSIONS: This method demonstrated that using Delta/DRG, decision-tree and sensitivity analysis offers physicians, hospitals and other health-care providers a method of evaluating the treatment of DRG categories to determine the most cost-effective management.

Hyperdynamic resuscitation improves survival in patients with life-threatening burns.

Our clinical experience has led to the conclusion, shared by others, that standard vital signs produce inadequate data for the resuscitation of severe burns. We reviewed three groups of burn patients including an index group (N = 53) whose resuscitation was guided by means of a pulmonary artery catheter, a control group (N = 33) collected from the burn registry for the period just before the index group, and a current group (N = 30) resuscitated with hyperdynamic end points defined empirically from surviving patients as guidelines. The mortality rate and organ failures decreased over time; the mortality rate of the control group was 48%, the index group 32%, and the protocol group 10% (p = 0.003). We concluded that hyperdynamic resuscitation does improve survival and reduces the incidence of organ failure.

Hemodynamic and oxygen transport monitoring in management of burns.

Burn resuscitation has been performed predominantly by means of the Parkland formula for the past 25 years. Normalization of heart rate, blood pressure, and production of 1 mL/kg/hr of urine were proposed as suitable guides to resuscitation. Recently, it has become apparent that the standard circulatory criteria of fluid replacement adequacy are too inaccurate to produce optimal hemodynamic end points. Our burn team has reported a 4-yr experience with use of the pulmonary artery catheter inserted on admission to the unit of severe burn injuries. This monitoring device allowed for additional fluid volume administration to enhance circulatory function with resulting production of maximal hemodynamic values. The ability to achieve hyperdynamic end points predicted survival in our series. Use of invasive monitoring to produce hyperdynamic circulatory end points has resulted in a significant decrease in overall mortality. Oxygen consumption (VO2) was important and there was a statistically significant difference in this variable which distinguished survivors from nonsurvivors. VO2 increased progressively in relation to burn size in survivors but stayed at a constant lower value in nonsurvivors. Elderly burn patients were resuscitated at lower end points than younger individuals because of volume intolerance. Inability to be aggressively resuscitated results in twice the mortality in burn-injured elderly patients. These experiences indicate that burn resuscitation as currently practiced with existing formulas produces inadequate circulatory responses, and both survival and organ function can be improved by maximizing circulatory end points.

Withdrawal and extended leave during residency training: results of a national survey.

BACKGROUND: Although national figures for medical student withdrawal and extended leave have long been reported, similar data have not been available for residents in training. METHOD: Data for this study came from the American Medical Association survey of the 1991-92 residency year, in which program directors were asked for information about residents who had taken extended leave or had withdrawn or been dismissed from their programs prior to completion. Data are reported for 89,368 residents enrolled in 6,302 programs (89.2% of all surveyed programs). RESULTS: During the 1991-92 year, 2,449 residents (2.7%) withdrew or were dismissed from their programs and 887 (1.0%) took extended leave. Specialty and program changes accounted for 56% of the withdrawals, while performance difficulties were implicated in 12.9%. Maternity or paternity leave was involved in 32.2% of extended leaves, followed by research sabbaticals (11.4%) and physical problems (10.5%). Women had higher rates of both withdrawal and extended leave than men. Withdrawal for performance difficulties was lowest among graduates of U.S. and Canadian allopathic schools as compared with graduates of osteopathic or foreign medical schools, and lowest among Caucasians as compared with those of other racial-ethnic identities. CONCLUSION: Although overall figures and percentages are low, there are small but persistent losses of residents annually that vary by specialty, gender, race-ethnicity, and education.

Survival in major burn injuries is predicted by early response to Swan-Ganz-guided resuscitation.

BACKGROUND: Two years ago the authors began to use Swan-Ganz catheters to generate more complex hemodynamic data as a better guide to resuscitation of burns. This study uses the information to identify differences between survivors and nonsurvivors. PATIENTS AND METHODS: Fifty-three consecutive patients with major burns were treated using Swan-Ganz-generated data. Additional information was collected, including demographics, intake and output, medications, and arterial blood gas (including calculated oxygen consumption). Statistical analysis incorporated adjustments for autocorrelation. RESULTS: The patients included 38 men and 15 women, averaged 43.7 years of age, and had a mean burn size of 40%. Thirteen patients suffered severe inhalation injury. Data collected hourly over 3 days were collapsed across 6-hour observation periods. Mean values, when plotted across time, discriminated the 37 survivors from the 16 nonsurvivors. Poor response to resuscitation as evidenced by increased use of colloid fluid and cardiotonic drugs plus failure to maximize oxygen consumption were associated with nonsurvival. CONCLUSIONS: Unsustained or inadequate response to hyperdynamic resuscitation of burns was associated with nonsurvival.

Domestic violence: an educational imperative?

OBJECTIVE: Domestic violence is the most common cause of injury to women. Obstetrician-gynecologists, who most women consider their primary care physicians, have a unique role in identifying battered women. This study was designed to assess the extent and nature of current training curricula regarding domestic violence education in obstetrics and gynecology residencies. STUDY DESIGN: A survey sent to all obstetrics and gynecology residencies requested demographic data, the curriculum in respect to domestic violence, availability of interested faculty, the prevalence of battering among patients, satisfaction with the current teaching, and knowledge of pending legislation. Respondents were also asked which of 10 common clinical presentations would prompt their faculty to discuss the possibility the patient was being battered. RESULTS: Eighty-three percent of programs responded. The "typical" program was urban, had five residents per year, and had faculties of full-time academicians and part-time private practitioners. Twenty-eight percent reported having at least one faculty member with expertise in domestic violence. One third reported a prevalence of battering of < or = 1% with 6% estimating fewer than 1 in 1000. Seventy-five percent did not recognize at least one clinical scenario as suggestive of battering. The majority were dissatisfied with their teaching and wanted help in curriculum development. Forty percent were unaware of pending legislation linking federal support of medical education to including domestic violence in curricula. CONCLUSIONS: The results of this survey highlight deficiencies in the education of obstetrics and gynecology residents about domestic violence. Programs report limited faculty interest, underestimate prevalence, fail to recognize common presentations, and are dissatisfied with their current curriculum. We are not preparing obstetrics and gynecology residents to care for patients with a common problem--domestic violence.

PIP: In the US, domestic violence is the most common cause of injury to women, and, because they are women's primary care physicians, obstetrician-gynecologists (OB-GYNs) are in a position to identify battered women. With legislation pending that would require federally-funded medical education to include domestic violence in its curriculum, a survey was conducted of all OB-GYN residencies to determine their current status in the provision of domestic violence education. With 83% of the programs responding (n = 264), it was found that 28% had at least one faculty member with expertise in domestic violence, that the incidence of domestic violence among clients was underestimated, and that 75% of respondents did not recognize at least 1 of the 10 common clinical scenarios as suggestive of battering (at least 44% failed to recognize the risk factors of no prenatal care, preterm labor, emergency room visits, and psychiatric diagnoses). Only 28% of respondents reported that they teach residents to ask all or almost all patients about battering. Most respondents expressed dissatisfaction with their coverage of this topic and asked for help in curriculum development. In addition, 40% were unaware of the pending federal legislation. This study concluded that there is a strong need to develop an OB-GYN curriculum that deals with domestic violence but that further study is needed to determine the optimal teaching methods.