The influence of FDG PET-CT on the detection of extrahepatic disease in patients being considered for resection of colorectal liver metastasis.

INTRODUCTION: The aim of this study was to evaluate the influence of flurodeoxyglucose positron emission tomography computed tomography (FDG PET-CT), as an adjunct to conventional CT staging, in the detection of extrahepatic disease in patients with potentially resectable colorectal liver metastasis. METHODS: Overall, 133 consecutive patients with colorectal liver metastases staged with CT and PET-CT referred to the East Lancashire regional hepatobiliary multidisciplinary team over a two-year period were included in this study. Abnormal findings on PET-CT were correlated with follow-up imaging and/or histology. All imaging was reviewed by specialist hepatobiliary radiologists for the presence/absence of extrahepatic disease. The influence of the PET-CT findings was categorised for each patient in relation to operability and other significant findings. RESULTS: PET-CT had a major impact on staging of extra hepatic disease in 20% of patients, in comparison with the initial CT. Six per cent of patients were upstaged from operable CT findings to inoperable findings on PET-CT because of the discovery of inoperable occult extrahepatic disease. Five per cent had operable local regional nodal disease detected on PET-CT. A further 3% had premalignant colorectal lesions detected on PET-CT. Six per cent of patients were downstaged from indeterminate or suspected inoperable CT findings to operable findings on PET-CT. CONCLUSIONS: The use of PET-CT in this setting may prevent futile operations, guide the resection of local regional nodal disease and downstage a number of patients thought to have extrahepatic disease on conventional imaging. This study has shown similar results to other recent studies and supports the use of PET-CT as a necessary staging modality in patients with potentially resectable colorectal liver metastases.

The sonographic appearances of breast implant rupture.

Implant rupture is a common late complication of breast implant procedures. Ruptures are often silent and difficult to diagnose clinically. This review demonstrates normal appearances and sonographic signs of implant rupture. Breast sonologists should be aware of these signs and pitfalls in interpretation when imaging breast implants.

Preferential edge habitat colonization by a specialist weevil, Rhinoncomimus latipes (Coleoptera: Curculionidae).

Understanding the behavioral basis of dispersal and colonization is critical in biological control systems, where success of a natural enemy depends in part on its ability to find and move to new host patches. We studied behavior of the specialist weevil Rhinoncomimus latipes Korotyaev, a biological control agent of mile-a-minute weed, Persicaria perfoliata (L.) H. Gross, by releasing weevils at the forest edge and monitoring their colonization of potted host plants arrayed along the edge, out into the open field, and into the forest. Both distance from the release cage and habitat where plants were located affected colonization, with more than twice as many weevils found on plants at 2 m than at 6 or 14 m; at 14 m, 6-8 times as many weevils colonized plants along the forest edge compared with plants in the open field or within the forest. In a second experiment, weevils that were released in an open field 12 m from the forest edge initially flew in all directions, but again ultimately colonized more plants at the edge than out in the open field. This species may be adapted to seek host plants at the forest edge, because P. perfoliata generally is found in riparian corridors in its native range and along forest edges in North America. Results suggest that R. latipes will move successfully to new P. perfoliata patches along wooded edges, but may not readily locate isolated patches in the open or those embedded in forests.

Severe transient left ventricular dysfunction induced by thyrotoxicosis.

We report on a 44-year-old woman presenting with chest pain and dyspnoea without previous stress-related events. By means of echocardiography severe left ventricular dysfunction and wall motion abnormalities resembling stress-induced cardiomyopathy (Tako Tsubo) were seen. Laboratory investigation revealed thyrotoxicosis and elevated cardiac markers. Six days after starting medical treatment, complete restoration of the left ventricular function was observed. The transient left ventricular dysfunction was induced by thyrotoxicosis resembling stress-induced cardiomyopathy that resolved completely after medical treatment.

Exploring the nature of same-sex relationships.

This study explored the relationship structure and experiences of 145 people in the United States, aged 50 and above, in long-term, same-sex relationships. A survey assessed relationship satisfaction and roles, caregiving, shared assets, and relationship protection and support. The ENRICH couple scales revealed high scores in communication, conflict resolution, and couple satisfaction. Most participants had taken steps to protect shared assets and assign legal authority to their partners. Participants expressed differing views regarding marriage. This study reveals distinctions based on gender and age that will inform practice with this population.

Increasing accuracy of antenatal ultrasound diagnosis of cleft lip with or without cleft palate, in cases referred to the North Thames London Region.

OBJECTIVES: To determine the accuracy of antenatal ultrasound diagnosis of cleft lip with or without cleft palate (CL +/- P) and isolated cleft palate (CP). METHODS: This was a retrospective review of 256 surviving cases referred in 2002-2003 for treatment of CL +/- P. RESULTS: We had referrals from 36 maternity units, 27 of which were in our local catchment area. There were 154 cases of CL +/- P, of which five had microform CL. Of the remaining 149, 88 (59%) were diagnosed on antenatal ultrasound examination. Among these 88 cases there were minor reporting errors in 22 (25%). These errors were in describing the side and type of the lip cleft in 10 cases, predicting if there was a CP in 10 cases, and recognizing the anomaly in two cases. There were 102 cases referred with isolated CP, of which 92 had overt CP and 10 submucous CP. None of these was diagnosed by antenatal ultrasound imaging. There was no significant difference in the accuracy of ultrasound diagnosis between district hospitals and teaching/tertiary units. CONCLUSIONS: There is a good awareness and ability to detect CL +/- P by obstetric units from which referrals are received. Inaccuracies in antenatal ultrasound reports occur frequently when attempting to determine the type of CL and when predicting if there is a CP. We recommend that families should continue to be referred to specialist centers for counseling immediately after antenatal diagnosis, and comprehensive advice should always be given about clefts of the lip and palate.

Assay variation confounds the diagnosis of hypovitaminosis D: a call for standardization.

Endemic hypovitaminosis D contributes to osteoporosis development. However, variation in 25-hydroxyvitamin D (25OHD) measurement is reported and confounds the diagnosis of vitamin D insufficiency/deficiency. This report emphasizes the marked variability observed in serum 25OHD measurements between laboratories.Initially, postmenopausal women had serum 25OHD determinations: 42 in laboratory A, 20 in laboratory B. Their mean (sem) serum 25OHD concentrations were 46 (2.1) and 21 (2.3) ng/ml in laboratories A and B, respectively. Furthermore, there was little overlap in serum 25OHD among these clinically similar individuals. Specifically, 17% of those measured in laboratory A but 90% in laboratory B were below an arbitrary threshold value of 32 ng/ml.Subsequently, serum was obtained from 10 healthy adults. Two aliquots from each individual, one of which was spiked with 20 ng/ml 25OHD, were sent to six laboratories. Substantial variability was noted between these six laboratories. The mean serum 25OHD concentration ranged from 17.1-35.6 ng/ml. Similarly, the mean increase produced by spiking with 20 ng/ml ranged from 7.7-18.0 ng/ml.In conclusion, 25OHD assays yield markedly differing results; whether an individual is found to have low or normal vitamin D status is a function of the laboratory used. If the medical community is to make progress in correcting widespread hypovitaminosis D, 25OHD measurement must be standardized.

Motility and chemotaxis of filamentous cells of Escherichia coli.

Filamentous cells of Escherichia coli can be produced by treatment with the antibiotic cephalexin, which blocks cell division but allows cell growth. To explore the effect of cell size on chemotactic activity, we studied the motility and chemotaxis of filamentous cells. The filaments, up to 50 times the length of normal E. coli organisms, were motile and had flagella along their entire lengths. Despite their increased size, the motility and chemotaxis of filaments were very similar to those properties of normal-sized cells. Unstimulated filaments of chemotactically normal bacteria ran and stopped repeatedly (while normal-sized bacteria run and tumble repeatedly). Filaments responded to attractants by prolonged running (like normal-sized bacteria) and to repellents by prolonged stopping (unlike normal-sized bacteria, which tumble), until adaptation restored unstimulated behavior (as occurs with normal-sized cells). Chemotaxis mutants that always ran when they were normal sized always ran when they were filament sized, and those mutants that always tumbled when they were normal sized always stopped when they were filament sized. Chemoreceptors in filaments were localized to regions both at the poles and at intervals along the filament. We suggest that the location of the chemoreceptors enables the chemotactic responses observed in filaments. The implications of this work with regard to the cytoplasmic diffusion of chemotaxis components in normal-sized and filamentous E. coli are discussed.

Organization and outcomes of inpatient AIDS care.

OBJECTIVE: To compare differences in AIDS patients' 30-day mortality and satisfaction with care in dedicated AIDS units, scattered-bed units in hospitals with and without dedicated AIDS units, and in magnet hospitals known to provide good nursing care. METHODS: Data were obtained on 1,205 consecutively admitted patients in 40 units in 20 hospitals and on 820 of their nurses. RESULTS: Mortality was lower and satisfaction was higher for AIDS patients in dedicated AIDS units and in nursing magnet hospitals. Primary nursing, end-of-life care counseling, and discharge planning were also more common. Higher nurse to patient ratios and AIDS physician specialty services were strongly associated with lower mortality. Patient satisfaction was strongly associated with organizational control of care by bedside nurses. Homosexuals were more likely to be admitted to dedicated AIDS units, which largely explains the under-representation of minorities and women. CONCLUSIONS: Dedicated AIDS units and magnet hospitals offer important benefits to AIDS patients, including lower odds on dying within 30 days of admission, higher patient satisfaction, and care meeting professional standards. Better nurse staffing, AIDS physician specialty services, and more organizational control by bedside nurses improve patient outcomes.

Organization and outcomes of inpatient AIDS care.

The establishment of AIDS hospitals and AIDS units within hospitals has been controversial. Unlike other specialty care, AIDS care arrangements were initially developed as much to segregate AIDS patients from other patients and staff as to provide the best possible care. Ten years after many of these units opened, little evidence was available about whether the benefits of aggregating AIDS patients outweighed the potential hazards of segregating people from the mainstream of hospital care. This Issue Brief describes a national study to determine how different organizational settings affect the outcomes of inpatient AIDS care.

Management of constipation in the critically ill patient.

Teamwork and a well-known problem-solving technique are used to give a flexible solution to the problem of bowel management in the critically ill patient. A literature review of constipation is linked to treatment of the critically ill patient. General and specific factors are discussed including nasogastric feeding pharmacology. Design and implementation of a protocol for bowel management for patients in the intensive care field of nursing are demonstrated.

Studying outcomes of organizational change in health services.

OBJECTIVES: The rapidly changing organizational context within which health care is delivered is altering provider-patient relations and processes of clinical decision-making, with significant implications for patient outcomes. Yet definitive research on such effects is lacking. The authors seek to underscore the contribution of organizational research to studies of clinical outcomes and demonstrates several approaches to further such efforts. METHODS: The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes. They use case examples from their ongoing research on hospitals to illustrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research. RESULTS: Several methodological issues are explored: (1) exploiting "targets of opportunity" and "natural experiments" is a promising strategy for studying patient outcomes related to organizational reform; (2) indices of organizational traits, constructed from individual survey responses, can illuminate the operant mechanisms by which structure affects outcomes; and (3) secondary data sources and innovative statistical matching procedures provide a feasible strategy for constructing study comparison groups. Extending the organizational outcomes research strategy to new areas of inquiry offers an opportunity to enhance our understanding of how nursing organization affects outcomes. CONCLUSIONS: Improving the effectiveness of medical care in a health-care system undergoing fundamental restructuring requires greater understanding of how organizational context affects clinical outcomes. A higher priority should be placed on organizational outcomes research by researchers and funding agencies.

Satisfaction with inpatient acquired immunodeficiency syndrome care. A national comparison of dedicated and scattered-bed units.

OBJECTIVES: This study sought to determine whether there were differences in acquired immunodeficiency syndrome (AIDS) patients' satisfaction with inpatient nursing care on dedicated AIDS units compared with conventional, multidiagnosis medical units. METHODS: Interview data were collected from more than 600 consecutive AIDS admissions in 40 patient care units in 20 hospitals in 11 high AIDS incidence cities. Ten hospitals with dedicated AIDS units were matched with comparable hospitals treating AIDS patients on multidiagnosis medical units. AIDS patients' satisfaction with nursing care on dedicated AIDS units was compared with AIDS patients' satisfaction with care on scattered-bed units in the same hospital and with AIDS patients' satisfaction on scattered-bed units in different, matched hospitals without dedicated units. Interhospital differences that were not controlled by design were controlled statistically, as were differences in patient characteristics and illness severity. RESULTS: Acquired immunodeficiency syndrome patients receiving care on dedicated AIDS units were significantly more satisfied with their nursing care. In hospitals with units of both types, dedicated AIDS units had a higher proportion of white patients, men, and homosexuals, whereas scattered-bed units had more minority patients and intravenous drug users. Controlling for these factors as well as for differences in illness severity and interhospital differences in patient satisfaction did not diminish the positive AIDS unit effect on patient satisfaction. CONCLUSIONS: Dedicated AIDS units achieve higher levels of satisfaction among patients with AIDS than general medical units. There is no evidence that patients feel isolated or stigmatized on dedicated AIDS units compared with patients on general units, and many patients have a clear preference for dedicated units.

Using existing health care systems to respond to the AIDS epidemic: research and recommendations for Chile.

Chile is a country with a relatively low prevalence of HIV infection, where successful prevention has the potential to change the future course of the epidemic. A controversial national prevention strategy based upon public education has emerged in response to characterizations of the epidemic as well-dispersed with a growing involvement of heterosexuals. This characterization is not consistent with the observed facts. There is a comparatively well-organized health care system in Santiago that is doing a good job of detecting HIV infection and already has in place the elements of a targeted intervention scheme. Chile should place priority on the use of the existing health care infrastructure for implementing both the traditional public health interventions for sexually transmitted diseases (contact tracing and partner notification) and the AIDS-necessitated strategy of focused counseling and education.

PIP: 93% of the 1016 cumulative AIDS cases reported through June 1994 in Chile have been among men. People aged 20-49 years comprise 85% of cases. The cases are concentrated in the Santiago metropolitan area with a second cluster in the urban sea coast region which includes Valparaiso and Vina-del-Mar. An additional 1627 people have been confirmed HIV seropositive. 86% of AIDS cases are the result of sexual intercourse. Of the 815 adult males diagnosed with AIDS as of the middle of 1994, 58% were homosexual, 24% were bisexual, and 18% were heterosexual. These figures suggested that HIV infection was spreading into the general heterosexual population of the country and prompted the government to implement a mass media HIV/AIDS campaign as the cornerstone of its AIDS prevention plan. However, interview findings suggest that the extent of bisexual- and heterosexual-related HIV transmission reflected in official statistics could be high by as much as 50%. Many men who have sex with men do not identify themselves as homosexual. HIV/AIDS route of infection statistics based upon self-identified sexual categories are therefore inaccurate. The AIDS epidemic in Chile to date is more like the largely homosexual epidemic in San Francisco during the 1980s than that occurring in the countries of the Caribbean or elsewhere with a heterosexual transmission pattern. A highly focused AIDS prevention program effectively slowed the spread of HIV in San Francisco. Rather than continue with the mass media prevention campaign, Chile should use its existing blood donor system combined with partner tracing and case investigation to capture a manageable number of HIV-positive people and identify nascent localized epidemics.

Analogue of aspartate and glutamate active at synapses are attractants for Escherichia coli.

1. This research was carried out to compare Escherichia coli bacteria with animals in their response to L-aspartate and L-glutamate and their analogues. 2. Various analogues of aspartate and glutamate known to be neurotransmitters at synapses were shown to be attractants for E. coli. 3. The amino acid sequences of the animal receptors and the bacterial receptor, however, have no detectable relationship. Based on the amino acid sequence, evolutionarily the two systems appear not to be related.

Renal tubule cell repair following acute renal injury.

Experimental data suggests the recovery of renal function after ischemic or nephrotoxic acute renal failure is due to a replicative repair process dependent upon predominantly paracrine release of growth factors. These growth factors promote renal proximal tubule cell proliferation and a differentiation phase dependent on the interaction between tubule cells and basement membrane. These insights identify the molecular basis of renal repair and ischemic and nephrotoxic acute renal failure, and may lead to potential therapeutic modalities that accelerate renal repair and lessen the morbidity and mortality associated with these renal disease processes. In this regard, there is a prominent vasoconstrictor response of the renal vasculature during the postischemic period of developing acute renal failure. The intravenous administration of pharmacologic doses of atrial natriuretic factor (ANF) in the postischemic period have proven efficacious by altering renal vascular resistance, so that renal blood flow and glomerular filtration rate improve. ANF also appears to protect renal tubular epithelial integrity and holds significant promise as a therapeutic agent in acute renal failure. Of equal or greater promise are the therapeutic interventions targeting the proliferative reparative zone during the postischemic period. The exogenous administration of epidermal growth factor or insulin-like growth factor-1 in the postischemic period have effectively decreased the degree of renal insufficiency as measured by the peak serum creatinine and has hastened renal recovery as measured by the duration of time required to return the baseline serum creatinine values. A similarly efficacious role for hepatocyte growth factor has also been recently demonstrated.

Lower Medicare mortality among a set of hospitals known for good nursing care.

The objective of this study is to investigate whether hospitals known to be good places to practice nursing have lower Medicare mortality than hospitals that are otherwise similar with respect to a variety of non-nursing organizational characteristics. Research to date on determinants of hospital mortality has not focused on the organization of nursing. We capitalize on the existence of a set of studies of 39 hospitals that, for reasons other than patient outcomes, have been singled out as hospitals known for good nursing care. We match these "magnet" hospitals with 195 control hospitals, selected from all nonmagnet U.S. hospitals with over 100 Medicare discharges, using a multivariate matched sampling procedure that controls for hospital characteristics. Medicare mortality rates of magnet versus control hospitals are compared using variance components models, which pool information on the five matches per magnet hospital, and adjust for differences in patient composition as measured by predicted mortality. The magnet hospitals' observed mortality rates are 7.7% lower (9 fewer deaths per 1,000 Medicare discharges) than the matched control hospitals (P = .011). After adjusting for differences in predicted mortality, the magnet hospitals have a 4.6% lower mortality rate (P = .026 [95% confidence interval 0.9 to 9.4 fewer deaths per 1,000]). The same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients.