Technology assessment and requirements analysis: a process to facilitate decision making in picture archiving and communications system implementation.

In a time of decreasing resources, managers need a tool to manage their resources effectively, support clinical requirements, and replace aging equipment in order to ensure adequate clinical care. To do this successfully, one must be able to perform technology assessment and capital equipment asset management. The lack of a commercial system that adequately performed technology needs assessment and addressed the unique needs of the military led to the development of an in-house Technology Assessment and Requirements Analysis (TARA) program. The TARA is a tool that provides an unbiased review of clinical operations and the resulting capital equipment requirements for military hospitals. The TARA report allows for the development of acquisition strategies for new equipment, enhances personnel management, and improves and streamlines clinical operations and processes.

Clinical services assessment and reengineering: lessons learned.

Healthcare enterprises often "acquire and install" picture archiving and communications systems (PACS) without examining many of the care delivery processes and information flows that will be affected. Many times these unexamined factors can delay or be the cause of failure of the PACS project. This article presents issues that were worked through as part of a PACS clinical services assessment and reengineering analysis for several US military medical treatment facilities.

Eastern Cooperative Oncology Group phase II trial of ifosfamide in the treatment of previously treated advanced urothelial carcinoma.

PURPOSE: Alkylating agents have modest activity in advanced urothelial carcinoma. Ifosfamide (IFX) is an agent as yet unstudied in advanced urothelial carcinoma. Despite recent advances in the treatment of this disease, there continues to be a need to identify new active agents and their toxicity spectra. Here we report results from the use of IFX in this population. PATIENTS AND METHODS: Ambulatory patients with advanced urothelial carcinoma were treated with IFX 3,750 mg/m2 and mesna 2250 mg/m2 both intravenously (IV) daily for 2 days every 3 weeks. Significant renal and CNS toxicity required a dose change of IFX to 1,500 mg/m2 IV with mesna 750 mg/m2 IV for 5 days every 3 weeks. Doses were modified for hematologic, renal, and CNS toxicity. RESULTS: Of 56 eligible patients entered onto the study, 26 received the 2-day schedule and 30 were treated on the 5-day regimen. All patients had progressive disease following prior systemic chemotherapy. There were five complete responses (CRs) and six partial responses (PRs) for an overall response rate of 20% (exact 95% confidence interval [CI], 10% to 32%). Renal and CNS toxicity was severe before the change in schedule, but manageable after the change. Major identified toxicities were gastrointestinal, myelosuppressive, renal, and CNS. There were four early deaths to which treatment probably contributed, but were multifactorial in etiology. CONCLUSION: IFX has significant activity, but also major toxicity in a heavily cisplatin-pretreated cohort with advanced urothelial carcinoma. A modification of dose and/or schedule from that described should be considered in future trials. Combination regimens using this agent should be explored.

Polyimides as biomaterials: preliminary biocompatibility testing.

A number of commercially available polyimide materials were evaluated in vitro using a selected battery of levels I and II testing protocols prescribed by the National Institutes of Health Guidelines for Blood-Material Interactions. These procedures consisted of electron spectroscopy for chemical analysis and contact angle characterization surface studies, and protein adsorption, cell culture cytotoxicity, clotting time and haemolysis biocompatibility testing. The polyimide surfaces were invariant from the bulk composition with 60-80% C, 10-20% O and 2-5% N, producing advancing contact angles in the hydrophobic range (80-100 degrees). Consequently, they adsorbed significant amounts of albumin (2-3 micrograms/cm2) and fibrinogen (0.5-0.8 microgram/cm2). The polyimides also displayed an insignificant level of cytotoxicity and haemolysis, and clotting times ranged from 63 to 98% of normal. These clotting times and haemolytic index values were intermediate between the values observed for Teflon and Silastic controls. These factors, along with the strong adherence of polyimides to metal oxide substrates, indicate that polyimide materials are good candidates for further testing as encapsulants for implantable biosensors.

Rehabilitative neurosurgery: posttraumatic syndromes.

Distinct chronic posttraumatic syndromes, ascribed to neurological deficits of patients suffering severe head injuries and being in prolonged coma, are much less frequently encountered in the literature than acute traumatic syndromes. The major components of the posttraumatic midbrain syndrome, resulting from compressive necrosis or vascular infarction at the midbrain level, are ipsilateral cerebellar signs (the predominant one being intention tremor), contralateral pyramidal signs (the predominant one being a spastic-dystonic hemiparesis), dysarthria, and mild to moderate intellectual impairment. Significant bilateral cerebellar dysfunction following head injury, without pyramidal, extrapyramidal, or pseudobulbar signs, constitutes a posttraumatic cerebellar syndrome. Its most disabling component, namely posttraumatic intention tremor, may be alleviated by thalamotomy. Following severe closed head injury, an infrequently encountered posttraumatic entity of dystonic hemiplegia or hemiparesis, which may be alleviated by thalamotomy, can occur, but does not have a specific neuroanatomical basis. Intention tremors following severe head injuries, rarely associated with hydrocephalus and without other significant cerebellar findings, can develop as a dysfunction of the cerebellofugal outflow system. While chronic posttraumatic syndromes can be complex and difficult to treat, cerebellar stimulation has been utilized ipsilaterally to modulate limb spasticity, and bilateral ventrolateral cryothalamectomies staged 4-6 months apart have been successful in alleviating severe (intractable) intention tremors.

An evaluation of recombinant leukocyte A interferon with aspirin in patients with metastatic renal cell cancer.

The authors designed a clinical trial to assess the impact of aspirin (ASA) (600 mg four times daily) on the constitutional sequelae of recombinant leukocyte A interferon (IFN-alpha 2A), 20 X 10(6) U/m2 thrice weekly, in 29 patients with advanced renal cell cancer (RCC). Aspirin provided no meaningful amelioration of side effects compared to our prior experience of IFN-alpha 2A alone. Interestingly, the objective response rate of 34% (10/29) was considerably higher than the 15% recently reported from an aggregate of 344 patients participating in 14 prospective clinical trials. In light of small numbers, subtle selection biases, and the well-recognized hazards of retrospective analyses, currently it is unclear if the apparent therapeutic advantage from ASA plus IFN-alpha 2A reflects chance occurrence or therapeutic potentiation from ASA. A randomized trial is planned to determine if ASA may have enhanced the efficacy of IFN-alpha 2A in patients with advanced RCC.

Congenital genetic murine (ch) hydrocephalus. A structural model of cellular dysplasia and disorganization with the molecular locus of deficient proteoglycan synthesis.

The recessively inherited ch hydrocephalic mouse has been sporadically investigated over the past 40 years as a genetic murine model for congenital hydrocephalus. Since central nervous system anomalies are commonly associated with congenital anomalies in the musculoskeletal and urogenital systems, and since congenital hydrocephalus is also associated with other developmental abnormalities, an understanding of the pathophysiology at the cellular and molecular levels of the genetic defects of this hydrocephalic murine model has application to related human disorders associated with hydrocephalus. A unifying hypothesis is presented that can interrelate the multisystem developmental abnormalities. While the basic cellular defect is a failure of mesenchymal differentiation, the molecular locus is a synthetic defect in the production of the chondroitin sulfate proteoglycan. The primary end results of defective proteoglycan synthesis at a multiorgan-multisystem level includes chondrodysplasia, renal dysplasia, failure of endochondral ossification and gonadal development, and defective development of the adrenal medulla and the sympathetic ganglia. The development of the severe, communicating, congenital hydrocephalus in the ch mouse may be either a primary or secondary manifestation of the mesenchymal maldifferentiation.

Bladder electromyography: response to electric stimulation and to terbutaline.

Four patients with traumatic spinal cord injuries and paraplegia received electric stimulation of the conus medullaris. An additional 5 patients with traumatic spinal cord injuries and paraplegia received terbutaline for asthma. All 9 patients were studied with bladder and external urethral sphincter electromyography (EMG). Bladder pressures were recorded in the electric stimulation group and cystometry in the terbutaline group. The electric impulses were recorded without attenuation, and bladder and external urethral sphincter contractility increased. Terbutaline reduced the bladder's electric activity and pressure at capacity without affecting external urethral sphincter function. More evaluations of terbutaline's effect on the bladder are necessary to determine its applicability to incontinence problems.

Diaphragm pacing in spinal muscular atrophy: case report.

A patient with a diagnosis of intermediate or benign spinal muscular atrophy was severely incapacitated from respiratory complications and alveolar hypoventilation and was confined to mechanical ventilatory support. After extensive diagnostic evaluation of her pulmonary status, including transcutaneous stimulation of the phrenic nerves associated with nasogastric and surface electrode recording of the diaphragmatic response, this patient had a phrenic neurostimulation system implanted bilaterally for diaphragm pacing. Although spinal muscular atrophy has not been previously recognized as an indication for diaphragm pacing, her subsequent social, physical, and psychological improvement indicate that it may be significantly beneficial in selected cases of alveolar hypoventilation due to spinal muscular atrophy or neuromuscular disease.

Transcutaneous electrical neurostimulation in functional pain.

Transcutaneous electrical neurostimulation (TENS) has recently emerged as a distinct therapeutic modality in the alleviation of acute and chronic pain. We applied this modality to 15 nonsurgical low-back pain patients having diagnoses of functional pain, with 40% initially having significant pain relief (50% of greater). However, this pain-alleviating effect of TENS did not last longer than two months. After initiation of neurostimulation, increased pain and/or bizarre and inappropriate sensations and behavior frequently developed. We also applied this modality in the diagnostic evaluation and treatment of 24 patients having diagnoses of postsurgical chronic intractable low-back pain of psychosomatic origin and achieved similar results. In both groups, we utilized a simplified poststimulation "normal-saline-sterile-water intramuscular injection test" to confirm the findings from transcutaneous electrical neurostimulation and to verify the functional basis of the present low-back pain.

Prevalence and incidence of pressure sores in acute spinal cord injuries.

The prevalence of pressure sores following acute spinal cord injury was determined on 549 patients who entered the Midwest Regional Spinal Cord Injury Care Centre from 1973 until June 1978. The compiled data was based upon system versus non-system entry, anatomical levels of injury, multiple site or single site location, complete or incomplete physiological injury, and the presence of pressure sores on admission or their development during system hospitalisation. The results showed that non-system patients had a significantly higher prevalence of pressure sores in all categories. The level of anatomical injury as well as the physiological intactness of the spinal cord were found to be the most important factors in the actual prevalence. The cervical region was found to have the highest prevalence of pressure sores at single and multiple sites. Complete lesions and quadraplegics had a higher prevalence of pressure sores than incomplete lesions and paraplegics. The probable explanations are presented.

Multiple neoplastic associations with central and peripheral von Recklinghausen's disease.

We have discussed the pathology of the diverse, numerous neoplasms associated with the central and peripheral types of von Recklinghausen's disease, as exemplified by two case reports. While overlap can occur between these two major types, characteristically this does not occur.