Changing the Culture: Increasing and Sustaining Anesthesiology Resident Physician Publication Rates.

Background: Academic inquiry is foundational to the advancement of medicine and resident training and must be demonstrated to the Accreditation Council for Graduate Medical Education. Past attempts at increasing publication rates have failed to identify educational best practice models. Our aim was to increase resident publication rates via culture and value changes that are universally implementable, affordable, effective, and sustainable. Methods: In 2018, a multifaceted initiative was implemented to shift departmental values and foster a culture of academic productivity. This culture change stressed the value of scientific publication through frequent, consistent messaging from department leaders. In addition, residents were provided the freedom to choose their scholarly activities. In this retrospective cohort innovation, resident authors were identified for 4 academic years before and after the intervention and publication rates were determined (2014-2018 vs 2018-2022). Resident authors and publications per resident per year were compared using descriptive statistics and Student t test. Results: The pre- and postintervention groups included 38 and 37 residents, respectively. Resident-authored publications increased from 7 preintervention to 24 postintervention, representing 343% of baseline. Mean ± SD publications per resident per year similarly increased 357% from 0.183 ± 0.16 to 0.654 ± 0.11 postintervention. Unpaired t test analysis demonstrated a significant difference in total publications per year (P = .002) and authorship rate (P = .003). Conclusions: A multifaceted academic initiative resulted in a threefold increase in resident publication rates. This initiative demonstrates that local advocacy by leaders, freedom of choice for authors, and supportive departmental culture are driving factors in publication rates.

Full flexion of the hips and knees in the supine position to treat an episode of acute hypotension and pulseless electrical activity in a patient with severe aortic stenosis.

This is a case report of a 77-year-old man with severe symptomatic aortic stenosis who underwent removal of an impacted ureteral stone under general anesthesia. During emergence from general anesthesia, his legs were lowered from lithotomy position, resulting in sudden hypotension with progression to pulseless electrical activity. The legs were raised and placed into full flexion of the hips and knees. This maneuver was temporally related to a return of spontaneous circulation and full recovery. Possible mechanisms for this effect are discussed.

Participatory planning in river catchments, an innovative toolkit tested in Southern Africa and North West England.

The European Union Water Framework Directive (WFD) offers an unparalleled opportunity for improving river basin management. Active participation is essential for its delivery. "End-of-pipe" solutions will not deliver the improvements needed to achieve its ambitious goals. This research tested DesignWays, a toolkit for participatory planning, as a mechanism for maximizing the long-term social and environmental benefits of such stakeholder and community participation. It examined the emerging role of "planning for sustainability" in the context of river catchments. Sustainable management of water requires integration, and recognition of interconnections between systems at different levels of scale. This is an endeavour in which systems thinking provides useful tools. The development of DesignWays was a conscious attempt to embed 'new paradigm' living systems metaphors into a practical planning tool. This paper begins with a description of DesignWays and its development in Southern Africa. An outline of the context of the action research in North-West England is followed by a description of the stages of the process, with highlights of the outcomes. This research had two major outcomes: a contribution to theory through an in-depth exploration of the theoretical basis of participatory, ecologically informed design; and a contribution to practice through investigating DesignWays' potential to meet key challenges of the WFD. This research points to the importance of understanding participatory planning as a societal process, aiming to make the process engaging and meaningful. It has pointed to the need to see participatory planning and education for sustainability as an integrated process. It demonstrated the benefits of an iterative process in which planning at the landscape level of scale informs, and is informed by, work at the site level. It has shown that an approach consistent with a living systems paradigm can contribute to the development of more integrated, ecologically sound plans.

Radiofrequency (electrosurgical) ablation of articular cartilage: a study in sheep.

The objective of this study was to examine the effect of a bipolar ablation probe on experimentally roughened articular cartilage and compare it with the traditional mechanical shaving technique using the knee joint of sheep. Twenty-eight skeletally mature ewes were divided randomly into two groups: one group was treated with a rotating shaving device and another group was treated using the bipolar ablation probe (Bipolar Arthroscopic Probe; Electroscope, Inc, Boulder, CO). Animals were killed at 0, 6, 12, and 24 weeks, and histological sections of the experimental limbs were compared with sections of the opposite limb using a modified Mankin scale. The following variables were used to determine scores: surface (0-6), cells (0-4), hypocellularity (0-3), matrix staining (transitional zone [0-4], radiate zone [0-4], and focal empty lacunae or hypereosinophilic cells (0-3). Differences in scores for all response variables were calculated as treated limb minus sham limb. Response variables were formed: score >0 recoded as 1 (favorable response treated better than sham), score of 0 recoded as 2 (neutral response no differences), and score <0 recoded as 3 (unfavorable response treated worse than sham). Bipolar ablative probe-treated limbs had 14.29% favorable responses and 35.71% favorable or neutral responses, whereas shave-treated limbs had 0% favorable and only 7.14% favorable or neutral responses. For all variables, bipolar ablative probe-treated limbs had more favorable responses. The less severe histological change in the bipolar ablative probe-treated joints compared with the shave-treated joints suggests that bipolar ablation of articular cartilage may be a better treatment for chondromalacia than the usual shaving methods of debridement. Further, there were no pathological changes in the subchondral bone.

Biochemical and molecular characterization of the insecticidal fragment of CryV.

Two C-terminal deletion constructs were made to study the effect of such deletions on the biological activity of the CryV protein of Bacillus thuringiensis subsp. kurstaki. The results of feeding on neonatal larvae of Ostrinia nubilalis (European corn borer [ECB]) indicated that the 50% lethal dose of the full-length CryV protein was 3.34 micrograms/g of diet (95% fiducial limits, 2.53 to 4.32 micrograms/g of diet). Removal of 71 amino acids (aa) from the C terminus had little effect on toxicity, whereas deletion of 184 aa abolished the insecticidal activity of the CryV protein completely. Truncations of the full-length CryV protein were also generated with trypsin and the midgut protease of ECB. The proteolytically treated products were characterized by determining their N-terminal amino acid sequences. The CryV protein was found to be cleaved by both proteases through a two-step process. Initially an intermediary form was generated which contained aa 45 of full-length CryV as its N-terminal end. The C-terminal end of this peptide was not experimentally determined. However, analysis of the deduced amino acid sequence of CryV indicated that the C-terminal end of the intermediary form is likely either aa 655 or 659. Further N-terminal processing of the intermediary form resulted in a protease-resistant core form. The core included aa 156 to aa 655 or 659. While the intermediary form retained 100% of the ECB larval toxicity, the core form exhibited only approximately 22% of the toxicity of the full-length protein.

Providing comfort in the resuscitation room.

Providing comfort in the resuscitation room may not be found high on the list of priorities of nurses working in the Accident and Emergency department. The resuscitation room is an acute care area where patients are very sick and physiological needs are of paramount importance. However, by looking more closely at comfort and what it is, this paper aims to help nurses identify what the components of comfort are and, therefore, recognise their worth and importance when caring for a patient in the resuscitation room.

Identification and characterization of a novel Bacillus thuringiensis delta-endotoxin entomocidal to coleopteran and lepidopteran larvae.

A new class of Bacillus thuringiensis delta-endotoxins, or insecticidal control proteins (ICPs), is defined by an apparently cryptic protein with a unique primary structure and novel entomocidal specificity for certain coleopteran and lepidopteran species. The discovery of a new group of ICPs will extend the use of this natural insecticide in integrated pest-management systems.

Identification and characterization of a serotype b-specific segment of the Haemophilus influenzae genome.

Within the region of the Haemophilus influenzae serotype b genome required for capsule expression, a 4.6-kilobase segment was cloned, used as a hybridization probe, and found to be specific for serotype b strains. Deletion mutagenesis within this segment defined a locus necessary for serotype b capsule production and another involved in maintenance of wild-type colony appearance.

Mutations affecting expression and maintenance of genes encoding the serotype b capsule of Haemophilus influenzae.

Deletion mutagenesis analysis of a duplicated gene necessary for Haemophilus influenzae serotype b capsule expression showed that only one functional copy of this gene is required for capsule production and for virulence in infant rats. Mutant strains generated in this study differed from each other and from the parental strain in their ability to maintain the large tandem duplication which contains the genes involved in serotype b capsule expression.

Clinically apparent rubella reinfection.

We report two cases of rubella reinfection in apparently immunocompetent young women. In both cases rubella-specific IgG had been detected on two occasions prior to an illness clinically diagnosed as rubella. Rubella-specific IgM was detected by various techniques in samples of serum collected at the time of the illness.

Arthroscopy and the maquet proximal tibial osteotomy.

This paper describes the techniques for combining arthroscopic treatment of unicompartmental osteoarthritic knees and proximal tibial osteotomy.

A preliminary study of the effect of pyridoxine administration in a subgroup of hyperkinetic children: a double-blind crossover comparison with methylphenidate.

A small sample of six patients with the putative "hyperkinetic syndrome" participated in a research protocol comparing administration of pyridoxine, methylphenidate, and placeboes. The children had had low whole blood serotonin levels and a history of previous responsiveness to methylphenidate. The results of the double-blind clinical evaluation showed trends suggesting that both pyridoxine and methylphenidate were more effective than placebo in suppressing the symptoms of hyperkinesis. Pyridoxine elevated whole-blood serotonin levels, methylphenidate did not. Clinical and laboratory evidence indicated that the pyridoxine effects persisted after the 3-week period when the vitamin had been given in this experimental design.

Inhibition of subtilisin BPN' with peptide chloromethyl ketones.

The kinetics of the reaction of a series of peptide chloromethyl ketones with subtilisin BPN' (EC 3.4.21.14) were investigated in order to correlate the rates of reaction in solution with the number of interactions which are observed in the cystallographic model of the inhibited enzyme (Robertus, J.D., Alden, R.A., Birktoft, J.J., Powers, J.C. and Wilcox, P.E. (1972) Biochemistry 11, 2439--2449). The second-order rate constant kobs/[I], measured at pH 7.0 in 9% 1,2-dimethoxyethane at 30 degress C, varied by a factor of 5900 from the slowest (Z-TrpCH2Cl) to the fastest inhibitor (Ac-Phe-Gly-Ala-LeuCH2Cl). Inhibitors with a P1 leucine or phenylalanine residue are equally effective. The increased reactivity of inhibitors containing alanine as the P2 residue is the result of a favorable contact between the methyl side chain of the alanyl residue and the S2 subsite of subtilisin. This result correlates nicely with the previously observed "secondary specificity" of subtilisin for substrates with alanine as the P2 residue. Teetrapeptide and tripeptide chloromethyl ketone inhibitors have kobs/[I] values of over 100-fold greater than those of most dipeptide and amino acid chloromethyl ketones. This again agress with the crystallographic model since tripeptide and tetrapeptide inhibitors could form a beta-sheet structure involving three or four hydrogen bonds with the enzyme while the others would form fewer hydrogen bonds. The S4 subsite of subtilisin exhibits a distinct preference for aromatic groups and our four most reactive inhibitors (Ac-Phe-Gly-Aca-LeuCH2Cl, Z-Gly-PheCH2Cl, Z-Gly-Gly-LeuCH2Cl, and Boc-Ala-Gly-PheCH2Cl) have either an aromatic (or a large hydrophobic) group as the P4 residue. The results demonstrate that the solution reactivity of peptide chloromethyl ketones can be explained on the basis of the crystal structures of chloromethyl ketone-inhibited substilisin derivatives and that substrate hydrolysis rates can be used to design effective chloromethyl ketone inhibitors for serine proteases.

Compression fixation of subtrochanteric fractures.

Compression fixation with a blade plate was used in the treatment of 11 fresh and 9 nonunited subtrochanteric fractures. Fifteen fractures united as fixed. Three settled into varus with eventual union in 2 and a fibrous nonunion with metal failure in one. One fracture became infected and the patient died of metastatic fibrosarcoma and one was lost to accurate long-term follow-up. The average Harris Hip Rating for 18 patients was 84, an average of 24 postoperatively. In each instance, technical errors accounted for suboptimal results. Compression fixation is designed for the subtrochanteric region for either fresh or nonunited fractures.

Developing a utilization review model for community mental health centers.

During their struggles to develop a utilization review model for a community mental health center, members of an interdisciplinary committee identified several issues they believe are important in establishing such a model. They include comprehensiveness of participation and of areas for review (the review committee should represent all disciplines and programs, and should be concerned with any aspect of center functioning), a problem-review approach in which subcommittees carry out documented studies of issues or problems, and specific provision for feedback and implementation of the results.