Effects of Trauma Center Consolidation on Adult Trauma at a Rural Level 1 Trauma Center.

OBJECTIVE: The aim was to determine the impact of consolidation of two rural level 1 trauma centers on adult trauma patients presenting to the remaining level 1 trauma center. To our knowledge, a study assessing the impact of trauma center consolidation on adult trauma patients had yet to be performed. METHODS: A single institution, retrospective study was conducted at a rural level 1 trauma center. Adult trauma patients who presented to our center from January 2017 to January 2022 were included. The cohorts spanned 33 months pre- and post-consolidation. Multiple demographic and outcome measures were gathered. Data were analyzed using the student's t-test and Chi-squared testing. RESULTS: There was a 33% increase in overall trauma activations and 9% increase in transfers from outside facilities post-consolidation. The post-consolidation group was significantly older, had higher mean injury severity score, and decreased hospital-free days. The post-consolidation group also saw an increase in ICU admission and surgical intervention. While there were no significant differences in ICU-free days or ventilator days, patients in the post-consolidation group with the highest level of activation who required both surgical intervention and ICU admission experienced decreased mortality. CONCLUSION: The consolidation of trauma services to a single level 1 trauma center in a rural Appalachian health system led to higher trauma volume and acuity, but most importantly decreased mortality for the most severely injured trauma patients.

Autofluorescence is a biomarker of neural stem cell activation state.

Neural stem cells (NSCs) must exit quiescence to produce neurons; however, our understanding of this process remains constrained by the technical limitations of current technologies. Fluorescence lifetime imaging (FLIM) of autofluorescent metabolic cofactors has been used in other cell types to study shifts in cell states driven by metabolic remodeling that change the optical properties of these endogenous fluorophores. Using this non-destructive, live-cell, and label-free strategy, we found that quiescent NSCs (qNSCs) and activated NSCs (aNSCs) have unique autofluorescence profiles. Specifically, qNSCs display an enrichment of autofluorescence localizing to a subset of lysosomes, which can be used as a graded marker of NSC quiescence to predict cell behavior at single-cell resolution. Coupling autofluorescence imaging with single-cell RNA sequencing, we provide resources revealing transcriptional features linked to deep quiescence and rapid NSC activation. Together, we describe an approach for tracking mouse NSC activation state and expand our understanding of adult neurogenesis.

Age-maintained human neurons demonstrate a developmental loss of intrinsic neurite growth ability.

Injury to adult mammalian central nervous system (CNS) axons results in limited regeneration. Rodent studies have revealed a developmental switch in CNS axon regenerative ability, yet whether this is conserved in humans is unknown. Using human fibroblasts from 8 gestational-weeks to 72 years-old, we performed direct reprogramming to transdifferentiate fibroblasts into induced neurons (Fib-iNs), avoiding pluripotency which restores cells to an embryonic state. We found that early gestational Fib-iNs grew longer neurites than all other ages, mirroring the developmental switch in regenerative ability in rodents. RNA-sequencing and screening revealed ARID1A as a developmentally-regulated modifier of neurite growth in human neurons. These data suggest that age-specific epigenetic changes may drive the intrinsic loss of neurite growth ability in human CNS neurons during development. One-Sentence Summary: Directly-reprogrammed human neurons demonstrate a developmental decrease in neurite growth ability.

Effect of Timing of Readmission to the ICU on Mortality in Trauma Patients Requiring Critical Care.

ICU readmission is associated with increased mortality. The primary goal of our investigation was to determine the impact of early ICU readmission on mortality and to identify clinical factors which contribute to early ICU readmission in the trauma population. We retrospectively reviewed 175 patients admitted to ICU in a single, academic Level I Trauma Center from January 2019 to December 2021. Early readmission was defined as readmission within 72 hours of discharge and late readmission as after 72 hours. Early readmission mortality rate was 2.8 times higher than late readmission. Statistically significant variables in early readmission were more operations >2 hours, shorter initial length of stay in ICU, lower hematocrit and paCO2 on ICU discharge, and presence of a psychiatric diagnosis. Additional prospective research is needed to guide the development of practice guidelines that reduce frequency, morbidity, and mortality associated with ICU readmission in the trauma population.

Outcomes After Lysis of Adhesions and Dilator Placement for Treatment of Vulvovaginal Agglutination Due to Lichen Planus.

OBJECTIVE: The aim of the study is to determine intraoperative and postoperative surgical outcomes for the treatment of vulvovaginal agglutination secondary to lichen planus (LP) following a standard protocol using intraoperative dilator placement and postoperative intravaginal steroid use. MATERIALS AND METHODS: This was a retrospective chart review of patients who underwent surgical management of vulvovaginal agglutination due to LP following a protocol that included surgical lysis of vulvovaginal adhesions, intraoperative dilator placement and removal 48 hours later, and high-potency intravaginal corticosteroid and regular dilator use thereafter. Demographic and clinical data were abstracted from the medical record and analyzed using descriptive statistics. RESULTS: Thirty-four patients, with mean age 51.2 ± 11 years and body mass index 32.8 ± 8.5 kg/m 2 , underwent lysis of vulvovaginal adhesions between 1999 and 2021 with 8 different surgeons at a single institution. The mean preoperative, immediate postoperative, and 6-week postoperative vaginal lengths were 2.8 ± 1.8 cm ( n = 18), 8.0 ± 1.9 cm ( n = 21), and 7.9 ± 2.2 cm ( n = 16), respectively. The mean estimated blood loss intraoperatively was 16 ± 15 mL. No patients had a documented surgical site infection or reoperation within 30 days after surgery. Of patients who had it documented ( n = 26), 70% (18/26) reported postoperative sexual activity. Where documented, 100% (18/18) reported preoperative dyspareunia, while 17% (3/18) did postoperatively. Six percent (2/34) had recurrent severe agglutination and 3% (1/34) underwent reoperation. CONCLUSIONS: Lysis of vulvovaginal adhesions, intraoperative dilator placement, and postoperative intravaginal corticosteroids with dilator use is a safe and effective treatment option to restore vaginal length for those with vulvovaginal LP.

Adult fibroblasts use aggresomes only in distinct cell-states.

The aggresome is a protein turnover system in which proteins are trafficked along microtubules to the centrosome for degradation. Despite extensive focus on aggresomes in immortalized cell lines, it remains unclear if the aggresome is conserved in all primary cells and all cell-states. Here we examined the aggresome in primary adult mouse dermal fibroblasts shifted into four distinct cell-states. We found that in response to proteasome inhibition, quiescent and immortalized fibroblasts formed aggresomes, whereas proliferating and senescent fibroblasts did not. Using this model, we generated a resource to provide a characterization of the proteostasis networks in which the aggresome is used and transcriptomic features associated with the presence or absence of aggresome formation. Using this resource, we validate a previously reported role for p38 MAPK signaling in aggresome formation and identify TAK1 as a novel driver of aggresome formation upstream of p38 MAPKs. Together, our data demonstrate that the aggresome is a non-universal protein degradation system which can be used cell-state specifically and provide a resource for studying aggresome formation and function.

Repair of episiotomy and obstetrical perineal lacerations (first-fourth).

Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal trauma is associated with both short- and long-term morbidity, including persistent pain, dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new mother's ability to care for her newborn. The morbidity experienced after perineal injury is dependent on the type of laceration incurred, the technique and materials used for repair, and the skill and knowledge of the birth attendant. After all vaginal deliveries, a systematic evaluation including visual inspection and vaginal, perineal, and rectal exams is recommended to accurately diagnose perineal lacerations. Optimal management of perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique and materials used for repair, providers experienced in perineal laceration repair, and close follow-up. In this article, we review the prevalence, classification, diagnosis, and evidence supporting different closure methods for first- through fourth-degree perineal lacerations and episiotomies. Recommended surgical techniques and materials for different perineal laceration repairs are provided. Finally, best practices for perioperative and postoperative care after advanced perineal trauma are reviewed.

Development of a Preoperative Clinical Risk Assessment Tool for Postoperative Complications After Hysterectomy.

STUDY OBJECTIVE: To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy. DESIGN: Retrospective analysis. SETTING: Michigan Surgical Quality Collaborative hospitals. PATIENTS: Women who underwent hysterectomy for gynecologic indications. INTERVENTIONS: Development of a nomogram to create a clinical risk assessment tool. MEASUREMENTS AND MAIN RESULTS: Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who had a complication and those who did not. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program, and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n = 1638). Preoperative factors associated with postoperative complications were sepsis (odds ratio [OR] 7.98; confidence interval [CI], 1.98-32.20), abdominal approach (OR 2.27; 95% CI, 1.70-3.05), dependent functional status (OR 2.20; 95% CI, 1.34-3.62), bleeding disorder (OR 2.10; 95% CI, 1.37-3.21), diabetes with HbA1c ≥9% (OR 1.93; 95% CI, 1.16-3.24), gynecologic cancer (OR 1.86; 95% CI, 1.49-2.31), blood transfusion (OR 1.84; 95% CI, 1.15-2.96), American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46; 95% CI, 1.24-1.73), government insurance (OR 1.3; 95% CI, 1.40-1.90), and body mass index ≥40 (OR 1.25; 95% CI, 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively). CONCLUSION: We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.

Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis.

BACKGROUND: Antiseptic vaginal preparation is recommended before gynecologic surgery; however, there is a lack of data regarding the effectiveness of different agents. OBJECTIVE: To compare rates of postoperative infectious complications and hospital utilization with preoperative vaginal preparation using povidone-iodine or chlorhexidine before hysterectomy. STUDY DESIGN: This was a retrospective analysis of patients who underwent hysterectomy for gynecologic indications at 70 hospitals in a statewide surgical collaborative between January 2017 and December 2019. The primary outcome was postoperative infectious complications (including urinary tract infection, surgical site infections involving superficial, deep, or organ space tissues, or cellulitis) within 30 days of surgery. To adjust for confounding, propensity score matching, 1:1 without replacement and with a caliper of.005 was performed to create cohorts that had vaginal preparation with either povidone-iodine or chlorhexidine and did not differ in observable characteristics. We compared the rates of infectious morbidity and hospital utilization (emergency department visits, readmission, reoperation) in the matched cohorts. RESULTS: In the statewide collaborative, there were 18,184 patients who received povidone-iodine and 3018 who received chlorhexidine. After propensity score matching of 2935 pairs, the povidone-iodine and chlorhexidine groups did not differ in demographics, comorbidities, choice of preoperative antibiotics, benign vs malignant surgical indication, and surgical approach. Povidone-iodine was associated with a lower rate of infectious morbidity (3.0% vs 4.3%; P=.01), urinary tract infection (1.1% vs 1.7%; P=.03) and emergency department visits (7.9% vs 9.7%; P=.01) than with chlorhexidine. There were nonsignificant trends of lower rates of surgical site infection (2.0% vs 2.7%; P=.07) and reoperation (1.6% vs 2.1%; P=.18). CONCLUSION: This propensity score matched analysis provides evidence that povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative.

The Fundamentals of Vaginal Surgery pilot study: developing, validating, and setting proficiency scores for a vaginal surgical skills simulation system.

BACKGROUND: Surgical training in the simulation lab can develop basic skills that translate to the operating room. Standardized, basic skills programs that are supported by validated assessment measures exist for open, laparoscopic, and endoscopic surgery; however, there is yet to be a nationally recognized and widely implemented basic skills program specifically for vaginal surgery. OBJECTIVE: Develop a vaginal surgical simulation system; evaluate robust validity evidence for the simulation system and its related performance measures; and establish a proficiency score that discriminates between novice and experienced vaginal surgeon performance. STUDY DESIGN: In this 3-phased study, we developed the Fundamentals of Vaginal Surgery simulation system consisting of (1) the Fundamentals of Vaginal Surgery Trainer, a task trainer; (2) a validated regimen of tasks to be performed on the trainer; and (3) performance measures to determine proficiency. In Phase I, we developed the task trainer and selected surgical tasks by performing a needs assessment and hierarchical task analyses, with review and consensus from an expert panel. In Phase II, we conducted a national survey of vaginal surgeons to collect validity evidence regarding test content, response process, and internal structure relevant to the simulation system. In Phase III, we compared performance of novice (first and second year residents) and experienced (third and fourth year residents, fellows, and faculty) surgeons on the simulation system to evaluate relevant relationships to other variables and consequences. Performance measures were analyzed to set a proficiency score that would discriminate between novice and expert (faculty) vaginal surgical performance. RESULTS: A novel task trainer and 6 basic vaginal surgical skills were developed in Phase I. In Phase II, the survey responses of 48 participants (27 faculty surgeons, 6 fellows, and 14 residents) were evaluated on the dimensions of test content, response process, and internal structure. To support evidence of test content, the participants deemed the task trainer and surgical tasks representative of intended surgical field and supportive of typical surgical actions (mean scores, 3.8-4.4/5). For response process, rater-data analysis revealed high rating variability regarding prototype color. This early evidence confirmed the value of a white prototype. For internal structure, there was high agreement among rater groups (obstetricians and gynecologists generalists vs Female Pelvic Medicine and Reconstructive Surgery specialists: interclass correlation coefficient range, 0.59-0.91; learners vs faculty interclass correlation coefficient range, 0.64-1.0). There were no differences in ratings across institution type, surgeon volume, expertise (P>.14). In Phase III, we analyzed performance from 23 participants (15 [65%] obstetricians and gynecologists residents, 3 [13%] fellows, and 5 [22%] Female Pelvic Medicine and Reconstructive Surgery faculty). Experienced surgeons scored significantly higher than novice surgeons (median, 467.5; interquartile range, [402.5-542.5] vs median, 261.5; interquartile range, [211.5-351.0]; P<.001). Based on these data, setting a proficiency score threshold at 400 results in 0% (0/6) novices attaining the score, with 100% (5/5) experts exceeding it. CONCLUSION: We present validity evidence relevant to all 5 sources which supports the use of this novel simulation system for basic vaginal surgical skills. To complement the system, a proficiency score of 400 was established to discriminate between novices and experts.

A spatio-temporal and kinematic description of self-selected walking in adults with Achondroplasia.

BACKGROUND: Achondroplasia is characterised by a shorter appendicular limb to torso ratio, compared to age matched individuals of average stature (controls). Despite the well documented shorter leg length of individuals with compared to controls, there are few complete descriptions of gait kinematics reported for the population. AIM: The aim of this study was to report the spatio-temporal and kinematic characteristics of self-selected walking (SSW) in a group with Achondroplasia (N = 10) and age matched group without Achondroplasia (controls, N = 17). METHOD: Whole body 3D analysis of both groups was conducted using a 14 camera VICON system. Spatio-temporal and kinematic variables were determined through a Plug-in-Gait model. SSW was obtained from an average of three trials equating to a total of ∼120 m walking. RESULTS: The group with Achondroplasia were 23 % slower (P < 0.001), had a 29 % shorter stride length (P < 0.001) and a 13 % higher stride frequency (P < 0.001) compared to controls. There were no differences in time normalised temporal measures of left toe off (P = 0.365), right heel contact (P = 0.442) or the duration of double support (P = 0.588) between groups. A number of discrete joint kinematic differences existed between groups, resulting in the group with Achondroplasia having more 'flexed' lower limbs than controls throughout the gait cycle. CONCLUSION: Differences in absolute spatio-temporal variables between groups is likely due to the shorter leg length of the group with Achondroplasia, while their more flexed position of the lower limbs may facilitate toe-clearance during the swing phase.

Deliberate Practice: Applying the Expert Performance Approach to Gynecologic Surgical Training.

Surgical training is shifting from the historical Halstedian apprenticeship model to outcomes-based methods. Surgical residents can reach a higher level of performance when utilizing deliberate practice and the expert performance approach. This article discusses methods for implementing deliberate practice and the expert performance approach into gynecologic surgical training programs.

A quantitative description of self-selected walking in adults with Achondroplasia using the gait profile score.

BACKGROUND: Achondroplasia is characterised by a shorter appendicular limb-to-torso ratio, compared to age matched individuals of average stature (controls). Previous work shows gait kinematics of individuals with Achondroplasia differing to controls, but no global quantification of gait has been made in adults with Achondroplasia. AIM: The aim of this study was to quantify gait differences between a group of adult males with Achondroplasia and controls during self-selected walking (SSW) using the Gait Profile Score (GPS). DESIGN: Whole body motion analysis of 10 adults with Achondroplasia (22 ± 3 yrs) who had not undergone leg lengthening and 17 adult controls (22 ± 2 yrs) was undertaken using a 14 camera VICON system (100 Hz). For each group, fifteen root mean squared Gait Variable Scores (GVS, units °) were computed from lower limb kinematic data and then summed to calculate GPS (°). RESULTS: The group with Achondroplasia had higher GVSs than controls in 10 of the 15 measures (P < 0.05) with the largest differences found in ankle plantar/dorsiflexion (P < 0.001), knee flexion/extension (P < 0.001), and hip internal/external rotation (P < 0.001). The GPS value of the group with Achondroplasia was 64% higher than controls (11.4° (2.0) v 4.1° (1.8), P < 0.001). CONCLUSION: Gait is quantitatively different in adults with Achondroplasia compared to controls. The differences in GPS between groups are due to differences in joint kinematics, which are possibly manifested by maintaining toe-clearance during swing. Gait models derived from the anatomy of individuals with Achondroplasia may improve these data.

A novel method to guide classification of para swimmers with limb deficiency.

The International Paralympic Committee has directed International Federations that govern Para sports to develop evidence-based classification systems. This study defined the impact of limb deficiency impairment on 100 m freestyle performance to guide an evidence-based classification system in Para Swimming, which will be implemented following the 2020 Tokyo Paralympic games. Impairment data and competitive race performances of 90 international swimmers with limb deficiency were collected. Ensemble partial least squares regression established the relationship between relative limb length measures and competitive 100 m freestyle performance. The model explained 80% of the variance in 100 m freestyle performance and found hand length and forearm length to be the most important predictors of performance. Based on the results of this model, Para swimmers were clustered into four-, five-, six-, and seven-class structures using nonparametric kernel density estimations. The validity of these classification structures, and effectiveness against the current classification system, were examined by establishing within-class variations in 100 m freestyle performance and differences between adjacent classes. The derived classification structures were found to be more effective than current classification based on these criteria. This study provides a novel method that can be used to improve the objectivity and transparency of decision-making in Para sport classification. Expert consensus from experienced coaches, Para swimmers, classifiers, and sport science and medicine personnel will benefit the translation of these findings into a revised classification system that is accepted by the Para swimming community.

Resection and Advancement Flap Closure of a Combined Vascular Malformation of the Mons Pubis.

BACKGROUND: Vascular malformations are congenital abnormalities that do not spontaneously regress and may require surgical resection for treatment. CASE: A healthy 23-year-old woman presented with a painless, slowly enlarging mass of the mons pubis. Ultrasonography and magnetic resonance imaging demonstrated a cystic mass with minimal Doppler flow. The final pathology showed a combined lymphatic-venous vascular malformation. A meshed advancement flap was used to close the skin after surgical resection. These flaps create a lattice of small cutaneous defects that heal rapidly by secondary intention and optimize wound healing. CONCLUSION: Lower genital tract vascular malformations are rare but often become symptomatic in adolescents or young women. Larger lesions may warrant surgical resection. Flap closures may aid in proper wound healing.

Zebrafish embryonic stromal trunk (ZEST) cells support hematopoietic stem and progenitor cell (HSPC) proliferation, survival, and differentiation.

Forward genetic screens in zebrafish have been used to identify genes essential for the generation of primitive blood and the emergence of hematopoietic stem cells (HSCs), but have not elucidated the genes essential for hematopoietic stem and progenitor cell (HSPC) proliferation and differentiation because of the lack of methodologies to functionally assess these processes. We previously described techniques used to test the developmental potential of HSPCs by culturing them on zebrafish kidney stromal (ZKS) cells, derived from the main site of hematopoiesis in the adult teleost. Here we describe an additional primary stromal cell line we refer to as zebrafish embryonic stromal trunk (ZEST) cells, derived from tissue surrounding the embryonic dorsal aorta, the site of HSC emergence in developing fish. ZEST cells encouraged HSPC differentiation toward the myeloid, lymphoid, and erythroid pathways when assessed by morphologic and quantitative reverse transcription polymerase chain reaction analyses. Additionally, ZEST cells significantly expanded the number of cultured HSPCs in vitro, indicating that these stromal cells are supportive of both HSPC proliferation and multilineage differentiation. Examination of ZEST cells indicates that they express numerous cytokines and Notch ligands and possess endothelial characteristics. Further characterization of ZEST cells should prove to be invaluable in understanding the complex signaling cascades instigated by the embryonic hematopoietic niche required to expand and differentiate HSPCs. Elucidating these processes and identifying possibilities for the modulation of these molecular pathways should allow the in vitro expansion of HSPCs for a multitude of therapeutic uses.

Biological hazards: an overview.

Recent developments include new guidance from the UK Department of Health on the management of hepatitis B infected healthcare workers and evidence of the value of antiretroviral treatment in reducing transmission of HIV. The possibility of greater occupational transmissibility of hepatitis C and increasing antibiotic resistance remain of concern.

Upper extremity kinematics and body roll during preferred-side breathing and breath-holding front crawl swimming.

Front crawl swimmers often restrict the number of breaths they take during a race because of the possible adverse effects of the breathing action on resistance or stroke mechanics. The aim of this study was to determine whether differences exist in the kinematics of the trunk and upper extremity used during preferred-side breathing and breath-holding front crawl swimming. Six male swimmers performed trials at their 200 m race pace under breathing and breath-holding conditions. The underwater arm stroke was filmed from the front and side using video cameras suspended over periscope systems. Video recordings were digitized at 50 Hz and the three-dimensional coordinates of the upper extremity obtained using a direct linear transformation algorithm. Body roll angles were obtained by digitizing video recordings of a balsa wood fin attached to the swimmers' backs. The swimmers performed the breathing action without any decrement in stroke length (mean +/- s: breathing 2.24 +/- 0.27 m; breath-holding 2.15 +/- 0.22 m). Stroke widths were similar in the breathing (0.28 +/- 0.07 m) and breath-holding (0.27 +/- 0.07 m) trials, despite swimmers rolling further when taking a breath (66 +/- 5 degrees) than when not (57 +/- 4 degrees). The timing of the four underwater phases of the stroke was also unaffected by the breathing action, with swimmers rolling back towards the neutral position during the insweep phase. In conclusion, the results suggest that front crawl swimmers can perform the breathing action without it interfering with their basic stroke parameters. The insweep phase of the stroke assists body roll and not vice versa as suggested in previous studies.

Estimating propulsive forces in swimming from three-dimensional kinematic data.

Propulsive forces are important determinants of swimming performance. The aim of this study was to quantify the measurement error (uncertainty) in propulsive forces calculated from kinematic data. Ten operators digitized underwater video recordings of a breaststroke swimmer's right arm action. Four landmarks on the hand were digitized at 50 Hz and their three-dimensional coordinates obtained using a DLT algorithm. Two angles (alpha and psi) defining the orientation of the hand relative to the fluid flow were calculated following the procedures of Schleihauf et al. (1983). The hydrodynamic force acting on the hand (FR) was calculated using the force coefficients of Schleihauf (1979). Errors in single measurements of hand speed, alpha and psi were estimated for each video field analysed. Errors in alpha and psi led to average errors in the lift and drag coefficients of 27 and 20% respectively, which, when combined with an average hand speed error of 6%, produced an average error in FR of 26%. Each of these errors was reduced by a factor of square root 10 when the mean of 10 measurements was used to calculate FR. Researchers should report both the estimated errors in their hydrodynamic data and the procedures used to reduce them.

Implications of the 1992 ethics code for diverse groups.

Previous renditions of the American Psychological Association's (APA's) code of ethics have clearly espoused psychologists' commitment to the ideal of having respect for the dignity and worth of the individual human being. The endorsement of the goal to protect fundamental human rights has always been highlighted in the Preambles of each revision of the code. The current code (APA, 1992) appears to have retreated from prioritizing this humanitarian stance. Ethnic minorities, women, gay men, and lesbians have reason to be apprehensive about the apparent downgrading in importance of psychologists' declaration of respect for the dignity and worth of the individual. All previous codes seemed to have been formulated from a perspective of protecting consumers. The new code appears to be driven by a need to protect psychologists. This article examines the possible impact of the shift in traditional priorities on diverse populations.