Technical Note: A simple FTA® based method for the direct STR amplification of human foetal tissues.

Short tandem repeats (STRs) or microsatellites are short, tandemly repeated DNA sequences that involve a repetitive unit of 1-6 bp. DNA isolation and purification from a large number and often compromised samples gives problems to forensic labs for STR typing. Many of the conventional methods used in the isolation and purification of DNA from forensic samples are time consuming, expensive, hazardous for health and are often associated with greater risks of cross contamination. FTA® technology is a method designed to simplify the collection, shipment, archiving and purification of nucleic acid from a wide variety of biological samples. We report a new method for the direct STR amplification which can amplify STR loci from human foetal tissues spotted on FTA cards, bye-passing the need of DNA purification. The STR loci amplified by this method was compared with conventional method of STR profiling and was found absolutely matching. Therefore, this new method is demonstrated to be very useful for fast, less expensive and non- hazardous forensic DNA analysis.

In Vitro Assessment of Different Toothbrush Designs on Enamel Surface Abrasion: A Profilometric Study.

AIM: The purpose of this study was to evaluate the impact of three different toothbrush designs on enamel surface abrasion. MATERIALS AND METHODS: Sixty intact freshly extracted maxillary central incisors were considered for the study. All of the extracted teeth's surfaces were severely trimmed, leaving only the labial surface intact. In the trial, a conventional teeth-whitening dentifrice slurry was utilized. A brushing model was created to deliver uniform force in unidirectional motion. Dontrix Gauge was used to control the tension of the spring. The force was kept constant at 180 ± 20 g. The mounted enamel samples were separated into three groups (20 samples each) at random: group A: toothbrushes have a flat trim bristle design, group B: toothbrushes have a zigzag pattern, and group C: toothbrushes have a bi-level bristle design. For 2 weeks, each sample was brushed twice daily for 2 minutes. A profilometer was used to measure the average surface roughness. RESULTS: After toothbrushing, the maximum mean surface roughness score was found in zigzag pattern group (2.10 ± 0.23), followed by bi-level bristle design group (2.06 ± 0.12) and the least was in the flat trim bristle design group (1.96 ± 0.09). There was a significant difference between the different toothbrush bristle pattern groups (p < 0.001). CONCLUSION: On conclusion, the results of this study showed that, in comparison to toothbrushes with zigzag patterns and bi-level bristle designs, flat trim toothbrush bristle designs cause the least amount of surface abrasion and are relatively safe to use. CLINICAL SIGNIFICANCE: Toothbrushing with toothpaste contributes significantly to dental abrasion. A variety of parameters, including toothpaste abrasivity and concentration, brushing frequency, brushing length, brushing force, and toothbrush bristle stiffness, have the potential to influence the abrasion process of dental hard tissue.

Need for cross-level iterative re-entry in models of visual processing.

Two main hypotheses regarding the directional flow of visual information processing in the brain have been proposed: feed-forward (bottom-up) and re-entrant (top-down). Early theories espoused feed-forward principles in which processing was said to advance from simple to increasingly complex attributes terminating at a higher area where conscious perceptions occur. That view is disconfirmed by advances in neuroanatomy and neurophysiology, which implicate re-entrant two-way signaling as the predominant form of communication between brain regions. With some notable exceptions, the notion of re-entrant processing has had a relatively modest effect on computational models of perception and cognition, which continue to be predominantly based on feed-forward or within-level re-entrant principles. In the present work we describe five sets of empirical findings that defy interpretation in terms of feed-forward or within-level re-entrant principles. We conclude by urging the adoption of psychophysical, biological, and computational models based on cross-level iterative re-entrant principles.

Study of the Reliability of High Resolution CT Scan Evaluation of Eustachian Tube as Predictor of Predisposition for Chronic Otitis Media.

Eustachian tube (ET) dysfunction is one of the predisposing factors for chronic otitis media (COM). This study looks at two parameters in High Resolution Computed Tomography of temporal bone namely tubotympanic angle (TTA) and pretympanic diameter (PTD) and its relationship with COM. The objectives of the study were to compare the tubotympanic angle and pretympanic diameter of the affected ear in patients with unilateral COM with that of healthy controls, and with contralateral non-COM ear. This was a retrospective study done at a tertiary referral hospital. Database of patients who underwent high resolution CT scan of temporal bone over a period of  three and half years, was studied. The TTA and PTD of ET were measured with the help of a senior radiologist well-versed in the imaging of temporal bone. Group A consisted of 45 patients with unilateral COM, while Group B comprised 50 patients without COM. Group A was further subgrouped as A1 (COM with cholesteatoma) and A2 (COM without cholesteatoma). The TTA and PTD in COM with cholesteatoma in the affected ear were 147.98 ± 5.89° and 2.84 ± 0.82 mm respectively, and in the unaffected ear, 144.81 ± 6.43° and 3.32 ± 1.19 mm respectively. In Group A, the TTA and PTD in the affected ear of unilateral COM were 146.17 ± 6.11°, 2.97 ± 0.87 mm and in Group B, it was 143.17 ± 6.01° and 3.48 ± 0.85 mm respectively. All these were statistically significant (p value < 0.05). Increased TTA and reduced PTD of ET may be a predisposing factor for the development of COM and cholesteatoma.

Using Temporal Data Mining on Patient Data for Clinical Decision Making in the Care of the Sick Newborn.

Background: In a neonatal intensive care unit, streaming healthcare data comes from many sources, but humans are unable to understand relationships between data variables. Data mining and analysis are just beginning to get utilized in critical care. We present a case study using electronic medical record data in the neonatal intensive care unit and explore possible avenues of advancement using temporal data analytics. Case Presentation: Electronic medical record data were collected for physiological monitor data. Heart rate, respiratory rate, oxygen saturation and temperature data were retrospectively analyzed by temporal data mining. Three premature babies were selected and data de-identified. The first case of a urinary tract infection showed nursing ability to synthesize data streams coming from a patient. For the second case of necrotizing enterocolitis, Temporal-Data-Mining analysis of combinations of clinical events based on deviations from the mean showed specific heuristic biomarkers related to events before discovery of necrotizing enterocolitis. Specific sequences 6-event and 5-event in length were identified with nursing unease at clinical deterioration, which were 100- and 87-times unlikely to occur randomly with 99.5% confidence. No such sequences were found in the rest of the 37 days for the second case and entire 133 days of stay in the third case of an uneventful premature baby. Conclusion: Temporal data mining is a possible clinical tool in providing useful information in the neonatal intensive care unit for diagnosis of adverse clinical occurrences such as necrotizing enterocolitis. There is the possibility of changing the clinical paradigm of episodic watchfulness to constant vigilance using real-time data gathering.

Heavy metals in coral reef sediments of Kavaratti Island, India: An integrated quality assessment using GIS and pollution indicators.

The present study aims to document the contamination levels and ecological risks of heavy metals in the sediments of Kavaratti lagoon, India. A total of 15 sediment samples were collected for the analysis of Al, Pb, Cd, Cu, Cr, Mn, Ni and Zn. The decreasing trend of heavy metals was observed in the lagoon sediment as Pb > Zn > Al > Mn > Ni > Cr > Cd > Cu. The Geo-accumulation index (Igeo) results indicate that Cu, Cr, Mn, Ni and Zn were uncontaminated, while Cd was strong to extremely contaminated and Al and Pb were moderately contaminated. The enrichment factors (EF) of Cd and Pb range from moderate to extremely high (EF > 1) indicating that they have anthropogenic origin on Kavaratti Island. The Contamination factor (Cf) indicated that Cd, Pb and Al belong to a high risk of contamination (Cf > 6). The pollution load index (PLI) value near one suggested that a moderate level of pollution occurs in the study area. The modified degree of contamination (mCd) shows that Al, Cd and Pb have an ultra- higher degree of contamination (mCd ≤ 32). The potential ecological risk (RI) index confirmed that Pb and Cd have considerable to the serious thread of ecological risk (RI > 600). Additionally, multivariate statistical analysis and pollution indexes showed that the Kavaratti lagoon is moderate to considerably polluted by heavy metals. Diesel-based power generation, activities related to shipping, untreated sewage, fishing and tourism activities are the main anthropogenic sources of heavy metal pollution on Kavaratti Island.

Pilot of a questionnaire study regarding perception of undergraduate medical students towards online classes: Process and perspectives.

BACKGROUND: The COVID-19 pandemic situation has forced a shift in medical education from physical classroom to virtual online teaching. However, students and teachers perceive this differently. It is important to study these perceptions to improve the teaching-learning process, and thus to validate the role of online learning in the country. OBJECTIVE: To document the process of a pilot for a questionnaire-based study regarding perception of undergraduate medical students towards on-going online classes. METHODS: Medical Education Department of a teaching hospital developed a new questionnaire with the primary objective of studying the satisfaction and usefulness of the online classes (e-Learning). Content validity was done. For the pilot work, 10% of the total student strength was targeted. Random purposive sampling from each phase of the undergraduate course was done to choose the participants. The questionnaire was administered via Google Classroom. It was an external, undeclared type of pilot. All the responses were documented and analysed for both changes in the questions as well as for statistical sample size derivation for the main study. RESULTS: Responses from 30 students were analysed for the pilot study. Based on the proportion of the level of satisfaction (23.3%) and usefulness (23.3%) of the on-going online classes observed, and with 20% relative precision and 95% confidence, the minimum sample size for the main study was calculated. The responses revealed the need for minor changes in the questionnaire tool for overall feasibility and achievement of the objectives of the main study. CONCLUSIONS: A pilot study is a necessary component for a research project, especially when it involves the use of a new tool. This paper shows the relevance of the same. The authors intend to convey the importance of documenting the processes of conduct of a pilot study, the issues involved therein, and the steps taken to resolve the same.

Preoperative screening for obstructive sleep apnea in cardiovascular patients - How useful is STOP-BANG questionnaire in the Indian context?

Background: Obstructive sleep apnea (OSA) is reported in a high proportion of cardiac surgical patients, up to 73%. STOP-BANG is a validated questionnaire for screening of outpatients for OSA with high sensitivity. There is sparse literature from India regarding the prevalence of OSA in preoperative cardiovascular patients and the utility of screening tools. Aims: We sought to study the utility of the STOP-BANG questionnaire as a screening tool for OSA in cardiovascular patients validating it with ambulatory level 3 polysomnography. Materials and Methods: It was a prospective study where consecutive patients getting admitted for coronary artery bypass surgery (CABG) from August 2017-February 2019 were recruited. All the patients were screened with the STOP-BANG questionnaire. 53 patients underwent overnight level 3 polysomnography using Apnea-Link. Correlations were made between clinical symptoms, STOP-BANG score, and OSA severity, measured using Apnea hypopnea index (AHI). Results: We had 120 patients(103 males) with a mean age 60 years. Snoring was the most common sleep complaint. Our cohort had a high prevalence of vascular risk factors (DM 72.3%, hypertension 59.2%, dyslipidemia 60%) and 11.7% were obese (BMI >30). The median STOP-BANG score was 3 (IQR 2) with 83 having scores ≥3. Median AHI was 5.6 with AHI ≥5 in 28 patients and AHI 15 or above in 14 patients. Among the clinical parameters, arousals with respiratory difficulty at night, higher neck circumference, and tonsillar hypertrophy showed a significant association with PSG-proven OSA.STOP-BANG scores 3 or above had a sensitivity of 75% in predicting OSA. Conclusions: Our study shows that in cardiovascular patients less symptomatic for sleep complaints, the STOP-BANG questionnaire is a useful screening tool for OSA in outpatient settings. Among clinical parameters, airway narrowing and neck circumference can predict OSA.

Congenital long QT syndrome and patent ductus arteriosus: A rare surgical scenario.

Congenital long QT syndrome (LQTS) is a rare cardiac condition characterized by abnormality of either sodium or potassium ion channels resulting in prolongation of QT interval and thereby predisposing to life-threatening arrhythmia. Once the syndrome is diagnosed, measures should be taken to avoid sudden cardiac death. We present a rare case of LQTS associated with patent ductus arteriosus in a child, and a unique approach was used in managing both conditions.

Perceptions of undergraduate medical students regarding institutional online teaching-learning programme.

BACKGROUND: Medical education all over the country has been forced to shift to e-learning, mainly online classes. In this scenario, the medical education department (MEU) of a teaching hospital under a deemed university felt the need to study the satisfaction and usefulness of these classes, as perceived by the undergraduate medical students. METHODS: Questionnaire survey was planned. A specially designed questionnaire was created, keeping in mind, the study objectives. It was validated, and a pilot was conducted, for modifications and to calculate sample size. The questionnaire was administered by email as Google Forms. The responses, which included quantitative and qualitative responses, were analysed, and feedback points noted. Percentage level of satisfaction and usefulness was calculated with 95% confidence interval. To test the statistical significance of the association of satisfaction levels amongst students of different Phases, chi square test was used. RESULTS: On a scale scoring for satisfaction, 53.6% scored moderate, 31% high, and 15.4% low satisfaction. 49.8% of the students were less satisfied about attending classes from home; 15.7% felt it was better. 57.1% of the students found the concept of online learning moderately useful, 31.4% found it minimally useful, 11.5%, highly useful. CONCLUSIONS: The undergraduate medical students perceived moderate satisfaction and usefulness with the on-going online classes. They expressed the desire to resume routine physical classes, especially for practicals and clinics. Points of improvement of the online teaching-learning programme were also obtained. This study revealed sufficient feedback to be shared with all stakeholders, regarding improvements in the online classes.

Prevalence of Voice Disorders in School Teachers in a District in South India.

BACKGROUND: Many professions tend to carry inherent risks for the practitioners. In such cases, it becomes mandatory for them to be aware of the risks and counselled about the preventive measures. The inevitable first step, however, is to ascertain the burden of risk. In the case of school teachers, it is known that they are prone to voice disorders of varying hues, at some point of their career. There should be an attempt to find the prevalence in the community. Presently, there is no such data documented from Kerala, a highly literate State in southern India. AIM AND OBJECTIVES: The primary objective of this study was to document the prevalence of subjective dysphonia among the school teacher community. The secondary objective was to compare the prevalence and severity of dysphonia between primary and secondary school teachers. MATERIALS AND METHODS: A cross-sectional study was conducted in 28 schools, using a screening questionnaire, based on similar ones used in other studies. All the schools were in the city of Kochi, the largest and most populous metropolitan area in Kerala. Teachers reporting a current voice complaint at the time of study were administered the validated vernacular version of the voice handicap index questionnaire (VHI 30). The completed questionnaires were collected and statistically analyzed. RESULTS: The screening questionnaire was administered to 702 teachers; 165 were Primary school teachers (Class I-V), 242 Secondary (Class VI-XII), while 279 teachers had to take classes in both sections. The reported prevalence was 45.4% for present difficulty related to their voice, 52.8% for some voice problem in the last 1 year, and 70.1% for problems experienced during the duration of their teaching career. Possible risk factors like age, total years of teaching, hours of daily teaching and number of students taught did not show any significant association with voice problem. CONCLUSIONS: Nearly, half of all the screened school teachers reported a current voice problem, increasing to nearly three-fourths for symptoms during entire career. This is clearly a significant burden which must be addressed at various levels. The secondary school teachers seem to bear a bigger burden in this study.

The correlation between micronuclei count and smoking behavior: a hospital-based study / Correlación entre recuento de micronúcleos y hábito tabáquico: un estudio hospitalario

Background: Micronucleus is a microscopically visible cyto-plasmic chromatin mass in the extranuclear vicinity, originating from aberrant mitosis, which consists of eccentric chromosomes that have failed to reach spindle poles during mitosis. The present study was designed to evaluate and compare cytogenetic changes in the buccal mucosa of smokers and non-smokers based on the occurrence of micronuclei. The study aimed to determine the correlation between the micronuclei count and the frequency and duration of smoking habit. Materials and Methods: Two groups (smokers and non-smokers) of 34 individuals each were examined. Cytological buccal smears were taken from participants using a moistened wooden spatula and stained with standard Papanicolaou stain. Presence of micronuclei was assessed at 40X magnification using a light microscope and a count per 500 cells was determined. The results of the study were analyzed statistically using Mann-Whitney U test, Spearman's rank correlation coefficient and Student t-test. Result: Smears from smokers showed a significant increase in the total number of micronuclei per 500 cell count compared to non-smokers. There was a strong positive correlation between the occurrence of micronuclei and the frequency and duration of smoking. A age-related increase in older age groups was also observed. Conclusion: The study reveals a strong positive correlation between the occurrence of micronuclei and the frequency and duration of smoking. This observation is vital in the utilization of the micronuclei detection in smears as a prognostic, educational and interventional tool in the management of patients with smoking habits.

Antecedentes: El micronúcleo es una masa de cromatina citoplasmática microscópicamente visible en el área extranuclear, que se origina a partir de la mitosis aberrante, y que consiste en cromosomas excéntricos que no han podido alcanzar los polos del huso durante la mitosis. El presente estudio fue diseñado para evaluar y comparar los cambios citogenéticos en la mucosa bucal de fumadores y no fumadores en función de la aparición de micronúcleos. El estudio tuvo como objetivo determinar la correlación entre el recuento de micronúcleos y la frecuencia y duración del hábito de fumar. Materiales and Métodos: Se examinaron dos grupos (fumadores y no fumadores) de 34 individuos cada uno. Se tomaron frotis bucales citológicos de todos los participantes con una espátula de madera humedecida y se tiñeron con la tinción estándar de Papanicolaou. La presencia de micronúcleos se evaluó al microscopio óptico con un aumento de 40X y se determinó un recuento por 500 células. Los resultados del estudio se analizaron estadísticamente utilizando la prueba U de Mann-Whitney, el coeficiente de correlación de rango de Spearman y la prueba t de Student. Resultados: Los frotis de fumadores mostraron un aumento significativo en el número total de micronúcleos por 500 células en comparación con los no fumadores. Hubo una fuerte correlación positiva entre la aparición de micronúcleos y la frecuencia y duración del tabaquismo. También se observó un aumento relacionado con la edad en los grupos de mayor edad. Conclusión: el estudio revela una fuerte correlación positiva entre la aparición de micronúcleos y la frecuencia y duración del tabaquismo. Esta observación es vital en la utilización de la detección de micronúcleos en frotis como una herramienta pronostica, educativa e intervencionista en el manejo de pacientes con hábitos de fumar.

Usefulness of a modified questionnaire as a screening tool for swallowing disorders in Parkinson disease: A pilot study.

AIMS: To determine the correlation between our questionnaire scores and two standard Parkinson's disease (PD) disability scores [Unified Parkinsons' Disease Rating Scale (UPDRS) and Hoehn and Yahr (H and Y)], and to study the correlation between the various subgroups of our dysphagia screening questionnaire. SETTINGS AND DESIGN: This study was conducted at a movement disorder clinic in a tertiary care hospital in Kochi, Kerala. This was a cross-sectional observational study. MATERIALS AND METHODS: A questionnaire was developed comprising 11 items, keeping in mind the most relevant swallowing issues in PD patients. The questions were subdivided into four groups representing the different stages of swallowing. Reliability and validity studies were conducted for the questionnaire. Corresponding UPDRS and H and Y scores were documented on the same day. STATISTICAL ANALYSIS USED: Mean and standard deviation (SD) values of the scores in each group and the correlation between scores (Pearson correlation coefficient) were done. RESULTS: Responses were obtained from 106 PD patients (67 males, 39 females), with a mean age of 66.9 years (SD, 8.62). Our questionnaire score showed a high coefficient of variation (145%) compared to the UPDRS and H and Y scores. There was also moderate correlation between our questionnaire score and the two standard scores with a significant P value. Finally, the highest mean scores were for questions from group A and the least for questions from group D. CONCLUSIONS: The association between worsening motor symptoms and swallowing difficulties has been documented in this study. The oral stage of swallowing remains the most affected in PD, which can be recognized early using our questionnaire.

Construction of a 3D Model of Epitympanic Folds and Spaces.

This article reports a technique for making a 3 dimensional(3D) model of the epitympanic folds and spaces in the middle ear. It is intended as a teaching model for both undergraduate and post-graduate medical students.

Discovering functional neuronal connectivity from serial patterns in spike train data.

Repeating patterns of precisely timed activity across a group of neurons (called frequent episodes) are indicative of networks in the underlying neural tissue. This letter develops statistical methods to determine functional connectivity among neurons based on nonoverlapping occurrences of episodes. We study the distribution of episode counts and develop a two-phase strategy for identifying functional connections. For the first phase, we develop statistical procedures that are used to screen all two-node episodes and identify possible functional connections (edges). For the second phase, we develop additional statistical procedures to prune the two-node episodes and remove false edges that can be attributed to chains or fan-out structures. The restriction to nonoverlapping occurrences makes the counting of all two-node episodes in phase 1 computationally efficient. The second (pruning) phase is critical since phase 1 can yield a large number of false connections. The scalability of the two-phase approach is examined through simulation. The method is then used to reconstruct the graph structure of observed neuronal networks, first from simulated data and then from recordings of cultured cortical neurons.

A combined approach of bedside clinical examination and flexible endoscopic evaluation of swallowing in poststroke dysphagia: A pilot study.

BACKGROUND: As with most neurologic conditions, stroke involves impairment of the swallowing mechanism. This could be a spectrum of issues, the worst of which is aspiration. At the same time, the prolonged presence of a naso-gastric tube (NGT) has its own morbidity. Flexible endoscopic evaluation of swallowing (FEES) is one reliable method to assess the structural and functional status of the oropharynx and larynx, during the swallowing process. OBJECTIVE: To study the utility of FEES in decision-making with respect to resumption of oral intake in stroke patients. To document the findings of FEES in stroke patients, and to look for correlations between these and the site of stroke. MATERIALS AND METHODS: Protocol insertion of naso-gastric tube in all stroke patients, at presentation. Initial assessment by a neurologist and swallowing therapist, depending on cognitive status of the patient. All patients underwent MRI Brain with diffusion weighted sequences. After detailed clinical examination, they underwent swallow exercises under the supervision of a trained swallowing therapist. The decision to remove NGT was taken clinically by the combined decision of neurologist and swallowing therapist. Then all patients underwent FEES by the ENT surgeon. The final decision for NGT removal was taken as per the FEES findings. RESULT: Sixteen stroke patients underwent the FEES procedure during a period of six months. The oropharyngeal and laryngeal findings varied depending on the area of stroke involvement. Of these, change in decision regarding swallowing rehabilitation or NGT removal was needed in four patients, following the FEES findings. CONCLUSIONS: FEES is an easy, efficient and reliable method to evaluate the swallowing status in stroke patients. In combination with good bedside clinical examination and swallow exercises, it can be a good tool in assessing patients with post- stroke dysphagia. Post-stroke rehabilitation and prevention of aspiration pneumonia can be effectively done with the help of FEES.

Etiology and Anti-microbial Sensitivity of Organisms Causing Community Acquired Pneumonia: A Single Hospital Study.

OBJECTIVE: The objective of this study was to identify the common etiological pathogens causing community acquired pneumonia (CAP) in our hospital and sensitivity patterns to the common antibiotics used. MATERIALS AND METHODS: This study was undertaken in a 750 bedded multi-specialty referral hospital in Kerala catering to both urban and semi-urban populations. It is a prospective study of patients who attended the medical out-patient department and those admitted with a clinical diagnosis of CAP, during the year 2009. Data were collected based on detailed patient interview, clinical examination and laboratory investigations. The latter included sputum culture and sensitivity pattern. These were tabulated and percentage incidence of etiological pathogens calculated. The antimicrobial sensitivity pattern was also classified by percentage and expressed as bar diagram. RESULTS: The study showed Streptococcus pneumoniae to be the most common etiological agent for CAP, in our hospital setting. The other organisms isolated in order of frequency were Klebsiella pneumoniae, Pseudomonas aeruginosa, Alpha hemolytic streptococci, Escherichia coli, Beta hemolytic streptococci and atypical coli. S. pneumoniae was most sensitive to linezolid, followed by amoxicillin-clavulanate (augmentin), cloxacillin and ceftriaxone. Overall, the common pathogens causing CAP showed highest sensitivity to amikacin, followed by ofloxacin, gentamycin, amoxicillin-clavulanate (augmentin), ceftriaxone and linezolid. The least sensitivity rates were shown to amoxicillin and cefoperazone. CONCLUSION: In a hospital setting, empirical management for cases of CAP is not advisable. The present study has shown S. pneumoniae as the most likely pathogen and either linezolid or amikacin as the most likely effective antimicrobial in cases of CAP, in our setting.

Revenue, relationships and routines: the social organization of acute myocardial infarction patient transfers in the United States.

Heart attack, or acute myocardial infarction (AMI), is a leading cause of death in the United States (U.S.). The most effective therapy for AMI is rapid revascularization: the mechanical opening of the clogged artery in the heart. Forty-four percent of patients with AMI who are admitted to a non-revascularization hospital in the U.S. are transferred to a hospital with that capacity. Yet, we know little about the process by which community hospitals complete these transfers, and why publicly available hospital quality data plays a small role in community hospitals' choice of transfer destinations. Therefore, we investigated how community hospital staff implement patient transfers and select destinations. We conducted a mixed methods study involving: interviews with staff at three community hospitals (n = 25) in a Midwestern state and analysis of U.S. national Medicare records for 1996-2006. Community hospitals in the U.S., including our field sites, typically had longstanding relationships with one key receiving hospital. Community hospitals addressed the need for rapid AMI patient transfers by routinizing the collective, interhospital work process. Routinization reduced staff uncertainty, coordinated their efforts and conserved their cognitive resources for patient care. While destination selection was nominally a physician role, the decision was routinized, such that staff immediately contacted a "usual" transfer destination upon AMI diagnosis. Transfer destination selection was primarily driven at an institutional level by organizational concerns and bed supply, rather than physician choice or patient preference. Transfer routinization emerged as a form of social order that invoked tradeoffs between process speed and efficiency and patient-centered, quality-driven decision making. We consider the implications of routinization and institutional imperatives for health policy, quality improvement and health informatics interventions.

Suprahyoid pharyngotomy for excision of laryngeal venous malformation.

We report an uncommon case of symptomatic venous malformation of the larynx in a 22-year-old man, and the successful surgical management thereof. A detailed radiologic investigation of the lesion was done, followed by surgical excision via a suprahyoid pharyngotomy using cold instruments. Long-term follow-up was maintained, and the patient had subjective and objective resolution of his symptoms and signs at 3 years postoperatively. We conclude that radiology can reveal hitherto unsuspected extensions of vascular malformations in the neck and that surgical excision is a viable mode of treatment in upper aerodigestive venous malformations.

Spatio-temporal Structure of US Critical Care Transfer Network.

Most Americans are in Intensive Care Units (ICUs) at some point during their lives. There is wide variation in the outcome quality of ICUs and so, thousands of patients who die each year in ICUs may have survived if they were at the appropriate hospital. In spite of a policy agenda from IOM calling for effective transfer of patients to more capable hospitals to improve outcomes, there appear to be substantial inefficiencies in the existing system. In particular, patients recurrently transfer to secondary hospitals rather than to a most-preferred option. We present data mining schemes and significance tests to discover these inefficient cascades. We analyze critical care transfer data in Medicare across nearly 5,000 hospitals in the United States over 10 years and present evidence that these transfers to secondary hospitals repeatedly cascade across multiple transfers, and that some hospitals seem to be involved in many cascades.