The vestibulocochlear bases for wartime posttraumatic stress disorder manifestations.

Preliminary findings based on earlier retrospective studies of 229 wartime head injuries managed by the Walter Reed Army Medical Center (WRAMC)/National Naval Medical Center (NNMC) Neurosurgery Service during the period 2003-08 detected a threefold rise in Posttraumatic Stress Disorder (PTSD) manifestations (10.45%) among Traumatic Brain Injuries (TBI) having concomitant vestibulocochlear injuries compared to 3% for the TBI group without vestibulo-cochlear damage (VCD), prompting the authors to undertake a more focused study of the vestibulo-auditory pathway in explaining the development of posttraumatic stress disorder manifestations among the mostly Blast-exposed head-injured. The subsequent historical review of PTSD pathophysiology studies, the evidence for an expanded vestibular system and of a dominant vestibular system, the vascular vulnerability of the vestibular nerves in stress states as well as the period of cortical imprinting has led to the formation of a coherent hypotheses utilizing the vestibulocochlear pathway in understanding the development of PTSD manifestations. Neuroimaging and neurophysiologic tests to further validate the vestibulocochlear concept on the development of PTSD manifestations are proposed.

Albright hereditary osteodystrophy and del(2) (q37.3) in four unrelated individuals.

Albright hereditary osteodystrophy (AHO) is a condition with characteristic physical findings (short stature, obesity, round face, brachydactyly) but variable biochemical changes (pseudohypoparathyroidism, pseudopseudohypoparathyroidism). Most patients with AHO have decreased activity of the guanine nucleotide-binding protein (GS protein) that stimulates adenylyl cyclase. The gene encoding the alpha subunit of the GS protein (GNAS1) has been mapped to the long arm of chromosome 20. We describe 4 unrelated individuals with apparent AHO, associated with small terminal deletions of chromosome 2. All 4 patients had normal serum calcium levels consistent with pseudopseudohypoparathyroidism. Del(2) (q37) is the first consistent karyotypic abnormality that has been documented in AHO [Phelan et al., 1993: Am J Hum Genet 53:484]. The finding of the same small terminal deletion in 4 unrelated individuals with a similar phenotype suggests that a gene locus in the 2q37 region is important in the pathogenesis of Albright syndrome. The association of Albright syndrome and the GNAS1 locus on chromosome 20 is well documented. The observation of a second potential disease locus on chromosome 2 may help explain the heterogeneity observed in this disorder.

Patterns and predictors of institutionalization in community-based dementia patients.

OBJECTIVE: To investigate patterns and predictors of institutionalization in a community-based sample of dementia patients. SETTING: The Mayo Clinic Alzheimer's Disease Patient Registry (ADPR), a community-based prospective registry. PATIENTS: Two hundred seventy-five participants, including 145 dementia patients and 130 controls on whom longitudinal follow-up data was available. The mean ages were 79.9 and 78.8 years, and the mean Mini-Mental State Examination (MMSE) scores at enrollment were 22.1 and 28.1 points for the demented cases and controls, respectively. MEASURES: Place of residence, marital status, number of direct support providers, global cognitive status, activities of daily living and instrumental activities of daily living were used in hazards modeling of institutionalization. RESULTS: The results from our community-based sample suggest a high rate of institutionalization for dementia patients. One-half of the sample of dementia patients were institutionalized within 2.5 years of enrollment in our patient registry. Identified assistance providers were absent in a significant proportion (36%) of our dementia sample. Marital status, global cognitive function, and functional status were significant terms in hazards models of institutionalization. Age, gender, number of direct caregivers, and dementia etiology were not associated with significant risk. Seventy-two percent of the dementia patients who died over the course of this study had been placed in nursing home care prior to death (with a mean length of stay of 2.8 years). CONCLUSIONS: Social (marital status) and disease-related variables (cognitive and functional status) are related to risk for institutionalization. These variables may be useful in estimating time to institutionalization in various clinical and research populations.

Deep venous thrombosis associated with large leiomyomata uteri. A case report.

BACKGROUND: The association of deep venous thrombosis (DVT) with uterine leiomyomata has been reported only rarely in the English-language literature. These concomitant findings occurred in a woman with no other known risk factors for development of DVT. CASE: A 49-year-old, Caucasian woman, gravida 3, para 3, with a past medical history significant for large uterine leiomyomata, menorrhagia and anemia, presented with acute edema of the left lower extremity. Doppler studies revealed compression of the left iliofemoral vein with associated thrombosis. No risk factors for DVT were identified. Intravenous heparin was initiated, with eventual preoperative placement of an inferior vena cava Greenfield filter. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed without complications. CONCLUSION: Large uterine leiomyomata are a potential cause of lower extremity venous stasis and resulting thrombosis and can be treated with hysterectomy.

A discharge planning program in orthopaedics: experiences in implementation and evaluation.

The acute care orthopaedic registered nurse plays a key role in assessing and communicating the continuing care needs of patient's and their families, coordinating community resources, and formulating a timely discharge plan to maximize rehabilitation and recovery. Developing and maintaining a staff nurse's discharge planning knowledge and skills can be a challenging endeavor. Discharge Planning Coordinators at a tertiary medical center developed and implemented a Discharge Planning Mentorship Program, an educational pilot program designed to enhance the knowledge and skill level of select nurses in the orthopaedic specialty practice, thus maximizing expert resources at the bedside. Program implementation and evaluation of role preparation, practice changes, and actualization challenges are discussed in this article. Overall, participants demonstrated increased skill in articulating and problem solving a patient's postdischarge needs, devised creative strategies to enhance communication between multiple levels of care, and developed a greater knowledge of community resources and reimbursement mechanisms for continuing care.

The impact of a state hospital closure on local jails: the Kansas experience.

In 1990, Kansas's Mental Health Reform legislation began transferring fiscal support for the delivery of mental health services away from state institutions and into the local community, culminating in the closure of one state hospital facility in 1997. Kansas jails were studied to determine the resulting impact of that hospital closure on the State's jail systems, including whether an increase in incarceration rates of persons with severe and persistent mental illnesses followed the closure of the hospital. Though a relationship between the hospital closure and incarceration rates cannot be substantiated, the results do provide a rare birds-eye view of the extent of and problems associated with the incarceration of persons with mental illness in a predominantly rural state.

Development of a discharge planning mentorship program.

Discharge planning coordinators at a tertiary medical center developed a Discharge Planning Mentorship Program. The group established the educational program to support the autonomy of the staff primary nurse in the discharge planning component of professional practice. To establish the program, the discharge planning coordinators used the underlying principle of "CollaMentoach." The term is an acronym combining the three core concepts of collaboration, mentoring, and coaching. Program planning and marketing, participant selection, curriculum development, and curriculum evaluation are included to guide staff development specialists and nurse managers in the formulation of a program to enhance staff nurse discharge planning skills.

Transcultural Patient Care Committee: actualizing concepts and developing skills.

This article describes activities of a Transcultural Patient Care Committee whose aim is to develop the knowledge and skills of medical center staff to provide culturally congruent care. The activities include staff development offerings, a transcultural patient care resource manual, and communication and assessment tools. These efforts have provided a foundation to assist staff with meeting the challenge of caring for multicultural patients.

Continuity of care: a nursing needs assessment instrument.

Based on testing of the Uniform Needs Assessment Instrument (UNAI), a nursing needs assessment tool for adult hospitalized patients was integrated into nursing practice. Some content and format changes to the UNAI occurred as a result of the research process. The revised assessment form is called the Nursing Needs Assessment Instrument (NNAI). Community providers, including nursing home and home health care personnel, use the NNAI to derive necessary admission data for assessing patients, planning care, and communicating with other staff regarding patient needs. Instituting an evidence-based practice change in hospital discharge forms enables the next care provider to consistently meet the patient's continuing needs.

Quality assurance for abdominal CT: a rapid, computer-assisted technique.

OBJECTIVE: Maintaining high standards in a large CT imaging department with multiple scanners, a large technical and clerical staff, and a rotating staff of radiologists is an ongoing challenge. We undertook a project to design and implement a simple, rapidly performed computer-assisted system of quality assurance (QA) for use in abdominal CT. In our project, we also analyzed the results of that QA system. MATERIALS AND METHODS: We graded 1810 abdominal CT studies done in a 50-week period, using a three-point scale to indicate the quality of the following five parameters of technical quality: IV contrast enhancement, oral contrast opacification, window settings and artifacts, conformity to radiologists' protocol, and completeness and accuracy of header and scout data. In addition, a parameter reflecting performance of the film library and clerical staff was similarly graded. To provide a measure of peer review for radiologists, any disagreements with prior CT study reports were recorded when comparison studies were reviewed in the process of CT interpretation. A commercially available spreadsheet and database software program was tailored to allow rapid, easily performed data entry and analysis. Tables and graphs showing performance of technologists and film library and clerical staff were generated. This customized program was made available on the radiology department computer network. Results generated by the program were further analyzed with linear regression models. RESULTS: Our QA system was successfully integrated into the routine operation of the abdominal CT division. During the first 11.5 months of operation, the system reflected improvement in each of the technical parameters with a statistically significant improvement in the combined average technical score (from 1.15 to 1.68 on a scale of 0-2; p < .0001). The "Throughout Speed/Old Exams" parameter for performance of the film library and clerical staff, which was analyzed separately from the technical parameters, also improved significantly (from 1.3 to 1.8; p < .02). Improvements were statistically significant, even when we controlled for potential variations in quality among different CT scanners and variations among the radiologists who rated the quality of the examination. Thirty-eight disagreements with previous scan interpretations (5% of all scan comparisons) were recorded for evaluation at peer review conferences. CONCLUSION: The ability to monitor performance continuously using a rapid, computer-assisted system has effected measurable improvement in our CT service. Technologist and film library and clerical staff performance improved for all parameters studied. Deficiencies were revealed and trends demonstrated. The QA system allowed us to identify disagreements in interpretation of CT examinations for subsequent peer review by radiologists. Our QA software program has been made available on the Internet as freeware to licensed Excel users via anonymous file transfer protocol at Internet Protocol 134.192.6.110.

Large-core biopsy guns: comparison for yield of breast tissue.

PURPOSE: To compare seven large-core, long-throw, 14-gauge biopsy guns for yield and quality of breast tissue obtained. MATERIALS AND METHODS: A two-phase, randomized and blinded study was performed. In the first phase, four fully automated 14-gauge biopsy guns (BIP, Manan, Biopsy, and ASAP) and one semiautomated device (Temno) were used to obtain breast cores from a cadaver. Samples were assessed for volume, number of fragments, and crush artifact. In the second phase, seven biopsy guns (previously mentioned guns plus Monopty and Ultra-Cut guns) were used to obtain cores from a breast parenchyma model. These cores were then evaluated for weight, volume, and number of fragments. RESULTS: The mean specimen volume of cadaveric breast tissue obtained was 17.9 mm3 for the BIP gun, 17.8 for the Manan gun, 14.9 for the Biopsy gun, 14.1 for the ASAP gun, and 9.9 for the Temno gun. The Temno gun obtained statistically significantly smaller volumes than all other guns. For the breast parenchyma model, mean obtained volumes were 24.5, 24.1, 16.2, 21.7, 17.5, 20.0, and 15.2 mm3, respectively. The BIP and Manan guns yielded statistically significantly larger cores than all other guns except the ASAP. CONCLUSION: Yields of breast tissue provided by each biopsy device differed statistically significantly. BIP and Manan biopsy guns yielded the greatest volume of core tissue, which may facilitate histopathologic diagnosis from breast biopsies performed with imaging guidance.