Financial Value Analysis of Surgical Residency Programs: An Argument Against Replacement.

OBJECTIVE: To quantify the replacement cost of patient care provided by surgical residents and build a Graduate Medical Education (GME) value analysis model. DESIGN: Our Graduate Medical Education Executive Steering Committee designed a resident replacement cost model, based on patient care hours (adjusted for educational activities and a clinical efficiency factor, differential cost of faculty supervision for residents vs. APPs, and current program financials (revenue minus expenses). Strategic value planning included: academic productivity (local and national conference presentations, book chapters and publications and Senior Staff recruitment and retention. SETTING: Department of Surgery at Baylor Scott & White Medical Center, a tertiary institution located in Temple, TX. PARTICIPANTS: Our replacement model was applied to a sample 30-position residency program. RESULTS: Modeling a 30-position residency program, replacement cost approaches 4.5 million dollars, based on a 1:3 Senior Staff-to-APP replacement ratio. A complete APP replacement complement has a projected cost of 3.1 million dollars, while replacement with Senior Staff approaches 9 million dollars. CONCLUSIONS: We present a novel model for residency value analysis allowing for reproducible and standardized results across multiple residency programs. Challenges inherent to GME, such as clinical efficiency and the cost of faculty supervision, are accounted for. Quantifying resident replacement cost and financial value is a powerful tool when discussing institutional workforce planning within the current financial climate of healthcare.

A stability indicating assay for a combination of morphine sulphate with levomepromazine hydrochloride used in palliative care.

WHAT IS KNOWN AND OBJECTIVE: Morphine is used routinely in clinical practice to manage moderate to severe pain, whereas levomepromazine is commonly used at low doses to manage intractable nausea and vomiting. While it has been reported that an injection combination of morphine sulphate (0·5 mg/mL) and levomepromazine (0·1 mg/mL) was physically compatible, data on the chemical stability of combinations of these drugs has not been reported. Thus, a method was required for the assessment of the stability of morphine sulphate/levomepromazine hydrochloride combinations. METHODS: A high-performance liquid chromatography (HPLC) method was developed to assess the stability of the combinations. The injections were stored at 4 °C in the dark at room temperature under natural light and at 37 °C under artificial lighting. RESULTS AND DISCUSSION: Morphine sulphate was stable under all storage conditions, but the degree of degradation of levomepromazine hydrochloride increased as the storage temperature increased. The disappearance of levomepromazine hydrochloride was correlated with the appearance of a sulphoxide degradant. WHAT IS NEW CONCLUSION: The injection combinations of morphine sulphate and levomepromazine hydrochloride were shown in the current study to have a limited storage life with respect to their levomepromazine hydrochloride content.

Advanced implant overdenture superstructure treatment planning with computer-assisted design systems.

The amount of available space between the residual ridge crest and the prosthetic teeth provide a challenge not only for the clinician but also for the dental technologist. This technical report demonstrates the applied use of a touch probe scanner (Pix30 3D Scanner, Dr. Picza, Roland DG Corporation; Irvine, CA, USA) used in conjunction with computer-assisted design (CAD) programs to reduce clinical chair time as well as reduce the cost of intraoral and laboratory components. Tooth arrangement and superstructure are scanned and positioned in various CAD programs to measure the available space for the superstructure. While there are limitations in the accuracy of the scanning process, these limitations have little effect on the treatment planning for complete overdentures as well as fixed prostheses. Once the scanning is complete, CAD programs can be used to improve planning, resulting in less wasted material, fewer errors in diagnosis, and reduction both in overall clinical and laboratory costs and clinical chair time.

Reduced-intensity conditioning using fludarabine with either antithymocyte globulin and BU, or low-dose TBI allowing allogeneic hematopoietic SCT.

In a single-center study, we analyzed the outcomes of 66 patients with advanced hematological malignancies receiving two reduced-intensity conditioning regimens for allogeneic transplantation: fludarabine and low-dose TBI (flu/TBI, n=25), or fludarabine, antithymocyte globulin and BU (flu/ATG/BU, n=41). The selection criteria were based on the hypothesis that flu/TBI patients were expected to achieve autologous recovery in the event of non-engraftment. Sixty-three patients (95%) engrafted. Regimen-related mortality at day 100 and 1 year was 6 and 15%, respectively. With median follow-up of 50.4 months, survival did not differ by regimen. Multivariate analysis confirmed that the type of regimen did not affect relapse. In patients achieving full donor chimerism by day 30, those conditioned with flu/TBI showed greater overall survival (P=0.02). Engraftment failure occurred in two patients (3%), both of whom received flu/TBI. We conclude that conditioning with flu/TBI or flu/ATG/BU yields comparable survival and remission outcomes. By contrast to our hypothesis, patients receiving flu/TBI who subsequently failed engraftment did not achieve autologous recovery. Yet, rapid attainment of full donor chimerism after flu/TBI is associated with greater survival than after flu/ATG/BU. Further, larger prospective randomized studies are required to define the advantage of one regimen over the other.

Evaluation of the stability of morphine sulphate in combination with Instillagel.

BACKGROUND AND OBJECTIVE: The Pharmacy Department at the Western General Hospital in Edinburgh prepares a topically applied product in which morphine sulphate is incorporated into Instillagel for use in reducing pain associated with rectal and other cancers. A stability indicating method was required for assessment of the stability of this combination. METHODS: A gradient high performance liquid chromatography method was developed to assess stability and an LC-MS method was used to characterize the degradants from forced degradation of the components in the formulation. RESULTS AND DISCUSSION: The method was found to have acceptable inter- and intra-day precisions. Under all storage conditions investigated morphine sulphate remained within 98.1% and 103.2% of the initial concentration, lidocaine hydrochloride within 96.07% and 104.9% and chlorhexidine gluconate within 97.3% and 105.5%, except for samples stored at 37 degrees C beyond 240 h. A sample of the admixture was stored up to 7 months at 37 degrees C and was found to be reasonably stable with only the chlorhexidine concentration declining appreciably to 92% of the initial concentration. Some of the degradants of chlorhexidine and morphine were characterized by liquid chromatography mass spectrometry. It could be concluded that the admixture was stable for over 22 days at 4 degrees C protected from light, over 22 days at 25 degrees C exposed to normal light, and for 7 months at 37 degrees C protected from light. CONCLUSION: The components in the combination were found to have good long-term stability.

71-year-old male with progressive dyspnoea and peripheral oedema: a case of cardiac amyloidosis.

We present the case of a 71-year-old male with progressive dyspnoea. On physical examination there was evidence of congestive heart failure. The complete blood count was normal and twelve-lead ECG showed low voltage in the standard leads. Chest x-ray showed cardiomegaly, pulmonary congestion and left pleural effusion. Two-dimensional echocardiography and Doppler ultrasound studies revealed biatrial enlargement and a restrictive diastolic filling pattern. Serum protein electrophoresis was abnormal showing a monoclonal elevation of IgG. Amyloid heart disease was suspected. Fat pad biopsy showed findings consistent with amyloid heart disease. Melphalan and prednisone were initiated to help slow the progression of disease.

Isolation and chondrocytic differentiation of equine bone marrow-derived mesenchymal stem cells.

OBJECTIVE: To isolate mesenchymal stem cells from adult horses and determine specific monolayer culture conditions required to enhance biochemically and phenotypically defined chondrocytic differentiation. ANIMALS: 2 adult horse bone marrow donors without skeletal or hematologic abnormalities. PROCEDURE: Bone marrow was aspirated from the sternebra, and mesenchymal stem cells were isolated by centrifugation and cultured in monolayers. Subcultures were established in 24-well plates on day 13. Culture medium was harvested every 2 days, and culture of 12 of the 24 wells was terminated on day 6 and of the remaining wells on day 12. Medium proteoglycan content was determined for all samples, and proteoglycan monomeric size was determined for pooled samples from days 2-6 and 8-12. Total nucleated cell numbers were determined at culture termination on days 6 and 12. Histologic, histochemical, and collagen immunohistochemical analyses of multiwell chamber slides harvested on day 6 or 12 were performed. RESULTS: Mesenchymal cells were an abundant cellular constituent of bone marrow aspirates, and separation of hematopoietic elements was achieved by centrifugation and delayed medium exchange. The remaining mesenchymal stem cells progressed from large, spindyloid, fibroblastic-appearing cells to a rounder shaped cell which formed colony plaques; isolated cells remained more spindyloid. Mesenchymal cell transformation toward a chondrocytic phenotype was verified by a shift in expression from collagen type I to type II, and an increase in quantity and molecular size of proteoglycans synthesized over time. CONCLUSIONS: Mesenchymal stem cells obtained from adult horses have the capacity to undergo chondrogenic differentiation in monolayer cultures and may provide a locally recruitable or transplantable autogenous cell source for articular cartilage repair.

Concurrent abomasal displacement and perforating ulceration in cattle: 21 cases (1985-1996).

OBJECTIVE: To evaluate the association of physical examination and clinicopathologic findings with surgical findings in cattle with concurrent abomasal displacement and perforating ulceration, to determine short- and long-term survival rates in these cattle, and to determine whether degree of peritonitis (focal vs diffuse) influences survival rates. DESIGN: Retrospective study. ANIMALS: 21 cattle with concurrent abomasal displacement and perforating ulceration and 42 cattle with uncomplicated abomasal displacement. PROCEDURE: Information on signalment, stage of lactation, physical examination findings, clinicopathologic data, surgical diagnosis, procedure(s) performed, and necropsy findings were retrieved from medical records of all cattle included in this study. Differences between physical examination findings of cattle with concurrent disease and those of cattle with uncomplicated displacements were evaluated, as were differences between survival rates in cattle with focal versus diffuse peritonitis. RESULTS: Cattle with concurrent disease had a greater probability of having pneumoperitoneum and signs of abdominal pain identified on physical examination than did cattle with uncomplicated diseases. There was no relationship between clinicopathologic data and survival time. Short-term survival rate was 38%, and degree of peritonitis significantly influenced survival time in cattle with concurrent abomasal displacement and perforating ulceration. Long-term survival rate in these cattle was 14%. CLINICAL IMPLICATIONS: Cattle with concurrent displaced abomasum and perforating ulceration have a poor chance for survival. In addition to detection of displaced abomasum, physical examination findings that can help lead to a presurgical diagnosis of this syndrome are pneumoperitoneum and signs of abdominal pain.

Cholelithiasis and cholecystitis in a dairy cow.

A 9-year-old Holstein cow was evaluated for colic and decreased milk production of 2 days' duration. Preoperative serum biochemical results suggested hepatic damage and cholestasis. On the basis of persistent signs of abdominal pain that were nonresponsive to analgesics, exploratory laparotomy was performed. The cow was found to have choleliths. Cholecystocentesis was performed, and samples were submitted for cytologic examination and bacterial culture. Bacterial culture yielded Escherichia coli and Clostridium perfringens. Using digital pressure, choleliths were reduced until they could be passed through the bile duct into the duodenum. The cow recovered from surgery without complications, and all serum biochemical test results returned to reference ranges. Cholelithiasis is rare in cattle but can result in signs of abdominal pain.

Abdominal surgery in foals: a review of 119 cases (1977-1994).

The case records of 119 young horses (all less than age one year) that underwent an exploratory celiotomy during a 17 year period were examined to determine the surgical findings, short- and long-term outcome, and prevalence of small intestinal disease compared to previous reports in the mature horse. Physical and laboratory values were compared for long-term survivors vs. nonsurvivors and the frequency of post operative intra-abdominal adhesions was determined. The most common cause for exploratory celiotomy was small intestinal strangulation, followed by enteritis and uroperitoneum. Six horses died during surgery, 23 were subjected to euthanasia at the time of surgery due to a grave prognosis, and 17 horses died or were destroyed after surgery, prior to discharge from the hospital; the short-term survival was 61%. Nine horses were lost to follow-up. Forty-one horses survived long-term (at least 6 months after surgery), 15 died or were subjected to euthanasia after discharge for reasons related to the prior abdominal surgery, and 8 died or were destroyed after discharge due to unrelated reasons, making the long-term survival 45%. Fifty-three (45%) of the horses presented as neonates, and 66 (55%) presented age 3-12 months. Uroperitoneum and meconium impaction were the most common disease in the neonate. Intussusception and enteritis were the most common diseases in older foals. The overall prevalence of small intestinal disease was 44%. Significant elevations in packed cell volume, heart rate, nucleated cell counts and total protein in abdominal fluid and rectal temperature were observed in nonsurvivors compared to survivors. Nonsurvivors had significantly decreased serum bicarbonate, chloride, sodium, and venous pH values. There was no evidence that location of the lesion affected long-term survival. Horses with a simple obstruction had a higher survival percentage than those with a strangulating obstruction, and horses that underwent an intestinal resection had a lower long-term survival than those horses undergoing only intestinal manipulation. Nineteen (33%) of the foals examined after the original surgery had evidence of intra-abdominal adhesions. Nine of these (16%) had adhesions that caused a clinical problem.

Natural concepts in pigeons.

Pigeons learned to discriminate pictures of trees, bodies of water, or a particular person in three separate experiments. Pictures being seen for the first time were discriminated almost as well as pictures seen in training. The pigeons in each experiment showed similar patterns of errors and correct discrimination.