Providing High-Quality Care During a Pandemic: Nursing Home Administrator Perspectives.

Nursing home administrators are responsible for promoting quality improvement (QI), a challenging task during a pandemic. In the current study, a convenience sample of 28 administrators of non-profit nursing homes was recruited for interviews regarding leadership during the coronavirus disease 2019 pandemic. The purpose was to elicit administrator insights into sustainable QI initiatives and factors contributing to QI success during a pandemic. Open-ended interview items focused on QI initiatives, pandemic-related advice to new administrators, and ways external parties can contribute to QI during a pandemic. Administrators highlighted QI initiatives in social connections, infection control, and innovative activities. Advice to new administrators included team development, maintaining a positive attitude, and extensive communication. Administrators recommended that external parties respect infection control measures, seek alternatives to restrictive regulations, and commend staff. Nurses may be better able to lead or assist in implementing nursing home QI initiatives informed by findings from this study. [Journal of Gerontological Nursing, 49(8), 14-18.].

Predictors of Retention and Drug Use Among Patients With Opioid Use Disorder Transferred to a Specialty "Second Chance" Methadone Program.

Background: Many patients in methadone treatment have difficulty achieving or maintaining drug abstinence, and many clinics have policies that lead to discharging these patients. We designed a pilot "Second Chance" (SC) program for patients scheduled to be discharged from other local methadone clinics to be transferred to our clinic. Aim: Determine whether SC patients' retention and opioid use is related to physical or mental health conditions, non-opioid substance use, or treatment features. Methods: From December 2012 to December 2014, this program enrolled 70 patients who were discharged from other clinics in the area; we were their last remaining option for methadone treatment. Unlike the clinic's standard policies, the treatment focus for SC patients was retention rather than abstinence. This program focused on connection to care (eg, psychiatric services) and enabled patients to continue receiving services despite ongoing substance use. Each patient was assessed at treatment entry and followed until June 2016 to evaluate outcomes. Results: SC patients receiving disability benefits (n = 37) vs. non-disabled (n = 33) had significantly (P < .05) higher rates of current DSM-IV Axis I psychiatric diagnosis (97% vs 70%), prescriptions for opioids (84% vs 55%) and benzodiazepines (65% vs 27%), and higher methadone doses at admission (58 vs 46 mg) but did not differ significantly in rates of 6-month or 1-year retention (77% and 56%, respectively) or all-drug use (39% positive urine drug screens). Methadone doses >65 mg predicted significantly longer retention and less opioid use, but these effects were not moderated by baseline characteristics. Conclusions: Patients in methadone treatment struggling to achieve abstinence may benefit from retention-oriented harm-reduction programs. Higher methadone doses can improve retention and opioid abstinence despite psychiatric comorbidities. Further work is needed to improve program implementation and outcomes in this complex population.

Biological Control of Pest Non-Marine Molluscs: A Pacific Perspective on Risks to Non-Target Organisms.

Classic biological control of pest non-marine molluscs has a long history of disastrous outcomes, and despite claims to the contrary, few advances have been made to ensure that contemporary biocontrol efforts targeting molluscs are safe and effective. For more than half a century, malacologists have warned of the dangers in applying practices developed in the field of insect biological control, where biocontrol agents are often highly host-specific, to the use of generalist predators and parasites against non-marine mollusc pests. Unfortunately, many of the lessons that should have been learned from these failed biocontrol programs have not been rigorously applied to contemporary efforts. Here, we briefly review the failures of past non-marine mollusc biocontrol efforts in the Pacific islands and their adverse environmental impacts that continue to reverberate across ecosystems. We highlight the fact that none of these past programs has ever been demonstrated to be effective against targeted species, and at least two (the snails Euglandina spp. and the flatworm Platydemus manokwari) are implicated in the extinction of hundreds of snail species endemic to Pacific islands. We also highlight other recent efforts, including the proposed use of sarcophagid flies and nematodes in the genus Phasmarhabditis, that clearly illustrate the false claims that past bad practices are not being repeated. We are not making the claim that biocontrol programs can never be safe and effective. Instead, we hope that in highlighting the need for robust controls, clear and measurable definitions of success, and a broader understanding of ecosystem level interactions within a rigorous scientific framework are all necessary before claims of success can be made by biocontrol advocates. Without such amendments to contemporary biocontrol programs, it will be impossible to avoid repeating the failures of non-marine mollusc biocontrol programs to date.

Methadone for Opioid Use Treatment during Pregnancy: Trends in Postpartum Dose Adjustments.

Objective This study examines methadone dose adjustment postpartum. Methods A retrospective study of women with methadone for opioid use treatment (OUT) during pregnancy was performed. Patient charts were reviewed and data were extracted. Methadone doses from five temporal data points for each patient were used: starting dose, day of delivery, and 1, 2, and 6 months postpartum. Results Over 26 months, 49 pregnancies to women using methadone for OUT were evaluated and 20 (41%) were included. The mean methadone starting dose was 47 mg, compared with 86 mg at the time of delivery. The mean dose postpartum remained unchanged from delivery and 75% of pregnancies required the same dose or higher 1 month postpartum. By 2 months postpartum, only 33% were able to decrease their methadone dose. Twelve pregnancies completed follow-up until 6 months postpartum; only 17% of patients were able to decrease their dose, with an overall mean dose decrease was 12%. There was no difference between the mean dose at delivery and the 6-month postpartum dose. Conclusion Patients using methadone for OUT during pregnancy achieved minimal dose decreases postpartum. Patients should be counseled that postpartum dose tapers may be challenging and about alternatives to methadone for OUT.

An ancillary genomics system to support the return of pharmacogenomic results.

Existing approaches to managing genetic and genomic test results from external laboratories typically include filing of text reports within the electronic health record, making them unavailable in many cases for clinical decision support. Even when structured computable results are available, the lack of adopted standards requires considerations for processing the results into actionable knowledge, in addition to storage and management of the data. Here, we describe the design and implementation of an ancillary genomics system used to receive and process heterogeneous results from external laboratories, which returns a descriptive phenotype to the electronic health record in support of pharmacogenetic clinical decision support.

Delving deeper: Relating the behaviour of a metabolic system to the properties of its components using symbolic metabolic control analysis.

High-level behaviour of metabolic systems results from the properties of, and interactions between, numerous molecular components. Reaching a complete understanding of metabolic behaviour based on the system's components is therefore a difficult task. This problem can be tackled by constructing and subsequently analysing kinetic models of metabolic pathways since such models aim to capture all the relevant properties of the system components and their interactions. Symbolic control analysis is a framework for analysing pathway models in order to reach a mechanistic understanding of their behaviour. By providing algebraic expressions for the sensitivities of system properties, such as metabolic flux or steady-state concentrations, in terms of the properties of individual reactions it allows one to trace the high level behaviour back to these low level components. Here we apply this method to a model of pyruvate branch metabolism in Lactococcus lactis in order to explain a previously observed negative flux response towards an increase in substrate concentration. With this method we are able to show, first, that the sensitivity of flux towards changes in reaction rates (represented by flux control coefficients) is determined by the individual metabolic branches of the pathway, and second, how the sensitivities of individual reaction rates towards their substrates (represented by elasticity coefficients) contribute to this flux control. We also quantify the contributions of enzyme binding and mass-action to enzyme elasticity separately, which allows for an even finer-grained understanding of flux control. These analytical tools allow us to analyse the control properties of a metabolic model and to arrive at a mechanistic understanding of the quantitative contributions of each of the enzymes to this control. Our analysis provides an example of the descriptive power of the general principles of symbolic control analysis.

PySCeSToolbox: a collection of metabolic pathway analysis tools.

Summary: PySCeSToolbox is an extension to the Python Simulator for Cellular Systems (PySCeS) that includes tools for performing generalized supply-demand analysis, symbolic metabolic control analysis, and a framework for investigating the kinetic and thermodynamic aspects of enzyme-catalyzed reactions. Each tool addresses a different aspect of metabolic behaviour, control, and regulation; the tools complement each other and can be used in conjunction to better understand higher level system behaviour. Availability and implementation: PySCeSToolbox is available on Linux, Mac OS X and Windows. It is licensed under the BSD 3-clause licence. Code, setup instructions and a link to documentation can be found at https://github.com/PySCeS/PyscesToolbox. Contact: jr@sun.ac.za. Supplementary information: Supplementary data are available at Bioinformatics online.

Tracing regulatory routes in metabolism using generalised supply-demand analysis.

BACKGROUND: Generalised supply-demand analysis is a conceptual framework that views metabolism as a molecular economy. Metabolic pathways are partitioned into so-called supply and demand blocks that produce and consume a particular intermediate metabolite. By studying the response of these reaction blocks to perturbations in the concentration of the linking metabolite, different regulatory routes of interaction between the metabolite and its supply and demand blocks can be identified and their contribution quantified. These responses are mediated not only through direct substrate/product interactions, but also through allosteric effects. Here we subject previously published kinetic models of pyruvate metabolism in Lactococcus lactis and aspartate-derived amino acid synthesis in Arabidopsis thaliana to generalised supply-demand analysis. RESULTS: Multiple routes of regulation are brought about by different mechanisms in each model, leading to behavioural and regulatory patterns that are generally difficult to predict from simple inspection of the reaction networks depicting the models. In the pyruvate model the moiety-conserved cycles of ATP/ADP and NADH/NAD(+) allow otherwise independent metabolic branches to communicate. This causes the flux of one ATP-producing reaction block to increase in response to an increasing ATP/ADP ratio, while an NADH-consuming block flux decreases in response to an increasing NADH/NAD(+) ratio for certain ratio value ranges. In the aspartate model, aspartate semialdehyde can inhibit its supply block directly or by increasing the concentration of two amino acids (Lys and Thr) that occur as intermediates in demand blocks and act as allosteric inhibitors of isoenzymes in the supply block. These different routes of interaction from aspartate semialdehyde are each seen to contribute differently to the regulation of the aspartate semialdehyde supply block. CONCLUSIONS: Indirect routes of regulation between a metabolic intermediate and a reaction block that either produces or consumes this intermediate can play a much larger regulatory role than routes mediated through direct interactions. These indirect routes of regulation can also result in counter-intuitive metabolic behaviour. Performing generalised supply-demand analysis on two previously published models demonstrated the utility of this method as an entry point in the analysis of metabolic behaviour and the potential for obtaining novel results from previously analysed models by using new approaches.

Extinction in a hyperdiverse endemic Hawaiian land snail family and implications for the underestimation of invertebrate extinction.

The International Union for Conservation of Nature (IUCN) Red List includes 832 species listed as extinct since 1600, a minuscule fraction of total biodiversity. This extinction rate is of the same order of magnitude as the background rate and has been used to downplay the biodiversity crisis. Invertebrates comprise 99% of biodiversity, yet the status of a negligible number has been assessed. We assessed extinction in the Hawaiian land snail family Amastridae (325 species, IUCN lists 33 as extinct). We did not use the stringent IUCN criteria, by which most invertebrates would be considered data deficient, but a more realistic approach comparing historical collections with modern surveys and expert knowledge. Of the 325 Amastridae species, 43 were originally described as fossil or subfossil and were assumed to be extinct. Of the remaining 282, we evaluated 88 as extinct and 15 as extant and determined that 179 species had insufficient evidence of extinction (though most are probably extinct). Results of statistical assessment of extinction probabilities were consistent with our expert evaluations of levels of extinction. Modeling various extinction scenarios yielded extinction rates of 0.4-14.0% of the amastrid fauna per decade. The true rate of amastrid extinction has not been constant; generally, it has increased over time. We estimated a realistic average extinction rate as approximately 5%/decade since the first half of the nineteenth century. In general, oceanic island biotas are especially susceptible to extinction and global rate generalizations do not reflect this. Our approach could be used for other invertebrates, especially those with restricted ranges (e.g., islands), and such an approach may be the only way to evaluate invertebrates rapidly enough to keep up with ongoing extinction.

Fetal anomalies and long-term effects associated with substance abuse in pregnancy: a literature review.

OBJECTIVES: Substance abuse in pregnancy remains a major public health problem. Fetal teratogenicity results from the effect of these substances during fetal development, particularly when used in combination. This review will focus on and attempt to clarify the existing literature regarding the association of substance abuse on the development of congenital anomalies and the long-term implications in exposed offspring. METHODS: Systematic review of available English literature using the PubMed database of all peer-reviewed articles on the subject. RESULTS: A total of 128 articles were included in this review. Alcohol was the most common substance associated with fetal anomalies, particularly facial dysmorphisms and alterations in the central nervous system development. Adverse maternal environments associated with risky behaviors and lack of adequate prenatal care precludes the timely detection of fetal anomalies, confounding most studies linking causality. In addition, although methodological differences and limited availability of well-designed trials exist, substance abuse in pregnancy has been associated with adverse long-term outcomes in infant growth, behavior, cognition, language and achievement. CONCLUSION: The literature summarized in this review suggests that drug exposure during pregnancy may increase the risk of congenital anomalies and long-term adverse effects in exposed children and adolescents. These conclusions must be tempered by the many confounders associated with drug use. A multidisciplinary approach is paramount for appropriate counseling regarding the known immediate and long-term risks of substance abuse in pregnancy.

COPD and air travel: does hypoxia-altitude simulation testing predict in-flight respiratory symptoms?

The reduced pressure in an aircraft cabin may cause significant hypoxaemia and respiratory symptoms in patients with chronic obstructive pulmonary disease (COPD). The current study evaluated whether there is a relationship between hypoxaemia obtained during hypoxia-altitude simulation testing (HAST), simulating an altitude of 2438 m, and the reporting of respiratory symptoms during air travel. 82 patients with moderate to very severe COPD answered an air travel questionnaire. Arterial oxygen tensions during HAST (PaO2HAST) in subjects with and without in-flight respiratory symptoms were compared. The same questionnaire was answered within 1 year after the HAST. Mean ± sd PaO2HAST was 6.3 ± 0.6 kPa and 62 (76%) of the patients had PaO2HAST <6.6 kPa. 38 (46%) patients had experienced respiratory symptoms during air travel. There was no difference in PaO2HAST in those with and those without in-flight respiratory symptoms (6.3 ± 0.7 kPa versus 6.3 ± 0.6 kPa, respectively; p=0.926). 54 (66%) patients travelled by air after the HAST, and patients equipped with supplemental oxygen (n = 23, 43%) reported less respiratory symptoms when flying with than those without such treatment (four (17%) versus 11 (48%) patients; p=0.039). In conclusion, no difference in PaO2HAST was found between COPD patients with and without respiratory symptoms during air travel.

Marked variability in peri-partum anesthetic management of patients on buprenorphine maintenance therapy (BMT): can there be an underlying acute opioid induced hyperalgesia precipitated by neuraxial opioids in BMT patients?

OBJECTIVES: To compare adequacy of peri-partum pain management with or without neuraxial opioids in patients on buprenorphine maintenance therapy (BMT). METHODS: After institutional review board approval for the study protocol, retrospective peripartum anesthesia/analgesia data of BMT patients for five-year period were accessed and analyzed. RESULTS: Out of reviewed 51 patient charts, nineteen patients were found eligible for final comparative analysis. The daily amounts of peri-partum rescue analgesics with vs without neuraxial opioids were equianalgesic doses of parenteral hydromorphone (10.7 +/- 13.8 mg vs 2.6 +/- 0.7 mg, P = 0.45 for vaginal delivery; 16.4 +/- 21.1 mg vs 5.3 +/- 3.6 mg, P = 0.42 for elective cesarean section (CS)), oral ibuprofen (1.1 +/- 0.5g vs 0.8 +/- 0.4g, P = 0.37 for vaginal delivery; 1.1 +/- 0.2g vs 1.6 +/- 0.6g, P = 0.29 for elective CS), and acetaminophen (0.2 +/- 0.4g vs 0 +/- 0g, P = 0.56 for vaginal delivery; 0.3 +/- 0.3g vs 0.2 +/- 0.2g, P = 0.81 for elective CS). In the patients who underwent emergent CS after failed labor (all had received epidural opioids), there was clinical trend for higher daily amounts ofperi-partum rescue analgesics (parenteral hydromorphone 35.6 +/- 37.5 mg; oral ibuprofen 1.2 +/- 0.4g; oral acetaminophen 1.2 +/- 0.5g), when compared with vaginal delivery patients or elective CS patients who all had received neuraxial opioids. CONCLUSIONS: As the study was underpowered (n = 19), future adequately powered studies are required to conclude for-or-against the use ofneuraxial opioids in BMT patients; and pro-nociceptive activation by neuraxial opioids may be worth investigating to improve our understanding of peripartum pain management of BMT patients.

Air travel and chronic obstructive pulmonary disease: a new algorithm for pre-flight evaluation.

BACKGROUND: The reduced pressure in the aircraft cabin may cause significant hypoxaemia and respiratory distress in patients with chronic obstructive pulmonary disease (COPD). Simple and reliable methods for predicting the need for supplemental oxygen during air travel have been requested. OBJECTIVE: To construct a pre-flight evaluation algorithm for patients with COPD. METHODS: In this prospective, cross-sectional study of 100 patients with COPD referred to hypoxia-altitude simulation test (HAST), sea level pulse oximetry at rest (SpO(2 SL)) and exercise desaturation (SpO(2 6MWT)) were used to evaluate whether the patient is fit to fly without further assessment, needs further evaluation with HAST or should receive in-flight supplemental oxygen without further evaluation. HAST was used as the reference method. RESULTS: An algorithm was constructed using a combination of SpO(2 SL) and SpO(2 6MWT). Categories for SpO(2 SL) were >95%, 92-95% and <92%, the cut-off value for SpO(2 6MWT) was calculated as 84%. Arterial oxygen pressure (PaO(2 HAST)) <6.6 kPa was the criterion for recommending supplemental oxygen. This algorithm had a sensitivity of 100% and a specificity of 80% when tested prospectively on an independent sample of patients with COPD (n=50). Patients with SpO(2 SL) >95% combined with SpO(2 6MWT) ≥84% may travel by air without further assessment. In-flight supplemental oxygen is recommended if SpO(2 SL)=92-95% combined with SpO(2 6MWT) <84% or if SpO(2 SL) <92%. Otherwise, HAST should be performed. CONCLUSIONS: The presented algorithm is simple and appears to be a reliable tool for pre-flight evaluation of patients with COPD.

Arterial oxygen pressure following whole-body vibration at altitude.

INTRODUCTION: Most helicopter operations are carried out at altitudes below 10,000 ft. At these altitudes, the risk of the crew experiencing hypoxia is low. For that reason, supplementary oxygen is not standard equipment on board most helicopters. Due to developments in military missions, high-altitude operations have become more frequent-as have the chances of the crew experiencing hypoxia. Helicopter crews are subjected to a higher load of whole-body vibration compared to fixed-wing aircraft crews. Whole-body vibration increases muscle work, with increased oxygen consumption as a result. We hypothesized that whole-body vibration, as experienced by helicopter crews, causes additional lowering of arterial oxygen levels under hypoxic conditions. METHODS: Data were collected from 10 subjects. They were all exposed to six different pressure altitudes in a hypobaric chamber, ranging from 1000 ft to 16,000 ft (approximately 305 m to approximately 4877 m). Arterial blood samples were drawn on two occasions at each altitude: after 14 min of rest and followed by 15 min of whole-body vibration (17 Hz, at 1.1 m x s(-2) in the z-axis) at each altitude. RESULTS: There was no significant effect of whole-body vibration on arterial oxygen pressure at altitudes up to 16,000 ft (approximately 4877 m), nor was there any effect on ventilation, seen as changes in arterial pressure of CO2. DISCUSSION: We contribute the lack of effect to the low vibration intensity used in this study. Since this vibration intensity was higher than experienced by helicopter crews during flight, we conclude that whole-body vibration does not contribute to hypoxia during high-altitude operations in helicopters.

Stage III uterine carcinosarcoma: 2009 International Federation of Gynecology and Obstetrics Staging System and Prognostic Determinants.

OBJECTIVES: (1) To determine the significance of positive peritoneal cytology and pelvic versus para-aortic lymph node involvement in uterine carcinosarcoma. (2) To evaluate the impact of isolated retroperitoneal lymph node involvement (IIIC-N) versus retroperitoneal lymph node involvement plus other evidence of extrauterine disease spread (IIIC-N+) on survival in patients with stage IIIC uterine carcinosarcoma. METHODS: Data were extracted from the Surveillance, Epidemiology, and End Results database between 1988 and 2005. Statistical analysis used χ, Kaplan-Meier method, and Cox proportional hazards model. RESULTS: A total of 690 women were identified. When comparing overall survival between patients with disease spread to uterine serosa and/or adnexa and those with positive peritoneal cytology, there was no significant difference (25.4% vs 15.5%, P = 0.2). However, although the 5-year overall survival was comparable between patients with positive pelvic lymph nodes and those with positive para-aortic lymph nodes (22.1% vs 25.4%, P = 1.0), it was significantly worse in stage IIIC-N(+) compared to stage IIIC-N patients (15.0% vs 33.4%, P < 0.001). Only patient's age (P < 0.001), race (P = 0.03), stage (P < 0.03), and lymphadenectomy (P < 0.001) were independent predictors of survival after adjusting for other contributing factors. In addition, the results of unadjusted analysis concerning the survival difference between different stage groups were confirmed on multivariate analysis. CONCLUSIONS: Positive peritoneal cytology is associated with poor prognosis in uterine carcinosarcoma, comparable to current International Federation of Gynecology and Obstetrics stage IIIA classification of disease. Although there does not seem to be a significant survival difference between patients with positive pelvic versus those with para-aortic lymph nodes, the prognosis seems to be much worse in patients with stage IIIC uterine carcinosarcoma with other evidence of extrauterine disease spread, suggesting the need for more aggressive therapy.

Stage IIA1 versus stage IIA2 cervical cancer: does the new staging criteria predict survival?

OBJECTIVE: (1) To determine the correlation of 2008 International Federation of Gynecology and Obstetrics staging system with survival in patients with stage IIA cervical cancer, (2) to elucidate the treatment patterns in stage IIA1 and stage IIA2 cervical cancer, and (3) to investigate whether radical hysterectomy or radiation influenced overall survival. METHODS: Data were extracted from the Surveillance, Epidemiology and End Results database between 1988 and 2005. Statistical analysis used χ test, Kaplan-Meier method, Cox regression, and logistic regression. RESULTS: Of the 560 women, 271 (48.4%) had stage IIA1, and 289 (51.6%) had stage IIA2 cervical cancer. Stage IIA2 patients were younger than stage IIA1 patients (mean age, 49 years vs 54 years; P = 0.01). Stage IIA1, compared with stage IIA2, differed significantly regarding the administration of primary radiation (47.2% vs 64.7%, P < 0.001) and adjuvant radiation (60.5% vs 77.5%, P = 0.006). The following variables were significantly associated with the performance of radical hysterectomy: patient age, 65 years or younger, tumor size, ≤ 2 cm or lesser, high tumor grade, and nonsquamous tumor histology. The incidence of adjuvant radiation after radical hysterectomy was high (48% [tumor size, ≤ 2 cm] to 86% [tumor size, >6 cm]). The 5-year overall survival was not significantly different between stages IIA1 and IIA2 (65.8% vs 59.5%, P = 0.2). Only patient age (P = 0.01), tumor size (P = 0.02), and lymph node status (P = 0.002) were independent predictors of survival. When controlled for other contributing factors, there was no significant difference in survival between patients treated by radical hysterectomy and primary radiation. CONCLUSIONS: The 2008 International Federation of Gynecology and Obstetrics staging criteria is not an independent predictor of survival in stage IIA cervical cancer. Given the equivalent efficacy of radical hysterectomy and radiation, attention should be paid to the high risk of adjuvant radiation in these patients.

COPD and air travel: oxygen equipment and preflight titration of supplemental oxygen.

BACKGROUND: Patients with COPD may need supplemental oxygen during air travel to avoid development of severe hypoxemia. The current study evaluated whether the hypoxia-altitude simulation test (HAST), in which patients breathe 15.1% oxygen simulating aircraft conditions, can be used to establish the optimal dose of supplemental oxygen. Also, the various types of oxygen-delivery equipment allowed for air travel were compared. METHODS: In a randomized crossover trial, 16 patients with COPD were exposed to alveolar hypoxia: in a hypobaric chamber (HC) at 2,438 m (8,000 ft) and with a HAST. During both tests, supplemental oxygen was given by nasal cannula (NC) with (1) continuous flow, (2) an oxygen-conserving device, and (3) a portable oxygen concentrator (POC). RESULTS: PaO(2) kPa (mm Hg) while in the HC and during the HAST with supplemental oxygen at 2 L/min (pulse setting 2) on devices 1 to 3 was (1) 8.6 ± 1.0 (65 ± 8) vs 12.5 ± 2.4 (94 ± 18) (P < .001), (2) 8.6 ± 1.6 (64 ± 12) vs 9.7 ± 1.5 (73 ± 11) (P < .001), and (3) 7.7 ± 0.9 (58 ± 7) vs 8.2 ± 1.1 (62 ± 8) (P= .003), respectively. CONCLUSIONS: The HAST may be used to identify patients needing supplemental oxygen during air travel. However, oxygen titration using an NC during a HAST causes accumulation of oxygen within the facemask and underestimates the oxygen dose required. When comparing the various types of oxygen-delivery equipment in an HC at 2,438 m (8,000 ft), compressed gaseous oxygen with continuous flow or with an oxygen-conserving device resulted in the same PaO(2), whereas a POC showed significantly lower PaO(2) values. TRIAL REGISTRY: ClinicalTrials.gov; No.: Identifier: NCT01019538; URL: clinicaltrials.gov.

The impact of a multidisciplinary conference in the management of cervical cytological and histological abnormalities: a university hospital experience.

OBJECTIVE: This study evaluates the impact of a cytology-colposcopy correlation conference (CCCC) on the management of preinvasive cervical lesions in a university hospital. METHODS: This is a retrospective analysis of 130 consecutive cases from the colposcopy clinic at our University Health Center that were presented in the CCCC during a period of 1 year (November 2006 to October 2007). Variables examined to assess the usefulness of CCCC included the actual number of times there was a recorded change in the diagnosis or management recommendation secondary to presentation in the conference. The algorithms from the 2001 American Society of Colposcopy and Cervical Pathology consensus guidelines for the management of cytologic and histologic abnormalities were used to identify the patients in whom the conference recommendations were a deviation from the standard society recommendations. RESULTS: The diagnosis was changed on review of the original cytology or biopsy 24 times (13%), downgraded 13 times (7%), and upgraded 11 times (6%). The conference recommendations were a modification of the standard 2001 American Society of Colposcopy and Cervical Pathology guidelines 38 times (21%) in 34 patients. The most common triage change was the recommendation for observation of unexplained high-grade cytology with negative or lower-grade biopsy (73%), followed by observation of high-grade lesion on biopsy (27%). This recommendation, while an option in the 2006 guidelines, was not given as a choice in the 2001 guidelines. CONCLUSIONS: The CCCC at our institution provided significant input into the management of patients with preinvasive cervical lesions, anticipating some of the changes made in the 2006 guidelines.

Current concepts in the evaluation of multiple myeloma with MR imaging and FDG PET/CT.

Multiple myeloma is a heterogeneous group of plasma cell neoplasms that primarily involve bone marrow but also may occur in the soft tissue. Although the disease varies in its manifestations and its course, it is eventually fatal in all cases. Over the past 2 decades, significant advances have been made in our understanding of the genetics and pathogenesis of multiple myeloma and in its treatment. The use of magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) has improved sensitivity for the detection of this disease. PET aids in the identification of active multiple myeloma on the basis of FDG uptake, and MR imaging helps identify multiple myeloma from its infiltration of normal fat within the bone marrow, which occurs in characteristic patterns that correlate with the disease stage. The increased sensitivity of these advanced cross-sectional imaging techniques has led to further refinement of the classic Durie and Salmon staging system. In addition, these imaging techniques allow a more reliable assessment of the disease response to treatment with current regimens, which may include autologous stem cell transplantation as well as various medications. In lesions that respond to chemotherapeutic agents, the replacement of previously infiltrated marrow by fat is seen at MR imaging and decreased FDG uptake is seen at FDG PET; however, a lengthy and intensive regimen may be necessary before the MR imaging appearance of marrow normalizes. Lytic lesions seen at CT almost always persist even after successful treatment. To provide an accurate assessment, radiologists must be familiar not only with the appearances of multiple myeloma and its mimics but also with common treatment-related findings.