The nurse outcomes and patient outcomes following the High-Quality Care Project.

BACKGROUND: There have been many single cross-sectional studies on nurse or patient outcomes. However, long-term evidence on improving nurse and patient outcomes is still limited. The High-Quality Care Project is a national project in China for improving nurse and patient outcomes by implementing primary nursing. AIM: (1) To assess the long-term changes in nurse and patient outcomes in the context of the High-Quality Care Project. (2) To explore the potential influences of primary nursing on nurse and patient outcomes based on this study and broader existing evidence. METHODS: The data of two cross-sectional studies were used for analysis. The two cross-sectional studies were conducted before (2009) and after (2016) the High-Quality Care Project. A total of 1376 nurses and 904 patients from 40 units of 10 tertiary hospitals were surveyed. Reliable and validated instruments were used to measure nurse and patient outcomes. Multilevel modelling was the main method for data analysis. RESULTS: Nurses in 2016 were more satisfied than nurses in 2009 with most dimensions of nurse work environment and job satisfaction. However, they were not more satisfied with burnout, global job satisfaction or intention to leave their job. Nurses in 2016 also reported better quality of patient care and patient safety while their patients reported higher patient satisfaction. CONCLUSION: The analysis of our results based on existing evidence indicates that primary nursing could be considered as a potentially effective way to improve nurse work environment and patient outcomes. More studies with rigorous study design from micro perspectives would be useful to further explore the direct effects of primary nursing on nurse or/and patient outcomes. IMPLICATIONS FOR NURSING AND NURSING POLICY: Policymakers, healthcare service leaders and nurse managers should make efforts to provide multi-level supports to cultivate an encouraging environment for nurses to practice primary nursing, because the implementation of primary nursing may improve the nurse work environment and patient outcomes. Furthermore, improving nurse participation in hospital affairs and developing nursing discipline and education for increasing nursing staff resource and nurses' capacity - which all need policy and management supports - are crucial to further improve nurse and patient outcomes.

A Comparison of the Diabetes Risk Score in HIV/AIDS Patients on Highly Active Antiretroviral Therapy (HAART) and HAART-Naïve Patients at the Limbe Regional Hospital, Cameroon.

BACKGROUND: Highly active antiretroviral therapy (HAART) has been associated with dysglycaemia. However, there is scarce data on the risk of developing diabetes mellitus (DM) in HIV/AIDS patients in Africa. OBJECTIVES: Primarily to quantify and compare the risk of having diabetes mellitus in HIV/AIDS patients on HAART and HAART-naïve patients in Limbe, Cameroon; and secondarily to determine if there is an association between HAART and increased DM risk. METHODS: A cross-sectional study was conducted at the Limbe Regional Hospital HIV treatment center between April and June 2013, involving 200 HIV/AIDS patients (100 on first-line HAART regimens for at least 12 months matched by age and gender to 100 HAART-naïve patients). The Diabetes Risk Score (DRS) was calculated using a clinically validated model based on routinely recorded primary care parameters. A DRS ≥ 7% was considered as indicative of an increased risk of developing DM. RESULTS: The median DRS was significantly higher in patients on HAART (2.30%) than in HAART-naïve patients (1.62%), p = 0.002. The prevalence of the increased DM risk (DRS ≥ 7%) was significantly higher in patients on HAART, 31% (95% CI: 22.13-41.03) than in HAART-naïve patients, 17% (95% CI: 10.23-25.82), p = 0.020. HAART was significantly associated with an increased DM risk, the odds ratio of the HAART group compared to the HAART-naïve group was 2.19 (95% CI: 1.12-4.30, p = 0.020). However, no association was found after adjusting for BMI-defined overweight, hypertension, age, sex, family history of DM and smoking (Odds ratio = 1.22, 95% CI: 0.42-3.59, p = 0.708). Higher BMI and hypertension accounted for the increased risk of DM in patients on HAART. Also, more than 82% of the participants were receiving or had ever used Zidovudine based HAART regimens. CONCLUSION: HIV/AIDS patients on HAART could be at a greater risk of having DM than HAART-naïve patients as a result of the effect of HAART on risk factors of DM such as BMI and blood pressure.

Prevalence of Hypertension in HIV/AIDS Patients on Highly Active Antiretroviral Therapy (HAART) Compared with HAART-Naïve Patients at the Limbe Regional Hospital, Cameroon.

BACKGROUND: Highly active antiretroviral therapy (HAART) has greatly reduced the morbidity and mortality of HIV/AIDS patients but has also been associated with increased metabolic complications and cardiovascular diseases. Data on the association between HAART and hypertension (HTN) in Africa are scarce. OBJECTIVES: Primarily to compare the prevalence of HTN in HIV/AIDS patients on HAART and HAART-naïve patients in Limbe, Cameroon; and secondarily to assess other socio-demographic and clinical factors associated with HTN in this population. METHODS: A cross-sectional study was conducted at the Limbe Regional Hospital HIV treatment center between April and June 2013, involving 200 HIV/AIDS patients (100 on first-line HAART regimens for at least 12 months matched by age and sex to 100 HAART-naïve patients). HTN was defined as a systolic blood pressure (BP) ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg. RESULTS: The prevalence of HTN in patients on HAART was twice (38%; 95% CI: 28.5-48.3) that of the HAART-naïve patients (19%; 95% CI, 11.8-28.1), p = 0.003. In multivariate analyses adjusted for age, gender, smoking, family history of HTN, and BMI-defined overweight, HAART was associated with HTN, the adjusted odds ratio of the HAART-treated versus HAART-naïve group was 2.20 (95% CI: 1.07-4.52), p = 0.032. HTN was associated with older age and male gender, in the HAART group and with BMI-defined overweight in the HAART-naïve group. CONCLUSION: The prevalence of hypertension in HIV/AIDS patients in Limbe stands out to be elevated, higher in patients on HAART compared to those not on treatment. Blood pressure and cardiovascular risk factors should be routinely monitored. Other factors such as diet, weight control and physical exercise should also be considered.

Liver and vascularized posterior rectus sheath fascia composite tissue allotransplantation.

Abdominal wall closure in pediatric solid organ recipients may be confounded by donor size discrepancy and structural insults from previous surgery. Here we describe the novel use of vascularized donor abdominal wall posterior rectus sheath fascia, as a composite tissue allotransplant (CTA), to achieve abdominal wall closure in a liver and double kidney pediatric recipient who could not be closed primarily due to donor/recipient size mismatch. The posterior rectus sheath fascia was procured in continuity with the liver and falciform ligament. Blood supply was achieved using the single hepatic artery anastomosis as part of the standard liver transplantation procedure. Specimens of posterior rectus sheath fascia taken on postoperative days 3 and 30 showed no signs of acute rejection. The patient succumbed to an overwhelming fungal infection on day 51, with no signs of intraabdominal involvement. The patient received no additional immunosuppression in conjunction with the posterior rectus sheath fascia allotransplant.

Species divergence and relationships in Stephanomeria (Compositae): PgiC phylogeny compared to prior biosystematic studies.

We present a maximum likelihood tree of 41 PgiC sequences for the monophyletic Stephanomeria, with 10 perennial and six annual species, widely distributed in western North America and exemplary of different speciation processes. The phylogenetic analysis represents the first use of PgiC sequences for Compositae. The annual species were originally delimited by biosystematic studies that provided evidence of their reproductive compatibility and chromosome structural homology. The perennial species are highly distinctive in morphology and have not been examined similarly. The PgiC tree provides more resolution than our previous ITS/ETS tree and reflects both past and ongoing hybridization and/or incomplete lineage sorting. Two major PgiC clades were resolved in Stephanomeria. One clade contains the genes from the annual species plus the perennial, insular endemic S. guadalupensis, which appears closely related to a monophyletic S. virgata. Stephanomeria exigua is not monophyletic. The second clade includes the genes from all other sampled perennial species and a monophyletic subclade of four genes from two annual species. The results are compared to previous studies, also using PgiC, of Clarkia (Onagraceae). Both molecular systematic and biosystematic approaches are essential to discern the very different courses of evolution in these two, well-studied genera of western North America.

Two separable conformers of TATP and analogues exist at room temperature.

[reaction: see text] TATP gives rise to two separable conformations because the barrier for interconversion between them is relatively high at room temperature. This kind of behavior is rare in cyclic organic systems and is the result of poor overlap in the "flip-flop" transition state. The crystal structure of the analogous tricyclohexanone triperoxide also indicates the presence of two conformers.

Reassessment of phylogenetic relationships in Clarkia sect. Sympherica.

Clarkia (Onagraceae) is a genus of 42 annual species, mostly native to California, that has served as a model for many studies of plant evolutionary biology, particularly morphological, cytological, and genetic divergence; reproductive isolation; and speciation. Section Sympherica is the largest section with eight diploid and one allotetraploid species. Species in the section have provided important evidence about the evolution of reproductive isolation (C. lingulata derived from C. biloba) and large morphological change (C. dudleyana thought to be sister to the morphologically distinct C. heterandra, recently transferred into Clarkia from the monotypic Heterogaura). Clarkia epilobioides, another diploid species in the section, was previously shown to be one parent of the allotetraploid C. delicata, the other parent being C. unguiculata from sect. Phaeostoma. Lewis and Lewis (1955) interpreted the parentage of C. delicata and other evidence of intersectional hybridization to mean that the diploid sections of the genus, though highly diverse, were closely related and should be maintained in the single genus Clarkia. Here we assess phylogenetic relationships among the species of sect. Sympherica and related species by analyzing the nucleotide sequences of PgiC1 and PgiC2, a pair of paralogous genes that encode the cytosolic isozyme of phosphoglucose isomerase (EC 5.3.1.9). The major results were the following: (1) C. unguiculata and both genomes of C. delicata are within a well-defined "Sympherica" clade; thus, C. delicata should not be considered an intersectional hybrid; (2) C. heterandra belongs in the clade and is closely related to C. unguiculata; and (3) on the evidence of PgiC1, C. dudleyana is not in the clade and is not closely related to C. heterandra.

The 5' leader of plant PgiC has an intron: the leader shows both the loss and maintenance of constraints compared with introns and exons in the coding region.

PgiC, a complex gene with 23 coding exons and 22 intervening introns, encodes the cytosolic isozyme of phosphoglucose isomerase (EC 5.3.1.9) in higher plants. Here, we report RNA ligase-mediated rapid amplification of cDNA ends experiments that showed that PgiC in Clarkia (Onagraceae) and Arabidopsis thaliana has an intron in the 5' leader. Comparison of the EMBL accessions of the cDNA and genomic sequences showed that this is also the case in rice (Oryza sativa), suggesting that a leader intron is generally present in higher plant PgiC. The intron is bounded by consensus 5'-GT and AG-3' splice sites but showed alternative splicing in Clarkia, resulting in mature transcripts that differ by 8-19 nt in length. The intron is located 18 or 10 nt upstream of the start codon in Clarkia, 2 nt upstream in Arabidopsis, and 9 nt in rice. PgiC in Clarkia was duplicated before the divergence of the extant species, many of which have two expressed genes PgiC1 and PgiC2. Full-length transcripts of both genes identified the transcription start and made it possible to identify the leader intron and leader exon (between the transcription start and leader intron) from previously obtained genomic sequences of both genes in other Clarkia species. These data permit the comparison of evolution in the leader exon and intron with the exons and introns of the coding region, a topic that has not been studied previously. Both the leader exon and the leader intron resemble introns of the coding region in base substitution rate and accumulation of gaps. But the leader intron splice junctions are not strictly conserved in position as are those of the coding region introns. Also, in base composition, the leader intron resembles the other introns, whereas the leader exon more nearly resembles the coding exons. A difference in base composition between coding exons and flanking introns is known to be important for the recognition of splice sites. Thus, the marked difference in base composition between the leader exon and leader intron is probably maintained by selection despite a high rate of sequence divergence.

Single mutations silence PGiC2 genes in two very recent allotetraploid species of Clarkia.

Our understanding of how polyploidy influences gene evolution is limited by the fact there have been few molecular descriptions of particular genes and their expression in polyploid plants and their diploid progenitors. Here we use evidence from sequencing of genomic DNA and cDNA obtained by reverse transcriptase-polymerase chain reaction and 3' rapid amplification of cDNA ends to describe PgiC genes and their expression in two allotetraploid species of the wildflower genus Clarkia, C. delicata and C. similis. PgiC encodes the cytosolic isozyme of phosphoglucose isomerase (EC 5.3.1.9) and was duplicated in the ancestral stock of Clarkia, giving rise to paralogous genes PgiC1 and PgiC2. The active form of the PGIC enzyme is a dimer of like subunits. The electrophoretic patterns in the parent species show three bands of activity, representing two homodimers and a heterodimer of intermediate mobility, and are encoded by two genes. The electrophoretic patterns in the tetraploids also show three bands, but the tetraploids were expected to have multiple PGIC isozymes encoded by four genes. Our molecular studies demonstrated that each tetraploid has two PgiC1 and two PgiC2 genes, as predicted. One gene in each of them has been silenced by a single mutation, and a functional protein is no longer produced. In C. similis, PgiC2(mod) was silenced by a mutation of a single nucleotide in exon 5 that created a stop codon. In C. delicata, a polymorphism exists between a normal allele and a defective allele of PgiC2(epi) that has a deletion of a splice junction in intron 19 that results in the synthesis of a transcript lacking an entire exon, an example of exon skipping. The three-banded PGIC electrophoretic pattern of both tetraploid species arises because isozymes encoded by two or three of the genes comigrate. A very recent origin for both tetraploids is suggested by the near identity of several of their PgiC genes to their corresponding diploid orthologues and the absence of any acceleration in mutation rates. The problem of assessing genetic redundancy in tetraploids is discussed.

Phylogeny of Stephanomeria and related genera (compositae-lactuceae) based on analysis of 18S-26S nuclear rDNA ITS and ETS sequences.

A phylogenetic analysis of DNA sequences from the internal transcribed spacer (ITS), the external transcribed spacer (ETS), and the 5.8S regions of 18S-26S nuclear rDNA from all diploid species of Stephanomeria and related genera shows that Stephanomeria does not include either Munzothamnus blairii (previously S. blairii) or Pleiacanthus spinosus (previously S. spinosa). Without these two taxa, Stephanomeria is a well-supported (100% bootstrap), monophyletic group of ten perennial and six annual species. Munzothamnus blairii and Pleiacanthus spinosus, both now considered members of monotypic genera, had been placed in Stephanomeria primarily because they have the same chromosome number as Stephanomeria and similar pollen surface features, but many disparities were ignored in previous classifications. Within Stephanomeria, an unsuspected sister relationship was detected between the montane S. lactucina and coastal S. cichoriacea. A second clade contained all the annual taxa and five of the perennial species. Among the annuals, strong bootstrap support was obtained for the previously recognized relationships between S. diegensis and S. exigua (98%) and between S. malheurensis and its progenitor, S. exigua subsp. coronaria (96%). Among the five perennial species that constitute a clade with the annuals, the recently described S. fluminea was shown to be sister to S. runcinata, and both of them were closely allied to S. tenuifolia and S. thurberi. The clade including the annuals (and five of the perennial species) was subtended by perennial lineages and pairwise divergence values among the annual taxa were much lower than among the perennial taxa as a group (though not too different than among the perennials in the same clade). The annuals probably originated recently within the genus.

Glutamine administration reduces Gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control.

OBJECTIVE: To determine the effect of intravenous glutamine supplementation vs. an isonitrogenous control on infectious morbidity in severely burned patients. Previous clinical studies in seriously ill patients suggest a beneficial effect of glutamine on infectious morbidity, but no trials have examined possible clinical benefits in severely burned patients. DESIGN: Prospective, double-blind, randomized trial. SETTING: Burn intensive care unit of a university hospital. PATIENTS: Twenty-six severe burn patients with total burn surface area of 25% to 90% and presence of full-thickness burns. Patients were evaluated for occurrence of bacteremia and antibiotic use during the first 30 days of their burn unit admission. Nutritional status and overall inflammation were also measured. INTERVENTION: Either intravenous glutamine or an isonitrogenous control amino acid solution was administered as a continuous infusion during burn intensive care unit stay. MEASUREMENTS AND MAIN RESULTS: The incidence of Gram-negative bacteremia was significantly reduced in the glutamine-supplemented group (8%) vs. control (43%; p <.04). No difference was seen in the incidence of Gram-positive bacteremia or fungemia. Average number of positive blood cultures, antibiotic usage, and mortality rates also were reduced but did not reach statistical significance. Significant improvements in serum transferrin and prealbumin were observed in glutamine-supplemented patients at 14 days after burn injury (p <.01 and.04, respectively). C-reactive protein was also significantly reduced at 14 days after burn injury in the glutamine group (p <.01). CONCLUSIONS: Significantly fewer bacteremic episodes with Gram-negative organisms occurred in the glutamine-supplemented patients. Glutamine supplementation improved measures of nutrition and decreased measures of overall inflammation. In addition, a trend toward lower mortality rate, decreased overall bacteremia incidence, and antibiotic usage in the glutamine group was observed. Glutamine's beneficial effects may be a result of improved gut integrity or immune function, but the precise mechanism of glutamine's protection is unknown.

Primary closure of complicated perineal wounds with myocutaneous and fasciocutaneous flaps after proctectomy for Crohn's disease.

BACKGROUND: The purpose of this study is to detail the use of advanced tissue transfer techniques to achieve primary closure of the perineal wound after proctectomy for Crohn's disease. METHODS: Between October 1984 and March 2000, we performed proctectomy with permanent intestinal stoma in 97 patients with Crohn's disease. Twelve of these patients (12.4%) required at least 1 myocutaneous flap to achieve primary closure of the perineal wound. Details of each patient's perioperative course were recorded prospectively. RESULTS: All 12 patients had fistulizing perineal Crohn's disease combined with Crohn's proctitis. Two patients had a simultaneous anal adenocarcinoma. Indications for flap closure included management of large perineal skin defects (n = 11), reconstruction of the posterior vaginal wall (n = 2), and the need to fill a large pelvic dead space (n = 3). (Three patients had a combination of the previous indications). In total, 6 rectus abdominis, 5 gluteus maximus, 1 posterior thigh, 3 chimeric posterior thigh, and 1 latissimus dorsi flaps were performed. Six patients required more than 1 flap. Three patients had complications develop related to the flaps (2 wound hematomas and 1 seroma). Complete perineal healing was achieved in all patients. CONCLUSIONS: Complex tissue flap closure of the perineal wound after proctectomy for perineal complications of Crohn's disease should be considered when simple closure is not possible or when reconstruction of the posterior wall of the vagina is necessary.

Reinventing patient-centered computing for the twenty-first century.

Despite evidence over the past decade that patients like and will use patient-centered computing systems in managing their health, patients have remained forgotten stakeholders in advances in clinical computing systems. We present a framework for patient empowerment and the technical realization of that framework in an architecture called CareLink. In an evaluation of the initial deployment of CareLink in the support of neonatal intensive care, we have demonstrated a reduction in the length of stay for very-low birthweight infants, and an improvement in family satisfaction with care delivery. With the ubiquitous adoption of the Internet into the general culture, patient-centered computing provides the opportunity to mend broken health care relationships and reconnect patients to the care delivery process. CareLink itself provides functionality to support both clinical care and research, and provides a living laboratory for the further study of patient-centered computing.

Male-produced sex attractant pheromone of the green stink bug, Acrosternum hilare (Say).

Sexually mature virgin adult males of the green stink bug, Acrosternum hilare attracted sexually mature virgin adult females in laboratory bioassays using a vertical Y-tube. There was no indication that males attracted other males, or that females attracted either sex. These results suggested that A. hilare males produce a sex pheromone. Extracts of odors collected from sexually mature males contained compounds that were not present in extracts from females or sexually immature males. (4S)-Cis-(Z)-bisabolene epoxide ((4S)-cis-Z-BAE) was the major sex-specific component of the extract. The crude extract was attractive to female A. hilare, but when separated into four fractions, only the portion containing (4S)-cis-Z-BAE and the minor component (4S)-trans-Z-BAE was attractive to females. This fraction was as attractive as the crude extract, suggesting that the former contained all the pheromone components. Neither synthetic (4S)-cis-Z-BAE nor (4S)-trans-Z-BAE alone was attractive to females, but a 95:5 cis:trans blend, mimicing the ratio naturally produced by males, was attractive to females in Y-tube bioassays. Bioassays in a field cage showed that significantly more A. hilare females were attracted to cotton string lures treated with 1 mg of a 95:5 blend of (4S)-cis-Z-BAE and (4S)-trans-Z-BAE placed inside a bouquet of alfalfa than to an alfalfa bouquet containing a pentane-treated control. In field cage studies, attraction of females was greatest during the late afternoon and evening hours, and female A. hilare approached the synthetic pheromone source almost exclusively by walking.

[Cerebrovascular accident and its impact on clients, their partners, the couple's relationship]. / L'AVC et ses conséquences sur le client, son conjoint et la relation de couple.

The purpose of this study was to examine how stroke in one partner affects the personal well-being of the other partner and the couple's relationship. Six couples were followed throughout the rehabilitation period in the rehabilitation center and community setting. Study findings revealed that following the stroke, both patients and their spouses needed to redefine who they were and then redefine their couple relationship. The patients had to adapt to changes in their body and it's functioning. For the spouses, the need to redefine who they were was related to changes in their roles and responsibilities. For the couple, the need to redefine the relationship was related to the changes in both partners. The results of this study suggest that nurses consider the effects of stroke on the patient, the spouse, and the couple relationship and focus nursing interventions that facilitate the need to redefine themselves within the context of change.

A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group.

BACKGROUND: After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. METHODS: As part of the National Polyp Study, we offered colonoscopic examination and double-contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. Although barium enema was performed first, the endoscopist did not know the results. RESULTS: A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, we performed 862 paired colonoscopic examinations and barium-enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 139 of the 392 colonoscopic examinations in which one or more polyps were detected (rate of detection, 35 percent; 95 percent confidence interval, 31 to 40 percent). The proportion of examinations in which adenomatous polyps were detected by barium enema colonoscopy was significantly related to the size of the adenomas (P=0.009); the rate was 32 percent for colonoscopic examinations in which the largest adenomas detected were 0.5 cm or less, 53 percent for those in which the largest adenomas detected were 0.6 to 1.0 cm, and 48 percent for those in which the largest adenomas detected exceeded 1.0 cm. Among the 139 paired examinations with positive results on barium enema and negative results on colonoscopic examination in the same location, 19 additional polyps, 12 of which were adenomas, were detected on colonoscopic reexamination. CONCLUSIONS: In patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more effective method of surveillance than double-contrast barium enema.

Frostbite of the upper extremity.

Human capacity for physiologic adaptation to cold is minimal; we survive by insulating ourselves with protective clothing. In addition to the irreversible direct injury caused by ice crystallization, the authors have outlined four possible mechanisms by which indirect injury may damage tissue. Other than rapid rewarming, there is no uniformly accepted protocol for the treatment of frostbite injury. Attempting to sort out the world's literature on frostbite in an effort to present a comprehensive treatment protocol is a daunting task. In addition to the probably irreversible direct injury caused by ice crystallization, the authors have outlined at least four possible mechanisms by which indirect injury may damage tissue. The literature is full of various treatment protocols that allegedly are beneficial despite addressing different mechanisms. Mills described 10 different categories of medications, each addressing one of four possible mechanisms, used in the clinical treatment of frostbite injury over a 30-year period. Analyzing this information is even more confusing when one realizes that there is little uniformity in animal models employed to generate these data. This is further complicated by the lack of clinical correlation with the most common experimental model--liquid nitrogen rapid freezing. The risk of frostbite is highest when psychiatric disturbance, intoxication, or unplanned circumstances lead to cold exposure without adequate protective clothing. As tissue freezes, both direct and indirect factors cause injury. Most therapies have been aimed at limiting indirect injury, in an attempt to limit progressive tissue loss. Rapid rewarming is universally accepted, but the benefits of other modalities are still controversial. Traditionally, observation and delayed amputation have been employed to manage frostbite. More recently, triple-phase bone scans have been used to distinguish between tissue that is irreversibly destined for necrosis and tissue that is at-risk for necrosis, but potentially salvageable. Early operation can be used to provide at-risk tissue with a new blood supply and preserve both function and length in the upper extremity.