Diabetic retinopathy screenings in West Virginia: an assessment of teleophthalmology implementation.

BACKGROUND: The prevalence of diabetes in the state of West Virginia (WV) is amongst the highest in the United States, making diabetic retinopathy (DR) and diabetic macular edema (DME) a major epidemiological concern within the state. Several challenges exist regarding access to eye care specialists for DR screening in this rural population. A statewide teleophthalmology program has been implemented. We analyzed real-world data acquired via these systems to explore the concordance between image findings and subsequent comprehensive eye exams and explore the impact of age on image gradeability and patient distance from the West Virginia University (WVU) Eye Institute on follow-up. METHODS: Nonmydriatic fundus images of diabetic eyes acquired at primary care clinics throughout WV were reviewed by retina specialists at the WVU Eye Institute. Analysis included the concordance between image interpretations and dilated examination findings, hemoglobin A1c (HbA1c) levels and DR presence, image gradeability and patient age, and distance from the WVU Eye Institute and follow-up compliance. RESULTS: From the 5,512 fundus images attempted, we found that 4,267 (77.41%) were deemed gradable.  Out of the 289 patients whose image results suggested DR, 152 patients (52.6%) followed up with comprehensive eye exams-finding 101 of these patients to truly have DR/DME and allowing us to determine a positive predictive value of 66.4%. Patients within the HbA1c range of 9.1-14.0% demonstrated significantly greater prevalence of DR/DME (p < 0.01).  We also found a statistically significant decrease in image gradeability with increased age.  When considering distance from the WVU Eye Institute, it was found that patients who resided within 25 miles demonstrated significantly greater compliance to follow-up (60% versus 43%, p < 0.01). CONCLUSIONS: The statewide implementation of a telemedicine program intended to tackle the growing burden of DR in WV appears to successfully bring concerning patient cases to the forefront of provider attention.  Teleophthalmology addresses the unique rural challenges of WV, but there is suboptimal compliance to essential follow-up with comprehensive eye exams. Obstacles remain to be addressed if these systems are to effectively improve outcomes in DR/DME patients and diabetic patients at risk of developing these sight-threatening pathologies.

Treatment of an influenza A outbreak in a teaching nursing home. Effectiveness of a protocol for prevention and control.

The safety and efficacy of current ACIP guidelines for the prevention and control of influenza in nursing home populations are uncertain. An outbreak of influenza A/Sichuan (H3N2) in a teaching nursing home during 1988 gave us the opportunity to evaluate the effectiveness of an influenza vaccination and amantadine prophylaxis protocol. Over 13 days, 12 of 60 residents developed influenza. Prior influenza vaccination had been given to 94% of the residents. Protection from infection occurred in those tested who had antibody levels greater than or equal to 1:16 to the A/Leningrad (H3N2) antigen contained in the standard 1987-88 trivalent vaccine. However, five of 17 vaccinated residents who were tested had antibody levels less than or equal to 1:16 at the start of the outbreak. Amantadine (less than or equal to 100 mg/day) was given to all but one resident starting on the third day of the outbreak, and to employees starting on the sixth day of the outbreaks. Seven residents developed illness after the start of amantadine, although amantadine appeared to ameliorate their symptoms. Although amantadine was generally well tolerated by residents, employees receiving amantadine identified a high incidence of side effects and only 44% of employees took at least 70% of the prescribed amantadine. In our opinion, early detection and protocol-directed intervention probably abated a more severe influenza outbreak. Therefore we support existing recommendations that formal nursing home policies be established to ensure that residents and employees receive annual influenza vaccine and that chemoprophylaxis be used when outbreaks of influenza A are suspected.

Endoscopic retrograde cholangiopancreatography in the management of pancreatic pseudocysts.

The value of ERCP was studied in 25 patients with pancreatic pseudocysts. There were no episodes of sepsis; however, acute pancreatitis developed in one patient for an overall complication rate of 4 percent. Results of ERCP were positive in 24 of the 25 patients (96 percent), with filling of the pseudocyst in 17 and pancreatic ductal obstruction in 7. Biliary tract abnormalities were found in seven patients and included common bile duct strictures in four, bile duct dilatation in two, and cystic duct obstruction in one. ERCP also detected six pseudocysts not diagnosed by ultrasonography, five of which were small and resolved with nonoperative therapy. ERCP is a safe diagnostic procedure for patients with pancreatic pseudocysts and may provide important information about coexistent biliary tract disease not otherwise available. It is also sufficiently sensitive to detect small pseudocysts that otherwise would be missed.

Surveillance for the detection of nosocomial infections and the potential for nosocomial outbreaks. II. Development of a laboratory-based system.

We describe the development of a surveillance system that uses thresholds for detecting nosocomial infections and the potential for nosocomial outbreaks based on data from microbiology laboratory records at our hospital from 1980 to 1982. These records were monitored weekly to determine the number of positive isolates by the identity of the organism and by the site of the culture. A mean of 225 specimens was processed weekly, with 60 of these yielding bacteria or fungi. The average number of organisms isolated per positive culture was 1.46. Two methods of establishing thresholds were compared, one based on percentiles of ranked isolates, the other based on the mean plus intervals of standard error. The system using thresholds established by the standard error method was consistently more useful to highlight weeks for which there was high risk of a problem occurring in less time than were the surveillance techniques traditionally employed.

Surveillance for the detection of nosocomial infections and the potential for nosocomial outbreaks. I. Microbiology culture surveillance is an effective method of detecting nosocomial infection.

A study was undertaken to determine the sensitivity and specificity of a laboratory-based surveillance system using numbers of positive cultures in our institution. A randomized retrospective review of 575 medical-surgical patient charts revealed 70 nosocomial infections in 41 patients. Review of microbiology records indicated positive cultures for 71%, cultures obtained but inadequate for 6%, no culture necessary for 7%, and no culture obtained for 16%. Patients over 60 years old were significantly more likely to have a nosocomial infection cultured than were younger patients (p less than 0.025). There was no significant difference in rate of nosocomial infections classified by clinical service, site of infection, or length of stay in the hospital. By randomly selecting 100 positive cultures and reviewing the charts of the affected patients, we found that 48% represented nosocomial infections. Thus laboratory-based surveillance was 84% sensitive and 48% specific for detecting nosocomial infections.

The formation and growth of the cortical layers in the cerebellum of the opossum.

The development of the cerebellar cortex in the opossum was analyzed in Nissl-stained sections using qualitative and quantitative methods. The young of the opossum are born 12-13 days after conception and mature for approximately 85 days in an external pouch providing an excellent model for embryological studies. Qualitative observations of cerebellar growth were made from birth to postnatal day (PN) 19. At birth the opossum cerebellar anlage can be divided into two layers, a ventricular layer and an intermediate layer; histologically his is comparable to the rat cerebellar anlage at embryonic day 13 (Altman and Bayer 1978) and the human cerebellar anlage prior to the seventh embryonic week (Rakic and Sidman 1970). By PN 3 the cerebellar anlage consists of five layers: the ventricular layer, the ventral intermediate layer, the acellular layer, the dorsal intermediate layer and the marginal layer. The external granular layer begins migrating over the dorsal surface of the cerebellum at PN 5. The immature Purkinje cell layer is first seen at PN 12 and is subsequently arranged as four clusters between PN 12 and PN 22. At PN 19 the opossum cerebellum is comparable to the rat cerebellum at birth (Korneliussen 1968c). A quantitative analysis of cerebellar growth was performed between PN 17 and PN 77 using vermal sections. The area and thickness of each of the cortical layers was determined from five vermal sagittal sections using two methods; a Zeiss Videoplan and a point counting system. The external granular layer increases in area from PN 17 to PN 75, however its maximal width is achieved between PN 19 and PN 33. The persistence of the EGL until after PN 105 suggests that synaptic contacts between granule cell axons and Purkinje cells may continue to form after PN 77 when the Purkinje cell is mature based on Golgi and fine structural features (Laxson and King 1983). Between PN 17 and PN 77 the area of the molecular layer and the area of the internal granular layer increase at a more rapid rate than the other cerebellar layers. The maturation of the cerebellum in the opossum is a lengthy process lasting approximately 77 days in comparison to rodent cerebellar growth which requires about 25 days (Korneliussen 1968c). Also, the entire process of cortical lamination occurs after birth while the opossum is maturing in an external pouch.

Iatrogenic disease in hospitalized elderly veterans.

To help determine whether or not the elderly are at unusually high risk for hospital-related complications, a study was made of consecutive admissions involving 48 patients less than 65 years old (mean 50.3 years) and 174 patients more than 65 years old (mean 73.1 years). They were prospectively followed during their hospital stays, and were monitored daily. According to admission data, they were classified as : Group 1, likely to die soon after admission; Group II, likely to die within a year; Group III, likely to live longer than a year. Complications were listed under the causal factors: trauma, infection, hospital procedures, drugs, and miscellaneous. About 90 per cent of all 222 patients in both age categories were in Group III. The overall complication rates were 29 per cent for patients under 65, and 45 per cent for those over 65 (P less than 0.05). For the under-65 Group III patients, the rates were 17 per cent and 42 per cent for medical and surgical patients, respectively; for the over-65 patients, the rates were 40 per cent (medical) and 43 per cent (surgical). This indicated a major increase in complications among medical patients more than 65 years old. Procedure-related problems were most common among surgical patients under 65. For over-65 patients, the complication rates for procedure-related, trauma, miscellaneous, infection, and drug toxicity categories were fairly evenly distributed within the range of 16.8-12.8 per cent, in that order. Major psychiatric deterioration was observed in 10.7 per cent of patients over 65, but in none of the younger subjects. Drug toxicity and traumatic complications were also more common in the older patients. These data confirm the disproportionately high incidence of iatrogenic diseases in hospital patients over the age of 65. Several of these complications are amenable to control.

Spinal projections from the medullary reticular formation of the North American opossum: heterogeneity.

Retrograde and orthograde transport techniques show that the nucleus reticularis gigantocellularis pars ventralis and the nucleus reticularis gigantocellularis project the entire length of the spinal cord. Double-labelling methods show that some of the neurons in each area innervate both cervical and lumbar levels. There is evidence, however, that neurons in the lateral part of the nucleus reticularis gigantocellularis pars ventralis and the dorsal extreme of the nucleus reticularis gigantocellularis project mainly to cervical and thoracic levels. The autoradiographic method shows that the above nuclei supply direct innervation to somatic and autonomic motor columns as well as to laminae V-VIII and X. The nucleus reticularis gigantocellularis pars ventralis provides additional projections to lamina I and the outer part of lamina II. Several areas of the medullary reticular formation project mainly, and in some cases exclusively, to cervical and thoracic levels. These areas include the nucleus reticularis parvocellularis, the nucleus reticularis lateralis, the nucleus retrofacialis, the nucleus ambiguus, the nucleus lateralis reticularis, caudal parts of the nuclei reticularis medullae oblongatae dorsalis and ventralis, and the nucleus supraspinalis. Autoradiographic experiments reveal that neurons in the ventrolateral medulla, particularly rostrally (the nucleus reticularis lateralis and neurons related to the nucleus lateralis reticularis), innervate sympathetic nuclei. Our results indicate that spinal projections from bulbar areas of the reticular formation are more complicated than previously supposed. Axons from separate areas project to different spinal levels and in some cases to different nuclear targets. These data are in conformity with the evolving concept of reticular heterogeneity.

Spinal projections from the mesencephalic and pontine reticular formation in the North American Opossum: a study using axonal transport techniques.

The results from several experimental approaches lead to the following conclusions. The nucleus cuneiformis projects to at least lumbar levels of the spinal cord. Its axons course through the ipsilateral sulcomarginal and ventral funiculi to distribute within lamina VIII and adjacent portions of lamina VII. Neurons within the nucleus reticularis pontis (RP), particularly within more medial parts of the nucleus, project through comparable routes to the same laminae. In addition, however, neurons within the lateral and dorsolateral RP relay through the lateral and dorsolateral funiculi, ipsilaterally, and the dorsolateral funiculus, contralaterally. Axons could be traced from the dorsolateral tracts to laminae IV through VII, lamina X and, in some instances, to laminae I and II. Injections of the dorsolateral pons also label the intermediolateral cell column and an area presumed to be the sacral parasympathetic nucleus. Many of the neurons which contribute to the contralateral bundle are located adjacent to the ventral nucleus of the lateral lemniscus. The nucleus reticularis gigantocellularis projects mainly via the sulcomarginal, ventral and lateral funiculi to laminae VIII and adjacent portions of lamina VII. The nucleus reticularis gigantocellularis pars ventralis innervates the same laminae; but, in addition, projects heavily to laminae I and II, to lateral portions of laminae IV through VII; to laminae IX and X and to the intermediolateral cell column. Axons destined for laminae I and II, as well as IV through VII and X, traverse the dorsolateral funiculi as described for the cat by Basbaum et al. ('78). Neurons within the nucleus reticularis parvocellularis project to cervical levels, mainly through the ventral funiculi. In general our results show that reticulospinal projections are more complex than suggested by degeneration methods and that laminae I, II. lateral parts of laminae IV-VII, laminae IX and X, as well as the intermediolateral cell column and sacral parasympathetic nucleus are targets of axons from specific areas.