A fully automated method for accurate measurement of geometrical distortion in magnetic resonance imaging of a 3D-lattice phantom.

This paper describes an automated method for extracting the apparent positions of fiducial points from 2D or 3D images of a phantom. We consider a 3D-lattice phantom for two main reasons: first, ease of manufacture and isotropy of its structure with respect to coordinate projections; second, a connected structure allowing to uniquely assess the adjacency relationship between fiducial points even if geometric distortions arising from main magnet inhomogeneity and gradient fields non-linearity is severe as observed in open-bore systems. In order to validate our proposed method and compare different choices for the parameters of our phantom (i.e. number and distance between grids and thickness of its branches) we developed in-house a software for simulating 2D or 3D volume images of the phantom, using customizable MRI sequence parameters and Spherical Harmonic Coefficients for the fields. We deem worthy of note that using simulated images is the only way to evaluate the estimated position error, since it allows to compare the estimates to their theoretical counterparts. Furthermore, the use of simulated images allows to evaluate the robustness of the method with respect to image quality in terms of Signal-to-Noise Ratios and geometric distortion, and allows to evaluate different phantom geometries without having to manufacture them. The proposed method can be easily extended to phantoms having an arbitrary overall shape, as long as it is a fully connected structure. Specifically, it is easy to design a phantom with fiducial points laying outside of the homogeneity sphere, so that indirect measurement of the fields becomes possible, for example by using the recent method proposed by Acquaviva et al. To the best of our knowledge, the proposed method outperforms other state-of-the-art methods, with an average positioning offset of 0.052 mm (with a 0.99 quantile of 0.12 mm) when working on images featuring a differential Signal-to-Noise Ratio within Region-of-Interest (ROI) equal to 105 (20.2 dB) and a ROI-to-background SNR of 20 dB. Estimating the positions of 6859 fiducial points in a volume, our highest density case, was carried out in less than 30 min on a desktop personal computer.

Clinical and financial analysis of an acute palliative care unit in an oncological department.

The aim of this article is to describe the clinical activity and medical intervention of an acute model of palliative care unit (APC), as well as the reimbursement procedures and economic viability. A sample of 504 patients admitted at an APC in 1 year was surveyed. Indications for admission, pain and symptom intensity, analgesic treatments, procedures, instrumental examinations and modalities of discharge were recorded. For each patient, tariff for reimbursement was calculated according to the existent disease related grouping (DRG) system. The mean age was 62 years, and 246 patients were males. The mean hospital stay was 5.4 days. Pain control was the most frequent indication for admission. All patients had laboratory tests and several instrumental examinations. Almost all patients were prescribed one or more opioids at significant doses, and different routes of administration, as well as medication as needed. 59 patients received blood cell transfusions and 34 interventional procedures. Only 40 patients died in the unit, 11 of them being sedated at the end of life. Treatment efficacy was considered optimal and mild in 264 and 226 patients respectively. A mean of 3019 euros for admission was reimbursed by the Health Care System. APCs are of paramount importance within an oncological department, as they provide effective and intensive treatments during the entire course of disease, providing a simultaneous and integrated approach. Our findings also suggest both a cost and quality incentive for oncological departments to develop APC.

Transmucosal fentanyl vs intravenous morphine in doses proportional to basal opioid regimen for episodic-breakthrough pain.

The use of supplemental doses of opioids is commonly suggested to manage breakthrough pain. A comparative study of intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) given in doses proportional to the basal opioid regimen was performed in 25 cancer patients receiving stable opioid doses. For each episode, when it occurred and 15 and 30 min after the treatment, pain intensity and opioid-related symptoms were recorded. Fifty-three couples of breakthrough events, each treated with IV-MO and OTFC, were recorded. In episodes treated with IV-MO, pain intensity decreased from a mean of 6.9 to 3.3 and to 1.7 at T1 and T2, respectively. In episodes treated with OTFC, pain intensity decreased from a mean of 6.9 to 4.1 and to 2.4 at T1 and T2, respectively. Statistical differences between the two treatments were found at T1 (P=0.013), but not at T2 (P=0.059). Adverse effects were comparable and were not significantly related with the IV-MO and OTFC doses. Intravenous morphine and OTFC in doses proportional to the scheduled daily dose of opioids were both safe and effective, IV-MO having a shorter onset than OTFC. Future comparative studies with appropriate design should compare titration methods and proportional methods of OTFC dosing.

Empathy in medical students as related to academic performance, clinical competence and gender.

CONTEXT: Empathy is a major component of a satisfactory doctor-patient relationship and the cultivation of empathy is a learning objective proposed by the Association of American Medical Colleges (AAMC) for all American medical schools. Therefore, it is important to address the measurement of empathy, its development and its correlates in medical schools. OBJECTIVES: We designed this study to test two hypotheses: firstly, that medical students with higher empathy scores would obtain higher ratings of clinical competence in core clinical clerkships; and secondly, that women would obtain higher empathy scores than men. MATERIALS AND SUBJECTS: A 20-item empathy scale developed by the authors (Jefferson Scale of Physician Empathy) was completed by 371 third-year medical students (198 men, 173 women). METHODS: Associations between empathy scores and ratings of clinical competence in six core clerkships, gender, and performance on objective examinations were studied by using t-test, analysis of variance, chi-square and correlation coefficients. RESULTS: Both research hypotheses were confirmed. Empathy scores were associated with ratings of clinical competence and gender, but not with performance in objective examinations such as the Medical College Admission Test (MCAT), and Steps 1 and 2 of the US Medical Licensing Examinations (USMLE). CONCLUSIONS: Empathy scores are associated with ratings of clinical competence and gender. The operational measure of empathy used in this study provides opportunities to further examine educational and clinical correlates of empathy, as well as stability and changes in empathy at different stages of undergraduate and graduate medical education.

The role of antithrombin III in critical patients in obstetrics.

A preliminary study was conducted to detect significant differences between the inflammatory cytokines network recorded in mild and severe preeclampsia compared with normal pregnancy. 36 patients were divided in two groups: (NP) normal pregnancy and (SPH) Severe Preeclampsia and HELLP syndrome. Inflammatory cytokines (IL 6, TNF, IL 10), Antithrombin III (AT III), Protein C (PC) and Tissue Factor Pathway Inhibitor (TFPI) plasma level and Organ Disfunction modified Score (ODS) were recorded. Results shows a difference (P<0,05 ) for AT III and other markers levels in the two groups and, inside of the SPH group, between Severe preeclampsia patients and HELLP syndrome patients. A correlation was found between coagulation natural inhibitors, specially antithrombin III, and the clinical scores. Performing a Caesarean section did not change these results. Based on results of the study we have designed a monitoring and a treatment protocol in our obstetric and general ICU. A multicentric study is now ongoing to validate the preliminary data on the substitutive treatment with AT III.

Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries.

PURPOSE: Cardiac auscultation is suffering from a declining interest caused by competing diagnostic technology and, possibly, inadequate teaching and testing of physicians-in-training. Because access to technology, traditional teaching practices, and methods of trainees' assessment vary among different countries, we speculated that trainees' proficiency in auscultation might also vary. SUBJECTS AND METHODS: We tested the cardiac auscultatory skills of 314 internal medicine residents (189 from the United States, 89 from Canada, and 36 from England) from 14 programs. All participants were asked to listen by stethophones to 12 prerecorded cardiac events and to answer a multiple-choice questionnaire. They also completed a survey concerning attitudes toward cardiac auscultation and auscultatory teaching received during training. RESULTS: Mean (+/- SD) identification scores for the 12 cardiac events ranged from 0% to 58% for American trainees (mean 22% +/- 12%), 0% to 58% for Canadians (mean 26% +/- 13%), and 0% to 42% for British trainees (mean 20% +/- 12%). Canadians' cumulative scores were slightly but significantly greater than those of American (P = 0.02) and British house officers (P = 0.05). British house officers improved the most during the 3 years of training (P < 0.05). Canadian and British trainees had received more auscultatory teaching during medical school and residency; they had also used audiotapes more frequently (all P < 0.001). CONCLUSIONS: Auscultatory proficiency was poor in all three countries. Although there were slight differences among countries, the most striking finding was the consistent inaccuracy of all trainees. This suggests that variables other than teaching and testing affect proficiency.

Pulmonary auscultatory skills during training in internal medicine and family practice.

We conducted a multicenter, cross-sectional assessment of pulmonary auscultatory skills among medical students and housestaff. Our study included 194 medical students, 18 pulmonary fellows, and 656 generalists-in-training from 17 internal medicine and 23 family practice programs in the Mid- Atlantic area of the United States. All participants listened to 10 pulmonary events recorded directly from patients, and answered by completing a multiple choice questionnaire. Proficiency scores were expressed as the percentage of respondents per year and type of training who correctly identified each event. In addition, we calculated a series of cumulative scores for sound recognition, disease identification, and basic knowledge of lung auscultation. Trainees' cumulative scores ranged from 0 to 85 for both internal medicine and family practice residents (median = 40). On average, internal medicine and family practice trainees recognized less than half of all respiratory events, with little improvement per year of training, and were not significantly better than medical students in their scores. Pulmonary fellows had the highest diagnostic and knowledge scores of all groups. These data indicate that there is very little difference in auscultatory proficiency between internal medicine and family practice trainees, and suggest the need for revisiting these time-honored skills during residency training.

Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency.

CONTEXT: Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically. OBJECTIVE, DESIGN, AND SETTING: To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area. PARTICIPANTS: A total of 453 physicians in training and 88 medical students. INTERVENTIONS: All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire. MAIN OUTCOME MEASURES: scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent. RESULTS: Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and .02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students. CONCLUSIONS: Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.

Physical diagnosis skills of physicians in training: a focused assessment.

OBJECTIVE: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient. METHODS: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university-affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self-motivated learning of physical diagnosis also were assessed for all the EM trainees. RESULTS: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9-72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching. CONCLUSIONS: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.

[Ultra-short and short surgical prophylaxis with pefloxacin]. / Ultra-short e short profilassi chirurgica con pefloxacina.

A multicentre study has been done to evaluate the effectiveness and safety of pefloxacin, a new fluoroquinolone, when given intravenously for surgical prophylaxis. 440 patients (224 males, 216 females), mean age 51.7 +/- 27.3 (SD) years and mean weight 68.4 +/- 12.6 kg, were admitted to the study. The diagnoses for admission included several surgically treated specialties (obstetrics and gynecology, orthopedics and traumatology, oncology and general surgery). Pefloxacin was provided in 5 ml ampoules containing 400 mg of active principle to administer by slow intravenous perfusion (1 hour) diluted in 5% glucose solution. The multicentre study was open and non-comparative. The physician could choose between two different dosage schedules to use for surgical prophylaxis. The ultrashort schedule consisted of treatment with 2 ampoules (800 mg), given in the hour before the operation (followed for 217 cases). The short schedule consisted of 2 ampoules (800 mg) given in the hour before the operation, another 2 ampoules 12 hours after surgery and 2 ampoules 24 hours after the surgery (followed for 223 cases). The prophylaxis with pefloxacin was effective, with control of the temperature, the ESR and wound healing in the post-operative period. The surgical wounds of 11.4% of cases (50/440) were erythematous and infiltrated on the 2nd day, and of 14.8% of cases (65/440) on the 3rd day, and then became normal on the next few days. 24 patients had infections after the operation, in 15 cases involving the surgical field (3.4%) and in 9 cases being infections of the respiratory or urinary systems.(ABSTRACT TRUNCATED AT 250 WORDS)