An international comparison of reimbursement for DIEAP flap breast reconstruction.

INTRODUCTION: The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. METHODS: Data were collected confidentially from the main international centres by an anonymous questionnaire. RESULTS: Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). CONCLUSION: Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential.

Prognostic scoring systems in burns: a review.

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

The use of the Cortrak Enteral Access System™ for post-pyloric (PP) feeding tube placement in a Burns Intensive Care Unit.

INTRODUCTION: 50% of critically ill patients fail to reach caloric targets with NG feeding. PP feeding may enhance caloric intake. PP feeding can be continued throughout theatre in patients with a secure airway. Blind PP tube placement is difficult. CEAS has been developed to assist tube placement and eliminate check X-rays of tube position. METHOD: All BITU patients with CEAS PP feeding tube placement were identified. Notes and X-rays were reviewed. Tube position, calorie deficit and time off feed were recorded. RESULTS: 44 tubes were placed in 21 patients using CEAS. 84% were PP, 16% NG. Position correlated to X-ray findings in 86%. In 16% position was NG on CEAS but was PP on X-ray. 10 patients required both CXR and AXR to confirm position, the remainder required CXR only. Time off feed varied from 0-24 h (mean 7.4 h). Calorie deficit ranged from 0-2465 kCal (mean 858 kCal). Average wait for X-ray was 3.4h. If X-ray wait was eliminated calorie deficit would be reduced by 45% to 393 kCal. CONCLUSION: The Cortrak system is safe and effective on BITU. It reduces calorie deficit, reduces X-ray exposure and is cost effective. We recommend its use on BITU.

Prospective study of elective bilateral versus unilateral femoral arterial puncture for uterine artery embolization.

The purpose of this study was to assess the effect of elective bilateral femoral arterial punctures for uterine artery embolization (UAE) of symptomatic fibroids on fluoroscopy and procedural time, patient dose, and ease of procedure. We conducted a prospective study of UAE with either the intention to catheterize both uterine arteries using a single femoral puncture (n = 12) or elective bilateral arterial punctures from the outset (n = 12). The same two operators undertook each case. Main outcome measures were total procedure time, fluoroscopy time, dose-area product (DAP), and total skin dose. A simulation was then performed on an anthropomorphic phantom using the mean in vivo fluoroscopy parameters to estimate the ovarian dose. Bilateral UAE was achieved in all patients. None of the patients with initial unilateral arterial puncture required further contralateral arterial puncture. The mean fluoroscopy time in the group with elective bilateral punctures was 12.8 min, compared with a mean of 16.6 min in patients with unilateral puncture (p = 0.046). There was no significant difference in overall procedure time (p = 0.68). No puncture-site complications were found. Additional catheters were required only following unilateral puncture. The simulated dose was 25% higher with unilateral puncture. Although there was no significant difference in measured in vivo patient dose between the two groups (DAP, p = 0.32), this is likely to reflect the wide variation in other patient characteristics. Allowing for the small study size, our results show that the use of elective bilateral arterial punctures reduces fluoroscopy time, requires less catheter manipulation, and, according to the simulation model, has the potential to reduce patient dose. The overall procedure time, however, is not significantly reduced.

Is there a relationship between the structure of Irish psychiatric multidisciplinary teams and patient outcome?

This study evaluated the structure of psychiatric multidisciplinary teams within eight Irish Health Boards over a two year period (1997 and 1998). Furthermore, it assessed the relationship between team structure and three measures of psychiatric outcome within individual Health Board areas. The findings suggest a significant variation between Health Boards in relation to the staffing of psychiatric multidisciplinary teams. Although there was no evidence that the structure of multidisciplinary teams influenced suicide rates or duration of hospitalization, it had a significant independent effect on admission rates to psychiatric units.

Effect of season and temperature on mortality in amphibians due to chytridiomycosis.

OBJECTIVE: To investigate the distribution and incidence of chytridiomycosis in eastern Australian frogs and to examine the effects of temperature on this disease. DESIGN: A pathological survey and a transmission experiment were conducted. PROCEDURE: Diagnostic pathology examinations were performed on free-living and captive, ill and dead amphibians collected opportunistically from eastern Australia between October 1993 and December 2000. We conducted a transmission experiment in the laboratory to investigate the effects of temperature: eight great barred frogs (Mixophyes fasciolatus) exposed to zoospores of Batrachochytrium dendrobatidis and six unexposed frogs were housed individually in each of three rooms held at 17 degrees C, 23 degrees C and 27 degrees C. RESULTS: Chytridiomycosis was the cause of death or morbidity for 133 (55.2%) of 241 free-living amphibians and for 66 (58.4%) of 113 captive amphibians. This disease occurred in 34 amphibian species, was widespread around the eastern seaboard of Australia and affected amphibians in a variety of habitats at high and low altitudes on or between the Great Dividing Range and the coast. The incidence of chytridiomycosis was higher in winter, with 53% of wild frogs from Queensland and New South Wales dying in July and August. Other diseases were much less common and were detected mostly in spring and summer. In experimental infections, lower temperatures enhanced the pathogenicity of B. dendrobatidis in M. fasciolatus. All 16 frogs exposed to B. dendrobatidis at 17 degrees C and 23 degrees C died, whereas 4 of 8 frogs exposed at 27 degrees C survived. However, the time until death for the frogs that died at 27 degrees C was shorter than at the lower temperatures. Infections in survivors were eliminated by 98 days. CONCLUSION: Chytridiomycosis is a major cause of mortality in free-living and captive amphibians in Australia and mortality rate increases at lower temperatures.

Enzyme microgels in packed-bed bioreactors with downstream amperometric detection using microfabricated interdigitated microsensor electrode arrays.

In this article, we describe the use of pH- responsive hydrogels as matrices for the immobilization of two enzymes, glucose oxidase (GOx) and glutamate oxidase (GlutOx). Spherical hydrogel beads were prepared by inverse suspension polymerization and the enzymes were immobilized by either physical entrapment or covalent immobilization within or on the hydrogel surface. Packed-bed bioreactors were prepared containing the bioactive hydrogels and these incorporated into flow injection (FI) systems for the quantitation of glucose and monosodium glutamate (MSG) respectively. The FI amperometric detector comprised a microfabricated interdigitated array within a thin-layer flow cell. For the FI manifold incorporating immobilized GOx, glucose response curves were found to be linear over the concentration range 1.8-280 mg dL(-1) (0.1-15.5 mM) with a detection limit of 1.4 mg dL(-1) (0.08 mM). Up to 20 samples can be manually analyzed per hour, with the hydrogel-GOx bioreactor exhibiting good within-day (0.19%) precision. The optimized FI manifold for MSG quantitation yielded a linear response range of up to 135 mg dL(-1) (8 mM) with a detection limit of 3.38 mg dL(-1) (0.2 mM) and a throughput of 30 samples h(-1). Analysis of commercially produced soup samples gave a within-day precision of 3.6%. Bioreactors containing these two physically entrapped enzymes retained > 60% of their initial activities after a storage period of up to 1 year.

Mapping membrane potential transients in crayfish (Procambarus clarkii) optic lobe neuropils with voltage-sensitive dyes.

Voltage-sensitive dyes NK 2761 and RH 155 were employed (in conjunction with a 12 x 12 photodiode array) to study membrane potential transients in optic lobe neuropils in the eye stalk of the crayfish Procambarus clarkii. By this means we investigated a pathway linking deutocerebral projection neurons, via hemiellipsoid body local interneurons, to an unidentified target (most likely neurons processing visual information) in the medulla terminalis. Rapid (10- to 20-ms duration), transient changes in absorption with the characteristics of action potentials were recorded from the optic nerve and the region occupied by deutocerebral projection neurons after stimulation of the olfactory globular tract in the optic nerve and were blocked by 1 microM tetrodotoxin. Action potentials appeared to propagate to the glomerular layer of the hemiellipsoid body where synaptic responses were recorded from a restricted region of the hemiellipsoid body occupied by dendrites of hemiellipsoid body neurons. Action potentials were also recorded from processes of hemiellipsoid body neurons located in the medulla terminalis. Synaptic responses in the hemiellipsoid body and medulla terminalis were eliminated by addition to the saline of 500 microM Cd2+ or 20 mM Co2+, whereas the action potential attributed to branches of deutocerebral projection neurons in the hemiellipsoid body remained unaffected. Action potentials of hemiellipsoid body neurons in the medulla terminalis evoked postsynaptic potentials (50- to 200-ms duration) with an unidentified target in the medulla terminalis. Transient absorption signals were not detected in either the internal or external medulla nor were they recorded from other parts of the optic lobes in response to electrical stimulation of axons of the deutocerebral projection neurons. Functional maps of optical activity, together with electrophysiological and pharmacological findings, suggest that gamma-aminobutyric acid affects synaptic transmission in glomeruli of the hemiellipsoid body. Synapses of the olfactory pathway located in the medulla terminalis may act as a "filter," modifying visual information processing during olfactory stimulation.

Functional organization of rat olfactory bulb glomeruli revealed by optical imaging.

The functional organization and synaptic physiology of olfactory bulb glomeruli were studied in rat in vitro slice preparations stained with the voltage-sensitive dye RH-155. Optical signals were recorded with a 100-element photodiode array at high temporal resolution. Pharmacological and ionic manipulations were used to investigate synaptic responses to stimulation of the olfactory nerve layer (ONL). ONL stimulation evoked a sodium-mediated compound action potential that propagated across the ONL and invaded individual glomeruli. This presynaptic volley evoked calcium-dependent synaptic responses the amplitudes of which were largest within the glomerular layer (GL); smaller amplitude responses were recorded in deeper layers of the olfactory bulb. Synaptic responses in the GL were attenuated by the non-NMDA ionotropic glutamate receptor antagonist CNQX; the residual component was suppressed by the NMDA glutamate receptor antagonist AP-5. The GABAA receptor antagonist bicuculline methiodide had little effect, whereas the GABAB receptor agonist baclofen dramatically attenuated ONL-evoked synaptic responses. The effects of baclofen were reversed by the GABAB receptor antagonist CGP35348. Paired-pulse depression of ONL-evoked synaptic responses in the GL was partially reversed by CGP35348. These findings suggest that olfactory nerve axons release glutamate to activate both NMDA and non-NMDA receptors on GL neurons, that GABAA receptor-mediated inhibition has little effect on these responses, and that GABAB receptor-mediated inhibition may act presynaptically on olfactory nerve axons to modulate their inputs to olfactory bulb neurons.

The anthropometric assessment of dysmorphic features in schizophrenia as an index of its developmental origins.

BACKGROUND: Evidence suggests that schizophrenia may be a disorder with origins in early intrauterine mal-development. We have constructed a comprehensive anthropometric scale for the evaluation of dysmorphic features as an index of the nature and timing of developmental disturbance. METHOD: A detailed set of craniofacial and bodily measures was compiled and applied to 174 patients with schizophrenia and 80 matched control subjects. RESULTS: Patients had significantly higher scores on this scale and displayed multiple anomalies of the craniofacial region with an overall narrowing and elongation of the mid-face and lower face. Twelve craniofacial anomalies independently distinguished patients from controls and these variables correctly classified 95% of patients and 80% of control subjects. CONCLUSIONS: This new scale, while procedurally more exacting than the Waldrop scale, more clearly defines the topography of anomalies previously suspected in individuals with schizophrenia. These findings constitute direct evidence for disturbed craniofacial development in schizophrenia and indicate origins in the foetal period during which the characteristic human facial pattern evolves in close association with brain differentiation.

Electrical conductivity of pH-responsive hydrogels.

The electrical conductivity of pH-responsive hydrogels based on cross-linked poly(2-hydroxyethyl methacrylate-co-dimethylaminoethyl methacrylate) copolymers has been studied as a function of pH over the range 5-10, for copolymers containing up to 20 mol% of the amine-containing comonomer. The conductivities of membranes equilibrated in buffered potassium chloride solutions were determined by measuring the electrical resistance of a membrane mounted between the chambers of a modified side-by-side diffusion cell. The conductivity, expressed as a fraction of the conductivity of the buffer in which the gels were equilibrated, ranged from 1% for the gels in the collapsed state to 70% for the most highly swollen gels. The observed results are qualitatively consistent with a proposed model in which the ion concentrations in the fluid phase of the gel are described by Donnan partitioning, and the ion mobilities by the free-volume theory of Yasuda. The results suggest that conductivity measurements may provide an alternative to diffusive transport studies for characterizing moderately swollen hydrogel membranes.

Evidence that calcium release-activated current mediates the biphasic electrical activity of mouse pancreatic beta-cells.

The electrical response of pancreatic beta-cells to step increases in glucose concentration is biphasic, consisting of a prolonged depolarization with action potentials (Phase 1) followed by membrane potential oscillations known as bursts. We have proposed that the Phase 1 response results from the combined depolarizing influences of potassium channel closure and an inward, nonselective cation current (ICRAN) that activates as intracellular calcium stores empty during exposure to basal glucose (Bertram et al., 1995). The stores refill during Phase 1, deactivating ICRAN and allowing steady-state bursting to commence. We support this hypothesis with additional simulations and experimental results indicating that Phase 1 duration is sensitive to the filling state of intracellular calcium stores. First, the duration of the Phase 1 transient increases with duration of prior exposure to basal (2.8 mM) glucose, reflecting the increased time required to fill calcium stores that have been emptying for longer periods. Second, Phase 1 duration is reduced when islets are exposed to elevated K+ to refill calcium stores in the presence of basal glucose. Third, when extracellular calcium is removed during the basal glucose exposure to reduce calcium influx into the stores, Phase 1 duration increases. Finally, no Phase 1 is observed following hyperpolarization of the beta-cell membrane with diazoxide in the continued presence of 11 mm glucose, a condition in which intracellular calcium stores remain full. Application of carbachol to empty calcium stores during basal glucose exposure did not increase Phase 1 duration as the model predicts. Despite this discrepancy, the good agreement between most of the experimental results and the model predictions provides evidence that a calcium release-activated current mediates the Phase 1 electrical response of the pancreatic beta-cell.

Prevalence and correlates of mixed-handedness in schizophrenia.

Increased rates of nonright-handedness have been reported in schizophrenia, but a clear distinction has not been made between left- and mixed-handedness. Handedness preferences in 96 patients fulfilling DSM-III criteria for schizophrenia and 43 normal comparison subjects were assessed with the Edinburgh Handedness Inventory. A 100% criterion was used to establish left- and right-handedness. Results were analyzed with mantel-Haenszel odds ratios adjusted for age and sex. The schizophrenic group showed a significant increase in the proportion of mixed-handers compared with the normal group. There was no increase in pure left-handedness in the schizophrenic relative to the normal group. Mixed-handedness in the schizophrenic patients was significantly associated with chronicity of illness. Mixed-handed patients were less likely to have a family history of psychotic illness than patients with strong right- or left-handedness. The results indicate a neurodevelopmental rather than a genetic origin for anomalous lateralization in schizophrenia.

Magnitude and modulation of pancreatic beta-cell gap junction electrical conductance in situ.

The parallel gap junction electrical conductance between a beta-cell and its nearest neighbors was measured by using an intracellular microelectrode to clamp the voltage of a beta-cell within a bursting islet of Langerhans. The holding current records consisted of bursts of inward current due to the synchronized oscillations in membrane potential of the surrounding cells. The membrane potential record of the impaled cell, obtained in current clamp mode, was used to estimate the behavior of the surrounding cells during voltage clamp, and the coupling conductance was calculated by dividing the magnitude of the current bursts by that of the voltage bursts. The histogram of coupling conductance magnitude from 26 cells was bimodal with peaks at 2.5 and 3.5 nS, indicating heterogeneity in extent of electrical communication within the islet of Langerhans. Gap junction conductance reversibly decreased when the temperature was lowered from 37 to 30 degrees C and when the extracellular calcium concentration was raised from 2.56 to 7.56 mM. The coupling conductance decreased slightly during the active phase of the burst. Activation of adenylate cyclase with forskolin (10 microM) resulted in an increase in cell-to-cell electrical coupling. We conclude that beta-cell gap junction conductance can be measured in situ under near physiological conditions. Furthermore, the magnitude and physiological regulation of beta-cell gap junction conductance suggest that intercellular electrical communication plays an important role in the function of the endocrine pancreas.

The role of creatine kinase in the diagnosis of neuroleptic malignant syndrome.

Elevation of serum creatine kinase (CK) concentrations occurs almost invariably in neuroleptic malignant syndrome (NMS). However, the role of CK levels in the diagnosis of the syndrome remains controversial. This study measured CK levels in patients who became pyrexial while on psychotropic medication and thereby mimicked some of the features of NMS. In all of these cases a diagnosis of infectious illness was made and patients responded to appropriate antibiotic therapy without alteration in psychotropic medication. Two other groups were studied for comparison--patients on psychotropics who were apyrexial and patients who became pyrexial but were not on psychotropics. Significant, unexpected elevations of CK were documented in 70% of those patients who became pyrexial while on psychotropics--in three cases elevation of concentrations to more than 1000 IU/l (ten times reference value) were found. Thirty per cent of patients who became pyrexial but were not on psychotropics also developed elevation of CK but this was of a much smaller magnitude (< 200 IU/l in five out of six cases). The results of the study suggest that elevation of CK is a non-specific finding, particularly in patients who become pyrexial on psychotropics. Use of CK as a diagnostic criterion may lead to overdiagnosis of NMS.

Adjuvant activity of respirable iron ore dust.

The influence of the respirable fraction of an iron ore dust on immunity has been studied. The iron ore dust enhanced the specific immune responses to both sheep erythrocytes and a bacterial lipopolysaccharide. The IgG class of antibody was enhanced significantly and its pattern of enhancement suggested that the iron ore dust was functioning as an adjuvant. In studies to test this possibility further, the pattern of antibody development over both the primary and the secondary immune response to sheep erythrocytes closely matched that of Freund's incomplete adjuvant and low levels of silica. The splenocytes, from animals that had received iron ore dust for various lengths of time, exhibited enhanced polyclonal mitogenic activity for phytohaemagglutinin, in vitro. These properties were seen when the dust had been inhaled or injected into the pleural cavity and persisted for over 1 year following the injection or inhalation of the dust. Attempts to show the induction of interleukin-1 by the macrophages from mice implanted intraperitoneally with the iron ore dust were unsuccessful.