Equivalence of a single saline nebulised dose of formoterol powder vs three doses of nebulised Albuterol every twenty minutes in acute asthma in children: a suitable cost effective approach for developing nations.

BACKGROUND: An increase in asthma prevalence is reported from developed as well as developing nations, with rising costs from acute asthma and great expenditures to health care systems. Venezuela's Ministry of Health ambulatory facilities care for 80 % or more of a mostly urban and impoverished population of 26 million inhabitants, registering close to a million acute asthma visits per year; a nebulised fixed fenoterol-ipratropium bromide combination (Bero-dual, Boehringer-Ingelheim) in repeated dosing is the standard treatment. OBJECTIVES: to simplify acute asthma care and management in a cost effective manner employing Formoterol Fumarate powder, a long acting beta agonist with immediate bronchodilator effects. METHODOLOGY: Fifty acute asthmatic children (5-12 years old) were randomly assigned (25 patients in each group) to receive either a nebulised single dose (US $1.35) of two 12 microg Formoterol Fumarate capsules (Foradil 12 microg/cap, Novartis Pharma AG, Basel, Switzerland) diluted in 2.5 ml of sterile saline solution; or 3 doses of Albuterol (US $ 6.73) every twenty minutes for one hour (Glaxo Smith Kline Albuterol ampoules, 2.5 mg/2.5 ml, at a dose of 0.15 mg/kg/dose, maximum dose 2.5 mg). Symptoms score, oxygen saturation and lung function testing were recorded before and one hour after commencing treatments. RESULTS: Both groups improved significantly on all parameters, except for FEV(1) in the Albuterol group. CONCLUSIONS: Single dose nebulised Formoterol Fumarate (dry powder) in sterile saline solution, as depicted in this trial, is equivalent to three doses of Albuterol every twenty minutes for one hour in acute asthma in children, simplifying acute care management and at one fifth of medication costs. A pursuit of simpler and more cost effective approaches is found wanting in developing nations with depressed economies and unique cultural and socio-medical contexts; also, in countries where pharmaco-economics orients quality of health policies, novel approaches like this are worth exploring.

Equivalence of a single saline nebulised dose of formoterol powder vs three doses of nebulised Albuterol every twenty minutes in acute asthma in children: a suitable cost effective approach for developing nations

Background: An increase in asthma prevalence is reported from developed as well as developing nations, with rising costs from acute asthma and great expenditures to health care systems. Venezuela’s Ministry of Health ambulatory facilities care for 80% or more of a mostly urban and impoverished population of 26 million inhabitants, registering close to a million acute asthma visits per year; a nebulised fixed fenoterol-ipratropium bromide combination (Berodual®, Boehringer-Ingelheim) in repeated dosing isthe standard treatment. Objectives: to simplify acute asthma care and management in a cost effective manner employing Formoterol Fumarate powder, a long acting beta agonist with immediate bronchodilator effects. Methodology: Fifty acute asthmatic children (5-12 years old) were randomly assigned (25 patients ineach group) to receive either a nebulised single dose (US $1.35) of two 12 g Formoterol Fumarate capsules (Foradil® 12 g/cap, Novartis Pharma AG, Basel, Switzerland) diluted in 2.5 ml of sterile saline solution; or 3 doses of Albuterol (US $ 6.73) every twenty minutes for one hour (Glaxo Smith Kline Albuterol ampoules, 2.5 mg/2.5 ml, at a dose of 0.15 mg/kg/dose, maximum dose 2.5 mg). Symptoms score, oxygen saturation and lung function testing were recorded before and one hour after commencing treatments. Results: Both groups improved significantly on all parameters, except for FEV 1 in the Albuterol group. Conclusions: Single dose nebulised Formoterol Fumarate (dry powder) in sterile saline solution, as depicted in this trial, is equivalent to three doses of Albuterol every twenty minutes for one hour in acute asthma in children, simplifying acute care management and at one fifth of medication costs. A pursuit of simpler and more cost effective approaches is found wanting in developing nations with depressed economies and unique cultural and socio-medical contexts; also, in countries where pharmaco-economics orients quality of health policies, novel approaches like this are worth exploring

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The impact of longer-than-average anesthesia times on the billing of academic anesthesiology departments.

UNLABELLED: Academic anesthesiology departments provide clinical services for surgical procedures that have longer-than-average surgical times and correspondingly increased anesthesia times. We examined the financial impact of these longer times in three ways: 1) the estimated loss in revenue if billing were done on a flat-fee system by using industry-averaged anesthesia times; 2) the estimation of incremental operating room (OR) sites necessitated by longer anesthesia times; and 3) the estimated potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration. Health Care Financing Administration average times per anesthesia procedure code were used as industry averages. Billing data were collected from four academic anesthesiology departments for 1 yr. Each claim billed with ASA units was included except for obstetric anesthesia care. All clinical sites that do not bill with ASA units were excluded. Base units were determined for each anesthesia procedure code. The mean commercial conversion factor (US$45 per ASA unit) for reimbursement was used to estimate the impact in dollar amounts. In all four groups, anesthesia times exceeded the Health Care Financing Administration average. The loss per group in billed ASA units if a flat-fee billing system were used ranged from 18,194 to 31,079 units per group, representing a 5% to 15% decrease (estimated billing decrease of US$818,719 to US$1,398,536 per group). The number of excess OR sites necessitated by longer surgical and anesthesia times ranged from 1.95 to 4.57 OR sites per group. The potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration was estimated to be from 13,273 to 21,368 ASA units. Longer-than-average anesthesia and surgical times result in extra hours or additional OR sites to be staffed and loss of potential reimbursement for the four academic anesthesiology departments. A flat-fee system would adversely affect academic anesthesiology departments. IMPLICATIONS: We examined the economic impact of longer-than-average anesthesia times on four academic anesthesiology departments in three ways: the estimated loss in revenue under a flat-fee system, the excess operating room sites staffed, and the potential gain in revenue if the surgeries were of average length. These results should be considered both in productivity measurements and strategies for operating room management.

The relationship between graft tensioning and the anterior-posterior laxity in the anterior cruciate ligament reconstructed goat knee.

The tension applied to the anterior cruciate ligament (ACL) graft at time of fixation is thought to influence graft healing, knee kinematics, and joint contact forces; however, the optimal tensioning procedure remains unclear. An animal model provides a means by which the effect of graft tensioning on healing can be studied. Prior to using the model, the relationship between graft tensioning and knee kinematics at time of surgery should be established. Our objective was to explore the relationship between graft tensioning and anterior-posterior (A-P) laxity of the reconstructed goat knee. Eight cadaver knees were tested. The A-P laxity values of the intact knee were measured with the knee at 30 degrees, 60 degrees. and 90 degrees flexion. The ACL was then severed and the laxity measurements were repeated. The ACL was reconstructed using a bone-patellar tendon-bone autograft. The laxity measurements were repeated for nine different tensioning conditions; three tension magnitudes (30, 60, and 90 N), each applied with the knee at three angles (30 degrees, 60 degrees and 90 degrees). Both graft tension and the knee angle at which it was applied produced significant changes on A-P laxity values. An increase in tension reduced laxity values. A tension level of 60 N applied with the knee flexed to 30 degrees was the best combination for restoring normal A-P laxity values at all knee angles tested.

Accuracy and repeatability of Roentgen stereophotogrammetric analysis (RSA) for measuring knee laxity in longitudinal studies.

Roentgen stereophotogrammetric analysis (RSA) can be used to assess temporal changes in anterior-posterior (A-P) knee laxity. However, the accuracy and precision of RSA is dependent on many factors and should be independently evaluated for a particular application. The objective of this study was to evaluate the use of RSA for measuring A-P knee laxity. The specific aims were to assess the variation or "noise" inherent to RSA, to determine the reproducibility of RSA for repeated A-P laxity testing, and to assess the accuracy of these measurements. Two experiments were performed. The first experiment utilized three rigid models of the tibiofemoral joint to assess the noise and to compare digitization errors of two independent examiners. No differences were found in the kinematic outputs of the RSA due to examiner, repeated trials, or the model used. In a second experiment, A-P laxity values between the A-P shear load limits of +/-60 N of five cadaver goat knees were measured to assess the error associated with repeated testing. The RSA laxity values were also compared to those obtained from a custom designed linkage system. The mean A-P laxity values with the knee 30 degrees, 60 degrees, and 90 degrees of flexion for the ACL-intact goat knee (+/-95% confidence interval) were 0.8 (+/-0.25), 0.9 (+/-0.29), and 0.4 (+/-0.22) mm, respectively. In the ACL-deficient knee, the A-P laxity values increased by an order of magnitude to 8.8 (+/-1.39), 7.6 (+/-1.32), and 3.1 (+/-1.20)mm, respectively. No significant differences were found between the A-P laxity values measured by RSA and the independent measurement technique. A highly significant linear relationship (r(2)=0.83) was also found between these techniques. This study suggests that the RSA method is an accurate and precise means to measure A-P knee laxity for repeated testing over time.

Designing meaningful industry metrics for clinical productivity for anesthesiology departments.

IMPLICATIONS: Clinical productivity measurements that account for differences in clinical settings and concurrencies provided more precise comparisons between two anesthesiology groups. The data show that different concurrencies confound the current industry standard, "per full-time equivalent" measurements, whereas "per operating room site" and "per case" measurements allowed for more meaningful comparisons.

Utilization of multiple imperfect assessments of the dependent variable in a logistic regression analysis.

Often, in biomedical research, there are multiple sources of imperfect information regarding a dichotomous variable of interest. For example, in a study we are conducting on the relationship between cocaine use and stroke risk, information on the cocaine use of each study patient is available from three fallible sources: patient interviews; urine toxicology testing, and medical record review. Regression analyses based on a rule for classifying patients from this information can result in biased estimation of associations and variances due to the misclassification of some subjects and to the assumption of certainty. We describe a likelihood-based method that directly incorporates multiple sources of information regarding an outcome variable into a regression analysis and takes into account the uncertainty in the classification. The method can be applied when some sources of information are missing for some subjects. We show how the availability of multiple sources can be exploited to generate estimates of the quality (for example, sensitivity and specificity) of each source and to model the degree to which missing data are informative. A fitting algorithm and issues of identifiability are discussed. We illustrate the method using data from our study.

Measurement of individual clinical productivity in an academic anesthesiology department.

BACKGROUND: The ability to measure productivity, work performed, or contributions toward the clinical mission has become an important issue facing anesthesiology departments in private practice and academic settings. Unfortunately, the practice and billing of anesthesia services makes it difficult to quantify individual productivity. This study examines the following methods of measuring individual productivity: normalized clinical days per year (nCD/yr); time units per operating-room day worked (TU/OR day); normalized time units per year (nTU/yr); total American Society of Anesthesiologists (ASA) units per OR day (tASA/OR day); and normalized total ASA units per year (ntASA/yr). METHODS: Billing and scheduling data for clinical activities of faculty members of an anesthesiology department at a university medical center were collected and analyzed for the 1998 fiscal year. All clinical sites and all clinical faculty anesthesiologists were included unless they spent less than 20% of their time during the fiscal year providing clinical care, i.e., less than 0.2 clinical full-time equivalent. Outliers, defined as faculty who had productivity greater or less than 1 SD from the mean, were examined in detail. RESULTS: Mean and median values were reported for each measurement, and different groups of outliers were identified. nCD/yr identified faculty who worked more than their clinical full-time equivalent would have predicted. TU/OR day and tASA/OR day identified apparently low-productivity faculty as those who worked a large portion of their time in obstetric anesthesia or an ambulatory surgicenter. tASA/OR day identified specialty anesthesiologists as apparently high-productivity faculty. nTU/yr and ntASA/yr were products of the per-OR day measurement and nCD/yr. CONCLUSION: Each of the measurements studied values certain types of productivity more than others. By defining what type of service is most important to reward, the most appropriate measure or combination of measures of productivity can be chosen. In the authors' department, nCD/yr is the most useful measure of individual productivity because it measures an individual anesthesiologist's contribution to daily staffing, includes all clinical sites, is independent of nonanesthesia factors, and is easy to collect and determine.

The effect of tubularization on the mechanical properties of patellar tendon grafts.

To determine the effect of tubularization on the prefailure mechanical properties of bone-patellar tendon-bone autografts used for anterior cruciate ligament repair, 10 bovine bone-patellar tendon-bone grafts were tested in tension before and after tubularization with running suture. The testing protocol involved a 5-N preload, 10 preconditioning cycles to 200 N, and a final test cycle to 950 N at 1000 N/sec. Five of the grafts were tested first as harvested (flat) and then again following tubularization. The remaining five grafts were tubularized prior to the initial testing, and final testing was done with the suture removed. Raw testing data were reduced to determine the amount of stretching associated with preconditioning, as well as laxity and stiffness of the preconditioned grafts. Tubularized grafts stretched significantly more than flat grafts during preconditioning: 3.5 times as much after the first preconditioning cycle (3.8+/-1.9 mm versus 1.1+/-0.78 mm) and 3.1 times as much after 10 cycles (5.0+/-2.1 mm versus 1.6+/-0.9 mm). There was no statistically significant difference in the stiffnesses of the tubularized and flat grafts, nor did tubularization have an effect on graft laxity. Interestingly, there was a slight increase in laxity the second time each graft was tested, regardless of whether the graft was flat or tubularized when it was first tested. These results highlight the importance of preconditioning patellar tendon grafts before fixation, especially those that have been tubularized.

Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction.

Arthroscopically guided reconstruction of the anterior cruciate ligament is a common orthopaedic procedure. While many associated complications have been described in the literature, postoperative septic arthritis has received little attention. Although rare after anterior cruciate ligament reconstruction, septic arthritis can have devastating consequences. From a group of 831 consecutive patients, we report 4 (0.48%) who sustained septic arthritis. All patients had similar symptoms and were treated by the same surgeon in the same manner. All underwent immediate arthroscopic lavage, open incision, drainage of associated wounds, debridement with graft retention, and treatment with intravenous and then oral antibiotics. The patients underwent an average of 2.75 procedures after the diagnosis to eradicate the infection and restore knee motion. All patients were evaluated at an average of 3 years after surgery. We found that previous knee surgery and meniscal repair were risk factors for the development of postoperative septic arthritis. The infection was successfully eradicated, the ligament graft was preserved, and knee stability and mobility were adequately restored in all patients. However, the clinical outcome of these patients appeared to be inferior to that of patients who had undergone uncomplicated anterior cruciate ligament reconstruction. This inferior outcome appeared to be secondary to damage to the articular cartilage from the infection.

Preoperative intra-articular morphine and bupivacaine for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine whether intra-articular injection of bupivacaine, morphine, or a combination prior to surgery provided pain control after arthroscopic anterior cruciate ligament (ACL) reconstruction. METHODS: These data were collected as a two-stage prospective, randomized, blinded observer study. All patients received a standard general anesthetic, which included an intra-articular injection 20 minutes prior to incision. In phase I, three solutions were assigned randomly in a 60-mL volume. Group 1 was saline, group 2 was 0.25% bupivacaine, and group 3 was 0.25% bupivacaine with 1 mg morphine sulfate (MS). Phase II was identical to phase I in technique and had four groups. Group 1 was 0.25% bupivacaine, group 2 was 1 mg MS in saline, group 3 was 0.25% bupivacaine with 1 mg MS, and group 4 was 0.25% bupivacaine with 3 mg MS. All groups in phases I and II contained 1:200,000 epinephrine, freshly added. Pain scores were evaluated at 0, 30, 60, 90, 120, and 240 minutes postoperative using a visual analog scale. For pain scores of 5 or greater, 50 microg fentanyl was administered at 5-minute intervals until pain was controlled. After transition from phase I to phase II of the postanesthesia care unit (PACU), hydrocodone/acetaminophen tablets were used. RESULTS: Thirty patients were entered into phase I of the study. Both treatment groups (2 and 3) had significant (P < .05) pain reduction on arrival to the PACU. Group 3 had significantly (P < .05) reduced need for fentanyl during the PACU stay. Forty-nine patients entered phase II of the study. In phase II, group 3 had the lowest pain scores on arrival to the PACU. At 120 and 240 minutes, pain scores were lower in groups 3 and 4. Fentanyl and hydrocodone uses were significantly lower during the PACU stay in groups 3 and 4. CONCLUSIONS: Presurgical injection of a solution of 0.25 % bupivacaine, morphine, and epinephrine provided pain control and decreased opioid use in the PACU. Increasing the morphine dose did not improve the clinical result.

Initial fixation strength of polylactic acid interference screws in anterior cruciate ligament reconstruction.

The initial fixation properties of bioresorbable polylactic acid (PLA) interference screws designed for anterior cruciate ligament reconstruction were evaluated using an in vitro bovine model. The surgical technique of interference screw fixation of the bone-patellar tendon-bone autograft complex performed clinically was reproduced in an adult bovine model. The reconstructed knee was tested oriented in 30 degrees of flexion to allow examination of the femoral and tibial fixation properties simultaneously. This model examined the initial fixation strength between PLA and metal interference screws as well as a partially degraded PLA implant. Data from this in vitro model indicate that PLA interference screws can provide similar initial fixation at both time 0 and after degradation for up to 28 days compared with metal interference screws for bone-tendon-bone ACL reconstructions.

Functional outcome analysis of operatively treated malleolar fractures.

OBJECTIVES: Assessment of functional outcome after malleolar fractures. DESIGN: Retrospective call-back review of 40 patients who agreed to assessment 8-24 months after malleolar fractures. SETTING: Acute care hospital/Level 1 trauma center with university-based orthopaedic residency. PTS/PARTICIPANTS: 1) 10 skeletally mature patients who agreed to a telephone request to return for review 8-24 months after isolated malleolar fractures (36 44B2.2, 3 44A2.3, 1 44C2.2). All had healed without apparent complications. 2) Control group of 40 age matched healthy individuals without ankle problems. INTERVENTION: ORIF with standard AO/ASIF techniques. MAIN OUTCOME MEASUREMENTS: Ankle score of Olerud and Molander, UCLA Activity Score, Pedometer count of average number of steps per day. RESULTS: Patients had a mean Ankle Score of 72 (+/-19.3) vs. 100 (+/-0) for controls (p < .01). The UCLA Activity Score averaged 6.0 (+/-1.95) for the patients vs. a mean of 9.43 (+/-1.0) for controls (p < .01). Patients took an average of 4,838 steps per day (+/-3,252) vs an average of 7,607 steps per day (+/-2,859) by controls (p < .01). CONCLUSIONS: Significant impaired function persists for most patients 8-24 months after malleolar fractures.

Meniscal and nonosseous ACL injuries in children and adolescents.

Meniscal and nonosseous anterior cruciate ligament (ACL) injuries are being recognized in children and adolescents more frequently. This increase appears to be the result of better diagnostic skills, newer imaging techniques, and the ever-increasing physical demands of organized youth sports. We retrospectively reviewed all cases of knee arthroscopy performed at Brown University School of Medicine from August 1991 to April 1994 in patients < or = 15 years. Of the 24 patients with suspected meniscal or nonosseous ACL injuries based on history and physical examination, 18 (75%) were confirmed at arthroscopy. Fifty-six percent of the patients with nonosseous ACL tears had coexistent meniscal lesions. Twenty-one percent of the meniscal tears were peripheral and showed evidence of spontaneous healing at time of arthroscopy. Seventeen of these patients underwent preoperative magnetic resonance imaging (MRI). Four of the five patients with lateral meniscal tears, all three of the patients with medial meniscal tears, and both of the patients with ACL tears were identified correctly by MRI. This study suggests that a history and physical examination consistent with a meniscal or nonosseous ACL injury will be confirmed by arthroscopy in up to three quarters of adolescent patients. Therefore, the use of MRI should be reserved for those patients in whom the clinical findings are still in question after a careful history and physical examination has been completed.

Role of ornithine as a proline precursor in healing wounds.

The successful healing of wounds requires the local synthesis of significant amounts of collagen. The amino acid pool that is the immediate precursor for collagen synthesis within wounds has not been specifically identified but is likely to include the free amino acids contained in the extracellular wound fluid. This fluid is here shown to be rich in proline and its metabolic precursors: ornithine, glutamate, and glutamine. While the metabolic origins for wound fluid glutamine and glutamate remain undetermined, ornithine is known to be synthesized locally through the catabolism of arginine by arginase. Experiments reported here tested the hypothesis that ornithine accumulating in the extracellular space of wounds serves as a precursor for proline contained in fibroblast secretory proteins. Results demonstrated that little ornithine is directly incorporated as protein-bound proline by wound-derived fibroblasts in culture and that the incorporation ornithine-derived proline into protein is markedly suppressed by preformed proline. In turn, the appearance of ornithine-derived free proline in the culture supernatants is quantitatively more important than its incorporation into protein and it is enhanced, rather than suppressed, by preformed proline. Therefore, ornithine may contribute to the synthesis of protein-bound proline in wounds by increasing the extracellular pool of free proline.

"Rib-hooks," "pressure points," and "hugs": technical hints for improving two-dimensional echocardiographic imaging.

The two-dimensional echocardiographic image has improved greatly over the past decade due in great part to improved technology. Yet it should be remembered that the skill of the cardiac sonographer is still an important factor in acquiring an adequate echocardiographic examination. This article has presented new approaches and adjustments to the standard approaches in acquiring routine two-dimensional images. It is the belief of the authors that the cardiac sonographers may improve their two-dimensional imaging by using the rib hooks, pressure points, and hugs described.

Biomechanical evaluation of interference screw fixation in a bovine patellar bone-tendon-bone autograft complex for anterior cruciate ligament reconstruction.

A bovine model was developed for biomechanical evaluation of anterior cruciate ligament (ACL) reconstruction using patellar bone-tendon-bone (b-t-b) autograft to examine the differences in time zero fixation mechanical properties of different interference screw lengths and diameters. The surgical technique of interference screw fixation of the b-t-b complex performed clinically was reproduced in a controlled animal model. The femur-patellar tendon graft-tibia complex was tested with anterior displacement of the tibia in 30 degrees of knee flexion to allow examination of the femoral and tibial fixation properties simultaneously. The statistical model concurrently explored differences between screw length and diameter while accounting for variations between graft properties. No statistically significant differences were found between the 7- and 9-mm screws with respect to peak load or energy to failure when using a 10-mm triangular graft in a 10-mm tunnel. The 7- and 9-mm screws were superior to the 5.5-mm screws with respect to these same parameters. Based on our results, the 7-mm interference screws can be used with equal confidence as the 9-mm screw, and the 20-mm length can be similarly exchanged for 30-mm length for patellar b-t-b graft fixation.

Nitric oxide production is required for murine resident peritoneal macrophages to suppress mitogen-stimulated T cell proliferation. Role of IFN-gamma in the induction of the nitric oxide-synthesizing pathway.

Lymphocyte proliferation in Con A- or LPS-stimulated murine splenic cell (SC) cultures was suppressed by the addition of excess macrophages. In Con A-stimulated cultures, suppression was associated with the expression of nitric oxide-synthesizing pathway (NOSP) activity as demonstrated by the accumulation of nitrite, a degradation product of nitric oxide (NO), in the culture supernatants. That NO, a cytotoxic and anti-proliferative metabolite of l-arginine, or other reactive nitrogen intermediates generated through the NOSP mediated the suppressive effect was suggested by the reversal of suppression brought about by the addition of a specific inhibitor of the NOSP (NG-monomethyl-l-arginine acetate) to the culture media. No NOSP activity was detectable in LPS-stimulated SC/macrophage cocultures. The role of T cell-derived IFN-gamma in the induction of the NOSP was investigated by the use of anti-IFN-gamma-mAb. Antibody-treated Con A supernatants failed to induce the NOSP in macrophages, and the addition of the mAb to Con A-stimulated SC/macrophage cocultures obviated the suppressive effects. Indomethacin and catalase only partially restored proliferation in Con A-stimulated SC/macrophage cocultures but were remarkably efficient in preventing macrophage-dependent suppression when LPS was used as the mitogenic stimulus. These results demonstrate a regulatory system of potential relevance in sites of predominant macrophage infiltration by which T cell-derived IFN-gamma activates the production of the mediator, NO, that suppresses T cell proliferation. In addition, these data demonstrate that, although the suppressive effects of excess macrophages appear to be expressed nonspecifically toward both T and B cells, suppression is mediated through a different mechanism in each case.

The JH/LVOH method in the quantification of aortic regurgitation: how the cardiac sonographer may avoid an important potential pitfall.

Color flow Doppler allows for methods in which to quantitate the severity of valvular regurgitation. In particular, the regurgitant jet height/left ventricular outflow tract height (JH/LVOH) method of quantitating the severity of aortic regurgitation has been validated and is routinely used in the adult echocardiography laboratory. A potential pitfall exists in the measurement of the LVOH. This article points out this potential source of error and, in addition, proposes steps that may be taken by the cardiac sonographer to avoid this potential measurement pitfall.