Anterior vertebral tethering for adolescent idiopathic scoliosis: our initial ten year clinical experience.

BACKGROUND: Anterior vertebral tethering (AVT) is a minimally invasive alternative to fusion surgery for adolescent idiopathic scoliosis (AIS) that offers the potential for definitive scoliosis treatment with the possibility of preservation of the growth, motion, function and overall health of the spine. This study represents our first ten years using AVT to treat AIS. METHODS: In this retrospective review we analyzed our first 74 AIS patients treated with AVT 2010-2020. Multiple Lenke curve types 33-70° were treated with skeletal maturity spanning Risser -1 to 5. RESULTS: Of 74 consecutive AIS patients treated with AVT, 52 patients (47 female, 5 male) had sufficient 2-year follow-up for inclusion. Forty-six of these 52 patients (88%) with 65 curves (35T, 30TL/L) were satisfactorily treated with AVT demonstrating curve correction from 48.6° pre-op (range 33°-70°) at age 15.1 years (range 9.2-18.8) and skeletal maturity of Risser 2.8 (range -1 to 5) to 23.2° post-op (range 0°-54°) and 24.0° final (range 0°-49°) at 3.3 years follow-up (range 2-10 years). Curve corrections from pre-op to post-op and pre-op to final were both significant (p < 0.001). The 0.8° change from post-op to final was not significant but did represent good control of scoliosis correction over time. Thoracic kyphosis and lumbar lordosis were maintained in a normal range throughout while axial rotation demonstrated a slight trend toward improvement. Skeletal maturity of Risser 4 or greater was achieved in all but one patient. Four of the 52 patients (8%) required additional procedures for tether rupture (3 replacements) or overcorrection (1 removal) to achieve satisfactory treatment status after AVT. An additional 6 of the 52 patients (12%), however, were not satisfactorily treated with AVT, requiring fusion for overcorrection (2) or inadequate correction (4). CONCLUSIONS: In this study, AIS was satisfactorily treated with AVT in the majority of patients over a broad range of curve magnitudes, curve types, and skeletal maturity. Though late revision surgery for overcorrection, inadequate correction, or tether rupture was not uncommon, the complication of overcorrection was eliminated after our first ten patients by a refinement of indications. LEVEL OF EVIDENCE: IV.

Chronic Pseudoaneurysm and Anterior Dislocation After Total Hip Arthroplasty Complicated by Arterial Injury: A Case Report.

CASE: A 64-year-old man presented 18 months after total hip arthroplasty complicated by vascular injury with a history of leg pain, inability to mobilize, and progressive chronic leg edema. It is presumed that there was persistent subtle bleeding over time with pseudoaneurysm formation and prosthetic hip dislocation secondary to the mass effect. CONCLUSION: Physicians should consider pseudoaneurysm as a possible diagnosis when confronted with a large intra-articular mass in the hip after a relatively short follow-up period, particularly in the context of a prior vascular injury at the time of the index procedure.

Surgical Management of Delayed Brachial Plexopathy After Clavicle Nonunion.

SUMMARY: Brachial plexopathy after conservative therapy or surgical treatment of clavicular fractures is an uncommon, yet serious complication that is associated with compression of the brachial plexus or the subclavian artery and vein because they traverse through the thoracic outlet. Surgical decompression of the brachial plexus is the recommended treatment if this condition is to occur. Although there are multiple reports of these cases in the literature, at present, there are no clear guidelines for their management. We are highlighting an institutional management algorithm, illustrated by a small retrospective case series, that uses a multidisciplinary approach in an effort to minimize complications associated with the management of clavicle nonunion.

Pediatric liver transplant following near catastrophic head bleed: Lessons learned.

Evaluation for liver transplant candidacy is a multidisciplinary effort that involves all aspects of clinical care including social work, nutrition, and a multitude of medical specialties. The prognosis of a pretransplant clinical condition is integrated into the decision to list a patient. Herein, we report a successful liver transplant and recovery of a 3-month-old male following a large right hemispheric subdural hematoma related to acute coagulopathy secondary to undiagnosed end-stage liver disease. On presentation with jaundice, lethargy, and unequal pupils, a CT scan was obtained which demonstrated a large right subdural hematoma with herniation. Once his coagulopathy was corrected, he went for decompressive craniectomy. He survived with medically controlled seizures and improving L-sided neglect and extremity weakness. Six weeks later, given his continued neurologic recovery and worsening liver function, the decision was made to list him for liver transplantation. One month later, he underwent orthotopic liver transplant. His post-operative hospital course was complicated by DVTs and heparin-induced thrombocytopenia, but no neurologic decline, and he was eventually discharged from the hospital on post-op day 26. Three years later, he has a well-functioning allograft and no clinically evident neurologic deficits. The prognosis following pediatric neurologic trauma remains somewhat unclear as recovery and neurologic examinations can be influenced by numerous extrinsic factors. This is one of the first reports of near full neurologic recovery of a pediatric liver transplant recipient following a large subdural hematoma with herniation.

Exogenous trehalose improves growth under limiting nitrogen through upregulation of nitrogen metabolism.

BACKGROUND: The trehalose (Tre) pathway has strong effects on growth and development in plants through regulation of carbon metabolism. Altering either Tre or trehalose 6-phosphate (T6P) can improve growth and productivity of plants as observed under different water availability. As yet, there are no reports of the effects of modification of Tre orT6P on plant performance under limiting nutrition. RESULTS: Here we report that nitrogen (N) metabolism is positively affected by exogenous application of Tre in nitrogen-deficient growing conditions. Spraying foliage of tobacco (Nicotiana tabacum) with trehalose partially alleviated symptoms of nitrogen deficiency through upregulation of nitrate and ammonia assimilation and increasing activities of nitrate reductase (NR), glycolate oxidase (GO), glutamine synthetase (GS) and glutamine oxoglutarate aminotransferase (GOGAT) with concomitant changes in ammonium (NH4+) and nitrate (NO3-) concentrations, glutamine and amino acids. Chlorophyll and total nitrogen content of leaves and rates of photosynthesis were increased compared to nitrogen-deficient plants without applied Tre. Total plant biomass accumulation was also higher in Tre -fed nitrogen-deficient plants, with a smaller proportion of dry weight partitioned to roots, compared to nitrogen-deficient plants without applied Tre. Consistent with higher nitrogen assimilation and growth, Tre application reduced foliar starch. Minimal effects of Tre feeding were observed on nitrogen-sufficient plants. CONCLUSIONS: The data show, for the first time, significant stimulatory effects of exogenous Tre on nitrogen metabolism and growth in plants growing under deficient nitrogen. Under such adverse conditions metabolism is regulated for survival rather than productivity. Application of Tre can alter this regulation towards maintenance of productive functions under low nitrogen. This has implications for considering approaches to modifying the Tre pathway for to improve crop nitrogen-use efficiency and production.

Transient Coma Due To Epidural Anesthesia: The Role of Loss of Sensory Input.

BACKGROUND: Epidural anesthesia is the most commonly used method of pain relief during labor in the USA. It is not classically associated with alterations in level of alertness. Coma during the procedure is rare, with a reported incidence of 0.1-0.3%. CASE REPORT: An otherwise healthy patient experienced almost complete loss of brainstem function following routine epidural anesthesia during delivery. The episode lasted for less than 3 hours and the patient made a full recovery. To our knowledge, this is the most detailed clinical observation to date of this condition. CONCLUSIONS: Clinicians should be aware of this rare and potentially serious complication of epidural anesthesia. The case highlights the need for sensory input to maintain alertness through the activity of the ascending reticular activating system.

Systems responses to progressive water stress in durum wheat.

Durum wheat is susceptible to terminal drought which can greatly decrease grain yield. Breeding to improve crop yield is hampered by inadequate knowledge of how the physiological and metabolic changes caused by drought are related to gene expression. To gain better insight into mechanisms defining resistance to water stress we studied the physiological and transcriptome responses of three durum breeding lines varying for yield stability under drought. Parents of a mapping population (Lahn x Cham1) and a recombinant inbred line (RIL2219) showed lowered flag leaf relative water content, water potential and photosynthesis when subjected to controlled water stress time transient experiments over a six-day period. RIL2219 lost less water and showed constitutively higher stomatal conductance, photosynthesis, transpiration, abscisic acid content and enhanced osmotic adjustment at equivalent leaf water compared to parents, thus defining a physiological strategy for high yield stability under water stress. Parallel analysis of the flag leaf transcriptome under stress uncovered global trends of early changes in regulatory pathways, reconfiguration of primary and secondary metabolism and lowered expression of transcripts in photosynthesis in all three lines. Differences in the number of genes, magnitude and profile of their expression response were also established amongst the lines with a high number belonging to regulatory pathways. In addition, we documented a large number of genes showing constitutive differences in leaf transcript expression between the genotypes at control non-stress conditions. Principal Coordinates Analysis uncovered a high level of structure in the transcriptome response to water stress in each wheat line suggesting genome-wide co-ordination of transcription. Utilising a systems-based approach of analysing the integrated wheat's response to water stress, in terms of biological robustness theory, the findings suggest that each durum line transcriptome responded to water stress in a genome-specific manner which contributes to an overall different strategy of resistance to water stress.

Source/sink interactions underpin crop yield: the case for trehalose 6-phosphate/SnRK1 in improvement of wheat.

Considerable interest has been evoked by the analysis of the regulatory pathway in carbohydrate metabolism and cell growth involving the non-reducing disaccharide trehalose (TRE). TRE is at small concentrations in mesophytes such as Arabidopsis thaliana and Triticum aestivum, excluding a role in osmoregulation once suggested for it. Studies of TRE metabolism, and genetic modification of it, have shown a very wide and more important role of the pathway in regulation of many processes in development, growth, and photosynthesis. It has now been established that rather than TRE, it is trehalose 6-phosphate (T6P) which has such profound effects. T6P is the intermediary in TRE synthesis formed from glucose-6-phosphate and UDP-glucose, derived from sucrose, by the action of trehalose phosphate synthase. The concentration of T6P is determined both by the rate of synthesis, which depends on the sucrose concentration, and also by the rate of breakdown by trehalose-6-phosphate phosphatase which produces TRE. Changing T6P concentrations by genetically modifying the enzymes of synthesis and breakdown has altered photosynthesis, sugar metabolism, growth, and development which affect responses to, and recovery from, environmental factors. Many of the effects of T6P on metabolism and growth occur via the interaction of T6P with the SnRK1 protein kinase system. T6P inhibits the activity of SnRK1, which de-represses genes encoding proteins involved in anabolism. Consequently, a large concentration of sucrose increases T6P and thereby inhibits SnRK1, so stimulating growth of cells and their metabolic activity. The T6P/SnRK1 mechanism offers an important new view of how the distribution of assimilates to organs, such as developing grains in cereal plants, is achieved. This review briefly summarizes the factors determining, and limiting, yield of wheat (particularly mass/grain which is highly conserved) and considers how T6P/SnRK1 might function to determine grain yield and might be altered to increase them. Increasing the potential rate of filling and mass/grain are ways in which total crop yield could be increased with good husbandry which maintains crop assimilation Cereal yields globally are not increasing, despite the greater production required to meet human demand. Careful targeting of T6P is showing much promise for optimization of source/sink for yield improvement and offers yet further possibilities for increasing sink demand and grain size in wheat.

Using goal analysis to drive improvements in performance and outcomes.

Economic pressures for public health and human services systems to control budgets are increasing the need for demonstrating value of support services provided to persons with intellectual disabilities. In this article, we build from earlier work that presented a method for assessing goal attainment to expand the study of goal characteristics as a means to gain an improved understanding of individual outcomes and service performance. The study results suggest a positive relationship between targeting intentional skill teaching in person-centered planning and service delivery and increasing the ability of individuals to live more independently in communities with decreased levels of paid staff support. Additional areas meriting further exploration are presented and implications for current system trends are discussed.

Genetic engineering to improve plant performance under drought: physiological evaluation of achievements, limitations, and possibilities.

Fully drought-resistant crop plants would be beneficial, but selection breeding has not produced them. Genetic modification of species by introduction of very many genes is claimed, predominantly, to have given drought resistance. This review analyses the physiological responses of genetically modified (GM) plants to water deficits, the mechanisms, and the consequences. The GM literature neglects physiology and is unspecific in definitions, which are considered here, together with methods of assessment and the type of drought resistance resulting. Experiments in soil with cessation of watering demonstrate drought resistance in GM plants as later stress development than in wild-type (WT) plants. This is caused by slower total water loss from the GM plants which have (or may have-morphology is often poorly defined) smaller total leaf area (LA) and/or decreased stomatal conductance (g (s)), associated with thicker laminae (denser mesophyll and smaller cells). Non-linear soil water characteristics result in extreme stress symptoms in WT before GM plants. Then, WT and GM plants are rewatered: faster and better recovery of GM plants is taken to show their greater drought resistance. Mechanisms targeted in genetic modification are then, incorrectly, considered responsible for the drought resistance. However, this is not valid as the initial conditions in WT and GM plants are not comparable. GM plants exhibit a form of 'drought resistance' for which the term 'delayed stress onset' is introduced. Claims that specific alterations to metabolism give drought resistance [for which the term 'constitutive metabolic dehydration tolerance' (CMDT) is suggested] are not critically demonstrated, and experimental tests are suggested. Small LA and g (s) may not decrease productivity in well-watered plants under laboratory conditions but may in the field. Optimization of GM traits to environment has not been analysed critically and is required in field trials, for example of recently released oilseed rape and maize which show 'drought resistance', probably due to delayed stress onset. Current evidence is that GM plants may not be better able to cope with drought than selection-bred cultivars.

Hyperaromatic stabilization of arenium ions: a remarkable cis stereoselectivity of nucleophilic trapping of ß-hydroxyarenium ions by water.

Cis- and trans-1,2-dihydrodiol isomers of benzene undergo acid-catalyzed dehydration to form phenol. In principle the isomeric substrates react through a common ß-hydroxybenzenium (cyclohexadienyl) carbocation. Notwithstanding, the isomers show a large difference in reactivity, k(cis)/k(trans) = 4500. This difference is reduced to k(cis)/k(trans) = 440 and 50 for the 1,2-dihydrodiols of naphthalene and 9,10-dihydrodiols of phenanthrene, respectively, and to 6.9 for the dihydrodiols of the nonaromatic 7,8-double bond of acenaphthylene. Because the difference in stabilities of cis- and trans-dihydrodiols should be no more than 2-3-fold, these results imply a high cis stereoselectivity for nucleophilic trapping of a ß-hydroxyarenium cation by water in the reverse of the carbocation-forming reaction. This is confirmed by studies of the 10-hydroxy-9-phenanthrenium ion generated from aqueous solvolyses of the trans-9,10-bromohydrin derivative of phenanthrene and the monotrichloroacetate ester of the phenanthrene cis-9,10-dihydrodiol. The cis stereoselectivity of forward and reverse reactions is explained by the formation (in the "forward" reaction) of different conformations of carbocation from cis- and trans-dihydrodiol reactants with respectively ß-C-H and ß-C-OH bonds in pseudoaxial positions with respect to the charge center of the carbocation optimal for hyperconjugation. Formation of different conformations is constrained by departure of the (protonated) OH leaving group from a pseudoaxial position. The difference in stability of the carbocations is suggested to stem (a) from the greater hyperconjugative ability of a C-H than a C-OH bond and (b) from enhanced conjugation arising from the stabilizing influence of an aromatic ring in the no-bond resonance structures representing the hyperconjugation (C(6)H(6)OH(+) ↔ C(6)H(5)OH H(+)). This is consistent with an earlier suggestion by Mulliken and a demonstration by Schleyer that the benzenium ion is subject to hyperconjugative aromatic stabilization. It is proposed that, in analogy with the terms homoconjugation and homoaromaticity, arenium ions should be considered as "hyperaromatic".

Hyperaromatic stabilization of arenium ions: cyclohexa- and cycloheptadienyl cations-experimental and calculated stabilities and ring currents.

Measurements of pK(R) show that the cycloheptadienyl cation is less stable than the cyclohexadienyl (benzenium) cation by 18 kcal mol(-1). This difference is ascribed here to "hyperaromaticity" of the latter. For the cycloheptadienyl cation a value of K(R) = [ROH][H(+)]/[R(+)] is assigned by combining a rate constant for reaction of the cation with water based on the azide clock with a rate constant for the acid-catalyzed formation of the cation accompanying equilibration of cycloheptadienol with its trifluoroethyl ether in TFE-water mixtures. Comparison of pK(R) = -16.1 with pK(R) = -2.6 for the cyclohexadienyl cation yields the difference in stabilities of the two ions. Interpretation of this difference in terms of hyperconjugative aromaticity is supported by the effect of benzannelation in reducing pK(R) for the benzenium ion: from -2.6 down to -3.5 for the 1H-naphthalenium and -6.0 for the 9H-anthracenium ions, respectively. MP2/6-311+G** and G3MP2 calculations of hydride ion affinities of benzenium ions show an order of stabilities for substituents at the methylene group consistent with their hyperconjugative abilities, i.e., (H(3)Si)(2) > cyclopropyl > H(2) > Me(2)> (HO)(2) > F(2). Calculations of ring currents show a similar ordering. No conventional ring current is seen for the cycloheptadienyl cation, whereas currents in the F(2)-substituted benzenium ion are consistent with antiaromaticity. Arenium ions where the methylene group is substituted with a single OH group show characteristic energy differences between conformations, with C-H or C-OH bonds respectively occupying or constrained to axial positions favorable to hyperconjugation. The differences were found to be 8.8, 6.3, 2.4, and 0.4 kcal mol(-1) for benzenium, naphthalenium, phenanthrenium, and cyclohexenyl cations, respectively.

American Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer.

BACKGROUND/PURPOSE: Although the use of minimally invasive surgical (MIS) techniques for children with cancer is being practiced by some, its role remains unclearly defined. The purpose of this review was to describe the current literature on MIS for thoracic and mediastinal lesions in children. METHODS: We performed a literature search for English studies that evaluated MIS techniques for biopsy or resection in children with suspected or established cancer. Only studies with greater than 20 patients were included in the review. RESULTS: Ten studies were included for review. Each represented institutional retrospective reviews of experience. Seven were single-institution studies, and 3 were multi-institutional. There were no prospective nor randomized identified. CONCLUSIONS: Based on primarily retrospective and observational data, the use of MIS for children with cancer who have pulmonary and mediastinal lesions seems to be effective and safe. Ideally, prospective studies are needed to evaluate this further.

Hyperaromatic stabilization of arenium ions.

Benzene-cis- and trans-1,2-dihydrodiols undergo acid-catalyzed dehydration at remarkably different rates: k(cis)/k(trans) = 4500. This is explained by formation of a ß-hydroxycarbocation intermediate in different initial conformations, one of which is stabilized by hyperconjugation amplified by an aromatic no-bond resonance structure (HOC(6)H(6)(+) ↔ HOC(6)H(5) H(+)). MP2 calculations and an unfavorable effect of benzoannelation on benzenium ion stability, implied by pK(R) measurements of -2.3, -8.0, and -11.9 for benzenium, 1-naphthalenium, and 9-phenanthrenium ions, respectively, support the explanation.

Test of time: a case study in the functioning of social systems as a defence against anxiety: rereading 50 years on.

In this paper I revisit Isabel Menzies's classic 'nursing paper' (I.E.P. Menzies [1960]. A case-study in the functioning of social systems as a defence against anxiety: A report on a study of the nursing service of a general hospital. Human Relations, 13, 95-121). I outline the main findings of the paper and connect it to the major theoretical developments made by the Tavistock Institute of Human Relations and consider the current relevance of the paper in the contemporary field of health and social care.

Best practice updates for pediatric/adolescent weight loss surgery.

The objective of this study is to update evidence-based best practice guidelines for pediatric/adolescent weight loss surgery (WLS). We performed a systematic search of English-language literature on WLS and pediatric, adolescent, gastric bypass, laparoscopic gastric banding, and extreme obesity published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. In light of evidence on the natural history of obesity and on outcomes of WLS in adolescents, guidelines for surgical treatment of obesity in this age group need to be updated. We recommend modification of selection criteria to include adolescents with BMI >or= 35 and specific obesity-related comorbidities for which there is clear evidence of important short-term morbidity (i.e., type 2 diabetes, severe steatohepatitis, pseudotumor cerebri, and moderate-to-severe obstructive sleep apnea). In addition, WLS should be considered for adolescents with extreme obesity (BMI >or= 40) and other comorbidities associated with long-term risks. We identified >1,085 papers; 186 of the most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in pediatric/adolescent WLS are required to address advances in technology and the growing evidence base in pediatric WLS. Key considerations in patient safety include carefully designed criteria for patient selection, multidisciplinary evaluation, choice of appropriate procedure, thorough screening and management of comorbidities, optimization of long-term compliance, and age-appropriate fully informed consent.

Musings about the effects of environment on photosynthesis.

Understanding of how plants respond to their environment, particularly to extreme conditions to which their metabolisms are not adapted, is advancing on many fronts. An enormous matrix of plant and environmental factors exists from which mechanisms and assessments of quantitative responses must be developed if further progress in understanding how to improve plant (and particularly crop) production is to be achieved. This Special Issue contains assessments of different areas of plant sciences, ranging from genome to field, but with a focus on photosynthesis. Photosynthesis is central to all aspects of plant biology as the provider of energy and assimilates for growth and reproduction, yet how it is regulated by abiotic stresses, such as salinity and water deficits, and by biotic stresses, such as insect herbivory, is still unclear. Differences in responses of C3, C4 and CAM plants are still uncertain and mechanisms unclarified. Gene distribution and transfer between chloroplasts and nucleus on an evolutionary time scale may reflect conditions in the cell and organelles relevant to the short-term effects of water deficits on photosynthetic rate and the function of ATP synthase. Regulation of conditions in tissues and cells depends not only on chloroplast functions but on mitochondrial activity, and their interaction and differences in responses have implications for understanding many aspects of cell metabolism. Adaptation of plant structure, such as stomatal frequency and composition of the photosynthetic machinery by changes to gene expression controlled by transcription factors, or arising from regulation of gene expression by redox state, is of major importance with implications for adaptation in the short- and long-term. The incisive and thought-provoking reviews in this Special Issue offer analyses of experimental information and develop concepts within the complex matrix, relating photosynthesis and associated metabolism to the environment and addressing mechanisms critically with a balanced assessment of the current state of the science.

Causes of decreased photosynthetic rate and metabolic capacity in water-deficient leaf cells: a critical evaluation of mechanisms and integration of processes.

BACKGROUND: Water deficit (WD) decreases photosynthetic rate (A) via decreased stomatal conductance to CO(2) (g(s)) and photosynthetic metabolic potential (A(pot)). The relative importance of g(s) and A(pot), and how they are affected by WD, are reviewed with respect to light intensity and to experimental approaches. SCOPE AND CONCLUSIONS: With progressive WD, A decreases as g(s) falls. Under low light during growth and WD, A is stimulated by elevated CO(2), showing that metabolism (A(pot)) is not impaired, but at high light A is not stimulated, showing inhibition. At a given intercellular CO(2) concentration (C(i)) A decreases, showing impaired metabolism (A(pot)). The C(i) and probably chloroplast CO(2) concentration (C(c)), decreases and then increases, together with the equilibrium CO(2) concentration, with greater WD. Estimation of C(c) and internal (mesophyll) conductance (g(i)) is considered uncertain. Photosystem activity is unaffected until very severe WD, maintaining electron (e(-)) transport (ET) and reductant content. Low A, together with photorespiration (PR), which is maintained or decreased, provides a smaller sink for e(-)(,) causing over-energization of energy transduction. Despite increased non-photochemical quenching (NPQ), excess energy and e(-) result in generation of reactive oxygen species (ROS). Evidence is considered that ROS damages ATP synthase so that ATP content decreases progressively with WD. Decreased ATP limits RuBP production by the Calvin cycle and thus A(pot). Rubisco activity is unlikely to determine A(pot). Sucrose synthesis is limited by lack of substrate and impaired enzyme regulation. With WD, PR decreases relative to light respiration (R(L)), and mitochondria consume reductant and synthesise ATP. With progressing WD at low A, R(L) increases C(i) and C(c). This review emphasises the effects of light intensity, considers techniques, and develops a qualitative model of photosynthetic metabolism under WD that explains many observations: testable hypotheses are suggested.

Assessing goal attainment for quality improvement.

Organizations that support persons with intellectual disabilities will likely experience increasing pressure to provide evidence of the benefits of services to participants in programs. In this article we propose a model for assessing goal attainment modified from scales used with other populations that both develops from the person-centered planning process and informs on program and organizational efficacy. Implications for assessing goal attainment and considerations for applying information to improve individual, program and organization quality are presented.