Chest radiograph interpretation skills of anesthesiologists.

OBJECTIVE: To assess the skills of anesthesiologists in the interpretation of chest radiographs. DESIGN: Randomized evaluation conducted among anesthesiologists and radiologists. SETTING: Postgraduate Assembly of the New York State Society of Anesthesiologists in 1999, and the Department of Radiology, New York University Medical Center. PARTICIPANTS: A total of 61 anesthesiologists (48 attending physicians; 13 residents); control group of 8 radiology residents (all participants volunteered). INTERVENTIONS: After completing a demographic survey, participants were asked to review a series of 10 chest radiographs. A brief clinical scenario accompanied each radiograph. No time limit was set for these interpretations. MEASUREMENTS AND MAIN RESULTS: The demographic characteristics of the anesthesiology participants included university faculty (46%), private group practitioners (41%), independent practitioners (11%), and 1 participant with an unspecified type of practice. Additional training among the participants included internal medicine (31%), surgery (19%), and pediatrics (3%); 34% did not specify any additional training. Of the participants, 92% were involved in cases requiring general anesthesia; 96% managed patients in the recovery room; and 34% managed patients in the intensive care unit. Of participants, 80% usually order chest radiographs, but only 42% interpret the films themselves. Misdiagnosed radiographs included pneumothorax by 11% of participants, free air under the diaphragm by 41%, bronchial perforation from a nasogastric tube by 28%, right mainstem intubation by 20%, superior vena cava perforation from a central venous catheter by 31%, normal film by 75%, negative pressure pulmonary edema by 16%, left lower lobe collapse by 80%, pulmonary infarction from a pulmonary artery catheter by 29%, and tension pneumothorax by 41%. Overall scores of the attending physicians were not significantly different from that of residents (p > 0.05). The control group of radiology residents scored significantly better (mean, 83.7; p = 0.009) than the anesthesia residents (mean, 62.8) and anesthesia attending physicians (mean, 62.5). CONCLUSION: Anesthesiologists are deficient in skills for the interpretation of chest radiographs. The skill level of university-based physicians is not greater than physicians in private practice, and skill level does not improve with level of training or experience. Most anesthesiologists rely on radiologists for interpretative results. Further training during the residency years may help improve diagnostic skills.

Preschool children's difficulty understanding the types of information obtained through the five senses.

Two studies explored 3- and 4-year-olds' (N = 60) understanding that the five senses can each lead to different types of knowledge. In Study 1, 40 children engaged in five scenarios in which they could only perform one sensory action to identify the property of an object (e.g., color, scent). After performing the action, children were asked how they found out the property and to show the experimenter how they had found it out. Using a Mr. Potato Head doll, children were also asked to indicate the sensory organ the doll would need to use to identify the property. In Study 2, 20 children presented with five Mr. Potato Head dolls, each sporting only one sensory organ (e.g., a nose), were asked which Mr. Potato Head could find out the property in question. The 3-year-olds performed significantly poorer than the 4-year-olds on all tasks, suggesting a marked transition in children's ability to recognize the origin of their modality-specific knowledge during the time period between 3 and 4 years of age.

Two-year-old children's sensitivity to the referential (in)efficacy of their own pointing gestures.

In three studies, two-year-old children communicated to a parent which of two out-of-reach objects contained a sticker. Across trials, the objects were positioned in different configurations so that it was possible or impossible for a child's pointing gesture to unambiguously specify one object. In Study 1, the objects used were two boxes distinguished by a different picture of a vehicle on the front, and children (n = 16; mean age 2;8) were significantly more likely to name the box's picture on trials where pointing alone could not unambiguously specify the box than on trials where it could. In Studies 2 and 3, the stickers were hidden inside different animal figures. Older two-year-olds (n = 16, mean age 2;9), but not younger two-year-olds (n = 16, mean age 2;4), showed an ability to recognize the referential (in)efficacy of their pointing gestures and to adapt their communication accordingly.

Satisfaction with epidural and intravenous patient-controlled analgesia.

OBJECTIVE: Postoperative intravenous (i.v.) versus epidural morphine patient-controlled analgesia (PCA) were compared regarding maintenance of initial PCA route, pain levels, side effects, and levels of satisfaction. Additionally, the role of preoperative attitudinal expectations in predicting postoperative levels of satisfaction with pain management as well as maintenance of initial PCA route was evaluated. DESIGN: After either abdominal or thoracic surgery, 70 eligible patients were randomized to receive morphine either through an epidural route (n = 37) or an intravenous PCA pump (n = 33). SETTING: A large tertiary university teaching hospital in a major northeastern city. OUTCOME MEASURES: Patients completed visual analogue rating scales 1 week before surgery regarding attitudes such as expectations of satisfaction with pain management after surgery and expectations of medication efficacy postsurgically. Postoperatively, beginning the day after surgery, patients were asked to complete visual analogue rating scales every 12 hours until they were discharged, for a maximum of 3 postoperative days. The scales evaluated included pain, ability to think, and satisfaction with pain control. RESULTS: There were no significant between-group differences on the postoperative visual analogue scales. Although the overall rate of changing the initial PCA route to which the patients were randomized was identical for both groups (30%), those patients who had thoracic surgery changed their route of PCA administration significantly less when their initial PCA route was epidural (20%) than when their initial PCA route was i.v. (46%) (P <.05). Patients who were satisfied with pain control postoperatively were more likely to have been started on i.v. PCA (P =.001), have lower preoperative expectations of postoperative satisfaction with pain (P <.001), and have higher preoperative expectations of medication effects on postoperative pain (P <.001). Additionally, older patients (P =.007) and patients with lower preoperative expectations of postoperative satisfaction with pain (P =.003) were more likely to adhere to their initial treatment protocol. CONCLUSIONS: Both techniques, i.v. and epidural PCA, result in high levels of satisfaction. Satisfaction with PCA can be accurately predicted in nearly three of four patients based on initial PCA route and preoperative attitudes. Additionally, maintaining the initial treatment plan can be accurately predicted based on age and preoperative attitudes. Patient expectations about pain relief should be addressed preoperatively, particularly with younger patients, for optimal results.

The effect of torque pressure on halo pin complication rates. A randomized prospective study.

At Thomas Jefferson University Hospital, 102 consecutive patients treated in a halo vest orthosis were randomized into one of two torque protocol groups based on their date of birth. The pins of patients who were born in even-numbered months were inserted with 8 inch-lbs of torque and those born in odd-numbered months were inserted with 6 inch-lbs. All patients were placed in an identical model halo using a standardized technique of application. The patients were followed prospectively, and all potential complications were evaluated by a member of the orthopedic attending staff, using protocols established at the onset of the study. Statistical analysis indicated no significant differences in halo pin loosening, infection, pain, or scarring between the torque protocols, but there was a trend toward a higher complication rate in the 8-inch-lbs group. There was no direct evidence of skull penetration in either group, and no patients developed a deep infection. Based on the results of this study, we conclude that insertion torque has no significant effect on halo pin complications within the ranges tested by this study. Our current protocol calls for routine insertion of halo pins with 6 inch-lbs of torque.

Young children's understanding of the role that sensory experiences play in knowledge acquisition.

3 studies investigated whether young children understand that the acquisition of certain types of knowledge depends on the modality of the sensory experience involved. 3-, 4-, and 5-year-old children were exposed to pairs of objects that either looked the same but felt different, or that felt the same but looked different. In Study 1, 36 children were asked to state, when one of these objects was hidden inside a toy tunnel, whether they would need to see the object or feel it in order to determine its identity. In Study 2, 48 children were asked to state which of 2 puppets knew that an object hidden inside a tunnel possessed a given visual or tactile property, when one puppet was looking at the object and the other was feeling it. In Study 3, 72 children were asked, in a scenario similar to Study 2, to state for each puppet whether he could tell, just by looking or by feeling, that the hidden object possessed a certain visual or tactile property. Children were also asked what was the best way to find out whether a given object possessed a certain visual or tactile property. Results of all 3 studies suggest that an appreciation of the different types of knowledge our senses can provide (i.e., modality-specific knowledge) develops between the ages of 3 and 5. The results are discussed in relation to young children's developing understanding of the role that informational access plays in knowledge acquisition.

Age-related decline in cell-mediated immunity in the C58 leukemic mouse strain.

The leukemia-prone C58 strain of mouse was examined for age-related changes in cellular immune function. Proliferative responses of lymphocytes to autologous and allogeneic stimulator cells [autologous mixed lymphocyte response (AMLR) and mixed lymphocyte response (MLR), respectively] and to mitogens were tested both prior to and around the usual age of disease onset which occurs at 7-8 months. Leukemia in these animals was defined by elevated peripheral blood and splenic white blood cell counts. The AMLR declined greater than 30% by 6-7 months of age and was virtually absent by 8 months of age even in animals that were not overtly leukemic. The MLR declined precipitously (greater than 95%) at 9 months of age. Both declines occurred at a younger age in C58 mice than in nonleukemic strains. Mixing experiments with cells from young and old animals indicate a defect in the Ly 1+23-, L3T4+ responding T cells. No evidence indicating a role for suppressor cell activity in this decline of cell-mediated immunity could be found. Deficiencies in cytokine (IL-2 and IL-1) production were not observed except in the oldest mice tested. Around the usual time of disease onset, splenic natural killer (NK) cell activity declines sharply even in nonleukemic mice. Cell-mixing experiments showed no evidence of suppressor cell activity by spleen cells from older mice, leukemic or nonleukemic, on the NK cell activity of young adult animals. Interferon alpha, beta treatment enhanced the NK activity of cells from old mice but did not restore the level of activity seen in young mice. Evidence has therefore been found for a premature decline in cellular immune function in two responses with proposed immunoregulatory roles, the AMLR and NK cell activity. It is possible that their decline could play a predisposing role in the onset of this retroviral leukemia or that these cell populations may be the target of the retrovirus.