Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Infusion device standardisation and dose error reduction software.

In 2004, the National Patient Safety Agency (NPSA) released a safety alert relating to the management and use of infusion devices in England and Wales. The alert called for the standardisation of infusion devices and a consideration of using centralised equipment systems to manage device storage. There has also been growing interest in smart-pump technology, such as dose error reduction software (DERS) as a way to reduce IV medication errors. However, questions remain about the progress that has been made towards infusion device standardisation and the adoption of DERS. In this article, the authors report the results of a survey investigating the extent to which the standardisation of infusion devices has occurred in the last 10 years and centralised equipment libraries are being used in practice, as well as the prevalence of DERS use within the UK. Findings indicate that while reported standardisation levels are high, use of centralised equipment libraries remains low, as does DERS usage.

Patient safety and interactive medical devices: Realigning work as imagined and work as done.

Medical devices are essential tools for modern healthcare delivery. However, significant issues can arise if medical devices are designed for 'work as imagined' when this is misaligned with 'work as done'. This problem can be compounded as the details of device design, in terms of usability and the way a device supports or changes working practices, often receives limited attention. The ways devices are designed and used affect patient safety and quality of care: inappropriate design can provoke user error, create system vulnerabilities and divert attention from other aspects of patient care. Current regulation involves a series of pre-market checks relating to device usability, but this assumes that devices are always used under the conditions and for the purposes intended (i.e. work as imagined); there are many reasons for devices being used in ways other than those assumed at development time. Greater attention needs to be paid to learning points in actual use and user experience (i.e. work as done). This needs to inform manufacturers' designs, management procurement decisions and local decisions about how devices are used in practice to achieve co-adaptation; without these, we foster risks and inefficiencies in healthcare.

Contraceptive methods and informed consent among women receiving medications with potential for adverse fetal effects: a Washington, Wyoming, Alaska, Montana, Idaho (WWAMI) region study.

BACKGROUND: Increasing diabetes, hypertension, and hypercholesterolemia rates expose some young women to medications with potential adverse fetal effects, such as angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and statins. This study examined whether quality improvement (QI) interventions promote informed consent and contraception to minimize risks with use of ACE-I/ARB/statins. METHODS: This longitudinal cohort study at 7 clinics abstracted medical records of 328 women aged 18 to 44 with ≥1 prescription for ACE-I/ARB/statins and ≥1 visit for hypertension, diabetes, or hypercholesterolemia during the previous year. We measured informed consent documentation and contraceptive methods before and after QI interventions in which providers contacted their patients to discuss medication risks and benefits. RESULTS: Of 179 women who were not surgically sterilized, only 11.7% had documented informed consent related to the risks of ACE-I/ARB/statin use. One hundred fifty-eight women were eligible for the QI intervention (not surgically sterilized, no documented informed consent); only 76 (48.1%) received the intervention. Before the intervention, 23.7% of these 76 were "at risk" of an adverse fetal effect. After the intervention, only 7.9% (P ≤ .001) were "at risk" because some women started contraception, discontinued ACE-I/ARB/statins, or changed drug class. CONCLUSIONS: Women prescribed ACE-I/ARB/statins were not consistently using contraception or were not consistently informed of the risks. Provider-implemented QI interventions improved care but were difficult to accomplish, suggesting that new interventions are needed.

PDA usage and training: targeting curriculum for residents and faculty.

BACKGROUND AND OBJECTIVES: Utilization of personal digital assistants (PDAs) in residency education is common, but information about their use and how residents are trained to use them is limited. Better understanding of resident and faculty PDA use and training is needed. METHODS: We used a cross-sectional survey of 598 residents and faculty from the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Family Medicine Residency Network regarding PDA usage and training. RESULTS: Use of PDAs is common among residents (94%) and faculty (79%). Ninety-six percent of faculty and residents report stable or increasing frequency of use over time. The common barriers to PDA use relate to lack of time, knowledge, and formal education. Approximately half of PDA users (52%) have received some formal training; however, the majority of users report being self-taught. Faculty and residents prefer either small-group or one-on-one settings with hands-on, self-directed, interactive formats for PDA training. Large-group settings in lecture, written, or computer program formats were considered less helpful or desirable. CONCLUSIONS: PDAs have become a commonly used clinical tool. Lack of time and adequate training present a barrier to optimal application of PDAs in family medicine residency education.

Cone excitation ratios correlate with color discrimination performance in the horse (Equus caballus).

Six horses (Equus caballus) were trained to discriminate color from grays in a counterbalanced sequence in which lightness cues were irrelevant. Subsequently, the pretrained colors were presented in a different sequence. Two sets of novel colors paired with novel grays were also tested. Performance was just as good in these transfer tests. Once the horse had learned to select the chromatic from the achromatic stimulus, regardless of the specific color, they were immediately able to apply this rule to novel stimuli. In terms of the underlying visual mechanisms, the present study showed for the first time that the spectral sensitivity of horse cone photopigments, measured as cone excitation ratios, was correlated with color discrimination performance, measured as accuracy, repeated errors, and latency of approach.

Processing of first-order motion in marmoset visual cortex is influenced by second-order motion.

We measured the responses of single neurons in marmoset visual cortex (V1, V2, and the third visual complex) to moving first-order stimuli and to combined first- and second-order stimuli in order to determine whether first-order motion processing was influenced by second-order motion. Beat stimuli were made by summing two gratings of similar spatial frequency, one of which was static and the other was moving. The beat is the product of a moving sinusoidal carrier (first-order motion) and a moving low-frequency contrast envelope (second-order motion). We compared responses to moving first-order gratings alone with responses to beat patterns with first-order and second-order motion in the same direction as each other, or in opposite directions to each other in order to distinguish first-order and second-order direction-selective responses. In the majority (72%, 67/93) of cells (V1 73%, 45/62; V2 70%, 16/23; third visual complex 75%, 6/8), responses to first-order motion were significantly influenced by the addition of a second-order signal. The second-order envelope was more influential when moving in the opposite direction to the first-order stimulus, reducing first-order direction sensitivity in V1, V2, and the third visual complex. We interpret these results as showing that first-order motion processing through early visual cortex is not separate from second-order motion processing; suggesting that both motion signals are processed by the same system.

Does duration of donor brain injury affect outcome after orthotopic pediatric heart transplantation?

OBJECTIVE: We tested the hypothesis that duration of donor brain injury and death would have an adverse effect on recipient rejection and mortality in pediatric heart transplantation. METHODS: Ninety-three cardiac transplants were performed at our center from July 1, 1997, through June 30, 2003. The primary study end points were the number of rejection episodes and the time to first rejection. Secondary outcomes were early and late mortality. RESULTS: Among 88 recipients of 93 cardiac allografts, 5 (6%) and 1 (1%) received second and third allografts, respectively. Overall patient mortality (3 early and 2 late) was 6% (5/88), and overall graft loss was 6% (6/93). Median time from donor brain injury to declaration of brain death (brain injury interval), time from brain death to donor cardiectomy (brain death interval), and graft ischemia time were 38, 24, and 3.3 hours, respectively. Cox regression analysis (adjusting for United Network for Organ Sharing status, ventilator dependence, extracorporeal membrane oxygenation and ventricular-assist device status, diagnosis of congenital heart disease, sex and cytomegalovirus mismatches, and type of immunosuppression) demonstrated that recipients of donor hearts with relatively long periods from brain injury to death declaration or from death to organ removal had significantly improved rejection-free survival (hazard ratios 0.3, P = .01, and 0.5, P = .05, for brain injury and brain death times, respectively). Prolonged donor heart ischemia did not impact rejection rate. Increasing brain injury interval, brain death interval, and graft ischemia time had no significant effect on mortality. CONCLUSION: Longer brain injury and death intervals correlated with improved freedom from rejection but had no effect on mortality.

Documenting procedures and deliveries during family practice residency: a survey of graduates' experiences, preferences, and recommendations.

BACKGROUND AND OBJECTIVES: The University of Washington Family Practice Residency Network (UW Network) is in the process of implementing a Palm Pilot-based procedure and delivery documentation system throughout 16 residency programs. Our study examined the experiences of past UW Network graduates in obtaining hospital privileges and in documenting procedures and deliveries. METHODS: A survey was mailed to 201 1999 and 2000 UW Network graduates, asking them questions about their experiences obtaining hospital privileges after graduation and documenting procedures and deliveries during their training. RESULTS: A total of 124 surveys (62% response rate) were analyzed. Ninety-four percent of the respondents had applied for hospital privileges, and 84% received all the privileges they requested. Forty-four percent indicated they had to provide some written documentation to get hospital privileges, but only 7% had to provide more than a numeric total of procedures or deliveries. Respondents predominantly used log cards and Palm Pilots for data collection. Palm Pilots were preferred over log cards, and the Palm Pilot systems received higher satisfaction ratings. CONCLUSIONS: For the majority of graduates, detailed delivery and procedure information was not necessary to obtain hospital privileges. Nevertheless, there are other reasons to document training experiences, and graduates strongly advise family practice residents to record their procedure and delivery experiences. Family practice residency programs should consider giving house staff handheld computers to record the procedures they perform.

The nature of V1 neural responses to 2D moving patterns depends on receptive-field structure in the marmoset monkey.

A plaid pattern is formed when two sinusoidal gratings of different orientations are added together. Previous work has shown that V1 neurons selectively encode the direction and orientation of the component gratings in a moving plaid but not the direction of the plaid itself (Movshon et al. 1985). We recorded the responses of 49 direction-selective neurons to moving gratings and plaid patterns in area V1 of the anesthetized marmoset monkey (Callithrix jacchus). The responses of V1 neurons to rectangular patches of varying lengths and widths containing gratings of optimal spatial frequency were used to measure size and aspect ratio of the receptive-field subunits. We measured responses to plaid patterns moving in different directions and graded the magnitude of the response to the direction of motion of the plaid and the response to the direction of motion of the component gratings. We found significant correlations between receptive-field structure and the type and strength of its response to moving plaid patterns. The strength of pattern and component responses was significantly correlated with the interrelated properties of direction tuning width (Spearman's r = 0.82, P < 0.001), and receptive-field subunit aspect ratio (Spearman's r = -0.79, P < 0.001). Neurons with broad direction tuning and short, wide receptive-field subunits gave their greatest response when the plaid moved in their preferred direction. Conversely, neurons with narrow direction tuning and long, narrow receptive-field subunits gave their greatest responses when the plaid moved in a direction such that one of its components moved in the preferred direction.