Medical specialists prefer to withdraw familiar technologies when discontinuing life support

OBJECTIVE: To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The hypothesis was that each specialty would be more comfortable withdrawing its "own" form of life support relative to other forms and other specialties. DESIGN: Mail survey. SETTING: 24 medical centers. PARTICIPANTS: 225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted to clinical practice. MEASUREMENTS: The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics. The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed their preferences in response to hypothetical clinical vignettes. RESULTS: In five of the six specialties, the specialists had a relative preference for withdrawing their "own" form of life support, compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of life support closely linked with their own specialty. CONCLUSIONS: Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to reach for different technologies first when ceasing treatment. Specialists' preferences for different ways to withdraw life support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained are physicians' patterns of practice.     

Effect of contrast concentration on abdominal enhancement in the rabbit: spiral computed tomography evaluation

BACKGROUND: Langerhans' cell histiocytosis (LCH) is an uncommon, poorly understood granulomatous disease, characterized by the idiopathic proliferation of Langerhan's cells or their marrow precursors. In 1985, the Philadelphia Work-shop adopted the term "Langerhans' cell histiocytosis" (LCH) to differentiate it from reactive and neoplastic causes of histiocytosis. METHODS: This study includes 73 pediatric patients diagnosed with this condition in Dublin, Ireland, and Nottingham, England, during a 34-year period (1959 to 1993). These patients are reviewed with respect to clinical presentation, difficulty with making a histological diagnosis, their management, and outcome. RESULTS: A total of 49 patients (67%) had head and neck involvement. Bony involvement was the most frequent sign, most frequently located in the skull. There were 11 deaths (15%) in this series, all associated with multisystem disease, and nine of these deaths were in children younger than 2 years of age. CONCLUSIONS: The role of otolaryngologists is important in the early and accurate evaluation, staging, and diagnosis of LCH. It may mimic more common diseases, such as otitis externa, acute mastoiditis, skin rash, gingivitis, or cervical lymphadenopathy. Patients with multisystem disease may be so ill at presentation that the head and neck lesions may be overlooked. The current management of LCH has become increasingly conservative, and in the 1990s, fewer cases are given chemotherapy or radiotherapy. The prognosis is very good for single-system disease and poor for multisystem disseminated disease with early onset.     

Characterization of laser hardened steels by laser induced ultrasonic surface waves

Ultrasonic surface waves are suitable for the characterization of surface hardened materials. This is shown on laser hardened turbine blades. The martensitic microstructure within the surface layer of surface hardened steels has a lower surface wave propagation velocity than the annealed or normalized substrate material. Because the propagation velocity depends on the ratio of layer thickness to wavelengthd/, its measurement allows the determination of the hardening depth. If the surface wave frequency is high enough, the surface wave propagates mainly within the hardened layer. A correlation of the surface wave velocity to the surface hardness has been found. Because the variation of the surface velocity in hardened steels is small, a high measurement accuracy is necessary to obtain the interesting hardening parameters with sufficient certainty. Therefore, a measuring arrangement has been developed where laser pulses, guided by optical fibers to the surface hardened structure, generate simultaneously surface wave pulses at two different positions. The two ultrasonic pulses are received by a piezoelectric transducer. The surface wave velocity is obtained from the time delay between these pulses which is determined by the cross-correlation method. To evaluate simultaneously surface waves with different penetration depths from the same signal acquisition, digital filtering has been used in connection with the cross-correlation.     

高性能混凝土结构在热带海洋环境下的服役寿命

近些年,高性能混凝土以其高强度,高抗渗性、抗冻融性、耐腐蚀性的特点得到了越来越广泛的应用。本文通过实验所得数据,简要分析了高性能混凝土在南海热带海洋环境下对混凝土结构服役寿命的影响。结果表明:运用高性能混凝土能大幅度延长混凝土结构的使用寿命。对于港口、防波堤等结构,在热带海洋环境下按照现行规范《水运工程混凝土施工规范》(JTS 202-2011)中规定的最小保护层厚度(65mm)进行设计,不能达到50年的寿命要求,必须增加保护层的厚度至75mm,或者施加附加防护措施,才能满足寿命要求。     

Gains and losses of the XII-VII component of the "baby-sitter" procedure: a morphometric analysis

The classic hypoglossal transfer to the facial nerve is invariably followed by complications caused by tongue atrophy. In 1984, Terzis introduced the "baby-sitter" procedure which involved a formal cross-facial procedure, in addition to partial neurectomy of the hypoglossal nerve, and an end-to-side coaptation with the ipsilateral facial nerve. This reported study provides, for the first time, quantification of the number of hypoglossal motor fibers needed to successfully restore eye sphincter function, using an end-to-side coaptation with preservation of the tongue. Thirty adult Sprague-Dawley rats were divided into six groups: control, denervated, perineurial window, 20 percent partial neurectomy (PN), 40 percent PN, and 80 percent PN. The procedure involves interposing a nerve graft (saphenous) between the partially severed XII nerve and the upper zygomatic branch of the facial nerve. Evaluation of the behavioral data (blink reflex) revealed good-to-superb return of the blinking mechanism in the 40 percent group, without significant tongue atrophy. Electrophysiologic data in the 40 percent neurectomy group demonstrated superiority to the other groups. Quantitative axonal morphometry of the coaptation sites and graft, as well as motor end-plates of the orbicularis oculi muscle and tongue showed the 40 percent partial neurectomy group to be the optimal group.     

Are there cognitive subtypes in adult attention deficit/hyperactivity disorder?

There has been increasing knowledge of the treatment, diagnosis, and demographics of adults with residual attention deficit/hyperactivity disorder (ADHD). However, less is known about the neuropsychological functioning in adults with residual ADHD. In comparing the clinical neuropsychological test performance of a group of adult clinic patients with residual ADHD (N = 30) with that of normal controls (N = 10), we found the patients performed worse on the Trail Making Test, a visual continuous performance test, and the "Brown-Peterson" Auditory Consonant Trigrams Test, but not on any other neuropsychological measures. This pattern indicated a deficit in the area of executive control type functioning, a functional deficit that could be linked to dysregulation of frontal lobe brain systems. Of equal interest was that patients diagnosed with ADHD/hyperactive impulsive type (ADHD+) and patients diagnosed with ADHD/inattentive type (ADHD-) had different types of executive system deficits. ADHD+ was associated with relative deficiency on the Wisconsin Card Sorting Test. ADHD- was associated with relative deficiency on the "Brown-Peterson" Auditory Consonant Trigrams Test, a measure of working memory, as well as less olfactory identification on a smell identification test. The data are discussed in terms of recent localization theories of frontal lobe function. The preliminary data suggest that the different cognitive weaknesses of ADD subtypes may be linked to dysregulation of separate frontal brain regions and/or neurotransmitter systems.     

Differences between completers and early dropouts from 2 HIV intervention trials: a health belief approach to understanding prevention program attrition

OBJECTIVES: The purpose of this study was to identify factors predicting program attrition among participants in human immunodeficiency virus (HIV) risk reduction trials. METHODS: Participants were gay/bisexual men and severely mentally ill adults recruited to take part in HIV risk reduction small-group interventions. Program completers were compared with participants who were assessed at baseline but then failed to attend any sessions. The health belief model provided a framework for selection of possible predictors of program attrition. RESULTS: Younger age was associated with early dropout in both samples. Other predictors among gay/bisexual men included involvement in an exclusive sexual relationship, minority ethnicity, injection drug use, and higher perceived severity of AIDS. Severely mentally ill dropouts were less knowledgeable about safer sex methods and more likely to hold positive outcome expectancies for condom use. CONCLUSIONS: Evaluation of intervention effectiveness among vulnerable population segments is threatened if there is selective attrition. Better methods are needed to attract and maintain participation in HIV prevention programs. Alternatively, wider application of "intention to treat" analysis of intervention outcomes is recommended to minimize selection bias due to program dropout.     

Integration of refractive micro-optical elements with differential-pair optical-thyristor arrays

We demonstrate a refractive micr-optical system by using ion-exchange microlenses and microprisms, which are combined to generate a superposition of two shifted images. The microlenses, fabricated with field-assisted Ag-Na exchange, achieve diffraction-limited imaging with a single-lens system and with a double-lens system for a field of 800 μm × 800 μm. Furthermore, we demonstrate cascading of two separate differential-pair optical-thyristor arrays by transcribing the information of a source array onto a second destination array.