OBJECTIVE. We performed this study to assess the usefulness of a computer auto- mated scan techno... more OBJECTIVE. We performed this study to assess the usefulness of a computer auto- mated scan technology (CAST) for individualizing scan delay during helical CT to improve the efficiency of hepatic enhancement. SUBJECTS AND METHODS. We prospectively evaluated I 83 patients who were randomized into five groups. Control patients received 100 or 150 ml of contrast material (320 mg IJml) with
Underrepresentation of minorities in research creates challenges to achieving equity in health ou... more Underrepresentation of minorities in research creates challenges to achieving equity in health outcomes. The legacy of unethical research involving minorities has affected their research participation. Regulations established to address such ethical breaches do not adequately address other significant barriers with profound ethical implications such as lack of trust, power differences, participant burden, limited access to healthcare and to research opportunities, and perceptions that researchers' priorities are not responsive to minority concerns. Efforts to address these issues benefit from intentional structural supports that include community advisory boards (CABs), shared financial resources, community health workers (CHWs), and community-based participatory research (CBPR) approaches. This presentation addresses formative and process data characterizing a community research infrastructure initiated in 2010 to ethically engage minorities in research as both partners and par...
Underrepresentation of racial minorities in research contributes to health inequities. Important ... more Underrepresentation of racial minorities in research contributes to health inequities. Important factors contributing to low levels of research participation include limited access to health care and research opportunities, lack of perceived relevance, power differences, participant burden, and absence of trust. We describe an enhanced model of community engagement in which we developed a community-linked research infrastructure to involve minorities in research both as participants and as partners engaged in issue selection, study design, and implementation. We implemented this effort in Jefferson County, Arkansas, which has a predominantly black population, bears a disproportionate burden of chronic disease, and has death rates above state and national averages. Building on existing community-academic partnerships, we engaged new partners and adapted a successful community health worker model to connect community residents to services and relevant research. We formed a community advisory board, a research collaborative, a health registry, and a resource directory. Newly formed community-academic partnerships resulted in many joint grant submissions and new projects. Community health workers contacted 2,665 black and 913 white community residents from December 2011 through April 2013. Eighty-five percent of blacks and 88% of whites were willing to be re-contacted about research of potential interest. Implementation challenges were addressed by balancing the needs of science with community needs and priorities. Our experience indicates investments in community-linked research infrastructure can be fruitful and should be considered by academic health centers when assessing institutional research infrastructure needs.
Too often, populations experiencing the greatest burden of disease and disparities in health outc... more Too often, populations experiencing the greatest burden of disease and disparities in health outcomes are left out of or ineffectively involved in academic-led efforts to address issues that impact them the most. Community-based participatory research (CBPR) is an approach increasingly being used to address these issues, but the science of CBPR is still viewed by many as a nascent field. Important to the development of the science of CBPR is documentation of the partnership process, particularly capacity building activities important to establishing the CBPR research infrastructure. This paper uses a CBPR Logic Model as a structure for documenting partnership capacity building activities of a long-term community-academic partnership addressing public health issues in Arkansas, U.S. Illustrative activities, programs, and experiences are described for each of the model's four constructs: context, group dynamics, interventions, and outcomes. Lessons learned through this process wer...
The goal of the preoperative workup in patients with suspected periampullary carcinoma is to esta... more The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.
Progress in Community Health Partnerships: Research, Education, and Action, 2007
Long-term care (LTC) is a major health policy issue owing to increasing LTC expenditures and the ... more Long-term care (LTC) is a major health policy issue owing to increasing LTC expenditures and the anticipated growth in the aging population. However, accessing LTC services, especially home- and community-based LTC services, is often difficult. This manuscript describes the Community Connector Program, the first known program to use a model in which community health workers (CHWs) help to connect adults in need of LTC to such services. We examine the community-university-government agency partnership created to implement and evaluate the program, summarize the evaluation design, and provide first-year implementation results. Descriptive statistics were used to characterize persons served and services to which persons were connected. The quasi-experimental evaluation design, which is planned to estimate the program's impact on LTC service utilization and costs within the Arkansas Medicaid program, is described. Community Connectors linked 686 persons (92% > or =18 years, 80% African American, 58% female) to at least one needed service. Only 39% of adults served needed LTC based on an LTC screening tool. Nearly all (93%) adults in need of LTC had health insurance; 53% had Medicare; 37%, both Medicare and Medicaid; and 11%, Medicaid. Community Connectors referred adults in need of LTC to 68 agencies and helped them to connect to services to address an average of two needs per adult. Preliminary results from the first-year implementation evaluation indicate the program is effective in linking persons to needed LTC, although program refinements were made to improve targeting of intended program recipients.
The rapidly developing science of nutrition has demanded specific knowledge concerning the physio... more The rapidly developing science of nutrition has demanded specific knowledge concerning the physiologic effects of indi vidual foods as they undergo the various phases of digestion, absorption, and utilization. Frequently, in dietetic practice, one food is substituted for another on the basis of a single food principle without regard for equally important compo nent parts of the diet. It is
Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but the... more Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but there is limited appreciation of which characteristics of patients or operations are reliable markers of increased wound infection risk. The purpose of the present study was to analyze all wound infections observed after infrainguinal bypass operations during 20 years of practice in a large teaching institution. Independent risk factors for wound infection development were identified. During the 20-year period ending 31 December, 1997, 978 male patients underwent infrainguinal bypass operations at the Minneapolis Department of Veterans Affairs Medical Center. Wound infections complicated the recovery of 129 of these patients during a 30-day postoperative surveillance interval. Multivariate logistic regression analysis was used to test the association between wound infection occurrence and putative risk factors that were either features of patients or characteristics of the operations. The following variables were examined: obesity, prosthetic graft placement, diabetes mellitus, steroid use, anticoagulation use, length of preoperative hospital stay, development of incisional hematoma, duration of operation, and the preoperative presence of a non-healing wound in the extremity being revascularized. The overall wound infection rate was 13.2% (129/978). In a final logistic regression model, obesity was a significant and independent predictor of wound infection (Relative Risk 2.6, 95% confidence interval, 1.35-4.90), as was development of a post-operative incisional hematoma (Relative Risk 6.44, 95% confidence interval, 2.95-14.08). No other explanatory variable was significantly associated with wound infection development.
To analyze hepatic enhancement by using Smart Prep protocols appropriate for children of differen... more To analyze hepatic enhancement by using Smart Prep protocols appropriate for children of different weight groups and 2:1 pitch helical CT imaging as the investigative tools. A group of 55 children ranging in weight between 20 and 180 lbs underwent 67 contrast-enhanced abdominal helical CT examinations using Smart Prep (GE Medical Systems, Milwaukee, Wisc.). Of these studies, 21 (31 %) were excluded because of failure to follow the prescribed Smart Prep protocols. Smart Prep protocols were established for nine different weight groups. Scan delay, aorta and liver time to peak, and liver enhancement over baseline were recorded. Optimal abdominal CT studies with adequate contrast enhancement of hepatic and portal veins were obtained in 46 patients. There was no significant difference in the time between peak aortic and the liver enhancement among different weight groups (mean time 12.0 +/- 7.1 s for all children). However, the mean hepatic enhancement over baseline in children weighing < 30 lbs was below 50 Hounsfield units (HU) compared to the rest of the children who had mean hepatic enhancement of > 50 HU. Two-thirds of the Smart Prep protocols were successfully implemented, and all of these resulted in good contrast enhancement of hepatic and portal veins. Optimal mean liver enhancement (> 50 HU) was seen in children >/= 30 lbs. Children < 30 lbs had mean liver enhancement of 33 HU +/- 7.2 above the baseline likely caused by contrast dose.
Pyogenic granuloma (PG) of the eyelid and orbit is typically associated with trauma or surgery. W... more Pyogenic granuloma (PG) of the eyelid and orbit is typically associated with trauma or surgery. We report a rare case of an orbital intraconal PG arising de novo in association with an orbital artery.
Return of bowel function after radical prostatectomy surgery may be the limiting factor in discha... more Return of bowel function after radical prostatectomy surgery may be the limiting factor in discharging these patients from the hospital. Recent studies have shown that postoperative epidural infusion of bupivacaine decreases time to return of bowel function compared with intravenous and epidural morphine in patients after abdominal surgery. This study focuses on the role of the intraoperative anesthetic technique on recovery of bowel function, intraoperative blood loss, and the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing radical retropubic prostatectomy and pelvic lymphadenectomy. Forty patients undergoing prostatectomy were randomized to either group A (general endotracheal anesthesia, including muscle relaxation and mechanical ventilation, followed by postoperative intravenous morphine patient-controlled analgesia) or group B (thoracic epidural anesthesia using bupivacaine, combined with "light" general anesthesia using a laryngeal mask airway and spontaneous ventilation, followed by epidural morphine analgesia). Intra- and postoperative data were collected on blood loss, volumes of crystalloid and colloid infused, blood transfused, duration of anesthesia and surgery, anesthetic and surgical complications, time to recovery of bowel function, quality of postoperative pain control, and time to discharge from hospital. Each patient underwent lower extremity venous ultrasonography to detect DVT. Twenty-one patients received general anesthesia and 19 received combined epidural and general anesthesia. Intraoperative blood loss was significantly lower in the epidural group, and times to first flatus and first bowel movement were also shorter in this group. There were no significant differences in duration of anesthesia or surgery, quality of postoperative analgesia, side effects of analgesia, or time to discharge from hospital. There was no DVT detected in any patient. The combined anesthetic technique of thoracic epidural anesthesia and "light" general anesthesia with spontaneous ventilation decreased intraoperative blood loss and shortened the time to return of bowel function. However, this earlier return of bowel function was not great enough to realize a difference in time to hospital discharge. There was no evidence of increased complications secondary to epidural anesthesia or of prolonged anesthetic time necessary to place epidural catheters.
1. J Pediatr Oncol Nurs. 1998 Jul;15(3 Suppl 1):10-7. Challenges and issues in conducting descrip... more 1. J Pediatr Oncol Nurs. 1998 Jul;15(3 Suppl 1):10-7. Challenges and issues in conducting descriptive decision-making studies in pediatric oncology: a tale of two studies. Hinds PS, Oakes L, Quargnenti A, Furman W, Sandlund JT, Bowman L, Olson MS, Heideman R. ...
Pediatric oncology nurses experience role-related stressors, some of which are inherent to the sp... more Pediatric oncology nurses experience role-related stressors, some of which are inherent to the speciality, and their consequences. Despite these difficulties, nurses continue in the specialty. One variable that helps to explain their continued commitment is "meaning", or what pediatric oncology nurses find to be most significant and satisfying in their roles. One technique for determining meaning in a role is to inquire about the peak (significant and positive) and nadir (significant and negative) role-related experiences and the consequences of both kinds of experiences. The purpose of this study was to identify the peak and nadir experiences of pediatric oncology nurses and the short- and long-term consequences of those experiences. Using an interview format that consisted of four open-ended questions and a convenience sampling plan, five nurses interviewed 26 nurses from one pediatric cancer center and 38 nurses from a national sample. The interviewers completed an initial training session on interviewing and repeated that training two more times during data collection. Written or taped oral consent was obtained at the time of each interview. Using a content analytical technique (Krippendorff, 1980), four nurses independently coded each interview. Agreement ratings ranged from 75% to 100% per coded theme for an overall agreement level of 92%. Training for the coding process occurred initially and periodically throughout the analysis period. Fifteen different themes for peak experiences were identified, the majority of which reflect the nurses' experience with patients dying, or with patients recovering and living normal lives, or with the close relationships that develop between nurses and patients. Multiple short- and long-term consequences were identified and included changes in (1) values (becoming less judgmental), (2) behaviors (giving more empathic care), and (3) perspective (accepting limitations of care). Twenty-three different nadir themes were identified. A shared characteristic of several of these themes is the nurses' regret over a perceived inadequacy in handling a situation. Another common element is witnessing patient suffering and feeling unable to adequately relieve the suffering or provide comfort to the patient. The short-term consequences of nadir experiences tend to be negative and include guilt, anger, or dread. The long-term consequences tend to be positive and similar to the long-term consequences of peak experiences. Study findings indicate that pediatric oncology nurses do find meaning in their roles and that those who continue in the speciality are able to experience positive long-term consequences. Study findings will be used to develop a new scale to measure role-related meaning and to develop interventions designed to assist nurses in finding meaning in their roles even during particularly stressful periods.
International Journal of Radiation Oncology*Biology*Physics, 2000
A thorough dose-volume analysis of a standard tangential radiation technique has not been publish... more A thorough dose-volume analysis of a standard tangential radiation technique has not been published. We evaluated the adequacy of a tangential radiation technique in delivering dose to the breast and regional lymphatics, as well as dose delivered to underlying critical structures. Treatment plans of 25 consecutive women with breast cancer undergoing lumpectomy and adjuvant breast radiotherapy were studied. Patients underwent two-dimensional (2D) treatment planning followed by treatment with standard breast tangents. These 2D plans were reconstructed without modification on our three-dimensional treatment planning system and analyzed with regard to dose-volume parameters. Adequate coverage of the breast (defined as 95% of the target receiving at least 95% of the prescribed dose) was achieved in 16 of 25 patients, with all patients having at least 85% of the breast volume treated to 95% of the prescribed dose. Only 1 patient (4%) had adequate coverage of the Level I axilla, and no patient had adequate coverage of the Level II axilla, Level III axilla, or the internal mammary lymph nodes. Three-dimensional treatment planning is superior in quantification of the dose received by the breast, regional lymphatics, and critical structures. The standard breast tangent technique delivers an adequate dose to the breast but does not therapeutically treat the regional lymph nodes in the majority of patients. If coverage of the axilla or internal mammary lymph nodes is desired, alternate beam arrangements or treatment fields will be necessary.
To understand the epidemiology, risks, and management of Clostridium difficile-associated disease... more To understand the epidemiology, risks, and management of Clostridium difficile-associated disease (CDAD) and to establish and evaluate reliable methods of surveillance. Case finding was done by daily ward and laboratory rounds. The criteria for CDAD diagnosis were: at least four unformed stools per day for 2 days and a positive culture or cytotoxin for C difficile, or positive endoscopy or autopsy for pseudomembranes. The surveillance covered all patients from 1982 through 1991 in the 820-bed Minneapolis Veterans Affairs Medical Center. The criteria were met by 908 patients. Medical service patients numbered 488; surgical patients, 420. Frequencies ranged from a high of 149 cases in 1982 to a low of 50 cases in 1989. Stool specimens were obtained on 898 (99%) of the 908 CDAD patients. Stools were culture-positive in 864 (96%) of 898, cytotoxin-positive in 569 (63%) of 898. Endoscopy was performed on 196 (22%) of the 908 patients, and 80 (41%) of 196 patients had pseudomembranes. Ten (1%) of the 908 patients were diagnosed by endoscopy without a stool specimen, or at autopsy. No treatment was needed for 135 (15%) of the 908 CDAD patients, and 19 (2%) of the 908 died before treatment was started. Oral metronidazole was the treatment for 632 (70%) of 908 patients (1% intolerance, 2% failure, 7% relapse) and oral vancomycin was given to 122 (13%) of 908 patients (1% intolerance, 1% failure, 10% relapse). Twelve patients had pseudomembranous colitis at autopsy, and it was the primary cause of death in 5 (0.6%) of 908. CDAD usually responds to oral metronidazole or vancomycin but is nonetheless responsible for a high morbidity and occasional mortality in patients even when the diagnosis and treatment are pursued aggressively.
OBJECTIVE. We performed this study to assess the usefulness of a computer auto- mated scan techno... more OBJECTIVE. We performed this study to assess the usefulness of a computer auto- mated scan technology (CAST) for individualizing scan delay during helical CT to improve the efficiency of hepatic enhancement. SUBJECTS AND METHODS. We prospectively evaluated I 83 patients who were randomized into five groups. Control patients received 100 or 150 ml of contrast material (320 mg IJml) with
Underrepresentation of minorities in research creates challenges to achieving equity in health ou... more Underrepresentation of minorities in research creates challenges to achieving equity in health outcomes. The legacy of unethical research involving minorities has affected their research participation. Regulations established to address such ethical breaches do not adequately address other significant barriers with profound ethical implications such as lack of trust, power differences, participant burden, limited access to healthcare and to research opportunities, and perceptions that researchers' priorities are not responsive to minority concerns. Efforts to address these issues benefit from intentional structural supports that include community advisory boards (CABs), shared financial resources, community health workers (CHWs), and community-based participatory research (CBPR) approaches. This presentation addresses formative and process data characterizing a community research infrastructure initiated in 2010 to ethically engage minorities in research as both partners and par...
Underrepresentation of racial minorities in research contributes to health inequities. Important ... more Underrepresentation of racial minorities in research contributes to health inequities. Important factors contributing to low levels of research participation include limited access to health care and research opportunities, lack of perceived relevance, power differences, participant burden, and absence of trust. We describe an enhanced model of community engagement in which we developed a community-linked research infrastructure to involve minorities in research both as participants and as partners engaged in issue selection, study design, and implementation. We implemented this effort in Jefferson County, Arkansas, which has a predominantly black population, bears a disproportionate burden of chronic disease, and has death rates above state and national averages. Building on existing community-academic partnerships, we engaged new partners and adapted a successful community health worker model to connect community residents to services and relevant research. We formed a community advisory board, a research collaborative, a health registry, and a resource directory. Newly formed community-academic partnerships resulted in many joint grant submissions and new projects. Community health workers contacted 2,665 black and 913 white community residents from December 2011 through April 2013. Eighty-five percent of blacks and 88% of whites were willing to be re-contacted about research of potential interest. Implementation challenges were addressed by balancing the needs of science with community needs and priorities. Our experience indicates investments in community-linked research infrastructure can be fruitful and should be considered by academic health centers when assessing institutional research infrastructure needs.
Too often, populations experiencing the greatest burden of disease and disparities in health outc... more Too often, populations experiencing the greatest burden of disease and disparities in health outcomes are left out of or ineffectively involved in academic-led efforts to address issues that impact them the most. Community-based participatory research (CBPR) is an approach increasingly being used to address these issues, but the science of CBPR is still viewed by many as a nascent field. Important to the development of the science of CBPR is documentation of the partnership process, particularly capacity building activities important to establishing the CBPR research infrastructure. This paper uses a CBPR Logic Model as a structure for documenting partnership capacity building activities of a long-term community-academic partnership addressing public health issues in Arkansas, U.S. Illustrative activities, programs, and experiences are described for each of the model's four constructs: context, group dynamics, interventions, and outcomes. Lessons learned through this process wer...
The goal of the preoperative workup in patients with suspected periampullary carcinoma is to esta... more The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.
Progress in Community Health Partnerships: Research, Education, and Action, 2007
Long-term care (LTC) is a major health policy issue owing to increasing LTC expenditures and the ... more Long-term care (LTC) is a major health policy issue owing to increasing LTC expenditures and the anticipated growth in the aging population. However, accessing LTC services, especially home- and community-based LTC services, is often difficult. This manuscript describes the Community Connector Program, the first known program to use a model in which community health workers (CHWs) help to connect adults in need of LTC to such services. We examine the community-university-government agency partnership created to implement and evaluate the program, summarize the evaluation design, and provide first-year implementation results. Descriptive statistics were used to characterize persons served and services to which persons were connected. The quasi-experimental evaluation design, which is planned to estimate the program's impact on LTC service utilization and costs within the Arkansas Medicaid program, is described. Community Connectors linked 686 persons (92% > or =18 years, 80% African American, 58% female) to at least one needed service. Only 39% of adults served needed LTC based on an LTC screening tool. Nearly all (93%) adults in need of LTC had health insurance; 53% had Medicare; 37%, both Medicare and Medicaid; and 11%, Medicaid. Community Connectors referred adults in need of LTC to 68 agencies and helped them to connect to services to address an average of two needs per adult. Preliminary results from the first-year implementation evaluation indicate the program is effective in linking persons to needed LTC, although program refinements were made to improve targeting of intended program recipients.
The rapidly developing science of nutrition has demanded specific knowledge concerning the physio... more The rapidly developing science of nutrition has demanded specific knowledge concerning the physiologic effects of indi vidual foods as they undergo the various phases of digestion, absorption, and utilization. Frequently, in dietetic practice, one food is substituted for another on the basis of a single food principle without regard for equally important compo nent parts of the diet. It is
Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but the... more Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but there is limited appreciation of which characteristics of patients or operations are reliable markers of increased wound infection risk. The purpose of the present study was to analyze all wound infections observed after infrainguinal bypass operations during 20 years of practice in a large teaching institution. Independent risk factors for wound infection development were identified. During the 20-year period ending 31 December, 1997, 978 male patients underwent infrainguinal bypass operations at the Minneapolis Department of Veterans Affairs Medical Center. Wound infections complicated the recovery of 129 of these patients during a 30-day postoperative surveillance interval. Multivariate logistic regression analysis was used to test the association between wound infection occurrence and putative risk factors that were either features of patients or characteristics of the operations. The following variables were examined: obesity, prosthetic graft placement, diabetes mellitus, steroid use, anticoagulation use, length of preoperative hospital stay, development of incisional hematoma, duration of operation, and the preoperative presence of a non-healing wound in the extremity being revascularized. The overall wound infection rate was 13.2% (129/978). In a final logistic regression model, obesity was a significant and independent predictor of wound infection (Relative Risk 2.6, 95% confidence interval, 1.35-4.90), as was development of a post-operative incisional hematoma (Relative Risk 6.44, 95% confidence interval, 2.95-14.08). No other explanatory variable was significantly associated with wound infection development.
To analyze hepatic enhancement by using Smart Prep protocols appropriate for children of differen... more To analyze hepatic enhancement by using Smart Prep protocols appropriate for children of different weight groups and 2:1 pitch helical CT imaging as the investigative tools. A group of 55 children ranging in weight between 20 and 180 lbs underwent 67 contrast-enhanced abdominal helical CT examinations using Smart Prep (GE Medical Systems, Milwaukee, Wisc.). Of these studies, 21 (31 %) were excluded because of failure to follow the prescribed Smart Prep protocols. Smart Prep protocols were established for nine different weight groups. Scan delay, aorta and liver time to peak, and liver enhancement over baseline were recorded. Optimal abdominal CT studies with adequate contrast enhancement of hepatic and portal veins were obtained in 46 patients. There was no significant difference in the time between peak aortic and the liver enhancement among different weight groups (mean time 12.0 +/- 7.1 s for all children). However, the mean hepatic enhancement over baseline in children weighing < 30 lbs was below 50 Hounsfield units (HU) compared to the rest of the children who had mean hepatic enhancement of > 50 HU. Two-thirds of the Smart Prep protocols were successfully implemented, and all of these resulted in good contrast enhancement of hepatic and portal veins. Optimal mean liver enhancement (> 50 HU) was seen in children >/= 30 lbs. Children < 30 lbs had mean liver enhancement of 33 HU +/- 7.2 above the baseline likely caused by contrast dose.
Pyogenic granuloma (PG) of the eyelid and orbit is typically associated with trauma or surgery. W... more Pyogenic granuloma (PG) of the eyelid and orbit is typically associated with trauma or surgery. We report a rare case of an orbital intraconal PG arising de novo in association with an orbital artery.
Return of bowel function after radical prostatectomy surgery may be the limiting factor in discha... more Return of bowel function after radical prostatectomy surgery may be the limiting factor in discharging these patients from the hospital. Recent studies have shown that postoperative epidural infusion of bupivacaine decreases time to return of bowel function compared with intravenous and epidural morphine in patients after abdominal surgery. This study focuses on the role of the intraoperative anesthetic technique on recovery of bowel function, intraoperative blood loss, and the incidence of postoperative deep venous thrombosis (DVT) in patients undergoing radical retropubic prostatectomy and pelvic lymphadenectomy. Forty patients undergoing prostatectomy were randomized to either group A (general endotracheal anesthesia, including muscle relaxation and mechanical ventilation, followed by postoperative intravenous morphine patient-controlled analgesia) or group B (thoracic epidural anesthesia using bupivacaine, combined with "light" general anesthesia using a laryngeal mask airway and spontaneous ventilation, followed by epidural morphine analgesia). Intra- and postoperative data were collected on blood loss, volumes of crystalloid and colloid infused, blood transfused, duration of anesthesia and surgery, anesthetic and surgical complications, time to recovery of bowel function, quality of postoperative pain control, and time to discharge from hospital. Each patient underwent lower extremity venous ultrasonography to detect DVT. Twenty-one patients received general anesthesia and 19 received combined epidural and general anesthesia. Intraoperative blood loss was significantly lower in the epidural group, and times to first flatus and first bowel movement were also shorter in this group. There were no significant differences in duration of anesthesia or surgery, quality of postoperative analgesia, side effects of analgesia, or time to discharge from hospital. There was no DVT detected in any patient. The combined anesthetic technique of thoracic epidural anesthesia and "light" general anesthesia with spontaneous ventilation decreased intraoperative blood loss and shortened the time to return of bowel function. However, this earlier return of bowel function was not great enough to realize a difference in time to hospital discharge. There was no evidence of increased complications secondary to epidural anesthesia or of prolonged anesthetic time necessary to place epidural catheters.
1. J Pediatr Oncol Nurs. 1998 Jul;15(3 Suppl 1):10-7. Challenges and issues in conducting descrip... more 1. J Pediatr Oncol Nurs. 1998 Jul;15(3 Suppl 1):10-7. Challenges and issues in conducting descriptive decision-making studies in pediatric oncology: a tale of two studies. Hinds PS, Oakes L, Quargnenti A, Furman W, Sandlund JT, Bowman L, Olson MS, Heideman R. ...
Pediatric oncology nurses experience role-related stressors, some of which are inherent to the sp... more Pediatric oncology nurses experience role-related stressors, some of which are inherent to the speciality, and their consequences. Despite these difficulties, nurses continue in the specialty. One variable that helps to explain their continued commitment is "meaning", or what pediatric oncology nurses find to be most significant and satisfying in their roles. One technique for determining meaning in a role is to inquire about the peak (significant and positive) and nadir (significant and negative) role-related experiences and the consequences of both kinds of experiences. The purpose of this study was to identify the peak and nadir experiences of pediatric oncology nurses and the short- and long-term consequences of those experiences. Using an interview format that consisted of four open-ended questions and a convenience sampling plan, five nurses interviewed 26 nurses from one pediatric cancer center and 38 nurses from a national sample. The interviewers completed an initial training session on interviewing and repeated that training two more times during data collection. Written or taped oral consent was obtained at the time of each interview. Using a content analytical technique (Krippendorff, 1980), four nurses independently coded each interview. Agreement ratings ranged from 75% to 100% per coded theme for an overall agreement level of 92%. Training for the coding process occurred initially and periodically throughout the analysis period. Fifteen different themes for peak experiences were identified, the majority of which reflect the nurses' experience with patients dying, or with patients recovering and living normal lives, or with the close relationships that develop between nurses and patients. Multiple short- and long-term consequences were identified and included changes in (1) values (becoming less judgmental), (2) behaviors (giving more empathic care), and (3) perspective (accepting limitations of care). Twenty-three different nadir themes were identified. A shared characteristic of several of these themes is the nurses' regret over a perceived inadequacy in handling a situation. Another common element is witnessing patient suffering and feeling unable to adequately relieve the suffering or provide comfort to the patient. The short-term consequences of nadir experiences tend to be negative and include guilt, anger, or dread. The long-term consequences tend to be positive and similar to the long-term consequences of peak experiences. Study findings indicate that pediatric oncology nurses do find meaning in their roles and that those who continue in the speciality are able to experience positive long-term consequences. Study findings will be used to develop a new scale to measure role-related meaning and to develop interventions designed to assist nurses in finding meaning in their roles even during particularly stressful periods.
International Journal of Radiation Oncology*Biology*Physics, 2000
A thorough dose-volume analysis of a standard tangential radiation technique has not been publish... more A thorough dose-volume analysis of a standard tangential radiation technique has not been published. We evaluated the adequacy of a tangential radiation technique in delivering dose to the breast and regional lymphatics, as well as dose delivered to underlying critical structures. Treatment plans of 25 consecutive women with breast cancer undergoing lumpectomy and adjuvant breast radiotherapy were studied. Patients underwent two-dimensional (2D) treatment planning followed by treatment with standard breast tangents. These 2D plans were reconstructed without modification on our three-dimensional treatment planning system and analyzed with regard to dose-volume parameters. Adequate coverage of the breast (defined as 95% of the target receiving at least 95% of the prescribed dose) was achieved in 16 of 25 patients, with all patients having at least 85% of the breast volume treated to 95% of the prescribed dose. Only 1 patient (4%) had adequate coverage of the Level I axilla, and no patient had adequate coverage of the Level II axilla, Level III axilla, or the internal mammary lymph nodes. Three-dimensional treatment planning is superior in quantification of the dose received by the breast, regional lymphatics, and critical structures. The standard breast tangent technique delivers an adequate dose to the breast but does not therapeutically treat the regional lymph nodes in the majority of patients. If coverage of the axilla or internal mammary lymph nodes is desired, alternate beam arrangements or treatment fields will be necessary.
To understand the epidemiology, risks, and management of Clostridium difficile-associated disease... more To understand the epidemiology, risks, and management of Clostridium difficile-associated disease (CDAD) and to establish and evaluate reliable methods of surveillance. Case finding was done by daily ward and laboratory rounds. The criteria for CDAD diagnosis were: at least four unformed stools per day for 2 days and a positive culture or cytotoxin for C difficile, or positive endoscopy or autopsy for pseudomembranes. The surveillance covered all patients from 1982 through 1991 in the 820-bed Minneapolis Veterans Affairs Medical Center. The criteria were met by 908 patients. Medical service patients numbered 488; surgical patients, 420. Frequencies ranged from a high of 149 cases in 1982 to a low of 50 cases in 1989. Stool specimens were obtained on 898 (99%) of the 908 CDAD patients. Stools were culture-positive in 864 (96%) of 898, cytotoxin-positive in 569 (63%) of 898. Endoscopy was performed on 196 (22%) of the 908 patients, and 80 (41%) of 196 patients had pseudomembranes. Ten (1%) of the 908 patients were diagnosed by endoscopy without a stool specimen, or at autopsy. No treatment was needed for 135 (15%) of the 908 CDAD patients, and 19 (2%) of the 908 died before treatment was started. Oral metronidazole was the treatment for 632 (70%) of 908 patients (1% intolerance, 2% failure, 7% relapse) and oral vancomycin was given to 122 (13%) of 908 patients (1% intolerance, 1% failure, 10% relapse). Twelve patients had pseudomembranous colitis at autopsy, and it was the primary cause of death in 5 (0.6%) of 908. CDAD usually responds to oral metronidazole or vancomycin but is nonetheless responsible for a high morbidity and occasional mortality in patients even when the diagnosis and treatment are pursued aggressively.
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Papers by Mary Olson