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Acquisition of vancomycin-resistant enterococci during scheduled antimicrobial rotation in an intensive care unit.

Scheduled rotation of treatment of gram-negative antimicrobial agents has been associated with reduction of serious gram-negative infections. The impact of this practice on other nosocomial infections has not been assessed. The purpose of this study was to determine if scheduled antimicrobial rotation reduced rates of acquisition of enteric vancomycin-resistant enterococci (VRE) among 740 patients admitted to an intensive care unit (ICU). The preferred gram-negative agent was ceftazidime during rotation 1 and ciprofloxacin during rotation 2. Unadjusted VRE acquisition rates were 8.5 cases per 1000 ICU days and 11.7 cases per 1000 ICU days during rotations 1 and 2, respectively (P<.01). However, scheduled antimicrobial rotation of ceftazidime with ciprofloxacin had no effect on the risk of acquiring VRE in the ICU after adjustment for known risk factors. Independent predictors of acquisition of VRE were enteral feedings, higher colonization pressure, and increased duration of anaerobic therapy. Our findings can confirm no additional beneficial or adverse effect on VRE acquisition among ICU patients as a result of this practice.

Anti-Bacterial Agents↗

In vitro assessment of platelet damage during rotator storage.

The measurement of beta-thromboglobulin (BTG) and platelet lactic dehydrogenase (LDH) as markers for alpha-granule release and platelet lysis, respectively, has been reported to correlate with the amount of damage incurred during the preparation and storage of platelet concentrates. We compared the concentrations of these markers in the supernatant plasma of platelets stored on platform, elliptical, and circular rotators. Significant BTG release occurred after 24 hours on all three rotators (P less than 0.01), but LDH discharge after 24 hours was significant (P less than 0.05) only with elliptical rotation. BTG and LDH levels were not significantly different at any time when platform and circular rotations were compared, but both markers were significantly (P less than .05) higher during elliptical rotation. The lower levels of BTG release and LDH discharge during platform and circular agitation implies that these rotators produce less in vitro platelet activation and damage than occurs with elliptical agitation.

Beta-Globulins↗

Using a generational time-step model to simulate dynamics of adaptation to transgenic corn and crop rotation by western corn rootworm (Coleoptera: Chrysomelidae).

We expanded a simulation model of the population dynamics and genetics of the western corn rootworm for a landscape of corn, soybean, and other crops to study the simultaneous development of resistance to both crop rotation and transgenic corn. Transgenic corn effective against corn rootworm was recently approved in 2003 and may be a very effective new technology for control of western corn rootworm in areas with or without the rotation-resistant variant. In simulations of areas with rotation-resistant populations, planting transgenic corn to only rotated cornfields was a robust strategy to prevent resistance to both traits. In these areas, planting transgenic corn to only continuous fields was not an effective strategy for preventing adaptation to crop rotation or transgenic corn. In areas without rotation-resistant phenotypes, gene expression of the allele for resistance to transgenic corn was the most important factor affecting the development of resistance to transgenic corn. If the allele for resistance to transgenic corn is recessive, resistance can be delayed longer than 15 yr, but if the resistant allele is dominant then resistance usually developed within 15 yr. In a sensitivity analysis, among the parameters investigated, initial allele frequency and density dependence were the two most important factors affecting the evolution of resistance. We compared the results of this simulation model with a more complicated model and results between the two were similar. This indicates that results from a simpler model with a generational time-step can compare favorably with a more complex model with a daily time-step.

Adaptation, Physiological↗

Saturation transfer electron spin resonance study on the rotational diffusion of calcium- and magnesium-dependent adenosine triphosphatase in sarcoplasmic reticulum membranes.

The technique of saturation transfer electron spin resonance has been applied to study the rotational diffusion of spin-labeled Ca2+, Mg2+-dependent ATPase molecules in the membranes of sarcoplasmic reticulum vesicles. Comparison of the present data with those for spin-labeled hemoglobin undergoing isotropic rotation leads to a value of 2 X 10(-4) s for the apparent rotational correlation time at 20 degrees C for the membrane-bound protein. Consideration of the anisotropy of the Brownian rotation of the membrane-bound ATPase suggests that the true correlation time for the expected axial rotation may be somewhat smaller than the apparent value. An Arrhenius plot of the rotational motion shows a break, which is interpreted as indicating the occurrence of a conformational change of the ATPase molecule at about 15 degrees C.

Adenosine Triphosphatases↗

A prospective, randomized trial of a six-week ambulatory medicine rotation.

BACKGROUND: Medical schools are placing increased emphasis on training students in the ambulatory setting, but few studies show the benefit or academic risk of such innovation. The authors studied the effect of such a new rotation with a rigorous study design. METHOD: From a group of 166 third-year students at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine assigned in 1990-91 to do six weeks of their third-year medicine clerkship at Walter Reed Army Medical Center, 106 volunteers were randomized to six weeks either on the usual rotation on the general medicine wards (69 students) or to a new ambulatory rotation (37 students). Multiple pre- and postclerkship parameters were used to evaluate clerkship skills and knowledge; eventual internship choice was determined. RESULTS: The randomization was successful. Postclerkship performances were the same in (1) the medicine subject examination of the National Board of Medical Examiners, (2) a multiple-choice test in interpreting laboratory results, (3) blinded rating by an expert panel of the quality of final written histories and physical exams, (4) blinded rating by an expert panel of the students' written case analyses of their own patients, and (5) a written multiple-step examination of problem-solving ability. Any differences between groups favored the ambulatory group. An increase in choice of primary care internships among students randomized to the ambulatory rotation was not significant. CONCLUSION: It is possible to study innovative rotations using a prospective, randomized design. Substituting a six-week block ambulatory experience for a ward rotation did not decrease students' abilities to write up or analyze complex cases.

Ambulatory Care↗

The impacts of supervision, patient mix, and numbers of students on the effectiveness of clinical rotations.

PURPOSE: This study investigated whether supervision, patient mix, and numbers of students influence the effectiveness of clinical rotations. METHOD: The authors administered a questionnaire to 1,208 medical students in 1999 to evaluate the rotations' quality. They computed four variables--overall effectiveness, supervision, patient mix, and number of students contemporaneously involved--and analyzed the data using analysis of variance. RESULTS: Supervision and patient mix positively influenced a rotation's effectiveness. A higher level of supervision and a higher level of patient mix led to higher overall effectiveness scores. The number of students did not significantly influence the effectiveness score, although a low number led to a higher score as compared with a high number. Furthermore, the two-way interaction between supervision and patient mix was significant. Supervision more strongly influenced the rotation's effectiveness when patient mix was limited than when it was high. Also, when the patient mix was limited and supervision was high, the average effectiveness score was still 7.7 (scale 1-10). CONCLUSIONS: The effectiveness of clinical rotations depends on the supervision provided and patient mix, but not the number of students. Furthermore, supervision more strongly influences effectiveness when patient mix is limited than when it is high. Finally, high-quality supervision guarantees at least a sufficient score for the rotation's effectiveness, irrespective of the level of patient mix.

Curriculum↗

Direct observation of students during clerkship rotations: a multiyear descriptive study.

PURPOSE: To determine how often students report that they are observed while performing physical examinations and taking histories during clerkship rotations. METHOD: From 1999-2001, 397 students at the University of Virginia School of Medicine were asked at the end of their third year to report the number of times they had been observed by a resident or faculty member while taking histories and performing physical examinations on six rotations. RESULTS: Three hundred and forty-five students (87%) returned the survey instrument; of these, 322 (81%) returned instruments with complete information. On average, the majority reported that they had never been observed by a faculty member while taking a history (51%), performing a focused physical examination (54%), or a complete physical examination (81%). The majority (60%) reported that they had never been observed by a resident while performing a complete physical examination. Faculty observations occurred most frequently during the four-week family medicine rotation and least frequently during the 12-week surgery rotation. The length of the clerkship rotation was inversely related to the number of reported observations, chi(2) (5, n = 295) = 127.85, p <.000. CONCLUSIONS: Although alternative assessments of clinical skills are becoming more common in medical education, faculty ratings based on direct observation are still prominent. The data in this study reflect that these observations may actually be occurring quite infrequently, if at all. Decreasing the evaluative weight of faculty and resident ratings during the clerkship rotation may be necessary. Otherwise, efforts should be made to increase the validity of these ratings.

Clinical Clerkship↗

Impact and value of junior rotation in radiology.

All junior medical students at the authors' institution are enrolled in a 2-week combined rotation in diagnostic radiology and anesthesia, with the time divided equally between the departments. The purpose of this rotation is to familiarize students with various imaging modalities and to introduce interpretation of conventional radiographs. The rotation is offered five times during the academic year, and each includes the same enrollment (about 20 students), educational structure (lectures, self-study, and case review) and method of evaluation (multiple choice examination). To assess the educational benefits of this short exposure to radiology, we gave a preexamination and postexamination at the beginning and the end of each rotation. Comparison of scores between the pretest and post-test showed a significant learning gain for all rotations (P less than 0.01). There was no difference between groups scheduled early in the academic year compared with those with more clinical experience at the end of the year. We conclude that a well-structured brief junior rotation in radiology can effectively improve students' knowledge of imaging and its role in clinical evaluation.

Curriculum↗

The gluteal fasciocutaneous rotation-advancement flap with V-Y closure in the management of sacral pressure sores.

The sacral region is one of the most frequent sites of pressure sore development, and local flaps in the gluteal region are usually preferred when surgical closure is needed. The authors used the gluteal fasciocutaneous rotation-advancement flap with V-Y closure to manage sacral pressure sores in 15 patients. The design was a combination of the classic rotation and V-Y advancement flap patterns. When the wound was closed, the tension at the distal end of the rotation flap was relieved by flap advancement and the combined rotation-advancement action was supported laterally with V-Y closure. A wide skin pedicle was preserved at the inferomedial part of the flap. This pedicle augmented the blood supply to the flap skin and kept the surgical incision small, thus helping to reduce the risk of fecal contamination and associated wound-healing problems. This flap can also be converted to any design of fasciocutaneous or musculocutaneous V-Y advancement flap, should such a change be required. The largest defects that were closed with a unilateral rotation-advancement flap and bilateral rotation-advancement flaps were 12 and 18 cm in diameter, respectively. In 1.5 to 35 months of follow-up, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. This technique is simple, can be performed quickly, has minimal associated morbidity, and yields a good outcome.

Adult↗

Rotation vector, a new method for representation of three-dimensional deformity in scoliosis.

Rotation vector for three-dimensional deformity, a new concept in scoliosis, is presented. This vector quantifies three-dimensional deformity in scoliosis. Rotation vectors are calculated between pairs of end plates. Any three-dimensional malalignments (scoliosis, lordosis [or kyphosis] and rotation) existing between a pair of end plates should be cancelled perfectly by rotating one end plate against the other about an axis represented by the rotation vector. A rotation vector suggests how the deformity in scoliosis should be corrected three-dimensionally.

Adolescent↗

Functional bowel disorders in rotating shift nurses may be related to sleep disturbances.

OBJECTIVES: To compare the frequency and severity of bowel disturbances between rotating shift and regular day nurses and to determine whether functional bowel disorders (FBD) were related to sleep disturbances. METHODS: Sixty regular day and 58 rotating shift nurses answered three standardized questionnaires: the Gastrointestinal Symptom Questionnaire; the Hospital Anxiety and Depression Scale; and the Irritable Bowel Syndrome Symptoms Evaluation Questionnaire, which included the Sleep Questionnaire, on the frequency and severity of gastrointestinal symptoms, sleep disturbances and psychological distress. Responses to these questions were numerically rated and the sums of individual symptom scores under the respective categories were computed and analysed using statistical tests, as appropriate. RESULTS: Although 22 out of 58 rotating shift nurses (38%) had FBD, only 12 out of 60 regular day nurses (20%) had it (P=0.04). The mean FBD symptom score (P<0.002), sleep disturbance score (P<0.0001) and anxiety score (P<0.002) were all significantly higher among the rotating shift nurses. FBD symptom scores were positively correlated with the sleep disturbance (P=0.0001), anxiety (P=0.0001), depression (P=0.0001), well-being (P=0.0001), fatigue (P=0.0001), and somatic pain scores (P=0.0001). Sleep disturbance (P=0.04), decreased well-being (P=0.04), anxiety (P=0.02), and somatic pain (P=0.03) were independent predictors of FBD symptoms. CONCLUSION: FBD were more common and severe among rotating shift nurses. The FBD symptom score was positively and independently correlated with the sleep disturbance score, suggesting that poor sleep might be associated with increased FBD symptoms in rotating shift nurses.

Adult↗

Rotational deformity in varus osteoarthritis of the knee: analysis with computed tomography.

UNLABELLED: Rotational deformities in varus osteoarthritis of the knee were evaluated with computed tomography. Preoperative computed tomography scans of 150 knees (114 patients) having total knee arthroplasty and 31 control knees (20 patients) were included. The femorotibial rotation was quantified using the clinical epicondylar axis of the femur and the tibial tuberosity (patella tendon) as the references. The knees with osteoarthritis were divided into three groups according to the femorotibial angle (Group 1, 0 degrees -9 degrees varus, n = 87; Group 2, 10 degrees -19 degrees varus, n = 51; Group 3, 20 degrees or greater varus, n = 12) and statistically analyzed. Rotational deformities (external rotation of the tibia) existed in knees with osteoarthritis and were larger in knees with increased varus deformities (mean +/- standard deviation, -2.24 degrees +/- 4.19 degrees in Group 1; 0.33 degrees +/- 4.14 degrees in Group 2; and 5.33 degrees +/- 5.71 degrees in Group 3). When the femorotibial rotation of each knee was stratified by the corresponding femorotibial angle, we found a correlation. The information should help minimize the rotational mismatch between the femoral and the tibial components in total knee arthroplasty and elucidate the pathogenesis of varus osteoarthritis of the knee. LEVEL OF EVIDENCE: Diagnostic study, Level III-1 (study of nonconsecutive patients--no consistently applied reference gold standard). See the Guidelines for Authors for a complete description of levels of evidence.

Aged↗

Implementation of formal learning objectives during a physical medicine and rehabilitation sports medicine rotation.

OBJECTIVE: To develop and implement formal learning objectives during a physical medicine and rehabilitation sports medicine rotation and characterize resident experiences with the objectives over a 16-mo period. DESIGN: Prospective, including learning objective development, implementation, and postrotation survey. RESULTS: A total of 69 learning objectives were developed by physical medicine and rehabilitation staff physician consensus, including 39 core objectives. Eighteen residents completed 4-wk sports medicine rotations from January 2003 through April 2004. Residents completed an average of 31 total objectives (45%; range, 3-52), of which 24 (62%; range, 3-35) were core. Residents completed the highest percentage of knee (60%), shoulder (57%), and ankle-foot (57%) objectives and reported that objectives related to these areas were most effective to facilitate learning. In general, residents reported that objective content was good and that the objectives delineated important concepts to learn during the rotation. Seventeen of 18 residents indicated that the objectives should be permanently implemented into the sports rotation and that similar objectives should be developed for other rotations. Based on our experience and the recommendations of residents, the average resident should be able to complete approximately 30 objectives during a typical 4-wk rotation. CONCLUSIONS: Successful implementation of specific, consensus-derived learning objectives is possible within the context of a busy clinical practice. Our initial physician staff and resident experience with the objectives suggests that this model may be useful as a supplementary educational tool in physical medicine and rehabilitation residency programs.

Clinical Competence↗

Tibial rotation is not restored after ACL reconstruction with a hamstring graft.

Recent research suggests ACL reconstruction does not restore tibial rotation to normal levels during high demand activities when a bone-patellar tendon-bone graft is used. We asked if an alternative graft, the semitendinosus-gracilis (ST/G) tendon graft, could restore tibial rotation during a high demand activity. Owing to its anatomic similarity with the normal ACL we hypothesized the ST/G graft could restore excessive tibial rotation to normal healthy levels along with a successful reinstatement of the clinical stability of the knee. We assessed tibial rotation in vivo, using gait analysis. We compared the knees of ACL reconstructed patients with an ST/G graft to their intact contralateral and healthy controls during a pivoting task that followed a stair descent. We also evaluated knee stability after ACL reconstruction with standard clinical tests. ACL reconstruction with the ST/G graft and with current techniques did not restore tibial rotation to previous physiological levels during an activity with increased rotational loading at the knee, although abnormal anteroposterior (AP) tibial translation was restored.

Adult↗

13C-13C rotational resonance in a transmembrane peptide: a comparison of the fluid and gel phases.

A comparative study of two doubly 13C labeled amphiphilic transmembrane peptides was undertaken to determine the potential of rotational resonance for measuring internuclear distances through the direct dipolar coupling in the presence of motion. The two peptides, having the sequence acetyl-K2-G-L16-K2-A-amide, differed only in the position of 13C labels. The first peptide, [1-13C]leu(11):[alpha-13C]leu(12), had labels on adjacent residues, at the carbonyl of leu(11) and the alpha carbon of leu(12). The second, [1-13C]leu(8):[alpha-(13)/C]leu(11), was labeled on consecutive turns of the alpha-helical peptide. The internuclear distance between labeled positions of the first peptide, which for an ideal alpha helix has a value of 2.48 A, is relatively independent of internal flexibility or peptide conformational change. The dipolar coupling between these two nuclei is sensitive to motional averaging by molecular reorientation, however, making this peptide ideal for investigating these motions. The internuclear distance between labels on the second peptide has an expected static ideal alpha-helix value of 4.6 A, but this is sensitive to internal flexibility. In addition, the dipolar coupling between these two nuclei is much weaker because of their larger separation, making this peptide a much more difficult test of the rotational resonance technique. The dipolar couplings between the labeled nuclei of these two peptides were measured by rotational resonance in the dry peptide powders and in multilamellar dispersions with dimyristoylphosphatidylcholine in the gel phase, at -10 degrees C, and in the fluid phase, at 40 degrees C. The results for the peptide having adjacent labels can be readily interpreted in terms of a simple model for the peptide motion. The results for the second peptide show that, in the fluid phase, the motionally averaged dipolar coupling is too small to be measured by rotational resonance. Rotational resonance, rotational echo double resonance, and related techniques can be used to obtain reliable and valuable dipolar couplings in static solid and membrane systems. The interpretation of these couplings in terms of internuclear distances is straightforward in the absence of molecular motion. These techniques hold considerable promise for membrane protein structural studies under conditions, such as at low temperatures, where molecular motion does not modulate the dipolar couplings. However, a typical membrane at physiological temperatures exhibits complex molecular motions. In the absence of an accurate and detailed description of both internal and whole body molecular motions, it is unlikely that techniques of this type, which are based on extracting distances from direct internuclear dipolar couplings, can be used to study molecular structure under these conditions. Furthermore, the reduction in the strengths of the dipolar couplings by these motions dramatically reduces the useful range of distances which can be measured.

Amino Acid Sequence↗

Rotational viscosity, dynamic phenomena, and dielectric properties in a long-chain liquid crystal: NMR study and theoretical treatment.

The rotational diffusion constants D(perpendicular) and D(parallel), rotational viscosity coefficients gamma(i) (i=1,2), the orientational correlation times tau(L)mn, and the dielectric permittivities for nematic liquid crystals (NLCs) are investigated. gamma(i) are calculated by a combination of existing statistical-mechanical approach (SMA) and NMR relaxation theory, both based on a rotational diffusion model. In the rotational diffusion model, it is assumed that the reorientation of an individual molecule is a stochastic Brownian motion in a certain potential of mean torque. According to the SMA, gamma(i) are found to be a function of temperature, density, rotational diffusion constant for tumbling motions, and the orientational order parameters. The order parameters and rotational diffusion constant are obtained from an analysis of NMR measurements. Reasonable agreement between the calculated and experimental values of gamma(i) for 4-n-octyloxy-4'-cyanobiphenyl (8OCB) is obtained. The orientational correlation times, and the longitudinal and transverse components of the real chi'(j)(omega) and imaginary chi"(j)(omega) (j= parallel, perpendicular) parts of the complex susceptibility tensor for 8OCB molecules in the nematic phase are also obtained.

Journal Article↗

Relaxation of surface charge on rotating dielectric spheres: Implications on dynamic electrorheological effects.

We have examined the effect of an oscillatory rotation of a polarized dielectric particle. The rotational motion leads to a redistribution of the polarization charge on the surface of the particle. We show that the time-averaged steady-state dipole moment is along the field direction, but its magnitude is reduced by a factor that depends on the angular velocity of rotation. As a result, the rotational motion of the particle reduces the electrorheological effect. We further assume that the relaxation of the polarized charge is arised from a finite conductivity of the particle or host medium. We calculate the relaxation time based on the Maxwell-Wagner theory, suitably generalized to include the rotational motion. Analytic expressions for the reduction factor and the relaxation time are given and their dependence on the angular velocity of rotation will be discussed.

Journal Article↗

Rotational dynamics of propane in Na-Y zeolite: a molecular dynamics and quasielastic neutron-scattering study.

We report results from molecular dynamics (MD) simulations and quasielastic neutron-scattering (QENS) measurements on the rotational dynamics of propane in Na-Y zeolite at room temperature with a loading of four molecules per alpha cage. Rotational part of the intermediate scattering function F(Q,t) obtained from the MD simulation suggests that rotational motion is faster relative to the translational motion. Various rotational models fitted to the MD data suggest that rotation is isotropic. It is found that the hydrogen atoms lie, on the average, on a sphere of radius 1.88+/-0.05 A, which is also the average distance of the hydrogen atoms from the center of mass of the propane molecule. Results from QENS measurements are in excellent agreement with those obtained from MD, suggesting that the intermolecular potential employed in the MD simulation provides a realistic description of propane motion within faujasite. The rotational diffusion constant D(R) is 1.05+/-0.09 x 10(12) sec(-1) from the QENS data, which may be compared with that obtained from the MD data (0.82+/-0.05 x 10(12) sec(-1)).

Journal Article↗