Public Accountability: Performance Measurement, The Extended State, And The Search For Trust

In an Academy partnership with the Kettering Foundation, National Academy of Pubic Administration Fellows Melvin J. Dubnick and H. George Frederickson have completed a study of accountability. The study, Public Accountability: Performance Measurement, The Extended State, and the Search for Trust, is a treatment of the strengths and weaknesses of contemporary applications of accountability to public affairs. The working title of the study was Public Accountability: From Ambulance Chasing to Accident Prevention, but that title was thought to lack the dignity such an important subject deserves. Dubnick and Frederickson challenge the often assumed relationship between performance measurement and accountability. They give special attention to accountability challenges associated with the outsourcing of government work, what they call the Extended State. And, they provide examples of effective public accountability in the context of high trust public-private partnerships

Valgus Deformity Correction in Total Knee Replacement: An Overview

Valgus deformity in total knee replacement is a much lesser encountered problem than varus deformity. The deformity can be caused by either bony or ligamentous pathology or both. Bone defects like lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodeling along with soft tissue pathologies like tight lateral collateral ligament (LCL), posterolateral capsule (PLC), popliteus tendon (POP), hamstring tendons, the lateral head of the gastrocnemius (LHG) and iliotibial band (ITB) can add to the magnitude of valgus deformity. Various sequences have been described to achieve balancing while doing a total knee replacement. Proper preoperative planning, clinical examination, necessary implant backup and good operative skill are mandatory to manage bone deformities or soft tissue pathology or both in valgus deformity. Obtaining an accurate axis restoration, component orientation and joint stability in a valgus knee with combined bony and ligamentous pathology may be a difficult task. The long-term results in valgus knees are relatively inferior to those with varus deformity. This chapter structure wise describes the pathology, classification of valgus deformity, radiographic planning, surgical approaches, method of valgus deformity correction, implant selection, associated deformities, precautions and intraoperative complications

Methods of DVT Prophylaxis after Total Knee Arthroplasty

Postoperative deep-vein thrombosis (DVT), venous thromboembolism (VTE), and pulmonary embolism are few of the most serious complications following total joint arthroplasty. Identification of risk factors and initiation of prophylactic measures are the most important measures to prevent the occurrence of DVT. Several protocols and guidelines are published for DVT prophylaxis in TKA, leaving the surgeon still perplexed. Pharmacological and mechanical prophylaxis methods are used to reduce the risk of postoperative symptomatic deep-vein thrombosis and pulmonary embolism. The use of pharmacological methods is based on a fine balance between their efficacy and the adverse effects associated with them. Each of these agents has their own advantages and disadvantages. Several newer agents are getting approved by FDA for the same. Hence, the choice should be carefully made based on the patient characteristics and risk stratification, and the onset of side effects has to be carefully monitored

Shock Losses in Transonic Compressor Blade Rows

The rather extensive study of the shock losses in transonic compressors can he summarized by the following remarks: 1. A simple flow model can be used to estimate shock losses at the design point for transonic compressor blade rows and results iii reasonable correlation of loss data. It is indicated that shock losses can constitute a sizable portion of the total losses in it transonic compressor rotor. This includes all blade elements at which sonic or higher relative velocities are obtained. 2. Shock losses can he shown to exist across the blade passage (free-stream loss) and by the method of superposition with the blade profile losses result in an estimated design total loss coefficient. 3. The shock configuration was experimentally determined by the rapid pressure rise between the blades as measured by the use of barium titanate crystals. At the minimum loss operating conditions the shock is very similar to that assumed in the simple How model. 4. Shock losses obtained from a more detailed flow model were compared with the losses obtained by the simple flow model. Measured loss distribution from blade to blade closely approaches the analytical shock loss distribution. The measured distribution shows the effect of a shock boundary layer interaction. 5. The analytical method (from the detailed flow model) of determining the shock location ahead of the blade seems to apply reasonably well over a range of incidence angles. The analytical shock losses do not vary a great deal with blade element incidence angles

Evaluation of soluble ST2 as a novel cardiovascular biomarker in patients with acute myocardial infarction

Background: Soluble ST-2 has considerable prognostic value and is used as an aid for risk stratification in identifying patients who are at high risk of cardiovascular disease. The main objective of the study was to analyze the level of soluble ST-2 biomarker in patients with acute myocardial infarction and chronic stable angina patients and secondly to evaluate the cardiovascular outcomes after 30 days.Methods: A total of 71 patients were enrolled into the study, patients were divided into two groups of which 50 patients were in test group (AMI patients) and the remaining 21 patients were in the control group (chronic stable angina). Then, 5ml of blood was collected from the patients and plasma soluble ST-2 was estimated from the sample using ELISA technique. Patients were then followed up to 30 days to ascertain the development of major adverse cardiovascular outcomes.Results: The median concentration of soluble ST-2 in test group was found to be 213.46pg/ml and in control group was found to be 124.53 pg/ml. Soluble ST-2 correlated significantly with left ventricular ejection fraction (LVEF) between the two groups (P value=0.01). Measurement of soluble ST-2 early after MI assists in the prediction of adverse cardiovascular events. In this study, soluble ST-2 was found to be higher in patients with acute myocardial infarction and also in patients with poor ejection fraction.Conclusions: Soluble ST-2 is a novel cardiovascular biomarker that is elevated in patients with acute myocardial infarction

Use of P wave configuration during atrial tachycardia to predict site of origin

Objectives.This study sought to construct an algorithm to differentiate left atrial from right atrial tachycardia foci on the basis of surface electrocardiograms (ECGs).Background.Atrial tachycardia is an uncommon form of supraventricular tachycardia, often resistant to drug therapy.Methods.A total of 31 consecutive patients with atrial tachycardia due to either abnormal automaticity or triggered rhythm underwent detailed atrial endocardial mapping and successful radiofrequency catheter ablation of a single atrial focus. P wave configuration was analyzed from 12-lead ECGs during tachycardia during either spontaneous or pharmacologically induced atrioventricular block. P waves inscribed above the isoelectric line (TP interval) were classified as positive, below as negative, above and below (or conversely, below and above) as biphasic and flat P waves as isoelectric (0). In 17 patients the tachycardia was located in the right atrium: crista terminalis (n = 4); right atrial appendage (n = 4); lateral wall (n = 4); posteroinferior right atrium (n = 3); tricuspid annulus (n = 1); and near the coronary sinus (n = 1). In 14 patients, atrial tachycardia was located in the left atrium: at the entrance of the right (n = 6) or left (n = 4) superior pulmonary veins; left inferior pulmonary vein (n = 1); inferior left atrium (n = 1); base of left atrial appendage (n = 1); and high lateral left atrium (n = 1).Results.There were no differences in P wave vectors between sites at the right atrial lateral wall versus the right atrial appendage or between sites at the entrance of right versus left superior pulmonary veins. However, analysis of P wave configuration showed that leads aVL and V1were most helpful in distinguishing right atrial from left atrial foci. The sensitivity and specificity of using a positive or biphasic P wave in lead aVL to predict a right atrial focus was 88% and 79%, respectively. The sensitivity and specificity of a positive P wave in lead V1in predicting a left atrial focus was 93% and 88%, respectively.Conclusions.1) Analyses of surface P wave configuration proved to be reasonably good in differentiating right atrial from left atrial tachycardia foci. 2) Leads II, III and aVF were helpful in providing clues for differentiating superior from inferior foci

Mode of onset of torsade de pointes in congenital long QT syndrome

Objectives.We sought to describe the mode of onset of spontaneous torsade de pointes in the congenital long QT syndrome.Background.Contemporary classifications of the long QT syndrome (LQTS) refer to the congenital LQTS as “adrenergic dependent” and to the acquired LQTS as “pause dependent.” Overlap between these two categories has been recognized, and a subgroup of patients with “idiopathic pause-dependent torsade” has been described. However, it is not known how commonly torsade is preceded by pauses in the congenital LQTS.Methods.We reviewed the electrocardiograms (ECGs) of all our patients with congenital LQTS evaluated for syncope or sudden death (30 patients). Documentation of the onset of torsade de pointes was available for 15 patients. All these patients had “definitive LQTS” by accepted clinical and ECG criteria.Results.Pause-dependent torsade de pointes was clearly documented in 14 of the 15 patients (95% confidence interval 68% to 100%). The cycle length of the pause leading to torsade was 1.3 ± 0.2 times longer than the basic cycle length, and most pauses leading to torsade were unequivocally longer than the preceding basic cycle length (80% of pauses were >80 ms longer than the preceding cycle length).Conclusions.The “long-short” sequence, which has been recognized as a hallmark of torsade de pointes in the acquired LQTS, plays a major role in the genesis of torsade in the congenital LQTS as well. Our findings have important therapeutic implications regarding the use of pacemakers for prevention of torsade in the congenital LQTS

Dose-dependent effects of Allopurinol on human foreskin fibroblast cell and human umbilical vein endothelial cell under hypoxia

Allopurinol, an inhibitor of xanthine oxidase, has been used in clinical trials of patients with cardiovascular and chronic kidney disease. These are two pathologies with extensive links to hypoxia and activation of the transcription factor hypoxia inducible factor (HIF) family. Here we analysed the effects of allopurinol treatment in two different cellular models, and their response to hypoxia. We explored the dose-dependent effect of allopurinol on Human Foreskin Fibroblasts (HFF) and Human Umbilical Vein Endothelial Cells (HUVEC) under hypoxia and normoxia. Under normoxia and hypoxia, high dose allopurinol reduced the accumulation of HIF-1α protein in HFF and HUVEC cells. Allopurinol had only marginal effects on HIF-1α mRNA level in both cellular systems. Interestingly, allopurinol effects over the HIF system were independent of prolyl-hydroxylase activity. Finally, allopurinol treatment reduced angiogenesis traits in HUVEC cells in an in vitro model. Taken together these results indicate that high doses of allopurinol inhibits the HIF system and pro-angiogenic traits in cells