Total joint arthroplasty (TJA) patients often receive allogeneic blood transfusion. In this study we sought to create and validate a clinical prediction rule for transfusion in TJA using data that are easily available when scheduling the procedure. Logistic regression modeling was applied to retrospective data from all TJA procedures performed in Edmonton, Alberta in 2000 (n = 1875). The area under the receiver operating curve for the resulting model in the training and validation data sets was 0.80 and 0.76 respectively. By assigning a simple score based on six independent predictors (age, gender, weight, hemoglobin, ASA operative risk classification and whether revision surgery was planned), it was possible to classify a given subject's risk of receiving allogeneic transfusion. We conclude that accurate prediction of transfusion risk in TJA is possible using a rule based on simple preoperative clinical and laboratory data. Such prediction could allow transfusion prevention strategies to be applied selectively to those at greatest risk.

P Pu ur rp po os se e: : Preoperative investigations are frequently ordered according to care maps or protocols. We hypothesized that selective ordering of investigations by anesthesiology staff would reduce the number and cost of testing.M Me et th ho od ds s: : Prospective descriptive double cohort study carried out over 17 weeks in a tertiary care preadmission clinic. In Group 1, testing followed usual practice (based on standing preoperative orders) while in Group 2 testing was initiated only on the order of an attending anesthesiologist or anesthesiology resident. Postoperative complications were categorized and confirmed by an internist blinded to group assignment. Fisher's exact test, Chisquare and Student's t test were used to compare the groups as appropriate. Statistical significance was inferred at P < 0.05. R Re es su ul lt ts s: : Data were obtained from 507 patients in Group 1 and 431 patients in Group 2. Demographics and ASA risk score were similar in both groups. The mean number of tests ordered did not differ between groups. The mean cost of investigations was reduced from $124 in Group 1 to $95 in Group 2 (P < 0.05). If data for patients assessed by staff anesthesiologists only were considered, the mean cost of testing was reduced to $73. The number and cost of tests ordered by anesthesia residents were similar to that in Group 1. More complications were noted in Group 2, but these did not appear to be related to the altered test ordering practice.C Co on nc cl lu us si io on n: : Selective test ordering by staff anesthesiologists reduces the number and cost of preoperative investigations. Educational efforts should be directed towards improving resident and staff preoperative test ordering practices. HE routine ordering of screening laboratory and radiological investigations prior to surgery has been the subject of considerable criticism, resulting in the development of guidelines, 1-3 computer programs 4 and procedure/disease based algorithms to guide test selection. 5,6 The latter are usually institution or region specific and are incorporated into clinical pathways or care maps designed to standardize pre-and postoperative management of elective surgical patients. Objectif 6Clinical pathways have proven to be cost effective, reducing laboratory and diagnostic charges without adversely affecting outcome.7 In many situations, particularly where the patient is healthy or the procedure is relatively non-invasive, no preoperative investigations are performed. 8In parallel with these developments, surgical preoperative assessment clinics have been established which obviate the need for hospital admission prior to the day of surgery.9 This process has proven to be cost-effective and well accepted by patients.10 Preadmission clinics are frequently not staffed by physicians but by nurses who function in a screening role, detecting medical or physical conditions that trigger an anesthesiology or internal medicine consultation.11,12 Indeed, even in clinics where patients are assessed preoperatively by...

The introduction of bamboo to montane rain forests of the Luquillo Mountains, Puerto Rico in the 1930s and 1940s has led to present-day bamboo monocultures in numerous riparian areas. When a non-native species invades a riparian ecosystem, in-stream detritivores can be affected. Bamboo dynamics expected to influence stream communities in the Luquillo Experimental Forest (LEF) were examined. Based on current distributions, bamboo has spread downstream at a rate of 8 m y−1. Mean growth rate of bamboo culms was 15.3 cm d−1. Leaf fall from bamboo stands exceeded that of native mixed-species forest by c. 30% over a 10-mo study. Bamboo leaves (k = −0.021), and leaves from another abundant riparian exotic, Syzygium jambos (Myrtaceae) (k = −0.018), decayed at relatively slow rates when submerged in streams in fine-mesh bags which excluded macro-invertebrate leaf processors. In a second study, with leaf processors present, bamboo decay rates remained unchanged (k = −0.021), while decay rates of S. jambos increased (k = −0.037). Elemental losses from bamboo leaves in streams were rapid, further suggesting a change in riparian zone / stream dynamics following bamboo invasion. As non-indigenous bamboos spread along Puerto Rico streams, they are likely to alter aquatic communities dependent on leaf input.

Purpose: Radical prostatectomy is associated with substantial blood loss frequently requiring allogeneic blood transfusion. We investigated the efficacy of deliberate hypotension using combined epidural/general anesthesia in reducing allogeneic transfusion requirements in patients undergoing radical prostatectomy. Methods:In a prospective, randomized, single-blind trial, 102 patients undergoing radical prostatectomy were allocated to either an epidural group (n = 51) or a control group (n = 51). In the epidural group, deliberate hypotension was achieved with a target mean arterial pressure of 55-60 mmHg. The trigger for allogeneic blood transfusion in both groups was a hematocrit value < 0.25. Results:Operative blood loss in the epidural group was significantly less than that in the control group (955 ± 517 mL vs 1477 ± 823 mL respectively, P < 0.001). The percentage of patients who reached the threshold trigger for allogenic transfusion was significantly less in the epidural group (8% vs 26%, respectively, P = 0.019) and the number of patients who were actually transfused during hospitalization was also significantly less (P = 0.028). There were no serious adverse events in either group during the study. Conclusion:Controlled hypotension using a combined epidural/general anesthetic technique is associated with significantly less blood loss, and a reduction in the use of allogeneic blood in patients undergoing radical prostatectomy compared to general anesthesia alone. Objectif

Responding to the call of Wheaton to discuss the position of older participants in lifestyle sports, this research presents an analysis of the experiences of middle-aged skateboarders. Through qualitative interviews, ethnographic observation, and discourse analysis of skateboard media, skateboarding is revealed to be an integral part of the biographies and identities of middle-aged skateboarders. These accounts challenge the imaging of skateboarding as a youth culture and indicate that age and time have an important currency to skateboarders. The value of age is not confined to middle-aged skateboarders but is also observable in skateboard media which corresponds with the values held more broadly in skateboard culture. The concept of temporal capital is proposed as a way to make sense of the experiences of middle-aged skateboarders, highlighting how time is at once a path to subcultural authenticity, but also a resource to be managed and scheduled for their continued engagement in skateboarding.

There is an increasing trend toward providing palliative care services within general hospitals. The history and work of three hospital palliative care teams is reviewed, one in New York, one in London, and one in Ontario, Canada. The evolution, leadership, structure, functioning, and financing of the teams is discussed. Indicators of success and survival, principally financial support, leadership, and acceptability within hospitals, are considered. It is recommended that the service traditionally limited to oncology patients be extended to other patient groups. It is also recommended that, taking into account cultural and institutional differences, standardized mechanisms be adopted so that services can be systematically audited and changes implemented. Research and education will become increasingly important if services within hospitals are to survive.

The aim of this study was to describe the roosts of Nyctophilus bifax in littoral rainforest in Iluka Nature Reserve on the north coast of New South Wales. Radio-telemetry was used to track 17 bats in November 1988 (lactation season) and 11 in May 1989 (mating season) to 87 roosts in 49 trees within the littoral rainforest. The bats frequently changed roosts, which were clustered within a small area. During November, lactating females moved twins between diurnal roosts and some carried twins while foraging. Twins represented a load of up to 95% of their mother's bodyweight. Bats roosted communally in foliage and tree hollows, beneath peeling bark, among epiphytes, and between strangler figs and host trees. Hollows were used more frequently when bats were lactating, while the use of foliage roosts was greater during the mating season. Roosts were concentrated in four tree species, although a wide range of other tree species was used. Roost trees used in November were taller (17 m) than those used in May (8.2 m), and refiect selection oi Syzygium leuhmannii and Acmena hemilampra, both trees of the forest interior. The converse applied for selection of Cupaniopsis anacardioides, a small tree of the littoral zone, in May. These results identify the need for conserving a diversity of roosts for this species of bat.

The importance of East Asia to the skateboard industry is multifaceted. It represents a dense commercial asset where the "cool" of skateboarding can be leveraged for consumption. It is also a global resource for touring professional skateboarders visiting countries such as China, Korea, and Japan to film and photograph their tricks in new locations. The success of such strategies are entwined with a regional network of skateboarders, a group whose subcultural capital is operationalized through network capital. Analysis of these connections highlights that Hong Kong's prominence in East Asian skateboarding is largely dependent on its position as a global city and hybrid entrepôt. By addressing the conservative culture of skateboarding, and the importance of Hong Kong as a global city rather than a "skateable" city, this article further contributes to the theorizing of skateboarding beyond discussions of space and resistance.