North Kansas City Research Articles

Instructional design for innovation and reform

Not enough attention is paid to the instructional design decisions that define students’ experiences. Lisa Dover Kingsley and Jennifer Perry Cheatham contend that while quality teaching is crucial, the structural decisions supporting meaningful engagement often go unexamined. Using innovations in North Kansas City, Missouri, as a throughline, they review key themes present in research on four elements of instructional design. They urge leaders to reconsider outdated and unexamined design practices with an equitable approach, centering the voices of students typically left out of such decisions. They offer practical shifts and entry points for leaders to consider as they build a more inclusive and effective instructional design.

Improving Outcomes through Implementation of an Infant Spinal Anesthesia Program for Urologic Surgery Patients.

Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months. An interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons, and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization. The team collected data retrospectively by reviewing electronic medical records (Cerner, North Kansas City, Mo.). The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy, or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart. Between August 1, 2018, and February 29, 2020, researchers identified 470 infants (235 preintervention and 235 postintervention) who underwent circumcision, open orchidopexy, or inguinal hernia repair. Following the interventions in this project, there was a statistically significant increase in successful spinal placement from 11% to 45% (P < 0.0001). This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.

Influence of COVID-19 shutdown on the workload of auniversity eye clinic

HintergrundDie Coronaviruserkrankung COVID-19 hat im Frühjahr 2020 zu einer deutlichen Minderleistung der elektiven Medizin in den Krankenhäusern geführt, wobei es für universitäre Polikliniken bisher keine entsprechenden Daten über das Ausmaß dieser Reduktion und die damit verbundenen Erlösminderungen gibt.Material und MethodeMithilfe der Daten des aus dem Krankenhausinformationssystems (IS-H/i.s.h.med unter SAP, Cerner Corporation, North Kansas City, MO, Vereinigte Staaten von Amerika und SAP SE, Walldorf, Deutschland) und der an unserer Klinik mitentwickelten Zeiterfassungs- und Managementsoftware TimeElement (Medizinische Hochschule Hannover, Hannover, Deutschland) wurden alle Patientenkontakte des COVID-19-Shutdowns über ca. 7 Wochen vom 18.03.2020 bis zum 08.05.2020 evaluiert und mit dem Vorjahreszeitraum 2019 verglichen. Zudem wurden die Fallzahlen für das erste und zweite Quartal 2019 und 2020 in Relation gesetzt.ErgebnisseIm COVID-19-Zeitraum reduzierte sich die Gesamtzahl der Patientenkontakte um 59,5 % gegenüber dem Vorjahr. Die Anzahl der abrechenbaren Fälle reduzierte sich um 74,8 %.Insbesondere der Hochschulambulanz‑/Selbstzahlerbereich verzeichnete mit einer Reduktion der Patientenkontakte auf 17,2 % des Ausgangswertes von 2019 den größten Patientenwegfall. Aus der reduzierten Arbeitsleistung resultierte ein Erlösverlust von mindestens 218.000 €. Über TimeElement ergab sich ein Rückgang aller diagnostischen Spezialleistungen von 69,4 %, wobei gerade auch Gesichtsfelduntersuchungen um ca. 75,3 % reduziert waren. OCT-Messungen verzeichneten einen Rückgang um 60,3 %. Das Patiententracking ergab allerdings auch eine Reduktion der durchschnittlichen Anwesenheitszeiten der Patienten um ca. 23 % (COVID-19: 145,8 ± 88,8 min vs. 2019: 189,6 ± 97,2 min).DiskussionDer COVID-19-Shutdown ließ die Arbeitsleistung unserer Poliklinik auf nur noch ca. 40 % der Patientenkontakte und die der funktionsdiagnostischen Untersuchungen auf nur noch ca. 30 %, verglichen zur Leistung aus dem Jahr 2019, einbrechen. Die Reduktion der Patientenzahl führte allerdings auch dazu, dass die Anwesenheitszeiten der Patienten deutlich geringer als bei regulärer Auslastung ausfielen. Die damit verbundenen finanziellen Verluste sind durchaus erheblich und offensichtlich nicht über gesetzlich geregelte Ausgleichszahlungen wie im stationären Bereich kompensiert.

Optimizing the Loading Level of Boric Acid in a Particle Bait: A Preliminary Study with Periplaneta americana (Blattodea: Blattidae)

Optimizing the Loading Level of Boric Acid in a Particle Bait: A Preliminary Study with <i>Periplaneta americana</i> (Blattodea: Blattidae)

Pediatric Orthopaedic Surgeon Time Utilization in Clinic: A Pilot Study

The purpose of this study is to quantify how pediatric orthopaedic surgeons spend time in clinic. Two pediatric orthopaedic surgeons were individually observed and activities were timed during 3 clinic sessions. One medical student observed and recorded the time using a data collection sheet and a watch. The duration of each clinic session was 4 hours and a new patient was seen every 20 minutes. Data was collected in 7 categories including: time with the patient; time with staff; time listening to the resident presentations, time teaching, time multitasking, time dictating, and time on the electronic medical record (EMR). The number of computer mouse clicks needed to complete each patient encounter was also recorded. The Cerner EMR system was used (Cerner Inc. North Kansas City, MO). Thirty-six percent of the physician's time was spent on the EMR. Thirty-five percent of time was spent with the patient, 7% was spent dictating, 7% teaching, 5% multitasking, 6% with staff, and 4% listening to resident presentations. Overall, during a 20-minute patient visit, 7.2 minutes was spent on the EMR. During a 4-hour clinic, 87 minutes was spent on the EMR. During a full day of clinic-two 4-hour sessions-173 minutes were spent on the EMR. The average number of computer mouse clicks to complete a patient encounter was 70 (range: 42 to 110). A total of 1680 clicks were needed to see 24 patients in a typical 2 session clinic. Pediatric orthopaedic surgeons spend more time on the EMR than with patients. About 70 computer mouse clicks are needed per patient encounter. The excessive computer time can diminish the patient-physician relationship. Click fatigue in physicians is real and needs to be resolved by improved EMR technology, utilization of medical scribes, or a return to partial use of paper. Level IV-an observational study.

Lost bed capacity in emergency departments: A descriptive analysis and data visualisation exploration.

To map utilisation of bed resources within an ED over time, in order to determine the proportions of patient stay spent receiving emergency care versus non-emergent care. To produce visualisations that effectively convey this bed utilisation. This was a retrospective cohort study using routinely collected administrative data, derived from the ED electronic health record (FirstNet; Cerner, North Kansas City, MO, USA), on all patients presenting to a single tertiary-level ED during a 1-month period and who were triaged to an acute area bed in order to undergo their emergency care. Resuscitation, subacute, fast track and paediatric area patients were excluded from analysis as firstly, in our institution the acute area processing appears to contribute most to barriers to patient flow and secondly, using acute area patients allowed us to approximate standardisation of acuity. Lost bed capacity (LBC) was defined as the time spent in an ED bed after an emergency clinician indicated that they were ready to depart the ED, as recorded in the electronic medical record. The overall proportion of time spent in an ED bed after completion of emergency care was 38.5% (interquartile range 21.8-47.2%). This time differed significantly between 'discharged' (1 min), 'admitted-ward' (72 min) and 'admitted-critical care' (110 min) groups. This was clearly revealed in our novel LBC heatmaps. A considerable proportion of ED length of stay is because of patients remaining in an ED bed after their emergency care is concluded. Absolute time is much greater for admitted patients than for discharged patients, and therefore efforts to reduce LBC are likely to reduce overall ED length of stay. LBC heatmaps may provide an intuitively useful, potentially automated tool to understand these problems.

A Systemwide Approach for Navigating the Dilemma of Oral Factor Xa Inhibitor Interference With Unfractionated Heparin Anti-Factor Xa Concentrations.

Oral factor Xa inhibitors are known to significantly increase heparin anti-Xa concentrations, which leads to inaccuracies when monitoring intravenous unfractionated heparin (IV UFH). Guidance for managing this laboratory interference is lacking, creating substantial uncertainty in clinical practice. To describe a strategy used by a large academic institution for managing the controversy of laboratory interference in the setting of oral factor Xa inhibitor use and provide effectiveness and safety data for this approach. In December 2016, a new Heparin IV Direct Oral Anticoagulant (DOAC) Interference PowerPlan (a comprehensive order set) was made available in the electronic health record (Cerner, North Kansas City, MO) throughout the health system. We retrospectively examined 169 patients with events reported in the error reporting system, RISKMASTER, and evaluated reports with and without the use of the PowerPlan. Effectiveness was determined through evaluation of thrombosis. The Naranjo criteria for causality were applied to assess thrombotic events. Of 56 events that were reported with apixaban when the PowerPlan was not ordered, 4 (7%) thrombotic events occurred within 7 days of UFH initiation. One out of the 4 events (25%) that occurred when the PowerPlan was not appropriately initiated was considered probable using the Naranjo Scale. Three additional events (75%) were possible using the Naranjo Scale. The Heparin IV DOAC Interference PowerPlan appears to be conducive to positive patient outcomes when evaluating voluntary reported events and may assist clinicians with managing the therapeutic dilemma of this laboratory interference.

Outcomes of Operatively Treated Jones Fractures in Major League Soccer Athletes

Objectives:Proximal 5th metatarsal fractures in athletes are common and have been studied in NCAA athletics as well as professional basketball (NBA), football (NFL), and European soccer (UEFA). Given that Jones fractures have not been studied in Major League Soccer (MLS), we sought to: (1) quantify the burden of fractures, (2) compare outcomes, re-fracture rates, and complication rates with other professional sports, (3) analyze factors for treatment failure, and (4) report return to play characteristics.Methods:A HealtheAthlete (Cerner Corporation, North Kansas City, MO) database was used to catalog all MLS injuries including and after the 2012 season. We extracted all possible Jones fracture injuries from these data from the 2013 to 2017 seasons (January 1, 2013 through December 31, 2017) using key words “toe,” “Jones,” “metatarsal,” “fracture,” and “fifth.” Over 12,000 unique injuries were cataloged; 141 were initially further investigated. Eighty-four were deemed benign, leaving 57 injuries; 12 were reported twice and 3 had 2 different dates of injury, leaving 42 injuries. We then contacted each team chief medical officer for more information including: demographics, date and mechanism of injury, injury classification (zone), prior or contralateral injury, limb dominance, imaging, operative vs. non-operative treatment, details regarding operative treatment if relevant, time to radiographic healing, time to return to sport, and complications including known re-fracture. Twenty-one injuries were further excluded, leaving 21 operatively treated Jones fractures in 18 players.Results:We analyzed 21 operatively treated Jones fractures in 18 players over the five-year study period. Fracture incidence was 0.37 ± 0.08 fractures per 1000 game exposure hours, or 0.063 ± 0.014 fractures per 1000 total exposure hours. Average age, weight, height, and BMI of players at time of fracture was 25.0 ± 3.7 years, 171.3 ± 17.2 lbs, 70.6 ± 3.2 inches, and 24.2 ± 1.9, respectively. 73.7% of players were right foot dominant, and 52.4% of players had right-sided injuries; 1 player reported bilateral injuries. Player position was reported as predominantly defense, midfield, or forward 44.4%, 16.7%, and 28.9%, respectively. 38.1% of injuries occurred in pre-season, with 38.1% associated with chronic, worsening pain, 23.8% with a rolled ankle/foot, 23.8% with a traumatic event, and 14.3% with a quick cut or pivot. One player reported concomitant medial sesamoiditis, otherwise there were no reported associated injuries. Five (24%) reported a prior contralateral fracture. Two (10%) reported a prior ipsilateral non-operatively treated stress fracture. Zone 2 injuries represented 81% of fractures, with the rest classified as zone 3. Average time into MLS career was 2.6 seasons; 8 (38%) occurred in the rookie season. Re-fracture rate was 4/18 players (22.2%), with 1 player’s initial fracture outside the study period; 2 players re-fracture occurred within the study period; and 1 player sustained a re-fracture while on loan (primary fracture included in the study). Average time to re-fracture was 390 days. Treatment for primary fractures (n = 18) included solid screw fixation in 11, cannulated screw fixation in 3, headless cannulated screw fixation in 3, and plate fixation with bone autograft in 1. Treatment for re-fractures (n = 3) included screw exchange with BMAC for 1, screw exchange and bone scaffold with PDGF in 1, and BMAC injection alone with bone stimulator for 1. Average time to radiographic union was 8.3 weeks. Average time to return to play was 10.4 weeks with one outlier removed. Complications include 4 re-fractures, 1 player with screw irritation who required exchange to headless screw with BMAC at 4 months post-op before return to play, 1 mild soft tissue irritation, and 1 mild persistent drainage that resolved with antibiotics. Overall, 20/21 (95%) of players returned to play. Currently, 5 players are retired, 7 remain in MLS, and 6 play in other worldwide professional leagues. Retired players averaged 2.8 years of play after injury. Player return to play characteristics were examined, including games played, games started, full games played, and minutes played; no statistical differences were found.Conclusion:Incidence of Jones fractures appears to be about 1.7x higher than previously reported in European professional soccer (UEFA) (Ekstrand and van Dijk Br J Sports Med 2013). However, articles examining Jones fractures incidence in NFL have shown increased prevalence in the NFL combine over the past few decades (Low et al J Surg Orth Adv 2004, Tu et al FAI 2018, Spang et al OJSM 2018). A significant number of injuries occur in pre-season (38%) and in players’ rookie seasons (38%), with the majority playing non-midfield positions. Return to play of 95% and re-fracture rate of 22% are comparable to rates in other professional sports. There does not appear to be any detrimental effect on players’ ability to perform after Jones fracture fixation.

Neutrophil-lymphocyte ratio predicts disease severity and outcome after lower extremity procedures

ObjectiveNeutrophil-lymphocyte ratio (NLR) has been associated with inferior outcomes after lower extremity interventions. NLR has been associated with systemic inflammation and atherosclerotic burden. We examined NLR, severity of peripheral artery disease (PAD), and outcomes after endovascular or open surgical procedures. MethodsInpatients undergoing lower extremity procedures (2008-2016) were selected from Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo) using International Classification of Diseases, Ninth Revision procedure codes. Disease severity was grouped into claudication, rest pain, and tissue loss. Outcomes were identified using International Classification of Diseases, Ninth Revision codes. NLR was calculated preoperatively and postoperatively. A χ2 analysis and multivariable logistic regression were performed. A receiver operating characteristic curve analysis was used to determine the cutoff for preoperative (low, <3.65; high, ≥3.65) and postoperative (low, <5.96; high, ≥5.96) NLR values. ResultsThere were 3687 patients evaluated; 2183 (59%) underwent endovascular procedures and 1504 (41%) had open procedures. Compared with black patients, claudication was more frequent in white patients (81.7% vs 72.7%; P < .0001), and tissue loss was less common (12.9% vs 20.9%; P < .0001). NLR values were higher for patients with tissue loss than for patients with rest pain or claudication (4.89, 4.33, and 3.11, respectively; P < .0001). Open procedures were associated with higher postoperative NLR values than endovascular procedures (6.8 vs 5.2; P < .0001). Mean preoperative and postoperative NLR values were greater in patients with more severe PAD. Multivariable analysis demonstrated that preoperative high NLR was strongly associated with in-hospital death (odds ratio [OR], 5.4; 95% confidence interval [CI], 1.68-17.07), cardiac complications (OR, 2.9; 95% CI, 1.57-5.40), amputation (OR, 2.5; 95% CI, 1.65-3.87), renal failure (OR, 1.9; 95% CI, 1.18-2.93), respiratory complications (OR, 1.7; 95% CI, 1.09-2.76), and prolonged length of stay (OR, 1.9; 95% CI, 1.89-3.71). ConclusionsPreoperative and postoperative NLR significantly increases with disease severity for PAD, providing further evidence of NLR as a biomarker of a patient's systemic inflammatory state. After adjustment for confounders, NLR still remained strongly associated with death and other adverse outcomes after intervention for PAD. Further study of the clinical association of NLR with other vascular disorders, such as symptomatic carotid stenosis and symptomatic and ruptured aortic aneurysmal disease, is planned to guide individualized treatment to prevent stroke or aneurysm rupture.

Hyalinized Neurofibromas: Not Just Rare Variants in Skin of the Female Breast.

Although classical neurofibromas are commonly encountered skin lesions, histologic variants are infrequent. We report a greater than 15-year retrospective review of a single institution's experience with the histopathologic diagnosis of neurofibroma of the female breast with a focus on the hyalinized variant. An electronic histopathology record review (CoPathPlus; Cerner Corp, North Kansas City, MO) was conducted from January 1, 2000, to October 16, 2015, for all "neurofibroma" diagnoses rendered in "females" at the anatomical site "breast". All cases were microscopically revisited and subclassified into 1 of 10 histopathologic categories. Immunohistochemistry (IHC) for S100, tryptase, and CD117 were performed on 19 hyalinized and 19 age-matched classical neurofibromas. During the study period, 62,021 breast specimens were reviewed at our institution. Of these, 86 (0.14%) were diagnosed as neurofibromas. Subclassification was as follows: 50 classical (58%), 19 hyalinized (22%), 6 diffuse (7%), 5 cellular (6%), 3 myxoid (4%), 2 epithelioid (2%), and 1 plexiform (1%). All hyalinized and age-matched classical neurofibromas were S100 positive. The mean number of IHC-positive mast cells per high-power field (hpf) was 34.5 by tryptase and 26.8 by CD117 for the hyalinized subset and 22.5 by tryptase and 19.3 by CD117 for the classical cohort. Published literature reports a 2.6% incidence of hyalinized neurofibromas at nonspecial cutaneous sites. Our series details a 22% incidence in the breast. Regarding pathophysiology, there is a statistically significant increase in the average number of IHC-positive mast cells per hpf in hyalinized variants when compared with classical neurofibromas of the breast both by tryptase (P = 0.00157) and CD117 (P = 0.00901).

Molecular testing in metastatic colorectal adenocarcinoma cytology cell pellets.

Mutational status for KRAS, NRAS, and BRAF genes should be performed on all colorectal carcinoma (CRC) specimens in order to guide targeted therapy selection for metastatic disease. Mutations are typically assessed via polymerase chain reaction and/or next generation sequencing (NGS) on formalin-fixed paraffin-embedded tissues. With minimally invasive diagnostic methodologies, the cytology cell pellet obtained by fine-needle aspiration (FNA) can serve as an alternative source of tumor deoxyribonucleic acid. An electronic record review of the cytopathology files (CoPathPlus, Cerner Corp., North Kansas City, Missouri) from September 1, 2015 through December 31, 2018 was conducted. All cytology specimens obtained via FNA and diagnosed as metastatic CRC on which NGS was performed were included. NGS for KRAS, NRAS, and BRAF mutations using the AmpliSeq Cancer Hotspot Panel v2.0 kit (Thermo Fisher Scientific, Waltham, Massachusetts) was performed on cytology cell pellets. Forty-eight cases were identified. Forty-six of 48 specimens (96%) were adequate for molecular testing. Of those adequate specimens, proportion of malignant cells in the sample ranged from 5% to 95% (mean 46%). Twenty-seven of 48 cases (56%) were positive for clinically relevant mutations. Twenty-four of 27 cases (89%) were positive for KRAS mutations, with exon 2 most frequently involved (22/24 cases, 92%). Two of 27 cases (7%) were positive for NRAS mutations and one case (1/27, 4%) was positive for a BRAF mutation involving codon 594. Mutational analysis performed on cytology cell pellets serves as a useful means of gathering clinically actionable information on tumor mutation status in metastatic CRC.

Outcomes associated with hyperglycemia after abdominal aortic aneurysm repair

ObjectiveWe evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair. MethodsWe used diagnosis and procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) to identify patients who underwent open or endovascular repair of a nonruptured AAA from September 2008 to March 2014 from the Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo). We evaluated the association between postoperative hyperglycemia (glucose concentration >180 mg/dL) and infections, in-hospital mortality, readmission, patients' characteristics, length of hospital stay, and medications. Multivariable logistic models examined the association of postoperative hyperglycemia with in-hospital infection and mortality. ResultsOf 2478 patients, 2071 (83.5%) had good postoperative glucose control (80-180 mg/dL), and 407 (16.5%) had suboptimal control (hyperglycemia). Patients who had postoperative hyperglycemia experienced longer hospital stays (9.5 vs 4.7 days; P < .0001), higher infection rates (18% vs 8%; P < .0001), higher in-hospital mortality (8.4 vs 1.2%; P <.0001), and more acute complications (ie, acute renal failure, fluid and electrolyte disorders, respiratory complications). After adjusting for patients' characteristics and medications, multivariable logistic regression models demonstrated that patients receiving postoperative insulin had nearly 1.6 times the odds of having an infectious complication (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12-2.2; P = .007) than those who did not. Hyperglycemic patients had 3.5 times the odds of in-hospital mortality (OR, 3.48; 95% CI, 1.78-6.80 [P = .0003]; 2.3% vs 1.2%; P < .001). When stratified by procedure type, patients with hyperglycemia who underwent endovascular repair had nearly 2 times the odds of an infectious complication (OR, 1.85; 95% CI, 0.98-3.51; P = .05) and 7.5 times the odds of in-hospital mortality (OR, 7.54; 95% CI, 1.95-29.1; P = .003). Patients who underwent an open AAA repair and who had hyperglycemia had three times the odds of dying in the hospital (OR, 3.05; 95% CI, 1.29-7.21; P = .01). ConclusionsAmong patients undergoing elective AAA repair, approximately one in six had postoperative hyperglycemia. After AAA repair in patients with and without diabetes, postoperative hyperglycemia was associated with adverse events, including in-hospital mortality and infections. Compared with those who had open surgery, patients undergoing endovascular repair who had postoperative hyperglycemia had greater risk of infection and death. After controlling for insulin administration and postoperative hyperglycemia, a diabetes diagnosis was associated with lower odds of both infection and in-hospital mortality. Our study suggests that hyperglycemia may be used as a clinical marker as it was found to be significantly associated with inferior outcomes after elective AAA repair. This retrospective study, however, cannot imply causation; further study using prospective methods is needed to elucidate the relationship between postoperative hyperglycemia and patient outcomes.

TISSUE DIAGNOSIS OF CHOLANGIOCARCINOMA

Purpose: Diagnosis of cholangiocarcinoma was a clinical challenge in the past. In an era of high technology, such as the common availability of higher resolution of computed tomogram (CT), endoscopic ultrasound, etc, it is not know whether the diagnosis for this disease is improved. The aim of this study was to determine the most common diagnosis modality for cholangiocarcinoma at the present time. Methods: After approved by Institutional Review Board at Emory University, a database of patients with cholangiocarcinoma was established. The database was obtained from the Department of Medical Records at Emory University hospital by using a computer program known as FOCUS (Emory University, Atlanta, GA). All patients with cholangiocarcinoma during the period of January 1999 to December 2003 were included in this database. All those patients' medical record were reviewed by abstraction of the database using Powerchart (Cerner Corp, North Kansas City, MO) to obtain the modality for diagnosis. Results: 52 patients with cholangiocarcinoma were identified in this period, 20 were male and 32 were female. Among those, 16 patients had diagnosis before they transferred to Emory. The other 36 patients had diagnosis at Emory. In those 36 patients, 22 patients had diagnosis before 2001. 12 patients had diagnosis after 2001. Before 2001, most of the patients (about 77%, 17/22), had diagnosis on surgical specimen, only 23% (5/22) had diagnosis on cytology from endoscopic retrograde cholangiopancreatography (ERCP) brushing or fine needle aspiration (FNA) guided by CT. In contrast to this, after 2001, more than half of the patients (about 60%, 8/14) had diagnosis on cytology specimens from ERCP or FNA guided by CT. About 40% (6/8) had diagnosis on surgical specimen. In general, 64% (23/36) patients' diagnosis were made from surgical specimen, the other 36% (12/36) diagnosis were made from cytology from ERCP or FNA quided by CT. Conclusions: Diagnosis of cholangiocarcinoma is still a clinical challenge, most of the patients had final diagnosis after obtained surgical specimen. Specific tumor markers may be needed to increase the diagnosis yield pre-surgery.

Point of view.

Spine and Scoliosis Surgery North Kansas City Hospital North Kansas City, Missouri The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.

Dural Compression as a Cause of Paraplegia During Operative Correction of Cervical Kyphosis in Ankylosing Spondylitis

*From Spine & Scoliosis Surgery, Inc., and the North Kansas City Hospital, North Kansas City, Missouri †From State University of New York at Buffalo and the Orthopaedic Department at Buffalo General Hospital, Buffalo, New York

Reducing Grain Dust with Oil Additives

ABSTRACT WHEAT and corn were treated with 0.04 percent Durkex 500 oil and 0.02 and 0.06 percent mineral oil, each with and without added malathion, to reduce grain dust emission during handling and prevent insect attack during storage. A sample without additives served as control. After applying the additives, the grain was conveyed immediately in a small elevator leg and the amount of dust generated was measured. All samples were stored at ambient temperature (15 to 25 C) and the dustiness measured after 1, 3, 6, 9, and 12 months of storage. Dust generation during handling of the grain was drastically reduced by as little as 0.02 percent added oil, however, the effect diminished after 1 month of storage for Durkex 500 oil and 6 months of storage for mineral oil. The application of malathion in combination with Durkex 500 oil or mineral oil did not affect the ef-fectiveness or persistence of malathion on treated wheat or corn. Treatments of oil and malathion had functional (milling and breadmaking) properties of wheat samples after 1, 3, 6, 9, and 12 months of storage. Hydrolytic and oxidative rancidity did not appear to be a problem. Control of the grain dust emitted during grain han-dling is badly needed to improve air quality and in-dustrial safety. Unfortunately, cost-effective control measures for dust have yet to be established. Although separation of dust from dust-laden air by bag filters, electronic precipitators, and cyclone collectors (Brown and Reed, 1926; Martin and Stephens, 1977), can be ef-fective, the costs of installation, operation, and maintenance for such equipment are expensive. This type of dust control allows explosible mixtures to occur. Moreover, the energy required by current methods of removing dust from dusty air may exceed the energy re-quired to move the grain. The problem of dust control can also be approached by prevention of dust emission. There are two broad Article was submitted for publication in July 1980; reviewed and ap-proved for publication by the Electric Power and Processing Division of ASAE in March 1981. Mention of firm names or trade product does not constitute endorse-ment by the U.S. Department of Agriculture over others of a similar nature not mentioned. The authors are: F. S. LAI, Research Chemical Engineer, B. S. MILLER, Research Leader, C. R. MARTIN, Agricultural Engineer, C. L. STOREY, Research Entomologist, L. BOLTE, Food Technologist Cereal, M. SHOGREN, Research Food Technologist, K. F. FINNEY, Research Leader, and J. K. QUINLAN, Research En-tomologist, USDA-SEA-AR, U.S. Grain Marketing Research Laboratory, Manhattan, KS. Acknowledgments: The authors are grateful for the help of G. M. Wyatt, L. E. Shakelford, W. Blodgett, and J. L. Wilson. 1626 categories of methods to prevent emission (a) applic-tion of additives to grain and (b) use of mechanical devices. (This paper deals with the first category; the sec-ond category will be discussed in another paper.) Water, because of its ease in application and low cost, is the ob-vious additive for use in preventing dust generation. Lai et al. (1979) found that water applied under specified conditions did not appreciably increase the moisture con-tent of grain and no spoilage was seen after storage for 1 year. However, water evaporates easily and must be add-ed every time grain is handled. Several kinds of additives merit consideration for use in reducing dust emission. Both animal and vegetable fats and oils are nutritious, but most are subject to ox-idative and/or hydrolytic rancidity. In tests of pregelatinized cornstarch (Hubinger Co., Keokuk, IA) and heated cornstarch paste (Corn Products, North Kan-sas City, MO) at the U.S. Grain Marketing Research Laboratory (USGMRL), application was tedious, the resulting starch film did not remain attached to the grain, and a relative large quantity (5 percent) of starch was needed to coat the grain surface. Guar gum (Henkel, Minneapolis, MN) and molasses were not suitable because of their expense and the difficulty of application. Grain treated with molasses became sticky and lost its free flowing property. Cocke et al. (1978) found that dust levels in wheat were reduced more than 92 percent by treatment with a hydrocarbon-based oil at levels as low as 0.07 percent. They also found that the dust levels were reduced when the additive was applied to shelled corn and soybeans. The objectives of this study were to (a) determine if edible oil can control dust emission, (b) determine the amount of oil needed to prevent dust formation, (c) measure the effectiveness of oil treatment after long periods of storage, (d) investigate the effect of oil and oil-malathion treatments on grain quality, (e) confirm the compatibility and biological effectiveness of oil-malathion mixtures and (f) determine the cost of an ef-fective concentration of oil.

Infrared Therapy for Skin Ulcers

North Kansas City Memorial Hospital selected a therapy team (a nurse, a physician, and a clinical engineer) to explore various methods of treating decubitus and other skin ulcers. The primary goal of the team was to find a technique that would be the most effective, and at the same time, least expensive to the patient and hospital. With few exceptions, the team found that most electromechanical devices used in treating decubitus ulcers were frequently cumbersome, required trained technicians to operate, and often involved patient transportation. Since all methods available to treat ulcers simply augment the body's normal healing process, the team believed that phototherapy would be the most acceptable and the least cumbersome and time-consuming. The therapeutic value of phototherapy is extensively documented in the literature. The in-

Infrared Therapy For Skin Ulcers

DONALD B. HYLAND, was the manager of the biomedical laboratory at North Kansas City Hospital, Kansas City, Mo. He is currently the director at Research Medical Center, Kansas City, Mo. VERDA JEAN KIRKLAND, B.N., was the quality assurance coordinator at North Kansas City Hospital at the time this article was written. She now is a staff nurse in the recovery room at North Kansas City Hospital.

Flowering Plants of Clay County, Missouri

Clay County, Missouri, lies north of the Missouri River and east from Kansas City. The principal towns are North Kansas City, Liberty, and Excelsior Springs. Numerous small towns are scattered through the rural areas. It comprises an area of 400 square miles and was organized in 1822. It is made up of rolling hills with bluffs and limestone outcrops along the river. The soil is mainly loessal, having been deposited in early Wisconsin time, although some is covered with glacial deposits. Native flood plain forests are found along some of the streams. There are few areas of native grassland. Most of the arable land is in cultivation but probably most of the native plants have been preserved in limited numbers. William Jewell College campus, from which most of the collections were made, is located in Liberty, near the center of the county. The campus consists of 106 acres varying in altitude from 850 to 990 feet.

The North Kansas City Urban District

T GHE North Kansas City Industrial District is a distinct physical, industrial, and political unit occupying a small bottom in a meander of the Missouri River immediately north of and adjacent to Kansas City, Missouri. Physically this area is separated from Greater Kansas City by the Missouri River; politically it is independent; industrially it has a distinctive development. The interrelations of its physical, political, and industrial conditions have unified the district. Thus unified, it offers an opportunity for interpreting (1) the morphology of the landscape, and (2) the localization of the identifying forms, in a unique industrial area. The purposes of this study are (1) to identify and classify the various physical and cultural landscape forms which are found within the district and to show their interrelationships, (2) to interpret the structure of the cultural landscape by an analysis of the grouping and distribution of these forms, (3) to account for the localization of the various forms and structural features, and (4) to predict, on the basis of these data, the probable future changes in the landscape.