Expert Consensus for the Use of Outpatient Rehabilitation Visits After Total Knee Arthroplasty: A Delphi Study

OBJECTIVE: There is no consensus for how to use rehabilitation visits after total knee arthroplasty (TKA). We sought to develop expert recommendations for outpatient rehabilitation visit usage after TKA. DESIGN: Delphi study. METHODS: First, we developed a broad list of preliminary visit usage recommendations, which were specific to patients' recovery status (ie, slow, typical, or fast recovery) and time since surgery. We then invited 49 TKA experts to participate on a Delphi panel. During round 1, we surveyed panelists regarding their level of agreement with each preliminary recommendation. We conducted additional Delphi rounds as needed to build consensus, which we defined using the RAND/UCLA method. We updated the survey each round based on panelist feedback and responses from the previous round. RESULTS: Thirty panelists agreed to participate, and 29 panelists completed 2 Delphi rounds. The panel reached consensus on recommendations related to visit frequency, visit timing, and the use of telerehabilitation. The panel recommended that outpatient rehabilitation should begin within 1 week after surgery at a frequency of 2 times per week for the first postoperative month regardless of recovery status. The panel recommended different visit frequencies depending on the patient's recovery status for postoperative months 2 to 3. The panel agreed that telerehabilitation can be recommended for most patients after TKA, but not for patients recovering slowly. CONCLUSION: We used the Delphi process to develop expert recommendations for the use of outpatient rehabilitation visits after TKA. We envision these recommendations could help patients decide how to use visits based on their own preferences. J Orthop Sports Phys Ther 2023;53(9):1-9. Epub: 10 July 2023. doi:10.2519/jospt.2023.11840.

Using a wearable camera to increase the accuracy of dietary analysis

BACKGROUND

Food diaries are commonly used to assess individual dietary intake in both the general and sporting populations. Despite the widespread use of such diaries, evidence suggests that individuals' self-reported energy intake frequently and substantially underestimate true energy intake.

PURPOSE

To examine the use of the Microsoft SenseCam wearable camera to help more accurately report dietary intake within various sporting populations.

METHODS

In 2011, a total of 47 participants were recruited to take part in this study (17 trainee jockeys, 15 elite Gaelic footballers, and 15 healthy physically active university students). Participants wore a SenseCam for 1 day (from morning until night) while simultaneously keeping a 1-day food diary. Comparisons were made between the energy intake reported in the food diary alone and the food diary in conjunction with information gathered from the SenseCam. Data analysis was conducted in 2012.

RESULTS

Mean total calorie intake using diary alone and diary and SenseCam were 2349±827.9 kcals vs 2631±893.4 kcal for the trainee jockeys; 2600±521.9 kcal vs 3191±770.2 kcal for the Gaelic footballers, and 2237±318.5 kcal vs 2487±404.6 kcal for the university students. This represented a difference of 10.7% (p≤0.001); 17.7% (p≤0.001); and 10.1% (p≤0.01) among measurement methods for trainee jockeys, Gaelic footballers, and university students, respectively.

CONCLUSIONS

Results from this first-generation study suggest that a more accurate estimate of total energy intake is provided when combining the use of a conventional food diary and a SenseCam. Additional information on portion size, forgotten foods, leftovers, and brand names can be obtained by using this novel sensing technology in conjunction with the diary, with improved dietary assessment a potential outcome.

Association of OPRM1 A118G variant with the relative reinforcing value of nicotine

RATIONALE

The endogenous opioid system has been implicated in substance abuse and response to pharmacotherapies for nicotine and alcohol addiction. We examined (1) the association of the functional OPRM1 A118G variant with the relative reinforcing value of nicotine and (2) the main and interacting effects of the mu-opioid receptor antagonist naltrexone on nicotine reinforcement.

METHODS

In a within-subject, double-blind human laboratory study, 30 smokers of each OPRM1 genotype (A/A vs. A/G or G/G) participated in two experimental sessions following 4 days of orally administered naltrexone 50 mg or placebo. Participants completed a validated assessment of the relative reinforcing value of nicotine. This cigarette choice paradigm assesses self-administration of 0.6 mg nicotine vs. 0.05 mg (denicotinized) cigarettes after a brief period of nicotine abstinence.

RESULTS

The relative reinforcing value of nicotine (number of nicotine cigarette puffs) was predicted by a significant OPRM1 by gender interaction. Among women, the low-activity G allele (A/G and G/G) was associated with a reduced reinforcing value of nicotine; among male smokers, there was no association with genotype. Smokers carrying a G allele were also significantly less likely to differentiate the nicotine vs. denicotinized cigarettes by subjective ratings of satisfaction and strength. No evidence for an effect of naltrexone on nicotine reinforcement was found in the overall sample or in the genotype or gender subgroups.

CONCLUSIONS

This study provides initial evidence for an association of the OPRM1 A118G variant with nicotine reinforcement in women.

Is preoperative pacing for bifascicular and trifascicular heart block necessary?

Whether to place a temporary pacing wire in patients with bi- or trifascicular block before anaesthesia is a dilemma because of concerns about progression to complete heart block (CHB). CHB usually occurs in patients with acute myocardial infarction, more commonly if there is pre-existing or new bundle–branch block. The cumulative incidence of chronic bi- and trifascicular heart block progressing to CHB in the general population at 5 years is 4.9%, or 1% per year (McAnulty et al, 1982).

A prospective double-blind randomized controlled trial comparing the suitability of KTP laser tonsillectomy with conventional dissection tonsillectomy for day case surgery

Tonsillectomy using a KTP laser has been performed increasingly but is not a routinely practised technique in the UK. In the USA, tonsillectomy is often performed as a day case procedure but, here in the UK, it is still standard practice to admit patients for overnight stay. We present the largest prospective double-blind randomized controlled trial to date (151 patients) comparing KTP laser with standard dissection tonsillectomy and assess the suitability of both procedures for day case surgery. We found that there was significantly less peroperative haemorrhage if tonsillectomy was performed using the KTP laser, but it did cause more postoperative pain, more depression in mood and a higher rate of both reactionary and secondary haemorrhage, which was not significant when compared with conventional dissection. There was no difference in operating time, and over 40% of patients in each group needed overnight admission. We conclude that KTP laser tonsillectomy offers no benefit apart from less intraoperative bleeding over standard dissection tonsillectomy. Discharge from hospital after tonsillectomy was found to be unpredictable. Tonsillectomy is therefore an unsuitable procedure for planned surgery through a day unit, but approximately 58% of patients could be discharged on the same day from an extended day surgery unit, and the rest have one night in hospital.

Sex differences in [123I]beta-CIT SPECT measures of dopamine and serotonin transporter availability in healthy smokers and nonsmokers

Nicotine and other constituents of tobacco smoke elevate dopamine (DA) and serotonin (5-HT) levels in brain and may cause homeostatic adaptations in DA and 5-HT transporters. Since sex steroids alter DA and 5-HT transporter expression, the effects of smoking on DA and 5-HT transporter availability may differ between sexes. In the present study, DA and 5-HT transporter availabilities were quantitated using single photon emission computed tomography (SPECT) imaging approximately 22 h after bolus administration of [123I]beta-CIT, an analog of cocaine which labels DA and 5-HT transporters. Forty-two subjects including 21 pairs of age-, race-, and gender-matched healthy smokers and nonsmokers (12 female and 9 male pairs) were imaged. Regional uptake was assessed by the outcome measures, V3", which is the ratio of specific (i.e., ROI-cerebellar activity) to nondisplaceable (cerebellar) activity, and V3, the ratio of specific to free plasma parent. Overall, striatal and diencephalic [123I]beta-CIT uptake was not altered by smoking, whereas brainstem [123I]beta-CIT uptake was modestly higher (10%) in smokers vs. nonsmokers. When subgrouped by sex, regardless of smoking status, [123I]beta-CIT uptake was higher in the striatum (10%), diencephalon (15%), and brainstem (15%) in females vs. males. The sex*smoking interaction was not significant in the striatum, diencephalon, or brainstem, despite the observation of 20% higher brainstem [123I]beta-CIT uptake in male smokers vs. nonsmokers and less than a 5% difference between female smokers and nonsmokers. The results demonstrate higher DA and 5-HT transporter availability in females vs. males and no overall effect of smoking with the exception of a modest elevation in brainstem 5-HT transporters in male smokers. Although these findings are preliminary and need validation with a more selective 5-HT transporter radiotracer, the results suggest that brainstem 5-HT transporters may be regulated by smoking in a sex-specific manner.

Application of cocaine to the nasal mucosa: a novel method

Topical vasoconstriction using four to 10 per cent cocaine is widely used for nasal surgery. A number of techniques are being used with equally satisfactory results. Here we describe a novel method of topical application of cocaine for nasal surgery. The method is simple, cheap and effective.

Immunoassays with rolling circle DNA amplification: a versatile platform for ultrasensitive antigen detection

We describe an adaptation of the rolling circle amplification (RCA) reporter system for the detection of protein Ags, termed "immunoRCA. " In immunoRCA, an oligonucleotide primer is covalently attached to an Ab; thus, in the presence of circular DNA, DNA polymerase, and nucleotides, amplification results in a long DNA molecule containing hundreds of copies of the circular DNA sequence that remain attached to the Ab and that can be detected in a variety of ways. Using immunoRCA, analytes were detected at sensitivities exceeding those of conventional enzyme immunoassays in ELISA and microparticle formats. The signal amplification afforded by immunoRCA also enabled immunoassays to be carried out in microspot and microarray formats with exquisite sensitivity. When Ags are present at concentrations down to fM levels, specifically bound Abs can be scored by counting discrete fluorescent signals arising from individual Ag-Ab complexes. Multiplex immunoRCA also was demonstrated by accurately quantifying Ags mixed in different ratios in a two-color, single-molecule-counting assay on a glass slide. ImmunoRCA thus combines high sensitivity and a very wide dynamic range with an unprecedented capability for single molecule detection. This Ag-detection method is of general applicability and is extendable to multiplexed immunoassays that employ a battery of different Abs, each labeled with a unique oligonucleotide primer, that can be discriminated by a color-coded visualization system. ImmunoRCA-profiling based on the simultaneous quantitation of multiple Ags should expand the power of immunoassays by exploiting the increased information content of ratio-based expression analysis.

Putting all the pieces together. The complete board needs the right mix of competencies

Now that most system and hospital boards are smaller, few can afford to include members who don't contribute to the organization's strategic plan. So boards are applying new criteria for choosing members--criteria based on candidates' personal characteristics, skills, knowledge, and perspective.

Design and synthesis of novel alpha(1)(a) adrenoceptor-selective antagonists. 1. Structure-activity relationship in dihydropyrimidinones

Dihydropyrimidinones such as compound 12 exhibited high binding affinity and subtype selectivity for the cloned human alpha(1a) receptor. Systematic modifications of 12 led to identification of highly potent and subtype-selective compounds such as (+)-30 and (+)-103, with high binding affinity (K(i) = 0.2 nM) for alpha(1a) receptor and greater than 1500-fold selectivity over alpha(1b) and alpha(1d) adrenoceptors. The compounds were found to be functional antagonists in human, rat, and dog prostate tissues. Compound (+)-103 exhibited excellent selectively to inhibit intraurethral pressure (IUP) as compared to lowering diastolic blood pressure (DBP) in mongrel dogs (K(b)(DBP)/K(b)(IUP) = 40) suggesting uroselectivity for alpha(1a)-selective compounds.

Design and synthesis of novel alpha(1)(a) adrenoceptor-selective antagonists. 3. Approaches to eliminate opioid agonist metabolites by using substituted phenylpiperazine side chains

Dihydropyrimidinones, such as 1, represent a novel class of alpha(1a) adrenoceptor antagonists with potential for the treatment of benign prostatic hyperplasia (BPH) (see part 1 of this series). Analysis of the metabolites of 1 revealed that 4-methoxycarbonyl-4-phenylpiperidine is formed as the major metabolite and is an agonist at the mu-opioid receptor. To circumvent any potential liability resulting from the metabolite, we decided to identify alternate templates devoid of agonist activity at the mu-opioid receptor to replace the 4-methoxycarbonyl-4-phenylpiperidine moiety. The present study describes the synthesis and SAR of dihydropyrimidinones linked to substituted 4-phenylpiperazine containing side chains. Compound (+)-38 was identified as a lead compound with a binding and functional profile comparable to that of 1. The putative metabolite 2-carboxamidophenylpiperazine has negligible affinity for the mu-opioid receptor.

Design and synthesis of novel alpha(1)(a) adrenoceptor-selective antagonists. 4. Structure-activity relationship in the dihydropyrimidine series

We have previously disclosed dihydropyridines such as 1a,b as selective alpha(1a) antagonists as a potential treatment for benign prostatic hyperplasia (BPH). The propensity of dihydropyridines toward an oxidation led us to find suitable replacements of the core unit. The accompanying papers describe the structure-activity relationship (SAR) of dihydropyrimidinones 2a,b as selective alpha(1a) antagonists. We report herein the SAR of dihydropyrimidines such as 4 and highlight the similarities and differences between the dihydropyrimidine and dihydropyrimidinone series of compounds.

Design and synthesis of novel alpha(1)(a) adrenoceptor-selective antagonists. 2. Approaches to eliminate opioid agonist metabolites via modification of linker and 4-methoxycarbonyl-4-phenylpiperidine moiety

We have previously described compound 1a as a high-affinity subtype selective alpha(1a) antagonist. In vitro and in vivo evaluation of compound 1a showed its major metabolite to be a mu-opioid agonist, 4-methoxycarbonyl-4-phenylpiperidine (3). Several dihydropyrimidinone analogues were synthesized with the goal of either minimizing the formation of 3 by modification of the linker or finding alternative piperidine moieties which when cleaved as a consequence of metabolism would not give rise to mu-opioid activity. Modification of the linker gave several compounds with good alpha(1a) binding affinity (K(i) = < 1 nM) and selectivity (>300-fold over alpha(1b) and alpha(1d)). In vitro analysis in the microsomal assay revealed these modifications did not significantly affect N-dealkylation and the formation of the piperidine 3. The second approach, however, yielded several piperidine replacements for 3, which did not show significant mu-opioid activity. Several of these compounds maintained good affinity at the alpha(1a) adrenoceptor and selectivity over alpha(1b) and alpha(1d). For example, the piperidine fragments of (+)-73 and (+)-83, viz. 4-cyano-4-phenylpiperidine and 4-methyl-4-phenylpiperidine, were essentially inactive at the mu-opioid receptor (IC(50) > 30 microM vs 3 microM for 3). Compounds (+)-73 and (+)-83 were subjected to detailed in vitro and in vivo characterization. Both these compounds, in addition to their excellent selectivity (>880-fold) over alpha(1b) and alpha(1d), also showed good selectivity over several other recombinant human G-protein coupled receptors. Compounds (+)-73 and (+)-83 showed good functional potency in isolated human prostate tissues, with K(b)s comparable to their in vitro alpha(1a) binding data. In addition, compound (+)-73 also exhibited good uroselectivity (DBP K(b)/IUP K(b) > 20-fold) in the in vivo experiments in dogs, similar to 1a.

Rapid exchange of A:T base pairs is essential for recognition of DNA homology by human Rad51 recombination protein

Human Rad51 belongs to a ubiquitous family of proteins that enable a single strand to recognize homology in duplex DNA, and thereby to initiate genetic exchanges and DNA repair, but the mechanism of recognition remains unknown. Kinetic analysis by fluorescence resonance energy transfer combined with the study of base substitutions and base mismatches reveals that recognition of homology, helix destabilization, exchange of base pairs, and initiation of strand exchange are integral parts of a rapid, concerted mechanism in which A:T base pairs play a critical role. Exchange of base pairs is essential for recognition of homology, and physical evidence indicates that such an exchange occurs early enough to mediate recognition.

Naturalistic follow-up of drinking behavior following participation in an alcohol administration study

Administration of alcohol to alcohol-dependent individuals for research purposes, while contributing significantly to the fund of knowledge on etiology and treatment of alcohol dependence, has often raised clinical and ethical concerns that such exposure may adversely affect the individual's motivation to reduce drinking or abstain from drinking. In an attempt to evaluate these concerns, we conducted a naturalistic follow-up of subsequent drinking among individuals who participated in an alcohol self-administration study and also received a brief motivational intervention. Twenty-one non-treatment-seeking alcoholics participated in a study examining the effects of naltrexone on alcohol self-administration. Assessment of drinking during the 3 months following the laboratory study indicated that participants had significantly reduced the total number of drinking days and the number of drinks consumed per occasion, as compared to baseline levels. The findings suggest that participation in alcohol administration research does not adversely influence the subsequent drinking of alcohol-dependent individuals. Further, when the alcohol administration research is conducted carefully, with specific attention to the clinical needs of the participants, the risks of adverse effects on participants' drinking behavior is minimal, and, in fact, there is scientific benefit to society and clinical benefit to the participants with regard to their alcoholism.

Giant cell tumour of the hyoid--first reported case

Giant cell tumours of bone are most commonly found in the epiphyses of weight-bearing long bones. They are rarely found in the head and neck and only 17 cases involving the laryngeal framework have been reported. To date, there have been no reports of a giant cell tumour arising from the hyoid bone. We present such a case which presented as a lump overlying the greater cornu of the hyoid, review the literature and discuss the management of this locally aggressive tumour.

Extracranial internal carotid artery aneurysm in a child: a diagnostic and surgical challenge

This paper reports the presentation and management of an extra-cranial internal carotid artery aneurysm in a 15-year-old male. To our knowledge there is no previous report of a similar case in childhood.

Stress-induced craving and stress response in cocaine dependent individuals

Two laboratory studies were conducted to examine the effects of acute psychological stress on craving and stress reactivity in cocaine abusers. In the first preliminary study, we examined the effects of a speech stressor task and a personalized stress imagery task on self-reported craving and emotional state in ten cocaine abusers. Both stressors led to significant decreases in neutral and joy states, and significant increases in fear ratings as compared to baseline ratings. In addition, the stress imagery condition led to significant increases in cocaine craving and sadness and anger ratings, as compared to baseline. Thus, the personalized stress imagery task appeared to be more effective than the speech stress task in inducing craving in the laboratory. The second study examined the effects of stress imagery as compared to neutral imagery on cocaine craving, subjective anxiety and physiological responses in a second group of ten cocaine abusers. The stress imagery task once again produced significant increases in cocaine craving along with increases in heart rate, salivary cortisol and subjective anxiety ratings. These data are the first to document that acute psychological stress consistently increases craving for cocaine in cocaine abusers. The studies also provide a promising method for examining the association between stress and drug craving in the laboratory.

Variable dose naltrexone-induced hypothalamic-pituitary-adrenal stimulation in abstinent alcoholics: a preliminary study

Opiate antagonists have been found to stimulate the hypothalamic-pituitary-adrenal axis. However, despite established usefulness in the management of alcoholism, systematic, oral dose-titrated natrexone-induced hypothalamic-pituitary-adrenal stimulation has never been studied in alcoholics. Six patients (5 males, 1 female) with DSM-IV alcohol dependence, who were at least 4 weeks abstinent from any alcohol [mean 55 days (+/-SE 7.5)], were given four challenges of oral naltrexone (0, 25, 50, and 100 mg) in a randomized order at least 3 days apart, after an overnight fast. Naltrexone was administered at 9 AM; serum ACTH, cortisol, and prolactin were measured at time 0 and at 9 time points over the next 4 hr. Subjects also filled out a side effect questionnaire and an alcohol urge questionnaire. Physiological measurements of blood pressure and pulse rate were taken at the same time points. Repeated-measures ANOVA of the changes in serum ACTHs over time revealed a significant effect of drug (placebo vs. any dose of naltrexone) (p < 0.05). Post-hoc analysis revealed a significant difference between placebo and the 25 mg dose (p < 0.01), the 50 mg dose (p < 0.01), but no significance between the placebo and the 100 mg dose (p = 0.1). A repeated-measures ANOVA of the changes in serum cortisols over time revealed a significant effect of drug (p < 0.01). Post-hoc analysis revealed a significant difference between placebo and the 25 mg dose (p < 0.01), between placebo and the 50 mg dose (p < 0.05), and placebo and the 100 mg dose (p < 0.01). There was a significant between dose difference in pulse rate changes over baseline (p < 0.01), and post-hoc analysis revealed a significant diminution in pulse rate at the 100 mg dose relative to placebo (p < 0.001), and to the other doses. There were no significant differences in reported side effects, alcohol urge questionnaire scores, or in other physiological measurements between doses. These data suggest a significant rise in ACTH and cortisol in response to naltrexone in alcoholics compared with placebo, with no differences between 25 mg, 50 mg, and 100 mg doses, and a significant diminution in pulse rate responses at the 100 mg dose.

4-Oxospiro[benzopyran-2,4'-piperidines] as selective alpha 1a-adrenergic receptor antagonists

The 4-oxospiro[benzopyran-2,4'-piperidine] ring system is contained within potent class III antiarrhythmic agents. We highlight how these agents can be chemically transformed into a new class of potent (< 1 nM) and selective (> 25-fold) alpha 1a-receptor subtype adrenergic antagonists.

Design and synthesis of N-alkylated saccharins as selective alpha-1a adrenergic receptor antagonists

Benign prostatic hyperplasia can be managed pharmacologically with alpha-1 adrenergic receptor antagonists. Agents that demonstrate selectivity for the alpha-1a receptor subtype may offer advantages in clinical applications with respect to hypotensive side effects. The N-alkylated saccharins reported here represent a new class of subtype selective alpha-1a adrenergic receptor antagonists which demonstrate potent effects on prostate function in vivo and are devoid of blood pressure side effects.

Association of alcohol or other drug dependence with alleles of the mu opioid receptor gene (OPRM1)

Opioidergic neurotransmission and, specifically, the mu opioid receptor have been implicated in the reinforcing effects of a variety of drugs of abuse. Consequently, the present study examined the association of a polymorphic (CA)n repeat at the OPRM1 locus (the gene coding for the mu opioid receptor) to alcohol or drug dependence in 320 Caucasian and 108 African-American substance-dependent or control subjects. Among Caucasians, suggestion of a modest association, which could be interpreted as statistically significant (p = 0.03), was observed between OPRM1 alleles and substance (alcohol, cocaine, or opioid) dependence. Analysis by specific substance showed only a trend level association to alcohol dependence. Comparisons among African Americans yielded no evidence for association. Further studies of the association between alleles of the OPRM1 gene and substance dependence appear warranted, particularly if they use a family-based approach to control for population stratification. Phenotypes other than a broad diagnostic categorization, such as opioid antagonist effects on drinking behavior in alcoholics, may provide more consistent evidence of a role for OPRM1 in behavioral variability.

Personal renewal for professional growth

When healthcare professionals burn out, they put themselves and their organizations at risk. The solution, career specialists say, begins with looking closely at conflicts between personal and professional values. Ultimately it might lead to further education, a career change or finding a way to spend more time in one's area of expertise.

Co-morbidity and familial aggregation of alcoholism and anxiety disorders

BACKGROUND

This study examined the patterns of familial aggregation and co-morbidity of alcoholism and anxiety disorders in the relatives of 165 probands selected for alcoholism and/or anxiety disorders compared to those of 61 unaffected controls.

METHODS

Probands were either selected from treatment settings or at random from the community. DSM-III-R diagnoses were obtained for all probands and their 1053 first-degree relatives, based on direct interview or family history information.

RESULTS

The findings indicate that: (1) alcoholism was associated with anxiety disorders in the relatives, particularly among females; (2) both alcoholism and anxiety disorders were highly familial; (3) the familial aggregation of alcoholism was attributable to alcohol dependence rather than to alcohol abuse, particularly among male relatives; and (4) the the pattern of co-aggregation of alcohol dependence and anxiety disorders in families differed according to the subtype of anxiety disorder; there was evidence of a partly shared diathesis underlying panic and alcoholism, whereas social phobia and alcoholism tended to aggregate independently.

CONCLUSIONS

The finding that the onset of social phobia tended to precede that of alcoholism, when taken together with the independence of familial aggregation of social phobia and alcoholism support a self-medication hypothesis as the explanation for the co-occurrence of social phobia and alcoholism. In contrast, the lack of a systematic pattern in the order of onset of panic and alcoholism among subjects with both disorders as well as evidence for shared underlying familial risk factors suggests that co-morbidity between panic disorder and alcoholism is not a consequence of self-medication of panic symptoms. The results of this study emphasize the importance of examining co-morbid disorders and subtypes thereof in identifying sources of heterogeneity in the pathogenesis of alcoholism.

Stress response dampening: effects of gender and family history of alcoholism and anxiety disorders

One hundred and fifteen non-alcoholic social drinkers, ages 21-30 years, were selected on the basis of parental history of alcoholism and/or anxiety disorders to participate in a laboratory study of stress response dampening (SRD) effects of alcohol. The following four risk groups were identified based on the diagnoses of both parents: 1) alcoholism (ALC+), (2) alcoholism and anxiety disorder (ALCANX+), (3) anxiety (ANX+), and (4) no psychiatric diagnoses (FH-). Subjects were randomly assigned to receive a placebo or alcohol (0.85 g/kg) beverage, following which cardiovascular measures and self-reports of anxiety were monitored prior to, during and after a speech stressor. Women with a family history of alcoholism and women with a family history of anxiety disorders showed strong SRD effects of alcohol on heart rate and pulse transit time. Men with a family history of anxiety disorders showed evidence of increased subjective response to stress during the alcohol beverage condition. Finally, SRD effects of alcohol were not found for male subjects, and this was attributed to their heavier drinking histories and lower breath alcohol levels as compared to women. Implications of the SRD effects in women are discussed in the context of the comorbid association between alcoholism and anxiety disorders.

The population-based approach to chronic care

Looking at the needs of a population rather than the episodes that land individuals in the hospital is one way to improve care. Find out the 10 steps to establishing population-based care programs, and learn some healthcare organizations' strategies for preventing acute episodes.

Total quality now! Putting QI on the fast track

To keep up with today's constantly changing healthcare needs, organizations are looking for ways to expedite improvements to their systems. Some have adopted one of the nationally recognized methods--blitz improvement teams, the Breakthrough Series, PICOS or interactive accelerated replication. Other organizations are designing their own improvement programs, borrowing concepts from TQM and picking up the pace. Whatever the method used, they agree on 10 components that are essential for a successful effort.

Independent healthcare organizations band together to keep unwanted suitors at bay: are these alliances working?

Competitive pressures are forcing a growing number of independent health-care organizations to consider allying with local rivals to create a market presence capable of keeping mega for-profit competitors at bay. Such moves, however, do not reflect "just a for-profit versus not-for-profit thing," says one consultant. "This is life and death."

Using PICOS workshops to identify and eliminate waste

"Any human activity that absorbs resources but creates no value," says Maureen Bisognano of the Institute for Healthcare Improvement, "is waste." At war with waste--in healthcare as well as in the automobile industry--is General Motors Corp. The battle plan is an accelerated change process known as PICOS. In a four-step, three-and-one-half-day workshop, GM facilitators work with teams from the healthcare organization to identify waste and plan ways to get rid of it. See if you can identify, within your organization, the seven types of waste they attack--then read about systems that have used PICOS successfully in battle.

KTP laser-resistant properties of the reinforced laryngeal mask airway

We have assessed, in vitro, the effect of KTP laser strike on the reinforced laryngeal mask airway (RLMA) under a variety of conditions. At power densities normally encountered in clinical practice, using a divergent KTP laser beam, the RLMA could not be penetrated and did not ignite with laser strike. The RLMA was penetrated at a high power density of 6.94 W mm-2 after 45-60 s. A flame appeared over the RLMA shaft at this power density after 12-35 s. The black marker line on the RLMA shaft was somewhat more vulnerable to the effects of laser strike. The flow of oxygen and nitrous oxide within the shaft did not appreciably alter the laser-resistant properties of the RLMA. The RLMA cuff was more vulnerable to laser strike than was the shaft and was penetrated at very low power densities. Filling the cuff with saline had a protective effect and penetration did not occur at power densities which caused penetration of air-filled cuffs (0.37 W mm-2).

Pathways: improving outcomes, not just 'cookbook medicine'

A Kaiser Permanente medical director cites four benefits to be derived from using clinical guidelines: better outcomes, faster patient recovery, reduced costs, and increased physician accountability. And, he notes, physicians are free to deviate from the guidelines--so long as they can justify their actions.

Getting physician buy-in to standardization efforts

The healthcare industry in recent years has been aggressively developing guidelines for physicians to follow in providing patient care--and physicians have just as aggressively resisted using them, arguing they stifle creativity in addressing patients' specific needs. But with studies showing that following best practices results in better outcomes and lower costs, systems are looking for ways to bring physicians on board. And they've learned a number of things to do and do not do--among them, do involve physicians in developing the guidelines, don't lock physicians into outdated protocols.

Report cards: how relevant are they for patients?

Two advocates for providing consumers the information they need to make informed choices among HMOs point out that the data being gathered for purchasers and others steeped in health plan analyses have little meaning for the end user. Foundation for Accountability President David Lansky, Ph.D., and PacifiCare's Vice President of Health Services Sam Ho, M.D., discuss the outcomes information consumers need, the style they need it in and the steps being having taken to ensure they get it.

HMOs: responding to bad report cards

Differentiating one health plan from another is becoming increasingly difficult. But a plethora of report cards on plans' performance are now available to help purchasers pick and choose managed care for their members. When a health plan receives a low score--or a score lower than its competitors, be it ever so slight--does it respond appropriately? Are leaders adequately following up to determine the significance of the scoring, rectify the problem--and communicate that to purchasers? Is quality improvement an outcome of publishing report cards? TQL spoke with health plan leaders, healthcare consultants and purchasers to find out what some plans are doing--and what many should be doing.

Multiple neoplasms following craniospinal irradiation for medulloblastoma in a patient with nevoid basal cell carcinoma syndrome. Case report

A 28-year-old man presented to the authors' hospital with multiple intracranial tumors. At 2 years of age, he had undergone resection of a medulloblastoma and received adjunctive craniospinal irradiation. Subsequently, he was diagnosed with nevoid basal cell carcinoma syndrome, Gorlin's syndrome. Since his first presentation, he has required surgery for multiple basal cell carcinomas, an osteochondroma of the rib, two meningiomas, a trigeminal schwannoma, and a pleomorphic liposarcoma, all of which arose within the radiation field. Despite this impressive list of benign and malignant neoplasms, the patient is relatively well and leads a normal life. The authors examine the relationships between Gorlin's syndrome and radiation therapy and the subsequent development of tumors.

Point/counterpoint: the proposed Grand Rapids merger

When the federal circuit court decided not to grant an injunction to prevent a merger of one city's two major hospitals, the FTC filed an appeal--and a complaint with an administrative law judge. FTC lawyers say this action is within the realm of their responsibility; one hospital's CEO says that FTC complaint has a taint of vengefulness.

Adding value: what healthcare can learn from industry

How can superior outcomes be provided to satisfied patients using the appropriate amount of resources? That's the $64,000 question that healthcare organizations are striving to answer--indeed, must answer--to survive in the managed care marketplace, says Stephen Shortell, Ph.D., A.C. Buehler Distinguished Professor of Health Services Management of Northwestern University. The business world can teach healthcare leaders how to increase their organizations' competitive edge, he says, in four areas: having a deep knowledge of the customer, looking for ways to add value, using innovation as a key to adding value and defining value in economic terms.

Changing antitrust prospects for hospital mergers

The courts recently decided in favor of plans in three cities to merge hospitals, despite government arguments that such mergers would be anticompetitive. Is this a harbinger of a change in prospects for merger? Lawyers and consultants say that final court disposition of current appeals could determine future government action to enforce the antitrust laws. In the meantime, they offer seven tips for optimizing chances of winning approval of a merger.

Seven steps for adding value to integrated delivery systems

"Value is a spectrum of needs that you seek to fulfill," says Dean C. Coddington, senior author of Making Integrated Health Care Work. And adding value to products and services is becoming more crucial as healthcare organizations look for ways to stand out among competitors. The seven basic components of value for an integrated system, says Mr. Coddington, are improving quality of care, improving service, improving accessibility, reducing unit costs, increasing operating efficiency, strengthening customer ties and enhancing product offerings. In this issue, The Quality Letter reports on how several systems have used these seven components to increase patient and purchaser satisfaction.

Prospective countywide evaluation of the effects of motor vehicle safety device use on hospital resource use and injury severity

STUDY OBJECTIVE

We evaluated the efficacy of safety devices (seat belts and air bags) on hospital resource use and injury severity while controlling for variables known to affect outcome of motor vehicle crashes.

METHODS

We conducted a prospective observational study of motor vehicle crash victims who were transported to the hospital in a suburban-rural county with a population of 1.4 million. Out-of-hospital providers recorded patient demographic characteristics, mechanism of injury (based on American College of Surgeons criteria), and use of seat belts or air bags. Hospital charts were reviewed for hospital admission, length of hospital stay, ICU stay, surgery, major nonorthopedic surgery or death, and severe injury (Injury Severity Score > 15).

RESULTS

The study group comprised 1,446 motor vehicle crash victims. Median age was 30 years, 47% were male, and 69% used safety devices. The use of safety devices reduced the likelihood of hospital admission (adjusted odds ratio [OR], .67; 95% confidence interval [CI], .46 to .98) surgery (adjusted OR, .52; 95% CI, .27 to 1.01), major surgery or death (adjusted OR, .14; 95% CI, .04 to .52), and severe injuries (adjusted OR of injury Severity Score > 15, .39; 95% CI, .19 to .83).

CONCLUSION

The use of safety devices is associated with decreased hospital resource use and less severe injuries for victims of motor vehicle crashes who are transported to the hospital by emergency medical services providers, even after adjustment for many other variables known to affect the outcome of motor vehicle crashes. Continued efforts to promote safety device use are warranted.