Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine.

BACKGROUND: Pain after shoulder surgery is often treated with interscalene nerve blocks. Single-injection blocks are effective, but time-limited. Adjuncts such as dexamethasone may help. We thus tested the hypothesis that adding dexamethasone significantly prolongs the duration of ropivacaine and bupivacaine analgesia and that the magnitude of the effect differs among the two local anaesthetics. METHODS: In a double-blinded trial utilizing single-injection interscalene block, patients were randomized to one of four groups: (i) ropivacaine: 0.5% ropivacaine; (ii) bupivacaine: 0.5% bupivacaine; (iii) ropivacaine and steroid: 0.5% ropivacaine mixed with dexamethasone 8 mg; and (iv) bupivacaine and steroid: 0.5% bupivacaine mixed with dexamethasone 8 mg. The primary outcome was time to first analgesic request after post-anaesthesia care unit discharge. The Kaplan-Meier survival density estimation and stratified Cox's proportional hazard regression were used to compare groups. RESULTS: Dexamethasone significantly prolonged the duration of analgesia of both ropivacaine [median (inter-quartile range) 11.8 (9.7, 13.8) vs 22.2 (18.0, 28.6) h, log-rank P<0.001] and bupivacaine [14.8 (11.8, 18.1) and 22.4 (20.5, 29.3) h, log-rank P<0.001]. Dexamethasone prolonged analgesia more with ropivacaine than bupivacaine (Cox's model interaction term P=0.0029). CONCLUSIONS: Dexamethasone prolongs analgesia from interscalene blocks using ropivacaine or bupivacaine, with the effect being stronger with ropivacaine. However, block duration was longer with plain bupivacaine than ropivacaine. Thus, although dexamethasone prolonged the action of ropivacaine more than that of bupivacaine, the combined effect of dexamethasone and either drug produced nearly the same 22 h of analgesia.

Point-source outbreak of coccidioidomycosis in construction workers.

Coccidioidomycosis results from inhaling spores of the fungus Coccidioides spp. in soil or airborne dust in endemic areas. We investigated an outbreak of coccidioidomycosis in a 12-person civilian construction crew that excavated soil during an underground pipe installation on Camp Roberts Military Base, California in October 2007. Ten (83.3%) workers developed symptoms of coccidioidomycosis; eight (66.7%) had serologically confirmed disease, seven had abnormal chest radiographs, and one developed disseminated infection; none used respiratory protection. A diagnosis of coccidioidomycosis in an eleventh worker followed his exposure to the outbreak site in 2008. Although episodic clusters of infections have occurred at Camp Roberts, the general area is not associated with the high disease rates found in California's San Joaquin Valley. Measures to minimize exposure to airborne spores during soil-disrupting activities should be taken before work begins in any coccidioides-endemic area, including regions with only historic evidence of disease activity.

Epidemiological features of a newly described serotype of Shigella boydii.

We report the clinical, microbiological, and epidemiological features of an emerging serotype, Shigella boydii 20. We interviewed patients about symptoms, and history of travel and visitors during the week before illness onset. Seventy-five per cent of the 56 patients were Hispanic. During the week before illness onset, 18 (32%) travelled abroad; 17 (94%) had visited Mexico. Eight (21%) out of 38 who had not travelled had foreign visitors. There were eight closely related patterns by PFGE with XbaI. S. boydii 20 may be related to travel to Mexico and Hispanic ethnicity. Prompt epidemiological investigation of clusters of S. boydii 20 infection may help identify specific vehicles and risk factors for infection.

Glial somatostatin-14 expression in the rat pituitary intermediate lobe: a possible neurotrophic function during development?

Somatostatin-14 was first detected on gestational day 17 in radially-oriented, bipolar cells spanning the width of the intermediate lobe of the rat pituitary. Cells were prominent, and constituted approximately 50% of the lobe area. The presence of vimentin, the cellular shape, and the localization identified these cells as glia. At postnatal day 6, somatostatin-14 and vimentin staining appeared in stellate-shaped cells. This is in agreement with the change from bipolar to stellate shape these glia undergo after the onset of innervation ([13] Gary et al. Int. J. Devl. Neurosci. 13, 555-565, 1995). Glia were more abundant, relative to melanotropes, throughout embryonic and early postnatal development compared to adulthood. Reverse transcription-polymerase chain reaction data showed a high level of prosomatostatin mRNA in the intermediate lobe, compared to the anterior and neural lobes from postnatal day 2 animals, and a significant drop in intermediate lobe content in the adult. The correlation between the number of glia and high expression of somatostatin in neonatal relative to adult tissue, together with the close apposition of incoming axons to the abundant, radially oriented glia during innervation of the lobe, support a neurotrophic function of glia-derived somatostatin.

Progress and problems in achieving the United States national target for completion of antituberculosis treatment.

SETTING: The target for antituberculosis treatment in the United States is for 90% of patients to complete therapy within 12 months. OBJECTIVE: To assess progress in achieving the US national target for tuberculosis treatment. DESIGN: A comparison of treatment outcome in two cohorts of patients with drug-susceptible tuberculosis in California-those reported in 1993-1994 (8488 patients) and 1995-1996 (7823 patients). Risk factors for delay in treatment completion (more than 12 months) were assessed. RESULTS: The percentage of cases completing treatment within 12 months increased in the 1995-1996 cohort (to 68.2%), primarily due to concomitant reductions in delays in treatment completion (to 11.1%) and defaulting (to 2.4%). Disparities in timely treatment completion narrowed over time and in nearly all subpopulations, especially in groups with lowest treatment completion in the 1993-1994 cohort. Remaining risk factors for delay in treatment completion included AIDS and older ages. A substantial percentage of patients died or moved before treatment completion. CONCLUSIONS: Despite recent improvements, completion of antituberculosis treatment in California has not reached the national target. Reaching this target will require further reductions in delays in treatment completion and deaths during treatment, and ensuring that patients who move eventually complete treatment.

Trends in intussusception-associated hospitalizations and deaths among US infants.

CONTEXT: The newly licensed tetravalent rhesus-human reassortant rotavirus vaccine has been withdrawn following reports of intussusception among vaccinated infants. OBJECTIVE: To describe the epidemiology of intussusception-associated hospitalizations and deaths among US infants. DESIGN: This retrospective cohort study examined hospital discharge data from the National Hospital Discharge Survey for 1988-1997, Indian Health Service (IHS) for 1980-1997, California for 1990-1997, Indiana for 1994-1998, Georgia for 1997-1998, and MarketScan for 1993-1996, and mortality data from the national multiple cause-of-death data for 1979-1997 and linked birth/infant death data for 1995-1997. PATIENTS: Infants (<1 year old) with an International Classification of Diseases, Ninth Revision, Clinical Modification code for intussusception (560.0) listed on their hospital discharge or mortality record, respectively. RESULTS: During 1994-1996, annual rates for intussusception-associated infant hospitalization varied among the data sets, being lowest for the IHS (18 per 100 000; 95% confidence interval [CI] = 9-35 per 100 000) and greatest for the National Hospital Discharge Survey (56 per 100 000; 95% CI = 33-79 per 100 000) data sets. Rates among IHS infants declined from 87 per 100 000 during 1980-1982 to 12 per 100 000 during 1995-1997 (relative risk =7.6, 95% CI = 3.2-18.2). Intussusception-associated hospitalizations were uncommon in the first 2 months of life, peaked from 5 to 7 months old, and showed no consistent seasonality. Intussusception-associated infant mortality rates declined from 6.4 per 1 000 000 live births during 1979-1981 to 2.3 per 1 000 000 live births during 1995-1997 (relative risk = 2.8, 95% CI = 1.8-4.3). Infants whose mothers were <20 years old, nonwhite, unmarried, and had an education level below grade 12 years were at an increased risk for intussusception-associated death. CONCLUSIONS: Intussusception-associated hospitalization rates varied among the data sets and decreased substantially over time in the IHS data. Although intussusception-associated infant deaths in the United States have declined substantially over the past 2 decades, some deaths seem to be related to reduced access to, or delays in seeking, health care and are potentially preventable.intussusception, hospitalizations, deaths, risk factors, infants.

Movement of tuberculosis patients and the failure to complete antituberculosis treatment.

The outcomes of tuberculosis (TB) patients who move before completing antituberculosis treatment have not been described. We studied a population-based cohort of 2,576 adult patients reported as having TB in California during 1993, including 147 patients who moved from one local health jurisdiction to another within California. We determined treatment outcomes (completed, defaulted, died, other) for 131 (89%) of these 147 patients. Patients who moved defaulted more often (relative risk [RR] = 5.5, 95% confidence interval [CI] = 4.1 to 7.4) than patients who did not move. Including these patients' treatment outcomes increased the known number of defaulters by 30%, from 141 to 183 persons. Additionally, diagnosis of TB in a state prison emerged as the strongest risk factor for defaulting from treatment. Patients who moved or defaulted were more likely to abuse drugs or alcohol, to be homeless or to be associated with congregate settings such as jails and prisons. On average, patients who defaulted after moving received less than three-quarters of their recommended treatment regimens. These patients may remain infectious or become infectious again. Our findings highlight the importance of ensuring complete treatment for TB patients who move; failure to do so will adversely affect patient health and TB control, especially in many high-risk populations and settings.

Differential innervation of individual melanotropes suggests a role for nonsynaptic inhibitory regulation of the developing and adult rat pituitary intermediate lobe.

Dopamine and GABA were detected in intermediate lobe axons around birth, and early axons were closely apposed to glial cells and processes, possibly using them for guidance. In the adult, axons containing colocalized dopamine and GABA were distributed in a distinct pattern within the lobe, with plexuses located dorsally and ventrally. Axons preferentially followed glial processes in interlobular septa, yet were also interspersed between melanotropes. Individual melanotropes were contacted by varying numbers of axon terminals, with some devoid of contacts. Boutons contained both small clear vesicles and large dense-cored vesicles; membrane specializations were not well-developed. From these findings we concluded that in addition to direct synaptic inhibition, dopamine and GABA could stimulate their receptors by mechanisms similar to "parasynaptic" [Schmitt (1984) Neuroscience, 13:991-1001] or "volume" [Agnati et al. (1995) Neuroscience, 69:711-726] transmission as proposed for the CNS. Humoral agents passing into the intermediate lobe from portal vessels, thus acting as classical hormones, further regulate the melanotropes. Moreover, approximately 50% of the axonal elements were closely apposed to glia, suggesting that glia could have regulatory roles. Previous studies from our laboratory [Chronwall et al. (1987) Endocrinology, 120:1201-1211; Chronwall et al. (1988) Endocrinology, 123:1992:1202] demonstrated heterogeneity in proopiomelanocortin (POMC) biosynthesis among individual melanotropes, prompting the hypothesis that the degree of innervation could govern the expression of certain molecules. We combined immunohistochemistry and in situ hybridization histochemistry to evaluate whether melanotrope molecular heterogenity is spatially correlated with axons and terminals. Tentatively, melanotropes expressing low levels of POMC and alpha1A subunit P/Q type Ca2+ channel mRNAs often were apposed to axons, whereas those with low levels of D2L receptor mRNA rarely were contacted by axons, suggesting that innervation could be one of the factors inducing and maintaining heterogeneity.

Ascendancy of primary care will create role intensification for physician executives.

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.

The evolution of the VPMA (vice-president, medical affairs).

In the past, the VPMA's role was clearly defined. So were the skills required to do the job. Initially VPMAs served an inside role in an organization as the liaison with the medical staff and the hospital administration. That role has matured and is currently evolving. Ultimately the expansion of the VPMA role will provide alternative career directions for physician executives. The wise physician executive learns from those who have knowledge--or who are in the process of acquiring it. That means keeping an eye on active managed care markets nationwide for trends that may be coming to his or her locale. The physician who does not do this kind of professional introspection and evaluation of the national market may find him- or herself professionally behind the curve.

Physician-hospital integration in a community hospital: a case study.

Over the past 20 years, the hospital environment and physicians' relationships with hospitals have changed dramatically. Hough has presented a concise description of this relational evolution. He describes hospitals during the period 1900 to 1975 as physicians' workshops; 1976 to 1985, hospitals were physicians' competitors; 1986 to 1995, hospitals have been and will be physicians' suitors; and, from 1996 on, Hough sees hospitals as physicians' partners. At St. Joseph Health System, we have already taken strong moves toward the final scenario envisioned by Hough. In this article, the author describes the historical underpinnings and the methodologies of the system's planning and implementation processes for new arrangements with staff and community physicians.

Losing sight of the shore: how a future integrated American health care organization might look.

American health care, both nationally and locally, has entered a time of uncertainty, yet with the certainty of change. In this article, the authors take a fresh look at patient/community needs and propose a new level of integration of administration/management, clinical services, education, and public health in the health care organization of the future.

Physician leaders see eye-to-eye.

Late in 1990, the American College of Physician Executives conducted a survey of hospital-based physician executives and chiefs of staff. Each was asked to judge the performance of the other in a wide range of activities. The results show a surprising degree of mutual regard and agreement. The differences, however, are also telling.

Psychological and mood disturbance associated with the diagnosis and treatment of testis cancer and other malignancies.

Eighty-seven men with testis cancer (TC) and 35 men with other cancers (OC) completed measures of mood (Profile of Mood States) and of personality and psychopathology (Millon Clinical Multiaxial Inventory). Effects of primary disease, phase of diagnosis and treatment, locoregional vs. cytotoxic treatment, age, and marital status on these measures were examined. TC patients appeared more distressed during treatment, particularly during cytotoxic as compared to locoregional treatment, than before or after treatment, and more distressed than OC patients. Being married appeared to buffer the stress of cancer and its treatment. Although treatment, particularly cytotoxic therapy, appeared to result in transient distress, results did not offer strong evidence that cancer and its treatment typically precipitate severe psychopathology.

Why some managers fail.

Among modern societies, the American culture is one of the most competitive. And within that culture, physicians are among the most success-oriented professionals. This is easy to understand, in that, for our patients, success is equated with well-being and continuance of life. This emphasis upon success is also finely honed in the physician executive. Commonly, our institutional goals revolve around providing a high-quality health care product in a cost-effective manner. For the physician executive, success is based largely upon the extent to which institutional goals have been attained or, in the present environment, if it has survived. But the actual ingredients for the physician executive's success will depend upon a variety of diverse factors, both personal and environmental.

A personal formula for motivation.

Have you ever wondered why some colleagues or subordinates are outstanding in their work while others are less so? Training and experience are extremely important factors but, by themselves, they will not ensure outstanding performance. The pivotal factor that activates all others is motivation. And underlying motivation is the fact that we all have needs that we desire to have fulfilled and that we make choices regarding the course of action or strategy to fulfill these needs. As managers, we do not typically create the "products" of the organization but rather must rely on subordinates. It is incumbent upon us to obtain from our employees desired behavior that will fulfill organizational goals. Indeed, it has been asserted that "one of the most basic responsibilities of the health service organization manager [is] motivating constructive participation of other organization members."

A compensation incentive plan for pathologists in academic practice.

To enhance physician productivity, this Department of Pathology designed an incentive plan that addresses the diversity of the academic pathologist's responsibilities. The author tells us why the plan was necessary and how it works.

A compensation incentive plan for hospital-based physicians.

The medical environment in which we currently practice is, at once, both frightening and exciting, full of opportunity for those who can best adapt. The number of practicing physicians is increasing at a rate greater than that of the population, while physicians' incomes are stabilizing, with actual buying power reduced. With more medical groups forming (more HMOs, IPAs, and PPOs), physicians are increasingly accepting salaried positions. Physician productivity will be one of the key factors in professional and economic survival. Increasingly, physicians, especially those who are hospital-based, have both revenue- and nonrevenue-generating responsibilities, including clinical, educational, research, and administrative activities. This article proposes a compensation incentive plan for hospital-based physicians that addresses these varied responsibilities.

Sample preparation by ultrafiltration for direct gas chromatographic analysis of ethylene glycol in plasma.

The application of ultrafiltration to sample preparation in the detection and quantification of ethylene glycol in plasma by gas chromatography is described. After addition of the butylene glycol internal standard and ultrafiltration, the sample is directly injected, obviating the need for further dilution. This simple, efficient method of sample preparation is also suitable for more sensitive gas chromatographic measurement of other volatiles.