UPBEAT: the impact of a psychogeriatric intervention in VA medical centers. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment.

BACKGROUND: The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualized interdisciplinary mental health treatment and care coordination to elderly veterans whose comorbid depression, anxiety, or alcohol abuse may result in overuse of inpatient services and underuse of outpatient services. OBJECTIVES: To determine whether proactive screening of hospitalized patients can identify unrecognized comorbid psychiatric conditions and whether comprehensive assessment and psychogeriatric intervention can improve care while reducing inpatient use. DESIGN: Randomized trial. SUBJECTS: Veterans aged 60 and older hospitalized for nonpsychiatric medical or surgical treatment in 9 VA sites (UPBEAT, 814; usual care, 873). MEASURES: The Mental Health Inventory (MHI) anxiety and depression subscales, the Alcohol Use Disorder Identification Test (AUDIT) scores, RAND 36-Item Health Survey Short Form (SF-36), inpatient days and costs, ambulatory care clinic stops and costs, and mortality and readmission rates. RESULTS: Mental health and general health status scores improved equally from baseline to 12-month follow-up in both groups. UPBEAT increased outpatient costs by $1,171 (P <0.001) per patient, but lowered inpatient costs by $3,027 (P = 0.017), for an overall savings of $1,856 (P = 0.156). Inpatient savings were attributable to fewer bed days of care (3.30 days; P = 0.016) rather than fewer admissions. Patients with 1 or more pre-enrollment and postenrollment hospitalizations had the greatest overall savings ($6,015; P = 0.069). CONCLUSIONS: UPBEAT appears to accelerate the transition from inpatient to outpatient care for acute nonpsychiatric admissions. Care coordination and increased access to ambulatory psychiatric services produces similar improvement in mental health and general health status as usual care.

Comparison of 4 analgesic agents for venipuncture.

This study compared pain on application, pain on venipuncture, cost, and convenience of 4 analgesic agents used for venipuncture. A convenience sample of 280 preoperative subjects was assigned randomly to 1 of 4 groups. Group 1 received 2.5% lidocaine--2.5% prilocaine cream (LPC) topically, Group 2 received dichlorotetrafluoroethane spray (DCTF), Group 3 received 0.5% lidocaine subcutaneously, and group 4 received normal saline with 0.9% benzyl alcohol (BA) subcutaneously. A 7-point verbal descriptor scale measured pain on application, and a 100-mm visual analogue scale measured pain on venipuncture. Cost was measured and compared on unit-dose basis. Convenience was measured with a questionnaire survey completed by the investigators. There was no significant difference (P < .05) among the groups for age, sex, ASA physical status, or difficulty of venipuncture. There was a significant difference in pain on application for all 4 agents (P < .05). The DCTF had the highest pain on application score (1.7 +/- 0.1), while the LPC had no pain on application (0.0 +/- 0). Lidocaine had a higher pain on application score (1.08 +/- 0.1) than the BA (0.52 +/- 0.1) but a lower score than DCTF. Lidocaine (1.3 +/- 0.3) was significantly less painful (P < .05) on venipuncture than LPC (2.18 +/- 0.3) and DCTF (2.5 +/- 0.3) but was not significantly different than BA (1.92 +/- 0.3). (All scores are given as mean +/- SEM.) There was a significant difference in cost and convenience among the 4 agents, with BA and lidocaine being the least expensive analgesic agents. Lidocaine, DCTF, and BA were equally convenient to use, while LPC was the least convenient, (P < .05). Lidocaine had low pain on venipuncture and low cost and convenience of use, but it was less than ideal in terms of pain on application. The BA had all the qualities of an ideal analgesic agent for venipuncture in this sample and should be considered as an analgesic agent for venipuncture.

Induction of anaesthesia with sevoflurane, preprogrammed propofol infusion or combined sevoflurane/propofol for laryngeal mask insertion: cardiovascular, movement and EEG bispectral index responses.

Inhalation induction with sevoflurane was compared with propofol or sevoflurane/propofol in 60 unpremedicated adults. Target concentrations for the three groups (with 60% nitrous oxide) were 3% end-tidal sevoflurane, 12 mg/l propofol and 1.5% sevoflurane/6 mg/l propofol respectively, prior to insertion of a laryngeal mask airway (LMA) at 10 minutes. Induction of anaesthesia was satisfactory in each group, but movement response to LMA insertion was observed in 20 patients (least in the sevoflurane group). Cardiovascular responses were similar except for a lower heart rate in the sevoflurane group. EEG bispectral index suggested a greater depth of anaesthesia in the inhalation induction group. A bispectral index of 60 separated patients responding to LMA insertion from nonresponders (P = 0.006), and had a sensitivity of 68% and specificity 70%. Movement response was not predicted by cardiovascular changes.

Compatibility of ketamine and morphine injections.

The compatibility of ketamine and morphine mixture was studied. In addition, pH adjustment to minimise local tissue irritation led to no change in stability of the mixture up to pH 5.9. It appears that ketamine and morphine mixtures are stable over a 24 h period.

A new optical transducer for arterial pressure measurement.

A new optical pressure transducer system (Viggo) has been assessed and compared with a standard P10 transducer (Spectramed) using a similar 20-gauge cannula, both in vitro in terms of linearity and frequency response and in vivo using an animal model. The linearity of the transducers was comparable; the resonant frequencies were 106 Hz and 75 Hz, respectively. However, the resonant frequency of the complete Spectramed system including 150-cm tubing was 11 Hz. The frequencies at which the output amplitude error exceeded 10% of the initial amplitude for the Viggo and for P10 with and without 150-cm tubing were 32 Hz, 24 Hz and 4 Hz, respectively. The principal advantage of the new transducer is that it is sufficiently compact to be mounted directly in the cannula at the wrist, so obviating the use of connecting tubing between the transducer and the cannula.

Cardiovascular effects of sedative infusions of propofol and midazolam after spinal anaesthesia.

The cardiovascular effects of intravenous sedation were studied in fifty patients after spinal anaesthesia for lower limb or pelvic surgery. Twenty patients received propofol (mean dosage 74 (SD 4) micrograms/kg/min for 0-20 minutes and 51 (SD 7) micrograms/kg/min for 20-40 minutes), twenty received midazolam (35 micrograms/kg + 2.54 (SD 0.2) micrograms/kg/min for 0-20 minutes and 1.35 (SD 0.2) micrograms/kg/min for 20-40 minutes) and ten patients received saline infusion only. The forearm vasoconstriction in response to the spinal anaesthesia was measured by strain gauge plethysmography. Spinal anaesthesia lowered systolic and diastolic blood pressure by 18 (SED 4) mmHg and 9 (SED 2) mmHg respectively. (SED = standard error of the difference.) This was associated with a 32% decrease in mean forearm blood flow. Propofol and midazolam caused similar additional reductions in systolic and diastolic blood pressure (10 (SED 4) mmHg and 4 (SED 2) mmHg) and a decrease in heart rate (P less than 0.005), but forearm vasoconstriction was not altered. In the control group, however, forearm vasoconstriction increased during 40 minutes in theatre (P less than 0.05). Recovery from propofol was far more rapid than after midazolam and was virtually complete in ten minutes. This was reflected by an increase in blood pressure and in forearm vasoconstriction in the recovery period.

Induction of ovulation and fertility in amenorrheic women by pulsatile low-dose gonadotropin-releasing hormone.

In functional hypothalamic amenorrhea, failure of ovulation probably results from deficient hypothalamic secretion of gonadotropin-releasing hormone (GnRH). We treated 14 infertile women in whom this condition was resistant to clomiphene with pulses of 5 to 15 micrograms of GnRH administered subcutaneously by portable pumps at 90-minute intervals in 36 cycles of treatment. Ovulation occurred in 30 cycles (83 per cent) and was followed by normal luteal function in 24. Singleton pregnancy occurred after 13 (54 per cent) of these cycles. Ovarian ultrasound consistently showed a single dominant follicle, and follicular-phase levels of gonadotropins and urinary estrone glucuronide were in the normal range in all cycles of treatment except two in which mild ovarian overstimulation occurred. Plasma profiles of GnRH and luteinizing hormone were highly pulsatile after subcutaneous administration of GnRH, and mean peak plasma levels of GnRH were comparable to those in pituitary portal blood. We conclude that treatment with low-dose subcutaneous pulses of GnRH is a safe, effective, and physiologic method of restoring reproductive function in hypothalamic amenorrhea and that it has advantages over gonadotropin therapy.