Barriers and resistance to informatics in behavioral health.

The levels of resistance to a new informatics system can vary widely both between and among specific groups. The relevance to today's behavioral medicine area is obvious. The aim of effective change management techniques is not to eliminate all resistance. This is typically impossible when a group of any size is involved. The aims are (1) to keep initial general resistance at reasonable levels, (2) to pre-vent that initial resistance from growing to serious levels, and (3) to identify and deal with any pockets of serious resistance that do occur despite the previous efforts. His article outlines areas of resistance to behavioral informatics and offers suggestions for overcoming the resistance.

The National Outcomes Management Project: a benchmarking collaborative.

Traditional evaluation of health care quality usually involves the measurement of the structure, process, and outcome of care. Most quality improvement programs involve a cycle that includes a setting of goals, a measurement of either process or outcomes, and a real-time or retrospective feedback of the results of data measurement. Benchmarking, a well-known efficient business technology, can lead to practice innovations necessary to survive in an environment that has a need for decreasing cost and increasing quality. The purpose of this article is to present a novel use of benchmarking in managed ambulatory behavioral health care and its application in a model collaborative outcome management project at more than 16 sites and nine states in the United States.

Acute exacerbation of COPD: factors associated with poor treatment outcome.

OBJECTIVES: To determine the effect of age, severity of lung disease, severity and frequency of exacerbation, steroid use, choice of an antibiotic, and the presence of comorbidity on the outcome of treatment for an acute exacerbation of COPD. DESIGN: A retrospective chart analysis over 24 months. SETTING: A university Veterans Affairs medical center. PATIENTS: Outpatients with COPD who were treated with an antibiotic over a period of 24 months for an acute exacerbation of COPD. METHODS: Severity of an acute exacerbation of COPD was defined using the criteria of Anthonisen et al: increased dyspnea, increased sputum volume, and increased sputum purulence. Severity of lung disease was stratified based on FEV(1) percent predicted using American Thoracic Society guidelines (stage I, FEV(1) > or = 50%; stage II, FEV(1) 35 to 49%; stage III, FEV(1) < 35%). Treatment outcome was judged successful when the patient had no return visit in 4 weeks for a respiratory problem. Failure was defined as a return visit for persistent respiratory symptoms that required a change of an antibiotic in < 4 weeks. RESULTS: One-hundred seven patients with COPD (mean age +/- SD, 66.9 +/- 9.5 years) experienced 232 exacerbations over 24 months. First-line antibiotics (trimethoprim-sulfamethoxazole, ampicillin/amoxicillin, and erythromycin) were used to treat 78% of all exacerbations. Treatment failure was noted in 12.1% of first exacerbations and 14. 7% of all exacerbations, with more than half the failures requiring hospitalization. Host factors that were independently associated with treatment failure included the following: FEV(1) < 35% (46.4% vs 22.4%; p = 0.047), use of home oxygen (60.7% vs 15.6%; p < 0. 0001), frequency of exacerbation (3.8 +/- 2.0 vs 1.6 +/- 0.91; p < 0. 001), history of previous pneumonia (64.3% vs 35.1 p < 0.007), history of sinusitis (28.6% vs 8.8%; p < 0.009) and use of maintenance steroids (32.1% vs 15.2% p = 0.052). Using stepwise logistic regression analysis to identify the top independent variables, the use of home oxygen (p = 0.0002) and frequency of exacerbation (p < 0.0001) correctly classified failures in 83.3% of the patients. Surprisingly, age, the choice of an antibiotic, and the presence of any one or more comorbidity did not affect the treatment outcome. CONCLUSION: The results of our study suggest that patient host factors and not antibiotic choice may determine treatment outcome. Prospective studies in appropriately stratified patients are needed to validate these findings.

Psychiatric practice variations in the diagnosis and treatment of major depression.

OBJECTIVE: Practice variations in the diagnosis, treatment, and outcomes of patients with major depression were examined within six psychiatric practices participating in a national outcomes-management project. METHODS: Six of 20 psychiatric clinics met selection criteria for this study and provided a database of 5, 106 patients. Patients completed the BASIS-32, the Short-Form-36 Health Survey, and a Beginning Services Survey. Treatment information was also obtained directly from the clinician or through a medical record review. RESULTS: Although 73.1 to 77 percent of patients screened positive for a depressive disorder, only 18.5 to 36.8 percent were diagnosed with major depression (p<.001). Between 39 and 72 percent of patients received psychotropic medications, a significant difference across sites (p<.001). In addition, the number of psychotherapy sessions was significantly different across sites (p<.001). CONCLUSIONS: Patient care varies considerably across psychiatric practices, a finding that is particularly relevant for developers of performance indicators and risk-adjustment strategies for mental health.

Likelihood of malignancy in a solitary pulmonary nodule: comparison of Bayesian analysis and results of FDG-PET scan.

OBJECTIVE: To compare the probability of cancer in a solitary pulmonary nodule using standard criteria with Bayesian analysis and result of 2-[F-18] fluoro-2-deoxy-D-glucose-positron emission tomographic (FDG-PET) scan. SETTING: A university hospital and a teaching Veteran Affairs Medical Center. METHODS: Retrospective analysis of 52 patients who had undergone both CT scan of the chest and a FDG-PET scan for evaluation of a solitary pulmonary nodule. FDG-PET scan was classified as abnormal or normal. Utilizing Bayesian analysis, the probability of cancer using "standard criteria" available in the literature, based on patient's age, history of previous malignancy, smoking history, size and edge of nodule, and presence or absence of calcification were calculated and compared to the probability of cancer based on an abnormal or normal FDG-PET scan. Histologic study of the nodules was the gold standard. RESULTS: The likelihood ratios for malignancy in a solitary pulmonary nodule with an abnormal FDG-PET scan was 7.11 (95% confidence interval [CI], 6.36 to 7.96), suggesting a high probability for malignancy, and 0.06 (95% CI, 0.05 to 0.07) when the PET scan was normal, suggesting a high probability for benign nodule. FDG-PET scan as a single test alone was more accurate than the standard criteria and standard criteria plus PET scan in correctly classifying nodules as malignant or benign. CONCLUSION: FDG-PET scan as a single test was a better predictor of malignancy in solitary pulmonary nodules than the standard criteria using Bayesian analysis. FDG-PET scan can be a useful adjunct test in the evaluation of solitary pulmonary nodules.

Mediastinal lymph node staging of non-small-cell lung cancer: a prospective comparison of computed tomography and positron emission tomography.

We compared the abilities of positron emission tomography and computed tomography to detect N2 or N3 lymph node metastases (N2 or N3) in patients with lung cancer. Positron emission tomography detects increased rates of glucose uptake, characteristic of malignant cells. Patients with peripheral tumors smaller than 2 cm and a normal mediastinum were ineligible. All patients underwent computed tomography, positron emission tomography, and surgical staging. The American Thoracic Society lymph node map was used. Computed and positron emission tomographic scans were read by separate radiologists blinded to surgical staging results. Lymph nodes were "positive" by computed tomography if larger than 1.0 cm in short-axis diameter. Standardized uptake values were recorded from areas on positron emission tomography corresponding to those from which biopsy specimens were taken; if greater than 4.2, they were called "positive." Seventy-five lymph node stations (2.8 per patient) were analyzed in 27 patients. Computed tomography incorrectly staged the mediastinum as positive for metastases in three patients and as negative for metastases in three patients. Sensitivity and specificity of computed tomographic scans were 67% and 83%, respectively. Positron emission tomography correctly staged the mediastinum in all 27 patients. When analyzed by individual node station, there were four false positive and four false negative results by computed tomography (sensitivity = 60%, specificity = 93%, positive predictive value = 60%). Positron emission tomography mislabeled one node station as positive (100% sensitive, 98% specific, positive predictive value 91%). The differences were significant when the data were analyzed both for individual lymph node stations (p = 0.039) and for patients (p = 0.031) (McNemar test). Positron emission tomography and computed tomography are more accurate than computed tomography alone in detecting mediastinal lymph node metastases from non-small-cell lung cancer.

PET-FDG imaging and transthoracic needle lung aspiration biopsy in evaluation of pulmonary lesions. A comparative risk-benefit analysis.

BACKGROUND AND OBJECTIVE: Positron emission tomography (PET) utilizing 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) has been demonstrated to be highly accurate in differentiating benign from malignant pulmonary nodules. Transthoracic fine-needle aspiration biopsy (TTNA) is generally the initial procedure of choice in the evaluation of peripheral lesions suspected to be malignant. Our objective was to determine whether PET-FDG imaging, a noninvasive test, was equally efficacious as TTNA in the evaluation of lung lesions suspected to be malignant. PATIENT SELECTION: Thirty-three patients with 35 lung lesions who had undergone both PET-FDG imaging and TTNA were retrospectively selected from an ongoing prospective study of PET-FDG imaging in the evaluation of solitary pulmonary nodules. MEASUREMENTS: Diagnostic efficacy was determined by calculating sensitivity, specificity, positive and negative predictive value, and overall predictive accuracy for both PET-FDG imaging and TTNA in differentiating benign from malignant lesions. Complication rate also was documented for the two tests. RESULTS: The PET imaging correctly identified all 26 malignant lesions, including 21 lesions diagnosed by TTNA and 7 of the 9 benign lung lesions. The TTNA was positive for malignancy in 21 lung lesions and missed the diagnosis of malignancy in 5 lesions. Diagnostic sensitivity, specificity, positive and negative predictive value, and overall predictive accuracy was 100, 78, 93, 100, and 94% for PET imaging and 81, 100, 100, 64, and 86 for TTNA, respectively. Pneumothorax was documented in 16 patients (46%), and 9 patients (26%) required a chest tube. There were no complications with PET imaging. CONCLUSION: We conclude that PET imaging of the lung is as efficacious as TTNA, with less risk, and offers an alternate noninvasive option in the evaluation and management of lung lesions suspected to be malignant.

Detection of scalene lymph node metastases from lung cancer. Positron emission tomography.

Preliminary data indicate that positron emission tomography (PET) following injection of fluorodeoxyglucose F18 (FDG) is sensitive and specific for detecting malignant cells in chest tumors and mediastinal lymph nodes. We report a case of non-small cell lung cancer metastatic to clinically normal scalene lymph nodes that was correctly staged by FDG-PET.

Positron emission tomography of lung tumors and mediastinal lymph nodes using [18F]fluorodeoxyglucose. The Members of the PET-Lung Tumor Study Group.

Positron emission tomography detects increased glucose uptake in malignant tissue using the glucose analogue [2-18F]fluoro-2-deoxy-D-glucose. We reviewed the scans obtained in 62 patients with lung tumors. All had undergone computed tomography and had tissue-based diagnoses: 22 had adenocarcinomas, 12 had squamous cell carcinomas, 13 had other malignancies, 1 had organizing pneumonia, 1 had a hamartoma, and 13 had granulomas. Positron emission tomography with [2-18F]fluoro-2-deoxy-D-glucose identified 44 of 47 malignancies. Two of three false-negative findings were tumors that were 1 cm2 or less and the other was a bronchioloalveolar carcinoma. All three false-positive findings were granulomas. The sensitivity and specificity of the technique were 93.6% and 80%, respectively, and the positive and negative predictive values were 93.6% and 80%, respectively. The differential uptake ratio was determined in all 62 patients. The mean differential uptake ratio (+/- the standard error of the mean) for malignant tumors was 6.4 +/- 0.56 and that for benign tumors was 1.14 +/- 0.26 (p < 0.0001, t test). Twenty-five of the patients had N2 lymph nodes evaluated pathologically. Positron emission tomography with [2-18F]fluoro-2-deoxy-D-glucose identified negative N2 nodes in 19 of 22 patients (86%) with negative nodes and positive N2 nodes in 2 of 3 patients (66%) with positive nodes, including one instance missed by computed tomography.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of low flow and high flow oxygen delivery on exercise tolerance and sensation of dyspnea. A study comparing the transtracheal catheter and nasal prongs.

HYPOTHESIS: We hypothesized that high flow transtracheal oxygen (HFTTO) will improve exercise tolerance as compared with low flow transtracheal oxygen (LFTTO) and that transtracheal oxygen (TTO) will increase exercise tolerance with less dyspnea as compared with nasal prongs (NP) at equivalent oxygen saturation (SaO2). PATIENT SELECTION: Ten subjects, six male and four female, who were already receiving TTO were recruited for the study. STUDY DESIGN: Each subject underwent a total of four modified progressive treadmill tests in a single-blind randomized fashion on two separate days. Two tests were performed with the patients receiving LFTTO and HFTTO while the other two were performed with low- and high-flow oxygen by NP. The flows were adjusted to provide equivalent oxygen saturations at rest for respective groups. RESULTS: The mean +/- SD exercise distance with HFTTO (1,134 +/- 631 ft) was 2.5 times greater than with LFTTO (446 +/- 328 ft; p < 0.006); and high-flow NP (HFNP [1207 +/- 763 ft]) was 2.38 times greater than with low-flow NP (LFNP[492 +/- 487 ft; p < 0.005]). There was no significant difference in exercise distance and dyspnea scores with HFTTO as compared with HFNP and LFTTO versus LFNP. CONCLUSION: We conclude that the use of high-flow oxygen via both transtracheal catheter and NP significantly increased exercise tolerance in our COPD patients when compared to low-flow oxygen. Transtracheal oxygen did not increase maximum exercise tolerance with less dyspnea as compared with oxygen via NP at equivalent SaO2.

Diagnostic efficacy of PET-FDG imaging in solitary pulmonary nodules. Potential role in evaluation and management.

BACKGROUND: Positron emission tomography (PET), a new noninvasive imaging modality, utilizing 2-[F-18]-fluoro-2-deoxy-D-glucose (FDG), has demonstrated increased FDG uptake in lung tumors. OBJECTIVE: To determine the diagnostic efficacy of PET-FDG imaging in differentiating benign from malignant solitary pulmonary nodules. PATIENT SELECTION: A prospective study of 30 patients who presented with indeterminate solitary pulmonary nodules less than 3 cm in size based on chest radiograph and computed tomographic (CT) scan. SETTING: Two tertiary care medical centers in Omaha, Neb: Creighton University Medical Center and the Omaha Veterans Administration Medical Center. MEASUREMENTS: Positron emission tomographic imaging of the lung was performed 1 h after intravenous injection of 10 mCi of F-18-FDG. Qualitative analysis of the images was performed independently by two observers by visual identification of the areas of increased FDG uptake in the lung nodules. Semiquantitative analysis was performed using computation of differential uptake ratio (DUR). Histologic specimens were obtained in 29 patients (thoracotomy 20, transthoracic needle aspiration biopsy 8, bronchoscopy 1). RESULTS: Positron emission tomographic imaging correctly identified 27 of 30 pulmonary nodules. Diagnostic accuracy was high with sensitivity of 95 percent and specificity of 80 percent. The positive and negative predictive value of PET imaging for solitary pulmonary nodules was 90 percent and 89 percent, respectively. The DUR values were significantly higher for malignant nodules (mean +/- SD, 5.55 +/- 2.79) than benign nodules (mean +/- SD, 0.95 +/- 0.99) (p < 0.001). There was one false-negative result in a patient with a 1-cm nodule identified as a scar adenocarcinoma. There were two false-positive cases and both had caseating granulomas with active inflammation and Histoplasma organisms. CONCLUSION: PET-FDG imaging of the lung, a new noninvasive diagnostic test, has a high degree of accuracy in differentiating benign from malignant pulmonary nodules. PET-FDG imaging could complement CT scanning in the evaluation and treatment of patients with solitary pulmonary nodules.

Solitary pulmonary nodules: detection of malignancy with PET with 2-[F-18]-fluoro-2-deoxy-D-glucose.

It is estimated that nearly one-third of solitary pulmonary nodules (SPNs) may represent bronchogenic carcinoma. The noninvasive imaging methods used currently (ie, plain radiography, computed tomography) are not reliable for accurate detection of malignancy in most SPNs. The authors prospectively evaluated use of positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) for identification of malignancy in 20 patients with noncalcific, radiographically indeterminate SPNs. PET-FDG imaging demonstrated focal hypermetabolism in 13 biopsy-proved malignant nodules, whereas no increased FDG uptake was seen in the seven benign SPNs. Semiquantitative analysis with computation of differential uptake ratios also helped clearly differentiate benign nodules (mean +/- standard deviation, 0.56 +/- 0.27) from malignant nodules (mean +/- standard deviation, 5.63 +/- 2.38) (P less than .001). Thus, PET-FDG imaging may be a potentially useful noninvasive technique for accurate differentiation of benign and malignant SPNs that are radiographically indeterminate.

Smell and taste function in subjects with chronic obstructive pulmonary disease. Effect of long-term oxygen via nasal cannulas.

It was hypothesized that subjects with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen via nasal cannulas have an impaired sense of smell and/or taste. To objectively evaluate the sense of smell and taste, this study used the University of Pennsylvania Identification Test (UPSIT), a 40-item "scratch-n-sniff" test and a 20-item taste test using the four basic taste sensations of sweet, salt, sour, and bitter. Twenty subjects (15 male, 5 female) with severe COPD receiving long-term oxygen therapy (group 1), and an equal number of age- and sex-matched subjects with COPD not receiving oxygen therapy (group 2), and a healthy control group (group 3) were studied. Twelve subjects (seven male, five female) from group 1 subsequently underwent transtracheal oxygen catheter installation. Mean +/- SD for the basic smell test was significantly greater in group 3 (35.35 +/- 3.58) as compared with group 1 (27.70 +/- 6.07) or group 2 (31.10 +/- 4.95) (p less than 0.005). The difference between group 1 and 2 was not significant (p = 0.066). However, when adjusted for pack years of smoking, there were no significant differences between the three groups. Mean +/- SD correct responses for the basic taste test were significantly greater in group 3 (15.75 +/- 1.81) as compared with group 2 (12.8 +/- 2.78) (p less than 0.005) and group 1 (14.00 +/- 2.33) (p less than 0.05). There was no significant difference between group 1 and 2. The corrected data for taste, adjusted for years since quitting smoking, did not alter the basic differences between the groups. Mean smell and taste test scores were essentially unchanged in 12 subjects after six months of transtracheal oxygen therapy. Long-term oxygen use via nasal cannulas in this group of subjects with COPD did not appear to impair their sense of smell and taste. Smoking had a significant but variable effect on the sense of smell and taste.

Persistent hypoxemia due to patent foramen ovale in a patient with adult respiratory distress syndrome.

This report describes a patient in the recovery phase of the adult respiratory distress syndrome in whom the persistence of severe hypoxemia was not corrected by a high fractional concentration of oxygen in the inspired gas and positive end-expiratory pressure. A right-to-left interatrial shunt was diagnosed by M-mode and cross-sectional echocardiography with saline injection, and the presence of a patent foramen ovale was confirmed at the time of cardiac surgery.

Chronic massive pancreatic pleural effusion.

Chronic massive pancreatic pleural effusion is an uncommon and often unrecognized clinical syndrome which results from an internal pancreatic fistula and usually presents as an exudative effusion of unknown cause. The effusion frequently occurs without clinical evidence of pancreatitis, but occasionally it may be associated with a pseudocyst of the pancreas. Chronic massive pancreatic pleural effusion is usually recurrent and characterized by very high levels of amylase in the pleural fluid. Morbidity and mortality are reduced when a definite diagnosis is established and appropriate therapy rendered. In this report, three cases of chronic massive pancreatic pleural effusions are presented. Two of the three had no demonstrable pancreatic disease, and the condition responded to conservative therapy. The third patient had a pancreatic pseudocyst and an internal pancreatic fistula which was corrected only after multiple surgical procedures.