Continuous peripheral nerve blockade as postoperative analgesia for open treatment of calcaneal fractures.

OBJECTIVE: To examine the cost and efficacy of methods of general and regional anesthetic for postoperative pain control after open repair of intra-articular calcaneal fractures. We compared single-injection popliteal fossa blocks and continuous infusion popliteal fossa blocks with drug delivered through a catheter from an infusion pump (CPNB) to general or spinal anesthetic alone in terms of hospital charges, length of hospital stay, and postoperative oral and intravenous narcotic use, antiemetic use, and safety. DESIGN: Retrospective review. SETTING: University Level I regional trauma center and associated orthopaedic surgery center. PATIENTS/PARTICIPANTS: Charts were reviewed for all patients undergoing open treatment of calcaneal fractures during a 9-year period. One hundred six of 203 met study inclusion criteria. INTERVENTION: All patients received either general or spinal anesthetic. Patients additionally received preoperative single-injection popliteal fossa blocks, CPNB, or no regional block. OUTCOME MEASUREMENTS: Data were compared from each group for total hospital cost, length of stay, operating room times, narcotic use, postoperative nausea, and hospital readmission. Eighteen patients from the CPNB group who were discharged within 24 hours of surgery were examined in a subgroup analysis of ambulatory treatment. RESULTS: There were no significant differences between the control group and the two regional anesthesia groups in total hospital cost, length of stay, narcotic use, or antiemetic use. However, subgroup analysis demonstrated that ambulatory CPNB patients had significantly lower total hospital costs and narcotic use compared with the remaining CPNB patients. There were no block-related complications. None of the short-stay patients required urgent medical attention or readmission after discharge. CONCLUSIONS: CPNB through an infusion pump may allow patients undergoing open treatment of calcaneal fractures to be safely discharged within 24 hours with a concomitant decrease in healthcare costs. These data suggest that this method of postoperative pain management might be applied to other patients with major foot and ankle trauma and/or reconstructive procedures and that wider use of continuous peripheral nerve blocks may lead to a reduction in healthcare costs.

Encephalitis and acute autonomic neuropathy.

We present a case of acute autonomic sensory and motor neuropathy complicating encephalitis. To our knowledge, this is only the second report of acute autonomic neuropathy with sensory and motor dysfunction associated with central nervous system dysfunction.Our patient also had a false positive cerebrospinal fluid 14-3-3.

The plasticity-pathology continuum: defining a role for the LTP phenomenon.

Long-term potentiation (LTP) is the most widely studied form of neuroplasticity and is believed by many in the field to be the substrate for learning and memory. For this reason, an understanding of the mechanisms underlying LTP is thought to be of fundamental importance to the neurosciences, but a definitive linkage of LTP to learning or memory has not been achieved. Much of the correlational data used to support this claim is ambiguous and controversial, precluding any solid conclusion about the functional relevance of this often artificially induced form of neuroplasticity. In spite of this fact, the belief that LTP is a mechanism subserving learning and/or memory has become so dominant in the field that the investigation of other potential roles or actions of LTP-like phenomena in the nervous system has been seriously hindered. The multiple subtypes of the phenomena and the myriad molecules apparently involved in these subtypes raise the possibility that observed forms of LTP may represent very different types of modification events, with vastly different consequences for neural function and survival. A relationship between LTP and neuropathology is suggested in part by the fact that many of the molecular processes involved in LTP induction or maintenance are the same as those activated during excitotoxic events in neurons. In addition, some LTP subtypes are clearly induced by pathological stimuli, e.g., anoxic LTP. Such data raise the possibility that LTP is part of a continuum of types of neural modification, some leading to beneficial alterations such as may occur in learning and others that may be primarily pathological in nature, as in kindling and excitotoxicity. In this article, we introduce a plasticity-pathology continuum model that is designed to place the various forms of neural modification into proper context. In vitro and kindling receptor regulation studies are used to provide a basis for evaluating the specific synaptic/cellular response modification along the continuum of events, from beneficial to detrimental, that will be induced by a particular stimulus.

A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement.

OBJECTIVES: In August 1993 a group of house staff and nursing staff at MetroHealth Medical Center formed a quality improvement team to evaluate the process of medical care on the inpatient wards. Using standard continuous quality improvement (CQI) methods, a team of medical interns, nurses, and other health professionals involved in patient care on the medicine inpatient service designed interdisciplinary, daily work rounds to improve the care of patients on the inpatient wards. METHODS: The authors conducted a randomized, controlled firm trial of the impact of interdisciplinary rounds on the inpatient medicine services. The trial lasted 6 months (November 1993-April 1994) and included 1,102 admissions randomly assigned to experimental or control teams by the pre-existing firm system. Of the 1,102 admissions included in the study, 535 were randomized to medical services with traditional rounds and 567 to medical services with interdisciplinary rounds. The outcomes studied included length of stay (LOS), total hospital charges, provider satisfaction, and ancillary service efficiency. RESULTS: Unadjusted analysis for log-transformed data showed lower length of stay and total charges for the interdisciplinary group. The mean LOS for interdisciplinary rounds was 5.46 days, compared with 6.06 days for traditional care (P = 0.006), whereas mean total charges were $6,681 and $8,090 (P = 0.002) for the two groups, respectively. After multivariate regression analysis using a propensity score that included gender, age, marital status, admission source, diagnosis-related group (DRG) weight, and primary diagnosis by International Classification of Diseases, Ninth Revision (ICD-9) cluster, these differences remained statistically significant. CONCLUSIONS: Previous studies of interdisciplinary teams have failed to show statistically significant cost savings. This study involving more patients shows both cost and LOS decreases with the use of interdisciplinary teams. At the end of the 6-month trial, interdisciplinary rounds were instituted on all medicine inpatient services.

Persistence of the interictal emotionality produced by long-term amygdala kindling in rats.

Long-term amygdala kindling in rats results in large and reliable increases in emotional behaviour that model the interictal emotionality often observed in temporal lobe epileptics [Kalynchuk L. E. et al. (1997) Biol. Psychiat. 41, 438-451; Pinel J. P. J. et al. (1977) Science 197, 1088-1089]. These experiments investigated the persistence of these kindling-induced increases in emotional behaviour after the cessation of the kindling stimulations. In Experiment 1, rats received 99 amygdala or sham stimulations. Then, they were tested on three tests of emotionality (i.e. activity in an unfamiliar open field, resistance to capture from the open field, and activity in an elevated-plus maze) either one day, one week, or one month after the final stimulation. The rats tested one day after the last stimulation displayed substantial decreases in open-field activity, increases in resistance to capture and increases in open-arm activity on the elevated-plus maze; these effects decreased, but not to control levels, in the rats tested one month after the final stimulation. In Experiment 2, rats received 99 amygdala or sham stimulations, and their resistance to capture was assessed one day later. Then, after a 60-day stimulation-free period, the rats received another zero, one, 10, or 30 amygdala stimulations and their resistance to capture was reassessed one day later. The high levels of resistance to capture observed in the rats tested one day after the 99 stimulations declined significantly during the 60-day stimulation-free period, but it remained significantly above control levels. However, the administration of 30 additional stimulations reinstated asymptotic levels of resistance to capture. These results provide the first systematic evidence that kindling-induced increases in emotional behaviour persist at significant levels for at least two months following the termination of kindling stimulations. Thus, they suggest that the neural changes underlying the genesis of interictal emotionality may be closely related to those mediating epileptogenesis itself.

An alternative to the LTP orthodoxy: a plasticity-pathology continuum model.

Long-term potentiation (LTP) is probably the most widely studied form of synaptic plasticity in the mammalian central nervous system. In the early descriptions, the term referred to a sustained increase in synaptic response following a brief high-frequency electrical tetanus. Apparently unique properties of the phenomenon triggered considerable excitement in the field: for many, LTP offered the promise of a potential substrate for learning and/or memory. In the more than 20 years since LTP was first discovered, investigators motivated by this promise have described a vast array of molecules and processes that may be involved in LTP induction and maintenance. And yet, the mechanisms by which LTP occurs have not been resolved. Instead, the compiled results have uncovered layer upon layer of intricacy, including multiple LTP forms and multiple molecular cascades involved in LTP expression. The generally stated thesis that LTP equates to learning and/or memory at a synaptic level has not faced a serious challenge despite the fact that workers in the field have not provided an unambiguous correlation of LTP with either. A number of investigators have now shifted their attention to a newer form of synaptic modification, long-term depression (LTP). Whatever studies of LTD reveal, it is clear that the fundamental questions about LTP remain unanswered: what is it really and what, if anything, is it used for? In this review, we summarize the data concerning putative LTP mechanisms and the evidence for LTP's role in learning and memory. We show that extant models are not sufficient to account for the various forms of LTP and that the experimental evidence does not justify the view that LTP equates to learning and memory. Instead, we suggest that LTP can be related to other forms of synaptic modification, e.g., LTD and kindling, in a neuroplasticity/pathology continuum of events. In particular, we suggest that neurotransmitter receptor regulation may be a key element leading to synaptic modification: in the adult nervous system, homeostatic receptor regulation normally compensates for alterations in synaptic input, while in the developing nervous system a form of 'homeodynamic' receptor regulation prevails. Our model proposes that homeodynamic receptor regulation leading to an LTP-like effect triggers, or acts in concert with, synaptogenesis to allow young neurons to modify response characteristics in response to altered input. In contrast, some forms of LTP in adult neurons may represent a 'failed' form of receptor regulation whose final outcome is neural death. The model suggests a series of experimentally verifiable hypotheses.

Medical leadership in an era of managed care and continual improvement.

Because clinicians control more than 70% of the total costs of medical care, the success of managed care systems in containing expenditures depends to a large degree on their leadership. Clinicians must make cultural changes and develop core competencies and technical skills to promote the continuous improvement needed for the success of managed care.

Managing rural health care reform.

Rural health care requires a response system that is unique and substantially different from other, more traditional systems of health care delivery. Any reform of the present rural health care system must offer services that include the public health sector as well as other aspects of the social "safety net." The authors present a vivid picture of the multiple realities operating in the rural environment, and they explore the opportunity for the creation of Accountable Health Plans suitable for the rural health care delivery mechanism.

How to start a direct patient care team.

Many American hospitals are embracing the philosophies of continuous quality improvement (CQI) or total quality management (TQM). To date, case studies in the literature have largely dealt with administrative processes. However, CQI can also improve direct patient care (clinical) processes using direct patient care teams. The establishment of such teams has been an elusive task at many organizations, largely because of the traditional paradigm of the appropriate relationship between provider and patient. However, similarities between direct patient care teams and other cross-functional teams far exceed differences. Using case studies from two teams (HIV and chest pain) at HCA West Paces Ferry Hospital and Southeastern Health Services, this article suggests ways facilitators can help providers examine, redesign, and improve direct patient care processes.

Quality improvement: an imperative for medical care.

For continuous process improvement to be successful at the site of care, an organizational structure for quality improvement should be in place. Quality improvement requires (1) an environment for quality improvement and (2) tools for improvement, including statistical and meeting tools. Physicians and all other care givers and support personnel must cooperate for process knowledge to be complete and usable. Perhaps there is no such thing as a purely "clinical" system, because the contiguous systems influence clinical behavior so completely they are almost inseparable. Process improvement specifications are not the same thing as standards as we now understand them. Process improvement specification are process based. They expect, are designed for, and handle divergent pathophysiologic conditions by focusing on processes. Individual institutions define and measure their outputs, but these outputs are judged against their customers' needs and expectations (thereby becoming outcomes) for performance, features, reliability, conformance, durability, serviceability, aesthetics, and perceived quality. Outcomes research as known today can help us understand the needs and expectations of our customers. Moreover, any team can improve the framework of quality improvement.

Applications of industrial quality improvement in health care.

Quality in medical care traditionally has been regarded as the professionally defined optimum that brings about the greatest improvement in health. That definition has been modified somewhat to include patient preferences for different treatment alternatives and costs. The question then arises how we can improve the efficiency of the health care system while maintaining or improving the quality of care. The answer is a focus on improvement in the process of care and, as needed, monitoring of all aspects of the process, not just untoward outcomes.

Enumerative, Bayesian, and analytic statistical analysis of nosocomial infection for quality improvement: first of two parts.

Readmission rates are used by the Health Care Financing Administration (HCFA) as an indicator of a hospital's quality of care. Specifically, HCFA seeks to relate readmission to complications of the primary admission. A recent study at the Cleveland Clinic Foundation examined patients readmitted within 30 days of dismissal during two non-consecutive months to the cardiovascular surgery, cardiology, and gastroenterology services at this 1,008 bed hospital, accounting for 31% (1640-5342) of all hospital discharges. Only 17% (25/149) of readmissions were due to a complication of the previous hospital admission. Examining those who were readmitted for complications of their primary admission, we found that 36% (9/25) of such readmitted patients had infections that occurred during their primary admission. Otherwise stated, 5.4% (9/149) of readmissions were for nosocomial infections. These patients were compared with 20 retrospectively matched, non-readmitted patients chosen randomly from a group of 100 patients retrospectively matched for gender, age, type, and date of surgery. Using these controls, a computer-based expert system was used to help identify patient variables that are associated with readmission due to nosocomial infection. We found if a patient had (1) a weight less than 66 Kilograms or (2) had a first postoperative total serum protein greater than 6.1 or (3) was reoperated, we could predict with 100% specificity and 60% sensitivity that the patient would have an unplanned readmission. Total readmission rates do not accurately reflect complications of the primary admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative study of the abuse liability of alprazolam, lorazepam, diazepam, methaqualone, and placebo.

Subjective effects of two benzodiazepines--alprazolam and lorazepam--were compared with two drugs of known abuse potential--diazepam and methaqualone--and placebo. This double-blind, crossover trial tested 30 casual recreational sedative users in a seminaturalistic setting. Methaqualone was more euphoriant and less sedative than the benzodiazepines. Diazepam and lorazepam were more euphoriant than placebo; alprazolam's euphoriant effect did not differ from these treatments. On other measures of abuse liability the benzodiazepines rated similarly, diazepam rating highest.

Weight changes in antidepressants: a comparison of amitriptyline and trazodone.

Weight data taken from a 6-week randomized double-blind study comparing amitriptyline, trazodone and placebo were analyzed to determine differential weight changes between the two drugs. In 272 depressed outpatients doses were increased over a period of 4 days to reach a maximum level of 200 mg amitriptyline or 400 mg trazodone. After grouping the subjects according to initial weights (ideal, overweight, 20% above, and underweight, 20% below) mean changes were determined for each treatment. The results indicate that amitriptyline, which differed from placebo and trazodone, produced significantly higher weight gains in the ideal and overweight groups. Trazodone on the other hand produced a slight weight loss in the overweight group. Due to a low number of patients in the underweight group, the results were not significantly statistically. The antidepressant effects of both trazodone and amitriptyline were the same and no correlations between Hamilton scores and weight change were found.