Validation of telephone-based behavioral assessments in aging services clients.

BACKGROUND: The Behavioral Health Laboratory (BHL), a telephone-based mental health assessment, is a cost-effective approach that can improve mental illness identification and management. The individual BHL instruments, which were originally designed to be administered in-person, have not yet been validated with an in-person BHL assessment. This study therefore aims to characterize the concordance between the BHL data gathered by telephone and in-person interviews. METHODS: A cross-sectional study was conducted with English-speaking aging services network (ASN) clients aged 60 years and older in Monroe County, NY who were randomized to a BHL interview either in-person (n = 55) or by telephone (n = 53). RESULTS: There was strong evidence of equivalence between telephone and in-person interviews for depressive disorders, generalized anxiety, panic disorder, drug misuse, psychosis, PTSD, mental illness symptom severity, and five of the six questions assessing suicidality. There was marginal equivalence in PHQ-9 total scores and one of the six questions assessing suicidal ideation, and no evidence of equivalence between interview modalities for assessing cognitive impairment. CONCLUSIONS: With a few exceptions, the BHL gathered nearly equivalent information via telephone as compared to in-person interviews. This suggests that the BHL may be a cost-effective approach appropriate for dissemination in a wide variety of settings including the ASN. Dissemination of the BHL has the potential to strengthen the linkages between primary care, mental healthcare, and social service providers and improve identification and management of those with late-life mental illness.

Site-specific mesenchymal control of inflammatory pain to yeast challenge in vulvodynia-afflicted and pain-free women.

Fibroblast strains were derived from 2 regions of the lower genital tract of localized provoked vulvodynia (LPV) cases and pain-free controls. Sixteen strains were derived from 4 cases and 4 controls, age and race matched, after presampling mechanical pain threshold assessments. Strains were challenged with 6 separate stimuli: live yeast species (Candida albicans, Candida glabrata, Candida tropicalis, and Saccharomyces cerevisiae), yeast extract (zymosan), or inactive vehicle. Production of prostaglandin E2 (PGE2) and interleukin 6 (IL-6) were proinflammatory response measures. Highest IL-6 and PGE2 occurred with vestibular strains after C albicans, C glabrata, and zymosan challenges, resulting in the ability to significantly predict IL-6 and PGE2 production by genital tract location. After C albicans and C glabrata challenge of all 16 fibroblast strains, adjusting for dual sampling of subjects, PGE2 and IL-6 production significantly predicted the presampling pain threshold from the genital tract site of sampling. At the same location of pain assessment and fibroblast sampling, in situ immunohistochemical (IHC)(+) fibroblasts for IL-6 and Cox-2 were quantified microscopically. The correlation between IL-6 production and IL-6 IHC(+) was statistically significant; however, biological significance is unknown because of the small number of IHC(+) IL-6 fibroblasts identified. A low fibroblast IL-6 IHC(+) count may result from most IL-6 produced by fibroblasts existing in a secreted extracellular state. Enhanced, site-specific, innate immune responsiveness to yeast pathogens by fibroblasts may be an early step in LPV pathogenesis. Fibroblast strain testing may offer an attractive and objective marker of LPV pathology in women with vulvodynia of inflammatory origin.

Clinical disease activity and acute phase reactant levels are discordant among patients with active rheumatoid arthritis: acute phase reactant levels contribute separately to predicting outcome at one year.

INTRODUCTION: Clinical trials of new treatments for rheumatoid arthritis (RA) typically require subjects to have an elevated acute phase reactant (APR), in addition to tender and swollen joints. However, despite the elevation of individual components of the Clinical Disease Activity Index (CDAI) (tender and swollen joint counts and patient and physician global assessment), some patients with active RA may have normal erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) levels and thus fail to meet entry criteria for clinical trials. We assessed the relationship between CDAI and APRs in the Consortium of Rheumatology Researchers of North America (CORRONA) registry by comparing baseline characteristics and one-year clinical outcomes of patients with active RA, grouped by baseline APR levels. METHODS: This was an observational study of 9,135 RA patients who had both ESR and CRP drawn and a visit at which CDAI was >2.8 (not in remission). RESULTS: Of 9,135 patients with active RA, 58% had neither elevated ESR nor CRP; only 16% had both elevated ESR and CRP and 26% had either ESR or CRP elevated. Among the 4,228 patients who had a one-year follow-up visit, both baseline and one-year follow-up modified Health Assessment Questionnaire (mHAQ) and CDAI scores were lowest for patients with active RA but with neither APR elevated; both mHAQ and CDAI scores increased sequentially with the increase in number of elevated APR levels at baseline. Each individual component of the CDAI followed the same trend, both at baseline and at one-year follow-up. The magnitude of improvement in both CDAI and mHAQ scores at one year was associated positively with the number of APRs elevated at baseline. CONCLUSIONS: In a large United States registry of RA patients, APR levels often do not correlate with disease activity as measured by joint counts and global assessments. These data strongly suggest that it is appropriate to obtain both ESR and CRP from RA patients at the initial visit. Requiring an elevation in APR levels as a criterion for inclusion of RA patients in studies of experimental agents may exclude some patients with active disease.

Factors independently associated with complications and length of stay after hip arthroplasty: analysis of the National Surgical Quality Improvement Program.

By analysis of the American College of Surgeons National Surgical Quality Improvement Program database, we identified factors associated with postoperative complications and increased hospital stay after total hip arthroplasty in 4281 patients. There was a minor complication rate of 2.7%, a major complication rate of 4.2%, and a mortality rate of 0.26% within 30 days of the procedure. After adjusted analysis, obesity, preoperative anemia, and longer operative time were all associated with wound complications. Preoperative anemia, higher American Society of Anesthesiologists class, and prolonged operative time were associated with development of a major complication. A predischarge major complication resulted in an increased length of stay of 6.248 days (±0.286, P < .0001). One in 25 hip arthroplasty patients developed a major postoperative complication, and 1 in 16, a medical complication after elective hip arthroplasty.

Pioglitazone inhibits platelet function and potentiates the effects of aspirin: a prospective observation study.

BACKGROUND: Thiazolidinediones (TZDs) are agonists of PPARγ and exert beneficial metabolic effects in patients with diabetes. They may also affect platelet function. OBJECTIVES: To characterize potential platelet inhibitory effect of pioglitazone alone and in the presence of aspirin. METHODS: 20 normal and 20 diabetic subjects were enrolled in a prospective study. On day 1, a blood sample was obtained at baseline and a second one after ingestion of 30mg of pioglitazone. PRP was prepared and platelet aggregation and release were evaluated using ADP, collagen and arachidonic acid as agonists. Subjects returned at 6-9days later after ingesting a single 81mg dose of aspirin and a third blood sample was obtained. The subjects then again ingested 30mg of pioglitazone and a fourth and final blood sample was obtained. Platelet aggregation and release were measured. PRP was incubated with thrombin to activate platelets, and the serum was separated and assayed for thromboxane B2, TGFß and CD40L RESULTS: Pioglitazone alone did not affect aggregation with arachidonic acid. However, following ingestion of both aspirin and pioglitazone aggregation was significantly decreased compared to aspirin alone (P<0.0001). Pioglitazone also potentiated aspirin-induced inhibition of ATP release using either arachidonic acid or collagen. Following pioglitazone alone, TXB(2) release was 32,719±3,585pg/ml which was significantly reduced compared to baseline (42,075±4,479, P=0.0004). Pioglitazone also potentiated the inhibition of TXB(2) release by aspirin. CONCLUSION: Pioglitazone inhibits platelet function and potentiates the inhibitory effects of aspirin.

Clinical comparison of two stylet angles for orotracheal intubation with the GlideScope video laryngoscope.

STUDY OBJECTIVE: To compare the success of orotracheal intubation in 62 seconds or less using the GlideScope video laryngoscope (GVL) and a 60 degrees or 90 degrees angled stylet with reverse loading of the endotracheal tube (ETT). DESIGN: Prospective, randomized study. SETTING: Operating room of a university hospital. PATIENTS: 120 ASA physical status I, II, and III adult patients undergoing elective surgery requiring general anesthesia with orotracheal intubation. INTERVENTIONS: Patients were randomly allocated to two groups (n = 60 each); both groups received general anesthesia and neuromuscular relaxation. A conventional ETT was styleted and then bent from its straight configuration just above the cuff, either at 60 degrees or 90 degrees against its concave natural curve (reverse loading). Four attending anesthesiologists, who were blinded as to stylet assignment (the 60 degrees or 90 degrees group), intubated the tracheas of all patients with the GVL using either the primary or secondary stylet. MEASUREMENTS: The primary outcome was success of orotracheal intubation in 62 seconds or less. The secondary outcome was actual time to intubation (TTI). MAIN RESULTS: The odds ratio (OR) for intubation success was higher in the 90 degrees group than the 60 degrees group (OR = 10.41; P < 0.03), as evidenced by 59 of 60 patients whose tracheas were intubated successfully within 62 seconds, compared with 51 of 60 patients in the 60 degrees group. Seven of the 9 failures were due to inability of the 60 degrees stylet to reach the glottic opening. The three remaining failures were associated with TTI of more than 62 seconds. CONCLUSIONS: The 90 degrees angled malleable stylet with reverse loading of the ETT provided more reliable ETT delivery to the glottic opening and had a higher success rate than the 60 degrees stylet.