The Success and Failure of a Radiology Quality Metric: The Case of OP-10.

PURPOSE: Medical quality metrics can serve various functions, including promoting quality improvement efforts within a medical system, and providing a basis for comparing quality among institutions. OP-10, an imaging efficiency quality measure based on the number of CT scans of the abdomen performed both with and without contrast is broadly used and publically reported, but it has not been investigated in actual practice. METHODS: In this project, we report on both a successful quality improvement effort built around measurement of OP-10, and on the identified potential limitations of OP-10 itself for comparing among institutions. We performed two quality improvement interventions in 2012 and 2014 directed at OP-10, encompassing building of institutional practice standards via creating multidisciplinary consensus, educating radiologists and clinicians, revising CT protocols, and providing performance measurement and feedback. Results were extracted from the radiology information system and analyzed using interrupted time series segmented regression and statistical process control charts. RESULTS: The proportion of inappropriate abdominal CT scans with and without contrast under OP-10 decreased, from 3,041 of 13,855 (21.9%) to 691 of 6,006 (11.5%) (P < .0001). However, 262 of 691 (37.8%) of the CT scans labeled as potential overuse by OP-10 could be considered appropriate under national guidelines. These discordant cases clustered in specific clinical areas (eg, urology and hepatology), indicating potential for bias against centers that serve referral populations in these areas. CONCLUSIONS: We conclude that OP-10 can be useful to drive internal quality improvement efforts but is potentially biased when used for interinstitutional comparisons.

Affective neuroscientific and neuropsychoanalytic approaches to two intractable psychiatric problems: why depression feels so bad and what addicts really want.

The affective foundations of depression and addictions are discussed from a cross-species - animal to human - perspective of translational psychiatric research. Depression is hypothesized to arise from an evolutionarily conserved mechanism to terminate protracted activation of separation-distress (PANIC/GRIEF) systems of the brain, a shutdown mechanism which may be in part mediated by down-regulation of dopamine based reward-SEEKING resources. This shutdown of the brain's core motivational machinery is organized by shifts in multiple peptide systems, particularly increased dynorphin (kappa opioids). Addictions are conceived to be primarily mediated by obsessive behaviors sustained by reward-SEEKING circuits in the case of psychostimulant abuse, and also powerful consummatory-PLEASURE responses in the case of opioid abuse, which in turn capture SEEKING circuits. Both forms of addiction, as well as others, eventually deplete reward-SEEKING resources, leading to a state of dysphoria which can only temporarily be reversed by drugs of abuse, thereby promoting a negative affect that sustains addictive cycles. In other words, the opponent affective process - the dysphoria of diminished SEEKING resources - that can be aroused by sustained over-arousal of separation-distress (PANIC/GRIEF) as well as direct pharmacological over-stimulation and depletion of SEEKING resources, may be a common denominator for the genesis of both depression and addiction. Envisioning the foundation of such psychiatric problems as being in imbalances of the basic mammalian emotional systems that engender prototype affective states may provide more robust translational research strategies, coordinated with, rather than simply focusing on, the underlying molecular dynamics. Emotional vocalizations might be one of the best ways to monitor the underlying affective dynamics in commonly used rodent models of psychiatric disorders.

Adaptation to motion sickness from torso rotation affects symptoms from supine head nodding.

INTRODUCTION: Space motion sickness affects more than 50% of astronauts. Adaptation to one kind of nauseogenic motion can affect the response to another. We hypothesized that repeated exposure to torso rotation (TR) would diminish motion sickness (MS) due to supine head nodding (HN), a ground-based analogue for space sickness. METHODS: During TR, standing subjects swept their gaze back and forth between two targets located 135 degrees to either side of straight ahead. For HN, the subject lay supine on a platform with his/her head and neck hanging over the edge. The head was pitched back and forth between the horizontal position and rotated back as far as possible. MS was quantified in 5 male and 20 female subjects using numerical estimates of discomfort and a more detailed questionnaire. Susceptibility to TR and HN was determined on three occasions for each stimulus. At least 1 mo separated any two tests. Subjects were exposed to TR once a day for 7 consecutive days 1 mo after the final control session. Within 24 h of the seventh session, and 1 mo later, susceptibility to HN was evaluated again. RESULTS: There was a significant decrease in MS susceptibility during repeated exposure to TR (time to stop 17.7 min on Day 1, 31.8 min on Day 7). In contrast, there was a significant increase in MS susceptibility to HN after repeated exposure to TR (mean time to stop 11.7 min before TR, 9.5 min after). Susceptibility to HN was back to normal (time to stop 11.4 min) 1 mo later. DISCUSSION: Subjects can adapt to TR by repeated exposure. At the same time, susceptibility to HN increases. Strategies for pre-adaptation to space motion sickness need to be chosen carefully as they could actually be counterproductive.

Motion sickness provoked by torso rotation predicts that caused by head nodding.

INTRODUCTION: Some degree of space motion sickness is experienced by at least 50% of astronauts early in flight. It is unpleasant and could be hazardous during an extravehicular activity or urgent re-entry in the first few days after launch. To date, there is no reliable ground-based test to predict who will be affected. METHODS: Head nodding (HN) in a supine position was used as a model of motion sickness caused by an unusual gravito-inertial environment. Torso rotation (TR) was used as a means of predicting susceptibility to development of symptoms caused by HN. Motion sickness was quantified in 26 subjects (5 men, 21 women, age range 18-52) using numerical estimates of discomfort and a more detailed questionnaire. Susceptibility to TR and HN was determined on three occasions for each stimulus, with test sessions at least 1 mo apart. RESULTS: Subjects reached their stopping point at a mean duration of 13.72 min +/- 1.06 CI) for TR and 11.31 min (+/- 0.38 CI) for HN. When susceptibility to HN was plotted as a function of susceptibility to TR and a linear regression line was added, the correlation coefficient was 0.744. DISCUSSION: Susceptibility to TR predicts susceptibility to HN. The method may be useful as a screening test for potential astronauts.

Panksepp's common sense view of affective neuroscience is not the commonsense view in large areas of neuroscience.

Jaak Panksepp's article 'Affective Consciousness: Core Emotional Feelings in Animals and Humans' is a excellent review and summary by a leading empirical contributor whose work for many years has been running counter to reigning behavioristic premises in neuroscience. It may unfortunately be true that he could not get this review published in many neuroscience journals because it attacks too many sacred (behavioristic) cows. Panksepp has given readers of Consciousness and Cognition a nicely condensed summary of much of his classic 1998 textbook, Affective Neuroscience. I'm reasonably confident that future neuroscience students will look on that textbook as one of the seminal publications on the subject of emotion and the brain, much as we might now look back on Luria's Higher Cortical Functions in Man, or Paul MacLean's classic work, The Triune Brain. There is probably little that I can add to his elegant presentation of the basic affective neuroscience findings, but I would like to highlight a few key issues for the reader.

2-year review of a novel vestibular rehabilitation program in Montreal and Laval, Quebec.

OBJECTIVE: To evaluate the benefits of a vestibular rehabilitation program (VRP) in the Montreal-Laval area. DESIGN: The VRP was conceptualized by a panel of experts including otolaryngologists, physiotherapists, and researchers from McGill University and its teaching hospitals. From February 1999 to December 2001, 117 patients were seen, and 88 of them completed the VRP. SETTING: The VRP has been established at the Jewish Rehabilitation Hospital in Laval, PQ, to provide specialized rehabilitation to clients suffering from vertigo, dizziness, and/or impaired balance owing to lesions or disorders of the vestibular system. MAIN OUTCOME MEASURES: Presence or absence of nystagmus or vertigo during the Dix-Hallpike test, Dizziness Handicap Inventory (DHI), and Dynamic Gait Index (DGI). RESULTS: Thirty-five patients with benign paroxysmal positional vertigo of the posterior canal were treated with canalith repositioning manoeuvres. All of the patients (100%) had absence of nystagmus or vertigo after one to four treatment sessions. Forty-six patients with vestibular deficits or dizziness-disequilibrium completed the VRP, which consisted mainly of individualized eye-head and balance home exercise programs. At the end of the VRP, there was a significant decrease in DHI score (31 vs 57; p < .01) and a significant increase in DGI score (18.4 vs 22.6; p < .01). CONCLUSIONS: A range of modest to major improvements was shown by comparing initial and discharge scores of patients who had completed vestibular rehabilitation. The VRP appears to be beneficial for patients with a variety of vestibular disorders. Further research is needed to continue optimizing vestibular rehabilitation.

Spatial navigation after surgical resection of an acoustic neuroma: pilot study.

OBJECTIVE: To characterize navigation errors made by patients with the absence of vestibular function on one side owing to surgical resection of an acoustic neuroma. METHODS: Seventeen young (18-38 years) and 9 older healthy individuals (67-83 years), as well as 5 patients 2 to 20 months following surgery (37-61 years), were studied. They sidestepped laterally with eyes closed toward memorized targets located 1.25 m to their right or left. They stopped when they judged that they were in front of the target. The position of head and body markers was recorded in three dimensions with a six-camera Vicon 512 system (Oxford Metrics Ltd., Oxford, UK). Navigation errors were (1) distance error, the distance between the end target and a perpendicular line drawn from the sternum to the plane of targets, and (2) deviation, the angle formed between the line joining the initial and end targets and the line joining the subject's shoulders. RESULTS: Mean distance error was 20.9 +/- 22.0 degrees cm in patients, 29.6 +/- 30.3 cm in young healthy subjects, and -1.7 +/- 18.4 cm in older subjects (p < .01 compared with young subjects). Mean deviation was symmetric and 8 degrees and -3 degrees in healthy young and older subjects, respectively. In contrast, patients had a significantly larger deviation when navigating toward the side of their lesion than the intact side (13 degrees +/- 9 degrees versus 3 degrees +/- 9 degrees; p < .01). CONCLUSIONS: Our results suggest that patients with vestibular deficits have impaired ability to control body rotations when walking sideways without vision toward the side of their vestibular lesion.

Vestibular suppression during space flight.

Normal movements performed while voluntarily fixing the head to the torso can lead to motion sickness in susceptible individuals. The underlying mechanism may involve excessive suppression of vestibular responses. A similar motor strategy is often adopted in the early days of a space flight and might contribute to the development of space motion sickness. In a recent experiment, we monitored the eye, head and upper torso rotations of four Life and Microgravity Spacelab crew members. For the purposes of this study, all data were excluded except for periods during which the subject was performing pure yaw-axis head movements. All subjects showed a significant increase in gaze slip on the first day of their mission, suggesting that increased vestibular suppression was occurring. Furthermore, this amount of increased suppression would have been more than adequate to produce motion sickness in susceptible individuals on the ground. The results support the theory of two, independent mechanisms for space motion sickness.