How to conduct cost and value analyses in health professions education: AMEE Guide No. 139

Growing demand for accountability, transparency, and efficiency in health professions education is expected to drive increased demand for, and use of, cost and value analyses. In this AMEE Guide, we introduce key concepts, methods, and literature that will enable novices in economics to conduct simple cost and value analyses, hold informed discussions with economic specialists, and undertake further learning on more advanced economic topics. The practical structure for conducting analyses provided in this guide will enable researchers to produce robust results that are meaningful and useful for improving educational practice. Key steps include defining the economic research question, identifying an appropriate economic study design, carefully identifying cost ingredients, quantifying, and pricing the ingredients consumed, and conducting sensitivity analyses to explore uncertainties in the results.

Treatments and rehabilitation in the acute and chronic state of traumatic brain injury

Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition of the devastating impact of TBI resulting from sports and other recreational activities, ranging from primarily sport-related concussions (SRC) but also more severe brain injuries requiring hospitalization. There are currently no established treatments for the underlying pathophysiology in TBI and while neuro-rehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity. In this narrative review, we highlight short- and long-term consequences of SRCs, and how the sideline management of these patients should be performed. We also cover the basic concepts of neuro-critical care management for more severely brain-injured patients with a focus on brain oedema and the necessity of improving intracranial conditions in terms of substrate delivery in order to facilitate recovery and improve outcome. Further, following the acute phase, promising new approaches to rehabilitation are covered for both patients with severe TBI and athletes suffering from SRC. These highlight the need for co-ordinated interdisciplinary rehabilitation, with a special focus on cognition, in order to promote recovery after TBI.

Reviewer acknowledgement 2015

The Editors of Mobile DNA would like to thank all our reviewers who have contributed to the journal in volume 5 (2014).

Cost analyses approaches in medical education: there are no simple solutions

CONTEXT

Medical education is expensive. Although we have made progress in working out 'what works' in medical education, there are few data on whether medical education offers value relative to cost. Research into cost and value in medical education is beset by problems. One of the major problems is the lack of clear definitions for many of the terms commonly used. Phrases such as cost-effectiveness analysis, cost-benefit analysis, cost-utility analysis and cost-feasibility analysis are used without authors explaining to readers what they mean (and sometimes without authors themselves understanding what they mean). Sometimes such terms are used interchangeably and sometimes they are used as rhetorical devices without any real evidence that backs up such rhetoric as to the cost-effectiveness or otherwise of educational interventions. The frequent misuse of these terms is surprising considering the importance of the topics under consideration and the need for precision in many aspects of medical education.

METHODS

Here we define commonly used terms in cost analyses and give examples of their usage in the context of medical education.

CONCLUSIONS

Cost-effectiveness analysis refers to the evaluation of two or more alternative educational approaches or interventions according to their costs and their effects in producing a certain outcome. Cost-benefit analysis refers to 'the evaluation of alternatives according to their costs and benefits when each is measured in monetary terms'. Cost-utility analysis is the examination of two or more alternatives according to their cost and their utility. In this context, utility means the satisfaction among individuals as a result of one or more outcome or the perceived value of the expected outcomes to a particular constituency. Cost-feasibility analysis involves simply measuring the cost of a proposed intervention in order to decide whether it is feasible.

Ventilation rates and health: multidisciplinary review of the scientific literature

The scientific literature through 2005 on the effects of ventilation rates on health in indoor environments has been reviewed by a multidisciplinary group. The group judged 27 papers published in peer-reviewed scientific journals as providing sufficient information on both ventilation rates and health effects to inform the relationship. Consistency was found across multiple investigations and different epidemiologic designs for different populations. Multiple health endpoints show similar relationships with ventilation rate. There is biological plausibility for an association of health outcomes with ventilation rates, although the literature does not provide clear evidence on particular agent(s) for the effects. Higher ventilation rates in offices, up to about 25 l/s per person, are associated with reduced prevalence of sick building syndrome (SBS) symptoms. The limited available data suggest that inflammation, respiratory infections, asthma symptoms and short-term sick leave increase with lower ventilation rates. Home ventilation rates above 0.5 air changes per hour (h(-1)) have been associated with a reduced risk of allergic manifestations among children in a Nordic climate. The need remains for more studies of the relationship between ventilation rates and health, especially in diverse climates, in locations with polluted outdoor air and in buildings other than offices.

PRACTICAL IMPLICATIONS

Ventilation with outdoor air plays an important role influencing human exposures to indoor pollutants. This review and assessment indicates that increasing ventilation rates above currently adopted standards and guidelines should result in reduced prevalence of negative health outcomes. Building operators and designers should avoid low ventilation rates unless alternative effective measures, such as source control or air cleaning, are employed to limit indoor pollutant levels.

Comparative functional genomics of the fission yeasts

The fission yeast clade--comprising Schizosaccharomyces pombe, S. octosporus, S. cryophilus, and S. japonicus--occupies the basal branch of Ascomycete fungi and is an important model of eukaryote biology. A comparative annotation of these genomes identified a near extinction of transposons and the associated innovation of transposon-free centromeres. Expression analysis established that meiotic genes are subject to antisense transcription during vegetative growth, which suggests a mechanism for their tight regulation. In addition, trans-acting regulators control new genes within the context of expanded functional modules for meiosis and stress response. Differences in gene content and regulation also explain why, unlike the budding yeast of Saccharomycotina, fission yeasts cannot use ethanol as a primary carbon source. These analyses elucidate the genome structure and gene regulation of fission yeast and provide tools for investigation across the Schizosaccharomyces clade.

Meeting report for mobile DNA 2010

An international conference on mobile DNA was held 24-28 April 2010 in Montreal, Canada. Sponsored by the American Society for Microbiology, the conference's goal was to bring together researchers from around the world who study transposition in diverse organisms using multiple experimental approaches. The meeting drew over 190 attendees and most contributed through poster presentations, invited talks and short talks selected from poster abstracts. The talks were organized into eight scientific sessions, which ranged in topic from the evolutionary dynamics of mobile genetic elements to transposition reaction mechanisms. Here we present highlights from the platform sessions with a focus on talks presented by the invited speakers.

Impairment and recovery in inhibitory control after traumatic brain injury in children: effect of age at injury, injury severity and lesion location

We examined the effect of traumatic brain injury (TBI) on inhibitory control, trajectories of recovery of inhibitory control, and the effect of age at injury, severity, and lesion location on recovery. Participants were 127 children with TBI aged 5-16 years and 117 controls of similar age. Latency of response inhibition was measured with the stop signal task within 1 month of the injury and again at 3, 6, 12, and 24 months. Performance of children with TBI was compared with that of controls. Growth curve analyses showed impairments in response inhibition postinjury. Compared with controls, TBI children improved over time in response inhibition. Younger TBI children recovered better on response inhibition than older TBI children. No significant effect of severity or right frontal lesion on recovery of response inhibition was found. TBI has an acute effect on inhibitory control but which recovers over time.

A new role for the transcriptional corepressor SIN3; regulation of centromeres

Centromeres play a vital role in maintaining the genomic stability of eukaryotes by coordinating the equal distribution of chromosomes to daughter cells during mitosis and meiosis. Fission yeast (S. pombe) centromeres consist of a 4-9 kb central core region and 30-100 kb of flanking inner (imr/B) and outer (otr/K) repeats. These sequences direct a laminar kinetochore structure similar to that of human centromeres. Centromeric heterochromatin is generally underacetylated. We have previously shown that inhibition of histone deacetylases (HDACs) caused hyperacetylation of centromeres and defective chromosome segregation. SIN3 is a HDAC corepressor that has the ability to mediate HDAC targeting in the repression of promoters. In this study, we have characterized S. pombe sin three corepressors (Pst1p and Pst2p) to investigate whether SIN3-HDAC is required in the regulation of centromeres. We show that only pst1-1 and not pst2Delta cells displayed anaphase defects and thiabendazole sensitivity. pst1-1 cells showed reduced centromeric silencing, increased histone acetylation in centromeric chromatin, and defective centromeric sister chromatid cohesion. The HDAC Clr6p and Pst1p coimmunoprecipitated, and Pst1p colocalized with centromeres, particularly in binucleate cells. These data are consistent with a model in which Pst1p-Clr6p temporally associate with centromeres to carry out the initial deacetylation necessary for subsequent steps in heterochromatin formation.

Resident research education in physical medicine and rehabilitation: a practical approach

The Accreditation Council for Graduate Medical Education includes training in research as a required component of physical medicine and rehabilitation residency programs. Unfortunately, there is a lack of practical information on how to meet this requirement. In this paper, information is provided for individuals involved in resident education on how to teach residents about research.

Identification and fine mapping of a region showing a high frequency of allelic imbalance on chromosome 16q23.2 that corresponds to a prostate cancer susceptibility locus

Linkage to a prostate cancer susceptibility locus was recently reported on chromosome 16q23. We now report a region exhibiting a high frequency of allelic imbalance (AI) corresponding to this locus in tumors from 51 men diagnosed with prostate cancer using the same linked markers. The highest frequency of AI was found at markers D16S3096 (45%) and D16S516 (53%) that map to chromosome 16q23.2. In addition, 19 of the 51 (37%) prostate tumors showed interstitial AI involving one or both of these markers. This result strongly suggests that a candidate prostate cancer tumor suppressor gene maps between markers D16S3096 and D16S516. We estimate that the distance between these markers is approximately 118 kb using a Stanford radiation hybrid panel. We observed a positive association with family history (P = 0.048) when comparing those men showing interstitial AI at markers D16S3096 and/or D16S516 with those without any imbalance at these two markers. Taken together, these data suggest that we have precisely localized a region of chromosome 16q23.2 that may harbor a prostate cancer tumor suppressor gene implicated in the development of non-familial and possibly familial forms of prostate cancer.

Clozapine in the treatment of neuroleptic-induced blepharospasm: a report of 4 cases

BACKGROUND

Blepharospasm, the forcible closure of eyelids, is an infrequent consequence of neuroleptic treatment that, when severe, can interfere with the ability to walk, drive, or work. Like tardive dyskinesia, blepharospasm can be disfiguring and aesthetically distressing, contributing to the increased stigmatization of patients.

CASE REPORTS

We report 4 patients with DSM-IV schizoaffective disorder, paranoid schizophrenia, or chronic undifferentiated schizophrenia who developed neuroleptic-induced blepharospasm. In all patients, blepharospasm remitted without the reemergence of psychosis within 3 to 5 months of treatment with clozapine, 100-200 mg/day.

CONCLUSION

The results suggest that clozapine may successfully treat neuroleptic-induced blepharospasm without the reemergence of psychosis in patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder.

Association between a CYP3A4 genetic variant and clinical presentation in African-American prostate cancer patients

Prostate cancer incidence, clinical presentation, and mortality rates vary among different ethnic groups. A genetic variant of CYP3A4, a gene involved in the oxidative deactivation of testosterone, has been associated recently with prostate cancer development in Caucasians. To further investigate this variant, we evaluated its genotype frequencies in different ethnic groups and its association with clinical presentation of prostate cancer in African Americans. CYP3A4 genotypes were assayed in healthy male Caucasian (n = 117), Hispanic (n = 121), African-American (n = 116), Chinese (n = 46), and Japanese (n = 34) volunteers using the TaqMan assay. The association between CYP3A4 genotype and prostate cancer presentation was determined in 174 affected African-American men. Genotype frequency of the CYP3A4 variant differed substantially across ethnic groups, with African Americans much more likely to carry one or two copies than any other group (two-sided P < 0.0001). Among African Americans, 46% (80 of 174) of men with prostate cancer were homozygous for the CYP3A4 variant, whereas only 28% (32 of 116) of African-American healthy volunteers were homozygous (two-sided P < 0.005). A consistent positive association was observed between being homozygous for the CYP3A4 variant in African-American prostate cancer patients and clinical characteristics. Men homozygous for the CYP3A4 variant were more likely to present with higher grade and stage of prostate cancer in a recessive model [odds ratio (OR), 1.7; 95% confidence interval (CI), 0.9-3.4]. This association was even stronger for men who were >65 years of age at diagnosis (n = 103; OR, 2.4; 95% CI, 1.1-5.4). In summary, the CYP3A4 genotype frequency in different ethnic groups broadly followed trends in prostate cancer incidence, presentation, and mortality in the United States. African-American prostate cancer patients had a higher frequency of being homozygous for the CYP3A4 variant than healthy African-American volunteers who were matched solely based on ethnicity. Among the patients, those who were homozygous for the CYP3A4 variant were more likely to present with clinically more advanced prostate cancer.

Topiramate as add-on treatment for patients with bipolar mania

OBJECTIVE

Anticonvulsant agents such as carbamazepine and valproate are alternatives to lithium in treating subjects with bipolar disorder. Topiramate (Topamax), a new antiepileptic agent, is a candidate drug for bipolar disorder. We evaluated topiramate as adjunctive treatment for bipolar patients.

METHODS

Eighteen patients with DSM-IV bipolar I disorder [mania (n = 12), hypomania (n = 1), mixed episode (n = 5), and rapid cycling (n = 6)], and two subjects with schizoaffective disorder bipolar type, resistant to current mood-stabilizer treatment were initiated on topiramate, 25 mg/day, increasing by 25-50 mg every 3 7 days to a target dose between 100 and 300 mg/day, as other medications were held constant for 5 weeks. The Young Mania Rating Scale (Y-MRS), Hamilton Depression Rating Scale (Ham-D), and Clinical Global Impression-Bipolar Version Scale (CGI-BP) were used to rate subjects weekly.

RESULTS

By 5 weeks, 12 (60%) subjects were responders, i.e., 50% reduction in the Y-MRS scores and a CGI of 'much' or 'very much improved'. Three subjects were 'minimally improved', four showed no change, and one was 'minimally worse'. Six subjects had parasthesia, three experienced fatigue, and two had 'word-finding' difficulties; in all cases, side effects were transient. All patients lost weight with a mean of 9.4 lb in 5 weeks, and a significant reduction in body mass index (BMI) occurred too.

CONCLUSIONS

Topiramate appears to have efficacy for the manic and mixed phases of bipolar illness. Other preliminary data suggest antidepressant efficacy too. Among obese bipolar subjects, the weight loss potential of topiramate may be beneficial. If controlled trials confirm these initial results, topiramate may be a significant addition to the available treatments for bipolar disorder.

Low incidence of myocardial recovery after left ventricular assist device implantation in patients with chronic heart failure

BACKGROUND

Mechanical, histological, and biochemical improvement has been described in patients after left ventricular assist device (LVAD) support. Explantation of the LVADs without heart transplantation has been described in selected patients who received this therapy as a bridge to transplantation.

METHODS AND RESULTS

A retrospective review of patients receiving a mechanical bridge to transplantation at Columbia Presbyterian Hospital after July 21, 1991, was performed to determine the incidence of patients in whom the device was successfully explanted. From August 1, 1996, to February 1, 1998, we prospectively attempted to identify potential explant candidates by the use of exercise testing. During this time, we recruited 39 consecutive patients after insertion of the Thermo Cardiosystems vented electric device to participate in the following study. Approximately 3 months after device implantation, a maximal exercise test with hemodynamic monitoring and respiratory gas analysis was performed with the LVAD in the automated mode. The electric device was interfaced with a pneumatic console such that the rate could be decreased to 20 cycles/min. Hemodynamic measurements were recorded as the device rate was decreased. A repeat exercise test was then performed if the patient remained hemodynamically stable. A retrospective chart review of 111 LVAD recipients at our institution identified only 5 successful explant patients. Eighteen of the 39 patients were studied. Fifteen patients exercised with maximal device support. At peak exercise, VO2 averaged 14.5+/-3.6 mL. kg-1. min-1; LVAD flow, 8.0+/-1.3 L/min; Fick cardiac output, 11.4+/-3.3 L/min; and pulmonary capillary wedge pressure, 13+/-4 mm Hg. Seven patients remained normotensive and could exercise at a fixed rate of 20 cycles/min. In these patients, peak VO2 declined from 17.3+/-3.9 to 13.0+/-6.1 mL. kg-1. min-1. In one of these patients, the device was explanted.

CONCLUSIONS

Significant myocardial recovery after LVAD therapy in patients with end-stage congestive heart failure occurs in a small percentage of patients. Most of these patients have dilated cardiomyopathy. Exercise testing may be a useful modality to identify those patients in whom the device can be explanted.

Comparison of exercise performance in patients with chronic severe heart failure versus left ventricular assist devices

BACKGROUND

Left ventricular assist devices (LVADs) are frequently used as a bridge to cardiac transplantation and may be useful as long-term therapy. The purpose of this study was to compare the exercise performance of LVAD patients with that of ambulatory heart failure patients.

METHODS AND RESULTS

Exercise testing with hemodynamic and respiratory gas measurements was performed in 65 congestive heart failure (CHF) patients (age 53+/-10 years) and 20 LVAD patients (age 49+/-8 years). Peak Vo2 was significantly higher in the LVAD than the CHF patients (CHF, 12+/-3; LVAD, 15. 9+/-3.8 mL . kg-1 . min-1; P<0.001), as was the Vo2 at the anaerobic threshold (CHF, 8.1+/-2.1; LVAD, 12.2+/-2.9 mL . kg-1 . min-1; P<0.001). At rest, mean arterial blood pressure (CHF, 87+/-11; LVAD, 94+/-9 mm Hg) and cardiac output (CHF, 4+/-1; LVAD, 4. 9+/-0.9 L/min) were increased, whereas mean pulmonary artery pressure (CHF, 28+/-11; LVAD, 18+/-4 mm Hg) and pulmonary artery wedge pressure (CHF, 16+/-10; LVAD 5+/-3 mm Hg) were reduced (all P<0.01). At peak exercise, heart rate (CHF,125+/-24; LVAD, 148+/-24 bpm), blood pressure (CHF, 87+/-14; LVAD,96+/-12 mm Hg), and cardiac output (CHF, 7.6+/-2.2; LVAD, 11.2+/-2.6 L/min) were higher (all P<0. 01), whereas mean pulmonary artery pressure (CHF, 48+/-12; LVAD, 30+/-5 mm Hg) and mean pulmonary capillary wedge pressure (CHF, 31+/-11; LVAD, 14+/-6 mm Hg) were lower in the LVAD group (both P<0. 001). In the LVAD patients, Fick cardiac output was higher than LVAD flow sensor value measurements (Fick, 11.6+/-2.5; LVAD, 8.1+/-1.2 L/min; P<0.001).

CONCLUSIONS

Hemodynamic measurements at rest and during exercise are significantly improved in patients with devices compared with those in ambulatory heart failure patients awaiting cardiac transplantation. Similarly, the exercise capacity of device patients is better than that of transplant candidates and in the majority of patients is similar to that of patients with mild CHF.

Depression, cognition, and functional correlates of recovery outcome after traumatic brain injury

The present study investigated the prevalence and magnitude of depressive symptomatology in a sample of patients who had sustained traumatic brain injury (TBI) six months earlier. Depression was examined as a function of recovery outcome status, and its association with neuropsychological functioning, personal competency, and employability was also explored. Subjects were 100 patients who had previously sustained moderate-to-severe TBI who were enrolled as research subjects in the UCLA Brain Injury Research Center, and 30 matched control subjects who had sustained traumatic injuries other than to the head six months prior to evaluation. The results showed a significant association between depression and recovery status as measured by the Glasgow Outcome Scale (GOS). A significant majority of depressed subjects were found in the poorer GOS outcome groups (severe and moderate disability), compared to TBI subjects who had good GOS outcomes, and control subjects. This association was also reflected in the magnitude of the mean depression scores on two self-report measures of depression. However, no association was found between depression status and performance on the neuropsychological measures. Effects of depression were found only on an examiner-rated Patient Competency scale, and a metacognition measure based on self-report. These results are discussed in terms of brain injury severity, recovery status, and metacognition issues in TBI and other disorders.

Neuropsychological, psychosocial and vocational correlates of the Glasgow Outcome Scale at 6 months post-injury: a study of moderate to severe traumatic brain injury patients

Traumatic brain injury (TBI) subjects at Glasgow Outcome Scale levels 3 (severe disability), 4 (moderate disability), 5 (good recovery), and an other-injury control group (OIC) were compared in terms of neuropsychological, psychosocial, and vocational functioning 6 months after injury. Subjects were a sample of 100 patients with a moderate to severe traumatic brain injury (TBI) and a matched sample of 30 other-injury control subjects (OIC) enrolled in the UCLA Brain Injury Research Center study of TBI outcome. Overall, the results showed a systematic decrease in mean neuropsychological test performance as a function of increasing GOS severity, as well as an increased prevalence of symptoms of depression and lower ratings on measures assessing employability and capacity for self care. TBI patients in the 'severe' and 'moderate disability' groups were distinctly inferior to the 'good recovery' and 'OIC' groups, who were quite similar to each other in terms of cognitive, psychosocial, and vocational outcomes. The results demonstrate overall support for the predictive and concurrent validity of the GOS 6 months post injury. Despite these results, which strengthen the utility and appeal of the GOS for multicentre studies, concerns still remain regarding GOS category 4 (moderate disability), which was shown to lack sufficient discriminability in this study.

Prostate rebiopsy is a poor surrogate of treatment efficacy in localized prostate cancer

PURPOSE

Many investigators use prostate rebiopsy as an indicator of treatment efficacy and tumor response of localized prostate cancer for therapies in which the gland remains in situ. Because of the inherent sampling error of needle directed biopsies, however, some men will have a false-negative rebiopsy even if they have had no therapy or if the therapeutic intervention was unsuccessful in eradicating the malignancy. We evaluate the risk of a false-negative biopsy and the clinical factors that influence this risk.

MATERIALS AND METHODS

A total of 90 patients undergoing radical prostatectomy for clinically localized disease underwent sextant biopsy of the prostate immediately after removal of the gland. Data collected included prostate specific antigen (PSA), hormonal status, age and biopsy core status.

RESULTS

Of the total study population 67.8% received neoadjuvant hormonal therapy. While all patients had pathologically confirmed adenocarcinoma within the prostatectomy specimen, 45.6% demonstrated a false-negative rebiopsy. Within a combined predictive model, PSA and hormonal status demonstrated a statistically significant effect on the false-negative rebiopsy rate. Predictive power of this combined model was high across the spectrum of risk for a false-negative rebiopsy.

CONCLUSIONS

This series demonstrates that the risk of a false-negative sextant biopsy in the presence of documented prostate cancer is high and is affected by several factors, including PSA and hormonal status. These data suggest that prostate sextant rebiopsy is an inaccurate method of assessing the therapeutic efficacy of treatments for carcinoma of the prostate in which the gland remains in situ following therapy.

Plasma oxytocin levels in autistic children

BACKGROUND

Social impairments are central to the syndrome of autism. The neuropeptide oxytocin (OT) has been implicated in the regulation of social behavior in animals but has not yet been examined in autistic subjects.

METHODS

To determine whether autistic children have abnormalities in OT, midday plasma samples from 29 autistic and 30 age-matched normal children, all prepubertal, were analyzed by radioimmunoassay for levels of OT.

RESULTS

Despite individual variability and overlapping group distributions, the autistic group had significantly lower plasma OT levels than the normal group. OT increased with age in the normal but not the autistic children. Elevated OT was associated with higher scores on social and developmental measures for the normal children, but was associated with lower scores for the autistic children. These relationships were strongest in a subset of autistic children identified as aloof.

CONCLUSIONS

Although making inferences to central OT functioning from peripheral measurement is difficult, the data suggest that OT abnormalities may exist in autism, and that more direct investigation of central nervous system OT function is warranted.

Transitional cell carcinoma in situ of the seminal vesicles: 8 cases with discussion of pathogenesis, and clinical and biological implications

PURPOSE

Mucosal migration of transitional cell carcinoma in situ is a potential mechanism for multifocal lower tract disease.

MATERIALS AND METHODS

The clinical course and pathological studies of 8 cases of carcinoma in situ are reviewed in detail.

RESULTS

The pattern of disease of carcinoma in situ of seminal vesicle provides circumstantial evidence for mucosal migration of cancer from a bladder or prostatic urethral origin.

CONCLUSIONS

A monoclonal origin of bladder cancer combined with mucosal spread of carcinoma in situ suggests that incomplete destruction of carcinoma in situ may adversely affect long-term results by permitting extension into the distal ureters, prostatic duct or seminal vesicles. Protracted intravesical treatment of carcinoma in situ without complete elimination of the disease allows the natural history of mucosal spread to become evident.

Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery

Recent concern regarding lidocaine neurotoxicity has prompted efforts to find alternatives to lidocaine spinal anesthesia. Small-dose dilute bupivacaine spinal anesthesia yields a comparably rapid recovery profile but may provide insufficient anesthesia. By exploiting the synergism between intrathecal opioids and local anesthetics, it may be possible to augment the spinal anesthesia without prolonging recovery. Fifty patients undergoing ambulatory surgical arthroscopy were randomized into two groups receiving spinal anesthesia with 3 ml 0.17% bupivacaine in 2.66% dextrose without (Group I) or with (Group II) the addition of 10 microg fentanyl. Median block levels reached T7 and T8, respectively (P = not significant [NS]). Mean times to two-segment regression, S2 regression, time out of bed, time to urination, and time to discharge were 53 vs 67 min (P < 0.01), 120 vs 146 min (P < 0.05), 146 vs 163 min (P = NS), 169 vs 177 min (P = NS), and 187 vs 195 min (P = NS) respectively. Motor blockade was similar between groups, but sensory blockade was significantly more intense in Group II (P < 0.01). Six of 25 blocks failed in Group I, whereas none failed in Group II. The addition of 10 microg fentanyl to spinal anesthesia with dilute small-dose bupivacaine intensifies and increases the duration of sensory blockade without increasing the intensity of motor blockade or prolonging recovery to micturition or street fitness.

IMPLICATIONS

Concerns about the neurotoxicity of lidocaine have prompted efforts to find alternatives to lidocaine spinal anesthesia. We studied 50 patients undergoing ambulatory surgical arthroscopy and found that although small-dose bupivacaine alone is inadequate for this procedure, the addition of fentanyl makes it reliable.

External beam radiotherapy versus radical prostatectomy for clinical stage T1-2 prostate cancer: therapeutic implications of stratification by pretreatment PSA levels and biopsy Gleason scores

PURPOSE

Prostate-specific antigen (PSA) has affected the management of prostate cancer by allowing better case selection. The comparison between the two definitive treatment modalities, radiotherapy (RT) and radical prostatectomy (RP), can now be made accurately with respect to case selection and treatment outcome.

PATIENTS AND METHODS

The charts of 787 patients with prostate carcinoma who were treated with either RP alone or RT alone between 1987 and 1993 were reviewed. Patients with stage T3 disease, without pretreatment PSA levels or biopsy Gleason scores (GS), with synchronous bladder cancers or receiving adjuvant therapy, were excluded. Patients with less than 2 years' follow-up were also excluded. Of the remaining 551 patients, 253 were treated with RT and 298 with RP. The median pretreatment PSA level for RP patients was 8.1 versus 12.1 for the RT patients. The median radiation dose was 68.4 Gy. Positive margins were reported in 49% after RP. The median follow-up time was 42 months (range: 24 to 108).

RESULTS

For the 551 patients, the 5-year biochemical relapse-free survival (bRFS) rate was 53%, with biochemical relapse being defined as either a detectable PSA level after RP, or two consecutive rising PSA levels after RT. All clinical relapses were associated with rising PSA levels. The 5-year bRFS rates for RT versus RP were 43% versus 57%, respectively. Multivariate time-to-failure analysis using the proportional hazards model for clinical parameters showed pretreatment PSA level and biopsy Gleason scores to be the only independent predictors of relapse. Clinical stage and treatment modality were not independent predictors of failure. Using PSA and GS, two risk groups were defined: low risk (PSA < or = 10.0 and GS < or = 6) and high risk (PSA > 10.0 or GS > or = 7). The 5-year RFS rates for the low-versus high-risk groups were 81% versus 34%, respectively. Forty-eight percent of RP patients were low-risk cases versus 33% of RT patients. The rate of surgical margin involvement in RP patients was 39% in the low-risk group versus 59% in the high-risk group. For low-risk patients, the 5-year RFS rates for patients treated with RT versus RP were 81% versus 80%, respectively. In this subgroup, the bRFS rates for patients with negative margins were identical to the bRFS rates of patients treated with radiotherapy. However, patients with positive surgical margins fared significantly worse. For high-risk patients, the 5-year RFS rates for patients treated with RT versus RP were 26% versus 37%, respectively. In this subgroup, there was a definite advantage to surgery if negative margins were achieved: 5-year bRFS 62%, compared to 26% for RT and 21% for surgery with positive margins.

CONCLUSIONS

By using biochemical failure as an endpoint, more failures are documented after RP or RT than previously suspected. However, case selection using pretreatment PSA levels and biopsy GS can result in large differences in control rates. Significantly more high-risk patients are treated with RT. By stratifying cases using PSA and biopsy GS, treatment outcome is equivalent after either radiotherapy or surgery. Further follow-up is needed to confirm these findings after 5 years. For low-risk cases, there is no difference between radiotherapy and surgery, even when negative margins are achieved. Positive surgical margins predict for poor outcome even in low-risk cases. Standard radiotherapy alone should not be used for lesions with aggressive features. The outcome in high-risk cases is better with surgery if negative margins are achieved. For such high-risk patients, several new treatment approaches are currently being investigated with either high-dose conformal radiotherapy with or without androgen blockade, or neoadjuvant androgen blockade or radical prostatectomy.

Spinal bupivacaine in ambulatory surgery: the effect of saline dilution

The safety of lidocaine spinal anesthesia has recently been called into question by reports of both permanent and transient neurologic toxicity. This study explored the possibility of adapting the longer acting spinal bupivacaine to ambulatory surgery. Sixty patients presenting for ambulatory arthroscopy were randomized to four groups receiving the following spinal anesthetics: Group I (15 mg bupivacaine), 3 mL of 0.5% spinal bupivacaine in 8% dextrose; Group II (10 mg bupivacaine), 2 mL of the 0.5% spinal bupivacaine+1 mL saline; Group III (7.5 mg bupivacaine), 1.5 mL of the 0.5% spinal bupivacaine%1.5 mL saline; Group IV (5 mg bupivacaine), 1 mL of the 0.5% spinal bupivacaine+2 mL saline. Maximum block height was T-5 in Group I versus T-8 in the other groups. Onset times to peak block were similar in all groups and averaged 14 min. Time to two-segment regression, complete regression, micturition, and discharge were significantly reduced from Group I to Group II and from Group II to Group III. Reductions in times between Groups III and IV did not achieve statistical significance. Times from placement of the spinal block until discharge were 471 +/- 35, 260 +/- 15,202 +/- 14, and 181 +/- 8 min, respectively, for the four groups. The intensity of motor block decreased significantly from group to group, such that 13 of the 15 patients in Group IV failed to achieve Bromage level 2 or 3. The intensity of sensory block also decreased from group to group with four patients in Group IV having pain intraoperatively that required further treatment. Therefore, Group III provided the optimum combination of adequate depth of anesthesia and rapid recovery. The results of this study indicate that spinal anesthesia with 7.5 mg of 0.5% bupivacaine in 8% dextrose diluted with an equal volume of saline provides an acceptable spinal anesthetic for ambulatory arthroscopy with a recovery profile appropriate to the ambulatory setting.

Activation of coagulation and fibrinolytic pathways in patients with left ventricular assist devices

Left ventricular assist devices have provided successful supportive therapy for patients awaiting cardiac transplantation for extended periods of time. Although thromboembolic events have complicated support with these devices, the HeartMate left ventricular assist device developed by Thermo Cardiosystems, Inc., Woburn, Massachusetts, was specifically designed with a textured blood-contacting surface to minimize this risk. Clinical experience with this device has been encouraging, inasmuch as minimal thromboembolic complications have occurred despite the absence of anticoagulation. The coagulation and fibrinolytic pathways in these individuals were investigated to better understand the hematologic status of patients treated with the Thermo Cardiosystems device. Despite apparently normal prothrombin and activated partial thromboplastin times, as well as platelet counts, evidence of significant thrombin generation and fibrinolysis was present. To eliminate underlying cardiac failure as the responsible factor for these abnormalities, we made similar measurements in patients with end-stage heart failure who were not supported by an assist device or anticoagulation. These measurements revealed no evidence of thrombin generation or fibrinolysis. These data demonstrate that patients supported with a left ventricular assist device, while successfully sustained without systemic anticoagulation, nevertheless have evidence of activation of coagulation. These phenomena appear to be related to the presence of the device rather than to the underlying cardiac abnormalities. Although procoagulant and fibrinolytic pathways are apparently balanced in these patients, these data underscore the potential for the development of bleeding or thrombosis in clinically relevant settings.

Correlation of clinical and pathologic factors with rising prostate-specific antigen profiles after radical prostatectomy alone for clinically localized prostate cancer

OBJECTIVES

To better identify factors affecting prostate-specific antigen (PSA) level elevation after radical prostatectomy alone in men with clinical Stage T1-2 prostate cancer, we have reviewed our experience in the PSA era with 337 cases. The identification of these factors permits better understanding of the impact of case selection on treatment outcome in prostate cancer.

METHODS

The charts of all patients treated with radical prostatectomy alone between 1987 and 1993 were reviewed. Patients with clinical Stage T3 disease, without preoperative Gleason scores or PSA levels, with synchronous bladder cancer, and who received adjuvant or neoadjuvant therapy were excluded. The distribution of cases by pretreatment PSA levels was as follows: 4 ng/mL or less (16%); greater than 4 to 10 ng/mL (48%); greater than 10 to 20 ng/mL (22%); and greater than 20 ng/mL (14%). The median pretreatment PSA level for the entire group was 8 ng/mL. Only 26 patients (8%) had pathologically positive pelvic lymph nodes. The overall margin involvement rate was 43%. Margin involvement rates increased with increasing preoperative PSA levels. One hundred eighty-two patients (54%) had surgical Gleason scores of 7 or higher and 208 (62%) had extracapsular extension. The median follow-up time was 36 months.

RESULTS

The 3- and 5-year relapse-free survival (RFS) rates were 74% and 61%, respectively, with relapse being defined as either a clinically detectable recurrence or detectable/rising PSA levels. Among preoperative factors, PSA level was the only independent factor predicting relapse (P = 0.006); the 5-year RFS was 89% in patients with preoperative PSA levels of 4 ng/mL or less; 62% for PSA level of 4 to 10 ng/mL; 56% for PSA level to 10 to 20 ng/mL; and 26% for a PSA level greater than 20 ng/mL. Among pathologic parameters, margin involvement was the most potent independent factor predicting relapse (P < 0.001), followed by Gleason score (P = 0.002) and capsular penetration (P = 0.006). The 5-year RFS rates for margin-positive versus margin-negative patients were 37% versus 80%, respectively (P < 0.001). With pretreatment PSA levels of 10 ng/mL or less, lymph node involvement was seen in 3%, and margin involvement in 36%; the 5-year RFS rate was 71%. With pretreatment PSA levels of greater than 10 ng/mL, lymph node involvement was seen in 16%, and margin involvement in 57%; the 5-year RFS rate was 42%. However, patients with an initial PSA level greater than 10 ng/mL and positive margins had a 5-year RFS rate of 22% versus 73% in patients with a PSA level of 10 ng/mL or less or negative margins (P < 0.001). All clinical relapses were accompanied by a rise in PSA. In patients manifesting a clinical recurrence, PSA elevations preceded clinical recurrences by an average of 15 months (range 0 to 71). Only 34 cases (10%) had clinical failures within 5 years.

CONCLUSIONS

Pretreatment PSA is the most potent clinical factor independently predicting biochemical relapse. The great range in the relapse-free survival rates predicted by preoperative PSA levels demonstrates the importance of pretreatment PSA levels in case selection. Gleason score, extracapsular extension, and surgical margin involvement are also independent predictors of biochemical relapse. Achieving negative margins, even in relatively advanced disease, provides excellent long-term local control.

Biliopancreatic Diversion in Prader-Willi Syndrome Associated with Obesity

BACKGROUND: Prader-Willi Syndrome (PRWS) is an uncommon neuroendocrine disorder of genetic origin, described in 1956 by Prader, Labhart and Willi. The main clinical manifestations in the adult are mental retardation, hyperphagia with gross obesity, hypogonadismcriptorhismus and short stature. The life expectancy of the affected individual ranges between 20 and 30 years rarely beyond - due to complications related to excessive obesity. Sustained dieting combined with behavior modification programs, as well as gastric restrictive surgery for obesity, proved to have a high failure rate in PRWS, due to the patients' inability to cooperate in changing their eating habits. METHODS: Biliopancreatic Diversion (BPD), which does not require the patient's cooperation in changing eating habits after surgery, was performed in two PRWS patients (13- and 22-years-old), both with excessive obesity, severe respiratory distress, day sleepiness and limited mobility. RESULTS: Two years after surgery, the 13-year-old had lost 80% of her overweight, while the 22-year-old, after 1 year, had lost 34%. Recent laboratory tests showed normal data in both patients. Their respiratory distress had subsided completely, their mobility improved dramatically, and their self-image and alertness enhanced. CONCLUSION: BPD resulted in an improved quality of life in these patients.

Classification of brain compartments and head injury lesions by neural networks applied to MRI

An automatic, neural network-based approach was applied to segment normal brain compartments and lesions on MR images. Two supervised networks, backpropagation (BPN) and counterpropagation, and two unsupervised networks, Kohonen learning vector quantizer and analog adaptive resonance theory, were trained on registered T2-weighted and proton density images. The classes of interest were background, gray matter, white matter, cerebrospinal fluid, macrocystic encephalomalacia, gliosis, and "unknown." A comprehensive feature vector was chosen to discriminate these classes. The BPN combined with feature conditioning, multiple discriminant analysis followed by Hotelling transform, produced the most accurate and consistent classification results. Classification of normal brain compartments were generally in agreement with expert interpretation of the images. Macrocystic encephalomalacia and gliosis were recognized and, except around the periphery, classified in agreement with the clinician's report used to train the neural network.

Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system

OBJECTIVE

This nonrandomized study using concurrent controls was performed to determine whether the HeartMate implantable pneumatic (IP) left ventricular assist system (LVAS) could provide sufficient hemodynamic support to allow rehabilitation of severely debilitated transplant candidates and to evaluate whether such support reduced mortality before and after transplantation.

METHODS

Outcomes of 75 LVAS patients were compared with outcomes of 33 control patients (not treated with an LVAS) at 17 centers in the United States. All patients were transplant candidates who met the following hemodynamic criteria: pulmonary capillary wedge pressure > or = 20 mm Hg with a systolic blood pressure < or = 80 mm Hg or a cardiac index < or = 2.0 L/minute/m2. In addition, none of the patients met predetermined exclusion criteria.

RESULTS

More LVAS patients than control patients survived to transplantation: 53 (71%) versus 12 (36%) (p = 0.001); and more LVAS patients were alive at 1 year: 48 (91%) versus 8 (67%) (p = 0.0001). The time to transplantation was longer in the group supported with the LVAS (average, 76 days; range, < 1-344 days) than in the control group (average, 12 days; range, 1-72 days). In the LVAS group, the average pump index (2.77 L/minute/m2) throughout support was 50% greater than the corresponding cardiac index (1.86 L/minute/m2) at implantation (p = 0.0001). In addition, 58% of LVAS patients with renal dysfunction survived, compared with 16% of the control patients (p < 0.001).

CONCLUSIONS

The LVAS provided adequate hemodynamic support and was effective in rehabilitating patients based on improved renal, hepatic, and physical capacity assessments over time. In the LVAS group, pretransplant mortality decreased by 55%, and the probability of surviving 1 year after transplant was significantly greater than in the control group (90% vs. 67%, p = 0.03). Thus, the HeartMate IP LVAS proved safe and effective as a bridge to transplant and decreased the risk of death for patients waiting for transplantation.

Personality traits in schizophrenia

In recent years there has been a renewed interest in the integration of descriptive and interpersonal approaches to mental illness. Much of the impetus for this stems from the introduction in 1980 of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) (American Psychiatric Association 1980), with subsequent research and clinical reports documenting important interactions between Axis I syndromes and Axis II personality trait factors. While many research efforts have described comorbidity in affective and anxiety disorders, less attention has been directed toward clarifying the relationships between stable and enduring character traits and Axis I symptoms in schizophrenia. In this paper we propose that schizophrenic patients display both adaptive and pathological personality traits throughout the illness, and that clinical and research efforts to address the interactions between syndromic and personality factors ("trait-state" interactions) will further our understanding of patterns of symptom presentation and treatment response in these patients.

Physical factors in the indoor environment

This comprehensive chapter presents a discussion of physical factors in the nonindustrial indoor environment that affect human health, comfort, productivity, and well-being. Areas stressed include the thermal environment, light, noise, and other mechanical energy.

Impact of bladder neck preservation during radical prostatectomy on continence and cancer control

OBJECTIVES

To assess the effect of preservation of the bladder neck and other factors on the rate of postoperative urinary continence and cancer control after radical prostatectomy.

METHODS

Prospective analysis of clinical and pathologic findings in 206 consecutive patients undergoing radical prostatectomy with a surgical technique that emphasizes preservation of periurethral supporting tissue, urethral length, incorporation of the posterior periurethral fascia into the vesicourethral anastomosis, and preservation of the bladder neck.

RESULTS

Uni- and multivariate statistical analysis demonstrated that patient age (p = 0.033) and vesical neck contracture (p = 0.047) were predictive of incomplete return of urinary control. Preservation of the vesical neck had no impact on return of continence, but was associated with a trend to a lower incidence of vesical neck contractures. A positive bladder neck margin occurred in 6.8% of surgical specimens and was associated with a higher grade, more advanced local stage, and other positive margins in all cases. The rate of local recurrence or prostate-specific antigen (PSA)-only failure was similarly independent of whether the vesical neck was preserved or resected and reconstructed.

CONCLUSIONS

Age greater than 65 and occurrence of a vesical neck contracture are adverse predictors for return of urinary continence after radical prostatectomy. Preservation of the bladder neck does not have an impact on return of urinary control but may be associated with a lower risk of vesical neck contracture. Preservation of the bladder neck does not compromise cancer control as assessed by local or PSA-only failure rates.

Renal cell carcinoma arising in a regressed multicystic dysplastic kidney

Controversy surrounds the management of multicystic dysplastic kidney. Recent advances in radiological imaging have resulted in a higher incidence of its detection, and they provide an accurate noninvasive means of diagnosis and followup. Consequently, the need for surgical removal of these lesions is being reevaluated. We report a case of renal cell carcinoma arising from solid renal dysplasia associated with a regressed multicystic dysplastic kidney. We emphasize the potential risk of nonoperative management of these lesions and further define the spectrum of malignant degeneration associated with renal dysplasia.

Volatile organic compounds and indoor air

Volatile organic compounds represent one of the two major pollutant categories implicated in the sick-building syndrome. This article reviews measurement and analytic methods, presents a summary of the etiologic considerations, and presents newer, nonregulatory intervention strategies that can be used to prevent complaints resulting from this pollutant category.

The frontal lobes and traumatic brain injury

The authors review 1) the pathophysiological, neuroimaging, and neurobehavioral evidence for frontal lobe involvement in closed head injury; 2) studies elucidating the cognitive deficits and behavioral disturbance related to frontal lobe lesions associated with head injury; and 3) pharmacologic treatment of the neuropsychiatric manifestations of frontal lobe injury, including emerging therapies.

A retrospective study of the effects of edentulism on the severity rating of tardive dyskinesia

Edentulism has been reported to be a risk factor in the development of spontaneous orofacial dyskinesia. This study aimed to determine whether edentulism increases the severity rating of tardive dyskinesia in psychiatric subjects treated with neuroleptic medication. The filed Abnormal Involuntary Movement Scale reports of 84 edentulous and 109 dentate outpatients with schizophrenic or schizoaffective disorder were examined retrospectively. To compare dyskinesia ratings in different body areas with dental status and gender, 2 x 2 multivariate analysis of variance was used. Results show that edentulous subjects had significantly higher dyskinesia ratings in the orofacial categories but not in other body areas. Gender had no influence on dyskinesia ratings. These results indicate that tooth loss may considerably increase the severity of tardive dyskinesia, a finding that suggests a possible role of preventive and prosthetic dentistry in the health care of patients at risk for this condition.

Should chronic treatment-refractory akathisia be an indication for the use of clozapine in schizophrenic patients?

BACKGROUND

Clozapine, an atypical neuroleptic, is an effective medication in a subgroup of schizophrenic patients who have either failed to respond to the typical neuroleptics or experienced intolerable side effects such as neuroleptic malignant syndrome and disabling tardive dyskinesia. Its efficacy for persistent and disabling akathisia is less clear. Akathisia, especially the chronic and disabling form, can be a treatment dilemma for the clinician and the patient.

METHOD

We describe three representative case illustrations of schizophrenic patients who had severe, persistent treatment-resistant akathisia. Two of them had refractory psychoses and the third had multiple disabling side effects during treatment with typical neuroleptics. Two had tardive dyskinesia. These patients were treated with clozapine while other neuroleptics were discontinued.

RESULTS

During a 2-year follow-up, these patients made impressive social and vocational strides coinciding with a fairly rapid remission of akathisia (under 3 months) and a lesser though notable improvement in the psychoses. Tardive dyskinesia also remitted, though over a period of 6 to 12 months.

CONCLUSION

Our experience leads us to suggest a trial of clozapine in a subgroup of schizophrenic patients, who in addition to refractory psychoses have persistent disabling akathisia. However, given the risk of agranulocytosis with clozapine, we suggest that the usual treatment strategies for akathisia be tried before clozapine is initiated in the approved manner. Future controlled trials of clozapine that specifically investigate persistent akathisia may answer this question more conclusively.