Cystic fibrosis learning network telehealth innovation lab during the COVID-19 pandemic: a success QI story for interdisciplinary care and agenda setting

INTRODUCTION

The Cystic Fibrosis Foundation chronic care guidelines recommend monitoring clinical status of a patient with cystic fibrosis (CF) through quarterly interdisciplinary visits. At the beginning of the COVID-19 pandemic, the Cystic Fibrosis Learning Network (CFLN) designed and initiated a telehealth (TH) innovation lab (TH ILab) to support transition from the classic CF care model of quarterly in-person office visits to a care model that included TH.

AIM

The specific aims of the TH ILab were to increase the percentage of virtual visits with interdisciplinary care (IDC) from 60% to 85% and increase the percentage of virtual visits in which patients and families participated in shared agenda setting (AS) from 52% to 85% by 31 December 2020.

METHODS

The model for improvement methodology was used to determine the ILab aims, theory, interventions and measures. In the testing phase of the ILab, data related to process and outcome measures as well as learnings from plan-do-study-act cycles were collected, analysed and shared weekly with the TH ILab teams. Participating centres created processes for IDC and AS for TH visits and developed and shared quality improvement tools specific to their local context with other centres during the ILab weekly meetings and via a secure CFLN-maintained platform.

RESULTS

Both specific aims were achieved ahead of the expected target date. By August 2020, 85% of the TH ILab visits provided IDC and 92% of patients were seen for CF care by teams from the TH ILab that participated in AS.

CONCLUSION

Shared learning through a collaborative, data-driven process in the CFLN TH ILab rapidly led to standardised TH IDC and AS, which achieved reliable and sustainable processes which could be reproduced by other networks.

Clinical Effects of Stabilized Stannous Fluoride Dentifrice in Reducing Plaque Microbial Virulence II: Metabonomic Changes

OBJECTIVES

The clinical effects of stannous fluoride (SnF2) dentifrice in reducing symptoms of gingivitis and reducing the virulence of subgingival plaque through suppression of activation of gene expression in toll receptor based reporter cells were previously reported. This study expanded analysis of the clinical study to include evaluation of dentifrice effects on salivary metabolites using 1H Nuclear Magnetic Resonance (1H NMR) systems biology-based metabonomics.

METHODS

The clinical design was reported previously (J Clin Dent2017;28:16-26). Participants included a cohort exhibiting high and low levels of gingival disease as presented at initiation of the study. Participants provided morning lavage saliva samples at baseline. Following this, participants were provided with a hygiene intervention, including a stabilized SnF2 dentifrice and a new soft bristle manual toothbrush. Following two and four weeks of assigned dentifrice use, participants again collected morning lavage saliva samples. Samples were analyzed by 1HNMR spectroscopy on a Bruker 600MHz NMR spectrometer. System-wide analyses were carried out by partial least squared (PLS) comparisons of aggregate spectra, and discrete metabolites with established spectral signatures were likewise directly compared.

RESULTS

PLS analysis showed significant differences in saliva composition for saliva collected from high bleeding and low bleeding cohorts. Clear shifts in saliva composition were observed in system-wide PLS analysis following intervention of SnF2 dentifrice for both cohorts. A number of discrete spectral changes were consistently observed with SnF2 dentifrice intervention, most notably including reductions in propionic acid and butyric acid, key short chain fatty acids associated with anaerobic metabolism in dental plaques.

CONCLUSIONS

These results collectively demonstrate that SnF2 dentifrice treatment was associated with broad scale modifications in saliva composition following intervention in both high and low diseased cohorts. Changes in overall salivary composition and specific reductions in saliva concentrations of propionic and butyric acid reductions occurred coincident with clinical improvements in gingivitis and gingival bleeding. These results provide support for the hypothesis that the effectiveness of SnF2 dentifrice in improving gingival health is associated with a modification of microbiome metabolism, including suppression of short chain fatty acid metabolites.

Randomized Controlled Trial Evaluating Use of Two Different Oxalate Products in Adults with Recession-Associated Dentin Hypersensitivity

A randomized positively controlled trial was conducted to evaluate the durable effects of 1.5% oxalate strips on dentin hypersensitivity. Informed consent and baseline measurements were obtained from adults with recession and air-related dentin hypersensitivity. Eligible subjects were randomized to one of two oxalate groups, either 1.5% oxalate gel strips (Crest® Sensi-Stop™ Strips, Procter and Gamble) or a professional oxalate-acid, potassium-salt solution (Super Seal® Dental Desensitizer Liner, Phoenix Dental). Test products were professionally administered at examiner-identified sensitive test sites following each manufacturer's instructions. Subjects received a blinded overwrapped anticavity paste and manual brush, two additional reapplication visits were scheduled over a 1-week period, and subjects returned 1 month later for evaluation. Sensitivity was evaluated using air and water stimuli measured by clinicians (Schiff Index) and subjects (visual analog scale), while safety was assessed by examination. The population (N = 80) was diverse with respect to gender, ethnicity, and age (22 to 82 years). At baseline, the overall mean (SD) air sensitivity was 1.34 (0.47), with individual subject means ranging from 1 to 2.5. Repeated treatment with both the commercial and professional oxalate treatments resulted in significant (P less than .05) reductions in sensitivity for all stimuli and methods. At the 1-month posttreatment recall, there were 84% to 86% reductions in clinically measured cool-air sensitivity for each oxalate group. Groups did not differ significantly (P > .57) on examiner or self-graded air or water sensitivity. In a clinical study, use of 1.5% oxalate gel strips yielded similar benefits as professionally applied oxalate treatments for adults with recession-based dentin hypersensitivity.

Comparative Effects of 1.5% Oxalate Strips Versus 5% Potassium Nitrate Dentifrice on Dentin Hypersensitivity

A randomized controlled trial was conducted to evaluate the safety and efficacy of a novel 1.5% oxalate sensitivity strip. Healthy adults with dentin hypersensitivity after a cool-air challenge were randomly assigned either three sensitivity strips (Crest® Sensi-Stop™ Strips, Procter and Gamble) plus regular toothpaste (experimental group) or 5% potassium nitrate dentifrice for twice-daily use (control group). First use was supervised, and response was measured immediately after first treatment and again 30 days later after direct provocation with air and tactile stimuli. A total of 79 subjects (mean age 37 years) were randomized and treated. After the first treatment, only the 1.5% oxalate strip group exhibited significant (P less than .0001) immediate sensitivity relief to both air and tactile stimulation. Repeated use improved response and, over 30 days, both treatments were effective. Between-group comparisons favored the episodic strips versus the daily-use dentifrice, with a majority of oxalate strip users having no measured air sensitivity at Day 30. Both treatments were well tolerated. A randomized clinical trial showed immediate and durable sensitivity relief for 1.5% oxalate strips and superior response when compared head-to-head versus a potassium nitrate dentifrice.

Response of chronic gingivitis to hygiene therapy and experimental gingivitis. Clinical, microbiological and metabonomic changes

PURPOSE

To compare the clinical, microbiological and metabonomic profiles of subjects with high and low levels of chronic gingival bleeding during a controlled oral hygiene regimen intervention including sequential phases of rigorous therapeutic oral hygiene followed by experimental gingivitis (EG).

METHODS

Two cohorts of qualified study subjects with differences in gingival bleeding on probing levels at their baseline clinical examination were entered into the study. These two cohorts were followed through three separate study phases including a 1-week baseline phase, a 2-week phase of rigorous oral hygiene including dental prophylaxis, and a 3-week EG phase of no oral hygiene to encourage relapse of gingivitis. The 58 subjects were assessed during each phase of the study for clinical presentation of gingivitis and concurrently had plaque sampled for real-time polymerase chain reaction (RTPCR) microbiological characterization and salivary lavage samples for 'systems biology' metabonomics assessment by 1H-NMR.

RESULTS

Subjects presenting with different levels of gingival bleeding on probing when they entered the study responded differently to rigorous oral hygiene and EG. Specifically, the high bleeding cohort responded sluggishly to rigorous oral hygiene and exhibited markedly greater relapse to gingivitis during EG. RTPCR analysis showed changes in bacterial populations that were associated with study phases, particularly the increases in putative periodontal pathogens during EG. However, the microbiological profiles of high- and low-susceptibility gingival bleeding patients were largely similar. Metabonomic analysis likewise revealed significant changes in metabolite composition during study phases associated with differences in plaque toxicity, especially the short chain carboxylic acids propionate and n-butyrate, which tracked clinical changes in gingivitis severity. Systems analysis of metabonomic changes suggested differences between cohorts, although analysis to date has not elucidated whether these differences are causative (population predictive) or simply diagnostic of clinical status within populations.

A clinical study to assess the effect of a stabilized stannous fluoride dentifrice on hypersensitivity relative to a marketed sodium fluoride/triclosan control

OBJECTIVE

To evaluate the efficacy of a marketed stabilized stannous fluoride (SnF2) dentifrice in reducing dentinal hypersensitivity as compared to a marketed sodium fluoride (NaF)/triclosan dentifrice over an eight-week period.

METHODS

Adults with confirmed dentinal hypersensitivity were enrolled in this randomized and controlled, parallel group, double blind, eight-week, single-center clinical trial. Random assignment to one of two dentifrice test groups via age, gender, and thermal sensitivity of enrolled test teeth was performed at baseline, with subjects assigned to twice-daily unsupervised brushing with either the marketed SnF2 dentifrice (Oral-B Pro-Expert, 0.454% SnF2 plus 0.077% NaF) or the marketed 0.32% NaF with 0.3% triclosan/copolymer dentifrice control (Colgate Total Advanced). Tactile sensitivity (Yeaple Probe) and thermal sensitivity (airblast/Schiff Air Index) evaluations of the selected test teeth were performed at baseline pre-treatment, and again at Weeks 2 and 8 of product use to compare the dentifrices' relative hypersensitivity protection effectiveness.

RESULTS

Ninety-seven (97) of the 100 enrolled subjects completed the trial and were fully evaluable. At both Week 2 and Week 8, for both the thermal and tactile evaluation measurements, subjects brushing with the marketed SnF2 dentifrice experienced statistically significantly (p < 0.0001) superior average dentinal hypersensitivity improvement versus subjects assigned to the NaF/triclosan control dentifrice. Between groups, superior relative mean reduction in thermal Schiff Air Index favored SnF2 by 24% at Week 2 and 68% at Week 8, while greater relative mean tactile Yeaple Probe benefits were observed for SnF2 relative to the control by 114% after Week 2 and 184% at Week 8. The dentifrices were well-tolerated.

CONCLUSION

Twice-daily brushing with a marketed SnF2 dentifrice provided superior dentinal hypersensitivity improvement versus a commercially available NaF/triclosan dentifrice, with significantly (p < 0.0001) greater relief after two weeks, and even larger relative benefits at eight weeks.

The assessment of vascular risk in men with erectile dysfunction: the role of the cardiologist and general physician

Erectile dysfunction (ED) and cardiovascular disease (CVD) share risk factors and frequently coexist, with endothelial dysfunction believed to be the pathophysiologic link. ED is common, affecting more than 70% of men with known CVD. In addition, clinical studies have demonstrated that ED in men with no known CVD often precedes a CVD event by 2-5 years. ED severity has been correlated with increasing plaque burden in patients with coronary artery disease. ED is an independent marker of increased CVD risk including all-cause and especially CVD mortality, particularly in men aged 30-60 years. Thus, ED identifies a window of opportunity for CVD risk mitigation. We recommend that a thorough history, physical exam (including visceral adiposity), assessment of ED severity and duration and evaluation including fasting plasma glucose, lipids, resting electrocardiogram, family history, lifestyle factors, serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio, and determination of the presence or absence of the metabolic syndrome be performed to characterise cardiovascular risk in all men with ED. Assessment of testosterone levels should also be considered and biomarkers may help to further quantify risk, even though their roles in development of CVD have not been firmly established. Finally, we recommend that a question about ED be included in assessment of CVD risk in all men and be added to CVD risk assessment guidelines.

Evaluation of anti-gingivitis benefits of stannous fluoride dentifrice among triclosan dentifrice users

PURPOSE

To evaluate the anti-gingivitis benefits of a 0.454% highly bioavailable stannous fluoride dentifrice (SnF2) relative to a 0.3% triclosan/copolymer dentifrice (triclosan/copolymer) among triclosan/copolymer dentifrice users with residual gingivitis.

METHODS

This was a randomized, controlled, double-blind, parallel group, 2-month clinical study. Self-reported triclosan/copolymer dentifrice users were recruited and provided with triclosan/copolymer dentifrice to use for 1 month. After this 1-month acclimation period, subjects who had residual gingivitis at the baseline visit were randomized to either the SnF2 dentifrice or the triclosan/copolymer dentifrice (positive control). Subjects performed their treatment unsupervised using their assigned dentifrice following manufacturers' usage instructions for 2 months. The Gingival Bleeding Index (GBI) and Modified Gingival Index (MGI) were used to measure gingivitis benefits at baseline and Month 2. An analysis of covariance was performed to compare treatment groups for the post-baseline scores as well as change from baseline, with the baseline score as a covariate. All comparisons were two-sided at the 0.05 level of significance.

RESULTS

A total of 150 subjects were randomized to treatment. Both treatment groups experienced significant reductions in number of bleeding sites, gingival bleeding index (GBI), and gingival inflammation (MGI) relative to baseline (P < 0.001). At Month 2, the SnF2 dentifrice group demonstrated significantly lower adjusted mean scores versus the triclosan/copolymer group for number of bleeding sites, GBI, and MGI (P < 0.001). Between-treatment group comparisons for change from baseline values showed that the improvement in number of bleeding sites from baseline for the SnF2 group was 49% greater versus that of the triclosan/copolymer group (P < 0.001), and the GBI and MGI improvements from baseline for the SnF2 group were 48% and 37%, greater, respectively, relative to the triclosan/copolymer group (P < 0.001).

Assessment of EndoPAT scores in men with vasculogenic and non-vasculogenic erectile dysfunction

PURPOSE

The role of endothelial function testing using peripheral artery tonometry (PAT) in the evaluation of ED is not well established. Endothelial dysfunction is expected to be more common in men presenting with general or vasculogenic ED, compared with men who develop ED after prostatectomy. This study evaluated whether PAT could help identify men in whom endothelial cell dysfunction was the underlying cause of ED.

MATERIALS AND METHODS

A chart review of 194 men with general ED and 98 men with postprostatectomy ED was performed to abstract data on demographics, medical comorbidities, SHIM-5 scores and EndoPAT scores. Patients with preoperative ED were excluded. Statistical analysis using Student's t-test and Chi-squared analysis was performed to compare the two groups of men with respect to these variables.

RESULTS

EndoPAT scores were not significantly different between men with general vs. postprostatectomy ED (1.97 vs. 2.08, p = 0.074). There was no relationship between EndoPAT and SHIM-5 scores in the general ED cohort. The prevalence of hypertension, hyperlipidaemia and cardiovascular (CV) disease was similar between the two groups, but diabetes and hypogonadism were more prevalent in men with general ED (21% vs. 9%, and 28% vs. 7%, p < 0.015). Overall, EndoPAT scores in postprostatectomy men with at least one risk factor were not significantly different compared with men with general ED with the same comorbidity, or a combination of two or more comorbidities.

CONCLUSIONS

The value of EndoPAT testing in the clinical evaluation of ED patients is questionable.

Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus

* A significant proportion of men with erectile dysfunction (ED) exhibit early signs of coronary artery disease (CAD), and this group may develop more severe CAD than men without ED (Level 1, Grade A). * The time interval among the onset of ED symptoms and the occurrence of CAD symptoms and cardiovascular events is estimated at 2-3 years and 3-5 years respectively; this interval allows for risk factor reduction (Level 2, Grade B). * ED is associated with increased all-cause mortality primarily due to increased cardiovascular mortality (Level 1, Grade A). * All men with ED should undergo a thorough medical assessment, including testosterone, fasting lipids, fasting glucose and blood pressure measurement. Following assessment, patients should be stratified according to the risk of future cardiovascular events. Those at high risk of cardiovascular disease should be evaluated by stress testing with selective use of computed tomography (CT) or coronary angiography (Level 1, Grade A). * Improvement in cardiovascular risk factors such as weight loss and increased physical activity has been reported to improve erectile function (Level 1, Grade A). * In men with ED, hypertension, diabetes and hyperlipidaemia should be treated aggressively, bearing in mind the potential side effects (Level 1, Grade A). * Management of ED is secondary to stabilising cardiovascular function, and controlling cardiovascular symptoms and exercise tolerance should be established prior to initiation of ED therapy (Level 1, Grade A). * Clinical evidence supports the use of phosphodiesterase 5 (PDE5) inhibitors as first-line therapy in men with CAD and comorbid ED and those with diabetes and ED (Level 1, Grade A). * Total testosterone and selectively free testosterone levels should be measured in all men with ED in accordance with contemporary guidelines and particularly in those who fail to respond to PDE5 inhibitors or have a chronic illness associated with low testosterone (Level 1, Grade A). * Testosterone replacement therapy may lead to symptomatic improvement (improved wellbeing) and enhance the effectiveness of PDE5 inhibitors (Level 1, Grade A). * Review of cardiovascular status and response to ED therapy should be performed at regular intervals (Level 1, Grade A).

A retrospective study of the relationship between biomarkers of atherosclerosis and erectile dysfunction in 988 men

Erectile dysfunction (ED) is associated with clinical atherosclerosis and several atherosclerotic risk factors including smoking, hypertension, dyslipidemia, diabetes mellitus, obesity and sedentary lifestyle. Clinical atherosclerosis is also associated with these same risk factors and with biomarkers of inflammation, thrombosis, endothelial cell activation. We evaluated the cross-sectional association between the degree of ED and levels of atherosclerotic biomarkers. A subcohort of 988 US male health professionals between the ages 46 and 81 years as part of an ongoing epidemiologic study had atherosclerotic biomarkers measured from blood collected in 1994-1995. These same men had in 2000, been retrospectively asked about erectile function in 1995 and in 2000. Biennial questionnaires since 1986 assessed medical conditions, medications, smoking, physical activity, body mass index, alcohol intake. The retrospective assessment of erectile function in 2000 for 1995 in these 988 men ranged from very good - 28.2%, good - 25.1%, fair - 19.2%, poor - 13.6%, to very poor - 13.9%. Men with poor to very poor erectile function compared to men with good and very good erectile function had 2.9 the odds of having elevated Factor VII levels (P=0.03), 1.9 times the odds of having elevated vascular cell adhesion molecule (P=0.13) and 2.0 times the odds of having elevated intracellular adhesion molecule (P=0.06) and 2.1 times the odds of having elevated total cholesterol/high-density lipoprotein ratio (P=0.02) comparing the top to bottom quintiles for each atherosclerotic biomarker after multivariate adjustment. Lipoprotein(a), homocysteine, interleukin-6 and tumor necrosis factor receptor, C-reactive protein and fibrinogen were not associated with the degree of erectile function after adjustment. We conclude that selected biomarkers for endothelial function, thrombosis and dyslipidemia but not inflammation are associated with the degree of ED in this cross-sectional analysis. Future studies evaluating the prospective association of ED, endothelial function and cardiovascular disease appear warranted.

Compulsive sexual behavior inventory: a preliminary study of reliability and validity

This preliminary study was designed to develop empirically a scale of compulsive sexual behavior (CSB) and to test its reliability and validity in a sample of individuals with nonparaphilic CSB (N = 15), in a sample of pedophiles (N = 35) in treatment for sexual offending, and in a sample of normal controls (N = 42). Following a factor analysis and a varimax rotation, those items with factor loadings on the rotated factors of greater than .60 were retained. Three factors were identified, which appeared to measure control, abuse, and violence. Cronbach's alphas indicated that the subscales have good reliability. The 28-item scale was then tested for validity by a linear discriminant function analysis. The scale successfully discriminated the nonparaphilic CSB sample and the pedophiles from controls. Further analysis indicated that this scale is a valid measure of CSB in that there were significant differences between the three groups on the control subscale. Pedophiles scored significantly lower than the other two groups on the abuse subscale, with the other two groups not scoring significantly differently from one another. This indicated that pedophiles were more abusive than the nonparaphilic CSB individuals or the controls. Pedophiles scored significantly lower than controls on the violence subscale. Nonparaphilic individuals with compulsive sexual behavior scored slightly lower on the violence subscale, although not significantly different. As a preliminary study, there are several limitations to this study, which should be addressed, in further studies with larger sample sizes.

Technical aspects of performing lymphoscintigraphy: optimization of methods used to obtain images

Sentinel node detection is an important part of the clinical management of newly diagnosed melanoma. Now there is a similar or even greater enthusiasm for sentinel node evaluation in patients with breast carcinoma. However, controversies exist regarding the dose, volume, and route of administration. Even the role of lymphoscintigraphy itself, in contrast to using only a hand-held gamma probe during surgery for sentinel node detection, is being debated. Nevertheless, many centers and surgeons find that lymphoscintigraphy images are valuable in the treatment of patients and they use lymphoscintigraphy as a guide during surgery and to confirm the results obtained with the hand-held probe. Centers just beginning to use lymphoscintigraphy may find the images especially useful. Given this fact, the authors wanted to define the practical and technical aspects of performing lymphoscintigraphy in patients with breast cancer and examined various methods for the optimization of the technique of image acquisition. The suggested technique is generally free of the controversies noted above and applies to most patients. It includes various maneuvers that aim to improve the rate of sentinel node visualization using the gamma camera and the accuracy of node detection. The recommendations presented here should prove useful for both those experienced and for those centers just beginning to use the technique of lymphoscintigraphy.

Unusual cervical spinal cord toxicity associated with intra-arterial carboplatin, intra-arterial or intravenous etoposide phosphate, and intravenous cyclophosphamide in conjunction with osmotic blood brain-barrier disruption in the vertebral artery

BACKGROUND AND PURPOSE

When the clinical and radiologic characteristics of an unusual cervical spinal cord complication of intra-arterial (IA) chemotherapy with blood brain-barrier (BBB) disruption in the vertebral circulation are documented. Seven cases are reported and analyzed in search of a pathophysiologic explanation.

METHODS

We retrospectively identified 94 patients who received a total of 380 standardized regimens of IA carboplatin, IA or IV etoposide phosphate, and IV cyclophosphamide infusion in conjunction with osmotic BBB disruption of the vertebral artery. We describe seven of those patients in whom unexpected neck pain developed followed by neurologic symptoms primarily in the upper extremities.

RESULTS

The symptoms correlated with MR abnormalities (T1 hypointensity, T2 hyperintensity, and unusual contrast enhancement) in the cervical spinal cord, usually involving the gray matter. The neurologic deficits and MR changes were generally transient. One patient who received a flu vaccination 48 hours before the chemotherapy incurred progressive myelitis and expired.

CONCLUSION

The pathophysiology of this complication is probably multifactorial but may be related to vascular streaming and an atypical inflammatory toxic reaction to carboplatin and etoposide. The complication has not recurred during a 6-month period following modification of the protocol.

Characteristics of postradical neck pain syndrome: a report of 25 cases

The postradical neck pain syndrome has been briefly described in the literature, but detailed characterization has not been reported. To further define this syndrome, 25 patients with persistent pain for at least 1 month following neck dissection were evaluated. The sample consisted of 13 men and 12 women with moderate to severe pain ranging from 1 month to 27 years in duration. All patients had at least one type of neuropathic pain: spontaneous, continuous burning pain (81%), shooting pain (69%), and/or allodynia (88%). Neuropathic pain sites were within the distribution of the superficial cervical plexus (SCP). Regional myofascial pain was also common (72%). Seventeen patients agreed to undergo diagnostic local anesthetic injections. Ten of these patients had both neuropathic and somatic (myofascial) pain. Local anesthetic injection of the SCP temporarily eliminated all neuropathic pain in the 17 patients who underwent the procedure. The 10 patients who also had myofascial pain reported temporary relief of their somatic pain following myofascial trigger point injections (TPI). Criteria for the postradical neck pain syndrome are proposed: (1) persistent, nonprogressive neuropathic pain involving one or more branches of the SCP, which may be accompanied by (2) regional nonprogressive somatic pain associated with myofascial pain trigger points in head and neck muscles.

The need for a thoughtful deployment strategy: evaluating clinicians' perceptions of critical deployment issues

This paper presents data collected from 899 clinicians across three Department of Veterans Affairs (VA) medical centers where existing terminal-based architecture was being replaced with client-server architecture. Surveys were conducted with physicians (n = 184), nurses (n = 355) and other clinicians (n = 360) gathering user characteristics and their perceptions of five deployment issues (e.g. adequacy of technical and institutional support and perceptions of the soon-to-be-implemented clinical workstation). Mean scores for the five deployment issues for all clinicians indicates perceptions are somewhat neutral. However, when data is analyzed according to job classification, significant (p = 0.05) differences in perceptions were noted among groups of clinicians (e.g., physicians and registered nurses). Results of analyzing data grouped by VA site (n = 3) indicates significant (p = 0.05) differences exist among sites in clinicians' perceptions of the deployment issues. A thoughtful deployment strategy including an in-depth assessment of clinician users by job classification and by location may produce important information, critical to the successful deployment of new technologies, in very large health management institutions.

Psychiatric comorbidity in pedophilic sex offenders

OBJECTIVE

The primary purpose of this research was to assess the rates of axis I and axis II psychiatric disorders, as defined in DSM-IV, in a group of pedophilic sex offenders.

METHOD

Forty-five male subjects with pedophilia who were participating in residential or outpatient sex offender treatment programs were recruited to participate. Subjects were interviewed by using the Structured Clinical Interview for DSM-IV.

RESULTS

Ninety-three percent of the subjects (N = 42) met the criteria for an axis I disorder other than pedophilia. The lifetime prevalence of mood disorder in this group was 67%. Sixty-four percent of the subjects met the criteria for an anxiety disorder, 60% for psychoactive substance use disorder, 53% for another paraphilia diagnosis, and 24% for a sexual dysfunction diagnosis.

CONCLUSIONS

Axis I and II comorbidity rates are high in this population. Untreated comorbid psychiatric disorders may play a role in treatment failure and recidivism.

Experience with gabapentin for neuropathic pain in the head and neck: report of ten cases

BACKGROUND AND OBJECTIVES

Gabapentin is an oral antiepileptic agent with an unknown mechanism of action. Recent case reports have suggested that gabapentin may be effective in the treatment of a variety of neuropathic pain states. This report presents baseline and follow-up data on ten patients who were treated with gabapentin when other pharmacologic interventions failed to relieve their neuropathic pain.

METHODS

Ten patients referred for treatment of unrelieved neuropathic pain in the head and neck region were included in this study. Baseline and follow-up information included measures of pain intensity and pain quality. All of the patients were started on 300 mg gabapentin three times per day, though daily doses of up to 2400 mg were required for pain relief.

RESULTS

Eight of the ten patients had no neuropathic pain on follow-up, whereas the remaining 2 patients reported only partial relief at follow-up. None of the patients complained of side effects. Gabapentin was effective in alleviating steady burning pain as well as lancinating pain and allodynia.

CONCLUSIONS

The results suggest that gabapentin may be effective in the management of some cases of neuropathic pain in the head and neck. However, controlled, double-blind longitudinal studies are needed to evaluate this possibility.

Cerebral hemodynamics: monitoring arteriojugular oxygen content differences

Arteriojugular oxygen difference (AJDO2) is used to manage the care of acute head-injured patients by monitoring the relationship between cerebral metabolism and blood flow. Blood samples from the jugular bulb and a peripheral artery are monitored either continuously or episodically to calculate AJDO2 and cerebral oxygen utilization. An understanding of cerebral oxygen transport physiology is essential to measuring AJDO2. A case study highlights the use of AJDO2 monitoring.

Cardiac growth after pediatric heart transplantation

BACKGROUND

To assess whether normal cardiac growth occurs after heart transplantation in the pediatric age group, we performed a study of 13 infants and children who underwent orthotopic heart transplantation at Stanford.

METHODS AND RESULTS

The echocardiographic data from a population of 93 normal children were analyzed to determine estimates of the fifth, 25th, 50th, 75th, and 95th percentiles of the normal pediatric population. Growth curves for each of the cardiac dimensions were stratified into six classes representing each of the percentile bands, and dimensions for the 13 patients were tracked between early postoperative (early) and point of maximal follow-up (late). Results were compared by Student's paired t test to determine whether normal growth was occurring. The mean age at transplant was 5.0 +/- 1.3 years (mean +/- SEM) (range, 0.4-12.8 years), duration of follow-up was 3.1 +/- 0.4 years (1.3-5.8 years), and change in body surface area was 0.24 +/- 0.03 m2 (0.12-0.50 m2). Both right ventricular (RV) and left ventricular (LV) chamber dimensions were within the normal range at both early and late time points and grew normally as assessed by a lack of class changes. Early wall thickness measurements were above the 95th percentile in seven of 13 patients (LV), 12 of 13 patients (septum), and four of 13 patients (RV). Wall thickness measurements remained above normal, and there were no significant class changes at late follow-up. Histological examination in five patients showed markedly increased septal myocyte width, indicating myocyte hypertrophy. Atrial and great vessel anastomotic sites showed no evidence of obstruction by Doppler and catheterization studies.

CONCLUSIONS

These data demonstrate that normal cardiac chamber dimensional growth occurs at greater than 3 years' follow-up after pediatric heart transplantation. Significant LV and septal (and to a lesser extent RV) hypertrophy persists and may have implications for long-term allograft growth and function.

Neurological basis of respiratory complications in achondroplasia

Evaluation of 32 individuals with achondroplasia revealed that 28% had a history of apnea and 22% had respiratory abnormalities on polysomnography. In those patients requiring posterior fossa decompressive surgery, improvement was noted in follow-up polysomnograms. Multimodality studies suggested that brainstem compression was common in achondroplasia and could account in part for the abnormal respiratory function in this disorder, including obstructive apnea, central apnea, and hypoxemia.

Acute spinal cord injury: MR imaging at 1.5 T

Thirty-seven magnetic resonance (MR) imaging studies were performed with a 1.5-T magnet and surface coils in 27 patients with suspected spinal cord injuries. Imaging was performed 1 day to 6 weeks after injury. Cord abnormalities were seen with MR in 19 patients, while skeletal and/or ligamentous injuries were seen in 21 (78%). Three types of MR signal patterns were seen in association with cord injuries. Acute intraspinal hemorrhage was seen in five patients with cord injuries and demonstrated decreased signal intensity on T2-weighted images obtained within 24 hours of injury. Cord edema and contusion had high signal intensity on T2-weighted images and were observed in 12 cases with cord injury. Neurologic recovery, determined in 16 patients, was insignificant in patients with intraspinal hemorrhage; however, patients with cord edema or contusion recovered significant neurologic function. MR at 1.5 T is extremely useful in the diagnosis of acute cord injury and also demonstrates potential in predicting neurologic recovery.

Anaesthesia for the achondroplastic dwarf

Over the past three years, 36 anaesthetics were administered to 27 patients with achondroplastic dwarfism. Twenty-four patients underwent craniectomy for foramen magnum stenosis. Sixteen of the operations were undertaken in the sitting position with nine incidents of venous air embolism (VAE), all of which occurred in patients under 12 years of age. Six major complications occurred: two C-1 level spinal cord infarctions, two brachial plexus palsies, one severe macroglossia, and one accidental extubation. Intravenous access in the small child with achondroplastic dwarfism is made difficult because of the excess, lax skin and subcutaneous tissue. Airway management and laryngoscopy were not difficult and we found that endotracheal tube size was best predicted by the patient's weight and not age. Blood loss was 38 +/- 9 mg X kg-1 in the prone position (n = 8) and 18 +/- 4 mg X kg-1 in the sitting position (n = 16), and was related to the surgical procedure rather than to dwarfism. Our data indicate that complications are more likely to occur in the sitting position, and that these complications are of a serious nature, and every precaution should be taken to avoid their occurrence.