Search

Poor lifestyle choices play a significant role in the development and progression of preventable chronic diseases, including cancer. In this study, we evaluate the effectiveness of a comprehensive lifestyle medicine intervention on chronic disease risk factors and quality of life in breast cancer survivors.This is a retrospective review of a clinical program from January 2016 to July 2017.It includes seven 2-h group medical visits held every other week at an outpatient wellness facility.Eligible participants are breast cancer survivors who have completed treatment, including those who remain on hormonal therapy.Patients receive education and experience in nutrition, culinary medicine, physical activity, and stress relief practices.Participants' weight, body mass index (BMI), body fat mass, lean body mass, and percent body fat were measured at visit 1 and visit 7. Standard validated questionnaires were used to measure perceived stress, depression, patient activation, physical and mental quality of life, dietary fat consumption, and dietary fruit, vegetable, and fiber consumption.A total of 31 patients participated in the group visits. Pre-post comparison data were not available for 10 patients. More than three-quarters of the 21 breast cancer survivors who attended 5 or more of the 7 group visits and provided data at the first and the last group visit decreased their body weight. On average, patients lost 4.9 pounds (-2.6%, p 0.01), and their BMI decreased by 0.8 kg/mBreast cancer survivors could employ the prescribed lifestyle modifications to produce clinically relevant health benefits. Interdisciplinary teams of health care professionals may help breast cancer survivors with chronic diseases implement evidence-based, individualized, and effective lifestyle prescription through group medical visits.

Healthy lifestyle modifications, including weight management, regular physical activity, prudent diet, and stress relief, have been identified as key components of tertiary cancer prevention. In this study, we evaluate the effectiveness of a comprehensive, lifestyle medicine intervention, Lifestyle 180Retrospective subgroup analysis of a clinical program.An outpatient medical facility.Lifestyle 180 participants with a diagnosis of past cancer.Sixty-four hours of intensive nutrition, culinary medicine, physical activity, and stress relief practices over a 6-month period, with 9- and 12-month follow-up.Pre-postanalysis (baseline vs. 12 months) included biometrics: weight, body mass index (BMI), waist circumference, and blood pressure; standard laboratory tests: lipids, C-reactive protein, fasting insulin/glucose, and insulin resistance; and empirically validated questionnaires: perceived stress, depression, and quality of life.Fifty-eight cancer survivors participated in Lifestyle 180. Average age was 63 years, roughly 75% of participants were female, and the greatest majority had a diagnosis of breast, prostate, or skin cancer. Diagnosis of hyperlipidemia, hypertension, diabetes, and prediabetes presented in 47%, 57%, 22%, and 50% of patients, respectively. Forty-five percent of patients were obese, 24% were overweight, and 16% were depressed. At 12 months, participants lost an average of 14 pounds (-6.6%, p 0.001) and 2.6 inches off their waist (-5.9%, p 0.001). BMI decreased significantly by an average of 2.4 kg/mCancer survivors participating in a comprehensive intervention could employ the prescribed lifestyle modifications to produce clinically relevant health and quality-of-life benefits. These data support the American Cancer Society (ACS) and American Society of Clinical Oncology (ASCO) recommendations to incorporate healthy lifestyle modifications into long-term cancer survivorship care.

Supplemental Digital Content is available in the text.

Preoperative cardiac risk stratification algorithms typically use a Bayesian approach to identify a low-risk category group for which the outcome is unlikely to be improved by further testing. This report suggests evaluating common carotid intima-media thickness (CCIMT) as measured by ultrasound to determine whether it strengthens and optimizes perioperative Bayesian risk indices. The idea proposes to use CCIMT Z score and vascular age to quantify atherosclerotic burden. CCIMT may be useful as part of shared decision-making for perioperative care. A website (www.suhitam.com/vascularage) designed by one of the authors (S.M.) is a useful resource.).

Insomnia is a common complaint of individuals presenting to healthcare providers and is associated with decreased quality of life and higher healthcare utilization. In-person cognitive behavioral therapy (CBT) is an effective treatment for insomnia but is hindered by cost and limited access to treatment. Initial research suggests that Web-based CBT may mitigate these obstacles.This study tests the effectiveness of a Web-based program for insomnia based on principles of CBT and stress management.We conducted a randomized trial with wait-list controls among adults with primary insomnia (n = 88). Two hundred sixty-three adults with comorbid insomnia were also included and analyzed separately. The intervention was a 6-week online program, and effectiveness was measured via the Insomnia Severity Index (ISI).Baseline ISI score for the intervention group (n = 43) was 17.0; 16.6 for the control group (n = 45). At first follow-up, the intervention group (n = 25) had a mean change from baseline of -7.3 (95% CI: -9.0, -5.6), sustained through second follow-up, while the control group (n = 35) had a change of -1.3 (-2.7, 0.1). The between-group difference was statistically significant (p 0.001). Participants in the comorbid insomnia group had a baseline ISI score of 16.7 with improvement similar to the primary insomnia group (-6.9; -7.6, -6.2).We observed clinically meaningful improvements in insomnia severity in adults with primary or comorbid insomnia. Sustained improvement over 4 months underscores the effectiveness of a well-constructed online CBT for insomnia program.Go! to Sleep

PURPOSE We investigated whether a tool using patient-entered wellness data to generate tailored electronic recommendations improved preventive care delivery. METHODS We conducted a mixed-methods retrospective study of primary care encounters utilizing an Integrated Wellness Tool with a matched-comparison before-and-after study design. Encounters took place at a single clinic within the Cleveland Clinic Health System. The primary outcome was preventive orders placed. Index patients were matched, based on propensity scores, with comparison patients seen in the same clinic several months earlier. RESULTS Five providers conducted 863 patient encounters using the tool during the study period. During encounters using the tool, providers placed more orders for smoking cessation programs (2.4 vs 0.5%, P < .01), lifestyle medicine (2.4 vs 0%, P < .01) and psychology (2.3 vs 1.0%, P = .04) consults, online nutrition (2.4 vs 1.4%, P = .04) and stress management (5.5 vs 0.9%, P < .01) programs, spirometry (5.9 vs 1.7%, P < .01) and polysomnography (6.3 vs 1.3%, P < .01) tests, and antidepressant (7.2 vs 3.9%, P = .01) and hypnotic (2.2 vs 0.7%, P = .01) medications when compared with matched encounters. CONCLUSIONS Patients are willing to enter lifestyle data, and these data influence provider orders.

Docosahexaenoic acid (DHA), a long-chain omega-3 polyunsaturated fatty acid, has been used to treat a range of different conditions, including periodontal disease (PD) and inflammatory bowel disease (IBD). That DHA helps with these oral and gastrointestinal diseases in which inflammation and bacterial dysbiosis play key roles, raises the question of whether DHA may assist in the prevention or treatment of other inflammatory conditions, such as the metabolic syndrome, which have also been linked with inflammation and alterations in normal host microbial populations. Here we review established and investigated associations between DHA, PD, and IBD. We conclude that by beneficially altering cytokine production and macrophage recruitment, the composition of intestinal microbiota and intestinal integrity, lipopolysaccharide- and adipose-induced inflammation, and insulin signaling, DHA may be a key tool in the prevention of metabolic syndrome.

Numerous studies reveal the cardiovascular benefits of consuming dietary fiber and, especially, cereal fiber. Cereal fiber is associated with cardiovascular risk reduction through multiple mechanisms and consuming a variety of cereal fiber sources offers health benefits specific to the source. Certain cereal fibers have been studied more extensively than others and provide greater support for their incorporation into a healthful diet. β-glucan from oats or barley, or a combination of whole oats and barley, and soluble fiber from psyllium reduces the risk of coronary heart disease; inulin-type fructans added to foods and beverages may modestly decrease serum triacylglycerols; arabinoxylan and resistant starch may improve glycemic control. Individuals with low cereal fiber intake should increase their intake of whole grains in order to receive the benefits of whole grains in addition to fiber. For those adjusting to the texture and palatability of whole grains, turning to added-fiber products rich in β-glucan and psyllium may allow them to reach their fiber goals without increasing caloric intake.

Purpose. Describe the specifications of the Smoking Prevalence, Savings, and Treatment (SmokingPaST) Framework and show how it can illustrate the impact of quit attempts, quit method, number of new smokers, smoking rates of immigrants and emigrants, and death rates of smokers and nonsmokers on future smoking prevalence rates, program costs, years of life saved, medical costs saved, cost effectiveness of programs, and return on investment (ROI). Framework Specifications. Mathematical relationships among factors in SmokingPaST are described. Input variables include baseline smoking rates among current adults, new adults, immigrants, and emigrants; population counts for these groups; annual quit attempts; and distribution of quit methods. Assumption variables include success rate by quit method, death rates of smokers and nonsmokers, annual medical costs of smoking, costs per person for four tobacco treatment methods, age distribution of quitters, and distribution of medical cost funding by source. Output variables include year-end adult smoking rates, successful quitters, years of life saved by quitting, medical costs saved by quitting and by not hiring smokers, total costs of smoking treatment programs, cost per quitter, cost per life-year saved, distribution of medical cost savings from quitting, and ROI of treatment costs. Applications. The Framework was applied at the employer, county, state, and national levels. Conclusions. The SmokingPaST Framework provides a conceptually simple framework that can be applied to any population. It illustrates that significant drops in smoking rates can be achieved and significant savings in medical costs can be captured by employers as well as state and federal governments through tobacco treatment and prevention programs. Savings are especially important for reducing state and federal government deficits and enhancing job competitiveness.

BACKGROUND: Strategies to limit adverse cardiac events after vascular surgery continue to evolve. Early recognition and treatment of myocardial ischemia may be a key to improving postoperative survival rates. Cardiac troponin I (cTnI) screening is an effective means of surveillance for postoperative myocardial ischemic injury and has long-term prognostic value. METHODS: We designed a Markov-based decision analysis model to determine the cost-effectiveness of routine surveillance with cTnI on postoperative Days 0, 1, 2, and 3, with an aim to institute tight heart rate control (60–65 bpm) with close monitoring and coronary care in the intensive care unit for 5 days in patients with cTnI 1.5 ng/mL. The key input variables obtained from published literature were as follows: probability of myocardial infarction, 0.049; cost of cTnI surveillance, $357; cost and efficacy of interventions, $13,145 and 0.55, respectively. The time horizon was lifetime and the target population being individuals aged 65 yr (median) undergoing elective open abdominal aortic surgery. The perspective for analysis was third-party payer. RESULTS: The incremental cost-effectiveness ratio for cTnI surveillance was $12,641 per quality-adjusted life year compared with standard care without cTnI surveillance. During one-way sensitivity analysis, probability of myocardial infarction and efficacy of interventions were found to influence the cost-effectiveness. Multivariate sensitivity analysis with second-order Monte Carlo simulation revealed that cTnI surveillance was favored in 90.75% of simulations at a commonly used threshold of $50,000 per quality-adjusted life year. CONCLUSIONS: In patients presenting for elective open abdominal aortic surgery, intensive surveillance with cTnI and early institution of aggressive -blockade is cost-effective. (Anesth Analg 2007;105:1346‐56)

Plant-based nutrition achieved coronary artery disease (CAD) arrest and reversal in a small study. However, there was skepticism that this approach could succeed in a larger group of patients. The purpose of our follow-up study was to define the degree of adherence and outcomes of 198 consecutive patient volunteers who received counseling to convert from a usual diet to plant-based nutrition.We followed 198 consecutive patients counseled in plant-based nutrition. These patients with established cardiovascular disease (CVD) were interested in transitioning to plant-based nutrition as an adjunct to usual cardiovascular care. We considered participants adherent if they eliminated dairy, fish, and meat, and added oil.Of the 198 patients with CVD, 177 (89%) were adherent. Major cardiac events judged to be recurrent disease totaled one stroke in the adherent cardiovascular participants—a recurrent event rate of .6%, significantly less than reported by other studies of plant-based nutrition therapy. Thirteen of 21 (62%) nonadherent participants experienced adverse events.Most of the volunteer patients with CVD responded to intensive counseling, and those who sustained plant-based nutrition for a mean of 3.7 years experienced a low rate of subsequent cardiac events. This dietary approach to treatment deserves a wider test to see if adherence can be sustained in broader populations. Plant-based nutrition has the potential for a large effect on the CVD epidemic.

Background Purified palmitoleic acid (16-1; omega-7) has shown lipid-lowering and anti-inflammatory benefits in open label, epidemiologic, and animal studies. Objective Our objective was to perform the first randomized controlled trial of purified palmitoleic acid supplementation in humans. Methods Adults with dyslipidemia and evidence of mild systemic inflammation (high-sensitivity C-reactive protein [hs-CRP] between 2 and 5 mg/L) were randomly allocated to receive either 220.5 mg of cis -palmitoleic acid (n = 30) or an identical capsule with placebo (1000 mg of medium chain triglycerides, n = 30) once per day for 30 days. Participants were asked to maintain their current diet. Serum lipids and hs-CRP were drawn at baseline and study completion. Results At 30 days, there were significant mean (95% confidence interval [CI]) reductions in CRP (−1.9 [−2.3 to −1.4] mg/L), triglyceride (−30.2 [−40.2 to −25.3] mg/dL), and low-density lipoprotein (LDL) (−8.9 [−12.0 to −5.8] mg/dL), and a significant increase in high-density lipoprotein (HDL) (2.4 [1.5, 3.3] mg/dL) in the intervention group compared with control. These changes equated to 44%, 15%, and 8% reductions in CRP, triglyceride, and LDL respectively, and a 5% increase in HDL compared with control. Conclusions Purified palmitoleic acid may be useful in the treatment of hypertriglyceridemia with the beneficial added effects of decreasing LDL and hs-CRP and raising HDL. Further study is needed to elucidate mechanisms and establish appropriate human doses.

Study Objectives: To compare patients' functional ability in the 24-hour postoperative period following a remifentanil compared to a hypnotic-fentanyl-treated anesthesia regimen using a 24-Hour Functional Ability Questionnaire. Design: Prospective, 1:1 single-blind, randomized, controlled effectiveness study. Setting: Multicenter study including 156 hospitals and ambulatory surgery facilities. Patients: 2438 patients (1496 outpatients and 942 inpatients) 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness of ≥30 minutes. Interventions: Patients were randomized to receive either intravenous remifentanil (0.5 μg/kg/min for induction and intubation; with the infusion rate decreased to 0.25 μg/kg/min after intubation) or fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given in the remifentanil patients and at the discretion of the anesthesiologists in the fentanyl patients. Measurements: A validated set of measurements of functional ability, rather than more traditional clinical psychological methods, to compare the recovery of patients from remifentanil- and fentanyl-treated anesthetic regimens up to 24 hours after surgery. Main Results: Remifentanil was statistically superior to fentanyl for the four functional assessments evaluated: walking without dizziness, thinking clearly, concentration, and communicating effectively. These differences reflect events occurring within the first 24 hours after anesthesia and surgery. Conclusions: A remifentanil-treated anesthetic demonstrated earlier return to some functions than a fentanyl-treated technique. Although functional assessment is a field that is still in its infancy, a questionnaire to assess functional ability during the 24 hours after anesthesia may provide more practical information about anesthetic recovery than previously used, traditional psychomotor evaluations.

This study prospectively determined whether there was a learning curve with the use of remifentanil, as indicated by decreased hemodynamic variability, improved recovery profile, and decreased incidence of opioid-related adverse events with increasing experience. Patients undergoing diverse surgical procedures (outpatient [n = 1340] and inpatient [n = 560]) were enrolled by investigators (n = 190) who had no previous experience with remifentanil use. Each investigator enrolled 10 patients. A standardized protocol for administration of remifentanil was used. Data were analyzed to determine differences between the first three patients and the last three patients enrolled for each anesthesiologist in the study. There were no differences in hemodynamic variables between the first triad and the last triad in either outpatients or inpatients. Requirements for hypnotic drugs and the doses of remifentanil used were also similar between groups. Analgesic medications administered at the end of surgery and in the postanesthesia care unit (PACU) were similar between groups, except that the last triad in the outpatient group received smaller doses of fentanyl compared with the first triad. Times to response to verbal command, tracheal extubation, and operating room discharge did not differ between groups. However, patients in the last triad undergoing outpatient surgery had shorter times to eligibility for PACU discharge, but times to eligibility for discharge home did not differ. The overall incidence of all adverse events (i.e., hypotension, hypertension, muscle rigidity, respiratory depression, apnea, nausea, and vomiting) was less in the last triad as compared with the first triad. When analyzed separately, only the incidence of vomiting (in the outpatient group) was decreased in the last triad as compared with the first triad. This study suggests that there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of PACU stay.This study demonstrated that anesthesiologists rapidly acquire the ability to use remifentanil with limited experience. However, there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of postanesthesia care unit stay.

BACKGROUND Methylnaltrexone is the first peripheral opioid receptor antagonist. It has the potential to prevent or reverse the peripherally mediated gastrointestinal effects of opioids. In previous human volunteer trials, we demonstrated that oral uncoated methylnaltrexone prevented morphine-induced delay in gastrointestinal transit time. METHODS This trial consisted of two studies: a pilot study and a controlled study. The lactulose hydrogen breath test was used to measure the oral-cecal transit time. RESULTS In the pilot study with three subjects, an oral dose of 6.4 mg/kg enteric-coated methylnaltrexone effectively reversed the effects of morphine, producing transit times shorter than baseline levels. Subsequently, in the controlled study with another nine subjects, the transit time increased after intravenous morphine administration in all nine subjects, and the lower dose (3.2 mg/kg) of enteric-coated methylnaltrexone completely prevented the morphine-induced change in oral-cecal transit time in all nine subjects. Morphine significantly increased oral-cecal transit time from baseline level of 96.7 +/- 54.1 minutes (mean +/- SD) to 155.0 +/- 53.6 minutes (P = .014). After enteric-coated methylnaltrexone and morphine, the transit time returned to the baseline level (93.3 +/- 56.0 minutes; P = .55 compared with placebo). Plasma concentrations after 6.4 mg/kg and 3.2 mg/kg enteric-coated methylnaltrexone were substantially lower compared with those after 6.4 mg/kg of the uncoated formulation. CONCLUSION Our results suggest that there is a prevailing direct and local luminal effect of enteric-coated methylnaltrexone and that the enteric-coated formulation exerts its gut pharmacologic actions more efficiently than the uncoated formulation.

In this era of medical technology assessment and evidence-based medicine, evaluating new methods to measure physiologic variables is facilitated by standardization of reporting results. It has been proposed that assessing repeatability be followed by assessing agreement with an established technique. If the “limits of agreement” (mean bias 6 2sd) are not clinically important, then one could use two measurements interchangeably. Generalizability to larger populations is facilitated by reporting confidence intervals. We identified 44 studies that compared methods of clinical measurement published during 1996 to 1998 in seven anesthesia journals. Although 42 of 44 (95.4%) used the limits of agreement methodology for analysis, several inadequacies and inconsistencies in reporting the results were noted. Limits of agreement were defined a priori in 7.1%, repeatability was evaluated in 21.4%, and relationship (pattern) between difference and average was evaluated in 7.1%. Only one of the articles reported confidence intervals. A computer macro for the Minitab statistical package (State College, PA) is described to facilitate reporting of Bland and Altman analysis with confidence intervals. We propose standardization of nomenclature in clinical measurement comparison studies. Implications: A literature review of anesthesia journals revealed several inadequacies and inconsistencies in statistical reports of results of comparison studies with regard to interchangeability of measurement methods. We encourage journal editors to evaluate submissions on this subject carefully to ensure that their readers can draw valid conclusions about the value of new technologies.

Background The authors hypothesized that myoclonus after etomidate is dose-related, could be suppressed when small doses of etomidate were administered before induction, and is unassociated with seizure-like activity on electroencephalogram (EEG). Methods Three studies were performed. In the first study, 36 men were randomly assigned to receive 0.025, 0.050, 0.075, 0.100, 0.200, or 0.300 mg/kg of etomidate. In a second crossover study, eight men were randomly allocated to receive either a pretreatment dose of 0.050 mg/kg etomidate or placebo 50 s before 0.300 mg/kg etomidate was injected. EEG was recorded for subjects in the first two studies. In a third study, 60 patients were randomly allocated to one of three pretreatment doses of etomidate: 0.030, 0.050, or 0.075 mg/kg before 0.300 mg/kg was given. Results In Study 1, myoclonus was not observed after 0.025 or 0.050 mg/kg etomidate. One volunteer had myoclonus after 0.075 mg/kg and another after 0.100 mg/kg etomidate; three had myoclonus after 0.200 mg/kg; and five after 0.300 mg/kg. Incidence of myoclonus was dose-related (P < or = 0.01). In Study 2, two volunteers (25%) with etomidate pretreatment had mild myoclonus compared to six (75%) with placebo pretreatment (P < or = 0.05). EEG changes, other than delta waves, were not seen during myoclonic epochs. In Study 3, myoclonus was less likely after the small pretreatment doses (0.030 or 0.050 mg/kg) than after the large dose (0.075 mg/kg, P < or = 0.01). Conclusions Incidence and intensity of myoclonus after induction with etomidate are dose-related, suppressed by pretreatment, and unassociated with seizure-like EEG activity.

Opioid compounds are commonly used analgesics. After opioid administration, troublesome subjective effects, such as dysphoria, dizziness, nausea, and pruritus, have been reported. While some if not all of these are believed to occur due to central nervous system effects of opioids, the anecdotal reports heard from volunteers in our other studies suggest that a peripheral opioid antagonist reduced some of these effects. In this double-blind randomized placebo-controlled study, we evaluated the efficacy of oral methylnaltrexone, a selective peripheral opioid receptor antagonist, to decrease subjective effects after administering morphine to normal human volunteers. After intravenous morphine injection (0.05 mg/kg), significant increases in subjective ratings were obtained on 'nauseous', 'skin itch', 'stimulated', and 'flushing'. Oral methylnaltrexone 19.2 mg/kg significantly decreased these four ratings. Plasma methylnaltrexone concentrations at two different oral doses were also measured to correlate between pharmacological effects of the compound and its plasma levels. Our results suggested that methylnaltrexone has a potential therapeutic value in decreasing some undesirable subjective effects associated with opioid medications.

This study was conducted to survey gut motility and transit in 19 volunteers receiving methadone maintenance who were opioid-dependent, and to measure the oral-cecal transit time in these individuals using the lactulose hydrogen breath test. None of these patients reported constipation problems before use of illicit drugs. During current long-term methadone therapy, 58% of patients experienced some degree of constipation, and two of these 19 patients reported that constipation was a very serious problem. Mean +/- standard deviation (SD) oral-cecal transit time in these individuals was 159+/-49.2 minutes, which is significantly longer than the transit time recorded in two previous studies of healthy volunteers (P < 0.01). These results indicate that tolerance to opioids does not appear to extend to gastrointestinal motility and transit. It seems that patients receiving long-term methadone therapy are a good model for use in evaluating gastrointestinal effects of opioid antagonists.

Topical capsaicin is known to be a safe and effective pain management adjunct for rheumatoid arthritis, osteoarthritis, neuralgias, and diabetic neuropathy. However, studies and case reports in the literature have indicated that other conditions may also benefit from capsaicin: painful or itching cutaneous disorders from operations, injuries, or tumors; neural dysfunction; or inflammation of the airways and urinary tract.To determine the effectiveness of capsaicin for painful cutaneous disorders and neural dysfunction, the authors analyzed data from 33 reports (MEDLINE search of 1966-96) on the efficacy of capsaicin. Outcome measures consisted of the response rate and degree of pain relief. Results from placebo-controlled trials were pooled when possible; effect of treatment was estimated by the method of DerSimonian and Laird.Pain relief for postmastectomy syndrome and cluster headache was greater with capsaicin than with placebo; also, psoriasis and pruritus responded better to capsaicin. Uncontrolled studies and case reports have indicated that pain or dysfunction was less at the end of capsaicin therapy for neck pain, loin pain/hematuria syndrome, oral mucositis, rhinopathy, reflex sympathetic dystrophy syndrome, detrusor hyperreflexia, and cutaneous pain due to tumor of the skin.Capsaicin is effective for psoriasis, pruritus, and cluster headache; it is often helpful for the itching and pain of postmastectomy pain syndrome, oral mucositis, cutaneous allergy, loin pain/hematuria syndrome, neck pain, amputation stump pain, and skin tumor; and it may be beneficial for neural dysfunction (detrusor hyperreflexia, reflex sympathetic dystrophy, and rhinopathy). A universal problem for many of the studies analyzed was the absence of a "burning placebo" such as camphor.

N-methylnaltrexone bromide (methylnaltrexone) is a quaternary opioid antagonist with a limited ability to cross the blood-brain barrier. In animal models it reverses at peripheral receptors such side effects of opioids as decreased gastrointestinal motility, emesis, and cough suppression without affecting the desired analgesic effect mediated by central nervous system receptors. Methylnaltrexone thus may be a clinically useful compound for the prevention and treatment of opioid-induced side effects. This study was designed to examine the safety and tolerance of methylnaltrexone in healthy human participants over a range of doses and to identify any adverse effects or toxicity associated with methylnaltrexone and the doses at which these adverse effects occur. Healthy male volunteers received intravenous methylnaltrexone in six ascending doses with a placebo randomly inserted into the sequence. Each participant was observed for subjective and hemodynamic changes. Electrocardiogram and laboratory studies were also performed. The dose-limiting adverse effect of methylnaltrexone was orthostatic hypotension at 0.64 mg/kg (n = 3) or 1.25 mg/kg (n = 5), which was transient and self-limiting. Plasma levels of methylnaltrexone in excess of 1,400 ng/mL were observed to be associated with orthostatic hypotension. There were no significant subjective changes, no release of histamine, and no changes in physical examination or laboratory studies during the course of the study. Pharmacokinetic analysis revealed an elimination half-life of 117.5 minutes (+/-53.2), and a clearance of 38.8 L/hr (+/-17.4) with a methylnaltrexone dose of 0.64 mg/kg. Our results indicate that methylnaltrexone is well tolerated at doses of 0.32 mg/kg in healthy humans.

A number of issues relating to patient education in anesthesia have been addressed in this review and, based upon the available data, some questions can be answered clearly. It is apparent both that a large minority of the American, British, and Australian public is under the misconception that anesthesiologists are not physicians and that the role of the anesthesiologist, both in and out of the operating room, is not fully understood. Many surgical patients, particularly younger ones, have fears about the anesthetic that are distinct from their fears about the surgery, the most common of them relating to waking up prematurely or not at all. Traditional attire for anesthesiologists is preferred by patients but does not appear to significantly influence patient satisfaction. While there are numerous putative advantages to improving patient rapport, good communication as judged by the patient is associated with a lower incidence of malpractice litigation. Preoperative instruction has been demonstrated to have benefit with regard to patient anxiety, postoperative pain, and length of hospitalization. It is also clear that patients' coping behavior varies considerably and strongly influences the usefulness of providing detailed preoperative information. Preoperative teaching should therefore be tailored accordingly. An issue that is less clear concerns the optimal methods for educating patients and the general public. Preliminary evaluation of videotape instruction has yielded somewhat encouraging results, but whether the preoperative visit, supplemented by videotape or in-hospital, on-demand television programming, or computer networks, such as the World Wide Web or home television, are the most effective and practical means for this education remains to be seen. How best to identify in a cost-effective way patients who would most likely benefit from more information is an important question that remains relatively unaddressed. Advances in surgical diagnosis and treatment and critical care have depended upon the development of anesthesia as a specialty. Our ability to continue to develop may depend upon our success in educating the public, politicians, and other health care professionals about what we do. The evaluation of educational methods for disseminating information about anesthesia thus may be important in determining the very future of our specialty and the quality of surgical and pain therapy that patients will receive.

Pulmonary macrophages play an important role in the host defense against infection, and the importance of this role is probably enhanced when the upper airway defenses are circumvented by endotracheal intubation. Studies in animals suggest that exposure to volatile anesthetics compromises the viability and function of alveolar macrophages. We studied the effect of surgery and anesthesia on the alveolar macrophages of 41 human subjects undergoing lower abdominal procedures of varying lengths during nitrous oxide-isoflurane anesthesia. Alveolar macrophages were harvested from bronchoalveolar lavage fluid obtained before incision and compared to those recovered just before emergence from anesthesia. Macrophages were analyzed for aggregation and viability, assessed by the ability of viable cells to exclude trypan blue dye. Operations lasting 2 h or less led to little aggregation and had little effect on viability. However, there was a strong correlation between loss of macrophages and the duration of surgery and anesthesia. Aggregation increased and viability decreased as a function of procedure length. Studies are needed to determine whether prolonged surgery contributes to the incidence of postoperative pulmonary complications by disturbing the function and survival of alveolar macrophages in humans.

Contrast-enhanced perfusion patterns of newly transplanted kidneys were determined in 10 patients. Albumin-stabilized sonicated microspheres were injected into the iliac-renal artery of the transplanted kidney while continuous two-dimensional ultrasound images were recorded. Doppler derived resistance index (RI) of the transplanted kidney's blood flow before injection of contrast (0.68±0.8) did not differ significantly from RI measured immediately after injection (0.72±0.13) or RI 24 h after surgery (0.69±0.11). Heart rate, mean arterial pressure, central venous pressure, and electrocardiogram (ECG) signs for ischemia did not change during contrast injections. Renal scintigraphy and renal biopsy revealed acute tubular necrosis and/or rejection in two patients at 24-48 h. Videodensitometry was used to assess the ratio of inner to outer peak pixel intensity from the recorded tomographic images in six patients. In both patients with acute rejection, the inner to outer cortex peak pixel intensity was greater than 1, whereas it was less than 1 in the remaining four patients with normal postoperative renal function. Visual scores (0-3) of contrast enhancement for three doses of Albunex® were evaluated (0.5 mL, 1.0 mL, 2.0 mL). Two milliliters always enabled perfusion assessment. In seven patients the identical dose of Albunex® was injected immediately before and 30 s after 2 mg of verapamil was injected directly into the renal artery at the time of surgery. The contrast enhancement score before verapamil (1.4±0.6) was significantly less than the enhancement score after (2.1±0.6), implying greater renal blood flow after verapamil. Evaluation of renal blood flow during kidney transplant surgery using contrast ultrasonography with sonicated albumin microspheres is feasible. Further applications for assessing regional renal blood flow changes during surgery (nontransplant) may be possible

Summary A history of the public–private partnership ‘SmartTots’ between the IARS and FDA is presented. In order to raise money for research to better understand the relationship between sedative and anesthetic agents and neurotoxicity in the developing brain, the FDA approached the IARS in 2008. A partnership was developed over the following 2 years, then a Scientific Advisory Board was created to develop a research agenda. The IARS contributed $200 000 in 2011 to provide initial funding; 33 proposals were submitted in response to a request for proposals in late 2011 and resulted in the awarding of two, $100 000 grants in 2012. An Executive Board was appointed under the leadership of Michael Roizen to spearhead additional fund-raising efforts, and a director of development is working with Dr. Roizen and the Board to raise funds from individuals and organizations. Dr. Roizen has personally committed to a matching grant for anesthesiologists, up to $50 000 per year for 20 years ($1 million). Readers of the journal are encouraged to go to the website www.smarttots.org in order to better understand the issue, to contribute to the research fund themselves, and to encourage their own professional organizations to partner with SmartTots in fund-raising.

Objective: As the population ages, the care of older persons becomes more important. At the same time, practice guidelines that provide recommendations for appropriate care are being published in greater numbers. The purpose of this work is to determine the proportion of guidelines that contain specific information about older persons. Design: Through a random sample of published guidelines listed in the AMA Directory of Practice Parameters, 1992 Edition, we determined the proportion of guidelines that contain specific age-related information. We also determined if, over time, there was a difference in the proportion of practice guidelines containing information about older persons. Results: 45.9% (95% CI, range 33.4–58.4) of guidelines that could conceivably pertain to older persons contain no age information; 24.6% (95% CI, range 13.8–35.4) of guidelines contain information only about persons less than 65 years of age; 29.5% (95% CI, range 18.1–41.0) of guidelines contain specific information about older persons. Moreover, there were no secular trends in the proportion of guidelines pertaining to older persons. Conclusions: Only a minority of practice guidelines contain information about older persons. Possible causes and solutions to this shortfall are discussed.

Lack of precise measurement or recommendations should not deter employers from taking action

Patient management decisions rarely incorporate standardized health status assessments, since accurate and reliable measures are difficult and expensive to obtain. In prior research with various methods for obtaining health data from patients, it was found that physicians' acceptance of a method was improved if it provided an individualized printout. It was also determined that patients will readily complete a health status questionnaire on a computer when the computer does not look like a computer. Patients' acceptance was greatest when they were presented with a single line of large, pressure-sensitive buttons with which they could respond to questions about their health histories. Using such an instrument, the HealthQuiz, the current study found the same discrepancy rate (3%) between patients' responses to health questions presented on HealthQuiz and during interview as between their responses to questions asked during two separate interviews. Further, to ascertain health status, rules determined by an expert panel were applied to patients' responses to health questions presented on the HealthQuiz screen. It was found that the numerical health status derived from answers to the automated presentation of questions was similar to numerical health status derived by a physician after a patient-physician interview.

ImplicationsThis study examines the management of patients diagnosed with pheochromocytoma at a major academic teaching hospital. The findings indicate that most patients can be safely managed as outpatients preoperatively, resulting in significantly shorter hospitalizations and no adverse sequelae.

No reliable, quantifiable index of tissue perfusion is currently available to assess the efforts of coronary artery bypass graft (CABG) surgery. We used two-dimensional transesophageal contrast echocardiography with sonicated Renografin-76 microbubbles to determine the distribution of myocardial blood flow during coronary artery bypass graft surgery in 15 patients. Sonicated Renografin-76 contrast agent was injected into the aortic root of all patients after institution of cardiopulmonary bypass and application of the aortic occlusive clamp. Eight patients had contrast agent injected directly into the free proximal end of the vein-CABG anastomosis. All patients again received aortic root injections during reperfusion after anastomosis of the proximal aortovein and distal coronary artery. Echocardiographic images of the left ventricle short axis at the level of the papillary muscles were obtained in real time and analyzed retrospectively from videotape. Injection of contrast provided information about the magnitude and geometric distribution of coronary artery-vein bypass run-off and enabled identification of poorly perfused myocardial regions. When predicted myocardial perfusion patterns, based on preoperative evaluation of epicardial vessel distribution derived from coronary angiography, were compared to actual perfusion patterns assessed with intraoperative echocardiography, contrast regional myocardial perfusion patterns were predicted 84% of the time (71-97%, 95% confidence limit). Regional myocardial perfusion deficits detected after coronary bypass grafting were associated with regional wall motion abnormalities detected after separation from cardiopulmonary bypass. Our technique makes possible on-line visualization of changes in regional blood flow in the heart before, during, and after CABG.(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND: Six Sigma methodology is a data management process that can be used to achieve a goal of near perfection in process performance. An audit of 615 surgeries over 2 mo revealed only 38% of noncardiac patients admitted on the day of surgery at our institution received perioperative antimicrobial prophylaxis within the target interval of < or =60 min before incision. METHODS: Six Sigma methodology was used to improve our process of timing of antimicrobial prophylaxis administration. A multidisciplinary team was assembled which identified seven process inputs by which patients receive antimicrobial prophylaxis. Interventions for improvement included reinforcement of use of preoperative antibiotic order forms, eliminating administration of antibiotics in the preoperative admission area, and sending appropriate antibiotics and IV tubing with the patient to the operating room. We concurrently developed a control plan to sustain this improvement using a recently deployed electronic anesthesia record keeping system using real-time measurement and reporting capabilities of antimicrobial prophylaxis administration. After defining the new process and undertaking a system-wide educational effort, implementation was begun with data collection and analysis occurring over the next 7 mo. RESULTS: For the 8-mo postintervention interval, there was a significant improvement with 86% of 1716 surgical patients receiving their antibiotic prophylaxis within the specified time frame (P < 0.01). The time interval for antibiotic administration before surgical incision also decreased from a preintervention mean of 88 (CI 56-119 min) to 38 min (CI 25-51 min) (P < 0.01). CONCLUSION: We conclude that Six Sigma methods were used to successfully improve our process for timing of perioperative antibiotic prophylaxis before surgical incision. An electronic anesthesia record keeping system is a useful tool to monitor this process improvement.

Preoperative patient evaluation can minimize the surgical burden and help prevent a crisis in perioperative medicine. Relieving the surgical burden involves a shift from practicing medicine to practicing preventive care in the preoperative environment, as well as motivating patients to adopt healthier behaviors over the long term.

Smoking is the single most cause of preventable disease and premature death in the United States. We discuss potential hazards that the anesthesiologist should be aware of when caring for patients who abuse tobacco. A review of recent preoperative smoking cessation initiatives is also provided in addition to recommendations on how anesthesiologists may use the preoperative visit as an opportunity to play a more active role in reducing the burden of tobacco-related disease.

We hypothesized that the concentration of propofol in the aqueous phase may be the most important variable responsible for the pain experienced during injection of the drug. The concentration of propofol in the aqueous phase (18.57 micrograms/mL) can be decreased by increasing the fat content of the solvent. To test this hypothesis, 36 patients were randomly allocated to one of three groups, each receiving a different formulation of propofol. Group A received 20 mL of propofol alone in a commercial preparation (Diprivan(R) with 10 mL of saline); Group B, 20 mL of propofol to which 5 mL of long-chain triglyceride (LCT) fat emulsion and 5 mL of saline and been added; and Group C, 20 mL of propofol and 10 mL of LCT fat emulsion. The propofol emulsion was injected over 30-60 s into a dorsal vein of the hand. Patients reported pain during injection as none, mild, moderate, or severe (almost intolerable). In Group A, 8 of 12 patients reported moderate or severe pain upon injection whereas in Group C only mild pain was reported by 6 of 12 patients. Our results suggest that a smaller concentration of propofol in the aqueous phase of the emulsion reduces pain on injection. With the addition of more lipid (10 mL), a higher percentage of propofol is absorbed by fat particles. If solvents that permit a smaller concentration of the drug in the aqueous phase of oil-in-water emulsions were used for propofol and other drugs that cause pain on injection, pain would be reduced and patient satisfaction may be increased.

Background A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria. Methods A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed. Five surgical centers (three community-based hospitals and two freestanding ambulatory surgical centers) were utilized. Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period. Outcome measures included PACU bypass rates and adverse events. Intervention consisted of a multidisciplinary educational program and routine feedback reports. Results The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4-31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1-84.2%, P < 0.001). During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome. Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures. Conclusions This study represents a substantial change in clinical practice in the perioperative setting. Same-day surgical patients given short-acting anesthetic agents and who are awake, alert, and mobile requiring no parenteral pain medications and with no bleeding or nausea at the end of an operative procedure can safely bypass the PACU.

The purpose of this study is to determine whether routine preoperative testing has a usefulness not previously recognized in a small preliminary study to decide if such a hypothesis might be worthy of testing in a larger study.Single-observer, prospective, observational study.Tertiary-care referral center in South India that performs 11 preoperative tests on each patient.One hundred twenty-seven adult patients scheduled for elective neurosurgery.Patients were studied to determine whether outcome was influenced by laboratory tests, which were either indicated by health history elicited by a computerized rule-based questionnaire or unindicated by patient history.Of the 1395 tests performed preoperatively, 513 (36.8%) were indicated and 882 (63.3%) were unindicated. Of 513 indicated tests, 17 (3.3%) prompted changes in patient care; 8 (0.91%) of 882 unindicated tests (P.001) prompted changes in care. All patients with anemia, significant electrocardiographic abnormalities, or HIV infection were detected by the computerized questionnaire. Among the changes in care prompted by unindicated tests, 4 patients received diabetic therapy or counseling, and 4 patients with abnormal silhouettes on chest radiograph had nonbeneficial echocardiography. Only screening for diabetes seemed to have usefulness as a routine preoperative test in this patient population.Although the incidence of unindicated preoperative screening tests is still more than 50%, no previously unidentified benefit was found to support this persistence of unwarranted testing. The limited number of patients in this study necessitates a larger study to ensure greater certainty before such a recommendation is made to the public. If similar results in another but larger study involving similar design, simple changes in the system of preoperative care may save the health care system the considerable expense of unwarranted testing.

Study Objective: We evaluate a computer-based intervention for screening and health promotion in the emergency department and determine its effect on patient recall of health advice. Methods: This controlled clinical trial, with alternating assignment of patients to a computer intervention (prevention group) or usual care, was conducted in a university hospital ED. The study group consisted of 542 adult patients with nonurgent conditions. The study intervention was a self-administered computer survey generating individualized health information. Outcome measures were (1) patient willingness to take a computerized health risk assessment, (2) disclosure of behavioral risk factors, (3) requests for health information, and (4) remembered health advice. Results: Eighty-nine percent (470/542) of eligible patients participated. Ninety percent were black. Eighty-five percent (210/248) of patients in the prevention group disclosed 1 or more major behavioral risk factors including current smoking (79/248; 32%), untreated hypertension (28/248; 13%), problem drinking (46/248; 19%), use of street drugs (33/248; 13%), major depression (87/248; 35%), unsafe sexual behavior (84/248; 33%), and several other injury-prone behaviors. Ninety-five percent of patients in the prevention group requested health information. On follow-up at 1 week, 62% (133/216) of the prevention group patients compared with 27% (48/180) of the control subjects remembered receiving advice on what they could do to improve their health (relative risk 2.3, 95% confidence interval 1.77 to 3.01). Conclusion: Using a self-administered computer-based health risk assessment, the majority of patients in our urban ED disclosed important health risks and requested information. They were more likely than a control group to remember receiving advice on what they could do to improve their health. Computer methodology may enable physicians to use patient waiting time for health promotion and to target at-risk patients for specific interventions. [Rhodes KV, Lauderdale DS, Stocking CB, Howes DS, Roizen MF, Levinson W. Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department. Ann Emerg Med. March 2001;37:284-291.]

The time available for pediatric ambulatory visits is rarely sufficient to permit a truly comprehensive health assessment. We hypothesized that a reliable, computerized, self-administered questionnaire could be designed to screen for a full range of pediatric health issues and provide a comprehensive health database for pediatric patients. An age and gender-specific pediatric questionnaire of 478 questions was formatted to elicit only a 'Yes," "No," or "Not Sure" response and structured in a branched, decision-tree format. The initial draft was reviewed for content by pediatric experts in Canada and the United States and revised in accordance with their suggestions. The questionnaire was divided into two modules, Medical Peds, covering biomedical issues and Prevent Peds, covering prevention, psychosocial, educational, and safety topics. Cognitive interviews were carried out with 132 parents in pediatric ambulatory care centers in Chicago and Halifax, with use of scripted and nonscripted probe questions, to ensure comprehensibility among patients with widely varying educational levels and health knowledge. Reliability was tested in 100 parents of children aged 1 month to 12 years, through use of five different test-retest sequences. Respondents' impressions were surveyed on completion of the procedure. Following content reviews, and cognitive and reliability testing, the total bank of questions was reduced to 375. As a result of the use of branching logic, individual parents answered an average of 111 Prevent Peds and 144 Medical Peds questions. Average time required to complete the entire questionnaire was 13 minutes for Prevent Peds and 19 minutes for Med Peds. Retesting within 36 hours showed an overall 97% concordance of response pairs in the Medical Peds and Prevent Peds questionnaires. There were no statistically significant differences in test-retest reliability between different sequence formats used, (e.g., HealthQuiz followed by personal interview, or HealthQuiz vs. HealthQuiz). A few questions that frequently elicited "Not Sure" responses were eliminated. As a result, the majority of questions elicited either a 'Yes" or "No" response. Pediatric HealthQuiz identified a wide spectrum of child health problems that are often overlooked in routine health visits. Parents completing Pediatric HealthQuiz indicated a high degree of satisfaction with the procedure. Most reported that they believed the information would improve their child's health care.

In this preliminary study, we evaluated the effects of methylnaltrexone, a peripheral opioid-receptor antagonist, on chronic opioid-induced gut motility and transit changes in four subjects with chronic methadone-induced constipation. Subjects participated in this single blind, placebo controlled study for up to 8 days. We gave placebo the first day; for the remainder of the study, we gave intravenous methylnaltrexone (0.05-0.45 mg/kg) twice daily. During the study period, we recorded oral-cecal transit time and opioid withdrawal symptoms, as well as laxation response based on the frequency and consistency of the stools. Subjects 1 and 2 who were administered methylnaltrexone 0.45 mg/kg, a dose previously administered in normal volunteers, showed immediate positive laxation. Subject 2, after positive laxation response, had severe abdominal cramping, but showed no opioid systemic signs of withdrawal. The subject was discontinued due to the cramping. In Subjects 3 and 4, we reduced the methylnaltrexone dose to 0.05-0.15 mg/kg. The latter two subjects also had an immediate laxation response during and after intravenous medication without significant side effects. The stool frequency of these four subjects increased from 1-2 times per week before the study to approximately 1.5 stool per day during the treatment period. Oral-cecal transit times of Subjects 1, 3, and 4 were reduced from 150, 150 and 150 min (after placebo) to 90, 60 and 60 min (with methylnaltrexone), respectively. Our preliminary results demonstrate that low dose intravenous methylnaltrexone effectively reversed chronic methadone-induced constipation and delay in gut transit time. Thus, we anticipate that cancer patients receiving chronic opioids may also have increased sensitivity to methylnaltrexone, and that low dose methylnaltrexone may have clinical utility in managing opioid-induced constipation in chronic-pain patients.

Despite worldwide enthusiasm for endoscopic surgery, this new technology is now on the top of McKinlay's “product life circle curve.” Critical questions are being asked about its benefits and burdens, but the concepts applied and the methodologies used for technology assessment are in a similar position as endoscopic surgery and need a critical evaluation. (1) There are incorrect and outdated concepts for the scientific basis of surgery (surgical theory) including the basic sciences involved; biomedicine still dominates, but assessment of outcome after operations is no longer possible without clinical epidemiology and social psychology. (2) Based on an outdated scientific theory for surgery, an outdated concept of disease is still propagated. It is denoted as mechanical and is based solely on biomedicine. Human subjects are reduced to biologic machines, and outcomes measurement excludes most dimensions of functioning and well-being. To achieve a valid result for outcome measures, a hermeneutic approach must be combined with the mechanical approach. (3) Based on an outdated model of disease, the outcomes used in endoscopic surgery rely too much on traditional measures, such as mortality rate, complication rate, hospital stay, and especially an endless list of biochemical mediators. Their alterations during the perioperative period have not yet been shown to be related to clinical or hermeneutic outcomes. A new method of assessment for clinical trials in endoscopic surgery and for other surgical problems is outlined, such as for surgical infections and for surgical oncology. It includes an index of recovery and objective health status assessed by the doctor, a quality-of-life self-report by the patient, and the true endpoint concept as a critical weighting of both types of outcome by patients and doctors.

Appropriate preoperative pain therapy for patients undergoing surgery may be withheld due to the fear that opioids will inhibit gastric emptying and increase the risk of aspiration. Previously, doses of 5 to 10 mg of morphine have been shown to delay gastric emptying time. However, the effect of lower doses of morphine on gastric emptying in humans has not been reported. In this study, the effects of intravenous morphine 0.05 mg/kg-3.5 mg for 70-kg body weight, a dose that can cause analgesia--on gastric emptying were evaluated in a double-blind, randomized, placebo-controlled study in 15 healthy human volunteers using the acetaminophen test. Our data indicated that this low dose of morphine significantly prolonged the gastric emptying time. Thus, even small doses of morphine inhibit gastric emptying. This effect may be important in patients undergoing surgery, in patients receiving other oral medications after surgery in ambulatory settings, and in instances of patient-controlled analgesia.