Cartilage mechanics in the guinea pig model of osteoarthritis studied with an osmotic loading method

OBJECTIVE: To determine the material properties of articular cartilage in the Hartley guinea pig model of spontaneous osteoarthritis. METHODS: Cartilage-bone samples from the medial femoral condyle and tibial plateau of 12 month-old guinea pig knees were subjected to osmotic loading. Site-matched swelling strains and fixed charge density values were used in a triphasic theoretical model for cartilage swelling to determine the modulus of the cartilage solid matrix. The degree of cartilage degeneration was assessed in adjacent tissue sections using a semi-quantitative histological grading scheme. RESULTS: Decreased values for both moduli and surface zone fixed charge density were associated with increasing grades of cartilage degeneration. Decreases in moduli reflect damage to the collagen matrix, which give rise to greater swelling strains. CONCLUSION: Histological evidence of cartilage degeneration was associated with impaired cartilage mechanics in the aging Hartley guinea pig.     

Testing the feasibility of implementation of clinical practice guidelines in long-term care facilities

OBJECTIVES: The purpose of this study was to explore the feasibility of implementing two specific Clinical Practice Guidelines (CPGs), Pain Management and Falls and Fall Risk, developed by the American Medical Directors Association. DESIGN: This study used a combined quantitative and qualitative design using a single-group repeated-measures design for the quantitative component. SETTING: The study was done in 23 long-term care facilities in Maryland. PARTICIPANTS: Of 40 facilities that participated in a training program for CPG implementation, 32 were interested in implementing CPGs and 23 volunteered to participate in the study. Evaluation of the Falls CPG was based on 127 randomly selected cases preimplementation and 119 randomly selected cases postimplementation from the 23 facilities. Evaluation of the Pain CPG included 64 randomly selected cases preimplementation and 74 randomly selected cases postimplementation from the 23 facilities. Qualitative data was obtained from 20 of the directors of nursing. INTERVENTION: Thirteen of the facilities implement-ed the Falls CPG, 10 facilities implemented the Pain CPG, and eight facilities implemented both CPGs. MEASUREMENTS: Process indicators of CPG implementation were used in this study. Process indicators included five measurable items that were indicative of CPG implementation such as evidence of a pain assessment. RESULTS: Less than half (45%) of the original 40 facilities actually implemented at least one of the CPGs. Based on process indicators in those facilities that did implement the CPGs, there was evidence that the guidelines were being implemented. Qualitative data led to the development of four major themes: challenges to implementation, benefits of implementation, process recommendations, and recommendations for changes in the CPGs. CONCLUSION: The study provides some support for the feasibility of CPG implementation in facilities that voluntarily attempted to implement the guidelines. In addition, the findings provide some useful suggestions for how to facilitate the implementation process.     

Guaifenesin as a treatment for primary dysmenorrhea

BACKGROUND: Dysmenorrhea is highly prevalent and causes much work loss and discomfort. A treatment with a new mechanism of action could benefit women of menstruating age. A study was undertaken to assess the efficacy of guaifenesin as a treatment for primary dysmenorrhea because of its effects of cervical dilation and cervical mucous thinning. METHODS: Thirty-four subjects with primary dysmenorrhea were enrolled in a double-blind, placebo-controlled study. Three treatment surveys measured 10 symptoms (lower abdominal pain, general abdominal pain, back pain, headache, nausea, diarrhea, constipation, menstrual flow, weakness, and activities of daily living) on a 100-mm visual analog scale. Nonstudy analgesic use was also measured. RESULTS: Twenty-five subjects returned the first treatment survey, and 17 returned all 3 surveys. Results were nonsignificant, but guaifenesin trended toward being better than placebo for dysmenorrhea pain and associated constitutional symptoms and caused no worsening of symptoms. Lower abdominal mean pain scores from the first survey decreased 38 mm for guaifenesin versus 7 mm for placebo. By the third survey, only 2 of 8 guaifenesin participants took nonstudy analgesics compared with all 9 placebo subjects. CONCLUSIONS: Guaifenesin may be useful in the treatment of primary dysmenorrhea. A larger study is needed to validate these initial findings.     

Trends in state certificate of need and moratoria programs for long term care providers

This study examined state policies for certificate of need or moratoria for new building, renovation, and remodeling of long-term care (LTC) providers, using a telephone survey of state officials in between 1990 and 2002. In 2002, the vast majority of states still continue to regulate the supply of nursing homes, hospital-based nursing homes, and facilities for the mentally retarded/developmentally disabled. Surprisingly, 18 percent of states regulate the supply of residential care facilities, 35 percent regulate home health agencies, and 37 percent regulate hospices. These state efforts to control supply are primarily based on cost containment strategies and assuring the appropriate distribution of LTC services. Where limits are placed on home and community service providers, however, access could be negatively impacted.     

Identifying potentially ineffective care in a community hospital

OBJECTIVES: To develop a formula to predict mortality for intensive care unit patients between day 5 in an intensive care unit and 100 days after hospital discharge from a community hospital. DESIGN: Retrospective 1-yr derivation study with validation on a subsequent year's intensive care unit population. SETTING: An 850-bed, not-for-profit community hospital with three adult intensive care units, including medical-surgical, cardiac-medical, and cardiac-surgical units. PATIENTS: The development patient set included 4045 consecutive adult admissions to the intensive care unit between July 1995 and June 1996. The validation sample consisted of 4084 admissions between July 1996 and June 1997. RESULTS: During the first year, 100-day posthospital discharge mortality was predicted by the combination Acute Physiology and Chronic Health Evaluation (APACHE) III predicted mortality on day 5 of >0.92 or the product of day 1 and day 5 APACHE predicted mortality of >0.40, with an increase in the APACHE predicted mortality from day 1 to day 5 of >0.10. Specificity in the development cohort was 0.99, sensitivity was 0.30, and positive predictive value was 0.95. The second-year validation study demonstrated a specificity, sensitivity, and positive predictive value of 0.98, 0.29, and 0.91, respectively, when applying the model to the validation sample. CONCLUSIONS: By using readily available APACHE III data, we were able to identify patients at high risk of dying between intensive care unit day 5 and 100 days after discharge. Although the low sensitivity limits the number of patients for whom death at 100 days is predicted, the high specificity and positive predictive value suggests this information may provide useful information for families and physicians. If these formulas can be validated in diverse institutional settings, decisions regarding short- and long-term outcomes may be improved by using objective survival predictions from two time points.     

Cost-effectiveness of inhaled nitric oxide in near-term and term infants with respiratory failure: eighteen- to 24-month follow-up for Canadian patients

OBJECTIVE: The objective of this article is to conduct a cost-effectiveness analysis, based on data up to 18-24 months of follow-up, of the use of inhaled nitrogen oxide vs. oxygen, administered to near-term and term infants with severe respiratory failure who were referred for consideration for extracorporeal membrane oxygenation. DESIGN: The cost-effectiveness analysis was conducted alongside a randomized controlled trial conducted by the Canadian Inhaled Nitric Oxide Study Group for patients with severe respiratory distress. SETTING: Patients were cared for in Canadian regional neonatal intensive care units; follow-up treatment was based on standard care. PATIENTS: Term and near-term neonates with severe respiratory failure determined by at least two oxygenation indexes (oxygenation index = mean arterial pressure x Fio2/Pao2) >/=25 at least 15 mins apart. INTERVENTIONS: Patients were randomized to inhaled nitrogen oxide or oxygen. If conditions deteriorated, they qualified for extracorporeal membrane oxygenation. Not all who qualified received extracorporeal membrane oxygenation. Standard care followed after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Timelines of analysis were from randomization until the follow-up, which occurred between 18 and 24 months after randomization. Costs included those for initial hospitalization (neonatal intensive care, medications, extracorporeal membrane oxygenation, transport) and standard medical services above routine care and developmental services received until follow-up. Outcomes included mortality rate, clinical outcomes, and a variety of neurodevelopmental indicators. Costs were not significantly different between interventions. While infants who received inhaled nitrogen oxide generally did better than those who received oxygen, the only variable that was significant was the number of seizure disorders. On economic grounds, inhaled nitrogen oxide was the preferred intervention.