The hospitalist: the new addition to the inpatient management team

To coordinate care and manage costs, physicians are being added to the inpatient management team. To assist the chief nurse executive in assimilating this new team member into the patient care provider group, the authors describe the role of the hospitalist, the goals of the organization in using the new role, questions to ask and steps to take to ensure success for the whole-care team and the organization.     

Comparison of the hospital cost of primary and revision total knee arthroplasty after cost containment

Revision total knee arthroplasty (TKA) consumes more time, more work, and more supplies than primary TKA. This study compared the hospital cost of primary and revision TKA after the introduction of cost-containment programs (implant standardization, clinical pathway, and competitive bid implant purchasing) at our hospital. Hospital financial records of 207 primary unilateral TKA operations and 32 revision TKA operations performed from October 1993 through September 1995 were analyzed. A cost-accounting system provided actual hospital cost data for each procedure. Accurate calculation of hospital income or loss was determined for all 239 procedures. The average hospital length of stay was 4.7 days for primary unilateral TKA and 5.1 days for revision TKA. There were 26 three-component revision operations and 6 one- or two-component revision operations. The average hospital cost was $10,421 for primary TKA and $11,906 for revision TKA. The average net hospital income (hospital revenue - hospital expense) was $3211 for primary TKA and $1853 for revision TKA. The payer mix included indemnity insurance, Medicare, Medicaid, managed care, and workmen's compensation. All payers were profitable except for Medicaid and selected managed care contracts for both primary and revision TKA. As a result of cost-containment programs, revision TKA can be profitable at our institution.     

Effectiveness of the A-V impulse hand pump

Acute swelling of the hand is a common problem after trauma or surgery and is associated with both pain and loss of function. We describe a prospective study of 47 patients in which we assessed the effects of a pneumatic compression device (A-V impulse hand pump) on the swollen hand. The pump reduced swelling by increasing the velocity of venous return as demonstrated by Duplex scanning of the median cubital vein. Continuous use of the pump for 48 hours gave a reduction of 78.6% in swelling of the injured hand compared with the opposite, uninjured side. Even when used intermittently, with the pump on for 12 hours out of 24, a statistically significant effect was seen. There was a subjective reduction in pain and an objective improvement in function of the hand. Use of the pump resulted in a nearly normal hand by the time of discharge from hospital after, on average, 48 hours.     

Suicide in the course of the treatment of depression

Five different mechanisms have been proposed whereby antidepressant treatment might lead to suicide: first by simply ameliorating depressions more rapidly; second by an action intrinsic to the specific antidepressant effects; third by toxicity in overdose; fourth by side-effects of specific antidepressants; and finally by virtue of treatment inefficacy. Evidence from randomized control trials (RCT), controlled case studies and epidemiological studies on this question is reviewed and it is concluded that antidepressants can be implicated in some cases of suicide during treatment. Modifications of clinical trial methods and pharmacogenetic studies would yield a richer data set to explore this issue further.     

The effects of sub-anaesthetic doses of ketamine on memory, cognitive performance and subjective experience in healthy volunteers

The cognitive and subjective effects of sub-anaesthetic doses of ketamine on healthy volunteers were examined. Twelve healthy volunteers received 25 mg ketamine, 10 mg ketamine and saline placebo, i.m. in a double-blind, Latin square design. A cognitive, perceptual and self-report test battery was administered over 45 min. The order of tests was rotated to control for timing effects. Ketamine (25 mg) significantly affected verbal learning and memory, parallel visual search, some measures of psychomotor performance, measures of arousal, subjective mood ratings and visual perception. Measures of attention and frontal lobe functioning were relatively unaffected. Thus, low doses of ketamine had selective, dose-related effects on memory, perceptual and psychomotor functions. The disruption of memory and perceptual processes may help to explain the unique subjective state induced by ketamine.     

Another look at the costs and benefits of government expenditures for family planning programs

"The Costs and Benefits of Government Expenditures for Family Planning Programs" by Mary Chamie and Stanley K. Henshaw in an earlier issue of "Family Planning Perspectives" is discussed. Several flaws in the Chamie-Henshaw analysis are pointed out; and some aspects of research on which their analysis was based are re-examined. Chamie and Henshaw used the terms "cost-benefit ratio," "cost-benefit equation," and "cost-benefit formula." These calculations should have been called a "taxpayer cost-effectiveness analysis." Points are raised regarding how welfare savings resulting from family planning services were estimated. The teenage income information is weak. The lower birth rates of teenage family planning patients reported in "The Impact of Family Planning Clinic Programs on Adolescent Pregnancy," in the same journal issue by a group of researchers headed by Jacqueline Darroch Forrest provided another important basis for estimation in the Chamie-Henshaw analysis. Hence, any inadequacies in the data generated by Forrest would weaken the reliability of the Chamie-Henshaw findings. Forrest and her coauthors estimated the impact of family planning programs on birth rates in 5 separate multiple regression models. The first 2 were cross-sectional analyses of 1970 and 1975-1976 data. The 3rd regression equation, a lagged dependent-variable model, measures the impact of family planning on birth rates in 1976 after the factors that may have produced high birth rates in certain areas had been taken into account. A 4th model relates the change in birth rates between 1970 and 1976 to the change in program enrollment by area. A 5th equation is the unobserved-variable model, an alternate and unconventional approach to measuring the impact of family planning program on birth rates.     

Use of artificial neural networks in evaluating prognostic factors determining the response to dendritic cells pulsed with PSMA peptides in prostate cancer patients

BACKGROUND: Our purpose was to compare the importance of over 22 measurements used in evaluating the clinical responses of patients with metastatic or locally recurrent prostate cancer, treated by dendritic cell (DC) infusions with prostate-specific membrane antigen (PSMA) peptides. METHODS: Artificial neural networks (ANNs) were employed for assessment, as well as the traditional methods of logistic regression. RESULTS: Twenty-six patients with metastatic disease and 37 patients with local recurrence were available for evaluation and comparison. ANN evaluation ranked the collective effects of DC infusion, immune responses (CD3+ cells, CD16+ cells, zeta chain+ cells), and cytokines, e.g., IL-6 and PSMA levels, very highly. Logistic regression identified all of these parameters to some degree, but in a different rank order. Patients with metastases showed a sharp rate of response secondary to the level of DC infusion, in contrast to those patients with local recurrence, in which it was more gradual. CONCLUSIONS: ANN analysis emphasizes the importance of level of DC infusion, immune parameters, cytokines, and markers such as PSMA in determining the response to PSMA peptide immunotherapy. The criteria of response were judged to be correct in 86% of metastatic patients and 83% of locally recurrent patients evaluated in this study.     

Infants born to narcotic dependent mothers: Physical growth patterns in the first 12 months of life

Objectives: To describe the physical growth patterns of infants born to narcotic dependent mothers (INDM) over a 12 months period and, if possible, to relate the growth to drug taking patterns during pregnancy.
Methodology: The growth of a cohort of 43 INDM was measured during the first 12 months of life. Weight and length measurements were compared with percentile charts and converted to Z scores. Questionnaire data about drug taking practices, demographic variables and the neonatal period (including withdrawal scores) were obtained.
Results: Twenty-four (55.8%) of INDM had evidence of neonatal drug withdrawal requiring treatment with phenobarbitone. At birth, Z scores for weight and length indicated relative intrauterine growth retardation. By 12 months, there had been some catch up growth, but Z scores for weight and length were still below zero. Persistent weight retardation at 12 months was correlated with methadone dosage during pregnancy, but not the need for phenobarbitone therapy.
Conclusions: The growth patterns of INDM in the first 12 months of life indicated that at birth there was evidence of intrauterine growth retardation, but by 12 months the growth was little different from the rest of the community. There appears to be some influence of narcotic agents taken while pregnant on subsequent growth of INDM.