The failure of physician education as a cost containment strategy. Report of a prospective controlled trial at a university hospital

To test the hypothesis that physician education is an effective strategy to reduce total hospital costs, we evaluated three educational interventions at a large university hospital. This prospective controlled study spanned two academic years and involved 1,663 patients and 226 house staff. In the first year, weekly lectures on cost containment (medicine and surgery) and audit with feedback (medicine only) both failed to produce a significant change in total hospital charges. The "dose" of the intervention was increased on medicine in the second year by combining the lecture and audit strategies. Again, total charges did not change significantly. While decreased use occurred for certain selected services, the impact was not great enough to affect total hospital charges significantly. We conclude that, in the absence of other cost containing incentives, physician education alone is not an effective hospital cost containment strategy.     

Evaluating Differences in Whole Blood,Serum, and Urine Screening Tests for Zika Virus,Puerto Rico,USA, 2016

We evaluated nucleic acid amplification testing (NAAT) for Zika virus on whole-blood specimens compared with NAAT on serum and urine specimens among asymptomatic pregnant women during the 2015–2016 Puerto Rico Zika outbreak. Using NAAT, more infections were detected in serum and urine than in whole blood specimens.     

Muscle belting An alternative operative procedure for posterior fixation suture

In posterior rectus belting, a modification of Cüppers' Fadenoperation (posterior fixation suture), a piece of silicone rubber is placed across the medial recti muscles and fixed to the sclera 12 mm behind the insertion. Performed as the only procedure, posterior belting was shown to be effective in 43 patients with excess esotropia at near fixation when bifocals were insufficient. Subsequent reoperations (should they become necessary) are both easier and quicker to perform than when following the standard posterior fixation suture. Secondary recess or resect surgery can be done while leaving the belts in place. B-mode ultrasonographic examination was used to demonstrate differences in anatomical outcome between the two techniques.     

Pneumococcal vaccine. Efficacy and associated cost savings

We evaluated the efficacy and cost savings of the pneumococcal pneumonia vaccine in a retrospective cohort study of 762 vaccinated and 1161 randomly selected unvaccinated age-sex matched persons in Blue Cross/Blue Shield of Minnesota using medical and pharmaceutical claims. The pneumonia incidence and the ratio of incidence in the postvaccination to prevaccination periods (rate ratio) were examined in the vaccine group by sex and risk factors. Vaccination significantly reduced pneumonia incidence, with overall efficacy of 69% and higher efficacy in women (86%) than in men (33%). We assigned persons to risk categories based on disease conditions as recorded in the claims by the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnostic codes. In the risk categories, efficacy varied from 50% to 75% and was confounded by sex. Immunocompromised and immunocompetent women had high efficacy (83% to 88%), while immunocompetent and immunocompromised men had lower efficacy (33%). Persons with a precondition of pneumonia exhibited similar vaccine efficacy to the overall cohort relative to the comparison group. Projected costs of pneumonia cases are 3.6 times the observed costs of vaccination and postvaccination pneumonia costs. We conclude that the pneumococcal pneumonia vaccine is efficacious in persons having had pneumonia, persons "at risk" of developing pneumonia, or persons over 50 years of age, and it corresponds to overall savings of $141 per person.     

Number and size spectra of non-myelinated axons of human premolars

The aim of this study was to determine the number and size of apical non-myelinated (C) axons of healthy human premolars. The material was derived from a large collection of specimens prepared for a previous quantitative investigation on the myelinated (A) axons of human premolars. A total of 16 teeth (six maxillary first and five each of mandibular first and second premolars), removed from adolescents for orthodontic reasons, were used. Root discs of about 0.6 mm thickness were prepared at about 2 mm cervical to the root apex and processed for light and electron microscopy. The number of non-myelinated axons was determined by taking a total census of such fibres that could be identified and reconstructed by standardized composite electron micrographs from each root disc. The measurement of axons was done on a statistically representative sample of axons (n=1810) using an electronic image processing unit. The 16 teeth had an average of 2000 ± 1023 non-myelinated axons at the juxta-apical level (range 534–3912). The average diameter of the non-myelinated axons was found to be 0.5 ± 0.4 m (range 0.05–2.4 m).     

Optimal Duration and Temperature of Prewarming

Background: Core hypothermia developing immediately after induction of anesthesia results largely from an internal core-to-peripheral redistribution of body heat. Although difficult to treat, redistribution can be prevented by prewarming. The benefits of prewarming may be limited by sweating, thermal discomfort, and efficacy of the warming device. Accordingly, the optimal heater temperature and minimum warming duration likely to substantially reduce redistribution hypothermia were evaluated.

Methods: Sweating, thermal comfort, and extremity heat content were evaluated in seven volunteers. They participated on two study days, each consisting of a 2-h control period followed by 2 h of forced-air warming with the heater set on "medium" ([nearly equal] 40 degrees Celsius) or "high" ([nearly equal] 43 degrees Celsius). Arm and leg tissue heat contents were determined from 19 intramuscular needle thermocouples, ten skin temperatures, and "deep" foot temperature.

Results: Half the volunteers started sweating during the second hour of warming. None of the volunteers felt uncomfortably warm during the first hour of heating, but many subsequently did. With the heater set on "high," arm and leg heat content increased 69 kcal during the first 30 min of warming and 136 kcal during the first hour of warming, representing 38% and 75%, respectively, of the values observed after 2 h of warming. The increase was only slightly less when the heater was set to "medium."     

Expression of the insecticidal bean alpha-amylase inhibitor transgene has minimal detrimental effect on the nutritional value of peas fed to rats at 30% of the diet.

The effect of expression of bean alpha-amylase inhibitor (alpha-AI) transgene on the nutritional value of peas has been evaluated by pair-feeding rats diets containing transgenic or parent peas at 300 and 650 g/kg, respectively, and at 150 g protein/kg diet, supplemented with essential amino acids to target requirements. The results were also compared with the effects of diets containing lactalbumin with or without 0.9 or 2.0 mg bean alpha-AI, levels equivalent to those in transgenic pea diets. When 300 and 650 g peas/kg diet were fed, the daily intake of alpha-AI was 11.5 or 26.3 mg alpha-AI, respectively. At the 300 g/kg level, the nutritional value of the transgenic and parent line peas was not significantly different. The weight gain and tissue weights of rats fed either of the two pea diets were not significantly different from each other or from those of rats given the lactalbumin diet even when this was supplemented with 0.9 g alpha-AI/kg. The digestibilities of protein and dry matter of the pea diets were slightly but significantly lower than those of the lactalbumin diet, probably due to the presence of naturally occurring antinutrients in peas. The nutritional value of diets containing peas at the higher (650 g) inclusion level was less than that of the lactalbumin diet. However, the differences between transgenic and parent pea lines were small, possibly because neither the purified recombinant alpha-AI nor that in transgenic peas inhibited starch digestion in the rat small intestine in vivo to the same extent as did bean alpha-AI. This was the case even though both forms of alpha-AI equally inhibited alpha-amylase in vitro. Thus, this short-term study indicated that transgenic peas expressing bean alpha-AI gene could be used in rat diets at 300 g/kg level without major harmful effects on their growth, metabolism and health, raising the possibility that transgenic peas may also be used at this level in the diet of farm animals.     

Intraoperative assessment of acute hemodynamic changes after partial left ventriculectomy

Partial left ventriculectomy (PLV) has been introduced as an alternative surgical therapy for patients with end-stage dilated cardiomyopathy. The physiological benefits of PLV are relatively unknown. Therefore, the objective of this study was to determine the acute effects of PLV by measuring cardiac function before and after PLV. Aortic and left ventricular pressures and aortic flow were measured in eight patients. Continuous, beat-to-beat data were recorded and compared pre-PLV and post-PLV with and without inferior vena cava (IVC) occlusions. PLV increased cardiac output (0.93+/-0.5, p = 0.01) as a result of increased stroke volume (5.12+/-4.24, p = 0.06) and heart rate (14.5+/-8.44, p = 0.02). Contractility (+/- dP/dt, 240.33+/-74.28, p = 0.001) and external work (650.8+/-320.4, p = 0.01) were also improved. Left ventricular end-diastolic elastance (0.15+/-0.14, p = 0.10) nearly doubled after PLV. Our results indicated an improved cardiac function as measured by increased cardiac output, stroke volume, ejection fraction (EF), and contractility.     

Axonal regeneration in the central nervous system of aplysia californica determined by anterograde transport of biocytin

Rhythmic biting, a component of consummatory feeding behavior in the sea hare Aplysia californica, is eliminated following bilateral cerebral-buccal connective (CBC) crushes and recovers within 14 days postlesion. To assess axonal regeneration after CBC lesions, we used biocytin backfills of CBCs followed by fluorescence labeling with streptavidin-lissamine rhodamine. Anterograde transport of biocytin showed up to 1 mm of outgrowth by regenerating axons at 3 days postlesion. At 7 days postlesion, the regenerated axons approached or had entered the ipsilateral buccal neuropil and exhibited numerous varicosities; the average rate of axonal growth was 326 microm/day for the longest, most rapidly growing axons labeled in the CBC. The number of varicosities on labeled axons, suggestive of intercellular interactions, was increased dramatically at all times postlesion. At 14 and 20 days postlesion, regenerated axons branched extensively in the ipsilateral buccal neuropil, entered the contralateral buccal neuropil, and entered peripheral nerves on both sides of the midline. At these later times postlesion, some labeled axons encircled unlabeled buccal cell bodies and exhibited branches containing numerous varicosities, indicative of axosomatic contacts. Some regenerating axons were observed in the sheath of the CBC, but the vast majority of labeled axons remained confined to the connective core, as in control preparations. The bilateral projections within the buccal ganglia of labeled cerebral-to-buccal axons and the large number of varicosities present on these processes are indicative of regenerating axons and synapses that likely contribute to the functional recovery of rhythmic biting.