Measuring the quality of depression care in a large integrated health system

BACKGROUND: Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement. OBJECTIVES: To assess the adequacy of depression care in the Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records, and to identify patient and provider characteristics associated with adequate depression care. RESEARCH DESIGN: This is a cohort study of patients from 14 VHA hospitals in the Northeastern United States which relied on existing databases. Subject eligibility criteria: at least one depression diagnosis during 1999, neither schizophrenia nor bipolar disease, and at least one antidepressant prescribed in the VHA during the period of depression care profiling (June 1, 1999 through August 31, 1999). Depression care was evaluated with process measures defined from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used multivariable regression to identify patient and provider characteristics predicting adequate care. SUBJECTS: There were 12,678 patients eligible for depression care profiling. RESULTS: Adequate dosage was identified in 90%; 45% of patients had adequate duration of antidepressants. Significant patient and provider characteristics predicting inadequate depression care were younger age (<65), black race, and treatment exclusively in primary care. CONCLUSIONS: Under-treatment of depression exists in the VHA, despite considerable mental health access and generous pharmacy benefits. Certain patient populations may be at higher risk for inadequate depression care. More work is needed to align current practice with best-practice guidelines and to identify optimal ways of using available data sources to monitor depression care quality.     

Translating probiotic science into practice

Scientific and clinical evidence on the health effects of probiotics has expanded rapidly in recent years and points towards benefits for a number of specific health conditions, particularly those related to the gut. Healthcare professionals are important conduits in the transfer of evidence‐based messages on probiotics, but research indicates many do not consider themselves to have good knowledge in this area. To identify potential solutions to support healthcare professionals, the British Nutrition Foundation held a one‐day roundtable event on 7 February 2019 to gather expert views on the content of, and best delivery mode for, evidence‐based resources to guide healthcare professional advice about the use of probiotics. This report describes the main themes emerging from the discussions and the group's recommendation for the development of a UK‐focused online toolkit for healthcare professionals, which assimilates, appraises and translates current scientific knowledge of probiotics to promote evidence‐based practice for the benefit of patients.     

A longitudinal study of the association between tooth loss and age-related hearing loss

The purpose of this study was to investigate cross-sectional and longitudinal associations between hearing acuity and tooth loss in 1156 US veterans taking part in the Veterans Affairs' Normative Aging (NAS) and Dental Longitudinal (DLS) Studies in the Boston, MA, area. The mean age was 48 years (SD = 8.9), 5.3% were edentulous, and 15.4% had < 17 teeth at baseline. Hearing acuity was determined by puretone, air- and bone-conduction audiometry, and speech discrimination tests at triennial examinations over a 20-year follow-up period. Hearing decline was defined as a change from baseline in the average puretone air-conduction thresholds of ≥ 20 dB at 0.25, 0.5, 1, 2, 3, 4, 6, and 8 kHz. The explanatory variables of interest were change since baseline in dentate status (cut points at < 1, < 17, and < 20 teeth), and in the number of teeth lost (linear). Linear and logistic regression models—which controlled for baseline audiological status, age, air-bone gap, and otoscopic examination at current visit—showed that subjects who went from having ≥ 17 to < 17 teeth had 1.64 times (95% CI, 1.24-2.17) as high odds of having hearing decline as those with no change in their dentate status. For every tooth lost since baseline, there was a 1.04 times as high odds (95% CI, 1.02-1.06) for hearing decline, when additional baseline and time-varying covariates were taken into account in the model.     

Postoperative radiation therapy for major salivary gland malignancies

Between 1966 and 1982 there have been 46 patients treated with surgery plus post-operative radiation therapy for malignant tumors of salivary gland origin. The indication(s) for radiotherapy included positive margins (42%), advanced local tumor (37%), positive nodes (33%), or high grade histology (48%). Overall actuarial local control at 5 years was 73%, being 100% for T1, 83% for T2, 80% for T3, and 43% for T4. Actuarial survival at 5 years was 80% for T1, 83% for T2, 60% for T3, and 48% for T4. Patients with positive nodes (N+) did worse than those with negative nodes (No), with locoregional control and survival at 5 years being 58% vs. 83%, (P = 0.025) and 38% vs. 80% (P = less than .01), respectively. We found no need for contralateral neck treatment even for those with positive nodes. Also, to date, none of eight patients with adenoid cystic histology has failed locally, as opposed to three of eight failures in patients treated with surgery alone. We believe that post-operative irradiation provides excellent locoregional control for appropriate patients with malignant tumors of major salivary glands.     

Die Einwirkung von Pilocarpin,Atropin und Pepton auf Blut und Lymphe

Ohne Zusammenfassung     

Corridor surgery: the current paradigm for skull base surgery

Introduction Clival chordomas are rare tumors, especially in the pediatric population. In this report, we present the case of a 3-year-old boy who was found to have a large posterior pharyngeal, clival, and posterior fossa tumor detected on a CT scan after a closed head injury. Discussion Further questioning revealed a history of ataxia and dysphagia. Imaging confirmed severe extrinsic brain stem compression. The tumor was resected in multiple stages utilizing a minimally invasive endoscopic endonasal technique along with open transfacetal, transcondylar approach through the carotid–vertebral window. The child suffered no permanent complications as a result of our treatment and his dysphagia significantly improved. Although a complete resection was not feasible due to vascular encasement by the tumor, extensive decompression was obtained with minimal morbidity. Conclusion We present this case to illustrate a new paradigm of skull base surgical approaches for large clival lesions in pediatric patients that allows aggressive resection with minimal morbidity.     

Long-Term Effects of Second-Generation Cholinesterase Inhibitors on Clinical Outcomes and Costs of Alzheimer’s Disease

Alzheimer’s disease, which is a common disorder among the elderly, not only has devastating health consequences, but also poses a substantial economic burden. Three second-generation cholinesterase inhibitors —donepezil, galantamine and rivastigmine — represent the best available treatment for patients with mild-to-moderate stages of the disease. While these drugs have been effective in short-term clinical trials, it is necessary to understand the outcomes over the longer term in order to assess the appropriateness of these treatments.Data on the effectiveness of these drugs from information beyond the short-term clinical trials (e.g. long-term clinical trials and non-trial data) are now emerging. In most cases, the results indicate that, at least for some patients, continued treatment with cholinesterase inhibitors is effective in slowing cognitive decline. Whether these results translate to clinically and economically relevant outcomes is less clear. The AD2000 trial in particular, a 1-year, placebo-controlled trial, seems to suggest that cognitive benefits, even if maintained over the mid-to-long term, may not adequately reflect overall deterioration in patients. Naturalistic studies, as well as analyses of administrative data, however, mostly suggest that these benefits are real and relevant.The cost effectiveness of treatment has been evaluated primarily through modeling. These studies have shown that the costs of treatment can be offset by savings in other areas as a result of slowed disease progression. When all medical costs are considered, relatively small delays in disease progression are required to offset treatment costs, but a large portion of these offsetting savings are a result of delayed institutionalization. To payors not responsible for institutional care costs, these predicted economic advantages are less relevant. While data are limited, some research indicates that reductions in other costs may be sufficiently large to fully offset the costs of treatment.Economic comparisons among active treatments have only been made in one study so far. Based on meta-analyses of trial data and a model estimating disease progression, that study concluded that galantamine provided the best health and economic projections. Head-to-head studies, however, are limited and provide conflicting results.While the treatment of patients with Alzheimer’s disease using cholinesterase inhibitors will likely continue to increase, there is no definitive answer regarding the appropriateness of long-term treatment. A reasonably complete answer will likely not be available until more long-term data from actual practice become available.     

Treatment of orbital capillary haemangioma with interferon

Background: Capillary haemangiomas are vascular tumours of childhood characterised by proliferative and involutional phases and affecting 1% to 2% of newborns. Recently, recombinant interferons have been used in the treatment of life and sight threatening complications of these tumours. Methods: The history, results of examination, investigations, management and outcome of two patients with sight-threatening orbital capillary haemangiomas treated with recombinant interferon alpha-2a and 2b respectively were reviewed. Results: Orbital and systemic lesions displayed good response to interferons. Side effects noted were transient pyrexia and elevated serum aminotransferase levels. Disturbed liver function test results occurred in one case and normalised with temporary cessation of therapy. Conclusions: The interferons are a useful alternative treatment of orbital capillary haemangioma in selected cases.     

Activation and coordination patterns of the suprahyoid muscles during swallowing

This study was undertaken to determine the activation and coordination patterns of the three suprahyoid muscles—geniohyoid, mylohyoid, and anterior belly of the digastric muscle—in elevating the larynx during swallowing. Electromyographic activity was also recorded from two intrinsic laryngeal muscles (vocalis and lateral cricoarytenoid) and the anterior genioglossus. Ten adults served as participants. Each participant produced 15 swallows of 15 mL of tap water both normally and with a 12-mm bite block placed between the molars. The electromyographic data were ensemble-averaged with a laboratory computer. Analyses showed that the three suprahyoid muscles were used selectively by different participants. Some participants used all three muscles for hyoid elevation, while others used different pairs of two of the muscles. The activation patterns of the suprahyoid muscles during swallowing also varied with respect to each other and the onset of the laryngeal constrictor muscles; however, use of at least one suprahyoid muscle always preceded the onset of the laryngeal adductors, indicating that larynx elevation consistently preceded glottal adduction. The way in which the muscles responded to the bite block varied considerably both within and among participants. Some maintained temporal stability but increased overall muscle activity; others reorganized temporal relations either with or without corresponding muscle activity adjustments. These findings suggest that the laryngeal elevation system is an adaptive function rather than an immutable action.