Initial steps taken by nine primary care practices to implement alcohol screening guidelines with hypertensive patients: the AA-TRIP project.

Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and discussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis in the United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages a day. The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol problems in primary care patients with hypertension. Medical providers are being trained using the Practice Partner Research Network's- Translating Research into Practice (PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical records, on-site academic detailing, practice feedback reports and annual network meetings) to help practices increase adherence to clinical guidelines. Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation of alcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all influenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were also relevant barriers requiring problem solving.     

Mediation as a new technique for resolving disputes in the mental health system

In the mental health service system, disputes take on various forms and exist in both clinical practice and management. Existing policy and administrative practice has favored a combination of medical and judicial/legal models to handle conflicts among consumers, mental health professionals, and others. The authors propose the addition of mediation as a third form of resolving issues, explicate some of the differences between mediation and current methods of resolving conflicts, and suggest benefits of using mediation.Noel Mazade is Executive Director, National Association of State Mental Health Program Directors Research Institute and a practicing mediator. Andrea Blanch is Director of Community Support Programs for the New York Office of Mental Health in Albany, NY.The views presented in this article are those of the authors only. Endorsement by the authors' organizational affiliations is not implied nor should it be inferred.     

Effect of climacteric transition and hormone replacement therapy on body weight and body fat distribution.

In the present study we evaluated the effects of climacteric modifications on body weight and fat distribution. From women attending a menopause clinic we selected 2175 untreated, normal healthy women who were divided into three groups: premenopausal (n = 540), perimenopausal (n = 750) and postmenopausal (n = 885), and compared them with 354 postmenopausal women receiving different forms of hormone replacement therapy (HRT). The total body fat tissue mass and distribution were analyzed using dual-energy X-ray absorptiometry. Body weight and body mass index (BMI) were significantly higher in perimenopausal and postmenopausal than in premenopausal women. Mean total body fat and fat as a percentage of soft tissue were significantly (p < 0.05) higher in the perimenopausal and postmenopausal groups than in the premenopausal group. Fat tissue and regional fat tissue as a percentage of total fat tissue were higher in the trunk (p < 0.0001) and arms (p < 0.0001) in perimenopausal and postmenopausal than in premenopausal women. In postmenopausal women, leg fat tissue was significantly (p < 0.05) lower than in premenopausal and perimenopausal groups. Total body and leg lean tissue were significantly lower (p < 0.05) in postmenopausal than in premenopausal and perimenopausal women. In age-matched women with similar BMI, total body fat as a percentage of soft tissue was significantly (p < 0.001) higher in the perimenopausal and postmenopausal groups than in the premenopausal group. As for body fat distribution, fat as a percentage of total fat tissue was significantly higher in the trunk (p < 0.0001) region in perimenopausal and postmenopausal women compared with the premenopausal group. In the legs, fat as a percentage of total fat tissue was significantly higher (p < 0.05) in the premenopausal than in the postmenopausal group. In the arms a slight but not significant (p < 0.18) difference was shown in fat distribution between the three untreated groups. In age-matched HRT-treated postmenopausal women, the fat tissue was similar to that in the premenopausal group. The present results confirm that endocrine changes during the menopausal transition, rather than the aging process, are related to changes in body weight and fat distribution. Perimenopausal and postmenopausal women show a shift to a central, android fat distribution that can be counteracted by HRT.     

Monitoring of Neuromuscular Blockade at the P6 Acupuncture Point Reduces the Incidence of Postoperative Nausea and Vomiting

Background: Electrical stimulation of the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting (PONV). Neuromuscular blockade during general anesthesia can be monitored with electrical peripheral nerve stimulation at the wrist. The authors tested the effect of neuromuscular monitoring over the P6 acupuncture point on the reduction of PONV.

Methods: In this prospective, double-blinded, randomized control trial, the authors investigated, with institutional review board approval and informed consent, 220 women undergoing elective laparoscopic surgery anesthetized with fentanyl, sevoflurane, and rocuronium. During anesthesia, neuromuscular blockade was monitored by a conventional nerve stimulator at a frequency of 1 Hz over the ulnar nerve (n = 110, control group) or over the median nerve (n = 110, P6 group) stimulating at the P6 acupuncture point at the same time. The authors evaluated the incidence of nausea and vomiting during the first 24 h.

Results: No differences in demographic and morphometric data were found between both groups. The 24-h incidence of PONV was 45% in the P6 acupuncture group versus 61% in the control group (P = 0.022). Nausea decreased from 56% in the control group to 40% in the P6 group (P = 0.022), but emesis decreased only from 28% to 23% (P = 0.439). Nausea decreased substantially during the first 6 h of the observation period (P = 0.009). Fewer subjects in the acupuncture group required ondansetron as rescue therapy (27% vs. 39%; P = 0.086).     

Free anterolateral thigh flap versus free forearm flap: Functional results in oral reconstruction.

Nowadays, microsurgery performed for oral reconstruction of cancer patients, has become the standard treatment in restoring oral functions. The free radial forearm flap (FRFF) is still apparently the first reconstructive choice in oral cavity cancers. Recently the anterolateral thigh flap (ALTF) seemed to challenge the superiority of FRFF. The lack of functional data on which to base this recent supposition is the reason for this new research. Twenty reconstructed patients were enrolled for this study. Speech, swallowing, and donor site complications were studied to assess differences between the two techniques. Results show that difference in function between ALTF and FRFF groups is statistically insignificant. Donor site risks and complications seem to be the only variables among groups. These variables may be used as indicators when making a surgical choice.     

Dosimetric Characteristics of the Siemens IGRT Carbon Fiber Tabletop

In this work, the dosimetric characteristics of a new commercial carbon fiber treatment table are investigated. The photon beam attenuation properties of the Siemens image-guided radiation therapy (IGRT) tabletop were studied in detail. Two sets of dosimetric measurements were performed. In the first experiment a polystyrene slab phantom was used: the central axis attenuation and the skin-sparing detriment were investigated. In the second experiment, the off-axis treatment table transmission was investigated using a polystyrene cylindrical phantom. Measurements were taken at the isocenter for a 360° rotation of the radiation beam. Our results show that the photon beam attenuation of the Siemens IGRT carbon fiber tabletop varies from a minimum of 2.1% (central axis) to a maximum of 4.6% (120° and 240° beam incidence). The beam entrance dose increases from 82% to 97% of the dose at the depth of maximum for a clinical 6-MV radiation field. The depth of maximum also decreases by 0.4 cm. Despite the wedge cross section of the table the beam attenuation properties of the IGRT tabletop remain constant along the longitudinal direction. American Association of Medical Dosimetrists.     

Portaclamp in video-assisted minimally invasive cardiac surgery: Surgical technique and preliminary clinical experience

Video-assisted minimally invasive cardiac surgery (VAMICS) is currently performed with various indications. However, despite the increasing evidence of its effectiveness, new approaches have to be defined to simplify this procedure, minimize its potential complications and limit its costs, for a wider use in the surgical community. The limited access to the aorta is a key point in VAMICS and mandates specific clamping modalities with their own limitations, costs and drawbacks. The Portaclamp (Cardio Life Research SA, Louvain la Neuve, Belgium), a new autoguided extravascular aortic cross-clamping system, has been recently proposed to facilitate VAMICS. Herein, we describe the Portaclamp approach and report our indications and preliminary clinical experience so to define its role in VAMICS.     

The treatment of idiopathic and secondary hydrarthrosis of the knee by intra-articular Rifamycin SV

Fifty-three patients, 28 females and 25 males, aged from 21 to 68 years, affected with mono- and bilateral intermittent hydrarthrosis of the knee and of a non-inflammatory nature, were included in an open study. All of the knees involved were treated with intra-articular infiltrations with Rifamycin SV. The weekly dosage of Rifamycin SV was 500 mg; the average duration of treatment was 6 weeks. Follow-up 1 year after the end of treatment showed a decrease or regression in joint effusion in all of the knees treated.     

Efficacy of Intraoperative Cooling Methods

Background: Patients may require perioperative cooling for a variety of reasons including treatment of a malignant hyperthermia crisis and induction of therapeutic hypothermia for neurosurgery. The authors compared heat transfer and core cooling rates with five cooling methods.

Methods: Six healthy volunteers were anesthetized with desflurane and nitrous oxide. The cooling methods were 1) circulating water (5 [degree sign] Celsius, full-length mattress and cover), 2) forced air (10 [degree sign] Celsius, full-length cover), 3) gastric lavage (500 ml iced water every 10 min), 4) bladder lavage (300 ml iced Ringer's solution every 10 min), and 5) ice-water immersion. Each method was applied for 40 min or until the volunteers' core temperatures approached 34 [degree sign] Celsius. The volunteers were rewarmed to normothermia between treatments. Core cooling rates were evaluated using linear regression.

Results: The first volunteer developed abdominal cramping and diarrhea after gastric lavage. Consequently, the technique was not again attempted. Bladder lavage increased heat loss 10 [nearly =] 10 W and decreased core temperature 0.8 +/- 0.3 [degree sign] Celsius/h (r2 = 0.99 +/- 0.002; means +/- SD). Forced-air and circulating-water cooling comparably increased heat flux, [nearly =] 170 W. Consequently, core cooling rates were similar during the two treatments at 1.7 +/- 0.5 [degree sign] Celsius/h (r2 = 0.99 +/- 0.001) and 1.6 +/- 1.1 [degree sign] Celsius/h (r2 = 0.98 +/- 0.02), respectively. Immersion in an ice water slurry increased heat loss [nearly =] 600-800 W and decreased core temperature 9.7 +/- 4.4 [degree sign] Celsius/h (r sup 2 = 0.98 +/- 0.01). Immersion cooling was associated with an afterdrop of [nearly =] 2 [degree sign] Celsius.