Utilization of acute inpatient psychiatric services: “Heavy users” in New York State

The severely and persistently mentally ill (SPMI) population are often forced to rely on emergency/acute inpatient services. The authors analyze Medicaid expenditures and state hospital utilization data to identify and describe the characteristics of heavy users of these services. Also described is New York State's intensive case management (ICM) initiative targeted at this heavy user group. It is postulated that ICM will alter the utilization patterns of participants from over-reliance on the most costly services and more effectively and efficiently serve the SPMI population, specifically the heavy user subpopulation.     

The impact of the “cisplatin era” of treatment on survival in testicular cancer

Summary The records of all testicular cancer patients evaluated and treated at our medical center during two consecutive 9-year periods were reviewed and analyzed for prognostic factors, particularly the impact of cisplatin-based combination chemotherapy. The data base of 244 patients was divided into two eras: 1970–1978, defined as the pre-cisplatin era (n=101) and 1979–1987, the cisplatin era (n=143). Statistically improved survival (P=0.024) was noted for the 165 nonseminoma patients and for a grouping of 143 patients treated with combination chemotherapy (P=0.004) during the cisplatin era. Stratification by stage revealed that stage II patients had the most significant survival advantage (P=0.001) during the cisplatin era; cancer mortality improved from 48% to 9%. Cancer death rates for stage III patients decreased from 58% to 39% which is clinically but not statistically significant (P=0.497). Stage I patients and the seminoma population did well during both eras, and the impact of cisplatin could not be statistically confirmed in this study for these subgroups. Multivariate statistical analysis confirmed the importance of the era of treatment for the nonseminoma population.     

Metabolism of desflurane and isoflurane to fluoride ion in surgical patients

The metabolism of isoflurane and the investigational volatile anaesthetic desflurane to fluoride ion was examined in 25 surgical patients. The patients were randomly assigned to four groups, to receive isoflurane or desflurane at either 0.65 MAC or 1.25 MAC. Anaesthesia was induced in all patients with thiopentone and midazolam and included nitrous oxide 60% in addition to the volatile agent. Blood was drawn before induction and at the end of the operation for determination of serum fluoride ion concentration. Plasma fluoride ion concentrations increased (+ 1.36 +/- 0.93 microM, P less than 0.01) in patients receiving isoflurane but were unchanged (-0.13 +/- 0.50 microM) in patients receiving desflurane. Metabolic release of fluoride ion is less with desflurane than with isoflurane during administration of the anaesthetics to surgical patients, and is unlikely to be of clinical significance.     

A comparison of the myocardial metabolic and haemodynamic changes produced by propofol-sufentanil and enflurane-sufentanil anaesthesia for patients having coronary artery bypass graft surgery

The purpose of this study was to compare propofol-sufentanil with enflurane-sufentanil anaesthesia for patients undergoing elective coronary artery bypass graft (CABG) surgery with respect to changes in (1) haemodynamic variables; (2) myocardial blood flow and metabolism; (3) serum cortisol, triglyceride, lipoprotein concentrations and liver function; and (4) recovery characteristics. Forty-seven patients with preserved ventricular function (ejection fraction greater than 40%, left ventricular end diastolic pressure less than or equal to 16 mmHg) were studied. Patients in Group A (n = 24) received sufentanil 0.2 microgram.kg-1 and propofol 1-2 mg.kg-1 for induction of anaesthesia which was maintained with a variable rate propofol (50-200 micrograms.kg-1.min-1) infusion and supplemental sufentanil (maximum total 5 micrograms.kg-1). Patients in Group B (n = 23) received sufentanil 5 micrograms.kg-1 for induction of anaesthesia which was maintained with enflurane and supplemental sufentanil (maximum total 7 micrograms.kg-1). Haemodynamic and myocardial metabolic profiles were determined at the awake-sedated, post-induction, post-intubation, first skin incision, post-sternotomy, and pre-cardiopulmonary bypass intervals. Induction of anaesthesia produced a larger reduction in systolic blood pressure in Group A (156 +/- 22 to 104 +/- 20 mmHg vs 152 +/- 26 to 124 +/- 24 mmHg; P less than 0.05). No statistical differences were detected at any other time or in any other variable including myocardial lactate production (n = 13 events in each group), time to tracheal extubation and time to discharge from the ICU. We concluded that, apart from hypotension on induction of anaesthesia, propofol-sufentanil anaesthesia produced anaesthetic conditions equivalent to enflurane-sufentanil anaesthesia for CABG surgery.     

Anaesthetic management of acute blunt thoracic trauma

Sunnybrook Health Science Centre is an adult regional trauma unit serving metropolitan Toronto and environs. We undertook a nvo-year retrospective review of patients admitted to our institution with blunt thoracic trauma. Three hundred and thirty-three patients with blunt trauma and an injury severity score (ISS) greater than 17 required emergency surgery. Of these, 208 had blunt thoracic injuries while 125 did not have chest injuries. Both groups were similar with respect to age but patients with thoracic trauma had a greater ISS. (P < 0.05) and greater intraoperative mortality (P < 0.01). The aetiology of the intraoperative deaths with one exception was exsanguination. Emergency thoracotomy or sternotomy indicated a poor prognosis with a mortality rate of 80%. The most common intraoperative problem was an elevated airway pressure. Awake intubation was undertaken in 77.5% of patients requiring anaesthesia and surgery because of the potentially compromised airways and difficult intubations due to the nature of the associated injuries. Finally, 74% of patients undergoing urgent surgery required mechanical postoperative ventilation. The presence of blunt chest trauma should be considered a marker of the severity of injury sustained by the patient.     

Sexual orientation and cognitive abilities

We asked whether homosexual and heterosexual men and women differ on standard measures of cognitive ability. Subjects were adults recruited for a family study of sexual orientation. They completed the Fy Scale of the California Psychological Inventory, a self-administered measure of psychological femininity, and were given subtests of the Wechsler Adult Intelligence Scale and the Primary Mental Abilities test which had been previously shown to discriminate between the sexes. We predicted that homosexual subjects would score significantly in the gender-atypical direction on the Fy scale. We also predicted that they would achieve scores on the tests of cognitive abilities significantly in the direction of the other gender. Comparisons were made between homosexual and heterosexual individuals within gender. Also, comparisons were made between heterosexual men and women to see if our results replicate differences typically found between the genders. As predicted, both homosexual men and women were strongly gender-atypical on the Fy scale relative to their heterosexual counterparts. However, neither differed from heterosexuals on any of the measures of cognitive abilities. Heterosexual men did better than women on the Primary Mental Abilities spatial relations test. We conclude that sexual orientation is not related to specific cognitive abilities.Supported in part by NIMH grant 32,170 to Dr. Pillard.     

Laparoscopic-assisted right hemicolectomy

A laparoscopic technique to assist in the performance of right hemicolectomy is described.     

The use of 111in-labeled lymphocyte imaging to evaluate graft rejection following cardiac transplantation in dogs

Lymphocytes separated from venous blood from six dogs who had heterotopic cardiac transplants have been labeled using ¹¹¹In-oxine. Labeled lymphocytes were reinjected into the dogs and imaging of the heart carried out over the successive 3 or 4 days. For comparison serial ECGs and punch biopsies of the heart were obtained. Abnormal uptake of labeled lymphocytes in the donor heart was clearly visible in three of the six dogs, faintly visible in two and not seen in one. 630 Ci ¹¹¹In was used in the dog where no uptake was seen and subsequent studies showed this amount of the radiopharmaceutical was toxic to lymphocytes. In the remaining five dogs the mean ratio of uptake of ¹¹¹In in donor to recipient heart was 14:1 (range 6.5:1–21:1). The lack of substantial uptake in the transplanted heart of two dogs is attributed to a delay in rejection relative to the time the labeled lymphocytes were injected. The results suggest that ¹¹¹In-labeled lymphocytes have potential as a noninvasive test for detecting rejection of cardiac transplants.J. McKillop is a Harkness Fellow of the Commonwealth FundJ. Wallwork is supported by National Heart Research Fund (UK)     

Pre-natal factors in the origin of germ cell tumours of childhood

The Manchester (England) Children's Tumour Registry is population-basedwith a high level of ascertainment. Pathologic review ensureddiagnostic accuracy. Routine monitoring of annual incidencerevealed a significant increase in germ cell tumours from 1per million person years to 4. Analysis of the children's caserecords and their mothers' obstetric records showed an associationbetween germ cell tumours and congenital malformations, particularlyof the central nervous system, in the children themselves andin their stillborn sibs. An association between infections inpregnancy and early onset of tumours in the offspring was demonstrated.Other factors such as chronic illness in the mothers and drug-takingduring pregnancy may be important, but further work is requiredto establish any definite associations.