A Prospective Analysis of the Effect of Blue-Dye Volume on Sentinel Lymph Node Mapping Success and Incidence of Allergic Reaction in Patients With Breast Cancer

Background This study examined whether the volume of isosulfan blue dye used in sentinel lymph node (SLN) mapping in breast cancer is related to the SLN identification rate or to the incidence of allergic reactions.Methods From January 2001 to November 2002, 1728 breast cancer patients underwent 1832 SLN mapping procedures with the combined technique of intraparenchymal blue dye and intradermal radioisotope. Details of each procedure and all allergic reactions were prospectively recorded. Bilateral synchronous SLN procedures were considered as one dye exposure but as two distinct procedures for determining mapping success. Dye-only success was defined as the proportion of cases in which the SLN was identified by blue dye alone. Overall dye success was defined as the proportion of cases in which the SLN was identified by blue dye with or without isotope.Results When stratified by volume of blue dye, there were no significant differences in dye-only successes, overall dye successes, or mapping failures. Allergic reactions were documented in 31 (1.8%) of 1728 patients. Hypotensive reactions occurred in 3 (.2%) of 1728 patients; 2 (.1%) required pressor support. There was a nonsignificant trend toward fewer allergic reactions with smaller volumes of blue dye.Conclusions In combined-technique SLN mapping protocols for breast cancer, using smaller volumes of blue dye may represent a means of optimizing the safety of the procedure without compromising its success.     

An open-label trial of quetiapine for antipsychotic-induced sexual dysfunction

This study evaluated the effect of switching outpatients with schizophrenia and antipsychotic-induced sexual dysfunction to open-label quetiapine treatment. Secondary objectives were to compare the antipsychotic and prolactin-related effects of quetiapine versus prestudy antipsychotic treatment. Eight patients with at least moderately severe antipsychotic-induced sexual dysfunction (N = 7 taking risperidone, 4-6 mg/d; N = 1 taking haloperidol, 10 mg/d) were evaluated prospectively after they switched to 6 weeks of quetiapine treatment. The assessments that we used included evaluations of sexual functioning (Arizona Sexual Experience Scale [ASEX]; McGahuey et al., 2000), psychopathology (Positive and Negative Syndrome Scale [PANSS]; Kay, Fiszbeinm, & Opler, 1997), adverse events, and plasma prolactin levels. Quetiapine was associated with clinically and statistically significant improvement in ASEX total scores (p = 0.008) and significantly decreased PANSS total scores (p = 0.03). Plasma prolactin levels tended to decrease after the transition to quetiapine (p = 0.09). Quetiapine appears to offer an option to reduce antipsychotic-induced sexual dysfunction for outpatients with schizophrenia.     

Preference assessment procedures for individuals with developmental disabilities

Significant advancements have been made in the development of procedures to systematically identify preferred stimuli that may function as reinforcers for persons with developmental disabilities. Indirect assessment procedures include care provider and client interviews, whereas direct assessment procedures involve systematically exposing participants to stimuli while recording their responses. These types of direct assessment procedures can be categorized as either approach-based or engagement-based. Approach-based procedures involve recording the individuals' approach responses to stimuli presented singly or concurrently with other stimuli, whereas engagement-based procedures involve recording duration of engagement with stimuli. Although the predictive validity of indirect preference assessment procedures has yet to be established, using them in combination with direct measures of preference may be most efficacious for identifying potential reinforcers. Recent research on preference assessment procedures used with persons with developmental disabilities is reviewed and the variables that one might consider prior to selecting which procedure to use in a given situation are discussed.     

The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2003 update

BACKGROUND: The Texas Medication Algorithm Project (TMAP) has been a public-academic collaboration in which guidelines for medication treatment of schizophrenia, bipolar disorder, and major depressive disorder were used in selected public outpatient clinics in Texas. Subsequently, these algorithms were implemented throughout Texas and are being used in other states. Guidelines require updating when significant new evidence emerges; the antipsychotic algorithm for schizophrenia was last updated in 1999. This article reports the recommendations developed in 2002 and 2003 by a group of experts, clinicians, and administrators. METHOD: A conference in January 2002 began the update process. Before the conference, experts in the pharmacologic treatment of schizophrenia, clinicians, and administrators reviewed literature topics and prepared presentations. Topics included ziprasidone's inclusion in the algorithm, the number of antipsychotics tried before clozapine, and the role of first generation antipsychotics. Data were rated according to Agency for Healthcare Research and Quality criteria. After discussing the presentations, conference attendees arrived at consensus recommendations. Consideration of aripiprazole's inclusion was subsequently handled by electronic communications. RESULTS: The antipsychotic algorithm for schizophrenia was updated to include ziprasidone and aripiprazole among the first-line agents. Relative to the prior algorithm, the number of stages before clozapine was reduced. First generation antipsychotics were included but not as first-line choices. For patients refusing or not responding to clozapine and clozapine augmentation, preference was given to trying monotherapy with another antipsychotic before resorting to antipsychotic combinations. CONCLUSION: Consensus on algorithm revisions was achieved, but only further well-controlled research will answer many key questions about sequence and type of medication treatments of schizophrenia.     

Development of a computerized assessment of clinician adherence to a treatment guideline for patients with bipolar disorder

The adoption of treatment guidelines for complex psychiatric illness is increasing. Treatment decisions in psychiatry depend on a number of variables, including severity of symptoms, past treatment history, patient preferences, medication tolerability, and clinical response. While patient outcomes may be improved by the use of treatment guidelines, there is no agreed upon standard by which to assess the degree to which clinician behavior corresponds to those recommendations. This report presents a method to assess clinician adherence to the complex multidimensional treatment guideline for bipolar disorder utilized in the Texas Medication Algorithm Project. The steps involved in the development of this system are presented, including the reliance on standardized documentation, defining core variables of interest, selecting criteria for operationalization of those variables, and computerization of the assessment of adherence. The computerized assessment represents an improvement over other assessment methods, which have relied on laborious and costly chart reviews to extract clinical information and to analyze provider behavior. However, it is limited by the specificity of decisions that guided the adherence scoring process. Preliminary findings using this system with 2035 clinical visits conducted for the bipolar disorder module of TMAP Phase 3 are presented. These data indicate that this system of guideline adherence monitoring is feasible.     

Occurrence of Epstein-Barr virus illness in children diagnosed with group A streptococcal pharyngitis

Epstein-Barr virus mononucleosis and group A streptococcal pharyngitis are acute infectious processes similar in both their clinical manifestations. Coinfections may occur and be a direct result of a synergistic effect on inflamed pharyngeal and tonsillar tissue. It was our observation that a population of children diagnosed with group A streptococcal pharyngitis and not responding to appropriate antimicrobial therapy had Epstein-Barr virus illness.