Hematological and Biochemical Assessment of Two Species of Freshwater Mussels, Quadrula quadrula and Amblema plicata, Following Translocation.

Nondestructive, sublethal, and sensitive health monitoring tools are needed to assess the health of freshwater mussels (family Unionidae). Recent developments to standardize hemocyte characterization have assisted in the hematologic assessment of wild and captive freshwater mussels. In this study, preliminary baseline hematological reference ranges were established for wild mapleleaf mussels Quadrula quadrula (n = 14) and threeridge mussels Amblema plicata (n = 20) collected from the Muskingum River in Devola, Ohio. Mussels were collected from the wild, and hemolymph was sampled from each mussel in the field upon capture (baseline sample). They were then transported live to a propagation facility. Subsequent hemolymph samples were collected at 2 and 4 weeks and quarterly thereafter for 11 months following translocation. Hemocyte counts, hemocyte morphology, and hemolymph chemistry (Na+ , Cl- , Mg2+ , P3- , K+ , Ca2+ , glucose, alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase]) were measured from each sample on each sampling occasion. Hemocyte counts were consistently greater in Q. quadrula than in A. plicata following transfer to captivity. Baseline hemocyte morphology and hemolymph chemistry varied between species. This study provides a foundation of reference ranges for hemocyte characterization for Q. quadrula, and A. plicata and a preliminary understanding of how hemocyte character might be expected to change when wild mussels are translocated into captivity, and thus be a useful technique for monitoring the health of freshwater mussels.

Human factors for capacity building: lessons learned from the OpenMRS implementers network.

OBJECTIVES: The overall objective of this project was to investigate ways to strengthen the OpenMRS community by (i) developing capacity and implementing a network focusing specifically on the needs of OpenMRS implementers, (ii) strengthening community-driven aspects of OpenMRS and providing a dedicated forum for implementation-specific issues, and; (iii) providing regional support for OpenMRS implementations as well as mentorship and training. METHODS: The methods used included (i) face-to-face networking using meetings and workshops; (ii) online collaboration tools, peer support and mentorship programmes; (iii) capacity and community development programmes, and; (iv) community outreach programmes. RESULTS: The community-driven approach, combined with a few simple interventions, has been a key factor in the growth and success of the OpenMRS Implementers Network. It has contributed to implementations in at least twenty-three different countries using basic online tools; and provided mentorship and peer support through an annual meeting, workshops and an internship program. The OpenMRS Implementers Network has formed collaborations with several other open source networks and is evolving regional OpenMRS Centres of Excellence to provide localized support for OpenMRS development and implementation. These initiatives are increasing the range of functionality and sustainability of open source software in the health domain, resulting in improved adoption and enterprise-readiness. CONCLUSIONS: Social organization and capacity development activities are important in growing a successful community-driven open source software model.

Adiposopathy and bariatric surgery: is 'sick fat' a surgical disease?

OBJECTIVE: To review how bariatric surgery in obese patients may effectively treat adiposopathy (pathogenic adipose tissue or 'sick fat'), and to provide clinicians a rationale as to why bariatric surgery is a potential treatment option for overweight patients with type 2 diabetes, hypertension, and dyslipidaemia. METHODS: A group of clinicians, researchers, and surgeons, all with a background in treating obesity and the adverse metabolic consequences of excessive body fat, reviewed the medical literature regarding the improvement in metabolic disease with bariatric surgery. RESULTS: Bariatric surgery improves metabolic disease through multiple, likely interrelated mechanisms including: (i) initial acute fasting and diminished caloric intake inherent with many gastrointestinal surgical procedures; (ii) favourable alterations in gastrointestinal endocrine and immune responses, especially with bariatric surgeries that reroute nutrient gastrointestinal delivery such as gastric bypass procedures; and (iii) a decrease in adipose tissue mass. Regarding adipose tissue mass, during positive caloric balance, impaired adipogenesis (resulting in limitations in adipocyte number or size) and visceral adiposity are anatomic manifestations of pathogenic adipose tissue (adiposopathy). This may cause adverse adipose tissue endocrine and immune responses that lead to metabolic disease. A decrease in adipocyte size and decrease in visceral adiposity, as often occurs with bariatric surgery, may effectively improve adiposopathy, and thus effectively treat metabolic disease. It is the relationship between bariatric surgery and its effects upon pathogenic adipose tissue that is the focus of this discussion. CONCLUSIONS: In selective obese patients with metabolic disease who are refractory to medical management, adiposopathy is a surgical disease.

Duplex ultrasound assessment of femoral venous flow during laparoscopic and open gastric bypass.

BACKGROUND: Pneumoperitoneum (PP) and the reverse Trendelenburg (RT) position have been shown to decrease femoral blood flow, resulting in venous stasis. However the effects of PP and RT on femoral venous flow have not been evaluated in morbidly obese patients undergoing laparoscopic gastric bypass (GBP). We analyzed the effects of PP and RT on peak systolic velocity and the cross-sectional area of the femoral vein during laparoscopic and open GBP. We further examined the efficacy of intermittent sequential compression devices in reversing the reduction of femoral peak systolic velocity. METHODS: Thirty patients with a body mass index (BMI) of 40-60 were randomly allocated to under go either laparoscopic (n = 14) or open (n = 16) GBP. A duplex ultrasound examination of the femoral vein was performed at baseline, during PP and combined PP and RT in the laparoscopic group, and at baseline and during RT in the open group. The ultrasound exam was performed first without the use of sequential compression devices and then with the sequential compression devices inflated to 45 mmHg. RESULTS: The two groups were similar in age, sex, BMI, and calf and thigh circumferences. During laparoscopic GBP, PP resulted in a 43% decrease in peak systolic velocity and a 52% increase in the cross-sectional area of the femoral vein; the combination of PP and RT decreased peak systolic velocity to 57% of baseline and increased the femoral cross-sectional area to 121% of baseline. During laparoscopic GBP, the use of sequential compression devices during PP and RT partially reversed the reduction of femoral peak systolic velocity, but femoral peak systolic velocity was still lower than baseline by 38%. During open GBP, RT resulted in a 38% reduction in peak systolic velocity and a 69% increase in the cross-sectional area of the femoral vein; the use of sequential compression devices during RT partially reversed these changes by increasing femoral peak systolic velocity by 26%; however, it was still lower than baseline by 22%. CONCLUSIONS: Pneumoperitoneum and reverse Trendelenburg position during laparoscopic and open GBP are independent factors for the development of venous stasis. Combining the reverse Trendelenburg position with pneumoperitoneum during laparoscopic GBP further reduces femoral peak systolic velocity and hence increases venous stasis. The use of sequential compression devices was partially effective in reversing the reduction of femoral peak systolic velocity, but it did not return femoral peak systolic velocity to baseline levels.

Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs.

OBJECTIVE: To compare outcomes, quality of life (QOL), and costs of laparoscopic and open gastric bypass (GBP). SUMMARY BACKGROUND DATA: Laparoscopic GBP has been reported to be a safe and effective approach for the treatment of morbid obesity. The authors performed a prospective randomized trial to compare outcomes, QOL, and costs of laparoscopic GBP with those of open GBP. METHODS: From May 1999 to March 2001, 155 patients with a body mass index (BMI) of 40 to 60 kg/m2 were randomly assigned to undergo laparoscopic (n = 79) or open (n = 76) GBP. The two groups were similar in age, sex ratio, mean BMI, and comorbidities. Main outcome measures included operative time, estimated blood loss, length of hospital stay, operative complications, percentage of excess body weight loss, and time to return to activities of daily living and work. Changes in QOL were assessed using the SF-36 Health Survey and the bariatric analysis of reporting outcome system (BAROS). Operative and hospital costs of the two operations were also compared. RESULTS: There were no deaths in either group. Mean operative time was longer for laparoscopic GBP than for open GBP, but operative blood loss was less. Two (2.5%) of the 79 patients in the laparoscopic group required conversion to laparotomy. Median length of hospital stay was shorter for laparoscopic GBP patients (3 vs 4 days). The rate of postoperative anastomotic leak was similar between groups. Wound-related complications such as infection (10.5 vs 1.3%) and incisional hernia (7.9 vs 0%) were more common after open GBP; late anastomotic stricture was less frequent after open GBP (2.6 vs 11.4%). Time to return to activities of daily living and work were shorter after laparoscopic GBP than after open GBP. Weight loss at 1 year was similar between groups. Preoperative SF-36 scores were similar between groups; however, at 1 month after surgery, laparoscopic patients had better physical conditioning, social functioning, general health, and less body pain than open GBP patients. At 6 months, the BAROS outcome was classified as good or better in 97% of laparoscopic GBP patients compared with 82% of open GBP patients. Operative costs were higher for laparoscopic GBP patients, but hospital costs were lower. CONCLUSIONS: Laparoscopic GBP is a safe and cost-effective alternative to open GBP. Despite a longer operative time, patients undergoing laparoscopic GBP benefited from less blood loss, a shorter hospital stay, and faster convalescence. Laparoscopic GBP patients had comparable weight loss at 1 year but a more rapid improvement in QOL than open GBP patients. The higher initial operative costs for laparoscopic GBP were adequately offset by the lower hospital costs.

Cardiopulmonary assessment of medetomidine, ketamine, and butorphanol anesthesia in captive Thomson's gazelles (Gazella thomsoni).

This investigation evaluated the cardiopulmonary effects of medetomidine, ketamine, and butorphanol anesthesia in captive juvenile Thomson's gazelles (Gazella thomsoni). Butorphanol was incorporated to reduce the dose of medetomidine necessary for immobilization and minimize medetomidine-induced adverse cardiovascular side effects. Medetomidine 40.1 +/- 3.6 microg/kg, ketamine 4.9 +/- 0.6 mg/kg, and butorphanol 0.40 +/- 0.04 mg/kg were administered intramuscularly by hand injection to nine gazelles. Times to initial effect and recumbency were within 8 min postinjection. Cardiopulmonary status was monitored every 5 min by measuring heart rate, respiratory rate, indirect blood pressure, end-tidal CO2, and indirect oxygen-hemoglobin saturation by pulse oximetry. Venous blood gases were collected every 15 min postinjection. Oxygen saturations less than 90% in three gazelles suggested hypoxemia. Subsequent immobilized gazelles were supplemented with intranasal oxygen throughout the anesthetic period. Sustained bradycardia (<60 beats per minute, as compared with anesthetized domestic calves, sheep, and goats) was noted in eight of nine gazelles. Heart and respiratory rates and rectal temperatures decreased slightly, whereas systolic, mean, and diastolic blood pressure values were consistent over the anesthetic period. Mild elevations in end tidal CO2 and PCO2 suggested hypoventilation. Local lidocaine blocks were necessary to perform castrations in all seven of the gazelles undergoing the procedure. Return to sternal recumbency occurred within 7 min and return to standing occurred within 12 min after reversal with atipamezole (0.2 +/- 0.03 mg/kg) and naloxone (0.02 +/- 0.001 mg/kg). Medetomidine, ketamine, and butorphanol can be used to safely anesthetize Thomson's gazelles for routine, noninvasive procedures. More invasive procedures, such as castration, can be readily performed with the additional use of local anesthetics.

Outcomes assessment and minimally invasive surgery: historical perspective and future directions.

BACKGROUND: Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations. METHODS: Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced. CONCLUSIONS: Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling.

Attrition in the new beneficiary survey and followup, and its correlates.

Panel surveys interview the same individuals more than once over a period of time. Attrition from the survey occurs when those individuals die, refuse to be interviewed again, or, for some other reason, cannot be contacted. If the original sample was representative of a specific population, then survey analysis may provide misleading conclusions about changes in population characteristics over time if these individuals leave the sample in a nonrandom way. Therefore, it is important to identify the characteristics of individuals who leave the survey for various reasons. This article explores the extent of and reasons for attrition in the New Beneficiary Survey (NBS) between the first interview in 1982 and the followup interview in 1991. Presented is a comparison of the characteristics of survivors (the reinterviewed sample) with attriters (those in the sample not reinterviewed) from the retired-worker and disabled-worker samples. The article explores a variety of potential determinants of attrition to the probability of attrition. These determinants are examined alone and in a multivariate framework. The NBS sample population is drawn from and linked to Social Security Administrative records, which have exact matched data on mortality as a cause of attrition. These data do not depend on survey-reported reasons for attrition; hence, it allows the examination of the differences in the patterns and predictors of attrition due to death and due to other reasons, primarily, the refusal to be interviewed. Attrition due to death must be identified precisely because misidentification of death as refusal to be interviewed may lead researchers to infer more selective attrition than might be the case. Different patterns of attrition are evident in the comparison of attrition levels and the determinants of attrition for the retired and disabled samples, both composed of persons with relatively high mortality risk. In particular, individuals' health, health insurance coverage, and level of education have different impacts on their likelihood of attrition. In general, it appears that refusal to be interviewed is more evenly spread across populations and characteristics than is death. The analysis shows that attrition due to death and attrition due to refusal are quite different processes, even though health conditions play a role in both processes. The results suggest that because attrition patterns (including death) may be quite different across population samples, sample-specific attrition patterns must be analyzed over the lifetime of any panel study. Long-term studies of panel attrition are necessary to provide researchers analyzing the data with information on potential biases due to nonrandom attrition.

Testing the HMO competitive strategy: an analysis of its impact on medical resources.

Competitive approaches to health care reform, including managed competition, are hypothesized to reduce health care expenditures and the resources devoted to medical care. Empirical evidence has been limited. The short- and long-run effects of an experiment closely resembling managed competition are analyzed. We examine effects on hospitals, technology diffusion, physicians, and health insurance premiums. The strategy reduces capital in hospitals, has minor effects on physicians and technology, and has only initial effects on average premiums.

Psychotherapy practice and research. Repairing a strained alliance.

Although the gap between psychotherapy practice and research has been present for some time, recent pressures for accountability from outside the system-managed health care and biological psychiatry-necessitate that we take steps to close this gap. One such step has been for psychotherapy researchers to specify a list of empirically validated therapies. However, as researchers who also have a strong allegiance to clinical practice, we are concerned that the conceptual and methodological constraints associated with outcome research may become clinical constraints for the practicing therapist. We firmly believe that, more than ever before, the time is ripe for us to develop a new outcome research paradigm that involves an active collaboration between researcher and practicing clinician.

The impact of laparoscopic cholecystectomy on the treatment of symptomatic cholelithiasis.

BACKGROUND: There has been a debate about the cost-effectiveness of laparoscopic cholecystectomy (LC), as well as a concern regarding its possible overutilization and changes in the indication for surgery. METHODS: A retrospective analysis of all cholecystectomies performed at UCDMC from 1988 to 1994 was done. The annual rate of cholecystectomy increased by 50% in 1990 when LC was introduced but has since stabilized at a rate 11% higher than the rate before LC. The disease status and severity did not change. RESULTS: The incidence of nonelective surgery remained stable at 31.2% to 37.5%. Elective cholecystectomy had lower mortality (0.16% vs 1.8%, P = 0. 029), morbidity (2.6% vs 11.2%, P = 0.0001), and conversion rate (2. 6% vs 16%, P = 0.0001) and a shorter length of stay (2.1 days vs 5.4 days), compared with nonelective procedure. CONCLUSIONS: The indication for surgery in cholelithiasis has not changed since the introduction of LC. In patients with symptomatic gallstones, early elective surgery is recommended and may be more cost-effective.

Combination therapy with colestipol and psyllium mucilloid in patients with hyperlipidemia.

OBJECTIVE: To test whether combining psyllium mucilloid with half the usual dose of colestipol reduces the adverse effects associated with colestipol and maintains or increases its efficacy in the treatment of hyperlipidemia. This strategy might make bile acid sequestrants, which are seldom used because they cause adverse effects such as bloating and constipation, more tolerable and less expensive. DESIGN: A randomized, parallel-group, double-blind, controlled trial. SETTING: An outpatient clinic in a tertiary care hospital. PATIENTS: 121 patients who had moderate primary hypercholesterolemia (total cholesterol level > 6 mmol/L and < 8 mmol/L; triglyceride level < 3 mmol/L) after following a low-fat diet for 1 year (National Cholesterol Education Program Step Two diet). INTERVENTION: 5 g of cellulose placebo; 5 g of colestipol; 2.5 g of colestipol plus 2.5 g of psyllium; or 5 g of psyllium three times daily before meals for 10 weeks. MAIN OUTCOME MEASURES: At baseline and at weeks 4 and 10, fasting blood lipid levels and apoprotein concentrations were measured and a quality-of-life instrument was completed. RESULTS: A combination of 2.5 g of psyllium and 2.5 g of colestipol was better tolerated than and as effective as either 5 g of colestipol alone or 5 g of psyllium alone. The combination therapy and colestipol alone did not differ significantly with respect to changes in individual lipid values. The ratio of total cholesterol to high-density lipoprotein cholesterol (HDL) was reduced by 18.2% (95% CI, 12.3% to 24%) with the combination therapy; by 10.6% (CI, 2.0% to 15.4%) with colestipol alone; by 6.1% (CI, 1.5% to 10.6%) with psyllium alone; and by 0.1% (CI, -4.8% to 7%) with placebo (P = 0.0002). Combination therapy reduced the ratio of total cholesterol to HDL significantly more than did colestipol alone or psyllium alone (P < 0.05). CONCLUSIONS: These findings suggest that adding psyllium to half the usual dose of bile acid sequestrant resins maintains the efficacy and improves the tolerability of these resins.

Market work, wages, and men's health.

In this paper, we investigate the complex interrelations among work-time, wages, and health identified in the Grossman model of the demand for health. Hansen's generalized method of moments techniques are employed to estimate a 3-equation simultaneous model designed to capture the time dependent character of these interrelationships. We then estimate simpler models with more restrictive assumptions commonly found in the literature and find substantial differences between these estimates and those from our simultaneous model. For example, the positive relationship between work-time and health found in other studies disappears when the relevant simultaneities are taken into account.

Medicaid, welfare dependency, and work: is there a causal link?

Medicaid exerts a strong "pull" on potential welfare recipients, increasing the probability that a number of single mothers will apply for and stay on welfare in order to be covered by Medicaid. However, the availability of private health insurance coverage exerts a strong positive influence on women's decisions to work and a strong negative effect on welfare participation rates. If private insurance coverage were as comprehensive as Medicaid and readily available at all jobs, its impact on promoting work would be substantially greater than is the impact of Medicaid in promoting the use of welfare.

The synthesis economic fertility model: a latent variable investigation of some critical attributes.

"This study uses Nicaraguan data to estimate a latent variable system of reduced-form demands for births, infant mortality, contraception, nutrition and breastfeeding. The estimates support some of the synthesis extensions to the standard fertility model, such as the concurrent increase of contraception, health, nutrition and fertility and decline in breastfeeding with income increases from initial low levels.... The initial stages of development may experience an increase in family size despite an increase in contraceptive use...as well as a profertility impact of reduced breastfeeding." Data are from a survey of women aged 15-45 that was conducted in Nicaragua from 1977 to 1978.

Physician responses to fee-for-service and capitation payment.

The ability to achieve reductions in health care costs is determined in part by physician payment mechanisms. This study observes the response to a change in the reimbursement mechanism by a group of physicians who participated in a fee-for-service plan and then formed an IPA using capitation payment for primary care physicians and a reduced fee schedule for specialists. Patient benefits were similar under the two plans. Analyses of data for a group of continuous enrollees show that the change in the physician payment mechanism was associated with a reduction in hospitalizations but increases in length of hospital stay and number of ambulatory visits. These increases may have occurred because capitation for primary care physicians and a reduced fee schedule for specialists led to a greater number of referrals with no incentive in place for reductions in length of stay for specialty admissions.

Diagnosis related groups (DRGs): efficiency and/or quality producing? Some evidence from surgical patients.

Hospital charges and length of stay for inguinal hernia and acute appendicitis patients were examined in a university hospital to determine the degree of variation with DRGs. Evidence presented here suggests that DRGs may lead to a reduction in medical care costs without a reduction in patient outcomes. Mode/year DRGs to take account of source of admission and maintaining outliers payments may be desirable to avoid patient selectivity and incentives for lowering quality of care of the most severely ill patients.

Health status and medical expenditures: more evidence of a link.

The hypothesis that one must include life-style changes in order to accurately capture the true relationship between medical expenditures and health status is explored, using data from 22 countries over a 20-year period. A simultaneous model is estimated using a variety of indicators for life style as well as health status. Changes in life style, aging of the population and changes in occupational risk are modeled as influences on medical expenditures: medical expenditures and changes in life style are modeled as having direct influences on health status. The results are consistent with the existence of a positive link between medical expenditures and health status.