Adenocarcinoma developing in a patient with midline granuloma.

A 51-year-old man with midline granuloma was treated successfully with a combination of local radiation and oral cyclophosphamide. Six years after therapy, adenocarcinoma of the lung developed. Possible relationships between these two diseases are discussed.

Randomized controlled trial of residents as gatekeepers.

BACKGROUND: Managed care advocates suggest that primary care gatekeepers may improve patient care and reduce costs. Training internal medicine residents in these gatekeeping functions has not been emphasized in most internal medicine programs. OBJECTIVE: To determine if residents could perform gatekeeper functions and if patient costs and satisfaction would be favorable. METHODS: Patients (n = 254) followed up by residents (n = 26) in continuity clinics at the Denver Veterans Affairs Medical Center in Denver, Colo, were divided into 2 groups. A control group of 128 was followed up by residents with no restrictions on appointments made for them. An intervention group of 126 patients were followed up by residents who had to approve all referrals made for their patients. A research nurse assisted with the approvals when the residents were rotating through other institutions. Utilization of resources, satisfaction with care, and health status were monitored over a 1-year period. RESULTS: A minor reduction of resource utilization was found in the intervention group, particularly in medication use. Significantly more visits were made to primary care providers in the intervention group (3.01 vs 2.59; P = .03). Patient satisfaction and health status were similar in both groups with a trend toward better satisfaction in the intervention group in some areas. CONCLUSIONS: Our study showed that residents can function as gatekeepers of highly complex patients and that satisfaction with care and utilization of resources does not suffer. Drug utilization and costs may be less when a gatekeeper exists.

Hypomagnesemia after cisplatin combination chemotherapy.

Sixty-six patients receiving a five-drug combination chemotherapy regimen containing low-dose cisplatin were studied for the presence of hypomagnesemia. Thirty-eight (76%) of 50 patients receiving treatment every four weeks became hypomagnesemic during treatment. The incidence increased with the cumulative cisplatin dose, ranging from 41% after a single course to 100% of patients receiving six cycles of therapy. The incidence seemed lower in patients receiving the combination with a greater interval (eight weeks v four weeks) between cycles. We report the incidence and severity of hypomagnesemia to be dose dependent. The cause of the higher incidence of hypomagnesemia observed in this series compared with others is unknown but may be related to an interaction of cisplatin with another drug contained in this regimen.

A mobile internal medicine clinic.

The Denver Veterans Administration Medical Center (DVAMC) established a mobile internal medicine clinic (MediVAn) to provide access to primary care for veterans living more than fifty miles from the center and to study the costs of such an outreach program. A fully equipped van staffed by an internist visited four Colorado cities weekly for scheduled appointments. In the first two years of operation there were 4,655 visits by 766 veterans with a mean age of 56 years, with 3.9 diagnoses, and receiving 3.0 medicines. The cost per MediVAn visit was $68, compared with $67 per outpatient visit at DVAMC. We conclude that a mobile medical clinic is a convenient method of delivering primary care over distances and is comparable in cost to outpatient hospital visits.

Synthesis, characterization, and water oxidation by a molecular chromophore-catalyst assembly prepared by atomic layer deposition. The "mummy" strategy.

A new strategy for preparing spatially-controlled, multi-component films consisting of molecular light absorbing chromophores and water oxidation catalysts on high surface area, mesoporous metal oxide surfaces is described. Atomic layer deposition (ALD) is used to embed a surface-bound chromophore in a thin layer of inert Al2O3, followed by catalyst binding to the new oxide surface. In a final step, catalyst surface-binding is stabilized by a subsequent ALD overlayer of Al2O3. The ALD assembly procedure bypasses synthetic difficulties arising from the preparation of phosphonic acid derivatized, covalently-linked assemblies. An ALD mummy-based assembly has been used to demonstrate photoelectrochemical dehydrogenation of hydroquinone. Electrocatalytic water oxidation at pH 8.8 is observed over a 2 hour electrolysis period and light-assisted water oxidation over a 6 hour photolysis period with O2 detected with a generator-collector electrode configuration.

Formation and Reactivity of the Osmium(IV)-Cyanoimido Complex [Os(IV) (bpy)(Cl)3 (NCN)](-).

Oxo-like reactivity exists for a new series of osmium complexes such as [Os(IV) (bpy)(Cl)3 (NCN)](-) (bpy=2,2'-bipyridine, see structure) containing the cyanoimido ligand. This ligand is formed directly at the metal center by the reaction of Os(VI) -nitrido precursors with tetraethylammonium cyanide. In the cyanoimido complexes there is an extensive electron-transfer chemistry at the metal center and an extensive functional-group chemistry based on the ligand.

Immunosuppression with medroxyprogesterone acetate.

PIP: The immunosuppressive effects of MPA (medroxyprogesterone acetate) were tested in clinical studies with laboratory dogs and rabbits. The laboratory procedures employed in the studies are explained and results are tabulated and graphed. 2 microscopic photographs illustrate the observed effects. MPA significantly prolonged the survival of dogs with renal allografts. MPA was shown to enhance the immunosuppressive activity of azathioprine in dogs with renal allografts. In rabbits, MPA extended survival of rabbit skin allografts and suppressed the primary humoral antibody response. The influence of MPA on circulating leukocytes and on the histology of lymph nodes, spleen, thymus, liver, and kidney was also assessed. MPA is probably not as potent an immunosuppressive agent as azathioprine or corticosteroids. It is, however, useful in humans due to its low toxicity. It is possible that high local progesterone levels in the fetus and placenta during pregnancy help to prevent fetal rejection.^ieng

Environmental noise as a cause of sleep disruption in an intermediate respiratory care unit.

Our laboratory previously reported continuously monitored peak sound levels in several areas at Rhode Island Hospital. The number of sound peaks greater than 80 A-weighted decibels (dBA) was found to be high in the intensive and intermediate respiratory care unit (IRCU) areas, even at night. Environmental noise of this magnitude is potentially sleep-disruptive. Therefore, we hypothesized that nocturnal peak sound levels of > or = 80 dBA would be associated with an increase in EEG arousals from sleep in patients in the IRCU. Six patients underwent sleep monitoring while environmental peak sound levels were continuously recorded. Each 8-hour period (2200 to 0600 hours) was broken down into 30-minute segments. If there were 10 minutes or more of wakefulness in a segment, that segment was dropped from further analysis. Of the remaining 61 segments, there was a very strong correlation (r = 0.57, p = 0.0001) between the number of sound peaks of > or = 80 dBA and arousals from sleep. These 61 periods were then classified as quiet, moderately loud, and very loud based on the number of sound peaks (< or = 5, 6-15, and > 15, respectively). Analysis of variance revealed a significant difference between the number of arousals (p = 0.001) in quiet periods and that in very loud periods. We conclude that environmental noise may be an important cause of sleep disruption in the IRCU.

Air leaking through the mouth during nocturnal nasal ventilation: effect on sleep quality.

Air leaking through the mouth has been reported in kyphoscoliotic patients receiving nasal ventilation via volume-limited ventilators. This study accessed the frequency of occurrence and effect on sleep quality of air leaking through the mouth during nocturnal nasal ventilation in patients with chest wall and neuromuscular disease using pressure-limited ventilation. Overnight and daytime polysomnography was performed in six stable experienced users of nocturnal nasal noninvasive positive-pressure ventilation (NPPV) who had chronic respiratory failure due to neuromuscular disease or chest wall deformity. All patients used the BiPAP S/T-D ventilatory support system (Respironics, Inc., Murrysville, PA). Measures included sleep scoring, leak quantitation, diaphragm and submental electromyograms (EMGs), and tidal and leak volumes. All patients had air leaking through the mouth for the majority of sleep. Sleep quality was diminished because of poor sleep efficiency and reduced percentages of slow-wave and rapid eye movement (REM) sleep. Air leaking through the mouth was associated with frequent arousals during stages 1 and 2 and REM sleep that contributed to sleep fragmentation, but arousals were infrequent during slow-wave sleep. Despite prevalent leaking, oxygenation was well maintained in all but one patient. Patients used a-combination of passive and active mechanisms to control air leaking. Although nasal ventilation improves nocturnal hypoventilation and symptoms in patients with restrictive thoracic disorders, air leaking through the mouth is very common during use. The leaking is associated with frequent arousals during lighter stages of sleep that interfere with progression to deeper stages, compromising sleep quality. Portable pressure-limited ventilators compensate for leaks, maintaining ventilation and oxygenation, but further studies are needed to determine which interfaces and ventilator techniques best control air leaking and optimize sleep quality.

Night terrors in an adult precipitated by sleep apnea.

Parasomnias are generally described as disorders of arousal that arise out of stage 3 and 4 nonrapid eye movement (NREM) sleep without identifiable cause. We present a case of a 35-year-old man who during nasal continuous positive airway pressure (nCPAP) treatment for severe obstructive sleep apnea experienced an intense night terror triggered by a residual obstructive apnea during rebound deep sleep. The role of rebound deep sleep was thought to be essential in creating a state of sleep with a high arousal threshold hypothesized to be important for the occurrence of parasomnias. This case supports the clinical wisdom that identifiable sources of arousal can trigger parasomnias.

Pulmonary embolism in younger adults.

To test the hypothesis that the clinical presentation and outcomes are different when pulmonary embolism occurs in younger (age 18 to 40 years) as compared to older (age greater than 40 years) adults, 40 younger patients were compared with older patients. No risk factors could be identified in 28 percent of the younger group. Normal physical examinations were more common (58 vs 28 percent, p = 0.01) among younger as compared with older adults. Hypoxemia was absent in 29 percent of the younger and 3 percent of the older group (p = 0.004); P(A-a)O2 was significantly lower among younger patients even after controlling for age. Mortality was decreased sevenfold (2.5 vs 18 percent, p = 0.03) among younger patients. These data indicate that pulmonary embolism tends to have a subtle presentation in younger adults. When diagnosed and treated, the mortality rate is substantially less among younger as compared with older patients.

Orbital herniation associated with noninvasive positive pressure ventilation.

A diagnosis of severe obstructive sleep apnea was made after a 52-year-old hypertensive man developed a large intracranial hemorrhage. Therapeutic noninvasive positive pressure ventilation (NPPV) for obstructive sleep apnea and hypoventilation was complicated by transient unilateral orbital herniation. As best as can be determined, this represents a new, potentially deleterious side effect of NPPV.

One negative polysomnogram does not exclude obstructive sleep apnea.

Night-to-night variability of apneas on overnight polymnography exists in patients with documented obstructive sleep apnea (OSA). In this study, we evaluated the possibility that this variability may be severe enough to miss the diagnosis of OSA in patients clinically at risk for the disease. We prospectively studied 11 patients who were deemed on clinical grounds to have probable OSA, but had a negative result on overnight polysomnography. Six of the 11 patients were found to have a positive second study with a significant rise in the apnea/hypopnea index (AHI) from 3.1 +/- 1.0 to 19.8 +/- 4.7 (mean +/- SEM, p < 0.01). The cause of the negative first study in these patients is unclear, but it does not seem related to risk factor pattern, sleep architecture, or test interval. The change in AHI was not found to be rapid eye movement (REM)-dependent. This study demonstrates that a negative first-night study is insufficient to exclude OSA in patients with one or more clinical markers of the disease.

Adverse environmental conditions in the respiratory and medical ICU settings.

Sleep deprivation and fragmentation occurring in the hospital setting may have a negative impact on the respiratory system by decreasing respiratory muscle function and ventilatory response to CO2. Sleep deprivation in a patient with respiratory failure may, therefore, impair recovery and weaning from mechanical ventilation. We postulate that light, sound, and interruption levels in a weaning unit are major factors resulting in sleep disorders and possibly circadian rhythm disruption. As an initial test of this hypothesis, we sampled interruption levels and continuously monitored light and sound levels for a minimum of seven consecutive days in a medical ICU, a multiple bed respiratory care unit (RCU) room, a single-bed RCU room, and a private room. Light levels in all areas maintained a day-night rhythm, with peak levels dependent on window orientation and shading. Peak sound levels were extremely high in all areas representing values significantly higher than those recommended by the Environmental Protection Agency as acceptable for a hospital environment. The number of sound peaks greater than 80 decibels, which may result in sleep arousals, was especially high in the intensive and respiratory care areas, but did show a day-night rhythm in all settings. Patient interruptions tended to be erratic, leaving little time for condensed sleep. We conclude that the potential for environmentally induced sleep disruption is high in all areas, but especially high in the intensive and respiratory care areas where the negative consequences may be the most severe.

Photophysics of phenyleneethynylene metal-organic oligomers. Probing the lowest excited state by time-resolved IR spectroscopy.

The long-lived excited state in a series of metal-organic phenyleneethynylene oligomers is probed by UV-visible and infrared transient absorption spectroscopy.

Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments.

Meta-analytic methods were used to synthesize the results of published randomized, controlled-outcome studies of psychosocial interventions with adult cancer patients. Forty-five studies reporting 62 treatment-control comparisons were identified. Samples were predominantly White, female, and from the United States. Beneficial effect size ds were .24 for emotional adjustment measures, .19 for functional adjustment measures, .26 for measures of treatment- and disease-related symptoms, and .28 for compound and global measures. The effect size of .17 found for medical measures was not statistically significant for the few reporting studies. Effect sizes for treatment-control comparisons did not significantly differ among several categories of treatment: behavioral interventions, nonbehavioral counseling and therapy, informational and educational methods, organized social support provided by other patients, and other nonhospice interventions.

Results of operative treatment of displaced external rotation-abduction fractures of the ankle.

One hundred and fifty patients with a displaced fracture of the ankle caused by external rotation-abduction forces were treated by open reduction and rigid internal fixation. After an average follow-up of three and one-half years, the results were satisfactory in 90 per cent. Less satisfactory results were noted in the more severely injured ankles. We found that the ruptured deltoid ligament did not need to be repaired if the lateral side was anatomically and rigidly fixed; in the Maisonneuve fracture, restoration of the fibular length was as important as stabilization of the fracture; with the use of the suprasyndesmotic screw, walking was permissible with the screw in situ; conforming the plate to the bend of the lateral malleolus was essential; and as much as two millimeters of lateral residual displacement of the lateral and medial malleoli was compatible with a satisfactory result, as was a similar displacement of the talus provided there was anatomical restoration of the lateral side.

Development and validation of the Penn State Worry Questionnaire.

The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.

A prospective study of preoperative chemotherapy and split-course irradiation for locally advanced or recurrent oral/pharyngeal squamous carcinoma.

Two courses of preoperative chemotherapy (methotrexate, bleomycin, cisplatin) were combined with split-course irradiation (2,000 rad/10 preop., 4,000 rad/20 postop.) and prospectively compared with standard therapy (surgery and/or irradiation alone) for locally advanced or recurrent oral/pharyngeal squamous cancer. The chemoradiotherapy arm (Ch-XRT) had 31 patients; the standard therapy arm 28 randomized (RC) and 20 concomitantly-treated (CC) patients. Treatment-related mortality was 17% for Ch-XRT; 10% for RC + CC. Number of patients NED at completion of treatment was 74% for Ch-XRT; 83% for RC + CC (NS). Median survival, however, was 17 months for Ch-XRT, 9 months for CC, and 12 months for RC. In addition, survival at 40 + months was 45% for Ch-XRT versus 21-22% for RC and CC (p less than 0.05). Thus, Ch-XRT seems to have promise in advanced oral/pharyngeal cancer, but needs revision to decrease toxicity.

Posterior surgical stabilization for atlantoaxial subluxation in rheumatoid arthritis.

Twelve patients with rheumatoid arthritis involving the cervical spine were treated with posterior surgical stabilization for atlantoaxial instability. There were two occiput C2 fusions with one death and ten C1-2 fusions with nine successful fusions, giving an overall 84% satisfactory results and 90% satisfactory results in the C1-2 fusions alone. It is proposed that careful attention to operative positioning and postoperative management are responsible for the better results reported in this series than recent reports of operative treatment of similar patients. The use of halo traction intraoperatively with careful attention to positioning of the neck and halo cast postoperatively are advocated.