Cost-effective reduction of neuromuscular-blocking drug expenditures

BACKGROUND: Anesthetic drug expenditures have been a focus of cost-containment efforts. The aim of this study was to determine whether expenditures for neuromuscular-blocking agents could be reduced without compromising outcome, and to determine whether such a cost-effective pattern of neuromuscular blocker use could be sustained. METHODS: Education, practice guidelines, and paperwork barriers were used to persuade anesthesiologists to substitute low-cost neuromuscular-blocking drugs (pancuronium or a metocurine-pancuronium combination) for a more costly neuromuscular-blocking drug (vecuronium). Neuromuscular-blocking drug use in all patients during a historical control period (6 months; n = 4,804) was compared with that during two consecutive 1-yr periods of intervention (n = 9,761/n = 10,695). Expenditures for vecuronium and for all neuromuscular-blocking drugs were compared for the control and intervention periods. The rate of complications related to neuromuscular-blocking drugs was determined by an ongoing continuous quality improvement program. RESULTS: Vecuronium use decreased by 76% during the first and second yr of intervention, compared with the historical period (P < 0.01). The cost of neuromuscular-blocking drugs decreased by 31% (P < 0.01) and 47% (P < 0.01) for the first and second yr, respectively. The complication rate related to neuromuscular-blocking drugs was 0.081% in the historical period and 0.11% and 0.093% during the intervention periods (P = 0.29 and 0.41). CONCLUSION: Practice guidelines, education, and paperwork barriers used together substantially reduced the expenditures for neuromuscular-blocking drugs for 2 yr without adversely affecting clinical outcome.     

A chemoenzymatic synthesis of UDP-(2-deoxy-2-fluoro)-galactose and evaluation of its interaction with galactosyltransferase

The left internal mammary artery-to-the left pulmonary artery shunt was created in a 16-year-old boy with single ventricle, severe pulmonary stenosis palliated by Glenn shunt at the age of two. Four years follow-up angiogram demonstrated a significant increase of the diameter of the left internal mammary artery from 4 to 7 mm. The internal mammary artery is a good alternative conduit for a systemic-to-pulmonary artery shunt for a cyanotic heart disease because of its growth potential.     

Offset compensation in comparators with minimum input-referred supply noise

The resolution of a comparator is determined by the dc input offset and the ac noise. For mixed-mode applications with significant digital switching, input-referred supply noise can be a significant source of error. This paper proposes an offset compensation technique that can simultaneously minimize input-referred supply noise. Demonstrated with digital offset compensation, this scheme reduces input-referred supply noise to a small fraction (13%) of one least significant bit (LSB) digital offset. In addition, the same analysis can be applied to analog offset compensation.     

Coupling efficiency enhancement in organic light-emitting devices using microlens array-theory and experiment

Microlens arrays are introduced on glass substrates to improve the out-coupling efficiency of organic light-emitting devices (OLEDs). The microlenses suppress waveguiding loss in the substrate. A theoretical model, based on electromagnetic wave propagation and geometric ray tracing, is developed to simulate the enhancement effects and optimize the structure parameters of the lens pattern. A simple soft-lithography approach is employed to fabricate the microlens array on glass substrates. With the use of an optimized lens pattern, an increase of over 85% in the coupling efficiency of the OLED is expected theoretically. An increase of 70% in the coupling efficiency is achieved experimentally, without detrimental effect to the electrical performance of the OLED.     

Multiclassification of tool wear with support vector machine by manufacturing loss consideration

Tool wear is a dynamic process, as a tool progresses from sharp to worn state and possibly to breakage. Thus the multiclassification of tool states is preferred, which can provide more timely and accurate estimation of tool states. Based on acoustic emission (AE) sensing, this paper proposes a new performance evaluation function for tool condition monitoring (TCM) by considering manufacturing loss. Firstly, two types of manufacturing loss due to misclassification (loss caused by under prediction and loss caused by over prediction) are analyzed, and both are utilized to compute corresponding weights of the proposed performance evaluation function. Then the expected loss of future misclassification is introduced to evaluate the recognition performance of TCM. Finally, a revised support vector machine (SVM) approach coupled with one-versus-one method is implemented to carry out the multiclassification of tool states. With this approach, a tool is replaced or continued not only based on the tool condition alone, but also the risk in cost incurred due to underutilized or overused tool. The experimental results show that the proposed method can reliably perform multiclassificaion of tool flank wear, and reduce the potential manufacturing loss.     

Management guidelines for progressive chronic renal failure. New Zealand Nephrologists Consensus Group

Consensus guidelines are provided for the conservative management of adult patients with chronic and progressive renal failure, together with a brief review of the evidence relating to various treatable complications. Blood pressure control, diet, hyperlipidaemia, calcium and phosphate metabolism, anaemia and acidosis are considered.     

HLA-DRB1*08 influences the development of disease in Mexican Mestizo with spondyloarthropathy

OBJECTIVE: HLA class II encoded factors may influence the phenotype of ankylosing spondylitis (AS). These include HLA DRB1*07 for peripheral arthritis, and polymorphism of the HLA-linked LMP2 locus and HLA DRB1*08 for acute anterior uveitis (AAU). We studied the relationship between DRB1*08 and disease phenotype in additional populations of individuals with AS. METHODS: The patient population included 385 unrelated HLA-B27 positive individuals with AS. These included 204 Caucasians and 2 populations of Mexican Mestizo with AS: 106 with predominately adult onset disease from Guadalajara and 75 with predominately juvenile onset disease from Mexico City. The control population of 428 individuals included 210 random and 36 HLA-B27 positive unrelated Canadian Caucasians and 173 random and 9 HLA-B27 positive Mexican Mestizo from Mexico City. DRB1*08 typing was by sequence specific polymerase chain reaction. RESULTS: A significantly higher prevalence of DRB1*08 was observed in Mexican patients with juvenile onset disease (44.9%) and especially those with undifferentiated spondyloarthropathy (55.6%) compared to normal unrelated Mexican Mestizo (25.4%) (p < 0.01 for both) and in patients with undifferentiated spondyloarthropathy versus B27 controls (11.1%) (p = 0.03), although no significant differences were observed in within patient group comparisons based on phenotypic features of disease such as AAU and age at onset. No significant relationship between DRB1*08 and disease phenotype was evident in Caucasian individuals. CONCLUSION: Our data suggest DRB1*08 may influence the phenotype of spondyloarthritis in Mexican Mestizo, but do not support the view that DRB1*08 influences the development of AAU, as reported in a Japanese population.     

Fathers of persons with mental illness: a preliminary study of coping capacity and service needs

The effects of a single dose of caffeine on specific information processing operations were examined by using a visual selective attention task in which subjects were asked to select between a left and right hand response on the basis of two different target letters. The target was presented on a predefined position in the visual field and was either presented alone or with flanker letters, calling for the correct, the incorrect or no specific response. A dose of 3 mg/kg body weight caffeine or lactose, dissolved in a cup of decaffeinated coffee, was administered double blind and deceptively to overnight abstinence coffee drinkers. Behavioural measures were supplemented by psychophysiological measures. The present results replicated the basic findings obtained in this paradigm. The results indicated that the time to localise the target decreased and response preparation started earlier after caffeine than after placebo. These caffeine effects did not interact with the time subjects spent on the task or with the reaction time distribution, which might be due to a high level of practice.