The effect of n-3 enriched nutrition therapy on post-operative cognitive dysfunction after cardiac surgery

Background: Postoperative cognitive dysfunction (POCD) occurs frequently after cardiac surgery. Some data suggest that inflammation plays a key role in the development of POCD. N-3 fatty acids have been shown to have a beneficial effect on inflammation. We hypothesised that perioperative n-3 enriched nutrition therapy would reduce the incidence of POCD in this group of patients. Methods: Randomized, double blind placebo controlled trial in patients aged 65 or older undergoing elective cardiac surgery with cardiopulmonary bypass. 2x 250 mL placebo (Ensure Plus™, Abbott Nutrition) or n-3 enriched nutrition therapy (ProSure™ Abbott Nutrition) were administered for ten days starting 5 days prior to surgery. Cognition was assessed preoperatively and 7 days after surgery with the Consortium to Establish a Registry for Alzheimer's Disease - Neuropsychological Assessment Battery (CERAD-NAB) [1]. Results: 16 patients were included. Mean age was 72 } 5.3 for placebo and 75 } 4.8 for ProSure™ respectively. CRP and IL-6 did not differ significantly between groups preoperatively and on postoperative days 1, 3, and 7. Preoperative CERAD total scores were 86 } 10 and 81 } 9 (p = n.s.) for Placebo and ProSure™, respectively. Postoperative scores were 88 } 12, and 77 } 19 (p = n.s.) The change in score was not different between the two groups (Placebo: +3 } 5; ProSure: -5 } 11). Conclusion: In this very small sample no effect of preoperatively started n-3 enriched nutritional supplements on inflammation or cognitive functions were detected. However, there is a large likelihood of a type II error and more patients need to be included to assess possible beneficial effects of this intervention in elderly patients undergoing elective cardiac surgery. 1 Chandler MJ, et al. Neurology. 2005;65:102-6.

The nine-year sustained cost-containment impact of swiss pilot physicians-pharmacists quality circles.

BACKGROUND: Six pioneer physicians-pharmacists quality circles (PPQCs) located in the Swiss canton of Fribourg (administratively corresponding to a state in the US) were under the responsibility of 6 trained community pharmacists moderating the prescribing process of 24 general practitioners (GPs). PPQCs are based on a multifaceted collaborative process mediated by community pharmacists for improving compliance with clinical guidelines within GPs' prescribing practices. OBJECTIVE: To assess, over a 9-year period (1999-2007), the cost-containment impact of the PPQCs. METHODS: The key elements of PPQCs are a structured continuous quality improvement and education process; local networking; feedback of comparative and detailed data regarding costs, drug choice, and frequency of prescribed drugs; and structured independent literature review for interdisciplinary continuing education. The data are issued from the community pharmacy invoices to the health insurance companies. The study analyzed the cost-containment impact of the PPQCs in comparison with GPs working in similar conditions of care without particular collaboration with pharmacists, the percentage of generic prescriptions for specific cardiovascular drug classes, and the percentage of drug costs or units prescribed for specific cardiovascular drugs. RESULTS: For the 9-year period, there was a 42% decrease in the drug costs in the PPQC group as compared to the control group, representing a $225,000 (USD) savings per GP only in 2007. These results are explained by better compliance with clinical and pharmacovigilance guidelines, larger distribution of generic drugs, a more balanced attitude toward marketing strategies, and interdisciplinary continuing education on the rational use of drugs. CONCLUSIONS: The PPQC work process has yielded sustainable results, such as significant cost savings, higher penetration of generics and reflection on patient safety, and the place of "new" drugs in therapy. The PPQCs may also constitute a solid basis for implementing more comprehensive collaborative programs, such as medication reviews, adherence-enhancing interventions, or disease management approaches.

Dietary restriction affects lifespan but not cognitive aging in Drosophila melanogaster.

Summary Dietary restriction extends lifespan in a wide variety of animals, including Drosophila, but its relationship to functional and cognitive aging is unclear. Here, we study the effects of dietary yeast content on fly performance in an aversive learning task (association between odor and mechanical shock). Learning performance declined at old age, but 50-day-old dietary-restricted flies learned as poorly as equal-aged flies maintained on yeast-rich diet, even though the former lived on average 9 days (14%) longer. Furthermore, at the middle age of 21 days, flies on low-yeast diets showed poorer short-term (5 min) memory than flies on rich diet. In contrast, dietary restriction enhanced 60-min memory of young (5 days old) flies. Thus, while dietary restriction had complex effects on learning performance in young to middle-aged flies, it did not attenuate aging-related decline of aversive learning performance. These results are consistent with the hypothesis that, in Drosophila, dietary restriction reduces mortality and thus leads to lifespan extension, but does not affect the rate with which somatic damage relevant for cognitive performance accumulates with age.

Total Cost of Transportation Analysis of Road and Highway Issues, TR-477, Phase 2, 2003

A prior project, HR-388, (which was entitled "Total Cost of Transportation analysis of road and highway issues"), explored the use of a total economic cost basis for evaluation of road based transportation issues. It was conducted as a proof-of-concept effort between 1996 and 2002, with the final report presented in May 2002. TR-477 rebuilt the analytical model using current data, then performed general, system level, county level, and road segment level analyses. The results are presented herein and will be distributed to all county engineers for information and local use.

Total Cost of Transportation Analysis of Road and Highway Issues, TR-477, Phase 2 Supplement, 2003

Please see TR-477 Phase 2 Final Report -- http://publications.iowa.gov/id/eprint/20041

Between manualized treatments and principle-guided psychotherapy: illustration in the case of Caroline

My case study of "Caroline"-a 26 year old presenting with depression, PTSD symptoms, and a history of sexual abuse as a teenager-represents a "third way" between (1) a strict adherence to a manualized treatment, and (2) a principle-guided therapy, in which the therapy follows particular theoretical concepts, but depends on the therapist's clinical judgement to flexibly apply them to the individual case. Specifically, in my therapy with Caroline (Kramer, 2009), I employed Foa and Rothbaum's (1998) cognitive-behavioral, "Prolonged Exposure" (PE) manual for PTSD, but deviated from it in certain ways based upon my evaluation of Caroline's individualized goals and reactions using Grawe and Caspar's "Plan Analysis," which is a cross-theoretical model for assessment and treatment planning. In their commentaries on my case study of Caroline, Caspar (2009) and Haldimann-Balli (see Appendix in Kramer, 2009) support my use of this third way. On the other hand, the other commentators-Muller (2009) and Hembree and Brinen (2009)-critique my handling of the case, arguing that strict adherence to the Foa and Rothbaum manual would have resulted in a more cost-effective therapy. In this article, I respond to the important issues raised by the four commentators.

Cost evaluation and comparison of three decision strategies to revascularize : results of the suspected CAD protocol of the european CMR registry

Background: Cardiac magnetic resonance (CMR) is accepted as a method to assess suspected coronary artery disease (CAD). Nonetheless, invasive coronary angiography (CXA) combined or not with fractional flow reserve (FFR) remains the main diagnostic test to evaluate CAD. Little data exist on the economic impact of the use of these procedures in a population with a low to intermediate pre-test probability. Objective: To compare the costs of 3 decision strategies to revascularize a patient with suspected CAD: 1) strategy guided by CMR 2) hypothetical strategy guided by CXA-FFR, 3) hypothetical strategy guided by CXA alone.

Strategy selection: An introduction to the modeling challenge

Modeling the mechanisms that determine how humans and other agents choose among different behavioral and cognitive processes-be they strategies, routines, actions, or operators-represents a paramount theoretical stumbling block across disciplines, ranging from the cognitive and decision sciences to economics, biology, and machine learning. By using the cognitive and decision sciences as a case study, we provide an introduction to what is also known as the strategy selection problem. First, we explain why many researchers assume humans and other animals to come equipped with a repertoire of behavioral and cognitive processes. Second, we expose three descriptive, predictive, and prescriptive challenges that are common to all disciplines which aim to model the choice among these processes. Third, we give an overview of different approaches to strategy selection. These include cost‐benefit, ecological, learning, memory, unified, connectionist, sequential sampling, and maximization approaches. We conclude by pointing to opportunities for future research and by stressing that the selection problem is far from being resolved.

Low-Cost Rural Surface Alternatives: Demonstration Project, TR-664, 2015

The goals of this project were to implement several stabilization methods for preventing or mitigating freeze-thaw damage to granular surfaced roads and identify the most effective and economical methods for the soil and climate conditions of Iowa. Several methods and technologies identified as potentially suitable for Iowa were selected from an extensive analysis of existing literature provided with Iowa Highway Research Board (IHRB) Project TR-632. Using the selected methods, demonstration sections were constructed in Hamilton County on a heavily traveled two-mile section of granular surfaced road that required frequent maintenance during previous thawing periods. Construction procedures and costs of the demonstration sections were documented, and subsequent maintenance requirements were tabulated through two seasonal freeze-thaw periods. Extensive laboratory and field tests were performed prior to construction, as well as before and after the two seasonal freeze-thaw periods, to monitor the performance of the demonstration sections. A weather station was installed at the project site and temperature sensors were embedded in the subgrade to monitor ground temperatures up to a depth of 5 ft and determine the duration and depths of ground freezing and thawing. An economic analysis was performed using the documented construction and maintenance costs, and the estimated cumulative costs per square yard were projected over a 20-year timeframe to determine break-even periods relative to the cost of continuing current maintenance practices. Overall, the sections with biaxial geogrid or macadam base courses had the best observed freeze-thaw performance in this study. These two stabilization methods have larger initial costs and longer break-even periods than aggregate columns, but counties should also weigh the benefits of improved ride quality and savings that these solutions can provide as excellent foundations for future paving or surface upgrades.

Surgical results in patients with chronic low back pain who failed multidisciplinary rehabilitation with cognitive intervention

Introduction¦Surgery for chronic low back pain (CLBP) is a controversial topic. One randomized controlled¦trial (RCT) showed superiority of surgery to physiotherapy only, whereas two more RCTs¦failed to show that surgery was better than multidisciplinary rehabilitation including cognitive¦intervention. The latter is therefore regarded as the golden standard of conservative¦treatment and in our unit it is whenever possible offered to patients prior to lumbar surgery¦for CLBP.¦The objective of this study was to compare results of lumbar surgery between one group of¦patients who failed to improve despite such rehabilitation and a second group of patients who¦underwent surgery following usual conservative therapies. Our hypothesis is that patients¦who failed such a comprehensive treatment would respond poorly to surgery.¦Patients and Methods¦43 patients (age 41.2±8.1 years, number of men 20) were operated between 2003 and 2009¦by a single surgeon for CLBP due to degenerative disc disease (36) or isthmic¦spondylolisthesis (7). Patients with sciatica or neurological abnormalities were excluded.¦Seventeen (40%) patients were operated having failed to improve following the¦aforementioned rehabilitation programme (Surgery following rehabilitation group) whereas¦the remaining 26 (60%) were operated having failed to improve with physiotherapy of varying¦intensity (Surgery following physiotherapy group). Oswestry disability index (ODI) pre¦operatively and at 2 years following surgery was prospectively evaluated. Fisher's exact test¦was used to compare groups.¦Results¦At two years following surgery, with an average follow up of 22 month, a 15 points ODI¦improvement was achieved for 9 (53%) patients of the surgery following rehabilitation group¦and in 15 (58%) patients of the surgery following physiotherapy group (p=1.0). A 50% ODI¦improvement was observed for 6 (35%) and 12 (46%) patients respectively (p=0.54).¦Discussion¦The main finding of this study was that surgery following failed multidisciplinary rehabilitation¦yields similar results to those of patients who only received usual physiotherapy treatment for¦CLBP prior to surgery. But surprisingly we found that it is possible with surgery to improve¦the quality of life of those CLBP sufferers who failed to respond to a comprehensive¦rehabilitation program and with a similar success rate to those reported in other series.¦But rehabilitation should still be offered as a treatment option in all CLBP patients prior to¦surgery, given that it is devoid of complications and that it will spare the need of surgery to a¦significant proportion of CLBP patients while not compromising surgical results in the¦remaining subjects who failed to improve.