Hospitalist Value in an ACO World.

The accountable care organization (ACO) concept is advocated as a promising value-based payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency. Focusing on the care of hospitalized patients and controlling a substantive portion of variable hospital expenses, hospitalists are poised to play an essential role in system-level transformational change to achieve clinical integration. Especially through hospital and health system quality improvement (QI) initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care and the patient and family caregiver experience.

The Fear-Avoidance Components Scale (FACS): Responsiveness to Functional Restoration Treatment in a Chronic Musculoskeletal Pain Disorder (CMPD) Population.

Objectives: To assess the clinical validity and factor structure of the Fear-Avoidance Components Scale (FACS), a new fear-avoidance measure.

Materials And Methods: In this study, 426 chronic musculoskeletal pain disorder patients were admitted to a Functional Restoration Program (FRP). They were categorized into 5 FACS severity levels, from subclinical to extreme, at admission, and again at discharge.

The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance.

Pain-related fear avoidance (FA), a common problem for patients with painful medical conditions, involves pain-related catastrophizing cognitions, hypervigilance, and avoidance behaviors, which can ultimately lead to decreased functioning, depression, and disability. Several patient-reported instruments have been developed to measure FA, but they have been criticized for limited construct validity, inadequate item specificity, lack of cutoff scores, and missing important FA components. The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions.

The Potential Utility of the Patient Health Questionnaire as a Screener for Psychiatric Comorbidity in a Chronic Disabling Occupational Musculoskeletal Disorder Population.

Objectives: The patient health questionnaire (PHQ) is designed for screening psychopathology in primary care settings. However, little is known about its clinical utility in other chronic pain populations, which usually have high psychiatric comorbidities.

Design: A consecutive cohort of 546 patients with chronic disabling occupational musculoskeletal disorder (CDOMD) was administered and compared upon psychosocial assessments, including the PHQ and a structured clinical interview for DSM-IV (SCID).

What is the best screening test for depression in chronic spinal pain patients?

Background Context: High prevalence rates of depression have been found in patients with chronic spinal disorder (CSD). The biopsychosocial model has become widely adopted and, with it, the role of psychopathology in the development and/or exacerbation of CSD has become increasingly recognized. Standardized diagnostic criteria, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), have been used to diagnose major depressive disorder (MDD).

Differences in regional cerebral blood flow response to a 5HT3 antagonist in early- and late-onset cocaine-dependent subjects.

5-hydroxytryptamine 3 (5HT3) receptors are important modulators of mesostriatal dopaminergic transmission and have been implicated in the pathophysiology of cocaine reward, withdrawal and self-administration. In addition, the 5HT3 antagonist ondansetron is effective in treating early-onset, but not late-onset, alcohol-dependent subjects. To explore the role of 5HT3 receptor systems in cocaine addiction using functioning imaging, we administered ondansetron to 23 abstinent, treatment-seeking cocaine-addicted and 22 sex-, age- and race-matched healthy control participants.

The development and psychometric validation of the central sensitization inventory.

Central sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term "central sensitivity syndrome (CSS)" has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs and quantifies the degree of these symptoms.

Time to Relapse Questionnaire (TRQ): a measure of sudden relapse in substance dependence.

Background: Relapse may occur suddenly, following a short period of craving, or after extended consideration. The time to relapse may reveal underlying mechanisms of relapse and have important implications for treatment.

Objective: The Time to Relapse Questionnaire (TRQ), a self-administered questionnaire, was designed to assess the time from the initial thought of drug use to actual use.

Altered neural cholinergic receptor systems in cocaine-addicted subjects.

Changes in the brain's cholinergic receptor systems underlie several neuropsychiatric disorders, including Alzheimer's disease, schizophrenia, and depression. An emerging preclinical literature also reveals that acetylcoholine may have an important function in addictive processes, including reward, learning, and memory. This study was designed to assess alterations in cholinergic receptor systems in limbic regions of abstinent cocaine-addicted subjects compared with healthy controls.

Adrenocortical and pituitary glucocorticoid feedback in abstinent alcohol-dependent women.

Background: The long-term ingestion of alcohol diminishes hypothalamic-pituitary-adrenal (HPA) axis reactivity in alcohol-dependent men, potentially altering future relapse risk. Although sex differences in HPA axis functioning are apparent in healthy controls, disruptions in this system have received little attention in alcohol-dependent women. In this study, we assessed the basal secretory profile of adrenocorticotropic hormone (ACTH) and cortisol, adrenocortical sensitivity in both the presence and absence of endogenous corticotropic pituitary activation, and feedback pituitary glucocorticoid sensitivity to dexamethasone.

Neural response to lidocaine in healthy subjects.

Recent studies suggest that some of cocaine's central nervous system (CNS) effects may be mediated through its sodium channel inhibiting local anesthetic properties. Local anesthetics that lack cocaine's strong affinity for the dopamine transporter (DAT) also produce sensory and mood effects, further suggesting a role for this neural pathway. Due to an absence of affinity at the DAT, the local anesthetic lidocaine may offer the potential to assess sodium channel activity in vivo in humans.

The role of acetylcholine in cocaine addiction.

Central nervous system cholinergic neurons arise from several discrete sources, project to multiple brain regions, and exert specific effects on reward, learning, and memory. These processes are critical for the development and persistence of addictive disorders. Although other neurotransmitters, including dopamine, glutamate, and serotonin, have been the primary focus of drug research to date, a growing preclinical literature reveals a critical role of acetylcholine (ACh) in the experience and progression of drug use.

Impulsivity, neural deficits, and the addictions: the "oops" factor in relapse.

Impulsive behaviors are observed in a wide range of psychiatric disorders, including substance use, bipolar, attention-deficit hyperactivity, antisocial and borderline personality, gambling, and eating disorders. The shared phenotype of impulsivity is thought to significantly contribute to both the etiology and perpetuation of these disorders. In this review, we focus upon the relevance of impulsivity to the addictive disorders, particularly substance use disorders.

Sex differences in medial and lateral orbitofrontal cortex hypoperfusion in cocaine-dependent men and women.

Background: The different clinical trajectories of cocaine-dependent men and women may be a consequence of distinct neurobiological substrates. Hypoperfusion of the orbitofrontal cortex (OFC) has previously been reported in individuals addicted to cocaine and has been posited as a biological mediator of relapse due to impulsivity or impaired decision making.

Objective: This study assessed regional cerebral blood flow (rCBF) between abstinent cocaine-dependent men and women and sex-matched healthy controls.

Dissection of hypothalamic-pituitary-adrenal axis pathology in 1-month-abstinent alcohol-dependent men, part 2: response to ovine corticotropin-releasing factor and naloxone.

Background: Pituitary and adrenal responsiveness is suppressed in abstinent alcohol-dependent individuals. To clarify the specific organizational disruption in hypothalamic-pituitary-adrenal functioning during early abstinence, the authors separately assessed each level of the stress-response axis. In this second of a two-part study, ovine corticotropin-releasing factor (oCRH) was used to stimulate the pituitary corticotrophs, and naloxone was used to activate the axis at the hypothalamic level.

Dissection of hypothalamic-pituitary-adrenal axis pathology in 1-month-abstinent alcohol-dependent men, part 1: adrenocortical and pituitary glucocorticoid responsiveness.

Background: Long-term ingestion of alcohol produces marked alterations in hypothalamic-pituitary-adrenal axis activity. The authors engaged in a series of studies to determine the distinct role of the hypothalamus and the pituitary and adrenal glands in the disturbances observed in abstinent alcohol-dependent subjects. In this first of a two-part study, the authors report on (1) the basal secretory profile of corticotropin and cortisol from 2000 to 0800 hrs, (2) adrenocortical sensitivity in both the presence and absence of endogenous pituitary activation, and (3) pituitary glucocorticoid sensitivity to dexamethasone.

Increased salivary cortisol concentrations during chronic alcohol intoxication in a naturalistic clinical sample of men.

Background: Cortisol, the primary glucocorticoid in humans, is intimately involved in the regulation of such varied and critical biological processes as emotion, cognition, reward, immune functioning, and energy utilization. A persistent increase in cortisol concentration as a result of chronic intoxication could therefore result in alcohol-related disorders such as sleep disruption, cognitive deficits, diabetes, and mood disturbances. Although moderate levels of acute alcohol ingestion are reported to produce an increase in cortisol levels, it is uncertain whether cortisol remains persistently increased during long-term chronic intoxication.

Regional cerebral blood flow in female cocaine-addicted subjects following limbic activation.

Background: Cocaine dependence follows a different disease course in men and women, possibly as a consequence of sex-specific neurobiologic responses to chronic cocaine use. We have previously reported that male cocaine-dependent subjects demonstrate a significantly different limbic response to the limbic-stimulus procaine, as measured by regional cerebral blood flow (rCBF), compared with male controls. In this study, we assessed the limbic rCBF response to procaine in female cocaine-addicted subjects (n=10) and female controls (n=10).

Gender differences in limbic responsiveness, by SPECT, following a pharmacologic challenge in healthy subjects.

Limbic system functioning is integral to the control and modulation of affect, motivation, reward, and memory. Neuropsychiatric disturbances involving disruptions in these cognitive and emotional dimensions exhibit different prevalence rates for men and women. Gender-specific differences in this integrated brain area may therefore be important in understanding both normal behavioral functioning and the etiologic underpinnings of neuropsychiatric disorders.

Thoracic Aortic Aneurysm Presenting as Pulmonary Vein Stenosis: A Case Presentation and Review of the Literature.

We present the case of a 66-year-old woman presenting with pulmonary vein stenosis with a large descending thoracic aortic aneurysm. Pulmonary vein stenosis is a rare condition and can be caused by extrinsic compression, as well as by inflammatory diseases, congenital anomalies and related surgical repair, tuberculosis, and pulmonary veno-occlusive disease. With obstruction to pulmonary vein flow, the velocity increases and becomes continuous.