Mercy Health - Lorain Hospital

IMPORTANCE: Eritoran is a synthetic lipid A antagonist that blocks lipopolysaccharide (LPS) from binding at the cell surface MD2-TLR4 receptor. LPS is a major component of the outer membrane of gram-negative bacteria and is a potent activator of the acute inflammatory response. OBJECTIVE: To determine if eritoran, a TLR4 antagonist, would significantly reduce sepsis-induced mortality. DESIGN, SETTING, AND PARTICIPANTS: We performed a randomized, double-blind, placebo-controlled, multinational phase 3 trial in 197 intensive care units. Patients were enrolled from June 2006 to September 2010 and final follow-up was completed in September 2011. INTERVENTIONS: Patients with severe sepsis (n = 1961) were randomized and treated within 12 hours of onset of first organ dysfunction in a 2:1 ratio with a 6-day course of either eritoran tetrasodium (105 mg total) or placebo, with n = 1304 and n = 657 patients, respectively. MAIN OUTCOME MEASURES: The primary end point was 28-day all-cause mortality. The secondary end points were all-cause mortality at 3, 6, and 12 months after beginning treatment. RESULTS: Baseline characteristics of the 2 study groups were similar. In the modified intent-to-treat analysis (randomized patients who received at least 1 dose) there was no significant difference in the primary end point of 28-day all-cause mortality with 28.1% (366/1304) in the eritoran group vs 26.9% (177/657) in the placebo group (P = .59; hazard ratio, 1.05; 95% CI, 0.88-1.26; difference in mortality rate, -1.1; 95% CI, -5.3 to 3.1) or in the key secondary end point of 1-year all-cause mortality with 44.1% (290/657) in the eritoran group vs 43.3% (565/1304) in the placebo group, Kaplan-Meier analysis of time to death by 1 year, P = .79 (hazard ratio, 0.98; 0.85-1.13). No significant differences were observed in any of the prespecified subgroups. Adverse events, including secondary infection rates, did not differ between study groups. CONCLUSIONS AND RELEVANCE: Among patients with severe sepsis, the use of eritoran, compared with placebo, did not result in reduced 28-day mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00334828.

PURPOSE: The Study of Urgent PC vs Sham Effectiveness in Treatment of Overactive Bladder Symptoms (SUmiT) was a multicenter, double-blind, randomized, controlled trial comparing the efficacy of percutaneous tibial nerve stimulation to sham through 12 weeks of therapy. The improvement in global response assessment, voiding diary parameters, and overactive bladder and quality of life questionnaires was evaluated. MATERIALS AND METHODS: A total of 220 adults with overactive bladder symptoms were randomized 1:1 to 12 weeks of treatment with weekly percutaneous tibial nerve stimulation or sham therapy. Overactive bladder and quality of life questionnaires as well as 3-day voiding diaries were completed at baseline and at 13 weeks. Subject global response assessments were completed at week 13. RESULTS: The 13-week subject global response assessment for overall bladder symptoms demonstrated that percutaneous tibial nerve stimulation subjects achieved statistically significant improvement in bladder symptoms with 54.5% reporting moderately or markedly improved responses compared to 20.9% of sham subjects from baseline (p <0.001). All individual global response assessment subset symptom components demonstrated statistically significant improvement from baseline to 13 weeks for percutaneous tibial nerve stimulation compared to sham. Voiding diary parameters after 12 weeks of therapy showed percutaneous tibial nerve stimulation subjects had statistically significant improvements in frequency, nighttime voids, voids with moderate to severe urgency and urinary urge incontinence episodes compared to sham. No serious device related adverse events or malfunctions were reported. CONCLUSIONS: This pivotal multicenter, double-blind, randomized, sham controlled trial provides level I evidence that percutaneous tibial nerve stimulation therapy is safe and effective in treating overactive bladder symptoms. The compelling efficacy of percutaneous tibial nerve stimulation demonstrated in this trial is consistent with other recently published reports and supports the use of peripheral neuromodulation therapy for overactive bladder.

PURPOSE: The Overactive Bladder Innovative Therapy trial was a randomized, multicenter, controlled study that compared the effectiveness of percutaneous tibial nerve stimulation to extended-release tolterodine. The reduction in overactive bladder symptoms along with global response assessments was evaluated. MATERIALS AND METHODS: A total of 100 adults with urinary frequency were randomized 1:1 to 12 weeks of treatment with weekly percutaneous tibial nerve stimulation or to 4 mg daily extended-release tolterodine. Voiding diaries and an overactive bladder questionnaire were completed at baseline and at the end of therapy to compare 24-hour voiding frequency, urinary urge incontinence episodes, voids causing waking, volume voided, urgency episodes and quality of life indices. Global response assessments were completed by subjects and investigators after 12 weeks of therapy. RESULTS: The global response assessment demonstrated that subject assessment of overactive bladder symptoms compared to baseline was statistically significant in the percutaneous tibial nerve stimulation arm with 79.5% reporting cure or improvement compared to 54.8% of subjects on tolterodine (p = 0.01). Assessments by investigators were similar but did not reach statistical significance (p = 0.05). After 12 weeks of therapy objective measures improved similarly in both groups for reductions in urinary frequency, urge urinary incontinence episodes, urge severity and nighttime voids, as well as for improvement in voided volume. There were no serious adverse events or device malfunctions. CONCLUSIONS: This multicenter, randomized trial demonstrates that percutaneous tibial nerve stimulation is safe with statistically significant improvements in patient assessment of overactive bladder symptoms, and with objective effectiveness comparable to that of pharmacotherapy. Percutaneous tibial nerve stimulation may be considered a clinically significant alternative therapy for overactive bladder.

PURPOSE: The Overactive Bladder Innovative Therapy Trial during phase 1 was a randomized trial demonstrating comparable effectiveness of percutaneous tibial nerve stimulation and extended-release tolterodine during 12 weeks of therapy for frequency, nocturia, urgency, voided volume and urge incontinence episodes. In this second phase of the Overactive Bladder Innovative Therapy Trial we assessed the sustained therapeutic efficacy of percutaneous tibial nerve stimulation in subjects with overactive bladder during 1 year. MATERIALS AND METHODS: After 12 weeks subjects randomized to weekly percutaneous tibial nerve stimulation with Urgent((R)) PC were offered an additional 9 months of treatment with assessments at 6 and 12 months from baseline. Outcome measures included voiding diary data, overactive bladder questionnaires, global response assessments and safety assessments. RESULTS: A total of 33 percutaneous tibial nerve stimulation responders continued therapy with 32 and 25 subjects completing 6 and 12 months of therapy, respectively. Subjects received a mean of 12.1 treatments during an average of 263 days, with a mean of 21 days (median 17) between treatments. Subject global response assessments showed sustained improvement from 12 weeks at 6 and 12 months, with 94% and 96% of responders, respectively. At 12 months mean improvements from baseline included a frequency of 2.8 voids daily (p <0.001), urge incontinence of 1.6 episodes daily (p <0.001), nocturia with 0.8 voids (p <0.05) and a voided volume of 39 cc (p <0.05). Overactive bladder questionnaire symptom severity was significantly improved from 12 weeks to 12 months (p <0.01) as well as from 6 to 12 months (p <0.01). No serious adverse events occurred. CONCLUSIONS: Statistically significant overactive bladder symptom improvement achieved with 12 weekly percutaneous tibial nerve stimulation treatments demonstrates excellent durability through 12 months. The durability of response demonstrates the effectiveness of percutaneous tibial nerve stimulation as a viable, long-term therapy for overactive bladder.

PURPOSE: We report the long-term efficacy and safety of percutaneous tibial nerve stimulation with the Urgent® PC Neuromodulation System for overactive bladder after 3 years of therapy. MATERIALS AND METHODS: Fifty participants in the randomized, double-blind SUmiT (Sham Effectiveness in Treatment of Overactive Bladder Symptoms) Trial who met the primary effectiveness end point after 12 weekly percutaneous tibial nerve stimulation treatments were enrolled in this prospective study to assess long-term outcomes with percutaneous tibial nerve stimulation. STEP (Sustained Therapeutic Effects of Percutaneous Tibial Nerve Stimulation) Study patients were prescribed a fixed schedule 14-week tapering protocol followed by a personal treatment plan aimed at sustaining overactive bladder symptom improvement. Overactive bladder and quality of life questionnaires were completed every 3 months and 3-day voiding diaries were completed every 6 months. RESULTS: A total of 29 patients completed the 36-month protocol and received a median of 1.1 treatments per month after a 14-week treatment tapering protocol. A Bayesian model estimated that 77% (95% CI 64-90) of patients maintained moderate or marked improvement in overactive bladder symptoms at 3 years. Compared to baseline, median voids per day decreased from 12.0 (IQR 10.3-13.7) to 8.7 (IQR 7.3-11.3), nighttime voids per night decreased from 2.7 (IQR 1.7-3.3) to 1.7 (IQR 1.0-2.7) and urge incontinence episodes per day decreased from 3.3 (IQR 0.7-6.0) to 0.3 (IQR 0.0-1.0) (all p <0.0001). All quality of life parameters remained markedly improved from baseline through 3 years (all p <0.0001). One patient experienced 2 mild treatment related adverse events of bleeding at the needle site during followup. CONCLUSIONS: Most STEP participants with an initial positive response to 12 weekly percutaneous tibial nerve stimulation treatments safely sustained overactive bladder symptom improvement to 3 years with an average of 1 treatment per month.

PURPOSE: Physician-obtained medication histories were compared to those obtained by a pharmacist. METHODS: Patients whose medication histories were obtained were included in the evaluation if they were at least 18 years old and admitted to an internal medicine service at the University of Virginia Medical Center. Data were collected in two phases. The first 20 patients identified for inclusion were asked to provide an accurate medication history to pilot test the medication history form used by the pharmacist and received no pharmacist follow-up or interventions. In the second phase, patients were asked to provide an accurate medication history, and a pharmacist intervened when discrepancies in the pharmacist-obtained medication history were identified. RESULTS: A total of 55 patients were included in the study. The pharmacists identified 614 medications for these patients, compared with 556 identified by the physicians (p < or = 0.001). The pharmacist documented significantly more medication doses and dosage schedules than did physicians (614 versus 446 and 614 versus 404, respectively) (p < or = 0.001 for both comparisons). The pharmacist identified 353 discrepancies, including 58 medications not initially identified from the physician-obtained histories. The pharmacist intervened for 161 discrepancies, correcting 142 after contacting the respective physician; 19 medication discrepancies could not be justified by the physician. CONCLUSION: A total of 353 discrepancies were identified when medication histories obtained by physicians were compared with those obtained by a pharmacist during the study. During the intervention phase, the majority of discrepancies identified were either corrected by the pharmacist after contacting the respective physician or justified by the physician.

Emergency medicine (EM) program directors have expressed a desire for more evaluative data to be included in application materials. This is consistent with frustrations expressed by program directors of multiple specialties, but mostly by those in specialties with more competitive matches. Some of the concerns about traditional narrative letters of recommendation included lack of uniform information, lack of relative value given for interval grading, and a perception of ambiguity with regard to terminology. The Council of Emergency Medicine Residency Directors established a task force in 1995 that created a standardized letter of recommendation form. This form, to be completed by EM faculty, requests that objective, comparative, and narrative information be reported regarding the residency applicant.

No abstract available

The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and therapeutic role of raloxifene hydrochloride are reviewed. Raloxifene is a selective estrogen-receptor modulator (SERM) that has been approved for use in the prevention and treatment of osteoporosis in postmenopausal women. A SERM interacts with estrogen receptors, functioning as an agonist in some tissues and an antagonist in other tissues. Because of their unique pharmacologic properties, these agents can achieve the desired effects of estrogen without the possible stimulatory effects on the breasts or uterus. Raloxifene is rapidly absorbed from the gastrointestinal tract and undergoes extensive first-pass glucuronidation. Approximately 60% of a dose is absorbed; however, absolute bioavailability is only 2%. The volume of distribution is 2348 L/kg for a single oral dose of 30-150 mg, and the elimination half-life averages 32.5 hours. In clinical trials in postmenopausal women, raloxifene had an estrogen-like effect on bone turnover and increased bone mineral density. It reduced the risk of fractures in women with osteoporosis. Raloxifene also seemed to reduce the risk of breast cancer and positively influenced blood lipid markers of cardiovascular disease. Raloxifene is generally well tolerated; the most common adverse effects are hot flashes and leg cramps. A serious adverse effect is venous thromboembolism. The recommended dosage is 60 mg/day orally without regard to meals. Ultimately, it will be information on cardiovascular or breast cancer benefits that will determine the future role of raloxifene. Raloxifene is an alternative to traditional hormone replacement therapy for the prevention and treatment of osteoporosis in selected postmenopausal women. More study is needed to verify possible benefits related to heart disease and breast cancer.

BACKGROUND: The National Quality Forum (NQF) has endorsed a performance measure designed to increase imaging efficiency for the evaluation of pulmonary embolism (PE) in the emergency department (ED). To our knowledge, no published data have examined the effect of patient-level predictors on performance. METHODS: To quantify the prevalence of avoidable imaging in ED patients with suspected PE, we performed a prospective, multicenter observational study of ED patients evaluated for PE from 2004 through 2007 at 11 US EDs. Adult patients tested for PE were enrolled, with data collected in a standardized instrument. The primary outcome was the proportion of imaging that was potentially avoidable according to the NQF measure. Avoidable imaging was defined as imaging in a patient with low pretest probability for PE, who either did not have a D-dimer test ordered or who had a negative D-dimer test result. We performed subanalyses testing alternative pretest probability cutoffs and imaging definitions on measure performance as well as a secondary analysis to identify factors associated with inappropriate imaging. χ(2) Test was used for bivariate analysis of categorical variables and multivariable logistic regression for the secondary analysis. RESULTS: We enrolled 5940 patients, of whom 4113 (69%) had low pretest probability of PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49). CONCLUSIONS: One-third of imaging performed for suspected PE may be categorized as avoidable. Improving adherence to established diagnostic protocols is likely to result in significantly fewer patients receiving unnecessary irradiation and substantial savings.

This survey assessed rural parents' (n = 374) perceptions of the characteristics, content, and comfort level of discussions about sexual issues with their teens. Almost all parents (94%) reported they had talked with their teens about sex. Two-thirds (65%) reported being comfortable talking with their teens about sexual issues. From a list of 17 potential topical areas in sexual communication, parents were most likely to discuss with their teens the responsibilities of being a parent (46%), sexually transmitted diseases (40%), dating behavior (37%), and not having sex until marriage (36%). Most parents (80%) believed that the majority of sexuality education should be provided by the family and supplemented by outside organizations, preferably schools. Almost all parents (92%) believed sexuality education should include information on birth control methods including condoms. Almost two of three parents (64%) believed schools should begin teaching sexuality education before students reach seventh grade. Parents (52%) claimed they could best be helped in communicating with their teens by receiving a regular newsletter regarding teen sexual issues.

AIMS: To evaluate the safety, sustained effectiveness, and treatment interval for percutaneous tibial nerve stimulation (PTNS) for overactive bladder (OAB) therapy through 24 months. METHODS: A prospective study following treatment success after 12 weekly PTNS treatments, subjects were prescribed a 14-week tapering protocol, followed by ongoing therapy with a Personal Treatment Plan determined by the investigator and subject to sustain subject OAB symptom improvement. Questionnaires were completed every 3 months, voiding diaries every 6 months; adverse events were reported throughout. RESULTS: Of 50 subjects enrolled, 35 remained in the study at 24 months. During the 24 months following initial treatment success and a 14-week tapering protocol, mean treatments per month was 1.3. Voiding diary and OAB-q data demonstrate sustained improvement reported at 13 weeks through 24 months. Improvements in frequency, urge incontinence episodes, night-time voids and moderate-to-severe urgency episodes from voiding diaries at 6, 12, 18, and 24 months were statistically significant compared to baseline (prior to initial 12 weekly treatments). Compared to baseline, OAB-q symptom severity scores and health related quality of life scores were statistically significant for improvement at each tested time point. Five mild adverse events of unknown relation to treatment were reported. CONCLUSION: Sustained safety and efficacy of PTNS were demonstrated over 24 months with initial success after 12 weekly treatments, followed by a 14-week prescribed tapering protocol and a Personalized Treatment Plan. With an average of 1.3 treatments per month, PTNS therapy is a safe, durable, and valuable long-term OAB treatment option to sustain clinically significant OAB symptom control.

BACKGROUND: The laparoscopic vertical sleeve gastrectomy (LSG) is derived from the biliopancreatic diversion with duodenal switch operation (Marceau et al., Obes Surg 3:29-35, 1993; Hess and Hess, Obes Surg 8:267-82, 1998; Chu et al., Surg Endosc 16:S069, 2002). Later, LSG was advocated as the first step of a two-stage procedure for super-obese patients (Regan et al., Obes Surg 13:861-4, 2003; Cottam et al., Surg Endosc 20:859-63, 2006). However, recent support is mounting that continues to establish LSG as the definitive procedure for surgical treatment of morbid obesity. We will report our experience with the LSG as a primary bariatric procedure and evaluate if this operation is suitable as a stand-alone procedure. METHODS: The study is a nonrandomized retrospective analysis of 204 patients from a single surgeon operated between July 2006 and April 2010. The study comprises of 155 women and 49 men with a mean age of 45 years (range, 19-70 years), a mean preoperative weight of 126.6 kg, and body mass index (BMI) of 45.7 kg/m(2). RESULTS: The mean percent excess weight loss (%EWL) was 49.9% (n = 159), 64.2% (n = 138), 67.9% (n = 77), 62.4% (n = 34), and 62.2% (n = 9) at 3, 6, 12, 24, and 36 months, respectively. For patients with BMI ≤43.0, the mean postoperative %EWL was 58.9% (n = 72), 74.1% (n = 67), 75.8% (n = 39), 72.1% (n = 17), and 78.7% (n = 5) at 3, 6, 12, 24, and 36 months, respectively. Operative complications include leak (0.0%), abscess (0.5%), hemorrhage (1.0%), sleeve stricture (1.0%), and severe gastroesphogeal reflux disease with need to convert to laparoscopic Roux-en-Y gastric bypass (0.5%). CONCLUSIONS: LSG yields excellent outcomes with low complication rates for morbidly obese patients. We advocate LSG as a safe and effective stand-alone procedure, especially with the lower BMI population (BMI 35.0-43.0 kg/m(2)).

BACKGROUND: Some practitioners and investigators have presumed relationships between pain scores and heart rate, blood pressure, or respiratory rate. Previous literature has not adequately addressed the association of pain and vital signs. OBJECTIVES: To identify any association between self-reported pain and heart rate, blood pressure, or respiratory rate. METHODS: In this retrospective, observational study, emergency department patients older than 17 years of age presenting between May 2004 and April 2005 with verifiable painful diagnoses (including nephrolithiasis, myocardial infarction, small bowel obstruction, fracture, burn, crush injury, stab wound, amputation, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital's database, including patients' age, gender, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate. RESULTS: Among 1,063 subjects, the most common diagnoses were nephrolithiasis (25%; n = 267) and fracture (23%; n = 249). The mean (+/- SD) triage pain score was 7 (+/- 3). The mean (+/- SD) heart rate was 85 (+/- 16) beats/min, mean (+/- SD) systolic blood pressure was 141 (+/- 23) mm Hg, and mean (+/- SD) respiratory rate was 19 (+/- 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores. CONCLUSIONS: No clinically significant associations were identified between self-reported triage pain scores and heart rate, blood pressure, or respiratory rate.

The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, interactions, and formulary considerations of atorvastatin relative to other hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) are discussed. Atorvastatin calcium, a synthetic stereoisomer of a pentasubstituted pyrrole, prevents the conversion of HMG-CoA by competitive and selective inhibition of HMG-CoA reductase. This limits cholesterol formation. Atorvastatin undergoes extensive first-pass metabolism; the first-pass effect is saturable at higher doses. Time to maximum plasma concentration ranges from one to four hours. The plasma elimination half-life is considerably longer than for other statins. Like other statins, atorvastatin reduces low-density-lipoprotein cholesterol (LDL-C) and total cholesterol in patients with hypercholesterolemia. However, the reductions achieved with atorvastatin exceed those for other statins. Atorvastatin recipients are more likely to achieve LDL-C goals and to do so more quickly. Atorvastatin also moderately reduces triglyceride levels in patients with hypertriglyceridemia and may play a role in the management of familial hypercholesterolemia. Adequate lipid control with atorvastatin monotherapy may preclude the need for combination drug therapy in some patients. The adverse effects of atorvastatin include mild gastrointestinal disturbances, increased liver enzyme levels, and myalgia. Drug interactions involving atorvastatin can be expected to parallel those of other statins metabolized via CYP3A4. Atorvastatin has become a popular addition to hospital formularies, even though formal pharmacoeconomic analyses are lacking. Atorvastatin effectively reduces blood lipids and may offer some advantages over other statins, but more studies are needed to clarify its optimal role in pharmacotherapy.

BACKGROUND AND OBJECTIVES: The Communication Assessment Tool (CAT), developed by Makoul et al assesses patient perceptions of physicians' interpersonal and communication skills. The objective of this study was to gather initial benchmarking data for the use of the CAT in family medicine residency programs. METHODS: Data were collected from patients seeing 127 residents from six family medicine residency programs. A total of 1,931 patients completed the paper and pencil version of the CAT following an appointment with a resident; 1,880 of the CAT forms met the inclusion criteria for analysis. RESULTS: The overall mean percentage of items from which residents were rated as excellent was 69.7%. Significant differences were found in the overall percentage of items rated as excellent based on training year, with PGY-1 (77.0%) residents being rated significantly higher than PGY-2 (69.5%) and PGY-3 (68.1%) residents. There were no significant differences found in the overall percentage of items rated as excellent based on the native language or gender of the residents. CONCLUSIONS: This initial benchmarking data can allow family medicine residency programs to compare the performance of their residents with the performance of residents from other programs. We recommend that the results of the CAT be used as both an evaluative and learning tool.

BACKGROUND: Clinical data on the efficacy of laser capsulorrhaphy for the treatment of multidirectional instability of the shoulder are limited. HYPOTHESIS: The diagnosis of multidirectional instability includes a spectrum of pathologic symptoms that warrants subclassification; laser capsulorrhaphy alone is not uniformly effective for all subtypes. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Twenty-five shoulders in 21 patients were treated with laser capsulorrhaphy for multidirectional instability. Functional outcomes at a mean duration of 32 months' follow-up (range, 24 to 48 months) were recorded. RESULTS: Instability recurred in 60% of patients with congenital multidirectional instability, 17% of patients with acquired multidirectional instability, and 33% of patients with posttraumatic multidirectional instability (overall recurrence rate, 40%). Generalized ligamentous laxity was a risk factor for recurrence. Patient satisfaction rates were 40%, 83%, and 22% for the congenital, acquired, and posttraumatic subgroups. Reasons for dissatisfaction included recurrent instability, persistent pain, and inability to return to athletic activity at desired capacity. The overall mean postoperative Simple Shoulder Test score was 84%. The mean postoperative numeric rating score for pain was 3.3 (10-point scale). CONCLUSIONS: Laser capsulorrhaphy may be effective for patients with acquired multidirectional instability secondary to repetitive microtrauma but is less predictable in the other subgroups.

Nurses often hear clients and their families express a strong desire to "go home" from the hospital or nursing home. The purpose of this article is to explore what they mean when they make this request and how this meaning of home can shape the practice of home and hospice care. To do this, definitions of home and a health-at-home model are described and applied through a case study.

Although depressive and anxious symptoms frequently coexist, clinical studies have tended to separate anxiety disorders from depression. A number of developments are now reversing this trend. One of these developments is the reworking of the concept of generalized anxiety disorder (GAD) from that of a residual category (anxiety after all other anxiety disorders are removed) to a generalized anxiety syndrome that includes symptoms of mild depression that are less severe than the symptoms of anxiety. GAD is thereby expanded to a broader concept, namely mixed anxiety/depression (MAD). A second major development, however, posits a different definition of MAD: a stable core of subsyndromal symptoms that do not reach the threshold for the diagnosis of GAD or depression, but which, under stress, will decompensate to an overt anxiety disorder or depression.

BACKGROUND AND PURPOSE: Obstructive sleep apnea (OSA) is common after acute ischemic stroke and predicts poor stroke recovery, but whether screening for OSA and treatment by continuous positive airway pressure (CPAP) improves neurological outcome is unknown. We used a cost-effectiveness model to estimate the magnitude of benefit that would be necessary to make polysomnography (PSG) and OSA treatment cost-effective in stroke patients. METHODS: A decision tree modeled 2 alternative strategies: PSG followed by 3 months of CPAP for those found to have OSA versus no screening. The primary outcome was the utility gained through OSA screening and treatment in relation to 2 common willingness-to-pay thresholds of $50,000 and $100,000 per quality-adjusted life year (QALY). RESULTS: Screening resulted in an incremental cost-effectiveness ratio of $49,421 per QALY. Screening is cost-effective as long as the treatment of stroke patients with OSA by CPAP improves patient utilities by >0.2 for a willingness-to-pay of $50,000 per QALY and 0.1 for a willingness-to-pay of $100,000 per QALY. CONCLUSIONS: A clinical trial assessing the effectiveness of CPAP in improving stroke outcome is warranted from a cost-effectiveness standpoint.