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Continuing medical education providers accredited by the Accreditation Council for Continuing Medical Education (ACCME) may apply organizational assessment strategies beyond the ACCME Essential Areas, Elements, and Criteria. The Malcolm Baldrige National Quality Program offers an organizational assessment strategy commonly used in business, health care, and education settings. An analysis of both standards pointed out useful associations between the ACCME Essential Areas and the Baldrige National Quality Program Education Criteria (2003). Including leadership, governance, and social responsibility, the Baldrige Education Criteria provide a more comprehensive organizational assessment and stronger emphasis on a wider variety of results. The present analysis suggests that a continuing medical education provider could meet, and possibly exceed, the ACCME standards by applying the Baldrige Education Criteria in a 'self-study' process to define, measure, monitor, and document fundamental organizational responsibilities and performance. [ABSTRACT FROM AUTHOR]

Personalized medicine in the treatment of cancer is based on the recognition that molecularly targeted therapies are most effective in patients whose tumors carry specific genetic or genomic alterations. These alterations, which often activate oncogenes that encode the components of signal transduction pathways, serve as predictive markers for sensitivity or resistance of individual tumors to drugs that target such pathways. In the recent past, individual mutations and other changes within tumors have been assayed to determine the likelihood of response or nonresponse to specific targeted therapies. However, with the development of increasing numbers of molecularly targeted drugs, attention has shifted to high-throughput testing of tumors for dozens of predictive markers. This approach to predictive testing has been termed molecular tumor profiling. This review describes the background to this field, the principal markers analyzed, and the methodologies that are being utilized or are under development for tumor profiling.

Unlabelled: Nonsteroidal antiinflammatory drugs (NSAIDs) provide effective postoperative analgesia after arthroscopic knee surgery. Some investigators have suggested that the preemptive administration of NSAIDs may reduce postoperative analgesic requirements and hypersensitivity. We evaluated the analgesic effect of administering rofecoxib either before or after surgical incision in patients undergoing arthroscopic knee surgery under local anesthesia. Sixty patients undergoing arthroscopic meniscectomy were randomized into three groups. All patients received intraarticular bupivacaine 0.25% pre- and postsurgery together with IV sedation using midazolam and propofol. The Preincisional group received a single 50 mg dose of rofecoxib 1 h before surgery, the Postincisional group received rofecoxib 50 mg after the completion of surgery, and the Placebo group received a placebo tablet before surgery. Pain scores, the time to first opioid use, and 24-h analgesic use were recorded. Analgesic duration, defined as the time from completion of surgery until first opioid use, was significantly longer in those patients receiving pre- (803 +/- 536 min) versus postincisional (461 +/- 344 min) rofecoxib or placebo (318 +/- 108 min). The 24 h acetaminophen/oxycodone use was less in the Preincisional group (1.5 +/- 0.6 pills) versus the Postincisional group (3.3 +/- 1.3 pills) or the Placebo group (5.5 +/- 1.6 pills). Pain scores with movement were lower in the Preincisional group at all postoperative time intervals. We conclude that rofecoxib provides effective postoperative analgesia for arthroscopic meniscectomy. Further, the administration of rofecoxib 50 mg before surgery provides a longer duration of postoperative analgesia, less 24 h opioid use, and lower incidental pain scores compared with administering the drug after the completion of surgery., Implications: The administration of rofecoxib 50 mg before arthroscopic knee surgery provides a longer duration of analgesia, less 24-h opioid use, and lower pain scores than administering the drug after the completion of surgery.

Unlabelled: Intraarticular (IA) morphine provides effective postoperative analgesia after arthroscopic knee surgery. Some investigators have suggested that the preemptive administration of opioids may reduce postoperative analgesic requirements and hypersensitivity. We evaluated the analgesic effect of administering IA morphine either before or after surgical incision in patients undergoing arthroscopic knee surgery under local anesthesia. Forty patients undergoing arthroscopic meniscectomy were randomized into two groups. All patients received IA bupivacaine 0.25% before and after surgery together with IV sedation using midazolam and propofol. The Preemptive IA Morphine group received a single 3-mg dose of morphine with their preoperative bupivacaine. The Post-IA Morphine group received 3 mg of morphine at the completion of surgery with the postoperative bupivacaine. After surgery, pain scores, the time to first opioid use, and 24-h analgesic use were recorded. Analgesic duration, defined as the time from completion of surgery until first opioid use, was significantly longer in those patients receiving preoperative (953 +/- 209 min) versus postoperative (556 +/- 121 min) IA morphine. The 24-h acetaminophen and oxycodone use was less in the Preemptive group (2.2 +/- 1.2 pills) versus the Postoperative group (3.0 +/- 1.2 pills). We conclude that IA morphine provides a longer duration of postoperative analgesia with less 24-h opioid use when administered before surgery., Implications: The administration of intraarticular morphine 3 mg before arthroscopic knee surgery provides a longer duration of analgesia with less 24-h opioid use compared with the administration of the drug at the completion of surgery.

Both clonidine, an alpha(2) agonist, and morphine, an opioid agonist, provide enhanced patient analgesia after arthroscopic knee surgery when administered via the intraarticular (IA) route. Clonidine potentiates morphine analgesia in the animal model. We designed this study to determine whether clonidine or morphine results in better analgesia and whether their combination would provide superior analgesia to either drug alone. We evaluated 60 patients undergoing arthroscopic knee meniscus repair under local anesthesia with sedation. After surgery, patients were randomized into four IA groups: Group B received 30 mL 0.25% bupivacaine; Group BC received 30 mL 0.25% bupivacaine and clonidine 1 microg/kg; Group BM received 30 mL 0.25% bupivacaine and morphine 3 mg; and Group BCM received 30 mL 0.25% bupivacaine, clonidine 1 microg/kg, and morphine 3 mg. This study revealed a significant benefit from the individual IA administration of both clonidine and morphine. The combination of these drugs resulted in decreased postoperative pain and analgesic use, as well as an increased analgesic duration compared with either drug alone. We conclude that IA clonidine and morphine improved comfort compared with either drug alone in patients undergoing knee arthroscopy.

We compared the effects of a cardioselective beta-adrenergic blocking drug, metoprolol, with a nonselective beta-adrenergic blocker, propranolol, on the response of 10 normal men to dynamic treadmill exercise. The volunteers underwent a standard graded exercise test to exhaustion while receiving placebo; propranolol, 40 mg every 6 hours; propranolol, 80 mg every 6 hours; metoprolol, 50 mg every 6 hours; or metoprolol, 100 mg every 6 hours. The drugs were given in a double-blind fashion for 48 hours before exercise. Five days were allowed between successive drug administrations and the order of drug administration was randomized. Heart rate, arterial pressure, oxygen consumption, minute ventilation and CO2 production were monitored. Plasma drug concentrations were measured at the time of exercise. Judged by plasma levels, propranolol was about three times more potent than metoprolol in attenuating heart rate. Both drugs produced a wide variation in plasma levels after a given oral dose, and both drugs attenuated the systolic blood pressure response to exercise. Neither drug affected diastolic blood pressure or maximum oxygen consumption, maximum minute ventilation or the anaerobic threshold. We conclude that there is no evidence that the cardioselective drug metoprolol is superior to propranolol in terms of the ability to perform or respond to short-term maximal exercise. In addition, the fact that maximal oxygen consumption and the anaerobic threshold were unaffected implies that fatigue during exercise while on beta-adrenergic blocking drugs is not due to an effect of these drugs in limiting blood flow to the exercising extremities.

We extended the quantitative seven-pinhole method to follow the dynamics of thallium redistribution after exercise. We observed a pattern of slow late thallium clearance that appears to be characteristic of myocardium supplied by obstructed coronary arteries. In 28 subjects, quantitative thallium scintigrams (seven-pinhole tomography, circumferential count profiles) and blood samples for thallium concentration were taken immediately, 2 hours and 4 hours after maximal treadmill exercise. Twenty subjects had coronary artery disease (CAD) and eight were normal. The rate of thallium clearance from the blood (TCB) was compared with the rate of thallium clearance from each segmental region of myocardium (TCM, derived by ratioing corresponding segments of the absolute circumferential count profiles) between the 2- and 4-hour images. In seven of the eight normal subjects, TCM exceeded TCB in all regions of all images (specificity 88%). Seventeen of the 20 CAD patients had at least one region where TCM was less than TCB (sensitivity 85%). Of the 13 patients with multivessel CAD, 11 had multiple regions with TCM less than TCB. Using this criterion, we detected 31 of 39 obstructed coronary arteries. Of the 37 regions that were abnormal by this analysis, 30 corresponded to obstructed coronary arteries. In contrast, while conventional circumferential count profile analysis also was abnormal in 17 of the 20 CAD patients, it diagnosed multivessel CAD in only five of the 13 patients that had it. These results show that slow late thallium clearance from myocardium is characteristic of regions of myocardium supplied by diseased coronary arteries and that observation of this phenomenon may improve diagnostic sensitivity for the presence of multivessel CAD.