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Objective: To apply Lean Sigma--a quality improvement strategy to eliminate waste and reduce variation and defects--to improve audiology scheduling and utilization in a large tertiary care referral center. The project goals included an increase in utilization rates of audiology block time and a reduction in appointment lead time., Study Design: Prospective quality improvement study., Setting: Academic tertiary care center., Subjects: All patients scheduling audiology clinic visits July 2013 to July 2014., Methods: Value stream mapping was performed for the audiology scheduling process, and wasteful steps were identified for elimination. Interventions included a 2-week block release, audiology template revision, and reduction of underutilized blocks. Schedule utilization and lead time for new patient diagnostic audiogram were measured for 5 months postintervention and compared with 5 months preintervention. Overall, 2995 preintervention and 3714 postintervention booked appointments were analyzed., Results: Block utilization increased from 77% to 90% after intervention (P < .0001). Utilization of joint-with-provider visits increased from 39% to 67% (P < .0001). Booked appointments increased from 2995 to 3714, with joint-with-provider booked appointments increasing from 317 to 1193. Appointment lead time averaged 24 days postintervention, compared with 29 days preintervention (P = .06). Average monthly relative value units measured 13,321 preintervention and 14,778 postintervention (P = .09)., Conclusion: Lean Sigma techniques were successfully used to increase appointment block utilization and streamline scheduling practices., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

We present a patient with acquired immunodeficiency syndrome (AIDS) with bilateral sequential optic neuropathies attributed to the 14484 mutation of Leber hereditary optic neuropathy (LHON). We discuss the potential interaction of the mitochondrial mutation with antiretroviral therapy and review the literature.

In this article we describe a case of adolescent squamous cell carcinoma of the gingiva. The tumor presented as an ulcerative lesion of the gingiva that was originally thought to be pseudoepitheliomatous hyperplasia. The pathologic differentiation between squamous cell carcinoma and pseudoepitheliomatous hyperplasia is discussed and a review of the literature with respect to pediatric and adolescent oral squamous cell carcinoma is presented. The reported case illustrates the difficulties that may be encountered in attempting to histopathologically distinguish between pseudoepitheliomatous hyperplasia and well-differentiated squamous cell carcinoma of the oral cavity.

The specific performance of the adult hepatic parenchymal cell is maintained and controlled by factors deriving from the stromal bed; the chemical nature of these factors is unknown. This study aimed to develop a serum-free hierarchical hepatocyte-nonparenchymal (stromal) cell coculture system. Hepatic stromal cells proliferated on crosslinked collagen in serum-free medium with epidermal growth factor, basic fibroblast growth factor, and hepatocyte-conditioned medium; cell type composition changed during the 2-wk culture period. During the first wk, the culture consisted of proliferating sinusoidal endothelial cells with well-preserved sieve plates, proliferating hepatic stellate cells, and partially activated Kupffer cells. The number of endothelial cells declined thereafter; stellate cells and Kupffer cells became the prominent cell types after 8 d. Hepatocytes were seeded onto stromal cells precultured for 4-14 d; they adhered to stellate and Kupffer cells, but spared the islands of endothelial cells. Stellate cells spread out on top of the hepatocytes; Kupffer cell extensions established multiple contacts to hepatocytes and stellate cells. Hepatocyte viability was maintained by coculture; the positive influence of stromal cell signals on hepatocyte differentiation became evident after 48 h; a strong improvement of cell responsiveness toward hormones could be observed in cocultured hepatocytes. Hierarchial hepatocyte coculture enhanced the glucagon-dependent increases in phosphoenolpyruvate carboxykinase activity and messenger ribonucleic acid (mRNA) content three- and twofold, respectively; glucagon-activated urea production was elevated twofold. Coculturing also stimulated glycogen deposition; basal synthesis was increased by 30% and the responsiveness toward insulin and glucose was elevated by 100 and 55%, respectively. The insulin-dependent rise in the glucokinase mRNA content was increased twofold in cocultured hepatocytes. It can be concluded that long-term signals from stromal cells maintain hepatocyte differentiation. This coculture model should, therefore, provide the technical basis for the investigation of stroma-derived differentiation factors.

Individuals 50 years of age or older continue to account for at least 10% of AIDS cases reported to the Centers for Disease Control and Prevention in recent years. Little research is devoted to addressing the specific issues affecting diagnosis, treatment, and prevention of AIDS in older Americans. Survival rates among elderly individuals infected with human immunodeficiency virus (HIV) are consistently decreased in comparison with those for younger patients. Elderly individuals also are less likely to use a condom during sexual intercourse or to participate in routine HIV testing. This article reviews the current literature concerning the changing epidemiology of AIDS among older Americans. The article also addresses AIDS-related morbidity and mortality, treatment issues, and HIV-prevention behaviors among the elderly. Enhanced clinician awareness of HIV in the elderly, along with further research concerning HIV treatment and prevention, is necessary to improve survival and outcome for those patients.

Identifying whether an utterance is a statement, question, greeting, and so forth is integral to effective automatic understanding of natural dialog. Little is known, however, about how such dialog acts (DAs) can be automatically classified in truly natural conversation. This study asks whether current approaches, which use mainly word information, could be improved by adding prosodic information. The study is based on more than 1000 conversations from the Switchboard corpus. DAs were hand-annotated, and prosodic features (duration, pause, F0, energy, and speaking rate) were automatically extracted for each DA. In training, decision trees based on these features were inferred; trees were then applied to unseen test data to evaluate performance. Performance was evaluated for prosody models alone, and after combining the prosody models with word information--either from true words or from the output of an automatic speech recognizer. For an overall classification task, as well as three subtasks, prosody made significant contributions to classification. Feature-specific analyses further revealed that although canonical features (such as F0 for questions) were important, less obvious features could compensate if canonical features were removed. Finally, in each task, integrating the prosodic model with a DA-specific statistical language model improved performance over that of the language model alone, especially for the case of recognized words. Results suggest that DAs are redundantly marked in natural conversation, and that a variety of automatically extractable prosodic features could aid dialog processing in speech applications.

The epidemic of dually diagnosed patients with HIV disease (HIV disease coexisting with substance abuse and/or mental illness) has become increasingly recognized. This phenomenon poses potential threats to the effectiveness of HIV primary care, even when delivered by expert clinicians. This article describes implementation strategies for the provision, documentation, and third party billing of interdisciplinary, interagency HIV primary care case management within the context of an academic medical center. Our approach, which is specific to our setting, has evolved as we have attempted to define an active role for the primary care physician as a member of the case management team.

Research articles cross-indexed in Index Medicus under the subject headings "quality of life" (QOL) and "spinal cord injury" (SCI) were examined in order to compare their relative merits in terms of research design, sampling techniques and the type of QOL criteria included. Of 3,710 citations indexed for the ten year period 1983 through 1992 under "quality of life," thirty-two research articles (< 1 percent) were cross-indexed with the subject heading "spinal cord injury." The modal design was a descriptive survey or case study (n = 23 or 72 percent). None of them were randomized clinical trials. Because of limited rigor of research design and poor validity of measurements, conclusions about the ability of rehabilitative care to improve the QOL for SCI persons could not be drawn from the studies reviewed. Meta-analysis indicated that severity of injury is associated with QOL, with more severe injury being correlated with poorer quality. The critique concludes that QOL research with SCI persons needs to be better designed and should include more uniform and valid criteria.

Non-Hodgkin's lymphomas have been recognized as an important and frequently fatal part of the spectrum of diseases associated with HIV infection. These are most often high-grade B-cell lymphomas usually of immunoblastic and small cell non-cleaved subtypes. Sporadic reports of T-cell lymphomas associated with HIV infection are found in the literature. Two have been reported to be CD30 positive presenting with lymph node and skin involvement. We report a case of an AIDS patient with a T-cell anaplastic large-cell lymphoma that was CD30-positive and presented in bone. This is most probably a sporadic event rather than another part of the AIDS-associated spectrum of disease.

Objective: To examine the effect of dronabinol (delta-9-tetrahydrocannabinol) on appetite and nutritional status in patients with symptomatic HIV infection and weight loss., Design: Double-blind, randomized, placebo-controlled, crossover trial with two five-week treatment periods separated by a two-week washout period. Patients received dronabinol 5 mg twice daily before meals or placebo., Setting: A university-based HIV/AIDS clinic and a large infectious disease private practice largely devoted to care of patients with HIV., Participants: Twelve HIV-infected patients who had had at least a 2.25-kg weight loss participated in the study. Five patients completed the protocol, and seven withdrew (two because of drug intolerance, two because of disease progression, two because of noncompliance, and one because of experimental antiretroviral therapy)., Main Outcome Measures: Main outcome measures included caloric intake, weight, percent body fat, serum prealbumin, and symptom distress., Results: During dronabinol treatment, subjects experienced increased percent body fat (one percent, p = 0.04); decreased symptom distress (p = 0.04); and trends toward weight gain (0.5 kg, p = 0.13), increased prealbumin (29.0 mg/L, p = 0.11), and improved appetite score (p = 0.14)., Conclusions: In a selected group of HIV-infected patients with weight loss, short-term treatment with dronabinol may result in improvement in nutritional status and symptom distress.