Defining treatment success in children with surgical conditions.

OBJECTIVES: Develop a score summarising how successfully a child with any surgical condition has been treated, and test the clinical validity of the score. DESIGN: Discrete choice experiment (DCE), and secondary analysis of data from six UK-wide prospective cohort studies. PARTICIPANTS: 253 people with lived experience of childhood surgical conditions, 114 health professionals caring for children with surgical conditions and 753 members of the general population completed the DCE. Data from 1383 children with surgical conditions were used in the secondary analysis. MAIN OUTCOME MEASURES: Normalised importance value of attribute (NIVA) for number/type of operations, hospital-treated infections, quality of life and duration of survival (reference attribute). RESULTS: Quality of life and duration of survival were the most important attributes in deciding whether a child had been successfully treated. Parents, carers and previously treated adults placed equal weight on both attributes (NIVA=0.996; 0.798 to 1.194). Healthcare professionals placed more weight on quality of life (NIVA=1.469; 0.950 to 1.987). The general population placed more weight on survival (NIVA=0.823; 95% CI 0.708 to 0.938). The resulting score (the Children's Surgery Outcome Reporting (CSOR) Treatment Success Score (TSS)) has the best possible value of 1, a value of 0 describes palliation and values less than 0 describe outcomes worse than palliation. CSOR TSSs varied clinically appropriately for infants whose data were included in the UK-wide cohort studies. CONCLUSIONS: The CSOR TSS summarises how successfully children with surgical conditions have been treated, and can therefore be used to compare hospitals' observed and expected outcomes.

Practice variation in physician referral for allogeneic hematopoietic cell transplantation.

Hematological malignancy patients not referred by their primary hematologist/medical oncologist suffer disparate access to allogeneic hematopoietic cell transplantation (HCT). However, investigation into physician, system and patient factors relevant to this decision making is lacking. We surveyed a national randomized sample of practicing hematologists/medical oncologists identified through the AMA (American Medical Association) masterfile. A modified Dillman approach was utilized to encourage survey response. From 1200 surveyed, a total of 113 physicians responded. In all, 68% were male, 62% identified as White/non-Hispanic, 79% practiced in non-academic settings and 80% reported spending 75-100% of their professional effort in clinical care. Using clinical vignettes, we detected significantly increased odds for HCT non-referral according to age (age 60 vs 30, odds ratio (OR) 8.3, 95% confidence interval (CI): 5.9-11.7, P<0.0001), insurance coverage (no coverage vs coverage, OR 6.9, 95% CI: 5.2-9.1, P<0.0001) and race (African-American vs Caucasian, OR 2.4, 95% CI: 1.9-2.9, P<0.0001). Physician (perception of HCT risks), system (insurance coverage) and patient (age, social support and co-morbid illness) factors were strongly endorsed by respondents as important determinants of their HCT referral practices. These data speak to important factors relevant to HCT referral practices, and highlight several opportunities for education and intervention to reduce current disparities.

Regulation of cell cycle progression by Swe1p and Hog1p following hypertonic stress.

Exposure of yeast cells to an increase in external osmolarity induces a temporary growth arrest. Recovery from this stress is mediated by the accumulation of intracellular glycerol and the transcription of several stress response genes. Increased external osmolarity causes a transient accumulation of 1N and 2N cells and a concomitant depletion of S phase cells. Hypertonic stress triggers a cell cycle delay in G2 phase cells that appears distinct from the morphogenesis checkpoint, which operates in early S phase cells. Hypertonic stress causes a decrease in CLB2 mRNA, phosphorylation of Cdc28p, and inhibition of Clb2p-Cdc28p kinase activity, whereas Clb2 protein levels are unaffected. Like the morphogenesis checkpoint, the osmotic stress-induced G2 delay is dependent upon the kinase Swe1p, but is not tightly correlated with inhibition of Clb2p-Cdc28p kinase activity. Thus, deletion of SWE1 does not prevent the hypertonic stress-induced inhibition of Clb2p-Cdc28p kinase activity. Mutation of the Swe1p phosphorylation site on Cdc28p (Y19) does not fully eliminate the Swe1p-dependent cell cycle delay, suggesting that Swe1p may have functions independent of Cdc28p phosphorylation. Conversely, deletion of the mitogen-activated protein kinase HOG1 does prevent Clb2p-Cdc28p inhibition by hypertonic stress, but does not block Cdc28p phosphorylation or alleviate the cell cycle delay. However, Hog1p does contribute to proper nuclear segregation after hypertonic stress in cells that lack Swe1p. These results suggest a hypertonic stress-induced cell cycle delay in G2 phase that is mediated in a novel way by Swe1p in cooperation with Hog1p.

Vice president Al Gore's health care agenda and the utilization of medical services: An empirical analysis.

OBJECTIVE: To estimate the impact of Vice President Al Gore's healthcare agenda on the utilization of physician and hospital services among 4 uninsured target populations: parents of publicly insured children; near elderly adults, ages 55-64; employed adults with disabilities; and adults employed in small firms or self-employed. METHODS: From the 1993 National Health Interview Survey, we select 4 representative samples of uninsured adults, ages 18-64, corresponding to the target groups described in Gore's healthcare agenda. For each adult in these samples, we estimate the change in medical service utilization caused by becoming insured using results from Craig and Ko.[1] The weighted average of these estimates represents the expected change in medical service utilization attributable to insurance. RESULTS: The increase in the utilization caused by insurance depends on the target group and the service in question. The increase in utilization of physician visits is 16% among parents of publicly insured children, 37% among the near elderly, 8% among the employed, disabled adults, and 21% among the self-employed. This effect is small compared with the increase in surgical procedures (31%, 110%, 316%, and 101%, respectively). However, given the size of the US healthcare system, this amounts to about a 0.5% increase in the production of medical services. Even if a universal coverage plan were instated in place of Gore's incremental coverage plan, production would increase by about 2%. CONCLUSIONS: Points 2 through 5 of Vice President Al Gore's healthcare agenda have an impact on the utilization of medical care by the 4 target populations. However, this impact varies by service and population, and its system-wide impact on the production of care is minor.

Monocyte tissue factor-like activity in post myocardial infarction patients.

It is widely recognized that thrombosis is the major event in the evolution of stable vascular disease to unstable ischaemic syndromes including myocardial infarction and stroke. The purpose of this case-control study was to establish clinical and laboratory data on the possible relationship between specific components of the haemostatic system and coronary heart disease. The procoagulant activity (PCA) of peripheral monocytes and polymorphonuclear neutrophils was assessed in 21 males who had suffered a myocardial infarction (MI) and in age-matched controls. In addition, total factor VII activity, fibrinogen, tissue factor pathway inhibitor (TFPI). D-dimers, tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI-1), tumour necrosis factor-alpha (TNF-alpha) and full blood counts were measured. Post MI patients had significantly higher monocyte PCA, higher plasma concentrations of TFPI, fibrinogen, t-PA, T/P100 and also higher total white blood cell and neutrophil counts compared to age-matched controls. This elevated procoagulant state in post MI patients could further exacerbate the disease process and increase the risk of subsequent acute ischaemic events.

The assessment of platelet derived growth factor concentration in post myocardial infarction and stable angina patients.

Platelet derived growth factor (PDGF) has been implicated in the pathogenesis of atherosclerosis. PDGF is released by aggregating platelets and monocytes which gather around sites of arterial injury. In the study reported here the concentration of plasma PDGF was measured in post myocardial infarction (MI) patients (n = 28), angina patients (n = 25), and control subjects (n = 27). Venous blood samples were taken and the concentration of PDGF determined by an enzyme linked immunosorbent assay (ELISA). Plasma PDGF concentrations were significantly higher in the post MI group compared to both the control and angina groups (P < or = 0.05). The increase in PDGF concentration may be due to increased activation of platelets or monocytes since these two cells are major sources of plasma PDGF. High concentrations of PDGF in the circulation could further accelerate the progression of the disease.

Cystic lesions of the prostate.

As the use of ultrasound (US) for evaluating the prostate gland has grown, so has the variety of cystic prostatic lesions that can be identified with US. We review many of these cystic lesions seen in our department over the past several years. Lesions discussed include müllerian duct cyst, prostatic utricle cyst, ejaculatory duct cyst, cystic degeneration in benign prostatic hyperplasia, prostatic retention cyst, cavitary prostatitis, and prostatic abscess. The defect from transurethral resection of the prostate gland, which may have a sonographic appearance similar to that of a cystic prostatic mass, is also discussed. A diagnostic algorithm based on a combination of sonographic findings and the results of transperineal needle aspiration is presented.

Acute diverticulitis in patients under 40 years of age: radiologic diagnosis.

During a 4-year period, eight patients 40 years old or younger had surgically proved diverticulitis at our institution. None of these patients had connective-tissue diseases or were on medication (i.e., steroids) that would predispose them to diverticulosis. The presenting clinical symptoms in this group of patients were often misleading, and in only one of the eight cases was the correct clinical diagnosis made at the time of admission. Of the three diagnostic studies that were performed (barium enema, sonography, and CT), barium enema was the most accurate, yielding evidence for diverticulitis in six of seven cases. The degree and extent of diverticulosis in these patients was minimal compared with that in the older patients. CT showed abdominal abscesses in two patients; in one, a mistaken diagnosis of Crohn disease was made; in the other, diverticulitis was correctly identified. In the three patients in whom sonography was performed, the findings were negative for diverticulitis. Our experience suggests that the diagnosis of acute diverticulitis should be considered in patients with abdominal pain who are less than 40 years old.

Computed tomography of vena caval anomalies with embryologic correlation.

Vena caval and left renal vein anomalies are not uncommon and are easily identified by CT, usually in an incidental fashion. A simple classification of these anomalies is presented (Table I). These anomalies become significant only when they are mistaken for pathologic masses or when one is planning surgical or radiologic vascular procedures. Detailed knowledge of these anomalies, in conjunction with the use of dynamic bolus CT, will permit easy diagnosis in nearly all cases.