Hidradenitis Suppurativa Area and Severity Index Revised (HASI-R): psychometric property assessment.

BACKGROUND: Validated, reliable, globally accepted outcome measurement instruments for hidradenitis suppurativa (HS) are needed. Current tools to measure the physical signs domain for HS rely on lesion counts, which are time-consuming and unreliable. OBJECTIVES: To assess the reliability and validity of the Hidradenitis suppurativa Area and Severity Index Revised (HASI-R) tool, a novel method for assessing HS severity, incorporating signs of inflammation and body surface area involved. METHODS: The measurement properties of the HASI-R tool were evaluated. The tool was created by combining the previously published HASI and Severity and Area Score for Hidradenitis instruments. Twenty raters evaluated 15 patients with HS in a hospital-based ambulatory dermatology clinic. The objectives of the study were to assess inter- and intra-rater reliability of the HASI-R and its components, as well as its construct and known-groups validity. Existing lesion count-based clinician-reported measures of HS and their components were also assessed. Raters were also asked their preferences regarding the various HS severity assessment tools. RESULTS: The HASI-R had moderate inter-rater reliability [intra-class correlation coefficients (ICC) 0·60]. This was better than all other HS physical sign outcome measures evaluated, which had poor inter-rater reliability (ICC < 0·5). HASI-R had the highest intra-rater reliability (ICC 0·91). The HASI-R had good construct validity and demonstrated known-groups validity. The HASI-R was also the most preferred tool by all raters. CONCLUSIONS: Results from the clinometric assessment of the HASI-R are encouraging, and support continued evaluation of this clinician-reported outcome measure.

Prevalence, knowledge and care patterns for gastro-oesophageal reflux disease in United States minority populations.

BACKGROUND: While there is evidence of ethnic variation in the prevalence of gastro-oesophageal reflux disease (GERD) symptoms, few population-based studies examine GERD symptom prevalence amongst the growing Hispanic minority in the US as well as Asians in the West. AIM: To examine the prevalence, awareness and care patterns for GERD across different ethnic groups. METHODS: A population-based, cross-sectional survey was fielded in English, Chinese and Spanish that assessed self-reported GERD prevalence, awareness and care patterns in four ethnic groups (Caucasian, African American, Asian, Hispanic). RESULTS: A total of 1172 subjects were included for analysis: 34.6% experienced GERD symptoms at least monthly, 26.2% at least weekly and 8.2% at least daily. Statistically significant differences in raw prevalence rates between racial groups were found: 50% of Hispanics experienced heartburn at least monthly, compared with 37% of Caucasians, 31% of African Americans and 20% of Asians (P > 0.0001). Significant differences in knowledge and care-seeking patterns by ethnicity were also observed. CONCLUSIONS: This study confirms the high prevalence of GERD symptoms in the US and introduces Hispanics as the ethnicity with the highest prevalence rate. Asians in the US have higher rates of symptoms than in the Far East. These data demonstrate a need for culturally appropriate education about GERD symptoms and treatment.

Review article: The advent of capsule endoscopy--a not-so-futuristic approach to obscure gastrointestinal bleeding.

Capsule endoscopy is a new, wireless, endoscopic examination of the small intestine. To date, two small clinical trials have been reported utilizing capsule endoscopy in patients with obscure gastrointestinal bleeding, and have shown its superiority to push enteroscopy in diagnosing the cause of blood loss. No outcome studies have been reported. This paper proposes a change in practice guidelines for obscure bleeding. It is our opinion that, in the future, with the advent of wireless capsule endoscopy, the evaluation of patients with obscure gastrointestinal bleeding will be very different from the practice of medicine today. We believe that capsule endoscopy will become the first-line method for the evaluation of patients with obscure bleeding, once upper endoscopy and colonoscopy have been shown to be negative. In patients with active bleeding, capsule endoscopy will confirm the small bowel as the site of bleeding, providing a location, or, if the study is negative for the small intestine, may indicate that the bleeding is either colonic or gastric in origin. In a patient with active bleeding within the small intestine, the capsule will guide further evaluation and therapy. A patient with a small bowel tumour detected by capsule endoscopy will proceed directly to laparoscopic surgery. If the site of bleeding is identified in the proximal small bowel and there is no mass, push enteroscopy will be used to re-identify the site and cauterize it. A distal small bowel site will require surgical intervention, coupled with intra-operative enteroscopy. Should the patient be too sick to undergo surgery, medical therapy utilizing hormonal agents will be considered. A colonic site will be evaluated by colonoscopy. In patients with a more occult or intermittent type of bleeding and in those whose upper endoscopies and colonoscopies are negative, capsule endoscopy will be used similarly to identify a bleeding lesion and thereby direct subsequent testing or treatment.

Inhibitor complexes of the Pseudomonas serine-carboxyl proteinase.

Crystal structures of the serine-carboxyl proteinase from Pseudomonas sp. 101 (PSCP), complexed with a number of inhibitors, have been solved and refined at high- to atomic-level resolution. All of these inhibitors (tyrostatin, pseudo-tyrostatin, AcIPF, AcIAF, and chymostatin, as well as previously studied iodotyrostatin and pseudo-iodotyrostatin) make covalent bonds to the active site Ser287 through their aldehyde moieties, while their side chains occupy subsites S1-S4 of the enzyme. The mode of binding of the inhibitors is almost identical for their P1 and P2 side chains, while significant differences are observed for P3 and P4 (if present). Kinetic parameters for the binding of these nanomolar inhibitors to PSCP have been established and correlated with the observed mode of binding. The preferences of this enzyme for a larger side chain in P2 as well as Tyr or Phe in P1 are explained by the size, shape, and characteristics of the S2 and S1 regions of the protein structure, respectively. Networks of hydrogen bonds involving glutamic and aspartic acids have been analyzed for the atomic-resolution structure of the native enzyme. PSCP contains a calcium-binding site that consists of Asp328, Asp348, three amide carbonyl groups, and a water molecule, in almost perfect octahedral coordination. The presence of Ca(2+) cation is necessary for the activity of the enzyme.

Hypogammaglobulinemia in lung transplant recipients.

BACKGROUND: Infectious complications continue to represent a significant source of morbidity and mortality in lung transplant recipients. Identifying specific, remediable immune defects is of potential value. After one lung transplant patient with recurrent infections was noted to be severely hypogammaglobulinemic, a screening program for humoral immune defects was instituted. The objectives were to define the prevalence of hypogammaglobulinemia in lung transplant recipients, assess levels of antibody to specific pathogens, and correlate infectious disease outcomes and survival with immunoglobulin levels. METHODS: All lung transplant recipients followed at a single center between October 1996 and June 1999 underwent a posttransplant humoral immune status survey as part of routine posttransplant follow-up. This survey consists of total immunoglobulin levels (IgG, IgM, IgA), IgG subclasses (IgG1-4), and antibody titers to Pneumococcus, diphtheria, and tetanus. Since February 1997, this survey has been incorporated into the pretransplant evaluation as well. Humoral survey results for October 1996 through July 1999 were recorded, and clinical information on major infectious disease outcomes was obtained from chart reviews, discharge summaries, the Cleveland Clinic Unified Transplant Database, and review of all microbiological studies and pathology results for each patient. RESULTS: Of 67 patients with humoral immune surveys drawn posttransplant, 47 (70%) had IgG levels less than 600 mg/dl (normal 717-1410 mg/dl), of which 25 (37%) had IgG levels less than 400 mg/dl ("lowest IgG group") and 22 (33%) had IgG levels between 400 and 600 mg/dl ("moderately low IgG group"). A total of 20 patients (30%) had IgG levels of more than 600 mg/dl ("normal IgG group"). Infections that were significantly more common in the lowest IgG group, and more common in the moderately low IgG group than the normal IgG group, included: number of pneumonias (P=0.0006), bacteremias (P=0.02), total bacterial infections (P=0.002), tissue-invasive cytomegalovirus (P=0.01), invasive aspergillosis (P=0.001), total fungal infections (P=0.001), and total infections (P=0.006). Median hospital days per posttransplant year was significantly different in the three groups (11.0 vs. 7.4 vs. 2.8 days, P=0.0003.) Invasive aspergillosis occurred in 44% of the lowest IgG group, 9% of the moderately low IgG group, and 0% of the normal IgG group (P<0.001). Survival was poorest in the lowest IgG group and intermediate in the moderately low IgG group. IgG subclass deficiencies occurred in a variety of patterns. Hypogammaglobulinemic patients lacked protective responses to Pneumococcus in 14/47 (30%), diphtheria in 15%, and tetanus in 19%. In a group of 48 patients screened pretransplant, 90% had normal immunoglobulin levels. CONCLUSIONS: Hypogammaglobulinemia in lung transplant recipients is more common than has been previously recognized. An IgG level of less than 400 mg/dl identifies a group at extremely high risk of bacterial and fungal infections, tissue-invasive cytomegalovirus, and poorer survival. Immunoglobulin monitoring may offer an opportunity for intensive surveillance, tapering of immunosuppression, and preemptive therapy for infection.

Evaluating health-related quality of life: cost comparison of computerized touch-screen technology and traditional paper systems.

We estimated and compared the costs for three different methods of administering and evaluating the Short Form-36 as a routine part of clinical practice from the provider perspective. In an outpatient pain management practice, we assessed a computer touch-screen system with facsimile and scanning scoring methods. Equipment, supply, and labor costs needed to construct, maintain, and generate reports for each system were measured. The annual fixed, variable, and total costs/survey were calculated. Sensitivity analyses were performed varying the number of surveys administered/year. The facsimile method was the least costly, $9.62 and $5.88/survey, at annual questionnaire volumes of 250 and 1000, respectively. When the annual survey volume increased to 1250 (5 surveys/day), the costs of the facsimile ($5.63/survey) and computer touch-screen ($5.65/survey) methods were nearly equivalent per survey administration. At volumes of 1500 and above, the least costly method was the computer touch screen at $5.47/survey. The system implemented in a clinical practice is dependent not only on questionnaire volume but also on personnel availability, equipment access, required speed of results, and the acceptable level of data error.

The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care.

OBJECTIVE: Immunizations and other cost-effective preventive services remain underused by many children, especially those living in poverty. Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns, we designed and tested an intervention combining these strategies. We studied whether a system of semiannual assessment and feedback, coupled with financial incentives, could improve pediatric preventive care in a Medicaid health maintenance organization (HMO). METHODOLOGY: We randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (where physicians received written feedback about compliance scores), a feedback and incentive group (where physicians received feedback and a financial bonus when compliance criteria were met), and a control group. We evaluated compliance with pediatric preventive care guidelines through semiannual chart audits during the years 1993 to 1995. RESULTS: Compliance with pediatric preventive care improved dramatically in the study period. Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores (from 56%-73%), as well as scores for immunizations (from 62%-79%) and other preventive care (from 54%-71%). However, no significant differences were observed between either intervention group and the control group, nor were there any interaction (group-by-time) effects. CONCLUSIONS: Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention.

Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care.

OBJECTIVES: A randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization (HMO). METHODS: Half of 52 primary care sites received the intervention, which included written feedback and a financial bonus. Mammography, breast exam, colorectal screening, and Pap testing compliance rates were evaluated. RESULTS: From 1993 to 1995, screening rates doubled overall (from 24% to 50%), with no significant differences between intervention and control group sites. CONCLUSIONS: Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO.

Construction of a psb C deletion strain in Synechocystis 6803.

Synechocystis 6803 is a cyanobacterium that carries out-oxygenic photosynthesis. We are interested in the introduction of mutations in the large extrinsic loop region of the CP43 protein of Photosystem II (PSII). CP43 appears to be required for the stable assembly of the PSII complex and also appears to play a role in photosynthetic oxygen evolution. Deletion of short segments of the large extrinsic loop results in mutants incapable of evolving oxygen. Alterations in psbC, the gene encoding CP43, are introduced into Synechocystis 6803 by transformation and homologous recombination. Specifically, plasmid constructs bearing the site-directed mutations are introduced into a deletion strain where the portion of the gene encoding the area of mutation has been deleted and replaced by a gene conferring antibiotic resistance. We have constructed a deletion strain of Synechocystis appropriate for the introduction of mutations in the large extrinsic loop of CP43 and have used it successfully to produce site-directed mutants.

Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals.

OBJECTIVE: To measure hospital- and surgeon-specific mortality rates for patients with coronary artery bypass graft (CABG) surgery and to examine possible reasons for any differences. DESIGN: Cohort study using hospital discharge abstracts and itemized bills. SETTING: Five major teaching hospitals in Philadelphia, Pa. PATIENTS: Consecutive sample of all 4613 patients over a 30-month period. MAIN OUTCOME MEASURE: In hospital mortality rates. RESULTS: We observed differences in hospital mortality rates for patients who underwent coronary artery catheterization and CABG surgery during the same admission (diagnosis related group 106) but not for patients who underwent only CABG surgery during the admission (diagnosis related group 107). There were threefold differences in surgeon-specific mortality rates. The hospital mortality rates for coronary artery catheterization and CABG surgery during the same admission changed during the study and coincided with moves of surgeons among study hospitals. Our measures of illness severity did identify patients who were more likely to die, but differences in severity of illness did not explain differences in hospital- or surgeon-specific mortality rates. Patient mortality rates were not associated with the volume of procedures performed by individual surgeons. We found inconclusive evidence for an association with surgeons' clinical skills, and to a lesser extent, with the hospital's volume of procedures and the hospital's organization and staffing. A greater intensity of hospital services was not necessary for a lower mortality rate. CONCLUSIONS: We conclude that studies of CABG mortality should examine mortality rates by diagnosis related group, collect data from more than 1 year, examine associations with surgeons' clinical skills, include information on hospital organization and staffing, and cautiously explore more efficient ways of providing care.

An academic medical center's experience with mandatory managed care for Medicaid recipients.

This paper reports on The Hospital of the University of Pennsylvania's experience and concerns as a participating primary care site in a Medicaid managed care program (HealthPASS), which was established in 1986. Enrollment is mandatory for approximately half of Philadelphia's medical assistance population. Participating primary care sites receive monthly capitation for enrollees and serve as "gatekeepers" for specialty and inpatient services. The report discusses why the academic medical center chose to participate in the program and how existing activities were modified to meet both increased demand for primary care and increased administrative requirements. It also identifies characteristics of the HealthPASS program and of the medical center that have impeded effective case management of care for the urban poor population that the program serves. Improving the quality of care for the medically indigent while controlling costs is essential, but political realities and the special needs of the Medicaid population must be acknowledged. Increased attention must be given to the impact that political compromises have on the design and effectiveness of a managed care program.

Impact of a mandatory Medicaid case management program on prenatal care and birth outcomes. A retrospective analysis.

This study examined the impact of Philadelphia's mandatory Medicaid case management program (HealthPASS) on adequacy of prenatal care and birth outcomes among enrollees. A sample of 217 deliveries for HealthPASS patients at the Hospital of the University of Pennsylvania (HUP) during 1988 was compared with a matched sample of 1988 deliveries at HUP for whom the payor was Pennsylvania's traditional fee-for-service Medicaid program. Inpatient charts for all 434 subjects were abstracted for information on sociodemographic characteristics, substance use during pregnancy (cigarettes, alcohol, and drugs), course and extent of prenatal care, and birth outcomes including birth weight, gestational age, and mortality. No significant differences were detected between HealthPASS and Medicaid groups, suggesting that the mandatory managed care program neither improved nor impeded access to needed services. These results were not surprising in view of the fact that HealthPASS actually did little to change provider or patient behavior with respect to obstetrical care. Both the HealthPASS and Medicaid groups experienced low rates of adequate prenatal care (39%) and high rates of low birth weight (20%). Also disturbing was the finding that at least 46% of women smoked during pregnancy, at least 20% drank alcohol, and at least 17% used cocaine. These findings support the need for continued efforts to improve both access to, and content of, prenatal care for the urban poor.