Transvaginal specimen extraction in a laparoscopic anterior resection of a sigmoid colon neoplasia with en bloc right salpingo-oophorectomy.

Laparoscopic colorectal surgery has well-known benefits. However, an abdominal incision, albeit much smaller than conventional surgery, is still needed. A transvaginal extraction of a sigmoid colon neoplasia with en bloc salpingo-oophorectomy and colorectal mechanical anastomosis is described. The technique is feasible and safe. The excellent recovery of the 86-year-old patient shows the potential future of the natural orifices endoscopic surgery.

Tumor desmoide intraabdominal / Intra-abdominal desmoid tumor

La fibromatosis agresiva o tumor desmoide es una rara enfermedad que se presenta de forma esporádica o asociada con la poliposis adenomatosa familiar. Desconocemos su etiología, las manifestaciones clínicas dependen de su situación anatómica y el diagnóstico es histopatológico. El tratamiento de elección es quirúrgico. Presentamos el caso de 1 paciente en el que se manifestó como una tumoración abdominal y fiebre por complicación del propio tumor. Se trata de una localización no habitual en esta forma de presentación; el paciente está asintomático 15 meses después de la intervención (AU)

Aggressive fibromatosis (desmoid tumor) are rare connective tissue tumors that occur sporadically or in association with familial adenomatous polyposis. The etiology is unknown and clinical findings depend on growth into neighboring structures. Biopsy is required to establish the diagnosis. The treatment of choice is surgery. We report a case with unusual localization in this form of presentation. The patient remains asymptomatic 15 months after surgery (AU)

Influencia del género, edad y conducta antisocial en variables de personalidad / Influence of the gender, age and antisocial behaviour in personality variables

Este estudio tiene por objetivo analizar la relación entreel género, edad y conducta antisocial en determinadasvariables relacionadas con el autoconcepto/depresión yotras vinculadas a recursos personales y valores éticomorales.Se utilizó una muestra de 1851 adolescentesde ambos sexos (49,92% hombres y 50,08% mujeres)de la Comunidad Autónoma de Madrid dividiéndola entres grupos diferentes de edad (14-15, 16 y 17-18 años).Los sujetos completaron un protocolo de cuestionariosreferidos a las variables autoconcepto positivo, autoconceptonegativo, autoestima, depresión, felicidad, satisfaccióncon el tiempo libre, participación en asociacióncultural, participación en asociación deportiva, prácticareligiosa y práctica de deportes.Para el análisis estadístico de los datos, se realizarondiversos análisis de varianza de dos vías que mostraronmayor presencia de empatía en los sujetos con baja conductaantisocial y mayor puntuación en búsqueda desensaciones, impulsividad y afán de aventura en jóvenescon alta conducta antisocial. En cuanto al género, loshombres puntúan más alto en búsqueda de sensacionesy las mujeres en empatía. Además, se comprueba comosegún aumenta la edad se incrementa la intensidad envariables referidas a búsqueda de sensaciones y empatía.Se discuten las implicaciones preventivas del estudio realizadopara la población adolescente

The aim of this paper is to analyze the influence betweenthe gender, age and antisocial behavior in personalitycharacteristics. It was used a sample of 1851 adolescents(49.92% men and 50.08% women) of the AutonomousCommunity of Madrid. There were accomplished threegroups of age: 14-15, 16 and 17-18 years. The subjectscompleted a protocol referred to antisocial behavior,sensation seeking, impulsiveness, venturesomeness andempathy.For the statistic analysis of the data, were accomplishedseveral variance analysis that showed greater presence ofempathy in youths with decrease antisocial behavior andgreater level in sensation seeking, impulsiveness andventuresomeness in subjects with high antisocial behavior. On the other hand, the men have more sensation seeking,while women show more empathy. Furthermore, accordingthe age increases, the intensity in variables referred tosensation seeking and empathy is increased. Thepreventive implications for the adolescents population ofthis study are discussed

[Intra-abdominal desmoid tumor]. / Tumor desmoide intraabdominal.

Aggressive fibromatosis (desmoid tumor) are rare connective tissue tumors that occur sporadically or in association with familial adenomatous polyposis. The etiology is unknown and clinical findings depend on growth into neighboring structures. Biopsy is required to establish the diagnosis. The treatment of choice is surgery. We report a case with unusual localization in this form of presentation. The patient remains asymptomatic 15 months after surgery.

Use of cancer susceptibility testing among primary care physicians.

Primary care physicians (PCPs) are assuming greater roles in cancer risk assessment and susceptibility testing of patients. The objective of this study was to assess the beliefs and practices of PCPs relative to genetic susceptibility testing for cancer. A cross-sectional survey was mailed to 726 PCPs in community-based practices in southeastern Pennsylvania and southern New Jersey. Data were collected on physician background, cognitive and psychosocial factors, practice environment, and patient factors. The main outcome measure was physician self-reported recommendation or referral of patients for cancer genetic susceptibility testing in a 12-month period prior to the survey. Of those surveyed, 475 (65%) PCPs responded. Complete survey data were available for 433 PCPs. Multivariable analyses show that factors positively associated with PCP recommendation/referral included: patient inquiry about their need for genetic testing for cancer (p < 0.001); PCP belief that patient age is the best predictor of cancer risk (p = 0.01); PCP self-reported frequency of collecting patient diet information (p = 0.01) and medical history information (p = 0.01); and PCP participation in an integrated health system (p = 0.01). PCP use of cancer genetic susceptibility testing may be influenced by patient inquiry, provider beliefs about factors that affect cancer risk, provider collection of risk-assessment data, and provider practice environment.

Complete diagnostic evaluation in colorectal cancer screening: research design and baseline findings.

BACKGROUND: While indicated by guidelines, complete diagnostic evaluation, or CDE (i.e., colonoscopy or combined flexible sigmoidoscopy plus barium enema X ray), is often not recommended and performed for persons with an abnormal screening fecal occult blood test (FOBT) result. We initiated a randomized trial to assess the impact of a physician-oriented intervention on CDE rates in primary care practices. METHODS: In 1998, we identified 1,184 primary care physicians (PCPs) in 584 practices whose patients received FOBTs that are mailed annually by a managed care organization screening program. A total of 470 PCPs in 318 practices completed a baseline survey. Practices were randomly assigned either to a Control Group (N = 198) or to an Intervention Group (N = 120). Control Group practices received the screening program. Intervention Group practices received the screening program and the intervention (i.e., CDE reminder-feedback plus educational outreach). Practice CDE recommendation and performance rates are the primary outcomes to be measured in the study. RESULTS: Baseline CDE recommendation and performance rates were low and were comparable in Control and Intervention Group practices (54 to 57% and 39 to 40%, respectively). PCPs in the practices tended to view FOBT screening and CDE favorably, but had concerns about screening efficacy, time involved in CDE, and patient discomfort and adherence. Control Group physicians were more likely than Intervention Group physicians to believe that a mail-out FOBT screening program helps in the practice of medicine. CONCLUSIONS: We were able to enroll a high proportion of targeted primary care practices, measure practice characteristics and CDE rates at baseline, and develop and implement the intervention. Study outcome analyses will take into account baseline differences in practice characteristics.

Prevalence of Raynaud's phenomenon in general practice in the east of Spain.

Our aim was to establish the prevalence of Raynaud's phenomenon in a general practice in the east of Spain and compare our results with those of other studies performed in geographical areas with similar climatic characteristics. Two hundred and seventy-six subjects visiting their general practitioner for whatever reason were randomly selected from a particular area of the city of Valencia. Each was interviewed by their GP following the guidelines of a structured questionnaire to establish whether they had Raynaud's phenomenon or not. There were 205 women and 71 men. The mean age was 54.43, with a standard deviation of 18.22. Raynaud's phenomenon was present in nine subjects, two men and seven women, with a prevalence of 2.8% and 3.4%, respectively. Of the nine positives (mean age 60.56 years, standard deviation 16.38), two were diagnosed with hypertension and two with migraine. None of them usually took Raynaud's phenomenon-related drugs or performed physical exercise. No patient had a family history of Raynaud's phenomenon or had already been diagnosed with it. All the positive males were affected only by the pallor stage. This study shows lower prevalences than those of other studies performed in different geographical areas with similar climatic conditions.

Measuring complete diagnostic evaluation in colorectal cancer screening.

Complete diagnostic evaluation, or CDE (i.e., a colonoscopy or combined barium enema X-ray and flexible sigmoidoscopy) is recommended for individuals who have an abnormal screening fecal occult blood test result. Accurate measures of CDE use are needed in colorectal cancer (CRC) screening programs. This study compares the sensitivity and specificity of different methods for measuring CDE recommendation and performance. We identified 17 primary-care practices with 120 patients who had a positive fecal occult blood test result in a CRC screening program operated by a managed-care organization. Approaches used to measure CDE recommendation and performance included external chart audit (ECA) only; internal chart audit (ICA) only; administrative data review (ADR) of electronic claims data; ICA plus ADR; and ECA plus ADR (the "gold standard"). Sensitivity and specificity of each method were assessed relative to CDE recommendation and performance as measured by ECA plus ADR. For CDE recommendation, sensitivity measures were ECA only, 0.926; ICA only, 0.790; ADR only, 0.617; and ICA plus ADR, 0.901. The specificity of each method for CDE recommendation was no less than 0.95. In terms of CDE performance, sensitivity measures were ECA only, 0.877; ICA only, 0.790; ADR only, 0.877; and ICA plus ADR, 0.965. The specificity of each method for CDE performance was 1.0. The ICA-plus-ADR method was a highly sensitive and specific measure of CDE use. This method should be considered in situations that involve primary-care physician follow-up of patients with abnormal CRC screening test results.

Preventive service utilisation as a predictor for emergency dental examinations.

OBJECTIVE: To quantify the relationship between receipt of routine dental care and the use of non-trauma related emergency dental services. DESIGN: A multiple logistic regression was run on administrative dental claim and encounter data. The model dependent variable was the use of non-trauma related emergency dental care. Predictors included previous year oral examinations, radiographs, dental cleanings and, as a control, member age. SETTING: Administrative data were obtained from a dental health maintenance organisation located in the state of Texas. SUBJECTS: Claim and encounter data for 2,947 insured members were used, representing experience from 1995 through 1996. OUTCOME MEASURES: The outcome of interest was the use of non-trauma related emergency dental services. RESULTS: Results demonstrated empirically that those who availed themselves of preventive dental services were significantly less likely to use non-trauma related emergency services (P<0.01). The probability of needing non-trauma related dental services in 1996 was 42.7% lower among those who had an examination in 1995 when compared with those who did not. When analysed in a simple logistic regression, dental cleanings in 1995 were also significantly associated with a decreased probability of needing non-trauma related emergency services. However, this relationship did not hold in the controlled model, which was probably due to multicollinearity. CONCLUSIONS: This study provides evidence of the value of periodic preventive dental examinations and services. Those who receive such services are less likely to use non-trauma related emergency dental services.

Pharmaceutically-based severity stratification of an asthmatic population.

Algorithms designed to precisely identify disease severity for a given patient within a managed care population are helpful in organizing targeted interventions. These algorithms are also attracting considerable attention within the medical research community. Several health risk screening instruments have been developed; however, these involve survey methodologies and have several shortcomings. We present a valid and efficient method for predicting healthcare resource utilization among asthmatics in an Health Maintenance Organization (HMO) population. First, various diagnosis, procedure and pharmacy billing codes were used to identify the asthmatics within the database. The screening algorithm awards points each time one of these codes is identified for an HMO member. By varying the number of points necessary to consider a patient asthmatic, the sensitivity, specificity, positive and negative predictive values of the algorithm can be adjusted. Once identified as asthmatic, subjects were then stratified into severity levels based on pharmacy data. Severity stratification was validated directly by measuring asthma-related bed days utilized during the 12 months following the date of stratification. Our identification algorithm estimated an asthma prevalence of 3.84% within the studied population, with age-specific prevalence estimates that closely mirrored previously published survey data. There was a monotonic relationship between pharmacy severity levels and inpatient resource utilization. For example, asthmatics in severity level 1 used only 92 hospital days per 1000 asthmatics in the year following characterization, while those in levels 2-5 used 133, 156, 277 and 1168 hospital days (P < 0.001), respectively. Results from this model can be used as adjusters in other predictive models or stand alone to represent a patient's severity of illness.

Physician intention to recommend complete diagnostic evaluation in colorectal cancer screening.

Primary care physicians (PCPs) often do not recommend complete diagnostic evaluation (CDE; i.e., diagnostic colonoscopy or the combination of flexible sigmoidoscopy and barium enema X-ray procedures) for patients with an abnormal screening fecal occult blood test (FOBT+) result. Information is needed to understand why PCPs do not recommend CDE. In the spring of 1994, a telephone survey was carried out using a random sample of 520 PCPs in Pennsylvania or New Jersey who had patients that were targeted for an FOBT screening program. Survey data were obtained from 363 (70%) PCPs on physician practice characteristics; personal background; perceptions concerning FOBT screening, CDE performance, and patient behavior; social influence related to CDE; and intention to recommend CDE for FOBT+ patients. Physician CDE intention scores were distributed as follows: low (22%), moderate (51%), and high (27%). Multivariate analyses demonstrate that physician board certification status, time in practice, belief in CDE efficacy, and belief that CDE is standard practice were positively associated with CDE intention, whereas concern about CDE-related costs was negatively associated with CDE intention. Among physicians in larger practices, perceived FOBT screening efficacy was negatively associated with CDE intention, and belief in the benefit of CDE was positively associated with outcome. There is substantial variability in CDE intention among PCPs. Physician perceptions about FOBT screening and follow-up are associated with CDE intention, are likely to influence CDE performance, and may be amenable to educational intervention. Additional research is needed to evaluate the impact of educational interventions on CDE intention and performance.

Ability to pay and the decision to medicate.

OBJECTIVES: It is widely recognized that ability to pay affects access to hospital and physician services. Much less is known about the economic determinants of prescription drug use, particularly among the elderly. The authors hypothesize that persons with higher incomes and better health insurance coverage are more likely to medicate common health problems than those with lower incomes and less comprehensive coverage. METHODS: A random sample of 4,066 elderly Pennsylvania Medicare beneficiaries were asked to complete a mail survey on health insurance, income, and medicine use for 23 common health problems. The relationship between ability to pay and medication decisions was analyzed using logistic and Poisson regression models with covariates for sociodemographic characteristics and health status. RESULTS: A strong and consistent relationship was found in the hypothesized direction. Other things being equal, elderly persons with Medicare supplementation were between 6% and 17% more likely to use prescription medicine to treat their health problems than are persons with Medicare coverage alone. The presence of prescription drug coverage significantly increased the odds of prescription treatment for 10 of the 22 conditions examined. The insurance effects were generally--but not exclusively--more pronounced for less serious compared with serious health problems. Income also was shown to have a strong independent effect on medication decisions. Elderly with annual incomes greater than $18,000 were 18% more likely to treat problems with prescription drugs than were persons with annual incomes less than $6,000. CONCLUSIONS: In sum, economic factors appeared to play an important role in medication decisions by the elderly. The magnitude of the impact was sufficiently high that it could have major negative consequences on the health of elderly persons who are poor and lack drug coverage.

The use of administrative data to risk-stratify asthmatic patients.

In this article, a simple methodology to risk-stratify asthmatics is presented and validated. Such a model can be used to identify those high risk and more severely ill asthmatics who could benefit the most from case management and increased educational efforts. Using logistic regression, the model was created to predict the probability of an asthma-related admission among all asthmatics who were members of a large HMO during calendar year 1994 (N = 54,573). The model used data from pharmacy, laboratory, and specialist claims, as well as encounter and demographic data available in U.S. Healthcare's administrative database. A member's prior asthma-specific utilization patterns, pharmaceutically determined severity of illness, and length of enrollment in the managed care organization had the most influence on the equation. A cross-validation of the model confirms how administrative data can be used to accurately risk-stratify those with a chronic disease. Finally, some additional research possibilities associated with the identification of high risk subscribers using only administrative data are outlined.

Biliary lithiasis in the elderly patient: morbidity and mortality due to biliary surgery.

BACKGROUND/AIMS: Diseases of the biliary tract are the most common conditions requiring intra-abdominal surgery in elderly patients. Complications and adverse outcomes of gallstones are more frequent in older people. The present study was undertaken to analyze factors that contributed to overall morbidity and mortality after open cholecystectomy. Laparoscopic surgery and other new techniques were compared with the open method. METHODOLOGY: We studied retrospectively 76 patients that were 80 years and older. Each patient underwent operation in our unit. 40 patients had fewer than 30 days of clinical history, and 69 patients (90.8%) were emergency admissions. From a clinical point of view, 33 patients (43.4%) had jaundice on arrival and 21 (27.6%) fever. The operative findings included gallbladder wall infection in 46 patients (60.5%) and common bile duct stones in 25. Uni- and multivariate analysis was performed to discriminate variables in mortality and morbidity. RESULTS: Nine patients (11.8%) died, and 38 had complications in the postoperative period. The main causes of death were pulmonary complications (4) and multisystem organ failure (3). Morbidity was mainly due to wound infection (14), urinary infection (13) and respiratory disease (10). Three variables influenced morbidity: sex (male), cardiovascular disease and jaundice upon admission. In the regression model only cardiovascular disease and jaundice were of independent influence. The mortality rate was associated with pre-operative jaundice. CONCLUSIONS: Mortality and morbidity are related mainly to preoperative presentation. Jaundice is the main determinant of the outcome.

Measuring the quality of inpatient health care.

A validated case mix and severity adjusted performance measurement system and methodology are presented. Using this methodology in a user-friendly interactive interface, those who are interested in the performance of a hospital or providers within a hospital can easily identify areas for quality improvement.