Effect of insurance status on postacute care among working age stroke survivors.

OBJECTIVE: Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors. METHODS: A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004-2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities. RESULTS: Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47-0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27-1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36-0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23-0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors. CONCLUSIONS: Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.

The Causative Classification of Stroke system: an international reliability and optimization study.

BACKGROUND: Valid and reliable ischemic stroke subtype determination is crucial for well-powered multicenter studies. The Causative Classification of Stroke System (CCS, available at http://ccs.mgh.harvard.edu) is a computerized, evidence-based algorithm that provides both causative and phenotypic stroke subtypes in a rule-based manner. We determined whether CCS demonstrates high interrater reliability in order to be useful for international multicenter studies. METHODS: Twenty members of the International Stroke Genetics Consortium from 13 centers in 8 countries, who were not involved in the design and development of the CCS, independently assessed the same 50 consecutive patients with acute ischemic stroke through reviews of abstracted case summaries. Agreement among ratings was measured by kappa statistic. RESULTS: The κ value for causative classification was 0.80 (95% confidence interval [CI] 0.78-0.81) for the 5-subtype, 0.79 (95% CI 0.77-0.80) for the 8-subtype, and 0.70 (95% CI 0.69-0.71) for the 16-subtype CCS. Correction of a software-related factor that generated ambiguity improved agreement: κ = 0.81 (95% CI 0.79-0.82) for the 5-subtype, 0.79 (95% CI 0.77-0.80) for the 8-subtype, and 0.79 (95% CI 0.78-0.80) for the 16-subtype CCS. The κ value for phenotypic classification was 0.79 (95% CI 0.77-0.82) for supra-aortic large artery atherosclerosis, 0.95 (95% CI 0.93-0.98) for cardioembolism, 0.88 (95% CI 0.85-0.91) for small artery occlusion, and 0.79 (0.76-0.82) for other uncommon causes. CONCLUSIONS: CCS allows classification of stroke subtypes by multiple investigators with high reliability, supporting its potential for improving stroke classification in multicenter studies and ensuring accurate means of communication among different researchers, institutions, and eras.

Predicting ischaemic stroke subtype from presenting systolic blood pressure: the BASIC Project.

OBJECTIVE: We hypothesized that low presenting systolic blood pressure (SBP) predicted cardioembolic stroke aetiology. DESIGN: Active and passive surveillance were used to identify all ischaemic strokes as part of the Brain Attack Surveillance in Corpus Christi (BASIC) population-based study. Multinomial logistic regression was used to examine the association between stroke subtype and first documented SBP in the medical record. SETTING: Nueces County, TX, USA (313,645 residents in 2000). The community is urban with the majority of the population residing in the city of Corpus Christi. The area is served by seven adult acute care hospitals. PATIENTS: Three hundred and eight cases with completed ischaemic stroke and determined subtype aetiology between January 2000 and December 2002. RESULTS: Lower presenting SBP was associated with stroke subtype (P = 0.001). This association remained significant in the final model adjusted for age and history of coronary artery disease. The odds of cardioembolic versus small vessel occlusion increased by 20% (OR = 1.20, 95% CI: 1.07-1.35) for every 10 mmHg decrease in presenting SBP. Other covariates including race/ethnicity, gender, history of hypertension, and diabetes were neither significant predictors of stroke subtype, nor did they confound the association of SBP and stroke subtype. A 5 year increase in age increased the odds of cardioembolic subtype by 25% (OR = 1.25, 95% CI: 1.07-1.47). CONCLUSIONS: Lower initial SBP and older age at ischaemic stroke presentation were associated with cardioembolic stroke. Suspicion of cardioembolic stroke should be increased in those presenting with low SBP.

Gender and ethnic differences in subarachnoid hemorrhage.

BACKGROUND: Mexican Americans (MAs) comprise the largest component of the largest minority group within the United States. The purpose of this study was to examine ethnic and gender differences in the epidemiology, presentation, and outcomes after subarachnoid hemorrhage (SAH) in a representative United States community. Targeted public health interventions are dependent on accurate assessments of groups at highest disease risk. METHODS: All patients with nontraumatic SAH older than 44 years were prospectively identified from January 1, 2000, to December 31, 2006, as part of the Brain Attack Surveillance In Corpus Christi project, an urban population-based study in southeast Texas. Risk ratios for cumulative SAH incidence comparing MAs with non Hispanic whites (NHWs) and women with men were calculated. Descriptive statistics for other clinical and demographic variables were computed overall, by gender, and by ethnicity. RESULTS: A total of 107 patients had a SAH during the time period (7-year cumulative incidence: 11/10,000); of these, 43 were NHW (40% of cases vs 53% of the population) and 64 were MA (60% of cases vs 48% of the population). The overall age-adjusted risk ratio for SAH in MAs compared with NHWs was 1.67 (95% CI: 1.13, 2.47), and in women compared to men was 1.74 (95% CI 1.16, 2.62). Overall in-hospital mortality was 32.2%. No ethnic difference was observed for discharge disability or in-hospital mortality. CONCLUSIONS: Subarachnoid hemorrhage disproportionately affects Mexican Americans and women. Public health interventions should target these groups to reduce the impact of this severe disease.

Lymphoid cell aggregates: a useful clue in the fine-needle aspiration diagnosis of follicular lymphomas.

Among the various types of lymphoma, follicular lymphoma (FL) is known to have significant limitations in cytologic diagnosis by the fine-needle aspiration (FNA) method. The diagnostic accuracy (DA) for non-Hodgkin's lymphoma (NHL) by FNA was evaluated by review of 82 cases of histologically proved NHL after prior FNA. The DA for all NHLs was 66% (54/82), and that for low-grade lymphomas, including small lymphocytic lymphoma, follicular small-cleaved cell lymphoma, and follicular mixed cell lymphoma, was 71% (12/17). The DA for FL was 69% (11/16). Review of individual surgical and cytologic materials from FLs revealed a tendency to show fibrosis in the cytologically false-negative group and diffuse areas of lymphoma in the true-positive group. The presence of "aggregation" of uniform lymphoid cells, probably due to cell adhesions with the support of dendritic reticulum cells, was seen in 55% of true-positive FL (6/11). In contrast, only 28% of true-positive diffuse large cell lymphomas (5/18) showed a mild degree of aggregation, and none of 7 cases of true-positive diffuse small-cleaved cell lymphoma showed this feature. The aggregation of cells was not pathognomonic of FL, but its presence with a homogeneous cellular constituent and the paucity of tingible-body macrophages helped us to predict FL. Also, it was a feature distinguishing FL from diffuse small-cleaved cell lymphoma (P = 0.025).

Endocervical glandular atypia and adenocarcinoma: a correlation of cytology and histology.

Of the 34,384 cervical smears sampled by cervical scraping and Cytobrush, reactive glandular atypia was found in 1.7%, low-grade glandular atypia in 0.08%, and high-grade glandular atypia/adenocarcinoma in 0.05%. Cells of reactive glandular atypia and low-grade atypia could be distinguished from those of high-grade atypia/adenocarcinoma by the architecture of the cellular aggregates, nuclear morphology, and nuclear-cytoplasmic ratios. Further histologic studies found that most reactive and low-grade atypias were associated with condyloma, squamous dysplasia, carcinoma in situ, and cervicitis. Eighty-two percent of women with cellular evidence of high-grade atypia/adenocarcinoma were confirmed to have in situ or invasive adenocarcinoma of the cervix. Although Cytobrush samples seem to improve the detection of early-stage glandular neoplasms, many minor atypias unrelated to cervical carcinogenesis are also detected.

Fine-needle aspiration of parotid gland lesions.

The results of 49 specimens obtained by fine-needle aspiration biopsy of parotid gland lesions were compared with the pathologic diagnoses of the surgically resected specimens. Cytologically, 33 lesions were diagnosed as benign, with 30 of these confirmed histologically and three false-negative results. Fourteen cytologic specimens were called malignant or suspicious for malignancy, with 11 of these confirmed histologically and three false-positive results. The concurrence rate for distinguishing benign from malignant disease was 87.2%. The sensitivity for malignancy was 78.6% and the specificity 90.9%. The pathology of the misdiagnosed lesions will be reviewed. Based on our data and a review of the literature, we conclude that fine needle aspiration biopsy of parotid gland masses, with the observation of certain caveats, is a helpful adjunctive test for diagnosis and treatment planning.

Pneumocystis carinii peritonitis. Antemortem confirmation of disseminated pneumocystosis by cytologic examination of body fluids.

Histologic confirmation of extrapulmonary Pneumocystis carinii infection in the acquired immunodeficiency syndrome has usually required organ biopsy when the diagnosis was made antemortem. Three cases of Pneumocystis peritonitis were studied in which confirmation of extrapulmonary dissemination was achieved by cytologic examination of ascitic fluid. Patients presented with characteristic choroidal lesions, transudative ascites, profound hypoalbuminemia, and hepatic dysfunction. Cytologic examination of ascitic fluid confirmed extrapulmonary dissemination of pneumocystis. All three patients died despite a minimum of 2 weeks of standard therapy. Cytologic examination of body fluids to confirm dissemination of Pneumocystis may obviate the need for organ biopsy. Disseminated pneumocystosis should be included in the differential diagnosis of ascites or peritonitis in a patient at risk for human immunodeficiency virus--associated opportunistic infections. The presence of transudative ascites may be characteristic of this syndrome.

Needle biopsies in breast cancer diagnosis: techniques in search of an audience.

Fine-needle aspiration cytology and Tru-cut needle biopsy have been described as excellent techniques in the diagnosis of breast cancer. Responses to questionnaires sent to 90 pathologists in San Diego County, however, proved that in only 2-10% of all new breast cancer cases are these techniques being used to make the initial diagnosis. This paradox appeared to be due mainly to a reluctance of clinicians to use these techniques. However, there also appeared to be a lack of confidence and training among pathologists in interpreting aspiration cytology specimens. In the authors' and other pathologists' opinion, reviewing breast aspiration cytology specimens requires special training and regular exposure to such material, whereas Tru-cut needle biopsy specimens can be interpreted accurately by almost any pathologist without special training. The results of our own series of needle biopsies and aspiration cytology in the diagnosis of breast cancer are presented and compared to those reported in several other published reports. These data indicate that approximately 90% (89% in our series) of all palpable breast cancers can be diagnosed by needle biopsy techniques.

[Erythrocyte concentrates, low in buffy coat: production, preservation and evaluation of its quality]. / Ubersicht Das buffy-coat-arme Erythrozytenkonzentrat Herstellung, Konservierung und Qualitätsbewertung.

Buffy coat-poor packed red cells were prepared from fresh ACD-, ACD-AG- and EDTA-blood, than resuspended with a preservation solution, containing glucose, adenine, guanosine, sucrose, citric acid and sodium citrate and stored at 4 degrees C for 6 weeks. The survival rate of resuspended red cells from ACD-AG-blood amounted to 77% after 6 weeks of storage. The ATP content of resuspended red cells was approximately 25% lower than in ACD-AG whole blood during storage caused probably by increased ATP consuming reactions at the red cell membrane. The P2G-content of resuspended red cells from ACD- and ACD-AG-blood decreased above 50% of the normal level during the first week, as fast as in ACD- and ACD-AG whole blood. The P2G-breakdown in red cells from EDTA-blood was delayed for a week due to the higher pH as in CPD blood. Additions of xylitol, inorganic phosphate, and bicarbonate in 6, 5 and 20 mM final concentrations in the red cell suspensions and an increased pH at the same time delayed the breakdown of ATP and P2G. Packed red cells can be administered fast enough at hematocrits to 0.60 that will be achieved by adding 50 to 100 ml preservation solution. Leukocytes and thrombocytes were reduceds to 70 to 80%. With increasing rate of reduction a higher loss of red cells occured. Buffy coat-poor red cell concentrate contains only few microaggregates. It diminishes the risc of febrile transfusion reactions and delays the appearance of alloimmunisation. The circulatory overload of patients is less frequent than after transfusions of red cell resuspensions containing a large resuspension volume.

[Viability, ATP and 2,3-DPG content of resuspended erythrocytes during several-week storage in cold]. / Verhalten von Lebensfähigkeit, ATP-und 2,3-DPG-Gehalt resuspendierter Erythrozyten während mehrwöchiger Kältelagerung.

Leukocyte-and thrombocyte-poor packed red cells obtained from ACD or. ACD-AG blood were resuspended to a hematocrit of about 55% and stored at 4 degrees C. The resuspension solution consisted of xylitol, inorganic phosphate, bicarbonate, adenine (A) and guanosine (G) solved in water. In one case glucose, citrate and sucrose were also added, in another one, sorbitol. The 2,3-DPG and the ATP level remained for a longer period in the sorbitol-xylitol-medium than in the glucose-xylitol-medium. The ATP content in the red cell suspension was higher than in packed cells. Higher ATP values were obtained in red blood cells from whole blood with adenine and guanosine. The survival rate of resuspended red blood cells in glucose-AG-citrate-sucrose medium was about 80--85% after 3 weeks of storage and 77% after 6 weeks with a higher range.

[Isoenzymes of alkaline phosphatase - reference values in young people and effects of protein diet (author's transl)]. / Isoenzyme der alkalischen Phosphatase - Referenzwerte im jugendlichen Alter und Einfluss der Eiweissernährung

In 260 normal students, 20-25 years old, the variation in the activities of serum alkaline phosphatase and its isoenzymes with sex, ABO blood groups, and protein intake were studied. The values are on the whole higher in males than in females. The activity of the intestinal isoenzyme was higher in subjects taking protein-rich diet than in those taking protein poor diet.

Synchronization of rabbit bone-marrow cells in vivo.

The recovery of the rabbit bone-marrow from anaemia was investigated during an eight-day period of daily punctures of the tibiae after six days of phenylhydrazine treatment. A maximum of erythroid (range, 37.1 to 44.0%) and a minimum of leukoid cells (range, 8.4 to 13.4%) was observed on the fifth day of recovery. The rest, about 50% cells were reticulum cells. Signs of recovery were observed in peripheral blood as soon as on the first day after phenylhydrazine treatment. This led to the assumption that the tibiae became repopulated with active erythropoietic cells during anaemia, and that the reticulum cells might play a role as erythroid precursors in this process.