"Narrowing the Gap": decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care.

OBJECTIVE: To evaluate the effectiveness of increased primary care access created by North Carolina's Medicaid managed care plan, Carolina Access (CA), in reducing unnecessary emergency department (ED) use in Guilford County. METHODS: Emergency department records of pediatric visits before and after the implementation of CA were analyzed. Variables included patient age, International Classification of Diseases, Ninth Revision discharge diagnosis, insurance status, date of visit, time of visit, and ZIP code. Visits were classified as either urgent or nonurgent based on discharge diagnosis. Rates of ED use per 1000 persons were calculated using county population and Medicaid enrollment figures. RESULTS: A total of 54,742 ED visits occurred between January 1, 1995, and December 31, 1997. Thirty-eight percent of these visits were by children (defined as those aged 0-18 years in this study) enrolled in the Medicaid program. After the implementation of CA, monthly ED rates per 1000 children with Medicaid insurance decreased 24% from 33.5 +/- 5.3 to 25.6 +/- 2.3 (P<.001), which translates to 158 fewer visits per month by children enrolled in the Medicaid program. Nonurgent visits among the population enrolled in the Medicaid program decreased from an average monthly rate per 1000 of 17.9 +/- 3.5 to 11.2 +/- 2.5 after the implementation of CA (P<.001), accounting for most of the decrease in total visits. (All data are given as mean +/- SD.) The rates of total and nonurgent visits among the population not enrolled in the Medicaid program increased slightly. CONCLUSIONS: For children with Medicaid insurance, we found a strong temporal relation between decreased visits to the ED and increased access to primary care services, services that were made available by the implementation of North Carolina's Medicaid managed care plan, CA. Specific services that may be responsible for the decreased ED use include the expanded availability of primary care physicians and the use of telephone triage systems. No similar decrease in ED use was seen among the non-Medicaid-insured group. Arch Pediatr Adolesc Med. 2000;154:791-795

The incidence of tuberculosis among North Carolina migrant farmworkers, 1991.

All locatable subjects (n = 94) for whom tuberculosis prevalence had been determined in an earlier study were tested with purified protein derivative (PPD) and control antigens, sputum sampling, and chest x-rays. Of the 46 who had been tuberculin negative (confirmed with control antigens) 3 years earlier, 2 had developed active tuberculosis in the interim and 14 (30%) were tuberculin positive. All had been engaged continuously in migrant farmwork. Lack of access to health care, an institutional feature of migrant farmwork, was significantly associated with primary infection.

Alloimmunization to RhD by platelet transfusions in autologous bone marrow transplant recipients.

Platelet transfusions from RhD-positive (D-positive) donors are often given to RhD-negative (D-negative) cancer patients. The low observed rate of alloimmunization has been attributed to disease and therapy-related immunosuppression. We have studied the occurrence of alloimmunization in 16 D-negative patients who did not have detectable anti-D prior to autologous bone marrow transplantation for malignant disease. All received D-positive platelets, but no other D-positive blood product. Three patients (19%) developed anti-D at 13, 24 and 83 days, respectively, after first receiving D-positive platelets, and after a total dose of 53, 65 and 119 D-positive platelet unit equivalents, respectively. Two of them also developed anti-C. The 13 patients in whom anti-D was not detected were also heavily transfused with D-positive platelets (mean +/- SD = 136 +/- 82 platelet unit equivalents). In 6 of them, the last recorded antibody screen was less than 3 months after the first D-positive platelets, and may not exclude a primary immune response. Thus, despite profound immunosuppression associated with autologous marrow transplantation, alloimmune responses to D-positive red cells in platelet concentrates can occur in some D-negative recipients.

Invasive carcinomas of the urinary bladder. Evaluation of tunica muscularis mucosae involvement.

Awareness of the existence of a tunica muscularis mucosae in the urinary bladder complicates the assessment of muscle invasive carcinomas on bladder biopsy. Sixty cystectomy specimens and select bladder biopsies were reviewed to analyze this problem. The patterns of development of the tunica muscularis mucosae were categorized as continuous, interrupted, scattered, or absent. Most bladders demonstrated several patterns of development rather than a uniform appearance. The most frequently observed pattern was that of scattered smooth muscle fibers seen in 33 of 40 (82.5%) cases. The rarity of carcinomatous invasion limited to the tunica muscularis mucosae is emphasized. The authors conclude that the potential for overstaging bladder carcinomas because of misinterpretation of this structure is small.

Disseminated penicilliosis in a patient with acquired immunodeficiency syndrome.

We describe a case of disseminated penicilliosis in a patient with the acquired immunodeficiency syndrome. Penicillium marneffei was cultured from the blood, bone marrow, sputum, stool, and skin; the yeast forms were demonstrated in skin and bone marrow biopsy specimens. To our knowledge, this is the first reported case of disseminated penicilliosis described in a patient with the acquired immunodeficiency syndrome. The differential diagnosis with Histoplasma capsulatum is reviewed.

Immunohistochemical identification of exocrine and neuroendocrine subsets of large cell lung carcinomas.

Formalin fixed, paraffin embedded sections of 52 cases of pulmonary large cell undifferentiated carcinoma (LCUC) as defined in the current WHO classification were studied immunohistochemically to assess features of exocrine and neuroendocrine (NE) differentiation. Monoclonal antibody 44-3A6 was applied to detect a membrane association protein related to exocrine differentiation. A panel of ten neuroendocrine markers including antibodies to synaptophysin, chromogranin A, serotonin, and seven neuropeptides was used to assess NE differentiation. The broad spectrum anticytokeratin antibody PKK1 was used to confirm the epithelial differentiation of these tumors. Exocrine differentiation was detected in 40/52 (77%) of surgically resected LCUC, despite the absence of recognizable glands by light microscopy. Eighteen of 52 (35%) LCUC exhibited NE differentiation; synaptophysin was the most frequently detected NE marker. Cytokeratin immunostaining with PKK1 was demonstrated in 41/52 (79%) cases. Subsets of LCUC were defined based on their expression of exocrine or NE phenotypic markers. Accordingly, 28/52 (54%) LCUC displayed an exocrine phenotype, 6/52 (12%) a NE phenotype, 12/52 (23%) had combined exocrine and NE phenotypes, and 6/52 (12%) exhibited neither phenotype. In this surgical series, there were no significant differences in stage at presentation for the four subsets. Interestingly, two year survival appeared decreased in patients with tumors displaying the "pure" NE phenotype.