Genome-wide association study of hepatitis C virus- and cryoglobulin-related vasculitis.

The host genetic basis of mixed cryoglobulin vasculitis is not well understood and has not been studied in large cohorts. A genome-wide association study was conducted among 356 hepatitis C virus (HCV) RNA-positive individuals with cryoglobulin-related vasculitis and 447 ethnically matched, HCV RNA-positive controls. All cases had both serum cryoglobulins and a vasculitis syndrome. A total of 899 641 markers from the Illumina HumanOmni1-Quad chip were analyzed using logistic regression adjusted for sex, as well as genetically determined ancestry. Replication of select single-nucleotide polymorphisms (SNPs) was conducted using 91 cases and 180 controls, adjusting for sex and country of origin. The most significant associations were identified on chromosome 6 near the NOTCH4 and MHC class II genes. A genome-wide significant association was detected on chromosome 6 at SNP rs9461776 (odds ratio=2.16, P=1.16E-07) between HLA-DRB1 and DQA1: this association was further replicated in additional independent samples (meta-analysis P=7.1 × 10(-9)). A genome-wide significant association with cryoglobulin-related vasculitis was identified with SNPs near NOTCH4 and MHC Class II genes. The two regions are correlated and it is difficult to disentangle which gene is responsible for the association with mixed cryoglobulinemia vasculitis in this extended major histocompatibility complex region.

Initial functional and economic status of patients with multivessel coronary artery disease randomized in the Bypass Angioplasty Revascularization Investigation (BARI).

Randomized trials of coronary angioplasty and bypass surgery have hypothesized that these procedures will have equivalent long-term rates of death and myocardial infarction. Functional status, quality of life, employment, and healthcare cost will therefore be critical measures of the efficacy of these alternative revascularization procedures. Patients at 7 sites in the Bypass Angioplasty Revascularization Investigation (BARI) were enrolled in an ancillary Study of Economics and Quality of Life (SEQOL). Physical function was assessed by the Duke Activity Status Index and emotional status by the Mental Health Inventory. Employment patterns and health care utilization were also measured at study entry and at 3-month intervals in follow-up. The 934 patients enrolled in SEQOL were similar to the 895 remaining BARI randomized patients. Most patients (63%) aged < or = 64 years were working, and almost all working patients (96%) intended to return to work. Patients aged > or = 65 years had lower household incomes but better health insurance coverage. Overall health ratings were significantly correlated with both physical and emotional status (p < 0.001). Patients enrolled in SEQOL are representative of the overall BARI population. Data collected in SEQOL will provide a detailed picture of the physical, emotional, and economic well-being after coronary angioplasty and bypass surgery.

The cost of burn care and implications for the future on quality of care.

The high cost of health care has become a nationwide concern and there are several national initiatives under way to reduce the rate of increase of these costs. Among the most recent initiatives has been the introduction of Medicare reimbursement based upon Diagnostic Related Groups (DRGs). This paper presents a retrospective analysis of the costs of care of burned patients admitted to the University of Alabama at Birmingham Burn Center and a profile of the financial impact of DRGs. Costs for burned patients were twice as high as for the average patient in the hospital and increased at a faster rate. Since 1977 the proportion of indigent patients and patients with very poor third-party coverage has greatly increased and those with good or excellent third-party coverage has decreased. If the care for Medicare patients had been reimbursed on the bases of DRG rates in 1982, payments would have exceeded costs by $2,981 but would have been $88,399 less than charges. In 1983, if the care for Medicare patients had been reimbursed on the bases of DRG rates, the payment would have been $409,629 less than costs and $634,583 less than charges. This very unfavorable reimbursement is because DRG reimbursement is essentially a flat rate and for long lengths of stay costs are much greater than reimbursements. Specific policies on methods to correct this discrepancy are suggested.

Costs and benefits associated with treatment for coronary artery disease.

Direct and indirect costs of medical and of surgical treatment are presented for patients entered into the Birmingham portion of the Coronary Artery Surgery Study. For comparison, similar results are shown for the Birmingham portion of the national Cooperative Unstable Angina Study. In the Unstable Angina Study, mean inpatient costs at the end of 1 year in the study were $6867 for medical therapy, $10,574 for surgical therapy and $23,045 for those who failed medical therapy and required late surgery. A stepwise multiple regression analysis shows that the single best predictor of cost was the number of myocardial infarctions that the patient had while in the study. A discriminant-function analysis identified 85% of the medical patients who required late surgery. A significantly lower proportion of surgical than medical patients returned to work. Total inpatient costs for patients in the Coronary Artery Surgery Study (i.e, patients with stable angina) were $3432, $11,100 and $13,554 for medical, surgical and late surgical patients, respectively, for the first year in the study. There was no significant difference in the percentage of medical and surgical patients who were working at the end of 1 year. According to their own perceptions, the surgical group was in the best and the late surgical group in the worst health.

Employment status after coronary artery bypass surgery.

With a few exceptions, prevailing data on return to work after coronary artery bypass surgery indicate no net gain in employment status for at least several years after the operation. Despite the improved surgical experience and advances in the medical management of postoperative patients, only limited employment benefits occur after surgery, and no gains in work rehabilitation over the past decade have been noted. Several characteristics--preoperative work status, nonwork income, occupation, relief of symptoms, age, perception of health, education and severity of disease--appear to be important for estimating the likelihood of employment after surgery. Other influences, such as attitudes of the family, employers and physicians, undoubtedly alter the probability of return to the work force, but are less well documented. Unless constructive approaches toward work rehabilitation are made, the possibility of return to gainful employment should not be considered an indication for or a necessary consequence of coronary artery bypass surgery.

A survey of the graduates of the University of Alabama School of Optometry. Screening for hypertension.

Systemic hypertension is a major health problem in the United States. Almost 16 million people with this disease are estimated to be untreated or inadequately treated. Optometry graduates of the University of Alabama in Birmingham School of Optometry have always received clinical and didactic training in the routine assessment of blood pressure. This study reports the results of a survey of these graduates to determine the number who screened for high blood pressure following graduation, their criteria for referral, their management of hypertensive patients, and their patient characteristics. Over 90% of the optometrists surveyed screened for high blood pressure, and they screened 57% of their patients. Twenty percent of these patients were found to have high blood pressure. These results indicate that optometrists are an important and significant resource in the detection of hypertension in many high risk groups.

Unstable angina pectoris: an examination of modes and costs of therapy.

Debate exists over the most appropriate form of treatment for patients with unstable angina pectoris. This study examined 106 patients randomized at the University of Alabama in Birmingham as part of the National Cooperative Study Group and focuses on the phenomenon of patients who fail medical therapy and thus require late surgery, and the costs of therapy. Discriminant function analysis revealed that the significant predictors (p less than 0.01) of patients who would later require surgery were: total number of vessels diseased, angina severly, presence of congestive heart failure, hypertension, and number of years that the patient had had angina. By means of this analysis, 85% of the late surgery patients were correctly predicted. Late surgery patients averaged 2.4 diseased vessels vs 1.5 for persistent medical patients (p less than 0.01). Mean charges for the first 2 years in the study were $6,226 (SD $2,967) for persistent medical patients, $10,416 (SD $2,146) for surgery patients, and $20,059 (SD $10,748) for late surgery patients (p less than 0.001). These data indicate that surgery is clearly an expensive procedure; but that it is more expensive for late surgery patients, who have total costs that are twice as high as surgical costs and 3.5 times as high as persistent medical costs.

Unstable angina pectoris: a comparison of the costs of medical and surgical treatment.

This study compares the inpatient costs of therapy of patients with unstable angina pectoris randomized to surgical or medical therapy at the University of Alabama in Birmingham as part of the National Cooperative Study Group. For 74 patients followed up for 2 years, the mean inpatient charges were $4,728 for 22 medically treated patients, $9,528 for 34 surgically treated patients and $20,215 for 18 patients who crossed over from medical to surgical therapy. Differences among the three groups were statistically significant (P less than 0.001). Stepwise multiple regression analysis of total inpatient charges with medical and procedural factors as explanatory variables showed that a history of congestive heart failure, the number of infarctions during the period of the study, the duration of the longest anginal attack, the type of unstable angina and the type of treatment were significant predictors of total inpatient cost, with an R2 value of 0.829 (P less than 0.001). These variables explain the cost of treatment. One should not infer that they will also predict the appropriate type of treatment for patients with unstable angina. Although the cost of surgical therapy was double the cost of therapy for patients treated only medically, those medically treated patients whose therapy failed and who subsequently required surgery incurred mean costs twice those of the surgically treated patients and four times of patients who received only medical therapy. Reassessment of previous criticism of the high cost of surgical therapy is indicated.

Colposcopy or cervical conization? An economic comparison.

Costs of colposcopic evaluation of patients with abnormal Papanicolaou smears versus evaluation by conization are compared. The average colposcopic evaluation costs $106, and the average conization costs $923.70. Additional savings ensue if a colposcopic diagnosis, rather than conization of the cervix, precedes a definitive hysterectomy. All criteria for an adequate colposcopic examination and tissue diagnosis must be met to make this comparison.

The costs of spinal cord injury.

An ongoing study of medical care and associated costs relative to spinal cord injury is being conducted at the University of Alabama in Birmingham, one of 11 federally funded Model Regional Spinal Cord Injury Centres. It was hypothesised such costs would be lower among patients admitted into an organised continuum of care (system) soon after injury than among patients whose entry into the organised system of care was delayed (non-system). A comprehensive economic data set has been acquired on 142 of 233 (61 per cent) patients admitted since implementation of the project. Analysis of these data reveals: (1) system patients require, on average, expenditures of almost $5,000 less than their non-system counterparts; (2) there is little difference in medical or associated costs and length of hospitalisation between tetraplegics and paraplegics; (3) spinal cord injuries secondary to motor vehicle accidents have higher associated costs and longer lengths of stay than do those injuries resulting from other causes including acts of violence.

Nail damage in spray operators exposed to paraquat

Nail damage in 55 persons due to contamination by diluted paraquat in a group of 296 spray operators employed on a sugar estate in Trinidad is described. The commonest lesion seen was transverse white bands of discoloration, but loss of nail surface, transverse ridging, gross deformity of the nail plate, and loss of nails occurred. The index, middle, and ring fingers of the right hand were predominantly affected and this could be ascribed to leakage from the knapsack sprayer. It is emphasized that, although the degree of contamination was unusually gross, it is nonetheless important to recognize that diluted material can cause nail damage. Simple hygienic precautions and proper maintenance of spraying equipment can prevent its occurence. Periodic medical examinations are recommended even for workers exposed only to diluted paraquat. The distribution of the nail lesions confirms that they are the result of a local action. Following cessation of further exposure subsequent nail growth is normal. (AU)

Bagassosis: an epidemiological and environmental survey - abstract

An epiemiological and environmental survey of 170 bagasse workers employed by a raw sugar producing company in Trinidad was carried out in order to assess the prevalence of respiratory symptoms, and to determine if exposure to bagasse was associated with alterations in ventilatory capacity. The epidemiological survey failed to reveal a significantly increased prevalence of respiratory symptoms in the more exposed group, but showed that the group of Indian workers who were regularly and continuously exposed to bagasse had a significantly lower ventilatory capacity than the control group (p < 0.001). This diminished ventilatory capacity was demonstrated despite negligible dust concentrations in the plant. Dust concentrations were measured using a Hexhlet sampler, the highest mean total dust concentration of 0.71 mg./m3 being found in the unloading area. However, the possibility that persistent exposure to low concentrations of bagasse may be the cause of the diminished ventilatory capacity must be considered (AU)

Bagassosis: an epidemiological, environmental, and clinical survey

An epidemiological and environmental survey of 170 bagasse workers employed by a raw sugar producing company in Trinidad was carried out in order to assess the prevalence of respiratory symptoms and to determine if exposure to bagasse was associated with alterations in ventilatory capacity. The epidemiological survey failed to reveal a significantly increased prevalence of respiratory symptoms in the more exposed group but showed that the group of Indian workers who were regularly and continously exposed to bagasse had a significantly lower ventilatory capacity than the control group. This diminished ventilatory capacity was demonstrated despite negligible dust concentrations in the plant. However, the possibility that persistence exposure to low concentrations of bagasse may be the cause must be considered. During a five-year period, 17 patients with bagassosis were seen, the clinical picture being similar to that described in extrinsic allergic alveolitis from other causes. The systematic variations demonstrated in some indices of ventilatory function in different racial groups is discussed.(AU)