Percutaneous retrieval of fractured intravascular catheters in premature infants.

BACKGROUND: Premature infants often require long-term indwelling intravascular catheters. Occasionally, catheters fracture and migrate into cardiovascular structures, risking perforation, infection, thrombosis, and interference with cardiac and valve function. This case series describes our experience with percutaneous retrieval of broken intravascular catheters. METHODS: A gooseneck micro-snare was used to retrieve fractured catheters in four premature infants, weighing between 840 and 1930 grams. RESULTS: All procedures were successful without complications. CONCLUSIONS: Gooseneck-snare retrieval of broken indwelling intravascular catheters can be performed safely and successfully in premature infants even those that weigh less than 1000 grams.

Efficacy of an exercise intervention among children with comorbid asthma and obesity.

OBJECTIVES: Children with comorbid asthma and obesity present with more severe and harder-to-control disease than asthmatic children at healthy weight. Weight loss has been shown to improve asthma symptoms, yet physical activity may be difficult due to exercise-induced bronchospasm. Children with asthma have lower exercise rates than non-asthmatics. The objective of this study was to retrospectively evaluate attrition rates and program outcome measures (Body Mass Index [BMI] and maximum oxygen consumption [VO2max]) among asthmatic and non-asthmatic participants. STUDY DESIGN: Clinical data were collected from the Healthy Hearts Program, a 12-week nutrition and activity intervention program for children who are overweight, obese, or at risk for heart disease and other conditions, and used for the study. METHODS: Intervention data and demographics were obtained from medical records at the Children's Heart Center Nevada. Descriptive statistics, paired t-tests, Cox regression analysis, and analysis of covariance were conducted. RESULTS: The mean age of this population (N = 232) was 11 years; 54% were male, 64% were Hispanic, and 37% had asthma. Median time in the program was 9 weeks, and 58% of the population completed the program. Unadjusted analyses showed significant BMI decreases in asthmatic (P = 0.002) and non-asthmatic (P = 0.001) participants and increases in cardiorespiratory function for asthmatic males and females (P = 0.003, P = 0.004) and non-asthmatic males and females (P < 0.001 for both). Asthmatic and non-asthmatic children both had improved exercise intensity (P = 0.033, P < 0.001). CONCLUSIONS: This program is both beneficial and practical for obese children with asthma for losing weight and improving cardiorespiratory function.

The arterial switch operation before Jatene.

Attempts at the arterial switch operation predated the Senning and the Mustard venous switch procedures. No patients survived the earlier arterial switch methods. Therefore, from the 1960s to the 1980s, venous switch surgeries became the dominant treatment method for transposition of the great arteries. The Brazilian cardiac surgeon, Adib Jatene, reported the first successful arterial switch in 1975. The history of the earlier arterial switches performed in the 1950s and 1960s is not well known. This article discusses that early history.

Overlapping covered stents to exclude a postcoarctation stenting aortic aneurysm.

An 18-year-old boy who underwent coil occlusion of a patent ductus arteriosus and stenting for aortic coarctation at 13 years of age had evidence of re-stenosis. Cardiac catheterization and angiography showed a 25-mmHg gradient across the stent and a large aneurysm originating at midstent level. The aneurysm measured 2 cm in width and 4.3 cm in length. At a subsequent catheterization procedure, two 4.5-cm-long overlapping Cheatham platinum covered stents were implanted, completely excluding the aneurysm. Computed tomographic (CT) angiography 2 years later showed no evidence of endoleak or re-stenosis.

Cigarette taxes and smoking during pregnancy.

OBJECTIVES: This study sought to estimate how changes in state cigarette excise taxes affect the smoking behavior of pregnant women. METHODS: Detailed information about mothers and their pregnancy was used to examine the impact of taxes on the propensity of pregnant women to smoke. The 1989 to 1995 Natality Detail Files were used in conducting analyses to assess the impact of taxes on smoking among different subpopulations. RESULTS: Higher cigarette excise taxes reduced smoking rates among pregnant women. A tax hike of $0.55 per pack would reduce maternal smoking by about 22%. Overall, a 10% increase in price would reduce smoking rates by 7%. Estimates for subpopulations suggested that nearly all would be very responsive to tax changes, including the subpopulations with the highest smoking rates. CONCLUSIONS: Smoking rates among pregnant women are responsive to tax hikes.

The impact of workplace smoking bans: results from a national survey.

OBJECTIVE: To estimate the impact of workplace smoking restrictions on the prevalence and intensity of smoking among all indoor workers and various demographic and industry groups. DESIGN: Detailed cross sectional data on worker self reported characteristics, smoking histories, and workplace smoking policies were used in multivariate statistical models to examine whether workplace smoking policies reduce cigarette consumption. After analysing the distribution of policies, four main types of workplace programme were defined: (1) 100% smoke-free environments, (2) work area bans in which smoking is allowed in some common areas, (3) bans in some but not all work and common areas, and (4) minimal or no restrictions. SETTING: After environmental tobacco smoke was identified as a health hazard in the mid-1980s, workplace smoking restrictions became more prevalent. By 1993, nearly 82% of indoor workers faced some restriction on workplace smoking and 47% worked in 100% smoke-free environments. PARTICIPANTS: The database included a nationally representative sample from the tobacco use supplements to the September 1992, January 1993, and May 1993 Current Population Surveys of 97,882 indoor workers who were not self employed. MAIN OUTCOME MEASURES: Prevalence of smoking and number of cigarettes smoked daily by smokers. RESULTS: Having a 100% smoke-free workplace reduced smoking prevalence by 6 percentage points and average daily consumption among smokers by 14% relative to workers subject to minimal or no restrictions. The impact of work area bans was lessened by allowing smoking in some common areas. Smoke-free policies reduced smoking for all demographic groups and in nearly all industries. CONCLUSIONS: Requiring all workplaces to be smoke free would reduce smoking prevalence by 10%. Workplace bans have their greatest impact on groups with the highest rates of smoking.

Vulnerability of rural hospitals to Medicare outpatient payment reform.

Because the Balanced Budget Act (BBA) of 1997 requires implementation of a Medicare prospective payment system (PPS) for hospital outpatient services, the authors evaluated the potential impact of outpatient PPS on rural hospitals. Areas examined include: (1) How dependent are rural hospitals on outpatient revenue? (2) Are they more likely than urban hospitals to be vulnerable to payment reform? (3) What types of rural hospitals will be most vulnerable to reform? Using Medicare cost report data, the authors found that small size and government ownership are more common among rural than urban hospitals and are the most important determinants of vulnerability to payment reform.

Do hospital-based rural health clinics improve the performance of the parent hospital?

This study shows that establishing an RHC may lead to beneficial impacts for the parent hospital, and that these benefits have been experienced by categories of hospitals that are now subject to the new limit on RHC reimbursement legislated by the Balanced Budget Act.

Hospital-physician arrangements and hospital financial performance.

OBJECTIVES: The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance. METHODS: Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance. RESULTS: Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements. CONCLUSIONS: Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.

The compensating behavior of smokers: taxes, tar, and nicotine.

Using data from the 1979 and 1987 National Health Interview Survey (NHIS), we test whether smokers alter their smoking habits in the face of higher taxes. Smokers in high-tax states are more likely to smoke cigarettes higher in tar and nicotine. Although taxes reduce the number of cigarettes consumed per day among remaining smokers, total daily tar and nicotine intake is unaffected. Young smokers, aged 18-24, are much more responsive to changes in taxes than are older smokers, and their total daily tar and nicotine intake actually increases after a tax hike. We illustrate that tax-induced compensating behavior may eliminate some health benefits generated by reduced smoking participation. A more appropriate tax might be based on the tar and nicotine content of cigarettes.

Primary care case management for Medicaid recipients: evaluation of the Maryland Access to Care program.

A growing number of states are implementing Medicaid managed care programs, and primary care case management (PCCM) is an important component of many of these systems. In this paper, we present results of an evaluation of one such PCCM program--the Maryland Access to Care (MAC) program. The evaluation uses five years of Medicaid claims and eligibility data from the period before and after the program's introduction to determine the program's impact on expenditures and service utilization. Results indicate that the program increased the probability that a Medicaid enrollee would use primary care and preventive services, but had little impact on use of specialty or emergency room services. The gatekeeper program also was successful at controlling expenditures once an enrollee entered the health care system, largely through reductions in the use of ancillary services. The post-MAC increase in the probability of using services was so great, however, that all savings per user were negated, resulting in an estimated increase of about 3.4% in Medicaid expenditures for the MAC-eligible population.

Participation in the Qualified Medical Beneficiary Program.

This article has three objectives: to estimate how many eligible elderly beneficiaries are participating in the Qualified Medicare Beneficiary (QMB) program; to determine the characteristics of participating and non participating eligibles; and to identify the most significant barriers to program participation. We used data from the Medicare Current Beneficiary Survey (MCBS) and the Medicare Buy-In file. We found that 41 percent of QMB eligibles are enrolled in the program; participation is higher for poor and less educated beneficiaries, those in poorer health, rural residents, African Americans, and Hispanics. Finally, we found that, in general, eligible beneficiaries are ill informed about the program.

General deterrence of drunk driving: evaluation of recent American policies.

A testable hypothesis of deterrence theory is that efforts to increase the expected cost of criminal activity by increasing the threat of punishment should, other things being equal, reduce the crime rate. In this paper, we examine whether the incidence of drinking and driving is responsive to escalation of the punitive threat. The recent national campaign against drunk driving provides a natural experiment in which to test the predictions of deterrence theory. Using state level data over the 1975-1986 period, we report no conclusive evidence that any specific form of punitive legislation is having a measurable effect on motor vehicle fatalities. We report suggestive evidence that multiple laws designed to increase the certainty of punishment (e.g., sobriety checkpoints and preliminary breath tests) have a synergistic deterrent effect. The most striking finding is that mandatory seat belt use laws and beer taxes may be more effective at reducing drunk driving fatalities than policies aimed at general deterrence.

An estimate of the lifesaving benefit of child restraint use legislation.

This paper presents the first econometric estimate of the lifesaving benefit of automobile child restraint use legislation. In contrast to previous econometric analyses of traffic safety regulations, modified count data models are employed to account for the rarity of childhood fatalities. Results of the modeling suggest that legislation reduces childhood car-occupant fatalities by 39% for infants, and 30% among toddlers. A simple simulation indicates that such legislation is currently saving the lives of about 160 children per year in the United States.

Plasma catecholamine responses to hypoxemia in fetal lambs.

The plasma catecholamine responses to hypoxemia were evaluated in 10 chronically catheterized fetal lambs in utero from 0.77 gestation to term using a highly sensitive radioenzymatic assay. Hypoxemia was produced by gradual constriction of the umbilical cord by an implanted cuff occluder. Fetal carotid arterial PO2 fell from 23 to 12 torr and was accompanied by an exponential increase in catecholamine concentration. Plasma norepinephrine (NE) increased from 256 +/- 31 to 1,888 +/- 384 pg/ml while epinephrine rose from 24 +/- 5 to 1,159 +/- 433 pg/ml. Fetal arterial PO2 returned to normal within 1 min of deflating the cuff occluder. Simultaneously, NE and epinephrine levels declined rapidly but, nevertheless, remained mildly elevated compared to controls. There was no maturational change in baseline NE levels during the last quarter of gestation, where as epinephrine was significantly higher after 125 days than between 115 and 125 days (37 +/- 7 vs. 16 +/- 6 pg/ml, p less than 0.05). However, maturation had no significant effect upon the magnitude of the epinephrine or NE response to hypoxemia. In conclusion, the late gestation fetal lamb is capable of manifesting a profound catecholamine response to hypoxemia which appears to play a major role in the compensatory cardiovascular adjustment to severe stress.

On Guntrip's analysis with Fairbairn and Winnicott.

Guntrip's paper is an account of his ananlytic experience, first with Fairbairn and then with Winnicott. Although attempting to be objective, he cannot disguise the fact that he is frustrated and dissatisfied. He raises this question: "How complete a result does psychoanalytic therapy achieve?" The question Guntrip is, in effect, asking himself, is: "What went wrong?" We suggest the following points: The failure of both analysts to recognize a very specific form of resistance and to deal with an unusual transference situation. Fiarbairn's insistence on giving oedipal interpretation to a patient who, as Winnicott recognized, did not have an oedipus complex. The failure of both analysts to recognize Guntrip's infantile megalomania; to expose his insistence that the blame for his neurosis must be attached to a "totally" bad mother; and the failure to recognize the intensity of his sibling rivalry. Psychoanalytic therapy is not merely "correct" interpretation and "correct" technique. It involves the interaction of two human beings. The countertransference of Fairbain and Winnicott prevented their perceiving and dealing with the essential problem of this exceptionally gifted patient.