Variation in tertiary prevention and health service utilization among the elderly: the role of urban-rural residence and supplemental insurance.

OBJECTIVES: Tertiary prevention seeks to reduce chronic disease progression and illness-related dysfunction. Using the Aday-Andersen model, we evaluated the impact of predisposing, need, and enabling factors on tertiary prevention, hypothesizing that urban-rural geographic differences in delivery would be detected. METHODS: A population-based telephone survey was conducted evaluating six common chronic indicator conditions: arthritis (n = 488), hypertension (n = 414), cardiac disease (n = 185), diabetes mellitus (n = 125), peptic ulcer disease (n = 125), and chronic obstructive pulmonary disease (n = 103). Subjects were 787 (70% women) home-dwelling elderly (age > 65 years) who had one or more of the indicator conditions and who resided in Iowa's 12 most rural and 10 most urban counties. Tertiary prevention measures included counseling for and/or treatment with: influenza and pneumococcal vaccination, smoking cessation, dietary modifications, exercise, drug side effects, chronic disease rehabilitation, aspirin/estrogen for cardiac disease, and foot/eye care for diabetes. Tertiary prevention scores were calculated to compare preventive services across disease categories and to examine relations, in particular, with enabling factors. RESULTS: Education beyond high school, alcohol use, cigarette smoking, and medical specialist use were all significantly greater among urban residents, whereas home services use was greater among rural residents. Respondents with either health maintenance organization or fee-for-service supplemental coverage had higher tertiary prevention scores than respondents without supplemental coverage. After adjustment for the significant effects of the number of diseases, higher income, and place of residence, rural respondents having health maintenance organization supplemental coverage had higher (better) tertiary prevention scores than other respondents. CONCLUSIONS: In this community-based study of elderly, enrollment in an health maintenance organization plan, as opposed to a fee-for-service supplement to Medicare, increased tertiary prevention quality for rural but not for urban residents. This study emphasizes that additional research is needed to evaluate the importance of specific types of insurance coverage for preventive services among the elderly.

Experience with desmoid tumor in a community teaching hospital.

Desmoid tumors are rare fibroblastic proliferations that occur primarily in the abdomen and extremities. They have an estimated incidence in the United States of two to four per million inhabitants per year. A recent case of desmoid tumor prompted us to review past medical records for previous cases with the same diagnosis. Since 1985, our institution has treated five patients with a total of eight desmoid tumors. Four patients (80%) were female with ages ranging from 24 to 32 years. The other patient was a 22-year-old male with a history of Gardner's syndrome and recurrent desmoid tumors. The majority of our patients were females in the fertile age group, substantiating the hormonal effects believed to play a role in the development of these lesions. In addition, it became obvious that more investigations must be done in appropriate treatment of desmoid tumors and the documentation of these tumors in registries would be of significant benefit.

[Phenylalanine-free amino acid mixture: metabolic effects in relation to a single dose]. / Phenylalaninfreie Aminosäurenmischung: Stoffwechselwirkung in Abhängigkeit von der Einzeldosis.

In the dietetic treatment of phenylketonuric patients phenylalanine free amino acid mixtures are given to meet the protein requirement of the patient. In four healthy probands we tested the metabolic effects of four different PKU-preparations given in variable amounts ingested with carbohydrate and fat containing meals. We determined glucose, insulin, amino acids, and urea in blood. Following the amino acid load we saw an increased insulin output with a hypoglycemic reaction or, with smaller amounts a lack of the normal postprandial blood glucose increase. Hyperaminoacidemias depended on the amount of amino acids ingested. The increase of blood urea found suggests that part of the amino acids were degraded. To compare the results we studied a PKU-patient. He showed corresponding but milder effects.