Disparities in timeliness of care for U.S. Medicare patients diagnosed with cancer.

BACKGROUND: Timeliness of care (rapid initiation of treatment after definitive diagnosis) is a key component of high-quality cancer treatment. The present study evaluated factors influencing timeliness of care for U.S. Medicare enrollees. METHODS: Data for Medicare enrollees diagnosed with breast, colorectal, lung, or prostate cancer while living in U.S. seer (Surveillance, Epidemiology and End Results) regions in 2000-2002 were analyzed. Patients were classified as experiencing delayed treatment if the interval between diagnosis and treatment was greater than the 95th percentile for each cancer site. The impacts of patient sociodemographic, clinical, and area-based factors on the likelihood of delayed treatment were analyzed using multivariate logistic regression. RESULTS: Black patients (compared with white patients) and patients initially treated with radiation therapy or chemotherapy (rather than surgery) had a greater likelihood of treatment delays across all four cancer sites. Hispanic status, dual Medicare-Medicaid status, location of initial treatment (inpatient vs. outpatient), and stage at diagnosis also affected timeliness of care for some cancer sites. Surprisingly, area-based factors reflecting availability of cancer care services were not significantly associated with timeliness of care or were associated with greater delays in areas with greater numbers of service providers. CONCLUSIONS: Multiple factors affected receipt of timely cancer care for members of the study population, all of whom had coverage of medical care services through Medicare. Because delays in treatment initiation can increase morbidity, decrease quality of life, shorten survival, and result in greater costs, prospective studies and tailored interventions are needed to address those factors among at-risk patient groups.

Bacterial cholangitis/cholangiohepatitis with or without concurrent cholecystitis in four dogs.

OBJECTIVES: To evaluate the clinical, clinical pathology, diagnostic imaging, microbiological and pathological features of cholangitis/cholangiohepatitis in the dog. METHODS: The study design was a retrospective review of cases of bacterial cholangitis/cholangiohepatitis presented to the University of Bristol during the period 1995 to 2000. The diagnosis was made based on hepatic histopathological findings and positive bile culture results. RESULTS: Four dogs met the inclusion criteria. Common presenting signs included anorexia (n=4), jaundice (n=4), vomiting (n=4) and pyrexia (n=2). All four dogs had a leucocytosis or neutrophilia reported at some time in their history along with serum bilirubin elevation. In addition, serum alkaline phosphatase and alanine transaminase activity was increased in all of the dogs in which it was measured both before and at the time of referral. In general, the diagnostic imaging findings were non-specific. Organisms cultured from bile aspirates were Escherichia coli (n=3), Clostridium species (n=2) and a faecal Streptococcus species (n=1). Two cases resolved with medical treatment alone; two with concurrent cholecystitis required cholecystectomy. Following surgery, both of these cases showed a resolution of clinical signs. CLINICAL SIGNIFICANCE: This report highlights the fact that bacterial cholangitis/cholangiohepatitis with or without concurrent cholecystitis should be considered as a potential differential in dogs presenting with signs referable to biliary tract disease.

Eosinophilic diseases in two Cavalier King Charles spaniels.

This report describes the clinical presentation of two Cavalier King Charles spaniels with different eosinophilic diseases. The first case presented with dyspnoea and a non-productive cough, and investigations demonstrated eosinophilic bronchopneumonopathy. The second dog was referred for the investigation of haemorrhagic vomiting and diarrhoea and was eventually diagnosed with eosinophilic enteritis. Both dogs had concurrent eosinophilic stomatitis, and both responded completely to immunosuppressive glucocorticoid therapy. This report is the first to describe the concurrence of eosinophilic stomatitis and systemic eosinophilic disease in Cavalier King Charles spaniels, and suggest that this breed may be predisposed to eosinophilic syndromes.

Clinical evaluation of a valveless non-absorber breathing system in spontaneously breathing canine patients.

A valveless non-absorber breathing system novel to veterinary anaesthesia is described. The performance of this system was evaluated in 35 anaesthetised spontaneously breathing dogs weighing between 2.1 and 56 kg. Fresh gas flows were reduced incrementally until rebreathing (defined as an increase in end-inspired carbon dioxide tension above 0.2 per cent) started to occur, as measured by capnography. A significant relationship (P < 0.0001) between critical fresh gas flow and bodyweight was determined, and a mean critical fresh gas flow rate of 145 +/- 21 ml/kg/minute was derived for 15 dogs weighing 10 kg or less (mean 6.7 +/- 2.6 kg) and one of 98 +/- 16 ml/kg/minute for the remaining 20 dogs weighing 11 kg or greater (mean 30.2 +/- 13.9 kg). The fresh gas requirements for each group were found to differ significantly (P < 0.0001), although the correlation between critical fresh gas flow and bodyweight was not significant (P = 0.054) in the dogs weighing 10 kg or less. It is suggested that the system may prove an economical and useful addition to the breathing systems currently used in canine anaesthesia.

A comparison of the 'Maxima' and the modified Ayre's T-piece breathing systems in spontaneously breathing cats.

OBJECTIVE: To compare the fresh gas flow requirements of the 'Maxima' and Jackson-Rees modified Ayre's T-piece (JRMATP) in spontaneously breathing anaesthetized in cats. STUDY DESIGN: Prospective randomized clinical study. ANIMALS OR SAMPLE POPULATION: Fifteen adult cats (6 male, 9 female, 3.1 ± 0.4 kg [ x¯ ± SD]). MATERIALS & METHODS: After pre-anaesthetic medication with acepromazine and pethidine, anaesthesia was induced using thiopentone and the trachea was intubated with a cuffed endotracheal tube. This was attached to either a 'Maxima' or a JRMATP breathing system; allocation was randomized. Anaesthesia was maintained with halothane delivered in a 1 : 1 oxygen : nitrous oxide mixture. Initial total fresh gas flow (FGF) was set at 600 mL kg-1 min-1. After 20 minutes, FGF was reduced in increments of 200 mL min-1 until rebreathing (inspired CO2 concentration >0.2%) occurred. At this point, FGF was increased to 600 mL kg-1 and the process was repeated with the other breathing system. The respiratory rate and airway pressure at the endotracheal tube connector were monitored throughout anaesthesia. RESULTS: The mean fresh gas flow that prevented rebreathing with the Maxima system (164 ± 39 mL kg-1) was significantly less (p < 0.0001) than that required in the modified T-piece (455 ± 0.77 mL kg-1). Respiratory rates and airway pressures at the endotracheal tube connector were not significantly affected by breathing system employed. CONCLUSIONS: In terms of the gas flow requirements that prevent rebreathing, the 'Maxima' breathing system is more efficient than the modified Ayre's T-piece in spontaneously breathing cats anaesthetised with halothane.

Health education for a breast and cervical cancer screening program: using the ecological model to assess local initiatives.

This study investigates the development and implementation of health education strategies at the local level for a statewide breast and cervical cancer control program. Baseline data on these initiatives were collected from 88 local screening programs in North Carolina. Using the ecological model as a framework, health education initiatives were assessed and analyzed to determine the level of activity occurring at the local level and the comprehensiveness of programs. Types and levels of interventions used are described and initial analysis is provided of the impact these strategies are having on recruiting women from target populations into these screening programs. Specific examples illustrating the variety of interventions used at the individual, network, organizational and community levels, and the impact of certain variables, such as the use of local health education staff, on the comprehensiveness of interventions utilized, are provided. The importance to practitioners of establishing process indicators in assessing local initiatives and challenges to conducting evaluations of these strategies are also discussed.

Mitral valve replacement for the treatment of congenital mitral dysplasia in a bull terrier.

A 10-month-old entire male bull terrier was presented with a history of collapse on exercise. Clinical examination, electrocardiography, radiography and echocardiography all supported a diagnosis of mitral valve dysplasia. There was no evidence of congestive heart failure. Surgical intervention consisted of open resection of the dysplastic mitral valve and its replacement with a bioprosthetic valve. The procedure was performed through a median sternotomy and the dog was placed on to full cardiopulmonary bypass. Total cardiopulmonary bypass time was 70 minutes. A full recovery was made and at the time of writing (17 months postoperatively) the dog is clincally normal requiring no medication.

Clinical and serologic features of patients with polymyositis or dermatomyositis.

The clinical and serologic features of 36 patients with polymyositis (PM) or dermatomyositis (DM) were observed over a 5-year period. The mean age of the patients at the time of diagnosis was 48.5 years, and 61% were female. According to widely accepted diagnostic criteria 50% had PM (group I), 14% DM (group II), 11% PM or DM associated with malignant disease (group III) and 25% PM or DM associated with a connective tissue disorder (group V). None of the patients had childhood PM or DM associated with vasculitis (group IV). All the patients had muscle weakness, and 94% of the patients tested had an elevated serum level of creatine kinase. The average delay from the onset of symptoms to diagnosis was 14 months overall but only 2.3 months for the DM patients. Of the 30 patients whose serum was tested, 73% had antinuclear antibodies, with antibodies to nuclear ribonucleoprotein being most common in group V patients and antibodies directed against the Jo-1 antigen being restricted to patients with PM alone (group I).

The expression of memorization in early childhood.

This experiment examined the expression and effectiveness of memorization in young children. Sixty children at each of the ages 4, 5, and 6 were randomly assigned to a memory group or to one of two control groups. All of the children were told that they could play with a group of toys during a brief activity period; the children in the memory condition were also instructed to memorize a specified subset of the toys. Mnemonic mediators were identified on the basis of differences in the activity period behaviors of children given memory and play instructions. Relative to the children in the play groups, the children in the memory conditions played with the toys less; further, their use of naming and visual examination as mnemonic mediators differentiated the groups at all ages and increased with age. Only the oldest subjects given memory instructions, however, demonstrated superior recall. The relationships between activity period behavior and recall among the different conditions were explored with regression techniques. although previous research has focused on identifying the earliest use of memory strategies, the present findings underscore the importance of examining the development of these skills.