Gas-forming liver abscess in a patient with multi-organ failure: role of imaging and management.

We present an unusual case of air-containing liver abscess demonstrated on plain film and ultrasonography with successful treatment utilizing ultrasound-guided drainage in a patient in septic shock. Although surgical drainage is often indicated, ultrasound-guided catheter drainage along with supportive antibiotic therapy can be a safe treatment alternative in critical patients.

Factors associated with the onset and remission of chronic daily headache in a population-based study.

The etiology and prognosis of chronic daily headache (CDH) are not well understood. The aim of this study is to describe factors that predict CDH onset or remission in an adult population. Potential cases (180+ headaches per year, n=1134) and controls (two to 104 headaches per year, n=798) were interviewed two times over an average 11 months of follow-up. Factors associated with CDH prevalence at baseline were evaluated. The incidence of CDH and risk factors for onset were assessed in controls whose headache frequency increased to 180+ per year at follow-up. Prognostic factors were assessed in CDH cases whose headache frequency fell at follow-up. CDH was more common in women, in whites, and those of less education. CDH cases were more likely to be previously married (divorced, widowed, separated), obese, and report a physician diagnosis of diabetes or arthritis. At follow-up, 3% of the controls reported 180 or more headaches per year. Obesity and baseline headache frequency were significantly associated with new onset CDH. In CDH cases, the projected 1-year remission rate to less than one headache per week was 14% and to less than 180 headaches per year was 57%. A better prognosis was associated with higher education, non-white race, being married, and with diagnosed diabetes. Individuals with less than a high-school education, whites, and those who were previously married had a higher risk of CDH at baseline and reduced likelihood of remission at follow-up. New onset CDH was associated with baseline headache frequency and obesity.

Coping strategies and health care-seeking behavior in a US national sample of adults with symptoms suggestive of overactive bladder.

BACKGROUND: Although millions of individuals have symptoms suggestive of overactive bladder (OAB), few ever seek or receive medical treatment for their condition. OBJECTIVE: The purpose of this study was to describe coping strategies and health care-seeking behavior in a community-based sample of adults with symptoms suggestive of OAB. METHODS: A cross-sectional household telephone survey of an age- and sex-stratified sample of adults was conducted. The survey consisted of general health-related questions as well as questions related to OAB symptoms. A total of 4896 adults completed the interview Respondents were considered to have OAB if they reported > or = 1 symptom of urinary urgency, frequency, or urge incontinence. A follow-up questionnaire was then mailed to a subsample of the telephone interview respondents. The mailed questionnaire contained questions related to type and severity of OAB symptoms, coping strategies, medical care/treatment, feelings/beliefs about OAB, and quality of life. Half of the phone respondents with urinary incontinence (n = 638) and a random sample of all other phone respondents received the mailed questionnaire (n = 873); 1,034 questionnaires were returned. RESULTS: Of the respondents with OAB, 69.6% tried > or = 1 nonmedical coping strategy. Respondents with incontinent OAB were significantly more likely than those with continent OAB or those with no OAB (controls) to use nonmedical coping strategies (incontinent OAB, 76.1%; continent OAB, 59.0%; controls, 31.9%; P < 0.001). Fewer than half of the respondents with OAB (43.5%) had spoken with a provider about OAB in the previous 12 months. Medical consultation was associated with sex, type and severity of OAB, number of nonmedical coping strategies tried, number of OAB information sources consulted, inclination to try new OAB medications, and feelings/beliefs about OAB. In 90% of patient-provider discussions about OAB, the patient initiated the topic. CONCLUSIONS: Individuals manage symptoms suggestive of OAB primarily by using nonmedical coping strategies rather than consulting health care providers. Results of this study support the need for improved clinical recognition of OAB and increased patient-provider communication about this condition.

Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact.

The prevalence and impact of abdominal pain, bloating, and diarrhea in the adult US population are largely unknown. We conducted a national, cross-sectional, telephone survey of US households to provide estimates of the frequency, duration, severity, and impact of specific digestive symptoms during the previous month. A total of 2510 subjects completed interviews (70.7% response rate). Among the respondents, 1017 (40.5%) reported one or more digestive symptoms within the month before the interview, including abdominal pain or discomfort 21.8%, bloating or distension 15.9%, and diarrhea or loose stools 26.9%. Women were more likely than men to report abdominal pain or discomfort (24.4% vs 17.5%) and bloating or distension (19.2% vs 10.5%), but not diarrhea or loose stools (27.1% vs 26.7%). Symptoms were less common among those > or =60 years of age. More than 65% of respondents rated symptoms as moderate or severe in intensity, and the majority reported limitations in daily activities. We conclude that digestive symptoms are more common than previously recognized and have a significant impact.

Upper gastrointestinal symptoms in a U.S. national sample of adults with diabetes.

BACKGROUND: Individuals with diabetes may be particularly susceptible to motility-related upper gastrointestinal (UGI) symptoms such as abdominal pain or discomfort, bloating, early satiety, nausea, and vomiting. We estimated the prevalence of UGI symptoms in a population-based sample of individuals with diabetes and determined whether cases and population controls differed in prevalence of UGI symptoms and in symptom features. METHODS: Individuals with diabetes (n = 483) and matched controls (n = 422) were recruited from a prior U.S. national health survey for a telephone interview on UGI symptoms. To confirm self-reported diabetes status, cases provided information on clinical management measures. Subjects were asked about UGI symptoms in the month before interview. Affirmative responses to initial questions triggered detailed questions about symptom frequency, timing, duration, and severity. Differences between cases and controls were evaluated. RESULTS: Cases not only had a significantly (P < 0.05) higher overall prevalence of one or more UGI symptoms in the past month (50%) than controls (38%), but they also reported a significantly greater number of UGI symptoms than controls. Almost 10% of cases reported three or more UGI symptoms in the past month compared with 2% of controls. Our study also identified UGI symptom features that were more relevant to cases and showed that one UGI symptom, heartburn, co-occurred significantly more often with UGI symptoms in cases than in controls. CONCLUSIONS: Upper GI symptoms are common in individuals with diabetes and more prevalent than in controls. The symptoms are non-specific and may reflect disruptions in motility or perception.

Food and nutrition surveillance: an international overview.

Systems providing routine food and nutrition surveillance (FNS) in local and national populations are essential to the understanding of relations between nutrition and health and the implementation of appropriate actions to promote the well-being of those populations. The purpose of an FNS program is to gather, interpret, and disseminate information about nutrition. Functions of FNS systems include national and regional planning, monitoring and evaluation of food and nutrition programs, provision of timely warnings of food shortages, problem identification, advocacy support, and monitoring food and nutrition effects of structural-adjustment policies. The characteristics of an FNS system are determined by its function. Successful FNS systems are community based and action oriented. We reviewed FNS systems throughout the world, with special emphasis on those in developing countries.

Risk factors for wasting and stunting among children in Metro Cebu, Philippines.

Risk factors for wasting and stunting were examined in a longitudinal study of 18 544 children younger than 30 mo in Metro Cebu, Philippines. Measures of household demographic and socioeconomic characteristics, maternal characteristics and behavior, and child biological variables were analyzed cross-sectionally in six child age-residence strata by using logistic regression. Our results support biological and epidemiologic evidence that wasting and stunting represent different processes of malnutrition. They also indicate that the principal risk factors for stunting and wasting in infants < 6 mo of age were either maternal behaviors or child biological characteristics under maternal control, eg, breast-feeding status and birth weight. After 6 mo of age, household socioeconomic characteristics emerged with behavioral and biological variables as important determinants of malnutrition, eg, father's education and presence of a television and/or radio. Household socioeconomic status influenced the risk of stunting earlier in rural than in urban barangays. Implications of the results for interventions are discussed.

The significance of children's age in estimating the effect of maternal time use on children's well-being.

The women's initiative launched by the United Nations Decade for Women has sparked unresolved controversy over the consequences of mothers' increased participation in economically productive activities on children's well-being. Clearly, in many developing countries, poor mothers face stringent time constraints requiring trade-offs in time allocated to various activities, including child caregiving. However, the impact of these trade-offs on children's well-being remains unclear. The effect of maternal time use on children's nutrition and health status requires more rigorous examination. In particular, the role of children's age in this relationship is critical. Although children's requirement for maternal care varies with factors such as their age (a proxy for stage of psychobiological and sociocultural development), season of year and family size and structure, children's age has not been highlighted in the debate or in the relevant research. This paper documents children's age as a critical factor in the relationship between maternal patterns of time use and the well-being of children 18-30 months of age in peri-urban Egypt. It describes differences in maternal patterns of daily time use according to children's age and illustrates the differential associations between maternal daily activity patterns and children's well-being by children's age. Quantitative data collected on 161 mother-toddler pairs included information on maternal daily time allocation, children's dietary energy intake and diarrheal morbidity, maternal hemoglobin, and household and individual sociodemographics. Data were stratified by children's age at 24 months and were analyzed cross-sectionally using multiple linear and logistic regression. Results indicated that the age of two is critical in Kalama. At this age, toddlers begin to receive less time-intensive care freeing mothers for economic and self production. With respect to children's well-being prior to age two, frequency of feeding was positively related to their energy intake and more time spent in household sanitation activities reduced children's risk of diarrhea (during the diarrhea season). After two years of age, the maternal behaviors measured did not affect children's energy intake; however, children's diarrheal risk was reduced (during the diarrhea season) when mothers held them more and allocated more time to household sanitation year-round. We recommend that other investigators carefully examine the relationships between children's well-being according to developmentally-defined child age intervals and maternal patterns of time use. Results will help to resolve concern over the effect of maternal participation in economically productive activities on children's well-being.

Trends in use of barium enema examination, colonoscopy, and sigmoidoscopy: is use commensurate with risk of disease?

PURPOSE: To assess replacement of barium enema examination with colonoscopy in relation to age- and sex-related risk factors, place of service, physician specialty, and cost. MATERIALS AND METHODS: Between 1985 and 1992, 894,777 insurance claims for barium enema examination and lower gastrointestinal endoscopy were retrospectively examined. Changes in use were investigated. Use of proctosigmoidoscopy and flexible sigmoidoscopy, two office-based endoscopic procedures, was also examined. RESULTS: Use of diagnostic colonoscopy increased from 191 to 406 services per 100,000 persons; colonoscopy with biopsy, from 77 to 183 services; and colonoscopy with lesion removal, from 77 to 202 services. Barium enema examination use declined from 929 to 511 services per 100,000 persons; diagnostic proctosigmoidoscopy, from 854 to 193 services; and diagnostic flexible sigmoidoscopy, from 656 to 620 services. Increases in use of colonoscopy in patients aged younger than 40 years were greater than overall increases. CONCLUSION: Colonoscopy has been replacing barium enema examination as the initial colorectal examination since 1985. Increased use of colonoscopy in patients with lower risk of neoplasia suggests that indications have become overly broad.

Self-referral in private offices for imaging studies performed in Pennsylvania Blue Shield subscribers during 1991.

PURPOSE: To define the frequency of physician self-referral for diagnostic imaging studies. MATERIALS AND METHODS: High-volume radiographic (n = 65) and ultrasound (US) (n = 29) procedural codes in claims filed by Pennsylvania Blue Shield subscribers were analyzed to determine private-office (nonhospital) utilization of these examinations by radiologists and nonradiologists during 1991. A total of 787,703 radiographic and 159,281 US claims were filed. RESULTS: Nonradiologists self-referred 550,878 radiographic examinations (69.9%) and 99,931 US examinations (62.7%). Patterns of utilization varied considerably by anatomic category: The imaging studies with the highest rates of utilization by nonradiologists were skeletal radiography, vascular US, and obstetric and pelvic US. Aggregate reimbursement allowance by Pennsylvania Blue Shield for all examinations in these 94 codes was approximately $68 million, of which $44 million (65%) went to non-radiologists.

An analysis of cesarean deliveries among Pennsylvania Blue Shield subscribers.

In recent years, increased attention has focused on the relatively high rate of Cesarean deliveries in the U.S. Though the medical necessity and indications for Cesarean deliveries have been heavily debated, there still remains considerable disagreement among professionals about which Cesarean deliveries are inappropriate. To contribute to an understanding of these issues, Pennsylvania Blue Shield prepared a profile of Cesarean deliveries in Pennsylvania relative to Blue Shield's claim experience. The results of the study are presented in this article.

Diagnostic radiology peer review: a method inclusive of all interpreters of radiographic examinations regardless of specialty.

A proposed method of assessing the quality of diagnostic radiographic examinations includes peer review designed to evaluate physicians, including nonradiologists, involved in the performance and interpretation of such examinations. A pilot project evaluated this system with randomly selected Pennsylvania Blue Shield data files of 10 providers billing for chest radiography interpretations during the second quarter of 1989. Of the 98 chest radiographs reviewed blindly, all inadequately marked radiographs and incomplete written reports were produced by nonradiologists. Technical quality of images obtained by radiologists did not significantly differ from that of images obtained by nonradiologists (P = .189). All five interpretive errors that could have seriously affected the patient's health care were produced by nonradiologists (P = .019). Four of these serious errors were made by providers billing for fewer than 25 radiographs. While administrative and time cost limitations are obvious, this method of peer review encompasses all physicians billing for a particular radiographic service, irrespective of specialty.

Addition of etoposide to cyclophosphamide, doxorubicin, and vincristine for remission induction and survival in patients with small cell lung cancer.

A total of 116 patients with small cell lung cancer were randomized to receive either: cyclophosphamide, 750 mg/m2, doxorubicin, 50 mg/m2, and vincristine, 2 mg iv (Regimen A), or the same drugs plus etoposide, 100 mg/m2 iv daily for 2 days (Regimen B) every 3 weeks. Complete responders received whole-brain radiation therapy. The overall response rates were 50% for Regimen A and 65% for Regimen B (P less than 0.05). The complete response rates were 18% for Regimen A and 44% for Regimen B (P less than 0.01). For patients with limited disease, the complete responders were 35% on Regimen A and 52% on Regimen B (P = 0.26); for those with extensive disease, the complete responders were 0% on Regimen A and 35% on Regimen B (P = 0.002). The median survival for complete responders was 17 months on Regimen A and 20 months on Regimen B. The difference is not statistically significant. Toxicity was tolerable for both groups; however, it was greater for the etoposide arm. We conclude that although etoposide improves the overall response rates in patients with small cell lung cancer, especially those with extensive disease, the addition of this drug does not lead to improved survival.

Emphysematous cholecystitis as a complication of hepatic arterial embolization.

We describe a case of emphysematous cholecystitis that developed 2 weeks after hepatic arterial embolization. Angiographers should be alert to the possibility of this complication developing under conditions when the cystic artery is not visualized on the post embolization arteriogram while present on the diagnostic study before embolization.