In vitro translation of RNA from the German cockroach Blattella germanica.

The translation of mRNA within total RNA of German (Blattella germanica) cockroaches was performed using a rabbit reticulocyte lysate system. Analysis of the translation products by SDS-PAGE and combined autoradiography revealed several synthesized proteins with apparent molecular weights ranging from 20 kD to 110 kD. SDS-PAGE/Western blotting of non-radiolabeled translation products and incubation with human serum with IgE to cockroach allergens showed the presence of a 36 kD and 50 kD allergen. The confirmation of the translation of the cockroach allergens from total RNA is an important first step in the cloning of cockroach allergens.

Efficacy, safety, hemodynamic effects, and pharmacokinetics of high-dose moricizine during short- and long-term therapy.

Moricizine, 15 mg/kg, was given to 10 patients with frequent ventricular ectopic depolarizations, eight of whom had previously been treated unsuccessfully with antiarrhythmic drugs. A single-blind inpatient study was followed by therapy for up to 6 months. Two patients developed aggravation of arrhythmia during inpatient therapy. Of the eight patients who completed the inpatient study, seven achieved greater than or equal to 80% suppression of total ventricular ectopic depolarizations (P less than 0.001). During inpatient therapy the mean of the individual patients' suppression of total ventricular ectopic depolarizations was 87.9%, paired ventricular beats 99.3%, nonsustained ventricular tachycardia 99.6%, and premature atrial contractions 89.0%. Suppression was maintained during long-term therapy. The PR interval increased 27% (P less than 0.001), QRS interval increased 10% (P less than 0.0001), QTc increased 1% (P not significant), and JTc decreased 2% (P not significant). Heart rate, blood pressure, and left ventricular performance at rest and exercise were unchanged by moricizine. Moricizine half-life was 9.2 +/- 3.4 hours. Plasma levels of moricizine decreased after 10 days of therapy, suggesting induction of metabolic enzyme systems.

Pharmacodynamics and side effects of flecainide acetate.

We compared side effects with flecainide trough levels and ECG intervals among 43 patients who received flecainide for up to 34 months. Flecainide plasma levels were higher when associated with cardiovascular side effects (mean 1063 ng/ml; range 296 to 2050 ng/ml) than when no side effects occurred (mean 609 ng/ml; range 89 to 1508 ng/ml; P less than 0.001). The PR interval (P less than 0.001), QRS interval (P less than 0.001), and the rate-corrected QT interval (P less than 0.001) were greater at the time of cardiovascular side effects, but the rate-corrected JT interval was not. The therapeutic-toxic window for flecainide plasma level was 381 ng/ml (at least 50% probability of efficacy) to 710 ng/ml (less than 10% probability of cardiovascular side effects). The risk of cardiovascular side effects increases at higher plasma levels of flecainide and is associated with greater increases in the PR and QRS intervals from baseline than are routinely observed during flecainide dosing.

Oral fluconazole therapy for patients with acquired immunodeficiency syndrome and cryptococcosis: experience with 22 patients.

PURPOSE: Cryptococcus neoformans causes infections in up to 10 percent of patients with the acquired immunodeficiency syndrome (AIDS). Nearly 50 percent of AIDS patients with previously treated cryptococcal meningitis will experience a relapse within six months. To reduce the likelihood of relapse, a maintenance regimen of amphotericin B is often administered weekly. However, the drug's intravenous route of administration and considerable toxicity have led to a search for alternative antifungal agents. In this report, we document our experience with fluconazole, a new oral triazole antifungal agent. PATIENTS AND METHODS: Twenty-two patients with AIDS and various forms of cryptococcosis were treated in an open-label study with 50 to 400 mg/day of fluconazole. The following laboratory studies were done on a monthly basis: complete blood cell count, liver function tests, serum creatinine level, serum cryptococcal antigen level, and serum fluconazole level. Lumbar puncture was performed in patients with meningitis every four to eight weeks to evaluate cerebrospinal fluid cryptococcal antigen, India ink preparation findings, fungal culture, fluconazole level, and protein, glucose, and cell count. RESULTS: Of seven patients with active culture-positive infections, four showed clinical and microbiologic responses (three of four with meningitis, one of three with extraneural cryptococcosis). Fifteen patients who had already undergone successful amphotericin B therapy for either meningitis (n = 14) or pneumonia (n = 1) received fluconazole as prophylaxis against relapse. Fourteen patients remained free of infection during 11 to 64 weeks of suppressive therapy; one patient with meningitis experienced relapse after 26 weeks of treatment. Reverse reactions were limited to increases in hepatic enzyme levels in four patients. CONCLUSION: These results appear sufficiently encouraging to warrant further trials of this oral agent in the suppression of chronic cryptococcosis and perhaps in the treatment of acute infection.

A controlled trial of propafenone for treatment of frequent and repetitive ventricular premature complexes.

The effectiveness of oral propafenone was evaluated for the treatment of ventricular premature complexes (VPCs) in 12 patients, using a single-blind, dose-ranging trial followed by a double-blind comparison with placebo, and then an open-label, long-term protocol. During dose ranging, 8 of 12 patients achieved greater than or equal to 80% suppression of total VPCs (mean 83%) (p less than 0.01 vs single-blind placebo). Paired VPCs were suppressed greater than or equal to 90% and ventricular tachycardia was eliminated in 11 of the 12 patients (p less than 0.01). The effectiveness of propafenone for treatment of VPCs was confirmed during the double-blind trial (p less than 0.05 vs double-blind placebo) and during treatment for 6 months (p less than 0.05 vs initial single-blind placebo). Propafenone prolonged the PR interval by 16% (p less than 0.01 vs single-blind placebo) and the QRS interval by 18% (p less than 0.001). Left ventricular systolic performance decreased as assessed by 2-dimensional echocardiography (p less than 0.01 vs single-blind placebo). Propafenone increased serum digoxin levels in 5 of 5 patients (mean increase of 83%). Side effects included exacerbation of congestive heart failure (1 patient) and conduction abnormalities (2 patients). Thus, propafenone is effective for treatment of total and repetitive VPCs. Although generally well tolerated, the drug reduces left ventricular systolic function and atrioventricular conduction and increases serum digoxin levels.

Variation in ophthalmic testing before cataract surgery. Results of a national survey of ophthalmologists.

Little information is available either for the clinical value of many ophthalmic tests performed preoperatively in the evaluation of patients for cataract surgery or for variation in ophthalmologists' use of such tests. To assess variation in ophthalmologists' use of ophthalmic tests, we conducted a national survey of American Academy of Ophthalmology members. Thirty-three percent, 17%, 37%, and 19% of the respondents reported that they "frequently" or "always" perform glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy, respectively, in patients being considered for cataract surgery who have no history of eye disease other than cataract. In contrast, 27%, 54%, 24%, and 48% of respondents reported that they never perform each of these four tests in such patients. Two ophthalmologist characteristics--a surgical volume of greater than 200 cataract extractions per year and performance of surgery in an ambulatory surgical center or private office (as opposed to a hospital)--were independently associated with an increased probability of performing each of these four tests frequently or always. Ten percent or less of the respondents reported that they frequently or always perform electroretinography, visual evoked response testing, photography of fundus or anterior segment, B-scan ultrasonography, formal color vision testing, and formal visual field testing in such patients. Thus, there is considerable variation in ophthalmologists' use of glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy. A small percentage of ophthalmologists may be overusing several other tests in the evaluation of patients being considered for cataract surgery.

Preoperative functional expectations and postoperative outcomes among patients undergoing first eye cataract surgery.

OBJECTIVE: To describe the relationship between patients' preoperative expectations regarding the outcome of cataract surgery and actual postoperative experience. METHODS: A longitudinal study of 772 patients undergoing first eye cataract surgery recruited from 75 ophthalmology practices in three metropolitan areas was conducted. Prior to surgery and approximately 4 months after surgery, a detailed interview was conducted that included general and vision-specific health status measures (including the Visual Function 12-Item Scale [VF-12]), patient-reported level of trouble and satisfaction with vision, and questions addressing patients' preoperative expectations regarding the outcomes of surgery. In addition, detailed clinical data were collected preoperatively and postoperatively. A total of 552 patients had only single eye cataract surgery by 4 months postoperatively and are included in this analysis. RESULTS: Patients' preoperative expectations regarding the impact of cataract surgery were very high and were unrelated to their demographic or ocular characteristics. The preoperative VF-12 score, however, was positively correlated with expected postoperative VF-12 score (Spearman correlation, .45, P < .001). Only 61% of patients achieved or surpassed their expected level of postoperative functioning. The difference between expected and actual postoperative VF-12 scores was not associated with patients' demographic characteristics or provider-related variables. Older patients (> 75 years) and patients with ocular comorbidity had a larger difference between expected and actual postoperative functioning than younger patients and those without ocular comorbidity. CONCLUSION: Expectations regarding visual functioning after cataract surgery are very high, and in most cases such expectations are fulfilled. In selected cases, more comprehensive counseling may reduce the discrepancy between expectations and actual outcomes of cataract surgery.

Postoperative management of cataract surgery patients by ophthalmologists and optometrists.

OBJECTIVES: To assess the frequency and content of post-operative examinations by ophthalmologists and optometrists for cataract surgery patients without operative complications and to assess the referral patterns of optometrists when complications are identified. DESIGN: In 1992 we conducted a survey of randomly selected members of the American Academy of Ophthalmology and American Optometric Association. Responses were obtained from 538 (82%) of 655 eligible ophthalmologists and 130 (84%) of 154 eligible optometrists. RESULTS: Eighty-eight percent of responding ophthalmologists reported that patients had 4 or more visits within 4 months after surgery, 97% of ophthalmologists performed the first postoperative examination on their cataract surgery patients, and 60% of ophthalmologists reported that no other eye professional saw their patients postoperatively. Forty-six percent of responding optometrists participated in postoperative care of cataract surgery patients, and usually performed their first postoperative examination 7 days after surgery; 78% of these optometrists reported that they saw patients 3 or more times after surgery. Postoperatively, 83% of ophthalmologists and 75% of optometrists usually performed at least 1 dilated fundus examination, 87% of ophthalmologists and 47% of optometrists performed 4 or more slit-lamp examinations, 74% of ophthalmologists and 42% of optometrists performed 4 or more tonometry tests, and 83% of both groups performed 2 or more refractions. More than 80% of responding optometrists involved in postoperative care of cataract surgery patients immediately refer a patient to an ophthalmologist if there is evidence of acute glaucoma or an unexplained decrease in vision in the eye that was operated on. For less urgent complications, most optometrists promptly make a referral to an ophthalmologist. CONCLUSIONS: In 1992, a small percentage of ophthalmologists and optometrists were performing fewer follow-up examinations and tests for cataract patients than recommended by the American Academy of Ophthalmology. Not all optometrists immediately refer to an ophthalmologist any acute complication that they identify postoperatively.

The content and cost of cataract surgery.

Although more than 1 million cataract surgeries are performed annually in the United States, little is known about the frequency of use or cost of various services provided in connection with this procedure. To assess the frequency with which various ophthalmic, optometric, anesthesia, and medical services are provided in conjunction with cataract surgery and to estimate the cost to Medicare associated with those services, we analyzed 1985 through 1988 Medicare claims records of a nationally representative 5% sample of Medicare beneficiaries. The experience of 57,103 Medicare beneficiaries who underwent extracapsular cataract surgery in 1986 or 1987 that was not combined with another ophthalmologic procedure formed the basis of our analysis. Projections for current costs were performed using 1991 charges allowed by Medicare for physician services. We estimate that the median charge allowed by Medicare for a "typical" episode of cataract surgery in 1991 was approximately $2500. In addition to the $3.4 billion that Medicare spent in 1991 on such "typical" episodes, Medicare spent more than $39 million on miscellaneous "atypical" preoperative ophthalmologic tests, such as specular microscopy (14% of cases) and potential acuity testing (8% of cases), more than $7 million on postoperative ophthalmologic diagnostic tests, such as fluorescein angiography (3% of cases), and more than $18 million on perioperative medical services (most commonly electrocardiography and chest roentgenography). The major determinants of the cost to Medicare associated with cataract surgery are the rate of performance of cataract surgery and neodymium-YAG laser capsulotomy and the charges allowed for these procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Cataract surgical techniques. Preferences and underlying beliefs.

To characterize the intraoperative procedures employed by cataract surgeons in the United States and the beliefs underlying the practices, a standardized questionnaire was sent to a systematic random sample of members of the American Academy of Ophthalmology in 1992. Of 667 surveyed ophthalmologists, 550 completed the questionnaire (response rate, 82.5%). Phacoemulsification was used for more than 75% of routine cataract surgery by 46% of respondents, whereas standard extracapsular surgery was used for more than 75% of routine cataract surgery by 41% of respondents. Preferential use of phacoemulsification was independently associated with more recent graduation from medical school and higher reported annual surgical volume. Continuous tear capsulotomy was employed by 52% of ophthalmologists. Preference for this technique was independently associated with both the use of phacoemulsification and higher annual surgical volume. Seventy-one percent of respondents used retrobulbar anesthesia, whereas 28% used peribulbar anesthesia. Use of peribulbar anesthesia was independently associated with both greater surgical volume and performance of surgery in an ambulatory surgical center. Beliefs regarding comparative safety and effectiveness were reported to influence surgeons' preferences strongly among all of the competing techniques studied. Those performing phacoemulsification, in comparison with those performing extracapsular cataract extraction, reported that the expectation of reduced astigmatism and shorter recovery time strongly influenced their choice of procedure. Variation in preferred intraoperative techniques is substantial for cataract surgery and the beliefs that underlie the preferences. Such variation highlights the need to determine which techniques maximize patient outcomes and are most cost-effective.

Variation in ophthalmic testing prior to cataract surgery. Results of a national survey of optometrists. Cataract Patient Outcome Research Team.

OBJECTIVE: To assess variation in optometrists' use of ophthalmic tests in the evaluation of patients being considered for cataract surgery who have no history of other eye disease. DESIGN/PARTICIPANTS: National survey of a systematic sample of practicing members of the American Optometric Association (St Louis, Mo), who had referred at least one patient to an ophthalmologist for consideration of cataract surgery in 1991. RESULTS: Ninety-two of 130 eligible responding optometrists reported that they routinely performed preoperative testing on patients being considered for cataract surgery. Of these 92 optometrists, 91 (99%) frequently or always performed refraction, and 82 (89%) frequently or always performed a dilated fundus examination in their evaluation of patients being considered for cataract surgery who had no history of other eye disease. None of these 92 optometrists reported using B-scan ultrasonography or electroretinograms frequently or always, and few used A-scan ultrasonography or visual evoked responses frequently or always. A substantial percentage frequently or always used formal visual field testing (47%), formal color vision testing (40%), fundus photography (24%), potential acuity measurement (25%), glare testing (23%), contrast sensitivity testing (19%), and specular microscopy (14%), while 11% to 81% of optometrists never performed these tests on such patients. More recent graduation from optometry school was associated with a decreased frequency of use of potential acuity measurement and contrast sensitivity testing and with an increased use of dilated fundus examinations. CONCLUSION: There is a substantial variation in optometrists self-reported use of a number of ophthalmic tests in the preoperative evaluation of patients being considered for cataract surgery who have no history of other eye disease.

The VF-14. An index of functional impairment in patients with cataract.

OBJECTIVE: To describe the development and the performance of a brief questionnaire designed to measure functional impairment caused by cataract (the VF-14). DESIGN: Observational cross-sectional study. Patients were recruited between July 15 and December 15, 1991. SETTING: Patients were recruited from the practices of 70 ophthalmologists, located in Columbus, Ohio (N = 21), St Louis, Mo (N = 26), and Houston, Tex (N = 23). PATIENTS: Seven hundred sixty-six patients undergoing cataract surgery for the first time. MAIN OUTCOME MEASURES: Preoperative best corrected visual acuity in each eye; scores on the VF-14, a new index of functional impairment in patients with cataract; patient reports of overall trouble and satisfaction with their vision; and scores on the Sickness Impact Profile, a measure of general health status. RESULTS: The VF-14 has high internal consistency (Cronbach's alpha = .85) and correlates more strongly with the overall self-rating of the amount of trouble and satisfaction patients have with their vision than do several measures of visual acuity or the Sickness Impact Profile score. The VF-14 score is moderately correlated with visual acuity in the better eye. CONCLUSIONS: The VF-14 is a reliable and valid measure of functional impairment caused by cataract and provides information not conveyed by visual acuity or a general measure of health status.

Do ophthalmologists, anesthesiologists, and internists agree about preoperative testing in healthy patients undergoing cataract surgery?

To assess variation in reported use of preoperative medical tests in patients undergoing cataract surgery and to identify factors that influence test use by different physician groups we performed a national survey of ophthalmologists, anesthesiologists, and internists. Participants included randomly selected members of American professional societies who provided care to one or more patients undergoing cataract surgery in 1991. Responses were obtained from 538 (82%) of 655 eligible ophthalmologists, 109 (76%) of 143 anesthesiologists, and 54 (44%) of 122 internists. Fifty percent of ophthalmologists, 40% of internists, and 33% of anesthesiologists frequently or always obtained a chest x-ray film, while 20% of ophthalmologists, 27% of internists, and 37% of anesthesiologists never obtained a chest x-ray film for patients being considered for cataract surgery who had no history of major medical problems (P < .01 for differences between ophthalmologists and the other groups). Similarly, 70% to 90% of ophthalmologists, 73% to 79% of internists, and 41% to 79% of anesthesiologists frequently or always obtained a complete blood cell count, electrolyte panel, and electrocardiogram, while 4% to 11% of ophthalmologists, 13% to 17% of internists, and 9% to 28% of anesthesiologists never obtained these tests for such patients. Many respondents (32% to 80%) believed tests were unnecessary but cited multiple reasons for obtaining tests (eg, medicolegal concerns and institutional requirements). Many physicians in each group viewed preoperative evaluations as screening opportunities or believed that one of the other two types of physicians "required" tests. We conclude that marked variation exists within and across physician specialties in the use and rationale for use of medical tests in patients undergoing cataract surgery.

Effect of patient factors on hospital costs for major bowel surgery: implications for managed health care.

BACKGROUND: We examined the effects of patient factors on hospital resource consumption for patients who had undergone major bowel operation (diagnosis-related groups [DRGs] 148 and 149) at an urban, university hospital. METHODS: We performed cross-sectional analysis of computerized hospital discharge abstracts and charts of 491 consecutive discharges in these DRGs. Total hospital charges and length of stay were dependent variables. Independent variables included admission status, admission service, previous admissions, payer type, service type, diagnosis, reoperation, and death. RESULTS: Patient factors accounted for significant variability in resource consumption. By univariate analysis all of the above variables significantly affected total charges, and all but service type significantly affected length of stay. By multivariate analysis DRGs 148/149 alone explained 4.2% of the variance, whereas all the variables together increased R2 to 52.1%. Logistic regression of reoperation and of death as dependent variables suggested that patient factors also accounted for significant variance in these outcomes. CONCLUSIONS: Because patient factors may not be directly controllable by hospitals or physicians, differences among hospitals in costs and in "quality" may relate more to differences in patient mix than to efficiency. DRGs alone are not a sufficient management tool, and additional measures are needed to adequately measure both efficiency and quality.

Pulmonary microvascular fluid flux in a large animal model of sepsis: evidence for increased pulmonary endothelial permeability accompanying surgically induced peritonitis in sheep.

To characterize some of the remote effects of systemic sepsis on the lung, we evaluated changes in pulmonary microvascular fluid flux before and during sepsis secondary to a peritoneal focus of inflammation in sheep. We induced peritonitis by cecal ligation, perforation, and devascularization. During a subsequent 72-hour study period, both the mean blood pressure and the pulmonary capillary wedge pressure were unchanged, while the cardiac index increased slightly. The PaO2 fell by 48 hours (98 +/- 8 to 84 +/- 10 mm Hg; p less than 0.05) (mean +/- SD) and subsequently remained low throughout the experiment. Simultaneously, pulmonary lymph flow increased by 24 hours (11.5 +/- 4.9 to 26.7 +/- 13 ml/hr; p less than 0.05) and remained elevated throughout the experiment while [L/P] total protein ratios remained unchanged at 24 hours (baseline: 0.59 +/- 0.15 at 24 hours: 0.65 +/- 0.16). Morphologic examination of the lung showed that this model of peritonitis was characterized by neutrophil emigration into the pulmonary interstitium by 24 hours and interstitial edema by 48 hours. Therefore this model of bacterial peritonitis in sheep demonstrates that one of the remote effects of surgically induced systemic sepsis is an increase in permeability of the pulmonary microvascular membrane.

Modification of cervical dystonia by selective sensory stimulation.

Cervical dystonia is often refractory to all forms of therapy. Many patients, however, are able to transiently abolish their spasms following a specific gesture that presumably enhances sensory input. Such observations prompted us to develop a protocol to determine if various forms of sensory stimulation could modify the motor control patterns in cervical dystonia. Surface EMG recordings of multiple neck and trunk muscles were obtained in 11 consecutive cervical dystonia patients. Baseline patterns of voluntary and involuntary muscle activation were established during a series of motor and non-motor tasks. The tasks were repeated during the application of vibratory or electrical stimulation to select muscle groups or to cutaneous and mixed nerves. Analysis of the results was made on the basis of paper and computer recordings of the data. Sensory stimulation decreased involuntary muscle activity and reduced spasms in 5 subjects. However, objective or subjective improvement usually occurred only after specific stimuli were applied to specific anatomical sites. In these cases, the protocol identified the site at which a specific sensory stimulus could be applied to control the dystonia. We conclude that selective sensory stimulation can beneficially modify cervical dystonia in some patients. Such findings warrant further investigation of the use of sensory stimulation for control of cervical dystonia.

Electrophrenic respiration in patients with high quadriplegia.

After determining that 15 patients with high spinal cord injuries who were permanently apneic had viable phrenic nerves, electrophrenic respiration units were implanted. Thirteen of the patients (86%) achieved full-time respiration and two more achieved half-time respiration. Despite the loss of 8 patients to unrelated problems, 7 now use electrophrenic respiration continuously, one having done so for 16 years. The patient selection criteria, neurophysiological evaluation method, surgical procedure, postoperative care, and methods for diagnosis of system failures are presented. A comparison of the cervical and thoracic procedures is made. The cervical approach is preferred. Complications consisted primarily of equipment failures. For the external components there were several cases of antenna connection and battery connection failures. The implanted receivers failed in 6 cases with an average lifetime of 48 months, ranging from 24 to 108 months. In one case fibrosis around the electrode resulted in failure to stimulate the phrenic nerve effectively. In another case, infection required removal of the system which was reimplanted later and has continued to provide successful ventilation.

The Severity of Illness Index as a severity adjustment to diagnosis-related groups.

This article discusses the Severity of Illness case-mix groups, and suggests a refinement to diagnosis-related groups (DRG's) designed to accommodate the important element of patient severity. An application of the suggested refinement is presented in a discussion of the efficient production of hospital services. The following areas are addressed. A brief summary of the goals and development of the Severity of Illness Index, and the methodology used to collect severity of illness data on hospital inpatients. Comparative analyses of the resulting case-mix groups within hospitals, and an application of severity-adjusted diagnosis-related groups case-mix definitions. The contribution of the variation in physician practice patterns to the variation in resource use per patient within a hospital. Cross-hospital comparisons. Some of the consequences of incorporating a patient severity refinement into the prospective payment system.

Primary cementless total hip arthroplasty in octogenarians. Two to eleven-year follow-up.

BACKGROUND: Cementless total hip arthroplasty is an accepted alternative to total hip arthroplasty with cement in younger patients, but it remains controversial for elderly patients. The purpose of this study was to evaluate the clinical and radiographic outcomes of cementless total hip arthroplasty with use of a proximally coated stem in patients who were at least eighty years of age at the time of the operation. METHODS: One hundred and twenty-three cementless total hip replacements were performed for the treatment of osteoarthritis in 114 patients between the ages of eighty and eighty-nine years. Seven patients (eight hips) died within two years after the surgery, seventeen patients (eighteen hips) died more than two years postoperatively but were not followed for at least two years, and five hips were lost to follow-up; this left ninety-two hips in eighty-six patients for review. The mean duration of follow-up was five years (range, two to eleven years). For the clinical evaluation, the Charnley modification of the Merle d'Aubigné and Postel scale was used. In addition, preoperative and postoperative Harris hip scores were available for sixty-nine hips. Seventy-eight hips were followed radiographically for two years or more. The focus of the radiographic evaluation was the status of the fixation of the femoral and acetabular components as well as cup wear. RESULTS: Perioperative medical complications occurred in association with 24% (thirty) of the 123 operations, but there were no deaths. The mean Charnley scores for pain and function for the ninety-two hips that were followed clinically for at least two years improved by 3.0 and 1.4 points, respectively. The sixty-nine hips for which preoperative and postoperative Harris hip scores were available had a mean improvement of 42 points, with a mean score of 82 points at the last follow-up evaluation. Mild thigh pain was present in four patients, but it did not limit their activity. There were no femoral component revisions. All of the femoral components were radiographically stable and had bone ingrowth. No acetabular component failed by loosening, but 41% (thirty) of the seventy-three hips with radiographs available for measurement of wear showed polyethylene wear. Of the seventy-eight cups that were followed radiographically for two years or more, 4% (three) were associated with lysis, but none had been revised. CONCLUSIONS: Cementless fixation in the elderly is safe, effective, and durable at the time of two to eleven-year follow-up.

Continuity of care: is it cost effective?

OBJECTIVE: To examine the association between the degree of healthcare provider continuity and healthcare utilization and costs. STUDY DESIGN: A longitudinal, prospective, observational study. PATIENTS AND METHODS: Data on patients with arthritis, asthma, epigastric pain/peptic ulcer disease, hypertension, and otitis media were collected at each of 6 health maintenance organizations (HMOs). Outcome variables included the number of prescriptions for the target disease and the cost, total number of prescriptions and the cost, the number of outpatient visits, and the number of hospital admissions. Disease-specific severity of illness, type of visit, and provider information were obtained at each encounter. HMO profit status, visit copay, gatekeeper strictness, formulary limitations, use of multisource (generic) drugs, gender, number of months in the study, age, and severity of illness were controlled in the analyses. RESULTS: There were 12,997 patients followed for more than 99,000 outpatient visits, 1000 hospitalizations, and more than 240,000 prescriptions. Increasing the number of primary or specialty care providers a patient encountered during the study generally was associated with increased utilization and costs when HMO and patient characteristics were controlled. The number of specialty care providers also increased as the number of primary care providers increased. The incremental increase in pharmacy costs per patient per year with each additional provider ranged between $19 in subjects with otitis media to $58 in subjects with hypertension. CONCLUSIONS: Continuity of care was associated with a reduction in resource utilization and costs. As healthcare delivery systems are designed, care continuity should be promoted.