External validation of ADNEX MR SCORING system: a single-centre retrospective study.

AIM: To evaluate the accuracy of the ADNEX MR SCORING system for characterising adnexal masses. MATERIALS AND METHODS: An institutional review board approved this retrospective study. The study population comprised 663 women who underwent magnetic resonance imaging (MRI) from January 2007 to December 2014 to characterise 778 adnexal masses that were indeterminate under ultrasonography (590 benign and 188 malignant). Two radiologists independently reviewed the MRI images. The masses were scored from 1 to 5 according to the ADNEX MR SCORING system. The diagnostic performance of the system was evaluated by receiver operating characteristic (ROC) analysis. Masses scored 4 or greater were considered malignant (including tumours of borderline malignancy or low malignant potential). RESULTS: The malignancy rates of masses with scores of 2, 3, 4 and 5 were 1.9% (8/419), 12.8% (19/149), 62.6% (57/91) and 87.4% (104/119) for reader 1 and 2.1% (9/424), 13.6% (20/147), 67.6% (71/105) and 86.3% (88/102) for reader 2, respectively. The areas under the ROC curves for the differentiation of benign and malignant masses were 0.929 and 0.923, respectively; the sensitivity, specificity and accuracy of diagnosis were 85.6% (161/188), 91.7% (541/590), and 90.2% (702/778) for reader 1 and 84.6% (159/188), 91.9% (542/590), and 90.1% (701/778) for reader 2, respectively. Tumours of borderline malignancy or low malignant potential had a higher rate of misclassification (46.1%) than other malignant tumours (6-7.4%). CONCLUSION: The ADNEX MR SCORING system was highly accurate in differentiating benign and malignant adnexal masses, although it may be less accurate for tumours of borderline malignancy or low malignant potential.

Sepsis patients' renal manifestation on contrast-enhanced CT.

AIM: To evaluate renal volume and attenuation changes in patients with sepsis on contrast-enhanced computed tomography (CT) with respect to the severity of sepsis. MATERIALS AND METHODS: Forty-four patients with sepsis who underwent CT before and after the onset of sepsis were retrospectively analysed. Renal volume and CT attenuation value of the renal cortex on contrast-enhanced CT were measured for each patient and changes in renal volume and CT attenuation value from before to after the onset of sepsis were calculated. The changes were correlated with the severity of sepsis (Sepsis-related Organ Failure Assessment [SOFA] score). The time course of the renal volume and CT attenuation changes were also evaluated. RESULTS: Renal volume increased by 17.6% and CT attenuation value decreased by 19% after the onset of sepsis with statistically significant differences (p<0.001 for both renal volume and CT attenuation changes). The renal volume and CT attenuation changes had significant correlations with the SOFA score (r=0.36, p=0.018 and -0.43, p=0.005, respectively). The time course of the renal volume and CT attenuation changes seemed to be gradual compared to that of the SOFA score and to lag behind the peak of the SOFA score. CONCLUSION: In patients with sepsis, the renal volume increases and the CT attenuation value decreases in proportion to the severity of sepsis. The changes may lag behind the peak of severity of sepsis and can be observed for a relatively long time after a patient's recovery from sepsis.

Reforming dental workforce education and practice in the USA.

The USA dental education programmes are facing challenges similar to those confronting countries around the globe, particularly amongst the industrialised nations. The purpose of this study was to evaluate the educational programmes of 15 USA dental schools to determine their impact on improving workforce diversity and oral health care access. The study investigates the predictors of public service plans of dental school seniors in Pipeline and non-Pipeline Program dental schools. We analysed baseline and post-intervention data collected in the American Dental Education Association (ADEA) Annual Survey of Dental School Seniors and a set of contextual variables. Public service plans (dependent variable) was predicted by four types of independent variables: intervention, contextual, community-based dental education (CBDE), and student characteristics. Findings from the study show that access to a state or federally sponsored loan repayment program was the most significant predictor of public service plans and that increasing educational debt was the most significant barrier. In the short-term we may be able to sustain the USA loan repayment programs to motivate senior dental students to provide public service to address the oral health care access crisis. However, in the long-term, a new workforce development initiative will be required to transform dental education and practice, modelled after the well-respected licensure programmes for Physician Assistants and/or Advanced Practice Registered Nurses, to expand oral health care access, particularly amongst vulnerable population subgroups, such as low-income children and families.

[Case of a giant pericardial cyst went under the thoracoscopic surgery using a double-balloon catheter].

A 45-year-old female was referred to our hospital due to right anterior chest pain. A chest X-ray and a computed tomographic examination showed a large cystic lesion in the right pleural cavity above the diaphragm. The internal surface of the cyst seemed to be smooth and the content was homogeneous suggesting clear liquid. Under the diagnosis of the benign pericardial cyst, a thoracoscopic surgery was performed using a double-balloon catheter. Aspiration of the cyst content by the double-balloon catheter minimized the spillage of the content into the thoracic cavity. Furthermore, the double-balloon catheter allowed the cyst wall to be more easily grasped and manipulated. We confirmed the usefulness of a double-balloon catheter for the thoracoscopic resection of giant cystic lesions.

Manganese accumulation in the brain: MR imaging.

Manganese (Mn) accumulation in the brain is detected as symmetrical high signal intensity in the globus pallidi on T1-weighted MR images without an abnormal signal on T2-weighted images. In this review, we present several cases of Mn accumulation in the brain due to acquired or congenital diseases of the abdomen including hepatic cirrhosis with a portosystemic shunt, congenital biliary atresia, primary biliary cirrhosis, congenital intrahepatic portosystemic shunt without liver dysfunction, Rendu-Osler-Weber syndrome with a diffuse intrahepatic portosystemic shunt, and patent ductus venosus. Other causes of Mn accumulation in the brain are Mn overload from total parenteral nutrition and welding-related Mn intoxication.

Subtypes of peripheral adenocarcinoma of the lung: differentiation by thin-section CT.

The purpose of this study was to scrutinize morphological characteristics of thin-section CT of the histopathological subtypes of adenocarcinoma of the lung. The subjects consisted of 83 patients with 87 adenocarcinomas measuring 3 cm or less in the largest. The tumors were divided into three groups (group I: Noguchi's histological subtypes type A and B tumors, group II: type C tumors, and group III: type D, E, and F tumors). In each group, tumor size, shape (round versus polygonal), presence of air bronchogram, bubble-like areas, coarse spiculation, pleural tag, and ratio of ground glass attenuation (GGA) were evaluated. Most of the group II lesions showed polygonal shape, whereas tumors in other groups were round in shape (P<0.01). Air bronchogram and bubble-like areas of low attenuation was seen more frequently in group II compared with those in group III (P<0.01). GGA areas were largest in group I and smallest in group III (P<0.01). We believe thin-section CT findings reflect the histopathological subtypes of adenocarcinoma of the lung. The presence of air bronchogram and bubble-like areas of low attenuation areas in particular is useful to differentiate replacement growth tumors from non-replacement growth tumors.

Multidetector-row CT findings of colonic perforation: direct visualization of ruptured colonic wall.

BACKGROUND: We examined the findings of contrast-enhanced multidetector-row computed tomography (MD-CT) in patients with colonic perforation. METHODS: Abdominal contrast-enhanced MD-CT findings in six patients with colonic perforation were reviewed retrospectively. Patients (three men and three women) were 74 to 88 years old (mean age = 78 years). Colonic perforation was confirmed by surgery. CT findings were correlated with surgical and pathologic findings. RESULT: The site of colonic perforation was suggested by the following combination of CT findings: free air, dirty mass, dirty fat sign, extraluminal fluid collection, bowel wall thickening, and interruption of colonic wall. The ruptured colonic wall was directly visualized in four cases (67%). CONCLUSION: Abdominal contrast-enhanced MD-CT may improve the accuracy of diagnosis and localization of colonic perforation.

[Two delayed cases of traumatic diaphragmatic hernia].

This report concerns 2 cases with blunt traumatic hernia of the diaphragm. The diagnosis of these cases had been delayed by 1 month and 6 years, respectively. The former was a left sided case, which had suddenly suffered severe dyspnea. An emergency operation revealed the dislocated stomach into the left thoracic cavity. The latter was a right sided case, which was discovered by chance during the laparoscopic cholecystectomy. The right lobe of the liver dislocated into the right thoracic cavity. The delayed case of traumatic diaphragmatic hernia tends to be overlooked without suspicion. In all patients with thoracoabdominal blunt injury, a rupture of the diaphragm must be suspected.

Identification of human urine stains by HPLC analysis of 17-ketosteroid conjugates.

A new method for identifying human urine stains utilizing high-performance liquid chromatographic (HPLC) analysis of five major 17-ketosteroid conjugates: dehydroepiandrosterone sulfate, etiocholanolone sulfate, etiocholanolone glucuronide, androsterone sulfate, and androsterone glucuronide was examined. Samples of urine stains were extracted with borate buffer solution (pH 9.3) and the extracts were applied onto a Sep-Pak tC18 cartridge. The analytes were eluted from the cartridge with methanol. The eluates were prelabeled with 2,4-dinitrophenylhydrazine in trichloroacetic acid-benzene solution and were separated by HPLC on a reversed-phase ODS column using a mobile phase of 80% methanol in a buffer consisting of 25 mM sodium acetate in 2% acetic acid. The eluates were monitored by a spectrophotometer at 380 nm. While all five 17-ketosteroid conjugates were clearly detected in the human urine stain samples, traces of only some of these conjugates were detected in the animal samples. Therefore, the presence of all five 17-ketosteroid conjugates indicated human specificity. In addition to the above finding, the properties of those five 17-ketosteroid conjugates were confirmed by electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS).

Screening for cervical cancer in HIV-infected women receiving care in the United States.

OBJECTIVE: We examined the sociodemographic, clinical and provider factors associated with screening for cervical cancer among HIV-infected women. METHODS: We studied a national sample representing 43,490 women receiving treatment of HIV infection who completed first follow-up surveys of the HIV Cost and Service Utilization Study (HCSUS). All women were asked, "In the past 12 months, have you had a Pap test?" Women reporting an abnormal Pap test result were asked whether they had been told antibiotics could cure abnormal cells, and whether they were scheduled for another Pap test or for a colposcopy within 3 months. RESULTS: Of the population represented, 81% had had a Pap test in the past 12 months. Women who reported having a gynecologist and primary care physician at the same clinical site were almost twice as likely (odds ratio, 1.9; 95% confidence interval, 1.3-3.0) as other women to report Pap testing. Among women who reported abnormal Pap test results and were not told antibiotics could cure abnormal cells, 95% were scheduled for a repeat Pap test or colposcopy, but 15% of the women had not received their repeat Pap test or colposcopy. CONCLUSION: Although Pap test rates and appropriate referral for abnormal findings were high among HIV-tested women, many women with initially abnormal Pap test results did not actually receive follow-up Pap testing or colposcopy. Providing gynecologic care at the same site as primary HIV care would likely improve delivery of needed gynecologic care for women.

Prevalence and predictors of highly active antiretroviral therapy use in patients with HIV infection in the united states. HCSUS Consortium. HIV Cost and Services Utilization.

BACKGROUND: Highly active antiretroviral therapy (HAART) became standard for HIV in 1996. Studies at that time showed that most people infected with HIV had initiated HAART, but that members of minority groups and poor people had lower HAART use. It is not known whether high levels of HAART use have been sustained or whether socioeconomic and racial disparities have diminished over time. OBJECTIVES: To determine the proportion of patients who had received and were receiving HAART by January 1998, and to evaluate predictors of HAART receipt. DESIGN AND PARTICIPANTS: Prospective cohort study of a national probability sample of 2267 adults receiving HIV care who completed baseline, first follow-up, and second follow-up interviews from January 1996 to January 1998. MAIN OUTCOME VARIABLES: Proportion currently using HAART at second follow-up (August 1997 to January 1998), contrasted with the cumulative proportions using HAART at any time before January 1998 and before December 1996. ANALYSES: Bivariate and multiple logistic regression analysis of population characteristics predicting current use of HAART at the time of the second follow-up interview. RESULTS: The proportion of patients ever having received HAART increased from 37% in December 1996 to 71% by January 1998, but only 53% of people were receiving HAART at the time of the second follow-up interview. Differences between sociodemographic groups in ever using HAART narrowed after 1996. In bivariate analysis, several groups remained significantly less likely to be using HAART at the time of the second follow-up interview: blacks, male and female drug users, female heterosexuals, people with less education, those uninsured and insured by Medicaid, those in the Northeast, and those with CD4 counts of >/=500 cells/microl (all p <.05). Using multiple logistic regression analysis, low CD4 count (for CD4 <50 cells/microl: odds ratio [OR], 3.20; p <.001) remained a significant predictor of current HAART use at the time of the second follow-up interview, but lack of insurance (OR, 0.71; p <.05) predicted not receiving HAART. CONCLUSIONS: The proportion of persons under HIV care in the United States who had ever received HAART increased to over 70% of the affected population by January 1998 and the disparities in use between groups narrowed but did not disappear. However, nearly half of those eligible for HAART according to the U.S. Department of Health and Human Services guidelines were not actually receiving it nearly 2 years after these medications were first introduced. Strategies to promote the initiation and continuation of HAART are needed for those without contraindications and those who can tolerate it.

[A tuberculosis outbreak in a mental hospital].

PURPOSE AND METHODS: We experienced a tuberculosis outbreak in a mental hospital and discussed preventive measures for nosocomial tuberculosis infection. RESULTS: There are 18 mental hospitals within the administrative area of Hachioji public health center (PHC). A Total of 18 pulmonary tuberculosis cases were diagnosed in one of these hospitals between December 1995 and November 1998. They were all inpatients and two of them had history of tuberculosis. Fifty-two persons became candidates for isoniazid (INH) chemoprophylaxis as a consequence of the first extraordinary health examination. Chest radiographs of the inpatients had not been taken regularly in this hospital. Our recognition of the tuberculosis outbreak was delayed by omission of not only the case notification from the doctor who had diagnosed tuberculosis but the information from the PHC that had received the application of public subsidy for medical treatment. All cultured bacilli from 8 patients were susceptible to INH, rifampicin, streptomycin and ethambutol. Restriction fragment length polymorphism (RFLP) analysis of 4 strains, which we could have obtained, demonstrated an identical pattern. CONCLUSIONS: To prevent tuberculosis outbreaks in mental hospitals, we should consider these problems as follows; 1) Physical conditions of inpatients should be observed carefully and suitable physical checkups on inpatients with tuberculosis symptoms should be carried out by mental hospitals. 2) The doctor who had diagnosed a patient as having tuberculosis must send the case notification to the nearest PHC. 3) The PHC that received the information should investigate the case carefully and notify all related PHC's. 4) Extraordinary health examinations should be done appropriately by leadership of the PHC. 5) RFLP analysis of the tubercle bacilli is very useful to probe the source and route of infection. 6) Criteria for chemoprophylaxis for more than middle-aged persons should be established.

Care of vaginal symptoms among HIV-infected women.

OBJECTIVE: Gynecologic disease is common in HIV-infected women. We examine the sociodemographic, clinical, and provider factors associated with the care of women with vaginal symptoms. METHODS: Women enrolled in the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults, were interviewed between January 1996 and April 1997. Women with vaginal symptoms who sought medical attention were asked, "Did your health care provider examine your vaginal area?" Women were also asked if they received medication for their symptoms. RESULTS: Among 154 women with vaginal symptoms, 127 sought care for their symptoms. Of those who sought care, 48% saw a gynecologist and 52% sought care from nongynecologists, most often their usual HIV care provider. Women who saw a gynecologist for their symptoms were more likely to have received a pelvic examination (92% versus 76%; p =.06) and vaginal fluid collection (98% versus 88%; p =.06) than those who saw their regular HIV provider. Fifteen percent of women received medication for their symptoms without having a pelvic examination; gynecologists were less likely to prescribe without an examination (8% versus 21%; p =.12). CONCLUSION: Gynecologists are more likely to provide adequate care of vaginal symptoms among HIV-infected women than nongynecologists who were HIV care providers. This specialty difference is consistent with quality of care studies for other medical conditions, but the potential gynecologic complications of inadequate evaluation and treatment warrants further investigation.

Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus.

OBJECTIVE: To identify health care and patient factors associated with delayed initial medical care for human immunodeficiency virus (HIV) infection. DESIGN: Survey of a national probability sample of persons with HIV in care. SETTING: Medical practices in the contiguous United States. PATIENTS: Cohort A (N = 1540) was diagnosed by February 1993 and was in care within 3 years; cohort B (N = 1960) was diagnosed by February 1995 and was in care within 1 year of diagnosis. MAIN OUTCOME MEASURE: More than 3- or 6-month delay. RESULTS: Delay of more than 3 months occurred for 29% of cohort A (median, 1 year) and 17% of cohort B. Having a usual source of care at diagnosis reduced delay, with adjusted odds ratios (ORs) of 0.61 (95% confidence interval [CI], 0.48-0.77) in cohort A and 0. 70 (95% CI, 0.50-0.99) in cohort B. Medicaid coverage at diagnosis showed lower adjusted ORs of delay compared with private insurance (cohort A: adjusted OR, 0.52; 95% CI, 0.30-0.92; cohort B: adjusted OR, 0.48; 95% CI, 0.27-0.85). Compared with whites, Latinos had 53% and 95% higher adjusted ORs of delay (P<.05) in cohorts A and B, respectively, and African Americans had a higher adjusted OR in cohort A (1.56; 95% CI, 1.19-2.04). The health care factors showed similar effects on delay of greater than 6 months. CONCLUSIONS: Medicaid insurance and a usual source of care were protective against delay after HIV diagnosis. After full adjustment, delay was still greater for Latinos and, to a lesser extent, African Americans compared with whites.

Perceived effectiveness of teaching methods for heath services administration education.

This article brings to the forefront the challenges of establishing an empirical link between teaching methods and education outcomes in the classroom. In the health administration education field, precious little empirical data exist on the effectiveness of various teaching methods and approaches on achieving education outcomes. Results are reported from the 1998 National Survey of program directors of the AUPHA graduate programs on the perceived effectiveness of a wide range of teaching methods, using a Likert scale, ranging from very effective to not very effective. The authors elaborate on the highest- and lowest-ranked teaching methods, and propose a research agenda for measuring education outcomes in the classroom.

A framework for evaluating the impact of health services management education.

The objectives of this paper are three-fold. The first is to propose a conceptual and analytical framework for planning and evaluating health services management education programs. The framework was developed in response to the health care industry restructuring and the emerging questions and concerns regarding how to strategically redesign the educational programs for the twenty-first century. Additionally, it was used to develop a questionnaire for the 1998 National Survey of Program Directors. The second objective is to suggest variables for operationalizing the framework as the field considers initiatives such as, "Evidence-Based Health Administration Education" (AUPHA Education Outcomes Task Force 1999; Griffith 2000) and other more standardized, quantifiable approaches to assessing program quality. The third objective is to report selected results from the 1998 National Survey of Program Directors focusing on the major changes impacting the health services industry and the implications for management education and development. In the future, ACEHSA and other accrediting commissions will likely consider evidence-based evaluation criteria for assessing and improving education program quality. The framework presented in this paper can be used as a starting point for conceptualizing and developing valid and reliable measures.

Angiosarcoma associated with chronic lymphedema (Stewart-Treves syndrome) of the leg: MR imaging.

Magnetic resonance (MR) imaging findings of two patients with Stewart-Treves syndrome are presented. MR imaging showed edematous changes in the subcutaneous fat and skin masses that proved to be angiosarcomas. MR signal intensity of the tumor was low compared with fat on T1-weighted images and intermediate and heterogeneous on T2-weighted images. In one patient, administration of intravenous Gd-DTPA showed marked enhancement in the early phase, which persisted until the delayed phase. These finding on dynamic MR imaging may reflect the abundant vascular spaces seen in these tumors.

Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study.

OBJECTIVE: To employ the behavioral model of health services use in examining the extent to which predisposing, enabling, and need factors explain the treatment of the HIV-positive population in the United States with highly active antiretroviral therapy (HAART). DATA SOURCE: A national probability sample of 2,776 adults under treatment for human immunodeficiency virus (HIV) infection. STUDY DESIGN: The article uses data from the baseline and six-month follow-up surveys. The key independent variables describe vulnerable population groups including women, drug users, ethnic minorities, and the less educated. The dependent variable is whether or not a respondent received HAART by December 1996. DATA COLLECTION: All interviews were conducted using computer-assisted personal interview instruments designed for this study. Ninety-two percent of the baseline interviews were conducted in person and the remainder over the telephone. PRINCIPAL FINDINGS: A multistage logit regression shows that the predisposing factors that have previously described vulnerable groups in the general population with limited access to medical care also define HIV-positive groups who are less likely to gain early access to HAART including women, injection drug users, African Americans, and the least educated (odds ratios, controlling for need, ranged from 0.35 to 0.59). CONCLUSIONS: Those HIV-positive persons with the greatest need (defined by a low CD4 count) are most likely to have early access to HAART, which suggests equitable access. However, some predisposing and enabling variables continue to be important as well, suggesting inequitable access, especially for African Americans and lower-income groups. Policymakers and clinicians need to be sensitized to the continued problems of African Americans and other vulnerable populations in gaining access to such potentially beneficial therapies. Higher income, anonymous test sites, and same-day appointments are important enabling resources.

Access to medical care reported by Asians and Pacific Islanders in a West Coast physician group association.

This study examines access to medical care for Asians and Pacific Islanders in the United States, using a survey of patients receiving care provided by a physician group practice association concentrated on the West Coast. Asians and Pacific Islanders who had used their health plan in the past year had worse access to health care than whites, blacks, Hispanics, and Native American or other ethnicities. The odds that Asians reported that they had adequate access ranged from about one quarter to three quarters that of whites, depending on the measure. Cultural differences and associated communication problems may explain the access problems experienced by Asians. Interventions need to be developed to address the problems with access to services, and better translation services may play an important role in improving access to care for Asians. Future studies need to clarify why Asians were more vulnerable to the access problems examined than other ethnic groups that might experience similar barriers.