Cognitive and motor assessment in autopsy-proven corticobasal degeneration.

OBJECTIVE: To investigate the clinical features of autopsy-proven corticobasal degeneration (CBD). METHODS: We evaluated symptoms, signs, and neuropsychological deficits longitudinally in 15 patients with autopsy-proven CBD and related these observations directly to the neuroanatomic distribution of disease. RESULTS: At presentation, a specific pattern of cognitive impairment was evident, whereas an extrapyramidal motor abnormality was present in less than half of the patients. Follow-up examination revealed persistent impairment of apraxia and executive functioning, worsening language performance, and preserved memory. The motor disorder emerged and worsened as the condition progressed. Statistical analysis associated cognitive deficits with tau-immunoreactive pathology that is significantly more prominent in frontal and parietal cortices and the basal ganglia than temporal neocortex and the hippocampus. CONCLUSION: The clinical diagnosis of corticobasal degeneration should depend on a specific pattern of impaired cognition as well as an extrapyramidal motor disorder, reflecting the neuroanatomic distribution of disease in frontal and parietal cortices and the basal ganglia.

Factors associated with clinical assessment of overactive bladder and selection of treatment.

BACKGROUND: Overactive bladder (OAB) affects >17 million individuals in the United States, but the symptoms of OAB are frequently underreported by patients and therefore untreated by physicians. OBJECTIVE: The purpose of this observational study was to investigate the demographic and clinical factors associated with the decision to treat OAB pharmacologically and identify factors associated with physicians' assessment of symptom severity. METHODS: We studied 31 physicians treating 217 patients with OAB and collected data on patient demographic characteristics, OAB symptoms, previous management strategies, physicians' assessments of OAB severity, and treatment prescribed. Stepwise logistic regression was used to identify factors associated with selecting pharmacologic treatment and with physician assessment of severity of OAB symptoms. RESULTS: The mean age of the patients was 61.3 years; approximately 82% were female, and approximately 73% were white. Participants with urinary incontinence were significantly (P < 0.001) more likely to be treated with medication than were those with only symptoms of nocturia or urinary frequency. Other significant factors associated with pharmacologic treatment were being white (odds ratio [OR], 9.5; 95% CI, 2.9-30.8); being black (OR, 5.9; 95% CI, 1.2-29.7); physician's clinical assessment of OAB as moderate (OR, 3.5; 95% CI, 1.5-8.2) or severe (OR, 3.8; 95% CI, 1.1-13.7); previous use of medication (OR, 2.9; 95% CI, 1.1-8.1); and number of incontinence episodes in the last 24 hours (OR, 1.2; 95% CI, 1.0-1.5). Factors associated with physician assessment of OAB severity included distress due to OAB symptoms (OR, 2.1; 95% CI, 1.3-3.2), number of incontinence episodes in the last 24 hours (OR, 1.2; 95% CI, 1.1-1.4), and use of previous treatment(s) (OR, 0.4; 95% CI, 0.2-0.8). CONCLUSIONS: Both demographic and clinical symptoms of OAB were associated with the decision to treat OAB with medication, whereas physicians' assessment of OAB severity was associated only with clinical symptoms. Urinary incontinence was the key symptom associated with the decision to treat patients with medication and with the assessment of OAB symptom severity.

The effects of beer taxes on physical child abuse.

The purpose of this paper is to examine the effects of alcohol regulation on physical child abuse. Given the positive relationship between alcohol consumption and violence, and the negative relationship between consumption and price, the principal hypothesis to be tested is that an increase in the price of alcohol will lead to a reduction in the incidence of violence. We also examine the effects of illegal drug prices and alcohol availability on the incidence of child abuse. Equations are estimated separately for mothers and fathers, and include state fixed effects. Results indicate that increases in the beer tax may decrease the incidence of violence committed by females but not by males.

Assessment of cerebral blood flow in Alzheimer's disease by spin-labeled magnetic resonance imaging.

To evaluate the utility of arterial spin-labeled blood flow magnetic resonance imaging for the detection of cerebral blood flow abnormalities in Alzheimer's disease, arterial spin-labeled blood flow images in 16 contiguous 5-mm axial sections were acquired in 18 patients diagnosed with probable Alzheimer's disease and 11 age-matched controls. Blood flow images from all subjects were transformed to a standard anatomical space for voxel-by-voxel statistical analysis. High quality blood flow images were obtained from all but 1 subject. Statistical analysis demonstrated significant flow decreases relative to control subjects in temporal, parietal, frontal, and posterior cingulate cortices. Increased severity of disease, as measured by Mini-Mental State Examination, correlated with posterior parietal and posterior cingulate decreases but not temporal decreases. Arterial spin-labeled magnetic resonance imaging was found to be an effective tool for characterizing flow decreases accompanying Alzheimer's disease. The absence of ionizing radiation or injection and the ability to obtain high quality anatomical images within the same scanning session make arterial spin labeling an attractive technique for the study of Alzheimer's disease, for the evaluation of pharmacological therapies, and, possibly, for early diagnosis.

Time and motion: a study of trauma surgeons' work at the bedside during the first 24 hours of blunt trauma care.

BACKGROUND: The current literature defines the costs of trauma care in terms of hospital costs and charges. We sought to define the qualitative and quantitative labor costs of trauma care by measuring the various components of bedside care provided by surgeons at a community hospital. METHODS: We conducted a prospective time-and-motion study during the initial 24 hours of blunt trauma patients' stay in the hospital at a Level II trauma center. The services provided by two surgeons and one nurse practitioner were examined. All patients were resuscitated and seen initially by one of the physicians. Ten service elements (SEs) were defined, and total time (TT) spent was the sum of time spent on all service elements for that patient. We defined labor cost as TT. Data on Injury Severity Score (ISS), alcohol intoxication, length of stay, operative procedures, and injury mechanism were also collected. Data are in minutes as means +/- SEM. Analysis of linear correlation was by Pearson correlation coefficient, and intergroup comparison of means was by two-tailed t test. RESULTS: Fifty-eight patients were studied. Mean ISS and length of stay were 11.8 +/- 3 and 4.6 +/- 3 days, respectively. A mean of seven SEs were provided per patient, and the number of SEs provided correlated directly with ISS (r = 0.75, p < 0.01). The mean TT spent was 171 +/- 9 minutes, and it correlated directly with ISS (r = 0.64, p < 0.01). For patients undergoing operative procedures by the trauma surgeon, the procedures consumed the greatest portion of TT: 73 +/- 6 minutes (24%). For patients not undergoing operative procedures, resuscitation and time spent in the radiology department consumed the majority of TT: 30 minutes for each SE (40% of TT). Serum ethanol was greater than 0.10 in 33 of 58 patients (57%), and these patients required significantly more TT (135 vs. 193 minutes; p < 0.05) than nonintoxicated patients. CONCLUSION: A significant labor cost (TT) was required for the care of blunt trauma patients, and the majority of that cost was not spent in the operating room but involved the performance of cognitive services. Significant correlation existed between ISS and labor cost. The presence of ethanol intoxication significantly increased this commitment. These data might be of use in creating provider reimbursement schemes for trauma care. This methodology may have applications in the design of hospital systems for trauma care.

The effects of price on the consequences of alcohol use and abuse.

Economists have examined the impact of alcohol prices on various outcomes related to alcohol consumption, including nonfatal and fatal motor vehicle accidents, other accidents, liver cirrhosis, and other alcohol-related mortality, crime, and education attainment. Price, in the context of this research, includes not only the monetary price of alcoholic beverages, but also a wide variety of other "costs" of drinking and heavy drinking, including the time spent obtaining alcoholic beverages and the legal costs associated with drinking and related behavior. This research clearly demonstrates that increases in the monetary prices of alcoholic beverages, which could be achieved by increasing taxes on alcohol, can significantly reduce many of the problems associated with alcohol use and abuse. In addition, control policies that raise other "costs" of drinking, including reduced availability of alcoholic beverages, higher legal drinking ages, and others, are also effective in reducing the consequences of alcohol use and abuse.

The demand for cocaine by young adults: a rational addiction approach.

This paper applies the rational addiction model to the demand for cocaine by young adults in the Monitoring the Future panel. The price of cocaine is added to this survey from the Drug Enforcement Administration's System to Retrieve Information from Drug Evidence. Results suggest that annual participation and frequency of use given participation are negatively related to the price of cocaine. In addition, current participation (frequency) is positively related to past and future participation (frequency). The long-run price elasticity of total consumption (participation multiplied by frequency given participation) of -1.35 is substantial.

Cigarette taxes. The straw to break the camel's back.

Teenage cigarette smoking is sensitive to the price of cigarettes. The most recent research suggests that a 10% increase in price would reduce the number of teenagers who smoke by 7%. If the proposed 43-cent hike in the Federal excise tax rate on cigarettes contained in the Hatch-Kennedy Bill were enacted, the number of teenage smokers would fall by approximately 16%. This translates into more than 2.6 million fewer smokers and more than 850,000 fewer smoking-related premature deaths in the current cohort of 0 to 17-year-olds. Adjusted for inflation, the current 24-cent-a-pack tax costs the buyer about half of the original cigarette tax of 8 cents imposed in 1951. A substantial tax hike would curb youth smoking; this strategy should move to the forefront of the antismoking campaign.

Who pays for failed organ procurement and what is the cost of altruism?

Our objective was to define medical complications and financial charges generated during the care of potential solid organ donors who fail to donate after consent has been obtained. A retrospective review of financial and medical records of potential organ donors was done at an urban level 1 trauma center. Total hospital stay (T1+T2) for the group was broken down into the interval between admission and diagnosis of lethality (T1) and between diagnosis of lethality and death (T2). Medical complications occurring during the hospital stay and charges generated during each time interval were abstracted. After consent was obtained, 19 of 53 (36%) potential donors failed to donate: 9 of 19 (47%) expired prior to legal determination of brain death; 10 patients failed to progress to brain death and were made DNR. Of these, 9 died within 24 hr, 1 survived 16 days; 6 of the 10 patients did not meet brain death criteria, and 4 were rejected by the OPO for reasons of infectious risks. There were 3.1+/-1.3 medical complications per patient. T1 was less than 4 hr in 16/19 (84%) potential donors and constituted a small percentage of the mean total hospital stay (37+/-10 hr). Charges generated during T1+T2 (33,997+/-25,843) and specifically during T2 (17,385+/-9453) were considerable. These charges were passed on to patients' families or third party payers though care was directed solely at organ procurement after diagnosis of lethality. We conclude that multiple medical complications are encountered in the care of potential organ donors; total hospital stays are short but expensive; more than 50% of charges generated during the total hospital stay arise from care provided after determination of lethality; and the goodwill of families to consent to organ donations of their loved ones appears to carry potential for significant financial burden.

Immunization. Past successes, future challenges.

Global eradication of smallpox, elimination of poliomyelitis in the Western Hemisphere, and a 90% decrease in Haemophilus influenzae meningitis in the Western Hemisphere mark some of the achievements of immunization programs around the world. Yet many serious problems continue to exist, particularly in the developing world. Advances in biotechnology and the renewed interest by industry, governments, and the World Health Organization in vaccine development and delivery in the field provide an exciting prospect for major advances in immunization in the next few decades.

Determinants of interest rates on tax-exempt hospital bonds.

The aim of this paper is to examine the determinants of interest rates on tax-exempt hospital bonds. The results highlight the potential and actual roles of Federal and state policy in the determination of these rates. The shift to a Prospective Payment System under Medicare has subsidized the borrowing costs of some hospitals at the expense of others. The selection of underwriters by negotiation rather than by competitive bidding results in higher interest rates. The Federal tax act of 1986 raised the cost of hospital debt by encouraging bond issues to contain call features.

Contractual considerations in veterinary practice.

Veterinary medicine is a profession based on contract. Many aspects of veterinary practice involve legally enforceable contract obligations. Legal rules established by statutes or court cases govern contract formation, interpretation, and enforcement. This article explains several legal principles governing contract law and applies some of these principles to common contractual settings in veterinary medicine.

Pregnancy wantedness and the early initiation of prenatal care.

The study examines the impact of the wantedness of a pregnancy on the demand for early prenatal care. Using a cohort of pregnant women in New York City, we estimate a prenatal care demand function in which we control for the probability of giving birth, given a woman is pregnant. We interpret this control as a measure of wantedness. The results indicate that if the black and Hispanic women who aborted had instead given birth, they would have delayed the initiation of prenatal care, on average, more than three-quarters of a month longer than the mean number of months of delay that were actually observed for the women who gave birth. By allowing women to terminate an unwanted pregnancy, induced abortion increases the average use of prenatal care among black and Hispanic women relative to what would have been observed if the women who aborted had instead given birth.

Health benefits of increases in alcohol and cigarette taxes.

Excise taxes on alcohol and cigarettes imposed by the Federal government of the United States have been very stable since 1951. This paper summarizes research that shows that increased taxation, which results in higher prices, would discourage alcohol abuse and cigarette smoking. One striking finding is that a policy to raise the Federal excise tax on beer in line with the rate of inflation over the last three decades would cut motor vehicle fatalities of 18 to 20 year olds, many of which are alcohol-related, by about 15%, saving more than 1,000 lives per year. A second is that over 800,000 premature deaths in the cohort of Americans 12 years and older in 1984 would be averted if the Federal excise tax on cigarettes were restored to its real value in 1951.

A cost-effectiveness analysis of strategies to reduce infant mortality.

This study compares the cost effectiveness of various health inputs and government programs in reducing race-specific neonatal mortality or death in the first 27 days of life. Approximately two thirds of all infant deaths occur within this period. The programs and inputs at issue are teenage family planning use; the supplemental food program for women, infants, and children (WIC); use of community health centers and maternal and infant care projects; abortion; prenatal care; and neonatal intensive care. Using an economic model of the family as the analytic framework, effectiveness is determined by using ordinary least squares and two-stage least squares to estimate infant health production functions across large counties in the United States in 1977. Estimates of costs are from a number of published sources. We find the early initiation of prenatal care to be the most cost-effective means of reducing the neonatal mortality rate for blacks and whites. Moreover, blacks benefit more per dollar of input use than whites. Neonatal intensive care, although the most effective means of reducing neonatal mortality rates, is one of the least cost-effective strategies.