Electronic chart review as an aid to postdischarge surgical site surveillance: increased case finding.

BACKGROUND: At the University of Michigan Hospitals and Health Centers, there is increasing use of an electronic medical record. Because orthopedic surgeons dictate all outpatient visits to the patient's electronic record, total knee arthroplasties were chosen to determine whether the use of electronic medical records increased case finding. METHODS: All patients who underwent a total knee arthroplasty during the study period (1996-1999) were followed prospectively with the use of the National Nosocomial Infection Surveillance System definitions. Traditional surveillance methods were used to ascertain infections. In addition, each patient's postdischarge outpatient clinic chart was reviewed electronically for 1 year after operation. RESULTS: From 1996 to 1999, 555 procedures were performed. Overall, 25 infections were identified after operation. Seven infections were identified through traditional surveillance methods, which resulted in an average surgical site infection rate of 1.3%. The use of electronic chart review surveillance after discharge revealed a rate of 4.5%, which was significantly higher than traditional surveillance (P <.01). Eighteen of 25 infections (72%) would not have been identified with the use of traditional surveillance methods. CONCLUSION: Postdischarge electronic chart review enhanced case finding significantly, which resulted in a more accurate infection rate. Awareness should be given to the institutions' surveillance methods and intensity when comparing to published rates.

Immunohistochemical features of paragangliomas.

Immunohistochemistry is part of the routine diagnosis of the neuroendocrine tumors. In our study, we included 52 paragangliomas with various localizations by routine histology and immunohistochemistry. In order to increase the diagnostic specificity, a complex immunohistochemistry panel has been performed consisting of Bcl-2, Ki-67, Bax and Pituitary Adenylate Cyclase-Activating Peptide (PACAP), somatostatin, VIP and Calcitonin Gene Related Peptide (CGRP). After heat induced antigen retrieval, the immunostaining was performed by StreptABC using DAB as a chromogen. We were the first to demonstrate the presence of Bax and PACAP in paragangliomas. Some of the used markers are of prognostic value. The relationship between Bcl-2 and Bax is decisive in generating the final response to the input apoptotic signals. The Ki-67 antigen staining has gained wide acceptance in prognostic evaluation of other tumor types. We noted a small number of Ki-67 positive cases, which signifies a low mitotic activity of these tumors and a relatively high number of Bax positivities (32.9%) and the much lower number of Bcl-2 positivities (11.39%), and could explain the benign behaviour of paragangliomas.

Inflammatory processes in a murine model of intra-abdominal abscess formation.

Abscess formation has been viewed as a host defense strategy to contain the spread of infection. However, abscesses are also serious and life-threatening manifestations of persisting microbial infection. The initiation of abscess formation, both clinically and experimentally, involves the release of bacteria and an abscess-potentiating agent (e.g., fecal fiber or an analog) into a sterile site, with host defense mechanisms being unable to eliminate the infecting organisms. Abscess formation is aided by a combination of factors that share a common feature: impairment of phagocytic killing and hence clearance of microorganisms. These include bacterial virulence factors (e.g., capsule formation, succinic acid production); complement activation by the abscess potentiating agent; fibrin deposition; and microbial sequestration within abscess neutrophils. Recruitment of cells into the peritoneal cavity follows mast cell activation in the pathogenesis of infection: histamine and tumor necrosis factor alpha can be detected in the peritoneal cavity within minutes of challenge with an abscess-inducing mixture. However, the role of mast cells in host defense is made less clear by the finding of diminished abscess formation (but no mortality or increased morbidity) in mast-cell-depleted mice. This may indicate that mast cell products have a role in not only the initiation of an inflammatory response but also the promotion of fibrin deposition and abscess formation.

Patients' perceived benefit from and satisfaction with asthma-related pharmacy services.

OBJECTIVE: To determine whether patients targeted to receive intervention from an asthma management program reported receiving more services and had greater perceived benefit and satisfaction with those services compared with asthma patients not targeted by the program. DESIGN: Mailed survey. SETTING: Community pharmacy. PATIENTS: 471 community-based patients receiving asthma medications from 44 intervention pharmacies and 1,164 patients from 46 usual care (control) pharmacies. MAIN OUTCOME MEASURES: Five-point agreement scale measuring asthma services received, perceived value of the services, and satisfaction. RESULTS: Usable surveys were received from 39.0% of intervention patients and 42.4% of controls. There were no statistically significant differences between groups in the frequency of provision of listed services. Approximately 60% of respondents from both groups received written materials on asthma medications and 54% received inhaler counseling; both were rated high for perceived benefit. Fewer than 20% reported being counseled about asthma triggers. Fewer than 5% reported pharmacists talking to physicians on their behalf. General satisfaction with pharmacy services was high (78.2% agree or strongly agree), but not statistically different between groups. More than 65% believed that pharmacists spend enough time counseling patients. Several comments indicated that patients did not expect or ask for information because they were unaware that services were available and/or they had already been counseled by their physician. Responses to the statement "my asthma is better controlled because of help given to me by the pharmacist" were equivocal and not different between groups. CONCLUSION: Overall, there were few differences between groups. General satisfaction with pharmacy services is high, but patients' perceived benefit and satisfaction with cognitive services is lower. Increased public awareness of pharmacists' capabilities and a more proactive approach to providing cognitive services is needed.

Clustering of Candida infections in the neonatal intensive care unit: concurrent emergence of multiple strains simulating intermittent outbreaks.

BACKGROUND: Clusters of Candida albicans and Candida parapsilosis infections were noted intermittently in our neonatal intensive care unit (NICU). We attempted to determine whether these clusters represented single strain outbreaks or coincidental emergence of unrelated strains. METHODS: A retrospective examination of the frequency of candidemia during a 9-year period, two point prevalence studies of colonization and assessment of strain relatedness of individual infant isolates during and in between clusters during a 2-year period with karyotyping and restriction endonuclease analysis of genomic DNA (REAG). RESULTS: C. albicans and C. parapsilosis infections emerged in a scattered pattern (1 to 2 cases every few months) with intermittent clustering of 3 cases/month. The colonization rate was 50% 5 weeks after an apparent cluster, equally distributed between C. albicans and C. parapsilosis, and 17.6% (exclusively with C. parapsilosis) 4 months after absence of invasive disease. Utilizing REAG or karyotyping singly we noted 12 and 16 DNA banding patterns, respectively, among 23 infant isolates. Few patterns were observed repeatedly over 2- to 20-month periods, implying recurrent emergence of the same strains. Combining karyotyping with REAG revealed a different epidemiologic pattern. It identified 20 distinct composites with identical composites in 3 infant pairs. All infants with identical composites were in the NICU concurrently. The frequency of strain relatedness was comparable among clustered cases (16.7%), scattered cases (7.7%) and simultaneously colonized infants (16.7%). CONCLUSIONS: These findings illustrate that Candida infections clustered periodically in our NICU but that these clusters were often caused by unrelated strains with infrequent cross-infection during and between clusters. With suboptimal typing this pattern of emergence can be mistaken for same strain outbreaks.

Mothers' beliefs about the causes of infant growth deficiency: is there attributional bias?

Tested for defensive attributional bias in mothers' causal explanations for infant (2-12.5 months) growth deficiency. Mothers of healthy babies (controls; n = 82), growth deficient babies without medical problems (n = 27) and growth deficient babies with mild medical problems (n = 22) rated their levels of agreement with 23 causes of growth problems which were designed to vary in the degree of personal threat to parenting self-esteem. Ratings were completed for the mother's (Own) baby and for a nonspecific (Other) baby. Findings partially support a theory of defensive attributional bias, with higher agreement when causes referred to Other (vs. Own) baby, and lower agreement with family-related than with medical/nutritional causes. Factors that may have influenced material experience of threat and implications of the findings for clinical practice are discussed.

Drug utilization evaluation identifies costs associated with high use of beta-adrenergic agonists.

BACKGROUND: Drug utilization evaluation is an effective mechanism to identify individual variability in drug use and to promote interventions that will improve patient outcomes. The present analysis is a novel approach incorporating medical claims information with pharmacy data. METHOD: This analysis was conducted during the 12 months of 1993 in four health maintenance organizations with approximately 673,000 members. Health care costs were identified in asthmatic patients, age 7 years and over, who used high doses of inhaled beta-adrenergic agonists, defined as more than 8 puffs per day. RESULTS: A total of 20,512 asthmatic patients were identified. From these patients, 1093 members or 5.3% received high doses of an inhaled bronchodilator. This second group was then stratified by concurrent use of inhaled anti-inflammatory therapy. Group A, 32% of the members, received > or = 4 puffs per day of an anti-inflammatory medicine; group B, 31% of the members, received <4 puffs per day of these medicines; and group C, 37% of the members, received no anti-inflammatory therapy. Examination of the linked medical claims and pharmacy database demonstrated that members using high doses of inhaled bronchodilators had annual charges for treatment related to their asthma that were 3.0 times higher than the average asthmatic patient ($1,346.52 versus $447.42). The high beta-agonist users had inpatient hospital and emergency department charges that grew proportionally as a percent of total annual expenses. Medication charges were 10% greater as a measure of total annual costs while fees for ambulatory services were down 11% for high users of beta-agonists compared with the average asthmatic patient. In patient hospital costs in group B were 12% higher than group A. CONCLUSION: Patients not following the National and International guidelines appear to be more likely to consume greater amounts of health care resources. This drug utilization evaluation demonstrates that there is a failure by the provider or patient with implementation and maintenance of these recommendations. Noncompliance with guidelines was associated with increased morbidity and cost for asthma related care. Interventions targeting these members may improve clinical outcomes and decrease total cost for the treatment of asthma.

Use of a pharmacy and medical claims database to document cost centers for 1993 annual asthma expenditures.

OBJECTIVE: To demonstrate the utility of a combined pharmacy and medical claims database in the assessment of the incidence and the cost centers of asthma care in a managed health care system. DESIGN: A retrospective observational study to document annual cost for asthma therapy by cost center during 1993. SETTING: Four affiliated health maintenance organizations. PARTICIPANTS: A total of 25,614 asthmatics identified from a population of approximately 673,000 members in the health maintenance organization. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Annual charges by cost center for asthma care analyzed by age and gender. RESULTS: The period prevalence of asthma was 3.8%. Annual direct medical charges for asthma were $467.40 per member. Inpatient hospital and emergency department charges were greater in children than adults. Adolescent girls had increased use of the emergency department and inpatient hospital facilities and lower charges for medications than their male counterparts. Their increased use of acute care facilities was responsible for 25% greater charges for total asthma care. The gender differences in cost centers continued for adults, with increased charges for inpatient hospital and emergency department charges and lower expenses for medications for women. CONCLUSIONS: Charges for acute care were inversely related to the dollars spent on pharmaceuticals. This study demonstrates the ability of a combined medical and pharmacy database to document the charges for care and possibly identify indicators of undertreated populations.

Pediatric psychologists' perceptions of their work settings.

Describes the results of a survey of pediatric psychologists' perceptions of their work settings. Respondents (n = 261) described heterogeneous work settings, professional activities, expectations for workload and administrative arrangements. Clinical activities were prominent, accounting for nearly half the respondents' time. Respondents generally reported high levels of overall satisfaction with their work environments. Highest ranked sources of satisfaction included professional autonomy, patient care, and relationships with colleagues. Highest ranked sources of dissatisfaction included lack of time for research, salary, and patient care workload. Pediatric psychologists in private practice reported higher work satisfaction than those in other settings. Findings have implications for the work-related functioning of pediatric psychologists that should be addressed in research and professional activity.

Personality development, problem solving, and behavior problems among preschool children with early histories of nonorganic failure-to-thrive: a controlled study.

Using a prospective study design, 48 preschool children with early histories of nonorganic failure-to-thrive (NOFT) and 47 physically healthy children of comparable age, sex, birth order, and family demographics were compared on measures of problem solving and personality development (ego control and ego resiliency). In responding to structured measures, NOFT children demonstrated deficits in behavioral organization, ego control, and ego resiliency compared with controls. Parents also identified higher levels of behavioral symptoms in children with early histories of NOFT compared with controls. However, home observational measures of ego control and ego resiliency did not differentiate the two groups. Deficiencies in problem solving and personality development and increased levels of behavioral symptoms in preschool children with early histories of NOFT may affect their future socioemotional development and learning.

Influences on the home environment of preschool children with early histories of nonorganic failure-to-thrive.

The home environments of 58 children with early histories of nonorganic failure-to-thrive (NOFTT) who received time-limited outreach intervention after hospitalization were assessed from 12 to 36 months of age. The type of outreach intervention did not affect the quality of home environment as assessed by the Home Observation for Measurement of the Environment inventory (HOME). We tested the efficacy of three sets of variables: characteristics of NOFTT (age of onset and duration), nutritional status (weight for height) at time of diagnosis, and family characteristics (maternal IQ and income) in predicting HOME scores at 36 months. Family characteristics (income and maternal IQ) were the only variables to predict HOME scores. HOME scores were less stable than in the standardization sample. A subgroup of NOFTT children (n = 7) whose HOME scores decreased over the 2-year follow-up period were more likely to have subsequent siblings than children whose HOME scores improved over the same time period (n = 11). Findings suggest the need to identify and provide preventive intervention for NOFTT children whose home environments are vulnerable to deterioration following diagnosis.

Structural characteristics and functional significance of the buccal fat pad (corpus adiposum buccae).

Corpus adiposum buccae (c.a.b.) was studied on 42 human subjects (fetuses and adults) using microdissection under magnifying glass after injection of the great vessels of the head with plastics, transparency technique of Spalteholtz and current histological methods. In fetuses, c.a.b. appeared as a well-developed mass located between Buccinator and inferior border of the Masseter. In adults, it emanated three prolongations among which the anteriorly directed molar prolongation was more conspicuous in edentulous old people. Externally, it was covered by a fine conjunctival wrap, which sent septa dividing the buccal fat pad in a series of minute fibroadipous compartments. C.a.b. contained a rich vascular network deriving from the branches of the facial and maxillary arteries. In this vascular net a more developed artery emanated branches to the prolongations of the c.a.b. The veins were tributaries of the pterygoid venous plexus. Beside the vessels, c.a.b. contained also lymphatics and myelinated nerves. The authors postulated that c.a.b. assumed the following functions: a) It filled up the masseter-zygomaticus-buccinator space forming an amortizing and a slipping platform for the masticatory muscles in action; b) in the baby, it resisted to the negative pressure which acted into the buccal cavity during sucking; c) its rich venous net, provided with valve-like structures, may be implicated in the exo-endocranial blood flow by means of the pterygoid plexus.

Prediction of weight for height following intervention in three-year-old children with early histories of nonorganic failure to thrive.

The present study assessed the weight for height outcomes of 59 3-year-old children who had been hospitalized for nonorganic failure to thrive (NOFT) as infants (average age of 5 months) and received time-limited outreach intervention. Although the majority of children attained normal weight for height, nearly one-third demonstrated at least mild wasting. Type of outreach intervention did not affect weight for height at outcome. The predictive efficacy of a variable set which included characteristics of NOFT (age of onset and duration), velocity of weight gain subsequent to diagnosis and environmental characteristics (income and home stimulation) was tested. Shorter duration of NOFT prior to diagnosis and greater initial rate of weight gain following hospitalization predicted weight for height at 36 months. The findings underscore the need for close monitoring of physical growth and nutritional status of NOFT children following hospitalization as well as comprehensive assessment and treatment for children who continue to demonstrate nutritional deficits. Additional studies of factors which affect the prognosis of NOFT children are needed.

The aberrant retroesophageal right subclavian artery.

Two cases with arteria lusoria were found at 278 routine dissections. These arteria arise as the last branches of the aortic arch and have a retroesophageal position. At the crossing point, the esophagus narrows due to the groove caused by the artery. The appearance of this malposition is the consequence of the perturbation in the organo-genesis of the right dorsal aorta and fourth branchial artery. The aberration can lead to disphagia lusoria.

[Anatomical variations of the nervus alveolaris inferior and their importance for the practice (author's transl)]. / Die anatomischen Variationen des Nervus alveolaris inferior und ihre Bedeutung in der Praxis.

The authors have studied the anatomic variations of the inferior alveolar nerve (N. alveolaris inferior) in 18 human heads. The mandibular nerve being free by medial abord. At about half of the studied cases the M. pterygoideus medialis presents a widened insertion extending on the posterior border of the Ramus mandibulae. Before entering into the mandibular channel the inferior alveolar nerve separated from the next elements by expansion of "aponévrose interptérygoidienne". At this level gets sympathic branches from the plexus caroticus externus et internus, making a plexiform structure interfering sometimes a vegetative ganglion formation. At 16.6% of the cases between the alveolar inferior nerve and the lingual nerve are established connection bridges more or less developed. They have an asymetric aspect. There were observed evident connections between the inferior alveolar nerve and the auriculotemporal nerve taking a mono- or pluriradicular form. The mylohyoidian nerve on his homonymous way gives 2--3 sensitive, or vegetative branches to the bone. Practically speaking are important the branches coming from the precanalicular portion of n. alveolaris inferior perforating the periost and penetrating independently in to mandibula through separated vents. These results are practically useful in Stomatological technique explaining from an anatomically point of view the inefficiency of mandibular anaesthesia in some cases although it is correctly applied.

Regeneration of intrahepatic biliary ducts after subtotal hepatectomy in rats.

The regenerative morphogenesis of intrahepatic biliary ducts in subtotally hepatectomized rats was studied at 3, 7, 14 and 21 days after operation. Histological findings showed that during the postmitotic stage of hepatoregeneration, between the 1st and 2nd postoperatory week the regenerated biliary structures appeared in close connection with the newly formed vasculo-connective portal spaces. The poorly differentiated periportal cells generated through a gradual metamorphosis the bordering cells of the regenerating intrahepatic biliary ducts. These plead for the similarity of histogenetic mechanisms in regenerative and embryofetal cholangiogenesis.