Disc displacement patterns in lumbar anterior spondylolisthesis: contribution to foraminal stenosis.

PURPOSE: To describe the particular disc displacement pattern seen at MRI in patients with spondylolisthesis, and its potential contribution to foraminal stenosis. METHODS: 38 patients with symptomatic lumbar anterior spondylolisthesis and 38 sex and aged matched control patients with herniated disc disease, at corresponding disc space levels, were included for study. In each case note was made of the presence, absence and direction of disc displacement and also the presence and location of neural contact with the displaced disc. RESULTS: In 33 of 38 (86.8%) patients in the spondylolisthesis group, the vertical disc displacement was upward. In the control group only 3 patients (7.8%) had upward vertical disc displacement. 19 patients (53%) from the spondylolisthesis group had exit foraminal nerve root contact, compared to 7 patients (18.4%) from the control group. 27 control patients (71%) had contact within the lateral recess, compared to only 6 patients (17%) with spondylolisthesis. Differences for upward displacement were significant (p<0.05). CONCLUSION: Disc displacement in patients with spondylolisthesis is predominately in a cephalad and lateral direction. Although this disc displacement pattern can occur in patients without spondylolisthesis, its incidence is much greater in the subset of patients with concomitant spondylolisthesis. In the setting of acquired osseous narrowing of the exit foramen, this described pattern of disc displacement superiorly and laterally in spondylolisthesis increases the susceptibility of spondylolisthesis patients to radicular symptoms and accounts for the exiting nerve root being more commonly affected than the traversing nerve root.

The effect of spousal caregiving and bereavement on depressive symptoms.

The objective of the study was to determine whether spousal caregiving and bereavement increases caregiver depressive symptoms. We followed 1,967 community-dwelling elderly couples from the 1993 Health and Retirement Study (HRS) until 2002 (five bi-annual surveys) or death. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression (CESD) scale. Adjusted depressive symptoms were higher for females for three of the four caregiving arrangements tested (as were unadjusted baseline levels). Depressive symptoms were lowest when neither spouse received caregiving (adjusted CESD of 2.97 for males; 3.44 for females, p<0.001). They were highest when females provided care to their husband with assistance from another caregiver, (4.01) compared to (3.37; p<0.001) when males so cared for their wife. A gender by caregiving arrangements interaction was not significant (p=0.13), showing no differential effect of caregiving on CESD by gender. Depressive symptoms peaked for bereaved spouses within three months of spousal death (4.67; p<0.001) but declined steadily to 2.75 (p<0.001) more than 15 months after death. Depressive symptoms initially increased for the community spouse after institutionalization of the care recipient, but later declined. We conclude that caregiving increases depressive symptoms in the caregiver, but does not have a differential effect by gender. Increases in depressive symptoms following bereavement are short-term.

Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement.

AIM: To assess the relationship between the severity of full-thickness supraspinatus tendon tears and the development of subcoracoid impingement. MATERIALS AND METHODS: Fifty-one magnetic resonance imaging (MRI) shoulder examination reports with full-thickness supraspinatus tears were retrospectively identified and reviewed by two dedicated musculoskeletal radiologists. The appearances of the rotator cuff muscles, biceps tendon and the lesser tubercle were recorded. The acromio-humeral distance and the axial coraco-humeral distance were measured. The data were recorded and analysed electronically. RESULTS: The kappa values for inter-observer agreement were: 0.91 for acromio-humeral distance and 0.85 for coraco-humeral distance measurements. Twenty-six patients had significant retraction of the supraspinatus tendon, 85% (22 cases) of this group had imaging evidence of tear or tendonopathy of the subscapularis tendon. Twenty-five patients had no significant retraction of the supraspinatus, 56% (14 cases) of this group had imaging evidence of a subscapularis tear or tendonopathy. The acromio-humeral distance was significantly less in patients with supraspinatus tears and retraction (p<0.05). The subscapularis tendon was significantly more likely to be abnormal if the supraspinatus was retracted than if no retraction was present (p<0.05). There were no significant differences in coraco-humeral distances between the groups. CONCLUSION: Subscapularis tendon signal and structural changes are frequently associated with full-thickness supraspinatus tendon tears, particularly if the supraspinatus is significantly retracted. In this static MRI series, the data do not support the occurrence of classical subcoracoid impingement as an aetiology; however, they may support the possibility of a dynamic mechanism, to which future studies could be directed.

Skeletal muscle metastasis from uterine leiomyosarcoma.

A case of a 68-year-old woman who presented with a rapidly enlarging painful right thigh mass is presented. She had a known diagnosis of uterine leiomyosarcoma following a hysterectomy for dysfunctional uterine bleeding. She subsequently developed a single hepatic metastatic deposit that responded well to radiofrequency ablation. Whole-body MRI and MRA revealed a vascular mass in the sartorius muscle and a smaller adjacent mass in the gracilis muscle, proven to represent metastatic leiomyosarcoma of uterine origin. To our knowledge, metastatic uterine leiomyosarcoma to the skeletal muscle has not been described previously in the English medical literature.

Toxicokinetics, available source, and route of entry of lead in fed and food-deprived bullfrog (Rana catesbeiana) larvae.

Several toxic effects of lead (Pb) have been documented in amphibians, but few studies have measured tissue levels of exposed specimens or examined toxicokinetics, availability of dietary versus waterborne sources, or route of entry. We modeled the toxicokinetics and examined the availability of dietary and waterborne Pb in both fed and food-deprived bullfrog (Rana catesbeiana) larvae. Uptake rates of Pb (1,000 microg Pb/L nominal exposure) were similar between fed and unfed larvae, but unfed larvae eliminated Pb slowly. Consequently, food-deprived larvae accumulated significantly more Pb compared to fed larvae. The intestinal tract contained > 90% of total body Pb in both fed and unfed larvae. Total body concentrations of Pb in fed larvae did not increase over 7 days although levels in food did increase. We concluded that food consumption influenced Pb accumulation through changes in elimination rates rather than in uptake rates. Pb appeared to enter the body of larvae through ingestion of contaminated water rather than food.

The relative effect of Alzheimer's disease and related dementias, disability, and comorbidities on cost of care for elderly persons.

OBJECTIVES: Our primary objectives were (a) to determine the relative impact of Alzheimer's disease and related dementias (ADRD), disability, and common comorbid health conditions on the cost of caring for community-dwelling elderly person and (b) to determine whether ADRD serves as an effect modifier for the effect of disability and common comorbidities on costs. METHODS: Participants were drawn from community respondents to the 1994 National Long Term Care Survey. The authors compared total cost of caring for persons without ADRD with that of those who had moderate and severe ADRD. Using regression analysis, the author identified the adjusted effect of ADRD, limitations in activities of daily living (ADLs), and common comorbidities on total costs. RESULTS: Persons with severe ADRD had higher median total costs ($10,234) than did persons with moderate ADRD ($4,318) and those without ADRD ($2,268, p <.001). However, disability measured by ADL limitations was a more important predictor of total cost than was ADRD status in both stratified and multivariate analyses. Comorbidities such as heart attack, stroke, and chronic obstructive pulmonary disease also increased costs. Severe ADRD was an effect modifier for ADL limitations, increasing the positive impact of disability on total costs among persons with severe ADRD, but not for comorbidities. DISCUSSION: Disability, severe ADRD, and comorbidity all had independent effects that increased total costs. Thus, any risk adjustment procedure should account for disability and comorbidity and not just ADRD status.

Hospital ownership and cost and quality of care: is there a dime's worth of difference?

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership.

The effect of middle- and old-age body mass index on short-term mortality in older people.

OBJECTIVES: To determine the effect of body mass index (BMI) at old age and at age 50 on short-term survival among persons age 65 and older. DESIGN: Cross-sectional, using the 4,791 respondents to the community interview of the 1994 National Long Term Care Survey (NLTCS). SETTING: United States of America. PARTICIPANTS: Persons age 65 and older who lived in community settings as of the 1994 NLTCS interview. MEASUREMENTS: Short-term mortality was measured from the date of the 1994 NLTCS through year-end 1995. BMI (kg/m2) (at three points: 1994 NLTCS, 1 year before, age 50) and all other variables, including three other modifiable risk factors known to be related to mortality--cigarette smoking, alcohol consumption, and exercise--were based on self-report. RESULTS: Both the unadjusted and adjusted nadirs of mortality in relation to BMI at old age were found in older persons with a BMI between 30 and 34.9; this was true for males and females in all age groups. The highest mortality rates were found for older persons with very low BMI (<18.5). In contrast, BMI at age 50 was positively related to mortality, with those in the lowest BMI category (<18.5) at age 50 having the lowest mortality. Persons who were obese at age 50 and who were no longer obese at the 1994 NLTCS had lower mortality than persons with stable weight. CONCLUSIONS: Weight reduction by middle-aged persons who are obese should be reinforced as a public health priority, because there is evidence that long-term weight loss results in better short-term survival. Further study of healthy older survivors to determine why they are not harmed by heavier weight in old age may provide useful insights into successful aging.

Medical training debt and service commitments: the rural consequences.

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

State scholarship, loan forgiveness, and related programs: the unheralded safety net.

CONTEXT: In the mid-1980s, states expanded their initiatives of scholarships, loan repayment programs, and similar incentives to recruit primary care practitioners into underserved areas. With no national coordination or mandate to publicize these efforts, little is known about these state programs and their recent growth. OBJECTIVES: To identify and describe state programs that provide financial support to physicians and midlevel practitioners in exchange for a period of service in underserved areas, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net. DESIGN: Cross-sectional, descriptive study of data collected by telephone, mail questionnaires, and through other available documents, (eg, program brochures, Web sites). SETTING AND PARTICIPANTS: All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physician assistants; and nurse midwives. We excluded local community initiatives and programs that received federal support, including that from the National Health Service Corps. MAIN OUTCOME MEASURES: Number and types of state support-for-service programs in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other practitioners in 1996; numbers in state programs relative to federal programs; and basic features of state programs. RESULTS: In 1996, there were 82 eligible programs operating in 41 states, including 29 loan repayment programs, 29 scholarship programs, 11 loan programs, 8 direct financial incentive programs, and 5 resident support programs. Programs more than doubled in number between 1990 (n = 39) and 1996 (n = 82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states' borders, an emphasis on primary care, and reliance on annual state appropriations and other public funding mechanisms. CONCLUSIONS: In 1996, states fielded an obligated primary care workforce comparable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their activities should be monitored, coordinated, and evaluated. State programs should not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access. JAMA. 2000;284:2084-2092.

How much do persons with Alzheimer's disease cost Medicare?

BACKGROUND: Medicare claims are increasingly being used to identify persons with chronic diseases such as Alzheimer's disease (AD) for the purpose of determining the cost to Medicare of caring for such persons. Past work has been limited by the use of only 1 or 2 years of claims data to identify cases, leading to worries that this might lead to an undercount of prevalent cases and bias cost findings. OBJECTIVES: To analyze the average total cost to the Medicare program in 1994 of persons with a claims-based diagnosis of AD, using a 12-year period of claims history to identify prevalent cases, and to investigate the effect on cost of time since diagnosis. DESIGN: A cross-sectional design with a 12-year retrospective period to identify persons with AD. SETTING: Medical care practices, hospitals, and other providers of services to Medicare beneficiaries in the US in 1994. SUBJECTS: Respondents to the screener (n = 10,858) and community (5429) and institutional (n = 1341) questionnaire of the 1994 National Long Term Care Survey, with and without a claims-based diagnosis of AD. MEASUREMENTS: Average total cost to Medicare in 1994, measured as the actual amount Medicare paid for inpatient, outpatient, home health, skilled nursing facility, hospice, and Part B services, including payments to physicians, and other items such as durable medical equipment. We also measured disability in a variety of ways, including cognition, activity limitations, and residence in a nursing home. RESULTS: The average total cost to Medicare of persons with a claims-based diagnosis of AD was $6021 versus $2310 (P < .001) for persons without a diagnosis. When adjusting for patient characteristics, the ratio of cost between persons with AD and those without was reduced to about 1.6 to 1. Time since diagnosis was an important predictor of average total cost in 1994, with each additional year since diagnosis resulting in a $248 (P = .04) decrease in total cost (about 10% of the total sample mean cost of $2426). There was mixed evidence that persons with a diagnosis of AD incurred less cost than otherwise similarly disabled Medicare beneficiaries. CONCLUSIONS: Time since diagnosis with AD is an important predictor of cost and one that should be explicitly included in any rate-setting formula. Expanding the period used to identify cases resulted in an increase in the unadjusted ratio of cost of a Medicare beneficiary with AD relative to one without primarily because our control group costs are lower compared with those of past work.

Do targeted efforts for the rural underserved help kill comprehensive reform?

There has been a shift during the past 60 years from a broad notion of the entire nation as underserved to a more focused effort to identify particular areas (often rural) thought to be underserved. This approach was formalized with the advent of the war on poverty. This focused approach has been cemented during the past 30 years, in part by the success of various federal health center programs that have remained funded during this period in spite of opposition. This paper concludes that the consensus view that rural underserved areas represent an "exception" phenomenon that is properly addressed with special responses (organizations or physicians) has had two major effects: (1) the political survivability of focused programmatic responses (such as Community Health Centers) has been enhanced; and (2) the existence of an "elastic net" policy network to advocate for the expansion of such remedial efforts may play a contributory role in helping to defeat comprehensive health reform.

Costs and outcomes of hip fracture and stroke, 1984 to 1994.

OBJECTIVES: This study quantified changes in Medicare payments and outcomes for hip fracture and stroke from 1984 to 1994. METHODS: We studied National Long Term Care Survey respondents who were hospitalized for hip fracture (n = 887) or stroke (n = 878) occurring between 1984 and 1994. Changes in Medicare payment and survival were primary outcomes. We also assessed changes in functional and cognitive status. RESULTS: Medicare payments within 6 months increased following hip fracture (103%) or stroke (51%). Survival improved for stroke (P < .001) and to a lesser extent for hip fracture (P = .16). Condition-specific improvements were found in functional and cognitive status. CONCLUSIONS: During the period 1984 to 1994, Medicare payments for hip fracture and stroke rose and there were some improvements in survival and other outcomes.

Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries.

BACKGROUND AND METHODS: We studied the effects of admission to a teaching hospital on the cost and quality of care for patients covered by Medicare (age, 65 years old or older). We used data from the National Long Term Care Survey and merged them with Medicare claims data. We selected the first hospitalization for hip fracture (802 patients), stroke (793), coronary heart disease (1007), or congestive heart failure (604) occurring between January 1, 1984 and December 31, 1994, and calculated all Medicare payments for inpatient and outpatient care during the six-month period after admission. Survival was assessed through 1995. Hospitals were classified as major or minor teaching hospitals (with minor hospitals defined as those in which the number of residents per bed was less than the median number for all teaching hospitals) or as private nonprofit, government (i.e., public), or private for-profit hospitals. RESULTS: Medicare payments for the six-month period after hospitalization were highest for patients initially admitted to teaching hospitals for the treatment of hip fracture, stroke, or coronary heart disease and for patients initially admitted to for-profit hospitals for the treatment of congestive heart failure. As compared with payments to for-profit hospitals, payments to major teaching hospitals for hip fracture were significantly higher, payments to government hospitals for coronary heart disease were lower, and payments to government and nonprofit hospitals for congestive heart failure were lower. After adjustment for patients' characteristics and social subsidies, major teaching hospitals had the lowest mortality rates (hazard ratio for death, 0.75, as compared with for-profit hospitals; 95 percent confidence interval, 0.62 to 0.91). For individual conditions, the only significant survival advantage associated with admission to major teaching hospitals was for hip fractures (hazard ratio, 0.54, as compared with for-profit hospitals; 95 percent confidence interval, 0.37 to 0.79). CONCLUSIONS: Although admission to a major teaching hospital may be associated with increased costs to the Medicare program, overall survival for patients with the common conditions we studied was better at these hospitals, especially for patients with hip fractures.

Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

OBJECTIVES: To determine the number and geographical distribution of general practitioners in the NHS who qualified medically in South Asia and to project their numbers as they retire. DESIGN: Retrospective analysis of yearly data and projection of future trends. SETTING: England and Wales. SUBJECTS: General practitioners who qualified medically in the countries of Bangladesh, India, Pakistan, and Sri Lanka and who were practising in the NHS on 1 October 1992. MAIN OUTCOME MEASURES: Proportion and age of general practitioners who qualified in South Asia by health authority; the Benzeval and Judge measure of population need at the health authority level. RESULTS: 4192 of 25 333 (16.5%) of all unrestricted general practitioners practising full time on 1 October 1992 qualified in South Asian medical schools. The proportion varied by health authority from 0.007% to 56.5%. Roughly two thirds who were practising in 1992 will have retired by 2007; in some health authorities this will represent a loss of one in four general practitioners. The practices that these doctors will leave seem to be in relatively deprived areas as measured by deprivation payments and a health authority measure of population need. CONCLUSION: Many general practitioners who qualified in South Asian medical schools will retire within the next decade. The impact will vary greatly by health authority. Those health authorities with the greatest number of such doctors are in some of the most deprived areas in the United Kingdom and have experienced the most difficulty in filling vacancies. Various responses will be required by workforce planners to mitigate the impact of these retirements.