The pursuit of the magic pill: the overuse of psychotropic medications in children with intellectual and developmental disabilities in the USA.

Children with intellectual and developmental disabilities (IDD) are likely to receive high-risk prescribing practices, such as polypharmacy, long-term use of psychotropic medications, and overuse of antipsychotics. Behavioural interventions, such as applied behavioural analysis, are evidence-based practices for children with IDD and should be the first-line treatment. Short-term use of psychotropic medications may be helpful in reducing the severity and frequency of challenging behaviours while evidence-based behavioural interventions are pursued. In this essay, we offer practical guidelines for better care.

Computer-assisted orthognathic surgery: evaluation of mandible registration accuracy and report of the first clinical cases of navigated sagittal split ramus osteotomy.

Intraoperative navigation is a helpful tool in complex anatomical regions or procedures. The mobility of the mandible in relation to the skull base limits the use of navigation tools on the lower jaw if the reference device is installed on the forehead. A new workflow that allows navigation-assisted sagittal split osteotomy in orthognathic surgery using a separate non-invasive mandibular registration technique has been developed. An evaluation of accuracy in different anatomical regions and with different registration techniques was performed on skull models and skulls with movable mandibles. The mean inaccuracy was 1.51mm, with no significant difference between anatomical sites. Using a splint-based reference device allows the movable mandible to be registered independently from the midface. Registration using metal points in the splint provides higher accuracy than using interdental anatomical landmarks. The workflow could be transferred successfully to patient treatment. Navigation-assisted osteotomy by Obwegeser-Dal Pont technique was performed without any complication in six patients. The mean deviation from the planned osteotomy line was 1.52mm. The navigated sagittal split ramus osteotomy seems to be a suitable technique to increase patient safety.

Similar patterns of frequency-dependent selection on animal personalities emerge in three species of social spiders.

Frequency-dependent selection is thought to be a major contributor to the maintenance of phenotypic variation. We tested for frequency-dependent selection on contrasting behavioural strategies, termed here 'personalities', in three species of social spiders, each thought to represent an independent evolutionary origin of sociality. The evolution of sociality in the spider genus Anelosimus is consistently met with the emergence of two temporally stable discrete personality types: an 'aggressive' or 'docile' form. We assessed how the foraging success of each phenotype changes as a function of its representation within a colony. We did this by creating experimental colonies of various compositions (six aggressives, three aggressives and three dociles, one aggressive and five dociles, six dociles), maintaining them in a common garden for 3 weeks, and tracking the mass gained by individuals of either phenotype. We found that both the docile and aggressive phenotypes experienced their greatest mass gain in mixed colonies of mostly docile individuals. However, the performance of both phenotypes decreased as the frequency of the aggressive phenotype increased. Nearly identical patterns of phenotype-specific frequency dependence were recovered in all three species. Naturally occurring colonies of these spiders exhibit mixtures dominated by the docile phenotype, suggesting that these spiders may have evolved mechanisms to maintain the compositions that maximize the success of the colony without compromising the expected reproductive output of either phenotype.

A case report of ascariasis of the common bile duct in a patient who had undergone cholecystectomy.

This is a case report of ascariasis of the common bile duct in a 65-year-old man from Colombia who had undergone prior cholecystectomy. The patient presented with postprandial epigastric pain and a 20-lb weight loss. The laboratory findings were remarkable for peripheral blood eosinophilia. The ultrasound finding was suggestive of periampullary or pancreatic neoplasm. He underwent endoscopic retrograde cholangiopancreatography with endoscopic extraction of a motile, live worm identified as Ascaris lumbricoides. Roundworm infestation should always be suspected in immigrants from endemic areas who present with hepatobiliary symptoms.

Factors affecting pension and health benefits availability in small and large business.

Factors affecting the provision of fringe benefits are receiving more attention as fringe benefits have become an increasingly important component of total compensation. Despite the importance of trends in fringe benefits to businesses and the economy, the effects of factors--including firm size--on the provision of fringe benefits have received only limited systematic attention. Studies have examined either worker characteristics or firm/establishment/ industry characteristics, but few have combined both types of characteristics to study a more comprehensive set of determinants. The author addresses this limitation using new data from a nationally representative sample of almost 600 firms. The focus of this study is on the two most important fringe benefits--pension plans and health insurance.

Diagnosis-related group refinement with diagnosis- and procedure-specific comorbidities and complications.

Diagnosis-related groups have been revised through more refined uses of secondary diagnoses. Under the refined diagnosis-related groups, patients are distinguished with respect to classes of secondary diagnoses that are disease- and procedure-specific. Each class represents a different level of utilization for a given principal diagnosis or surgical procedure. The refined system was evaluated with national data from the Medicare program. Estimates of hospital costs and utilization based on refined diagnosis-related groups were more precise than those based on unrefined diagnosis-related groups. This approach to diagnosis-related group refinement does not represent a radical departure from the current diagnosis-related group framework and does not require new data collection efforts. Moreover, a payment system based on the refined model is less affected by the ordering of the diagnoses than under the existing diagnosis-related group system. How the refined diagnosis-related group framework can accommodate future refinements at all levels of the classification scheme is also discussed.

Calcification and fibrosis in mesenteric carcinoid tumor: CT findings and pathologic correlation.

OBJECTIVE: The purposes of this study were to determine the frequency and characteristics of calcification and fibrosis in mesenteric carcinoid tumor as seen on CT scans and to evaluate their possible role in diagnosis. MATERIALS AND METHODS: The CT findings in 29 cases of proved mesenteric carcinoid tumor were analyzed retrospectively. Tumors were assessed for size, margin, density, radiating strands, calcification, and associated thickening of the small-bowel wall. Matching histologic sections were available for 21 of the cases. They were reviewed independently for histologic pattern, degree of fibrosis, degree of infiltration along neurovascular bundles, necrosis, lymph node architecture, and calcification or ossification within the mass. CT and pathologic findings were then assessed for possible relationships. RESULTS: Calcification was detected by CT in 70% (21 of 30) of mesenteric masses. Three patterns of calcification were noted: small, stippled calcification (n = 11); coarse, dense calcification (n = 7); and diffuse calcification (n = 3). All calcification was localized within areas of poorly cellular mature fibrous tissue. The degree of radiating strands detected by CT tended to increase with the degree of fibrosis seen histopathologically (p = .06). CONCLUSION: Calcification in mesenteric carcinoid tumors was observed by CT in most cases of this series. The triad of a calcified mesenteric mass, radiating strands, and adjacent bowel-wall thickening should be considered highly suggestive of carcinoid tumor.

Inflammatory conditions of the stomach and duodenum.

Upper gastrointestinal inflammatory processes are exceedingly common and have a wide spectrum of causes and manifestations. The broad category of acid-peptic disease incorporates the most common and important conditions. Concepts of pathophysiology of gastritis and duodenitis and their relationship to ulcers and neoplasm continue to evolve. The role of infection, especially H. pylori, remains under intense investigation. The spectrum of gastroduodenal inflammation in the immunocompromised host continues to expand and becomes increasingly important. A variety of granulomatous processes, both infectious and idiopathic, involve the upper gastrointestinal tract in overlapping patterns. Although investigation of ulcers and syphilis occupied the attention of the earliest gastrointestinal radiologists, related problems continue to challenge today's radiologic imagers, clinicians, and investigators.

Gastric syphilis: radiologic findings.

Syphilis, a venereal infection caused by the spirochetal bacterium Treponema pallidum, has long been considered a primary public health concern in the United States. With the onset of the antibiotic era, the prevalence of the disease dramatically plummeted, as did interest in its radiologic manifestations. Rolfs and Nakashima [1] have shown that the prevalence of primary and secondary syphilis increased 34% from 1981 to 1989, to its highest level since 1949. Given this dramatic increase, classic manifestations of syphilis may warrant renewed attention. In its secondary and tertiary stages, syphilis can cause a wide range of gastric lesions that can mimic many other entities, from gastritis or benign ulcer disease to gastric carcinoma. Indeed, the acute gastritis of early secondary syphilis produces the earliest radiologically detectable signs of the disease. Cases of gastric syphilis submitted to the Armed Forces Institute of Pathology and cases drawn from the University of Cincinnati teaching file are used to illustrate the varied findings in this disease.

Peutz-Jeghers syndrome.

The Peutz-Jeghers polyp is an unusual type of hamartomatous polyp; its characteristic feature is a smooth muscle core arising from the muscularis mucosae and extending into the polyp. Peutz-Jeghers polyps vary in size and shape; are found in the stomach, small bowel, and colon; and are usually multiple. Peutz-Jeghers syndrome is an inherited condition that often remains undiagnosed until after the polyps are identified, despite mucocutaneous pigmented lesions on the lips and mouth of children or young adults. In the past, standard therapy involved removal of the polyps that produced intussusception, but now endoscopic removal of all polyps is recommended. The polyps are not premalignant, but a definite association exists between Peutz-Jeghers syndrome and gastrointestinal carcinoma. Evidence shows that the syndrome is associated with an increased risk of extraintestinal malignancy, especially carcinomas of the pancreas, breast, and reproductive organs.

Esophageal inflammation and stricture: complication of chronic granulomatous disease of childhood.

Esophagitis in children with immunodeficiency is most commonly due to opportunistic infection. The authors describe three patients with chronic granulomatous disease (CGD) of childhood who developed esophageal strictures that were believed to be complications of the primary disease. At radiologic examination, all three patients initially had a focal narrowing of the upper thoracic esophagus. Endoscopy showed no signs of opportunistic infection or Barrett esophagus. Biopsy of the strictures in two patients revealed findings consistent with CGD. In two of the three patients, inflammation extended to involve the middle and distal esophagus. Long-term response to balloon dilation was poor in the first two patients. The third patient was lost to follow-up after a partial clinical and radiographic response to dilation.

Procedure codes: potential modifiers of diagnosis-related groups.

Proposals to make complexity-of-illness adjustments to the diagnosis-related group system have relied on secondary diagnosis codes and additional clinical information obtained from the hospital record. Another potential mechanism for modifying diagnosis-related groups involves the use of non-operating room procedure codes. The use of these codes has the advantage of reliably identifying costly subgroups of patients and thus the potential to provide for fairer compensation to hospitals caring for the sickest patients. There are a number of disadvantages, however, and therefore the criteria with which to evaluate procedures as potential modifiers are suggested.

Improving DRGs. Use of procedure codes for assisted respiration to adjust for complexity of illness.

Medicare's diagnosis related groups (DRGs) payment system has been criticized for not making adequate allowances for severity of illness differences within DRGs. The respiratory diseases major diagnostic category (MDC) has been a particular target; therefore, ability of several procedure codes that identify patients with assisted respiration (temporary tracheostomy, endotracheal intubation, and mechanical respiratory assistance) to identify high-cost patients in that MDC was examined. Total charges were used as the dependent variable in a 10% sample of Medicare hospital discharges from 1985. A consistent and strong association was found between the procedures and total charges for both Medicare "outliers" and "nonoutliers." Patients requiring either intubation or mechanical respiratory assistance had average charges two to three times higher, and patients with tracheostomy four to five times higher than charges for patients without assisted respiration. Patients with assisted respiration tended to resemble each other more than they resembled the other patients in their respective DRGs without assisted respiration. These findings provide the basis for recent revisions in Medicare's classification scheme for the respiratory diseases MDC.