Transit Use and Health Care Costs: A Cross-sectional Analysis.

INTRODUCTION: Greater transit use is associated with higher levels of physical activity, which is associated with lower health risks and better health outcomes. However, there is scant evidence about whether health care costs differ based on level of transit ridership. METHODS: A sample (n=947) of members of Kaiser Permanente in the Portland, Oregon area were surveyed in 2015 about their typical use of various modes of travel including transit. Electronic medical record-derived health care costs were obtained among these members for the prior three years. Analysis examined proportional costs between High transit users (3+ days/week), Low transit users (1-2 days/week), and Non-users adjusting for age and sex, and then individually (base models) and together for demographic and health status variables. RESULTS: In separate base models across individual covariates, High transit users had lower total health care costs (59-69% of Non-user's costs) and medication costs (31-37% of Non-users' costs) than Non-users. Low transit users also had lower total health care (69%-76% of Non-users' costs) and medication costs (43-57% transit of Non-user's costs) than Non-users. High transit users' outpatient costs were also lower (77-82% of Non-users). In fully-adjusted models, total health care and medication costs were lower among High transit users' (67% and 39%) and Low transit users' (75% and 48%) compared to Non-users, but outpatient costs did not differ by transit use. CONCLUSIONS: Findings have implications for the potential cost benefit of encouraging and supporting more transit use, although controlled longitudinal and experimental evidence is needed to confirm findings and understand mechanisms.

Patterns of medication use and imaging following initial diagnosis of sarcoidosis.

INTRODUCTION: Sarcoidosis is a rare inflammatory disease with unclear natural history. Using a large, retrospective, longitudinal, population-based cohort, we sought to define its natural history in order to guide future clinical studies. METHODS: We identified 722 newly diagnosed cases of sarcoidosis within Kaiser Permanente Northwest health care records between 1995 and 2015. We investigated immunosuppressive medication use in the two years following diagnosis, analyzed demographic and clinical characteristics, and quantified chest imaging and pulmonary function testing (PFTs) across the clinical course. RESULTS: Over two years of follow-up, 41% of patients were treated with prednisone. Of those, 75% tapered off their first course within 100 days, although half of those patients required recurrent therapy. Five percent of the entire cohort remained on prednisone for longer than one year, with an average daily dose of 10-20 mg. Chest imaging was associated with early prednisone use, and chest CT was associated with changes in prednisone dose. PFTs or demographics were not associated with prednisone use. Cumulative prednisone doses were significantly higher in African Americans (1,845 mg additional) and those who had a chest CT (2,015 mg additional). Overall, PFTs were less frequently obtained than chest imaging and had no significant change over disease course. DISCUSSION: The natural history of sarcoidosis varies greatly. For those requiring therapy, corticosteroid burden is high. Chest imaging drives medication dose changes as compared to PFTs, but neither outcome fully captures the entire history of disease. Prospective cohorts are needed with purposefully collected, repeated measures that include objective clinical assessments and symptoms.

Benefit of continuous positive airway pressure on work quality in patients with severe obstructive sleep apnea.

BACKGROUND: The objective of this prospective study was to assess the effect of CPAP therapy on job productivity and work quality for patients with severe obstructive sleep apnea (OSA). METHODS: A convenience sample of patients diagnosed with severe OSA using polysomnography or polygraphy and with a therapeutic indication for CPAP was enrolled in our study. Patients completed two self-administered questionnaires: the first before CPAP therapy and the second during the first 6 months after CPAP treatment. OSA symptoms were evaluated through self-administered questionnaires assessing potential effects on occupational activity: excessive daytime sleepiness was rated by the Epworth Sleepiness Scale (ESS), emotional status was rated by the Hospital Anxiety and Depression (HAD) scale, work quality was rated by the Work Role Functioning Questionnaire (WRFQ). RESULTS: Forty patients (30 men, mean age 47.3 ± 8.3, mean BMI 31.6 ± 7.4, mean apnea-hypopnea index 51.8 ± 16.3) showed a beneficial effect of CPAP therapy on ESS score (mean 11.6 to 8.2, p < 0.0001), the anxiety dimension (mean 57.5% to 20%, p = 0.0002), and the overall anxiety-depressive score (mean 50% to 22.5%, p = 0.0006). Mean WRFQ scores were significantly improved in the second questionnaire for the dimensions of timetable requirements (69.3% to 83.5%, p < 0.0001), productivity requirements (71.4% to 82.2%, p < 0.0001), mental requirements (72.0% to 84.3%, p < 0.0001), and social requirements (82.6% to 91.4%, p < 0.003). CONCLUSIONS: We observed that adherence to CPAP therapy for patients with severe OSA mitigates the impact of symptoms on work including excessive daytime sleepiness, impairment of work ability, and anxiety and depressive disorders.

Predicting the risk of Clostridium difficile infection following an outpatient visit: development and external validation of a pragmatic, prognostic risk score.

Increasing morbidity related to Clostridium difficile infection (CDI) has heightened interest in the identification of patients who would most benefit from recognition of risk and intervention. We sought to develop and validate a prognostic risk score to predict CDI risk for individual patients following an outpatient healthcare visit. We assembled a cohort of Kaiser Permanente Northwest (KPNW) patients with an index outpatient visit between 2005 and 2008, and identified CDI in the year following that visit. Applying Cox regression, we synthesized a priori predictors into a CDI risk score, which we validated among a Kaiser Permanente Colorado (KPCO) cohort. We calculated and plotted the observed 1-year CDI risk for each decile of predicted risk for both cohorts. Among 356 920 KPNW patients, 608 experienced CDI, giving a 1-year incidence of 2.2 CDIs per 1000 patients. The Cox model differentiated between patients who do and do not develop CDI: there was a C-statistic of 0.83 for KPNW. The simpler points-based risk score, derived from the Cox model, was validated successfully among 296 550 KPCO patients, with no decline in the area under the receiver operating characteristic curve: 0.785 (KPNW) vs. 0.790 (KPCO). The predicted risk for CDI agreed closely with the observed risk. Our CDI risk score utilized data collected during usual care to successfully identify patients who developed CDI, discriminating them from patients at the lowest risk for CDI. Our prognostic CDI risk score provides a decision-making tool for clinicians in the outpatient setting.

The retrobulbar sinus is superior to the lateral tail vein for the injection of contrast media in small animal cardiac imaging.

Cardiac perfusion studies using computed tomography are a common tool in clinical practice. Recent technical advances and the availability of dedicated small animal scanners allow the transfer of these techniques to the preclinical sector in general and to mouse models of cardiac diseases in particular. This necessitates new requirements for contrast injection techniques as a rapid transport of contrast media from the intravenous access to the animal heart. Clinical contrast agents containing high iodine concentrations are used within small animal studies although they exhibit a high viscosity which might limit their transport within the vasculature. The authors provide a comparison of the transport of contrast media following an injection into the lateral tail vein and an injection into the retrobulbar sinus and discuss the anatomy involved. The temporal evolution of a contrast bolus and its in vivo distribution is visualized. It is demonstrated that injecting contrast agents into the lateral tail vein of mice results in a retrograde blood flow to the liver veins and therefore does not deliver a detectable contrast bolus to the heart, and thus it cannot be used for cardiac perfusion studies. By contrast, boli injected into the retrobulbar sinus are rapidly transported to the heart and provide ventricular contrast enabling perfusion studies similar to those in human patients. The results demonstrate that an injection into the retrobulbar sinus is superior to an injection into the lateral tail vein for the delivery of contrast boli to the animal heart, while all drawbacks of an injection into the lateral tail vein are overcome.

Constrained reconstructions for 4D intervention guidance.

Image-guided interventions are an increasingly important part of clinical minimally invasive procedures. However, up to now they cannot be performed under 4D (3D + time) guidance due to the exceedingly high x-ray dose. In this work we investigate the applicability of compressed sensing reconstructions for highly undersampled CT datasets combined with the incorporation of prior images in order to yield low dose 4D intervention guidance. We present a new reconstruction scheme prior image dynamic interventional CT (PrIDICT) that accounts for specific image features in intervention guidance and compare it to PICCS and ASD-POCS. The optimal parameters for the dose per projection and the numbers of projections per reconstruction are determined in phantom simulations and measurements. In vivo experiments in six pigs are performed in a cone-beam CT; measured doses are compared to current gold-standard intervention guidance represented by a clinical fluoroscopy system. Phantom studies show maximum image quality for identical overall doses in the range of 14 to 21 projections per reconstruction. In vivo studies reveal that interventional materials can be followed in 4D visualization and that PrIDICT, compared to PICCS and ASD-POCS, shows superior reconstruction results and fewer artifacts in the periphery with dose in the order of biplane fluoroscopy. These results suggest that 4D intervention guidance can be realized with today's flat detector and gantry systems using the herein presented reconstruction scheme.

Electrophoretic deposition of thermites onto micro-engineered electrodes prepared by direct-ink writing.

This work combines electrophoretic deposition (EPD) with direct-ink writing (DIW) to prepare thin films of Al/CuO thermites onto patterned two- and three-dimensional silver electrodes. DIW was used to write the electrodes using a silver nanoparticle ink, and EPD was performed in a subsequent step to deposit the thermite onto the conductive electrodes. Unlike conventional lithographic techniques, DIW is a low-cost and versatile alternative to print fine-featured electrodes, and adds the benefit of printing self-supported three-dimensional structures. EPD provides a method for depositing the composite thermite only onto the conductive electrodes, and with controlled thicknesses, which provides fine spatial and mass control, respectively. EPD has previously been shown to produce well-mixed thermite composites which can pack to reasonably high densities without the need for any postprocessing. Homogeneous mixing is particularly important in reactive composities, where good mixing can enhance the reaction kinetics by decreasing the transport distance between the components. Several two- and three-dimensional designs were investigated to highlight the versatility of using DIW and EPD together. In addition to energetic applications, we anticipate that this combination of techniques will have a variety of other applications, which would benefit from the controlled placement of a thin film of one material onto a conductive architecture of a second material.

Fully automated intrinsic respiratory and cardiac gating for small animal CT.

A fully automated, intrinsic gating algorithm for small animal cone-beam CT is described and evaluated. A parameter representing the organ motion, derived from the raw projection images, is used for both cardiac and respiratory gating. The proposed algorithm makes it possible to reconstruct motion-corrected still images as well as to generate four-dimensional (4D) datasets representing the cardiac and pulmonary anatomy of free-breathing animals without the use of electrocardiogram (ECG) or respiratory sensors. Variation analysis of projections from several rotations is used to place a region of interest (ROI) on the diaphragm. The ROI is cranially extended to include the heart. The centre of mass (COM) variation within this ROI, the filtered frequency response and the local maxima are used to derive a binary motion-gating parameter for phase-sensitive gated reconstruction. This algorithm was implemented on a flat-panel-based cone-beam CT scanner and evaluated using a moving phantom and animal scans (seven rats and eight mice). Volumes were determined using a semiautomatic segmentation. In all cases robust gating signals could be obtained. The maximum volume error in phantom studies was less than 6%. By utilizing extrinsic gating via externally placed cardiac and respiratory sensors, the functional parameters (e.g. cardiac ejection fraction) and image quality were equivalent to this current gold standard. This algorithm obviates the necessity of both gating hardware and user interaction. The simplicity of the proposed algorithm enables adoption in a wide range of small animal cone-beam CT scanners.

[Arthritis revealing an osteoid osteoma in a patient with spondylarthropathy]. / Arthrite au cours d'une spondylarthropathie révélatrice d'un ostéome ostéoïde.

Intra-articular osteoid osteoma is rare and difficult to diagnose. We report a 38-year-old woman who presented with an inflammatory monoarticular arthritis in the right ankle in the context of a spondylarthropathy, otherwise well-controlled by leflunomide. This monoarthritis was resistant to all types of treatment. Investigations led to the diagnosis of an intra-articular osteoid osteoma. This original observation is the first description of an osteoid osteoma developing in a patient already known to have inflammatory rheumatism. All previous reported cases were monoarthritis consecutive to the osteoid osteoma itself and interpreted as incipient inflammatory rheumatism.

A litmus test for exploitation: James Stacey Taylor's stakes and kidneys.

James Stacy Taylor advances a thorough argument for the legalization of markets in current (live) human kidneys. The market is seemly the most abhorrent type of market, a market where the least well-off sell part of their body to the most well off. Though rigorously defended overall, his arguments concerning exploitation are thin. I examine a number of prominent bioethicists' account of exploitation: most importantly, Ruth Sample's exploitation as degradation. I do so in the context of Taylor's argument, with the aim of buttressing Taylor's position that a regulated kidney market is morally allowable. I argue that Sample fails to provide normative grounds consistent with her claim that exploitation is wrong. I then reformulate her account for consistency and plausibility. Still, this seemingly more plausible view does not show that Taylor's regulated kidney market is prohibitively exploitative of impoverished persons. I tack into place one more piece of support for Taylor's conclusion. (wc. 148).

Attitudes towards dog ownership on St. Kitts, West Indies.

A structured face-to- face interview was held with 64 arbitrarily selected local people attending a vegetable market in the capital of St. Kitts on a Saturday morning. Most (67%) respondents liked dogs and many (57%) owned one (41%) or two (29%) for protection (67%) and as a pet (65%). The main reason people disliked dogs were because they feared them (56%) and because they created a mess (50%). Generally people had purebred (40%) male (56%) dogs which were always outside (50%), in fenced yards (43%), on chains (34%) or running free (22%). All owners fed their dogs, mainly on table scraps (44%) or commercial dog food (39%). Only 16% of animals were neutered and many had puppies (range 3-11) and there was a high mortality rate (>2 puppies in 73% of litters). Only 24% of the dogs were over 4 years. Relatively few owners (55%) took their dogs to the veterinarian, principally for vaccination and checkups (85%) but when their animal was ill (24%). Most people (54%) used insecticides for external parasites on their dogs and some (44%) dewormed their animals. Many people (24%) had been bitten by a dog but 64% did not believe people could acquire diseases from dogs. Only 6% of respondents thought there were too many dogs on the island.

Attitudes towards dog ownership on St. Kitts, West Indies.

A structured face-to- face interview was held with 64 arbitrarily selected local people attending a vegetable market in the capital of St. Kitts on a Saturday morning. Most (67%) respondents liked dogs and many (57%) owned one (41%) or two (29%) for protection (67%) and as a pet (65%). The main reason people disliked dogs were because they feared them (56%) and because they created a mess (50%). Generally people had purebred (40%) male (56%) dogs which were always outside (50%), in fenced yards (43%), on chains (34%) or running free (22%). All owners fed their dogs, mainly on table scraps (44%) or commercial dog food (39%). Only 16% of animals were neutered and many had puppies (range 3-11) and there was a high mortality rate (>2 puppies in 73% of litters). Only 24% of the dogs were over 4 years. Relatively few owners (55%) took their dogs to the veterinarian, principally for vaccination and checkups (85%) but when their animal was ill (24%). Most people (54%) used insecticides for external parasites on their dogs and some (44%) dewormed their animals. Many people (24%) had been bitten by a dog but 64% did not believe people could acquire diseases from dogs. Only 6% of respondents thought there were too many dogs on the island.

Diffusive diffraction phenomenon in a porous polymer material observed by NMR using radio-frequency field gradients.

Pulsed field gradient NMR diffusion experiments can, in principle, lead to the "diffusive diffraction" phenomenon. In practice, its observation by gradients of the static magnetic field is difficult in real systems because they involve internal gradients due to the static magnetic field (necessary for polarizing nuclear spins). This latter drawback can be circumvented by using gradients of the radio-frequency (rf) field (the other magnetic field used in any NMR experiment). For the first time, by means of rf gradients, a so-called diffusive diffraction peak has been observed in a real porous system and its position provides a value of the mean distance between pores; this can be further complemented by the mean pore size determined from the dependence of the apparent diffusion coefficient with respect to the diffusion interval.

[Ankylosing spondylitis and osteoporosis]. / Spondylarthrite ankylosante et ostéoporose.

PURPOSE: Ankylosing Spondylitis (AS) is an inflammatory rheumatism characterized by its disease course with flares leading to progressive ankylosis of the spine related to paravertebral ligamentous and discal structures ossification. AS patients suffer significantly more vertebral fractures than control groups. These fractures could affect cervical spine. They are due to either ankylosis-related flawed spine compliance or AS-induced osteoporosis. CURRENT KNOWLEDGE AND KEY POINTS: The physiopathology of this osteoporosis is multi-factorial, but essentially linked to AS-related inflammatory phenomenons. It is marked by reduced bone density (at lumbar spine and femoral neck), increased bone turnover (with increased urinary C-telopeptide cross-linked collagen type 1), but without any significant change in phosphocalcic blood parameters. Histological features are depressed bone formation, with either maintained or increased resorption. FUTURE PROSPECTS: The screening of this osteoporosis is based upon investigating people at risk (progressive inflammatory AS) using dual-energy x-ray absorptiometry and biochemical markers of bone turnover. Treatment is based upon a modulation of both inflammatory phenomenons and bone remodelling using bisphosphonates and anti-TNF alpha.

[Radicular syndrome and synovial cyst of the zygapophyseal joints: two case-reports]. / Kyste synovial articulaire postérieur lombaire révélé par un syndrome pluriradiculaire: à propos de deux cas.

INTRODUCTION: Multiradicular nerve root compression, and long lasting radicular syndrome occur very often. They happen particularly on degenerative spine. Huge synovial cyst of the zygapophyseal joints may account for it, expand in the epidural area and cause radicular syndrome. EXEGESIS: Two cases of huge synovial cysts spreading into the spinal channel are reported here. Diagnostic and therapeutic modalities are discussed. On degenerative spine, facet joints osteoarthritis may result in synovial cysts. Physical examination findings are radicular syndrome. CONCLUSION: Huge synovial cysts may result in multiple nerve root compression syndrome, as reported in our two cases. Typically, there's no history of preceding trauma and symptoms appear progressively. Magnetic resonance imaging of the spine shows an intra-spinal round mass with typical signal intensity and capsular formation. Treatment consists either in facet joint steroid injection performed with radiologic guidance or in surgical excision.

Forceful sacrococcygeal injections in the treatment of postdiscectomy sciatica. A controlled study versus glucocorticoid injections.

UNLABELLED: The role of epidural fibrosis in postoperative sciatica is unclear. Few therapeutic trials have been published. We evaluated the mechanical effects of forceful saline injections through the sacrococcygeal hiatus comparatively with glucocorticoid injections. PATIENTS AND METHODS: Forty-seven patients with postdiscectomy sciatica but no evidence of compression by computed tomography or magnetic resonance imaging were included in a multicenter, randomized, controlled, parallel-group study comparing forceful injections of saline (20 ml) with or without prednisolone acetate (125 mg) to epidural prednisolone acetate (125 mg) alone. Each of the three treatments was given once a month for three consecutive months. Outcome measures were pain severity on a visual analog scale (VAS) and the scores on the Dallas algofunctional self-questionnaire on day 0, day 60, and day 120. Analysis of variance for repeated measures and Student's t test for paired series were used to evaluate the data. RESULTS: Forty-seven patients were evaluated. The VAS score improved significantly between day 0 and day 30 in the glucocorticoid group as compared to the forceful injection group (P = 0.01). No other significant differences were found across the groups. The VAS score improved steadily in the forceful injection group, producing a nearly significant difference on day 120 as compared to baseline (P = 0.08). CONCLUSION: Forceful epidural injections produced a non-significant improvement in postdiscectomy sciatica four months after surgery. Epidural glucocorticoids used alone induced short-lived pain relief.

Treatment resistant Lyme arthritis caused by Borrelia garinii.

Lyme arthritis is caused in Europe by three main pathogenic species of Borrelia burgdorferi sensu lato: Borrelia burgdorferi sensu stricto, Borrelia garinii, and Borrelia afzelii. Because few synovial samples have yet been analysed by species-specific DNA amplification methods, further studies are needed to define the spectra of clinical manifestations associated with these different species. Two cases of treatment resistant Lyme arthritis are reported here, in which DNA amplification of the flagellin gene followed by dot-blot hybridisation in the synovial fluid identified B garinii as the causative agent. Clinical and biological data did not differ from the usual descriptions of Lyme arthritis, but as the recently reported molecular mimicry between OspA and hLFA1 is not applicable to B garinii, the pathogenesis of the present cases remains unclear. Future studies should aim at assessing the role of B garinii in European Lyme arthritis and its possible pathogenic and therapeutic consequences.

Fatal Aspergillus fumigatus Myositis in an immunocompetent patient.

A 69-year old farmer developed Aspergillus myositis in the right psoas and paravertebral muscles extending to the retroperitoneum and the fifth lumbar vertebra. The infection appeared after two local instillations of steroid for back pain. Although the patient was not immunocompromised, surgical drainage and antifungal therapy failed to cure him; he died of a bacterial pulmonary superinfection while cultures of the abscess drainage fluid grew Aspergillus. The likely portal of entry in this patient was direct inoculation during infiltration of the steroid; the steroid probably caused a local impairment in host defenses. Only six cases of Aspergillus myositis have been reported previously. All of them occurred in severely immunosuppressed patients and the outcome was fatal in all cases.