A national profile of the use of intensive care by Medicare patients with cancer.

BACKGROUND: The broad picture of intensive care unit (ICU) outcomes and expenditures cannot be discerned from previous studies that were conducted at single hospitals and focused on narrow subsets of patients. METHODS: This study provides a comprehensive national profile of ICU used by Medicare patients with cancer. The data source was the Medicare Provider Analysis and Review file for fiscal year 1990, representing 100% of all hospital admissions that occurred within 723 ICD-9-CM codes and organized into 11 code groups. Using screening criteria, admissions were categorized as surgical (both major and minor procedures) or nonsurgical (no procedures) and with and without involvement of the ICU. The categories were compared using the following outcome variables: total hospital charges, ICU charges, ancillary charges, average length of stay, and in-hospital mortality. RESULTS: This study population accounted for nearly 800,000 admissions, of which 143,458 (18.1%) involved the use of the ICU. Actual ICU charges represented 4.9% of the $9.3 billion in total hospital charges. Intensive care unit use is associated positively with service intensity, and 73% of all the admissions involving the ICU were for major procedures. Only 2% involved no procedures. Admissions involving use of the ICU generate higher charges and longer lengths of stay than non-ICU admissions, although the differences decrease with declining treatment intensity and resource use. In-hospital mortality rates, for those cases that used the ICU, were 9.8% for major procedures, 21.2% for minor procedures, and 37.6% for cases involving no procedures. CONCLUSIONS: Contrary to the conclusions drawn from previous research, these findings suggest that patients who receive less intense service and use fewer hospital resources are more likely to die in the hospital than those who receive more care, with or without a stay in the ICU during the hospitalization. A global view of ICU use does not support the conclusion that a disproportionate share of special care resources is expended on futile care of the terminally ill or excessive monitoring of low risk patients, although these problems undoubtedly exist. Analysis of comprehensive national data regarding the use of intensive care provides a perspective that challenges some of the conclusions based on more limited studies that were conducted in single hospitals and focused on nonsurvivors or subsets of patients narrowly defined in other ways.

A feedback system for reducing excessive laboratory tests.

At the James A. Haley Veterans Hospital in Tampa, Fla, a program has been implemented to reduce the amount of potentially excessive laboratory testing. The major program components are a set of test frequency guidelines and a system of feedback to resident physicians that compares their test ordering patterns against the predetermined guidelines. The guidelines are analyte specific and differentiate between normal and abnormal test values reported during 1-day and 7-day time periods. The feedback process includes both systematic reporting of objective data and individual and group education and counseling sessions related to the appropriate use of laboratory tests. A reduction in the percentage of tests that fell outside the guidelines (outliers) was achieved following implementation of the program.

The weight of the infratentorial portion of the adult brain and analysis of the infratentorial/whole brain weight ratio.

A direct relationship exists between the weights of the infratentorial portion (ITP) of the brain and the whole brain. With aging, the weight of the ITP decreases, but the decrease begins later and is smaller than for the forebrain. With whole brain weights, there are significant differences in the weight of the ITP between sexes and between the races. The weight of the ITP increases slightly with increase in body weight. The infratentorial/whole brain ratio is stable during adult life and does not vary with body dimensions. The ratio increases after age 80 because of the accelerated loss of mass of the forebrain. The ratio is the same for both races, but it is significantly higher for the females than for the males. The difference is best accounted for by an arrest in the growth of the forebrain in the female during adolescence.

Analysis of brain weight. I. Adult brain weight in relation to sex, race, and age.

The weights of fresh brains obtained at consecutive autopsies over a period of five years were reviewed. Brains with lesions, such as large tumor, hemorrhage, infarct, or edema, were excluded. Analysis of the brain weight of 1,261 subjects, aged 25 to 80 years, show that the mean brain weight decreases in order from white men to black men to white women to black women. These differences are statistically significant and become apparent at age 6 years. The rate of decrease for the brain weight after age 25 years is highest for white men, followed by black women, white women, and black men, and, except that between white men and white women, the differences are statistically insignificant. Contrary to earlier reports, the mass decreases rapidly after age 80 years. In evaluating an individual brain weight, it is important to compare it with the norm for each subgroup of a given age.

Analysis of brain weight. II. Adult brain weight in relation to body height, weight, and surface area.

Analysis of 1,261 adult subjects, ages 25 to 80 years, showed that there is a positive relationship between the brain weight and the body dimensions. The brain weight, however, increases at a slower rate than the body dimensions. There is indication that only a small portion of the brain varies with variation in the body dimensions. Among parameters, the brain weight correlates best with the body surface area, followed by the body height and body weight. The brain weight is related to the body weight partly because it increases with increasing height. When adjusted to body dimensions, the brain weight is greater for white men than for black men and for white women than for black men. Our study also shows that the loss of brain mass proceeds at a slightly faster rate than loss of body mass.

How cost effective is videomicroscopy?

Insisting that videomicroscopy not be viewed as a luxury to be employed only in large educational institutions and only by audiographics departments, the author substantiates his point by documenting here what it cost to institute such a system in his own pathology department.

Relations between surface charge and in vitro lysis of red blood cells in paroxysmal nocturnal haemoglobinuria.

The effects of neuraminadase on the electrophoretic mobility and in vitro lysis of PNH, glutathione treated and normal erythrocytes was determined. Neuraminidase strongly affected the in vitro haemolysis of PNH and glutathione treated erythrocytes by substantially elevating the lysis in the Ham acid test while virtually eliminating lysis in the sucrose test. Findings suggest that membrane bound sialic acid or the level of cell surface charge may have a role in the susceptibility of PNH erythrocytes to complement mediated lysis.

Subacute myelo-optico-neuropathy (SMON) following pneumonitis. Serologic confirmation three and a half years after death.

A case of fulminant subacute myelooptico-neuropathy that occurred in a native American women following pneumonitis instead of the usual gastrointestinal dysfunction is reported. After the acute stage, which left the patient paraplegic and partially blind, she suffered an exacerbation which resulted in her death 11 months after the onset of illness. Autopsy disclosed symmetric optic and spinal demyelination. Neutralizing antibody titer against subacute, myelo-optico-neuropathy virus was determined on postmortem serum 3 1/2 years after death and found significantly elevated.

Surface charge of erythrocytes in paroxysmal nocturnal haemogloninuria.

The electrophoretic mobility of erythrocytes from 3 patients with PNH was measured by standard techniques. Erythrocyte mobility is a measure of the net negative surface charge of these cells. In each of the 3 patients studied in mobility was significantly increased over normal cells indicating that there is an increase in negative surface charge of PNH erythrocytes. Following the Ham's and sucrose lysis tests; surviving cells showed mean mobilities that were not statistically different from normal cells. This suggests that these cells with higher surface charge are vulnerable to complement lysis.

Determination of erythrocyte adenosine triphosphate by liquid chromatography.

A method for measuring erythrocyte adenosine triphosphate utilizing anion exchange high-pressure liquid chromatography is described. The method is not subject to interferences inherent in methods involving hexokinase or the firefly system. The method is highly sensitive, reproducible and rapid. Adenosine diphosphate and adenosine monophosphate can also be analyzed if desired.

Cytologic detection of early Paget's disease of breast with improved cellular collection method.

Improved cellular collection method and cytologic criteria for diagnosis of Paget's disease of the breast are presented. When indicated, the cytologic test is highly recommended for the early detection and pre-operative diagnosis of the minimal breast cancer10.

Significance of cytoplasmic microtubules in lupus nephritis.

Twenty-five renal and three skin biopsies from 14 cases of systemic lupus erythematosus with lupus nephritis were examined by electron microscope. Seventy-five renal biopsies from nonlupus cases consisting of 35 adults and 40 children were used for comparative study. Clusters of cytoplasmic microtubules, which have been referred to as virus-like particles, were observed in the endothelial cells of glomerular and peritubular capillaries in renal biopsies of all lupus cases. The clusters of microtubules were larger and more numerous in the initial biopsies with mild glomerular changes and in the second biopsies from two cases during a period of more severe relapse. Clusters of microtubules were fewer and smaller in renal biopsies with more advanced glomerular changes. Skin biopsies showed similar cytoplasmic inclusions in arterioles and capillaries. Cytoplasmic microtubules were also observed in 3 adults and 13 children of 75 patients who had no systemic lupus erythematosus. Although the formation of the cytoplasmic microtubules may be related to a virus infection, this suggestion cannot be confirmed from the morphologic findings of this study. Of additional interest is the evidence that these microtubules are not cytoplasmic changes secondary to corticosteroid therapy. It is concluded that the presence of many large clusters of cytoplasmic microtubules is specific for lupus nephritis, and it may be substantiated by similar findings in the skin.