Bacterial immune evasion via an IL-10 mediated host response, a novel pathophysiologic mechanism for chronic rhinosinusitis.

BACKGROUND: Staphylococcus aureus is a frequently implicated pathogen in chronic rhinosinusitis (CRS). S. aureus may promote commensalism by downregulating pro-inflammatory T cell host responses via an IL-10 mediated pathway. This finding, coupled with the observation that S. aureus and CD8+ T cell numbers are inversely correlated in CRS mucosa, suggests that S. aureus may evade immune destruction via IL-10 induction. To support this hypothesis, we evaluated i) whether IL-10 levels differ in CRS compared to controls (CTL) using microarray and immunohistochemistry and ii) whether IL-10 levels correlate with S. aureus and CD8+ T cell levels. METHODOLOGY: Sinus epithelial brush samples from 12 patients undergoing ESS for CRS and 10 CTLs underwent microarray analysis of IL-10 gene expression. Microarray results were verified on simultaneously obtained surgical biopsy samples by immunohistochemistry staining for IL-10. Potential mechanisms were assessed by immunohistochemistry for CD8+ T cells and S. aureus. RESULTS: IL-10 gene expression was significantly higher in CRS vs CTL subjects at the time of surgery. Immunohistochemistry confirmed increased levels of intraepithelial IL-10. A strong inverse correlation was observed between intraepithelial IL-10 and CD8+ T cell levels as was intraepithelial IL-10 and S. aureus. CONCLUSION: Elevated IL-10 levels in sinus mucosa may be a potential pathophysiologic feature of CRS in association with a significant downregulation of host CD8+ T cell levels. While S. aureus is believed to play a role in IL-10 induction, a comparatively weaker relationship between S. aureus and IL-10 levels suggests other bacterial species may also induce IL-10 production as a common survival strategy in CRS.

The impact of risk information exposure on women's beliefs about direct-to-consumer genetic testing for BRCA mutations.

Despite an increase in direct-to-consumer (DTC) genetic testing, little is known about how variations in website content might alter consumer behavior. We evaluated the impact of risk information provision on women's attitudes about DTC BRCA testing. We conducted a randomized experiment; women viewed a 'mock' BRCA testing website without [control group (CG)] or with information on the potential risks of DTC testing [RG; framed two ways: unattributed risk (UR) information and risk information presented by experts (ER)]. Seven hundred and sixty-seven women participated; mean age was 37 years, mean education was 15 years, and 79% of subjects were white. Women in the RG had less positive beliefs about DTC testing (mean RG = 23.8, CG = 25.2; p = 0.001), lower intentions to get tested (RG = 2.8, CG = 3.1; p = 0.03), were more likely to prefer clinic-based testing (RG = 5.1, CG = 4.8; p = 0.03) and to report that they had seen enough risk information (RG = 5.3, CG = 4.7; p < 0.001). UR and ER exposure produced similar effects. Effects did not differ for women with or without a personal/family history of breast/ovarian cancer. Exposing women to the potential risks of DTC BRCA testing altered their beliefs, preferences, and intentions. Risk messages appear to be salient to women irrespective of their chance of having a BRCA mutation.

A direct comparison of robotic and laparoscopic hernia repair: patient-reported outcomes and cost analysis.

PURPOSE: Hernia repair is one of the most commonly performed surgeries in the United States. Since the introduction of the Da Vinci robot, robot-assisted hernia repairs have become more common. In this study we aim to directly compare robotic and laparoscopic hernia repairs as well as explore potential cost differences. We hypothesize that robot-assisted hernia repairs are associated with better patient-reported outcomes. METHODS: We conducted retrospective review to create a cohort study of 53 robotic (37 inguinal and 16 ventral) and 101 laparoscopic (68 inguinal and 33 ventral) hernia repairs. Patient-reported outcomes were measured using the Carolinas Comfort Scale (CCS). Operative details were examined, and a cost analysis was performed. RESULTS: Combining both hernia types together as well as looking at inguinal and ventral repairs separately, we found that there was no difference in hernia recurrence or 1-year CCS between robotic and laparoscopic hernia repair. For ventral hernia repairs alone, robotic procedure was associated with a decreased length of stay. We found that our robotic cases did have longer operative times and higher costs. The operative times did decrease to a length comparable to that of the laparoscopic cases as experience operating with the robot increased. CONCLUSION: In comparison to laparoscopic hernia repair, robotic hernia repair does not improve long-term patient-reported surgical outcomes. However, it does increase the cost of the operation and, in general, result in longer operative times.

Are women benefiting from the Affordable Care Act? A real-world evaluation of the impact of the Affordable Care Act on out-of-pocket costs for contraceptives.

OBJECTIVES: The Affordable Care Act (ACA) mandated that, starting between August 1, 2012 and July 31, 2013, health plans cover most Food and Drug Administration (FDA)-approved contraceptive methods for women without cost sharing. This study examined the impact of the ACA on out-of-pocket expenses for contraceptives. STUDY DESIGN: Women (ages 15-44years) with claims for any contraceptives in years 2011, 2012 and 2013 were identified from the MarketScan Commercial database. The proportions of women using contraceptives [including permanent contraceptives (PCs) and non-PCs: oral contraceptives (OCs), injectables, patches, rings, implants and intrauterine devices (IUDs)] in study years were determined, as well as changes in out-of-pocket expenses for contraceptives during 2011-2013. Demographics, including age, U.S. geographic region of residence and health plan type, were also evaluated. RESULTS: The number of women identified with any contraceptive usage in 2011 was 2,447,316 (mean age: 27.6years), in 2012 was 2,515,296 (mean age: 27.4years) and in 2013 was 2,243,253 (mean age: 27.4years). In 2011, 2012 and 2013, the proportions of women with any contraceptive usage were 26.3%, 26.2% and 26.9%, respectively. Over the three study years, mean total out-of-pocket expenses for PCs and non-PCs decreased from $298 to $82 and from $94 to $30, respectively. For non-PCs, mean total out-of-pocket expenses for OCs and IUDs decreased from $86 to $26 and from $83 to $20. CONCLUSIONS: Implementation of the ACA has saved women a substantial amount in out-of-pocket expenses for contraceptives. IMPLICATIONS: Mean total out-of-pocket expenses for FDA-approved contraceptives decreased approximately 70% from 2011 to 2013. Implementation of the ACA has saved women a substantial amount in out-of-pocket expenses for contraceptives. Longer-term studies, including clinical outcomes, are warranted.

Effects of atrial natriuretic peptide on coronary vascular resistance in the intact awake dog.

Atrial natriuretic peptide has been reported to cause vasoconstriction, vasodilation or no change of coronary vascular resistance in isolated perfused hearts or in open chest animal models. Because general anesthesia and acute surgical trauma may perturb baseline coronary hemodynamics and alter responses to experimental interventions, this study examined the effects of human atrial natriuretic peptide (arginine-102-tyrosine-126) and rat atriopeptin II (serine-103-arginine-125) on the coronary circulation of unsedated, awake dogs. Studies were performed in 12 chronically instrumented animals in which a surgically implanted electromagnetic flow probe and intracoronary catheter allowed measurement of left circumflex coronary blood flow during intraarterial administration of the atrial natriuretic peptides. Bolus doses of both human atrial natriuretic peptide and rat atriopeptin II produced dose-dependent coronary vasodilation; the threshold for coronary vasodilation was 0.2 micrograms/kg body weight for both agents. Coronary vasodilation produced by human atrial natriuretic peptide was not antagonized by adenosine receptor blockade or by cyclooxygenase inhibition with indomethacin. Thus, atrial natriuretic peptides produced dose-dependent coronary vasodilation in intact awake dogs that was not dependent on adenosine-mediated or prostaglandin-mediated mechanisms.

Effect of nifedipine on myocardial blood flow during exercise in dogs with chronic coronary artery occlusion.

The effect of nifedipine, 0.010 mg/kg intravenously, on myocardial blood flow was studied in 15 dogs 4 weeks after placement of an Ameroid constrictor on either the left circumflex or left anterior descending coronary artery to produce total coronary occlusion. Myocardial blood flow was measured with radionuclide-labeled microspheres at rest and during two levels of treadmill exercise to achieve a heart rate of 190 (light exercise) and 230 (heavy exercise) beats/min. During control conditions, increasing exercise resulted in a progressive increase in myocardial blood flow in normally perfused areas, but was associated with worsening subendocardial hypoperfusion in collateral-dependent areas. Nifedipine administration resulted in a transient reduction of arterial pressure and an increase in heart rate. To determine whether nifedipine exerted significant persistent effects on the coronary collateral circulation, measurements of myocardial blood flow were repeated beginning 30 minutes after nifedipine administration, at a time when heart rate and arterial pressure had returned to control levels. In normally perfused areas, nifedipine did not significantly alter myocardial blood flow at rest, but increased mean myocardial blood flow from 2.06 +/- 0.15 to 2.40 +/- 0.20 ml/min per g during light exercise (p less than 0.01), while blood flow during heavy exercise was not significantly altered. In collateral-dependent myocardial areas, the volume and transmural distribution of myocardial blood flow were not significantly altered after nifedipine administration either at rest or during exercise. These results fail to demonstrate persistent vasodilation of the coronary collateral vessels after the systemic hemodynamic effects of nifedipine have subsided.

Restenosis after coronary angioplasty: a multivariate statistical model to relate lesion and procedure variables to restenosis. The M-HEART Investigators.

The Multi-Hospital Eastern Atlantic Restenosis Trial group obtained follow-up angiography in 510 patients with 598 successfully dilated coronary lesions who were enrolled in a controlled trial of the effects of a single dose of 1 g of methylprednisolone on restenosis after coronary angioplasty. The overall restenosis rate was 39.6%. The strongest univariate relations to the restenosis rate were found for lesion location (saphenous vein graft, 68%; left anterior descending artery, 45%; left circumflex artery and right coronary artery, 32%; p = 0.002); lesion length (less than or equal to 4.6 mm, 33%; greater than 4.6 mm, 45%; p = 0.001); percent stenosis before angioplasty (less than or equal to 73%, 25%; greater than 73%, 43%; p = 0.005), percent stenosis after angioplasty (less than or equal to 21%, 33%; greater than 21%, 46%; p = 0.017) and arterial diameter (less than 2.9 mm, 44%; greater than or equal to 2.9 mm, 34%; p = 0.036). Two multivariate models to predict restenosis probability were developed with use of stepwise logistic regression. The preprocedural model, which included only variables whose values were known before angioplasty, entered lesion length, vein graft location, left anterior descending artery location, percent stenosis before angioplasty, eccentric lesion and arterial diameter. The postprocedural model, which also included variables whose values were known after angioplasty was performed, was similar to the preangioplasty model except that it also entered postangioplasty percent stenosis and "optimal" balloon sizing but did not enter eccentric lesion. These data indicate that the probability of restenosis after angioplasty is determined predominantly by the characteristics of the lesion being dilated. They are consistent with the known intimal proliferative mechanism of restenosis, offer a means of identifying lesions at unusually high or low risk of restenosis, and of predicting the likelihood that a particular lesion will restenose after angioplasty and provide a rationale for stratification by restenosis probability in the design of future studies of restenosis.

Predictors of the success or failure of medical therapy in patients with chronic recurrent sustained ventricular tachycardia: a discriminant analysis.

To identify predictors of the success or failure of medical therapy in chronic recurrent sustained ventricular tachycardia, univariate and multivariate statistical techniques were used to retrospectively analyze data in 84 patients with this arrhythmia. By univariate analysis, four factors were associated with successful medical treatment: age less than 45 years, ejection fraction greater than 50%, hypokinesia as the only contraction abnormality and the absence of organic heart disease. Four other findings, the induction of ventricular tachycardia with a single ventricular extrastimulus, an HV interval greater than 60 ms, the presence of a left ventricular aneurysm and Q waves on a baseline electrocardiogram, correlated with medical failure. However, none of these variables alone accurately predicted treatment results in more than 75% of cases. By discriminant analysis, a function incorporating eight variables was constructed which correctly classified 81% of patients. Moreover, three-quarters of the patients could be classified into groups with a high or low probability of success where accuracy increased to 90%. When the discriminant function was tested prospectively in 31 similar patients, 25 (81%) fell into the groups with a high or low probability of success. In the latter group, of 20 patients predicted to fail medical therapy, 19 (95%) did fail a complete trial of medical therapy. The overall accuracy remained a high 92%. In clinical application this function would allow patients with a high probability of responding to medical therapy to be selected for serial electrophysiologic drug testing. In patients with a low probability of responding to medical therapy, serial studies could be avoided and alternate forms of therapy explored.

Stroke complicating acute myocardial infarction. A meta-analysis of risk modification by anticoagulation and thrombolytic therapy.

BACKGROUND: The objective of this meta-analysis was to examine the impact of systemic anticoagulation and thrombolysis on the total incidence of stroke following myocardial infarction. Additionally, we sought to compare the relative risk of stroke with different thrombolytic agents. METHODS: A computerized and manual literature search for controlled clinical trials of anticoagulants and thrombolytic agents in myocardial infarction reporting on total strokes in treated and control patients was used. Pooling was performed by calculating the Mantel-Haenszel odds ratio and 95% confidence interval (CI). RESULTS: The Mantel-Haenszel pooled odds ratio for anticoagulation trials was 0.46 (95% CI, 0.30 to 0.64), suggesting a benefit of anticoagulant therapy. However, a statistically significant degree of variability (heterogeneity) was present among study results. The odds ratios for all thrombolytic trials, tissue plasminogen activator, and streptokinase trials, respectively, were 1.08 (95% CI, 0.87 to 1.35), 1.28 (95% CI, 0.76 to 2.17), and 1.02 (95% CI, 0.80 to 1.30), suggesting no overall excess of stroke with thrombolysis. The pooled odds ratio for three studies directly comparing streptokinase and tissue plasminogen activator was 0.73 (95% CI, 0.61 to 0.86), suggesting an excess of stroke for patients treated with tissue plasminogen activator in comparison with streptokinase-treated patients. CONCLUSIONS: The available data may support a role for anticoagulants in reducing the incidence of stroke after myocardial infarction, but the heterogeneity among the trials makes interpretation of this effect difficult. Although the available data do not indicate an increase in stroke with thrombolysis, a direct comparison of tissue plasminogen activator and streptokinase reveals an excess of strokes with tissue plasminogen activator.

Cost and quality effects of alternative treatments for persistent gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease is commonly encountered by general internists and gastroenterologists. METHODS: We used decision analysis to assess the clinical and economic effects of three treatments--phase 1 therapy alone or combined with omeprazole or ranitidine hydrochloride therapy--for patients with persistent, symptomatic grade 2 or higher gastroesophageal reflux disease. To the maximum extent possible, data were obtained from the published literature. We convened an expert consensus panel to estimate specific data points when they were unavailable or contradictory in the literature, including estimates of optimal and actual clinical practice patterns. A 7-month model was used to correspond to the time frame of available clinical trial data. The perspective of the analysis was that of the payer. The costs of medical care for various clinical outcomes were based on actual mean payments made by Independence Blue Cross of Philadelphia and Pennsylvania Blue Shield. RESULTS: Although the retail payments for daily omeprazole therapy are the highest among the three interventions tested, it produced both the lowest expected overall payments for medical care and the most effective strategy for treating symptoms during the 7-month model. Omeprazole therapy was consistently approximately $1800 less costly than ranitidine therapy and $2700 less costly than phase 1 therapy alone during the period examined, regardless of whether empiric or nonempiric treatment strategies were used. Even when payments for major complications (the most important cost variable) were reduced by 80%, omeprazole therapy resulted in payments 17% and 22% lower than those associated with ranitidine therapy and phase 1 therapy alone, respectively. Omeprazole also produced the most symptom-free months during the 7-month follow-up period. The clinical and economic outcomes of performing an initial diagnostic workup, compared with treating patients empirically, were equal. CONCLUSIONS: We conclude that omeprazole therapy is the preferred initial therapeutic approach for patients with persistent, symptomatic gastroesophageal reflux disease in whom phase 1 therapy fails. Assessment of long-term approaches must await the results of extended clinical studies.

Cost savings in duodenal ulcer therapy through Helicobacter pylori eradication compared with conventional therapies: results of a randomized, double-blind, multicenter trial. Gastrointestinal Utilization Trial Study Group.

BACKGROUND: We hypothesized that treatment of duodenal ulcer disease with antibiotic therapy directed toward Helicobacter pylori infection is more cost-effective than therapy with antisecretory agents. METHODS: A randomized, double-blind, multicenter clinical trial of adult patients with active duodenal ulcer and H. pylori infection was conducted. Patients were randomized to receive 500 mg of clarithromycin 3 times a day plus 40 mg of omeprazole daily for 14 days followed by 20 mg of omeprazole daily for an additional 14 days (group 1), 20 mg of omeprazole daily for 28 days (group 2), or 150 mg of ranitidine hydrochloride twice a day for 28 days (group 3). The use of ulcer-related health care resources was documented during monthly interviews for 1 year after the initial therapy. Clinical success was evaluated 4 to 6 weeks and 1 year after the end of therapy. RESULTS: Of the 819 patients enrolled, 727 completed the study. Group 1 included 243 patients; group 2, 248 patients; and group 3, 236 patients. Patients in group 1 used fewer ulcer-related health care resources during the 1 year after therapy compared with groups 2 and 3 (comparisons are given as group 1 vs group 2 and group 1 vs group 3, respectively): the number of endoscopies performed, 28 vs 76 (P<.001) and vs 71 (P<.001); patients receiving drugs to treat an ulcer, 118 vs 180 (P<.001) and vs 168 (P<.001); clinic visits, 83 vs 135 (P=.05) and vs 161 (P<.001); hospitalizations, 0 vs 5 (P=.045) and vs 6 (P=.02); and length of hospital stay, 0 vs 24 days (P=.04) and vs 37 (P=.04). When ulcer-related costs were defined as the outcome variable in a multivariate linear regression analysis, therapy was determined to have a significant influence on costs (group 1 vs group 2, P<.001; group 1 vs group 3, P=.008). Clinical success rates at the end of the study and cure of H. pylori infection were significantly greater in group 1 compared with groups 2 and 3 (P<.001). Therapy with clarithromycin plus omeprazole provided savings of $1.94 and $2.96 (compared with therapy with omeprazole and with ranitidine hydrochloride, respectively) per dollar spent within the first year after therapy. This incremental cost-benefit translates to savings of $547 or $835 per patient in group 1 (compared with patients in group 2 or group 3, respectively) during the first year after therapy. CONCLUSIONS: Combination therapy with clarithromycin and omeprazole resulted in significantly fewer uses of ulcer-related health care resources than conventional antisecretory therapy during a 1-year follow-up and significant savings in associated costs during the same period. Patients who received clarithromycin plus omeprazole also showed a significantly improved clinical outcome compared with patients who received only omeprazole or ranitidine.

The utility of preoperative electrocardiograms in the ambulatory surgical patient.

To determine the utility of preoperative screening electrocardiograms (ECGs) among ambulatory surgery patients, we reviewed the charts of 751 consecutive adult patients who underwent ambulatory surgery. Data were collected on demographic characteristics, coexisting medical problems, American Society of Anesthesiologists physical status score, preoperative ECG results, adverse intraoperative cardiovascular events, and postoperative cardiovascular complications. In our study population of relatively healthy outpatients, preoperative ECGs were abnormal in 42.7% of patients. Age, increased physical status score, and male gender were associated with a greater incidence of abnormal preoperative ECGs. There were 12 adverse cardiovascular perioperative events among the 751 patients (1.6%), and the preoperative ECG may have been clinically useful in six of these 12 patients. Neither preoperative ECGs nor results of preoperative screening questionnaires were predictive of adverse cardiovascular perioperative events. These findings question the utility of preoperative ECGs in the ambulatory surgery setting, especially among younger, relatively healthy patients.

Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease.

BACKGROUND: The purpose of this study was to estimate the sensitivity and specificity of diagnostic tests for gallstones and acute cholecystitis. METHODS: All English-language articles published from 1966 through 1992 about tests used in the diagnosis of biliary tract disease were identified through MEDLINE. From 1614 titles, 666 abstracts were examined and 322 articles were read to identify 61 articles with information about sensitivity and specificity. Application of exclusion criteria based on clinical and methodologic criteria left 30 articles for analysis. Cluster-sampling methods were adapted to obtain combined estimates of sensitivities and specificities. Adjustments were made to estimates that were biased because the gold standard was applied preferentially to patients with positive test results. RESULTS: Ultrasound has the best unadjusted sensitivity (0.97; 95% confidence interval, 0.95 to 0.99) and specificity (0.95; 95% confidence interval, 0.88 to 1.00) for evaluating patients with suspected gallstones. Adjusted values are 0.84 (0.76 to 0.92) and 0.99 (0.97 to 1.00), respectively. Adjusted and unadjusted results for oral cholecystogram were lower. Radionuclide scanning has the best sensitivity (0.97; 95% confidence interval, 0.96 to 0.98) and specificity (0.90; 95% confidence interval, 0.86 to 0.95) for evaluating patients with suspected acute cholecystitis; test performance is unaffected by delayed imaging. Unadjusted sensitivity and specificity of ultrasound in evaluating patients with suspected acute cholecystitis are 0.94 (0.92 to 0.96) and 0.78 (0.61 to 0.96); adjusted values are 0.88 (0.74 to 1.00) and 0.80 (0.62 to 0.98). CONCLUSIONS: Ultrasound is superior to oral cholecystogram for diagnosing cholelithiasis, and radionuclide scanning is the test of choice for acute cholecystitis. However, sensitivities and specificities are somewhat lower than commonly reported. We recommend estimates that are midway between the adjusted and unadjusted values.

Patient use and assessment of conventional and alternative therapies for HIV infection and AIDS.

OBJECTIVE: To investigate the extent of recourse to alternative therapies among 184 HIV-positive patients who continued to attend conventional medical clinics. The study describes the specific alternative therapeutic modalities that were more commonly sought by our respondents, and provides data on the subjective assessment of the efficacy of both conventional and alternative therapies. METHODS: Demographic and behavioral information were obtained from standard, self-administered, anonymous questionnaires distributed at three HIV clinics in the Philadelphia area. RESULTS: Forty per cent of patients reported having used alternative or complementary therapies. Forty-two per cent of respondents who had been enrolled in clinical trials had used alternative therapies at some stage. Recourse to such therapies was significantly associated with risk-group affiliation, duration of seropositivity, and sex. The decision to use alternative therapies was not significantly related to age, race, education, religion or severity of symptoms. Of respondents using alternatives, 10% expected the unconventional treatments to cure their HIV infection, and 36% expected them to delay the onset of symptoms. CONCLUSION: The results of this study will contribute to conventional practitioners' understanding of those unconventional explanations and therapies for HIV infection that many patients find relevant and meaningful. Health-care workers should be aware of their patients' interest in participating in decisions about their treatment--whether alternative or conventional--and be prepared to work with them to achieve satisfactory outcomes.

Prostate Cancer Intervention Versus Observation Trial: economic analysis in study design and conditions of uncertainty.

The Prostate Cancer Intervention Versus Observation Trial (PIVOT) compares radical prostatectomy with palliative expectant management of patients with clinically localized prostate disease. As with all clinical trials, several of the assumptions underlying PIVOT are characterized by uncertainty. Economic analysis has the potential to clarify some of these important issues, thereby guiding study design and interpretation and enhancing the clinical usefulness of the findings. One important uncertainty about the trial relates to the true clinical state of potentially eligible patients. While clinical examination is an insensitive method by which to stage prostate cancer, several diagnostic tests, such as bone scanning and magnetic resonance imaging with rectal coil, are more accurate but more expensive. Another issue is whether to start the trial with the screening of patients or at the time of prostate cancer diagnosis. Economic analysis can assess these trade-offs between study cost and validity. A second potential role for health economics is in dealing with the considerable uncertainty surrounding the study's findings and conclusions and their interpretation. While the stated primary outcome of the trial is survival, a multidimensional outcome (particularly one that incorporates factors of survival, quality of life, and cost) is likely to be more clinically relevant in the prostate cancer population, given the only modest improvements in survival hypothesized for radical prostatectomy. To develop such a measure, quantitative assessment of patient preferences is required, in addition to the measures currently included in the study. Assessment of costs of care are important, given the large and growing size of the study's target population.(ABSTRACT TRUNCATED AT 250 WORDS)

Predicting success of intensive dialysis in the treatment of uremic pericarditis.

To identify predictors of the success or failure of daily intensive dialysis in uremic pericarditis, a retrospective examination was made of initial clinical, laboratory, and echocardiographic data in 97 patients using univariate and multivariate statistical analysis. In this group, 67 patients showed response to intensive dialysis, and 30 patients did not (22 required surgery and eight died). By univariate analysis, nine factors correlated with intensive dialysis failure (p less than 0.10): admission temperature over 102 degrees F, rales, admission blood pressure under 100 mm Hg, jugular venous distension, peritoneal dialysis treatment only because of severe hemodynamic instability, white blood cell count over 15,000/mm3, white blood cell count left shift, large effusion by echocardiography, and both anterior and posterior effusion by echocardiography. Echocardiographic left ventricular size and function were not useful predictors of success or failure; there was no difference in response to hemodialysis in patients with pericarditis before dialysis (69 percent) versus patients with pericarditis during a maintenance program (67 percent). By discriminant analysis, a seven-variable function was constructed that divided the patients into three groups: (1) those likely to show response to intensive dialysis (48 patients, predictive value of 98 percent), (2) those with an intermediate (38 percent) chance of showing response to intensive dialysis (30 patients), and (3) those unlikely to show response to intensive dialysis (14 patients, predictive value of 100 percent). When the function was applied prospectively to 12 patients (eight with success and four with failure), all were classified correctly. Thus, discriminant analysis of patients with uremic pericarditis allows improved selection of patients with uremic pericarditis likely to have response to daily intensive dialysis and early consideration of alternative forms of treatment in patients unlikely to show response to intensive dialysis. However, the model should be validated in the particular institution where it is to be used before its application.

Hematuria and clinical findings as indications for intravenous pyelography in pediatric blunt renal trauma.

The essential aids in the evaluation of suspected blunt urinary tract injury are urinalysis and IVP. In 78 consecutive children who had IVPs because of trauma from January 1982 to March 1986, the following were evaluated: (1) the yield of IVP; (2) the correlations between IVP and hematuria, mechanism of injury, and associated clinical findings; and (3) the effect of IVP on patient management. Of the 26 children (33%) with abnormal IVP findings, 13 had congenital urinary tract anomalies only and 13 had urinary tract injuries (eight renal contusions, four renal lacerations with extravasation, and one bladder rupture). The number of RBCs per high-power field correlated with IVP evidence of injury (P less than .05). If only those patients with greater than or equal to 20 RBCs per high-power field had received IVPs, 42% of IVPs would have been avoided and no injuries or surgically correctable anomalies would have been overlooked. Urinary tract injury occurred significantly more often in patients with extremity fractures (P less than .05) and pelvic fractures (P less than .05). Mechanism of injury, admission to the hospital, and flank tenderness or hematoma were not associated with IVP evidence of trauma (P greater than .05), however. In four patients with trauma, results of IVP led to lengthened hospitalization or further diagnostic studies but did not result in surgery. Two patients in whom ureteropelvic junction obstruction was discovered incidentally had delayed corrective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effectiveness of rapid latex agglutination testing and throat culture for streptococcal pharyngitis.

Decision analysis was used to evaluate the cost-effectiveness of four alternative strategies for management of pharyngitis in children ("treat all," "antigen test alone," "culture alone," "antigen test + culture"). In the model, estimates of test sensitivity and specificity, disease prevalence, treatment rates after positive test results, rates of complications for treated and untreated patient-cases, rates of antibiotic-induced complications, treatment effectiveness, and direct dollar costs of diagnosis and therapy were used. Results were expressed in terms of severe penicillin reactions per disease case prevented and dollars per complication prevented. Sensitivity analysis was performed to assess the impact of changes in parameter estimates on model outcomes. With treat all, 90% of streptococcal complications were prevented and there were low short-term direct dollar costs. However, treat all is associated with a high rate of penicillin allergy (70% of which occurs in uninfected children) and is the least cost-effective strategy when the costs of treating complications are included. The marginal cost of antigen test + culture is less than the cost of either one-test strategy. Antigen test + culture is the most cost-effective strategy when the costs of managing the complications of streptococcal infection are considered. Antigen test + culture is the most clinically effective strategy, and its benefits are obtained at a modest marginal cost relative to the one-test strategy.

Clinical and cost-effectiveness of outpatient strategies for management of febrile infants.

Young infants with fever are at risk for serious bacterial infection, but no consensus exists on the optimal approach to diagnosis and treatment. Although the traditional recommendation is always to perform all sepsis tests, including lumbar puncture, and administer intravenous (IV) antibiotics until culture results are negative, recent studies suggest administering intramuscular (IM) ceftriaxone with outpatient follow-up or using laboratory and clinical data to exclude low-risk patients from hospitalization, further testing, and antibiotic treatment. A decision analysis model was used to evaluate six strategies for the diagnosis and treatment of infants aged 28 to 90 days with temperature greater than or equal to 38.0 degrees C. Data from the literature, data from a 1991 study of 503 febrile infants, and direct, short-term costs from the Children's Hospital of Philadelphia were used as model inputs. The model was run for a hypothetical cohort of 100,000 febrile infants who did not require admission for focal infection or for other reasons that clearly necessitated admission. The model included six strategies: (1) no intervention; (2) all sepsis tests (lumbar puncture, blood culture, urine culture, white blood cell count, and urinalysis) followed by hospitalization and IV antibiotics for all infants; (3) all sepsis tests followed by IM ceftriaxone and outpatient management for most infants; (4) blood and urine cultures with white blood cell count and urinalysis followed by either lumbar puncture and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants; (5) white blood cell count and urinalysis followed by either lumbar puncture, blood and urine cultures, and IV antibiotics for high-risk infants or outpatient management without antibiotics for low risk infants; and (6) clinical judgment followed by either all sepsis tests and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants. The two "all sepsis tests" strategies prevented the most cases of death or neurologic impairment, 78% (when IV antibiotics were used) and 76% (when IM ceftriaxone was used) of all potential cases. The most cost-effective strategy was to use all sepsis tests followed by IM ceftriaxone for all patients without meningitis, at an incremental cost of only $3900 per sequela prevented relative to no intervention. Strategies under which only those patients selected as high-risk by laboratory criteria received antibiotic treatment were less effective but incurred lower rates of antibiotic complications. Clinical judgment alone was the least clinically effective and the second least cost-effective strategy.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of dilation of the distal coronary bed on flow and resistance in severely stenotic coronary arteries in the dog.

Studies were performed to evaluate the hemodynamic response of severely stenotic coronary arteries to dilation of the distal coronary bed. A critical stenosis was produced with an adjustable wire snare on the left anterior descending or circumflex arteries of open chest dogs. Coronary flow, distal coronary pressure and aortic pressure were measured. In one group of experiments, coronary arteriolar dilatation was induced by transient occlusion of the artery distal to the stenosis. After the release of a transient occlusion in vessels without a critical stenosis, flow increased (from 33 +/- 4 to 85 +/- 8 ml/min, P less than 0.01), distal pressure decreased slightly (from 86 +/- 4 to 80 +/- 4 mm Hg, P less than 0.01), and large vessel resistance did not change significantly (from 0.06 +/- 0.02 to 0.08 +/- 0.03 units). After the release of a transient occlusion in vessels with a critical stenosis, flow decreased (from 23 +/- 3 to 12 +/- 2 ml/min, P less than 0.01), distal pressure decreased to persistently low levels (from 63 +/- 2 to 29 +/- 2 mm Hg, P less than 0.01), and large vessel resistance increased (from 1.4 +/- 0.3 to 6.7 +/- 1.8 units, P less than 0.01). In a separate group of experiments, radio-opaque contrast medium was used to dilate the distal coronary bed. In these studies dilation of the distal coronary of arteries with a critical stenosis again resulted in a decrease in coronary blood flow (from 35 +/- 4 to 19 +/- 3 ml/min, P less than 0.01), a decrease in distal coronary pressure (from 84 +/- 6 to 35 +/- 6 mm Hg, P less than 0.01) and an increase in large arterial resistance (from 1.0 +/- 0.2 to 5.5 +/- 1.2 units, P less than 0.02). Therefore, in coronary vessels with severe stenosis, dilation of the distal coronary bed may result in a paradoxical decrease in coronary blood flow.