Comparing claims data and self-reported data with the medical record for Pap smear rates

The objective of this study was to assess and compare the relative accuracy of claims data and patient self-reported information with medical records for Pap smear rates. A retrospective analysis of information obtained from administrative claims files, patient medical records, and a telephone survey was performed of 400 women age 19 through 75 years who were randomly selected for participation in the study. The data were obtained from a large multispecialty group practice in Minneapolis, Minnesota for the study years 1991 through 1993. Information from administrative claims regarding Pap smear status corresponded highly with information in the medical record (sensitivity 95% or higher; specificity 95% or higher; kappa 0.896 or better). Self-reported information from the telephone survey did not correspond well with medical record information nor with results in administrative claims.

Energy expenditure during walking by children who have proximal femoral focal deficiency

The energy expended during walking by sixteen children who had proximal femoral focal deficiency was measured to compare the outcomes after Syme amputation (seven subjects) with those after Van Nes rotational osteotomy (nine subjects). Multivariate regression analysis revealed that the subjects who had had a Van Nes procedure had a mean oxygen cost (energy per unit of body mass expended per distance walked) that was 0.12 milliliter per kilogram of body mass per meter lower than that of the subjects who had had a Syme amputation (p = 0.001). The subjects who had had a Van Nes procedure tended to walk faster (p = 0.07). A significant decrease in the oxygen cost as a function of increasing age was observed for both groups (p < 0.0001, r2= 0.79). We believe that the reduced energy expenditure associated with the Van Nes rotational osteotomy is one of several factors to consider when deciding which operation should be done for children who have proximal femoral focal deficiency.

Taking health status into account when setting capitation rates: a comparison of risk-adjustment methods

OBJECTIVE

To compare performance of different health status measures for risk-adjusting capitation rates.

DESIGN

Cross-sectional study. Health status measures derived from 1 year were used to predict resources for that year and the next.

SETTING

Group-network health maintenance organization in Minnesota.

PARTICIPANTS

Sample of 18- to 64-year-old (n=3825) and elderly (aged > or = 65 years; n=1955) members enrolled in a network-model health maintenance organization in Minnesota.

MAIN OUTCOME MEASURES

Total expenditures in the year concurrent with the health status survey (July 1991 through June 1992) and total expenditures in the year following the survey (July 1992 through June 1993).

RESULTS

Capitation adjustment based on demographic measures performed least well. Both self-reported health status measures and diagnoses predicted future expenditures twice as well as demographics. When predicting costs for groups of patients rather than individuals, the demographic model worked well for average groups but tended to overpredict healthier groups and underpredict sicker groups. Ambulatory Care Groups based on diagnoses performed better than self-reported health status both in the retrospective models and across healthier and sicker groups.

CONCLUSIONS

Without risk adjustment, capitation rates are likely to overpay or underpay physicians for certain patient groups. It is possible to improve prediction using health status measures for risk adjustment. When selection bias is suspected and administrative data are available, we recommend a risk-adjustment method based on diagnostic information. If diagnostic data are not available, we recommend a system based on simple self-reported measures, such as chronic conditions, rather than complex functional status measures.

Physical therapy to improve functioning of older people in residential care facilities

BACKGROUND AND PURPOSE

The purpose of this study was to determine the effectiveness of an individualized physical therapy mobility training program on the gait, balance, and functional performance of elderly individuals living in residential care facilities.

SUBJECTS

Twenty-seven elderly individuals with impaired balance and difficulty performing at least one functional activity participated in the study. The subjects ranged in age from 71 to 97 years (mean = 87.1, SD = 6.7).

METHODS

Balance and gait speed were assessed at baseline and following physical therapy that consisted of exercises to improve specific functional limitations. Outcomes were reassessed 1 month following completion of the physical therapy.

RESULTS

Gait and balance outcomes were analyzed using a one-way repeated-measures analysis of variance. Improvement was obtained in balance, which was maintained at 1 month follow-up. Gait speed did not improve to a level of statistical significance.

CONCLUSION AND DISCUSSION

After physical therapy, subjects improved in balance and functional performance. An improvement in gait speed may require a longer duration of treatment.

Using wound debridement to help achieve the goals of care

The removal of devitalized tissue, particulate matter, or foreign materials from a wound, debridement, is often the first goal of wound care. Debridement can be accomplished surgically (instrument/sharp), chemically, mechanically or by means of autolysis. Each procedure has distinct advantages, disadvantages, indications for use and risks, and a combination of methods will often expedite the process while limiting the chance of complications. Depending on the method used as well as a variety of local and systemic factors, chronic wound debridement can take anywhere from a few days to more than a month. Even though wound debridement is often discussed separately, particularly when managing patients with chronic wounds, it should not be viewed in isolation. Rather, it is one aspect of total patient care. Measures to facilitate the healing process in general should be employed at all times, because debridement and wound healing can occur simultaneously.

Screening for balance and mobility impairment in elderly individuals living in residential care facilities

BACKGROUND AND PURPOSE

The rapid growth of the elderly population has resulted in a corresponding rise in the number of elderly individuals who experience disability during their lifetimes. The purpose of this study was to test the usefulness of four established clinical measures of balance, gait, and subjective perceptions of fear of falling as screening methods for referring community-dwelling elderly individuals living in residential care facilities for detailed physical therapy evaluation and possible intervention.

SUBJECTS

The subjects were a convenience sample of 53 elderly individuals living in two residential care facilities for the elderly.

METHODS

Subjects were tested on each of four clinical measures of balance and mobility. Their performance on these measures was compared with a physical therapist's brief evaluation of disability and appropriateness for more detailed evaluation. The usefulness of these tools as screening methods was determined by calculating sensitivity and specificity levels using the physical therapist's evaluation as a standard.

RESULTS

The sensitivity and specificity levels of the four clinical measures in their application as screening tests for referral to physical therapy were as follows: Berg Balance Scale, 84% and 78%; balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests, Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of 70% when a subject tested positive on at least one test.

CONCLUSION AND DISCUSSION

These findings indicate the feasibility of developing screening methods for referring community-dwelling elderly individuals for a detailed physical therapy evaluation based on established clinical assessment measures, with a combination of tests measuring balance and gait demonstrating the most promising results.

Biotechnology core facilities: trends and update

A survey of 128 biotechnology core facilities has provided data on the finances, services, space requirements, and personnel. An average facility had four full-time personnel and 7.5 major instrument systems, and occupied 969 sq. ft. Average total income was $244,000/year, but annual user fee income was only $125,000. Typically, facilities required substantial institutional support or grants. Cost recovery (user fee income divided by total income) averaged 49%. During the last 5 years user fee income, total income, and cost recovery have increased. In-house charges for protein sequencing and peptide synthesis increased approximately 30%, while oligonucleotide synthesis charges decreased by 74%. The costs (charges corrected for subsidy from non-user fee income) for most services did not significantly change, except that oligonucleotide synthesis costs decreased by 25% in 1992. DNA synthesis had the highest throughout per month (116 samples), followed by amino acid analysis (86 samples) and DNA sequencing (67 samples). Other services averaged from 5 to 60 samples. DNA synthesis and purification were the services used by the greatest number of principal investigators. A number of services including DNA sequencing, mass spectrometry, capillary electrophoresis, RNA synthesis, electroblotting, and carbohydrate analysis have been introduced in the last 3 years. Although these services are characterized by high levels of methods development and non-user runs, they are offered by twice the percentage of facilities as in 1989, and are increasingly contributing to facility income.

Depressant insect selective neurotoxins from scorpion venom: chemistry, action, and gene cloning

The present study examines the similarity in the symptoms and binding properties between the depressant and excitatory insect-selective neurotoxins, derived from scorpion venom. A comparison of their primary structures and neuromuscular effects is presented. A new depressant toxin (LqhIT2) was purified from the venom of the scorpion Leiurus quinquestriatus hebraeus. The effects of this toxin on a prepupal housefly neuromuscular preparation mimic its effects on the intact insect, i.e, a brief period of repetitive bursts of regular junction potentials (JPs) is followed by reduced amplitude JPs ending with a block of the neuromuscular transmission. "Loose" patch clamp recordings indicate that the repetitive activity has a presynaptic origin (the motor nerve) and resembles the effect of the excitatory toxin AaIT. The final synaptic block is supposed to be the end result of neuronal membrane depolarization. Such an effect is not caused by an excitatory toxin, which induces long "trains" of repetitive firing. The amino acid sequences of three depressant toxins were determined by automatic Edman degradation indicating a high degree of sequence homology. This conservation differs from those of other groups of scorpion toxins. The opposing pharmacological effects of depressant toxins are discussed in light of the above neuromuscular effects and sequence analysis. A genetic approach in the study of the structure-function relationships of the depressant toxins was initiated by isolating cDNA clones encoding the LqhIT2 and BjIT2 toxins. Their sequence analysis revealed the precursor form of these toxins: A 21 amino acid residue signal peptide followed by a 61 amino acid region of the mature toxin, and three additional amino acids at the carboxy terminus.

Development of recombinant viral insecticides by expression of an insect-specific toxin and insect-specific enzyme in nuclear polyhedrosis viruses

As supplements to classical chemical insecticides, two approaches to develop recombinant baculovirus insecticides are described. In one approach an insect-specific toxin is expressed leading to a dramatic reduction in time to death. In the second approach an insect juvenile hormone esterase is expressed which leads to a reduction in feeding. Modifications of the wildtype esterase led to viruses which reduced the time to death as effectively as did the toxin-expressing virus. In both cases existing recombinant viruses are viewed as leads, and approaches to further improvement in the engineered viruses are suggested. Many of these approaches are based on analogy with the development of classical synthetic insecticides. Using these viruses as examples, the potential utility and limitations of recombinant viruses and other biological insecticides are discussed.

Development of a recombinant baculovirus expressing an insect-selective neurotoxin: potential for pest control

Recombinant nuclear polyhedrosis viruses (NPVs) expressing insect-selective toxins, hormones, or enzymes could enhance their insecticidal properties. We have constructed a recombinant, polyhedrin-positive Autographa californica NPV (AcNPV) that is orally infectious and expresses an insect-selective toxin (AaIT), isolated from the scorpion Androctonus australis, under the control of the p10 promoter. Bioassays with the recombinant baculovirus on 2nd instar larvae of Heliothis virescens demonstrated a significant decrease in the time to kill (LT50 88.0 hours) compared to wild-type AcNPV (LT50 125 hours). Production of AaIT was confirmed by western blot analysis of larval hemolymph from infected H. virescens, and bioassays with larvae of Sarcophaga falculata.

Insecticidal effects of an insect-specific neurotoxin expressed by a recombinant baculovirus

The scorpion Androctonus australis has a peptide (AaIT) which selectively targets the insect sodium channel. This mode of action is similar to that of many widely used chemical insecticides. When Bombyx mori larvae were infected with a recombinant baculovirus carrying a synthetic AaIT gene, the expressed protein was secreted into the hemolymph and caused symptoms consistent with sodium channel blocking, including tremors and feeding cessation at 40 hr p.i. followed by paralysis and death by 60 hr p.i. Larvae infected with control virus died by 96 hr p.i. These results indicate that foreign genes can be used in recombinant baculoviruses to reduce insect feeding damage and increase the rate of insect kill.

Evaluation of an alginate dressing for pressure ulcers

Pressure ulcers that secrete moderate to large amounts of fluid often cause leakage from under dressings, odor, staining of clothing, denuding of the skin, and pain. Two highly absorbent dressings derived from seaweed have been introduced into the U.S. market for use in the management of exuding wounds. Severely debilitated patients with full-thickness pressure ulcers were treated for one week to three months with one of these alginate dressings (Kaltostat). The handling and performance characteristics of the dressing are discussed.

Functional duality and structural uniqueness of depressant insect-selective neurotoxins

Depressant insect-selective neurotoxins derived from scorpion venoms (a) induce in blowfly larvae a short, transient phase of contraction similar to that induced by excitatory neurotoxins followed by a prolonged flaccid paralysis and (b) displace excitatory toxins from their binding sites on insect neuronal membranes. The present study was undertaken in order to examine the basis of these similarities by comparing the primary structures and neuromuscular effects of depressant and excitatory toxins. A new depressant toxin (LqhIT2) was purified from the venom of the Israeli yellow scorpion. The effects of this toxin on a prepupal housefly neuromuscular preparation mimic the effects on the intact animal; i.e., a brief period of repetitive bursts of junction potentials is followed by suppression of their amplitude and finally by a block of neuromuscular transmission. Loose patch clamp recordings indicate that the repetitive activity has a presynaptic origin in the motor nerve and closely resembles the effect of the excitatory toxin AaIT. The final synaptic block is attributed to neuronal membrane depolarization, which results in an increase in spontaneous transmitter release; this effect is not induced by excitatory toxin. The amino acid sequences of three depressant toxins were determined by automatic Edman degradation. The depressant toxins comprise a well-defined family of polypeptides with a high degree of sequence conservation. This group differs considerably in primary structure from the excitatory toxin, with which it shares identical or related binding sites, and from the two groups of scorpion toxins that affect sodium conductance in mammals. The two opposing pharmacological effects of depressant toxins are discussed in light of the above data.