Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents

Importance

Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population.

Objective

To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period.

Design, Setting, and Participants

This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020.

Exposure

Race and ethnicity.

Main Outcomes and Measures

Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death.

Results

Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85).

Conclusions and Relevance

Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

Evaluating the effects of grass management technologies on the physical, environmental, and financial performance of Irish pasture-based dairy farms

Grass management technologies (grass measuring devices and grassland management decision support tools) have been identified as important tools to improve the performance of pasture-based dairy farms. They have the potential to significantly improve the efficiency and sustainability of dairy systems by increasing milk production through enhanced pasture growth and utilization, which would reduce the need for supplementary feeds, along with increased output, therefore increasing farm profitability and environmental sustainability. Despite the several potential benefits of grass management technologies, there is a lack of empirical research around the effects of these technologies on the performance of pasture-based dairy systems. The current study aimed to fill this knowledge gap by using a 2018 nationally representative survey of Irish dairy farms and a propensity score matching approach to determine the effects of adopting grass management technologies on the physical, environmental, and financial performance of Irish pasture-based dairy farms. The findings showed that dairy farms utilizing grass management technologies had, on average, higher farm physical, environmental, and financial performance (in terms of grazed pasture use, total pasture use, length of the grazing season, milk yield, milk solids, greenhouse gas emissions per kilogram of fat- and protein-corrected milk, gross output, and gross margin) compared with dairy farms not utilizing these technologies. However, when controlling for selection bias, we can only attribute a positive causal effect of grass management technology adoption on the use of grazed pasture per cow, grazing season length, milk yield per cow, and milk solids per cow. This might be due to dairy farmers not yet using the technologies to their full potential, 2018 being an unusual year in terms of weather (and therefore not being able to capture the full range of farm performance benefits), or because grass management technologies need to be adopted in association with other technologies and practices to achieve their expected performance outcomes. Future research should include updated farm-level data to capture the weather and learning effects and so be able to determine the impact of grass management technologies on a wider range of performance indicators.

HOSPICE UTILIZATION AMONG MEDICAID-ONLY AND DUALLY ELIGIBLE DECEDENTS IN CONNECTICUT

Individuals with Medicaid as their health care payer source may be either “Medicaid-only,” or “dually eligible,” i.e., qualifying for both Medicaid and Medicare. Medicare included hospice as a full Medicare benefit in 1982; Hospice is an optional Medicaid benefit for states; Connecticut added the Medicaid hospice benefit in 2010. This study explores hospice use in Connecticut’s Medicaid program by comparing hospice use and length of hospice enrollment by Medicaid-only vs. dually eligible and by diagnosis for decedents who died between 2017 and 2020 and had a hospice-appropriate diagnosis. This analysis of 2,990 Medicaid-only and 24,881 dually eligible decedents finds that dually eligible decedents had a significantly (p<.001) higher rate of hospice use (48.1%) compared to Medicaid-only decedents (29.9%). Medicaid-only decedents received hospice for a median of 12 days vs. 13 days for the dually eligible (p=.12). Dually eligible decedents consistently received hospice more often than Medicaid-only decedents across all diagnoses (cancer (p<.05) circulatory (p<.001), dementia (p<.001), respiratory (p<.001) and stroke (p<.001)). Dually eligible decedents had significantly more days of hospice than Medicaid-only decedents for subgroups with a circulatory (p<.05) or stroke (p<.05) diagnosis, but Medicaid-only decedents with a dementia diagnosis had more days of hospice than their dually-eligible counterparts. Additional multi-variate analysis will demonstrate how other factors, like age, may account for differences. Recommendations include encouraging physician use of hospice screening tools and developing education interventions with physicians and patients to increase understanding of the availability and benefits of hospice with particular focus on Medicaid-only patients.

Do Patients Continue to Use Video Visits? Factors Related to Continued Video Visit Use

Many studies have assessed the factors associated with overall video visit use during the COVID-19 pandemic, but little is known about who is most likely to continue to use video visits and why. The authors combined a survey with electronic health record data to identify factors affecting the continued use of video visit. In August 2020, a stratified random sample of 20,000 active patients from a large health care system were invited to complete an email survey on health care seeking preferences during the COVID. Weighted logistic regression models were applied, adjusting for sampling frame and response bias, to identify factors associated with video visit experience, and separately for preference of continued use of video visits. Actual video visit utilization was also estimated within 12 months after the survey. Three thousand three hundred fifty-one (17.2%) patients completed the survey. Of these, 1208 (36%) reported having at least 1 video visit in the past, lowest for African American (33%) and highest for Hispanic (41%). Of these, 38% would prefer a video visit in the future. The strongest predictors of future video visit use were comfort using video interactions (odds ratio [OR] = 5.30, 95% confidence interval [95% CI]: 3.57-7.85) and satisfaction with the overall quality (OR = 3.94, 95% CI: 2.66-5.86). Interestingly, despite a significantly higher satisfaction for Hispanic (40%-55%) and African American (40%-50%) compared with Asian (29%-39%), Hispanic (OR = 0.46, 95% CI: 0.12-0.88) and African American (OR = 0.54, 95% CI: 0.16-0.90) were less likely to prefer a future video visit. Disparity exists in the use of video visit. The association between patient satisfaction and continued video visit varies by race/ethnicity, which may change the future long-term video visit use among race/ethnicity groups.

Establishing nationally representative benchmarks of farm-gate nitrogen and phosphorus balances and use efficiencies on Irish farms to encourage improvements

Agriculture faces considerable challenges of achieving more sustainable production that minimises nitrogen (N) and phosphorus (P) losses and meets international obligations for water quality and greenhouse gas emissions. This must involve reducing nutrient balance (NB) surpluses and increasing nutrient use efficiencies (NUEs), which could also improve farm profitability (a win-win). To set targets and motivate improvements in Ireland, nationally representative benchmarks were established for different farm categories (sector, soil group and production intensity). Annual farm-gate NBs (kg ha^-1) and NUEs (%) for N and P were calculated for 1446 nationally representative farms from 2008 to 2015 using import and export data collected by the Teagasc National Farm Survey (part of the EU Farm Accountancy Data Network). Benchmarks for each category were established using quantile regression analysis and percentile rankings to identify farms with the lowest NB surplus per production intensity and highest gross margins (€ ha^-1). Within all categories, large ranges in NBs and NUEs between benchmark farms and poorer performers show considerable room for nutrient management improvements. Results show that as agriculture intensifies, nutrient surpluses, use efficiencies and gross margins increase, but benchmark farms minimise surpluses to relatively low levels (i.e. are more sustainable). This is due to, per ha, lower fertiliser and feed imports, greater exports of agricultural products, and for dairy, sheep and suckler cattle, relatively high stocking rates. For the ambitious scenario of all non-benchmark farms reaching the optimal benchmark zone, moderate reductions in farm nutrient surpluses were found with great improvements in profitability, leading to a 31% and 9% decrease in N and P surplus nationally, predominantly from dairy and non-suckler cattle. The study also identifies excessive surpluses for each level of production intensity, which could be used by policy in setting upper limits to improve sustainability.

Outcomes of a Brief Cognitive Skills-Based Intervention (COPE) for Adolescents in the Primary Care Setting

INTRODUCTION

Approximately 25% of adolescents have behavioral disorders, yet few receive treatment. Primary care (PC) screening for depression and anxiety is recommended; however treatments, such as cognitive behavioral therapy (CBT), are rarely available in PC settings. Our aim was to determine whether the use of a CBT-based intervention (COPE for Teens) is associated with improved outcomes on measures of depression and anxiety, and to understand the patient experience.

METHODS

Health record data were examined, including questionnaires on depression (PHQ-A), anxiety (GAD-7), and experience with COPE. Differences between pre- and post-intervention scores were evaluated by paired t-tests. Questionnaire data were analyzed via thematic coding.

RESULTS

Thirty-seven patients (73% female; ages 12-18) completed pre- and post-intervention measures. Comparison showed decrease in PHQ-A scores by 2.1 (p = 0.0067) and GAD-7 scores by 2.3 (p = 0.0081). Questionnaire data demonstrate satisfaction with COPE.

DISCUSSION

Among these 37 adolescents, COPE provided effective PC-based behavioral treatment and a positive experience. Increased availability of COPE could improve care for adolescents.

Community-Based Palliative Care and Advance Care Planning Documentation: Evidence from a Multispecialty Group

BACKGROUND/OBJECTIVES

With the growing public demand for access to critical health data across care settings, it is essential that advance care planning (ACP) information be included in the electronic health record (EHR) so that multiple clinicians can access it and understand individuals' preferences for end-of-life care. Community-based palliative care programs often incorporate ACP services. This study examined whether a community-based palliative care program is associated with digitally extractable ACP documentation in the EHR.

DESIGN

Observational study using propensity score-weighted generalized estimation equations to examine patterns of digitally extractable ACP documentation.

SETTING

Palo Alto Medical Foundation (PAMF), a multispecialty ambulatory healthcare system in northern California.

PARTICIPANTS

Individuals aged 65 and older with serious illnesses between January 1, 2013, and December 31, 2014 (N = 3,444).

INTERVENTION

Community-based palliative care program in PAMF.

MEASUREMENTS

Digitally extractable ACP in EHR.

RESULTS

We found that only 14% (n = 483) of individuals with serious illnesses had digitally extractable ACP in electronic health records. Of the 6% of individuals receiving palliative care, 65% had ACP, versus 11% of those not receiving palliative care. Study results showed a strong positive association between palliative care and ACP.

CONCLUSION

Only a small percentage of individuals with serious illnesses had ACP documentation in the EHR. Individuals with serious illnesses infrequently used palliative care delivered by board-certified palliative care specialists. Palliative care service use was associated with higher rates of ACP after controlling for organizational and individual characteristics using a propensity score weighting method. Scalable interventions targeted at non-palliative care clinicians for universal access to ACP are needed.

Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment

CONTEXT

Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic.

OBJECTIVES

In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice.

METHODS

Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates.

RESULTS

Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices.

CONCLUSION

Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.

Using Unlicensed Health Coaches to Improve Care for Insured Patients with Diabetes and Hypertension: Patient and Physician Perspectives on Recruitment and Uptake

Health coach programs using low-cost unlicensed providers have largely targeted uninsured or underserved populations, raising questions about uptake and effectiveness for insured patients. This observational study evaluated the referral process, uptake, and effectiveness of a health coach program for patients with diabetes and/or hypertension at a multispecialty clinic. Data included appointment observations; interviews with patients, physicians, and health coaches; patient and physician characteristics; and measures of utilization and clinical outcomes. Out of 1313 eligible patients, 308 (23.5%) were referred over a 12-month period and 169 (54.9%) had at least 1 health coach appointment. Although the health coach program did not change patients' biometrics, physicians and patients reported improved care processes and reduced physician workload. Barriers to enrollment included variability in physician referral practices, patient willingness, and scheduling difficulties. Modifications to physician and health coach workflow are needed to determine the program's true effectiveness.

Bacteriophage therapy to reduce Campylobacter jejuni colonization of broiler chickens

Colonization of broiler chickens by the enteric pathogen Campylobacter jejuni is widespread and difficult to prevent. Bacteriophage therapy is one possible means by which this colonization could be controlled, thus limiting the entry of campylobacters into the human food chain. Prior to evaluating the efficacy of phage therapy, experimental models of Campylobacter colonization of broiler chickens were established by using low-passage C. jejuni isolates HPC5 and GIIC8 from United Kingdom broiler flocks. The screening of 53 lytic bacteriophage isolates against a panel of 50 Campylobacter isolates from broiler chickens and 80 strains isolated after human infection identified two phage candidates with broad host lysis. These phages, CP8 and CP34, were orally administered in antacid suspension, at different dosages, to 25-day-old broiler chickens experimentally colonized with the C. jejuni broiler isolates. Phage treatment of C. jejuni-colonized birds resulted in Campylobacter counts falling between 0.5 and 5 log10 CFU/g of cecal contents compared to untreated controls over a 5-day period postadministration. These reductions were dependent on the phage-Campylobacter combination, the dose of phage applied, and the time elapsed after administration. Campylobacters resistant to bacteriophage infection were recovered from phage-treated chickens at a frequency of <4%. These resistant types were compromised in their ability to colonize experimental chickens and rapidly reverted to a phage-sensitive phenotype in vivo. The selection of appropriate phage and their dose optimization are key elements for the success of phage therapy to reduce campylobacters in broiler chickens.

Correlation of Campylobacter bacteriophage with reduced presence of hosts in broiler chicken ceca

Campylobacter jejuni and Campylobacter-specific bacteriophage were enumerated from broiler chicken ceca selected from 90 United Kingdom flocks (n = 205). C. jejuni counts in the presence of bacteriophage (mean log(10) 5.1 CFU/g) were associated with a significant (P < 0.001) reduction compared to samples with Campylobacter alone (mean log(10) 6.9 CFU/g).

Longitudinal study of Campylobacter jejuni bacteriophages and their hosts from broiler chickens

A longitudinal study of bacteriophages and their hosts was carried out at a broiler house that had been identified as having a population of Campylobacter-specific bacteriophages. Cloacal and excreta samples were collected from three successive broiler flocks reared in the same barn. Campylobacter jejuni was isolated from each flock, whereas bacteriophages could be isolated from flocks 1 and 2 but were not isolated from flock 3. The bacteriophages isolated from flocks 1 and 2 were closely related to each other in terms of host range, morphology, genome size, and genetic content. All Campylobacter isolates from flock 1 were genotypically indistinguishable by pulsed-field gel electrophoresis (PFGE). PFGE and multilocus sequence typing indicated that this C. jejuni type was maintained from flock 1 to flock 2 but was largely superseded by three genetically distinct C. jejuni types insensitive to the resident bacteriophages. All isolates from the third batch of birds were insensitive to bacteriophages and genotypically distinct. These results are significant because this is the first study of an environmental population of C. jejuni bacteriophages and their influence on the Campylobacter populations of broiler house chickens. The role of developing bacteriophage resistance was investigated as this is a possible obstacle to the use of bacteriophage therapy to reduce the numbers of campylobacters in chickens. In this broiler house succession was largely due to incursion of new genotypes rather than to de novo development of resistance.

Catecholamines in human saliva

Catecholamines are readily detectable in human saliva but their origin is unclear. Norepinephrine (NE) was stable in saliva stored at 4 degrees for 2 hours but 11 +/- 3% degraded after storage at 25 degrees for 1 hour. We intravenously infused 3H-NE into humans and measured levels of 3H-NE and its metabolites in both saliva and forearm venous plasma (a site whose plasma NE levels reflect both local uptake and release of NE). 3H-NE levels in saliva continued to rise for 1 hour even though forearm plasma levels had plateaued by 5 min. By 65 min into the infusion the ratio of 3H-NE:non-radioactive NE was similar in saliva and forearm venous plasma. The ratio of NE:epinephrine (E) was similar in saliva and forearm venous plasma at all time points. Chewing induced salivation, and at least tripled the amount of NE, E and 3H-NE released into saliva per minute, but decreased their concentration in saliva by as much as one half. Saliva NE level was unaltered after 15 min of standing but was increased by 31% after 1 hour of upright posture. Our data imply that the NE present in human saliva comes from both the bloodstream and from salivary sympathetic nerves. The finding that diffusion of blood NE into saliva takes roughly 1 hour to complete suggests that NE in saliva is a poor index of acute changes in sympathetic activity.

Congenital diaphragmatic herniation: antenatal detection and outcome

201 fetuses and babies with a congenital diaphragmatic herniation or eventration (referred to collectively as CDH) were notified to the Northern Region Congenital Abnormality Survey (NorCAS) in the 13-year period from 1985 to 1997, an incidence of 0.25 per 1000 births. The 1-year survival of all pregnancies associated with CDH was 37%. The 1-year survival of livebirths was 50%. Antenatal scan detected the diaphragmatic defect or associated structural abnormality in 50%. Another major structural abnormality was present in 62 (31%); one of these babies survived and 26 pregnancies were terminated. This group contained four of the six antepartum stillbirths, all three intrapartum stillbirths and four of the five spontaneous miscarriages. Non-isolated CDH occurred in association with Fryns (5), Goldenhar (1) and de Lange (1) syndromes, and in 16 of 17 with a chromosome anomaly. 53% of the 139 fetuses with isolated CDH survived to 1 year of age, and 59% of the 124 liveborn survived. Of 37 fetuses with isolated CDH detected before 25 weeks gestation, 12 pregnancies were terminated. There were 11 survivors among the 25 continuing pregnancies (44%). The overall survival of babies with CDH is very poor but, when a defect is identified by ultrasound before 25 weeks gestation, chromosome analysis and a careful ultrasound scan may suggest which fetuses have an isolated diaphragmatic abnormality and a greater chance of survival.

Serologic markers for Chlamydia pneumoniae in asthma

BACKGROUND

Chlamydia pneumoniae infection has been reported as a possible etiologic agent in asthma, which in primary care settings often appears to be initiated by acute respiratory infections.

OBJECTIVE

To determine if serologic markers for C. pneumoniae are associated with adult asthma that first became symptomatic after an acute respiratory illness (asthma associated with infection: AAWI).

METHODS

Serum samples from 164 primary care outpatients, mean age 44 years, (68 with AAWI; 36 with atopic, occupational or exercise-induced asthma (non-AAWI); 16 nonasthmatic patients with acute bronchitis; and 44 asymptomatic nonasthmatic controls) were tested for the presence of C. pneumoniae-specific IgG and IgA antibodies. Levels of chlamydial heat shock protein 60 (CHSP60) antibody were also measured. Those positive for CHSP60 were tested for C. pneumoniae-specific IgE antibodies by immunoblotting.

RESULTS

Statistically significant differences in IgG and IgA seroreactivity were noted between groups: acute bronchitis and AAWI had the highest levels (93% to 94% IgG seroreactivity, 69% to 75% IgA seroreactivity) whereas non-AAWI and asymptomatic controls had the lowest levels (61% to 84% IgG seroreactivity, 31% to 43% IgA seroreactivity, P < .02 after adjustment for age, sex and smoking). CHSP60 antibodies were significantly more prevalent in AAWI than in non-AAWI (19% versus 3%, P = .02). IgE antibodies against C. pneumoniae 60, 62, and/or 70 kD antigens were detected in 5 of 13 CHSP60 positive AAWI patients. Persistent IgG, IgA, and CHSP60 seroreactivities were noted in all seropositive asthma patients with serial serum samples.

CONCLUSIONS

Serologic markers of C. pneumoniae infection were associated with acute bronchitis and with asthma that first became symptomatic following respiratory illness. Serologic responses to C. pneumoniae may be useful in the classification and diagnosis of asthma.

Congenital anterior abdominal wall defects in the north of England, 1986-1996: occurrence and outcome

The aim was to describe trends in prevalence, maternal age-specific prevalence, associated anomalies, clinical outcomes and the sensitivity of antenatal diagnosis of congenital anterior abdominal wall defects (in particular gastroschisis and exomphalos). Data were identified from a population-based register of major congenital abnormalities in the Northern health region of England, the Northern Congenital Abnormality Survey (NorCAS), between 1986 and 1996. 296 cases were notified; there were 133 cases of gastroschisis, 98 exomphalos, 30 limb-body wall defects and 23 other anterior abdominal wall defects. 12 cases could not be classified. In 19 (6 per cent) the initial diagnosis was changed following case review. 30 (30.6 per cent) cases of exomphalos were associated with a chromosomal anomaly compared with 1 (0.8 per cent) case of gastroschisis. The total prevalence for the 11 years was 6.33 (95 per cent CI=5.57-7.08) per 10 000 live births, still births and terminations of pregnancy, and the overall birth prevalence was 4.30 (95 per cent CI=3.68-4.93) per 10 000 live births and still births. For gastroschisis, there was a significant increase over the study period in both the total prevalence (1.48 in 1986 to 5.29 per 10 000 in 1996; chi(2)=8.41, p=0.00433) and the birth prevalence (1.48 in 1986 to 4.72 per 10 000 in 1996; chi(2)=7.42, p=0.00644), but there was no such significant increase for exomphalos (total prevalence chi(2)=2.29, p=0.13055; birth prevalence chi(2)=0.16, p=0.69348). The maternal age-specific prevalence was highest in the 11-19 year age group for gastroschisis but in the 35-39 year age group for exomphalos. Fewer pregnancies with gastroschisis resulted in a termination and a greater proportion of cases were alive at one year compared with exomphalos. The sensitivity of abnormality detection by ultrasonography was 75 per cent and 77.3 per cent for gastroschisis and exomphalos, respectively. Antenatal diagnosis improved from 47.4 per cent during 1986-91 to 80 per cent between 1992-96 for gastroschisis (chi(2)=5.7, p=0.00169), and from 55.6 per cent to 68.8 per cent for isolated exomphalos, although this increase was not significant. Total and birth prevalence of gastroschisis increased in the Northern region between 1986 and 1996. For exomphalos, there was a trend towards an increase in total prevalence and towards a decrease in birth prevalence. This decreasing trend has been accompanied by improvements in antenatal detection and subsequent termination of cases of exomphalos associated with other anomalies.

A 10 year audit of antenatal ultrasound detection of renal disease

During a 10 year period, a renal tract anomaly was suspected on antenatal ultrasound in 125 fetuses, an incidence of five per 1000 births. 107 live births resulted. Three of six babies with renal failure were stented antenatally. A chromosome anomaly was present in three fetuses (2.4%). No live birth resulted in 14 pregnancies associated with oligohydramnios and no visible fetal bladder. Of those with renal agenesis or bilateral cystic dysplasia, one had a chromosome defect and a further four had extrarenal anomalies. Nine fetuses demonstrated isolated parenchymal hyperechogenicity and trisomy occurred in two of four with bilateral change in enlarged kidneys. All 14 babies with unilateral renal cysts had normal renal function postnatally, but only three of the cystic kidneys showed function. Antenatally, typical multicystic change was seen in 10, and smaller unevenly distributed cysts in four kidneys. Contralateral parenchymal echogenicity and/or pelvicalyceal distension indicating dysplasia was identified in four fetuses. Of 78 fetuses with isolated pelvic with or without calyceal distension the outcome was completely normal in 59% with unilateral, and in 48% with bilateral changes. One baby with unilateral and three with bilateral changes required dialysis or renal transplantation. One of four babies with antenatal ureteric distension had renal failure. Only one of six fetuses with bladder distension is alive in renal failure after in utero stenting.

L-selectin expression affects T-cell circulation following isoproterenol infusion in humans

beta-Adrenergic receptor agonists have been shown to affect leukocyte migration. This study examined the expression of cellular adhesion molecules on lymphocyte, monocyte, and granulocyte distribution following an infusion of isoproterenol (20 and 40 ng/kg/min for 15 min each) in 12 healthy subjects. Leukocyte populations and adhesion molecule expression were determined via flow cytometry. Isoproterenol led to an expected lymphocytosis and leukocytosis. L-selectin expression varied across leukocytes and influenced cell trafficking in response to isoproterenol. Approximately 60% of CD8+ T-cells expressed L-selectin (CD8+CD62L+) and these cells showed no appreciable response to isoproterenol. In contrast, CD8+CD62L- cells showed a robust increase in number and distribution of approximately 100% over baseline (p's < .001). Across CD4+ T-helpers, L-selectin was expressed on approximately 86% of cells. CD4+CD62L+ cells decreased in number and distribution (p's < .001) with isoproterenol, while CD4+CD62L- cells showed a modest increase (p's < or = .05). In contrast to lymphocytes, nearly all monocytes and granulocytes expressed L-selectin; these cells increased and decreased respectively in response to isoproterenol (p's < or = .05). CD11a (the beta 2-integrin LFA-1) was expressed on > 95% of all leukocytes and these data were thus similar to the overall leukocytosis data. CD54 (ICAM-1) was expressed on approximately 60% of mixed lymphocytes and was unchanged in response to isoproterenol. The findings indicate that L-selectin expression influences T-cell trafficking in response to beta-adrenergic stimulation and help further illuminate catecholamine-mediated sympathetic and immune interactions.

The antenatal diagnosis of fetal abnormalities: a 10 year audit of influencing factors

During the 10 years 1984-1993, a total of 438 fetuses and children with a congenital abnormality, identified antenatally or in the first year of life, were registered from the North Tees Health District with the Northern Region Congenital Abnormality Survey (NorCAS). This represented an abnormality rate of 2% of all births. In total, 252 structural abnormalities (57.5%) were detected by antenatal ultrasound examination. In spite of a targeted education programme, identification of cardiac lesions remained poor. The detection of structural abnormality by antenatal scan rose from 52% in 1984 to 85% in 1993, due mainly to improvements in image quality and resolution of ultrasound equipment. Also important was audit, based both on review of images and feedback from a comprehensive central register (NorCAS).

Race and sex differences in cardiovascular recovery from acute stress

To evaluate the effects of race and gender on recovery, i.e. the relative return to baseline after a stress challenge, cardiovascular and catecholamine measures were examined before, during and after two standardized laboratory stressors (a speaking and a mirror tracing task) in a group of 85 Black and White men and women (mean age 35.6 years, range 20 to 52). For the speech task, White men showed the least systolic (p < 0.025) and diastolic (p < 0.05) blood pressure recovery as compared to Black men and women. For the mirror star tracing task, total peripheral resistance (p < 0.03) recovery was least for Whites as compared to Blacks and heart rate (p < 0.04) recovery was least for White women as compared to Black women and men. There were no significant group effects in terms of catecholamine recovery from either task. The findings extend prior studies on race and gender by suggesting that these same characteristics affect recovery from stressors.

Psychologic characteristics associated with acute stressor-induced leukocyte subset redistribution

This study examined relationships between psychologic characteristics and enumerative immune responses to an acute laboratory stressor. Lymphocyte subsets were measured in 104 subjects at rest and following a 6-minute laboratory naturalistic speaking stressor. Multiple linear regression was utilized to assess relationships between immune reactivity (change scores) and anger expression, hostility, anxiety, depression, and stress. The task resulted in significant increases over baseline in WBC (p < 0.001), T-suppressor/cytotoxic CD8 cells (p = 0.010) natural killer CD56 cells (p < 0.0001), and CD57 (p < 0.0001) cells, and significant decreases in T-cells (p = 0.012), T-helper cells (p = 0.003), B-cells (p < 0.001), and the T-helper/suppressor ratio (p < 0.001). In general, the regression suggested that moderate associations exist between certain psychologic attributes and acute subset redistribution. For example, the increase in natural killer cell subsets was significantly negatively associated with anger expression, hostility, and depression. Suppressor/cytotoxic (CD8) cell reactivity was associated with baseline as well as with the task-induced changes in anxiety. B-cell (CD19) responses were related to the subject's age, expression of anger, and depression scores. As with the cardiovascular reactivity literature, these findings suggest that a relationship exists between certain psychologic characteristics such as anger and anxiety and immune reactivity to acute stress.

Menstrual cycle effects on catecholamine and cardiovascular responses to acute stress in black but not white normotensive women

This study examined cardiovascular and catecholamine responses to two standardized laboratory stressors in 33 healthy age- and weight-matched black and white normotensive women (mean age, 32 years) during two phases of the menstrual cycle. Subjects were studied in a randomized order at the same time of day on two separate occasions approximately six weeks apart, once during the follicular phase (days 7 to 10 after menses) and once during the luteal phase (days 7 to 10 after the leutenizing hormone surge) of the menstrual cycle. Black women has higher systolic (P=.01) and diastolic (P=.01) pressures compared with white women. Black women showed greater diastolic pressure (P <.01) and plasma epinephrine (P <.05) responses to stress during the follicular compared with the luteal phase of the menstrual cycle; white women showed no significant changes in these variables. The findings extend the literature on race differences in responsivity to stress and indicate that in contrast to white women, reproductive hormones do influence cardiovascular and catecholamine responsivity to stress in black women.

The antenatal diagnosis and management of abdominal wall defects: the northern region experience

One hundred and twenty abdominal wall defects were notified to the Northern Region Fetal Abnormality Survey in the five years 1988 to 1992. Gastroschisis occurred in 56, exomphalos in 43, amnion rupture in 11, ectopia vesicae in seven and ectopia cordis in three. Ultrasound failed to identify gastroschisis in 14 and incorrectly diagnosed exomphalos in eight. There was no associated chromosome abnormality and the survival rate, excluding first trimester loss, was 87%. Ultrasound failed to identify exomphalos in ten and incorrectly diagnosed gastroschisis in two. Another structural abnormality was present in 40% and a chromosome anomaly in 28%. Excluding spontaneous first trimester loss, the survival rate was 34%. Delivery of babies away from the regional paediatric surgical centre did not adversely affect the outcome in gastroschisis or exomphalos although closure was delayed, on average, by 2 h. There was one survivor of 11 fetuses with amnion rupture sequence. Six of the seven babies with ectopia vesicae and two of the three with ectopia cordis survived.

A technique for improved blood sampling during sleep studies

Research protocols often require that blood samples be drawn during sleep. This study compares the efficacy of obtaining nocturnal blood samples using a standard heparinized intravenous setup versus the same intravenous setup used in conjunction with a small chemical heating pad. The chemical heating pad significantly improved the number of blood samples obtained and the maintenance of intravenous patency. The use of a chemical heating pad is an economical way to resolve the frustration of lost blood samples while maintaining a reasonable environment to monitor sleep.

Effects of chronic stress on beta-adrenergic receptors in the homeless

This study examined the role of chronic life stress (homelessness), coping style, and hypertension on beta-adrenergic receptors in a sample of homeless men. Sixteen healthy normotensive subjects and nine untreated hypertensive subjects were studied. Life stress was measured with the Brown and Harris categorization; coping style was measured with the Ways of Coping Scale. Lymphocyte beta-adrenergic receptors were characterized in terms of receptor density (Bmax). Individuals with high life stress had lower Bmax (p < .005). In multiple regression analyses, 50% of the variance in Bmax was accounted for by life stress and coping style (p = .01). Receptor measures may be useful for characterizing the physiological response to continuing life adversity.

Case report: the antenatal ultrasound diagnosis of megalourethra

The antenatal ultrasound findings in a fetus which postnatally had fusiform megalourethra, rectal agenesis, recto-vesical fistula and unilateral renal hypoplasia are described. At 16 weeks gestation a cystic area was seen arising from the perineum. It later became evident that this was the urethra. Initially, an echogenic mass was noted in the pelvis, but by the second trimester, fluid-filled loops of bowel were evident. This combination of developmental abnormalities though rare is well defined. Only one previously recorded case has been suspected antenatally.

Antenatal detection of congenital diaphragmatic hernias: the northern region experience

This study analyses 7 years of data relating to congenital diaphragmatic herniation in the Northern Region. Ninety-nine confirmed cases were notified to the Northern Region Fetal Abnormality Survey between 1985 and 1991, which is an incidence of 0.35 per 1000 births. A specific diagnosis of CDH was made by antenatal ultrasound in 21 fetuses. The rate of detection improved from 6% to 41% but this had no impact on survival; severe pulmonary hypoplasia was found in the majority dying in the first 48 h. Another structural abnormality occurred in 29% and was the primary antenatal scan diagnosis in 11 fetuses. No other reliable indicator of outcome was identified, including the gestation when detected. The incidence of chromosomal abnormality was 5% and Fryns' syndrome 4%.

Does reactivity testing in the laboratory reflect blood pressure changes elsewhere?

This study examines whether reactivity testing in a laboratory setting might identify individuals whose blood pressure (BP) fluctuates excessively outside of the laboratory. Eighty-eight normotensive and untreated hypertensive patients were studied. Patients' BPs were obtained repeatedly on two separate screening occasions. They were subsequently admitted to a research ward, and 4 days later their BPs were measured at resting baseline and in response to a series of stressful tasks. Blood pressure declined by 14/11 mm Hg +/- 1.2/1.1 mm Hg (SE) from screening to the in-patient resting baseline. The four stressful tasks all led to increases in BP over the in-patient resting baseline level. Individuals with increased amounts of task-induced reactivity in the laboratory were also more likely to be those whose BP declined the most from out-patient screening to hospitalized baseline. The average correlation between the drop in BP associated with hospitalization and the BP reactivity to each stressor task was r = 0.33 for systolic BP (p < 0.01) and r = 0.24 for diastolic BP (p < 0.05). Reactivity responses in a laboratory setting may convey information about blood pressure fluctuation in the real world.

Noise-induced stress as a predictor of burnout in critical care nurses

In this study we found that, for 100 critical care nurses, noise-induced occupational stress was positively related to burnout as measured by Jones's Staff Burnout Scale for Health Professionals (r = 0.369, p less than 0.001) and the emotional exhaustion subscale of Maslach's Burnout Inventory (r = 0.300, p less than 0.01). Hierarchical multiple regressions confirmed these results once variance in burnout linked with life stressors and other occupational stressors was accounted for. Furthermore, an interaction term, noise-induced stress X intrinsic sensitivity to noise in the person, did not account for significant variance in burnout once independent variance linked with noise-induced stress was identified. That is, nurses with intrinsic sensitivity to noise were no more at risk for burnout linked with noise-induced stress than were less sensitive nurses. This result is discussed as evidence that there are exceptionally high levels of noise in critical care units. The critical care unit noises that are most distressing to nurses are identified and discussed in terms of stress theory.

The stress interview as a tool for examining physiological reactivity

Most studies of cardiovascular reactivity utilize tasks that are highly standardized and controlled. However, there is some concern whether the information obtained from these tasks is relevant to understanding the cardiovascular responses to behavioral stimuli encountered in real life. Historically, various forms of a stress interview have been used to examine physiological concomitants of emotional arousal. However, these tools fell into disuse because of ethical concerns, their intensive time requirements, and the perception that the interviews could not be standardized. We have developed a short (16-minute) interview that is not aversive or threatening. In studies on 24 normotensives and 19 hypertensives, the interview elicited greater blood pressure elevations than those elicited by mathematical calculations or cold pressor (p less than 0.0001). The interview increased systolic and diastolic pressures by 38/32 mm Hg in hypertensives and 31/24 mm Hg in normotensives. The variance in BP elicited by this interview is not appreciably greater than that found in highly structured tasks such as mathematical calculations. The test-retest stability of the interview is comparable to that of resting baseline blood pressure and is superior to that of mathematical calculations or cold pressor. Techniques such as the interview may be at least as useful as highly standardized tasks and possibly more valid as models for examining cardiovascular reactivity.

Ultrasonography, HIDA scintigraphy or both in the diagnosis of acute cholecystitis?

The benefit of early surgery for patients with acute cholecystitis is now accepted but rapid accurate pre-operative diagnosis is important and the single best investigation has not yet been clearly established. All 47 patients with suspected acute cholecystitis admitted to a district general hospital during a 6 month period underwent ultrasonic examination and scintigraphy with HIDA within 48 h of admission. In 23 patients acute cholecystitis was proven. Ultrasound correctly diagnosed this in 21 patients but in 2, changes attributed to chronic cholecystitis only were detected. Two false positive ultrasound results also occurred, one in a patient with adenomyomatosis and acute pancreatitis, the other in a case of duodenitis. HIDA scan was diagnostic in 19 patients but in the remaining 4 the presence of abnormal liver function tests accounted for non-visualization of the biliary tree (a non-diagnostic result). In the absence of jaundice a HIDA scan is the more specific test for confirming acute cholecystitis.

Low-frequency voltage noise in a mammalian bone cell clone

Measurements were made of plasma membrane voltage noise in cells of a bone cell clone. The measurements were made under conditions intended to approximate in vivo conditions more closely than in previous electrical measurements on small mammalian cells. Mononucleate cells of normal size, imbedded in a collagen matrix, were used. The electrical state of the cell membrane under normal conditions was characterized by low-frequency random fluctuations (noise) of high magnitude. Hyperpolarizing spikes were observed in some cells. Power spectrum analysis revealed that the random fluctuations were actually a sum of incoherent spike patterns, with spikes of the same time width as those seen in the clearly spiking patterns. This analysis, combined with similar measurements in a high [K+], low [Na+] medium, showed that the fluctuation/spiking phenomenon resulted from modulation of K+ and Na+ transport by a control process at a level higher than that of the individual channels. This process persisted when the membrane potential was depolarized. These results indicate that the membrane potential is not part of the feedback loop producing the fluctuation/spiking phenomenon.

High bile duct cancer: incidence and pattern of investigation in the General Hospital setting

Between 1 April 1977 and 30 November 1979, 16 cases of high bile duct carcinoma presented at North Tees District Hospital, giving an incidence of one per 40000 population per annum for Teesside. Results of this prospective study emphasize the potential accuracy of preoperative assessment using techniques which should be available in a district general hospital. Ultrasound revealed the site of obstruction in every patient in whom it was used (n = 13), and often indicated a neoplastic aetiology (n = 10). Percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiography (ERC) correctly demonstrated the site of obstruction in each patient and suggested a primary bile duct carcinoma in 12 patients. Although intraoperative cholangiography gave additional information in some patients, it was not sufficiently reliable to dispense with either PTC or ERC. Histological proof of a primary bile duct carcinoma was obtained in 15 patients. In the 10 patients without obvious metastatic disease frozen section analysis was positive in 7, but was negative in 3 patients with multiple strictures where malignant cells were relatively infrequent and were found in the perineural lymphatics on paraffin sections. In this difficult group of patients the approach described eliminates the possibility of a false negative laparotomy, enables careful planning of the necessary surgical technique and also the consideration of nonoperative management.

The diagnosis of primary bile duct carcinoma (cholangiocarcinoma) in the jaundiced patient

One hundred and ten patients with obstructive jaundice were investigated in the established manner; an initial abdominal ultrasonic B scan was followed by fine needles percutaneous transhepatic cholangiography (PTC) and/or endoscopic retrograde cholangiography (ERC). This yielded 15 cases of histologically proven primary bile duct carcinoma (cholangiocarcinoma), which is an incidence of 13.6%. Primary bile duct carcinoma is suggested on ultrasonic examination by: (i) Attenuation of the ultrasound beam in the bile duct area especially if the shadowing is multiple and/or from the intrahepatic ducts. (ii) Delineation of a mass associated with the bile ducts. (iii) A high level of duct obstruction with a normal pancreatic appearance. On direct cholangiography a stricture of the duct system which is branched, short, multiple or tapering also suggests primary bile duct malignancy. It is possible to diagnose primary bile duct carcinoma on ultrasonic examination alone once this condition is recognised as occurring with significant frequency. PTC and ERC aid delineation of the extent of the tumour and exclude biliary duct stone as the cause of jaundice.

The role of upper abdominal ultrasonography in suspected acute cholecystitis

Ultrasonic investigation of the upper abdomen was performed as an initial imaging procedure in 117 consecutive patients regarded on clinical examination as probably suffering from acute cholecystitis. All patients were studied within 72 h and the majority within 48 h of admission. All were followed up for a minimum of 12 months and the ultimate clinical diagnosis recorded and compared with the initial ultrasonic diagnosis. Despite the clinical suspicion at referral, only about half were ultimately found to have biliary tract or closely related pathology. In a further 10% totally unexpected and unrelated causes for the symptoms were detected. 87% of gallstones were detected on the initial ultrasonic examination, which compares well with previously reported series. In all cases where there was a right upper quadrant mass at presentation, the organ from which this arose was demonstrated. The results of this initial study indicate that upper abdominal ultrasonic examination is a valuable inital screening procedure in patients presenting with acute right upper abdominal symptoms.

The role of diagnostic radiology in the diagnosis and management of rhabdomyosarcoma in young persons

Rhabdomyosarcoma is a rare tumour of mesenchyme-like tissue in which differentiation of rhabdomyoblasts has occurred. It is found mainly in infants and children. The prognosis, until recent years very grave, has been improved by a combination of chemotherapy and radiotherapy occasionally with surgery. Survival depends on the extent of the disease at the time of diagnosis. Diagnostic radiology has an important role to play in the demonstration of this, illustrations of which are given from a series of seven cases. The primary tumour has no pathognomonic appearances and is demonstrated essentially as a soft tissue mass lesion which displaces adjacent soft tissue structures such as arteries, veins, bladder and colon, or erodes adjacent bones whether in the extremities or the skull. The main role of diagnostic radiology is the detection of metastases. Chest radiography and skeletal survey are mandatory. Lymphangiography may reveal filling defects in regional lymph nodes but these are indistinguishable from any other metastases. Arteriography as well as revealing displacement of larger vessels, may show typical tumour neovascularity in the lesion. Serial skeletal radiographs are of help in assessing response of metastases to therapy.