Use of sentinel snails for the detection of Schistosoma haematobium transmission on Zanzibar and observations on transmission patterns

Urogenital schistosomiasis is an important public health issue in Zanzibar. Transmission of the parasite to the human population is related to the distribution of the intermediate snail host, Bulinus globosus. We measured B. globosus abundance and Schistosoma haematobium prevalence within snails in a series of naturally occurring populations and compared prevalence detected by observing cercarial shedding for patent infections, and by PCR using DraI repeat. A total of 2146 B. globosus were collected throughout the study period from 2003 to 2007; of these 85 (3.96%) were shedding cercariae. The levels of infection detected by PCR were consistently higher (40-100 percent). Levels of exposure to miracidia in the field were measured using sentinel snails. B. globosus (a susceptible host) and B. nasutus (a non-susceptible host) were placed in cages at transmission sites for 72h to observe rates of penetration by miracidia. Both B. globosus and B. nasutus tested positive for S. haematobium by PCR (up to 24% infected) indicating frequent contamination of the waterbodies with S. haematobium miracidia. The use of sentinel snails coupled with PCR diagnostics could be a sensitive tool for mapping and monitoring transmission of schistosomiasis in areas of low prevalence.

Parasitological and malacological surveys reveal urogenital schistosomiasis on Mafia Island, Tanzania to be an imported infection

To confirm the local endemicity of Schistosoma haematobium on Mafia Island, Tanzania, conjoint parasitological and malacological surveys were undertaken in July 2006 with parasitological investigations supplemented with case-history questionnaires. A total of 238 children (125 girls and 113 boys, mean age of 13.9 years) across 9 primary schools were examined. The prevalence of micro-haematuria and egg-patent infection was 18.1% (CI95=9.6-33.6) and 4.2% (CI95=1.9-7.6), respectively but a strong female bias was observed for micro-haematuria (5.6F:1M) contrasting with a strong male bias for the presence of eggs (1F:4M). All egg-patent infections were of light-intensity (<10eggs/10ml). No clear associations between infection prevalence and local water-contact, by school, were found and all 10 of the egg-positive children had a travel history to the nearby mainland or Zanzibar. Inspection of community diagnostic registers at Kilindoni Hospital revealed a low proportion (<2%) of egg-patent infection for 20,306 samples tested in the 2000-2005 period. A total of 43 freshwater sites, a third of which were previously sampled in 1999 and 2002, were surveyed and 11 species of freshwater mollusc were found. Four species of Bulinus (B. nasutus, B. forskalii, B. barthi and B. sp.) were encountered across 13 sites with B. nasutus restricted to 3 of these towards the north of the island. No collected snail was observed to shed schistosome cercariae. Further characterisation of B. nasutus and S. haematobium included infection challenge on two occasions, with miracidia obtained from egg-patent children from Mafia and Unguja islands as well as DNA barcoding of snails and schistosomes. B. nasutus was shown refractory to infection. With the substantial travel to and from Mafia, the refractory nature of local snails and evidence from DNA barcoding in schistosomes and snails, we conclude that urogenital schistosomiasis is an imported infection.

Early differential gene expression in haemocytes from resistant and susceptible Biomphalaria glabrata strains in response to Schistosoma mansoni

The outcome of infection in the host snail Biomphalaria glabrata with the digenean parasite Schistosoma mansoni is determined by the initial molecular interplay occurring between them. The mechanisms by which schistosomes evade snail immune recognition to ensure survival are not fully understood, but one possibility is that the snail internal defence system is manipulated by the schistosome enabling the parasite to establish infection. This study provides novel insights into the nature of schistosome resistance and susceptibility in B. glabrata at the transcriptomic level by simultaneously comparing gene expression in haemocytes from parasite-exposed and control groups of both schistosome-resistant and schistosome-susceptible strains, 2 h post exposure to S. mansoni miracidia, using an novel 5K cDNA microarray. Differences in gene expression, including those for immune/stress response, signal transduction and matrix/adhesion genes were identified between the two snail strains and tests for asymmetric distributions of gene function also identified immune-related gene expression in resistant snails, but not in susceptible. Gene set enrichment analysis revealed that genes involved in mitochondrial electron transport, ubiquinone biosynthesis and electron carrier activity were consistently up-regulated in resistant snails but down-regulated in susceptible. This supports the hypothesis that schistosome-resistant snails recognize schistosomes and mount an appropriate defence response, while in schistosome-susceptible snails the parasite suppresses this defence response, early in infection.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting

PURPOSE

To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting.

MATERIALS AND METHODS

Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared.

RESULTS

The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01).

CONCLUSIONS

There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Confirmed infection with intestinal schistosomiasis in semi-captive wild-born chimpanzees on Ngamba Island, Uganda

BACKGROUND

Intestinal schistosomiasis, caused by Schistosoma mansoni, is endemic to Lake Victoria, with high prevalence of the disease observed in human lakeshore communities. However, nonhuman primates have recently been overlooked as potential hosts of the disease, despite known susceptibility.

METHODS

Using a variety of stool, urine, and serological diagnostic methods, 39 semi-captive wild-born chimpanzees and 37 staff members at Ngamba Island Chimpanzee Sanctuary, Lake Victoria, Uganda, were examined for S. mansoni infection. Miracidia recovered from stool were DNA barcoded to investigate cross-over between humans and chimpanzees. The island was also surveyed for Biomphalaria intermediate host snails, which were examined for infection with S. mansoni.

RESULTS

Chimpanzees were unequivocally shown to be infected with intestinal schistosomiasis with a seroprevalence in excess of 90%. Three egg-positive cases were detected, although the sensitivity of the diagnostic tests varied due to earlier prophylactic praziquantel treatment. Miracidia hatched from chimpanzee stool revealed three DNA haplotypes commonly found in humans living throughout Lake Victoria, including staff on Ngamba Island, as well as two novel haplotypes. At one site, a snail was observed shedding schistosome cercariae.

CONCLUSIONS

The anthropozoonotic potential of intestinal schistosomiasis on Ngamba Island is greater than previously thought. Moreover, the ability of chimpanzees to void schistosome eggs capable of hatching into viable miracidia further suggests that these nonhuman primates may be capable of maintaining a local zoonotic transmission of schistosomiasis independently of humans. The implications for management of captive and wild primate populations at risk of exposure are discussed.

Prostate-specific antigen lewels in 1695 men without evidence of prostate cancer: Findings of the American cancer society national prostate cancer detection project

The American Cancer Society National Prostate Cancer Detection Project is a prospective, multidisciplinary, and multicenter trial to assess the potential for early detection of prostate cancer by transrectal ultrasonography (TRUS), digital rectal examination (DRE), and serum prostate-specific antigen assay (PSA). By November 1990, 2805 men between the ages of 55 and 70 years with no known signs or symptoms of prostate cancer were enrolled in the study, which is planned to run for 5 years. Annual TRUS, DRE, and PSA tests were done on these subjects, and biopsies were recommended for suspicious lesions when detected. To study the performance of PSA testing in presumed normal subjects, all men were eliminated who had (1) prostate cancer detected on their initial examinations and proven by biopsy or (2) cancer detected during the year or subsequent examinations. Additionally, all men with TRUS or DRE findings that were interpreted as suspicious for cancer but who are being followed and have not yet had biopsies done were removed from this series. This left a unique, extensively screened group of 1695 men who were free of prostate cancer, as far as could be determined. Analyses of the PSA levels in this large population in the appropriate age range for increasing risk of prostate cancer revealed several important findings. First, there was a direct relationship between serum PSA levels and estimated prostate volume for both the currently available monoclonal and polyclonal PSA assays. Individuals with benign prostatic hyperplasia and larger gland volume have a higher normal limit of PSA than men with normal gland volume. Second, analyses showed no relationship between age and PSA levels or between symptoms of prostatism and PSA levels independent of gland enlargement. It was concluded that volume-adjusted upper limits of normal PSA can be determined for different levels of specificity desired. This information may be applicable to the use of PSA in men not already suspected of having prostate cancer and may increase its effectiveness as a tool for early detection.

Molecular characterization of freshwater snails in the genus Bulinus: a role for barcodes?

Background

Reliable and consistent methods are required for the identification and classification of freshwater snails belonging to the genus Bulinus (Gastropoda, Planorbidae) which act as intermediate hosts for schistosomes of both medical and veterinary importance. The current project worked towards two main objectives, the development of a cost effective, simple screening method for the routine identification of Bulinus isolates and the use of resultant sequencing data to produce a model of relationships within the group.

Results

Phylogenetic analysis of the DNA sequence for a large section (1009 bp) of the mitochondrial gene cytochrome oxidase subunit 1 (cox1) for isolates of Bulinus demonstrated superior resolution over that employing the second internal transcribed spacer (its2) of the ribosomal gene complex. Removal of transitional substitutions within cox1 because of saturation effects still allowed identification of snails at species group level. Within groups, some species could be identified with ease but there were regions where the high degree of molecular diversity meant that clear identification of species was problematic, this was particularly so within the B. africanus group.

Conclusion

The sequence diversity within cox1 is such that a barcoding approach may offer the best method for characterization of populations and species within the genus from different geographical locations. The study has confirmed the definition of some accepted species within the species groups but additionally has revealed some unrecognized isolates which underlines the need to use molecular markers in addition to more traditional methods of identification. A barcoding approach based on part of the cox1 gene as defined by the Folmer primers is proposed.

Biomphalaria glabrata transcriptome: identification of cell-signalling, transcriptional control and immune-related genes from open reading frame expressed sequence tags (ORESTES)

Biomphalaria glabrata is the major intermediate snail host for Schistosoma mansoni, one of the important schistosomes infecting man. Much remains to be discovered concerning specific molecules mediating the defence events in these intermediate hosts, triggered by invading schistosomes. An expressed sequence tag (EST) gene discovery strategy known as ORESTES has been employed to identify transcripts that might be involved in snail-schistosome interactions in order to examine gene expression patterns in infected B. glabrata. Over 3930 ESTs were sequenced from cDNA libraries made from both schistosome-exposed and unexposed snails using different tissue types, producing a database of 1843 non-redundant clones. The non-redundant set has been assessed for gene ontology and KEGG pathway assignments. This approach has revealed a number of signalling, antioxidant and immune-related gene homologues that, based on current understanding of molluscan and other comparative systems, might play an important role in the molluscan defence response towards infection.

A phylogeny based on three mitochondrial genes supports the division of Schistosoma intercalatum into two separate species

Two recognized strains of Schistosoma intercalatum, one from the Democratic Republic of Congo (DRC), formerly Zaire, and the other from Cameroon, have been investigated using DNA sequences from 3 mitochondrial genes, cytochrome oxidase subunit 1 (cox1), NADH dehydrogenase subunit 6 (nad6) and the small ribosomal RNA gene (rrnS). In addition, partial DNA sequences from the nuclear large subunit ribosomal RNA gene (lsrDNA) were included within the study. Although partial lsrDNA alone reveals little taxonomic information, phylogenetic analysis of the mitochondrial data demonstrates a clear dichotomy between the 2 purported strains and it is proposed that they should be treated as distinct taxa. The 'original' S. intercalatum now falls relatively basal in the S. haematobium group, while the proposed new species is more derived and sister taxon to S. bovis and S. curassoni.

Intraoperative ultrasound of the biliary system: techniques and clinical applications

Intraoperative ultrasonography (IOUS) of the intra- and extrabepatic biliary system is being used with increased frequency in many medical centers. The value of IOUS in facilitating surgery in patients with complicated diseases of the gallbladder or with stones in the bile ducts is well recognized. However, a variety of less common diseases affect the intrahepatic ducts, many of which require sophisticated surgical techniques when resection is being undertaken. In many situations, these operations can be facilitated by the use of IOUS, both for depicting segmental and ductal anatomy, and in guiding resections and anastomoses. This report summarizes the techniques currently used for performing IOUS of the biliary system, and illustrates the spectrum of clinical applications that may require IOUS guidance.

Application of single strand conformational polymorphism (SSCP) analysis with fluorescent primers for differentiation of Schistosoma haematobium group species

To assess the utility of single-stranded conformational polymorphism (SSCP) analysis for the differentiation of schistosomes, using methods adapted for a Perkin Elmer ABI Prism 377 automated sequencer, 3 isolates of Schistosoma haematobium, 2 of S. intercalatum and single isolates of S. curassoni and S. bovis were selected for study. Two fluorescently labelled, double-stranded polymerase chain reaction products, amplified from the mitochondrial cytochrome oxidase subunit 1 (CO1) gene and the nuclear ribosomal second internal transcribed spacer (ITS2), were generated from single male and female worms. Changes in electrophoretic mobility of fragments within an SSCP profile revealed variation at individual, isolate and species levels. The mutational basis between representative SSCP profiles was confirmed by direct sequencing, demonstrating that single point substitutions were detectable. SSCP analysis has considerable potential as an alternative molecular method of identification and characterization of schistosomes. More broadly, fluorescence-based SSCP analysis is applicable to almost any gene target from any species of parasite and is a powerful molecular tool for genetic profiling.

What older people want from long-term care, and how they can get it

Seniors' long-term care preferences resemble those of younger persons with disabilities, but the two groups are treated differently. Younger persons with disabilities pursue the goal of social integration, whereas safety and efficiency receive undue emphasis and ageist differences prevail in the way older persons are served. Among the changes needed to help older consumers get what they want are empowering older persons and their agents to make better decisions, including providing them with more structure and better consumer information; revising attitudes toward safety and protection; and developing more vigorous advocacy by and for seniors.

Peroxide-enhanced anal endosonography: technique, image interpretation, and clinical applications

Because current techniques for examination and imaging of perianal fistulas tend to underestimate the extent, location, and course of perianal fistulas--information essential for decisions about surgical management--the use of hydrogen peroxide was investigated as an image-enhancing contrast agent for confirmation of the presence of and improvement in the depiction of fistulas during endoanal ultrasonography (US). After conventional endoanal US was performed with a side-fire 7.5- or 10.0-MHz rotating endoprobe, external perianal openings were cannulated and approximately 1 mL of peroxide was administered. After reinsertion of the endoprobe, the entire course of the echogenic fistula, including its relation to the internal and external sphincters and the levator ani muscle, was depicted in real time in three dimensions. This depiction of fistulas permits accurate classification, which facilitates surgical planning. In experience with more than 60 patients, peroxide-enhanced endoanal US was found to be a useful technique for documentation of the presence, number, and internal course of perianal fistulas and for characterization of abnormalities seen at endosonography performed without use of contrast enhancement. In addition, the technique permitted surgeons to stratify patients into treatment groups and has been especially useful for planning surgical treatments.

Long-term care and a good quality of life: bringing them closer together

Long-term care policies and programs in the United States suffer from a major flaw: They are balanced toward a model of nursing home care that, regardless of its technical quality, tends to be associated with a poor quality of life for consumers. This article proposes quality-of-life domains-namely, security, comfort, meaningful activity, relationships, enjoyment, dignity, autonomy, privacy, individuality, spiritual well-being, and functional competence. It argues that these kinds of quality-of-life outcomes are minimized in current quality assessment and given credence only after health and safety outcomes are considered. Five trends are reviewed that might lead to a more consumer-centered emphasis on quality of life: the disability rights movement, the emphasis on consumer direction, the growth of assisted living, increasing attention to physical environments, and efforts to bring about culture change in nursing homes. Building on these trends, the article concludes with strategies to move beyond current stalemates and polarized arguments toward forms of long-term care that are more compatible with a good quality of life.

Intraoperative ultrasound

Intraoperative ultrasound is an exciting arena for real-time depiction and evaluation of relevant anatomy and pathology. The information provided by this technique often is pivotal to the surgeon, and not infrequently impacts the nature and extent of the surgical procedure. As more radiologists develop an interest and become facile with IOUS, and as more surgeons appreciate the benefits of this modality, the numbers and applications for this technique will continue to expand. This, coupled with continued commercial and technical improvements, and increasing demand for minimally invasive surgery, ensures that the future of IOUS will be a bright one.

State-of-the-art ultrasonography is as accurate as helical computed tomography and computed tomographic angiography for detecting unresectable periampullary cancer

OBJECTIVE

To compare the ability of state-of-the-art ultrasonography with that of helical computed tomography and computed tomographic angiography in detecting unresectable periampullary cancer. In most patients periampullary cancer is unresectable because of either distant metastasis or local vascular involvement. The advent of gray scale and color Doppler ultrasonography has improved the ability of ultrasonography to detect vascular involvement.

METHODS

Twenty-three consecutive patients with periampullary cancer were enrolled for prospective staging of their disease by comparing helical computed tomography and computed tomographic angiography with gray scale and color Doppler ultrasonography of the abdomen. Portal vein, superior mesenteric vein, splenic vein, and superior mesenteric artery involvement was graded 0 to 4, grade 0 being no vascular involvement and grade 4 being total occlusion of the vessel. Agreement between ultrasonography and computed tomographic angiography for determining vascular involvement was measured by chi2 analysis.

RESULTS

Two patients (9%) were excluded because excessive overlying bowel gas hampered the ability of ultrasonography to visualize the pancreas. For the remaining 21 patients, there was significant agreement between ultrasonography and computed tomographic angiography for detecting vascular involvement in all vessels (P < .001; portal vein, kappa = 0.67; superior mesenteric vein, kappa = 0.67; splenic vein, kappa = 0.85; and superior mesenteric artery, kappa = 0.59). Ultrasonography was in agreement with computed tomographic angiography in all cases of unresectability. Both modalities were equally poor in preoperatively showing lymphadenopathy and metastases.

CONCLUSIONS

Provided that there is adequate visualization on ultrasonography of the head of the pancreas in the periampullary region, then state-of-the-art gray scale and color Doppler ultrasonography are as accurate as helical computed tomography and computed tomographic angiography for detecting the unresectability of periampullary cancer. If performed as the initial investigation and the region of the pancreatic head is clearly shown, and if vascular encasement or occlusion or distant metastasis is identified, further investigations are unnecessary.

Outcome trajectories for assisted living and nursing facility residents in Oregon

OBJECTIVE

To compare assisted living residents and nursing home residents on outcome trajectories for three outcomes: ability to perform activities of daily living (ADLs), psychological well-being, and pain and discomfort.

DATA SOURCES/STUDY SETTING

A representative sample of one-third of the census from 38 participating assisted living facilities (N = 605) and two-fifths of the census from 31 participating nursing facilities (N = 610).

STUDY DESIGN

A longitudinal design using hierarchical linear models to examine how setting (being in an assisted living setting or in a nursing home) affected growth trajectories for each outcome studied when adjusting for other resident characteristics.

DATA COLLECTION

Residents or their proxies were interviewed and chart reviews done at baseline, six months, and one year. All baseline data were collected between August 1995 and May 1996.

PRINCIPAL FINDINGS

We found differences in case mix between assisted living and nursing facility residents but no differences in outcome trajectories for ADLs, psychological well-being, and pain and discomfort. For ADLs and pain and discomfort on average, residents in both settings experienced change over the study period. For psychological well-being, residents experienced no change on average.

CONCLUSIONS

The lack of difference in growth trajectories for ADLs, pain and discomfort, and psychological well-being between the two settings was noteworthy.

Assessment in long-term care

Long-term care has begun to rely heavily on assessment as a basis for determining eligibility and payment for services, as well as for planning needed care. Mandated assessments have been introduced into nursing homes and will soon be required for home health care and rehabilitation. Many states use a formal structured assessment process to establish clients' eligibility for institutional or community-based care. The common feature of such assessment is attention to physical functioning, but other domains are also relevant, including affect, social function, cognition, pain and discomfort, and satisfaction. Taken together, this cluster is often referred to as quality of life. While some measures attempt to infer this information from clients' behavior, it is best obtained directly from clients' responses whenever possible. The other major component of a long term care assessment relates to obtaining information on clients' preferences and values. These data are important both for weighting the individual components of an assessment and for directly addressing preferences about the care and lifestyle available.

Hepatic colon cancer metastases in mice: dynamic in vivo correlation with hypoechoic rims visible at US

PURPOSE

To use videomicroscopy of tumor-bearing livers of live mice to depict tumors directly to determine the exact nature of rims seen on corresponding ultrasonographic (US) scans.

MATERIALS AND METHODS

Seventy-six hepatic colorectal cancer metastases were studied in exteriorized livers of 18 mice by using intravital microscopy, US, and histologic examination of the same tumors.

RESULTS

Hypoechoic rims correlated with distended sinusoidal spaces in vivo. These spaces surrounded only locally invasive tumors (mean diameter, 0.85 mm) that had obstructed the supplying terminal portal venules. These spaces, containing adherent leukocytes and tumor cells, gave rise to new tumor vasculature. Results of histologic examination of rims (portal inflammation, congested or compressed sinusoids, cell atrophy) correlated with leukocyte endothelial adherence, occluded sinusoids, and new vessel formation in vivo.

CONCLUSION

Unlike results from previous studies, dynamic in vivo observations of peritumoral rims demonstrated distended sinusoidal spaces giving rise to new tumor-penetrating vessels. These sinusoids arose around locally invasive tumors and were associated with more advanced intrahepatic disease. These dynamic observations provide a pathophysiologic explanation for previous histologic correlates of peritumoral rims.

Radiologic features of complications arising from dropped gallstones in laparoscopic cholecystectomy patients

OBJECTIVE

Because laparoscopic cholecystectomy has become the accepted treatment for symptomatic cholelithiasis, radiologists frequently encounter patients who have had this surgery. Although the radiologic features of postoperative bile duct injury are well documented, the imaging features of less well-known complications remain poorly described. One such unusual complication is abscess formation caused by dropped gallstones.

CONCLUSION

Although the incidence of dropped gallstones is an uncommon complication of laparoscopic cholecystectomy, it should be recognized as a potential source of both intraabdominal and intrathoracic abscess formation in any patient presenting months to years after undergoing laparoscopic cholecystectomy. These abscesses are not necessarily confined to the right upper quadrant.

Natural infection with schistosomes of the Schistosoma haematobium group in a dog in Zambia

Post-mortem examination of an adult male Jack Russell dog from Zambia revealed that it was heavily infected with schistosomes. The dog had been admitted, with a history of retching, 4 days before its death. At necropsy, the liver was found to be enlarged, with multiple pin-point yellowish-white foci scattered diffusely throughout the organ. Multiple pin-point recent and old haemorrhages were seen on the mucosal surface of the gastrointestinal tract, particularly in the stomach and proximal duodenum. Large numbers of schistosome worm pairs and eggs were found in all mesenteric, gastric and hepatic veins. Histological examination of the intestines, mesenteric lymph nodes, liver, spleen, pancreas, stomach and lungs revealed numerous strongly fibrotic, encapsulated, epithelioid-giant cell granulomata containing dead, degenerating and viable eggs. A few examples of the Splendore-Hoeppli phenomenon were also detected. The eggs collected at necropsy had a terminal spine and an average length and breadth of 187.6+/-14.1 microm and 57. 3+/-4.1 microm, respectively. DNA analysis of female worms indicated that the schistosomes were either Schistosoma haematobium or a hybrid of Schistosoma mattheei and S. haematobium.

Minimally invasive treatment of malignant hepatic tumors: at the threshold of a major breakthrough

Six existing minimally invasive techniques for the treatment of primary and secondary malignant hepatic tumors--radio-frequency ablation, microwave ablation, laser ablation, cryoablation, ethanol ablation, and chemoembolization--are reviewed and debated by noted authorities from six institutions from around the world. All of the authors currently believe that surgery remains the treatment of choice for patients with resectable hepatic tumors. However, the clinical results of each of the minimally invasive techniques presented have exceeded those obtained with conventional chemotherapy or radiation therapy. Thus, for nonsurgical patients, these techniques are becoming standard independent or adjuvant therapies. In addition, with continued improvement in technology and increasing clinical experience, one or more of these minimally invasive techniques may soon challenge surgical resection as the treatment of choice for patients with limited hepatic tumor.

Choosing an adult foster home or a nursing home: residents' perceptions about decision making and control

Representative samples of 260 Oregon foster care residents and 179 cognitively intact nursing home residents were queried retrospectively about the nature and circumstances surrounding their decision to move to a foster care or nursing home, including the alternatives they considered, the circumstances leading to the move, their perception of the decision-making process and who influenced it, the characteristics important to them in choosing the care environment, and their perception of their own control over the move. Statistically significant differences were identified in the characteristics of the setting that each group deemed important, the circumstances surrounding the decision, the people influencing it, and the perceived control over the decision.

Chronic inflammatory pseudotumor arising in the hepatobiliary-pancreatic system: progressive multisystemic organ involvement in four patients

OBJECTIVE

Inflammatory pseudotumor is a benign process that can involve most organ systems. The purpose of this report was to evaluate the imaging features of multifocal chronic inflammatory pseudotumor in four patients who presented with clinical, radiographic, and biopsy evidence of pancreatic or biliary malignancy.

CONCLUSION

To our knowledge, this is the first report in the radiology literature describing the imaging features of progressive multifocal inflammatory pseudotumor originating from a primary pancreatic or biliary focus. Even on retrospective review, no distinguishing imaging features were identified that could discriminate benign from malignant disease. These findings emphasize the importance of histopathologic analysis in the diagnosis of malignancy, particularly in patients with previously diagnosed inflammatory pseudotumor.

Goals of home care: therapeutic, compensatory, either, or both?

This article classifies home care goals into two broad categories: therapeutic goals, in which home care providers strive for measurable improvement on parameters of physical, psychological, or social functioning and compensatory (or empowering) goals, in which home care providers strive to provide services to compensate for functional impairment, thus enabling consumers to pursue their own goals. Therapeutic goals are loosely associated with "medical models" of care and compensatory goals with "social models." From a consumer perspective therapeutic and compensatory goals are important, and artificial distinctions between the two should be eliminated. However, this merger should be effected in such a way that therapeutic approaches can be incorporated into programs with relatively low unit costs.

Ethical and legal issues in long-term care: food for futuristic thought

The nursing home is a community, albeit an artificial one, where strangers come together. Ethicists are now giving thought to the nature of that community and the obligations of people within it to each other.

Staging of rectal cancer after polypectomy: usefulness of endorectal US

PURPOSE

To determine the usefulness of endorectal ultrasonography (US) in staging rectal cancer discovered at polypectomy.

MATERIALS AND METHODS

Before surgical resection, endorectal US was performed in 18 consecutive patients with adenocarcinoma discovered in polypectomy specimens. A rotating 7-10-MHz endoprobe with an inflatable balloon was used in all cases. The precise depth of penetration (T stage) was determined with endorectal US and correlated with the histopathologic findings.

RESULTS

For detection of residual tumor after polypectomy, endorectal US had a sensitivity of 100%, specificity of 44%, positive predictive value of 64%, and negative predictive value of 100%. Although the precise T stage was correctly predicted with endorectal US in only eight patients (44%), endorectal US was able to demonstrate whether the tumor was limited to the bowel wall in 16 patients (89%).

CONCLUSION

Endorectal US is an accurate technique for localizing tumors to or beyond the rectal wall in patients who have undergone diagnostic polypectomy. Although inaccuracies in determining the specific T stage may occur, endorectal US facilitates surgical planning in the vast majority of patients and should therefore remain the local staging technique of choice in this specific patient population.

Adding values: an experiment in systematic attention to values and preferences of community long-term care clients

OBJECTIVES

We tested the effects of providing case managers with tools to assess and respond to client values and preferences on their subsequent knowledge of clients' values and their practices in arranging long-term care.

METHOD

Using a quasi-experimental design with newly enrolled, cognitively intact clients, we compared case managers, clients, and care plans at the experimental and control agency.

RESULTS

Three weeks after enrollment, experimental clients were significantly more likely to report that case managers had asked them about their own preferences and offered them choices about services. Actual client values reported at the 3-month follow-up were similar for the two groups, with experimental case managers only slightly more accurate judges of their clients' responses to values questions. At follow-up, experimental case managers reported more case activity tailoring plans to client preferences, a finding confirmed by record reviews. Client acuity, measured by ADL functioning and prior hospital use, was associated with less perceived discussion of client preferences during the initial care planning process, but more case activity related to client preferences during the first three months.

DISCUSSION

The study suggests it is possible to sensitize case managers to the importance of assessing and acting on client values. Getting them to do so consistently, however, may require changes in the practice environment.

Placement of a PTFE-covered Wallstent through a 12 Fr sheath for the exclusion of a common iliac artery aneurysm

We describe a technique for transfemoral endovascular exclusion of an iliac artery aneurysm with a reconstrained polytetrafluoroethylene (PTFE)-covered Wallstent inserted through a 12 Fr sheath after right femoral artery cutdown. The procedure was successfully performed, with evidence of complete aneurysm exclusion at 4-month follow-up. This technique reduces the caliber of the introducer needed to deploy the covered Wallstent. It should be noted that because of a leak, an additional covered Palmaz stent was also deployed.

Goals for Alzheimer's care in nursing homes: what kind of differences do special care units expect to make?

Special Care Units (SCUs) for people with dementia have been enthusiastically promoted although many residents with dementia live elsewhere in their nursing home. In response to open-ended questions during personal interviews, coordinators of all 64 SCUs in Minnesota nursing homes described their goals and criteria for success. They then rated the importance of a list of possible goals and their unit's success in achieving them. Unit coordinators of 173 nursing home units in facilities with SCUs and 135 units in facilities without SCUs answered the same questions about people with dementia in their own units. When unprompted, respondents both in and outside SCUs were varied, sparse (averaging 3.1 goals per person), vague, process-oriented rather than outcome-oriented, and sometimes unrealistic. Yet, respondents later strongly endorsed most of the 24 goals the researchers suggested. ANOVA and regression analyses revealed few statistically significant differences according to unit type, although SCU coordinators were more likely to aspire to fewer medications, reduced disruptive behavior, and reduced agitation and anxiety, and were less likely to want residents to sleep through the night. Some differences were only between SCUs and non-SCUs in facilities without SCUs. Characteristics of facilities, coordinators, and case mix (e.g., proportion of dementia on the unit) were as predictive of goals and perceptions of success as SCU units. Findings reinforce the lack of conceptual clarity about expectations for direct and indirect effects of SCUs.

Comparison of the intergenic spacers and 3' end regions of the large subunit (28S) ribosomal RNA gene from three species of Schistosoma

The sequences for the entire intergenic spacer (IGS) and 3' end region of the large subunit (28S) ribosomal RNA gene are presented for Schistosoma intercalatum, S. haematobium and S. mansoni. The IGS was found to have at least 2 size formats for S. intercalatum and S. haematobium and the region for all 3 species contains numerous repeats and evidence of recombination. An A + T rich sequence found in S. intercalatum and S. haematobium is described and its possible function and origins are discussed. The amplification of this region by means of the polymerase chain reaction can be used to discriminate clearly between the 3 species involved in this study. The putative end of the 28S gene is identified.

Effects of post-hospital Medicare home health and informal care on patient functional status

OBJECTIVE

To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures.

STUDY SETTING/DATA SOURCES

Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS).

ANALYSIS

The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status.

DATA COLLECTION/EXTRACTION METHODS

Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care.

PRINCIPAL FINDINGS

More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status.

CONCLUSIONS

Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes.

Variation in state spending for long-term care: factors associated with more balanced systems

Pressures to turn over responsibility for long-term care to the states will exacerbate the already sizable difference in such efforts. This article describes the nature of the interstate variation in the types and amounts of long-term care provided under Medicaid. The average Medicaid long-term care expenditure on persons sixty-five years and older varies from $2,720 in New York to $380 in Arizona. Likewise, payments for home and community-based services (HCBS) vary from $1,180 in New York to $29 in Mississippi. Only a modest portion (28 percent) of the variance in total long-term care expenditures appears to be related to differences in population characteristics, and even less (7 percent) appears to be related to differences in HCBS expenditures. When supply factors (e.g., nursing home beds) are added, the explained variance increases to 52 percent and 17 percent, respectively. Medicare replaces some--but not most--of the difference in Medicaid home and community-based services payments.

Care-related preferences and values of elderly community-based LTC consumers: can case managers learn what's important to clients?

This article describes the development and implementation of a brief values assessment protocol to be used by case managers working in community-based long-term care (LTC) for the elderly and presents data on the values and preferences of 790 LTC clients at two locations. The importance that clients placed on selected issues related to their care (e.g., privacy, daily routines, activities, involvement of family in care, the trade-off between freedom and safety) varied as did the specific content of those issues. Associations were found between the content and strength of preferences. The work has implications for research and practice.

Observations on the early detection of prostate cancer from the American Cancer Society National Prostate Cancer Detection Project

BACKGROUND

The American Cancer Society National Prostate Cancer Detection Project (ACS-NPCDP) was established in 1987. The experience of the ACS-NPCDP demonstrates the yield and impact of periodic examinations for the early detection of prostate cancer.

METHODS

A cohort of 2999 well men ages 55-70 years was tested annually at 10 clinical centers by prostate specific antigen (PSA), transrectal ultrasound (TRUS), and digital rectal examination (DRE). Biopsies were performed on men with suspicious findings. Pathologic findings were reviewed. The initial study outcomes were the detection yield of multimodality testing and the comparative sensitivity and specificity of the different tests employed. Longer term outcomes included patient quality of life and survival.

RESULTS

The cancer detection rate declined significantly across the years of intervention. DRE had lower sensitivity than TRUS or PSA, particularly in later years of follow-up. The specificity of TRUS was lower than that of DRE. Fewer than 9% of the cancers detected in this study were clinically advanced at the time of diagnosis. Ninety-four percent of patients in whom cancer was detected are alive after an average follow-up of 54 months. In one case, death occurred after surgery. Two deaths were attributed to prostate cancer, and eleven other deaths were unrelated to prostate cancer or its treatment.

CONCLUSIONS

Results of the ACS-NPCDP indicate that a combined-modality approach to prostate cancer detection yields high levels of early detection with infrequent adverse outcomes. Continued follow-up is required to evaluate long term morbidity and mortality.

Everyday matters in the lives of nursing home residents: wish for and perception of choice and control

OBJECTIVES

This study examined the importance that nursing home residents and nursing assistants ascribed to control and choice over everyday issues, the satisfaction of residents with their control and choice over these issues, and the nursing assistants' impressions of the extent to which control and choice exist for nursing home residents on everyday matters.

DESIGN

Cross-sectional in-person interviews with a stratified representative sample of nursing home residents and nursing assistants using semi-structured interview protocols with both fixed-choice and open-ended questions.

SETTING

A random sample of 25 nursing homes in the Twin Cities, MN area; a random sample of five nursing homes in North Little Rock, AR; all five nursing homes in Sante Fe, NM; and five purposively selected nursing homes in each of New York City and Los Angeles, CA.

PARTICIPANTS

One hundred thirty-five cognitively intact residents, three from each facility, were selected and included the resident council chair, one randomly selected short-stay resident, and one randomly selected long-stay resident from each facility. Also participating were 134 nursing assistants (1 selected randomly from each shift from those employed at least two-thirds time and who had worked in the facility for at least 3 months).

MEASUREMENTS

The most important measurements were ordinal-level ratings of the importance of choice and control for nursing home residents over 10 selected areas of everyday life; ordinal measures of residents' satisfaction with their choice and control over these areas; and nursing assistants' ratings of the extent to which they thought it possible for residents to achieve choice and control. Open-ended comments were also elicited. Also measured were demographic data, ADL status, frequency of trips away from the nursing home, frequency of receiving visitors, and (for nursing assistants) length of employment, wages, job satisfaction, and extent to which they knew the residents under their care.

MAJOR RESULTS

Cognitively intact nursing home residents attach importance to choice and control over matters such as bedtime, rising time, food, roommates, care routines, use of money, use of the telephone, trips out of the nursing home, and initiating contact with a physician. Nursing assistants view such control as important to residents. Residents and staff differ significantly in the importance attached to particular items, with staff placing lower importance than residents on use of the telephone and personal expenditures and higher importance on control and choice over visitors and formal nursing home activities. Residents were not very satisfied with their control and choice, and nursing assistants viewed them as unlikely to experience control and choice. Nursing home, resident, and staff characteristics were not associated with the patterns of results.

CONCLUSIONS

A self-defeating cycle has been identified where neither resident nor staff are optimistic about achieving more resident control and choice, which both groups perceive as desirable. To end this cycle, suggestions are offered for structuring the role of the nursing assistant, physician and nurse leadership, changes in nursing home routines and practices, and public policy changes.

The substitutability of adult foster care for nursing home care in Oregon

OBJECTIVES

This study investigates the degree of substitutability of adult foster care for nursing home care in Oregon.

METHODS

Using three tests, the authors determined (1) the extent to which an additional adult foster care resident in a county reduces the number of nursing home residents in that county, (2) which characteristics of residents and facilities are important in sorting residents into either nursing homes or adult foster care facilities, and (3) the price elasticity of demand for adult foster care, using the county as the unit of observation.

RESULTS

It was found that for every additional foster care resident in a county, a nursing home loses 0.85 residents-almost a one-to-one substitution ratio.

CONCLUSIONS

Despite the high degree of substitutability, residents perceive important differences in the characteristics of the two forms of care. Indeed, private residents are, on average, willing to pay twice as much for nursing home care as for adult foster care, suggesting that these differences are important. Finally, private consumers are sensitive to price differences among adult foster care facilities. The implications for policy are discussed.

Strategies for imaging biliary neoplasms

Biliary tract neoplasms are rare, develop in either intra- or extrahepatic locations, and are represented by a spectrum of imaging characteristics. These tumors may be imaged using a variety of traditional methods, such as ERCP, PTC, ultrasound, or CT, and some newer innovative cross-sectional techniques, such as MR- or CT-cholangiography. The choice of imaging technique depends on whether the study is for diagnostic, staging, or therapeutic purposes. Because these tumors are frequently small, secondary features such as intrahepatic ductal dilatation or even hepatic metastases, may be the initial finding on screening studies. Benign tumors, postsurgical strictures, or even biliary sludge may mimic features of malignant tumors, and the radiologist must be aware of these potential sources of interpretative error.

Pitfalls and sources of error in staging rectal cancer with endorectal us

Endorectal ultrasound (US) is an accurate technique for local staging of rectal cancer. Because the choice of surgery depends on the level of tumor invasion and lymph node involvement, the surgeon relies largely on endorectal US findings when planning treatment. However, staging inaccuracies can occur due to over or underestimation of tumor depth, misinterpretation of lymph node involvement, and operator inexperience. Technical pitfalls in US of the rectal wall include proximity of the lesion to the anal verge, improper balloon inflation, a nonperpendicular imaging plane, shadowing artifacts due to air or stool, reverberation artifacts, refraction artifacts, and a transducer gain setting that is too high. Sources of error in tumor staging with endorectal US include interpretation differences, endosonologist bias, tumor location, tumor stenosis, peritumoral inflammation, postbiopsy and postsurgical changes, post irradiation changes, hemorrhage, and pedunculated or villous tumors. Node size and appearance are not reliable indicators of lymph node involvement. Awareness of these sources of error will improve the technical quality of endorectal US studies and allow more accurate tumor staging.

Intraoperative ultrasonography of the pancreas: techniques and clinical applications

Intraoperative ultrasound of the pancreas is a dynamic clinical diagnostic field providing crucial information to the surgeon at the time of exploration, and impacting on clinical management decisions and choices of surgical techniques. It is a rapid and effective technique for imaging the entire pancreas, differentiating normal from pathological processes, imaging the pancreatic and common bile ducts, and demonstrating the exact relationship between pathological processes of the pancreas and the adjacent arterial and venous structures, the common bile duct, and the duodenal wall. The demand for intraoperative ultrasound (IOUS) of the pancreas is expected to increase, particularly as management algorithms become accepted clinical practice, due to advances in intraoperative tumor ablation and radiotherapeutic techniques, as well as technical improvements in laparoscopic ultrasound methods and instrumentation. Not only is IOUS of the pancreas becoming a recognized modality for visualizing and characterizing solid and cystic lesions of the pancreas, but it also has superior lesion detection rates over other non-invasive preoperative imaging modalities. Provisional studies from our department suggest that data from IOUS significantly affects surgical decision making.

Agency approaches to common quality problems in home care: a scenario study

In a study of best practices in home care quality assurance (QA), a sample of 128 respondents from exemplary home care agencies were presented with 7 brief scenarios depicting common problems in home care quality. Agency respondents were asked to describe their likelihood of identifying the problem in each scenario, how they would identify the problem, and how they would correct it. We found that agencies expressed considerable confidence they would identify the problems, but were unlikely to view their QA efforts as contributing to detecting the problems. Identification was more often perceived to come from ordinary care, with considerable burden placed on paraprofessional staff or clients to bring the problem to the attention of the agency. Medically-oriented agencies were significantly more likely than socially-oriented to rely on formal QA to identify deteriorating patient conditions and depression. Across all agencies, a relationship existed between the type of problem in the scenario and the most frequent responses about detection and correction nodes. Once the problem was identified, agencies presented an appropriate and fairly wide range of corrective strategies. The implications for making QA more organically related to clinical care are discussed.

Case management as a force for quality assurance and quality improvement in home care

To examine the extent to which case managers engage consciously in quality assurance activities for the services they purchase or arrange, semi-structured interviews were conducted with representatives of 75 case management agencies responsible for allocating home and community-based services with public funds, and 17 private, fee-for-service case management agencies. Relatively few agencies had developed formal criteria for defining quality, or systematic ways to assess it. Several types of quality oversight provided by case managers were identified: on-site review by case managers themselves, administrative review, and independent review by quality assurance staff. This article contains examples of best practices and discusses the policy implications of having case managers adopt a more explicit and rigorous role in assuring the quality of the services their clients receive.