Orphan G-Protein Coupled Receptor GPRC5B Is Critical for Lymphatic Development

Numerous studies have focused on the molecular signaling pathways that govern the development and growth of lymphatics in the hopes of elucidating promising druggable targets. G protein-coupled receptors (GPCRs) are currently the largest family of membrane receptors targeted by FDA-approved drugs, but there remain many unexplored receptors, including orphan GPCRs with no known biological ligand or physiological function. Thus, we sought to illuminate the cadre of GPCRs expressed at high levels in lymphatic endothelial cells and identified four orphan receptors: GPRC5B, AGDRF5/GPR116, FZD8 and GPR61. Compared to blood endothelial cells, GPRC5B is the most abundant GPCR expressed in cultured human lymphatic endothelial cells (LECs), and in situ RNAscope shows high mRNA levels in lymphatics of mice. Using genetic engineering approaches in both zebrafish and mice, we characterized the function of GPRC5B in lymphatic development. Morphant gprc5b zebrafish exhibited failure of thoracic duct formation, and Gprc5b^-/- mice suffered from embryonic hydrops fetalis and hemorrhage associated with subcutaneous edema and blood-filled lymphatic vessels. Compared to Gprc5^+/+ littermate controls, Gprc5b^-/- embryos exhibited attenuated developmental lymphangiogenesis. During the postnatal period, ~30% of Gprc5b^-/- mice were growth-restricted or died prior to weaning, with associated attenuation of postnatal cardiac lymphatic growth. In cultured human primary LECs, expression of GPRC5B is required to maintain cell proliferation and viability. Collectively, we identify a novel role for the lymphatic-enriched orphan GPRC5B receptor in lymphangiogenesis of fish, mice and human cells. Elucidating the roles of orphan GPCRs in lymphatics provides new avenues for discovery of druggable targets to treat lymphatic-related conditions such as lymphedema and cancer.

Dermal Lymphatic Capillaries Do Not Obey Murray's Law

Lymphatic vessels serve as a major conduit for the transport of interstitial fluid, immune cells, lipids and drugs. Therefore, increased knowledge about their development and function is relevant to clinical issues ranging from chronic inflammation and edema, to cancer metastasis to targeted drug delivery. Murray's Law is a widely-applied branching rule upheld in diverse circulatory systems including leaf venation, sponge canals, and various human organs for optimal fluid transport. Considering the unique and diverse functions of lymphatic fluid transport, we specifically address the branching of developing lymphatic capillaries, and the flow of lymph through these vessels. Using an empirically-generated dataset from wild type and genetic lymphatic insufficiency mouse models we confirmed that branching blood capillaries consistently follow Murray's Law. However surprisingly, we found that the optimization law for lymphatic vessels follows a different pattern, namely a Murray's Law exponent of ~1.45. In this case, the daughter vessels are smaller relative to the parent than would be predicted by the hypothesized radius-cubed law for impermeable vessels. By implementing a computational fluid dynamics model, we further examined the extent to which the assumptions of Murray's Law were violated. We found that the flow profiles were predominantly parabolic and reasonably followed the assumptions of Murray's Law. These data suggest an alternate hypothesis for optimization of the branching structure of the lymphatic system, which may have bearing on the unique physiological functions of lymphatics compared to the blood vascular system. Thus, it may be the case that the lymphatic branching structure is optimized to enhance lymph mixing, particle exchange, or immune cell transport, which are particularly germane to the use of lymphatics as drug delivery routes.

Lymphatic mimicry in maternal endothelial cells promotes placental spiral artery remodeling

Molecular heterogeneity of endothelial cells underlies their highly specialized functions during changing physiological conditions within diverse vascular beds. For example, placental spiral arteries (SAs) undergo remarkable remodeling to meet the ever-growing demands of the fetus - a process which is deficient in preeclampsia. The extent to which maternal endothelial cells coordinate with immune cells and pregnancy hormones to promote SA remodeling remains largely unknown. Here we found that remodeled SAs expressed the lymphatic markers PROX1, LYVE1, and VEGFR3, mimicking lymphatic identity. Uterine natural killer (uNK) cells, which are required for SA remodeling and secrete VEGFC, were both sufficient and necessary for VEGFR3 activation in vitro and in mice lacking uNK cells, respectively. Using Flt4Chy/+ mice with kinase inactive VEGFR3 and Vegfcfl/fl Vav1-Cre mice, we demonstrated that SA remodeling required VEGFR3 signaling, and that disrupted maternal VEGFR3 signaling contributed to late-gestation fetal growth restriction. Collectively, we identified a novel instance of lymphatic mimicry by which maternal endothelial cells promote SA remodeling, furthering our understanding of the vascular heterogeneity employed for the mitigation of pregnancy complications such as fetal growth restriction and preeclampsia.

Center of pressure metrics derived from spatially registered typically developing data

BACKGROUND

Pedobarography is a commonly used testing procedure in clinical gait analysis, yet has limited roles in quantification for treatment planning, outcome assessment, and classification. Spatial registration between plantar pressure and motion capture data allows for accurate quantitative assessment and metric development based on a typically developing cohort.

RESEARCH QUESTION

This study assesses the validity of new center of pressure based metrics of anatomically registered pedobarography data by evaluating kinematic relationships over a broad spectrum of feet and by evaluating the sensitivity of these metrics to pathologies, interventions, and outcomes in two common clinical foot pathologies.

METHODS

3D trajectories from retroreflective markers were recorded to establish a single foot axis simultaneous with plantar pressure mat data spatially calibrated to a global coordinate system. Indices for clinical populations were determined as mediolateral (MLI, |MLI|, MFI) and anteroposterior (API, |API|) deviations of center of pressure excursions from typically developing feet. 198 feet were retrospectively identified to evaluate relationships between mediolateral (ML) indices and foot kinematics over a spectrum of foot pathologies. Additional feet from two broad pathologic foot types, planovalgus (PV) and cavovarus (CV), were assessed pre and post-surgery to determine sensitivity to pathology, surgical intervention, and outcomes.

RESULTS

ML indices and supination were highly correlated (r² > 0.5). Two mediolateral indices (MLI, MFI) and one anteroposterior index (|API|) demonstrated significant differences between typical and PV feet, with the MFI index also exhibiting significant improvement with surgery. All three mediolateral indices and |API| demonstrated differences between typical and cavovarus feet, with |API| significantly improving with surgery. Changes in API also correlated with patient goals.

SIGNIFICANCE

Spatial registration between plantar pressure center of pressure and motion capture data allows calculation of indices that reflect foot function and are sensitive to foot pathologies and treatment outcomes.

Author Correction: Notch signaling pathway is a potential therapeutic target for extracranial vascular malformations

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Calcitonin-Receptor-Like Receptor Signaling Governs Intestinal Lymphatic Innervation and Lipid Uptake

The absorption of dietary fat requires complex neuroendocrine-mediated regulation of chylomicron trafficking through enterocytes and intestinal lymphatic vessels. Calcitonin-receptor-like receptor (Calcrl) is a G protein-coupled receptor that can bind either a lymphangiogenic ligand adrenomedullin, with coreceptor RAMP2, or the neuropeptide CGRP, with coreceptor RAMP1. The extent to which this common GPCR controls lipid absorption via lymphatics or enteric innervation remains unclear. We used conditional and inducible genetic deletion of Calcrl in lymphatics to elucidate the pathophysiological consequences of this receptor pathway under conditions of high-fat diet. Inefficient absorption of dietary fat coupled with altered lymphatic endothelial junctions in Calcrl ^fl/fl /Prox1-CreER ^T2 mice results in excessive, transcellular lipid accumulation and abnormal enterocyte chylomicron processing and failure to gain weight. Interestingly, Calcrl ^fl/fl /Prox1-CreER ^T2 animals show reduced and disorganized mucosal and submucosal innervation. Consistently, mice with genetic loss of the CGRP coreceptor RAMP1 also displayed mucosal and submucosal innervation deficits, substantiating the CGRP-biased function of Calcrl in the neurolymphocrine axis. Thus, the common Calcrl receptor is a critical regulator of lipid absorption through its cell-specific functions in neurolymphocrine crosstalk.

Notch signaling pathway is a potential therapeutic target for extracranial vascular malformations

Notch expression has been shown to be aberrant in brain arteriovenous malformations (AVM), and targeting Notch has been suggested as an approach to their treatment. It is unclear whether extracranial vascular malformations follow the same patterning and Notch pathway defects. In this study, we examined human extracranial venous (VM) (n = 3), lymphatic (LM) (n = 10), and AV (n = 6) malformations, as well as sporadic brain AVMs (n = 3). In addition to showing that extracranial AVMs demonstrate interrupted elastin and that AVMs and LMs demonstrate abnormal α-smooth muscle actin just as brain AVMS do, our results demonstrate that NOTCH1, 2, 3 and 4 proteins are overexpressed to varying degrees in both the endothelial and mural lining of the malformed vessels in all types of malformations. We further show that two gamma secretase inhibitors (GSIs), DAPT (GSI-IX) and RO4929097, cause dose-dependent inhibition of Notch target gene expression (Hey1) and rate of migration of monolayer cultures of lymphatic endothelial cells (hLECs) and blood endothelial cells (HUVEC). GSIs also inhibit HUVEC network formation. hLECs are more sensitive to GSIs compared to HUVEC. GSIs have been found to be safe in clinical trials in patients with Alzheimer’s disease or cancer. Our results provide further rationale to support testing of Notch inhibitors in patients with extracranial vascular malformations.

hCALCRL mutation causes autosomal recessive nonimmune hydrops fetalis with lymphatic dysplasia

Using genetic, pharmacological and animal model approaches, we elucidate a novel human mutation in a G protein coupled receptor that impairs receptor oligomerization and trafficking leading to fatal, non-immune hydrops fetalis associated with arrested lymphatic development.

We report the first case of nonimmune hydrops fetalis (NIHF) associated with a recessive, in-frame deletion of V205 in the G protein–coupled receptor, Calcitonin Receptor-Like Receptor (hCALCRL). Homozygosity results in fetal demise from hydrops fetalis, while heterozygosity in females is associated with spontaneous miscarriage and subfertility. Using molecular dynamic modeling and in vitro biochemical assays, we show that the hCLR(V205del) mutant results in misfolding of the first extracellular loop, reducing association with its requisite receptor chaperone, receptor activity modifying protein (RAMP), translocation to the plasma membrane and signaling. Using three independent genetic mouse models we establish that the adrenomedullin–CLR–RAMP2 axis is both necessary and sufficient for driving lymphatic vascular proliferation. Genetic ablation of either lymphatic endothelial Calcrl or nonendothelial Ramp2 leads to severe NIHF with embryonic demise and placental pathologies, similar to that observed in humans. Our results highlight a novel candidate gene for human congenital NIHF and provide structure–function insights of this signaling axis for human physiology.

Lymphatic deletion of calcitonin receptor-like receptor exacerbates intestinal inflammation

Lymphatics play a critical role in maintaining gastrointestinal homeostasis and in the absorption of dietary lipids, yet their roles in intestinal inflammation remain elusive. Given the increasing prevalence of inflammatory bowel disease, we investigated whether lymphatic vessels contribute to, or may be causative of, disease progression. We generated a mouse model with temporal and spatial deletion of the key lymphangiogenic receptor for the adrenomedullin peptide, calcitonin receptor-like receptor (Calcrl), and found that the loss of lymphatic Calcrl was sufficient to induce intestinal lymphangiectasia, characterized by dilated lacteals and protein-losing enteropathy. Upon indomethacin challenge, Calcrl^fl/fl/Prox1-CreER^T2 mice demonstrated persistent inflammation and failure to recover and thrive. The epithelium and crypts of Calcrl^fl/fl/Prox1-CreER^T2 mice exhibited exacerbated hallmarks of disease progression, and the lacteals demonstrated an inability to absorb lipids. Furthermore, we identified Calcrl/adrenomedullin signaling as an essential upstream regulator of the Notch pathway, previously shown to be critical for intestinal lacteal maintenance and junctional integrity. In conclusion, lymphatic insufficiency and lymphangiectasia caused by loss of lymphatic Calcrl exacerbates intestinal recovery following mucosal injury and underscores the importance of lymphatic function in promoting recovery from intestinal inflammation.

A comparative perspective on longevity: the effect of body size dominates over ecology in moths

Both physiologically and ecologically based explanations have been proposed to account for among-species differences in lifespan, but they remain poorly tested. Phylogenetically explicit comparative analyses are still scarce and those that exist are biased towards homoeothermic vertebrates. Insect studies can significantly contribute as lifespan can feasibly be measured in a high number of species, and the selective forces that have shaped it may differ largely between species and from those acting on larger animals. We recorded adult lifespan in 98 species of geometrid moths. Phylogenetic comparative analyses were applied to study variation in species-specific values of lifespan and to reveal its ecological and life-history correlates. Among-species and between-gender differences in lifespan were found to be notably limited; there was also no evidence of phylogenetic signal in this trait. Larger moth species were found to live longer, with this result supporting a physiological rather than ecological explanation of this relationship. Species-specific lifespan values could not be explained by traits such as reproductive season and larval diet breadth, strengthening the evidence for the dominance of physiological determinants of longevity over ecological ones.

Docosahexaenoic Acid and Periodontitis in Adults: A Randomized Controlled Trial

Periodontitis is a common chronic inflammatory disease initiated by bacteria, resulting in bone resorption, tooth loss, and systemic inflammation. Long-chain omega-3 fatty acids such as docosahexaenoic acid (DHA) reduce periodontitis in animals. We aimed to determine whether DHA supplementation with low-dose aspirin would reduce periodontitis in humans. We conducted a double-blind placebo-controlled parallel trial lasting 3 mo. Fifty-five adults with moderate periodontitis were randomized to 2,000 mg of DHA or identical soy/corn oil capsules. All participants received 81 mg of aspirin but received no other treatments. We analyzed the primary outcome of per-pocket change in pocket depth using mixed models among teeth with pocket depth ≥5 mm. Secondary outcomes assessed with generalized estimating equations included gingival index, plaque index, and bleeding on probing. Gingival crevicular fluid samples were analyzed for changes in high-sensitivity C-reactive protein (hsCRP) and interleukins 6 and 1β (IL-6 and IL-1β). Plasma was analyzed for changes in systemic inflammatory markers, including hsCRP. We confirmed adherence with erythrocyte fatty acid measurement. Forty-six participants completed the trial. While similar at baseline, the proportion of DHA in red blood cell plasma membranes increased from 3.6% ± 0.9% to 6.2% ± 1.6% in the intervention group but did not change among controls. DHA supplementation decreased mean pocket depth (-0.29 ± 0.13; p = .03) and gingival index (-0.26 ± 0.13; p = .04). Plaque index and bleeding on probing did not change. Significant adjusted differences were found between DHA and control for both gingival crevicular fluid hsCRP (-5.3 ng/mL, standard error [SE] = 2.4, p = .03) and IL-1β (-20.1 pg/mL, SE = 8.2, p = .02) but not IL-6 (0.02 pg/mL, SE = 0.71, p = .98) or systemic hsCRP (-1.19 mg/L, SE = 0.90, p = .20). In this randomized controlled trial, aspirin-triggered DHA supplementation significantly improved periodontal outcomes in people with periodontitis, indicating its potential therapeutic efficacy (clinicaltrials.gov NCT01976806).

The operative correction of symptomatic flat foot deformities in children: the relationship between static alignment and dynamic loading

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available. We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group.

BRG1 promotes COUP-TFII expression and venous specification during embryonic vascular development

Arteries and veins acquire distinct molecular identities prior to the onset of embryonic blood circulation, and their specification is crucial for vascular development. The transcription factor COUP-TFII currently functions at the top of a signaling pathway governing venous fate. It promotes venous identity by inhibiting Notch signaling and subsequent arterialization of endothelial cells, yet nothing is known about what regulates COUP-TFII expression in veins. We now report that the chromatin-remodeling enzyme BRG1 promotes COUP-TFII expression in venous endothelial cells during murine embryonic development. Conditional deletion of Brg1 from vascular endothelial cells resulted in downregulated COUP-TFII expression and aberrant expression of arterial markers on veins. BRG1 promotes COUP-TFII expression by binding conserved regulatory elements within the COUP-TFII promoter and remodeling chromatin to make the promoter accessible to transcriptional machinery. This study provides the first description of a factor promoting COUP-TFII expression in vascular endothelium and highlights a novel role for chromatin remodeling in venous specification.

Decreased neuroautonomic complexity in men during an acute major depressive episode: analysis of heart rate dynamics

Major depression affects multiple physiologic systems. Therefore, analysis of signals that reflect integrated function may be useful in probing dynamical changes in this syndrome. Increasing evidence supports the conceptual framework that complex variability is a marker of healthy, adaptive control mechanisms and that dynamical complexity decreases with aging and disease. We tested the hypothesis that heart rate (HR) dynamics in non-medicated, young to middle-aged males during an acute major depressive episode would exhibit lower complexity compared with healthy counterparts. We analyzed HR time series, a neuroautonomically regulated signal, during sleep, using the multiscale entropy method. Our results show that the complexity of the HR dynamics is significantly lower for depressed than for non-depressed subjects for the entire night (P<0.02) and combined sleep stages 1 and 2 (P<0.02). These findings raise the possibility of using the complexity of physiologic signals as the basis of novel dynamical biomarkers of depression.

Clinical gait analysis

Technologies and techniques that have evolved to aid in the assessment of human locomotion and some of the difficulties associated with the clinical application of quantitative gait analysis are examined. The parameters used for the clinical description of gait are outlined, and examples of application of clinical gait analysis are listed. Problems encountered in measuring and assessing gait patterns are discussed. Some commercially available motion measurement systems are described. Future research directions are suggested.

Eusociality and the success of the termites: insights from a supertree of dictyopteran families

Sociality in insects may negatively impact on species richness. We tested whether termites have experienced shifts in diversification rates through time. Supertree methods were used to synthesize family-level relationships within termites, cockroaches and mantids. A deep positive shift in diversification rate is found within termites, but not in the cockroaches from which they evolved. The shift is responsible for most of their extant species richness suggesting that eusociality is not necessarily detrimental to species richness, and may sometimes have a positive effect. Mechanistic studies of speciation and extinction in eusocial insects are advocated.

World Association for the Advancement of Veterinary Parasitology (WAAVP) guidelines for evaluating the effectiveness of anthelmintics in chickens and turkeys

These guidelines have been prepared to assist in the planning, operation and interpretation of studies designed to assess the effectiveness of drugs against helminth parasites of chickens and turkeys. They are the first to be compiled under the auspices of the World Association for the Advancement of Veterinary Parasitology (WAAVP) for these parasites. The advantages and disadvantages of the widely used critical and controlled tests are discussed. Information is provided on the selection of animals for experiments, animal housing, feed, dose determination studies, confirmatory and field trials, record keeping and necropsy procedures. This document should help investigators and those involved in product approval and registration in conducting and evaluating studies concerned with determining the effectiveness and safety of anthelmintic drugs.

Physician-reviewers' perceptions and judgments about quality of care

OBJECTIVE

Although Peer Review Organizations (PROs) and researchers rely on physicians to assess quality of care, little is known about what physicians think about when they judge quality. We sought to identify features of individual cases that are associated with physicians' judgments.

DESIGN

Using 1994 Medicare data, we selected hospitalizations for 1134 beneficiaries in 42 acute care hospitals in California and Connecticut. The sample was enriched with 17 surgical and six medical complications identified using diagnosis and procedure codes. PRO physicians confirmed quality problems using a structured implicit chart review instrument and provided written open-ended comments about each case. We coded physicians' comments for factors presumed to influence judgments about quality.

RESULTS

In crude and adjusted comparisons, reviewers questioned quality more frequently in cases with serious or fatal outcomes, technical mishaps and inadequate documentation. Among surgical (but not medical) patients, they were less likely to record poor quality among patients presenting with an acute illness.

CONCLUSION

Factors other than the adequacy of key processes of care are associated with physician-reviewers' judgments about quality.

Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey

BACKGROUND

Little is known about perceptions of complementary and alternative medical (CAM) therapy relative to conventional therapy among patients who use both.

OBJECTIVE

To document perceptions about CAM therapies among persons who use CAM and conventional therapies.

DESIGN

Nationally representative, random-household telephone survey.

SETTING

The 48 contiguous U.S. states.

PARTICIPANTS

831 adults who saw a medical doctor and used CAM therapies in 1997.

MEASUREMENTS

Perceptions about helpfulness and patterns of CAM therapy use relative to conventional therapy use and reasons for nondisclosure of CAM therapies.

RESULTS

Of 831 respondents who saw a medical doctor and used CAM therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone. Of 411 respondents who reported seeing both a medical doctor and a CAM provider, 70% typically saw a medical doctor before or concurrent with their visits to a CAM provider; 15% typically saw a CAM provider before seeing a medical doctor. Perceived confidence in CAM providers was not substantially different from confidence in medical doctors. Among the 831 respondents who in the past year had used a CAM therapy and seen a medical doctor, 63% to 72% did not disclose at least one type of CAM therapy to the medical doctor. Among 507 respondents who reported their reasons for nondisclosure of use of 726 alternative therapies, common reasons for nondisclosure were "It wasn't important for the doctor to know" (61%), "The doctor never asked" (60%), "It was none of the doctor's business" (31%), and "The doctor would not understand" (20%). Fewer respondents (14%) thought their doctor would disapprove of or discourage CAM use, and 2% thought their doctor might not continue as their provider. Respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions but considered conventional care to be more helpful than CAM therapy for treatment of hypertension.

CONCLUSIONS

National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care. Adults who use both appear to value both and tend to be less concerned about their medical doctor's disapproval than about their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management.

Long-term trends in the use of complementary and alternative medical therapies in the United States

BACKGROUND

Although recent research has shown that many people in the United States use complementary and alternative medical (CAM) therapies, little is known about time trends in use.

OBJECTIVE

To present data on time trends in CAM therapy use in the United States over the past half-century.

DESIGN

Nationally representative telephone survey of 2055 respondents that obtained information on current use, lifetime use, and age at first use for 20 CAM therapies.

SETTING

The 48 contiguous U.S. states.

PARTICIPANTS

Household residents 18 years of age and older.

MEASUREMENT

Retrospective self-reports of age at first use for each of 20 CAM therapies.

RESULTS

Previously reported analyses of these data showed that more than one third of the U.S. population was currently using CAM therapy in the year of the interview (1997). Subsequent analyses of lifetime use and age at onset showed that 67.6% of respondents had used at least one CAM therapy in their lifetime. Lifetime use steadily increased with age across three age cohorts: Approximately 3 of every 10 respondents in the pre-baby boom cohort, 5 of 10 in the baby boom cohort, and 7 of 10 in the post-baby boom cohort reported using some type of CAM therapy by age 33 years. Of respondents who ever used a CAM therapy, nearly half continued to use many years later. A wide range of individual CAM therapies increased in use over time, and the growth was similar across all major sociodemographic sectors of the study sample.

CONCLUSIONS

Use of CAM therapies by a large proportion of the study sample is the result of a secular trend that began at least a half century ago. This trend suggests a continuing demand for CAM therapies that will affect health care delivery for the foreseeable future.

Use of screening and preventive services among women with disabilities

Roughly 54 million Americans have some disability; at older ages, women are more likely to be disabled than men. Many people with disabilities today live virtually normal life spans, and therefore routine screening and preventive services are essential to their overall quality of care. We used the 1994-1995 National Health Interview Survey (NHIS), with Disability, Family Resources, and Healthy People 2000 supplements, to examine screening and preventive service use for adult women with disabilities living in the community--about 18.4% of women (estimated 18.28 million). Disability was associated with higher age-adjusted rates of: poverty; living alone; low education; inability to work; obesity; and being frequently depressed or anxious. Disabled women generally reported screening and preventive services at rates comparable to all women. Women with major lower extremity mobility difficulties had much lower adjusted odds of Papanicolaou smears (odds ratio, 0.6; 95% confidence interval, 0.4-0.9), mammograms (odds ratio, 0.7; 95% confidence interval, 0.5-0.9), and smoking queries (odds ratio, 0.6; 95% confidence interval, 0.5-0.8). Various approaches exist to improve access for disabled women to health care services.

Are aggressive treatment strategies less cost-effective for older patients? The case of ventilator support and aggressive care for patients with acute respiratory failure

OBJECTIVES

A common assumption is that life-sustaining treatments are much less cost-effective for older patients than for younger patients. We estimated the incremental cost-effectiveness of providing mechanical ventilation and intensive care for patients of various ages who had acute respiratory failure.

DESIGN

Retrospective analysis of data on acute respiratory failure from Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

SETTING

Acute hospital.

PARTICIPANTS

1,005 with acute respiratory failure; 963 received ventilator support and 42 had ventilator support withheld.

MEASUREMENTS

We studied 1,005 patients enrolled in a five-center study of seriously ill patients (SUPPORT) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or = 10) requiring ventilator support. For cost-effectiveness analyses, we estimated life expectancy based on long-term follow-up of SUPPORT patients and estimated utilities (quality-of-life weights) using time-tradeoff questions. We used hospital fiscal data and Medicare data to estimate healthcare costs. We divided patients into three age groups (< 65, 65-74, and > or = 75 years); for each age group, we performed separate analyses for patients with a < or = 50% probability of surviving at least 2 months (high-risk group) and those with a > 50% probability of surviving at least 2 months (low-risk group).

RESULTS

Of the 963 patients who received ventilator support, 44% were female; 48% survived 6 months; and the median (25th, 75th percentile) age was 63 (46, 75) years. For the 42 patients for whom ventilator support was withheld, the median survival was 3 days. For low-risk patients (> 50% estimated 2-month survival), the incremental cost (1998 dollars) per quality-adjusted life-year (QALY) saved by providing ventilator support and aggressive care increased across the three age groups ($32,000 for patients age < 65, $44,000 for those age 65-74, and $46,000 for those age > or = 75). For high-risk patients, the incremental cost-effectiveness was much less favorable and was least favorable for younger patients ($130,000 for patients age < 65, $100,000 for those age 65-74, and $96,000 for those age > or = 75). When we varied our assumptions from 50% to 200% of our baseline estimates in sensitivity analyses, results were most sensitive to the costs of the index hospitalization.

CONCLUSIONS

For patients with relatively good short-term prognoses, we found that ventilator support and aggressive care were economically worthwhile, even for patients 75 years and older. For patients with poor short-term prognoses, ventilator support and aggressive care were much less cost-effective for adults of all ages.

Perceptions of human immunodeficiency virus and sexually transmitted disease risk among low-income adults: a pilot study

Sexual risk-taking research and subsequent intervention programs have focused almost exclusively on adolescents and men who have sex with men. In comparison, less research has been conducted into adult heterosexual risk-taking behavior. The purposes of this pilot study were to test a survey instrument, assess how low-income adults perceive their risk of human immunodeficiency virus (HIV) and sexually transmitted disease (STD) infection, and determine the degree to which condom use is a function of age. The Health Belief Model was used to guide the development of the survey instrument. In the Health Belief Model, age is a mediating factor that influences a person's likelihood to take action to change his or her lifestyle. Respondents perceived that their vulnerability to infection declined because of increased age and decreased frequency of coitus. Condom use was found to significantly decline as the age of the respondents increased. Although this is only a pilot study, the findings highlight the need for HIV and STD education for all age groups and genders.

Mobility difficulties are not only a problem of old age

BACKGROUND

Lower extremity mobility difficulties often result from common medical conditions and can disrupt both physical and emotional well-being.

OBJECTIVES

To assess the national prevalence of mobility difficulties among noninstitutionalized adults and to examine associations with demographic characteristics and other physical and mental health problems.

DESIGN

Cross-sectional survey using the 1994-1995 National Health Interview Survey-Disability Supplement (NHIS-D). We constructed measures of minor, moderate, and major lower extremity mobility difficulties using questions about ability to walk, climb stairs, and stand, and use of mobility aids (e.g., canes, wheelchairs). Age and gender adjustment used direct standardization methods in Software for the Statistical Analysis of Correlated Data (SUDAAN).

PARTICIPANTS

Noninstitutionalized, civilian U.S. residents aged 18 years and older. National Health Interview Survey sampling weights with SUDAAN provided nationally representative population estimates.

RESULTS

An estimated 19 million people (10.1%) reported some mobility difficulty. The mean age of those with minor, moderate, or major difficulty ranged from 59 to 67 years. Of those reporting major difficulties, 32% said their problems began at aged 50 years or younger. Adjusted problem rates were higher among women (11.8%) than men (8.8%), and higher among African American (15.0%) than whites (10.0%). Persons with mobility difficulties were more likely to be poorly educated, living alone, impoverished, obese, and having problems conducting daily activities. Among persons with major mobility difficulties, 30.6% reported being frequently depressed or anxious, compared to 3.8% for persons without mobility difficulties.

CONCLUSIONS

Reports of mobility difficulties are common, including among middle-aged adults. Associations with poor performance of daily activities, depression, anxiety, and poverty highlight the need for comprehensive care for persons with mobility problems.

An evaluation of the posterior leaf spring orthosis using joint kinematics and kinetics

The primary function of the posterior leaf spring orthosis (PLS) is to prevent excessive equinus or drop foot in swing. The name of the orthosis, posterior leaf "spring," suggests that it also mechanically augments push-off in stance. The purpose of this study was to determine the effect of the PLS on ankle function by using computerized gait-analysis techniques. Multiple barefoot versus brace walks were compared in 31 children with cerebral palsy. Results indicate that the PLS reduces excessive equinus in swing and is sufficiently flexible to allow ankle dorsiflexion in midstance. In terminal stance, the peak power-generating capabilities of the ankle were reduced when the child was wearing the PLS. Energy results indicate that more mechanical energy was absorbed during midstance and less produced during terminal stance with the PLS. Therefore, the PLS improved ankle function but did not augment ankle function through storage and return of mechanical, or spring, energy.

Preferences for cardiopulmonary resuscitation

PURPOSE

To examine nurse-patient communication about preferences for cardiopulmonary resuscitation (CPR).

DESIGN

Prospective cohort. Sampled were patients and nurses caring for patients enrolled in SUPPORT (1989-91), a multicenter study of seriously-ill hospitalized adults at four U.S. hospitals.

METHODS

Information about patient preferences was obtained by interviews with patients and their designated surrogates. For selected patients, nurses were interviewed prospectively about their understanding of patients' preferences and whether they discussed these preferences with their patients. Nurse demographic information was obtained by questionnaire. Additional patient data were obtained by interview and chart review. Logistic regression was used to identify independent correlates of nurse-patient communication and nurses' understanding of patients' preferences.

FINDINGS

For 1,763 study patients, 1,427 nurse interviews (response rate 81%) were obtained. The median age of interviewed nurses was 29 years; 96% were women, 68% had a bachelor's or master's degree, and 62% had worked for 5 years or more as a nurse. Nurses reported discussions about CPR with 13% of their patients, and these discussions were more likely if the nurse thought the patient did not want CPR (adjusted odds ratio [AOR] 2.68; 95% CI 1.84 to 3.90), if the nurse had spent more time with the patient (AOR 1.05; 95% CI 1.02 to 1.08) per 5 additional days, if the patient had metastatic cancer (AOR 3.56; 95% CI 1.86 to 6.78), or if the patient was in an intensive care unit at the time of study entry (AOR 2.08; 95% CI 1.26 to 3.42). Diagnosis and study site were also associated with nurses' reports of discussions with patients. Of 551 patients with available data, 58% (n = 317) wanted CPR and 30% (n = 164) did not. Nurses understood patients' CPR preferences correctly for 74% of the patients. Nurses were more likely to understand patients' preferences to forego CPR if the patient was 75 years of age or older (AOR 6.6; 95% CI 2.0 to 22.0) or if the nurse and patient had discussed the patient's preferences (AOR 25.3; 95% CI 6.5 to 98.6) or if the patient had cancer (AOR 10.9; 95% CI 2.3 to 50.1). Nurses' understanding of patients' preferences for CPR was no better than that of physicians or patients' surrogate decision-makers.

CONCLUSIONS

In this sample of seriously ill hospitalized adults, discussions between patients and nurses about CPR were infrequent. Nurses' understanding of patients' preferences for care was similar to that of physicians and patients' surrogate decision-makers. Educational interventions should focus on increasing the frequency of nurse-patient discussions about end-of-life care and improving nurses' understanding of patients' preferences for care.

Brief communication: detecting depression: providing high quality primary care for HIV-infected patients

Depression is common among HIV-infected patients, but little is known about risk factors for depression in this population. Several studies before protease inhibitors became available have reported inconsistent associations between depression and disease severity. Delivering high quality HIV care includes adequate detection and treatment of depression. The objective of this study was to describe the prevalence and correlates of depression among a contemporary group of HIV-infected patients. The setting and design for the study was a chart abstraction for HIV-infected patients in a primary care practice in Boston, Mass, in June 1997. Among 275 HIV-infected patients, depression was documented in 147 patient charts (53%), half of whom (n = 73, 27%) also received antidepressant medications. We used multivariable logistic regression to identify risk factors for depression among patients with both a chart diagnosis of depression and current antidepressant medication use. We observed increased risk of depression among patients with a history of substance use (odds ratio 2.7, 95% confidence interval 1.5-4.7), recent medical hospitalization (2.6, 1.4-5.0), and homosexual risk behavior (2.1, 1.1-4.2). Depression remains a common problem for HIV-infected patients, particularly among those with history of substance abuse, medical hospitalization, or homosexual risk behavior. Routine screening for depression in this population with special attention to those at higher risk may offer opportunities for earlier diagnosis and treatment.

Relationship between smoking and weight control efforts among adults in the united states

BACKGROUND

The effect of weight control concerns on smoking among adults is unclear. We examined the association between smoking behavior and weight control efforts among US adults.

METHODS

A total of 17 317 adults responded to the Year 2000 Supplement of the 1995 National Health Interview Survey (83% combined response rate). Respondents provided sociodemographic and health information, including their smoking history and whether they were trying to lose weight, maintain weight, or gain weight.

RESULTS

Rates of smoking were lower among adults who were trying to lose or maintain weight than among those not trying to control weight (25% vs 31%; P<.001). After adjustment for sex, race, education, income, marital status, region of the country, and body mass index, the relationship between trying to lose weight and current smoking varied according to age. Among adults younger than 30 years, those trying to lose weight were more likely to smoke currently (odds ratio, 1.36 [95% confidence interval, 1.09-1.70]), whereas older adults trying to lose weight were as likely or less likely to smoke compared with adults not trying to control weight. After adjustment, smokers of all ages who were trying to lose weight were more likely to express a desire to quit smoking. Results were similar after stratification by sex and body mass index.

CONCLUSIONS

Adults younger than 30 years are more likely to smoke if they are trying to lose weight. However, smokers of all ages who are trying to lose weight are more likely to want to stop smoking. Patients' weight control efforts should not discourage clinicians from counseling about smoking cessation. Education about smoking and healthy weight control methods should target young adults.

Physician views on caring for hospitalized patients and the hospitalist model of inpatient care

We surveyed 241 board-certified internists affiliated with a large teaching hospital (Boston, Mass) before implementing a hospitalist service to determine attitudes towards providing inpatient care and the hospitalist model. Of physicians surveyed, 66% responded. Most disagreed that inpatient care is "an inefficient use of my time," only 10% felt a hospitalist service would improve patient satisfaction, and 54% felt it would hurt patient-doctor relationships. Multivariable analyses suggest that physicians physically furthest from their inpatient site were had more favorable attitudes toward the hospitalist model; more experienced and busier physicians were more negative. Future investigations should determine strategies for implementing the hospitalist model which address physicians' concerns.

The use of complementary and alternative therapies to treat anxiety and depression in the United States

OBJECTIVE

This study presents data on the use of complementary and alternative therapies to treat anxiety and depression in the United States.

METHOD

The data came from a nationally representative survey of 2,055 respondents (1997-1998) that obtained information on the use of 24 complementary and alternative therapies for the treatment of specific chronic conditions.

RESULTS

A total of 9.4% of the respondents reported suffering from "anxiety attacks" in the past 12 months; 7.2% reported "severe depression." A total of 56.7% of those with anxiety attacks and 53.6% of those with severe depression reported using complementary and alternative therapies to treat these conditions during the past 12 months. Only 20.0% of those with anxiety attacks and 19.3% of those with severe depression visited a complementary or alternative therapist. A total of 65.9% of the respondents seen by a conventional provider for anxiety attacks and 66.7% of those seen by a conventional provider for severe depression also used complementary and alternative therapies to treat these conditions. The perceived helpfulness of these therapies in treating anxiety and depression was similar to that of conventional therapies.

CONCLUSIONS

Complementary and alternative therapies are used more than conventional therapies by people with self-defined anxiety attacks and severe depression. Most patients visiting conventional mental health providers for these problems also use complementary and alternative therapies. Use of these therapies will likely increase as insurance coverage expands. Asking patients about their use could prevent adverse effects and maximize the usefulness of therapies subsequently proven to be effective.

Inability of an "energy transfer diagnostician" to distinguish between fertile and infertile women

CONTEXT

Various forms of "energy healing" have become popular in the United States.

OBJECTIVE

To test the assertion that an energy healer can, without physical contact, distinguish the presence or absence of internal organ pathology in individuals who lack overt physical findings.

DESIGN

Observational randomized study, in which we tested the assertion by a well-recognized alternative healer that he had particular skill in using energy transfer to detect the presence or absence of fertility disorders in women.

PATIENTS

Convenience sample of 37 women, 28 of whom had documented pathology resulting in infertility, and 9 of whom were fertile.

OUTCOMES

The healer was provided with no medical history and performed diagnostic evaluations without physical contact with the blindfolded, clothed, and silent subjects. We compared to random chance the ability of the healer to establish a diagnosis of fertility or fertility disorder.

SETTING

Teaching hospital.

MAIN RESULTS

The healer was unable to distinguish the presence or absence of fertility disorders in the study subjects.

CONCLUSION

This study points to further need for fair yet rigorous assessment of claims that energy transfer can lead to accurate clinical diagnoses.

A review of current weight management: research and recommendations

PURPOSE

To review current research and recommendations on weight loss and weight control and provide suggestions for health care providers who furnish weight management counseling.

DATA SOURCES

Scientific publications, clinical guidelines, and government sources.

CONCLUSIONS

Research reaffirms the long-held understanding that weight loss can be accomplished only through a reduction in the number of calories consumed and an increase in exercise. Weight maintenance requires life-long behavioral change combining moderate exercise, lower fat intake, increased fruit and vegetable consumption, as well as social support. Fad diets and medications are not the answer to long-term weight maintenance.

IMPLICATIONS FOR PRACTICE

The essential components of a weight loss or weight management program include: calorie reduction of 300-500 calories per day, appropriate exercise, variety in food choices, increased consumption of grains, fruits, and vegetables, and reduction of fat to no more than 30% of daily calories. Clients should be referred to dietitian and exercise consultants as needed.

Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

OBJECTIVES

The goal of this study was to determine factors associated with receiving cardiologist care among patients with an acute exacerbation of congestive heart failure.

BACKGROUND

Because cardiologist care for acute cardiovascular illness may improve care, barriers to specialty care could impact patient outcomes.

METHODS

We studied 1,298 patients hospitalized with acute exacerbation of congestive heart failure who were cared for by cardiologists or generalist physicians. Using multivariable logistic models we determined factors independently associated with attending cardiologist care.

RESULTS

Patients were less likely to receive care from a cardiologist if they were black (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.35, 0.80), had an income of less than $11,000 (AOR 0.65, 95% CI 0.45, 0.93) or were older than 80 years of age (AOR 0.23, 95% CI 0.12, 0.46). Patients were more likely to receive cardiologist care if they had college level education (AOR 1.89, 95% CI 1.02, 3.51), a history of myocardial infarction (AOR 1.59, 95% CI 1.17, 2.16), a serum sodium less than 133 on admission (AOR 1.96, 95% CI 1.30, 2.95) or a systolic blood pressure less than 90 on admission (AOR 1.97, 95% CI 1.20, 3.24). Patients who stated a desire for life extending care were also more likely to receive care from a cardiologist (AOR 1.40, 95% CI 1.04, 1.90).

CONCLUSIONS

After adjusting for severity of illness and patient preferences for care, patient sociodemographic factors were strongly associated with receiving care from a cardiologist. Future investigations are required to determine whether these associations represent unmeasured preferences for care or inequities in our health care system.

Outcomes and cost-effectiveness of ventilator support and aggressive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome

PURPOSE

Many patients with acute respiratory failure die despite prolonged and costly treatment. Our objective was to estimate the cost-effectiveness of providing rather than withholding mechanical ventilation and intensive care for patients with acute respiratory failure due to pneumonia or acute respiratory distress syndrome.

SUBJECTS AND METHODS

We studied 1,005 patients enrolled in a five-center study of seriously ill patients (the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments [SUPPORT]) with acute respiratory failure (pneumonia or acute respiratory distress syndrome and an Acute Physiology Score > or =10) who required ventilator support. We estimated life expectancy based on long-term follow-up of SUPPORT patients. Utilities were estimated using time-tradeoff questions. Costs (in 1998 dollars) were based on hospital fiscal data and Medicare data.

RESULTS

Of the 963 patients who received ventilator support, 48% survived for at least 6 months. At 6 months, survivors reported a median of 1 dependence in activities of daily living, and 72% rated their quality of life as good, very good, or excellent. Among the 42 patients in whom ventilator support was withheld, the median survival was 3 days. Among patients whose estimated probability of surviving at least 2 months from the time of ventilator support ("prognostic estimate") was 70% or more, the incremental cost per quality-adjusted life-year (QALY) saved by providing rather than withholding ventilator support and aggressive care was $29,000. For medium-risk patients (prognostic estimate 51% to 70%), the incremental cost-effectiveness was $44,000 per QALY, and for high-risk patients (prognostic estimate < or =50%), it was $110,000 per QALY. When assumptions were varied from 50% to 200% of baseline estimates, the results ranged from $19,000 to $48,000 for low-risk patients, from $29,000 to $76, 000 for medium-risk patients, and from $67,000 to $200,000 for high-risk patients.

CONCLUSIONS

Ventilator support and intensive care for acute respiratory failure due to pneumonia or acute respiratory distress syndrome are relatively cost-effective for patients with >50% probability of surviving 2 months. However, for patients with an expected 2-month survival < or =50%, the cost per QALY is more than threefold greater at >$100,000.

Does a physician's ability to accurately assess the likelihood of pulmonary embolism increase with training?

PURPOSE

Pulmonary embolism (PE), an elusive diagnosis, is detected by a diagnostic work-up that is often guided by the physician's level of clinical suspicion. The ability to accurately assess PE risk on solely clinical grounds may increase with the physician's level of training. This study documented the ability of house staff practicing in an academic teaching hospital to accurately assess the clinical likelihood of PE in patients.

METHOD

During a seven-month period, all 245 patients with suspected acute PE who had had lung scans ordered via a computerized order-entry system were enrolled in the study. When ordering the lung scans, all physicians (interns, residents, and attending physicians) were required to also enter their levels of clinical suspicion on a scale of 0 to 100. The physicians' levels of clinical suspicion were correlated with the final determinations of PE, and receiver operating characteristic (ROC) curves were calculated for patients' and physicians' subgroups.

RESULTS

Attending physicians were most able to diagnose PE; residents were moderately able to make the diagnosis, and interns were least able to diagnose PE. The area under the ROC curve for a correct identification of patients with PE was greatest for attending physicians (0.839), intermediate for residents (0.601), and least for interns (0.594).

CONCLUSION

The ability to correctly assess a patient's likelihood of PE increases with a physician's level of training, suggesting that more senior physicians should be involved in the diagnostic work-up of patients with suspected acute PE. More instruction may help medical students, interns, and residents navigate clinical scenarios in which the diagnosis is uncertain or in which sequential tests must be performed to reach the correct diagnosis.

Baby CareLink: using the internet and telemedicine to improve care for high-risk infants

OBJECTIVE

To evaluate an Internet-based telemedicine program designed to reduce the costs of care, to provide enhanced medical, informational, and emotional support to families of very low birth weight (VLBW) infants during and after their neonatal intensive care unit (NICU) stay.

BACKGROUND

Baby CareLink is a multifaceted telemedicine program that incorporates videoconferencing and World Wide Web (WWW) technologies to enhance interactions between families, staff, and community providers. The videoconferencing module allows virtual visits and distance learning from a family's home during an infant's hospitalization as well as virtual house calls and remote monitoring after discharge. Baby CareLink's WWW site contains information on issues that confront these families. In addition, its security architecture allows efficient and confidential sharing of patient-based data and communications among authorized hospital and community users.

DESIGN/METHODS

A randomized trial of Baby CareLink was conducted in a cohort of VLBW infants born between November 1997 and April 1999. Eligible infants were randomized within 10 days of birth. Families of intervention group infants were given access to the Baby CareLink telemedicine application. A multimedia computer with WWW browser and videoconferencing equipment was installed in their home within 3 weeks of birth. The control group received care as usually practiced in this NICU. Quality of care was assessed using a standardized family satisfaction survey administered after discharge. In addition, the effect of Baby CareLink on hospital length of stay as well as family visitation and interactions with infant and staff were measured.

RESULTS

Of the 176 VLBW infants admitted during the study period, 30 control and 26 study patients were enrolled. The groups were similar in patient and family characteristics as well as rates of inpatient morbidity. The CareLink group reported higher overall quality of care. Families in the CareLink group reported significantly fewer problems with the overall quality of care received by their family (mean problem score: 3% vs 13%). In addition, CareLink families also reported greater satisfaction with the unit's physical environment and visitation policies (mean problem score: 13% vs 50%). The frequency of family visits, telephone calls to the NICU, and holding of the infant did not differ between groups. The duration of hospitalization until ultimate discharge home was similar in the 2 groups (68.5 +/- 28.3 vs 70.6 +/- 35.6 days). Among infants born weighing <1000 g (n = 31) there was a tendency toward shorter lengths of stay (77.4 +/- 26.2 vs 93.1 +/- 35.6 days). All infants in the CareLink group were discharged directly to home whereas 6/30 (20%) of control infants were transferred to community hospitals before ultimate discharge home.

CONCLUSIONS

CareLink significantly improves family satisfaction with inpatient VLBW care and definitively lowers costs associated with hospital to hospital transfer. Our data suggest the use of telemedicine and the Internet support the educational and emotional needs of families facilitating earlier discharge to home of VLBW infants. We believe that further extension of the Baby CareLink model to the postdischarge period will significantly improve the coordination and efficiency of care.

Mobility problems and perceptions of disability by self-respondents and proxy respondents

BACKGROUND

The Americans With Disabilities Act defines disability on the basis of physical or mental impairments or external perceptions of impairment.

OBJECTIVES

The objective of this study was to examine perceptions of disability among people with lower-extremity mobility difficulties.

RESEARCH DESIGN

This study used a cross-sectional, nationally representative survey, the 1994 to 1995 National Health Interview Survey-Disability (NHIS-D) supplement. Using SAS-callable SUDAAN for all analyses, we produced national population estimates.

SUBJECTS

This study included 142,572 noninstitutionalized, civilian residents of the United States who were > or =18 years of age, with 80,423 self-respondents and 49,883 proxy respondents.

MEASURES

We created a 4-level mobility variable using NHIS-D questions about the ability to walk, climb stairs, stand and the use of mobility aids. We examined associations between mobility and answers to 2 questions about self- and external perceptions of disability.

RESULTS

The results showed that 3.1% (estimated 5.82 million persons) reported major mobility difficulties, including 3.7% of self-respondents and 2.7% of those with proxy respondents. Among persons with major mobility problems, 70.8% perceived themselves as disabled, whereas 64.8% thought other people see them as disabled. Also, 80.5% of manual wheelchair users saw themselves as disabled. Proxies were somewhat more likely to perceive disability than self-respondents, although differences were not generally statistically significant. In multivariable regressions, mobility level was the strongest predictor of self-perceived disability, followed by general health status.

CONCLUSIONS

Mobility problems increase the likelihood that people will see themselves as disabled, but these perceptions are not universal. Although the schematic of wheelchair users has become an international symbol of disability, many people with serious mobility problems do not view themselves as disabled.

An examination of the knee function during gait in children with myelomeningocele

In this retrospective study, 37 patients with myelomeningocele who had undergone gait analysis were examined. Patients were divided into groups based on the level of involvement (29 sides: L4; 26 sides: L5; 19 sides: S1-2). Results showed increased knee flexion and associated knee extensor moments with increasing level of neurologic involvement. The mean coronal plane knee position in stance was normal in all groups and not related to coronal plane knee moment. However, there was an increased incidence of a net knee adductor moment in stance with increasing involvement (mean, 0.02 +/-0.18 N.m/kg for the L4 group). The presence of a visual valgus thrust based on video records was not reliable in predicting an abnormal knee coronal plane moment. An abnormal knee adductor moment in stance was most highly related to coronal plane trunk motion (r = -0.62) and not tibial torsion (r = -0.340). Increased transverse plane range of motion of the knee was most highly related to transverse plane trunk motion (r = 0.67).

Does clinical evidence support ICD-9-CM diagnosis coding of complications?

BACKGROUND

Hospital discharge diagnoses, coded by use of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), increasingly determine reimbursement and support quality monitoring. Prior studies of coding validity have investigated whether coding guidelines were met, not whether the clinical condition was actually present.

OBJECTIVE

To determine whether clinical evidence in medical records confirms selected ICD-9-CM discharge diagnoses coded by hospitals.

RESEARCH DESIGN AND SUBJECTS

Retrospective record review of 485 randomly sampled 1994 hospitalizations of elderly Medicare beneficiaries in Califomia and Connecticut.

MAIN OUTCOME MEASURE

Proportion of patients with specified ICD-9-CM codes representing potential complications who had clinical evidence confirming the coded condition.

RESULTS

Clinical evidence supported most postoperative acute myocardial infarction diagnoses, but fewer than 60% of other diagnoses had confirmatory clinical evidence by explicit clinical criteria; 30% of medical and 19% of surgical patients lacked objective confirmatory evidence in the medical record. Across 11 surgical and 2 medical complications, objective clinical criteria or physicians' notes supported the coded diagnosis in >90% of patients for 2 complications, 80% to 90% of patients for 4 complications, 70% to <80% of patients for 5 complications, and <70% for 2 complications. For some complications (postoperative pneumonia, aspiration pneumonia, and hemorrhage or hematoma), a large fraction of patients had only a physician's note reporting the complication.

CONCLUSIONS

Our findings raise questions about whether the clinical conditions represented by ICD-9-CM codes used by the Complications Screening Program were in fact always present. These findings highlight concerns about the clinical validity of using ICD-9-CM codes for quality monitoring.

Use of administrative data to find substandard care: validation of the complications screening program

OBJECTIVE

The use of administrative data to identify inpatient complications is technically feasible and inexpensive but unproven as a quality measure. Our objective was to validate whether a screening method that uses data from standard hospital discharge abstracts identifies complications of care and potential quality problems.

DESIGN

This was a case-control study with structured implicit physician reviews.

SETTING

Acute-care hospitals in California and Connecticut in 1994.

PATIENTS

The study included 1,025 Medicare beneficiaries greater than 265 years of age.

METHODS

Using administrative data, we stratified acute-care hospitals by observed-to-expected complication rates and randomly selected hospitals within each state. We randomly selected cases flagged with 1 of 17 surgical complications and 6 medical complications. We randomly selected controls from unflagged cases.

MAIN OUTCOME MEASURE

Peer-review organization physicians' judgments about the presence of the flagged complication and potential quality-of-care problems.

RESULTS

Physicians confirmed flagged complications in 68.4% of surgical and 27.2% of medical cases. They identified potential quality problems in 29.5% of flagged surgical and 15.7% of medical cases but in only 2.1% of surgical and medical controls. The rate of physician-identified potential quality problems among flagged cases exceeded 25% in 9 surgical screens and 1 medical screen. Reviewers noted several potentially mitigating circumstances that affected their judgments about quality, including factors related to the patients' illness, the complexity of the case, and technical difficulties that clinicians encountered.

CONCLUSIONS

For some types of complications, screening administrative data may offer an efficient approach for identifying potentially problematic cases for physician review. Understanding the basis for physicians' judgments about quality requires more investigation.

Identification of in-hospital complications from claims data. Is it valid?

OBJECTIVES

This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital.

METHODS

We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California.

RESULTS

Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record. For 13% of the surgical cases and 58% of the medical cases, the condition represented by the code was judged to be present on admission rather than occurring in-hospital. The positive predictive value of the claim was greater than 80% for the surgical risk pool, suggesting the value of the CSP as a screening tool.

CONCLUSIONS

The CSP has validity as a screen for most surgical complications but only for 1 medical complication. The CSP does not have validity as a "stand-alone" tool to identify more than a few in-hospital surgery-related events. The addition of an indicator to the Medicare claim to capture the timing of secondary diagnoses would improve the validity of the CSP for identifying both surgical and medical in-hospital events.

Patient-centered quality measures for Asian Americans: research in progress

We aim to develop and validate a questionnaire that examines quality of care from the patient's perspective for limited-English-proficient Asian Americans (AA) of Chinese and Vietnamese descent. We will conduct focus groups of patients to identify issues important to them, with an emphasis on communication and access to care. We will then draft a questionnaire and test its validity using standard survey research methods and direct observation of patient-provider encounters. Subsequent field testing will involve face-to-face patient interviews 1 month after an outpatient visit. We will evaluate alternate modes of administration to test feasibility and to maximize response. The result of our study will be a validated, culturally sensitive, patient-centered instrument that measures health care quality for limited-English-proficient AA patients. Our research will provide a template for developing future quality measures for other vulnerable populations.

How to create an effective scientific exhibit: analysis of award-winning exhibits from the 1998 RSNA meeting

Although the most important component of an effective scientific exhibit is content, the way in which an exhibit is constructed can greatly influence its overall effectiveness. Choice of format should be determined by carefully analyzing the purpose of one's exhibit, expected audience, and data at hand, as well as type of meeting and funding. Depending on the type of data to be presented and available equipment and budget, the most appropriate style for a scientific exhibit may be a traditional mat board, computer-generated tiles or large-print backboard panel, traditional mat board with viewbox exhibit, matted transparency tiles with viewbox exhibit, or computer-generated large-film display. The authors analyzed 993 of 1, 041 (95.4%) scientific exhibits on display at the 84th RSNA Scientific Assembly and Annual Meeting and categorized each exhibit according to the following characteristics: display type and size, color scheme, display font size, and graphic styles. These characteristics were then correlated with scientific exhibit and design awards as well as invitations for submission to RadioGraphics. Chance of winning an award or being asked to publish the presentation in RadioGraphics was significantly increased for viewbox exhibits (compared with backboard panel exhibits) and for larger exhibits (compared with smaller exhibits).

Discussion of hormone replacement therapy between physicians and their patients

We determined the relationship between patients' socioeconomic status and discussions with their primary care physicians about hormone replacement therapy (HRT) among women facing a decision about HRT within the prior year. The study included telephone interviews and medical record reviews. The setting was a general medicine practice of an urban teaching hospital in Boston, Mass. Women ages 50-65 visiting an academic teaching practice over a 3-month period were selected randomly. Of the 198 potential subjects, 118 (60%) agreed to participate in the survey. We examined discussions of HRT by women who had faced the decision to initiate HRT within the previous year. Women who were not on HRT or had been on therapy for less than 1 year were asked if they had discussed HRT with their physician in the past year. Socioeconomic factors and comorbidities were elicited during the survey and abstracted by chart review. The mean age of the 118 participants was 57; 36% were black, 54% were white, 10% were other race, 17% had less than a high school education, 14% had diabetes, 31% had had a hysterectomy, and 7% had a history of breast cancer. Of the 80 women who did not use HRT or had used it for less than 1 year, 49 (61%) reported a discussion of HRT. In bivariable analysis, patients of white race were more likely to report a discussion than black patients (72% versus 43%, odds ratio [OR] 3.6, 95% confidence interval [CI] 1.3-9.7). After adjustment for history of osteoporosis and age, white patients were more likely to report a discussion (adjusted OR 3.3, 95% CI 1.1-9.8). Further adjustment for the presence of 2 or more cardiac risk factors did not change the result. Neither level of education nor family income were significantly associated with HRT discussion. Compared with white women, the African-American women we studied were less likely to discuss HRT with their physicians. Further study is needed to determine whether the failure to discuss HRT is due to failure to initiate a discussion on the part of patients, physicians, or both.

Mobility impairments and use of screening and preventive services

OBJECTIVES

Primary care for people with disabilities often concentrates on underlying debilitating disorders to the exclusion of preventive health concerns. This study examined use of screening and preventive services among adults with mobility problems (difficulty walking, climbing stairs, or standing for extended periods).

METHODS

The responses of non-institutionalized adults to the 1994 National Health Interview Survey, including the disability and Healthy People 2000 supplements, were analyzed. Multivariable logistic regressions predicted service use on the basis of mobility level, demographic characteristics, and indicators of health care access.

RESULTS

Ten percent of the sample reported some mobility impairment; 3% experienced major problems. People with mobility problems were as likely as others to receive pneumonia and influenza immunizations but were less likely to receive other services. Adjusted odds ratios for women with major mobility difficulties were 0.6 (95% confidence interval [CI] = 0.4, 0.9) for the Papanicolaou test and 0.7 (95% CI = 0.5, 0.9) for mammography.

CONCLUSIONS

More attention should be paid to screening and preventive services for people with mobility difficulties. Shortened appointment times, physically inaccessible care sites, and inadequate equipment could further compromise preventive care for this population.

Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care?

BACKGROUND

Compared with thinner women, obese women have higher mortality rates for breast and cervical cancer. In addition, obesity leads to adverse social and psychological consequences. Whether obesity limits access to screening for breast and cervical cancer is unclear.

OBJECTIVE

To examine the relation between obesity and screening with Papanicolaou (Pap) smears and mammography.

DESIGN

Population-based survey.

SETTING

United States.

PARTICIPANTS

11 435 women who responded to the "Year 2000 Supplement" of the 1994 National Health Interview Survey.

MEASUREMENTS

Screening with Pap smears and mammography was assessed by questionnaire.

RESULTS

In women 18 to 75 years of age who had not previously undergone hysterectomy (n = 8394), fewer overweight women (78%) and obese women (78%) than normal-weight women (84%) had had Pap smears in the previous 3 years (P < 0.001). After adjustment for sociodemographic information, insurance and access to care, illness burden, and provider specialty, rate differences for screening with Pap smears were still seen among overweight (-3.5% [95% CI, -5.9% to -1.1%]) and obese women (-5.3% [CI, -8.0% to -2.6%]). In women 50 to 75 years of age (n = 3502), fewer overweight women (64%) and obese women (62%) than normal-weight women (68%) had had mammography in the previous 2 years (P < 0.002). After adjustment, rate differences were -2.8% (CI, -6.7% to 0.9%) for overweight women and -5.4% (CI, -10.8% to -0.1%) for obese women.

CONCLUSIONS

Overweight and obese women were less likely to be screened for cervical and breast cancer with Pap smears and mammography, even after adjustment for other known barriers to care. Because overweight and obese women have higher mortality rates for cervical and breast cancer, they should be targeted for increased screening.

The last six months of life for patients with congestive heart failure

OBJECTIVE

To characterize the experiences of patients with congestive heart failure (CHF) during their last 6 months of life.

DESIGN

A retrospective analysis of data from a prospective cohort study.

SETTING

Five geographically diverse tertiary care academic medical centers.

PARTICIPANTS

A total of 1404 patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) with a diagnosis of an acute exacerbation of CHF, of whom 539 patients died within 1 year of their index hospitalization.

METHODS

Data from interviews with patients or their surrogates were collected and chart abstractions performed at several time points in SUPPORT. To describe progression to death, we constructed four observational windows backward in time, beginning with patients' dates of death and ending with their date of entry into the SUPPORT project or 6 months before death, whichever came first. For each outcome, patients contributed information to all windows for which they had data collected. We describe frequency distributions for each outcome over time and report tests for trend.

OUTCOME MEASURES

Outcomes examined over time included: percentage of days spent in a hospital; model-based prognostic estimates of 6-month survival; functional status; occurrence of severe physical and emotional symptoms, including pain, depression and anxiety; patients' preferences for care; and the financial impact of patients' illnesses on their families.

RESULTS

As death approached, patients' prognoses became poorer and illnesses more severe. Median Acute Physiology Scores for hospitalized patients rose from 33 in the interval 6 months to 3 months before death, to 44 within 3 days of death. However, the median model-based estimate of 6-month survival was 54% even within 3 days of death. Number of functional impairments, median depression scores and percent of patients reporting severe pain or dyspnea increased as death approached, with 41% of patient surrogates reporting that the patient was in severe pain and 63% reporting that the patient was severely short of breath during the 3 days before death. Perceived quality of life did not change appreciably, with 29 to 58 % of patients reporting good to excellent quality of life in all intervals before death. As death approached, patients were more likely to prefer Do Not Resuscitate (DNR) status, with the percent of patients preferring DNR rising from 33% at 6 months to 3 months before death to 47% at 1 month to 3 days before death (P < .05). The frequency with which DNR orders were written for hospitalized patients also increased as death approached. The patients' illnesses had marked financial impact on their families, with 23 % of patients' families reporting the loss of most or all of family savings at the time of the patient's death.

CONCLUSIONS

As death approaches during the last 6 months of life in CHF, illness becomes more severe, disability and the experience of certain symptoms more frequent, and patient preference not to be resuscitated more common. However, there is no significant decrement in quality of life as death approaches. Reflecting the unpredictable course of CHF during the last month of life, many patients have good median model-based 6-month prognoses and enjoy good to excellent quality of life.

Indications for pelvic sonography-Do patients and doctors agree?

PURPOSE

Often, it seems that the patient history provided by the referring clinician on the sonography requisition form differs from that given by the patient during the sonographic examination. Because such a discrepancy in the history may delay the scan and disrupt the daily work flow while the referring clinician is contacted for clarification, we sought to document the incidence and cause of such discrepancies at our institution.

METHODS

During a 3-month period, all outpatients who were referred for a pelvic sonographic examination were asked to indicate their understanding of why the examination had been requested. The health care providers' reasons for requesting sonography were recorded using a computer order entry system. Each pair of responses (health care provider and patient) were classified as either concordant or discordant. Patient and physician characteristics were fit into a logistic regression model with concordance of history as the outcome variable.

RESULTS

One hundred fifty-six (90%) of the 173 patients enrolled in our study indicated that their health care provider had discussed with them the reason for ordering the sonographic examination. The histories provided by the patient and health care provider were concordant in 134 (77%) of 173 cases. The histories provided by the patient and health care provider were more likely to be concordant if the patient's insurance was a managed care plan or if the patient had a college or graduate level education, had been cared for by the same health care provider for more than 2 years, or had been seen by a female health care provider. Concordance of history was not associated with a higher incidence of abnormal sonographic findings.

CONCLUSIONS

It appears that health care providers, despite increased demands on their time, adequately discuss with their patients the reasons for ordering a pelvic sonographic examination. However, our study suggests that health care providers may need to spend additional time with patients whose education is limited and that male physicians may need to pay particular attention to their communication with female patients.

Improving cost efficiency on a vascular surgery service

BACKGROUND

A vascular task force (VTF) consisting of two vascular surgeons and other key personnel was established to reduce costs and improve efficiency in the management of patients on a vascular surgery service.

METHODS

The VTF met monthly beginning in 1994 to study and implement changes in the management of patients with (1) abdominal vascular, (2), carotid endarterectomy (3) distal bypass, and (4) other vascular procedures, including amputations. Length of stay, and fixed and variable costs were assessed for change over time using Pearson correlation coefficients.

RESULTS

Improvements in efficiency (length of stay) and decreases in costs (fixed and variable costs) from fiscal year 1993 to fiscal year 1996 were significant for the total group of vascular patients (P </=0.001), with some intergroup differences. The major improvements were in the abdominal vascular and carotid endarterectomy groups, where length of stay and fixed and variable costs were reduced significantly (P </=0.01). Management of distal bypass and other vascular surgery patients showed less striking improvement.

CONCLUSION

Vascular surgeons in collaboration with other dedicated personnel involved in the care of vascular patients can improve efficiency and reduce costs. Advances were greatest in patients who required operations for carotid and abdominal vascular disorders and least for patients who required distal bypasses and other vascular procedures.