Tripler Army Medical Center

OBJECTIVE: The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. RESEARCH DESIGN AND METHODS: In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic (n = 200), waiting room at a diabetes specialty clinic (n = 179), a diabetes management study program (n = 167), and an ongoing diabetes management program (n = 158). RESULTS: Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high (r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high (r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (alpha > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas diet-controlled subjects displayed the lowest scores (P < 0.001). CONCLUSIONS: The DDS has a consistent, generalizable factor structure and good internal reliability and validity across four different clinical sites. The new instrument may serve as a valuable measure of diabetes-related emotional distress for use in research and clinical practice.

Clinical predictions made by mental health practitioners are compared with those using statistical approaches. Sixty-seven studies were identified from a comprehensive search of 56 years of research; 92 effect sizes were derived from these studies. The overall effect of clinical versus statistical prediction showed a somewhat greater accuracy for statistical methods. The most stringent sample of studies, from which 48 effect sizes were extracted, indicated a 13% increase in accuracy using statistical versus clinical methods. Several variables influenced this overall effect. Clinical and statistical prediction accuracy varied by type of prediction, the setting in which predictor data were gathered, the type of statistical formula used, and the amount of information available to the clinicians and the formulas. Recommendations are provided about when and under what conditions counseling psychologists might use statistical formulas as well as when they can rely on clinical methods. Implications for clinical judgment research and training are discussed.

Twenty-four pH monitoring the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studies with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic pateitns with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.

BACKGROUND: Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the "critical" cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, "subcritical" amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability. PURPOSE: To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable. RESULTS: The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences (P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure (P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile's increasing bone loss predictive of a worse functional outcome. CONCLUSION: While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that "critical" bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

BACKGROUND: Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations. HYPOTHESIS: Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment. STUDY DESIGN: Prospective, randomized clinical trial. METHODS: Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months. RESULTS: Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability. CONCLUSIONS: Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.

METHODS: Comparisons of death-related variables during the 3 eras were performed. RESULTS: The number of deaths declined over the study period, with 987 deaths in the pre-HAART era, 159 deaths in the early HAART era (1997-1999), and 78 deaths in the late HAART era (2000-2003) (P < 0.01). The annual death rate peaked in 1995 (10.3 per 100 patients) and then declined to <2 deaths per 100 persons in the late HAART era (P < 0.01). The proportion of deaths attributable to infection decreased, but infection remained the leading cause of death in our cohort, followed by cancer. Of those who died, there was an increasing proportion of non-HIV-related deaths (32% vs. 9%; P < 0.01), including cardiac disease (22% vs. 8%; P < 0.01) and trauma (8% vs. 2%; P = 0.01) in the post-HAART versus pre-HAART era. Despite the absence of intravenous drug use and the low prevalence of hepatitis C coinfection in our cohort, an increasing proportion of deaths in the HAART era were attributable to liver disease, although the numbers are small. CONCLUSIONS: Despite increasing concerns regarding antiretroviral resistance, the death rate among HIV-infected persons in our cohort continues to decline. Our data show a lower death rate than that reported among many other US HIV-infected populations; this may be the result of open access to health care. A shift in the causes of death toward non-HIV-related causes suggests that a more comprehensive health care approach may be needed for optimal life expectancy; this may include enhanced screening for malignancy and heart disease as well as preventive measures for liver disease and accidents.

BACKGROUND AND PURPOSE: Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteoarthritis (OA) of the knee. The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinically based physical therapy program. SUBJECTS: One hundred thirty-four subjects with OA of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [+/-SD]=64+/-10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [+/-SD]=62+/-9 years). METHODS: Subjects in the clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6-minute walk distances had improved about 10% in both groups. At 1 year, both groups were substantially and about equally improved over baseline measurements. Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group. DISCUSSION AND CONCLUSION: Although both groups improved by 1 month, subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home. Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program. The results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Two case studies are presented to demonstrate that children who experience trauma-related nightmares may benefit from cognitive-behavioral therapy for this sleep problem. The treatment was adapted from the empirically supported adult treatment for chronic trauma-related nightmares: exposure, relaxation, and rescripting therapy (ERRT). Pretreatment and posttreatment nightmare frequency and severity were measured in addition to subjective nightmare-related distress, behavioral problems, sleep quality and quantity, and symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression. Improvement in nightmare and sleep disturbance frequencies were found as well as reductions in parents’ reports of child behavior problems. This study provides preliminary support for the use of ERRT with children.

OBJECTIVE: We prospectively compared MR imaging, MR arthrography, and CT arthrography to determine the sensitivity of each technique in detecting glenoid labral tears and in determining whether the labrum is detached or degenerated. SUBJECTS AND METHODS: Thirty patients 19-39 years old (mean, 27 years old) who had either signs and symptoms of shoulder instability or shoulder pain of unexplained origin were referred for diagnostic imaging. Each patient underwent MR imaging, followed by MR arthrography after intraarticular injection of 25 ml of a dilute solution of gadopentetate dimeglumine. Twenty-eight of thirty patients underwent CT arthrography after intraarticular injection of air and radiographic contrast material. Each patient also underwent arthroscopy or open surgery. RESULTS: At surgery, labral tears were found in 28 patients; a detached fragment was found in 26 patients. The labrum was found to be degenerated in 18. A labral tear was detected on MR images in 26 (93%) of 28, on MR arthrograms in 27 (96%) of 28, and on CT arthrograms in 19 (73%) of 26. A detached labral fragment was detected on MR images in 12 (46%) of 26, on MR arthrograms in 25 (96%) of 26, and on CT arthrograms in 13 (52%) of 25. Labral degeneration was detected on MR images in two (11%) of 18, on MR arthrograms in 10 (56%) of 18, and on CT arthrograms in four (24%) of 17. MR arthrography was the best of the three imaging techniques for showing the inferior part of the glenoid labrum and inferior glenohumeral ligament. CONCLUSION: MR arthrography and MR imaging both showed labral tears with greater sensitivity than CT arthrography did. MR arthrography was the most sensitive of the three techniques for detecting a detached labral fragment and labral degeneration. Furthermore, MR arthrography afforded the best visualization of the inferior part of the labrum and the inferior glenohumeral ligament. MR imaging and MR arthrography also enabled direct visualization of rotator cuff disease and other unsuspected associated abnormalities.

We present a 6-generation kindred of over 221 members, 43 of whom were affected with von Hippel-Lindau (vHL) disease. Through a simple screening protocol, we diagnosed vHL retrospectively in 15 cases, and for the first time in 28, 11 of whom were presymptomatic. We found many complications of vHL in previously diagnosed relatives and in new cases. This study has demonstrated the utility and benefit of preventive surveillance in those known to have vHL, and of presymptomatic screening for affected relatives in families with vHL. The features of vHL were reviewed in our 43 cases and 511 cases from the medical literature. The patterns, frequencies, and ages of onset for each lesion were compared. Renal malignancies caused almost as much mortality in vHL as CNS malignancies. This family was exceptional for absence of pheochromocytoma and erythrocythemia, for more renal and pancreatic cysts and malignancies, and for slightly fewer eye or CNS lesions. Bilateral renal adenocarcinomata were found presymptomatically in five young subjects, who had bilateral nephrectomy and hemodialysis. Three survived long-term after renal transplants. Five relatives had pancreatic malignancies, which are definite although uncommon manifestations of vHL. Recommendations are made for family screening, which was economical and effective. Bayesian calculations help to predict risks for genetic counseling. The molecular basis of vHL may soon be found, since it has been linked to DNA markers on the short arm of chromosome 3.

BACKGROUND: The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. METHODS: After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached. RESULTS: 17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary). CONCLUSIONS: Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

OBJECTIVE: To determine the efficacy of azithromycin in the treatment of patients with typical cat-scratch disease. DESIGN: Prospective, randomized, double blind, placebo-controlled clinical trial. SETTING: Large military medical center and its referring clinics. PATIENTS: Active duty military members and their dependents with laboratory-confirmed, clinically typical cat-scratch disease. INTERVENTION: Study participants assigned by randomization to treatment with oral azithromycin or placebo for 5 days. OUTCOME MEASURES: Lymph node volume was calculated using three dimensional ultrasonography at entry and at weekly intervals. The ultrasonographer was blinded to the treatment groups. Endpoint evaluations were predetermined as time in days to 80% resolution of the initial total lymph node volume. RESULTS: Demographic and clinical data showed that the azithromycin and placebo treatment groups were comparable at entry although the placebo group tended to be older. Eighty percent decrease of initial lymph node volume was documented in 7 of 14 azithromycin-treated patients compared with 1 of 15 placebo-treated controls during the first 30 days of observation (P = 0.026). After 30 days there was no significant difference in rate or degree of resolution between the two groups. CONCLUSIONS: Treatment of patients with typical cat-scratch disease with oral azithromycin for five days affords significant clinical benefit as measured by total decrease in lymph node volume within the first month of treatment.

IMPORTANCE: Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. OBJECTIVE: To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies. DATA SOURCES: The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea. STUDY SELECTION: Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded. DATA EXTRACTION: Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015. MAIN OUTCOMES AND MEASURES: The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h. RESULTS: Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were -47.8 (25.0) and -44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates. CONCLUSIONS AND RELEVANCE: Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections are not commonly recognized in healthy patients without predisposing risk. We performed a retrospective study of patients hospitalized with community-acquired MRSA infections from 1992 to 1996 in Honolulu to determine if community-acquired MRSA infections occurred in patients without known risk. Patients hospitalized within the previous 6 months or transferred from other hospitals or nursing homes were excluded. Epidemiological and clinical data were obtained from an inpatient chart review. Ten (71%) of 14 patients with community-acquired MRSA infection had no discernible characteristics of MRSA infections. Thirteen (93%) patients had skin or soft-tissue infections and one patient had MRSA pneumonia. Isolates from patients with MRSA infection were more likely to be susceptible to ciprofloxacin (P = .05), clindamycin (P = .03), and erythromycin (P = .01) than were those from MRSA-colonized patients. In our population, the majority of community-acquired MRSA infections occurred in previously healthy individuals without characteristics suggestive of MRSA transmission.

The properties of antibodies to steroid-protein conjugates were investigated many years ago by Lieberman and his coworkers (1). Recently antibodies to an estradiol-protein conjugate have been used for assay of estradiol in human plasma (2). This report describes a method, using antibodies to an aldosterone-protein conjugate, to measure aldosterone in extracts of plasma purified by one column and one paper chromatography. 1,2-3H-aldosterone (New England Nuclear Corp., 29.5 c/mM) was purified every two weeks by paper chromatography in the system benzene:methanol:water 100:50:25. The purity of the labelled steroid was also examined once by acetylation and chromatography of the diacetate. Aldosterone was used as obtained from Mann Research Laboratories. The source and purification of solvents and the preparation of columns were as previously described (3). Silica gel (Merck, no. 7734) purified as previously described for Al2O3 (3). The source and method for washing chromatography paper and precoated thin layer chromatography plates and the composition of the scintillation fluid were as described earlier (4).

A prospective randomized study was done on 45 patients to evaluate the effectiveness of the Hill, Nissen or Belsey anti-reflux procedure. All patients had symptoms of GE reflux unresponsive to medical therapy, a + standard acid reflux test (SART), and esophagitis (38/45) or + Burnstein test (7/45). Esophageal symptomatic, radiographic, manometric and pH (SART and 24-hr monitoring) evaluation was done pre- and 154 days (ave.) postsurgery. All procedures improved the symptoms of pyrosis. The best improvement was seen after the Nissen repair. All procedures increased the distal esophageal sphincter (DES) pressures over preoperative levels. The Nissen and Belsey increased it more than the Hill. Sphincter length and dynamics remained unchanged. The Nissen procedure placed more of the manometric sphincter below the respiratory inversion point in the positive pressure environment of the abdomen. The esophageal length was increased by the Nissen and Hill repairs. This was thought to account for the high incidence of temporary postsurgery dysphagia following the Nissen and Hill repairs and the lower incidence following the Belsey repair. Reflux was most effectively prevented by the Nissen repair, as shown by the SART and the 24-hr esophageal pH monitoring, a sensitive measurement of frequency and duration of reflux. The average length of hospital stay was 20 days for Belsey and 12 days for both Nissen and Hill procedure. Postsurgery complications were more common following the thoracic than the abdominal approach. Ability to vomit postrepair was greatest with the Hill and least with the Belsey and Nissen repair. All procedures temporarily increased amount of flatus. It is concluded that the Nissen repair best controls reflux and its symptoms by providing the greatest increase in DES pressure and placing more of the sphincter in the positive abdominal environment. This is accomplished with the lowest morbidity but at the expense of temporary postoperative dysphagia and a 50% chance of being unable to vomit after the repair.

BACKGROUND AND PURPOSE: Subdural hemorrhage (SDH) is often associated with infants experiencing nonaccidental injury (NAI). A study of the appearance and natural evolution of these birth-related hemorrhages, particularly SDH, is important in the forensic evaluation of NAI. The purpose of this study was to determine the normal incidence, size, distribution, and natural history of SDH in asymptomatic term neonates as detected by sonography (US) and MR imaging within 72 hours of birth. MATERIALS AND METHODS: Birth history, delivery method, duration of each stage of labor, pharmaceutic augmentation, and complications during delivery as well as postnatal physical examination were recorded. Brain MR imaging and US were performed on 101 asymptomatic term infants at 3-7 days, 2 weeks, 1 month, and 3 months. Clinical follow-up at 24 months was recorded. RESULTS: Forty-six neonates had SDH by MR imaging within 72 hours of delivery. SDH was seen in both vaginal and cesarean deliveries. All neonates were asymptomatic, with normal findings on physical examination. All 46 had supratentorial SDH seen in the posterior cranium. Twenty (43%) also had infratentorial SDH. US detected 11 of the 20 (55%) infratentorial SDHs and no supratentorial SDH. Most SDHs present at birth were <or=3 mm and had resolved by 1 month, and all resolved by 3 months on MR imaging. Most children with SDHs had normal findings on developmental examinations at 24 months. CONCLUSION: SDH in asymptomatic term neonates after delivery is limited in size and location.

Recent advancements and developments in molecular biotechnology have allowed more precise reclassification of many microorganisms. With the use of these new taxonomy tools, several organisms previously thought to belong to other genera have been recently described as bartonellae. Of the 11 organisms now described as Bartonella spp., only four have been shown to be pathogenic for humans. Table 1 lists the four Bartonella human pathogens along with the their known epidemiology and the scope and range of disease associated with each. All are now considered to be bacteria and can be grown on blood-enriched agar although primary isolation in some may best be achieved in cell tissue culture. B. bacilliformis infection is limited to certain geographic regions in South America where the only human reservoir and the sandfly vector(s) that spreads the disease reside together. Specific antibiotic treatment is dramatically effective in treating the highly fatal, acute intraerythrocytic hemolytic form of the disease, but their effectiveness in treating the vascular proliferative forms (verruga peruana) or the chronic asymptomatic, bacteremic, carrier state of the disease has not been effective. This disease should remain confined to its present endemic geographic areas in South American unless asymptomatic bacteremic persons from these areas migrate to areas where sandflies and humans exist that are capable of establishing this infection in new endemic areas. B. quintana and B. henselae cause a wide range of clinical diseases in humans, the type and extent of which varies significantly with the immune status of the host. In immunocompetent hosts the pathologic response is granulomatous, suppurative, extracellular and intracellular, generally self-limited and usually unresponsive to antibiotic treatment, even to those drugs to which the organism is shown to be sensitive in vitro. In contrast, in immunocompromised hosts the pathologic response is vasculoproliferative, organisms may be seen intracellularly but they are often seen in abundance in extracellular clumps and infection is usually progressive and fatal unless treated. In these patients clinical response to treatment with drugs that are effective in vitro against these organisms has usually been dramatic. Of these agents those that penetrate cells and are found in high concentrations intracellularly, such as erythromycin, clarithromycin, azithromycin, rifampin, doxycycline and gentamicin, appear to be most effective. These agents not only appear to provide the most dramatic treatment response in patients with BA, BP and PRFB and other manifestations of B. henselae (and B. quintana as well) in immunocompromised persons, they appear to be the most promising agents for treatment of persons with both typical and atypical CSD. Further studies will be necessary to more clearly elucidated the mechanisms responsible for the diverse clinical presentations of infection with these organisms in human hosts relative to their immune status. In addition clarification of the epidemiology of B. elizabethae infections in humans may be helpful in understanding the nature of infection with Bartonella organisms.

The objective of this study was to describe the health care utilization and prospective predictors of high-cost primary-care back pain patients. In the primary-care clinics of a large, staff model health maintenance organization in western Washington State, 1059 subjects were selected from consecutive patients presenting for back pain. The design was a 1-year prospective cohort study. Patients' were interviewed 1 month after an index primary-care back pain visit. Costs (back pain and total) and utilization (back pain primary-care follow-up visits, back pain specialty visits, back pain hospitalizations, back pain radiologic procedures, and pain medicine fills) were tracked over the next 11 months. Predictors assessed at 1 month were back pain diagnosis (disc disorder/sciatica, arthritis, vs. other), chronic pain grade (measure of pain intensity and related dysfunction), pain persistence (days with pain in prior 6 months), depressive symptomatology, and back pain-related disability compensation (ever/never). For the sample, 21% of patients with back pain costs > or = $600 (high back pain costs) accounted for 66% of back pain costs, 42% of total costs, 55% of primary-care follow-up visits for back pain, 91% of back pain specialty visits, 100% of back pain hospitalizations, 51% of back pain radiologic procedures, and 52% of pain medicine fills. The 21% with total costs > or = $2700 (high total costs) accounted for 67.7% of total costs, 52% of back pain costs, 29% of primary-care follow-up visits for back pain, 66% of back pain specialty visits, 100% of back pain hospitalizations, 39% of back pain radiologic procedures, and 42% of pain medicine fills. Multivariable logistic regression analyses indicated that increasing chronic pain grade, more persistent pain, and disc disorder/sciatica were strong independent predictors of high total and high back pain costs. Increasing depressive symptoms significantly predicted high total but not high back pain costs. Back pain disability compensation predicted high back pain but not high total costs. A minority of primary-care back pain patients accounted for a majority of health-care costs. Patients with high back pain costs accounted for more back pain-related health-care utilization than did patients with high total costs. Factors predicting subsequent high costs suggest behavioral interventions targeting dysfunction, pain persistence, and depression may reduce health-care utilization and prevent accumulation of high health-care costs among primary-care back pain patients.