Tick Bites and Lyme Disease in an Endemic Setting: Problematic Use of Serologic Testing and Prophylactic Antibiotic Therapy

Context.— The use of serologic testing to diagnose Lyme disease (LD) is a source of controversy. Expert recommendations also discourage the routine use of antibiotic therapy for prophylaxis of LD following tick bites, but the extent to which physicians in endemic areas have adopted these recommendations is not known. Objective.— To assess the pattern of use of serologic testing and antibiotic therapy for tick bites and LD and associated charges for management in an endemic area. Design.— Active surveillance of patient-physician encounters for tick bites and LD. Setting.— Primary care practices on the Eastern Shore of Maryland. Patients.— Consecutive sample of 232 patients with tick bites, LD (defined by physician diagnosis in medical record), and suspected LD (physician notation of possible, but not definite LD) seen in 1995. Main Outcome Measures.— Serologic testing for LD, test results, antibiotic therapy, and direct costs of management. Results.— Surveillance identified 142 patients (61.2%) with diagnoses of tick bites, 40 patients (17.2%) with LD, and 50 patients (21.6%) with suspected LD. Of the 142 patients seen for tick bites, 95 (67%) underwent serologic testing for LD. Of these, 93 patients had initial negative or equivocal results; 24 (26%) of the 93 had convalescent testing, with 1 seroconversion. Seventy-eight patients (55%) with a diagnosis of tick bite received antibiotic therapy. No patients with tick bite developed clinical LD. Serologic testing for LD was performed for 36 patients (90%) with a diagnosis of LD and 46 patients (92%) with suspected LD. In most cases, antibiotics were prescribed before serologic test results became available. Convalescent testing was not performed for 37 (86%) of the 43 patients with suspected LD who had initial negative or equivocal results. Of these 37 patients, 25 (68%) did not receive antibiotic therapy. Direct charges for treatment of these 232 patients totaled $47595, one third of which was attributable to serologic testing. A total of 32% of direct charges were for patients with tick bites, 48% were for patients with LD, and 20% were for patients with suspected LD. Conclusions.— In this setting, most patients consulting physicians for tick bites received prophylactic antibiotic therapy of unproven efficacy and underwent unnecessary, costly serologic testing. Despite almost universal use in this study, serologic testing for LD did not appear to influence treatment of patients diagnosed as having LD.      

Synthesis and Antitumour Activity of New Derivatives of Flavone-8-acetic Acid (FAA). Part 1: 6-Methyl Derivatives

A range of 17 derivatives of flavone-8-acetic acid (FAA) with a 6-methyl substituent have been prepared and their anti-tumour activity evaluated in vitro against a panel of human and murine tumour cell lines and in vivo against MAC 15A. While many of the compounds show activity comparable to FAA in vitro, this essentially disappears in vivo, possibly due to degradation before the compounds can reach the tumour site.     

An expert system for determining medicaid eligibility

The eligibility requirements for AFDC Medicaid are so extensive and complicated that most health care providers do not attempt to ascertain whether or not a particular patient is eligible for the program, even when no other source of payment is available. This results in lost revenue for health service providers nationwide amounting to hundreds of millions of dollars per year. Computer technology, in the form of expert systems, offers an opportunity to rationalize the Medicaid eligibility determination process and to do real-time assessment of patient eligibility. This article presents an expert system called MEDELEX (MEdicaidELigibilityEXpert) for determining Medicaid eligibility. The program (when run on an 8 MHz MS-DOS microcomputer with at least 640 KB of RAM) requires about 20 min for data entry and 5 sec for the actual eligibility determination. The expert system was written in Prolog and has been designed in such a way that it can be readily modified to take into account the state-to-state variability in eligibility requirements for AFDC Medicaid.     

Involvement of Ca+ mobilization in the amplifying effect of serotonin on responses of rabbit isolated ear artery to exogenous noradrenaline

Summary The present study examined the involvement of Ca⁺ mobilization in the amplifying effect of serotonin on steady-state responses of rabbit isolated perfused ear artery to exogenous noradrenaline (NA; 0.001–3 ol/l). In contrast to its marked amplifying effect on responses to NA, serotonin in the subconstrictor concentration of 100 nmol/l had no effect on responses to KCl. The Ca⁺-entry blocking drug diltiazem (10 gmol/1) decreased responses to NA; in addition, the amplifying effect of serotonin on responses to NA was reduced by diltiazem. Lowering the concentration of Ca⁺ in the Krebs-Henseleit perfusion solution from 2.5 to 0.25 mmol/l also reduced both responses to NA and the amplifying effect of serotonin. Using the method of Manzini et al. (1982), separate intra- and extracellular Ca⁺-dependent responses to NA were obtained. Serotonin had no effect on intracellular Ca⁺-dependent responses to NA but enhanced extracellular Ca²⁺-dependent NA responses. These results suggest that the amplifying effect of serotonin on responses of rabbit ear artery to exogenous NA involves a selective enhancement of the component of the NA response which is dependent on extracellular Ca⁺; serotonin may increase NA-evoked entry of Ca²⁺ into the vascular smooth muscle cells through receptor-operated Ca⁺ channels. Send offprint requests to A. G. Meehan at the above address     

Biological responses to overload training in endurance sports

Summary Five subjects undertook 10 days of twice daily interval training sessions on a treadmill followed by 5 days of active recovery. On days 1, 6, 11, and 16 the subjects were required to undertake a test of submaximal and maximal work capacity on a treadmill combined with a performance test consisting of a run to exhaustion with the treadmill set at 18 km · h^–1 and 1% gradient. Also on these days a pre-exercise blood sample was collected and analysed for a range of haematological, biochemical and immunological parameters. The subjects experienced a significant fall in performance on day 11 which had returned to pretraining levels on day 16. Serum ferritin concentrations were depressed significantly from pretraining concentrations at the conclusion of the recovery period while the expression of lymphocyte activation antigens (CD25⁺ and HLA-DR⁺) was increased both after the training phase and the recovery phase. The number of CD56⁺ cells in the peripheral circulation was depressed at the conclusion of the recovery period. Several parameters previously reported to change in association with overload training failing to reflect the decrease in performance experienced by subjects in this study, suggesting that overtraining may best be diagnosed through a multifactorial approach to the recognition of symptoms. The most important factor to consider may be a decrease in the level of performance following a regeneration period. The magnitude of this decreased performance necessary for the diagnosis of overtraining and the nature of an appropriate regeneration period are, however, difficult to define and may vary depending upon the training background of the subjects and the nature of the preceding training. It may or may not be associated with biochemical, haematological, physiological and immunological indicators. Individual cases may present a different range of symptoms and diagnosis of overtraining should not be excluded based on the failure of blood parameters to demonstrate variation. However, blood parameters may be useful to identify possible aetiology in each separate case report of overtraining. An outstanding factor to emerge from this study was the difficulty associated with an objective diagnosis of overtraining and this is a possible reason why there have been new accounts of overtraining research in the literature.