Evaluating HMO/IPA contracts for family physicians: one group's experiences

This article reports the experience of a 15-person primary care group with two health maintenance organization/independent practice association (HMO/IPA) contracts. In 1986 the group received over $1.5 million in capitated payments from the plan to cover medical care of approximately 4,000 patients. The expenses exceeded the income for one plan. Analysis of primary care, specialty care, and ancillary services provides insight into factors that must be considered in evaluating HMO/IPA contracts. Eleven questions that should be asked before signing contracts and guidelines for utilization review and quality assurance are reviewed.     

Radiographic changes induced after cervical facet radiofrequency denervation

BACKGROUND CONTEXT: Paraspinal infections after zygapophyseal (facet) radiofrequency denervation (RFD) are a serious but rare complication of this procedure. We are aware of only one case report of an epidural abscess after facet joint injection. PURPOSE: To report post-procedure inflammatory changes after cervical facet RFD. STUDY DESIGN: Case report. PATIENT SAMPLE: A 35-year-old Caucasian female. METHODS: Retrospective case review. RESULTS: The patient underwent cervical RFD and was admitted to the hospital 7 days after her procedure with severe neck pain. Magnetic resonance imaging (MRI) with contrast revealed what appeared to be evidence of a paraspinal muscle abscess although blood tests were negative. She was treated with antibiotic therapy, yet she never developed systemic signs of infection. A follow-up MRI without contrast revealed no evidence of infection, and she was discharged home on hospital day 6. At her first follow-up visit, she was still experiencing scalp pain and paraspinal muscle spasm. During subsequent follow-up visits, she has continued to improve clinically without experiencing signs of infection. Another follow-up MRI 6 weeks after her discharge home revealed persistent minimal left paraspinal enhancement at C2-3, possibly representing post-procedure granulation tissue with no evidence of abscess. CONCLUSIONS: Post-procedural MRI findings after radiofrequency lesioning can resemble radiographic findings associated with a paraspinal abscess. Patients with radiographic findings consistent with abscess should only be treated if clinical signs or symptoms of systemic infection are present.     

Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

THIS IS THE FIRST OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500 000 to 900 000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology / American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.     

Clinical illness associated with a commercial tick and flea product in dogs and cats

A commercial flea and tick product containing 9.0% fenvalerate for use in dogs and cats was suspected of causing illness. An acute toxicity study was performed in 10 dogs and 10 cats exposed to the product orally (po) and dermally at differing doses. Samples were obtained for DEET and fenvalerate analysis. Oral dosing of dogs and cats produced severe clinical illness at doses as low as 0.66% of a can (7 ounce spray can)/kg body weight. Dermal application of the product resulted in minor clinical abnormalities in dogs. Oral exposure at 0.5% can/kg body weight resulted in severe illness, and dermal application caused severe illness or death in cats at 20% and 40% of a can/kg body weight. The cats receiving 10% of a can/kg body weight dermally became depressed for several hours but recovered uneventfully. Serum DEET concentrations closely paralleled the clinical signs observed in the animals. Serum concentrations of DEET above 20 ppm were considered diagnostic for intoxication. Urine concentrations of DEET above 1 ppm and tissue (liver, bile, and kidney) concentrations of DEET above 10 ppm were supportive of poisoning; values near 100 ppm were diagnostic for fatal poisoning.     

Transient myeloproliferative disorder. In a neonate with Down syndrome. Immunophenotypic studies

This report describes the results of bone marrow leukocyte immunophenotypic studies, DNA index measurement, and chromosome analysis in a newborn with Down syndrome and transient myeloproliferative disorder. The infant's initial leukocytosis with immature cells in the peripheral blood and thrombocytopenia resolved without treatment by 6 months of age, and he was well at 2 years of age. The lack of specific reactivity between the patient's morphologically immature cells and multiple monoclonal antibodies directed against lymphoid and myeloid leukemia cells may be characteristic of this disorder. Other cases should be examined for immunophenotype to correlate the results with chromosomal analysis and to provide a basis for comparison in those who subsequently develop true acute leukemia.