The extended columellar strut-tip graft

The extended columellar strut-tip graft is a structural unit used in endonasal rhinoplasty that combines the attributes of the columellar strut and the tip graft. It is used to provide projection and contour to the nasal tip. Our goal with this study was to evaluate a 15-year experience with 155 patients who underwent rhinoplasty with the extended columellar strut-tip graft. Of these, 110 underwent secondary rhinoplasty, and 45 underwent primary rhinoplasty. There were 6 patients in the secondary rhinoplasty group who experienced complications: in 3, the graft became visible postoperatively, and 3 patients had graft placement asymmetry. These 6 patients underwent surgery in the initial years of graft development. One patient with graft edge visibility and 1 patient with graft asymmetry underwent revision surgery with satisfactory results. The extended columella strut-tip graft is a reliable method to provide nasal tip projection and contour. The successful use of the graft requires precise diagnosis and surgical technique.     

Impact of malpractice reforms on the supply of physician services

Context  Proponents of restrictions on malpractice lawsuits claim that tort reform will improve access to medical care. Objective  To estimate the effects of changes in state malpractice law on the supply of physicians. Design  Differences-in-differences regression analysis that matched data on the number of physicians in each state between 1985 and 2001 from the American Medical Association’s Physician Masterfile with data on state tort laws and state demographic, political, population, and health care market characteristics. Main Outcome Measure  Effect on physician supply of "direct" malpractice reforms that reduce the size of awards (eg, caps on damages). Results  The adoption of "direct" malpractice reforms led to greater growth in the overall supply of physicians. Three years after adoption, direct reforms increased physician supply by 3.3%, controlling for fixed differences across states, population, states’ health care market and political characteristics, and other differences in malpractice law. Direct reforms had a larger effect on the supply of nongroup vs group physicians, on the supply of most (but not all) specialties with high malpractice insurance premiums, on states with high levels of managed care, and on supply through retirements and entries than through the propensity of physicians to move between states. Direct reforms had similar effects on less experienced and more experienced physicians. Conclusion  Tort reform increased physician supply. Further research is needed to determine whether reform-induced increases in physician supply benefited patients.      

Addressing the psychosocial and communication challenges posed by radiological/nuclear terrorism: key developments since NCRP Report No. 138

One of the most innovative aspects of NCRP Report No. 138 (Management of Terrorist Incidents Involving Radioactive Material) was the high priority it accorded to psychosocial and communication issues. While previous discussions of radiological and nuclear terrorism had occasionally referred to these topics, NCRP Report No. 138 was the first report of its kind to recognize the profound challenges posed by these issues and to place them at the heart of preparedness and response efforts. In the years since the report's release, a host of important developments have taken place in relation to psychosocial and communication issues. This paper reviews key changes and advances in five broad areas: (1) training exercises, (2) policy and guidance development, (3) findings on hospital and clinician needs, (4) survey research on public perceptions of radiological terrorism, and (5) risk communication for radiological and nuclear terrorism situations. The article concludes with a discussion of continuing psychosocial and communication challenges, including critical areas needing further attention as the nation moves to meet the threat of terrorism involving radioactive materials.     

Renal insulin resistance syndrome, adiponectin and cardiovascular events in patients with kidney disease: the mild and moderate kidney disease study

The relationship among insulin resistance, adiponectin, and cardiovascular (CV) morbidity in patients with mild and moderate kidney disease was investigated. Insulin sensitivity (Homeostasis Model Assessment of Insulin Resistance [HOMA-IR]) and adiponectin plasma levels were assessed in 227 nondiabetic renal patients at different degrees of renal dysfunction and in 76 healthy subjects of similar age and gender distribution and body mass index. In renal patients, association with prevalent CV events was evaluated, and incident CV events were evaluated in a prospective study. HOMA-IR was markedly higher in patients than in healthy subjects (3.59 +/- 3.55 versus 1.39 +/- 0.51; P < 0.01). In renal patients, HOMA-IR was significantly correlated with body mass index (r = 0.477; P < 0.01), triglycerides (r = 0.384; P < 0.01), adiponectin plasma levels (r = -0.253; P < 0.01), and age (r = 0.164; P < 0.05), but not with renal function (GFR by iod-thalamate clearance). Patients with previous CV events were significantly older, had higher HOMA-IR and serum triglycerides, and had lower adiponectin plasma levels (all P < 0.05). Logistic regression analysis revealed age (P < 0.001) and adiponectin (P < 0.002) as independent variables related to prevalent CV events. In the prospective study, median follow-up was 54 mo. Patients who experienced CV events had significantly higher serum glucose and lower adiponectin plasma levels (both P < 0.05). In patients with chronic kidney diseases, a syndrome of insulin resistance is present even in the earliest stage of renal dysfunction, and several components of this syndrome are associated with CV events. Moreover, hypoadiponectinemia is a novel putative CV risk factor in patients with mild and moderate renal failure.     

Detecting Medicare abuse

This paper identifies which types of patients and hospitals have abusive Medicare billings that are responsive to law enforcement. For a 20% random sample of elderly Medicare beneficiaries hospitalized from 1994 to 1998 with one or more of six illnesses that are prone to abuse, we obtain longitudinal claims data linked with social security death records, hospital characteristics, and state/year-level anti-fraud enforcement efforts. We show that increased enforcement leads certain types of types of patients and hospitals to have lower billings, without adverse consequences for patients' health outcomes.     

Lack of toxicity of therapy-induced T cell responses against the universal tumour antigen survivin

Prognosis of disseminated melanoma remains gloomy as neither chemotherapeutic nor unspecific immune modulatory approaches were able to improve the overall survival of these patients. Hence, specific immunotherapy has received increasing attention. Disappointing clinical results, however, indicate that the choice of suitable antigens is of special importance. To this end, the inhibitor of apoptosis (IAP) protein survivin, which is over-expressed in several tumours but is largely undetectable in adult tissues, appears to be a promising target for vaccination purposes, since down-regulation or loss of expression is associated with impaired tumour progression. Consequently, five heavily pretreated stage IV melanoma patients were vaccinated with the HLA-A2 restricted survivin(96-104) epitope presented by autologous dendritic cells (DCs) in a compassionate use setting. Four of these patients mounted strong T cell responses to this epitope as measured by ELISPOT assay. Furthermore, in situ peptide/HLA-A2 multimer staining confirmed that these survivin reactive cells infiltrated both visceral and soft tissue metastases.     

Peroperative transcranial sonography for electrode placement into the targeted subthalamic nucleus of patients with Parkinson disease: technical note

BACKGROUND: In the search for a better preoperative knowledge of the position of probes and electrodes, we assessed the feasibility and the usefulness of transcranial sonography during surgery for the implantation of stimulation electrodes into the subthalamic nucleus (STN) of patients with Parkinson's disease. METHODS: Transcranial sonography was carried out during stereotactic surgery in 8 patients with Parkinson's disease who had a suitable temporal bone window on the side receiving the electrode. Test stimulation parameters were 130 Hz, 0.1 ms, up to 0 to 4.5 V. RESULTS: The test probe with a diameter of 0.8 mm was visualized through the temporal preauricular window. The correct anatomic position of the electrode tip could be indirectly assessed thanks to the topographic relationship of the STN with the hyperechogenic substantia nigra and the nucleus ruber. The tip position of the final electrode was easily documented. A laterality of 10.5 to 11.5 mm, verified by teleradiographic ventriculography and plain films, was correlated with the best response of symptoms of Parkinson's disease to electrical impulses delivered to the STN. CONCLUSIONS: Transcranial sonography is easily feasible during stereotactic surgery. In combination with the clinical effects of electrostimulation on the symptoms of Parkinson's disease and with stereotactic x-ray images, it enables the assessment and the documentation of the correct position of implanted STN electrodes in real time.     

Pathologic features and clinical significance of "backwash" ileitis in ulcerative colitis

Patients with ulcerative colitis (UC) may develop inflammation in the distal ileum thought to be due to "backwash" of cecal contents ("backwash ileitis"). However, a systematic analysis of ileal changes in UC has never been performed, and the prevalence and criteria for "backwash" ileitis have not been defined. The aim of this study was to evaluate the prevalence and spectrum of inflammatory changes in the ileum in patients with UC and to correlate ileal changes with outcome after total proctocolectomy and ileal pouch-anal anastomosis. Routinely processed ileocolonic resection specimens from 200 consecutive patients with clinically and pathologically confirmed UC were evaluated for a wide variety of pathologic features in the ileum and colon. The ileal data were correlated with both the clinical features and the pathologic findings in the colon. Follow-up data were obtained to confirm absence of Crohn's disease and to evaluate outcome of ileo-anal pouches. Overall, 34 of 200 (17%) UC patients had inflammatory changes in the ileum (male/female ratio, 16/18; mean age, 42 years); 32 of 34 (94%) had pancolitis, which was significantly higher than the rate of pancolitis (39%) in patients without ileal disease (N = 166) (P < 0.001), but there were no other differences between patients with or without ileal pathology. In the colon, 22 of 34 (65%) patients had severe activity. Ileal changes included villous atrophy and crypt regeneration without increased inflammation (N = 3), increased neutrophilic and mononuclear inflammation in the lamina propria (N = 6), patchy cryptitis and crypt abscesses (N = 21) and focal superficial surface erosions (N = 4), some with pyloric metaplasia (N = 2 of 4). In general, the severity of ileal changes paralleled the severity of colonic activity. However, 2 of 4 (50%) patients with superficial erosions in the ileum had subtotal or left-sided colitis only, and had only mild colonic activity. Other cases showed only mild to moderate colonic activity and patchy or discontinuous involvement of the distal ileum. Upon follow-up of patients with erosions (mean, 48.5 months; range, 26-102 months), none developed manifestations of Crohn's disease anywhere in the gastrointestinal tract. The presence of inflammatory changes in the ileum had no effect on the prevalence of pouch complications or on the occurrence of dysplasia or cancer. Ileal changes in UC are not uncommon (prevalence, 17%), are generally mild in nature (villous atrophy, increased inflammation, scattered crypt abscesses), and are not associated with an increased rate of ileo-anal pouch complications, dysplasia, or carcinoma. In some cases, our findings are consistent with a backwash etiology. However, rarely, ileal erosions may occur in patients without cecal involvement, which may indicate that other pathogenetic mechanisms should be considered in the etiology of ileitis in UC patients.