Reduction mammaplasty: defining medical necessity.

The authors evaluated existing and new criteria for defining the medical necessity for breast reduction surgery. Two cohorts of women (those requesting breast reduction surgery [N = 266] and a group of controls [N = 184]) completed a questionnaire including breast-specific symptom severity, the Short Form 36, the EuroQol, the McGill Pain Questionnaire, and the Multidimensional Body Self Relations Questionnaire. To evaluate prediction validity, the most widely accepted decision criteria and a new definition of medical necessity were applied to the data set to determine whether women meeting the definition had more favorable outcomes than those who did not as measured by validated self-report instruments. For existing criteria, women not meeting and meeting the criterion gained equal benefit from surgery. Women meeting the new definition (> or = 2 of 7 physical symptoms all or most of the time) had significantly greater improvement scores on 4 of the 5 health burden measures compared to women not meeting this definition. The authors conclude that medical necessity for breast reduction surgery is better defined by self-report of symptoms than by existing criteria.     

Validation of a simplified carbon-14-urea breath test for routine use for detecting Helicobacter [correction of Heliobacter] pylori noninvasively

A carbon-14 (14C) urea breath test for detecting Helicobacter pylori with multiple breath sampling was developed. Carbon-14-urea (110 kBq) administered orally to 18 normal subjects and to 82 patients with Helicobacter infection. The exhaled 14C-labeled CO2 was trapped at 10-min intervals for 90 min. The total 14C activity exhaled over 90 min was integrated and expressed in %activity of the total dose given. In normals, a mean of 0.59% +/- 0.24% was measured, resulting in an upper limit of normal of 1.07%. In 82 patients, a sensitivity of 90.2%, a specificity of 83.8%, and a positive predictive value of 90.2% was found. The single probes at intervals of 40-60 min correlated best with the integrated result, with r ranging from 0.986 to 0.990. The test's diagnostic accuracy did not change at all when reevaluated with the 40-, 50-, or 60-min sample data alone. Thus, the 14C-urea breath test can be applied routinely as a noninvasive, low-cost and one-sample test with high diagnostic accuracy in detecting Helicobacter pylori colonization.     

Mechanisms of non-opsonized zymosan-induced and luminol-enhanced chemiluminescence in whole blood and isolated phagocytes

A luminol-dependent non-opsonized zymosan-induced chemiluminescence method for phagocytes in small quantities of whole blood (40 microliters; final dilution: 1:14) is described. It was characterized with reference to cellular and humoral components, and also applied to isolated neutrophils, eosinophils and monocytes. Normal values for whole blood chemiluminescence and for neutrophils, eosinophils and monocytes are presented. From the chemiluminescence characteristic of distinct phagocytes and their frequency distribution pattern in whole blood, it is concluded that whole blood chemiluminescence has its source predominantly in neutrophils. The question as to the origin of chemiluminescence in phagocytes of whole blood and isolated neutrophils is investigated. The results support the importance of the myeloperoxidase-H2O2-halide system, but also go beyond this. The release of arachidonic acid by phospholipase A2 and of diacylglycerol and inositol trisphosphate by phospholipase C, the metabolism of arachidonic acid by the cyclooxygenase and lipoxygenase pathway, the activation of membrane NADPH oxidase by diacylglycerol and the calcium mobilisation by inositol trisphosphate are necessary for the chemiluminescence reaction. Inhibition of either mechanism suppresses the chemiluminescence response. The interaction of non-opsonized zymosan with plasma opsonins, phagocyte Fc- and complement receptors, respectively, for the initiation of chemiluminescence, was investigated. Non-opsonized zymosan initiates a chemiluminescence response in blood phagocytes in the absence of opsonin from the interaction of the zymosan polysaccharide component glucan with the complement receptor type 3. In the presence of plasma this receptor type also mediates the major chemiluminescence response brought about by the zymosan-coated cleavage products of complement fraction three, iC3b and to a minor degree C3b, while immunoglobulin G-coated zymosan interaction with the Fc-receptor is in this case of minor importance.     

Pulse Oximetry as a Fifth Vital Sign in Emergency Geriatric Assessment

Abstract. Objective: To determine the utility of pulse oximetry as a routine fifth vital sign in emergency geriatric assessment.
Methods: Prospective study using pulse oximetry to measure O₂ saturation in geriatric patients presenting to ED triage. Saturation values were disclosed to clinicians only after they had completed medical evaluations and were ready to release or admit each patient. The authors measured changes in medical management and diagnoses initiated after the disclosure of pulse oximetry values. The study included 1,963 consecutive adults aged ≤ 65 years presenting to triage at a university ED. Measurements included changes in select diagnostic tests: chest radiography, complete blood count (CBC), spirometry, arterial blood gases (ABGs), pulse oximetry, and ventilation-perfusion scans; treatments: antibiotics, β-agonists, and supplemental O₂; and hospital admission and final diagnoses that occurred after complete ED evaluation when physicians were informed of triage pulse oximetry values.
Results: 397 (20.2%) geriatric patients had triage pulse oximetry values <95%. Physicians ordered repeat oximetry for 51 patients, additional chest radiography for 23, CBC for 16, ABGs for 15, spirometry for 5, and ventilation-perfusion scans for none. Physicians ordered 49 new therapies for 44 patients, including antibiotics for 14, supplemental O₂ for 29, and 3-agonists for 6. Nine patients initially scheduled for ED release were subsequently admitted to the hospital. Physicians changed or added diagnoses for 27 patients.
Conclusions: Using pulse oximetry as a routine fifth vital sign resulted in important changes in the diagnoses and treatments of a small proportion of emergency geriatric patients.     

Comparative efficacy of eletriptan 40 mg versus sumatriptan 100 mg

OBJECTIVE: To confirm the efficacy advantage of eletriptan 40 mg over sumatriptan 100 mg. Background.-Eletriptan 80 mg has demonstrated significantly greater efficacy when compared to both sumatriptan 50 mg and 100 mg in two studies. Eletriptan 40 mg demonstrated significantly greater efficacy than sumatriptan 100 mg in one previous trial. METHODS: Two thousand one hundred thirteen patients with a diagnosis of migraine according to International Headache Society criteria were randomized using a double-blind, double-dummy, parallel-group design, and treated for a single migraine attack with either eletriptan 40 mg, sumatriptan 100 mg, or placebo. The primary endpoint was 2-hour headache response. Secondary endpoints included headache response rates at 1 hour, pain-free rates, absence of associated symptoms, functional response at 1 and 2 hours, and sustained headache response. RESULTS: Headache response rates at 2 hours postdose were significantly higher for eletriptan 40 mg (67%) than for sumatriptan 100 mg (59%; P <.001) and placebo (26%; P <.0001). Eletriptan 40 mg consistently showed significant (P <.01) efficacy over sumatriptan 100 mg across secondary clinical outcomes, including 1-hour headache response; 2-hour pain-free response; absence of nausea, photophobia, and phonophobia; functional improvement; use of rescue medication; treatment acceptability; and sustained headache response (P <.05). Overall, treatment-related adverse events were low, nausea being the only adverse event with an incidence of 2% or higher (4.9% with eletriptan, 4.2% sumatriptan, 2.8% placebo). CONCLUSION: This trial confirmed that eletriptan 40 mg offers superior efficacy in treating migraine pain and associated symptoms and in restoring patient functioning when compared with sumatriptan 100 mg.     

Long-Term Therapy with the Guanine Nucleoside Analog Penciclovir Controls Chronic Duck Hepatitis B Virus Infection In Vivo

Ducks congenitally infected with duck hepatitis B virus (DHBV) were treated with the antiviral guanine nucleoside analog penciclovir for 12 or 24 weeks at a dosage of 10 mg/kg of body weight per day. By the completion of both 12 and 24 weeks of therapy, molecular hybridization studies of the liver tissue revealed that the viral DNA, RNA, and protein levels were significantly reduced compared to those in the placebo-treated controls. Penciclovir treatment for 12 or 24 weeks was not associated with any toxicity, establishing the efficacy and safety of long-term penciclovir therapy in chronic DHBV infection.     

alpha(2C)-Adrenergic receptors mediate spinal analgesia and adrenergic-opioid synergy.

The alpha(2A)-adrenergic receptor (AR) subtype mediates antinociception induced by the alpha(2)AR agonists clonidine, dexmedetomidine, norepinephrine, and 5-bromo-N-(4,5-dihydro-1H-imidazol-2-yl)-6-quinoxalinamine (UK-14,304) as well as antinociceptive synergy of UK-14,304 with opioid agonists [D-Ala(2),N-Me-Phe(4),Gly(5)-ol]-enkephalin and deltorphin II. Differential localization of alpha(2)-adrenergic (alpha(2A)-, alpha(2B)-(,) alpha(2C)-) and opioid (mu-, delta-, kappa-) subtypes suggests differential involvement of subtype pairs in opioid-adrenergic analgesic synergy. The present study applies a novel imidazoline(1)/alpha(2)-adrenergic receptor analgesic, moxonidine, to test for involvement of alpha(2B)- and alpha(2C)ARs in antinociception and antinociceptive synergy, because spinal antinociceptive activity of moxonidine shows minimal dependence on alpha(2A)AR. Intrathecal administration of moxonidine produced similar (2-3-fold) decreases in both mutant mice with a functional knockout of alpha(2A)AR (D79N-alpha(2A)AR) and alpha(2C)AR knockout (KO) mice. The potency of moxonidine was not altered in alpha(2B)KO mice, indicating that this subtype does not participate in moxonidine-induced spinal antinociception. Moxonidine-mediated antinociception was dose dependently inhibited by the selective alpha(2)-receptor antagonist SK&F 86466 in both D79N-alpha(2A) mice and alpha(2C)KO mice, indicating that alpha(2)AR activation is required in the absence of either alpha(2A)- or alpha(2C)AR. Spinal administration of antisense oligodeoxynucleotides directed against the alpha(2C)AR decreased both alpha(2C)AR immunoreactivity and the antinociceptive potency of moxonidine. Isobolographic analysis demonstrates that moxonidine-deltorphin antinociceptive synergy is present in the D79N-alpha(2A) mice but not in the alpha(2C)AR-KO mice. These results confirm that the alpha(2C)AR subtype contributes to spinal antinociception and synergy with opioids.     

Effect of warm and cold applications on the resolution of IV infiltrations

Differences in pain intensity, surface area measurements of induration and erythema, and interstitial fluid volume when warm versus cold applications were randomly made to an intentional intravenous infiltrate of 5 mL of a designated solution were examined. Three solutions were used: 0.5 saline (154 mOsm), normal saline (308 mOsm), and 3% saline (1027 mOsm). Differences in volume were determined by magnetic resonance imaging (MRI) at three intervals postinfiltration. The sample was 18 healthy adults between 20 and 45 years. There was no difference in remaining infiltrate when 0.5 saline or normal saline were used, but a significant (p < 0.001) difference was found with 3% saline. For all solutions there was a significant (p < 0.001) difference in the volume of infiltrate remaining when warmth was applied and this effect held across MRI readings and solutions. Pain intensity did not differ by treatment but a significant (p < 0.005) difference was found by solution, with 3% saline producing the greatest difference. Erythema was absent with all solutions. Surface induration was affected by solution and decreased over time (p = 0.001). There was no effect of warmth or cold on surface area induration. © 1993 John Wiley & Sons, Inc.     

Treatment practices and barriers for depression and anxiety by primary care advanced practice nurses in Wyoming

PURPOSE: The aim of this study was to investigate barriers to treatment and screening related to depression and anxiety and the diagnostic and treatment practices of primary care advanced practice nurses (APNs) in the state of Wyoming. DATA SOURCES: Every primary care APN in Wyoming received a mailed questionnaire asking them about treatment barriers, screening and treatment practices, and attitudes toward depression and anxiety. CONCLUSIONS: Wyoming APNs in primary care routinely identify, evaluate, and treat patients with both depression and anxiety. APNs generally felt positive about treating these patients, although they reported that their patients encounter a number of financial barriers in accessing treatment. Routine screening practices for depression and anxiety were relatively low among the APNs, and they used a wide variety of interventions for these patients. IMPLICATIONS FOR PRACTICE: The findings identify a lack of standardized approaches to assessment, referral, and treatment, especially pharmacologic intervention, and may indicate the need for alterations in the educational preparation of primary providers in order to improve clinical outcomes of treatment for depression and anxiety.     

A case study of comorbidities: vocal cord dysfunction,asthma, and panic disorder

The purpose of this case study was to describe the nature of the symptom episodes experienced by a 24-year-old woman diagnosed with VCD, asthma, and panic disorder. A multiple card sort procedure was used to identify the type, order of presentation, and severity of symptoms experienced by the participant during her typical symptom episodes. Seven types of symptom episodes were investigated including VCD, asthma, and panic episodes; and co-occurring or combined episodes of VCD and asthma; VCD and panic; asthma and panic; and VCD, asthma, and panic. The variability and complexity of the participant's symptom episodes, which are described, led to the development of a new VCD/asthma/panic comorbidities symptom classification system.