Three‐dimensional transthoracic echocardiographic identification of individual cusps of the pulmonary valve: Potential misidentification by the two‐dimensional technique

We demonstrate the incremental value of live/real time three‐dimensional transthoracic echocardiography (3DTTE) over the two‐dimensional modality in the identification of all three cusps of the pulmonary valve in patients in whom only two leaflets could be detected by the latter technique. This was because of the ability of 3DTTE to view the cusps enface permitting assessment of relationship to one another and the surrounding cardiac structures. In addition, 3DTTE showed not only the potential errors that can occur in pulmonary valve cusp identification when the two‐dimensional modality is used alone but also how some of these errors can be avoided by paying attention to the surrounding structures.     

Physician credentials and practices associated with childhood immunization rates: Private practice pediatricians serving poor children in New York City

Private practice physicians in New York City’s poorest neighborhoods are typically foreign trained, have generally substandard clinical practices, and have been accused of rushing Medicaid patients through to turn a profit. However, they also represent a sizable share of physician capacity in medically underserved neighborhoods. This article documents the level of credentials, systems, and immunization-related procedures among these physicians. Furthermore, it assesses the relationship between such characteristics and childhood immunization rates. The analysis utilizes a cross-sectional comparison of immunization rates in 60 private practices that submitted 2,500 or more Medicaid claims for children. Immunization data were gathered from medical records for 2,948 randomly selected children under 3 years of age. Half of sampled physicians were board certified (55%), and half were accepted by the Medicaid P referred P hysicians and Children (P P AC) program (51.7%). Of physicians, 43% saw patients only on a walk-in basis, while only 17% scheduled the next appointment while the patient was still in the office. There were 75% of the physicians who reported usually immunizing at acute care visits. Immunization rates were higher among PPAC physicians compared to others (41% vs. 29% up to date for diphtheria and tetanus toxoids and pertussis [DTP]/Haemophilus influenzae type b [Hib], polio, and measles-mumps-rubella [MMR], P=.01), and board-certified physicians showed a trend tovard better immunization rates (39% vs. 30%, P=.07). Physicians who reported usually immunizing at acute care visits also had higher rates than those who did not (38% vs. 27%, P=.05). Scheduling a date and time for the next immunization showed a trend toward association with immunization coverage (37% vs. 28%, P=.10). Private practice physicians who provide high volumes of care reimbursed by Medicaid have improved their credentials and affiliations over time, thereby expanding reimbursement options. Credentials and affiliations were at least as effective in distinguishing relatively high- and low-performing physicians, as were immunization-related practices, suggesting that they are useful markers for higher quality care. The relative success of the P P AC programshould informefforts to inprove the capacity and quality of primary care for vulnerable children. Appointment and reminder systems that effectively manage the flow of children back into the office for immunizations and the vigilant use of acute care visits for immunizations go hand in hand. Opportunity exists for payers and plans to encourage and support these actions. This research was supported by the Centers for Disease Control and Prevention through contract 9775565 with the New York City Department of Health.     

Neutrophil Elastase Increases Airway Epithelial Nonheme Iron Levels

Alpha‐1‐antitrypsin (A1AT) deficiency is characterized by increased neutrophil elastase (NE) activity and oxidative stress in the lung. We hypothesized that NE exposure generates reactive oxygen species by increasing lung nonheme iron. To test this hypothesis, we measured bronchoalveolar lavage (BAL) iron and ferritin levels, using inductively coupled plasma (ICP) optical emission spectroscopy and an ELISA, respectively, in A1AT‐deficient patients and healthy subjects. To confirm the role of NE in regulating lung iron homeostasis, we administered intratracheally NE or control buffer to rats and measured BAL and lung iron and ferritin. Our results demonstrated that A1AT‐deficient patients and rats postelastase exposure have elevated levels of iron and ferritin in the BAL. To investigate the mechanism of NE‐induced increased iron levels, we exposed normal human airway epithelial cells to either NE or control vehicle in the presence or absence of ferritin, and quantified intracellular iron uptake using calcein fluorescence and ICP mass spectroscopy. We also tested whether NE degraded ferritin in vitro using ELISA and western analysis. We demonstrated in vitro that NE increased intracellular nonheme iron levels and degraded ferritin. Our results suggest that NE digests ferritin increasing the extracellular iron pool available for cellular uptake.     

Risk factors associated with anal sphincter tear difference among midwife,private obstetrician,and resident deliveries

To identify risk factors that account for the difference in anal sphincter tear (AST) among midwife, private obstetrician, and resident deliveries. We performed a retrospective review of our obstetrical database and used logistic regression analysis to identify risk factors for AST. The relationship between delivery technique and AST was evaluated by comparing AST increase between vaginal deliveries without and with an episiotomy among the three categories of providers. After adjusting for risk factors, private obstetricians (OR: 1.81, 95% CI: 1.27-2.56) and residents (OR: 1.60, 95% CI: 1.20-2.15) had a higher rate of AST during vaginal delivery than midwives. Episiotomy increased the odds of AST by four-fold for midwives, two-fold for private obstetricians, and eight-fold for residents. Although midwife and resident's delivery methods were associated with more AST, neither experienced this complication more frequently than private obstetricians. This suggests that midwives and residents probably misdiagnosed some AST.     

Should response rules be used to decide continued subsidy of very expensive drugs? A checklist for decision makers

Response rules are increasingly used by the Pharmaceuticals Benefits Scheme (PBS) in Australia and the National Institute of Clinical Excellence (NICE) in the U.K. to limit continued subsidy of very expensive drugs to patients who demonstrate an ‘adequate’ response. By targeting therapy to patients who appear to benefit most, policy makers aim to increase the cost‐effectiveness of therapy. However, the value of response rules in fulfilling this aim is unproven. We present a four‐item checklist that may be used to help decision makers identify when a response rule is appropriate. As an example, we apply our checklist to the response rules used for tumour necrosis factor (TNF) inhibitors in rheumatoid arthritis. On the basis of the checklist we find that the response rules in both countries are inadequate and may cause therapy to be inappropriately ceased in some and continued in others. Careful assessment is needed before decision makers adopt a response rule as a way of increasing the cost effectiveness of therapy. Copyright © 2009 John Wiley & Sons, Ltd.