Circumstances surrounding the deaths of children due to asthma. A case-control study

Features of the courses in 12 children who died of an acute attack of asthma were compared with those in 12 children of comparable age and sex who had a life-threatening attack of asthma but survived. Information obtained by structured interviews with the families and physicians and from the medical records was used to characterize (1) the patient, family, severity, and treatment of asthma primarily in the 6 months before the attack and (2) medical circumstances and patient characteristics present on the day of and/or during the acute episode. Patients in the study (mean age, 14.1 years) and controls (mean age, 13.8 years) were in early to late adolescence, had similar long-term medication use histories and an overall rating of the severity of asthma. For the analysis of the information concerning the 6 months before the attacks, the study patients had a greater frequency of respiratory failure requiring intubation, a decrease in steroid use in the month before the attack, history of family disturbance, abnormal reaction to separation or loss, and expressed hopelessness and despair. For the period more immediately surrounding the acute attack, study patients more often had attacks starting during sleep, but less frequently experienced vomiting during the course of the attacks. Treatment of the attack by the parents was poor (primarily because of delays) in 7 of the 12 children who died, but was also a factor in 6 of the 12 controls. Our data suggest that certain characteristics of asthmatic children may place them at greater risk for death due to their asthma. In addition, we postulate that there may be inherent differences in the mechanisms of the acute attacks between the children who died and those who survived.     

Kinder and gentler: physicians and managed care, 1997-2001

Despite the managed care backlash, an overwhelming majority of U.S. physicians continue to contract with managed care health plans. In fact, according to a new Center for Studying Health System Change (HSC) study, between 1997 and 2001 physicians reported a modest increase in the proportion of practice revenue from managed care contracts and the average number of contracts. At the same time, the nature of physicians' relationships with health plans changed, with a significant decrease in plans' use of capitation, or fixed monthly payments for each patient regardless of the amount of care provided. Meanwhile, physician practices moved away from using direct financial incentives to influence doctors' clinical decision making, but did experience an increase in the overall influence of treatment guidelines and other practices commonly associated with managed care.     

Financial Indicators for Critical Access Hospitals

CONTEXT: There is a growing recognition of the need to measure and report hospital financial performance. However, there exists little comparative financial indicator data specifically for critical access hospitals (CAHs). CAHs differ from other hospitals on a number of dimensions that might affect appropriate indicators of performance, including differences in Medicare reimbursement, limits on bed size and average length of stay, and relaxed staffing rules. PURPOSE: To develop comparative financial indicators specifically designed for CAHs using Medicare cost report data. METHODS: A technical advisory group of individuals with extensive experience in rural hospital finance and operations provided advice to a research team from the University of North Carolina at Chapel Hill. Twenty indicators deemed appropriate for assessment of CAH financial condition were chosen and formulas determined. Issues 1 and 2 of the CAH Financial Indicators Report were mailed to the chief executive officers of 853 CAHs in the summer of 2004 and 1,092 CAHs in the summer of 2005, respectively. Each report included indicator values specifically for their CAH, indicator medians for peer groups, and an evaluation form. FINDINGS: Chief executive officers found the indicators to be useful and the underlying formulas to be appropriate. The multiple years of data provide snapshots of the industry as a whole, rather than trend data for a constant set of hospitals. CONCLUSIONS: The CAH Financial Indicators Report is a useful first step toward comparative financial indicators for CAHs.     

Nonsurgical fluoroscopically guided dacryocystoplasty of common canalicular obstructions

Purpose: To assess dacryocystoplasty in the treatment of epiphora due to obstructions of the common canaliculus. Methods: Twenty patients with severe epiphora due to partial (n = 16) or complete (n = 4) obstruction of the common canaliculus underwent fluoroscopically guided dacryocystoplasty. In all cases of incomplete obstruction balloon dilation was performed. Stent implantation was attempted in cases with complete obstruction. Dacryocystography and clinical follow-up was performed at intervals of 1 week, and 3, 6, 12, and 18 months after the procedure. The mean follow-up was 6 months (range 3–18 months). Results: Balloon dilation was technically successfully performed in all patients with incomplete obstructions (n = 16). In three of four patients with complete obstruction stent implantation was performed successfully. Subsequent to failure of stent implantation in one of these patients balloon dilation was performed instead. The long-term primary patency rate in patients with incomplete obstructions was 88% (n = 14/16). In three of four cases with complete obstruction long-term patency was achieved during follow-up. Severe complications, infections, or punctal splitting were not observed. Conclusion: Fluoroscopically guided balloon dacryocystoplasty is a feasible nonsurgical therapy in canalicular obstructions with good clinical results that may be used as an alternative to surgical procedures. In patients with complete obstructions stent placement is possible but further investigations are needed to assess the procedural and long-term results.     

Specific c-K-ras Gene Mutations as a Tumor-Response Marker in Locally Advanced Rectal Cancer Treated With Preoperative Chemoradiotherapy

Background: Forty percent of patients with colorectal cancer develop mutations in the K-ras gene.Objective: Our objective was to evaluate whether the presence of c-K-ras gene mutations is a useful tumor-response marker in patients with locally advanced rectal cancer treated with preoperative chemoradiotherapy.Material and Methods: Thirty seven patients with locally advanced rectal cancer were treated with preoperative chemoradiotherapy. Four to six weeks later, surgery was performed. Specimens were classified according to the UICC-AJC classification. A segment of the tumor was obtained to analyze specific c-K-ras gene mutations. Restriction fragment length polymorphism (RFLP) and single strand confirmation polymorphism (SSCP) techniques were used with a set of probes to detect specific c-K-ras mutations in codons 12, 13, and 61. The 37 patients were divided into Group A (with mutations) and Group B (without mutations).Results: All 37 patients completed the scheduled treatment. Group A consisted of 12 patients, whose tumors were classified and specific c-K-ras mutations were located as follows: eight in codon 12, two in codon 13, and one in codon 61. Group B consisted of 25 patients. The tumors were classified and there were more early-stage tumors in Group A, whereas in Group B there were more advanced-stage tumors (P 5 .05, respectively). The mean follow-up was 36.2 6 18.3 months. All Group A patients survived, whereas 8 of the 25 patients in Group B died due to progressive metastatic disease. Survival in Group A was 100%, whereas in Group B it was 59% (P 5 .03).Conclusions: The presence of specific c-K-ras mutations is an indicator of tumor response in patients with locally advanced rectal cancer treated with preoperative chemoradiotherapy and surgery. Therefore, responding patients may be more amenable to less radical surgical procedures based on c-K-ras mutations.