Cost of Comorbid Alcohol and Drug Problems

The authors measured the comorbid effect of alcohol and other drug (AOD) problems on medical, surgical, and psychiatric inpatient charges and length of stay (LOS) in an urban hospital by use of retrospective study of hospital clinical computer data comparing AOD-affected patients with non-AOD-affected patients in terms of cost, diagnostic, demographic, and utilization variables (N = 14,768). Patients were men and women with and without comorbid history of AOD problems, admitted for medical, surgical, and psychiatric reasons. For 10 of the 20 most frequent Diagnosis-Related Groups (DRGs), total hospital charges and LOS were significantly lower in patients with comorbid AOD problems (P < 0.001). Overall, for the most frequent 20 DRGs, total charges and LOS remained significantly lower for the AOD group. Most physicians believed that AOD-affected patients were often less ill than non-AOD patients within the same DRG. Alcohol/drug-affected patients had robustly lower costs and LOS. Fragmentation of psychosocial costs and addiction treatment from general health care and the fee-for-service DRG system appear to financially reward acute-care hospitals to repeatedly treat secondary AOD sequelae without providing any apparent incentives for the treatment of the primary alcohol/drug condition itself.     

Comorbidity and social phobia: evidence from clinical,epidemiologic, and genetic studies

This paper reviews evidence from clinical, epidemiologic, and family studies regarding the association between social phobia and other syndromes. Social phobia is strongly associated with other anxiety disorders, substance abuse, and affective disorders in both clinical and community samples. An average of 80% of social phobics identified in community samples meet diagnostic criteria for another lifetime condition. Social phobia is most strongly associated with other subtypes of anxiety disorders, with an average of 50% of social phobics in the community reporting a concomitant anxiety disorder including another phobic disorder, generalized anciety, or panic disorder. Approximately 20% of subjects in the community meet lifetime criteria for a major depressive disorder. The onset of social phobia generally precedes that of all other disorders, with the exception of simple phobia. Both clinical severity and treated prevalence are consistently greater among social phobics with comorbid disorders The results of family and twin studies reveal that shared etiologic factors explain a substantial proportion of the comorbidity between social phobia and depression, whereas the association between social phobia and alcoholism derives from a nonfamilial causal relationship between the two conditions. Clinical and phenomenologic implications of these findings are discussed.     

Anosognosia in mild cognitive impairment: Relationship to activation of cortical midline structures involved in self-appraisal.

Awareness of cognitive dysfunction shown by individuals with Mild Cognitive Impairment (MCI), a condition conferring risk for Alzheimer's disease (AD), is variable. Anosognosia, or unawareness of loss of function, is beginning to be recognized as an important clinical symptom of MCI. However, little is known about the brain substrates underlying this symptom. We hypothesized that MCI participants' activation of cortical midline structures (CMS) during self-appraisal would covary with level of insight into cognitive difficulties (indexed by a discrepancy score between patient and informant ratings of cognitive decline in each MCI participant). To address this hypothesis, we first compared 16 MCI participants and 16 age-matched controls, examining brain regions showing conjoint or differential BOLD response during self-appraisal. Second, we used regression to investigate the relationship between awareness of deficit in MCI and BOLD activity during self-appraisal, controlling for extent of memory impairment. Between-group comparisons indicated that MCI participants show subtly attenuated CMS activity during self-appraisal. Regression analysis revealed a highly significant relationship between BOLD response during self-appraisal and self-awareness of deficit in MCI. This finding highlights the level of anosognosia in MCI as an important predictor of response to self-appraisal in cortical midline structures, brain regions vulnerable to changes in early AD.     

Treatment of a juvenile patient with a maxillary all-ceramic resin-bonded fixed partial denture: a case report.

Treatment of juvenile patients with a missing maxillary incisor is difficult, because an implant cannot be placed until growth is completed. The other minimally invasive alternatives are also problematic: Removable dentures are rarely accepted by juvenile patients, and the conventional resin-bonded fixed partial denture often provides a poor esthetic result because the metal retainer causes the abutment teeth to lose their natural translucency and to become grayish. Moreover, the alveolar ridge defect makes it easy to identify the prosthesis in the pontic area. The present case report describes the prosthetic treatment of a juvenile patient who had lost a maxillary incisor to trauma. To avoid the disadvantages of conventional therapies, subepithelial connective tissue was grafted to reshape the alveolar ridge. The space was closed with an all-ceramic resin-bonded fixed partial denture.     

Thrombotic microangiopathies in the 1980s: clinical features, response to treatment, and the impact of the human immunodeficiency virus epidemic.

We reviewed the medical records of 44 adults with 50 consecutive episodes of thrombotic thrombocytopenia purpura (TTP) or hemolytic uremic syndrome (HUS) seen at the University of California, San Francisco affiliated hospitals during the past decade. Patients were treated according to a uniform plan in which initial therapy included daily large volume plasmapheresis using fresh frozen plasma. Patients not responding completely to initial therapy were treated with a salvage regimen including splenectomy, dextran, and corticosteroids. At the time of diagnosis, the lactate dehydrogenase (LDH) was elevated in 98% of cases, with a median value of 1,208 U/L. Other clinical features were present inconsistently, and only 34% of "TTP" episodes involved the classic pentad of hemolytic anemia, thrombocytopenia, neurologic disorders, noninfectious fever, and renal impairment. Primary treatment with plasma exchange produced complete remission in 56% (27 of 48) of the episodes. Previously splenectomized patients uniformly responded to plasma therapy (12 of 12). In patients not responding completely to primary therapy, salvage splenectomy produced complete responses in 81% (13 of 16) of the cases. The pattern of clinical response to therapy was consistent, with initial resolution of neurologic dysfunction (median, 3 days) followed by normalization of LDH levels (5 days) and platelet count (7 days). Normalization of renal function occurred significantly later (15 days). Although short-term responses to plasma therapy in human immunodeficiency virus (HIV)-seropositive patients did not differ from other patients, no HIV-positive patient survived more than 2 years from diagnosis of thrombotic microangiopathy (TMA). We conclude that the diagnosis of TMA requires a high degree of clinical suspicion and that the diagnostic criteria should consist of microangiopathic hemolytic anemia, thrombocytopenia, and an elevated LDH. Initial therapy with plasma exchange leads to disease control in the majority of cases, but an optimal treatment strategy requires the use of alternative methods if initial remission is transient or not achieved. Salvage therapy with splenectomy, steroids, and dextran is highly effective in this setting.     

Reliability and validity of dyspnea measures in patients with obstructive lung disease

Dyspnea, the clinical term for shortness of breath, is the primary symptom and an important outcome measure in evaluations of patients with lung disease. It is a subjective symptom that has proved difficult to quantify. Many dyspnea measures are available, yet it is difficult, based on the existing literature, to determine the most reliable and valid. In this study, we evaluated 6 measures of dyspnea for reliability and validity: (a) Baseline Dyspnea Index (BDI) and Transition Dyspnea Index, (b) UCSD Shortness of Breath Questionnaire (SOBQ), (c) American Thoracic Society Dyspnea Scale, (d) Oxygen Cost Diagram, (e) Visual Analog Scale, and (f) Borg Scale. Subjects were 143 patients (74 women and 69 men) with obstructive lung disease, ages 40 to 86, FEV., 0.36 to 3.53 L, FVC 1.07 to 5.74 L. Dyspnea measures were assessed for test-retest reliability, internal consistency, interrater reliability, and construct validity (i.e.. correlations among dyspnea measures and correlations of dyspnea measures with exercise tolerance, health-related quality of life, lung function, anxiety, and depression). Results suggest that the SOBQ and BDI demonstrated the highest levels of reliability and validity among the dyspnea measures examined. This research was supported by University of California Tobacco Related Disease Research Program Grant 2RT026S, National Heart. Lung, and Blood Institute Grant HL 34732 to Robert M. Kaplan, and National Institutes of Health NHLBI Preventive Pulmonary Academic Award No. HL02215 to Andrew L. Ries.