bluuebunny/crossref_metadata_2025 huggingface dataset:
Racial Differences in the Cost of Treating Men with Early‐Stage Prostate Cancer
Authors: Brandeis Judson , Pashos Chris L. , Henning James M. , Litwin Mark S.
Published: March 2003

OBJECTIVE: To compare the cost and resource utilization in the evaluation, treatment, and 6‐month follow‐up of African‐American and White men undergoing either external beam radiation therapy (XRT) or radical prostatectomy (RP) for early‐stage prostate cancer.

DESIGN: Retrospective analysis of cost and resource utilization data from encrypted patient‐specific hospital inpatient, hospital outpatient, and physician/supplier data files.

SETTING: National Medicare claims data from 1993 through 1996.

PARTICIPANTS: A random 5% national sample of Medicare beneficiaries from the Health Care Financing Administration Public Use Files for 1993 through 1996.

MEASUREMENTS: Inpatient, outpatient, and physician/supplier Medicare costs.

RESULTS: African‐American men undergoing RP for early‐stage prostate cancer had significantly higher costs ($21,878 vs $18,786, P < .0001) than did White men. Most of the difference occurred in the inpatient setting. African‐American men undergoing XRT had significantly greater costs ($18,131 vs $15,734, p < .0001) than did White men. Most of this difference was generated by longer duration of XRT treatments.

CONCLUSIONS: In early‐stage prostate cancer, charges for RP and XRT in African‐American men are higher when compared with those for White men.
Low Vision in the Geriatric Population: Rehabilitation and Management
Authors: Watson Gale R.
Published: March 2003

Older persons represent the fastest growing segment of individuals with visual impairments in industrialized countries. This population is expected to grow dramatically in the coming years. This article discusses the common agerelated changes in vision and the most prevalent visual impairments associated with aging, and the resulting functional implications. It includes information for health care professionals about preparing an older person to benefit from low‐vision rehabilitation services, environmental evaluations and modifications, and orientation to the environment. The importance of functional assessment and instruction in the use of visual skills and vision devices is stressed. The article also emphasizes the need for teamwork to provide a full scope of rehabilitation services to older adults with low vision, and the importance of support by family members and caregivers to maximize coping, adjustment, independence and quality of life.
Advance Care Planning and End‐of‐Life Care for Hospitalized Nursing Home Residents
Authors: Happ Mary Beth , Capezuti Elizabeth , Strumpf Neville E. , Wagner Laura , Cunningham Sarah , Evans Lois , Maislin Greg
Published: March 2003

OBJECTIVES: To describe advance care planning (ACP) and end‐of‐life care for nursing home residents who are hospitalized in the last 6 weeks of life.

DESIGN: Constant comparative analysis of deceased nursing home resident cases.

SETTING: A not‐for‐profit Jewish nursing home.

PARTICIPANTS: Forty‐three deceased residents hospitalized within the last 6 weeks of life at a tertiary medical center.

MEASUREMENTS: Trained nurse reviewers abstracted data from nursing home records and gerontological advanced practice nurse field notes. Clinical and outcome data from the original study were used to describe the sample. Data were analyzed using the constant comparative method and validated in interviews with a gerontological advanced practice nurse and social worker.

RESULTS: The analysis revealed distinct characteristics and identifiable transition points in ACP and end‐of‐life care with frail nursing home residents. ACP was addressed by social workers as part of the nursing home admission process, focused primarily on cardiopulmonary resuscitation preference, and reviewed only after the crisis of acute illness and hospitalization. Advance directive forms specifying preferences or limitations for life‐sustaining treatment contained inconsistent language and vague conditions for implementation. ACP review generally resulted in gradual limitation of life‐sustaining treatment. Transition points included nursing home admission, acute illness or hospitalization, and decline toward death. Relatively few nursing home residents received hospice services, with most hospice referrals and palliative care treatment delayed until the week before death. Most residents in this sample died without family present and with little documented evidence of pain or symptom management.

CONCLUSION: Limiting discussion of advance care plans to cardiopulmonary resuscitation falsely dichotomized and oversimplified the choices about medical treatment and care at end‐of‐life, especially palliative care alternatives, for these older nursing home residents. Formal hospice services were underutilized, and palliative care efforts by nursing home staff were often inconsistent with accepted standards. These results reinforce the need for research and program initiatives in long‐term care to improve and facilitate individualized ACP and palliative care at end of life.
Low Serum Vitamin D Does Not Predict New Disability or Loss of Muscle Strength in Older Women
Authors: Verreault René , Semba Richard D. , Volpato Stefano , Ferrucci Luigi , Fried Linda P. , Guralnik Jack M.
Published: March 2003

OBJECTIVES: To determine whether serum levels of 25‐hydroxyvitamin D (25(OH)D) and parathyroid hormone (PTH) predict accelerated decline in muscular strength or onset of new disability in mobility and upper extremity functioning over a 3‐year follow‐up.

DESIGN: A community‐based prospective cohort study.

PARTICIPANTS: Six hundred twenty‐eight moderately to severely disabled women aged 65 and older living in the community.

MEASUREMENTS: Subjects were divided into three groups of baseline 25(OH)D serum levels (deficiency: <25 nmol/L; low normal: 25–52 nmol/L; high normal: ≥53 nmol/L) and into tertiles of PTH levels. Objective performance measures (hip flexor, knee extensor, and grip strengths; walking speed; and time for repeated chair stands) and disability in activities involving mobility and upper extremity function were assessed at baseline and every 6 months for 3 years. Decline in performance measures and onset of new disability were compared between 25(OH)D and PTH groups using random effects models and proportional hazards models, respectively, while adjusting for age, race, education, body mass index, baseline performance, and chronic conditions.

RESULTS: The annual rate of decline over 3 years in muscular strength, walking speed, and time to perform repeated chair stands was similar across 25(OH)D groups. We observed a nonsignificantly faster decline in proximal muscle strength and walking speed with increasing PTH levels. There was no association for either measure between serum levels and the risk of incident disability in activities relating to mobility and upper extremity function.

CONCLUSION: This study does not support the hypothesis that vitamin D deficiency is associated with loss in muscular strength and decline in mobility and upper extremity functioning over time in older women who were moderately to severely disabled at baseline.
The Use of Life‐Sustaining Treatments in Hospitalized Persons Aged 80 and Older
Authors: Somogyi‐Zalud Emese , Zhong Zhenshao , Hamel Mary Beth , Lynn Joanne
Published: March 2003

OBJECTIVES: To characterize the use of life‐sustaining treatments in hospitalized patients aged 80 and older.

DESIGN: A prospective cohort study.

SETTING: Four teaching hospitals in the United States that participated in the Hospitalized Elderly Longitudinal Project (HELP).

PARTICIPANTS: Hospitalized patients aged 80 and older.

MEASUREMENTS: We report the rates of admissions to intensive and coronary care units and the rates of use of cardiopulmonary resuscitation (CPR), ventilators, right heart catheterization, artificial nutrition and hydration, surgical interventions, hemodialysis, and blood transfusions.

RESULTS: Of the 1,266 patients enrolled in HELP, 72 died during the enrollment hospitalization. The median age of those who died was 86 (range 83–89). Of the patients who died, the median number of activities of daily living impairments was two (range 1–4) before hospitalization, and 70% reported their baseline quality of life as fair or poor. Most patients who died had stated that they did not want aggressive care; 70% wanted their care focused on comfort rather than prolonging life, and 80% had a do‐not‐resuscitate order. However, the majority (63%) of the patients received one or more life‐sustaining treatments before they died. Fifty‐four percent were admitted to intensive or coronary care units, 43% were on a ventilator, 18% received CPR, 18% received tube feeding, 17% underwent surgery, 15% had right heart catheterization, 14% received blood transfusions, and 6% had hemodialysis. Intensive care did not affect survival time.

CONCLUSION: The use of life‐sustaining treatments was prevalent in very old patients who died in the course of hospitalization, despite the fact that the majority had a preference for comfort care. This lack of congruence warrants further investigation and efforts to provide care that is more consistent with patients' preferences.
Profiles of Older Medicare Decedents
Authors: Lunney June R. , Lynn Joanne , Hogan Christopher
Published: March 2003

OBJECTIVES: To evaluate the usefulness of a clinical scheme to classify older decedents to better understand the issues associated with healthcare use and costs in the last year of life.

DESIGN: We analyzed Medicare claims data for a random sample of 0.1% of all Medicare beneficiaries with expenditures between 1993 and 1998. This sample yielded 7,966 deaths.

SETTING: Medicare claims data.

PARTICIPANTS: Medicare beneficiaries.

MEASUREMENTS: We classified decedents into groups representing four trajectories at the end of life: sudden death, terminal illness, organ failure, and frailty.

RESULTS: Ninety‐two percent of decedents were captured by the profiling strategy. The four trajectory groups had distinct patterns of demographics, care delivery, and Medicare expenditures. Frailty was a dominant pattern, with 47% of all decedents, whereas sudden death claimed only 7%; cancer claimed 22%, and organ system failure, 16%.

CONCLUSIONS: The clinical scheme to classify decedents appears to fit most decedents and to form groups with substantial clinical differences. Acknowledging the differences among these groups may be a fruitful way to evaluate expenditures and develop strategies to improve care at the end of life.
Racial and Ethnic Differences in Place of Death: United States, 1993
Authors: Iwashyna Theodore J. , Chang Virginia W.
Published: March 2003

OBJECTIVES: To examine racial and ethnic differences in place of death, adjusting for likely confounders.

DESIGN: A retrospective cohort analyzed using multinomial logistic regression.

SETTING: United States in 1993.

PARTICIPANTS: A nationally representative sample of 22,658 deaths in 1993 from the National Mortality Followback Survey.

MEASUREMENTS: Place of death as determined on the death certificate, with controls for age, sex, income, education, and cause of death. The outcomes of interest were death in a hospital during an inpatient stay, death in a nursing home, death in a private residence, or death in some other place.

RESULTS: After adjustment, 43% of whites die after an inpatient hospital stay, as do 50% of blacks and 56% of Mexican Americans. Twenty percent of whites, 22% of Mexican Americans, and 14% of blacks die in nursing homes. Twenty‐two percent of whites, 18% of blacks, and 9% of Mexicans die in a private residence.

CONCLUSIONS: There are substantial differences between whites, blacks, and Mexican Americans in place of death that cannot be explained by differences in age, sex, income, education, and causes of death between the groups.
Serum Interleukin‐6 and Hemoglobin as Physiological Correlates in the Geriatric Syndrome of Frailty: A Pilot Study
Authors: Leng Sean , Chaves Paulo , Koenig Kathleen , Walston Jeremy
Published: March 2003

OBJECTIVES: To determine specific physiological correlates of the geriatric syndrome of frailty that warrant further investigation.

DESIGN: Population‐based case‐control study.

SETTING: General Clinical Research Center at Johns Hopkins Bayview Medical Center.

PARTICIPANTS: Community‐dwelling adults aged 74 and older from Baltimore, Maryland.

MEASUREMENTS: Frailty status was determined using a recently validated screening tool that consists of weight loss, fatigue, low levels of physical activity, and measurements of grip strength and walking speed. Serum interleukin‐6 (IL‐6) was measured using enzyme‐linked immunosorbent assay, and standard complete blood count was performed using a Coulter counter.

RESULTS: Eleven frail and 19 nonfrail subjects with mean age ± standard deviation of 84.9 ± 6.7 vs 81.3 ± 4.1 years, respectively, completed the study. The frail subjects had significantly higher serum IL‐6 levels and significantly lower hemoglobin and hematocrit than the nonfrail subjects (4.4 ± 2.9 vs 2.8 ± 1.6 pg/mL, 12.1 ± 1.1 vs 13.9 ± 1.0 g/dL, and 35.8%± 3.1% vs 40.6%± 2.8%, respectively). No significant difference was observed in mean corpuscular volume, red blood cell distribution width, or white blood cell and platelet counts between the frail and nonfrail groups. Furthermore, there was an inverse correlation between serum IL‐6 level and hemoglobin (Pearson's correlation coefficient: −0.46) and hematocrit (−0.48) in the frail group but not in the nonfrail group.

CONCLUSION: These results suggest that frail subjects have evidence of inflammation and lower hemoglobin and hematocrit levels. This subclinical anemia is normocytic and is hence unlikely due to myelosuppression or iron deficiency and is potentially related to the increased chronic inflammatory state marked by serum IL‐6 elevation. Further studies are indicated to better characterize the immune and hematological changes that underlie frailty.
Outcomes of a Community‐Based Dissemination of the Health Enhancement Program
Authors: Phelan Elizabeth A. , Williams Barbara , Leveille Suzanne , Snyder Susan , Wagner Edward H. , LoGerfo James P.
Published: March 2003

OBJECTIVES: We previously found in an efficacy trial that a health promotion program prevented functional decline and reduced hospitalizations in community‐dwelling older people with chronic conditions. We sought to evaluate the effectiveness of the program in its dissemination phase.

DESIGN: Outcome evaluation using a within‐group, pretest‐posttest design.

SETTING: Fourteen senior centers located throughout western Washington.

PARTICIPANTS: Three hundred four community‐dwelling men and women aged 65 and older.

INTERVENTION: A disability‐prevention, chronic disease–self‐management program.

MEASUREMENTS: Participant characteristics, risk factors for disability, change in health and functional status, and healthcare use over 1 year of enrollment; participant satisfaction.

RESULTS: Participants were 71% female, had a mean age of 76, and reported three chronic health conditions on average. The percentage of participants found to be depressed decreased (28% at time of enrollment vs 17% at 1‐year follow‐up, P = .005). The percentage of physically inactive participants decreased (56% vs 38%, P = .001). Physical activity level and exercise readiness improved (Physician‐based Assessment and Counseling for Exercise mean score 4.3 vs 5.1, P = .001). At follow‐up, 83% rated their health the same as or better than a year ago, compared with 73% at time of enrollment. The proportion with impaired functional status, as measured by bed days and restricted activity days, stayed the same. The proportion hospitalized remained stable (23% at enrollment and follow‐up, P = 1.0).

CONCLUSIONS: Under real world conditions, the Health Enhancement Program reaches older people at risk of functional decline. Those enrolled for 1 year experience a reduction in disability risk factors, improvement in health status, no decrements in functional status, and no increase in self‐reported healthcare use.
Predictors of Functional Change: A Longitudinal Study of Nondemented People Aged 65 and Older
Authors: Wang Li , Van Belle Gerald , Kukull Walter B. , Larson Eric B.
Published: March 2003

OBJECTIVES: To identify factors associated with functional change in an older population and investigate interactions among selected potential risk factors.

DESIGN: A population‐based prospective cohort study.

SETTING: A random sample was selected from the Group Health Cooperative members in the Seattle area from 1994 to 1996 and followed biennially.

PARTICIPANTS: Two thousand five hundred eighty‐one people aged 65 and older, cognitively intact at baseline.

MEASUREMENTS: Functional status was measured by activities of daily living, instrumental activities of daily living, and performance‐based physical function testing.

RESULTS: The cohort status at the time of these analyses was: deceased, 391; withdrawn, 179; dementia, 152; and on study, 1,873. The mean follow‐up time was 3.4 years. Using linear regressions with Generalized Estimating Equation, selected medical conditions (diabetes mellitus, hypertension, coronary heart disease, cerebrovascular disease (CVD), osteoporosis, arthritis, and cancer), low cognitive function, depression, and smoking were associated with worse functional outcomes. Exercise and moderate alcohol use were associated with better functional outcomes. Over the follow‐up period, coronary heart disease, CVD, and depression were associated with increased rates of functional decline. Exercise and moderate alcohol consumption were associated with decreased rates of functional decline. Significant interactions were observed between exercise and coronary heart disease, moderate alcohol use and CVD, and cognition and CVD.

CONCLUSIONS: Our study has identified not only risk factors associated with functional decline but also the interactions among these factors. These observations, along with other published research, add to the growing understanding of the underlying process of functional change and could provide a basis to design effective strategies to delay functional decline.
The ETHNIC(S) Mnemonic: A Clinical Tool for Ethnogeriatric Education
Authors: Kobylarz Fred A. , Heath John M. , Agsf  , Like Robert C.
Published: March 2003

Geriatrics healthcare providers need to be aware of the effect that culture has on establishing treatment priorities, influencing adherence, and addressing end‐of‐life care issues for older patients and their caregivers. The mnemonic ETHNIC(S) (Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, Spirituality/Seniors) presented in this article provides a framework that practitioners can use in providing culturally appropriate geriatric care. ETHNIC(S) can serve as a clinically applicable tool for eliciting and negotiating cultural issues during healthcare encounters and as a new instructional strategy to be incorporated into ethnogeriatric curricula for all healthcare disciplines.
Optimizing Coding and Reimbursement to Improve Management of Alzheimer's Disease and Related Dementias
Authors: Fillit Howard , Geldmacher David S. , Welter Richard Todd , Maslow Katie , Fraser Malcolm
Published: March 2003

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD‐9‐CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long‐term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients.

Relevant English‐language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD‐9‐CM code for AD—331.0—and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD‐9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time‐intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD‐9‐CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time‐intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.
Healing Pressure Ulcers with Collagen or Hydrocolloid: A Randomized, Controlled Trial
Authors: Graumlich James F. , Blough Linda S. , McLaughlin Richard G. , Milbrandt Joseph C. , Calderon Cesar L. , Agha Syed Abbas , Scheibel L. William
Published: March 2003

OBJECTIVES:To compare the effects of topical collagen and hydrocolloid on pressure ulcer healing.

DESIGN:Randomized (allocation concealed), single‐blind (outcome assessors), controlled trial with 8‐week follow‐up.

SETTING:Eleven nursing homes in central Illinois.

PARTICIPANTS:Sixty‐five patient‐residents with Stage II or III pressure ulcers: median age 83.1, median Braden score 12, 63% female, 80% Stage II ulcers, and 20% Stage III ulcers. Exclusion criteria included cellulitis and osteomyelitis.

INTERVENTION:Thirty‐five patients were allocated to topical collagen daily, 30 to topical hydrocolloid twice weekly.

MEASUREMENTS:The primary outcome was complete healing within 8 weeks. Secondary outcomes were time to heal, ulcer area healed per day, linear healing of wound edge, and cost of therapy.

RESULTS:Analysis by intention to treat revealed similar complete ulcer healing within 8 weeks in collagen (51%) and hydrocolloid (50%) recipients (difference 1%, 95% confidence interval (CI) = 26–29%). Mean healing time was similar: collagen healed in 5 weeks (95% CI = 4–6), hydrocolloid healed in 6 weeks (95% CI = 5–7). Mean area healed per day was 6 mm2/d in both treatment groups. Mean linear healing of the wound edge was 3 mm in both groups. In multivariate analysis, baseline ulcer depth was the only independent predictor of complete ulcer healing within 8 weeks (odds ratio = 0.56, 95% CI = 0.38–0.81). Cost analysis favored hydrocolloid.

CONCLUSIONS:There were no significant differences in healing outcome between collagen and hydrocolloid. Collagen was more expensive and offered no major benefits to patients otherwise eligible for hydrocolloid treatment. J Am Geriatr Soc 51:147–154, 2003.
Does an Exercise and Incontinence Intervention Save Healthcare Costs in a Nursing Home Population?
Authors: Schnelle John F. , Kapur Kanika , Alessi Cathy , Osterweil Dan , Beck John G. , Al‐Samarrai Nahla R. , Ouslander Joseph G.
Published: March 2003

OBJECTIVES: To determine whether an intervention that combines low‐intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents.

DESIGN: Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6‐month baseline and an 8‐month intervention phase.

SETTING: Four nursing homes.

PARTICIPANTS: One hundred ninety incontinent, long‐stay nursing home residents.

INTERVENTION: Low‐intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months.

MEASUREMENTS: Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6‐month baseline period and throughout the 8‐month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%.

RESULTS: The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention.

CONCLUSION: The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor‐intensive interventions for frail nursing home residents will have to be justified based on functional and quality‐of‐life outcomes and are unlikely to be offset by savings in medical care costs in this population.
The Value of Positron Emission Tomography in the Clinical Evaluation of Dementia
Authors: Gill Sudeep S. , Rochon Paula A. , Guttman Mark , Laupacis Andreas
Published: March 2003

Positron emission tomography (PET) has been promoted as a means of improving the diagnosis of Alzheimer's disease (AD), but the evidence to support its incremental value is unclear. To assess the evidence regarding the use of PET in the clinical evaluation of AD, a systematic review of the English‐language literature indexed in MEDLINE (1975–January 2001), the Cochrane Library (issue 4, 2000), and health technology assessment (HTA) reports was conducted. Articles identified by this review process were graded for methodological and reporting quality using a standardized grading scheme. Sixteen original articles and seven HTA reports were identified. In general, the articles addressed: using PET to differentiate AD from normal aging or non‐Alzheimer's dementias, PET imaging compared with single positron emission computed tomography imaging, using PET to predict the progression of dementia, and agreement and reliability in the interpretation of PET images. Serious problems with study design and methodology in all articles were identified. Previous HTA reports have generally recommended that PET not be used in the clinical evaluation of dementia. In conclusion, there is little evidence to support the addition of PET to the routine clinical evaluation of patients with suspected or established dementia. Suggestions for future research in this area are offered.
Ability of anaesthetists to identify a marked lumbar interspace. (Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, United Kingdom) Anaesthesia 2000;55:1122–1126.
Authors: Broadbent C. R. , Maxwell W. B. , Ferrie R. , Wilson D. J. , Gawne‐Cain M. , Russell: R.
Published: March 2003

This article assessed anesthetists' ability to identify correctly a marked lumbar interspace in 100 patients undergoing spinal magnetic resonance imaging scans. Using ink, the first anesthetist marked an interspace on the lower spine and attempted to identify its level with the patient in the sitting position. The second anesthetist attempted to identify the level with the patient in the flexed lateral position. A marker capsule was taped over the ink mark and a routine scan performed. The actual level of markers ranged from 1 space below to 4 spaces above the level at which the anesthetist believed it to be. The marker was 1 space higher than assumed in 51% of cases and was identified correctly in only 29%. Accuracy was unaffected by patient position (sitting or lateral), although it was impaired by obesity and positioning of the markers high on the lower back. The spinal cord terminated below L1 in 19% of the patients. This, together with the risk of accidentally selecting a higher interspace than intended for intrathecal injection, implies that spinal cord trauma is more likely when higher interspaces are selected.

Comment by Alan Kaye, M.D. Previous studies have demonstrated inaccuracies regarding identification of lumbar interspaces. This study by Broadbent et al involved 104 patients scheduled for lumbar magnetic resonance imaging and essentially anesthesiologists were asked to mark with washable ink the skin overlying any interspace on the lower spine after palpation of the lumbar region. Different positions were evaluated including sitting and lateral. Only 29% were demonstrated to be correct through magnetic resonance imaging. Within the lumbar region, there were tremendous errors by the anesthesiologist at all levels. Further, a common mistake included the assumption of location based on the landmark provided from the iliac crest. Therefore, with the potential of neurological damage from misidentification of the vertebral column, the authors recommend lower rather than higher sites when more than 1 site is identified. The authors provide a clever investigation; however, this is a relative small study population and there is little mention of the variation existing within the population studied. However, this study suggests that if an option exists as to which lumbar space to enter, the lower would seem safer and more prudent to minimize the potential of neurologic injury.
Methodoloic issues in acute migraine clinical trials. (Albert Einstein College of Medicine, Bronx, NY) Neurology 2000;55:S3–S7.
Authors: Lipton: Richard B.
Published: March 2003

This article discusses the importance of clinical trials that provide physicians and patients with the information they need to assess the efficacy, safety, and comparative benefits of current and emerging therapies. The study design and methods, including determination of appropriate, dosage are considered key issues. The selection of primary efficacy end points was considered another critical factor. Secondary end points, such as relief of migraine‐associated symptoms, need for the use of escape medication, and quality of life measurements were also discussed.
Assessing symptom distress in cancer patients. The M.D. Anderson symptom inventory. (The University of Texas M. D. Anderson Cancer Center, Houston, Texas) Cancer 2000;89:1634–1646.
Authors: Cleeland Charles S. , Mendoza Tito R. , Wang Xin Shelley , Chou Chyi , Harle Margaret T. , Morrissey Marilyn , Engstrom: Martha C.
Published: March 2003

The purpose of this project was to develop the M. D. Anderson Symptom Inventory (MDASI), a brief measure of the severity and impact of cancer‐related symptoms. A list of symptoms was generated from symptom inventories and by panels of clinicians. Twenty‐six symptoms and 6 interference items were rated by a validation sample of 527 outpatients, a sample of 30 inpatients from the blood and bone marrow transplantation service, and a cross‐validation sample of 113 outpatients. Clinical judgement and statistical techniques were used to reduce the number of symptoms. Reliability, validity, and sensitivity of the MDASI were examined. Cluster analysis, best subset analysis, and clinical judgement reduced the number of symptoms to a “core” list of 13 that accounted for 64% of the variance in symptom distress. Factor analysis demonstrated a similar pattern in both outpatient samples, and two symptom factors and the interference scale were reliable. Expected differences in symptom pattern and severity were found between patients with “good” versus “poor” performance status and between patients in active therapy and patients who were seen for follow‐up. Patients rated fatigue‐related symptoms as the most severe. Groups of patients classified by disease or treatment had severe symptoms that were not on the “core” list. Conclude the core items of the MDASI accounted for the majority of symptom distress reported by cancer patients in active treatment and those who were followed after treatment. The MDASI should prove useful for symptom surveys, clinical trials, and patient monitoring, and its format should allow Internet or telephone administration.
Phenotypic inflammation switch in rats shown by calcitonin gene‐related peptide immunoreactive dorsal root ganglion neurons innervating the lumbar facet joints. (School of Medicine, Chiba University, Chiba, Japan) Spine. 2001;26:1009–1013.
Authors: Ohtori Seiji , Takahashi Kazuhisa , Chiba Tanemichi , Yamagata Masatsune , Sameda Hiroaki , Moriya Hideshige
Published: March 2003

This study's objective was to determine by inflammatory stimulation the changes in calcitonin gene‐related peptide‐immunoreactive dorsal root ganglion neurons innervating the L5‐L6 facet. Retrograde transport of fluorogold was used in 20 rats: 10 in the control group and 10 in the inflammatory group. Using the dorsal approach, fluorogold crystals were injected into the left L5‐L6 facet joint. Then 5 days after application, complete Freund's adjuvant (50 injected μg Mycobacterium butyricum in oil saline emulsion) was injected into the same L5‐L6 facet joint (inflammatory group). Of the total fluorogold‐labeled dorsal root ganglion neurons from T13‐L6, the number and cross‐sectional area of the cell profiles of fluorogold‐labeled, calcitonin gene‐related peptide‐immunoreactive neurons in the bilateral dorsal root ganglia of both groups were evaluated. Fluorogold‐labeled neurons were distributed throughout the ipsilateral dorsal root ganglia from L1‐L5 in both groups. Of the fluorogold‐labeled neurons, the ratios of the calcitonin gene‐related peptide‐immunoreactive L1, L2, L3, L4, and L5 dorsal root ganglion neurons, respectively, were 17%, 24%, 44%, 56%, and 50% in the control group and 50%, 39%, 51%, 61%, and 56% in the inflammatory group. The ratios of the calcitonin gene‐related peptide‐immunoreactive L1 and L2 dorsal root ganglion neurons labeled by fluorogold were significantly higher in the inflammatory group than in the control group (P < 0.05). The mean cross‐sectional area of fluorogold‐labeled, calcitonin gene‐related peptide‐immunoreactive cells from the L1‐L5 dorsal root ganglia increased from 621 ± 64 μm2 to 893 ± 63 μm2 in the inflammatory group (P < 0.01).

Comment by Octavio Calvillo, M.D., Ph.D. This is a bench research study that demonstrated sympathetic activation of dorsal root ganglia distal to the pain response. The authors sought to establish the degree of innervation of the L5‐6 facet joint of the rat from sympathetic fibers of L1 and 2 and to adjacent L3‐5 segmental fibers. From histological analysis, they found that inflammation increased the production of CGRP‐Ir in the dorsal root ganglion of L1 and L2. Additionally, the nerve fibers were noted to increase in size with the inflammation. These findings lend support for upper lumbar dorsal root blockade for non‐segmental levels of inflammation.
Characteristics of patients with herpes zoster on presentation to practitioners in France. (University Claude Bernard, Lyon, France) Clin Infectious Dis. 2001;33:62–69.
Authors: Chidiac Christian , Bruxelle Jean , Daures Jean‐Pierre , Hoang‐Xuan Thanh , Morel Patrice , Leplège Alain , El Hasnaoui Abdelkader , De Labareyre Cécile
Published: March 2003

There have been many epidemiological studies of chickenpox, but only a few of herpes zoster. We report data from an observational study, conducted in France during a 1‐year period, of 9038 patients who presented with acute herpes zoster (n = 8103) or postherpetic neuralgia (PHN) at the office practices of 4635 general practitioners or dermatologists. The incidence of herpes zoster in France was found to be similar to that in the literature: from 1.4 to 4.8 cases per 1000 population per year. The patient profiles and clinical patterns delineated as well as the management decisions made according to the type of treating physician. The impact of herpes zoster on quality of life was evaluated on the basis of the Medical Outcome Study Short Form 36 (MOS SF 36 scale, which is widely used for assessing quality of life in the field of health. This study provided reference data on the substantial deterioration in quality of life associated with herpes zoster and PHN.
Herpes zoster ophthalmicus. (Singapore National Eye Center, Singapore) J Pediatric Ophthalmology Strabismus. 2001;38:174–176.
Authors: Ang Leonard Pek‐Kiang , Eong Kah‐Guan Au , Ong Su‐Guan
Published: March 2003

This case report discussed 2 children with herpes zoster ophthalmicus as the first manifestation of varicella‐zoster virus infection. Both children's mothers had varicella while they were pregnant, but the children did not have a history of clinical varicella following birth. The authors concluded that the children were infected transplacentally with complete resolution of the features of the disease at the time of delivery. Such cases of childhood herpes zoster without a history of clinical varicella infection are rare in literature.
Phenol block of peripheral nerve condition: titrating for optimum effect. (Sungkyunkwan University of Medicine, Seoul, Korea). Arch Phys Med Rehabil. 2001;82:671–676.
Authors: Sung Duk Hyun , Han Tai Ryoon , Park Won‐Hah , Bang Heui Je , Kim Jong‐Moon , Chung Seung‐Hyun , Woo Eung‐Je
Published: March 2003

This experimental study was conducted to verify the dose‐response relationship in phenol nerve block and to determine the concentration and volume of phenol injectate required for effective nerve conduction block. The test group consisted of 71 New Zealand white rabbits. Group I (n = 48) received tibial nerve block by perineural injection (phenol, n = 40; saline, n = 8), Group II (n = 21) by submerging the nerve in phenol solution. The 6 subgroups of Group I each received different concentrations (3%, 4%, 5%) and volumes (0.1 mL, 0.2 mL, 0.3 mL). Compound muscle action potential (CMAP) and tension of triceps surae muscles by electric stimulation of the sciatic nerve were measured preintervention and at day 1, and weeks 1, 2, 4, and 8 postblock. Histologic studies were performed on 2 animals from group I. Two rabbits in Group I died before results were obtained. In the remaining animals, CMAP amplitude reduced significantly as the volume of 5% phenol solution increased from 0.1 mL, 0.2 mL, to 0.3 mL. A high concentration of phenol produced a more pronounced conduction block; however, no significant difference existed among the 3 concentrations. Submerged tibial nerve had a greater degree of conduction block than perineurally injected nerve. Depth of the degeneration area in nerve fascicle varied with distance from the injection point. Conclude that the nerve block effect of phenol can be titrated by adjusting the concentration and volume of phenol solution if the technique of application and localization of a block site are standardized.
Acupuncture for chronic low back pain: diagnosis and treatment patterns among acupuncturists evaluating the same patient. (Washington University School of Medicine, St. Louis, MO) Southern Med J. 2001;94:486–492.
Authors: Kalauokalani Donna , Sherman Karen J. , Cherkin Daniel C.
Published: March 2003

In this case study 7 office‐based acupuncturists practicing Traditional Chinese Medicine evaluated the same patient with chronic low back pain and provided data regarding principal assessment techniques, diagnoses, and therapeutic recommendations. A high diagnostic agreement existed among 5 of 7 acupuncturists. However, recommended treatments included varying numbers and locations of acupuncture points. Recommendations varied between 5 and 14 points requiring 7 to 26 needles, since many points were intended for bilateral application. Of 28 acupuncture points selected, only 4 (14%) were prescribed by 2 or more acupuncturists. Most recommended various forms of adjuvant heat. Conclude that 7 acupuncturists agreed considerably in the diagnoses for the same patient with chronic low back pain, but treatment recommendations varied substantially. Clinicians and researchers must recognize treatment recommendation variations and the challenges they present for study design interpretation.
Palliative Medicine — Part 2
Authors: Reddy Suresh K. , FFARCS  , Rajagopal Arun , Govidraj Nirupama
Published: March 2003

With the recent release of the report from The Institute of Medicine regarding terminal patients, palliative medicine could receive much needed attention among medical specialties in the form of improving education, advanced research, and improved reimbursements. Thus, we continue our two‐part series on palliative medicine. In this section, we discuss the assessment and management of symptoms like constipation, nausea/vomiting, hypercalcemia, and hydration.
A comparison of methods of determining the 100 percent survival of preserved red cells
Authors: Valeri C.R. , Pivacek L.E. , Ouellet R. , Gray A.
Published: March 2003

Studies were done to compare three methods to determine the 100 percent survival value from which to estimate the 24‐hour posttransfusion survival of preserved red cells. The following methods using small aliquots of 51Cr‐labeled autologous preserved red cells were evaluated: First, the 125I‐albumin method, which is an indirect measurement of the recipient's red cell volume derived from the plasma volume measured using 125I‐labeled albumin and the total body hematocrit. Second, the body surface area method (BSA) in which the recipient's red cell volume is derived from a body surface area nomogram. Third, an extrapolation method, which extrapolates to zero time the radioactivity associated with the red cells in the recipient's circulation from 10 to 20 or 15 to 30 minutes after transfusion. The three methods gave similar results in all studies in which less than 20 percent of the transfused red cells were nonviable (24‐hour posttransfusion survival values of between 80–100%), but not when more than 20 percent of the red cells were nonviable. When 21 to 35 percent of the transfused red cells were nonviable (24‐hour posttransfusion survivals of 65 to 79%), values with the 125I‐albumin method and the body surface area method were about 5 percent lower (p less than 0.001) than values with the extrapolation method. When greater than 35 percent of the red cells were nonviable (24‐hour posttransfusion survival values of less than 65%), values with the 125I‐albumin method and the body surface area method were about 10 percent lower (p less than 0.001) than those obtained by the extrapolation method.(ABSTRACT TRUNCATED AT 250 WORDS)
Reduction of the volume of stored platelet concentrates for use in neonatal patients
Authors: Moroff G. , Friedman A. , Robkin‐Kline L. , Gautier G. , Luban N.L.
Published: March 2003

Premature infants and neonatal patients who require platelet transfusions may develop circulatory overload when administered a 50‐ml unit of platelet concentrate. We evaluated the influence of centrifugation and resuspension steps used to reduce the volume of stored platelet concentrates on platelet properties by in vitro methods and by determining post‐transfusion increments in neonatal patients. In vitro studies were conducted with platelet concentrates stored at 20 to 24 degrees C for 1 and 5 days in CLX (Cutter) and PL732 (Fenwal) containers and for 1 and 2 days in PL146 containers (Fenwal). With platelets stored in any of the three containers, platelet morphology, mean platelet volume, hypotonic stress response, synergistic aggregation, and platelet factor 3 activity were not affected by the processing steps. The centrifugation and resuspension steps did not cause an enhanced discharge of lactate dehydrogenase from platelets. Similar results were obtained when the platelet concentrates were stored on either a flatbed or an end‐over‐end tumbler agitator. The in vitro platelet recovery following volume reduction was at least 85 percent. In vivo studies were conducted with platelets stored in the PL732 and PL146 containers. Infusion of platelet concentrates after volume reduction produced a mean corrected increment of 18,947 +/− 14,824 when platelets were stored in the PL146 container and 16,178 +/− 15,699 when platelets were stored in the PL732 container. These results indicate that the volume of stored platelet concentrates can be reduced in a manner which maintains platelet properties.
Dihydroxyacetone, pyruvate, and phosphate effects on 2,3 DPG and ATP in citrate‐phosphate‐dextrose‐adenine blood preservation
Authors: Dawson RB , Fagan DS , Meyer DR
Published: March 2003

Blood was stored with various combinations of 60 mM dihydroxyacetone (DHA), 80 mM pyruvate and 10 mM phosphate in citrate‐phosphate‐dextrose‐ adenine‐one (CPDA‐1) preservative for 42 days. During that time, DHA was found to have a beneficial effect on 2,3 diphosphoglycerate (2,3 DPG), although a deleterious effect on adenosine triphosphate (ATP). Preservatives containing pyruvate gave similar results. However, DHA and phosphate together in CPDA‐1 improved both 2,3 DPG and ATP. The adverse effect on 2,3 DPG levels that phosphate normally shows was reversed by the addition of DHA. These results indicate that the addition of phosphate alone, rather than pyruvate, or pyruvate and phosphate, to DHA in CPDA‐1 would be preferable to the presently licensed CPDA‐1 preservative.
Incorporation of plasticizer into red cells during storage
Authors: Rock G. , Tocchi M. , Ganz P. R. , Tackaberry E. S.
Published: March 2003

The development of flexible plastic blood bags has permitted effective blood component production and therapy. However, the plasticizer di(2‐ ethylhexyl)phthalate (DEHP), whose toxicity in humans is still undefined, is known to leach from the plastic into stored blood. Despite the availability of bags made of plastics not using DEHP, the collection and storage of red cells is still done in DEHP plasticized packs, and in fact the storage life for red cells has recently been increased up to 49 days using new anticoagulant‐preservative solutions. We examined the relationship between DEHP and stored red cells. We found that 28 percent of available 14C‐DEHP binds immediately to sites in both the membrane and cytosol fractions of the red cells, and that the total amount and distribution of 14C‐DEHP does not change significantly over 7 days. When red cell concentrates were stored with or without DEHP, using either plastic (polyolefin) bags not containing DEHP or glass, definite reduction in the osmotic stability of the red cells was found in the absence of DEHP. Plasma‐free hemoglobin levels were 90.3 mg per dl after 35 days of storage in plastic packs containing DEHP and 181.7 mg per dl in the polyolefin bags. The advantages of improved in vitro stability of red cells stored in plastics containing DEHP must be weighed against the potential hazards of patient exposure to DEHP.