Laboratory practices in reporting flow cytometry phenotyping results for leukemia/lymphoma specimens: results of a survey

Laboratory directors who routinely utilize flow cytometry for at least part of their diagnostic evaluations in leukemias or lymphomas were surveyed by mail. The survey consisted of 12 questions about the flow cytometry procedures used by the laboratory in evaluating leukemias and lymphomas and on the format and content of their official report. It also requested an example of a typical leukemia/lymphoma report and solicited write-in comments about additional important aspects of using flow cytometry to evaluate leukemia and lymphomas not covered by the questionnaire. The goal of the survey, which was sponsored by the Clinical Cytometry Society (CCS), was to document what directors of flow cytometry laboratories currently consider to be the appropriate contents of a clinical leukemia/lymphoma phenotyping analysis and in what manner and detail they report such flow cytometry results to clinicians. The survey indicated that a large number of markers are routinely evaluated to phenotype leukemias (mean = 19) and lymphomas (mean = 16). Light scatter gating, using CD45/14 to monitor the gate selected, is currently employed by a 2:1 ratio over the next most population gating strategy (CD45 vs. 90 degrees LS). Peripheral blood, bone marrow, and lymphoid tissue constitute the majority of clinical specimens evaluated for leukemia and/or lymphoma. Two-color analysis, primarily for surface markers, is currently the standard method for flow cytometry measurements in routine diagnostic studies of leukemia and lymphoma. The official flow cytometry laboratory report is most commonly an individual-lab-generated, paper report form. A discussion of the potential benefits that might result from the development of improved computerized reporting software and from the increased use of antibody-defined, lineage gating is offered. A composite report format is presented that demonstrates the flow measurements and quality control data included in the best of the example clinical reports submitted as part of the survey and considered important by a majority of our survey respondents. The example report is intended to be a basis for further discussion within the flow cytometry community on whether minimum reporting standards for leukemia and/or lymphoma flow cytometry results can and should be developed.     

Older adults, reimbursement, and referrals: Implications for psychologists after Medicare reimbursement changes and before health care reform.

Psychologists' current provision of mental health services to older adults was investigated by a mail survey. One half of licensed psychologists in a metropolitan region in the Northeast were randomly sampled, with a return rate of 61% (n?=?37). 75% saw older adult clients (aged 65 and over), and 72% accepted Medicare payments. Older adults composed 8% of their practice. Solopracticing physicians were the chief referral link to and from the medical community. Barriers to providing mental health services included client's lack of social support network and low levels of reimbursement. The challenges of continuing psychologists' recent advances in serving the mental health needs of older adults in an era of health care reform and managed care are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bacterial endocarditis: results of a survey in a children''s hospital in France

Recent studies have shown the insulin-like effect of vanadyl sulphate or sodium ortho (or meta-)vanadate administered orally to rats. Toxicity of these drugs and reluctance by the animals to drink the solutions and take food, concerning the amelioration of some diabetes syndrome discussed in 1994 by Domingo et al. (1), McNeill et al. (2) and Wiliams and Malabu (3), prompted us to investigate a new vanadate complex: disodium bis(oxalato)oxovanadate (IV), Na2[VO(OX)2]H2O. The main object of the experiment was to study whether this complex administered as 3 mmol/l solution in 0.5% NaCl during 7 days could act on the subcellular level and influence the activity of liver Golgi membrane galactosyltransferase activity. Free blood sugar level was lowered (but was still higher than in the control group) in diabetic rats after seven days of vanadate action and was accompanied by lowered, however not statistically significant, serum triglyceride levels. The yields of isolated Golgi-rich membrane fractions were about half of the level in diabetic groups (untreated and treated with vanadium) compared with the control groups. Purity of these membrane fractions, expressed as nmol Gal transferred per mg of proteins and per h, was the same in four groups investigated and showed the possibility to compare them. Activity of galactosyltransferase calculated in nmol Gal transferred per 1 g of liver and per 1 h or per whole liver in the same time (as a possibility of glycosylation of the secretory and membrane glycoproteins) was lower in both diabetic groups. However, after vanadium treatment (D+V group), the activity was higher than in untreated diabetic rats (D group) in three of five investigated animals. Vanadyl-oxalate complex did not normalize in a statistically significant manner the enzyme activity which was significantly lower in diabetes than in control. This is similar to insulin influence on the galactosyltransferase activity reported previously by Kaczmarski et al. in 1981 (4) and Kordowiak et al. in 1981 (5).     

Economic impact on physicians and hospitals of proposed changes in Medicare reimbursement for coronary interventions

BACKGROUND: The federal government is implementing changes in reimbursement for angioplasty and coronary stenting. These include reductions in physician reimbursement and a redesignation of intracoronary stents to a different diagnosis-related group than other methods of intracoronary intervention. OBJECTIVE: The aim of this study was to examine the financial impact on physicians and hospitals of proposed federal reimbursement policies for percutaneous coronary revascularization procedures. METHODS: We modeled the financial effects of 3 different stenting strategies: strategy I is the most conservative, with stents reserved for addressing lab complications; strategy II stents are used for suboptimal results after attempts at conventional percutaneous transluminal coronary angioplasty (PTCA); strategy III is the most aggressive, with initial stenting of all accessible lesions. We used economic data on PTCA and stent costs from a 1996 dataset and made assumptions about PTCA and stent success rates and restenosis rates based on published data. RESULTS: Under current reimbursement policies, physician revenues and profits are approximately equal under all 3 stenting strategies. After the proposed changes, there is a slight financial incentive for physicians to pursue the more aggressive strategy III, but the major financial effect is a substantial overall decline in revenues with any of the 3 strategies. For hospitals, the present situation strongly favors the more conservative strategies, but after the proposed changes the more aggressive stenting strategies will be more profitable, thus realigning physician and hospital incentives. Health care delivery organizations that combine physician and hospital income streams achieve the greatest financial stability. CONCLUSIONS: Current reimbursement policies for angioplasty and stenting have created misaligned incentives between physicians and hospitals. Proposed changes do not present physicians with large economic incentives to pursue aggressive versus conservative stent strategies but substantially address the current disparity in hospital financial incentives.     

External defibrillation: the need for uniformity in analyzing and reporting results

A 74-year-old woman was scheduled for surgical treatment of a carpal tunnel syndrome. An intravenous (i.v.) regional anaesthetic was performed using 1% prilocaine standard technique. Three minutes after injection of the local anaesthetic mild to moderate central nervous system symptoms developed, along with tachycardia, sweating and peri-oral paraesthesia. The evolution was favourable, no convulsions or other more serious events occurred. Despite showing adequate pressure inflation the tourniquet failed to accomplish its purpose. The patient recovered well without any sequelae.     

Difficulties in family practice residency training: Recommendations for training health psychologists in primary care settings.

We attempt to pursue a model for health psychologists by developing recommendations for behavioral science input into family practice residencies, gleaned from experiences of several health psychologists specifically trained to be directors of behavioral science programs of such medicine departments. This information is accumulated and based on a 7-year period at one university-based, inner-city program and two community-based hospitals. These recommendations are offered in the hope that health psychology training specialists will anticipate roadblocks associated with family practice residency training programs and will plan accordingly. Specifically, we make recommendations regarding program overview and training background, roadblocks (including medicine as the final authority), theoretical versus practical teaching orientation, resident time constraints, administrative support and priorities, and training effectiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective survey of hospital ambulatory dental emergencies. Part 2: Follow-up to emergency treatment

Two hundred and fifty-three patients treated for dental emergencies at the University Hospital dental clinic over a three-month period were surveyed by telephone 24 to 48 hours and one year after treatment. The purpose was to investigate the success of treatment in resolving the chief complaint of pain and to determine the compliance with further dental care for the original dental problem. The results of the telephone survey showed that: patients available for questioning totaled 49.1% at 24 to 48 hours and 28.9% at one year; an 80.7% success rate was recorded in resolving pain within 24 to 48 hours; and the original emergency problem did not motivate a large number of these patients to seek further dental care.     

Hypertension in Haitians: results of a pilot survey of a public teaching hospital multispecialty clinic

Little is known about hypertension in Haitians. We performed a pilot survey of ambulatory Haitian patients in a multispecialty clinic at a large public teaching hospital. Approximately 10% of the clinic population was of Haitian origin. Clinical data were collected on 88 consecutive Haitian patients. Of these 88, 77 (87.5%) were hypertensive (SBP > or = 140 or DBP > or = 90 mm Hg or taking antihypertensive medication). The characteristics of the hypertensive patients were: age 54.1 +/- 13.0 (s.d.) years; 27 men, 50 women; 12/64 (19%) smoked; 7/63 (11%) used alcohol. Diabetes was present in 21/77 (27%). In patients for whom height and weight were available, obesity was present in 52%. Using JNC V criteria, 18 (23%) had Stage 1, 16 (21%) Stage 2, 18 (23%) Stage 3, and 25 (33%) Stage 4 hypertension. Despite 63/77 (82%) being treated for hypertension, only 20 (26%) were controlled (< 140/< 90 mm Hg). Of those under treatment, 29 were taking one drug; 18 (two drugs); 12 (three drugs); and four (four drugs). Target organ damage was evident in 37 (48%), including coronary artery disease (8), CHF (6), chronic renal failure (15), stroke (9), and LVH by ECG (19). There was evidence of severe noncompliance in 32 (42%). We conclude that in this clinic sample, hypertension was highly prevalent and unusually severe in terms of blood pressure (BP) level, refractoriness to treatment, and target organ consequences. Further studies are indicated.     

Genesis of residency programs in dental public health: reflections of the first dental public health resident?

BACKGROUND: Combinatorial methods based on binary patterning of polar and nonpolar residues have been used to generate large libraries of de novo alpha-helical proteins. Within such libraries, the ability to find structures that resemble natural proteins requires a rapid method to sort through large collections of proteins and detect those possessing 'native-like' features. The current paper presents such a method and applies it to an initial collection of de novo proteins. RESULTS: We present a method to identify proteins with native-like properties from libraries of de novo sequences expressed in vivo. A novel 'rapid prep' freeze/thaw procedure was used to prepare samples; chromatographic purification was not required. The semi-crude samples were analyzed for native-like features by one-dimensional 1H NMR spectroscopy. Using this method, we demonstrate that native-like features can readily be observed for several proteins among a collection of sequences designed by binary patterning of polar and nonpolar amino acids. CONCLUSIONS: Native-like properties can be detected using a method that requires neither isotopic enrichment nor chromatographic purification. The method is inexpensive, rapid, and suitable for parallel processing. It can therefore be employed to screen for native-like properties among large collections of de novo sequences. Using this method, we demonstrate that although the binary code strategy does not explicitly design tertiary packing, it can nonetheless generate proteins that possess native-like properties. The use of combinatorial methods to produce large collections of proteins coupled with the availability of a rapid assay for detecting native-like properties will facilitate the design and isolation of novel proteins with desirable properties.     

Morbidity and mortality with outpatient anesthesia: the experience of a residency training program

PURPOSE: Previous studies regarding anesthetic-related morbidity and mortality rates in the oral surgery office have usually taken the form of a survey. This retrospective investigation of outpatient anesthetic morbidity and mortality was undertaken to compare the safety record of an oral and maxillofacial surgery training program with that of private practitioners. MATERIALS AND METHODS: Records from all outpatient general anesthesia cases performed in the Department of Oral and Maxillofacial Surgery at the Boston University Goldman School of Graduate Dentistry between August 13, 1990, and September 30, 1994, were reviewed for the incidence of nineteen separate categories of morbidity. RESULTS: There were 1,126 general anesthetics performed. There were 26 recorded incidents of morbidity (2.3%), none of which resulted in any postoperative sequelae. There were no deaths. The most common complication encountered was laryngospasm, with nine recorded incidents (0.8%). The second most common complication was cardiac dysrhythmia with eight recorded incidents (0.8%). CONCLUSIONS: The low incidence of anesthetic-related morbidity seen in this study can most likely be attributed to proper patient selection. A carefully reviewed medical history and physical examination are the two most useful methods to prevent anesthetic emergencies. Another factor considered when selecting the proper anesthetic method includes the length and difficulty of the surgical procedure, with outpatient general anesthesia being reserved for those procedures that are predicted to be relatively short (30 to 45 minutes), and with little potential for airway difficulties.     

An overview of the problem: exercise training and orthostatic intolerance

The questions, whether endurance exercise training (a) induces orthostatic intolerance and (b) alters blood pressure regulation during orthostasis, have been debated since the early 1970s. This symposium presents data that both support and discount the concepts. In addition, data were presented that document invasive and noninvasive techniques of measurement used during investigations of baroreflex and hemodynamic mechanisms of blood pressure regulation during lower body negative pressure (LBNP), a laboratory technique that simulates orthostasis. These techniques and the results obtained enabled the formulation of a hypothetical mechanism of explanation of the "pro and con" of the debated questions.     

Referral selection bias in the Medicare hospital mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence?

OBJECTIVE: Although the Health Care Financing Administration (HCFA) uses Medicare hospital mortality data as a measure of hospital quality of care, concerns have been raised regarding the validity of this concept. A problem that has not been fully evaluated in these data is the potential confounding effect of illness severity factors associated with referral selection and hospital mortality on comparisons of risk-adjusted hospital mortality. We address this issue. DATA SOURCES AND STUDY SETTING: We analyzed the 1988 Medicare hospitalization data file (MEDPAR). We selected data on patients treated at the two Mayo Clinic-associated hospitals in Rochester, Minnesota, and a group of seven other hospitals that treat many patients from large geographic areas. These hospitals have had observed mortality rates substantially lower than those predicted by the HCFA model for the period 1987-1990. STUDY DESIGN: Using the multiple logistic regression model applied by HCFA to the 1988 data, we evaluated the relationship between distance from patient residence to the admitting hospital and risk-adjusted hospital mortality. PRINCIPAL FINDINGS: Among patients admitted to Mayo Rochester-affiliated hospitals, residence outside Olmsted County, Minnesota was independently associated with a 33 percent lower 30-day mortality rate (p < .001) than that associated with residence in Olmsted County. When patients at Mayo hospitals were stratified by residence (Olmsted County versus non-Olmsted County), the observed mortality was similar to that predicted for community patients (9.6 percent versus 10.2 percent, p = .26), whereas hospital mortality for referral patients was substantially lower than predicted (5.0 percent versus 7.5 percent, p = < .001). After incorporation of the HCFA risk adjustment methods, distance from patient residence to the hospitals was also independently associated with mortality among the Mayo Rochester-affiliated hospitals and seven other referral center hospitals. CONCLUSIONS: The HCFA Medicare hospital mortality model should be used with extreme caution to evaluate hospital quality of care for national referral centers because of residual confounding due to severity of illness factors associated with geographic referral that are inadequately captured in the extant prediction model.     

Evaluating Internet end-to-end performance: overview of test methodology and results

OBJECTIVE: An evaluation of Internet end-to-end performance was conducted for the purpose of better understanding the overall performance of Internet pathways typical of those used to access information in National Library of Medicine (NLM) databases and, by extension, other Internet-based biomedical information resources. DESIGN: The evaluation used a three-level test strategy: 1) user testing to collect empirical data on internet performance as perceived by users when accessing NLM Web-based databases, 2) technical testing to analyze the Internet paths between the NLM and the user's desktop computer terminal, and 3) technical testing between the NLM and the World Wide Web ("Web") server computer at the user's institution to help characterize the relative performance of Internet pathways. MEASUREMENTS: Time to download the front pages of NLM Web sites and conduct standardized searches of NLM databases, data transmission capacity between NLM and remote locations (known as the bulk transfer capacity [BTC]), "ping" round-trip time as an indication of the latency of the network pathways, and the network routing of the data transmissions (number and sequencing of hops). RESULTS: Based on 347 user tests spread over 16 locations, the median time per location to download the main NLM home page ranged from 2 to 59 seconds, and 1 to 24 seconds for the other NLM Web sites tested. The median time to conduct standardized searches and get search results ranged from 2 to 14 seconds for PubMed and 4 to 18 seconds for Internet Grateful Med. The overall problem rate was about 1 percent; that is, on the average, users experienced a problem once every 100 test measurements. The user terminal tests at five locations and Web host tests at 13 locations provided profiles of BTC, RTT, and network routing for both dial-up and fixed Internet connections. CONCLUSION: The evaluation framework provided a profile of typical Internet performance and insights into network performance and time-of-day/day-of-week variability. This profile should serve as a frame of reference to help identify and diagnose connectivity problems and should contribute to the evolving concept of Internet quality of service.     

The racial segregation of hospital care revisited: Medicare discharge patterns and their implications

OBJECTIVES: This paper measures current patterns of hospital segregation among Medicare beneficiaries. METHODS: Data from the fiscal year 1993 Medicare Provider Analysis and Review (MEDPAR) file, the index of dissimilarity, and a linear regression model are used to test the effects of standard metropolitan area characteristics on hospital segregation. RESULTS: The overall hospital segregation index was 0.529, ranging by state from 0.154 to 0.746. Hospital segregation in 126 standard metropolitan areas was positively related to population size, hospital density, and residential segregation and negatively related to income inequities and location in the South. CONCLUSIONS: Racial segregation remains high and may produce both reporting biases and unequal effects of public policy.     

Orthopedic residents' perceptions of the content and adequacy of their residency training

The content and adequacy of orthopedic surgery residency training can be evaluated by several means. The Accreditation Council for Graduate Medical Education and the Residency Review Committee set standards with which residency programs must comply in order to be accredited. Residents' perceptions of the content and adequacy of their training is another means of evaluating orthopedic residency training. A questionnaire was sent to all graduating orthopedic residents in the United States, Canada, and Puerto Rico. The questionnaire provided program and individual resident demographics, as well as the residents' rating of specific areas of residency training on a 5-point scale (1=superior, 2=above average, 3=average, 4=below average, 5=inadequate). Completed surveys were received from 454 of the 698 graduating orthopedic surgery residents listed by the American Academy of Orthopaedic Surgeons; the response rate was therefore 65.0%. Our respondents were representative of the entire population in terms of geographic and sex distribution. Respondents rated their general orthopedic training at 1.9. The areas of training that had the best ratings included trauma/fracture (1.8), adult reconstruction (1.9), and pediatrics (1.9). The worst rating was reported for training in foot and ankle (2.7). Factors related to better ratings for general orthopedic training included male sex of residents, programs with more full-time faculty, programs with more hours of weekly teaching conferences, programs with one or more faculty present at all teaching conferences and programs in which residents first operate independently at or before postgraduate year 4. Sixty-six percent of all respondents were planning to hold a fellowship immediately after graduation. The most common fellowships taken included sports medicine (20.5% of all respondents), hand (12.1%), and spine (9.5%). Younger graduating residents, those from larger programs (more residents per year), and those from the Mideast (U.S.), and New England regions were most likely to enter a fellowship after graduation.