Discordance of databases designed for claims payment versus clinical information systems. Implications for outcomes research

OBJECTIVE: To determine the suitability of insurance claims information for use in clinical outcomes research in ischemic heart disease. DESIGN: Concordance study of two databases. SETTING: Tertiary care referral center. PATIENTS: A total of 12,937 consecutive patients hospitalized for cardiac catheterization for suspected ischemic heart disease between July 1985 and May 1990. INTERVENTIONS: Two-by-two tables were used to compute overall and kappa measures of agreement comparing clinical versus claims data for 12 important predictors of prognosis in patients with ischemic heart disease. MEASUREMENTS: Kappa statistics (agreement adjusted for chance agreement) were used to quantify agreement rates. RESULTS: Agreement rates between the clinical and claims databases ranged from 0.83 for the diagnosis of diabetes to 0.09 for the diagnosis of unstable angina (kappa values). Claims data failed to identify more than one half of the patients with prognostically important conditions, including mitral insufficiency, congestive heart failure, peripheral vascular disease, old myocardial infarction, hyperlipidemia, cerebrovascular disease, tobacco use, angina, and unstable angina, when compared with the clinical information system. CONCLUSIONS: Our results suggest that insurance claims data lack important diagnostic and prognostic information when compared with concurrently collected clinical data in the study of ischemic heart disease. Thus, insurance claims data are not as useful as clinical data for identifying clinically relevant patient groups and for adjusting for risk in outcome studies, such as analyses of hospital mortality.     

Effects of induced hypertension on transcranial Doppler ultrasound velocities in patients after subarachnoid hemorrhage

BACKGROUND AND PURPOSE: Transcranial doppler ultrasound (TCD) is used after subarachnoid hemorrhage to detect cerebral vasospasm and is often treated with induced hypertension. Cerebral autoregulation, however, may be disturbed in this population, raising the possibility that TCD velocities may be elevated by induced hypertension. To study this possibility, we performed continuous TCD monitoring of the middle cerebral artery during the induction and withdrawal of induced hypertension in patients after subarachnoid hemorrhage. METHODS: Twenty-eight patients were studied during the induction and withdrawal of hypertension using primarily phenylephrine. Continuous monitoring was performed on the middle cerebral artery with the highest flow velocity. Treatment was based on rising TCD velocities or clinical evidence for cerebral vasospasm. Mean arterial pressure and mean TCD velocities were recorded every minute. A change of > 15% from starting TCD values was considered significant. Cerebral autoregulation was calculated as a percentage of intact autoregulation. Patients were subsequently divided into groups of disturbed and intact autoregulation. RESULTS: In 10 of 19 patients (53%), TCD velocities changed by > 15% and paralleled changes in mean arterial pressure. This directly altered the TCD interpretation of the grade of vasospasm in 7 of 19 patients (36%). Three additional patients had smaller absolute changes in TCD velocities. No clinical difference could be identified between patients with disturbed and intact autoregulation. CONCLUSIONS: In patients with disturbed autoregulation after subarachnoid hemorrhage, induced hypertension can alter cerebral blood flow velocities. The level of autoregulation needs to be considered when interpreting TCD velocities in patients after subarachnoid hemorrhage.     

Treatment of carbon monoxide poisoning with hyperbaric oxygen

This report describes differences in humoral immune response of acute and chronic phases of human Chagas disease. The reactivities of IgG, IgM, and IgA anti-Trypanosoma cruzi antibodies in serum samples from both groups of patients were compared by enzyme-linked immunosorbent assay (ELISA) employing either one of four antigenic fractions: mouse laminin (LAM), which reacts through Gal alpha 1-3Gal epitopes expressed on trypomastigote surface: whole intact trypomastigotes (TCT); trypomastigotes excreted/secreted antigens (TESA); and epimastigote alkaline extract (EAE). The selection of T. cruzi antigen preparations was based on their relative content of surface and internal antigens found in trypomastigote forms. The proportion of IgG reactive to carbohydrate epitopes was assessed through the decay of IgG reactivity from acute and chronic sera after m-periodate oxidation of solid-phase bound antigens. Trypomastigote and TESA antigens recognized by IgG from acute and chronic sera were also compared by immunoblotting. ELISA and immunoblotting data showed that: (1) the proportion of IgG directed to trypomastigote surface antigens was higher in acute than in chronic sera, whereas the opposite was found for internal antigens, (2) acute sera contained a higher percentage of IgG reactive to trypomastigote carbohydrate epitopes than chronic sera, and (3) anti-T. cruzi IgA was found exclusively in acute sera and led to 100% positivity when LAM, TCT, and TESA were employed as antigens. IgA ELISA with these antigens and IgG immunoblotting pattern with TESA could be useful as serological markers for the acute phase of human Chagas disease.     

Diversity of monogeneans in Southeast Asia

The diversity of monogeneans from Southeast Asia was examined using information from the literature to show their diversity at different taxonomic (subclass, family, genera, species) levels. Knowledge of monogeneans is still incomplete in Southeast Asia and the present numbers of monogeneans are likely an underestimate of what is present on/in aquatic organisms in the region, since so few hosts have been examined. An estimate of the possible numbers of monogeneans that could be present on/in fishes and turtles in Peninsular Malaysia indicates that only 8% of the monogeneans are presently known. Analysis of the available data on monogenean diversity (or species richness) at different taxonomic levels will provide useful information on their distribution patterns. There is an uneven distribution of investigations on this topic and Malayan fauna is considered to be representative of the Southeast Asian fauna. Southeast Asian (Sundaland) monogeneans are related (at the generic level) to the monogenean fauna of South China, India and Africa.     

Laminaria augmentation of midtrimester pregnancy termination by intramuscular prostaglandin 15 (S) 15-methyl F2 alpha

A group of 15 midtrimester gravid patients underwent intracervical laminaria tent insertion prior to repeated intramuscular injections of 250mu g of prostaglandin 15 (S) 15-methyl F2 alpha at two-hour intervals for elective termination of pregnancy. This group was compared with a previously reported group of 80 patients who had received identical treatment without laminaria insertion. A significant reduction in mean abortion time and an increased 24-hour abortion rate were observed with the addition of laminaria. There was a proportionate decrease in gastrointestinal side effects as well as a reduced need for analgesia in the laminaria group with no complications attributable to the laminaria insertion.     

Correlation of histopathologic characteristics of primary tumor and uninvolved regional lymph nodes in Dukes' class C colonic carcinoma with prognosis

Ninety-two patients with Dukes' class C colonic carcinoma, divided equally into those who survived 5 years or more and those surviving less than 5 years after resection for cure, underwent evaluation of multiple histopathologic characteristics of the primary tumor and the uninvolved regional lymph nodes. These characteristics were analyzed by the chi-square test for correlation with survival. A statistically significant correlation (P less than 0.05) in the group who survived 5 years or more was observed for Broders' grades 1 and 2, tumor not involving serosa, and a pushing tumor margin. Of the 14 patients who had a pushing tumor margin and tumor not involving serosa, 12 (86%) survived 5 years or more. Seven patients had an infiltrating tumor margin and peritumor venous invasion, and of this group, only one (14%) survived 5 years or more. Histopathologic characteristics of host immune reaction at the tumor or in the uninvolved regional lymph nodes did not correlate with survival.     

Photoaffinity labeling of the human erythrocyte nucleoside transporter by N6-(p-Azidobenzyl)adenosine and nitrobenzylthioinosine. Evidence that the transporter is a band 4.5 polypeptide

N6-(p-Azidobenzyl)adenosine (ABA) and nitrobenzylthioinosine (NBMPR) were employed as covalent probes of the nucleoside transport mechanism in human erythrocytes. NBMPR, a potent inhibitor of nucleoside transport, binds tightly (KD 0.3-1 nM) to specific sites on nucleoside transporter elements. ABA, a less potent inhibitor of uridine influx, competitively inhibited NBMPR binding (Ki 15 nM). [3H]ABA was bound tightly (KD 13.4 nM) but reversibly to sites on erythrocytes which appeared to be those which bind NBMPR. ABA binding was inhibited by uridine and adenosine. Irradiation with UV light caused site-bound [3H]ABA on erythrocyte membranes to become covalently bound and, similarly, photoactivation resulted in covalent attachment of membrane-bound [3H]NBMPR. In the presence of dithiothreitol, a free radical scavenger, photoactivation of the site-bound 3H-ligand on membranes depleted of extrinsic membrane proteins resulted in selective incorporation of 3H into band 4.5 of the membrane polypeptides which were resolved on sodium dodecyl sulfate-polyacrylamide gel electropherograms. This result, when considered with previous findings, indicates that the NBMPR-binding component of the nucleoside transport mechanism (or the entire mechanism, if the NBMPR site is an integral part) is a band 4.5 polypeptide.     

Usefulness of chromosome examination in the diagnosis of malignant pleural effusions

To determine whether chromosome analysis could facilitate the diagnosis of malignant pleural effusions, we examined chromosomes in effusions from 104 unselected patients. An effusion was regarded as malignant if at least three of 30 metaphase cells were hyperdiploid or contained a marker chromosome. Results were compared with standard cytologic diagnoses. All 22 benign effusions were diagnosed correctly by cytologic examination, but one nosed correctly by cytologic examination, but one (acute rheumatoid lung disease) was misclassified as positive by chromosome criteria. Of the 82 malignant effusions, 53 (65 per cent) were diagnosed correctly by cytologic tests, as compared with 58 (71 per cent) by chromosome analysis (P greater than 0.2). Among patients with malignant neoplasms, 13 had leukemia or lymphoma; only four of these (31 per cent) were diagnosed by cytologic tests as compared with 11 (85 per cent) by chromosome analysis (P less than 0.01). The combination of standard cytologic and chromosome analyses correctly identified 83 per cent of the neoplasms, a result significantly better than that with either technic alone (P less than 0.01).     

A case of veno-occlusive disease of the liver in Britain associated with herbal tea consumption

Veno-occlusive disease of the liver with clinical and pathological features similar to those of the condition occurring in the Caribbean is described in a young woman resident in Britain. The diagnosis was made from liver biopsies and hepatic venography and was confirmed at necropsy. Small amounts of pyrroliziding alkaloids were recovered from a sample of mate (Paraguay) tea, owned by the patient, to which she was addicted. It seems probable that the consumption of large amounts of this tea over a period of years was the cause of the hepatic disease.