A cost comparison of balloon angioplasty and stenting versus endarterectomy for the treatment of carotid artery stenosis

PURPOSE: Percutaneous transluminal angioplasty with stenting (PTAS) of the carotid artery has been advocated as an alternative treatment for high-grade stenosis. Rationale for this approach includes less morbidity, shorter recovery, and lower cost when compared with carotid endarterectomy (CEA). METHODS: The clinical results and hospital charges of patients who underwent elective treatment for carotid stenosis were reviewed. During a concurrent 14-month period, 218 patients were admitted 229 times for 234 procedures for the treatment of 239 carotid bifurcation stenoses, 109 by PTAS and 130 by CEA. Hospital charges were reviewed for each hospitalization and were categorized according to radiology, operating room, cardiac catheterization laboratory, and all other hospital charges. RESULTS: The combined incidence of postprocedure strokes and deaths were: PTAS, eight strokes (7.7%) and one death (0.9%); CEA, two strokes (1.5%) and two deaths (1.5%). Total hospital charges per admission for the two groups were $30,140 for PTAS and $21,670 for CEA. The average postprocedure length of stay for PTAS was 2.9 days (median, 2 days) and for CEA was 3.1 days (median, 3 days). Cardiac catheterization laboratory charges for the PTAS group were $12,968, whereas the operating room charges for the CEA group were $4263. When hospitalizations that were extended by complications were excluded, the average total charges for the PTAS group (n = 84) dropped to $24,848 (mean length of stay, 1.9 days) and for the CEA group (n = 111) to $19,247 (mean length of stay, 2.6 days). CONCLUSIONS: After evaluating hospital charges, PTAS for the treatment of carotid stenosis cannot currently be justified on the basis of reduced costs alone. With future cost-containing measures, total hospital charges can be reduced in both groups.     

Lorazepam-valproate interaction: studies in normal subjects and isolated perfused rat liver

Valproate (VPA) has been shown to interact with all the major antiepileptic drugs (AEDs) through two mechanisms of action: displacement from albumin binding sites and inhibition of drug metabolism. More recently, evidence showed that VPA inhibits the elimination of drugs metabolized by glucuronide conjugation. Lorazepam (LZP), which is primarily eliminated by conjugation with glucuronic acid, is administered concurrently with VPA both in treatment of epilepsy and in patients treated with VPA for psychiatric disorders. Therefore, a significant drug interaction is likely. We investigated such interaction both in in vitro isolated perfused rat liver (IPRL) and in normal subjects. LZP [2 mg, intravenous (i.v.) bolus] was administered to 8 normal volunteers before and after chronic dosing with VPA. In 6 of 8 subjects, VPA significantly decreased LZP plasma clearance by an average of 40% (p < 0.05) and increased LZP concentrations by decreasing formation clearance of the LZP glucuronide. In the IPRL studies, VPA also significantly decreased formation of LZP glucuronide (from 0.72 +/- 0.14 to 0.22 +/- 0.15 ml/h/kg, p < 0.05), indicating that IPRL is a useful tool for evaluation of the effect of VPA on drugs eliminated by glucuronide conjugation.     

The Clausius inequality corrected for heat transfer involving radiation

The objective of this paper is to prove that the Clausius inequality must be re-stated to have general applicability for heat transfer involving radiative fluxes. The integrand (đQ/T) of the Clausius expression applies to heat conduction and convection, but does not hold for most radiative transfer scenarios, with the exception of reversible infinitesimal net blackbody radiation transfer. In other cases involving radiative transfer, the equality holds for a cycle even though irreversible heat addition by radiative transfer occurs. This is without the erroneous presumption of entropy destruction anywhere in the cycle. Thus, the Clausius inequality indicates reversibility for a cycle that includes an irreversible process. Further, in some radiative cases the quantity đQ/T, where T is the boundary temperature, is not the entropy transfer at the system boundary, and in fact, primarily represents entropy production within the system. It is also clear that in another case considered, the quantity đQ/T had no physical meaning whatsoever. Consequently, the Clausius expression has been re-stated so that it is applicable to cycles with processes involving any form of heat transfer. A new integrand (đQ_cc/T + đS_Net,Rad) is presented, allowing the Clausius inequality to generally apply to all heat transfer scenarios. The work in this paper emphasizes the need to re-state other fundamental equations allowing applicability to all heat transfer processes, and draws attention to the unique character of radiative entropy calculations.     

Effect of process distillation on mutagenicity and cell-transformation activity of solvent-refined,coal-derived liquids

Blended SRC-II process streams, representing a full boiling range distillate material, were fractionally distilled into non-overlapping 50 °F cuts with boiling points between 300 and 850 °F. Another set of 18 distillate cuts were obtained with boiling points ranging between 138 and 1055 °F. Distillate cuts were assayed for mutagenic activity using the histidine reversion assay with Salmonella typhimurium strains TA98, TA100, TA1535 and TA1537, as well as for mammalian-cell transformation activity in the Syrian hamster embryo test, and DNA damage in the prophage induction assay. Samples were also separated into chemical class fractions by alumina column chromatography and analysed by high resolution gas chromatography so that the chemical composition of the cuts could be related to their relative activity in the different assays. In the mammalian cell transformation and microbial mutagenicity assays, significant activity was found almost exclusively in distillate cuts with components boiling > 700 °F, with the highest activity in the transformation assay observed for cuts > 800 °F. All of the distillate cuts showed increased levels of DNA damage as expressed by lambda prophage induction in Escherichia coli 8177. However, the greatest activity was associated with distillate cuts with boiling points in the 800 °F + range. Chemical analysis of the 50 °F distillate cuts showed a variety of polycyclic aromatic hydrocarbons (PAH) and amino-PAH compounds to be present in the distillate cuts boiling > 700 °F and essentially absent from cuts boiling < 700 °F. The sample set of non-overlapping (50 °F) cuts were reblended according to the proportions of each cut found in the original blend material. These reblended composites were then assayed to compare their activity with that predicted from the activities of the component distillate cuts. The reblending experiments indicated the microbial mutagenicity response was essentially additive. Mammalian cell transformation activities were non-additive, indicating a compositional effect on the expression of transforming agents in the complex mixture.     

Entities,identities, identifiers and credentials — what does it all mean?

This paper looks at the concepts of entities, identities, identifiers and credentials, their definitions, and how they combine to authenticate an identity to an account, or function, within a service. Credentials can be divided into several different types on the basis of their use, origin and characteristics. In particular, types such as composite, dynamic and derived credentials will be considered, and their applicability within an identity management system. Each credential must be managed through its entire life cycle from initial registration, general use and suspension, to deletion. The notion of public (i.e. freely distributable) and private (i.e. known only to you) aspects of a credential is explored. The bindings, by trusted third parties, of identifiers and public credentials into permits and instruments of proof is explained along with the convenience, but greater exposure, of local information. Several scenarios are analysed in terms of how different types of credentials are employed during the authentication process.     

Ni catalyst promotion of a Cis-selective Pd catalyst for canola oil hydrogenation

A Ni catalyst was added to a cis-selective Pd catalyst in an attempt to further improve the Pd catalyst's cis-selectivity and activity for canola oil hydrogenation. The system was tested under reaction conditions known to be suitable for cis-selective hydrogenation with the Pd catalyst (50 ppm Pd, 70 °C, and 5.2 MPa). Although inactive on its own under these conditions, the addition of 100 ppm Ni increased the hydrogenation activity (from 2.12 to 2.49 10⁻² min⁻¹). Further addition of Ni up to 1000 ppm resulted in no further improvements in activity. The trans isomer contents of the oils hydrogenated with Pd and the Pd/Ni systems were similar. The level of conjugated dienes decreased rapidly during hydrogenation with both Pd alone and with the Pd/Ni combination and no changes in conjugation were detected in the presence of the Ni catalyst alone. The increased activity of the Pd/Ni system over Pd alone was attributed to adsorption of catalyst poisons from the oil by Ni.     

Underrecognition of cervical Neisseria gonorrhoeae and Chlamydia trachomatis infections in the emergency department

OBJECTIVES: 1) To quantify the frequency of underrecognized Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in women tested in the ED, 2) to describe and compare the characteristics of those treated and not treated during the initial visit, and 3) to quantify the delay interval until treatment was provided. METHODS: A 2-year, retrospective consecutive case series was performed from June 1, 1992, to May 31, 1994. There were 148 women with > or = 1 discrete occurrence of culture-proven cervical N. gonorrhoeae or C. trachomatis infection studied. All the patients were evaluated in a university-affiliated, tertiary care hospital-based ED with a large rural referral area. The main outcome measures were the proportions of patients with positive cultures both treated and not treated in the ED, the clinical characteristics of each group, and the proportion remaining untreated or experiencing treatment delays of > 2 weeks after attempted phone, mail, and public health follow-up. RESULTS: Of 157 occurrences of positive cultures for N. gonorrhoeae or C. trachomatis, 86 (53%) were treated with a regimen suggested by the CDC prior to ED release. The proportion of women with isolated C. trachomatis infections that were underrecognized and untreated initially was larger than the proportions with isolated N. gonorrhoeae or combined infections (79% vs 27% and 53%, respectively, p < 0.0001). Women with findings suggestive of advanced disease (history of fever or chills, or examination evidence of temperature > 38 degrees C, purulent vaginal discharge, or any uterine/salpinx/ovarian tenderness) were more often recognized and treated with appropriate antibiotics initially (p = 0.02 to < 0.00001 for all). After phone, mail, and public health follow-up, treatment could not be documented for 25% of the occurrences, in all cases due to an inability to locate the patient. An additional 20% of the women did not receive treatment for 14-60 days. CONCLUSIONS: In this population, both N. gonorrhoeae and C. trachomatis cervical infections are frequently underrecognized in the ED, with isolated C. trachomatis infections associated with significantly higher proportions of underrecognition. Many affected women remain untreated for extended intervals, creating public and individual health risks. Improved point of contact detection, follow-up, and treatment policies are needed to limit these risks.