Direct medical costs for surgical and medical treatment of condylomata acuminata

OBJECTIVE

To determine which treatment modalities for condylomata acuminata are associated with the lowest direct medical costs.

DESIGN

Cost-effectiveness analysis.

SETTING

Ambulatory private practice, primary or specialty care.

PATIENTS OR OTHER PARTICIPANTS

Adults with no presenting complaints other than condylomata acuminata.

INTERVENTIONS

Construction of a cost-effectiveness model. From a literature review, extraction of commonly accepted guidelines regarding duration and frequency as well as reports of efficacies of typical treatment regimens; from Medicare physician fee schedules, costs of physician visits and physician-administered treatments; from published data, average wholesale prices of medications.

MAIN OUTCOME MEASURE

Estimated direct medical costs per complete clearance associated with different treatment options for condylomata acuminata.

RESULTS

Mean direct medical costs per complete clearance are lowest for surgical excision ($285). Other low-cost modalities are loop electrosurgical excision procedure ($316), electrodesiccation ($347), carbon dioxide laser ($416), podofilox ($424), and pulsed-dye laser ($479). Higher-cost modalities are cryotherapy ($951), trichloroacetic acid ($986), imiquimod ($1255), podophyllum resin ($1632), and interferon alfa-2b ($6665).

CONCLUSION

Surgical modalities, including excision, electrodesiccation, loop electrosurgical excision procedure, and laser, as well as podofilox are low-cost options for the treatment of condylomata acuminata.

Analysis on distribution of insertion sequence IS431 in clinical isolates of staphylococci

Distribution of insertion sequence IS431 in clinical isolates of Staphylococcus aureus, Staphylococcus epidermidis, and Staphylococcus haemolyticus was investigated. Except for methicillin susceptible-S. aureus (MSSA), IS431 was detected in all isolates of the three staphylococcal species. In MSSA, only 20% of isolates with distinct coagulase types and genetic types possessed IS431. In a few MSSA isolates, an IS431 variant with internal deletion was found.

Expression and fast-flow purification of a polyhistidine-tagged myoglobin-like aerotaxis transducer

A Co(2+)-affinity, fast-flow perfusion chromatography method to purify a polyhistidine-tagged myoglobin-like aerotaxis transducer HemAT-Hs has been developed. The method relies upon a six-histidine affinity tag fused to the C-terminus and N-terminus of HemAT-Hs for expression in the native host, an extremely halophilic Archaeon Halobacterium salinarum, and in the heterologous host Escherichia coli, respectively. The His-tagged HemAT-Hs can be purified rapidly using either low or high ionic strength buffers. Purified His-tagged HemAT-Hs in high or low salt buffers demonstrated no difference in spectral characteristics and retained reversible oxygen binding capacity. This fast-flow Co(2+)-affinity perfusion chromatography provides a simple method for preparation of halophilic heme containing soluble proteins for biophysical and structural studies.

Randomized trial of parathyroidectomy in mild asymptomatic primary hyperparathyroidism: patient description and effects on the SF-36 health survey

BACKGROUND

The treatment of patients with asymptomatic primary hyperparathyroidism remains controversial despite a National Institutes of Health consensus statement. This statement also recommended a randomized clinical trial because none exists to address this issue.

METHODS

Informed consent was obtained from 53 asymptomatic patients with confirmed asymptomatic primary hyperparathyroidism who participated in this randomized trial of parathyroidectomy versus observation. Patients completed the SF-36 Health Survey, an instrument that measures wellness, every 6 months for 2 years. Average annual changes were compared.

RESULTS

Fifty-three patients (42 female, 11 male) with asymptomatic, mild (serum calcium level, 10.1-11.5 mg/dL) asymptomatic primary hyperparathyroidism who agreed to participate were randomized into either a surgical group or an observation group. The mean calcium level was 10.31 mg/dL. The only demographic difference between groups was age, with the operative group being older (66.7 vs 62.6 years; P <.03). The scores on 2 of the 9 domains of the SF-36 were significantly different (P <.007 and <.012, respectively); both favored the operative group.

CONCLUSIONS

Improved function is seen after parathyroidectomy when compared with patients who did not undergo operation. This study supports surgical management of mild primary hyperparathyroidism at the time of diagnosis because many patients have reversible nonclassic symptoms of the disease.

Tuberous xanthomas in sitosterolemia

Sitosterolemia is an autosomal recessive lipid disorder in which plasma plant sterol levels are extremely elevated and cholesterol levels are often elevated but may be normal. Clinically sitosterolemia is characterized by xanthomas, premature vascular disease, and arthritis. Adolescent boys and girls with sitosterolemia are susceptible to fatal cardiac events. Dermatologists may have a vital role in the diagnosis of this rare but serious condition because early detection and treatment are important in preventing the associated atherosclerotic heart disease. We present a 7-year-old girl with sitosterolemia and tuberous xanthomas.

Surgical management of pyoderma gangrenosum: case report and review

BACKGROUND

Commonly used treatments for pyoderma gangrenosum are medical, with immunosuppressive agents employed most often.

OBJECTIVE

To report a case and discuss the indications for radical surgical treatment of pyoderma gangrenosum.

METHODS

Analysis of a case of Crohn's disease-associated pyoderma gangrenosum treated with immunosuppression followed by amputation, and a review of the literature on surgical management of pyoderma gangrenosum.

RESULTS

In unstable patients with intractable multiple medical problems, surgical treatment of pyoderma gangrenosum may be indicated by the existence of these life-threatening comorbidities. The recent literature suggests that surgical management of pyoderma gangrenosum may also be appropriate in other special circumstances.

CONCLUSIONS

Surgical management, including amputation, may have a role in the management of pyoderma gangrenosum. Further research is needed to delineate precisely the circumstances and patient factors that are appropriate indications for such surgery.

Characterization of methanol-soluble and methanol-insoluble proteins from developing peanut seed

The 85% methanol-soluble proteins are known to specifically contribute to the production of flavor of roasted peanut. To determine the nature of the 85% methanol-soluble proteins, they were isolated from the peanut seed, and the 85% methanol-soluble (MS) and 85% methanol-insoluble (MIS) fractions were characterized using polyacrylamide gel electrophoresis (PAGE) and capillary electrophoresis. The results showed that the 85% MS fraction contained lower amounts (9-10%) of protein than the MIS fraction (15-33%). Protein content of the MIS fraction increased more significantly during seed maturation than it did in the MS fraction. Unlike the protein, free amino acids and soluble sugars levels of the MS fraction decreased significantly during seed maturation. The 85% MS fraction contained predominantly low molecular weight (<20 kDa) proteins/polypeptides, whereas the MIS fraction contained a mixture of polypeptides with molecular weight between 14 kDa and 90 kDa. SDS-PAGE showed no major changes in the polypeptide composition of the MS fraction during seed maturation. Capillary electrophoretic analysis revealed major qualitative and quantitative changes in the protein and polypeptide composition of the MS and MIS fractions during seed maturation. Fatty acid analysis of these fractions indicated that the MS fraction is lipoprotein in nature and rich in oleic and linoleic acids.

Genome sequence of Halobacterium species NRC-1

We report the complete sequence of an extreme halophile, Halobacterium sp. NRC-1, harboring a dynamic 2,571,010-bp genome containing 91 insertion sequences representing 12 families and organized into a large chromosome and 2 related minichromosomes. The Halobacterium NRC-1 genome codes for 2,630 predicted proteins, 36% of which are unrelated to any previously reported. Analysis of the genome sequence shows the presence of pathways for uptake and utilization of amino acids, active sodium-proton antiporter and potassium uptake systems, sophisticated photosensory and signal transduction pathways, and DNA replication, transcription, and translation systems resembling more complex eukaryotic organisms. Whole proteome comparisons show the definite archaeal nature of this halophile with additional similarities to the Gram-positive Bacillus subtilis and other bacteria. The ease of culturing Halobacterium and the availability of methods for its genetic manipulation in the laboratory, including construction of gene knockouts and replacements, indicate this halophile can serve as an excellent model system among the archaea.

The relation between mitral annulus motion and ejection fraction: a nonlinear function

In previous studies of the relation between mitral annulus motion (MAM) and left ventricular ejection fraction (EF), a linear relationship has been suggested. In this meta-analysis of 434 patients, we show that the relation is nonlinear and that a linear regression model overestimates EF in the lower range of MAM. The relation is better described by an S function and is influenced by age and heart size.

Effect of delay on racial differences in thrombolysis for acute myocardial infarction

OBJECTIVE

To analyze the effect of delay times on racial differences in thrombolysis for acute myocardial infarction.

BACKGROUND

Lower rates of thrombolytic therapy in blacks with acute myocardial infarction have recently been reported, but the reasons for this disparity are unknown. We hypothesized that lower rates of thrombolysis are caused by delay in presentation after symptom onset.

METHODS

From November 1992 through November 1996, consecutive patients with a first acute myocardial infarction presenting to a large, urban teaching hospital were prospectively enrolled. Delay times were determined retrospectively from review of medical records. Patients were prospectively followed up for in-hospital cardiac events and death. A multivariable regression model was built to relate presentation times and other variables to thrombolysis administration.

RESULTS

A total of 395 patients were included in the study, of which 33% were black. Symptom onset to emergency department presentation and door-to-needle times were significantly longer in blacks. Thrombolysis was administered significantly less often in blacks compared with whites (47% vs 68%, P =.001). Black race and age above 60 years were independently associated with delayed presentation and prolonged door-to-needle times. Black race, time to presentation, and non-Q-wave myocardial infarction were independently associated with not receiving thrombolysis. In-hospital mortality rates were similar in both groups.

CONCLUSIONS

Blacks presented later than whites for first acute myocardial infarction. Late arrival strongly influenced the rate of thrombolysis administration. Lower rates of thrombolysis and prolonged door-to-needle times were apparent in blacks after adjustment for delay times and other clinical factors, a finding that merits further investigation.

Electrocardiographic presentation of blacks with first myocardial infarction does not explain race differences in thrombolysis administration

BACKGROUND

Previous studies have suggested that thrombolysis is used less often in blacks than in whites. However, whether the greater prevalence of contraindications or less specific electrocardiographic manifestations of myocardial infarction (MI) account for this difference is unclear.

METHODS AND RESULTS

We studied 498 consecutive patients (32% blacks) with first MI. Initial electrocardiograms were analyzed, blinded to race and outcome, for ST-segment deviation and bundle branch block to determine eligibility for thrombolysis. The relation of electrocardiographic eligibility for thrombolysis and actual use of thrombolysis in both races was explored. Among blacks, 45% received thrombolysis compared with 66% of whites (P <.001). A similar proportion of blacks and whites were eligible for thrombolysis (59% and 66% respectively, P =. 116), but 62% of electrocardiography-eligible blacks were treated with thrombolysis compared with 75% of whites (P =.016). After accounting for eligibility for electrocardiography and other clinical variables likely to affect the decision to administer thrombolysis by means of conditional logistic regression, blacks were still less likely to receive thrombolysis (relative risk 0.73; 95% confidence interval 0.55 to 0.97).

CONCLUSIONS

We conclude that the differences in thrombolysis administration to blacks and whites are not accounted for by differences in electrocardiographic presentation or other measured variables. Unmeasured differences in clinical presentation of MI may explain racial differences in thrombolysis and merits further study.

Dermatomyositis as a presentation of pulmonary inflammatory pseudotumor (Myofibroblastic tumor)

Inflammatory pseudotumor (IPT) is a rare pulmonary tumor of uncertain etiology that usually presents as an asymptomatic radiographic finding. We describe a case of pulmonary IPT presenting as dermatomyositis with complete resolution following surgical resection.

Use of the double-bladed scalpel in peripheral margin control of dermatofibrosarcoma protuberans

BACKGROUND

The double-bladed scalpel previously has not been cited in the published literature for use in Mohs micrographic surgery.

OBJECTIVE

To allow for maximum tissue conservation and greatest possible intraoperative efficiency for peripheral margin control of a massive tumor.

METHODS

We describe the use of the double-bladed scalpel during Mohs surgery for peripheral margin control of a large dermatofibrosarcoma protuberans (DFSP).

RESULTS AND CONCLUSION

While not necessary for the majority of routine Mohs cases, utilization of the double-bladed scalpel may be timesaving, especially when used for peripheral margin control of a massive tumor.

Effects of first myocardial infarction on left ventricular systolic and diastolic function with the use of mitral annular velocity determined by pulsed wave doppler tissue imaging

This study was undertaken to assess the effect of a first myocardial infarction (MI) on the systolic and diastolic velocity profiles of the mitral annulus determined by pulsed wave Doppler tissue imaging and thereby evaluate left ventricular (LV) function after MI. Seventy-eight patients with a first MI were examined before discharge. Peak systolic, peak early diastolic, and peak late diastolic velocities were recorded at 4 different sites on the mitral annulus corresponding to the septum, anterior, lateral, and inferior sites of the left ventricle. In addition, the amplitude of mitral annular motion at the 4 above LV sites, the ejection fraction, and conventional Doppler diastolic parameters were recorded. Nineteen age-matched healthy subjects served as controls. Compared with healthy subjects, the MI patients had a significantly reduced peak systolic velocity at the mitral annulus, especially at the infarction sites. A relatively good linear correlation was found between the ejection fraction and the mean systolic velocity from the 4 LV sites (r = 0.74, P <.001). The correlation was also good when the mean peak systolic mitral annular velocity was tested against the magnitude of the mean mitral annular motion (r = 0.77, P <.001). When the patients were divided into 2 different groups with respect to an ejection fraction > or =0.50 or <0.50, a cutoff point of mean systolic mitral annular velocity of > or =7.5 cm/s had a sensitivity of 79% and a specificity of 88% in predicting a preserved global LV systolic function. Similar to systolic velocities, the early diastolic velocity was also reduced, especially at the infarction sites. The peak mitral annular early diastolic velocity correlated well with both LV ejection fraction (r =.66, P <.001) and mean systolic mitral annular motion (r = 0.68, P <.001). However, no correlation existed between the early diastolic velocity and conventional diastolic Doppler parameters. The reduced peak systolic mitral annular velocity seems to be an expression of regionally reduced systolic function. The peak early diastolic velocity is also reduced, especially at the infarction sites, and reflects regional diastolic dysfunction. Thus, quantification of myocardial velocity by Doppler tissue imaging opens up a new possibility of assessing LV function along its long axis.

Fatal left main coronary artery embolism from aortic valve endocarditis following cardiac catheterization

Coronary artery embolization has been associated with sudden cardiac death. It is more commonly seen with aortic valve endocarditis. It manifests as acute myocardial ischemia or infarction, causing instability of the cardiac rhythm, which may be fatal. We report a patient with aortic valve endocarditis who had sudden cardiac death following coronary angiography. Autopsy revealed embolic occlusion of the left main coronary artery.

Right ventricular function in patients with first inferior myocardial infarction: assessment by tricuspid annular motion and tricuspid annular velocity

BACKGROUND

Unlike left ventricular function, right ventricular (RV) function has not been widely studied after a myocardial infarction (MI). The current study describes RV function determined by tricuspid annular motion and tricuspid annular velocity after MI.

METHODS AND RESULTS

Thirty-eight patients with a first acute inferior MI were prospectively compared with 33 patients with a first anterior MI and 24 age-matched healthy individuals. Association of RV infarction in inferior MI was defined as the presence of >/=1-mm ST-segment elevation at the right precordial lead, V(4)R, of the electrocardiograms. From the echocardiographic apical 4-chamber views, the systolic motion of the tricuspid annulus was recorded at the RV free wall with the use of 2-dimensional guided M-mode recordings. Peak systolic and peak early and late diastolic velocities of the tricuspid annulus at the RV free wall also were recorded with the use of pulsed-wave Doppler tissue imaging. The tricuspid annular motion was reduced in inferior MI compared with that in healthy individuals (20.5 and 25 mm, P <.001). The peak systolic velocity of the tricuspid annulus was significantly reduced in inferior MI compared with that in healthy individuals (12 vs 14.5 cm/s, P <.001) and patients with anterior MI (12 and 14.5 cm/s, P <.001). Patients with inferior MI were divided into 2 subgroups: those with and those without electrocardiographic signs of RV infarction. The tricuspid annular motion was significantly lower in patients with RV infarction than in patients without RV infarction (17 and 22.7 mm, P <.001). In addition, compared with patients without electrocardiographic signs of RV infarction, patients with RV infarction also had a significantly decreased peak systolic tricuspid annular velocity (13.3 and 10.3 cm/s, P <.001) and peak early diastolic velocity (13 and 8.2 cm/s, P <.001).

CONCLUSIONS

These results suggest that tricuspid annular motion and tricuspid annular velocity can be used to assess RV function in association with inferior MI.

Myoglobin-like aerotaxis transducers in Archaea and Bacteria

Haem-containing proteins such as haemoglobin and myoglobin play an essential role in oxygen transport and storage. Comparison of the amino-acid sequences of globins from Bacteria and Eukarya suggests that they share an early common ancestor, even though the proteins perform different functions in these two kingdoms. Until now, no members of the globin family have been found in the third kingdom, Archaea. Recent studies of biological signalling in the Bacteria and Eukarya have revealed a new class of haem-containing proteins that serve as sensors. Until now, no haem-based sensor has been described in the Archaea. Here we report the first myoglobin-like, haem-containing protein in the Archaea, and the first haem-based aerotactic transducer in the Bacteria (termed HemAT-Hs for the archaeon Halobacterium salinarum, and HemAT-Bs for Bacillus subtilis). These proteins exhibit spectral properties similar to those of myoglobin and trigger aerotactic responses.

Successful percutaneous stenting of a right gastroepiploic coronary bypass graft using monorail delivery system: a case report

The right gastroepiploic artery (RGEA) is being successfully used as an arterial conduit in a selected group of patients undergoing coronary artery bypass graft surgery. However, myocardial ischemia may result due to spasm, occlusion, and stenosis of this graft. The anastamosis site at distal right coronary artery (RCA) or posterior descending artery (PDA) is the most common location for stenosis of an in situ gastroepiploic coronary bypass graft. Balloon angioplasty of such stenoses has been reported with optimal short-term results. Stent deployment would decrease the restenosis rate, so that repeat procedures could be minimized for these technically challenging lesions. We describe a case of successful deployment of a stent with monorail delivery system at the anastamotic site stenosis of an in situ gastroepiploic right coronary artery bypass graft. This percutaneous coronary intervention could prevent redo coronary artery bypass graft surgery. Cathet. Cardiovasc. Intervent. 49:197-199, 2000.