Managing patient demographics

The Harvard Community Health Plan commissioned a cross-functional project team to improve the accuracy of the members' data base because inaccurate patient phone numbers and addresses were a major obstacle for clinicians seeking to provide high-quality service to patients. Accurate demographic information is essential to enable clinicians to contact patients quickly regarding lab results or follow-up care. The team members applied a quality improvement problem-solving methodology that required them to focus on the few vital problems and to test problems using data analysis. As a result, the team saw firsthand that staff members were not to blame for the inaccurate demographic information; the problem was in the automated system that obtains, updates, and maintains the records.

Inactivated hepatitis A vaccine in childhood: implications for disease control

The experience to date with the Merck inactivated hepatitis A vaccine in healthy children 2-16 years old is reviewed. Comparison of response to increasing doses indicates that an intramuscular dose of 25 units results in seroconversion of 99% of children by week 4 following a single dose. Antibody persistence rate is nearly 100% six months later, whether or not a second priming dose is given at week 8. This vaccine has proven highly immunogenic in children and has a favourable safety/tolerability profile. It should be useful for pre-exposure prophylaxis and control of hepatitis A, and should eventually replace immune globulin (Ig) for this indication.

Aminoglutethimide in malignant melanoma. A phase II study

The role of steroid hormones has been suggested in the growth of malignant melanoma, and since aromatase activity has been found in melanoma tissue, we carried out a phase II study of aminoglutethimide, an aromatase inhibitor in malignant melanoma patients. Fifteen heavily pretreated patients entered the study. No response was observed--the treatment was well tolerated. We concluded that aminoglutethimide is very unlikely to be useful in melanoma patients.

Estrogen and progesterone withdrawal increases cerebral vasoreactivity to serotonin in rabbit basilar artery

An in vitro animal model which examines the effects of sex hormone variations during the menstrual cycle on basilar artery reactivity is presented. Three groups of rabbits were utilized: a chronically depleted control group which received no further hormonal treatment after bilateral surgical oophorectomy (O), simulating menopause, and two groups of intact females, one of which was treated to mimic the estrogen and progesterone surge during the luteal phase (H) and the third group which was acutely estrogen and progesterone depleted after the luteal surges to simulate the immediate premenstrual state (W). We show that both acute and chronic estrogen and progesterone withdrawal significantly increase serotonin sensitivity (ED50) in basilar artery rings. There was no difference between groups for maximum contraction (Tmax) to serotonin, nor optimal resting tension. Furthermore, there was no difference in vasoreactivity and contractility to norepinephrine between groups. In order to distinguish between the effects of chronic and acute treatment we examined acute estrogen and progesterone superfusion in basilar artery rings from intact non-treated female rabbits. Acute superfusion of pre-contracted and non-pre-contracted artery segments resulted in significant dilatation only when supraphysiologic concentrations of estrogen and progesterone were used. We conclude that both acute and chronic female sex hormone withdrawal selectively increases cerebral vasoreactivity to serotonin.

Methotrexate in rheumatoid arthritis: effects on disease activity in a multicenter prospective study

One hundred and twenty-three patients with rheumatoid arthritis (RA) who successfully completed a randomized trial comparing oral methotrexate (MTX) to auranofin enrolled in a longterm prospective study of oral MTX. Of the 91 patients who completed 24 months of therapy, a significant (p = 0.0001) improvement was noted compared to baseline in all clinical disease variables and the Westergren erythrocyte sedimentation rate (ESR). Marked improvement occurred in 94 (76%) and 98 (80%) of the patients in the joint pain/tenderness index and joint swelling index at the last evaluable visit (mean 26 months). Of the 77 patients with an elevated ESR at baseline, 29 (38%) patients normalized it (less than 20 mm/h) while receiving therapy (p less than 0.01). A significant reduction in prednisone dose was also seen. Adverse events occurred frequently but were generally mild in severity. Twenty-seven patients (22%) withdrew during the study. Four (3%) withdrew due to lack of efficacy, and 6 (5%) because of adverse experiences. The overall probability of continuing therapy in the study for 48 months was projected at 72%. This large prospective study supports the observation of earlier smaller studies that MTX is an effective drug in the treatment of RA.

Systemic lupus erythematosus and lymphoma: association with antiphospholipid syndrome

A woman with a history of polyarthralgias appeared to develop systemic lupus erythematosus and lymphoma simultaneously. The diagnosis of the concurrent lymphoma was made on biopsy of a left axillary lymph node. Generalized lymphadenopathy, splenomegaly and pruritus had given rise to suspicion of an underlying lymphoma. The lymphoma responded well to chemotherapy. Her condition was further complicated by an arterial occlusion involving the right 2nd toe which was eventually amputated, transient ischemic attacks (amaurosis fugax), livedo reticularis and thrombocytopenia which were accompanied by elevations of IgM anticardiolipin antibodies and a biological false test for syphilis. The lupus anticoagulant test was not performed as she was given anticoagulation therapy.

Low-dose methotrexate compared with auranofin in adult rheumatoid arthritis. A thirty-six-week, double-blind trial

Weekly treatment with low-dose oral methotrexate (MTX) was compared with daily auranofin (AUR) treatment in a 36-week double-blind, randomized, multicenter study of 281 patients with active, adult-onset rheumatoid arthritis. Both treatment groups showed significant improvement by the usual measures of clinical efficacy. The response with MTX occurred earlier and was consistently greater than that with AUR. An intent-to-treat analysis showed significantly greater improvement (P less than 0.01) with MTX for painful and swollen joint counts and physician and patient global assessments of disease activity. Adverse reactions were reported more frequently in the AUR group, and more AUR-treated patients were withdrawn from the study because of toxicity. MTX was thus more effective and better tolerated than AUR in this study.

[Necrosectomy and bursa lavage in necrotizing pancreatitis. Results of a prospective clinical study]

In a prospectively performed clinical trial a surgical management protocol including necrosectomy and postoperative local lavage of the necrosis cavity and the omental bursa was applied in 95 patients with necrotizing pancreatitis. In 80% of them severe organ failures occurred preoperatively, in spite of intensive care treatment. The median value of early prognostic signs of these patients was 4.5. Intraoperatively 59% showed extended pancreatic necroses and 66% an extension of the necroses into extrapancreatic tissue structures; in 42% bacteria were detected in the necrotic material. After necrosectomy the postoperative local lavage was performed for an average period of 25 days with 8 1 of lavage fluid per 24 hours in median. The average intensive care period came to 7.0 days, the average postoperative hospital time was 60 days. The hospital mortality amounted to 8.4%. The advantage of this management protocol including necrosectomy and postoperative local lavage lies in the continuous emptying of vasoactive and toxic substances, germs and necrotic material.

Necrosectomy and postoperative local lavage in necrotizing pancreatitis

Necrosectomy with postoperative continuous local lavage was performed in a prospective study involving 95 patients with necrotizing pancreatitis. In the same period 567 patients with oedematous-interstitial pancreatitis were treated non-operatively with a hospital mortality rate of 0.7 per cent. In patients with necrotizing pancreatitis the median Ranson criteria score was 4.5 points; operation was required at a median of 7 days after the onset of symptoms because of non-response to conservative treatment. In all, 59 per cent of the patients (56 out of 95) developed extended intrapancreatic parenchymal necrosis, 70 per cent had ascites, and 66 per cent had intra- and extrapancreatic necrosis; 42 per cent of the patients had bacterial infection of the necrotic tissue. For lavage a median of 8 l/24 h of fluid were instilled postoperatively for 25 days (median). The lavage fluid showed high levels of immunoreactive trypsin, phospholipase A2, and endotoxin in the early postoperative period. Hospital mortality rate was 8.4 per cent. Necrosectomy and continuous postoperative lavage can achieve high survival rates in patients with necrotizing pancreatitis. Postoperative local lavage allows the continuous non-operative evacuation of biologically active compounds and devitalized tissue, and avoids damage to remaining vital exocrine and endocrine pancreatic tissue.

Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis

Local septic complications in acute pancreatitis need to be exactly characterized and defined in order to develop improved concepts for their prevention, early diagnosis, and therapy. While up to now all local septic complications have been termed abscesses, the present study for the first time delineates the morphologic, clinical, and laboratory criteria needed to distinguish between two separate clinical entities: the infected necrosis (IN) and the pancreatic abscess (PA). IN is defined as a diffuse bacterial inflammation of necrotic pancreatic and peripancreatic tissue, but without any significant pus collections. On the other hand, the morphologic substrate of PA is a localized collection of pus surrounded by a more or less distinct capsula. IN becomes clinically evident during the early phase of acute pancreatitis (AP). The patients with IN present both the signs of sepsis and the laboratory findings of AP. Thus in these patients the most fulminant course of AP is observed; 51.8% and 35.7% of them have pulmonary or renal insufficiency, respectively. The mortality of the patients with IN is high and amounts to 32.1%. Pancreatic abscess, on the other hand, does not develop before the fifth week after onset of symptoms and after subsidence of the acute phase of pancreatitis. In these patients laboratory signs of AP-like amylasemia, hypocalcemia, hyperglycemia, and rise of LDH are rarely observed. Corresponding to the lack of pathophysiologic effects of AP per se, pulmonary and renal insufficiencies occur in only 33.3% and 16.7%, respectively, and mortality in these patients is 22.2%. While an abscess may readily be identified by computed tomography, the differentiation between IN and non-IN can be very difficult.(ABSTRACT TRUNCATED AT 250 WORDS)

Sepsis indicators in acute pancreatitis

Twenty-one routine clinical and laboratory data in 161 patients with necrotizing pancreatitis (NP) undergoing surgical treatment were analyzed. The necrotic tissue at operation was bacterially infected in 41% of the patients. The goal of the study was to evaluate whether there was any special clinical feature in cases of an infection. The parameters were recorded during 48 h after admission as well as during 48 h before operation, and the frequencies submitted to both a univariate and a multivariate analysis (logistic regression model). In the period after admission, patients with infected necrosis significantly more often had a rectal temperature greater than 38.5 degrees C (p = 0.001). Before operation (i.e., after maximum conservative treatment), four findings were significantly related to an infection: rectal temperature greater than 38.5 degrees C, base excess greater than -4 mmol/L, hematocrit less than 35% (all p = 0.0001), and paO2 less than 60 mm Hg (p = 0.001). The multivariate analysis, which calculates and quantifies the mutual influence of factors, showed a combination of three findings (rectal temperature greater than 38.5 degrees C, base excess greater than -4 mmol/L, and hematocrit less than 35%) to be related to necrosis infection before operation. All three criteria in a patient imply a probability of infection of 83%. It is noteworthy that the sepsis indicators were equally distributed in patients with focal, extended, or subtotal/total infected necrosis, but correlated with the necrosis extent in sterile necrotizing pancreatitis. Moreover, all parameters not related to the pancreatic infection [e.g., hyperglycemia, hypocalcemia, rise of lactic dehydrogenase (LDH), and the white blood cell count] correlated with the three necrosis categories.

Identification of pancreas necrosis in severe acute pancreatitis: imaging procedures versus clinical staging

One hundred and five of 395 patients with acute pancreatitis were surgically treated in our clinic from 1981 to 1984. Ninety three of these patients were examined with contrast enhanced computed tomography and/or ultrasound and were clinically assessed according to Ranson's objective criteria before operation. At operation, 77 patients showed necrotising pancreatitis and 16 showed biliary acute interstitial pancreatitis. Ninety per cent of the cases with extensive and 79% of those with minor necroses of the pancreas had been demonstrated with contrast enhanced computed tomography. Ultrasound failed to be diagnostic in 24% of the patients due to meteorism; the sensitivity of the diagnostic studies for pancreatic necrosis was 73% regardless of the extent of the process. Using the early objective signs, seven patients with acute interstitial pancreatitis were classified as having a severe attack, whereas 30 patients with necrotising pancreatitis were categorised as mild attacks. We conclude that the contrast enhanced computed tomography is an aid in deciding on conservative or surgical treatment in a case of acute pancreatitis. Ultrasound does not appear to be an adequate method for determining pancreatic necrosis. The early objective signs fail to sufficiently identify the necrotising form of acute pancreatitis.

Comparison of myointimal hyperplasia in laser-assisted and suture anastomosed arteries. A preliminary report

Use of the milliwatt CO2 laser to perform microvascular anastomoses is associated with characteristic histologic changes, including intimal hyperplasia and medial necrosis. The extent of myointimal proliferation after both suture and laser-assisted vascular anastomosis was assessed in the rat femoral artery model. At 2 weeks the average intimal height of the laser-anastomosed vessels was 11.7 +/- 2.2 microns (mean +/- standard error of the mean) vs. 21.3 +/- 3.2 microns for sutured arteries (p less than 0.05). By 6 weeks the groups were equivalent (laser, 25.6 +/- 4.6 microns; suture, 17.3 +/- 1.2 microns; p, not significant). The medial changes associated with the laser-assisted method appear to inhibit the proliferative response at 2 weeks but are reversed by 6 weeks.

Bacterial contamination of pancreatic necrosis. A prospective clinical study

In a prospective clinical study including 114 patients with acute necrotizing pancreatitis, but excluding patients with a pancreatic abscess, necrotic material obtained at surgery was tested bacteriologically. Intestinal microorganisms were cultured in 39.4% of the cases. The contamination rate was 23.8% in patients operated on during the first 7 days of the attack; it rose to 71.4% in the third week and decreased to 32.5% after the fourth week. Intra- and extrapancreatic necrosis was more widespread and pancreatitis-associated ascites was more frequent in patients with proven contamination. The number of objective signs was 4.5 (median) and postoperative mortality was 37.8% in bacteriologically positive subjects, whereas the number was 3.5 (median) and mortality was 8.7% in bacteriologically negative patients. Morphologic and clinical alterations were more severe, and the mortality rate was significantly elevated, in patients with a short history of disease and bacterial contamination of necrotic tissue. All 5 patients with pancreatic sepsis who were operated on in the first 7 days of the disease, as compared with 2 of 16 patients with sterile necrosis, died. Thus, it is demonstrated that bacterial contamination of pancreatic necrosis occurs early and frequently, causing a significant increase in morbidity and mortality, particularly when it develops in the initial stages of the attack.

Diagnosis and treatment of myofacial pain-dysfunction (MPD) syndrome

The successful management of patients with MPD syndrome is dependent on establishing an accurate diagnosis and using proper therapy based on an understanding of the etiology of the disorder. Establishing an accurate diagnosis is accomplished by taking a careful history, doing a thorough examination, and having a knowledge of the various other conditions that can produce signs and symptoms similar to those of MPD syndrome. Using proper therapy is related to recognition that MPD syndrome is a stress-induced psychophysiologic disease originating in the muscles of mastication and not an organic disease arising in the temporomandibular joint. Thus, therapy should be directed at reducing stress, relaxing tense jaw muscles, and creating an awareness by the patient of the causes of the problem, rather than at analyzing occlusion, measuring joint spaces, and producing irreversible structural changes in the dentition and the articulation. Because good results can be achieved with these uncomplicated, reversible forms of therapy, it is important that the clinician does not succumb to an unproven fad or use of an irreversible procedure that will not achieve better results.