Impact of Hypoalbuminemia on Ceftriaxone Treatment Failure in Patients With Enterobacterales Bacteremia: A Propensity-Matched, Retrospective Cohort Study

Background

Ceftriaxone is frequently prescribed due to its convenience of dosing and robust antimicrobial activity. However, patients with hypoalbuminemia may experience suboptimal ceftriaxone exposure due to the high degree of protein binding. We aimed to evaluate the impact of hypoalbuminemia on treatment failure among hospitalized adults with Enterobacterales bacteremia who received ceftriaxone therapy.

Methods

We conducted an observational cohort study among patients with Enterobacterales bacteremia who received >72 hours of ceftriaxone initiated within 48 hours of index culture. A propensity-score model was used to match and compare patients with hypoalbuminemia. The primary outcome was treatment failure, defined as a composite of (1) escalation from ceftriaxone to ertapenem or an intravenous antibacterial agent with activity against Pseudomonas aeruginosa, or (2) inpatient death. Secondary outcomes included hospital length of stay, duration of antibiotic therapy, and time to infection resolution.

Results

Of 260 patients included, the majority developed bacteremia from a urinary source (71.5%), and Escherichia coli was the most common pathogen identified (72.3%). Patients with hypoalbuminemia experienced numerically higher rates of treatment failure, although not reaching statistical significance (12.3% vs 7.7%; P = .21). Among patients receiving care in the intensive care unit, the impact of hypoalbuminemia on treatment failure was more pronounced (24.4% vs 7.3%; P = .07).

Conclusions

Hypoalbuminemia may not have a significant impact on clinical outcomes among patients with Enterobacterales bacteremia treated with ceftriaxone. However, critically ill patients may be subject to higher incidence of treatment failure in the presence of hypoalbuminemia.

Descriptive analysis evaluating the use of direct oral anticoagulation therapy in heart and lung transplant recipients

BACKGROUND

Direct oral anticoagulants (DOACs) are widely utilized following cardiothoracic transplantation with limited guidance regarding drug-drug interactions (DDIs), periprocedural management, and DOAC-specific monitoring.

METHODS

We performed a single-center, retrospective, descriptive analysis of adult cardiothoracic transplant recipients initiated on DOAC therapy between May 2016 and July 2021. The primary endpoint for this analysis was the percentage of patients dosed per package labeling. Secondary endpoints included DOAC prescribing in the context of DDIs, renal dysfunction, and periprocedural management, as well as thromboembolism and major bleeding at 12 months.

RESULTS

A total of 125 patients were included in this analysis with a median age of 62 years. At initiation, 63.2% of patients were dosed according to package labeling. The most common reason for non-labeled dosing was concomitant azole antifungal therapy. DOAC therapy was held for 82 procedures with no reported thrombotic events and one major bleed in the setting of AKI. Hemodialysis-dependence was associated with a reduced risk of thrombosis (0 vs. 10 events per 100 PY, p = .002) and an increased risk of major bleeding (23 vs. 8 events per 100 PY, p = .006). Additionally, DOAC-specific anti-xa guided dosing was associated with a reduced risk of major bleeding (0 vs. 13 events per 100 PY, p < .001).

CONCLUSION

Our findings show that deviation from package labeling is common following cardiothoracic transplantation and its association with clinical outcomes warrants further study.

Real-world Assessment of 2879 COVID-19 Patients Treated With Monoclonal Antibody Therapy: A Propensity Score-Matched Cohort Study

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread globally and cause significant morbidity and mortality. Antispike protein monoclonal antibody (mAb) therapy has been shown to prevent progression to severe coronavirus disease 2019 (COVID-19). The objective of this study was to report the outcomes of high-risk, SARS-CoV-2-positive patients infused with 1 of the 3 mAb therapies available through Food and Drug Administration Emergency Use Authorization (EUA).

Methods

A total of 4328 SARS-CoV-2-positive patients who satisfied EUA criteria for eligibility for receiving mAb therapy were infused with bamlanivimab or the combination therapies bamlanivimab-etesevimab or casirivimab-imdevimab from November 22, 2020, to May 31, 2021, at 6 infusion clinics and multiple emergency departments within the 8 Houston Methodist Hospitals in Houston, Texas. The primary outcome of hospital admission within 14 and 28 days postinfusion was assessed relative to a propensity score-matched cohort, matched based on age, race/ethnicity, median income by zip code, body mass index, comorbidities, and positive polymerase chain reaction date. Secondary outcomes included intensive care unit admission and mortality.

Results

A total of 2879 infused patients and matched controls were included in the analysis, including 1718 patients infused with bamlanivimab, 346 patients infused with bamlanivimab-etesevimab, and 815 patients infused with casirivimab-imdevimab. Hospital admission and mortality rates were significantly decreased overall in mAb-infused patients relative to matched controls. Among the infused cohort, those who received casirivimab-imdevimab had a significantly decreased rate of admission relative to the other 2 mAb therapy groups (adjusted risk ratio,0.51; P=.001).

Conclusions

Treatment with bamlanivimab, bamlanivimab-etesevimab, or casirivimab-imdevimab significantly decreased the number of patients who progressed to severe COVID-19 disease and required hospitalization.

Clinical Outcomes Following Tocilizumab Administration in Mechanically Ventilated Coronavirus Disease 2019 Patients

Effective treatments for the critically ill patient with novel coronavirus disease 2019 are desperately needed. Given the role of cytokine release syndrome in the pathogenesis of coronavirus disease 2019-associated respiratory distress, therapies aimed at mitigating cytokine release, such as the interleukin-6 receptor-inhibiting monoclonal antibody tocilizumab, represent potential treatment strategies. Therefore, we examined the outcomes of critically ill coronavirus disease 2019 patients treated with tocilizumab and factors associated with clinical improvement.

DESIGN

A retrospective cohort analysis of 21-day outcomes for consecutive mechanically ventilated patients treated with tocilizumab from March 24, 2020, to May 4, 2020.

SETTING

Nine ICUs at six hospitals within a hospital system in Houston, Texas, United States.

PATIENTS

The first 62 coronavirus disease 2019 patients on invasive mechanical ventilation who were treated with tocilizumab, which was considered for all patients with severe disease.

INTERVENTIONS

Tocilizumab was administered either at a weight-based dose of 4-8 mg/kg or at a flat dose of 400 mg, with repeat administration in some patients at the physician's discretion.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were mortality and clinical improvement, defined as extubation. By day 21 post-tocilizumab, clinical improvement occurred in 36 patients (58%) and 13 patients (21%) died. In both univariable and multivariable analyses, age less than 60 years was associated with clinical improvement. Transient transaminitis was the most common adverse reaction, occurring in 25 patients (40%).

CONCLUSIONS

Based on clinical outcomes and mortality rates seen in previous reports of mechanically ventilated patients, tocilizumab, as part of the management strategy for severe coronavirus disease 2019, represents a promising option. These findings support the need for evaluation of tocilizumab in a randomized controlled trial.

Comparison of the Bligh and Dyer and Folch methods for total lipid determination in a broad range of marine tissue

For many studies, it is important to measure the total lipid content of biological samples accurately. The Bligh and Dyer method of extraction was developed as a rapid but effective method for determining total lipid content in fish muscle. However, it is also widely used in studies measuring total lipid content of whole fish and other tissues. Although some investigators may have used modified Bligh and Dyer procedures, rarely have modifications been specified nor has their effectiveness been quantitatively evaluated. Thus, we compared this method with that of the classic Folch extraction in determining total lipid content of fish samples ranging from 0.5 to 26.6% lipid. We performed both methods as originally specified, i.e., using the chloroform/methanol/water ratios of 1:2:0.8 and 2:2:1.8 (before and after dilution, respectively) for Bligh and Dyer and of 8:4:3 for Folch, and with the initial solvent/sample ratios of (3+1):1 (Bligh and Dyer) and 20:1 (Folch). We also compared these with several other solvent/sample ratios. In samples containing <2% lipid, the results of the two methods did not differ. However, for samples containing >2% lipid, the Bligh and Dyer method produced significantly lower estimates of lipid content, and this underestimation increased significantly with increasing lipid content of the sample. In the highest lipid samples, lipid content was underestimated by up to 50% using the Bligh and Dyer method. However, we found a highly significant linear relationship between the two methods, which will permit the correction of reported lipid levels in samples previously analyzed using an unmodified Bligh and Dyer extraction. In the future, modifications to procedures and solvent/sample ratios should be described.

Comparison of subperiosteal vs subgaleal elevation techniques used in forehead lifts

OBJECTIVES

To compare eyebrow and forehead elevation and tension among the following 3 surgical techniques: subperiosteal dissection to the supraorbital rim, subperiosteal dissection with release (elevation, incision, and spread) of periosteum at the supraorbital rim, and subgaleal dissection to the supraorbital rim, and to determine the optimal method of elevation in an aesthetically accepted range for the endoscopic forehead lift.

DESIGN

A randomized, self-controlled study using an open approach to the forehead in cadaver heads. Each half of head was compared with the other in the following 2 study groups: subperiosteal dissection without release vs subperiosteal dissection with release of periosteum (group 1) and subperiosteal dissection with release of periosteum vs subgaleal dissection.

SETTING

Anatomy laboratory at a university medical center.

SUBJECTS

Eight cadaver heads fixed with ethylene glycol in each group.

INTERVENTION

Predissection distances in millimeters from fixed anatomic landmarks were measured. The forehead flaps were elevated using a coronal incision and divided with a midline incision for side-to-side comparison. Cadaver heads and side of surgical intervention were selected randomly. The flap tensions associated with incremental flap advancement of 0.5 and 1.0 cm were measured. Traction of 2.2 kg was then applied to each flap, and distances between the fixed landmarks were measured.

MAIN OUTCOME MEASURES

Mean predissection and postdissection distance of brow and forehead elevation for each dissection type and mean distance and median tension of brow and forehead elevation within each group.

RESULTS

The mean postdissection brow measurements at rest were significantly greater than the mean predissection measurements at most landmarks in all dissections for both groups (P<.05). The mean postdissection brow and forehead measurements with 2.2 kg of traction were significantly greater than the mean predissection measurements at all landmarks in all dissections for both groups (P<.05). The mean increase in distance from predissection to postdissection (at rest and with 2.2 kg of traction) did not significantly differ between the different dissection types (P>.05). For group 1, the median flap tension for subperiosteal dissection without release was greater than that for subperiosteal dissection with release (P>.05). For group 2, subperiosteal dissection with release had greater median flap tension than subgaleal dissection (P>.05).

CONCLUSIONS

All 3 methods of dissection significantly elevated the brow at rest for most landmarks. All 3 methods of dissection significantly elevated the brow and forehead when traction was applied to the flap. Brow and forehead elevation at rest and with 2.2 kg of traction did not significantly differ between the dissections. Subgaleal dissection was associated with less flap tension compared with the subperiosteal dissection with or without release. The data support the use of all 3 methods of forehead dissection for brow elevation and subgaleal forehead dissection as the optimal approach for the forehead lift, whether performed endoscopically or open.

Clinical and histologic response of subcutaneous expanded polytetrafluoroethylene (Gore-Tex) and porous high-density polyethylene (Medpor) implants to acute and early infection

OBJECTIVE

To examine the responses of subcutaneously implanted expanded polytetrafluoroethylene (e-PTFE, Gore-Tex) and porous high-density polyethylene (PHDPE, Medpor) to experimentally induced infection.

DESIGN

Sprague-Dawley rats were implanted subcutaneously with either e-PTFE or PHDPE implants. Inocula of Staphylococcus aureus were injected directly over the implants and the wounds were observed for clinical signs of infection. After the animals were killed, the implants were harvested and underwent Histologic examination.

SUBJECTS

Twenty-eight adult male Sprague-Dawley rats weighing 200 to 250 g.

INTERVENTION

A 8-mm diameter, 1-mm-thick implant of either e-PTFE or PHDPE was placed in a subcutaneous pocket over each animal's dorsum. Either at the time of implantation or 14 days afterward, an inoculum of 10(9) colony-forming units of S aureus was injected transcutaneously directly over each implant. The animals were observed for 7 days before being killed. The implants were harvested and examined by both conventional light and scanning electron microscopy, and the degree of capsule reaction, infection, inflammation, and implant degradation was evaluated.

RESULTS

Implants inoculated at the time of implantation were more likely to become clinically infected. Results for e-PTFE and PHDPE implants were similar in this group (5 of 5 e-PTFE and 5 of 5 PHDPE implants infected). The PHDPE implants inoculated 14 days after implantation were less likely to become infected (1 of 4 infected) than e-PTFE implants (3 of 4 infected), and were statistically less likely to become infected than PHDPE implants inoculated immediately after implantation (25% vs 100%; P < .02). Histologically, this resistance to infection correlated with increasing fibrovascular ingrowth into the PHDPE implants. The infected PHDPE implant had little to no ingrowth compared with PHDPE control implants. The uninfected e-PTFE implant had evidence of early fibrovascular ingrowth into the peripheral pores of the implant.

CONCLUSIONS

Because of differences in pore size, PHDPE promotes faster fibrovascular ingrowth. The presence of vascularized host tissue in and around the implant lends stability and resistance to experimentally induced infection. Conservative management of clinical implant infections should be considered if bacterial seeding occurs after substantial fibrovascular ingrowth is present. Future alloplast designs should include pore sizes that will encourage invasion of the implant by host tissue.

Core services and the New Zealand health reforms

The last 5 years have seen dramatic changes in health care provision in New Zealand. Amidst considerable controversy, the 14 Area Health Boards were abolished in July 1993. The State now funds 4 Regional Health Authorities (still on the basis of a weighted population formula) from Vote Health (the health sector's share of public expenditure). The role of the National Advisory Committee on Core Health and Disability Support Services and other bodies in determining the annual policy and service obligations faced by the 4 Regional Health Authorities is discussed.

Short-term myeloid reconstitution following TBI is not adversely affected by doses of FK506 that abrogate lethal GVHD

Studies were undertaken to determine whether the doses of FK506 that are effective for acute GVHD prophylaxis following lethal irradiation and bone marrow transplantation (BMT) would also suppress myeloid cell reconstitution. FK506 (3 mg/kg/day) abrogated acute lethal graft versus host disease (GVHD) in lethally irradiated C57BL/10SnJ (H-2b) recipient mice given histoincompatible BM plus spleen cells from B10.BR (H-2k) donors and this dose was used in all of the studies. Endogenous and exogenous myeloid repopulation was studied in mice given daily injections of either FK506, an equivalent amount of carrier solvent or no treatment throughout the interval between total body irradiation (TBI) and the day of assay. Repopulation was studied after 400 or 500 cGy TBI (endogenous) and after 950 cGy TBI plus injection with syngeneic BM (exogenous). No consistent adverse effects of FK506 were seen during either exogenous or endogenous recovery. Parameters studied included hematocrit (Hct), WBC count, cells per humerus, spleen weight, splenic colony-forming units, % spleen or BM 59Fe uptake and colony forming cells per humerus. Similarly, when lethally irradiated secondary recipients were reconstituted with BM from FK506 treated primary recipients (lethal irradiation plus exogenous BM), no consistent effects were observed. These data suggest that FK506 given to prevent GVHD would not compromise the myeloid recovery that is critical for survival in the interval of time following shortly after BMT.

Rapamycin but not FK506 inhibits the proliferation of mononuclear phagocytes induced by colony-stimulating factors

FK506, CsA, and rapamycin are potent inhibitors of T lymphocyte activation; relatively little is known of their effects on cells of the monocyte/macrophage lineage. Studies were undertaken to determine the effects of these drugs on the proliferative response of bone marrow-derived mononuclear phagocytes (BMMP) to CSFs. Rapamycin inhibited the proliferation of BMMP cultured in the presence of 10% L cell-conditioned medium, used as a source of macrophage CSF. The inhibition by rapamycin was dose dependent and apparent at concentrations of 0.1 nM or greater. In a similar fashion, rapamycin inhibited the proliferation of BMMP stimulated by the recombinant forms of murine IL-3 and murine granulocyte-macrophage CSF, and human macrophage CSF. In contrast, neither FK506 nor CsA at concentrations as high as 1000 nM diminished the proliferation of BMMP cultured under identical conditions. FK506, but not CsA, blocked the inhibitory effects of rapamycin on the response of BMMP to CSFs. In summary, these data indicate that rapamycin inhibits the proliferation of BMMP in response to CSFs. These results imply that patients receiving rapamycin, but not FK506 or CsA, may have an impaired ability to generate a functional mononuclear phagocyte population.

Cross-species graft-versus-host-disease is accompanied by a donor-derived cellular immune response

Acute graft-versus-host-disease is classically described as reactivity of donor lymphocytes to recipient alloantigens. To date there is debate as to whether GVHD can be induced across a species barrier. We recently reported the induction of stable xenogeneic chimerism (rat-->mouse) and donor-specific transplantation tolerance using the transplantation of untreated rat bone marrow cells into B10 mouse recipients. Survival of chimeras was excellent, and there was no evidence of GVHD. We now describe the induction of xenogeneic GVHD by transplanting large numbers of donor rat spleen cells with the bone marrow inoculum. All chimeras that received bone marrow and untreated spleen cells developed an external appearance compatible with GVHD and had a median survival time of 14 days. Mice that received equivalent numbers of untreated rat bone marrow alone appeared healthy, had no evidence for GVHD, and survived > 90 days. The usual epithelial target tissues for allogeneic GVHD in those mice that received xenogeneic bone marrow and spleen cells showed the presence of tissue injury and histologic features compatible with GVHD. Donor rat MHC class I and class II positive cells were prominent cell types present in the tongues of mice that developed features of GVHD, and this was accompanied by a significant inflammatory tissue response with loss of the dermal-epidermal architecture. In contrast, fully xenogeneic chimeras without GVHD had no evidence for tissue injury or pathologic cellular infiltrates when examined by immunohistochemical analysis. These data suggest that although fully xenogeneic chimeras resist GVHD, GVHD can be induced across a species barrier if sufficient numbers of donor rat spleen cells are added to the bone marrow inoculum. Further comparisons of these models may provide an approach to study the mechanisms responsible for xenoreactivity in vivo.

HIV infection in autologous and allogeneic bone marrow transplant patients: a retrospective analysis of the Marseille bone marrow transplant population

Twelve HIV-positive patients who either underwent or seroconverted after bone marrow transplantation (BMT) at the University of Marseille between 1981 and 1985 were reviewed in order to observe their rates of development of AIDS. Two patients were HIV positive prior to transplantation, while ten seroconverted after transplantation. Six patients underwent autologous BMT and six underwent allogeneic BMT; all of their respective donors were seronegative. Eleven patients developed AIDS (92%), with a mean AIDS-free time (AFT) of 1 year 8 months after BMT. Seven of those subjects died, with a mean survival over a 5-year follow-up period of 2.14 years after BMT. Five autologous recipients had a mean AFT of 2 years 3 months, with the sixth patient being AIDS free. The mean AFT for the allogeneic recipients was 1 year 2 months (p = NS), all of whom developed AIDS. These data suggest that the development of AIDS was rapid from the time when our patients seroconverted. However, this was not initially accompanied by poor survival. In summary, BMT may be indicated for HIV-positive patients who required myeloablation, despite an enhanced development of AIDS.

Anatomic importance of the retrofacial air tract

The retrofacial air tract is a constant and relevant anatomic landmark for the temporal bone surgeon. By purposefully dissecting this space, one is able to safely identify the facial nerve, endolymphatic sac, and jugular bulb. The retrofacial air tract also provides access to the petrous apex. Forty temporal bones of varying degrees of pneumatization were dissected in order to study the retrofacial air tract. A well-developed air tract was easily identified in all specimens. We describe our anatomic findings and discuss the surgical relevance and important of the retrofacial air tract.

Advances in non-invasive measures of vocal acoustics

Objective assessment of vocal pitch, loudness, and quality is a crucial adjunct to endoscopy in the diagnosis and treatment of vocal pathology. Historically, this assessment was made through subjective, perceptual measures that were questionable in terms of validity and reliability. Recent advances in electronic technology now permit objective analysis of the acoustic characteristics of voice. Kay Elemetric's Visi-Pitch, DSP 5500 Digital Spectrograph, and Nasometer are representative of these new instruments and are used as illustrations in the discussion of the assessment of speech acoustics.

Non-invasive assessment of phonatory and respiratory dynamics

Evaluation of vocal pathology and the accompanying dysphonia should include an assessment of laryngeal structure and mobility as well as respiratory dynamics. Laryngeal structure is best observed through laryngoscopy which provides an accurate assessment of the tissues and their mobility. Respiratory measures of lung volume, air-flow and pressure, and breathing dynamics are typically determined via spirometry and pneumotachography. While the above are traditional invasive procedures which interfere with normal speech production, recent advances in electronic technology have resulted in the development of non-invasive procedures to assess phonatory and respiratory dynamics. These procedures, when used as an adjunct to laryngoscopy, can provide information that is useful in the diagnosis and management of vocal tract dysfunction. The Laryngograph and Computer-Aided Fluency Establishment Trainer, described here, are examples of this new technology.

Infratemporal fossa and lateral skull base dissection: long-term results

In 1981, we described a new surgical technique featuring en bloc removal of infratemporal fossa malignancies. This approach offered a systematic resection of cancers in this region and was designated "stylohamular dissection" because the medial boundary of the bloc is surgical plane between the styloid process and the hamulus of the pterygoid. All structures lateral to this plane are removed, sparing the internal carotid artery. Since 1977, twenty infratemporal fossa and lateral skull base dissections have been performed for palliation of metastatic or recurrent disease in the infratemporal fossa. Most patients obtained palliation of trismus, facial pain, or relief from an unmanageable ulcerating lesion. This technique offers improved average disease-free intervals, as well as enhanced survival rates compared to non-en bloc resections. A summary of the case presentations, survival statistics, and surgical technique with detailed cadaver dissections are presented.

Transplantation in HIV+ patients

Twenty-five whole-organ recipients treated from 1981 through September 1988 were HIV carriers. Eleven were infected before transplantation, although this was not known until later in 8 recipients. The other 14 were infected perioperatively. Ten of the 25 recipients were infants or children. The organs transplanted were the liver (n = 15), and the heart or kidney (n = 5, each). After a mean follow-up of 2.75 years (range, 0.7-6.6 years), 13 recipients are alive. Survival is 7/15, 2/5, and 4/5 of the liver, heart, and kidney recipients, respectively. The best results were in the pediatric group (70% survival) in which only 1 of 10 patients died of AIDS. In contrast, AIDS caused the death of 5 of 15 adult recipients and was the leading cause of death. Transplantation plus immunosuppression appeared to shorten the AIDS-free time in HIV+ patients as compared to nontransplant hemophiliac and transfusion control groups. Accrual of HIV+ transplant recipients has slowed markedly since the systematic screening of donors, recipients, and blood products was begun in 1985.

Correlation of high resolution computed tomography and gross anatomic sections of the temporal bone. Part III. Cochlear and vestibular aqueducts

Gross anatomic sections of isolated temporal bones (TB) were compared with high resolution computed tomography (CT) scans obtained utilizing contiguous 1.5-mm thick slices in the transaxial, coronal, and sagittal planes. Each TB was then sectioned at 2.0-mm intervals in planes parallel to those of the CT scans. Both the cochlear and vestibular aqueducts were best visualized in the coronal plane; the transaxial plane proved less reliable and the sagittal plane was not useful at all. The cochlear aqueduct in the coronal plane appears as a funnel-shaped configuration with its widest portion opening into the subarachnoid space. The vestibular aqueduct at its opening into the epidural space is well visualized in the coronal plane, and as it traverses the bone toward the vestibule it appears as an oval to spherical lucency, whereas in transaxial sections it is seen as a small longitudinal lucency.

The value of postoperative chest radiology after major abdominal surgery

A prospective study was carried out in which a chest radiograph was performed routinely on the third postoperative day on 35 consecutive patients who had elective abdominal surgery. The aim was to determine whether clinical symptoms and signs could be correlated with the radiographic appearances and whether the routine use of such an X ray could detect serious chest pathology before clinical signs developed. Thirteen patients (37%) had radiological evidence of complications and all had symptoms and (or) signs which suggested postoperative chest pathology. The 22 patients (63%) who had no radiological abnormality, could be subdivided clinically into those who were normal (29%) and those who had symptoms and (or) signs (34%). There was no significant difference between the groups in terms of previous surgery, sex, smoking, nature of surgical incision, age or duration of anaesthesia. There was a poor correlation between the diagnosis of the chest abnormality detected clinically and the diagnosis suggested by the radiographs. These findings suggest that a routine postoperative chest X ray is unnecessary in the absence of clinically detectable chest pathology.

Economics of health care: challenges for the immediate future

A number of widely held but largely false assumptions as to the nature of health and health care contributed to the very slow growth in the demand for health economics during the formative years of our health care system. A growing realisation, however, that hard rationing decisions are unavoidable has led to an increasing appreciation of the fact that policy makers and managers often lack the necessary basic information or the techniques relevant to the purpose. This paper proposes the formation of a centre for health economics and policy and outlines in broad terms its possible nature and research agenda.

Correlation of high-resolution computed tomography and gross anatomic sections of the temporal bone: II. Vestibular apparatus

High-resolution computed tomography (CT) of isolated temporal bones was performed in the transaxial, coronal, and sagittal planes at 1.5-mm intervals. The temporal bones were then sectioned at 2.0-mm intervals in planes parallel to the CT scans. The structures making up the vestibular apparatus were identified, and the planes in which each is best visualized were selected for the illustrations. The vestibule, oval window, tympanic cavity, and tympanic portion of the facial nerve are best seen in the transaxial and coronal planes; the arch of the superior semicircular canal in the transaxial plane and its limbs in the coronal plane; the arch of the posterior semicircular canal in the coronal and sagittal planes and its limbs in the transaxial plane; and the common crus in the sagittal plane. The horseshoe-shaped lateral semicircular canal is displayed in the transaxial plane, and the relationship of its lateral limb to the tympanic segment of the facial nerve is best demonstrated in the sagittal plane. The ampullae of all three canals can be appreciated equally well in all three planes.

Microsurgical anatomy of the jugular foramen region

The popularization of skull base approaches for lesions at the jugular foramen requires a thorough understanding of the normal anatomic features of this region. We present a series of color photographs with a review of the vital structures at the skull base in the region of the jugular foramen exposed via the infratemporal fossa approach. The jugular bulb and its relationship to the ninth, tenth, eleventh, and twelfth cranial nerves and to the internal carotid artery and otic capsule are demonstrated. All relationships are described in the lateral surgical position. The clinical usefulness of a thorough understanding of these anatomic associations is discussed.

Caries experience and sex related tea consumption amongst 13-14-year-old children in Palmyra, Syrian Arab Republic

Associations were examined between caries experience and the volume of tea consumed/day by schoolchildren in Palmyra, Syria. Girls had significantly high DMFT scores and consumed less tea than boys.

Correlation of high-resolution computed tomography and gross anatomic sections of the temporal bone: Part I. The facial nerve

Detailed anatomic analysis of the human temporal bone has been made possible by correlating high-resolution computed tomography (CT) with gross anatomic sections. Serial CT scans of isolated temporal bones were obtained in the transaxial (horizontal), coronal, and sagittal planes at 1.5-mm intervals. The temporal bone was sectioned at 2.0-mm intervals in planes parallel to the CT scans. Based on a correlation of these sections, the facial nerve canal was divided into four segments and the planes in which each is best observed are described and illustrated. The first segment in the internal auditory canal is best visualized in the sagittal plane, the labyrinthine segment and geniculate ganglion in the coronal and transaxial planes, the tympanic portion in the sagittal plane, the genu, between the tympanic and mastoid portion, in the sagittal plane, and the mastoid portion and the stylomastoid foramen in the coronal and sagittal planes.

Clinical appearance of permanent successors after nonextraction treatment of grossly carious primary molars in highly anxious children

After taking into account the local constraints, a treatment plan was devised to introduce children to dental procedures in gradual stages. An alternative nonextraction approach was adopted. Children between the ages of five and ten years were chosen for the acclimatization program; and 65 percent of their permanent successors to treated primary molars showed no defects.

Preservation of the dissected and surgical anatomic detail in the human temporal bone

Preservation and usefulness of human gross temporal bones that have been dissected or drilled have always been a problem. This article describes application of the technique of plastination developed by von Hagens to the temporal bone. The use of this technique permits development of a collection of both anatomically dissected and surgically drilled temporal bones which can be studied by the otolaryngologist at any level. The procedure involves impregnation of the specimen with uncured polymers--a silicone rubber of medium viscosity followed by curing in a vapor bath. The advantages of this technique are that the plastinated temporal bone can be studied and handled without any unpleasant odor and there is no need for liquid preservation. The potential problem of the specimen drying out and becoming useless is thus avoided.

Sphenoethmoidectomy: the case for ethmoid marsupialization

The authors report 510 sphenoethmoidectomies performed on 255 patients between 1969 and 1985. An overall polyp recurrence rate of 19.2% and less than a 1% complication rate are reported during that time. In patients followed jointly by the otolaryngologists and allergist, including 374 consecutive sphenoethmoidectomies on 187 patients who had this operation performed by the senior author, there was an overall polyp recurrence rate of 15% and a complication rate which was again less than 1%. Recent improvements in recurrence rates and diminished complication rates are attributed to better visualization and adherence to the concept of complete exenteration or marsupialization of the ethmoid labyrinth including middle turbinate resection in every case. Cooperation between the otolaryngologist and allergist is stressed, along with the realization that pulmonary and sinus diseases are frequently interrelated and may both be benefited by the performance of sphenoethmoidectomy in the patient with hyperplastic rhinosinusitis.

Immediate and delayed effects of an enzyme-dependent mineralizing mouthrinse on dental plaque

Twenty-two children aged 13 to 14 years rinsed for 3 X 1 min periods with a supersaturated calcium phosphate solution containing urea and monofluorophosphate. Plaque sampled one min after the last rinse showed a marked increase in water-extractable F and a smaller increase in Ca but no increase in water-extractable P. Water-insoluble forms of all three ions were elevated, however. The mean plaque pH was 8.28. Plaque sampled 24 hr after the last rinse showed significant increases in water-insoluble F and Ca only, and no increase in pH. The prompt pH rise and disappearance of water-soluble P suggest that, on exposure to the mineralizing solution, urea and monofluorophosphate are rapidly hydrolyzed by plaque enzymes to provide catabolites which cause the immediate precipitation of fluoridated calcium phosphate.

Increases in fluoride, calcium, and phosphate in dental plaque resulting from the use of a mineralizing mouthrinse containing urea and monofluorophosphate

A mouthrinse used ten times over a four-day period increased the concentration of acid-extractable fluoride in immature plaque by 320%, calcium by 190%, and phosphate by 97%. Corresponding increases in mature plaque were smaller, yet significant. Diffusion of the ions from plaque was restricted, and hence a prolonged caries-inhibitory effect can be expected.

Caries progression in primary molars: 24-month results from a minimal treatment programme

A 2-stage topical treatment regimen (AgF followed by SnF2) was used in an attempt to limit caries progression in the primary molars of children participating in a minimal treatment programme. The children lived in an isolated community in western New South Wales (fluoride in water less than 0.2 parts/10(6)) and were from a low socioeconomic background. The progression, over a 24-month period, of 281 established lesions in the approximal and occlusal surfaces of primary molars in 54 subjects (mean age 7.0 years) was determined from bitewing radiographs. Of the lesions studied, the majority (69%) were in dentine at baseline. At 24 months, 74% of the approximal surface lesions and 90% of the occlusal surface lesions that were in enamel at baseline remained unchanged. The greatest change occurred in the approximal surface lesions that were within 1 mm of the pulp at baseline. Only 35% of the lesions required any treatment other than topical metal fluoride therapy during the 24-month period.

Contralateral laryngoplasty after supraglottic laryngectomy with vertical extension

Eight patients with supraglottic carcinoma extending onto an arytenoid or true vocal cord have undergone supraglottic laryngectomy with vertical extension including the resection of an arytenoid. In these patients, the contralateral superior thyroid cornua was used to reconstruct the resulting defect. In this technique, the thyroid cornua is mobilized and green-stick fractured across the posterior commissure, maintaining its blood supply by leaving the inferior and middle pharyngeal constrictor attached. This muscle-cartilage pedicle flap provides bulk for the posterior glottis and can be anchored anteriorly to form the framework for a new vocal cord. Hypopharyngeal and pyriform sinus mucosa is then mobilized to cover the newly reconstructed hemilarynx. This reconstruction has provided a competent glottis with a good vocal baffle in every patient in this series. Preservation of airway, voice, and laryngeal sphincter is comparable with that achieved after routine supraglottic laryngectomy without resection of an arytenoid. Using this technique, the surgeon can rely on a pedicle graft with surprising accessibility, bulk, and reach.