A comparison of the Charlson comorbidity index derived from medical record data and administrative billing data

The objective of this article is to compare the Charlson comorbidity index derived from medical record data (Chart Index) with the same index derived from billing data (ICD-9 Index) to determine how well each predicted inpatient and 30-day mortality, length of stay, and complications among Medicare beneficiaries hospitalized for carotid endarterectomy. Economic and time constraints have increased the need for risk adjusters derived from administrative data, yet few studies have compared these measures with those derived from chart review. Using logistic regression, the Chart Index was found to be a significant predictor of inpatient mortality, 30-day mortality, length of stay, and complications, after controlling for age, gender, and neurologic and medical risk factors (P values = 0.004, 0.056, 0.0001, and 0.042, respectively). The ICD-9 Index approached significance as a predictor of the outcomes (P values = 0.092, 0.100, 0.093, and 0.080, respectively). The Chart Index was shown to be superior to the ICD-9 Index within this patient sample.

Early detection and treatment of renal disease in hospitalized diabetic and hypertensive patients: important differences between practice and published guidelines

This study was performed to ascertain the degree to which the care of hospitalized diabetic and hypertensive patients conforms to published guidelines for the detection and management of early renal disease. It was designed as a retrospective chart audit. Six hospitals, four nonurban referral centers, and two urban teaching institutions provided the data. Patients were a random sample of Medicare beneficiaries, with a mean age (SD) of 65.6 (9.1) years, admitted during 1994 with a primary or secondary diagnosis of either diabetes (n = 260) or hypertension (n = 327). A urinalysis was obtained for 163 (62.7%) of the diabetic patients. Among diabetics who had their urine tested, 31.3% had 1+ or greater dipstick proteinuria. A serum creatinine was obtained for 298 (91%) of the hypertensive patients, and 11.8% had a value of 1.5 mg/dL or greater. Abnormal renal function tests were recorded in the discharge summaries of 7.8% of the diabetic and 11.4% of the hypertensive patients. Patients with abnormal renal function were no more likely to be treated with angiotensin-converting enzyme inhibitors (ACEIs). Nonsteroidal antiinflammatory drugs (NSAIDs) were prescribed for 6% of diabetic and 8.8% of hypertensive patients with abnormal renal function at discharge. Despite the high prevalence of renal functional abnormalities detected by routine laboratory tests administered to elderly hospitalized diabetic and hypertensive patients, the medical records of these patients did not document awareness or appropriate management of the potential underlying kidney disease.

Process of care and outcomes for elderly patients hospitalized with peptic ulcer disease: results from a quality improvement project

CONTEXT

Since publication in 1994 of guidelines for management of peptic ulcer disease (PUD), trends in physician practice and outcomes related to guideline application have not been evaluated.

OBJECTIVES

To describe changes in process of care that occurred in a quality improvement program for patients hospitalized with PUD and to evaluate associations between in-hospital treatment of PUD and 1-year rehospitalization for PUD and mortality in a subset of these patients.

DESIGN, SETTING, AND PATIENTS

Cohort study of 4292 sequential Medicare beneficiaries hospitalized at acute care hospitals with a principal diagnosis of PUD in 5 states (Colorado, Georgia, Connecticut, Oklahoma, and Virginia) in 1995 (baseline) and 1997 (remeasurement); outcomes were evaluated for 752 patients in Colorado.

MAIN OUTCOME MEASURES

Changes in rates of screening for Helicobacter pylori infection, treatment for H pylori infection, screening for nonsteroidal anti-inflammatory drug (NSAID) use, counseling about NSAID use; outcomes included rehospitalization for PUD and all-cause mortality within 1 year of discharge in Colorado.

RESULTS

Screening for H pylori infection increased significantly (12%-19% increase; P<.001) in each of the 5 states. Treatment of H pylori infection increased in each state and was significantly increased for the entire group of hospitalizations examined (8% increase overall; P =.001). Despite increased screening, detection of H pylori infection was less frequent than expected in every state, (13%-24%) and did not increase in any state. Screening for and counseling about NSAIDs did not significantly increase overall or in any state. In the Colorado cohort, the proportion of patients rehospitalized was unchanged in 1995 (8.9%) and 1997 (6.8%), and 124 patients (16%) in the combined 1995 and 1997 cohorts died within 1 year. Treatment for H pylori was not associated with a reduction in rehospitalization within 1 year (adjusted odds ratio [OR], 1.24; 95% confidence interval [CI], 0.65-2.36) or with a reduction in mortality (adjusted OR, 1.08; 95% CI, 0.68-1.71). Counseling about NSAID use was associated with a decrease in risk of 1-year rehospitalization for PUD (adjusted OR, 0.47; 95% CI, 0.22-0.99) and risk of all-cause mortality (adjusted OR, 0.44; 95% CI, 0.26-0.75).

CONCLUSIONS

This quality improvement program for elderly patients with PUD resulted in increased screening for H pylori and increased treatment of H pylori infection but no change in counseling about NSAID use. However, with the low prevalence of H pylori detected, treatment of H pylori infection was not associated with a reduction in repeat hospitalization for PUD or subsequent mortality, whereas counseling about the risks of using NSAIDs was associated with a reduction in the risk of both outcomes.

Sugar repression in the methylotrophic yeast Hansenula polymorpha studied by using hexokinase-negative, glucokinase-negative and double kinase-negative mutants

Two glucose-phosphorylating enzymes, a hexokinase phosphorylating both glucose and fructose, and a glucose-specific glucokinase were electrophoretically separated in the methylotrophic yeast Hansenula polymorpha. Hexokinase-negative, glucokinase-negative and double kinase-negative mutants were isolated in H. polymorpha by using mutagenesis, selection and genetic crosses. Regulation of synthesis of the sugar-repressed alcohol oxidase, catalase and maltase was studied in different hexose kinase mutants. In the wild type and in mutants possessing either hexokinase or glucokinase, glucose repressed the synthesis of maltase, alcohol oxidase and catalase. Glucose repression of alcohol oxidase and catalase was abolished in mutants lacking both glucose-phosphorylating enzymes (i.e. in double kinase-negative mutants). Thus, glucose repression in H. polymorpha cells requires a glucose-phosphorylating enzyme, either hexokinase or glucokinase. The presence of fructose-phosphorylating hexokinase in the cell was specifically needed for fructose repression of alcohol oxidase, catalase and maltase. Hence, glucose or fructose has to be phosphorylated in order to cause repression of the synthesis of these enzymes in H. polymorpha suggesting that sugar repression in this yeast therefore relies on the catalytic activity of hexose kinases.

Case report. Combined adrenal adenoma and myelolipoma

A case of both adrenal myelolipoma and adenoma is presented. The diagnosis of myelolipoma was suggested preoperatively by computed tomography in which one of the masses had negative attenuation coefficients.

Glucose transport in a methylotrophic yeast Hansenula polymorpha

Glucose transport was studied in a methylotrophic yeast Hansenula polymorpha. Two kinetically different glucose transport systems were revealed in cells grown under different growth conditions. Glucose-repressed cells exhibited a low-affinity transport system (Km for glucose 1.75 mM) while glucose-derepressed and ethanol-grown cells had a high-affinity transport system (Km for glucose 0.05-0.06 mM). The high- and low-affinity transport systems differed in substrate specificity, sensitivity to pH, dinitrophenol and protonophore carbonyl cyanide-m-chlorophenyl-hydrazone. The kinetic rearrangement of the glucose transport system in response to altered growth conditions was dependent on de novo protein synthesis.

Head progression distance during the first stage of labor as a predictor for delivery outcome

Objectives: To assess if measurement of the head progression distance (PD) during the first stage of labor in nulliparous women can predict the delivery method.Methods: A prospective study was conducted on consecutive nulliparous women beyond 37 week's gestation during the first stage of labor. Transperineal ultrasound was performed to assess the PD. Analysis was performed on the relationships between PD during rest and during voluntary pushing and the fetal and maternal characteristics, delivery mode, and immediate postnatal outcomes.Results: Eighty seven suitable nulliparous women were suitable for analysis. PD was found to be significantly longer in women who delivered vaginally (VD) compared to those who underwent a cesarean section (CS) for obstructed labor: PD at rest was 2.51 ± 1.71 cm in women who delivered vaginally compared to 1.48 ± 1.9 cm in women who delivered by CS (p = .01). The PD during pushing was 3.43 ± 1.8 cm for a VD compared to 1.5 ± 2.1 cm for CS (p = .015). Logistic regression and receiver-operating characteristics curve analysis demonstrated a moderate predictive value of PD with respect to the mode of delivery (area under the curve was 0.67 during both resting and pushing period).Conclusion: PD measurements during the first stage of labor among nulliparous women differ significantly both in rest and during pushing between patients who delivered vaginally compared to CS and can therefore assist in predicting the mode of delivery.

Breast cancer fear in girls: a major “side effect” of breast cancer in loved ones and a backlash of ubiquitous media coverage

Abstract #5078

Background: Breast cancer significantly impacts girls' lives: it affects 1:8 women and directly impacts those most influential in girls' lives (e.g. mothers, friends' mothers, teachers, coaches). Plus, girls are often exposed to powerful media messages meant to raise breast cancer awareness. Our hypothesis is that these factors could generate significant fear and misunderstanding in adolescent and pre-adolescent girls.&#x2028; Methods: To better understand the impact of breast cancer fear in girls, the nonprofit organization Breastcancer.org and the Taking Care of Your “Girls” book project, together with the Lankenau Hospital Health Education Center, conducted an in-school online survey in girls ages 8 to 18 years (median 15), prior to the delivery of a Breast Health Assembly in 7 Philadelphia and Atlanta areas schools. 2450 girls attended the assemblies, of which 1709 participated in the survey (about 70% question completion rate).&#x2028; Results: In total, 73% of girls had a relative or close acquaintance who had had breast cancer (most often: a friend's mother [49% n=580/1201]). Although only 3.34% (n=40/1196) of girls' mothers had had breast cancer, girls were most fearful of breast cancer affecting their mothers. While only 46% (n=768/1573) thought breast cancer was common in grandmothers, 76% (n=1192/1572) reported it was most common in mothers. Although only 3.35 % (n=53/1580) believed that breast cancer was common in teens, 26% (477/1554) said that they've already feared having breast cancer themselves. The most common triggers for this fear were a misinterpretation of a normal breast finding, a news report on breast cancer, or a new breast cancer diagnosis in someone they knew. Over 20% believed that infection, drug use, stress, and tanning could cause breast cancer; and 10-20% reported their belief that caffeine, getting bumped or bruised in the breast, and antiperspirants could cause it. In addition, 8.5% thought that breast-feeding increased breast cancer risk.&#x2028; Discussion: 73% of the girls in this study have one or more women close to them who've had breast cancer and all girls are sensitive to the media. These factors seem to contribute to their fear of the disease and their tendency to overestimate breast cancer risk (in themselves and their mothers). Furthermore, they were un- or misinformed about true breast cancer risk factors and effective breast health measures. The impact of a girl's unrealistic fear of breast cancer is unknown. We are concerned that it may deter rather than motivate healthy behaviors. Breast health programs are necessary to replace fear and inaccurate information with facts and reassurance. These results might be useful in the design of education and intervention strategies to improve psychological wellbeing and the achievement of long-term public health goals.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5078.

What Do Obstetricians Really Think about Ultrasound in the Delivery Room?

BACKGROUND

In recent years, the role of intrapartum sonography has expanded in childbirth management, in subjective clinical situations such as arrested deliveries, or prior to instrumental deliveries.

OBJECTIVES

To assess the current use of intrapartum ultrasound by obstetricians in Israel.

METHODS

An anonymous questionnaire was completed by 79 obstetricians in second- and third level- hospitals in Israel. The results were analyzed according to main subspecialty (sonography, delivery), experience and gender.

RESULTS

A questionnaire was completed by 56 senior obstetricians and 23 interns with an average experience of 14.3 and 2.4 years, respectively. All obstetricians performed ultrasound examinations in the delivery room for basic indications such as fetal presentation during twin delivery and to rule out placenta previa. Sonographers consistently reported advanced indications as compared to senior members of delivery teams and interns in the assessment of prolonged first (52% vs. 14% vs. 14%) and second stage of labor (88% vs. 52% vs. 62%) and in assessment of fetal head station (60% vs. 30% vs. 22%), head progression during descent (48% vs. 23% vs. 11%), diagnosis of head position (88% vs. 68% vs. 60%), spine direction (92% vs. 59% vs. 53%) and asynclytism (41% vs. 20% vs. 29%).

CONCLUSIONS

Ultrasound is currently used by all physicians in the delivery room for basic indications. However, obstetric teams report a low use of advanced intrapartum ultrasound and prefer to rely on their clinical experience. Advanced intrapartum sonographic imaging should be an integral part of obstetric qualifications. A steep learning curve, along with high reproducibility, suggests that ultrasound devices will become a common tool in labor and delivery management.

0978 Snoo: A Wellness Device To Improve Infant Sleep

Introduction

One of the primary contributors to new parent sleep deprivation is infant sleep disturbances. Evidence shows that increasing sleep in infants has a positive effect on parental sleep. SNOO, a wellness device, was developed to provide sleeping babies 3 of the 5 S’s (safe swaddling, sound and swinging) in a response fashion (increasing levels of motion and white noise if babies cry) to soothe crying and improve infant sleep.

Methods

The current study compares infant sleep derived from SNOO to a reference group of a compilation of 13 peer reviewed studies of normative sleep data on sleep in traditional cribs/bassinets. Participants were 7157 babies using SNOO beginning within one week of birth and for at least 6 hours per night for 6 months. Sleep metrics calculated on a day to day basis include Longest Sleep Period: Maximum uninterrupted sleep at night (7 PM - 7 AM); Total Sleep Duration: Total time spent sleeping at night (7 PM - 7 AM); and Night Awakenings: Number of times parents attended to the baby (10 PM - 6 AM).

Results

Improvement in the longest sleep duration varied with age. Across the 6 month collection period, longest sleep period increased between 42 minutes - 2 hours 0 minutes and total sleep duration increased between 33 minutes - 1 hour 24 minutes. Babies in SNOO averaged one less waking per night compared to the reference population (1.09±.89 vs 1.89 ±1.1). The improvements in all three sleep metrics were statistically significant with p’s &lt; 0.0005 across all ages from birth to 6 months.

Conclusion

This large-scale study suggests that infant sleep can be significantly improved by using SNOO compared to babies who slept in normal cribs or bassinets. We believe there are myriad areas of public health that may be positively impacted as a result of this significant level of improvement of infant sleep.

Support

Happiest Baby, Inc.

Attitudes and Concerns of Pre-Pubescent and Pubescent Girls about Breast Health and Breast Cancer: An Unmet Need

Background: Prior research has indicated that girls have unaddressed fears about breast health and breast cancer. In a Breastcancer.org online survey (SABCS 2008 Abstract#5078), 26% of girls have already worried they may have breast cancer and 73% reported that a relative or close acquaintance had already been diagnosed. Their fears are magnified by the current trend of early onset of breast development and their sensitivity to high media coverage of breast cancer. We hypothesize that girls have limited opportunities and are without the emotional capacity and communication skills necessary to gather and process this information at home, in school, and in the doctor's office.Methods: Breastcancer.org, the Taking Care of Your “Girls” book project, and the Lankenau Hospital Health Education Center conducted an online survey of girls in middle and high schools prior to the delivery of its in-school Basic Breast Health Assembly Program in 13 Philadelphia, Atlanta, Washington, and Los Angeles area schools. 4246 girls attended an assembly, of which 3397 participated in the student survey. 1067 adult female family members (AFFM)—mostly mothers—completed the family member survey.Results: In total, 33% of girls had already learned about breast health and breast cancer in school. 48% of girls wanted to attend the Assembly Program; 93% of AFFMs wanted their girls to participate in the Assembly Program. 50% of girls said they felt uneasy starting the conversation about these topics with their AFFM, 97% of AFFMs said they felt comfortable starting the conversation with their girls, but only 43% of the girls report having the conversation. Of the girls who talked to a parent, 91% talked to their mothers and only 1% talked with their fathers. Girls and AFFMs offered many tips on how to start and sustain a healthy dialogue on these topics: listen, be open, make it fun, pick a private place and time, share experiences, provide facts, and call in experts when you need more information.42%, 18%, and 23% of girls, respectively, have talked to a doctor, sister, or friend about these topics. 50% of girls want to learn breast self-exams from their doctors.Discussion: This survey indicates that girls have unmet informational needs on breast health and breast cancer. This was a source of anxiety for both girls and their AFFMs. There was a willingness to engage in educational activities by both girls and AFFMs, but the dialogue opportunities and communication skills were seen as lacking. Girls identified AFFMs, schools, and doctors as their preferred sources of this information.Girls' ability to express their anxiety, replace fears with facts, learn breast healthy behaviors, and deal with a loved ones' diagnosis requires education, modeling, and an ongoing dialogue. This survey provides guidance for educators and healthcare professionals regarding research into interventions seeking to correct this previously underappreciated gap in public health education.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1037.