Treatment rates and healthcare costs of patients with fragility fracture by site of care: a real-world data analysis

In a characterization of treatment rates and healthcare costs among patients with an osteoporotic-related fragility fracture overall and by site of care, costs were high and treatment rates were low.

PURPOSE

Osteoporotic fractures can be debilitating, even fatal, among older adults. The cost of osteoporosis and related fractures is projected to increase to more than $25 billion by 2025. The objective of this analysis is to characterize disease-related treatment rates and healthcare costs of patients with an osteoporotic fragility fracture overall and by site of fracture diagnosis.

METHODS

In this retrospective analysis, individuals with fragility fractures were identified in the Merative MarketScan® Commercial and Medicare Databases among women 50 years of age or older and diagnosed with fragility fracture between 1/1/2013 and 6/30/2018 (earliest fracture diagnosis = index). Cohorts were categorized by clinical site of care where the diagnosis of fragility fracture was made and were continuously followed for 12 months prior to and following index. Sites of care were inpatient admission, outpatient office, outpatient hospital, emergency room hospital, and urgent care.

RESULTS

Of the 108,965 eligible patients with fragility fracture (mean age 68.8), most were diagnosed during an inpatient admission or outpatient office visit (42.7%, 31.9%). The mean annual healthcare costs among patients with fragility fracture were $44,311 (± $67,427) and were highest for those diagnosed in an inpatient setting ($71,561 ± $84,072). Compared with other sites of care at fracture diagnosis, patients diagnosed during an inpatient admission also had highest proportion of subsequent fractures (33.2%), osteoporosis diagnosis (27.7%), and osteoporosis therapy (17.2%) during follow-up.

CONCLUSION

The site of care for diagnosis of fragility fracture affects treatment rates and healthcare costs. Further studies are needed to determine how attitude or knowledge about osteoporosis treatment or healthcare experiences differ at various clinical sites of care in the medical management of osteoporosis.

Hormone therapy for postmenopausal osteoporosis management

Menopausal hormone therapy (MHT) has been used for prevention and treatment of postmenopausal osteoporosis for several decades. However, public concerns were raised over the safety of MHT after the initial report was published in 2002 by the Women's Health Initiative. We conducted a historical review on this subject, primarily focusing on level I evidence from randomized controlled trials, systematic reviews and meta-analyses, and summarized high-quality evidence on the efficacy and safety of MHT in management of postmenopausal osteoporosis. Clinical issues were also discussed on MHT initiation, identification of treatment candidates and treatment duration, as well as discontinuation of MHT.

Uterine bleeding with hormone therapies in menopausal women: a systematic review

Uterine bleeding is a common reason why women discontinue menopausal hormone therapy (HT). This systematic review compared bleeding profiles reported in studies for continuous-combined HT approved in North America and Europe for moderate to severe vasomotor symptoms in postmenopausal women with a uterus. Non-head-to-head studies showed that uterine bleeding varies by formulation and administration route, with oral having a better bleeding profile than transdermal formulations. Cumulative amenorrhea over a year ranged from 18 to 61% with oral HT and from 9 to 27% with transdermal HT, as reported for continuous-combined HT containing 17β-estradiol (E2)/progesterone (P4) (56%), E2/norethisterone acetate (NETA) (49%), E2/drospirenone (45%), conjugated equine estrogens/medroxyprogesterone acetate (18-54%), ethinyl estradiol/NETA (31-61%), E2/levonorgestrel patch (16%), and E2/NETA patch (9-27%). Amenorrhea rates and the mean number of bleeding/spotting days improved over time. The oral E2/P4 combination was amongst those with lower bleeding rates and may be an appropriate alternative for millions of women seeking bioidentical HT and/or those who have bleeding concerns with other HT.

Treatment of moderate to severe dyspareunia with intravaginal prasterone therapy: a review

The loss of sex steroids (e.g. estradiol, dehydroepiandrosterone [DHEA], progesterone) that causes menopause commonly affects a woman's general health and produces bothersome physical changes that may interfere with normal sexual and genitourinary functioning. Although both over-the-counter and prescription treatments are available, there remains a large unmet need, as less than 10% of women are treated. Adrenal DHEA and its sulfate are the most abundant steroids in humans. Here we review the development of intravaginal prasterone, the synthetic equivalent to endogenous DHEA. Prasterone is approved by the US Food and Drug Administration for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. Prasterone has been shown to decrease the pain associated with dyspareunia, and to improve vaginal pH, as well as superficial and parabasal cell counts, while maintaining serum hormone levels within the range of those seen in normal postmenopausal women. Unlike other menopausal prescription therapies, intravaginal prasterone does not carry a boxed warning, thus allowing the clinician and patient to engage in meaningful and reassuring discussion around a new approach that treats this common, debilitating condition.

Estrogen therapy for osteoporosis in the modern era

Menopause predisposes women to osteoporosis due to declining estrogen levels. This results in a decrease in bone mineral density (BMD) and an increase in fractures. Osteoporotic fractures lead to substantial morbidity and mortality, and are considered one of the largest public health priorities by the World Health Organization (WHO). It is therefore essential for menopausal women to receive appropriate guidance for the prevention and management of osteoporosis. The Women's Health Initiative (WHI) randomized controlled trial first proved hormonal therapy (HT) reduces the incidence of all osteoporosis-related fractures in postmenopausal women. However, the study concluded that the adverse effects outweighed the potential benefits on bone, leading to a significant decrease in HT use for menopausal symptoms. Additionally, HT was not used as first-line therapy for osteoporosis and fractures. Subsequent studies have challenged these initial conclusions and have shown significant efficacy of HT in various doses, durations, regimens, and routes of administration. These studies support that HT improves BMD and reduces fracture risk in women with and without osteoporosis. Furthermore, the studies suggest that low-dose and transdermal HT are less likely associated with the adverse effects of breast cancer, endometrial hyperplasia, coronary artery disease (CAD), and venous thromboembolism (VTE) previously observed in standard-dose oral HT regimens. Given the need for estrogen in menopausal women and evidence supporting the cost effectiveness, safety, and efficacy of HT, we propose that HT should be considered for the primary prevention and treatment of osteoporosis in appropriate candidates. HT should be individualized and the once "lowest dose for shortest period of time" concept should no longer be used. This review will focus on the prior and current studies for various HT formulations used for the prevention and treatment of osteoporosis, exploring the safety profile of low-dose and transdermal HT that have been shown to be safer than oral standard-dose HT.

Hypothalamic and basal ganglia projections to the posterior thalamus: possible role in modulation of migraine headache and photophobia

Migraine attacks are typically described as unilateral, throbbing pain that is usually accompanied by nausea, vomiting, and exaggerated sensitivities to light, noise and smell. The headache phase of a migraine attack is mediated by activation of the trigeminovascular pathway; a nociceptive pathway that originates in the meninges and carries pain signals through meningeal nociceptors to the spinal trigeminal nucleus and from there to the cortex through relay neurons in the thalamus. Recent studies in our lab have identified a population of trigeminovascular neurons in the posterior (Po) and lateral posterior (LP) thalamic nuclei that may be involved in the perception of whole-body allodynia (abnormal skin sensitivity) and photophobia (abnormal sensitivity to light) during migraine. The purpose of the current study was to identify sub-cortical areas that are in position to directly regulate the activity of these thalamic trigeminovascular neurons. Such process begins with anatomical mapping of neuronal projections to the posterior thalamus of the rat by performing discrete injections of the retrograde tracer Fluorogold into the Po/LP region. Such injections yielded retrogradely labeled neurons in the nucleus of the diagonal band of Broca, the dopaminergic cells group A11/A13, the ventromedial and ventral tuberomammillary nuclei of the hypothalamus. We also found that some of these neurons contain acetylcholine, dopamine, cholecystokinin and histamine, respectively. Accordingly, we speculate that these forebrain/hypothalamic projections to Po and LP may play a role in those migraine attacks triggered by disrupted sleep, skipping meals and emotional reactions.

Osteoporosis management in post-menopausal women

Osteoporosis is most prevalent in women over the age of 50 as the hormonal influence of estrogen on bone health dissipates with the onset of menopause. The progressive changes in bone structure, quality and density lead to pathological fractures and an increase in morbidity and mortality among menopausal women. This review will examine the 2010 North American Menopause Society (NAMS) position statement and other recent publications to summarize the data and combinations of therapies used to treat women 50 years or older with osteoporosis. To review the latest research and guidelines for osteoporosis management we performed a PubMed search using the parameters Linked to free full text, Humans, Female, Review, English, Middle Age (45-64 years and 45+ years), Age 65+ years, and published in the last five years. Articles were sorted by relevance and hand searching of these articles was done to further increase the yield. While a perfect treatment has yet to be discovered to completely cure this progressive disease, many breakthroughs have been made in order to prevent fractures and improve quality of life. Calcium and vitamin D supplementation are recommended for patients undergoing pharmacological treatment, however, trials looking at their effectiveness have mixed findings. Bisphosphonates are considered the first line therapy in the treatment of osteoporosis and reduce vertebral fractures by 40% to 70% and non-vertebral fractures by 20% to 35%. Calcitonin showed promise during early trials in 2000 with a 33% reduction in fractures but these results have not been replicated and this therapy is now relegated to a second line treatment. Teriparatide is recommended for patients with severe osteoporosis and has been shown to reduce vertebral fractures 65% and non-vertebral fractures 53%. Selective estrogen receptor modulators (SERMs) are another useful therapy resulting in a 55% reduction in vertebral fractures without any documented advantage when looking at non-vertebral fractures. The currently available SERMs for this indication include raloxifene, available in the USA, and bazedoxifene, in Europe. Estrogen is effective, with a 27% reduction in fractures, but often is reserved for concomitant use for other menopausal symptoms or in patients intolerant of other available osteoporosis therapies. The newly approved monoclonal antibody for osteoporosis treatment in postmenopausal women, denosumab, leads to a 68% and 19% reduction of vertebral and non-vertebral fractures, respectively. In conclusion, the 2010 NAMS position statement provides an excellent framework to discuss treatment options with patients. Lifestyle optimization should be the bedrock of any good treatment approach. When pharmacological intervention is warranted, many good therapies are available which have been shown to reduce the risk of fractures in osteoporotic patients. Any treatment plan, however, will be ineffective if the patient is not compliant. Therefore, a detailed discussion regarding each therapeutic intervention should ensue, including its usefulness and side effects.

Opsonization effects on Mycobacterium avium subsp. paratuberculosis--macrophage interactions

High antibody titers in ruminants infected with Mycobacterium avium subsp. paratuberculosis correlates with disease progression. Effects of humoral responses during mycobacterial infection are not completely understood. This study suggests that activation status may be an important factor in determining macrophage ability to limit proliferation of opsonized M. avium subsp. paratuberculosis.

Evidence for direct CP violation in B0-->K+pi- decays

We report evidence for direct CP violation in the decay B0-->K+pi(-) with 253 fb(-1) of data collected with the Belle detector at the KEKB e(+)e(-) collider. Using 275x10(6) BB pairs we observe a B-->K+/-pi(-/+) signal with 2140+/-53 events. The measured CP violating asymmetry is A(CP)(K+pi(-))=-0.101+/-0.025(stat)+/-0.005(syst), corresponding to a significance of 3.9sigma including systematics. We also search for CP violation in the decays B+-->K+pi(0) and B+-->pi(+)pi(0). The measured CP violating asymmetries are A(CP)(K+pi(0))=0.04+/-0.05(stat)+/-0.02(syst) and A(CP)(pi(+)pi(0))=-0.02+/-0.10(stat)+/-0.01(syst), corresponding to the intervals -0.05<A(CP)(K+pi(0))<0.13 and -0.18<A(CP)(pi(+)pi(0))<0.14 at 90% confidence level.

Observation of B+-->psi(3770)K+

We report the first observation of the decay B+-->psi(3770)K+ where the psi(3770) is reconstructed in the D0(-)D(0) and D+D- decay channels. The obtained branching fraction is B(B+-->psi(3770)K+)=(0.48+/-0.11+/-0.07)x10(-3). We have measured the branching fraction for the decay B+-->D0(-)D0K+ to be (1.17+/-0.21+/-0.15)x10(-3) and set a 90% confidence level upper limit of 0.90 x 10(-3) for the decay B+-->D+D-K+. We also present the results of a search for possible decays to D(-)D and D0(-)D(0)pi(0) of the recently observed X(3872) particle. The analysis is based on 88 fb(-1) of data collected at the Upsilon(4S) resonance by the Belle detector at the KEKB asymmetric-energy e(+)e(-) collider.

Serial Measurements Increase the Accuracy of Laser Doppler Assessment of Burn Wounds

Traditional methods of judging burn depth by clinical evaluation of the wound based on appearance and sensation remain in wide use but are subject to individual variation by examiner. In addition to the clinical difficulties with burn wound management, observer dependency of wound assessment complicates clinical trials of burn wound therapy. A laser Doppler flowmeter with a multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. Serial measurement with laser Doppler flowmetry had an 88% specificity and a positive predictive value of 81% for identifying nonhealing wounds. These results suggest that laser Doppler flowmetry is a potentially useful tool for burn wound assessment.

Observation of B+ --> chi(c0)K+

Using a sample of 31.3x10(6) BB pairs collected with the Belle detector at the Upsilon(4S) resonance, we make the first observation of the charged B meson decay to chi(c0) and a charged kaon. The measured branching fraction is B(B+-->chi(c0)K+) = (6.0(+2.1)(-1.8)+/-1.1)x10(-4), where the first error is statistical, and the second is systematic.

Observation of B --> J/psi K(1)(1270)

We report the first observation of the exclusive decay process B-->J/psi K(1)(1270) using a sample of 11.2M BB macro meson pairs collected in the Belle detector at the KEKB asymmetric energy e(+)e(-) collider. We measure branching fractions of B[B(0)-->J/psi K(0)(1)(1270)] = (1.30+/-0.34+/-0.32) x 10(-3) and B[B(+)-->J/psi K(+)(1)(1270)] = (1.80+/-0.34+/-0.39) x 10(-3), where the first error is statistical and the second is systematic. These modes constitute approximately 15% of the total number of B-->J/psi X decays. No evidence is seen for B-->J/psi K(1)(1400) and we set an upper limit for this branching fraction.

Observation of Cabibbo suppressed B --> D(*)K- decays at Belle

We report observations of the Cabibbo suppressed decays B-->D((*))K- using a 10.4 fb(-1) data sample accumulated at the Upsilon(4S) resonance with the Belle detector at the KEKB e(+)e(-) storage ring. We find that the ratios of Cabibbo suppressed to Cabibbo favored branching fractions are B(B--->D0K-)/B(B--->D0pi(-)) = 0.079+/-0.009+/-0.006, B(B(0)-->D+K-)/B(B(0)-->D+pi(-)) = 0.068+/-0.015+/-0.007, B(B--->D(*0)K-)/B(B--->D(*0)pi(-)) = 0.078+/-0.019+/-0.009, and B(B(0)-->D(*+)K-)/B(B(0)-->D(*+)pi(-)) = 0.074+/-0.015+/-0.006. These are the first observations of the B-->D+K-, D(*0)K-, and D(*+)K- decay processes.

Observation of large CP violation in the neutral B meson system

We present a measurement of the standard model CP violation parameter sin2 phi(1) based on a 29.1 fb(-1) data sample collected at the Upsilon(4S) resonance with the Belle detector at the KEKB asymmetric-energy e(+)e(-) collider. One neutral B meson is fully reconstructed as a J/psi K(S), psi(2S)K(S), chi(c1)K(S), eta(c)K(S), J/psi K(L), or J/psi K(*0) decay and the flavor of the accompanying B meson is identified from its decay products. From the asymmetry in the distribution of the time intervals between the two B meson decay points, we determine sin2 phi(1) = 0.99+/-0.14(stat)+/-0.06(syst). We conclude that we have observed CP violation in the neutral B meson system.

Measurement of B(0)(d)-B_(0)(d) mixing rate from the time evolution of dilepton events at the upsilon(4S)

We report a determination of the B(0)(d)-&B_(0)(d) mixing parameter Deltam(d) based on the time evolution of dilepton yields in Upsilon(4S) decays. The measurement is based on a 5.9 fb(-1) data sample collected by the Belle detector at KEKB. The proper-time difference distributions for same-sign and opposite-sign dilepton events are simultaneously fitted to an expression containing Deltam(d) as a free parameter. Using both muons and electrons, we obtain Deltam(d) = 0.463+/-0.008 (stat)+/-0.016 (syst) ps(-1). This is the first determination of Deltam(d) from time evolution measurements at the Upsilon(4S). We also place limits on possible CPT violations.

Measurement of the CP violation parameter sin2 phi(1) in B(0)(d) meson decays

We present a measurement of the standard model CP violation parameter sin2 phi(1) (also known as sin2beta) based on a 10.5 fb(-1) data sample collected at the Upsilon(4S) resonance with the Belle detector at the KEKB asymmetric e(+)e(-) collider. One neutral B meson is reconstructed in the J/psiK(S), psi(2S)K(S), chi(c1)K(S), eta(c)K(S), J/psiK(L), or J/psipi(0) CP-eigenstate decay channel and the flavor of the accompanying B meson is identified from its charged particle decay products. From the asymmetry in the distribution of the time interval between the two B-meson decay points, we determine sin2 phi(1) = 0.58(+0.32)(-0.34)(stat)+0.09-0.10(syst).

Peanut challenge: a retrospective study of 140 patients

BACKGROUND

Accurate diagnosis of peanut allergy is essential given that it is a lifelong and potentially fatal food allergy. Diagnosis relies on patient history, prick skin test (PST), and in many situations, food challenge. More information is required on the safety of food challenge and the informational value of a PST.

OBJECTIVES

Primary: to assess the safety of peanut challenges. Secondary: to estimate the sensitivity, specificity, and the positive and negative predictive values of PST to peanut performed in those who underwent a peanut challenge.

METHODS

A retrospective study of peanut challenges performed at a tertiary care paediatric hospital allergy clinic between January 1994 and November 1998.

RESULTS

Of the 140 peanut challenges performed on 140 patients, 18 were positive. The most frequent adverse clinical effects of positive peanut challenges were: urticaria, oropharyngeal irritation, rhinitis, vomiting and abdominal pain. Among the 18 patients who had a positive result, 10 required medical treatment (antihistamines, +/- epinephrine, +/- salbutamol) to control the allergic reaction. The sensitivity, specificity, and the positive and negative predictive values of PST to peanut in this group of children undergoing a peanut challenge were 100%, 62.3%, 28.1% and 100%, respectively.

CONCLUSIONS

Given the poor positive predictive value and specificity of PST, a peanut challenge is usually required to diagnose peanut allergy with certainty when the PST is positive. In cases of a clear history of anaphylaxis to peanut and a positive PST, challenges are unwarranted. When the history is strongly suggestive and the PST is borderline positive, i.e. 3 or 4 mm, peanut challenge is generally necessary to confirm the diagnosis. Given the excellent negative predictive value and sensitivity of PST, a blinded peanut challenge is usually unnecessary in the context of a negative PST except for patients with a history strongly suggestive of immediate hypersensitivity. These patients should be individually assessed for the need to undergo a blinded challenge. The peanut challenge is a useful and safe diagnostic tool when performed by qualified personnel under appropriate conditions.

The psychological burden of peanut allergy as perceived by adults with peanut allergy and the parents of peanut-allergic children

BACKGROUND

Peanut-allergic patients are affected by a condition which forces them and their families to exercise extreme dietary vigilance and experience constant uncertainty throughout their lives.

OBJECTIVE

To compare the quality of life and family relations of children and adults with a peanut allergy to that of children and adults with a rheumatological disease.

METHODS

Patients with a confirmed diagnosis of peanut allergy or a rheumatological disease completed (for children less than 18 years, by proxy) self-report questionnaires regarding the impact of their condition on their quality of life and family relations. A vertical visual analogue scale and the Impact on Family Questionnaire (IFQ) served as outcome measures.

RESULTS

One hundred and fifty-three peanut-allergic children were compared with 69 children with a rheumatological disease while 37 peanut-allergic adults were compared with 42 adults with a rheumatological disease. The parents of peanut-allergic children, compared to the parents of children with a rheumatological disease, reported that their children had significantly more disruption in their daily activities. Furthermore, the parents of peanut-allergic children reported more impairment in the familial-social dimension of the IFQ. Conversely, adults with a chronic rheumatological disease reported more disruption in their family relations than peanut-allergic adults.

CONCLUSION

Given the considerable disruption in daily activities and family relations reported by the parents of peanut-allergic children, accurate diagnosis of peanut allergy is essential. Our work should make health care professionals dealing with children with confirmed peanut allergy more aware of the support that these families may require. Furthermore, we hope to motivate food industries to offer more 'peanut free' products to decrease the dietary restrictions of these patients while minimizing their potential for accidental ingestion.

Uninterrupted moderately accelerated radiotherapy in the treatment of unresectable/advanced head and neck cancer: one institution's experience and a comparative review

Conventional radiotherapy alone in treatment of unresectable or locally advanced head and neck cancer has poor results. To improve outcome without significant increase in acute and late morbidity, we began a moderately accelerated hyperfractionation radiation therapy protocol without breaks for treatment of unresectable/advanced head and neck malignancies. From August 1984 to June 1995, 48 patients with unresectable or advanced carcinoma of the head and neck were treated using a protocol of accelerated hyperfractionation radiation therapy at Kaiser Permanente Medical Center, Los Angeles. Patients were treated twice a day using 150 cGy per fraction, 4 days per week, to a final dose of 60 Gy. Two patients were excluded from this analysis because they did not complete treatment. With a median follow-up of 33 months, 31 (67%) patients have had disease recurrence, 30 (65%) of whom had a locoregional component to their failures. At the last follow-up, 12 patients (26%) were alive with no evidence of disease, 30 patients had died of disease, and 4 had died of intercurrent disease without recurrence. Nine (19%) patients required treatment interruptions averaging 8 days in duration. This accelerated regimen resulted in outcomes similar to those with conventional radiotherapy, most likely because of a conservative total dose. Further refinement of fractionation schedules with potential incorporation of chemotherapy must be investigated.

Antimicrobial mixtures used to store harvested skin: antimicrobial activities tested at refrigerator (4 degrees C) temperatures

Tissue culture media used by skin and tissue banks to store tissue were tested, with and without antimicrobial mixtures, for their ability to inhibit the growth of bacteria during incubation at refrigerator temperatures. Reductions in bacterial load were found after incubation at 4 degrees C in both the basal tissue culture media with and without the addition of antimicrobial mixtures. The presence of antimicrobials enhanced the degree and rapidity of reduction. Variations occurred among the different formulations, with or without added antimicrobials. No one formulation for either the basal tissue culture medium or antimicrobial mixture was ideal. Methods described in this study can be used to establish optimum basal medium and antimicrobial mixture formulations for general use by skin and tissue banks.

Antimicrobial mixtures used by tissue banks for harvested skin: comparative in vitro activity

The activities of antimicrobial combinations from three geographically diverse skin/tissue banks used in the processing of skin/ tissue were compared using bacteria and yeast isolated from burn patients. All formulations showed 90% or more effectiveness against bacteria generally susceptible to antibiotics but were less effective (60-80%) when tested against bacteria resistant to specific antimicrobials. Anti-yeast activity was present when an appropriate antifungal agent was included in the combination. All formulations were stable for at least six weeks. Results of this study raise certain questions about the use of these antimicrobial combinations in contemporary skin/tissue banking and point the way toward areas for future study.

Risk of incontinence with transurethral resection of the prostate after radiation therapy for prostate cancer

BACKGROUND

It has been reported that transurethral resection of the prostate (TURP) after definitive radiation therapy for prostate cancer is associated with a significant risk of incontinence. The presumed reason for incontinence is external sphincter damage from TURP or pre-existing damage from either extension of prostate cancer or radiation therapy.

METHODS

We reviewed seven recent cases of TURP for bladder outlet obstruction in patients who had undergone radiation therapy for clinical stage T(3-4)M(0)N(0) adenocarcinoma of the prostate. All seven men progressed to either chronic retention or debilitating obstructive symptoms with weak peak flows from 3.4 to 5.1 cc/s (mean 4 cc/s). Each of them subsequently underwent a limited TURP.

RESULTS

Voiding symptoms were reduced in all patients and peak flows were improved to 6.3 to 20 cc/s (mean 14.8 cc/s) with mean follow-up 35 m. No patient developed stress urinary incontinence postoperatively.

CONCLUSION

These results suggest that TURP can be performed successfully after radiation therapy with minimal risk of stress incontinence.

Lack of effect of sleep on energy expenditure and physiologic measures in critically ill burn patients

OBJECTIVE

Energy expenditure measurements, performed while patients are in standardized resting conditions, are often used as an indicator of care by which to evaluate the adequacy of nutrition support regimens. Little attention has been directed toward examining potential errors incurred by deriving daily energy needs based on a single 15- to 20-minute measurement. This study was designed to differentiate energy expenditure during periods of sleep (defined as time spent in any of the standard sleep stages) and wakefulness in pediatric burn patients.

DESIGN

Twenty-four-hour indirect calorimetry, polysomnography, and physiologic assessments (mean arterial pressure, heart rate, body temperature, oxygen saturation, and respiratory rate) were conducted simultaneously in 14 patients, who were thermally injured and tracheally intubated, for a total of 45 24-hour intervals.

SUBJECTS

Mean age of the patients was 10.8+/-1.2 years. Mean total body surface area of the injury was 55.7+/-4.7%, and mean full-thickness burn was 48.8+/-6.0%.

STATISTICAL ANALYSES PERFORMED

A nested general linear analysis of variance model was used to evaluate the association between sleep, wakefulness, and energy needs; adjustments were made for postburn day and multiple test runs per patient.

RESULTS

On average, subjects slept 699+/-46 minutes/day. They experienced a large number of awakenings from sleep (mean=53+/-6.3 awakenings per 24 hours). Patients had mean energy expenditure of 2,529+/-396 kcal/day while awake and 2,360+/-291 kcal/day while asleep, and these mean values did not differ significantly. No differences in physiologic measurements during the awake and sleep states were found.

APPLICATIONS

There appears to be little difference in the metabolism of seriously injured burn patients while asleep and while awake. The study deemphasizes the importance of performing indirect calorimetry at rest in critically ill pediatric burn patients, and it supports the extrapolation of daily energy expenditure from a 15- to 20-minute steady-state measurement obtained during either sleep or wakefulness.

Emergency room management of minor burn injuries: a quality management evaluation

The vast majority of acute burns are initially seen and treated in emergency departments (EDs). Most of the individuals caring for these patients have little or no specialized training in the multidisciplinary approach to the burned patient. Burns of limited severity are treated immediately and then followed on an outpatient basis; therefore reviews of documented practices in emergency departments were not found. It was hypothesized that follow-up care may be suboptimal in this population. The medical records of 791 patients treated at three EDs in a Midwestern regional referral area from January 1991 through December 1991 were evaluated to assess the documentation of care provided. The three hospitals included a tertiary care teaching facility, a pediatric facility, and a community-based teaching hospital. Only the charts of patients treated and released from the ED were evaluated. The data demonstrate that there was suboptimal documentation of diagnosis, treatment, and follow-up care of the thermally injured patients who were initially treated in these EDs. Burn team members should develop educational and clinical relationships with EDs in the referral area to optimize both the delivery and documentation of outpatient burn care. This is especially important in today's health care environment, in which reimbursement is based on services rendered.

Clinical evaluation of an acellular allograft dermal matrix in full-thickness burns

A multicenter clinical study assessed the ability of an acellular allograft dermal matrix to function as a permanent dermal transplant in full-thickness and deep partial-thickness burns. The study consisted of a pilot phase (24 patients) to identify the optimum protocol and a study phase (43 patients) to evaluate graft performance. Each patient had both a test and a mirror-image or contiguous control site. At the test site, the dermal matrix was grafted to the excised wound base and a split-thickness autograft was simultaneously applied over it. The control site was grafted with a split-thickness autograft alone. Fourteen-day take rates of the dermal matrix were statistically equivalent to the control autografts. Histology of the dermal matrix showed fibroblast infiltration, neovascularization, and neoepithelialization without evidence of rejection. Wound assessment over time showed that thin split-thickness autografts plus allograft dermal matrix were equivalent to thicker split-thickness autografts.

Outcome of care. Complications from radiation therapy treatment

This study was undertaken to examine radiation treatment complications. From September 1987 through December 1989, 29,380 patients were screened at their follow-up visits for possible radiation complications. Of these patients, 1,380 were singled out for further study. These 1,380 charts were examined by a radiation oncologist and physicist to determine if there was a radiation complication, the severity of the complication, and whether a calculation or setup error could account for the complications. Of the 1,380 patients studied, 178 (3% of new patients treated each year) were determined to have radiation complications. These complications were divided into four categories of severity and entered into our computerized tumor registry as follows: complication type R1, complete recovery from symptoms, n = 59; R2, injury requiring medications to control injury, n = 104; S1, surgical intervention for one organ, n = 12; and S2, surgical intervention for two organs, n = 3. We believe that a baseline complication rate of 5% is acceptable in radiation oncology practices. However, the examination and documentation of the outcome of care in the form of radiation complications can help improve patient care and keep the radiation oncologist abreast of treatment outcome trends in the department.

Treatment selection for base of tongue carcinoma

Sixty-two previously untreated patients with squamous cell carcinoma of the base of tongue were retrospectively analyzed. The American Joint Committee on Cancer (AJCC) Stage distribution was I-3, II-7, III-24, and IV-28. The choice of treatment was nonrandomized. The local control was 10/18 with high-dose preoperative radiation, 17/30 with external beam radiation only, and 4/14 with external beam plus interstitial implantation. The median survival for the three treatment regimens were 63, 51, and 13 months, respectively. Preoperative radiation is suggested for tumors with inferior (laryngeal) spread or those with extensive superior extension (to tonsillar fossa and beyond). For centrally placed lesions in the base of the tongue (with or without lateral hypopharyngeal wall spread), radiation alone is recommended. An interstitial implantation should be restricted to lesions equal to or less than 4 x 3 x 2.5 cm3. Since this insertion is technically more demanding than for tumors of the mobile tongue, they should be performed by the more experienced brachytherapist.

Gallium-67 scanning for malignant melanoma

Melanoma is characterized by a tendency to metastasize widely throughout the body and its relative affinity for gallium-67. Because of the ability of this nuclide to image tumor sites in numerous organ systems, it has been used to detect metastases in patients with malignant melanoma. The effectiveness of this technique, however, has been controversial. This article documents the retrospective analysis of results from 296 gallium-67 scintiscans from 222 patients with melanoma. Patients were placed in two groups. The low suspicion group (148 patients undergoing 191 scans) consisted of patients with no evidence of disease; the gallium scans were performed solely for screening purposes. There were 175 true-negative scans, nine true-positive scans (eight of the nine were positive only at the untreated primary site), three false-negative scans, and four false-positive scans. Therefore, in only one patient (0.5%) did a "screening" gallium scan reveal disease that was not expected. The high suspicion group (85 patients undergoing 105 scans) consisted of patients with established evidence of metastatic disease; the gallium scan was performed to confirm those findings and to search for involvement of other organ systems. Of these scans, ten were true-negative, 73 true-positive, 21 false-negative, and one false-positive. In this group the 20% false-negative results indicate that gallium scanning is considerably less sensitive than the combination of clinical and standard radiographic assessment. It was concluded that gallium-67 scintiscanning of patients with melanoma, whether for screening or evaluation of patients with known metastases, provides little information that affects clinical staging or therapeutic design. Therefore, the technique is of limited value for routinely investigating the extent of disease.

Early coverage of deep hand burns with groin flaps

Deep burns of the hands require skin flap coverage in order to protect the exposed vital structures. The groin flap is a safe and effective method of obtaining early closure of these defects. We have used groin flaps to cover deep hand burn defects in nine patients. In each case, groin flaps effectively covered the various defects, such as the volar aspect of the wrist, dorsum of the hand, first web space, thumb, and fingers.

Lack of effect of Lactobacillus on gastrointestinal bacterial colonization in premature infants

Studies were carried out on premature infants in the neonatal intensive care unit to determine the effect of feeding of lactobacilli on colonization of the gastrointestinal tract by antibiotic-resistant gram-negative enteric organisms. Thirty premature infants were matched by birth weight and gestational age, randomized and fed double blind either lactobacilli-containing formula or non-lactobacilli-containing formula within 72 hours of delivery. The two study groups were screened weekly by culture for stool lactobacilli, for gram-negative bacteria and for antibiotic resistance of these bacteria. Lactobacilli were cultured from the stools of 13 of 15 patients receiving lactobacilli and from 3 of 15 patients not receiving lactobacilli (P less than 0.001). Gram-negative enteric organisms were isolated during 40 of the 86 weeks (47%) of hospitalization for patients receiving lactobacilli and during 28 of 57 weeks (49%) for patients not receiving lactobacilli. There was no significant difference between the study groups in the number of resistant organisms or in the proportion of resistant organisms per gram-negative enteric isolates (4 of 40 vs. 0 of 28). These results suggest that facultative gram-negative enteric bacterial colonization, with either total or aminoglycoside-resistant strains, is not decreased by oral feedings of Lactobacillus acidophilus in premature infants.

Classification and surgical correction of postburn axillary contractures

Postburn axillary contractures should be surgically corrected as soon as the diagnosis has been established in order to avoid deeper tissue involvement. We have classified axillary contractures based upon local anatomic conditions and present procedures for correction of each type that we find most suitable. Type I contractures are characterized by a linear web at either axillary fold with minimal adjacent scarring. A double Z-plasty with Y-V advancement is the procedure of choice. Type II contractures involve either axillary fold, with adjacent skin scarring. A double incisional release on both sides of the hair-bearing area is the procedure of choice. Type III contractures are characterized by linear webs at both axillary folds without involvement of the adjacent skin. The procedure of choice in these cases is a double incisional release. Type IV axillary contractures involve the hair-bearing area and the periaxillary region. This diffuse scar contracture is best treated by a single incisional release.

Route of delivery for patients with immune thrombocytopenic purpura

Over the past 15 years, we managed 19 pregnancies in 18 women afflicted with immune thrombocytopenic purpura. Our policy has been to treat the mother with corticosteroids if her platelet count was below 100 X 10(9)/L and to use cesarean section only for obstetric indications; 14 patients received corticosteroids. The perinatal outcomes were intrauterine fetal death (two), neonatal death (0), and live birth (17). The methods of delivery for the 17 live-born infants were spontaneous vaginal (seven), low forceps or midforceps (five), cesarean section (five). Although seven of the live-born infants (41%) were thrombocytopenic (less than 100 X 10(9)/L), only two received therapy, and none suffered significant hemorrhagic morbidity. Maternal treatment with corticosteroids did not affect the neonatal platelet count, nor was there a correlation between maternal and neonatal platelet counts. On the basis of our experience, we think that cesarean section is not routinely indicated as the method of delivery for parturient patients with immune thrombocytopenic purpura.

Characterization of a sex pheromone in the jird (Meriones tristrami)

The Israeli jird (Meriones tristrami) is a semidesert crecitid rodent found throughout the Mid-East. Jirds use a midventral sebaceous gland to scent-mark objects, the ground, and conspecifics. Volatile compounds from the male gland extract were found to containn-aliphatic acetates by thin-layer chromatography, gas chromatography, and mass spectroscopy. In a digital olfactometer, female jirds demonstrated preference for male glandular extract and many of then-aliphatic acetates. Other biologically important odors were also presented to the female jirds. Behavioral observations combined with olfactory bioassays implicate the involvement of the ventral sebaceous gland in jird sexual behavior.