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Biomedical subjects

C Comstock

Publications and source records attributed to C Comstock.

17 recordsLinked to original sources
PubMed2000

Eye examinations for VA patients with diabetes: standardizing performance measures.

OBJECTIVE: To demonstrate the potential of the Health Plan Employer Data and Information Set (HEDIS) for the calculation of a performance measure for eye exams in the diabetic population using Veterans Health Administration (VA) administrative data. DESIGN: We calculated a 1-year HEDIS-defined patient denominator and three alternative denominators that considered coding factors in identifying a VA patient as diabetic. We calculated the HEDIS-defined numerator, along with alternative specifications that captured other types of eye exams. Finally, we supplemented national data with VA pharmacy and Medicare claims data to identify all VA diabetic patients at 14 selected VA facilities and to establish a more accurate picture of non-VA health care utilization. RESULTS: The national average annual HEDIS-defined eye exam rate in the VA was 26% in fiscal 1997 compared with 39% for managed care organizations. Medicare utilization raised this by 15 percentage points at 14 northeastern VA hospitals. Over 2 years, at least two-thirds of diabetic VA patients had some type of eye exam through VA or Medicare. CONCLUSION: A HEDIS measure of eye exams for VA patients with diabetes can be calculated using VA administrative data only. However, the question remains to what extent the denominator and numerator accurately and completely identify all diabetic patients using VA services and all appropriate eye exams. We recommend caution in interpreting the results of performance measurement across different health care sectors based on what we currently know are data system limitations.

Adult↗
PubMed1996

Private sector coverage of people with dual diagnoses.

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

Adult↗
PubMed1995

Reimplantation of a contaminated and devitalized bone fragment after autoclaving in an open fracture.

This case report describes a technique for dealing with open fractures with segmental bone loss and a critical need for restoration of anatomical alignment. In the majority of cases, autogenous bone graft can and should be used successfully. Regardless of the treatment option chosen though, meticulous debridement and sound judgment in regards to wound care and bony stabilization remain the foundation to a successful outcome. Autoclaving a devitalized bone fragment with subsequent reimplantation as described in this case report, although not the procedure of choice, does offer the orthopaedist another option in dealing with the difficult segmental fracture.

Adult↗
PubMed1994

A clinical and radiographic study of the "safe area" using the direct lateral approach for total hip arthroplasty.

The purpose of this clinical and radiographic study is to determine whether the surgeon can remain within the 5 cm "safe zone" while using the direct lateral approach during total hip arthroplasty (THA) without endangering the superior gluteal nerve. The direct lateral approach was used in a prospective, consecutive series of 36 primary THAs in 31 patients performed by one surgeon. At the time of closure of the abductor muscle layer, a small metallic clip was placed at the superior extent of the incision into the gluteus medius. After surgery, the patients were mobilized on crutches with protected weight bearing for either a 6-week (hybrid THA) or 12-week (uncemented THA) period. Before surgery, and at 3, 6, and 12 months after surgery, abductor strength and the Trendelenburg sign were measured by the same physical therapist. The vertical distance from the superior pole of the greater trochanter to the base of the clip was measured on all radiographs of the pelvis and corrected for magnification. Before surgery, only 25 of the 36 hips demonstrated abduction strength of 4/5 or greater. Three months after surgery, 34 hips had a grade of 4/5 or greater for abductor strength. The Trendelenburg sign was positive in 24 of 34 hips before surgery, in 5 hips at 3 months, in 1 hip at 6 months, but negative in all hips by 12 months. The clip was located 3.2 +/- 1.3 cm (mean +/- SD) vertically from the superior pole of the greater trochanter. In 34 of 36 hips (95%), the 5 cm safe zone was respected.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Pudendal nerve palsy after femoral intramedullary nailing.

Pudendal nerve palsy after femoral intramedullary (IM) nailing was retrospectively reviewed in 65 nailings performed on 63 patients. Ten pudendal nerve palsies (15%) were noted in eight male patients and two female patients. Three male patients had autonomic involvement affecting erections. All palsies were transient (3-173 days), and occurred in patients done in the supine position as opposed to the lateral position. A possible etiology is the smaller perineal post used in the supine position that may penetrate the pelvis deeper, compressing the pudendal nerve. Other factors may be operating time and amount of traction. As prevention, the perineal post must always be adequately padded, and the operating time and amount of traction should be minimized to decrease the incidence of pudendal nerve palsy. Because pudendal nerve palsy appears to be a common complication in femoral IM nailing, the patient must be informed of this possibility.

Adolescent↗
PubMed1990

Coronary heart disease in Massachusetts: the years of change (1980-1984).

During this decade, diagnosis and treatment of coronary heart disease (CHD) have become far more aggressive and invasive than in prior decades. This study documents rates of hospitalization, use of various treatment options, a case fatality in the state of Massachusetts during 4 of the first 5 years of this decade (1980, 1982, 1983, and 1984). The data base was that of the Massachusetts Health Data Consortium (MHDC), covering all hospital discharges in the state, a total of 3.8 million discharge records for this period. Of these, about 190,000 (5%) fell into two active symptomatic categories of CHD: chronic active coronary disease (CACD) and acute myocardial infarction (AMI). Total hospitalization rate for these CHD categories increased by 17%; this was due both to an increased rate of hospital transfers (or readmissions) and to a larger cohort of patients under care. The case fatality rate for hospitalized CHD decreased approximately 16%, from 9.7% (1980) to 8.1% (1984). In CACD the frequency of coronary angiography (CA) rose; the use of percutaneous transluminal coronary angioplasty (PTCA) increased much faster than the rate of coronary artery bypass grafting (CABG), with a resultant increase in PTCA as a fraction of total interventions. Similar findings were recorded for AMI, but with much more marked changes, the total intervention rate increasing almost twenty-fold from 1980 to 1984. The statewide mortality rate for hospitalized CHD patients remained essentially unchanged at 71 to 74 hospital deaths per 100,000 population.

Angiography↗
PubMed1987

Ligand-receptor dynamics and signal amplification in the neutrophil.

Intact neutrophils appear to exhibit interconverting formyl peptide receptor states. The first may be active in transduction and has a dissociation half-time of less than 10 sec. The second appears to be inactive and has a dissociation half-time of approximately 2 min. Neutrophil signals and responses are transient following "pulse" stimulation (when the stimulus is presented and then rapidly removed). The responses decay to baseline following a latency period comparable to the lifetime of the activated receptor. These results are consistent with the notion of transient interconverting receptor states and are discussed in terms of the biochemistry and amplification of the cell activation pathways. We examined the effect of guanine nucleotides on ligand-receptor dynamics at 37 degrees C in neutrophils permeabilized with digitonin, using continuous fluorometric measurements. The permeabilized cells exhibit a single class of slowly-dissociating receptor with a half-time similar to the inactive state. When guanine nucleotide is added, the receptors dissociate with a half-time similar to the first state. The effect of guanine nucleotide is inhibited by Ca++ concentrations above 10 microM. When receptors in permeabilized cells are ADP-ribosylated in the presence of pertussis toxin, the rapidly dissociating state is detected. These results suggest that the dynamics of ligand-receptor interaction under physiological conditions are controlled by a pertussis-toxin-sensitive guanine-nucleotide-binding protein. Guanine nucleotide regulates interconverting states of the formyl peptide receptor and mimics the dynamic states of the receptor observed in the intact cell during stimulation. A model which accounts for these data is described.

Calcium↗
PubMed1985

Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts.

This article presents an analysis of over 140,000 selected surgical procedures performed in Massachusetts in 1980, giving the per capita rates of 14 common procedures and of four less frequently performed procedures. The analysis defines 172 geographic areas for the commonly performed procedures and 45 for the less frequently performed procedures. Per capita surgical rates among the defined areas are significantly different from both a statistical and a clinical point of view. Twofold and threefold variations occur frequently across geographic areas. In certain areas, some surgical services appear to be provided at rates substantially different from the statewide rate. We discuss the importance of these data for physicians as well as the implications for the distribution and quality of clinical care and for containment of medical care costs.

Costs and Cost Analysis↗
PubMed1977

Percutaneous needle localisation of breast lesions prior to biopsy: analysis of failures.

Mammography can detect clinically occult breast cancer. But with minimal or no physical findings the lesion can be quite difficult for the surgeon to find within the recumbent breast at biopsy. Percutaneous needle localisation, the placement of a needle in or in the vicinity of such a clinically silent lesion, provides an internal landmark to assist the surgeon. Review of our experience of 90 procedures using this technique disclosed a success rate of approximately 90%. The biopsies diagnosed 14 cancers before local or distant metastasis could be found. The eleven of the fourteen who had axillary dissection were found to have negative nodes. Identifiable causes of failure were sought and discussed in the 7 documented failures. Faulty needle placement was judged noncontributory in all but one case. Needle movement between time of placement and time of biopsy could never be excluded and is in fact suspected in two failures. Immediate re-sampling, or larger initial specimens would have salvaged the procedure in most instances of failure. We feel poor communication and poor mutual understanding of the localization procedure to be the major contributing cause of failure. Even so, we have been able to use the technique with 90% success. The development of mammography brought with it the opportunity to detect small non-palpable carcinomas and the surgical problem of removing them at biopsy. While the suspect lesions identified by mammography are frequently benign, the cancers found are usually small and some only microscopic in size. The literature contains many descriptions of various techniques for localising such lesions prior to biopsy. We are reporting our experience with percutaneous needle localisation. To our knowledge, we have the distinction of being the first to report difficulty with a localisation technique and will analyse possible reasons. Some of the problems are common to all the localisation techniques.

Adult↗
PubMed1977

A simple device for dependent compression mammography.

The authors describe an inexpensive device which displaces the dependent breast from the chest wall for optimum and uniform compression of breast tissue during mammography. Exposure is reduced, detail is enhanced, and superimposed structures are spread out. The filming time is about five minutes, and repeat or additional views are rarely necessary. The authors feel that by using this device, they have not missed any posterior lesions in more than 10 years of use. Even dense breasts are adequately visualized with this technique.

Female↗
PubMed1975

Roentgenology of sporotrichosis.

Localized cutaneous as well as unifocal and multifocal systemic sporotrichosis may all produce roentgenographic findings. Localized cutaneous nodules may occasionally extend to the bone below producing a locally erosive lesion similar to those more commonly found in blastomycosis. More frequently, sporotrichosis involves the joints, either alone or with accompanying skin nodules. The joint changes are those of a pyogenic arthritis of the knees, elbows, hands, or feet which is difficult to distinguish from pyarthrosis produced by other organisms. The pulmonary findings depend upon whether or not the lung is the only site of infection. If there are no other areas of involvement, the pulmonary findings may be indistinguishable from those of secondary tuberculosis. However, if the skin on joints are also involved, small nodules appear and apparently do not proceed to cavitation.

Adult↗
PubMedDate not supplied

Do individuals with substance abuse diagnoses incur higher charges than individuals with other chronic conditions?

Concerns about high costs have led to limits on the services covered by most insurance plans for substance abuse treatment. But, the commonly used comparison group for cost analyses, all enrollees in a health-care plan, may not be appropriate because addiction is a chronic condition. Therefore, to determine whether substance abusers incur higher charges than patients with other serious chronic conditions, we used health insurance information for employees and dependents over 3 years (1989 to 1991) for two firms with a total of almost 40,000 employees to do alternate comparisons. We compared average annual charges for patients with the following diagnoses: substance abuse, substance abuse with mental illness, arthritis, asthma, and diabetes. Patients who undergo treatment for abusing alcohol, drugs, or both often (but not always) incur higher charges than people with other chronic conditions. Clear differences in average charges emerge between patients with and without mental health claims.

Adult↗
PubMedDate not supplied

Fetal schistocytic hemolytic anemia and umbilical vein varix.

A rare case of schistocytic hemolytic anemia presenting in a fetus secondary to a varix of the intra-abdominal umbilical vein is reported. A patient was referred to our hospital at 32 weeks of gestation because of an abnormal hypoechoic finding in the fetal liver. Prenatal ultrasound showed turbulent flow through a 12-mm diameter dilatation of the fetal intra-abdominal umbilical vein consistent with a varix. Cardiomegaly also was noted. At birth, the 1098-g, growth-retarded, male neonate was in severe congestive heart failure secondary to anemia as the initial hemoglobin was 5 g/dL. Additional evaluation found the anemia to be secondary to schistocytic hemolysis. After the neonate received a transfusion of packed erythrocytes and supportive care, the anemia quickly resolved, and he was discharged to home doing well after a 6-week stay in the neonatal intensive care unit. Prompt recognition of the varix prenatally and thorough evaluation of the newborn postnatally led to appropriate diagnosis and treatment.

Adult↗