Trauma: an annotated bibliography of the recent literature.
Explore the source record for details and available documents.
Humans↗
Biomedical subjects
C J McCabe
Publications and source records attributed to C J McCabe.
Health economics in rheumatology.
Economic evaluations of health-care technologies are playing an increasingly central role in determining which therapies are available to clinicians in the treatment of a whole range of conditions. In rheumatology, a large body of work has already been done on the cost effectiveness of alternative non-steroidal anti-inflammatory drugs (NSAIDs), and much of the current work on disease modifying therapies incorporates economic evaluations. This chapter describes the main techniques of economic evaluation and reviews the strengths and weaknesses of each. Two published economic evaluations are discussed in order to highlight what economic evaluations can offer to the care of people with rheumatoid arthritis, as well as the current limitations of economic evaluation. The objective of this chapter is to equip readers with a critical understanding of economic evaluation that can be used in considering the increasing volume of health economic data that they encounter in their clinical work.
Cost-Benefit Analysis↗
Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination.
PURPOSE: To evaluate a focused, helical computed tomographic (CT) technique for imaging the appendix in patients suspected of having appendicitis. MATERIALS AND METHODS: One hundred patients prospectively underwent appendix CT examination, with use of oral and colon contrast media and contiguous, thin-collimation, helical CT imaging of the right lower quadrant. Results were correlated with the results of surgery and pathologic examination from 61 patients or from clinical follow-up in 39 patients. RESULTS: CT scans were positive for appendicitis in 59 patients: true-positive in 56 patients on the basis of surgery and pathologic examination, and false-positive in two patients on the basis of clinical follow-up; in the case of the other positive scan, the clinical outcome was indeterminate. CT scans were negative for appendicitis in 41 patients: true-negative in five patients on the basis of surgery and pathologic examination, and true-negative in 36 patients on the basis of clinical follow-up. CT had a sensitivity of 100%, a specificity of 95%, a positive predictive value of 97%, a negative predictive value of 100%, and an accuracy of 98%. The normal appendix was always identified. CT helped establish alternative diagnoses in 33 of the 41 patients (80%) in whom the results of CT were negative for appendicitis. CONCLUSION: Appendix CT examination can help diagnose or exclude appendicitis and establish an alternative diagnosis.
Acute Disease↗
Thyroid hormone and estrogen receptor expression in normal pituitary and nonfunctioning tumors of the anterior pituitary.
Nonfunctioning tumors (NFTs) of the anterior pituitary often express elevated levels of the glycoprotein hormone alpha-subunit, which, under normal physiological conditions, is under negative feedback control by thyroid and gonadal steroid hormones. We postulate that inappropriately elevated levels of expression of alpha-subunit in the face of normal levels of these target organ hormones may reflect an abnormality of thyroid hormone receptors (TRs) and/or gonadal steroid receptors in NFTs. Using immunocytochemistry and Western blotting we have examined TR and estrogen receptor (ER) protein expression in normal human anterior pituitary glands and NFTs. Pretranslational expression of these receptors was examined using semiquantitative reverse transcriptase-PCR. Expression of all TR variant and ER proteins was reduced in pituitary tumors compared with that in normal pituitaries. The expression of messenger ribonucleic acids encoding the TR beta1 and TR beta2 isoforms and ER was also significantly reduced in tumors compared with normal tissues, although there was no difference between tumors and normals in the level of expression of TR alpha1 and alpha2 messenger ribonucleic acids. We suggest that reduced expression of TRs and ER may account for inappropriate expression of the glycoprotein hormone alpha-subunit gene in some NFTs and may contribute to uncontrolled tumor growth.
Female↗
A focused appendiceal CT technique to reduce the cost of caring for patients with clinically suspected appendicitis.
OBJECTIVE: This investigation analyzed the potential impact on hospitalwide variable costs and total costs of introducing a focused helical CT technique for diagnosing appendicitis. MATERIALS AND METHODS: This investigation had three components. First, we retrospectively reviewed the records of 651 patients who had admitting diagnoses of appendicitis. Second, we determined variable costs and total costs for the components of these patients' care. Third, we projected change in costs if the focused appendiceal CT technique had been used to guide patient management. RESULTS: Using focused appendiceal CT in 100 patients would have decreased the number of nontherapeutic appendectomies by 13. The average length of stay for observation would have also decreased by 1 day because the diagnosis of an abnormal appendix or an alternative diagnosis would have been made more quickly. Savings in variable costs and total costs would have been $23,030 and $45,556 per 100 patients, respectively. CONCLUSION: Routine use of focused appendiceal CT would lower the costs of caring for patients with clinically suspected appendicitis.
Adolescent↗
Helical CT combined with contrast material administered only through the colon for imaging of suspected appendicitis.
OBJECTIVE: Helical CT combined with contrast material administered by mouth and through the colon has been shown to be accurate for appendiceal imaging. This investigation was performed to determine if helical CT combined with contrast material administered only through the colon has comparable accuracy. SUBJECTS AND METHODS: One hundred patients prospectively underwent appendiceal CT imaging with thin-collimation, helical scanning limited to the lower abdomen and upper pelvis after contrast material was administered only through the colon. CT results were correlated with surgical and pathologic findings at appendectomy (56 patients), other surgery (three patients), or clinical follow-up at least 2 months after the CT scan (41 patients). RESULTS: Fifty-three CT scans were interpreted as positive for appendicitis, including 52 true-positives (with surgical-pathologic correlation) and on false-positive (with clinical follow-up). Forty-seven CT scans were interpreted as negative for appendicitis, including 40 true-negatives with clinical follow-up, three true-negatives with appendectomy and pathologic correlation, three true-negatives with other surgery and pathologic correlation, and one false-negative with appendectomy and pathologic correlation. CT had a 98% sensitivity, 98% specificity, 98% positive predictive value, 98% negative predictive value, and 98% accuracy for diagnosing or excluding appendicitis. In 47 normal appendix cases at CT, the appendix was seen in 44 cases (94%), and an alternative diagnosis was identified in 29 cases (62%). CONCLUSION: For diagnosing appendicitis, helical CT combined with contrast material administered only through the colon proved to be as accurate (98%) as helical CT combined with contrast material administered by mouth and through the colon. Helical CT with contrast material administered only through the colon also could be performed immediately and without any of the potential patient risks or discomforts of contrast material administered i.v. or by mouth.
Adult↗
Neonatal screening for inborn errors of metabolism: cost, yield and outcome.
OBJECTIVES. To systematically review the literature on inborn errors of metabolism, neonatal screening technology and screening programmes in order to analyse the costs and benefits of introducing screening based on tandem mass-spectrometry (tandem MS) for a wide range of disorders of amino acid and organic acid metabolism in the UK. To evaluate screening for cystic fibrosis, Duchenne muscular dystrophy and other disorders which are tested on an individual basis. HOW THE RESEARCH WAS CONDUCTED. Systematic searches were carried out of the literature on inborn errors of metabolism, neonatal screening programmes, tandem MS-based neonatal screening technology, economic evaluations of neonatal screening programmes and psychological aspects of neonatal screening. Background material on the biology of inherited metabolic disease, the basic philosophy, and the history and current status of the UK screening programme was also collected. Relevant papers in the grey literature and recent publications were identified by hand-searching. Each paper was graded. For each disease an aggregate grade for the state of knowledge in six key areas was awarded. Additional data were prospectively collected on activity and costs in UK neonatal screening laboratories, and expert clinical opinion on current treatment modalities and outcomes. These data were used to construct a decision-analysis model of neonatal screening technologies, comparing tandem MS with the existing phenylketonuria screening methods. This model determined the cost per additional case identified and, for each disease, the additional treatment costs per case, and the cost per life-year saved. All costs and benefits were discounted at 6% per annum. One-way sensitivity analysis was performed showing the effect of varying the discount rate, the incidence rate of each disorder, the number of neonates screened and the cost of tandem MS, on the cost per life-year gained. RESEARCH FINDINGS. The UK screening programmes for phenylketonuria and congenital hypothyroidism have largely achieved the expected objectives and are cost-effective. Current concerns are the difficulty of maintaining adequate coverage, perceived organisational weaknesses, and a lack of overview. For many of the organic acid disorders it was necessary to rely on data obtained from clinically-diagnosed cases. Many of these diseases can be treated very effectively and a sensitive screening test was available for most of the diseases. Except for cystic fibrosis, there have been no randomised controlled trials of the overall effectiveness of neonatal screening. Despite the anxiety generated by the screening process, there is strong parental support for screening. The effects of diagnosis through screening on subsequent reproductive behaviour is less clear. Conflicts exist between current concepts and the traditional principles of screening. The availability of effective treatment is not an absolute prerequisite: early diagnosis is of value to the family concerned and, to the extent that is leads to increased use of prenatal diagnosis, may help to reduce the overall burden of disease. Neonatal screening is also of value in diseases which present early but with non-specific symptoms. Indeed, almost all of the diseases considered could merit neonatal screening. The majority of economic evaluations failed to incorporate the health benefits from screening, and therefore failed to address the value of the information which the screening programmes provided to parents. The marginal cost of changing from present technology to tandem MS would be approximately 0.60 pounds per baby at a workload of 100,000 samples a year, and 0.87 pounds at 50,000 samples per year. The ability to screen for a wider range of diseases would lead to the identification of some 20 additional cases per 100,000 infants screened, giving a laboratory cost per additional diagnosis of 3000 pounds at an annual workload of 100,000 babies per year.(ABSTRACT TRUNCATED)
Cost-Benefit Analysis↗
Delayed appendectomy for appendicitis: causes and consequences.
This study was undertaken to describe the causes and consequences of delayed diagnosis and intervention in cases of appendicitis. The hospital records of adult patients undergoing appendectomy during a 4-year period (November 1989 to November 1993) were reviewed, with concentration on 40 patients who had a delay of 72 hours or more from initial symptoms to operation. The initial medical contact points for patients were walk-in clinics and community emergency departments. Definitive care was provided in a general hospital. Patients were adults with appendicitis who underwent an operation for definitive management 72 or more hours after the onset of symptoms. Length of hospital stay, reasons for delay in diagnosis, incidence of perforation, and complications were recorded. Delay in diagnosis and treatment was attributed to factors controlled by the patient in 15 cases (27.5%) and by the physician in 25 cases (62.5%). Perforation, postoperative complications, and hospital length of stay were related to the delay in diagnosis; with delay, the mean hospital length of stay was 9 days, the incidence of perforation was 90%, and major complications were recorded in 60% of the patients. Early diagnosis and surgical management for appendicitis remains an important and, at times, elusive goal. Delays of 72 hours or more have serious consequences. Patient education and the experience, intuitiveness, and persistence of the physician are important elements to improving these findings.
Adolescent↗
Cost of care for a geographically determined population of low birthweight infants to age 8-9 years. I. Children without disability.
AIM: To determine the extra cost of healthcare associated with low birthweight, in a cohort study of a geographically defined population in five health districts that comprise Merseyside. METHODS: The study comprised all children of birthweight < or = 1500 g and a 10% random sample of those weighing 1501-2000 g, without clinical disability, born in 1980 and 1981 to mothers resident in Merseyside, and their controls, matched by age, sex, and school class, followed up to age 8-9 years. RESULTS: The cost of care associated with the initial admission to the neonatal special/intensive care unit and subsequent use of hospital and family practitioner services was assessed. There were 641 survivors without disability and 227 non-survivors who weighed < or = 2000 g at birth. The mean cost of neonatal care per low birthweight child was 13 times greater than for a control child. For children weighing < or = 1000 g at birth, neonatal costs were 55 times greater than for the control children. Low birthweight children continue to use hospital and family practitioner services more intensively than controls to age 8-9 years. CONCLUSION: Low birthweight children used hospital and family practitioner services more intensively throughout the follow up period. Whether the increased use of health services persists into adolescence and adulthood is yet to be determined.
Child Care↗
Cost of care for a geographically determined population of low birthweight infants to age 8-9 years. II. Children with disability.
AIM: To determine the cost of health and educational service provision for low birthweight children with a clinical disability. METHODS: Cohort study of a geographically defined population in five health districts that comprise the County of Merseyside was undertaken. All children with a clinical disability born in 1980 and 1981 to mothers resident in the County of Merseyside were followed up to age 8-9 years. The cost of care associated with the initial admission to the neonatal special/intensive care unit and subsequent use of hospital, family practitioner, and special education services was assessed. RESULTS: There were 52 children with a disability; the disability rate in children of birthweight < or = 2000 g was estimated at 7.7%. Of the total expenditure to age 8-9 years, special education was the largest category (52%) and neonatal care accounted for 35%. The disabled children accounted for 38% of the cost of the whole cohort of 693 disabled and non-disabled children who weighed < or = 2000 g at birth. CONCLUSION: In a cohort of low birthweight children, those who are disabled account for a disproportionate amount of the total expenditure to age 8-9. The cost of long term care for disabled young persons and adults will increasingly dominate the cost of care for the whole cohort of low birthweight children.
Child Care↗
Measuring the mental health status of a population: a comparison of the GHQ-12 and the SF-36 (MHI-5).
BACKGROUND: A comparison of the performance of the 5-item mental health dimension of SF-36 (MRI-5) with that of the 12-item General Health Questionnaire (GHQ-12) in a defined, non-patient population, using standard statistical tests. METHODS: A postal survey of 3000 patients aged 16-64 years was conducted. Patients were randomly selected from the practice lists of two general practices chosen to represent populations with different socio-economic characteristics. RESULTS: Considerable evidence was found for the internal consistency of both instruments (Cronbach's alpha 0.91 and 0.84 for GHQ-12 and the MHI-5 respectively) and for their construct validity in terms of distinguishing between groups with measured health differences. Both instruments showed a significant difference in the mean scores for men and women. In contrast to the GHQ-12, no correlation was found between age and score for the MHI-5. Both instruments were equally sensitive to socio-economic characteristics and to levels of social support. The scores on the two instruments were highly correlated (Spearman rank correlation-0.73). CONCLUSION: The MHI-5 has comparable psychometric performance to the GHQ-12, and can be used to measure and compare mental health in defined populations. Operational advantages of the MHI-5 over the GHQ-12 are that it is in the public domain, is part of a general health measure (SF-36) and is shorter.
Adolescent↗
Nonoperative management of blunt splenic injury in adults: age over 55 years as a powerful indicator for failure.
BACKGROUND: Selective nonoperative management of adults with blunt splenic injury continues to evolve. Predictive factors associated with successful nonoperative management have primarily been clinical criteria such as hemodynamic stability and the degree of associated injuries. This study evaluates the role of patient selection in the safety and success of nonoperative management of adults with blunt splenic injury. STUDY DESIGN: Herein, we present a retrospective analysis of the management and outcome of 135 adult (16 years of age or older) patients with blunt splenic injury at a large urban Level 1 trauma center during a six-year period. RESULT: A total of 46 adult patients were treated nonoperatively after blunt splenic injury during the study period. Patient ages ranged from 16 to 93 years (mean, 36.9 years) with 11 patients 55 years of age or older. Nonoperative management was successful in 24 (52 percent) patients. Patients failing nonoperative management were significantly older than patients successfully observed (mean age, 48.1 and 26.7 years, respectively). There were ten (91 percent) failures among the 11 patients 55 years of age or older compared to 12 (34 percent) failures among younger adults despite similar mean computed tomography splenic injury grading and Injury Severity Scores (p < 0.01). Complications were significantly more prevalent in older patients than in younger patients who failed observation (p < 0.01). CONCLUSIONS: Nonoperative management of adults with blunt splenic injury commonly fails in older patients independent of other clinical and radiographic variables. We conclude that age over 55 years is a contraindication to nonoperative management of patients with blunt splenic injury.
Adult↗
An economic evaluation of a clinical trial to compare automated percutaneous lumbar discectomy with microdiscectomy in the treatment of contained lumbar disc herniation.
STUDY DESIGN: A cost-effectiveness study of automated percutaneous lumbar discectomy (APLD) vs. microdiscectomy in the treatment of contained lumbar herniation in a randomized controlled trial. OBJECTIVES: To quantify hospital costs and other public sector expenditure; to collect socioeconomic data that might bear on the recovery rate of patients and their private costs; and to relate costs to clinical outcomes. SUMMARY OF BACKGROUND DATA: The authors are aware of no similar economic evaluation in this field. METHODS: The surgical procedures were costed from detailed lists of the time spent and resources used. Socioeconomic patient data were collected by questionnaires administered around the time of the operation and on follow-up at 6 months. Statistical analysis was by the chi-square method. RESULTS: There was no evidence that either procedure imposed significantly greater costs on patients or nonhospital medical services. CONCLUSION: It was demonstrated that, within the restrictions imposed by the data set, automated percutaneous lumbar discectomy was less cost-effective than microdiscectomy.
Cost-Benefit Analysis↗
Trauma: an annotated bibliography of the recent literature.
Explore the source record for details and available documents.
Humans↗
Traumatic subarachnoid-pleural fistula: case report.
Traumatic subarachnoid-pleural fistula was recently diagnosed in an 18-year-old male after a gunshot wound in the chest and spinal column. The diagnosis was suggested by persistent pleural drainage and headache in the setting of signs of spinal injury at the thoracic level. Computed tomographic myelography delineated the dural injury. The fistulous connection was defined and repaired at operation. This paper describes the diagnostic and therapeutic features encountered in the management of this rare disorder.
Adolescent↗
Trauma: an annotated bibliography of the recent literature.
Explore the source record for details and available documents.
Humans↗
Traumatic diaphragmatic hernia. Occult marker of serious injury.
OBJECTIVE: Recent experience with traumatic diaphragmatic hernias at the Massachusetts General Hospital was reviewed to identify pitfalls in the diagnosis and treatment of this injury. SUMMARY BACKGROUND DATA: Traumatic diaphragmatic disruption is a common injury and a marker of severe trauma. It occurs in 5% of hospitalized automobile accident victims and 10% of victims of penetrating chest trauma. Numerous reports describe splenic rupture in 25% of patients with blunt diaphragmatic rupture, liver lacerations in 25%, pelvic fracture in 40%, and thoracic aortic tears in 5%. Diaphragmatic rupture is a predictor of serious associated injuries which, unfortunately, is itself often occult. METHODS: A chart review of all patients admitted to the Trauma Service with traumatic diaphragmatic hernias was undertaken for the period of January 1982 to June 1992. RESULTS: Data on 68 patients sustaining blunt (n = 25) and penetrating (n = 43) diaphragmatic rupture or laceration were presented. The diagnosis was made preoperatively in only 21 (31%). Associated injuries were frequent in those injured by either blunt or penetrating trauma. Sixty-six patients underwent repair, 54 (82%) through a laparotomy alone and 12 (18%) with the addition of a thoracotomy. There were five (7.4%) deaths that were caused by coagulopathy, hemorrhagic shock, multisystem organ failure, and pulmonary embolism. Complications were twice as frequent in the blunt-trauma group and included abscess, pneumonia, and the sequelae of closed head injuries. CONCLUSIONS: The recognition of diaphragmatic rupture is important because of the frequency and severity of associated injuries. The difficulties in reaching the diagnosis require an aggressive search in patients at risk.
Adolescent↗
Trauma: an annotated bibliography of the recent literature.
Explore the source record for details and available documents.
Emergency Medicine↗