Biomedical subjects
Publications and source records attributed to J D Thompson.
The inventors of diagnosis-related groups talk about what's happened to their invention, both in the U.S. and abroad. DRGs were used as the basis for Medicare's prospective payment system, but John D. Thompson and Robert B. Fetter, winners of the 1992 Baxter Foundation Prize for Health Services Research, say things haven't turned out exactly as they'd expected.
Residual disease remains a major problem in the treatment of human neoplasia. To effectively monitor minimal leukemic activity after bone marrow transplantation (BMT), we used a competitive polymerase chain reaction (PCR) amplification technique to quantify expression of the characteristic bcr-abl fusion message in patients with chronic myelogenous leukemia (CML). Quantitative results were obtained between the 0.001% and 0.1% level in control experiments. This represents a significant advantage over cytogenetic and Southern blotting techniques routinely used to diagnose CML, which may not be sensitive below the 1% level. To illustrate the potential clinical usefulness of the quantitative PCR strategy, we compared results of bcr-abl messenger RNA expression with those obtained using cytogenetic and Southern blotting techniques, in a study of consecutive BM and peripheral blood (PB) samples from two CML patients at high risk for relapse after BMT. One patient received a syngeneic transplant during the chronic phase of the disease and relapse was apparent at the molecular level 4.5 months after BMT, while the patient was in complete clinical remission. The second patient was treated with an allogeneic BMT during the accelerated phase of the disease. A slow, but progressive decrease in bcr-abl expression was observed during the first 12 months after BMT, and expression was undetectable thereafter. Our results indicate that the competitive PCR technique can be used to monitor disease activity in patients at high risk of relapse, while the patients are in complete clinical remission, which should facilitate the early detection of relapse or the identification of progressive disappearance of leukemic activity. The approach used may serve as a model for the study of residual disease in an increasing number of other hematologic malignancies that express cancer-specific RNAs.
OBJECTIVE: The management of a rectovaginal fistula is a significant challenge for the patient and the surgeon, with many acceptable surgical techniques for repair. The transverse transperineal repair is a method that preserves an intact external anal sphincter, allows wide mobilization of rectal and vaginal tissues, and closes the fistula with at least five layers of tissue. We have used this technique in patients with rectovaginal fistulas in the lower vagina for the past several years and recently reviewed our results. STUDY DESIGN: A chart review of 21 patients who had a transverse transperineal repair of a rectovaginal fistula in the lower vagina in our institutions from 1983 to 1990 was performed. RESULTS: All patients had a satisfactory recovery with no recurrence of a fistula during a follow-up period ranging from 3 months to 8 years (mean 18 months). The series includes seven patients with Crohn's disease and/or previous failed repairs. CONCLUSIONS: Our experience suggests this method provides excellent anatomic and physiologic results with minimal morbidity.
The incidence and contributing factors associated with post-casting peroneal nerve palsy were examined in a series of 110 consecutive pediatric femoral shaft fractures treated with early hip spica cast application. Four patients with peroneal nerve palsy were identified. All four had 90 degrees/90 degrees casts placed and underwent cast wedging for alignment. All palsies resolved with immediate cast removal. Other treatment options for certain femur fractures with significant initial shortening should be considered. We advise pre- and post-cast neurologic examination and avoidance of forceful distraction. Fracture manipulation, through wedging, should be delayed.
The rel proto-oncogene has been mapped to chromosome region 2p11.2-14, a site associated with nonrandom rearrangements in non-Hodgkin's lymphoma. We have characterized an abnormal rel mRNA from a cell line derived from a diffuse large cell lymphoma, in which the evolutionarily conserved N-terminal half of the rel coding region was fused with the C-terminal coding region of an unrelated gene. In addition, rearrangement or amplification of the rel locus was found in the lymphomatous tissue of two follicular and one diffuse large cell lymphoma. The findings suggest involvement of rel in the pathogenesis of large cell lymphoma.
Many hematologic malignancies are associated with recurrent cytogenetic abnormalities. Often these rearrangements result in gene fusion, leading to altered gene expression and/or activity. As the gene affected by these rearrangements are characterized at the molecular level, one particular group, the DNA binding transcriptional regulatory genes, are becoming more prominent. In this communication, we review how these genetic rearrangements effect the structure and expression of transcriptional regulatory proteins, and discuss how these abnormalities may be used quantitative diagnostic markers to analyze disease activity.
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Knowledge of the molecular biology of cancer and other diseases has grown enormously in the past decade. The role certain genes play in disease states is clearer, creating new opportunities for diagnostic applications of molecular biological techniques in clinical medicine. The measurement of an abundance of certain nucleic acids could be valuable as a diagnostic or prognostic test. For example, aberrant expression of growth-promoting genes has correlated with the type and severity of certain neoplasias. Also, the determination of an abundance of exogenous sequences, arising from viruses or other pathogens, can be useful for evaluating virus load and activity during infection. Changes in the levels of these sequences could provide a means to determine the efficacy of therapy. Nucleic acid sequences can be measured by molecular hybridization using complementary nucleic acids as probes. Strategies for performing quantitative molecular hybridization, and their application in the clinic, are discussed.
This paper examines the extent to which changes (prospective payment, alternative delivery systems, etc.) in the hospital environment and the general decline in hospital days affect small-area variations in hospital use rates for 18 selected diagnoses in nine hospital service areas in Connecticut. After adjusting for coding changes between DRGs, we found that variation across the service areas did not, in general, differ for any one of the years 1981-86. In one instance (cardiac catheterization), however, we found that a DRG-specific change in knowledge and technology decreased the extent of small-area variation for that diagnosis.
Forty-one children who had forty-two open fractures of the tibial metaphysis or diaphysis were studied retrospectively. Twelve fractures were Type I; eighteen, Type II; six, Type IIIA; four, Type IIIB; and two, Type IIIC, according to the classification of Gustilo et al. All fractures were irrigated and debrided, and antibiotics were given for a minimum of forty-eight hours after the injury. Twenty fractures were initially treated with external fixation and twenty-two, with immobilization in a plaster cast. Three patients had an early infection of the wound, one of which was associated with osteomyelitis; all were successfully treated. The average time to healing of the fracture was five months (range, two to twenty-one months). The time to union was related to the severity of the soft-tissue injury, the pattern of the fracture, the amount of segmental bone loss, the occurrence of infection, and the use of external fixation. There were six delayed unions. Four patients had an angular malunion of more than 10 degrees, which spontaneously corrected in three. One patient who had a proximal metaphyseal-diaphyseal segmental fracture had a progressive valgus deformity. Four patients who had a severe fracture that was treated with external fixation had more than one centimeter of tibial over-growth. There were no amputations. The incidences of compartment syndrome, vascular injury, infection, and delayed union were similar to those reported for open tibial fractures in adults.
We describe a new human subfamily of alpha satellite DNA. The restriction endonuclease XbaI cleaves this subfamily into a collection of fragments which are heterogeneous with respect to size. We compared the sequences of 6 clones from four different XbaI size classes. Clones from a single size class were not necessarily more related than clones from different classes. Clones from different size classes were found to produce almost identical hybridization patterns with XbaI-digested human genomic DNA. All clones were found to share a common dimeric repeat organization, with dimers exhibiting about 84% sequence identities, indicating that the clones evolved from a common progenitor alphoid dimer. We show that this subfamily, and the EcoRI dimer subfamily originally described by Wu and Manuelidis, evolved from different progenitor alphoid dimers, and therefore represent distinct human alphoid subfamilies.
For increased clinical applications of nucleic acid probes to gene diagnosis, current procedures must be modified to become more amenable to the rapid processing of many samples with as few manipulations as possible. Here we summarize progress in the development of a strategy for performing molecular hybridization directly in lysate of biological samples dissolved in solutions containing the chaotropic agent, guanidine thiocyanate. Hybrids are purified by a process referred to as "reversible target capture," in which specific nucleic acid sequences are rapidly purified from crude lysate. We illustrate the use of this strategy to assay HIV-1 RNA and to rapidly purify HIV-1 RNA before enzymatic amplification by the polymerase chain reaction method.
Radial head subluxation secondary to traumatic rupture of the annular ligament has been well described in the literature. Annular ligament reconstruction utilizing fascia lata graft has been proposed and described, but no follow-up reports have been published. A 21-year-old man was treated by annular ligament reconstruction for recurrent radial head subluxation with a good result and no recurrent subluxation at more than four years postoperatively. The operative technique is as follows: a fascia lata graft 1.5 x 12 cm was anchored through a drill hole in the posterolateral ulna, passed around the radial neck, and sutured back onto itself to reconstruct an annular ligament.
At an average of 18.4 months after fracture, 20 adult patients with nondisplaced radial head or neck fractures were examined regarding manner of treatment and functional outcome: 11 patients were initially immobilized in 90 degrees flexion and nine patients were immobilized in straight extension. Loss of range of motion of the injured elbow averaged 1 degree loss of flexion, 2 degrees loss of extension, 1 degree loss of supination, and 2 degrees loss of pronation. No patient reported any functional impairment, and only five patients (25%) reported any symptoms referable to the injured elbow on follow-up. The manner of initial treatment did not seem to affect ultimate outcome; symptomatic treatment and splinting followed by early range of motion would appear to produce uniformly good results.
The Yale Nursing Intensity Project explored the use of patient classification, done primarily for staffing, as a measurement of nursing resources. Cross-hospital comparisons showed considerable interesting variation, yet to be explained, in minutes of care but there was considerable consistency in the relative nursing intensity of DRGs. Because of differences in staffing and charging practices, intensive care and routine floor care should be separated in any further study of nursing intensity. And because different clinical services show large differences in nursing resource use, costing nursing should be done at least at the service level, if not the actual unit level. A method for establishing a nationwide data set in which nursing could be included is suggested. The virtue of this approach is to provide cross-hospital evidence on which policy decisions about weighting DRGs for nursing in deciding reimbursement levels could be made. In addition, such a system would require hospitals to account for nursing separately from other hospital costs, with attendant benefits for nursing management.
The Biocept-G test (Wampole) is a commercial modification of the radioreceptor assay for human chorionic gonadotropin (hCG) which takes 1 hours to process and has a sensitivity of 200 mIU/ml for hCG. Over a 9 1/2-month period, 70 consecutive patients with proven ectopic pregnancy were evaluated by the Biocept-G test, 2-minute urine slide test, and culdocentesis. Of 67 of these patients, 94% had a positive Biocept-G test, 82% had a positive culdocentesis, and 69% had a positive urine slide test. Sixty-nine (97%) of the 70 patients had either a positive Biocept-G and/or a positive culdocentesis, while only 1.7% had both a negative culdocentesis and a negative Biocept-G. Thirty-two patients underwent laparoscopy or laparotomy during this time period to rule out ectopic pregnancy but were not found to have this condition. The Biocept-G had a 94% accuracy rate in determining the presence or absence of intrauterine pregnancy in this group, compared to an 82% accuracy rate for the urine slide test. The Biocept-G has the highest true-positive rate for ectopic pregnancy published to date for a rapidly performed, commercially available pregnancy test.
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This paper outlines the system for cost accounting and managerial control which is an extension of the usually accepted departmental costing systems and takes as its units the 383 Diagnosis Related Groups (DRGs) considered to be the hospital's products. It is held that such an approach offers hospital managers a more powerful, analytic, budgeting, and cost-finding tool and offers the opportunity to involve the medical staff in the issues of how their practice patterns are affecting hospital costs.