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Objectives: This study was conducted to determine efficacy and tolerability of the continued subcutaneous insulin infusion (CSII) via an insulin pump for treatment of Cystic Fibrosis Related Diabetes (CFRD). We also tested the hypothesis that CSII would improve body weight, blood sugar control, lean body mass, whole body protein turnover, hepatic glucose production (HGP)., Methods: We recruited 9 CF patients with established diabetes and placed them on insulin pump therapy for six months. Each subject kept daily blood sugar records before and during pump use. Prior to the pump placement and at the end of six months, each patient underwent the following measurements: 1) whole body protein turnover using the stable isotope [1-(13)C] leucine; 2) DEXA scan for measurement of lean body mass; 3) anthropometric measurements; 4) Hemoglobin A1c. Patient data was compared to baseline data and the mean change from baseline was analyzed., Results: There was significant improvement in both fasting and post-prandial blood glucose levels, body weight, HbA1C, and lean mass. Protein catabolism as measured by leucine rate of appearance was significantly lower, as was hepatic glucose production. No patient developed hypoglycemia during the study., Conclusions: This study demonstrates that CSII is safe and effective for treatment of CFRD and that metabolic benefits are also present.

The incidence of diabetes is high in cystic fibrosis (CF) and is an important cause of morbidity and mortality. Understanding the pathophysiology is imperative. Studies have documented increased endogenous (mostly hepatic) glucose production (HGP) but have not distinguished the relative contribution of gluconeogenesis (GNG). The purpose of this study was to quantitate GNG, to determine its contribution to high HGP, and to measure insulin's suppression of GNG. We recruited 31 adult CF subjects (age, 26.2+/-7.9 years; 12 female subjects) and quantified GNG by measuring the incorporation of H into the second and fifth carbons of glucose. Hepatic glucose production was measured using [6,6-H2]glucose. Protein breakdown was measured using [1-C]leucine. Data were compared with that from 11 healthy volunteers (age, 27.5+/-7.0 years) who underwent both GNG and clamp studies. Thirteen CF subjects and all controls had a hyperinsulinemic euglycemic clamp during measures of GNG. Other measures included glucose tolerance and glucagon and cortisol levels. Rate of GNG was higher in CF subjects than controls and comprised a greater percentage of fasting HGP (GNG as percent of HGP: CF=68%; controls=44%; P=0.034). Suppression of GNG by insulin was significantly lower in CF than in controls and was lower in CF subjects with abnormal glucose tolerance than in those with normal glucose tolerance. Gluconeogenesis correlated with protein breakdown. These studies suggest that high HGP in CF is mostly from elevated rates of GNG and that resistance to insulin's suppression of GNG may contribute to abnormal glucose tolerance in CF.

The management and prognostication of patients with urothelial carcinomas (UCs), the most common histological type of bladder cancer, is mainly based on clinicopathological parameters. Several markers have been proposed to monitor this disease, including individual cell cycle-related proteins such as p53, pRb, p16, p21 and p27. Other putative markers are the oncogene products of FGFR3 and the ErbB family, proliferation markers including Ki-67, Aurora-A and survivin and different components within the immune system. In this review, a total of 12 parameters were evaluated and their discriminatory power compared. It is concluded that, in single-marker analyses, the proliferation markers Ki-67, survivin and Aurora-A offer the best potential to predict disease progression since they were all able to demonstrate independent prognostic power in repeated studies. Markers related to the immune system (e.g. CD8+ cells, regulatory T cells and cyclooxygenase-2 expression) or oncogene products of the ErbB family and FGFR3 are less powerful predictors of outcome or have not been equally well studied. The cell cycle-related proteins p53, pRb, p16, p21 and p27 have been extensively studied, but their usefulness as single prognostic markers remains unclear. However, in multimarker analyses, these markers appear to add prognostic information, indicating that they may contribute to more accurate treatment of UC., (Copyright 2008 S. Karger AG, Basel.)

Rationale: Cystic fibrosis is a recessive genetic disease characterized by dehydration of the airway surface liquid and impaired mucociliary clearance. As a result, individuals with the disease have difficulty clearing pathogens from the lung and experience chronic pulmonary infections and inflammation. Death is usually a result of respiratory failure. Newly introduced therapies and aggressive management of the lung disease have resulted in great improvements in length and quality of life, with the result that the median expected survival age has reached 36 years. However, as the number of treatments expands, the medical regimen becomes increasingly burdensome in time, money, and health resources. Hence, it is important that treatments should be recommended on the basis of available evidence of efficacy and safety., Objectives: The Cystic Fibrosis Foundation therefore established a committee to examine the clinical evidence for each therapy and to provide guidance for the prescription of these therapies., Methods: The committee members developed and refined a series of questions related to drug therapies used in the maintenance of pulmonary function. We addressed the questions in one of three ways, based on available evidence: (1) commissioned systematic review, (2) modified systematic review, or (3) summary of existing Cochrane reviews., Conclusions: It is hoped that the guidelines provided in this article will facilitate the appropriate application of these treatments to improve and extend the lives of all individuals with cystic fibrosis.

Background: The necessity for surgical excision of papillary lesions identified on percutaneous breast biopsy remains controversial. We reviewed data from patients with papillary lesions found on core needle biopsies to identify features associated with carcinoma., Methods: A retrospective chart review was performed on patients with papillary lesions diagnosed from image-guided breast biopsies over a 10-year period. Patients had surgical excision or were followed-up radiographically for a 2-year minimum., Results: Papillary lesions were identified in 154 core needle biopsies. Ninety-five lesions were diagnosed as either benign or atypical. Eighty-nine of these patients had surgical excisions of their lesions. Malignancy was discovered in 22 (25%) of these lesions. Only atypical lesions on biopsy were malignant (P < .005). Forty-six percent of patients age 65 or older were found to have cancer at surgical excision (P < .01)., Conclusions: Papillary lesions found on core needle biopsy frequently harbor malignancy (25%). Atypia and age 65 or older are significant risk factors for malignancy.

Fibromatosis is an uncommon breast lesion that can mimic breast carcinoma in its clinical presentation. We present a case in which excisional biopsy was necessary to establish a diagnosis of fibromatosis. Clinical, diagnostic imaging, and pathologic features are discussed. Magnetic resonance imaging (MRI) has emerged as a tool for further characterization of breast lesions and as a screening modality in high-risk patient populations. Ours marks the second case in which dynamic MRI has been correlated with histologically confirmed primary mammary fibromatosis. Unlike the previous report, MRI in this case mimics breast carcinoma in its morphologic and pharmacokinetic features of enhancement. Wide local excision with clear margins remains the treatment of choice. Current data on radiotherapy and pharmacologic therapy for mammary fibromatosis are reviewed.

Background: In humans and animals, corticosteroid excess is associated with impairment in declarative memory and changes in hippocampal structure. In animals, phenytoin pretreatment blocks the effects of stress on memory and hippocampal histology, although no studies have examined the use of phenytoin to prevent corticosteroid-associated memory changes in humans. Mood changes are also common with corticosteroids, but few treatment data are available. This report examines whether phenytoin can prevent mood or declarative memory changes secondary to bursts of prescription corticosteroids., Methods: Thirty-nine patients with allergies or pulmonary or rheumatologic illnesses and given systemic corticosteroid therapy were randomized to receive either phenytoin (300 mg/day) or placebo concurrently with the corticosteroids. Mood was assessed with the Hamilton Rating Scale for Depression, Young Mania Rating Scale, and Activation (ACT) subscale of the Internal State Scale; declarative memory was assessed with the Rey Auditory Verbal Learning Test (RAVLT) at baseline and after approximately 7 days of corticosteroid plus phenytoin or placebo therapy., Results: The two groups were similar in age, gender, education, and corticosteroid dose. The phenytoin-treated group showed significantly smaller increases on the ACT, a mania self-report scale, than the placebo-treated group. Groups did not differ significantly on RAVLT change scores., Conclusions: This is the first placebo-controlled study to examine whether a medication can prevent mood and memory changes secondary to corticosteroids. Phenytoin blocked the hypomanic effects of prescription corticosteroids; however, phenytoin did not block the declarative memory effects of corticosteroids.

The potential for malignancy detection using dynamic infrared imaging (DIRI) has been investigated in an animal model of human malignancy. Malignancy was apparent in images formed at the vasomotor and cardiogenic frequencies of tumour bearing mice. The observation of malignancy was removed by the administration of an agent that blocks vasodilation caused by nitric oxide (NO). Image patterns similar to those that characterize malignancy could be mimicked in normal mice using an NO producing agent. Apparently DIRI allows for cancer detection in this model through vasodilation caused by malignancy generated NO. Dynamic infrared detection of vasomotor and cardiogenic surface perfusion was validated in human subjects by a comparison with laser Doppler flowmetry (LDF). Dynamic infrared imaging technology was then applied to breast cancer detection. It is shown that dynamic infrared images formed at the vasomotor and cardiogenic frequencies of the normal and malignant breast have image pattern differences, which may allow for breast cancer detection.

Objectives: This study compared the epidemiology of non-fatal injury among urban and rural residents of Colorado., Design: A stratified probability sample with random digit dial methods was used to survey Colorado residents by telephone regarding injuries experienced in the last 12 months. Questions on the cause of the injury, the activity at the time of the injury, and the place of injury were based on the Nordic Medico Statistical Committee's (NOMESCO) classification of external causes of injuries., Subjects: A total of 1425 urban and 1275 rural Colorado residents aged 18 and older were interviewed., Results: Age, gender, marital status, and rural residency were found to increase the odds of self reported injury. The adjusted odds ratio for self reported injury was 1.3 (95% confidence interval (CI) 1.01 to 1.68) for rural compared with urban residents. Rural residence (odds ratio 1.02, 95% CI 0.51 to 7.01) was not a risk factor for injury among the highest risk group, those who were single and never married. No differences in injury characteristics were found by urban-rural status., Conclusions: The increased odds of self reported injury among rural residents were not explained by differences in the causes of injury or other injury characteristics. The differences in the importance of rural residence in increased odds of injury by marital status warrants further understanding and may be important in the development of injury prevention programs. Based on comparison with a similar survey, the NOMESCO coding system appears to be a viable alternative survey tool for gathering information on injury characteristics.

Have the warm tropical waters and currents of the southern Gulf of California, Mexico (also known as the Sea of Cortez), formed a barrier to gene flow, resulting in disjunct populations in the upper gulf that are isolated from the outer Pacific Coast? Phylogeographic and genetic divergences of the spotted sand bass, Paralabrax maculatofasciatus, from three Gulf of California and two outer Pacific coastal locations were tested using mitochondrial DNA (mtDNA) control region sequences. Sequence data from two congeners that are sympatrically distributed along the outer Pacific Coast, the barred sand bass, P. nebulifer, and the kelp bass, P. clathratus, were used to gauge the levels of genetic divergences. Differences among the three species and between the northern gulf and outer Pacific coastal populations of P. maculatofasciatus also were analyzed using 40 allozymic presumptive gene loci. Allozyme and mtDNA analyses each revealed many fixed differences among the species. Three significant allozymic frequency differences and two fixed mtDNA substitutions differentiated the gulf and outer Pacific coastal populations of P. maculatofasciatus. Three unique mtDNA haplotypes and three unique allozyme alleles were identified from the outer Pacific coastal population. The gulf sites contained four unique mtDNA haplotypes and six unique allozyme alleles. Partitioning of the mtDNA variation revealed that 72% of the variance occurred between the gulf and outer Pacific Coast, 20% between sampling sites in the two regions, and 8% within the sites. There appears to be little gene flow across the waters of the southern Baja Penninsula, producing divergence estimated as 120,000 to 600,000 years between the outer Pacific coastal and the Gulf of California populations. This separation level may date to a hypothesized seaway closure near La Paz, Mexico, during the mid-Pleistocene, and characterizes other fish populations. A second pattern of deeper allopatric species-level divergences in some other fishes may date to a Pliocene closure of a mid Baja Penninsular seaway. Significant differences also were discerned in P. maculatofasciatus between the San Diego and central Baja California coastal sites and between the upper/central and the lower gulf locations. Variation between locations in the two regions may be indicative of larval retention and low adult migration, which needs to be tested further.

Objective: Our goal was to compare the quality of diabetic care received by patients in rural and urban communities., Study Design: We performed a retrospective analysis of claims data captured by the Medicare program., Population: We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994., Outcome Measures: The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination., Results: A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests., Conclusions: Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

This study of personnel in local health departments (LHDs) focused on two predominantly rural states: Idaho and Wyoming. Although in the same region of the country, the structure of local public health is different in each state. Idaho's regionalized LHDs are relatively autonomous, whereas Wyoming's are county based, with many public health functions retained at the state level. The majority of professionals are nurses followed by environmental health workers and sanitarians, similar to data reported nationally. With increased emphasis on core public health functions of policy, assurance, and assessment, rural LHDs will be challenged to redirect the functions of their workforce.

To explain the very high frequency of cystic fibrosis (CF) mutations in most populations of European descent, it has been proposed that CF heterozygotes have a survival advantage when infected with Vibrio cholerae or Escherichia coli, the toxins of which induce diarrhea by stimulation of active intestinal chloride secretion. Two assumptions underlie this hypothesis: (1) chloride conductance by the CF transmembrane conductance regulator (CFTR) is the rate-limiting step for active intestinal chloride secretion at all levels of expression, from approximately zero in patients with CF to normal levels in people who are not carriers of a mutation; and (2) heterozygotes have smaller amounts of functional intestinal CFTR than do people who are not carriers, and heterozygotes therefore secrete less chloride when exposed to secretagogues. The authors used an intestinal perfusion technique to measure in vivo basal and prostaglandin-stimulated jejunal chloride secretion in normal subjects, CF heterozygotes, and patients with CF. Patients with CF had essentially no active chloride secretion in the basal state, and secretion was not stimulated by a prostaglandin analogue. However, CF heterozygotes secreted chloride at the same rate as did people without a CF mutation. If heterozygotes are assumed to have less-than-normal intestinal CFTR function, these results mean that CFTR expression is not rate limiting for active chloride secretion in heterozygotes. The results do not support the theory that the very high frequency of CF mutations is due to a survival advantage that is conferred on heterozygotes who contract diarrheal illnesses mediated by intestinal hypersecretion of chloride.

Objective: The study purpose was to evaluate the rate of development and the rate of change for benign and malignant breast calcifications at the lumpectomy bed., Materials and Methods: Retrospective review identified 53 new calcifications at the lumpectomy bed in patients with available mammograms and medical records. Breast Imaging Reporting and Data System (BI-RADS) categories were retrospectively assigned on the basis of initial prospective recommendation for yearly follow-up (category 2), 6-month follow-up (category 3), or biopsy (category 4 or 5). Outcomes were defined as benign for no recurrence at the lumpectomy bed on biopsy or follow-up and malignant if biopsy-proven at the lumpectomy bed., Results: The median rate of development after lumpectomy was 23 months (range, 2-174 months) for benign and 39 months (range, 15-112 months) for malignant calcifications. Fifteen (28%) of 53 calcifications were classified as BI-RADS category 3. Twelve (80%) of 15 were downgraded to BI-RADS category 2 at a median follow-up of 6.5 months (range, 6-16 months); none represented recurrent disease. Three (20%) of 15 were upgraded to BI-RADS category 4 at the 6-month follow-up, one despite stability (benign) and two for increasing pleomorphism (malignant). Nine (17%) of 53 calcifications were classified as BI-RADS category 4 or 5; six (67%) of the nine were malignant and three (33%) were benign at biopsy. Twenty-nine (55%) of 53 calcifications were classified as BI-RADS category 2, none representing recurrent disease., Conclusion: Benign calcifications at the lumpectomy bed usually develop earlier than malignant calcifications, but the rate of development overlaps. Most calcifications initially placed in the probably benign category evolve quickly to more benign or more malignant morphology. Most calcifications heralding recurrence appear suspicious on first presentation.

Duct carcinoma in situ (DCIS) is a malignant neoplasm of the breast that is limited to the glandular component. The introduction of mammographic screening allows for earlier detection of carcinoma, at the stage of DCIS, before it invades the surrounding stroma. Although DCIS has been studied extensively, its quantification remains a dilemma. Several methods for measuring DCIS exist, including clinical measurement, radiographic assessment, and gross pathologic assessment. Other methods have been employedfor this purpose, such as counting the number of tissue sections involved, direct measuring of DCIS from glass slides, and even counting the number of ducts involved. Furthermore, there is no consensus for assessing adequacy of margins. The myriad of techniques for quantifying DCIS has profound implications for treatment and for prognostic evaluation. The inherent difficulties in quantifying DCIS are multifactorial, and the need to establish a standardized approach for reporting the extent of DCIS by correlating radiographic, clinical, gross, and histologic findings is imperative.

This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. Health Care Financing Administration's National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.

Objectives: This study explored reproductive health care in rural Washington State, reasons given by providers for not offering abortions, and providers' willingness to use medical abortifacients., Methods: Physicians, midwives, nurse practitioners, and physician assistants in rural Washington completed an inventory of reproductive health services that they provide, whether and why they do not perform abortions, and whether they would use medical abortifacients., Results: Of the respondents, 89.2% reported providing reproductive health care. Only 1.2% reported performing surgical abortions, and 26.1% indicated that they would probably prescribe medical abortifacients., Conclusions: Few providers offer surgical abortions in rural Washington. Greater numbers report a willingness to prescribe medical abortifacients.

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.

Objectives: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician., Methods: The Health Care Financing Administration's National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994., Results: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician., Conclusions: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician--regardless of specialty--may reduce emergency department use.

We use data on Washington State abortions and births for 1983-1984 and 1993-1994 to analyze trends for urban and rural women, using the demographic measures total abortion and total fertility rates. These express pacing of childbearing in a single number which is simple to calculate and interpret, and is age-standardized. We find significant urban-rural differences. Total abortion rates decline and total fertility rates increase in both areas. However, the relative magnitudes of pacing decreases in abortions for rural women and increases in births for urban women are striking. The demographic measures are useful interpretive tools, and can be applied to a broad range of questions.

Context: Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology., Data Source: 1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State., Results: For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists.", Conclusion: Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists."

Purpose: To correlate histopathologic findings with detection method and mammographic appearance in primary and locally recurrent breast carcinoma after breast-conservation therapy., Materials and Methods: Medical records and mammographic findings were retrospectively reviewed; 26 patients with 27 local recurrences after breast-conservation therapy were identified., Results: Primary histopathologic findings included six in situ and 20 invasive carcinomas. Of the 27 recurrences, 19 (70%) were at or adjacent to the lumpectomy site and eight (30%) were elsewhere in the breast. All primary ductal carcinoma in situ (DCIS) cases manifested mammographically as microcalcifications and recurred as DCIS with microcalcifications. Eleven primary invasive carcinomas (10 masses, one case of microcalcifications) were detected only mammographically, three were detected only with physical examination, and six (six masses) were detected with both. Among these 20 recurrences, 14 (five masses, nine cases of microcalcifications) were detected only mammographically, one was detected only with physical examination, and five (five masses) were detected with both. Seventeen (85%) of 20 primary invasive carcinomas recurred invasively: 16 (94%) with similar histopathologic findings and eight (47%) with similar mammographic findings., Conclusion: In local recurrence after breast-conservation therapy for DCIS, histopathologic findings, detection method, and mammographic findings are usually similar. Histopathologic findings of primary invasive breast carcinoma and local recurrence are usually similar, but the detection method and mammographic findings vary. This is relevant to the interpretation of new clinical or mammographic findings following lumpectomy.

Context: Fewer rural health providers offer abortion services than a decade ago. It is unknown how the reduction in service availability has affected women's pregnancy outcomes, the extent to which they must travel to obtain an abortion or whether abortions are delayed as a result., Methods: Population, birth and fetal death data, as well as pregnancy termination reports, obtained from Washington State were used to calculate abortion rates and ratios and birthrates for Washington residents in 1983-1984 and in 1993-1994. Residence of abortion patients was classified by county only, and location of providers was recorded as large urban county, small urban county, large rural county or small rural county. Distances that women traveled to obtain an abortion were calculated. Chi-square tests were used to compare urban and rural rates and ratios within time periods, and to compare changes that occurred between time periods., Results: Birthrates and abortion rates decreased for both rural and urban Washington women between 1983-1984 and 1993-1994, but the magnitude of the decrease was greater for rural women. The rural abortion rate fell 27%, from 14.9 abortions per 1,000 women to 10.9 per 1,000, while the urban rate dropped 17%, from 21.8 to 18.2 per 1,000. The decline in the abortion rate was larger for adolescents than it was for other age-groups. In rural areas, the abortion rate decreased from 16.5 per 1,000 adolescents aged 10-19 in 1983-1984 to 10.8 per 1,000 in 1993-1994, while it declined from 23.3 per 1,000 to 16.9 per 1,000 in urban areas. From the earlier to the later time period, rural women traveled on average 12 miles farther each way to obtain an abortion, and the proportion who obtained the procedure in a rural county decreased from 25% to 3%. In the earlier time period, 62% of rural women traveled 50 miles or more to obtain an abortion, compared with 73% in 1993-1994. From 1983-1984 to 1993-1994, the proportion of rural women who traveled out of state for an abortion increased from 8% to 14%. The proportion of rural women terminating their pregnancy after the first trimester increased from 8% in 1983-1984 to 15% in 1993-1994., Conclusion: Rural Washington women are traveling farther and more often to urban and out-of-state locations for abortion services, and are obtaining their abortions at a later gestational age, which is associated with a decade-long decline in the number of abortion providers.

Context: The National Practitioner Data Bank (NPDB) is believed to be an important source of information for peer review activities by the majority of those who use it. However, concern has been raised that hospitals may be underreporting physicians with performance problems to the NPDB., Objective: To examine variation in clinical privileges action reporting by hospitals to the NPDB, changes in reporting over time, and the association of hospital characteristics with reporting., Design: Retrospective cohort study of privileges action reports to the NPDB between 1991 and 1995, linked with the 1992 and 1995 databases from the Annual Survey of Hospitals conducted by the American Hospital Association., Setting and Participants: A total of 4743 short-term, nonfederal, general medical/surgical hospitals throughout the United States that were continuously open between 1991-1995 and registered with the NPDB., Main Outcome Measures: (1) Reporting of 1 or more privileges actions during the 5-year study period and (2) privileges action reporting rates (numbers of actions reported per 100000 admissions)., Results: Study hospitals reported 3328 privileges actions between 1991 and 1995; 34.2% reported 1 or more actions during the period. The range of privileges action reporting rates for these hospitals was 0.40 to 52.27 per 100000 admissions, with an overall rate of 2.36 per 100000 admissions. The proportion of hospitals reporting an action decreased from 11.6% in 1991 to 10.0% in 1995 (P=.008). After adjustment for other factors, urban hospitals had significantly higher reporting than rural hospitals (adjusted odds ratio [OR], 1.21 [95% confidence interval [CI], 1.02-1.43]), while members of the Council of Teaching Hospitals of the Association of American Medical Colleges had significantly lower reporting than nonmembers (adjusted OR, 0.54 [95% CI, 0.40-0.73]). There were notable regional differences in reporting, with the east south Central region having the lowest rate per 100000 admissions (1.49 [95% CI, 1.33-1.65])., Conclusions: The results of this study indicate a low and declining level of hospital privileges action reporting to the NPDB. Several potential explanations exist, 1 of which is that the information reported to the NPDB is incomplete.

Objective: To compare health maintenance procedure rates of Medicare patients with different levels of disability., Study Design: Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL)., Results: Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community., Conclusions: Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

We used mitochondrial DNA sequence variation of Sebastes from the southeastern Pacific and three localities in the South Atlantic to address long-standing systematic and evolutionary issues regarding the number of species in the Southern Hemisphere. Sequences of the hypervariable mitochondrial control region were obtained from 10 specimens of S. capensis from South Africa (n = 5) and from Tristan da Cunha Island (n = 5) and 27 of S. oculatus from Valparaiso, Chile (n = 10), and the Falkland Islands (n = 17). Results of the study include (1) significant levels of genetic differentiation among the sampled populations (phi ST = 0.225, P < .000001), thus indicating limited gene flow; (2) corroboration of the existence of two different lineages of austral Sebastes corresponding to S. capensis and S. oculatus; (3) finding that S. capensis is not restricted to Tristan da Cunha and South Africa, but is widespread across the South Atlantic; (4) the position of S. capensis as the ancestral lineage of the austral Sebastes; (5) the existence of a third evolutionary lineage with high levels of genetic divergence, particularly abundant in the south-western Atlantic, which may be recognized as a third austral species of Sebastes.

This article reports the results of mammography screening among socioeconomically disadvantaged women in Bronx, NY using a federally funded low-cost or no-cost cancer screening service. The New York State Department of Health provided funds for the uninsured through the Bronx Breast Health Partnership. All women < or = 40 years underwent screening mammography using both a mobile van unit and hospital-based mammographic x-ray unit, both American College of Radiology (ACR) accredited. Return visits were coordinated by a follow-up clinic at Montefiore Medical Center using a patient navigator who acted as an advocate for patients with abnormal screening findings. The overall detection rate of 12.9 per 1000 women screened was significantly higher than the New York State detection rate of 6 per 1000 and 5.1 per 1000 nationally. Availability of a patient navigator was an essential factor in the effectiveness of the work-up of problem cases. Low-cost or no-cost breast cancer screening programs can improve the availability, accessibility, acceptability, and utilization of mammography among underserved and uninsured women who are least likely to be screened otherwise.

Sebastomus is one of the most species-rich subgenera of Sebastes, whose monophyly is well supported by morphological and molecular data. We present the first description of the complete nucleotide sequence of the mitochondrial cytochrome b gene and the partial sequence of the control region of the 14 species of Sebastomus. We used these data in phylogenetic analyses to investigate their evolutionary relationships. Extremely low levels of sequence divergence indicated a recent ancestry of these species, suggesting a very rapid radiation within the last million years. The molecular data revealed two main clades within Sebastomus, each with species of different affinities that invaded new habitats from the subgeneric center of distribution. The rapid speciation in this lineage was manifested in the poor resolution of some nodes in the phylogeny. Internal fertilization and viviparity in Sebastes may have played an important role in the sudden acquisition of reproductive barriers during its radiation. The mitochondrial DNA data suggest that prolific speciation in Sebastomus may have been associated with rapid lineage sorting punctuated by allopatric reproductive isolation subsequent to dispersal events and, perhaps, by sympatric reproductive isolation associated with internal fertilization., (Copyright 1999 Academic Press.)

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

Purpose: To report the specialty and rural/urban distribution a mean of 19 years after graduation for a cohort of students from a family physician curricular pathway., Method: Specialty and location information for medical students who had entered the University of Washington between 1968 and 1973 was obtained from the 1994 Physician Masterfile of the American Medical Association., Results: Of the 239 family physician pathway graduates, 173 (72%) had intended family practice at graduation, and 136 (57%) were family physicians two decades later. The proportions of all graduates in family practice and of graduates serving rural Washington as family physicians had increased over that of a cohort of students who had entered the University of Washington prior to the introduction of the pathway curriculum. These proportions surpassed the goals set at the time the new curriculum was introduced., Conclusion: With early identification and support of students interested in family practice, an increased number entered the specialty and were still family physicians in mid-career.

Background and Objectives: The continued availability of legal abortions in the United States depends on the willingness of future physicians to provide this procedure. This paper explores the attitudes toward abortion issues of first- and second-year medical students at a large regional primary care-oriented medical school., Methods: We anonymously surveyed 286 first- and second-year medical students at the University of Washington., Results: The response rate to the written survey was 76.6%. Women were slightly overrepresented among the respondents. The majority of students supported the broad provision of reproductive health services; 58.1% felt that first-trimester abortions should be available to patients under most circumstances. Of the 43.4% of students who anticipated a career in family practice, most expected to provide abortions in their future practices. Older students and women were more likely to support the provision of abortion services., Conclusions: Despite continuing pressure on abortion providers, most first- and second-year medical students at a fairly typical state-supported medical school intend to incorporate this procedure into their future practices.

Objectives: Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington State's expansion of such services on prenatal care use and low-birthweight rates., Methods: The change in prenatal care use and low-birthweight rates among Washington's Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state., Results: The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washington's low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorado's rate increased slightly (10.4% to 10.6%, P = .74). Washington's improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions., Conclusions: A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

We describe 8 patients affected with Costello syndrome including an affected sib pair and review the literature on 29 previously reported cases. We emphasize an association with advanced parental age, which is consistent with autosomal dominant inheritance with germline mosaicism. The pathogenesis appears to involve metabolic dysfunction, with growth disturbance, storage disorder appearance, acanthosis nigricans, hypertrophic cardiomyopathy, and occasional abnormalities of glucose metabolism. Although the cause is currently unknown, Costello syndrome is interesting because of a potential genetic-metabolic etiology.

Background: The maternal serum alpha-fetoprotein test (MSAFP) was developed to screen for neural tube defects. Little is known about the adoption of the MSAFP test. This study examines the effect of provider specialty and geographic location and patient insurance status on MSAFP test use in Washington State., Methods: We conducted a retrospective cohort study of MSAFP use in low-risk obstetric patients of five provider groups. MSAFP use was examined for Medicaid and privately insured patients, as well as for the patients of the five provider types., Results: Patients of urban and rural obstetrician-gynecologists were most likely to have MSAFP testing (80.4 percent and 77.0 percent, respectively); patients of urban certified nurse midwives and rural family physicians were least likely to have MSAFP testing (64.2 percent and 62.2 percent, respectively). Patients of certified nurse midwives were more likely to decline MSAFP testing when offered (26.1 percent). Medicaid-insured women were significantly less likely to have MSAFP testing than privately insured women (60.5 percent versus 79.1 percent, P < or = 0.05)., Conclusions: Providers and patients did not uniformly use MSAFP screening. Efforts should be made to ensure that all patients are adequately informed of screening tests for neural tube defects.

Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care., Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation., Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different., Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Purpose: To evaluate the clinical, imaging, and histopathologic features of breast carcinoma in the retroareolar tissues and to determine whether there are any characteristics common to this location., Materials and Methods: Thirty-five patients (age range, 38-77 years) with 37 retroareolar carcinomas were identified retrospectively. Retroareolar carcinoma was defined as that within 2 cm of the nipple-areolar complex. Mammographically occult tumors were identified by using histopathologic records (n = 4) or clinical examination findings (n = 6)., Results: Twenty-nine (78%) tumors had clinical findings, including palpable mass (n = 29), associated nipple inversion or retraction (n = 4), and associated nipple discharge (n = 2). Twenty-seven (73%) tumors had mammographic findings of mass (n = 16), mass with calcifications (n = 5), and microcalcifications (n = 6; four of these microcalcifications were associated with a mammographically occult palpable mass). Ultrasound was performed in 17 tumors, all of which were hypoechoic. The stage of 31 carcinomas was known: one was stage 0, 17 were stage I, and 13 were stage II. Histopathologic analysis revealed 35 ductal carcinomas and two invasive lobular carcinomas., Conclusion: Retroareolar carcinoma usually manifests as a palpable mass. Mammography is less sensitive in this area than in other areas of the breast. Ultrasound can be a valuable adjunct in the assessment of retroareolar malignancy.

Objective: To compare influenza vaccination billing rates for patients seen by physiatrists with those of four other specialties: neurology, rheumatology, family practice, and internal medicine., Design: Retrospective cohort analysis using Medicare billing data., Patients: 234,164 Medicare outpatients seen in Washington state between September 1 and December 31, 1994., Results: Based on Medicare's billing data, only 6 of 99 physiatrists ordered vaccinations, and they immunized only 159 (6%) of the patients seen. An additional 1,109 (42%) patients seen by physiatrists were vaccinated by other physicians. Physiatric patients were less likely to have been vaccinated than those seen by internists, family practitioners, or rheumatologists (p < .002), but equally likely as those seen by neurologists (p = .07). A significantly smaller percentage of physiatrists ordered vaccinations than all other specialties (p < .04). Utilizing pre-existing survey data, the misclassification rate (those immunized but not billed) was estimated at 22% of our original cohort. Thus, approximately 800 patients, one third of those seeing physiatrists, may not have been immunized. We estimated the increase in hospitalization costs to be $117 per nonvaccinated patient (total >$90,000)., Conclusions: Missed opportunities for vaccination by physiatrists appear to be more frequent than in other specialties and have potentially large health and economic costs.

Context: Despite increased emphasis on primary care in the United States, most care continues to be provided by specialists. The extent to which specialists incorporate elements of primary care in their approach to ambulatory patients is unknown., Objectives: To examine the extent to which selected medical and surgical subspecialties provide generalist care to Medicare patients, and to compare patterns of care between specialists and generalists., Design: A cross-sectional study of all ambulatory care recorded in Part B of the Washington State Medicare Claims Database in 1994 and 1995., Setting: Ambulatory practices in Washington State., Patients: Medicare beneficiaries 65 years or older who made office visits to the study physicians., Main Outcome Measures: The extent to which individual specialties accounted for the majority of visits made by patients to physicians (a measure of continuity), provided care outside the traditional domain of their specialty (a measure of comprehensiveness), and provided influenza immunization., Results: A total of 373 505 patients constituted the sample. Patients had an average of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and family physicians differ systematically from the practices of most specialists. Approximately half (49.8%) of all ambulatory visits to general internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medical specialist and 11.7% of surgical specialist visits. The rate of influenza immunization was 55.4% for patients who received the majority of their care from generalists, 47.7% from medical specialists, and 39.6% from surgical specialists. Pulmonologists, general surgeons, and gynecologists were more likely than other specialists to provide services outside their specialty., Conclusions: Most specialists do not assume the principal care responsibility for elderly patients, although a substantial proportion of patients see only specialists for their care. Selected specialties assume the generalist role more often, particularly when they provide the majority of outpatient care for an individual patient.

Context: Women in rural areas are highly dependent on public clinics for family planning services, yet little information has been collected on rural family planning providers, especially on their funding and operation., Methods: All 31 family planning clinic sites in rural Washington State were surveyed about their sponsorship, staffing, service provision and population coverage., Results: Clinic sites were located in 25 of the 53 discrete rural health service areas of Washington State. While the three wealthiest areas had clinics, eight of the poorest areas had no clinics. Eight clinics were Planned Parenthood affiliates, eight were private freestanding clinics and 15 were local health department sites. Clinic sites were small (with the equivalent of 2.4 full-time staff members, on average) and offered a mean of 18 of 43 potential reproductive and women's health care services; general primary care services were rarely provided. Only one clinic offered abortions., Conclusion: Family planning clinics in rural Washington State offer an important but limited number of services. Many rural areas have no local family planning clinic. Given these clinics' reliance on federal and state funding, decreased public support might seriously impair family planning provision in rural areas.

Objectives: This study examined whether Medicaid-insured women at low risk receive less adequate obstetrical care than privately insured women., Methods: Low-risk women who were cared for by a random sample of obstetrical providers in Washington State were randomly selected. Information on all prenatal and intrapartum services was abstracted from medical records. Service information was aggregated into standardized resource-use units. Results compared Medicaid-insured women with those who were privately insured., Results: Medicaid-insured women were significantly younger (22.5 years vs 26.9 years) and averaged 6% fewer visits than privately insured women. Nonetheless, Medicaid status had no meaningful association with prenatal, intrapartum, or overall resource use. Some variation occurred in individual resources received. Medicaid-insured women had 38.8% more resources expended on testing for sexually transmitted diseases. Privately insured women had more resources expended on alpha-fetoprotein testing and on amniocentesis. There were no meaningful differences in birthweight or gestational age at delivery., Conclusions: In this study of women who entered obstetrical care at low risk, similar care and resources were expended on Medicaid-insured and on privately insured women.