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Erik J Groessl,1,2 Steven R Tally,1 Naomi Hillery1 1Health Services Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, CA, USA; 2VA San Diego Healthcare System, San Diego, CA, USACorrespondence: Erik J Groessl, University of California San Diego, Health Services Research Center, 9500 Gilman Drive, Mail Code 0994, San Diego, CA, 92037, USA, Tel +1 858 622 1771, Email egroessl@health.ucsd.eduPurpose: Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality, and is associated with significant respiratory impairment, decreased quality of life, and high health care costs. Recent evidence indicates significant clinical benefit results from adding humidified high-flow therapy (HHFT) to standard long-term oxygen therapy (LTOT) as a home-based therapy in persons with severe COPD. The objective was to evaluate the cost-effectiveness of adding HHFT to standard treatment of COPD patients using LTOT with US healthcare cost estimates.Patients and Methods: A Markov state-transition model was developed using data from a prospective clinical trial of adding HHFT to standard therapy for persons with severe COPD using LTOT. The analysis was conducted from the US health care system perspective using a 5-year time horizon and 3% discount rate. QALYs and downstream healthcare costs were modeled. One-way and probabilistic sensitivity analyses were used to examine the impact of input parameters on the incremental net monetary benefit (NMB).Results: Incremental QALYs accrued were 0.058 (2.047 vs 1.989 QALYs for HHFT and standard therapy groups respectively). Incremental total costs were -$3939 ($47,516 vs $51,455 for HHFT and standard therapy groups respectively). Thus, HHFT was the dominant treatment in the analysis, resulting on both better health and lower total costs. Varying utility and cost inputs individually never resulted in NMB approaching 0. Probabilistic analyses indicate that HHFT is cost-effective in 84% of simulations.Conclusion: Our results indicate that the reductions in acute exacerbations of COPD (AECOPDs) that result from adding HHFT for persons with COPD on LTOT will produce both health benefit (QALYs) and cost savings. Cost savings occur because the HHFT device costs are more than offset by reductions in costly COPD exacerbations. Health care systems and payors can benefit from wider implementation of HHFT with existing treatments.Keywords: COPD, acute exacerbations, cost-effectiveness, humidified high flow therapy

Septic arthritis of native joints is uncommon, but the condition can be threatening to life and limb if left untreated.1 Septic arthritis of the acromioclavicular (AC) joint of the shoulder is particularly rare and has only appeared sparsely in medical literature, mainly through individual case reports. Early recognition and treatment of the condition is vital, but diagnosis of septic AC arthritis can be difficult due to its presentation with vague symptoms and nonspecific laboratory findings. This case report describes the care of a patient with poorly managed diabetes who presented to the emergency department with one month of pain and swelling of the left shoulder and two weeks of pain and swelling in the right ankle. Imaging revealed fluid in the AC joint, and laboratory evaluation showed an elevation in inflammatory markers, including leukocyte count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The patient's hospital course was complicated by methicillin-sensitive Staphylococcus Aureus bacteremia without evidence of sepsis. The patient underwent open debridement and washout of both the ankle and AC joint without complication. After recovery, the patient was discharged to a rehabilitative center with IV antibiotics and weekly follow up care with infectious disease specialists. This case illustrates the importance of early diagnosis and treatment of septic arthritis, even in less common joint spaces, to prevent progression of this dangerous disease., Topics: Septic arthritis, acromioclavicular joint, diabetes, bacteremia., (© 2024 Tally, et al.)

San Diego County Mental Health system clients completed a questionnaire after the October 2007 wildfires. As compared to those not in an evacuation area, those residing in an evacuation area reported significantly more impact of the fires. Clients who evacuated were most affected, followed by those in an evacuation area who did not evacuate. Evacuation strongly impacted client-reported emotional effects of the fire, confusion about whether to evacuate, and ability to obtain medications. Gender and clinical diagnosis interacted with evacuation status for some fire impact variables. Loss of control and disruption of routine are discussed as possibly related factors.

Background: The ability to perform many daily tasks relies on good visual acuity at various distances. A review of existing measures of visual function revealed gaps in task content, particularly tasks that rely on intermediate vision., Purpose: This research sought to extend the content base and visual range coverage of tasks used to assess visual function., Methods: Ophthalmology patients (n = 72) with myopia, hyperopia, presbyopia, astigmatism, cataracts, and/or glaucoma were involved in various qualitative sub-studies, including life event journaling, telephone interviews, and both on-line and face-to-face focus groups. The resulting journal entries and transcripts were thematically analyzed to identify visual tasks that rely on visual acuity in the near, intermediate, and distant visual ranges., Results: A wide variety of distance-specific visual tasks were identified. Certain types of tasks relied on distance vision, such as; ambulation, driving, leisure and sports, and social functions. Other task groupings such as technology use and activities of daily living relied primarily on near and intermediate vision. Two new content areas were identified, technology use and safe task performance., Conclusions: This thematic analysis provides a rich body of information about tasks that affect daily life and are made more difficult by poor visual acuity at various distance ranges.

Objective: To compare the responsiveness to clinical change of five widely used preference-based health-related quality-of-life indexes in two longitudinal cohorts., Study Design and Setting: Five generic instruments were simultaneously administered to 376 adults undergoing cataract surgery and 160 adults in heart failure management programs. Patients were assessed at baseline and reevaluated after 1 and 6 months. The measures were the Short Form (SF)-6D (based on responses scored from SF-36v2), Self-Administered Quality of Well-being Scale (QWB-SA), the EuroQol-5D developed by the EuroQol Group, the Health Utilities Indexes Mark 2 (HUI2) and Mark 3 (HUI3). Cataract patients completed the National Eye Institute Visual Functioning Questionnaire-25, and heart failure patients completed the Minnesota Living with Heart Failure Questionnaire. Responsiveness was estimated by the standardized response mean., Results: For cataract patients, mean changes between baseline and 1-month follow-up for the generic indices ranged from 0.00 (SF-6D) to 0.052 (HUI3) and were statistically significant for all indexes except the SF-6D. For heart failure patients, only the SF-6D showed significant change from baseline to 1 month, whereas only the QWB-SA change was significant between 1 and 6 months., Conclusions: Preference-based methods for measuring health outcomes are not equally responsive to change., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: We evaluate the effects of mode and order of administration on health-related quality of life (HRQOL) scores., Method: We analyzed HRQOL data from the Clinical Outcomes and Measurement of Health Study (COMHS). In COMHS, we enrolled patients with heart failure or cataracts at three sites (University of California, San Diego, University of California, Los Angeles, and University of Wisconsin). Patients completed self-administered HRQOL instruments at baseline and months 1 and 6 post-baseline, including the EuroQol (EQ-5D), Health Utilities Index (HUI), Quality of Well-Being Scale--self-administered (QWB-SA), and the Short Form (SF)-36v2. At the 6 months follow-up, individuals were randomized to mail or telephone administration first, followed by the other mode of administration. We used repeated measures mixed effects models, adjusting for site, patient age, education, gender, and race., Results: Included were 121 individuals entering a heart failure program and 326 individuals scheduled for cataract surgery who completed the survey by mail or phone at the 6-month follow-up. The majority of the sample was female (53%) and white (86%). About a quarter of the sample had high school education or less (26%). The average age was 66 (36-91 range). HRQOL scores were higher (more positive) for phone administration following mail administration. The largest differences in scores between phone and mail responses occurred for comparisons of telephone responses for those who were randomized to a mail survey first compared with mail responses for those randomized to a telephone survey first (i.e., mode effects for responses that were given on the second administration of the HRQOL measures). The QWB-SA was the only measure that did not display the pattern of mode effects. The biggest differences between modes were 4 points on the SF-36v2 physical health and mental health component summary scores, 0.06 on the SF-6D, 0.03 on the QWB-SA, 0.08 on the EQ-5D, 0.04 on the HUI2, and 0.10 on the HUI3., Conclusions: Telephone administration yields significantly more positive HRQOL scores for all of the generic HRQOL measures except for the QWB-SA. The magnitude of effects was clearly important, with some differences as large as a half-standard deviation. These findings confirm the importance of considering mode of administration when interpreting HRQOL scores.

Aim: The aim of this study was to analyze the Literature covering the characteristics of secondary ruptured abdominal aortic aneurysm (AAA) following endovascular repair with aortic stent graft (ASG)., Methods: The study based on a Pubmed search of articles describing the characteristics of secondary ruptured AAA after ASG between January 1995 and May 2008. A total of 105 articles were selected, including the following characteristics: aneurysm diameter evolution, delay between implantation and rupture, average follow-up time, mechanisms implicated, results following further repair., Results: Out of a total of 23 002 ASG cases reported, of which 47.4% (10 911) were carried out by ASG suppliers themselves, 227 ruptures (1%) have been described. After exclusion of the perioperatory ruptures (occurring within the first month), the average duration of implantation at rupture was 27+/-16 months, with an average follow-up of 22.4+/-14 months. When the evolution of the sac was mentioned, AAA diameter decreased or remained stable before rupture in 55.7% of the cases. Mechanisms of rupture have been reported in 168 cases and consisted in a failure of the ASG in 76.1% of the cases. When patients were operated, the mortality rate was 39%., Conclusion: This study showed how little is actually known about rupture of stented AAA. The available data were provided by studies sponsored by companies in 47.4% of the cases, and had usually too short follow-up considering the average of duration of implantation at rupture. Rupture mechanisms were not reported in all cases, but a failure of the ASG was considered as responsible for the rupture in a majority of the cases. The absence of warning signs of rupture emphasizes the need of caution about the durability of ASG and also the need to undertake further studies with longer follow-ups.

The purpose of this report is to propose an in vitro approach to predicting the long-term dilative behavior of knitted polyester prosthetic grafts. Various techniques were applied to five warp knitted fabric prosthetic grafts in order to determine the following fabric properties: knitted fabric structure, textile structure, number and respective linear density of threads and strands, and length of yarn in each stitch. Following these investigations, the prosthetic grafts underwent testing to determine specific strength at break, breaking extension, and stress-strain curve. On two prosthetic grafts, image analysis was performed during circumferential tensile strength testing in order to monitor changes in structural features as a function of stress. Changes in the distance between two wales and two courses of stitches and stitch surface were measured. In addition to surface deformation, thickness was measured, using an induction sensor. Study of fabric structure showed many differences between the five models made by different manufacturers. Knit fabric structure was Indeforma in three cases and half-tricot in two. Strand number and size varied greatly from one model to another. Pattern also varied from one model to another, with knit stitch density varying from 1 to 3. Specific strength at break testing showed great differences in the mechanical properties of the grafts. These differences were especially obvious in the first part of the rheograms, which reflects the ability of the graft to comply in response to low-strength forces, i.e., much lower than those necessary to cause rupture. Image analysis of stitch behavior under stress further confirmed differences in graft behavior depending on the fabric structure adopted by the manufacturers. The in vitro approach proposed in this study to analyze the fabric characteristics of knitted prosthetic grafts effectively revealed differences in construction and behavior. These differences could account for differences in the dilative behavior of grafts in vivo.

Background: We conducted a randomized controlled trial to evaluate the effects of patient decision support Web sites on decision quality for men considering prostate cancer screening., Methods: Men older than 50 years (N = 611) were randomly assigned to 1 of 4 Internet conditions: traditional didactic decision aid providing information about prostate-specific antigen (PSA) screening options and outcomes; chronic disease trajectory model for prostate cancer followed by a time-trade-off exercise; both the didactic decision aid and the chronic disease trajectory model; or links to public prostate cancer-specific Web sites from credible sources (control condition). Participants completed questionnaires at baseline and after their physical examination. Primary outcome measures were PSA test choice, prostate cancer treatment preferences, knowledge and concern about prostate cancer, and decisional conflict., Results: Participants assigned to view public Web sites were less likely to review information (116 participants [76.8%] reviewed) than those assigned to experimental groups (399 [86.7%] reviewed; P = .004). Greater reductions in PSA screening from pretest to posttest were observed among participants assigned to the traditional decision aid (-9.1%) or chronic disease trajectory model (-8.7%), compared with participants assigned to the combination (-5.3%) or control (-3.3%) groups (P = .047). Preferences for watchful waiting increased significantly in all 4 groups (baseline, 219 [35.8%]; follow-up, 303 [66.2%]; P < .001). Knowledge scores were lowest for those assigned to public Web sites (mean [SD] score, 7.49 [0.19] of questions correct) and highest for the traditional decision aid (8.65 [0.18] of questions correct; P = .005)., Conclusion: Public Web sites about prostate cancer provide less effective decision support than a specially designed Internet decision aid.

This study examined the correlates of symptoms of depressed mood among adolescents in 2 dramatically different cultures (n = 502 in Tianjin, People's Republic of China; n = 201 in greater Los Angeles). Gender, stressful life events, perceived parental warmth, and conflict with parents were associated in the expected direction with depressive symptoms in each cultural setting. As predicted, regression analyses showed that the quality of family relationships and grades in school had significantly stronger associations with depressive symptoms among Chinese youths than among U.S. youths, whereas gender differences in depressive symptoms were greater among the U.S. youths. Peer warmth moderated the effects of particular risk factors for depressive symptoms in each cultural setting.

We report the case of an 84 year-old man who suffered of paraplegia after surgery of an abdominal aortic aneurysm. The neurologic status did not improve during 5 years of follow-up. This complication is rare in light of the review of the literature. It is more frequent after emergency (1.4%) and redux (19%) surgery than after elective surgery (1.1%). Its mechanisms are anatomic (occlusion of the Adamkievitz artery and of the pelvic collateral arteries) and hemodynamic mechanisms (thromboembolism, low systemic tension, long supra-renal clamping). Since pre-operative aortography to detect anatomic variations is not realistic, its only prevention remains maintenance of intra-operative hemodynamic, systemic heparinization, and preservation of the pelvic collateral circulation.

A 7 cm diameter tumor of the left atrium is reported in a 78 year-old woman with a past history of pT3N1M0 colonic adenocarcinoma. The histological examination of the atrial tumor disclosed areas of highly vascularized myxoid stroma with cells strongly reactive for vimentin. Multiple mucoid spaces lined by a single layer of goblet cells were scattered among those typical areas of myxoma. No nuclear atypia was observed. Cytoplasm of the glandular cells was immunoreactive for epithelial antisera (keratin, EMA), CEA and CA19.9. Two years later, the patient was doing well, with no local recurrence of the cardiac myxoma and no secondary location of the colonic adenocarcinoma. The histological characteristics, the absence of atypia, the absence of tumoral extension or neoplastic lymphatic vascular thrombi in the pedicle or in the interatrial septum, and the finding of typical myxomatous areas supported the diagnosis of cardiac myxoma with glandular component. To our knowledge, 21 cases of myxoma with glandular mucinous component, focal or prominent, have been previously published in the literature. These myxoma were generally sporadic cases with the same clinical features and prognosis as typical myxoma. Immunoreactivity of these glandular structures was constant for epithelial markers. The positive immunostaining by CEA, and by CA19.9 in our case, reflects the histogenetic endodermal origin.

Myxomas rarely are located on the mitral valve. We report the case of a 44-year-old man operated on successfully with mitral valve conservation, which is the 21st case of mitral valve myxoma reported in the western literature. Among the cases reported in the literature, the diagnosis was made at the time of autopsy in 6 cases, with premortem heart failure in 1 case. A clinical diagnosis was made in 15 cases on the basis of the following symptoms: peripheral embolism in 9 cases, cardiac signs in 4 cases, and constitutional manifestations in 2 cases. The clinical presentation of mitral valve myxoma differs slightly from that of other cardiac myxomas in that it has a lower incidence of constitutional manifestations. The gold standard for noninvasive diagnosis and localization of cardiac myxomas is transesophageal echocardiography. It allows for the detection of early, small valvular tumors and may help to characterize better their location and echostructure, facilitating the choice of an optimal surgical approach through preoperative study of the integrity and mobility of the valve. Conservative operative treatment by resection of the area of implantation of the myxoma followed by suture repair of the valve and annuloplasty may be recommended as the most appropriate treatment option for this rare condition.

Endarterectomy of the carotid bifurcation through a longitudinal arteriotomy of the common and internal carotid arteries followed by a direct closure is still accepted as the main surgical technique for carotid stenoses. However, this technique is complicated in about 10% of the cases by a restenosis. Mechanisms of myointimal hyperplasia leading to restenosis are not completely explained. The technique of eversion endarterectomy of the internal carotid artery has been said to be an alternate technique which could decrease the incidence of restenosis. We described the three main techniques of eversion endarterectomy and their results. The technique of eversion endarterectomy after proximal section of the internal carotid artery is the most frequently used. It allows to treat easily length excess of the internal carotid artery. Its results are good in terms of neurologic morbidity and mortality. However, randomized comparative studies are still required in order to determine its role on the incidence of restenosis despite the first encouraging results of first non comparative studies. The technique of eversion endarterectomy after distal section of the internal carotid artery has been proposed by Chevalier who reported also good short term results and no delayed restenosis.

Cystic adventitial disease is an uncommon vascular anomaly first described in 1947 in the external iliac artery. The preferential localization is the popliteal artery although other arteries and veins may also be involved though not always recognized. There have been 45 extra-popliteal localizations of adventitial cysts reported in the literature. Thirty cases involved an artery an 15 a vein. The iliofemoral axis, with 33 reported cases, is the preferential localization of these extra-popliteal adventitial cysts (including 22 arteries and 11 veins). All the other cases also involved a vessel near an articulation (knee, ankle, elbow, wrist). Despite a preferential popliteal arterial localization only one case involved the popliteal vein. The diagnosis is rarely made before surgery, probably because of the nonspecific clinical presentation. Ultrasonography should allow better recognition of these adventitial cysts, eliminating an aneurysm or a synovial cyst, and evidencing the localization of the cyst within the vessel wall.

Infection of pigs by the whipworm (Trichuris suis) resulted in profuse diarrhea on postinfection days 17 to 21. Anorexia, retardation of growth, dehydration, and emaciation were observed in infected pigs. Scanning electron micrography showed nematodes embedded in the mucosa of the cecum and colon, with resultant disruption of the mucosa. Infected pigs had decreased values of albumin, amylase, calcium and creatine phosphokinase, but increased values of alpha-, beta-, and gamma- globulins, total iron-binding capacity, copper, potassium, uric acid, and aspartate aminotransferase.