Subsequent Medical Care Research Articles

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Sir: We appreciate Dr. Freshwater’s comments. Thumb replantation is a technically difficult procedure. Comments and discussion about this procedure should benefit us all. The intent of the article was to present a different technique for revascularization of an amputated thumb. The technique combines a vein transposition from the dorsum of the index metacarpal to the thumb, providing venous outflow with one anastomosis. An arterial conduit, rather than a venous conduit, is used to re-establish arterial inflow. As cited, others have described these techniques for different circumstances. We combined these techniques to provide blood supply to the replanted thumb. Our data do not allow us to claim that this technique is better than another. Rather, it is a suitable alternative. Arterial grafts have advantages and disadvantages over vein grafts. The article discusses these elements. Having used both arterial and venous grafts, we prefer arterial grafts, but we cannot prove that they are better. To our knowledge, to date, the use of an arterial graft has not impaired subsequent medical care to a patient. Our patients have had no local vascular issues following arterial graft harvest. Our cardiac surgeons do use radial artery for coronary bypass but have not progressed to using the deep inferior epigastric artery. In that regard, our patients have been fortunate. Are arterial grafts more than is needed? We cannot say. Have we used a free flap for reconstruction when a less invasive technique would have allowed healing of a wound? Yes. But in the end, the sum total of the advantages and disadvantages of the free flap outweighed that of the less involved alternatives. We believe the same is true of arterial grafts in this instance. We appreciate the reviewer’s insightful comments on our article and will incorporate them into future medical decisions. W. Bradford Rockwell, M.D. Jaime Haidenberg, M.D. K. Bo Foreman, Ph.D. Plastic Surgery University of Utah Salt Lake City, Utah

Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction

Prior studies have demonstrated an inconsistent association between patients' arrival time for acute myocardial infarction (AMI) and their subsequent medical care and outcomes. Using a contemporary national clinical registry, we examined differences in medical care and in-hospital mortality among AMI patients admitted during regular hours (weekdays 7 am to 7 pm) versus off-hours (weekends, holidays, and 7 pm to 7 am weeknights). The study cohort included 62,814 AMI patients from the Get With the Guidelines-Coronary Artery Disease database admitted to 379 hospitals throughout the United States from July 2000 through September 2005. Overall, 33 982 (54.1%) patients arrived during off-hours. Compared with those arriving during regular hours, eligible off-hour patients were slightly less likely to receive primary percutaneous coronary intervention (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 to 0.98), had longer door-to-balloon times (median, 110 versus 85 minutes; P<0.0001), and were less likely to achieve door-to-balloon < or = 90 minutes (adjusted OR, 0.34; 95% CI, 0.29 to 0.39). Arrival during off-hours was associated with slightly lower overall revascularization rates (adjusted OR, 0.94; 95% CI, 0.90 to 0.97). No measurable differences, however, were found in in-hospital mortality between regular hours and off-hours in the overall AMI, ST-elevated MI, and non-ST-elevated MI cohorts (adjusted OR, 0.99; 95% CI, 0.93 to 1.06; adjusted OR, 1.05; 95% CI, 0.94 to 1.18; and adjusted OR, 0.97; 95% CI, 0.90 to 1.04, respectively). Similar observations were made across most age and sex subgroups and with an alternative definition for arrival time (weekends/holidays versus weekdays). Despite slightly fewer primary percutaneous coronary interventions and overall revascularizations and significantly longer door-to-balloon times, patients presenting with AMI during off-hours had in-hospital mortality similar to those presenting during regular hours.

Current status of the rehabilitation of post-mastectomy women in the Federal Republic of Germany

The effectiveness of rehabilitation measures in acute in-patient clinics was assessed by questioning 220 women who had had a mastectomy. As criteria were used: function of the shoulder-arm region on the operated side; prevention of oedema and infection on the operated side; emotional support; supply of an external breast prosthesis. The results indicate that rehabilitation measures need to be improved. Deficiencies in counselling and supervision were noted with regard to oedema and infection prevention in 71%, emotional support in 69%, and supply of a prosthesis in 56%. The interviews also revealed that rehabilitation depended primarily on personal engagement of the medical personnel, less on the size and type of clinic. Increasing importance is ascribed to subsequent (long-term) medical care and supervision, as is provided in the FRG under insurance regulations.

Patterns of Health Services Use Associated With Veterans Affairs Outpatient Substance-Use Treatment

This study examined service use and costs associated with receiving intensive outpatient (IOP) substance-use treatment. Veterans Affairs national databases were used to identify all veterans receiving IOP substance-use treatment in fiscal year (FY) 1999. Changes in the use of health services (2 years pretreatment compared with 2 years posttreatment) were examined. Three IOP treatment groups were defined: (1) veterans attending 1-5 IOP visits (n=2,384), (2) 6-14 IOP visits (n=2,940), and (3) >or= 15 IOP visits (n=3,005). In addition, a demographically matched no-treatment group was defined as veterans in primary care with a substance-use diagnosis and no substance-use treatment in FY 1999 (n = 7,328). General medical, psychiatric, and substance-use encounters in inpatient and outpatient settings were retrieved for the 4 years. Generalized estimating equations analyses were used to compare changes in service use across the three IOP groups controlling for demographic characteristics and comorbidity. Total outpatient visits increased in all three treatment groups after IOP, with the largest increase observed in the group with >or= 15 visits (mean visits = 5, 44, and 57, respectively). In comparison, total visits decreased in the no-treatment group (-7). This pattern was similar across settings (general medical, psychiatric, and substance use). Total inpatient days decreased among the four groups, with the no-treatment group having the least amount of decrease (mean change in days = .34, .32, .18, and .03, respectively). Analysis of cost data showed similar findings. Results indicated that more intense IOP treatment is associated with increases in subsequent psychiatric, substance-use, medical, and total outpatient care and decreases in expensive inpatient care.

The quality of self-care counselling by pharmacy practitioners, supported by IT-based clinical guidelines

The primary objective of the study was to assess the quality of self-care counselling from pharmacy practitioners, supported by national clinical guidelines. The research questions addressed (1) the distribution of symptoms among customers in need of self-care counselling, (2) the quality of the self-care advice provided by pharmacy practitioners, (3) the degree of customer compliance with appropriate pharmacy advice versus the extent of symptom relief, (4) and versus a subsequent medical care visit, and (5) which resource the customers would have turned to in the first place for their ailments, had the pharmacy practitioner not been available. Three large community pharmacies with non-prescription self-selection departments in central Sweden. Ten pharmacy practitioners counselled all customers > or = 18 years old, with whom a dialogue was initiated on advice or products for self-care. The counselling was based on national clinical guidelines for self-care advice in the form of a software decision support program. The data collection consisted of documentation of background customer information, independent assessments of the quality of the advice provided and of telephone follow-ups. Of all documented symptoms (n = 250), the most common were allergy (26.4%), musculoskeletal symptoms (8.4%) and dyspepsia (7.2%). Independent assessments of the documentation by a physician and a pharmacist found that self-care advice was appropriate to give 97.6% of the customers and that the advice provided was correct in 88.4% of the cases. In total, 217 cases (86.8%) were fully approved by both the physician and the pharmacist. Among the 182 customers who claimed that they complied completely with appropriate advice provided, 135 (74.2%) experienced a great improvement in symptoms. Among the 21 who had only partly followed the advice, six (28.6%) reported the same level of improvement (p < 0.001). If the pharmacy practitioner had not been available, 56.8% of the customers would have turned to medical care in the first instance. The study demonstrates the high quality of pharmacy practitioners' self-care counselling supported by IT-based national clinical guidelines, including a favourable impact on customers' ailments. Furthermore, it reveals that pharmacy practitioners greatly relieve the pressure on the health-care system, resulting in reduced costs to society.

Survival of severe amlodipine intoxication due to medical intensive care

We report the case of attempted suicide with amlodipine, chlorthalidone and mefenamic acid and subsequent medical intensive care measures which resulted in total recovery of a 42-year-old male. After admission to the medical intensive care unit the intoxicated patient was deeply hypotensive and needed fluid replacement, dobutamine and norepinephrine. Additionally insulin and calcium gluconate were given. Since hypotension persisted and the patient developed oliguria, terlipressin was applied and finally showed an effect on blood pressure and on urinary output. A volume overload of 7 L in the first 24 h resulted in a pulmonary edema. The patient was started on non-invasive ventilation with continuous positive airway pressure (CPAP) and frusemide was added to the therapy with good success. Quantitative determination of amlodipine in plasma samples was performed by liquid chromatography–tandem mass spectrometry (LC–MS/MS). The highest amlodipine concentrations was measured in the plasma sample collected approximately 8 h after ingestion of the drug, and was 393 μg/L. Four days later, it was possible to stop the treatment with catecholamines, at that time the amlodipine plasma concentration had declined to 132 μg/L, still tenfold higher than therapeutic (5–18 μg/L). Elimination half-life of amlodipine is approximately 55 h. After 6 days in the intensive care unit the patient was transferred to psychiatric treatment. Intensive care management and plasma levels in this intoxication case are compared to data from literature on other cases.

Medical Cost-Offset Following Treatment Referral for Alcohol and Other Drug Use Disorders in a Group Model HMO

The purpose of this study was to determine whether specialty alcohol and other drug (AOD) treatment is associated with reduced subsequent medical care costs. AOD treatment costs and medical costs in a group model health maintenance organization (HMO) were collected for up to 6 years on 1,472 HMO members who were recommended for specialty AOD treatment, and on 738 members without AOD diagnoses or treatment. Addiction Severity Index measures were also obtained from a sample of 293 of those recommended for treatment. Changes in medical costs did not differ between treatment and comparison groups. Nor did individuals with improved treatment outcomes have greater reductions in medical costs. AOD treatment costs were not inversely related to subsequent medical costs, except for a subgroup with recent AOD treatment. In the interviewed sample, better treatment outcomes did not predict lower subsequent medical costs. Multiple treatment episodes may hold promise for producing cost-offsets.

Discharge planning and patient satisfaction in an emergency short‐stay unit

To determine the adequacy of discharge planning from an emergency short-stay unit (ESSU), and patient knowledge of and satisfaction with the ESSU. Prospective follow up of patients discharged from an ESSU using patient surveys and a computerized patient information system, with descriptive and comparative data analysis. Eighty-five per cent of respondents stated that they received adequate discharge instruction, and 89% that they benefited from their ESSU admission. However, 29% of patients made unscheduled visits to another medical practitioner post discharge and 9% were readmitted to hospital for the same problem with which they were discharged from the ESSU. Patient satisfaction with all aspects of care in the ESSU was high. Most patients discharged from an ESSU are provided with adequate discharge instruction, but a sizeable proportion require subsequent medical care for the same problem after discharge. Patient satisfaction with all aspects of care in an ESSU is high.

Cost-benefit analysis of an integrated approach to reduce psychosocial trauma following neurosurgery compared with standard care: two-year prospective comparative study of enhanced specialist liaison nurse service for aneurysmal subarachnoid hemorrhage (ASAH) patients and carers

Background Dysfunctional psychosocial stress often follows standard treatment for aneurysmal subarachnoid hemorrhage (ASAH). An enhanced Specialist Liaison Nurse (SLN) service sought to reduce this stress in a 2-year comparative prospective study, and was designed to determine if such a service would be cost-effective? Method Clinical data based on consultant notes, included Glasgow Coma Scale (GCS) and high-risk bleed score. Psychosocial outcomes used a standardized patient/carer designed questionnaire to compare outcomes of the SLN cohort ( n = 184) with retrospective 18/12 control ASAH cohort ( n = 142). Costs-benefits analysis identified savings in reduced need for subsequent medical care, time-off-work, and contributions to the economy. Results The cohorts were socio-clinically well matched; 54% aged less than 55 years, 83% were middle-class and 32% had children still in school; 65% of SLN patients had high risk bleeds, and 81% were Grade 1 and 2 on the G.C.S. The SLN patients and carers had statistically significantly reduced psychosocial trauma compared to controls, with early and easy accessibility being the key to success of SLN. Net savings of $280,000 per annum at 2003 prices, from reduced time-off work, re-admissions and saved medical time. Prospectively, more than $3.03 million is added to the national economy by the 80% of employed patients returning to work. Conclusions We conclude that an integrated ASAH treatment yields major psychosocial and economic benefits. Dysfunctional stress after an ASAH is not inevitable in the majority of patients. High-technology neurosurgery is not just a public cost but also improves and saves lives and generates revenue.

Involvement of detoxification system enzymes in pathogenesis of some common multifactorial diseases. Predictive genetic testing

The review summarizes the original data concerning involvement of some genes participating in Phase I and Phase 2 of detoxification systems in the origin, progression and treatment efficiency of such common multifactorial diseases as endometriosis, bronchial asthma, alcoholic cirrhosis, habitual miscarriages, gestosis, lung cancer, chronic bronchitis etc. Of special theoretical and practical value of these studies is an identification of highly nonrandom association of particular functionally inferior alleles of the genes belonging to glutathione-S- transferase super-gene family (GSTM1 (0), GSTT1 (0), GSTPi (s) as well as N-acetyl transferase - NAT-2 (s) with these diseases. Thus molecular testing of these alleles might be recommended as feasible predictive test for personal predisposition evaluation, for estimation of remote prognosis and for the treatment strategy in at least some of these diseases. Somewhat about 5-7% of all population in the North-West of Russia possess the most unfavorable combinations of GST genes genotypes (GSTM10/0; GSTTI0/0, GSTPi s/s). Early identification of these individuals by means of genetic screening supplemented with subsequent adequate social and medical care should be considered as feasible social program for efficient prevention of these diseases at the national level. Relying on these data as well as on the polymorphism studies and common mutation identification of other genes the idea of Genetic Form for the pregnant women is suggested and briefly discussed. Implementation of new sophisticated and highly productive molecular techniques amenable for the widespread population gene polymorphism screening becomes highly advisable.

Ecological genetics and predictive medicine

The review highlights present state and some future perspectives of new but quickly expanding area of predictive medicine. Its basic background dealing with molecular testing of genetic polymorphisms as well as its practical and theoretical implications are discussed. Original data concerning the involvement of the genes participating in Phase 1 and Phase 2 of detoxification systems as well as of the genes controlling mineral bone density in the origin, progression and treatment efficiency of some common multifactorial diseases such as endometriosis, bronchial asthma, alcoholic cirrhosis, habitual miscarriages, gestosis, lung cancer, chronic bronchitis and osteoporosis are briefly outlined. Of special theoretical and practical value of these studies is an identification of highly nonrandom association of particular functionally inferior alleles of the genes belonging to glutathione-S-transferase super-gene family (GSTM1 (0), GSTT1 (0), GSTPi (s) as well as N-acetyl transferase - NAT-2 (s) with some of these diseases. Molecular testing of the relevant alleles might be recommended as feasible predictive test for personal predisposition evaluation, for estimation of remote prognosis and for the treatment strategy in at least some of these diseases. Early identification of these individuals by means of genetic screening supplemented with subsequent adequate social and medical care should be considered as feasible social program for efficient prevention of these diseases at the national level. Relying on these data as well as on the polymorphism studies and common mutation identification of other genes the idea of Genetic Form for the Pregnant Women is suggested and briefly discussed.

The Swenoteca Medical Care Program as a Resource for Patients and Physicians

The aim of the thesis is to describe and analyse men's experience of testicular cancer, the interaction with caregivers during the course of the disease and in the subsequent medical care process and the attitude of close relatives during this period and how they describe their life during the medical care process.The results reported in article I describe, on the basis of audio-taped dialogues between patients and physicians and interviews between patients and physicians, the impact the medical care program SWENOTECA has on the interaction between patient and physician and on how the patients experience their disease and the follow-up of care and treatment. As a result of the medical care program SWENOTECA, oncological care and treatment is framed in a structured care context which gives the patients a perspective of the future and very much influences their sense of safety and security. Article II describes how, in interviews, men reconstructed their discovery of a testicular tumour, how they express their thoughts about and attitudes towards cancer. The men have a functionally oriented approach to their body, which means that the ability to work and carry out their day-to-day duties is a more important sign that they are not ill than are individual physical changes in an organ. In article III, the audio-taped dialogues between patients and physicians have been analysed in order to determine how routinization in the dialogue affects the patient's ability to talk about sensitive subjects and bring up questions and problems on his own initiative. A consequence of the routinised medical care context is that follow-up consultations between patients and physicians focus on restoring trust in the value of the check-ups and the prospects of the disease being cured. In article IV, interviews with close relatives of men treated for testicular cancer are analysed. In these interviews, the parties discussed how cancer affected family life and daily routines as well as how relationships and closeness developed and what the future held. Testicular cancer is something that very much affects the men's close relatives. They do not regard themselves, or are regarded by others, as people with needs of their own and the sorrow and fear they feel results in social isolation during the period of the disease.

Pigmented renal clear cell carcinoma with melanocytic differentiation

Renal cell carcinoma (RCC) is the most common malignant tumor of the adult kidney, and its incidence has been steadily rising. RCC consists of several subtypes, each of which has its own clinical features, and cytogenetic and molecular characteristics. Recognizing histologic patterns of RCC is important not only for correct diagnosis, but also for providing insight into the biological behavior of the tumor and subsequent appropriate medical care for the patient. Pigments other than hemosiderin has been observed in RCC, but none of them have been proved to be melanin. Melanotic tumors, either primary or metastatic, are rare in the kidney. We present an unusual case of melanin-pigmented clear cell RCC with melanocytic differentiation, an unusual variant that may lead to errors in diagnosis and treatment. HUM PATHOL 32:233-236. This is a US Government work. There are no restrictions on its use.

Therapeutic Trials in HIV Infection: Which Benefits for Which Patients?

Purpose: The purpose of our study was to make an assessment of the HIV patients’ overall opinion of therapeutic trials, to analyze the motivations and the reasons linked to this perception, and to determine if their involvement in a therapeutic trial is a help or a hindrance to their treatment. Method: All the inpatients and outpatients attending the Dijon University Hospital AIDS day care unit during the first 4 months of 1999 were given an anonymous questionnaire designed to record the patients’ attitudes toward therapeutic trials, their motivations, and the perceived risks. The questionnaire was often completed in consultation with a psychoanalyst. Results: Two hundred and seven (207) patients were surveyed; 194 of them had a favorable opinion of therapeutic trials. The main motivations to take part in a therapeutic trial were altruistic. In contrast, individualistic considerations and relational motivations (such as to modify the relationship between the caregiver and the patient) were more closely associated with a negative perception. Conclusion: Most of the patients will benefit or at least will not be harmed by being involved in a trial. However, the patients’ attitudes toward the principle of therapeutic trials have to be determined before these patients are included in a given therapeutic trial. This is necessary to avoid the risk of subsequent medical care being altered because participation was either induced or compelled.

Costs induced by hip fractures: a prospective controlled study in Belgium. Belgian Hip Fracture Study Group.

The economic burden of hip fractures is thought to be important, but the excess medical costs they induce remain largely unknown. We assessed the direct medical costs induced by hip fractures during and after hospitalization. Hospital costs of 170 consecutive Belgian women with hip fracture were gathered. During the year following discharge, all medical costs were collected for the 159 hip fracture women who survived the acute hospitalization stay. A similar collection of data was performed on a comparison group of 159 age-and residence-matched women without a history of hip fracture. The mean cost of the acute hospital stay was 8,667 Belgian francs and the mean 1-year hip-fracture-related extra costs after hospitalization was 6,636 Belgian francs. During the year following the acute hospital stay, 19% of the hip fracture women and 4% of the comparison women were newly admitted to nursing homes (p<0.001). Although health care costs increased with age, hip-fracture-related extra costs after hospitalization seemed similar in those below or above 81 years old. These extra costs amounted to 7,710 Belgian francs in women not living in nursing homes at the time of fracture, and to 3,479 Belgian francs in women who lived in nursing homes. Health or mental status before hip fracture seemed not to affect extra costs. Taking into account the higher mortality of women with hip fracture, the extra costs during the acute hospital stay and during the 1-year follow-up amounted to a mean 15,151 Belgian francs. In conclusion, both acute hospital stays and subsequent medical care contribute significantly to medical costs induced by hip fractures.

Cardiac risk stratification for high-risk vascular surgery.

The best strategy for cardiac risk assessment before high-risk vascular surgery remains controversial. A cardiac risk stratification protocol was evaluated in patients undergoing high-risk vascular surgery. Our investigation paralleled the elaboration of the American College of Cardiology/ American Heart Association (ACC/AHA) Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery and is highly comparable to the proposed guidelines. A cardiac risk stratification protocol was evaluated prospectively in 203 patients scheduled for aortic surgery. Key points of the study were cardiac mortality/morbidity and cost-effectiveness. Patients were stratified into low (n = 101), intermediate (n = 79), and high (n = 23) cardiac risk after clinical predictors. After stratification, the degree of estimated functional capacity assessed by treadmill exercise and daily living activities and expressed by metabolic equivalents (METs) was critical for further cardiac evaluation. In intermediate-risk patients with an estimated functional capacity < 5 METs and in all high-risk patients, noninvasive cardiac testing and/or subsequent medical care were performed. Noninvasive testing was considered necessary in 41 patients, coronary angiography in 7, and myocardial revascularization in 1. Overall hospital mortality was 3.5%. Cardiac mortality and morbidity were 1% and 12.4%, respectively. Cardiac risk stratification for high-risk vascular surgery patients, according to a protocol similar to the ACC/AHA Guidelines for Cardiovascular Evaluation for Noncardiac Surgery, demonstrated excellent clinical outcome. This approach appears to be a safe and economical strategy for preoperative cardiac evaluation.

Suicide and HIV infection. Mortality follow-up of 4147 HIV-seropositive military service applicants.

To examine the risk of suicide among individuals positive for the human immunodeficiency virus (HIV) following screening for evidence of HIV infection. Prior studies have reported a 7- to 36-fold increased risk of suicide for persons with the acquired immunodeficiency syndrome. Prospective cohort study. Military service applicants from throughout the United States. Death from suicide. The National Death Index was searched for mortality among 4147 HIV-positive military service applicants and 12437 HIV-negative applicants disqualified from military service due to other medical conditions (matched 1:3 on age, race, sex, and screening date and location) identified by the US Department of Defense between October 1985 and December 1993. Death certificates were obtained from individual states. Identifiers and HIV status of living applicants were known only by the Department of Defense. The HIV-positive applicants were 92% male, 37% white, and 56% black. Median age was 24 years (range, 17-57 years). Median follow-up time was 70 months (range, 0-99 months). Ten HIV-positive (49 per 100 000 person-years) and 24 HIV-negative applicants (36 per 100 000 person-years) died of suicide (rate ratio [RR], 1.35; 95% confidence interval [CI]= 0.58-2.93). Suicide rates among both HIV-positive (RR, 2.08; 95% CI, 1.00-3.82) and HIV-negative (RR, 1.67; 95% CI, 1.07-2.48) applicants are marginally higher than those for the US general population, after adjustment for age, race, and sex. Time from screening to death was less than 3 months for 3 of 10 HIV-positive and 2 of 24 HIV-negative applicants who died of suicide. The HIV-positive individuals do not appear to have a significantly increased risk of death from suicide in the months following HIV screening in this study population. Because suicide risk is reported to be greatly increased after symptomatic HIV disease is present, clinicians should consider asking persons with HIV infection about suicide risk factors during both initial counseling and subsequent medical care.

Suicide and HIV Infection

To examine the risk of suicide among individuals positive for the human immunodeficiency virus (HIV) following screening for evidence of HIV infection. Prior studies have reported a 7- to 36-fold increased risk of suicide for persons with the acquired immunodeficiency syndrome.Prospective cohort study.Military service applicants from throughout the United States.Death from suicide.The National Death Index was searched for mortality among 4147 HIV-positive military service applicants and 12437 HIV-negative applicants disqualified from military service due to other medical conditions (matched 1:3 on age, race, sex, and screening date and location) identified by the US Department of Defense between October 1985 and December 1993. Death certificates were obtained from individual states. Identifiers and HIV status of living applicants were known only by the Department of Defense.The HIV-positive applicants were 92% male, 37% white, and 56% black. Median age was 24 years (range, 17-57 years). Median follow-up time was 70 months (range, 0-99 months). Ten HIV-positive (49 per 100 000 person-years) and 24 HIV-negative applicants (36 per 100 000 person-years) died of suicide (rate ratio [RR], 1.35; 95% confidence interval [CI]= 0.58-2.93). Suicide rates among both HIV-positive (RR, 2.08; 95% CI, 1.00-3.82) and HIV-negative (RR, 1.67; 95% CI, 1.07-2.48) applicants are marginally higher than those for the US general population, after adjustment for age, race, and sex. Time from screening to death was less than 3 months for 3 of 10 HIV-positive and 2 of 24 HIV-negative applicants who died of suicide.The HIV-positive individuals do not appear to have a significantly increased risk of death from suicide in the months following HIV screening in this study population. Because suicide risk is reported to be greatly increased after symptomatic HIV disease is present, clinicians should consider asking persons with HIV infection about suicide risk factors during both initial counseling and subsequent medical care.

Extracorporeal liver assist device

The liver has the unique property of regeneration in an acute setting if given enough time. Currently the only successful intervention for liver failure, both acute and chronic, is orthotopic liver transplantation. The increasing cost of transplantation and subsequent medical care, coupled with the decreasing availability of transplantable organs, magnifies the need for an alternative solution. A liver assist device that is metabolically similar to a native liver will advance the treatment regimen and decrease the need for surgery.

Damned on arrival: A preliminary study of the relationship between homicide, emergency medical care, and race

This article examines the effect of racial differences in access to emergency transportation and subsequent medical care of assault victims on the chance that the victim would die and the assailant subsequently would be charged with homicide. Examination of female homicide offender records in Alabama from the 1930s to 1985 found a relationship between the race of the offender and the time of death of the victim. These findings suggest that racial differences in access to emergency transportation and subsequent medical care of her victim increased the chances that an African American assailant subsequently would be charged with homicide 24 percent more often than her Caucasian counterpart. Because of limitations in the first data set, the analysis was extended to homicide victims reported in the 1988 United States Mortality Detail Files. Analysis of the national victim data replicates the Alabama inmate findings. Extending the analysis by residence replicates the results for metropolitan and nonmetropolitan residences. Extending the analysis by cause of homicide finds the same difference among victims by gun, a larger difference among victims by cutting and piercing, and a smaller difference among victims by all other causes. Racial inequities in the administration of justice traditionally have focused on detecting bias in the administration of justice. These findings suggest that racial inequities in the delivery of medical care are responsible for a substantial portion of the racial differences in both victims and convictions for homicide.