The rate of hospitalizations due to ambulatory care-sensitive conditions (ACSCs) has been widely accepted as an indicator of access and quality of primary care. This study aimed to examine the trends and geographic variation of ACSC hospitalizations in US veterans health-care system, to identify factors associated with ACSC hospitalizations and to develop a quality indicator that can monitor access and effectiveness of primary care at hospital level. Using fiscal years 1997-2007 data, we found total ACSC hospitalizations per 1000 ACSC patients decreased by 58%; ACSC hospitalizations as percentage of total hospitalizations decreased 9%. However, significant geographic variations of ACSC hospitalizations remained and we found that adjustment of case-mix or confounding factors was essential in making meaningful comparisons among hospitals in a health-care system. Further, this study also reveals that low-income veterans still had higher ACSC hospitalization rates and patient travel time less than 30 minutes to the nearest VA providers was associated with fewer ACSC hospitalizations, which possess important policy implications.

Bone marrow aspirate particle smears, biopsy imprints, and biopsy sections were compared to determine the accuracy of the three samples in assessing for overall cellularity, differential cell count, megakaryocyte density, iron stores, and tumor infiltration. Aspirate particle smears and biopsy imprints were stained by Wright-Giemsa method. Aspirate particle smears were also stained with Prussian-blue. Biopsy sections were 1 1/2-2 micron thick and were prepared from non-decalcified plastic embedded samples and stained with combined Prussian-blue-hematoxylin-eosin, and Giemsa. One hundred-eight sets of specimens from 99 patients were examined. In 20 cases, chi-square analysis showed a comparable degree of cellularity (p less than 0.001) and megakaryocyte density (p less than 0.001) among the three preparations. Differential count comparison by regression analysis indicated that mean percentages of neutrophilic cells in the proliferation compartment were comparable in the three groups (p less than 0.01). A better correlation was obtained among the three groups in the percent neutrophilic cells in the maturation-storage compartment, normoblasts, eosinophils, and plasma cells (p less than 0.001). Lymphocytes in the aspirate smears correlated with the biopsy imprints (p less than 0.01) but not with the biopsy sections (p greater than 0.05). Monocytes did not correlate in any of the groups (p greater than 0.05). In 47 cases, chi-square analysis of iron stores in the aspirate particle smears correlated well with those in the biopsy sections (p less than 0.001). Fifty-two marrows that were done for staging nonhematological malignancies revealed malignant cells in 21 cases, biopsy sections were positive in all, biopsy imprints were positive in 19 (90%), and aspirate particle smears were positive in 7 (33%). Thirty-six marrows done for staging non-Hodgkin's lymphoma showed malignant cells in 13 cases. Twelve (92%) biopsy sections, three (23%) biopsy imprints, and nine (69%) aspirate particle smears contained lymphoma cells. In conclusion, a satisfactory evaluation of marrow samples for diagnostic studies can be achieved by examination of biopsy sections along with aspirate particle smears or biopsy imprints. Any of the three marrow preparations alone is not sufficient for accurate diagnosis in all cases. The biopsy imprint is an accurate modality for identifying nonhematological tumor metastasis in the bone marrow.

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Digital rectal examination is underutilized when screening for prostate cancer. This leads to nondetection of some prostate cancers. Although the DRE rate was poor among all health care providers, female providers and physician extenders outperformed male providers and physicians, respectively.

Relapsing thrombotic thrombocytopenic purpura (TTP) is a rare disorder with most individuals experiencing 1 to 5 relapses. We report a patient with 18 episodes of thrombotic thrombocytopenic purpura (TTP), the highest number of relapses thus far described. The last 11 episodes were treated with regimens containing cyclosporine. The patient's medical record was reviewed for pertinent clinical, laboratory, and treatment data. We summarized various parameters for each episode and compared characteristics of relapses treated with vs. without cyclosporine. The initial episode of TTP was unusual in that it failed to respond to plasmapheresis, glucocorticoids, and fresh frozen plasma (FFP). It remitted only following splenectomy. Episodes 2-7 responded to FFP plus prednisone. Episode 8 failed to respond to prednisone plus FFP but remitted promptly with cyclosporine plus prednisone. Subsequently, 2 relapses responded to cyclosporine alone, 2 to cyclosporine plus FFP, 4 to cyclosporine plus prednisone ± FFP, and 2 to cyclosporine, FFP, prednisone, and plasma exchange. There was no difference in remission duration, or in severity or duration of relapses treated with vs. without cyclosporine. Use of cyclosporine, however, significantly decreased the requirement for prednisone and the length of maintenance therapy; thus it is effective mainly as an adjunctive therapy for TTP. Am.

A 62-year-old man with B-cell chronic lymphocytic leukemia had three separate episodes of pure red cell aplasia (PRCA). The last episode was treated with cyclosporin-A (CyA) and prednisone. After the patient was on the therapy for 2 weeks, erythropoietic recovery was observed and with continued therapy the hematocrit (Hct) became normal. The PRCA remission was associated with a fall in the blood lymphocyte count, and a reduction in the spleen and lymph node size and bone marrow lymphocyte density. At diagnosis of PRCA the blood T-cells bearing IgG Fc receptors (T gamma cells) were increased, and the marrow contained very few or no late-stage erythroid progenitors. After remission of PRCA the T gamma cell fraction decreased, and the marrow erythroid progenitor's number became normal. We speculate that therapy with CyA and prednisone inhibited the production of interleukins-1 and -2 from monocytes and T-cells, respectively, and was responsible for the reduction of the T gamma cell fraction and B-cell leukemic mass in this patient. Further, we believe that normalization of T gamma cells in association with the therapy was responsible for the PRCA remission.

We describe the characteristics of response to treatment with cyclosporine (CYA) plus prednisone in seven episodes of pure red cell aplasia (PRCA) in four patients with B cell chronic lymphocytic leukemia (CLL). Fourteen episodes of PRCA occurred in four patients with CLL. Eleven episodes were treated with conventional therapies which included an alkylating agent and prednisone. Four episodes that failed to respond to conventional therapies and an additional three episodes were treated with CYA and prednisone. Six of the seven episodes, including three of four which had failed conventional therapies, responded to CYA plus prednisone compared with six of eleven episodes treated with conventional therapies. Response to CYA and prednisone occurred without a reduction in leukemic mass. In contrast, PRCA remission did not occur until after leukemic mass reduction in three of four patients treated successfully with conventional therapies. Time to response was shorter (14 +/- 3 days) with CYA plus prednisone than with conventional therapies (154 +/- 97 days) in three of four patients. These results indicate that CYA plus prednisone is an effective therapy for the induction of remission from PRCA in patients with CLL.

Rifampin increases total serum bilirubin levels in patients with and without Gilbert's syndrome. On fasting for 12 to 24 h, an absolute increase of bilirubin to >1.9 mg/dl 2 to 6 h after the administration of 900 mg of rifampin distinguishes patients with Gilbert's syndrome from those without it. In the nonfasting state, an increase in total serum bilirubin to > 1.5 mg/dl 4 to 6 h after the administration of rifampin distinguishes persons with Gilbert's syndrome from those without it.