Wednesday, November 02, 2016

Skepticism about accountable care organizations

Here is a JAMA Viewpoint piece expressing a negative opinion about ACOs. (A companion article in the same issue was favorable). Key points:

The authors point out that any cost savings attributable to the ACOs appear to be nominal. Moreover they tend to be offset by the bonuses paid out to the participants. These bonuses cannot be considered optional because they are inherent to the core notion of the ACO: that “quality” will be rewarded.

The model creates incentives to integrate services. Thus smaller hospitals close or are merged, resulting in monopolies among health care delivery systems. This reduces competition and tends to drive costs up, not down.

Tuesday, November 01, 2016

Accountable care organizations: how are they working?

The authors of this JAMA Viewpoint article say the model has been a success, but the arguments are unconvincing. Here are some caveats:

The experiment is in its infancy.

Overall the results are mixed.

Cost savings have been modest and in some cases are diminishing and may prove to be transient. That's what we saw in the managed care experiment of a couple of decades ago.

Statements about quality improvement are suspect because real quality cannot be measured. Outcome data are very soft.

Monday, October 31, 2016

Multiple clinical manifestations of IgG4 related disease (IgG4-RD)

Here are some key issues addressed in a recent review.

What are some of the IgG4 related diseases?

These may coexist in the same patient:

Autoimmune pancreatitis type 1
Mikulicz disease (salivary gland infiltration)
Constrictive pericarditis
Coronary artery aneurysm
Inflammatory abdominal aortic aneurysm (and the related condition retroperitoneal fibrosis)
Sclerosing mediastinitis
Riedel's thyroiditis (and other forms of thyroid involvement)
Sclerosing mastitis
Pulmonary mass or interstitial disease
Lymphadenopathy (Castleman like and other forms)
Tubulointerstitial nephritis
Sclerosing cholangitis (which differs in some features from primary sclerosing cholangitis)

How is IgG4-RD diagnosed?

This has been in a state of some controversy and flux. From the article:

According to an international symposium held in 2011, the diagnosis of IgG4-RD requires both an appropriate histological appearance and increased numbers of IgG4-positive plasma cells (or an elevated IgG4:IgG ratio) in tissue...

In 2011, an “All Japan IgG4 Team,” with the aim to draft comprehensive diagnostic criteria for IgG4-RD 51 ( Table 3 ), proposed three major items 51 69 (1) single or multiple organs involved with diffuse or localized swelling, masses, nodules, and/or hypertrophic lesions; (2) elevated serum IgG4 levels (greater than or equal to 135 mg/dL); and (3) histopathologic features that include marked lymphocytic and plasma cell infiltration and fibrosis, with IgG4-positive plasma cell infiltration (IgG4/IgG-positive cell ratio of greater than or equal to 40% and IgG4-positive plasma cells exceeding 10/HPF). Based on these criteria, patients can be classified into the categories of definite, probable, or possible IgG4-RD.

How do autoimmune pancreatitis (AP) types 1 and 2 differ?

Age: older onset (6th decade) typical of type 1
Gender: male predominance in type 1, not 2
Relationship to IgG4: present in type 1, not clearly present in 2
Histology: lymphoplasmacytic sclerosing pancreatitis in type 1, idiopathic duct centric pancreatitis in 2
Abdominal pain: common in type 2, not in 1
Other organ involvement common in 1, not 2
Steroid responsiveness characterizes both types but type 1 is more prone to relapse.

Sunday, October 30, 2016

IgG-4 related disease overview

Here is an overview from Disease of the Month. IgG-4 diseases include one of the two types of autoimmune pancreatitis and several other conditions:

Immunoglobulin G4-related disease is a rare but increasingly recognized multisystem entity characterized by lymphoplasmacytic tissue infiltration...Related manifestations of this disease include Reidel’s thyroiditis, chronic sclerosing dacryoadenitis, autoimmune pancreatitis (type 1 AIP), retroperitoneal fibrosis, and tubulointerstitial nephritis. Usually occurring in older men, the diagnosis is primarily based upon finding of histopahtologic changes..

Saturday, October 29, 2016

High flow nasal cannula vs NIPPV post extubation

Question Is high-flow nasal cannula noninferior to noninvasive ventilation for preventing reintubation and postextubation respiratory failure?

Findings In this multicenter randomized noninferiority clinical trial that included 604 adults, the proportion requiring reintubation was 22.8% with high-flow therapy vs 19.1% with noninvasive ventilation, and postextubation respiratory failure was observed in 26.9% with high-flow therapy vs 39.8% with noninvasive ventilation, reaching the noninferiority threshold.

Meaning High-flow nasal cannula immediately after scheduled extubation was not inferior to noninvasive mechanical ventilation for risk of reintubation and postextubation respiratory failure in patients at high risk of reintubation.

Friday, October 28, 2016

Epilepsy driving laws by state

Here is the database from the epilepsy foundation.

Wednesday, October 26, 2016

Cystic lung disease as a manifestation of Sjogren Syndrome

From a recent paper in Chest:

Methods Eighty-four patients with primary or secondary SS and chest imaging, chest radiograph, or CT scan were retrospectively evaluated for CLD. Thirteen patients with cysts were found. Baseline characteristics of all patients were collected. A multivariate logistic regression model was used to look for predictors of CLD in patients with CT scan. Additional imaging, SS activity, and complications from CLD and SS were collected for the patients with cysts.

Results CLD had a frequency of 15.4% for all patients with chest imaging. Not all cysts were evident on radiography, and CLD frequency was 30.9% for the patients with chest CT scan. Six patients had cysts without other radiographic findings. CLD was associated with older age (OR, 1.1; 95% CI, 1.0-1.16), a diagnosis of secondary SS (OR, 12.1; 95% CI, 1.12-130.4), and seropositivity for anti-SS-related antigen A/Ro autoantibodies (OR, 26.9; 95% CI, 1.44-93.61). There was no radiologic progression of CLD for 12 patients after a 4-year median follow-up. Lung function did not exhibit temporal worsening. CLD did not correlate with a specific pattern in pulmonary function testing. Two patients had secondary infectious complications of the cysts.

And here is a nice general review of cystic lung disease and its various associations.