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BACKGROUND: Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States. METHODS: A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypothetical MCO with 10 000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitoring were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules. RESULTS: An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236,363 from $238,086, while increases were observed in pH monitoring (from $16 739 to $21 973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs. CONCLUSIONS: Timely and increased use of pH monitoring as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.

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Capitation risk contracting has the potential to combine insurance functions with medical care functions. Success depends on a careful consideration of the capitation rate and a thorough understanding of all capitation contract issues. Proper incentives to physicians in a specialty network stimulate a major reengineering effort to squeeze the inefficiency out of the system. Within the network, true peer review can effectively diminish variability in medical care. Such variability leads to increased cost without benefit to health status. The superior medical management of a capitated specialty network can create added value by coordinating more cost-effective and appropriate evaluation and therapy.

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In vitro studies suggested that increased flux of glucose through the hexosamine biosynthesis pathway (HexNSP) contributes to glucose-induced insulin resistance. Glutamine:fructose-6- phosphate amidotransferase (GFAT) catalyzes glucose flux via HexSNP; its major products are uridine diphosphate (UDP)-N-acetyl hexosamines (UDP-HexNAc). We examined whether streptozotocin (STZ)-induced diabetes (4-10 days) or sustained hyperglycemia (1-2 h) in normal rats alters absolute or relative concentrations of nucleotide-linked sugars in skeletal muscle and liver in vivo. UDP-HexNAc and UDP-hexoses (UDP-Hex) were increased and decreased, respectively, in muscles of diabetic rats, resulting in an approximately 50% increase in the UDP-HexNAc:UDPHex ratio (P < 0.01). No significant changes in nucleotide sugars were observed in livers of diabetic rats. In muscles of normal rats, UDP-HexNAc concentrations increased (P < 0.01) and UDP-Hex decreased (P < 0.01) during hyperglycemia. The UDP-HexNAc:UDP-Hex ratio increased approximately 40% (P < 0.01) and correlated strongly with plasma glucose concentrations. Changes in liver were similar to muscle but were less marked. GFAT activity in muscle and liver was unaffected by 1-2 h of hyperglycemia. GFAT activity decreased 30-50% in muscle, liver, and epididymal fat of diabetic rats, and this was reversible with insulin therapy. No significant change in GFAT mRNA expression was detected, suggesting post-transcriptional regulation. The data suggest that glucose flux via HexNSP increases in muscle during hyperglycemic hyperinsulinemia and that the relative flux of glucose via HexNSP is increased in muscle in STZ-induced diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

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Returning to full activity is of primary concern for the injured patient with a second-degree ankle sprain. This is especially true of a member of the United States Marine Corps. Unfortunately, many patients are not referred to physical therapy for comprehensive management of acute ankle sprains. An ankle protocol based on previous clinical experience was developed which included an acute and rehabilitative phase. An air stirrup orthosis was used as an adjunct to therapy to resume activities safely. This combination allowed Marines to return to full duty in less than 2 weeks.

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A case of pyogenic orchitis due to infection with Salmonella enteritidis ser. Paratyphi B is discussed. Unlike previously reported cases of Salmonella orchitis, this patient developed infection by bacteremic spread and not by direct extension from the epididymis. Therapy with chloramphenicol resulted in an excellent clinical response.

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When small or large bowel is distended with fluid, certain characteristic features can be seen on ultrasound which cannot be visualized when the bowel is collapsed. The proximal and distal portions of the small bowel can frequently be differentiated both in vitro and in vivo by the echoes emanating from the valvulae conniventes ("keyboard sign"). This depends upon the angle at which the bowel segment is scanned in relation to its long axis, the relative amount of intraluminal fluid and gas, the diameter of the bowel in relation to the beam width of the transducer, and the intrinsic resolution of the scanning system. Similarly, the ascending and transverse colon can be recognized by haustral sacculations, the distal rectosigmoid colon and rectum by the rectal valves. The tubular shape, characteristic arrangement and location, and peristaltic motion of most fluid-filled bowel segments are helpful in differentiating loops of bowel from cystic masses in the abdomen or pelvis.

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