Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans

This report addresses diabetes care in the managed care setting and improvement in care brought about by collaboration between 6 Medicare managed care plans (MCPs) and a Peer Review Organization (PRO). The objective was to improve the quality of care of outpatient diabetes patients provided by primary care physicians through the mutual collaboration of 6 Medicare managed care plans and a Medicare Peer Review Organization. The design involved pre-post intervention trial based on 2 random samples, a baseline sample drawn in 1995 and a remeasurement sample drawn in 1996. Medical records of patients in both samples were reviewed by the PRO to determine provision of 14 quality indicator services over a 1-year period. The setting was 6 Arizona Medicare managed care plans comprising approximately 40% of the Arizona Medicare population. Two random samples were drawn from type 2 diabetes patients continuously enrolled in the same managed care plan for at least 1 year. The intervention was comparative feedback of baseline data by the PRO, enabling each plan to compare itself to any other plan on any or all indicators. Each plan developed and implemented its own intervention in response to the 1995 baseline results. The main outcome measures were mean HbA1c, the proportion of HbA1c values below 8%, and positive change in provision of 14 quality indicator services. At postintervention remeasurement, mean HbA1c values fell from 8.9 +/- 2.2 to 7.9% +/- 2.1, and the proportion of patients with HbA1c values below 8.0% rose from 40% to 61.6%. The proportion of the 14 indicator services provided to patients rose from 35% to 55%. The mean number of physician office visits fell 13% and the number of services provided per visit doubled. We conclude that improving the process of care improves glycemic control. Better outpatient diabetes management in competing, capitated managed care plans is an attainable goal when mediated through a neutral third party such as a PRO.

Vertical or asymmetric nystagmus need not imply neurological disease

AIM

To indicate that congenital idiopathic nystagmus (CIN) and sensory defect nystagmus (SDN) can be vertical or asymmetric in some children.

METHODS

Of 276 children presenting with nystagmus for electrophysiological testing, 14 were identified as having CIN or SDN, yet had a nystagmus which was either vertical (n=11) or horizontal asymmetric (n=3). Flash electroretinograms and flash and pattern visual evoked potentials (VEPs) were recorded in all patients. Eye movement assessment, including horizontal optokinetic nystagmus (OKN) testing, was carried out in 11/14 patients.

RESULTS

Eight patients (seven with vertical, one with asymmetric horizontal nystagmus) had congenital cone dysfunction. One patient with vertical and another with asymmetric nystagmus had cone-rod dystrophy. One patient with vertical upbeat had congenital stationary night blindness. Two patients (one downbeat, one upbeat nystagmus) had normal electrophysiological, clinical, and brain magnetic resonance imaging findings and were classified as having CIN. One patient with asymmetric nystagmus showed electrophysiological and clinical findings associated with albinism. Horizontal OKN was present in 80% of patients tested, including the three cases with horizontal asymmetric nystagmus. This is atypical in both CIN and SDN, where the OKN is usually absent.

CONCLUSIONS

Vertical and asymmetric nystagmus are most commonly associated with serious intracranial pathology and its presence is an indication for neuroimaging studies. However, such nystagmus can occur in children with retinal disease, albinism, and in cases with CIN. These findings stress the importance of non-invasive VEP/ERG testing in all cases of typical and also atypical nystagmus.

Lactic acidosis associated with stavudine administration: a report of five cases

Type "B" lactic acidosis has been described in patients receiving the nucleoside analogs zidovudine, didanosine, and fialuridine. Lactic acidosis has also been described in 4 patients receiving combination therapy with stavudine and lamivudine. We describe the development of chronic type "B" lactic acidosis in 3 patients receiving stavudine as a single agent and in 2 patients receiving combination therapy with stavudine and either lamivudine or delavirdine, a nonnucleoside analog. All patients presented with abdominal pain, vomiting, and hepatic steatosis. Other signs of mitochondrial toxicity included pancreatitis and myopathy (2 cases). The mean duration of stavudine therapy was 9.4 months, and the mean observed peak lactate level+/-SD was 10.3+/-5 mmol/L. After discontinuation of stavudine treatment, lactic acidosis improved in 4 patients after 4-60 weeks, and 1 patient died. Evaluations for other causes of lactic acidosis, including hypoxemia, malignancy, sepsis, and cardiogenic shock, were negative.

Quantifying the sustainability of grazed pastures on the Northern Tablelands of New South Wales

An experiment was conducted to examine the effect of deep-rooted perennial grasses on the water and nitrogen economy of 3 mature pasture communities with different botanical compositions but the same fertiliser history. One pasture was dominated by volunteer naturalised pasture grasses (Eleusine tristachya and Danthonia spp.) (termed ‘degraded’), another was phalaris (Phalaris aquatica) dominant (phalaris), and a third was dominated by phalaris into which white clover (Trifolium repens) had been recently sown (phalaris–white clover). Two replicates of each pasture type were grazed continuously over 4 years with young weaner sheep changed each year. Measurements of hydrology, nutrient cycling, botanical composition and animal production were made in order to quantify the sustainability characteristics of each of the pasture types. Data are summarised as absolute measures at various points in time and also as trends over time. The ranking of standardised treatment measures was then summed to provide an index of sustainability with or without a weighting assumed to be representative of the relative importance of various layers of sustainability viewed from the perspective of a hypothetical ‘typical’ grazier. The results show that the phalaris–white clover treatment was substantially more sustainable, in both ecological and economic terms, than either of the other treatments. The unweighted index for the phalaris–white clover pasture was 3.61 compared to 2.08 and 1.98 for the phalaris and ‘degraded’ pastures, respectively.

Productivity and pasture intake of defaunated crossbred sheep flocks

From a flock of pregnant crossbred ewes, 63 were established as protozoa-free by treatment with alkanate 3SL3 and 64 ewes were maintained as controls. The controls included 20 ewes, which had been defaunated and subsequently re-inoculated with protozoa. After lambing, both flocks were grazed in a 6-paddock rotation until weaning at 20 weeks of age. Defaunated ewes were heavier than control ewes throughout lactation and had a higher urinary allantoin concentration than the control ewes. Intake and apparent digestibility of pasture dry matter by ewes did not differ between groups although these estimates were confounded by differences in pasture composition between the paddocks used. Both groups selected a diet with digestibility approximately 10% units higher than the bulk digestibility of pasture on offer. Control ewes selected a higher proportion of white clover in their diet than was available in the pasture (24% v. 2%) but defaunated ewes did not exhibit preferential selection for clover. Lambs from defaunated ewes were heavier at birth, remained heavier until weaning and grew more wool than lambs from control ewes. Contamination of fauna-free ewes and lambs with protozoa was first observed at weaning and protozoa were detected in 41 out of 60 lambs, 4 weeks after contamination was first detected. Study of defaunated ewes returned to a flock of untreated ewes confirmed rapid spread of contamination into defaunated ewes with small entodiniomorph protozoa establishing first.

Electromagnetic field strength levels surrounding electronic article surveillance (EAS) systems

Electronic article surveillance (EAS) is used in many applications throughout the world to prevent theft. EAS systems produce electromagnetic (EM) energy around exits to create an EM interrogation zone through which protected items must pass before leaving the establishment. Specially designed EAS tags are attached to these items and must either be deactivated or removed prior to passing through the EAS EM interrogation zone to prevent the alarm from sounding. Recent reports in the scientific literature have noted the possibility that EM energy transmitted by EAS systems may interfere with the proper operation of sensitive electronic medical devices. The Food and Drug Administration has the regulatory responsibility to ensure the safety and effectiveness of medical devices. Because of the possibility of electromagnetic interference (EMI) between EAS systems and electronic medical devices, in situ measurements of the electric and magnetic fields were made around various types of EAS systems. Field strength levels were measured around four types of EAS systems: audio frequency magnetic, pulsed magnetic resonant, radio frequency, and microwave. Field strengths from these EAS systems varied with magnetic fields as high as 1073.6 Am(-1) (in close proximity to the audio frequency magnetic EAS system towers), and electric fields up to 23.8 Vm(-1) (in close proximity to the microwave EAS system towers). Medical devices are only required to withstand 3 Vm(-1) by the International Electrotechnical Commission's current medical device standards. The modulation scheme of the signal transmitted by some types of EAS systems (especially the pulsed magnetic resonant) has been shown to be more likely to cause EMI with electronic medical devices. This study complements other work in the field by attaching specific characteristics to EAS transmitted EM energy. The quantitative data could be used to relate medical device EMI with specific field strength levels and signal waveforms. This is one of several efforts being made by the FDA, the electronic medical device industry and the EAS industry to mitigate the potential for EMI between EAS and medical devices.

Visual-evoked potential evidence of chiasmal hypoplasia

PURPOSE

To show that chiasmal hypoplasia or aplasia need not be an isolated developmental anomaly and to examine the spectrum of associated clinical findings to explore the possibility that these patients may represent a phenotypic manifestation of a developmental gene anomaly.

DESIGN

An observational case series.

PARTICIPANTS

Five infants, between several weeks and 7 months of age, in whom the electrophysiologic characteristic of chiasmal hypoplasia had been noted were included.

METHODS

Flash electroretinography and flash and pattern visual-evoked potentials (VEPs) were elicited from all patients. Clinical ophthalmologic examinations, including funduscopy, were performed, and all patients had magnetic resonance imaging (MRI) brain scans.

MAIN OUTCOME MEASURES

The occipital distribution of monocular VEP response peaks was studied. The symmetry of lateral channel responses was compared for monocular stimulation.

RESULTS

All five patients had a crossed asymmetry in the monocular VEP occipital distribution, which is consistent with a paucity of fibers crossing at the chiasm. The MRI findings supported this electrophysiologic observation, illustrating degrees of chiasmal hypoplasia and variable coincidence of other midline abnormalities of the brain. Optic disc appearances varied from normal to hypoplastic and colobomatous.

CONCLUSIONS

The ophthalmologic and MRI findings of five patients who showed a crossed asymmetry in monocular flash VEPs are consistent with a paucity of axons crossing at the chiasm. The similarities between achiasmia in humans and mice due to a Pax2 gene anomaly are discussed.

Differential alteration by thalidomide of the glutathione content of rat vs. rabbit conceptuses in vitro

Thalidomide has been shown to cause limb reduction defects in rabbits with much greater potency than in rats, possibly due to inherent biochemical differences between the two species. Whole embryo culture was used to make direct comparisons between thalidomide-sensitive New Zealand White rabbits and thalidomide-resistant Sprague-Dawley rats, focusing on the possible roles of glutathione (GSH) and cysteine in mechanisms of thalidomide teratogenicity. Conceptuses were treated by adding thalidomide (0, 5, 15, and 30 microM) directly to the culture media containing conceptuses of similar gestational stages. Embryos and visceral yolk sacs (VYS) were measured for changes in GSH and cysteine content using HPLC after 24 h of exposure in vitro. Thalidomide-induced (15 and 30 microM) depletion of VYS GSH occurred only in the rabbit, where GSH concentrations (pmol/microg protein) fell significantly to about 50% of control. Rat VYS did not show a significant GSH depletion at any thalidomide concentration tested. Comparison between species showed that the control rabbit VYS contained 35% less GSH than the control rat VYS. Control rat embryos and control rabbit embryos contained similar concentrations of GSH, but thalidomide treatment preferentially depleted GSH in the rabbit at lower thalidomide concentrations (5 micro/M). Cysteine concentrations were not significantly altered from control in the embryo or VYS of either species when treated with thalidomide. However, although control cysteine concentrations did not differ significantly between rat and rabbit VYS, control cysteine levels in rabbit embryos were 65% lower than those in control rat embryos. Rabbit conceptuses displayed lower species-specific GSH and cysteine levels and a greater propensity for thalidomide-induced GSH depletion than in rat conceptuses, consistent with the greater sensitivity of the rabbit to thalidomide teratogenicity. These thalidomide-induced and inherent species differences implicate a possible role for GSH and redox status in the mechanisms of thalidomide teratogenicity.

A unique effect of clonazepam on frontal lobe seizure control

In a 16-year-old female, clonazepam (CZP) changed randomly occurring intractable tonic seizures of frontal lobe origin to a few sleep seizures when used as an adjunctive therapy. The significance of this change in the seizure pattern is discussed with an explanation of possible pathophysiologic mechanism.

Electron backscatter diffraction of grain and subgrain structures - resolution considerations

Characterization of microstructures containing small grains or low-angle grain boundaries by electron backscattered diffraction (EBSD) is limited by the spatial and angular resolution limits of the technique. It was found that the best effective spatial resolution (60 nm) for aluminium alloys in a tungsten-filament scanning electron microscope (SEM) was obtained for an intermediate probe current which provided a compromise between pattern quality and specimen interaction volume. The same specimens and EBSD equipment when used with a field-emission gun SEM showed an improvement in spatial resolution by a factor of 2-3. For characterizing low-angle boundary microstructures, the precision of determining relative orientations is a limiting factor. It was found that the orientation noise was directly related to the probe current and this was interpreted in terms of the effect of probe current on the quality of the diffraction patterns.

Regulation and characterization of the Na+/H+ exchanger

The Na+/H+ exchanger is a ubiquitous protein present in all mammalian cell types that functions to remove one intracellular H+ for one extracellular Na+. Several isoforms of the protein exist, which are referred to as NHE1 to NHE6 (for Na+/H+ exchanger one through six). The NHE1 protein was the first isoform cloned and studied in a variety of systems. This review summarizes recent papers on this protein, particularly those that have examined regulation of the protein and its expression and activity.

Suicide within 12 months of contact with mental health services: national clinical survey

OBJECTIVE

To describe the clinical circumstances in which psychiatric patients commit suicide.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death.

MAIN OUTCOME MEASURES

Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending.

RESULTS

10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases.

CONCLUSIONS

Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

Mental disorder and clinical care in people convicted of homicide: national clinical survey

OBJECTIVES

To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

Eighteen month sample of people convicted of homicide.

MAIN OUTCOME MEASURES

Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services.

RESULTS

718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide.

CONCLUSIONS

There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions.

A trial of simple versus intensified dietary modification for prevention of progression to diabetes mellitus in women with impaired glucose tolerance

Women with impaired glucose tolerance are at high risk of developing noninsulin dependent diabetes mellitus (NIDDM). The Mercy Hospital for Women has a long-term follow-up programme for women with gestational diabetes, which identifies many women with impaired glucose tolerance. Two hundred of these women were entered into a randomized controlled trial of intensive versus routine dietary advice. Seven women were lost to follow-up. The annual incidence rates of diabetes mellitus for the 2 groups were 6.1% (intervention) and 7.3% (control), an incident rate ratio of 0.83, 95% confidence interval 0.47-1.48, p = 0.50. Overall, there was a return to normal glucose tolerance in 44% of patients. Multivariate analysis showed that body mass index, fasting and 2-hour plasma glucose levels at trial entry were significantly associated with an increased risk of diabetes mellitus. Impaired glucose tolerance is an important condition that should be treated with advice about lifestyle modification (diet and/or exercise). We consider that future trials in the management of women with previous gestational diabetes who have impaired glucose tolerance should investigate the effect of pharmacological intervention in addition to diet and/or exercise, the latter providing a therapy that it would be unethical to exclude on the evidence presently available.

Pyridine nucleotide flux and glutathione oxidation in the cultured rat conceptus

It is proposed that protection of the developing embryo from chemical and environmental insults that produces oxidative stress requires a proper glutathione (GSH) and pyridine nucleotide status in both the embryo and extra-embryonic membranes. Modulation of pyridine nucleotide flux [NAD(H) and NAD(P)H] in the visceral yolk sac (VYS) by the thiol oxidants diamide and tert-butyl hydroperoxide (tBH) was studied in real time using microfiberoptic sensors in GD 10 rat conceptuses. Consecutive 5-min exposures to 125- and 250-microM diamide resulted in a fluorescence decrease of 14 and 32 Arbitrary Fluorescence Units (AFU). An additional consecutive exposure to 500-microM diamide caused an attenuated decrease followed by a rebound increase of 22 AFU. Consecutive 5-min exposures to tBH at 250 and 500 microM produced fluorescence decreases similar to that of 500 microM diamide, but the decreases were attenuated at 1000 microM. However, there was variability in the rebound increase. A 5-min exposure to tBH (500 microM) alone caused a fluorescence decrease of 14 AFU followed by a rebound increase of 8 AFU. The rate of fluorescence decrease was attenuated by 50% with pretreatment with the glutathione reductase (GSSG-Rd) inhibitor, BCNU (1,3, bis(2 chloroethyl)-1-nitrosourea), indicating that the decrease in surface fluorescence was probably attributable to a decrease in NADPH. Decreases in fluorescence, observed from the surface of the VYS, correlated with decreases in GSH/GSSG ratios in the embryos and the VYS. After exposure to tBH, GSH levels in conceptuses decreased at the end of 5 and 15 min, with a corresponding increase in oxidized glutathione (GSSG) at the end of 3, 5, and 15 min. Our results demonstrate that the increased production of GSSG on exposure to thiol oxidants correlates with a decrease in the reduced pyridine nucleotide, implying the presence of an active GSSG-Rd pathway in the conceptus during organogenesis, and implicating an important role of the pyridine nucleotides in the restoration of GSH homeostasis in the developing rat conceptus during organogenesis.

Amiloride and the Na(+)/H(+) exchanger protein: mechanism and significance of inhibition of the Na(+)/H(+) exchanger (review)

Amiloride and its derivatives are important tools for studying NHE-1, the ubiquitous isoform of the sodium/hydrogen exchanger protein family. Three residues in putative transmembrane domains IV and IX have been implicated in amiloride binding and several models of the proposed amiloride-binding site have been reported. Though it has been shown that sodium ions and amiloride molecules interact at unique regions of the NHE-1 protein, physiological experiments reveal a competitive relationship between the two under some circumstances. The two binding sites are thus on closely related but distinct regions on the protein.

Hypokalaemic paralysis revealing Sjögren syndrome in an elderly man

A 73 year old white man presented with life threatening hypokalaemic paralysis requiring admission to an intensive care unit. Biochemical investigations showed severe hypokalaemia with hyperchloraemic metabolic acidosis, a spot urine pH of 6.5, and a positive urinary anion gap, establishing the diagnosis of distal renal tubular acidosis. Autoimmune tests revealed Sjögren syndrome as the underlying cause of the distal renal tubular acidosis. Full recovery followed potassium and alkali replacement. This dramatic presentation of Sjögren syndrome has not previously been reported in an elderly man.

Iodinated and fluorinated steroid 2'-aryl-[3,2-c] pyrazoles as potential glucocorticoid receptor imaging agents

We have synthesized several halogenated steroids as potential glucocorticoid receptor mediated imaging agents. These compounds are analogs of aryl-pyrazolo steroids, similar to the potent glucocorticoid, cortivazol. Compounds containing the halogens, iodine, bromine, and fluorine, as well as the E- and Z-iodovinyl side chain at the para position of 2'-phenyl-11 beta,17,21-trihydroxy-16 alpha-methyl-20-oxo-pregn-4-eno[3,2-c] pyrazole were prepared. They were tested as ligands for the glucocorticoid receptor by competition for the binding of [3H]dexamethasone and for glucocorticoid potency by the induction of alkaline phosphatase in HeLa cells. None of the iodinated steroids were good ligands for the glucocorticoid receptor or potent glucocorticoids. The bromo analog was only slightly better than the iodinated steroids as a ligand, and it had a potency in the HeLa cell assay about half that of dexamethasone. The fluoro analog good binding to the glucocorticoid receptor and was a very potent glucocorticoid, approximately seven times that of dexamethasone. Consequently, it appears that the fluoro steroid, 2'-(4-fluorophenyl)-11 beta,17,21-trihydroxy-16 alpha-methyl-20-oxo-pregn-4-eno[3,2-c] pyrazole, when labeled with 18F, would make an excellent glucocorticoid receptor-mediated imaging agent for positron emission tomography.