"Carving out" conditions from global capitation rates: protecting high-cost patients, physicians, and health plans in a managed care environment

The purposes of this study were (1) to develop a method for identifying individuals with high-cost medical conditions, (2) to determine the percentage of healthcare spending they represent, and (3) to explore policy implications of "carving out" their care from managed care capitation. Annual payments over a 2-year period to enrollees of three health plans--a traditional managed care organization, and a state Medicaid program--were determined by using a cross-sectional analysis of insurance claims data. The main outcome measures were the number of enrollees with total annual payments in excess of $25,000 and the contribution of these high-cost enrollees to each health plan's total costs. Forty-one groups of diagnosis and procedure codes representing a combination of acute and chronic conditions were included on the list of carve-out conditions. Pulmonary insufficiency and respiratory failure together accounted for the largest number of high-cost individuals in each health plan. Solid organ and bone marrow transplants, AIDS, and most malignancies that required high-dose chemotherapy were also important. The carve-out list identified more than one third of high-cost individuals enrolled in the Medicaid program, approximately 20% of high-cost managed care enrollees, and 10% of high-cost fee-for-service enrollees. These data confirm that it is possible to identify high-cost individuals in health plans by using a carve-out list. Carving out high-cost patients from capitation risk arrangements may protect patients, physicians, and managed care organizations.

Interactional processes in families with depressed and non-depressed adolescents: reinforcement of depressive behavior

Problem-solving interactions were observed in 86 families of depressed adolescents and 408 families of non-depressed adolescents. Sequential analyses indicated that mothers of depressed adolescents were more likely than mothers of non-depressed adolescents to increase facilitative behavior in response to adolescent depressive behavior. Additionally, fathers of depressed adolescents were more likely than their counterparts in families of non-depressed adolescents to decrease aggressive behavior subsequent to adolescent depressive behavior. These analyses suggest that parents of depressed adolescents may be inadvertently reinforcing depressive behavior. Decreases in adolescent depressive symptomatology from year 1 to year 2 were not accompanied by changes in family interaction patterns.

Numbers of deaths related to intrapartum asphyxia and timing of birth in all Wales perinatal survey, 1993-5

OBJECTIVES

To investigate the relation between the timing of birth and the occurrence of death related to an intrapartum event.

DESIGN

Analysis of 107,206 births to Welsh residents in 1993-5, including 608 cases of stillbirth and 407 of neonatal death identified in the all Wales perinatal survey, the cause of death classified with the clinicopathological system.

SUBJECTS

79 normally formed babies stillborn or who died in the neonatal period, birth weight > 1499 g, for whom cause of death was related to an intrapartum event.

MAIN OUTCOME MEASURES

Relative risk of death due to an intrapartum event according to the hour, day, and month of birth.

RESULTS

Mortality was higher in babies born between 9.00 pm and 8.59 am than in those born between 9.00 am and 8.59 pm; relative risk (95% confidence interval) 2.18 (1.37 to 3.47). July and August births also had a higher death rate than births in other months; relative risk 1.99 (1.23 to 3.23). Weekened births had a higher death rate but it was not significant.

CONCLUSIONS

The excess of deaths at night and during months when annual leave is popular may indicate an overreliance on inexperienced staff at these times. Errors of judgement may also be related to physical and mental fatigue, demanding a more disciplined systematic approach at night. Mistakes may be ameliorated by increasing shiftwork, but shifts should be carefully designed to avoid undue disruption of circardian rhythms. In addition, greater supervision by senior staff may be required at night and during summer months.

New AUG initiation codons in a long 5' UTR create four dominant negative alleles of the Drosophila C2H2 zinc-finger gene ovo

Promoters active in the germline produce OVO-A and OVO-B mRNAs encoding isoforms of a putative transcription factor. The isoforms have a common C2H2 zinc-finger domain but different N-termini that include potential effector domains. Single point mutations in three dominant-negative ovoD mutations result in new in-frame initiation codons in OVO-B mRNAs and amino acid substitutions within charged regions of OVO-A proteins. Three lines of evidence suggest that the dominant activity is due to the new initiation codons in OVO-B mRNAs and not the amino acid substitutions in OVO-A. First, we made a fourth ovoD allele by inserting a new in-frame AUG. This ovoD4 allele encodes a nearly full-length OVO-A isoform from OVO-B mRNAs. Second, engineered stop codons in ovoD1 downstream of the new AUG abolished dominant negative activity. Third, a substantial deletion of an OVO-A region encoding a highly charged amino acid domain fully rescued loss-of-function ovo alleles. These data suggest that ovoD mutations result in inappropriate expression of OVO-A in the female germline.

Regulation of CCR2 chemokine receptor mRNA stability

During inflammatory and immunological responses, leukocytes respond to external stimuli by altering the stability of cytokine and cytokine receptor messages. Change in message stability is an effective mechanism for rapidly regulating steady state levels of mRNA. Cytokine messages containing A-U-rich elements located in the 3' untranslated region (ARE) are the best studied examples of this process. AREs have been shown to act as targeting motifs for degradation of cytokine and transcription factor messages. We have recently observed that the interleukin-8 (IL-8) receptor messages, IL-8RA and B (CXCR1 and CXCR2), also undergo changes in stability in response to the inflammatory stimulator lipopolysaccharide (LPS). To determine whether regulation of message stability is a common mechanism for modulation of chemokine receptor mRNA we explored whether the stability of the CC chemokine receptor message for CCR2 (monocyte chemotactic protein-1 receptor) is also regulated by LPS. We found that LPS induces a rapid loss of steady state levels of CCR2 message through message degradation. Furthermore, LPS stimulated the decay of Poly(A) CCR2 mRNA faster than total CCR2 RNA, indicating that deadenylation is the first step in LPS-induced CCR2 RNA degradation. We conclude from these experiments that LPS stimulates the rapid degradation of CCR2 messages through a two-step process, deadenylation followed by degradation of the message body. In contrast to the results obtained for CCR2 mRNA, macrophage inflammatory protein-1alpha messages, which contain an ARE motif, were stabilized by LPS stimulation, indicating that chemokine and chemokine receptor mRNA stability are regulated by different and opposing mechanisms.

Activity of a new glycopeptide antibiotic (LY333328) against enterococci and other resistant gram-positive organisms

A new semi-synthetic glycopeptide, LY333328, was tested for in-vitro activity against 197 strains of enterococci including strains resistant to other glycopeptides. Activity was also assessed against species with intrinsic resistance to glycopeptides. For strains of enterococci tested the LY333328 MIC90s were < or = 0.5 mg/L. Enterococcus faecalis was less susceptible to LY333328 than other enterococci with a maximum MIC of 2.0 mg/L. Glycopeptide-resistant strains of enterococci were not more resistant to LY333328 than glycopeptide-susceptible strains but intrinsically resistant species had MICs between 4 and 8 mg/L.

Family support and conflict: prospective relations to adolescent depression

The relations between family support, family conflict, and adolescent depressive symptomatology were examined longitudinally in a sample of 231 female and 189 male adolescents and their mothers. Structural equation models revealed that less supportive and more conflictual family environments were associated with greater depressive symptomatology both concurrently and prospectively over a 1-year period. Conversely, adolescent depressive symptomatology did not predict deterioration in family relationships. Depressive symptomatology and, to a greater extent, family characteristics showed high levels of stability over the 1-year period. Counter to our expectations, the relations between family variable and depressive symptomatology were similar for boys and girls. The results suggest that the quality of family interactions is relevant for understanding the development of depressive symptoms in adolescents.

The use of sonication for the efficient delivery of plasmid DNA into cells

PURPOSE

Ultrasonic methods have considerable potential for the introduction of macromolecules into cells. In this paper we demonstrate that, under controlled conditions, application of 20 kHz ultrasound to a suspension of yeast cells facilitates the delivery of plasmid DNA into these cells.

METHODS

Aliquots of growing yeast cells (Saccharomyces cerevisae, strain AH22) were suspended in buffer and exposed to 20 kHz ultrasound from a laboratory (probe-type) sonicator in the presence of microgram quantities of plasmid DNA. Efficiency of DNA delivery was scored as the number of cells transformed.

RESULTS

Cell transformation was optimal at 30 seconds sonication using an output of 2.0 watts and resulted in a 20 fold enhancement over control values. At extended sonication times, fewer cells showed evidence of transformation because of reduced cell viability. The increased DNA uptake and the decreased cell viability were both attributable to acoustic cavitation events during sonication. The extent of acoustic cavitation was measured and it was found that there was an increase in cavitation events with increased sonication time. Cell viability was shown to be directly related to the number of cavitation events. The effects of sonication on plasmid DNA were investigated and indicated that the structural integrity of plasmid DNA was unaffected by the sonication conditions employed.

CONCLUSIONS

Under controlled conditions, ultrasound is an effective means of delivering plasmid DNA into cells. The subsequent expression of DNA molecules in cells depends upon a balance between transient cell damage and cell death.

Production of a urokinase plasminogen activator-IgG fusion protein (uPA-IgG) in the baculovirus expression system

Numerous studies have demonstrated the importance of urokinase plasminogen activator (uPA) and its receptor, uPAR, in the processes of tumor progression and metastasis. Thus, the uPA/uPAR interaction may represent an important target for inhibiting metastatic disease. The baculovirus expression system was used to produce high levels of a secreted uPA-Immunoglobulin G fusion protein (uPA-IgG) which could then be used for displacing uPA from the surface of tumor cells. The recombinant uPA-IgG fusion protein was placed under the control of either the viral polyhedrin promoter or a copy of the viral basic protein promoter. Recombinant viruses were then used to infect Sf9 and BTI-Tn-5B1-4 cells. Infection of both cell types resulted in the production of secreted uPA-IgG. The molecular mass of the secreted protein as determined by SDS-PAGE was approximately 40 kDa. The highest level of secreted uPA-IgG, 444 microg/ml, was found in the culture medium of BTI-Tn-5B1-4 cells 72 h post-infection with the basic protein promoter-uPA-IgG virus. In the case of Sf9 cells, the highest level of secreted protein was 195 microg/ml. The amount of cell-associated uPA-IgG in infected BTI-Tn-5B1-4 cells was significantly less than that of infected Sf9 cells, reflecting the superior secretory capability of the BTI-Tn-5B1-4 cells. The uPA-IgG was readily purified using a combination of zinc chelate and sephacryl S-100 column chromatography. Routinely, greater than 100 mg of greater than 95% pure protein could be obtained per liter of culture medium collected at 72 h post-infection of BTI-Tn-5B1-4 cells with the basic protein promoter virus. BIAcore analysis and competition binding assays using LOX human malignant melanoma cells expressing uPAR indicated that the purified recombinant protein possessed similar ligand binding characteristics to that of human uPA.