ERISA and health plans

This Issue Brief is designed to provide a basic understanding of the relationship of the Employee Retirement Income Security Act of 1974 (ERISA) to health plans. It is based, in part, on an Employee Benefit Research Institute-Education and Research Fund (EBRI-ERF) educational briefing held in March 1995. This report includes a section by Peter Schmidt of Arnold & Porter, a section about multiemployer plans written by Judy Mazo of The Segal Company; and a section about ERISA and state health reform written by Kala Ladenheim of the Intergovernmental Health Policy Project. Starting in the late 1980s, three trends converged to make ERISA a critical factor in state health reforms: increasingly comprehensive state health policy experimentation; changes in the makeup of the insurance market (including the rise in self-insurance and the growth of managed care); and increasingly expansive interpretations of ERISA by federal courts. The changing interpretations of ERISA's relationship to three categories of state health initiatives--insurance mandates, medical high risk pools, and uncompensated care pools--illustrate how these forces are playing out today. ERISA does have a very broad preemptive effect. Federal statutes do not need to say anything about preemption in order to preempt state law. For example, if there is a direct conflict, it would be quite clear under the Supremacy Clause [of the U.S. Constitution] that ERISA, or any federal statue, would preempt a directly conflicting state statute. States can indirectly regulate health care plans that provide benefits through insurance contracts by establishing the terms of the contract. And they also raise money by imposing premium taxes. But they cannot do the same with respect to self-funded plans. That is one of the factors that has caused a great rise in the number of self-funded plans. State regulation [of employee benefits] can create three kinds of problems: cost of taxes, fees, or other charges; cost of dealing with substantive, possibly inconsistent, benefit standards; and cost of identifying, understanding, and complying with the regulations themselves.

Cellular distribution of the mRNA for the kappa-opioid receptor in the human neocortex: a non-isotopic in situ hybridization study

Opioid receptors (OR) provide primary interaction sites of the human brain with opiates. Presently kappa-OR mRNA expression was studied in different cortical areas (A4, A10, A17) by in situ hybridization using digoxigenin-labeled oligonucleotides and an alkaline phosphatase-mediated color reaction. kappa-OR mRNA was expressed mainly in layers II/III and V pyramidal and layer VI multiform neurons. A4 giant pyramidal and A17 giant stellate neurons stood out labeled. These findings fit in with our data on kappa-OR protein distribution. Combined cellular assessment of protein and mRNA will enable the study kappa-OR expression under physiological and pathological conditions.

Testicular germ-cell tumors in childhood and adolescence

Testicular germ-cell tumors are relatively rare in childhood and adolescence, accounting for only 3.9% of all neoplasms. However, they have become a model for curable cancer. Furthermore, most of them have accurate serum markers [beta-human chorionic gonadotropin and alpha-fetoprotein], which provide in clinical stage I disease after semicastration a "wait and see" program. MAHO 82, 88, and 92 were cooperative studies on the treatment of testicular germ-cell tumors in childhood and adolescence. Between 1982 and 1993, 137 patients were registered. In all, 76 patients suffered from yolk-sac tumors (YST); 30, from differentiated teratomas (TD); 29, from malignant teratomas of either intermediate (MTI), undifferentiated (MTU), or trophoblastic type (MTT); and 2, from seminomas. All patients received semicastration. Chemotherapy was given to 53 patients on the basis of disease stage and histology. Standard therapy consisted of four courses of vinblastine, bleomycin and cisplatin. However, if viable tumor was suspected after two courses, delayed laparotomy was performed (seven patients). If there was then complete tumor regression, standard therapy was continued (four patients). If there was an incomplete tumor response, the patients received as salvage therapy three courses of etoposide (VP-16), ifosfamide, and cisplatin (three patients). Among the patients with YST, 73 had stage I disease and 3, higher-stage disease; 1 of these died due to tumor progression. In all, 56 patients were followed according to the "wait and see" policy; 9 of these needed a delayed standard chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Testicular germ cell tumors. Results of the GPO MAHO studies -82, -88, -92

The MAHO studies 82, 88 and 92 were cooperative studies for the treatment of testicular germ cell tumors in childhood. Between 1992 and 1993 137 Patients were registered: 76 suffered from yolk sac tumors (YST), 30 from differentiated teratomas (TD), 29 from malignant teratomas of either intermediate (MTI), undifferentiated (MTU) or trophoblastic type (MTT) and 2 from seminoma. All patients received semicastratio. Chemotherapy was administered to 53 patients based on stage and histology. Standard therapy consisted of four courses of vinblastine, bleomycin and cisplatinum. However, if viable tumor was suspected after two courses delayed laparotomy was performed (7 patients). If there was then complete tumor regression, standard therapy was continued (4 pts). If there was incomplete tumor response, the patients received a salvage therapy with 3 courses of VP 16, ifosfamide and cisplatinum (3 pts). Results YST: 73 patients had stage I, 3 patients higher stages. 56 were followed according to "watch and wait" policy. 9 of these needed a delayed standard chemotherapy, one died. The disease free survival of all 76 patients is 98%. TD: 30 patients had stage I. The disease free survival is 100%. Malignant teratomas (MTI, MTU, MTT): 13 patients had stage I. 8 received adjuvant chemotherapy and 5 lymphadenectomy without chemotherapy. All patients survived disease free. 10 patients had stage II and received chemotherapy. All patients survived disease free. 6 patients had stage III. 3 died. Altogether 26 of 29 patients survived disease free. In summary, the probability of disease free survival of all 137 patients suffering from testicular germ cell tumors is 97% after a median observation time of 60 months.

Building an empowered work team

A work team taps into each member's unique talents, which allows valuable skills to be shared across medical units. As a result, continuous quality improvement efforts were more objective and systematic; leadership skills were gained, both individually and jointly. The obstacles encountered, stakeholders' responses and the team's productivity analysis are described.

Protection against EHV-1 challenge infection in the murine model after vaccination with various formulations of recombinant glycoprotein gp14 (gB)

Four formulations of the equine herpesvirus type 1 (EHV-1) glycoprotein gp 14 (gB), were tested for their ability to protect mice against intranasal (inas) EHV-1 challenge infection. The preparations tested included (i) a truncated gp14 produced in Escherichia coli or (ii) a truncated gp14 expressed in insect cells by a recombinant baculovirus, (iii) truncated gp14 coexpressed with human immunodeficiency virus type 1 (HIV-1) gag virus-like particles (VLP) in insect cells, and (iv) a gp14-DNA vaccine under the control of the cytomegalovirus immediate early promoter. All antigen preparations and the DNA vaccine elicited a humoral and delayed-type hypersensitivity (DTH) immune response to EHV-1 after intramuscular (im) immunization. After inas immunization, only the VLP-gp14 preparation produced both a good humoral and a prominent DTH immune response; gp14 expressed by insect cells elicited high titers of EHV-1-specific antibodies, whereas gp14 produced in E. coli and the DNA vaccine elicited only low antibody titers. Glycoprotein gp14 expressed by bacteria, however, induced a strong DTH reaction after inas application. Mice were completely protected against EHV-1 challenge infection after both the im and the inas immunization with the VLP-gp14 preparation. Protection was less efficient after immunization with the E. coli and insect cell gp14s as well as after DNA vaccination. Although the transmembrane domain of EHV-1 gp14 was deleted, recombinant gp14 could be demonstrated in insect cell membranes at late times postinfection and aggregated with the VLPs. It is suggested that the transmembrane domain is not required for gp14-association with membranes in that system.

Homicide in the bathtub

Retrospective analysis of the deaths investigated in the Institute of Forensic Medicine of the University of Cologne (1980-1993) revealed 215 fatalities in the bathtub comprising 11 homicides. In six cases mouth and nose were found beneath the surface of the water, and signs of drowning were encountered in four cases. In two cases drowning was the cause of death, the remaining fatalities being due to strangulation or sharp violence. Four corpses had merely been deposited in the bathtub, four homicides were committed in the bath, and three victims were put into the bathtub to control or ensure the occurrence of death. Two homicides were not recognized before autopsy. The particular difficulties of establishing the diagnosis of strangulation under the conditions of water-logging are discussed.

Death in the bathtub involving children

Retrospective analysis of 215 deaths in the bathtub (Institute of Forensic Medicine, University of Cologne, 1980-1993) revealed 12 fatalities involving children, seven boys and five girls, aged from 9 months to 13 years. The manner and cause of death was seven accidents (five by drowning, two by scalding burns), two natural deaths (epilepsy, heart failure due to Hurler's syndrome), one homicide (stabbing) and two undetermined cases (one probable seizure, one subdural hematoma associated with signs of maltreatment). Seven children < 4 years old died without exception from accidental drowning or scalding. Three toddlers had been left alone and unattended in the bathtub for a 'short time' (< or = 15 min) and two in the care of elder siblings. The immersion time and the amount of water required to cause lethal drowning are expressed in the terms of pathophysiology.

Sex differences in age development of a mouse inbred strain: body composition, adipocyte size and organ weights of liver, heart and muscles

The mouse inbred strain HLG has only recently been submitted for international registration. It has been widely used in radiological studies. Since these mice tend to become obese, they may be of interest for studies concerning fat metabolism. Therefore, the present ageing study examines the sex-specific development of body weight, body composition, adipocyte size as well as the organ weight of liver, heart and thigh muscles of the inbred strain HLG (54 males/53 virgin females) between day 40 and 360 of life. The body weight development showed a distinct sexual dimorphism, quickly increasing in the case of males but comparatively protracted in females until maturity. Significantly higher values for body and fat-free dry weight as well as body water were found in males of all ages. Body fat and adipocyte diameter were only higher in the 80 and 120 day-old males. Thus, the increase in female body weight resulted largely through a rise in body fat as additionally evidenced by the sex-specific correlation of characteristics. A 2-fold analysis of variance showed sex differences in the relative weights of liver and muscle, but not of the heart. A sex-specific close correlation was observed between body and liver weights in males until day 180. Correlations between body fat and other characteristics were only rarely found. Differences in coefficients of variation largely depended on the characteristics. A higher variability was also found for some characteristics in the youngest groups (40 days). A sex-specific difference was only seen in the case of body fat content for 60 day-old mice (female > male).

Calcitonin gene-related peptide (CGRP) in the nipple of the rat mammary gland

The distribution of nerve fibres immunoreactive to calcitonin gene-related peptide (CGRP) was investigated by immunohistochemistry in nipples and mammary glands from lactating and non-lactating rats and compared to the immunoreactivity of other neuropeptides including substance P (SP), neuropeptide Y (NPY), vasoactive intestinal peptide (VIP) and somatostatin (SOM). The study revealed an extensive innervation of the mammary nipples, in which CGRP-immunoreactive (IR) nerve fibres were abundantly present in the epidermis, dermal connective tissue and intralobular connective tissue of the mammary gland parenchyma. Several of the dermal CGRP-IR fibres seemed to follow blood vessels, or formed "ringlet-like" structures. The latter were mostly observed in the dermal connective tissue of the nipple from the lactating rat and may have a mechanoreceptive function, e.g. for the suckling stimuli. The location of SP-IR appeared to be comparable to CGRP-IR, but in fewer fibres. Dense NPY-IR networks of nerve fibres were closely associated with the fascicles of smooth musculature in the core of the nipple base. In contrast, VIP-IR fibres were only sparsely present, and SOM-IR was not detected in the mammary nipples. The immunoreactive content of CGRP and SP was determined by radioimmunoassays. The total amount of immunoreactive CGRP was significantly higher in the nipples from the pregnant and the lactating rats when compared to SP. The maximum concentration of CGRP (65.9 +/- 4.0 pmol/g) measured in the nipples of the pregnant (day 10) rats exceeded almost ninefold the maximum concentration of SP (7.7 +/- 2.0 pmol/g).(ABSTRACT TRUNCATED AT 250 WORDS)

Antegrade-retrograde urethrotomy for treatment of severe strictures of the urethra: experience and literature review

In cases of urethral stricture that are nonpassable when using conventional internal urethrotomy, open urethroplasty can be avoided by performing combined antegrade-retrograde urethrotomy (ARUT). A rigid cystoscope is guided through a dilated suprapubic cystostomy channel toward the stricture in the membranous or bulbar urethra. A urethrotome is inserted in retrograde fashion, and the "cut to the light" procedure is performed. Using the ARUT method, realignment was achieved in nine patients; four of whom had strictures induced by trauma or urethritis and five of which were the result of previous transurethral management. Recurrent stricture in four of seven cases necessitated further urethrotomy. There was no recurrence in five of seven patients for at least 5 months subsequent to the last treatment. All patients were spared open surgery. The antegrade-retrograde technique was described in 1978, but to date, only 70 cases have been reported in the literature. The primary success rate is 25%. Successful retreatment following recurrence was observed in 65%. We recommend ARUT as a first-choice treatment for severe strictures of the bulbar and membranous urethra.

Cosmic dosimetry using TLD aboard spacecrafts of the "Cosmos" series

Thermoluminescent (TL) detectors were used for dosimetric investigations on the outer surface as well as inside Soviet spacecrafts of the "Cosmos" series. At the outer surface, ultrathin TL detectors, based on CaF2-PTFE and LiF, were arranged in special stacks and exposed to unshielded cosmic radiation. The strong decrease of dose within a few mg/cm2 demonstrates that weakly penetrating radiation is dominating in the radiation field under investigation. On the basis of glow curve analysis of LiF thermoluminescent detectors it could be shown, that the high doses are caused by electrons.

[Inheritance of notched ears in Highland cattle]

The present study describes an anomaly of the pinna of the ear and its distribution in Highland Cattle. The investigation is based on a questionnaire survey in farms in Bavaria keeping robust breeds and on registering data in 15 selected farms. In the year 1991, there were registered 548 Highland stud book cows in 108 farms. In four herds animals of the breed Highland Cattle were observed which showed crop ears. Always both ears were affected and this ear defect could be already observed in newborn calves. Crop ears appeared in very different forms. In some cases only small changes of the external ear could be recognized, in more severe cases, grooves in the external ear could be found and in the most severe case, the external ear was totally deformed and drastically reduced in size. In one herd, 45 animals out of the progeny of 46 of one affected breeding bull showed crop ears. The pedigrees indicated that this defect of the ear pinna is inherited and a single autosomal gene with nearly additive (incomplete dominant) action may be involved. Homozygote recessive animals are free from crop ears, animals homozygote for the mutated allele carry totally deformed external ears and heterozygote animals do not show as severe forms of crop ears as homozygote ones.

Basic experimental studies on corpus cavernosum electromyography and smooth-muscle electromyography of the urinary bladder

In contrast to the extensive work on in vitro experiments for elucidation of the electrical properties of smooth musculature, the acquisition of knowledge on electrical signal behaviour from smooth-muscle cells in an in vivo situation remains very limited and rare. Smooth-muscle electromyographic recording from the smooth musculature of the genitourinary tract, in particular from the penile cavernous bodies and the urinary bladder, has recently become one of the most interesting issues in both impotence research as well as neurophysiological assessment of the urinary bladder. However, the inadequate available data on corpus cavernosum and EMG recordings remains controversial due to the significant discrepancy between basic physiology of the smooth musculature, technical prerequisites and the expected clinical impact from the smooth-muscle EMG of genitourinary organs. This article is an attempt to describe the fundamentals of smooth-muscle EMG signal behaviour and the technical prerequisites for data acquisition and analysis of electrical activity from smooth-muscle cells of the cavernous bodies and urinary bladder. A description is given of the technical aspects, including methodology and interpretation of the recorded data, and also of the possible interference by artefacts (endogeneous and exogeneous) that might limit the clinical relevance of this encouraging method. The advantages, pitfalls and limitations of online analogous data registration and the possibility of computer-assisted smooth-muscle electrical activity recording and analysis are demonstrated by basic in vivo studies on cavernous bodies and also the detrusor muscle.

Investigation of the low-energy component of primary cosmic radiation on the outside of spacecrafts

We have developed a method to investigate the low-energy radiation environment on the outside of spacecrafts. Thereby, ultra-thin thermoluminescent (TL) detectors on the base of CaF2:Mn-PTFE are arranged in stacks and exposed to the unshielded cosmic radiation. The dose distribution within a stack is determined by successive evaluation of the thin TL sheets. The analysis of LiF thermoluminescent detector glow curves permits conclusions on the dose contribution caused by either low-energy electrons or by protons. The method was applied aboard Russian COSMOS spacecrafts as well as the MIR station. It was shown that along low-earth orbits dose rates up to 10 Gy/day within the first few mg/cm2 are typical, mainly as a result of the electron impact.

Immunohistochemical localization of kappa opioid receptors in the human frontal cortex

The cellular and subcellular kappa opioid receptor distribution in human frontal cortex was studied using the monoclonal antibody (KA8). kappa opioid receptor-like immunoreactivity was mainly localized in pyramidal neurons of layers II/III and V. In addition, some round and ovoid neurons were found immunolabeled mainly in layer VI. At the ultrastructural level the immunoprecipitate was attached to the cell membrane but was not associated with synaptic specializations. Furthermore, labeling was present in the neuronal perikarya associated with free ribosomes and in the dendrites partly decorating microtubular structures. Previous autoradiographic findings remained restricted to the level of laminar distribution. By contrast, the monoclonal antibody KA8 provides a unique tool to study the cerebral kappa opioid receptor distribution on the cellular and subcellular level.

Changing indications for penetrating keratoplasty

The indications for penetrating keratoplasty have changed over the past several years. One hundred and eighty cases of penetrating keratoplasty performed in the Department of Ophthalmology, Naestved Centralsygehus, Denmark, from January 1984 to December 1993, were analysed. Overall pseudophakic bullous keratopathy was the most common indication for penetrating keratoplasty (28.3%). This was followed by keratitis (13.9%), Fuchs' dystrophy (13.9%), regraft (11.1%), aphakic bullous keratopathy (10.0%) and keratoconus (6.7%). Pseudophakic bullous keratopathy was the most common indication for penetrating keratoplasty in 1989 and in each year from 1991 to 1993. Before 1989 the most common indications were keratitis (18.0%) and aphakic bullous keratopathy (14.8%). The emergence of pseudophakic bullous keratopathy, as the most common indication for penetrating keratoplasty, correlates well with the dramatic increase in the number of cataract extractions with intraocular lens implantation performed since the early 1980s. Especially semiflexible, closed-loop anterior chamber lenses used in our department in the early years of the period, have been the cause of subsequent corneal edema.