Home care in New York City: providers, payers, and clients

Estimates based on 1980 data indicate that almost two-thirds of the disabled elderly in New York City receive care only from informal sources. Another one-fifth use a combination of informal and formal sources of care. Thus, only about 15 percent are exclusively dependent on various agencies and programs that constitute the formal home care system. Over 200 organizations in 1986 offered some form of home care service in New York City. Among these were at least 100 proprietary businesses, 61 nonprofit personal care agencies, and 36 nonprofit certified home health agencies. In 1984, 166,739 different New York City residents received home care services provided by the four largest types of formal providers of care: certified home health agencies; Long Term Home Health Care Programs; Human Resources Administration home attendant agencies and homemaker/housekeeper agencies; and Department for Aging homemaker/housekeeper programs. While women age 65 and older living alone are the largest client group for home care services, persons below age 65 account for approximately one-fourth of program caseloads of the four major home care providers in New York City. An estimate of one-day home care use in 1984 shows that the four major types of providers served 59,554 persons with total annual expenditures of $499.3 million, while nursing homes cared for 36,072 persons with annual expenditures of almost $1.4 billion. It is thus evident that more people are receiving organized, extended care at home on a given day in New York City than in nursing homes. Medicaid, the major payer for home care in New York City, spent $412.4 million on home care services in 1984, accounting for 82.6 percent of total publicly funded expenditures for home care services. Of this amount, 89 percent was for personal care services provided through the Human Resources Administration's personal care program. More details on home care in New York City follow, along with a discussion of policy perspectives surrounding the provision of and payment for home care services in the future.

Phase I trial of tiazofurin administered by i.v. bolus daily for 5 days, with pharmacokinetic evaluation

Tiazofurin is a novel C-nucleoside with significant antitumor activity in murine tumor models. In a phase I clinical trial, patients received tiazofurin by bolus iv infusion daily for 5 days. Six doses ranging from 550 to 4100 mg/m2/day were evaluated. Thirty-one treatment courses were initiated in 21 patients. Tiazofurin induced multiple, transient toxic effects at all but the lowest dose level, and treatment interruption was a common result. Nine of 28 treatment courses initiated at doses greater than or equal to 1100 mg/m2/day were interrupted at less than 5 days; only five of eight courses initiated at 1100 mg/m2/day were completed. Symptoms leading to treatment interruption included headache, nausea and emesis, and lethargy and malaise. Other significant, transient toxic effects included skeletal muscle injury manifest as pain, weakness, or serum biochemical abnormalities; mucocutaneous effects; and mental or mood changes. One case each of transient pericarditis and fatal cardiomyopathy occurred at the highest dose. Myelosuppression was observed but was transient and not dose limiting. In addition to leukopenia and thrombocytopenia, unexpected declines in serum hemoglobin were observed, although these were of uncertain significance. Tiazofurin induced significant increases in uric acid production which could be reversed with coadministration of allopurinol. Pharmacokinetic analysis revealed tiazofurin plasma elimination to be at least biphasic, with a beta-half-time of 4.2 hours; most of an injected dose could be recovered from the urine as unaltered compound within 24 hours. From this study we conclude that an appropriate dose for phase II trials with this schedule is less than or equal to 1000 mg/m2/day. The schedule may be a difficult one for clinical evaluation of antitumor activity, however, because of the possibility of frequent treatment interruption due to multiple systemic toxic effects.

Water-soluble N-substituted iminodiacetato(1,2-diaminocyclohexane)-platinum(II) complexes as potential antitumor agents

A series of water-soluble N-substituted iminodiacetato(1,2-diaminocyclohexane)-platinum(II) complexes (IDP) were synthesized and tested for chemical stability, antitumor activity, and toxicity. The results obtained suggest that these complexes are relatively stable for more than 48 h when dissolved in water or phosphate buffer. All complexes had good in vitro cytotoxicity and were not cross-resistant with cis-dichloro-diammineplatinum(II) (DDP) in a DDP-resistant cell line in vitro. When the complexes were administered as a single i.p. injection to C57BL/6 X DBA/2F1 (hereafter called B6D2F1) mice inoculated with L1210 leukemia cells, a significant increase in mean survival time was observed, but there were few long-term survivors. When the complexes were administered on Days 1, 5, and 9 after tumor inoculation, however, cure rates of 50 to 85% were obtained. The oncolytic activity of the IDP complexes against L1210 ascites appeared much greater than that of DDP. The IDP complexes also had good antitumor activity when administered i.p. on Days 1, 5, and 9 following i.p. inoculation of B16 melanoma to B6D2F1 mice. Five of the six IDP complexes had no significant nephrotoxicity (as evidenced by lack of elevated blood urea nitrogen levels). N-Benzyl-iminodiacetato(1,2-diaminocyclohexane)-platinum(II) resolved into three distinct peaks of UV-absorbing material that corresponded with three distinct peaks of platinum-containing material. The exact chemical identity of the active component of this mixture is currently under investigation. The results obtained to date, however, suggest that the N-substituted iminodiacetato(1,2-diaminocyclohexane)-platinum(II) complexes are good candidates for further developmental studies.

Furanose-pyranose isomerization of reduced pyrimidine and cyclic urea ribosides

Tetrahydrouridine (THU, 2) and other fully reduced cyclic urea ribofuranosyl nucleosides undergo a rapid, acid-catalyzed isomerization to their more stable ribopyranosyl form. This isomerization is characterized by a change in spectral properties and by a greater than 10-fold decrease in potency for those nucleosides that act as potent inhibitors of cytidine deaminase in their ribofuranose form. 1-(beta-D-Ribopyranosyl)hexahydropyrimidin-2-one (7) was synthesized and used in conjunction with its furanose isomer 6 as a model compound for more extensive 1H and 13C NMR, mass spectral, and kinetic studies of this isomerization. The 0.4 delta upfield shift and 4-Hz increase in the J1',2' coupling constant for the pyranose anomeric proton in the 1H NMR spectrum is indicative of a pyranose beta-CI conformation in which the aglycon and C-2' and C-4' hydroxyls are equatorial. The mass spectra of trimethylsilylated pyranose nucleosides also show a characteristic large shift in the m/z 204-217 abundance and the appearance of two new rearrangement ions at M-133 and M-206. For furanose 6 the rate of isomerization is pH and temperature dependent with pyranose 7 predominating by a factor of 6-9 equilibrium. At pH 1 and 37 degrees C, furanose 6 has an initial half-life of less than 12 min. Accordingly, this isomerization may explain the observed lack of enhanced ara-C levels in studies evaluating the oral administration of an ara-C and THU combination to species with an acidic stomach content.

Synthesis and antitumor activities of unsymmetrically substituted 1,4-bis[(aminoalkyl)amino]anthracene-9,10-diones and related systems

A number of unsymmetrically substituted 1,4-bis[(aminoalkyl)amino]anthracene-9,10-diones have been synthesized and evaluated for their antitumor activity against L1210 in vitro and in vivo. The high activity of several compounds observed in vitro was not paralleled by comparable activity in vivo. The activities of the substituted 1,4-bis[(aminoalkyl)amino]anthracene-9,10-diones as inhibitors of cell growth were generally much higher than those of the related 1-[(aminoalkyl)amino]-4-methoxyanthracene-9,10-diones, and this correlated with the relative abilities of compounds of the two types to interact with calf thymus DNA.

Synthesis of pyrimidin-2-one nucleosides as acid-stable inhibitors of cytidine deaminase

One of the problems encountered in the use of tetrahydrouridine (THU, 2) and saturated 2-oxo-1,3-diazepine nucleosides as orally administered cytidine deaminase (CDA) inhibitors is their acid instability. Under acid conditions these compounds are rapidly converted into inactive ribopyranoside forms. A solution this problem was sought by functionalizing the acid-stable but less potent CDA inhibitor 1-beta-D-ribofuranosyl-2(1H)-pyrimidinone (1) with the hope of increasing its potency to the level achieved with THU. The selection of the hydroxymethyl substituent at C-4, which led to the synthesis of 4-(hydroxymethyl)-1-beta-D-ribofuranosyl-2(1H)-pyrimidinone (10), 3,4-dihydro-4-(hydroxymethyl)-1-beta-D-ribofuranosyl-2(1H)-pyrimidinone (7), and 3,4,5,6-tetrahydro-4-(dihydroxymethyl)-1-beta-D-ribofuranosyl-2(1H)-p yrimidinone (28) was based on the transition-state (TS) concept. The key intermediate precursor, 4-[(benzoyloxy)methyl]-1-(2,3,5-tri-O-benzoyl-beta-D-ribofuranosyl)-2(H) -pyrimidinone (24), was obtained via the classical Hilbert-Johnson reaction between 2-methoxy-4-[(benzoyloxy)methyl]pyrimidine (20) and 2,3,5-tri-O-benzoyl-1-D-ribofuranosyl bromide (21). Deprotection of 24 afforded compound 10, while its sodium borohydride reduction products afforded compounds 7 and 28 after removal of the blocking groups. Syntheses of 3,4-dihydro-1-beta-D-ribofuranosyl-2(1H)-pyrimidinone (9) and 3,6-dihydro-1-beta-D-ribofuranosyl-2(1H)-pyrimidinone (8), which lack the hydroxymethyl substituent, was accomplished in a similar fashion. The new compounds bearing the hydroxymethyl substituent were more acid stable than THU, and their CDA inhibitory potency, expressed in terms of Ki values, spanned from 10(-4) to 10(-7) M in a manner consistent with the TS theory. Compound 7, in particular, was superior to its parent 1 and equipotent to THU (Ki = 4 X 10(-7) M) when examined against mouse kidney CDA. The superior acid stability of this compound coupled to its potent inhibitory properties against CDA should provide a means of testing oral combinations of rapidly deaminated drugs, viz. ara-C, without the complications associated with the acid instability of THU.

Ascorbato(1,2-diaminocyclohexane):platinum(II) complexes, a new series of water-soluble antitumor drugs

Dichloro-1,2-diaminocyclohexane (DACH):platinum(II), the prototype DACH:platinum complex, had good antitumor activity, was not cross-resistant with cis-dichlorodiammineplatinum(II) (DDP), but was, unfortunately, virtually insoluble in water and was, therefore, not evaluated clinically. This paper summarizes some of the chemical and biological attributes of a series of cis-bisascorbato-DACH:platinum(II) complexes (DAP). Although the primary emphasis has been placed on the DAP complex consisting of the isomeric mixture DACH, a series of complexes using the isomers of either DACH or ascorbic acid have also been synthesized. The synthetic procedure entailed reacting the water-soluble sulfato-DACH:platinum(II) with barium ascorbate, and the water-soluble product DAP was removed from the BaSO4 precipitate by filtration. Based upon elemental analysis, all the complexes had stoichiometric composition of one DACH:one platinum and two ascorbate monoanions. High-pressure liquid chromatography of cis-bisascorbato (mixed-isomer DACH):platinum revealed a series of platinum-containing, ultraviolet-absorbing peaks. All the DAP complexes had significant in vitro cytotoxicity against L1210 leukemia cells (L1210/0) with 50%-inhibitory dose values ranging from 2 to 5 micrograms/ml. None of the complexes was cross-resistant with DDP when tested in vitro against L1210 cells 50-fold resistant to DDP (L1210/DDP). The cis-bisascorbato (mixed-isomer DACH):platinum (DAP-1) was administered i.p. to C57BL X DBA/2 F1 mice inoculated i.p. with 10(6) L1210/0 cells. When administered on Days 1, 5, and 9, the DAP-1 complex consistently produced treated:control values in excess of 200% with several long-term survivors (alive 60 days after tumor inoculation). Further, the DAP-1 complex was totally non-cross-resistant with DDP when tested in vivo against a DDP-resistant L1210 line. Toxicological investigations revealed that DAP-1 was relatively nonnephrotoxic but did cause the expected bone marrow and gastrointestinal toxicity. In summary, the DAP complexes are highly water-soluble, nonnephrotoxic platinum complexes with sufficient antitumor activity to warrant further pharmacological, biochemical, and chemical investigations.

Metabolism and biliary excretion of trimetrexate by the isolated perfused rat liver

The metabolism and biliary excretion of trimetrexate (TMTX), a lipid soluble antifolate, were examined using a recirculating isolated perfused rat liver system. Elimination of TMTX into perfusate was biphasic and dose-independent, with distribution and elimination half-lives of 2 and 13 min. Two metabolites, M1 and M2, both known to inhibit dihydrofolate reductase activity, were present in perfusate only in small concentrations. However, of the total TMTX dose, approximately 50% was excreted in bile as M1, and 20% as M2. Up to 75% of the total dose was accounted for as TMTX, M1, or M2 in perfusate and bile.

Synthesis and antineoplastic evaluations of 5,8-bis[(aminoalkyl)amino]-1-azaanthracene-9,10-diones

Several 5,8-bis[(aminoalkyl)amino]-1-azaanthracene-9,10-diones have been synthesized and evaluated for antitumor activity against L1210 leukemia both in vitro and in vivo. Comparisons are made to the corresponding carbocyclic analogues. One of the aza analogues showed modest in vivo activity.

Efficacy and toxicity of 4-(2-sulfonatoethylthio)-cyclophosphamide cyclohexylamine salt (ASTA Z 7557, INN mafosfamide) after intraperitoneal administration to mice

4-(2-sulfonatoethylthio)-cyclophosphamide cyclohexylamine salt (AZ; ASTA Z 7557) is a cyclophosphamide (CP) analog designed to be without acute bladder toxicity and to undergo spontaneous activation yielding phosphoramide mustard (PM). Studies in murine systems with intraperitoneal (i.p.) administration suggest that AZ may have a therapeutic index favorable to CP without an associated risk of bladder toxicity. Pericapsular hepatic fibrosis after i.p. administration suggests that regional AZ therapy may cause local toxicity. Further study of this compound, especially with intravenous (i.v.) administration, will be of interest.

Synthesis and antitumor activity of new platinum complexes

A new type of antitumor platinum complex has been prepared and examined for antitumor activity against L1210 leukemia both in vitro and in vivo. The coordination environment of platinum in these complexes consists of three anionic chloride ions and a positively charged amine. The positive charge is introduced by monoprotonation or monoalkylation of a diamine. Platinum(IV) derivatives have been prepared for several of the complexes, and a water-soluble sulfate derivative has been prepared for one of them. Several of these complexes exhibit significant in vitro activity, and trichloro(3-aminoquinuclidinium)platinum(II) (QTP) exhibits significant in vivo activity as well. An increase in life span of approximately 40% has been observed using QTP. QTP is toxic at doses slightly in excess of effective doses.

Clinical and clinical pharmacologic studies of mitoxantrone

The drug mitoxantrone was given to 31 patients in a phase I clinical trial. The schedule of administration was once weekly for 3 weeks followed by 3 weeks of observation before further treatment. Dose range was from 1.5 to 6 mg/m2. Leukopenia was the dose-limiting toxic effect and thrombocytopenia was mild. Partial alopecia occurred in four of 12 patients evaluable for hair loss. Pharmacokinetic studies employing a fluorometric assay based on DNA binding measured by displacement of ethidium bromide revealed a first-phase half-life of about 15 minutes, with a prolonged subsequent phase. A dose of 6 mg/m2/week x 3 was well-tolerated in patients not heavily pretreated with myelosuppression therapy. Only minor clinical activity was seen with mitoxantrone.

Clinical and clinical pharmacologic studies of aziridinylbenzoquinone

Thirty patients were entered in a phase I trial of aziridinylbenzoquinone (AZQ). These patients were treated with a single iv dose of AZQ daily for 5 days at doses ranging from 0.5 mg/m2 to 10.0 mg/m2. The dose-limiting and only significant toxic effects were leukopenia and thrombocytopenia, which appeared with relative consistency at iv dosages of 4.0--4.5 mg/m2/day x 5 in patients with extensive prior treatment and 7.0 mg/m2/day x 5 in patients with little prior treatment. One patient with colon cancer achieved a partial response of 4+ months. No other evidence of antitumor activity was observed. Pharmacologic studies revealed that the drug disappeared from the plasma in a biphasic manner (alpha-half-life = 1.5 minutes, beta-half-life = 18 minutes). With our method of analysis by high-performance liquid chromatography, no metabolites were found in the serum.

Enzymatic assays for 2,4-diamino-5-methyl-6-[(3,4,5-trimethoxyanilino)methyl]quinazoline, a promising new "nonclassical" antifolate

2,4-Diamino-5-methyl-6-[(3,4,5-trimethoxyanilino)-methyl]quinazoline (I) is a promising new "nonclassical" antifolate. Inhibition of dihydrofolate reductase from bacterial (Lactobacillus casei)and mammalian (beef liver) sources was employed to develop useful enzymatic assays for this compound. A linear relationship was obtained by plotting the I concentration versus 1/V. The resultant standard curves maintained linearity particularly well between the 30 and 70% control range, with a correlation coefficient of 0.99 for both enzyme systems. The two enzyme systems are characterized by differences in sensitivity, stability, and day-to-day variation. The ID50 for the beef liver reductase system was 1.6 X 10(-9) M (+/-0.03); for the L. casei system, it was 1.35 X 10(-8) M (+/- 0.2). The apparent advantage for the beef liver enzyme was offset somewhat by its relative instability and its higher day-to-day variability. Studies in mice demonstrated that these assays are suitable for pharmacokinetic studies in vivo. Such studies indicated that I has a serum t1/2 of 45 min in mice; a similar serum t1/2 (50 min) was estimated in studies with 14C-labeled I in position 6.

Cyclic urea nucleosides. Cytidine deaminase activity as a function of aglycon ring size

Five beta-D-ribofuranosyl cyclic urea nucleosides (14-18), ranging in ring size from five to eight membered, were synthesized and evaluated as cytidine deaminase (CDA) inhibitors. The precursor protected nucleosides (9-13) were prepared by a condensation procedure utilizing persilylated ureas with a halo sugar under the specific catalytic activity of a HgO/HgBr2 mixture which provided exclusively the beta-anomers. Catalytic hydrogenation of known 1-(2,3,5-tri-O-benzoyl-beta-ribofuranosyl)-1,2-dihydropyrimidin-2-one (19) afforded nucleoside 10 identical with that obtained by the mercury-catalyzed condensation procedure. CDA activity varies significantly with the ring size of the urea aglycon the reaches its maximum level for the seven-membered analogues 16 and 17. The unexpected high potency of nucleoside 17 (Ki = 2.5 X 10(-8) M, human liver enzyme) is reported. This compound represents the most potent inhibitor of human liver CDA yet discovered.

A recommended scheme for the evaluation of kits in the clinical laboratory

A scheme for kit evaluation in the individual clinical chemistry laboratory is presented. Recommendations for assessing accuracy, precision, and stability are included along with a scheme for preparing for the evaluation and writing the final report.

Pharmacologic and toxicologic evaluation of thioproline: a proposed nontoxic inducer of reverse transformation

The ability of thioproline to act as a nontoxic inducer of reverse transformation was examined. Thioproline was unable to effect reproducibly morphologic changes characteristic of the reversed transformed state of HeLa, WI-38VA13, C1300 neuroblastoma, and CHO-K1 cell lines. Reversal of transformed cells with dibutyryl cyclic AMP was, however, readily demonstrated in both the CHO-K1 and C1300 cell lines. Thioproline produced severe, life-threatening CNS toxicity in both mice and rats at levels far below those previously reported to be without any toxic effects. We conclude that not only is thioproline incapable of producing a reversal of the transformed state in HeLa and other cell lines in vitro, it is also a compound that must be described as a strongly CNS toxic agent.

Activity of 2,4-diaminoquinazoline compounds against Candida species

Forty recent clinical isolates of three different Candida sp. were tested in the microtiter system for susceptibility to two new 2,4-diaminoquinazoline (DAQ) compounds, amphotericin B and flucytosine. The two DAQ preparations showed activity similar to amphotericin B and flucytosine. The geometric mean minimal inhibitory concentrations for these four drugs were as follows: DAQ 1A, 0.64 mug/ml; DAQ 2A, 1.39 mug/ml; amphotericin B, 1.03 mug/ml; and flucytosine, 0.72 mug/ml. An additional seven DAQ compounds were tested but showed less or no activity against 17 Candida isolates. Forty-eight-hour viability studies with DAQ 2A alone or in combination with amphotericin B, flucytosine, or sulfamethoxazole were carried out with one isolate of intermediate susceptibility to each of these agents except sulfamethoxazole. For this isolate the combination of DAQ 2A and sulfamethoxazole was synergistic, and the combination of DAQ 2A and AMB was either synergistic or additive, whereas the combination of DAQ 2A and flucytosine was antagonistic. Although regrowth of cultures exposed to DAQ 2A was noted over a 48-h period, neither degradation of the drug nor development of resistance to the drug could be detected. Swiss white mice receiving DAQ 1A at a dose of 6 mg/kg for 5 days showed no obvious signs of toxicity, including weight loss.