Stable carbon isotopic evidence for carbon limitation in hydrothermal vent vestimentiferans

Stable carbon isotope composition (delta(13)C values) can be used to evaluate an animal's source of nutritional carbon. Most animals with chemoautotrophic endosymbionts have quite negative tissue delta(13)C values due to discrimination against (13)C associated with chemoautotrophic assimilation of inorganic carbon. However, the delta(13)C values of hydrothermal vent (HTV) vestimentiferans are significantly higher than the values reported for non-HTV vestimentiferans or other invertebrates with chemoautotrophic endosymbionts. Tissue delta(13)C values of two species of HTV vestimentiferans increase with increasing size of the animals. This relation supports the hypothesis that the relatively high delta(13)C values are the result of inorganic carbon limitation during carbon fixation. A more favorable relation between gas exchange and carbon fixation in the smaller individuals is expected, due to differences in the geometric scaling of gas-exchange surfaces and trophosome volume.

Astrocyte-derived kynurenic acid modulates basal and evoked cortical acetylcholine release

We tested the hypothesis that fluctuations in the levels of kynurenic acid (KYNA), an endogenous antagonist of the alpha7 nicotinic acetylcholine (ACh) receptor, modulate extracellular ACh levels in the medial prefrontal cortex in rats. Decreases in cortical KYNA levels were achieved by local perfusion of S-ESBA, a selective inhibitor of the astrocytic enzyme kynurenine aminotransferase II (KAT II), which catalyses the formation of KYNA from its precursor L-kynurenine. At 5 mm, S-ESBA caused a 30% reduction in extracellular KYNA levels, which was accompanied by a two-threefold increase in basal cortical ACh levels. Co-perfusion of KYNA in the endogenous range (100 nm), which by itself tended to reduce basal ACh levels, blocked the ability of S-ESBA to raise extracellular ACh levels. KYNA perfusion (100 nm) also prevented the evoked ACh release caused by d-amphetamine (2.0 mg/kg). This effect was duplicated by the systemic administration of kynurenine (50 mg/kg), which resulted in a significant increase in cortical KYNA formation. Jointly, these data indicate that astrocytes, by producing and releasing KYNA, have the ability to modulate cortical cholinergic neurotransmission under both basal and stimulated conditions. As cortical KYNA levels are elevated in individuals with schizophrenia, and in light of the established role of cortical ACh in executive functions, our findings suggest that drugs capable of attenuating the production of KYNA may be of benefit in the treatment of cognitive deficits in schizophrenia.

Does patent ductus arteriosus affect feed tolerance in preterm neonates?

Patent ductus arteriosus (PDA), especially PDA with sepsis, has been reported as a risk factor for feed intolerance in preterm neonates. In this study, the start to full feeds interval was found to be longest in preterm neonates (<or=28 weeks' gestation) with sepsis, followed by that in preterm neonates with sepsis and PDA, and in those with PDA alone.

Is surgical ligation of patent ductus arteriosus necessary? The Western Australian experience of conservative management

BACKGROUND

Surgical ligation of patent ductus arteriosus (PDA) is widely practised in preterm infants despite no clear evidence that this improves outcomes. Geographical isolation meant that ductal ligation was not an option in King Edward Memorial Hospital until recently.

OBJECTIVE

A retrospective data analysis to test the hypothesis that outcomes of infants with persistent PDA were no worse than those of infants with no significant duct or a duct that closed after medical treatment.

PATIENTS AND METHODS

A total of 252 infants (gestation < or =28 weeks) born between 1 January 2000 and 30 June 2002 were divided into three groups: group 1, no significant PDA (n = 154); group 2, significant PDA which closed after medical treatment (n = 65); group 3, significant PDA remaining patent after medical treatment (n = 33). A significant PDA was defined by a left atrium to aortic root ratio of >1.4 or a ductal diameter >1.5 mm with a left to right shunt.

RESULTS

Twenty four (10%) infants died at median (interquartile range) 15.5 (9-35) days. After adjustment for gestational age, relative to group 1, the infants from group 3 were at a 4.02 times increased risk of death (95% confidence interval 1.12 to 14.51). There was no significant difference between groups in the incidence of chronic lung disease, chronic lung disease or death, necrotising enterocolitis, intraventricular haemorrhage, duration of oxygen, or hospital stay.

CONCLUSION

Mortality was higher in infants with a persistent PDA, but other morbidities were not significantly different. A randomised trial is needed to determine whether surgical ligation will reduce mortality in such infants.

The biology of cortical granules

An egg-that took weeks to months to make in the adult-can be extraordinarily transformed within minutes during its fertilization. This review will focus on the molecular biology of the specialized secretory vesicles of fertilization, the cortical granules. We will discuss their role in the fertilization process, their contents, how they are made, and the molecular mechanisms that regulate their secretion at fertilization. This population of secretory vesicles has inherent interest for our understanding of the fertilization process. In addition, they have import because they enhance our understanding of the basic processes of secretory vesicle construction and regulation, since oocytes across species utilize this vesicle type. Here, we examine diverse animals in a comparative approach to help us understand how these vesicles function throughout phylogeny and to establish conserved themes of function.

Clozapine use in patients with schizophrenia and the risk of diabetes, hyperlipidemia, and hypertension: a claims-based approach

BACKGROUND

Numerous case reports have linked clozapine to the development of diabetes mellitus and hyperlipidemia in patients with schizophrenia. However, investigators have been unable to clearly demonstrate this association when compared with a control group receiving conventional antipsychotics.

METHODS

Medical and pharmacy claims from the Iowa Medicaid program were used to compare incidence rates for diabetes, hyperlipidemia, and hypertension in 552 patients receiving clozapine and 2461 patients receiving conventional antipsychotics (eg, haloperidol, chlorpromazine hydrochloride), with the use of a retrospective cohort design. Logistic regression was used to compare incidence rates adjusting for age, sex, and duration of available follow-up.

RESULTS

No significant differences in overall incidence rates for diabetes, hyperlipidemia, or hypertension were observed in patients receiving clozapine vs conventional antipsychotics. However, among younger patients (aged 20-34 years), clozapine administration was associated with a significantly increased relative risk of diabetes (2.5 [95% confidence interval, 1.2-5.4]) and hyperlipidemia (2.4 [95% confidence interval, 1.1-5.2]), but not hypertension (0.9 [95% confidence interval, 0.4-2.0]).

CONCLUSIONS

These data suggest that clozapine may not be an independent cause of diabetes or hyperlipidemia, but instead acts as an effect modifier in susceptible populations by increasing weight or affecting insulin secretion and resistance. This finding requires confirmation in other settings and patient populations and with the other atypical antipsychotics (risperidone, olanzapine, and quetiapine fumarate). The potential long-term medical and economic implications of the early induction of diabetes and hyperlipidemia in patients with schizophrenia warrant further study.

Trace contaminant concentrations in the Kara Sea and its adjacent rivers, Russia

Trace organic (chlorinated pesticides, PCBs, PAHs and dioxins/furans) and trace metal concentrations were measured in surficial sediment and biological tissues (i.e., worms, crustaceans, bivalve molluscs, and fish livers) collected from the Russian Arctic. Total DDT, chlordane, PCB and PAH concentrations ranged from ND to 1.2, ND to <0.1, ND to 1.5 and <20-810 ng g(-1), respectively, in a suite of 40 surficial sediment samples from the Kara Sea and the adjacent Ob and Yenisey Rivers. High sedimentary concentrations of contaminants were found in the lower part of the Yenisey River below the salt wedge. Total dioxins/furans were analysed in a subset of 20 sediment samples and ranged from 1.4 to 410 pg g(-1). The highest trace organic contaminant concentrations were found in organisms, particularly fish livers. Concentrations as high as 89 ng g(-1) chlordane; 1010 ng g(-1) total DDTs; 460 ng g(-1) total PCBs; and 1110 ng g(-1) total PAH, were detected. A subset of 11 tissue samples was analysed for dioxins and furans with total concentrations ranging from 12 to 61 pg g(-1). Concentrations of many trace organic and metal contaminants in the Kara Sea appear to originate from riverine sources and atmospheric transport from more temperate areas. Most organic contaminant concentrations in sediments were low; however, contaminants are being concentrated in organisms and may pose a health hazard for inhabitants of coastal villages.

Organic carbon flow in the Ob, Yenisey Rivers and Kara Sea of the Arctic region

Stable carbon isotope and elemental C/N ratios of the organic fraction of a set of samples along a transect in the Ob and Yenisey Rivers into the Kara Sea in the Arctic were measured. Previously, the concentrations of 239,240Pu and 137Cs in these same samples had been determined. The coupled measurements were carried out to assess possible connectivity between organic carbon flow into the Kara Sea and transport of radioactive nuclides in this marine environment. Organic carbon flow into the Kara Sea is influenced significantly by terrigenous sources carried by the Ob and Yenisey Rivers. The carbon isotope-organic carbon relationship provides evidence that a rich source of terrigenous carbon exists in the riverine system. A weak, but significant relationship between stable carbon isotope ratio and 137Cs suggests that most of the 137Cs is derived from riverine particles, as compared to Pu which is also derived from in situ scavenging within the water column.

The geographic distribution of population health and contaminant body burden in gulf of Mexico oysters

As part of NOAA's National Status and Trends Mussel Watch Program, oysters were sampled along the Gulf of Mexico coast each winter from 1986 to 1993 (The present analysis deals with 1986-1993 Mussel Watch data; the Mussel Watch project itself continues at this printing) and analyzed for trace metal, polynuclear aromatic hydrocarbons and pesticide body burden, plus a series of biological variables designed to assess population status and health. We identified contaminant and biological variables in which large-scale spatial processes played an important role in establishing population values by examining the likelihood that neighboring bays tended to have populations with body burdens or population attributes more similar than expected by chance. Local or watershed-dependent factors, such as land use and freshwater inflow, are important in controlling the bay-to-bay variation in body burden in most contaminants. However, the bay-to-bay variations in body burden of some metals (As, Cd, Hg, Ni, Se) appear to be principally influenced by larger-scale climatic factors. These metals and the biological variable shell length demonstrated a strong degree of similarity between bays over a large regional area reminiscent of the pattern shown by climatic factors, such as temperature and precipitation. In contrast, among the organics, none of the PAHs showed even a moderately strong climatic signal. Among the pesticides, only two did (dieldrin, total DDTs). These pesticides and the biological variables, reproductive stage and Perkinsus marinus prevalence and infection intensity, had spatial patterns that suggested both a local and a regional influence to their geographic distributions. This same pattern is exhibited by freshwater runoff. Metal contaminants also behaved distinctively compared to organics in the temporal influence of climate in establishing the interannual variability in body burden. For the organics, trends in interannual variability were strongly influenced by climate, whereas spatial trends were not. In contrast, most metals were unaffected by climatic forcing both spatially and temporally. However, all of the metals having a spatial pattern strongly influenced by climate (As, Cd, Hg, Ni, Se) also exhibited interannual variations related to variations in climate.

Ocean storage of nuclear wastes? Experiences from the Russian Arctic

An international demonstration (RD&D) project for ocean storage of radioactive wastes should be proposed, to study the feasibility of the concept of ocean storage of nuclear waste. This international project should utilize the scientific, engineering and technical capabilities of selected universities, oceanographic institutions, NGOs and industries. This project would need to be an independent (non-governmental) study, utilizing the capabilities of selected universities, oceanographic institutions, environmental NGOs (Non-Governmental Organizations) and industries. Scientists and engineers first need to conduct an engineering, environmental, and economic feasibility study of the concept. The goal of the project would be to determine if ocean-based storage reduced the risks to the environment and public health to a greater degree than land-based storage. This would require comparing the risks and factors involved and making the data and information available to anyone, anywhere, anytime on the internet. The mere presence of an investigation of the ocean storage option could facilitate scientific and engineering competition between the two options, could subsequently reduce environmental and public risks and provide better protection and cost benefits in the system utilized. One of the primary concerns of the scientific community would be related to the sensitivity and precision of the monitoring of individaul containers on the ocean bottom. An advantage of the land-based option is that if there is a release, its presence could be detected at very low levels and be contained in the storage facility. On the ocean bottom, a release from a container might not be easily detected due to dispersion. Therefore the containment system would have to be a system within a system with monitoring between the two providing greater protection. Ocean storage may have greater technical and political hurdles than land-based options, but it may provide greater protection over time, because it negates the threat of terrorism, it therefore merit further study. In the future if the use of nuclear energy and nuclear wastes increases, the global society could benefit from this international project, because it could reduce environmental and public health risks and promote energy independence.

Information gained from linking SEER Cancer Registry Data to state-level hospital discharge abstracts. Surveillance, Epidemiology, and End Results

OBJECTIVES

Our goal was to link patients from the Iowa Surveillance, Epidemiology, and End Results (SEER) Registry to their respective inpatient discharge abstracts from an Iowa Health Care Cost and Utilization Project (HCUP)-formatted database and evaluate whether this linkage provides information related to cancer treatment variation.

METHODS

Computer algorithms linked patients from the Iowa SEER Registry to discharge abstracts using 5 variables consistently defined between the databases (hospital identification, date of birth, admission date, discharge date, and zip code). Abstracts were reviewed for validity, and links not passing face validity were excluded.

SUBJECTS

Our sample contained 7,296 patients with early-stage breast cancer (I, IIa, IIb) with surgery from the Iowa SEER Registry from 1989 through 1994 with contacts only with Iowa hospitals.

RESULTS

Inpatient discharges abstracts were linked to 86.4% of the patients in our sample. More than 96% of the linked discharges for Medicare patients had a corresponding Medicare claim. Over 45% of the linked patients were not covered by Medicare. Comorbidity indexes were comparable to other published sources. Significant differences in diagnosis, comorbidities, and treatment were found across third-party payers.

CONCLUSIONS

This linkage provides a valuable source of comorbidity and insurance data and perhaps the only source of secondary clinical information for the uninsured. This linkage is best suited for cancers requiring inpatient stays for treatment and for those states where border crossing for treatment is low.

Direct molecular interaction of a conserved yolk granule protein in sea urchins

The regulation of yolk storage in oocytes and subsequent utilization in embryos is critical for embryogenesis. In sea urchins, the major yolk protein is made in the intestines, transported to the ovaries and accumulated in developing oocytes within membrane-bound vesicles comprising approximately 10% of the mass of an egg. Here, a non-yolk protein that accumulates specifically in yolk granules is reported. This protein was identified by cDNA cloning and, by use of antibodies to the recombinant protein, it was shown that this molecule is stored selectively in yolk granules of oocytes and embryos. No accumulation was seen in the accessory cells, testis, or intestines. In situ ribonucleic acid (RNA) hybridizations showed that the transcript accumulated only in oocytes, and was more highly concentrated in young oocytes. However, later in oogenesis, the messenger ribonucleic acid (mRNA) levels decreased significantly so that no signal was detectable in mature haploid eggs or at any later stage in development. However, by immunofluorescence and western blot analysis, the 30 kDa band was present throughout development. The predicted sequence of this protein shows that it is a member of the bep, HLC-32, EBP family of sea urchin proteins, but as it does not accumulate at the cell surface, nor in the hyaline layer in the two species studied here, as do other members of the family, it has been referred to as YP30 (30 kDa protein of the yolk platelet). To address its potential function, yeast two-hybrid analysis was performed to screen for proteins that potentially interact with YP30. It was found that it binds itself, and forms strongly interacting dimers. It is hypothesized that YP30 participates in the packaging and storage of major yolk protein during oogenesis, or in the utilization of the major yolk protein in development.

The marginal benefits of invasive treatments for acute myocardial infarction: does insurance coverage matter?

This paper applies instrumental variable (IV) techniques and estimates the average benefits of invasive surgical treatments for marginal acute myocardial infarction (AMI) patients by insurance coverage. The study uses data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases for the state of Washington, for years 1988-1993. We observed differences in average benefits for marginal patients across insurance subpopulations that cannot be explained by differences in measured clinical circumstances. Our empirical results show that the insurance subpopulations with the greatest estimated marginal benefits are those with the lowest expected payment generosity to providers. Because of the relatively weak explanatory power of our instruments for three insurance subpopulations, and because many of the parameter estimates across the insurance subpopulations are not statistically different from each other, policy recommendations should be approached cautiously. However, our application of IV techniques to AMI patients demonstrates the usefulness of this approach to estimate treatment effects across patient populations (e.g., across types of insurance coverage) for medical conditions of interest to policymakers. These estimates may help determine whether treatments are overutilized or underutilized.

Immunodominance among EBV-derived epitopes restricted by HLA-B27 does not correlate with epitope abundance in EBV-transformed B-lymphoblastoid cell lines

Using synthetic peptides, the HLA-B27-restricted CTL response to EBV in asymptomatic virus carriers has been mapped to four epitope regions in EBV latent cycle Ags. One of these peptide-defined epitopes (RRIYDLIEL) tends to be immunodominant and is recognized in the context of all three B27 subtypes studied, B*2702, B*2704, and B*2705. The other peptide-defined epitopes induce responses only in the context of one subtype, the immunogenic combinations being RRARSLSAERY/B*2702, RRRWRRLTV/B*2704, and FRKAQIQGL/B*2705. We used immunoaffinity chromatography to isolate the naturally presented viral peptides associated with these MHC class I molecules on the surface of EBV-transformed B-LCL. Using CTL reconstitution assays in conjunction with mass spectrometry, we established that the naturally processed and presented peptides are identical with the previously identified synthetic sequences. Despite the subtype-specific immunogenicity of three of the four epitopes, all four epitope peptides were found in association with each of the three different HLA-B27 subtypes. Indeed, those peptides that failed to induce a response in the context of a particular HLA-B27 subtype were frequently presented at greater abundance by that subtype than were the immunogenic peptides. Furthermore, among the peptides that did induce a response, immunodominance did not correlate with epitope abundance; in fact the immunodominant RRIYDLIEL epitope was least abundant, being present at less than one copy per cell. The relationship of this unexpected finding to the persistence of EBV is discussed.

Cytotoxic T-lymphocyte responses to a polymorphic Epstein-Barr virus epitope identify healthy carriers with coresident viral strains

Cytotoxic T-lymphocyte (CTL) responses to Epstein-Barr virus (EBV) tend to focus on a few immunodominant viral epitopes; where these epitope sequences are polymorphic between EBV strains, host CTL specificities should reflect the identity of the resident strain. In studying responses in HLA-B27-positive virus carriers, we identified 2 of 15 individuals who had strong CTL memory to the pan-B27 epitope RRIYDLIEL (RRIY) from nuclear antigen EBNA3C but whose endogenous EBV strain, isolated in vitro, encoded a variant sequence RKIYDLIEL (RKIY) which did not form stable complexes with B27 molecules and which was poorly recognized by RRIY-specific CTLs. To check if such individuals were also carrying an epitope-positive strain (either related to or distinct from the in vitro isolate), we screened DNA from freshly isolated peripheral blood mononuclear cells for amplifiable virus sequences across the EBNA3C epitope, across a different region of EBNA3C with type 1-type 2 sequence divergence, and across a polymorphic region of EBNA1. This showed that one of the unexplained RRIY responders carried two distinct type 1 strains, one with an RKIY and one with an RRIY epitope sequence. The other responder carried an RKIY-positive type 1 strain and a type 2 virus whose epitope sequence of RRIFDLIEL was antigenically cross-reactive with RRIY. Of 15 EBV-seropositive donors analyzed by such assays, 12 appeared to be carrying a single virus strain, one was coinfected with distinct type 1 strains, and two were carrying both type 1 and type 2 viruses. This implies that a small but significant percentage of healthy virus carriers harbor multiple, perhaps sequentially acquired, EBV strains.

Market factors and the availability of community pharmacies

The purpose of this study was to examine the relationships between the availability of community pharmacies and 4 types of market factors. A composite data set was created that linked, at the county level, data on: (1) type and number of pharmacies; (2) population characteristics; (3) payer variables; (4) health care system factors; and (5) competitive factors. In this exploratory study, secondary data were used to assess the association between the availability of community pharmacies and the influence of market factors. To assess the market influences on availability of community pharmacies, 2 regressions were performed. In 1 model, the number of community pharmacies per 10,000 population was the dependent variable, whereas the dependent variable in the other regression was the proportion of independently owned community pharmacies. The independent variables in each regression were the market factors--population characteristics, payer variables, health care system factors, and competitive variables. Squared terms were included for 8 of 15 market factors to account for nonlinearities in the relationships. Multiple market factors were correlated with both the number of community pharmacies and the proportion of independently owned pharmacies in an area. Several of the relationships were not linear and changed direction within the range of data. Counties with either a low or a high percentage of elderly people had fewer pharmacies and a lower proportion of independently owned pharmacies compared with counties with a moderate percentage of elderly people. Counties that were scarcely or highly rural had fewer community pharmacies but a higher proportion of independently owned pharmacies than counties that were moderately rural. Areas with a greater percentage of the population earning less than the poverty level had more pharmacies, especially independently owned ones. Fewer community pharmacies were found in areas with higher health maintenance organization penetration rates. The number of hospital admissions was positively associated with the number of pharmacies but negatively associated with the proportion of independently owned pharmacies. The availability of community pharmacies varies across the country. In light of the trend toward fewer independently owned pharmacies, potential problems in accessing pharmacy services could develop in certain areas, including those that are highly rural and those with a high percentage of people earning less than the poverty level. Future research and policy issues are identified.

Injuries in water polo

Water polo is the only true "contact" sport of the aquatic disciplines. This article deals with the most common, aggressive, acute injuries, and the repetitive, overuse strains and sprains facing any athlete. Research to date demonstrates that the combination of swimming and throwing (without the benefit of a firm base of support) places a unique demand on the water polo athlete. The shoulder continues to be the most recognized and studied area of injury, with lacerations and traumatic fractures of the face and hand the next most prevalent. The premiere of women's water polo in the Sydney (Australia) 2000 Olympic games will draw more attention to this exciting, challenging sport.

Factors affecting bargaining outcomes between pharmacies and insurers

OBJECTIVE

To model the bargaining power of pharmacies and insurers in price negotiations and test whether it varies with characteristics of the pharmacy, insurer, and pharmacy market.

DATA SOURCES/STUDY SETTING

Data from four sources. Pharmacy/insurer transactions were taken from Medstat's universe of 6.8 million pharmacy claims in their 1994 Marketscan database. Sources Informatics, Inc. supplied a three-digit zip code-level summary database containing pharmacy payments and self-reported costs for retail (cash-paying) customers for the top 200 pharmaceutical products by prescription size in 1994. The National Council of Prescription Drug Programs supplied their 1994 pharmacy database. Zip code-level socioeconomic and commercial information was taken from Bureau of the Census' 1990 Summary Tape File 3B and 1994 Zip Code Business Patterns database.

STUDY DESIGN

The provider/insurer bargaining model first employed in Brooks, Dor, and Wong (1997, 1998) was adapted to the circumstances surrounding pharmacy and insurer bargaining.

DATA COLLECTION/EXTRACTION METHODS

The units of observation in this study were single Medstat claims for each unique insurer/pharmacy combination in the database for selected pharmaceutical products. The four products selected varied in the conditions they treat, whether they are used to treat chronic or acute conditions, and by their sales volume. Used in the analysis were 9,758 Zantac, 2,681 Humulin, 3,437 Mevacor, and 1,860 Dilantin observations.

PRINCIPAL FINDINGS

We find statistically significant variation in pharmacy bargaining power. Pharmacy bargaining power varies significantly across markets, insurers, and pharmacy types. With respect to market structure, pharmacy bargaining power is negatively related to pharmacies per capita and pharmacies per employer and positively related to pharmacy concentration at higher concentration levels. In addition, the higher the percentage of independent pharmacies in an area, the lower the pharmacy bargaining power. With respect to socioeconomic conditions, pharmacy bargaining power is higher in areas with lower per capita income and higher rates of public assistance.

CONCLUSIONS

The bargaining power of pharmacies in contract negotiations with insurers varies considerably with exogenous factors. Local area pharmacy ownership concentration enhances pharmacy bargaining. As a result, anti-trust law prohibiting the collective bargaining of independent pharmacies with insurers leaves independents at a disadvantage with respect to chains.

Varying health care provider objectives and cost-shifting: the case of retail pharmacy in the US

In this paper we investigate the relationship between health care provider objectives, cost-shifting, and prices by exploring the relationship between state Medicaid pharmacy reimbursements and average prices paid by pharmacy retail customers for four distinct pharmaceutical products across the US in 1994. We develop a more general theory than past researchers to enable provider objectives to vary with Medicaid pharmacy reimbursement levels. We find that provider objectives and the direction of relationship between Medicaid pharmacy reimbursements and retail prices vary with Medicaid pharmacy reimbursement levels. At high Medicaid pharmacy reimbursement levels we find a consistent negative relationship across products. At low Medicaid pharmacy reimbursement levels, the direction of the relationship is product-specific. As a result, policy-makers should be aware that policies affecting reimbursements from government-sponsored health insurance will also affect retail customers that include the uninsured. Paradoxically, for certain products if a state cuts a generous Medicaid reimbursement level this could hurt uninsured patients, whereas cuts in a stingy Medicaid reimbursement rate may help uninsured patients.

HLA-B27 subtype polymorphism and CTL epitope choice: studies with EBV peptides link immunogenicity with stability of the B27:peptide complex

HLA-B27-restricted CTL responses to EBV are principally directed against two of the EBV nuclear Ags, EBNAs 3B and 3C. We have previously described a target epitope derived from EBNA 3C (residues 258-266, sequence RRIYDLIEL) that is immunodominant in the context of at least three different B27 subtypes, including B*2705 and B*2702. In this study, we show that this peptide binds well to B*2705 and B*2702 in a cell surface binding assay, and that the two B27:peptide complexes are relatively stable, with t1/2 of 20 and 37 h, respectively. We now identify another B27-restricted epitope derived from EBNA 3B (residues 243-253, sequence RRARSLSAERY), which again accords well with the B*2705/B*2702 consensus motifs, having an arginine residue at position 2 and a tyrosine residue at the carboxyl terminus. In this case, five of five B*2702-positive donors respond to the epitope, whereas there was no response in any B*2705-positive donor studied. This peptide binds at least as well to B*2705 as to its restriction element B*2702; however, the two class I:peptide complexes show marked differences in stability, with t1/2 of 9 and 42 h, respectively. Thus, the stability of B27:peptide complexes can vary markedly between different B27 subtypes in ways that may not be apparent from cell surface binding assays and cannot be predicted from currently known peptide consensus motifs, yet which may critically influence CTL epitope choice.

Relationship between peptide binding and T cell epitope selection: a study with subtypes of HLA-B27

The effect of HLA-B27 polymorphism on antigen presentation was analysed by comparing the binding of three Epstein-Barr virus-derived peptide epitopes to HLA-B27 subtypes with their immunogenicity and antigenicity in the context of these subtypes. The effect of altering the major anchor residue Arg2 on binding or on recognition by peptide-specific cytotoxic T lymphocytes (CTL) was also examined. The three peptides bound significantly to all the B*2701-B*2706 subtypes. This did not correlate with the peptides being immunogenic or recognized by specific CTL in the context of only particular subtypes. In addition, of the three viral epitopes tested, those that were immunogenic in B*2702- or B*2705-restricted responses bound to these subtypes less efficiently than one peptide that was immunogenic only in the B*2704 context. Thus, among several potentially immunogenic peptides from the same virus, the antiviral response is not necessarily directed against the one that binds best to the restricting subtype. These results indicate that HLA-B27 polymorphism influences antigen presentation in ways other than simply peptide affinity. Synthetic analogues lacking the canonical Arg2 motif of HLA-B27-bound peptides, even when binding much worse to the restricting subtype, were recognized equally by CTL specific for the parental peptide. This indicates that Arg2 is not required to maintain the structure of the epitope. The implications of these results for pathogenetic models of HLA-B27-associated disease are discussed.

Hospital-insurer bargaining: an empirical investigation of appendectomy pricing

Employers' increased sensitivity to health care costs has forced insurers to seek ways to lower costs through effective bargaining with providers. What factors determine the prices negotiated between hospitals and insurers? The hospital-insurer interaction is captured in the context of a bargaining model, in which the gains from bargaining are explicitly defined. Appendectomy was chosen because it is a well-defined procedure with little clinical variation. Our results show that certain hospital institutional arrangements (e.g. hospital affiliations), HMO penetration, and greater hospital concentration improve hospitals' bargaining position. Furthermore, hospitals' bargaining effectiveness has diminished over time and varies across states.

Conserved CTL epitopes within EBV latent membrane protein 2: a potential target for CTL-based tumor therapy

In healthy virus carriers, EBV is subject to strong CTL responses that principally target the EBV nuclear Ag (EBNA) 3A, 3B, 3C subset of virus proteins. In vitro-reactivated CTLs of this kind have proved very effective in treating EBV-positive immunoblastic lymphoma, a malignancy that expresses the full range of virus proteins. However, targeting other EBV-positive tumors will require CTLs that recognize some of the subdominant viral Ags since in nasopharyngeal carcinoma and EBV-positive Hodgkin's disease, EBNA1, latent membrane protein (LMP) 1, and LMP2 are the only virus proteins present. Studying healthy virus carriers (Caucasian and Chinese), we identified five CTL target epitopes in LMP2 restricted through HLA alleles particularly common in the southern Chinese population, which is most at risk for nasopharyngeal carcinoma (HLA-A2, 50%; A11, 50%; A24, 30%; and B40, 32%). Furthermore, we analyzed the effect of HLA subtype polymorphism, especially in the context of A2 for which four subtypes are present at significant frequency in the Chinese population. As to virus polymorphism, LMP2 epitope sequences (in contrast to EBNA 3A, 3B, and 3C epitopes) were shown to be antigenically conserved among EBV isolates from different world populations, including viruses present in nasopharyngeal carcinoma and Hodgkin's disease biopsy samples. Thus, nasopharyngeal carcinoma and Hodgkin's disease are predicted to express LMP2 proteins that contain conserved CTL target epitopes restricted through common HLA alleles; boosting responses to these epitopes could form the basis of a CTL-based therapy for these malignancies.

Conserved CTL epitopes within EBV latent membrane protein 2: a potential target for CTL-based tumor therapy

In healthy virus carriers, EBV is subject to strong CTL responses that principally target the EBV nuclear Ag (EBNA) 3A, 3B, 3C subset of virus proteins. In vitro-reactivated CTLs of this kind have proved very effective in treating EBV-positive immunoblastic lymphoma, a malignancy that expresses the full range of virus proteins. However, targeting other EBV-positive tumors will require CTLs that recognize some of the subdominant viral Ags since in nasopharyngeal carcinoma and EBV-positive Hodgkin's disease, EBNA1, latent membrane protein (LMP) 1, and LMP2 are the only virus proteins present. Studying healthy virus carriers (Caucasian and Chinese), we identified five CTL target epitopes in LMP2 restricted through HLA alleles particularly common in the southern Chinese population, which is most at risk for nasopharyngeal carcinoma (HLA-A2, 50%; A11, 50%; A24, 30%; and B40, 32%). Furthermore, we analyzed the effect of HLA subtype polymorphism, especially in the context of A2 for which four subtypes are present at significant frequency in the Chinese population. As to virus polymorphism, LMP2 epitope sequences (in contrast to EBNA 3A, 3B, and 3C epitopes) were shown to be antigenically conserved among EBV isolates from different world populations, including viruses present in nasopharyngeal carcinoma and Hodgkin's disease biopsy samples. Thus, nasopharyngeal carcinoma and Hodgkin's disease are predicted to express LMP2 proteins that contain conserved CTL target epitopes restricted through common HLA alleles; boosting responses to these epitopes could form the basis of a CTL-based therapy for these malignancies.

NIST SRM 1945, whale blubber, NIST SRM 1974a, organics in mussel tissue, and NIST SRM 1941a, organics in marine sediment as certified reference materials for polychlorinated dioxins and furans in marine ecosystems

Few natural matrix Standard Reference Materials are available for the validation of analytical methods measuring polychlorinated dioxins and furans (PCDDs and PCDFs) in marine ecosystems. The concentrations of PCDDs and PCDFs in NIST SRM 1945, SRM 1974a, and SRM 1941a are of interest because the analysis of marine mammal, mussel tissues and sediments have become important tools in the determination of organochlorine contamination of the environment. Because these SRMs have been demonstrated to be homogenous for other organic contaminants, they would be expected to be reliable standards for validation of polychlorinated dioxins and furans in marine mammals, mussels and sediments as well.