Co-administration of drugs and blood products

The addition of a drug to a blood product intravenous line raises the question of physical and chemical compatibility of the drug with the blood and any preservatives or additives in the blood product. This clinical scenario is encountered frequently, however the practice has not been well studied. Protocols at most institutions prohibit the addition of drugs to blood products. We investigated the addition of analgesic drugs used for patient-controlled analgesia (morphine 1 mg/ml, pethidine 10 mg/ml and ketamine 1 mg/ml) to a standard red cell concentrate, resuspended red blood cells. The red cells were analysed by a Blood Transfusion Service Haematologist and subjected to standard quality control tests. The morphology of the red cells in resuspended red blood cell preparations was unchanged by the addition of these drugs at any stage during storage. The drug concentration in the resuspended red blood cell serum was measured at 0 and at 20 minutes and there was no decrease in concentration which showed that there was no loss of free drug in the resuspended red blood cell serum. This study demonstrates that the concern regarding injury to red cells in standard red cell concentrates by addition of these drugs is unjustified.

Hiring of diagnostic radiologists in 1998

OBJECTIVE

We sought to determine the 1998 hiring activities of physician practices with respect to diagnostic radiologists.

MATERIALS AND METHODS

A survey was mailed to a sample of 970 radiology practices in the spring through fall of 1999; 73.0% responded. Responses were weighted to represent all practices in the United States providing diagnostic radiology services. Findings were compared with results of similar surveys from previous years.

RESULTS

In 1998, multiradiologist groups sought to hire 2299 (+/-148 [standard error]) diagnostic radiologists, an increase of 20% from 1977. Positions offered in 1998 were split almost equally between expansion positions and replacements for those who had left a practice. Another 422 (+/-58) positions had been vacated that practices did not seek to refill. In 1998, 621 (+/-57) diagnostic radiologists left active practice, which is more than the usual number of approximately 400 annually but less than the approximately 800 of 1996 and 1997. There was no significant association between hiring activity and the self-perceived effect of managed care on a group.

CONCLUSION

The pace of hiring and turnover of diagnostic radiologists increased in 1998. Positions available continue to exceed radiologists available to fill them; the excess was approximately 330 positions, which is not significantly different from the excess reported for 1997, but is higher than the (not statistically significant) net shortfall of 51 positions estimated for 1996.

The zinc finger protein schnurri acts as a Smad partner in mediating the transcriptional response to decapentaplegic

In Drosophila, a BMP-related ligand Decapentaplegic (Dpp) is essential for cell fate specification during embryogenesis and in imaginal disc development. Dpp signaling culminates in the phosphorylation and nuclear translocation of Mothers against dpp (Mad), a receptor-specific Smad that can bind DNA and regulate the transcription of Dpp-responsive genes. Genetic analysis has implicated Schnurri (Shn), a zinc finger protein that shares homology with mammalian transcription factors, in the Dpp signal transduction pathway. However, a direct role for Shn in regulating the transcriptional response to Dpp has not been demonstrated. In this study we show that Shn acts as a DNA-binding Mad cofactor in the nuclear response to Dpp. Shn can bind DNA in a sequence-specific manner and recognizes sites within a well-characterized Dpp-responsive promoter element, the B enhancer of the Ultrabithorax (Ubx) gene. The Shn-binding sites are relevant for in vivo expression, since mutations in these sites affect the ability of the enhancer to respond to Dpp. Furthermore we find that Shn and Mad can interact directly through discrete domains. To examine the relative contribution of the two proteins in the regulation of endogenous Dpp target genes we developed a cell culture assay and show that Shn and Mad act synergistically to induce transcription. Our results suggest that cooperative interactions between these two transcription factors could play an important role in the regulation of Dpp target genes. This is the first evidence that Dpp/BMP signaling in flies requires the direct interaction of Mad with a partner transcription factor.

Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims

CONTEXT

Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.

OBJECTIVE

To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.

DESIGN

A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.

SETTING AND SUBJECTS

A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.

MAIN OUTCOME MEASURES

Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).

RESULTS

For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).

CONCLUSIONS

This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333.

Ex vivo expanded peripheral blood progenitor cells provide rapid neutrophil recovery after high-dose chemotherapy in patients with breast cancer

Ex vivo expanded peripheral blood progenitor cells (PBPCs) have been proposed as a source of hematopoietic support to decrease or eliminate the period of neutropenia after high-dose chemotherapy. CD34 cells were selected from rhG-CSF mobilized PBPCs from patients with breast cancer and were cultured for 10 days in defined media containing 100 ng/mL each of rhSCF, rhG-CSF, and PEG-rhMGDF in 1 L Teflon bags at 20 000 cells/mL. After culture the cells were washed and reinfused on day 0 of transplantation. On day +1, cohort 1 patients (n = 10) also received an unexpanded CD34-selected PBPC product. These patients engrafted neutrophils (absolute neutrophil count, >500/microL) in a median of 6 (range, 5-14) days. Cohort 2 patients (n = 11), who received expanded PBPCs only, engrafted neutrophils in a median of 8 (range, 4-16) days. In comparison, the median time to neutrophil engraftment in a historical control group of patients (n = 100) was 9 days (range, 7-30 days). All surviving patients are now past the 15-month posttransplantation stage with no evidence of late graft failure. The total number of nucleated cells harvested after expansion culture was shown to be the best predictor of time to neutrophil engraftment, with all patients receiving more than 4 x 10(7) cells/kg, engrafting neutrophils by day 8. No significant effect on platelet recovery was observed in any patient. These data demonstrate that PBPCs expanded under the conditions defined can shorten the time to engraftment of neutrophils compared with historical controls and that the rate of engraftment is related to the dose of expanded cells transplanted.

The rise and fall of i-STAT point-of-care blood gas testing in an acute care hospital

In response to a $350,000 laboratory budget cut and closure of an intensive care unit-based laboratory and a desire to maintain turnaround times of 10 minutes or less, a multidisciplinary group developed and implemented point-of-care (POC) testing. Only blood gases (pH, PO2, and PCO2) and ionized calcium values were deemed essential stat tests. Three commercially available POC blood gas devices were evaluated; all yielded results comparable to in-house reference methods. The 1 device with a US Food and Drug Administration-approved method for ionized calcium testing and with an existing interface for laboratory information systems was selected. Fiscal analysis predicted annual savings of approximately $225,000. POC blood gas analysis was implemented in April 1996 coincident with closure of the intensive care unit-based laboratory. Clinical laboratories and POC blood gas test volumes remained constant through August 1998; in contrast, the number of ionized calcium tests decreased dramatically after April 1996. In August 1998, clinically significant (i.e., artificial ventilation parameters would have been altered based on test results) discrepant PCO2 values were observed sporadically and noted only with patient specimens, not with commercial controls or electronic simulators. Because investigation failed to identify the cause, use of the POC device was discontinued in September 1998.

General practitioners' views on patient care research

BACKGROUND

Little research has been undertaken into the factors affecting recruitment by Australian general practitioners of patients for clinical trials. Understanding the differences between recruiters and non-recruiters will assist researchers in better supporting general practitioners involved in such research.

METHOD

A survey of general practitioners involved in recruiting patients for clinical trials for the RACGP Research Program was undertaken.

RESULTS

Recruiters were more likely to be interested in learning more about research, to perceive involvement as worthwhile, to desire a good relationship with Research Program staff and to feel the doctor-patient relationship assists recruitment.

DISCUSSION

Recruiters in general are average general practitioners, male, middle-aged and work in group practices. Most felt some discomfort in recruiting patients, but believed the strong doctor-patient relationship assisted in the process.

CONCLUSION

The Research Program needs to recruit general practitioners interested in research, choose topics of interest, keep recruitment protocols simple and stay in contact.

Who declines employer-sponsored health insurance and is uninsured?

Twenty percent of all uninsured persons are offered health insurance by their employer or a family member's employer but choose not to enroll in the offered plan(s). Most persons who do not "take up" or enroll in available employer-sponsored coverage cite cost as the main reason why. This Issue Brief, based on two surveys conducted as part of the Center for Studying Health System Change's (HSC) Community Tracking Study, presents new findings on who declines employer-sponsored coverage and is uninsured as a result. Given the importance of cost in an individual's decision whether to enroll in employer-sponsored coverage, policy makers need to consider ways to address the problem identified by this study: low take-up rates among lower-income workers.

Subclassifying atypical squamous cells in Thin-Prep cervical cytology correlates with detection of high-risk human papillomavirus DNA

Recent studies have proposed subclassifying ASCUS into "favor reactive" (ASFR), "not otherwise specified" (ASNOS), and "favor squamous intraepithelial lesion (SIL)" (ASFS). This study explored the reproducibility of these diagnoses with Thin-Prep cytology and their association with high-risk human papillomavirus DNA (HRHPV). Three pathologists and 1 cytotechnologist with 2 to 25 years of experience reviewed 144 Thin-Prep (Cytyc, Boxborough, MA) specimens previously diagnosed as normal, ASFR, ASNOS, ASFS, and SIL. Interobserver reproducibility was computed with the kappa statistic. The original laboratory diagnosis was compared with the presence of HRHPV types. Interobserver reproducibility for a normal or SIL diagnosis was very good (kappa = .68 and .63). Reproducibility for ASFR, ASNOS, and ASFS ranged from poor to fair (kappa = .21, .19, and .32). In a weighted analysis, kappa values for ASFR/ASNOS and ASFS/SIL were .36 and .62, respectively. HRHPV-positivity for preparations originally diagnosed as N, ASFR, ASNOS, ASFS, and SIL were 5.7%, 8.8%, 17.4%, 47.8%, and 54.5%, respectively. The difference in index of HRHPV for either N or ASFR and ASFS or SIL was significant (P < .001). Reproducibility for ASCUS is generally poor, but better reproducibility is obtained by combining ASFS with SIL and, to a lesser degree, ASNOS with ASFR. ASFS and SIL confer a similar index of HRHPV and merit similar management. ASFR may be managed with cytologic follow-up; but this may depend upon the individual laboratory. HPV testing, in conjunction with cytologic and biopsy follow-up, appears useful for estimating the significance of ASCUS subgroups in laboratory practice.

Biased selection and Medicare HMOs: analysis of the 1989-1994 experience

This article presents the results of an analysis of the preenrollment and postdisenrollment experiences of Medicare-risk HMO enrollees. The results indicate that in the 6 months prior to their enrollment, new HMO enrollees use on average 37 percent fewer services than do beneficiaries in traditional fee-for-service Medicare. Furthermore, HMO disenrollees use 60 percent more services in the six months after disenrollment than do fee-for-service beneficiaries. Finally, new enrollees had relatively lower chronic-condition expenditures and mortality rates, whereas disenrollees had higher values for both. These findings suggest that the overall results, in part, reflect permanent differences between the HMO and fee-for-service Medicare populations. Moving to an annual enrollment with a 90-day cooling-off period appears to be a reasonable approach to addressing these differences in enrollees.

Medicare beneficiaries covered by Medicaid buy-in agreements

About 13 percent of Medicare beneficiaries receive some assistance from Medicaid. States "buy in" Medicare coverage for these low-income beneficiaries. For those eligible, states also provide benefits beyond those covered by Medicare. Buy-in beneficiaries are different from other Medicare beneficiaries in many ways. They have lower incomes, which is consistent with the policy intent. They use more health services in general but do not appear to receive timely, appropriate care relative to several disease-specific standards. As policymakers consider restructuring Medicare and Medicaid, careful attention needs to be paid to the effects of changes on these beneficiaries.