Agency problems in hospitals participating in self-management project under global budget system in Taiwan

OBJECTIVE

The main purposes of this study are to clarify the agency problems in the hospitals participating in self-management project within the context of Global Budgeting Payment System regulated by Taiwan government, and also to provide some suggestions for hospital administrator and health policy maker in reducing the waste of healthcare resources resulting from agency problems.

METHOD

For the purposes above, this study examines the relationships between two agency problems (ex ante moral hazard and ex post moral hazard) aroused among the hospitals and Bureau of National Health Insurance in Taiwan's health care sector. This study empirically tested the theoretical model at organization level.

RESULTS

The findings suggest that the hospital's ex ante moral hazards before participating the self-management project do have some influence on its ex post moral hazards after participating the self-management project.

CONCLUSION

This study concludes that the goal conflict between the agents and the principal certainly exist. The principal tries hard to control the expenditure escalation and keep the financial balance, but the agents have to subsist within limited healthcare resources. Therefore, the agency cost would definitely occur due to the conflicts between both parties. According to the results of the research, some suggestions and related management concepts were proposed at the end of the paper.

A susceptibility gene for type 2 diabetes confers substantial risk for diabetes complicating cystic fibrosis

AIMS/HYPOTHESIS

Insulin-requiring diabetes affects 25-50% of young adults with cystic fibrosis (CF). Although the cause of diabetes in CF is unknown, recent heritability studies in CF twins and siblings indicate that genetic modifiers play a substantial role. We sought to assess whether genes conferring risk for diabetes in the general population may play a risk modifying role in CF.

METHODS

We tested whether a family history of type 2 diabetes affected diabetes risk in CF patients in 539 families in the CF Twin and Sibling family-based study. A type 2 diabetes susceptibility gene (transcription factor 7-like 2, or TCF7L2) was evaluated for association with diabetes in CF using 998 patients from the family-based study and 802 unrelated CF patients in an independent case-control study.

RESULTS

Family history of type 2 diabetes increased the risk of diabetes in CF (OR 3.1; p = 0.0009). A variant in TCF7L2 associated with type 2 diabetes (the T allele at rs7903146) was associated with diabetes in CF in the family study (p = 0.004) and in the case-control study (p = 0.02; combined p = 0.0002). In the family-based study, variation in TCF7L2 increased the risk of diabetes about three-fold (HR 1.75 per allele, 95% CI 1.3-2.4; p = 0.0006), and decreased the mean age at diabetes diagnosis by 7 years. In CF patients not treated with systemic glucocorticoids, the effect of TCF7L2 was even greater (HR 2.9 per allele, 95% CI 1.7-4.9, p = 0.00011).

CONCLUSIONS/INTERPRETATION

A genetic variant conferring risk for type 2 diabetes in the general population is a modifier of risk for diabetes in CF.

Emergency peripartum hysterectomy in a teaching hospital in Eastern Taiwan

This study aims to review the incidence, indications, risk factors and complications associated with emergency peripartum hysterectomy in a teaching hospital. We reviewed records of patients undertaking emergency peripartum hysterectomy performed at our institution from 1998 to 2004. Emergency peripartum hysterectomy was defined as one performed for haemorrhage unresponsive to other treatments <24 h after delivery. Eight cases of emergency peripartum hysterectomy were performed. The rate of peripartum hysterectomy was 0.25%. The main indications for hysterectomy were uterine atony and abnormal placentation. No maternal death occurred. Use of peripartum hysterectomy may become necessary in managing obstetrical haemorrhage refractory to other measures.

A phase I study of gemcitabine plus dasatinib (GD) or gemcitabine plus dasatinib plus cetuximab (GDC) in refractory solid tumors

e15506

Background: Dasatinib (D) is a small molecule tyrosine kinase inhibitor with activity against both bcr-abl and src. Cetuximab (C) is a monoclonal antibody that blocks EGFR. Preclinical models suggest D reverses resistance to G. In addition, src and EGFR pathways interact; synergism of dual blockade by D + C is possible. We evaluated two combination regimens, GD and GDC, in a Phase I dose escalation study. Methods: Patients (pts) with advanced solid tumors were enrolled in cohorts of 3–6 to either GD or GDC. G was dosed in mg/m2 weekly for 3 of 4 weeks, D was dosed in mg PO BID, and C was dosed at 250 mg/m2 weekly after loading dose of C=400; cycle length was 28 days. Dose levels were as follows: 1) G 1000 + D 50 ± C; 2) G 1,000 + D 70 ± C; 3) G 1,000 + D 100 ± C. Standard cycle 1 DLT definitions were used. Eligible pts had advanced solid tumors, adequate organ and marrow function, and no co-morbidities that would increase risk of toxicity. Serum, plasma, and skin biopsy biomarkers were obtained pre- and on treatment. Results: 25 pts have been enrolled, including 21 with pancreatic adenocarcinoma, 3 of whom had received prior G. 21 pts were evaluable for toxicity and 18 for efficacy. Four DLT were observed: Gr 3 ANC with infection (GDC1, n=1), Gr 3 ALT (GD2, n=2), and Gr 5 pneumonitis (GDC2, n=1). Possible treatment-related adverse events in later cycles included: Gr3–4 ANC (n=4), Gr4 colitis (n=1), Gr3 bilirubin (n=2), Gr3 Hgb (n=2), Gr3 Plt (n=2), Gr3 edema/fluid retention syndrome (n=1), and Gr3 vomiting (n=2). One previously untreated pt had a partial response. Eight of 18 pts, 3 of whom had received prior G, had stable disease as best response, median duration = 5 months (range 1–7). Biomarker results are pending. Conclusions: The MTD of the GD arm is G1000/D50BID. Stable disease in previous G-refractory pts was noted. Hematologic toxicities were dose-limiting; later toxicities including hematologic, LFT changes, pneumonitis, and fluid retention were seen. To address these toxicities, once daily dosing of D will be explored, followed by an expanded cohort of G + daily D vs G + bid D in pts with treatment-naïve pancreatic cancer.

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Hyperglycemia in vitro up-regulates growth-related cell cycle proteins of adult mouse pancreatic islets

To study effects of glucose on growth-related proteins of adult islets, we cultured mice islets in medium containing either 5.5 mmol/L (LG) or 20 mmol/L (HG) glucose. Total islet proteins were processed for sodium dodecyl sulfate polyacrylamide gel and Western blotting using antibodies against beta-actin (housekeeping), p27kip1 (G1/G0 checkpoint), cyclin D1 (G1/S), cyclin B1 (G2/M), and FoxM1. At day 1, protein levels p27, B1, D1, and FoxM1 of islets on LG and HG were 0.48- and 0.63-fold; 7.09- and 11.58-fold; 1.25- and 1.38-fold; and 1.75- and 1.75-folds, the value of day 0, determinations respectively. At day 3, the proteins of p27, B1, D1, and FoxM1 of islets in LG and HG were 0.84- and 0.84-fold; 3.08- and 17.17-fold; 1.41- and 1.54-fold; and 0.83- and 1.17-fold of those on day 0, respectively. On day 7 the values were 1.19- and 1.09-fold; 3.15- and 14.81-fold; 0.86- and 1.44-fold; and 2.75- and 3.42-fold that of day 0, respectively. At day 1, the ratios of protein in islets after HG verse LG were 1.25, 2.38, 0.94, and 1.00 for p27, B1, D1, and FoxM1, respectively. At days 3 and 7, the protein ratios of HG/LG were 0.81 and 0.82, 5.47 and 2.64, 0.81 and 1.51, and 1.11 and 1.24 for p27, B1, D1, and FoxM1, respectively. In conclusion, adult mouse islets rapidly respond to cultivation by reducing p27 and increasing B1; HG attenuates p27 elevation but enhances B1 and D1 elevations, which favor islet entry into the cell cycle.

Establishment of an integrated management model for the secondary prevention of cervical cancer - an experience in taiwan hospital

In the present study, secondary data analysis was utilized to evaluate the efficiency of the integrated management model (IMM) on the Pap smear test for screening of women's uterine cervical cancer. The data of female patients receiving a Pap smear test were collected both before (from July to December, 2006) and after (from January to June, 2007) introducing the IMM in a regional hospital in Tainan. The result revealed an increment of participation rate from 5.1% to 15.4% (p < 0.001) among the female patients in the OPD (out-patient department), although the post-IMM participation rate was still much lower than that of general hospital data in Taiwan. Since IMM has proved efficacious for the management of various diseases, improvement in our IMM for the female uterine cervical cancer's prevention and management is conceivable. Studies on influencing factors should be carried out to allow strategies for resolution of problems to be designed, documented and implemented.

Celecoxib reduces microvessel density in patients treated with nasopharyngeal carcinoma and induces changes in gene expression

BACKGROUND

Celecoxib is a selective cyclooxygenase-2 inhibitor with antitumor and antiangiogenic activity. We sought to determine pharmacodynamic change in tumors of patients with nasopharyngeal carcinoma (NPC) treated with celecoxib.

METHODS

Tumor biopsies were obtained before and after treatment with celecoxib 400 mg b.i.d. for 14 days in patients with newly diagnosed, untreated NPC. Tumor angiogenesis and cell proliferation were assessed by immunohistochemistry and gene expression by microarray analysis. Plasma celecoxib concentrations were obtained on days 8 and 14.

RESULTS

Paired samples were analyzed in 15 patients. Microvessel density was reduced in post-treatment samples and mean celecoxib levels reached therapeutic levels. Thirty-five genes (27 down-regulated, eight up-regulated) were differentially expressed on microarray analysis (p < 0.001). Down-regulated genes included cell cycle regulation-related (cyclin-dependent kinase 2, YES1), transcription factor (TRIP-Br2), whereas the antigen processing and presentation-related gene HLA-DM B was up-regulated.

CONCLUSION

Celecoxib reduced angiogenesis and induced tumor transcriptional changes. Further characterization of these transcriptional changes in vivo is needed to provide further insights into the effects of celecoxib in neoplastic tissue. Our findings provide a rationale for clinical studies aimed at assessing the efficacy of celecoxib in the treatment of NPC.

Photonic bus with loop signal routing and multichannel wavelength selection on a single silicon-on-insulator platform

We have demonstrated a silicon-on-insulator-based photonic bus with integrated splitters, a demultiplexer, attenuators, and a multiplexer for loop signal routing and multichannel optical wavelength selection. The integrated photonic bus has demonstrated a 33+ dB optical cross talk, a 32+ dB extinction ratio, and a rise time of 7.6 micros with two-stage Mach-Zehnder attenuators.

Phase II study of the combination of thalidomide and irinotecan in patients with recurrent anaplastic gliomas not on enzyme inducing anticonvulsants

1564

Background: Patients with recurrent anaplastic glioma (AG) have few treatment options after initial alkylating agent therapy. In this study, the efficacy of thalidomide and irinotecan against recurrent AG was tested to assess if synergistic activity of cytotoxic and antiangiogenic agents could affect clinical outcome. Methods: Patients with recurrent AG with a KPS≥70 not on enzyme inducing anticonvulsants and with fewer than three relapses after radiation therapy and chemotherapies were eligible; the total planned enrollment is 39 patients. Irinotecan is administered at 125 mg/m2 weekly for 4 weeks followed by 2 weeks rest; thalidomide is initiated at 100 mg daily and escalated weekly up to 400 mg daily. Warfarin (1 mg) is given for prevention of venous thromboembolism (VTE). Patients undergo clinical and radiologic evaluations every 6-weeks. The primary endpoint is progression free survival at 6 months (PFS-6). To determine possible radiologic correlates to treatment effects, DCE- MR perfusion-imaging studies are obtained at baseline and subsequent follow up visits. Results: 17 are evaluable for response; the remainder were inevaluable. All evaluable patients had previously failed temozolomide and 9 had also failed nitrosourea therapy. The median age is 44 yrs and median KPS is 90. Four patients are alive and progression free at 6-months whereas 9 have progressed; the median progression free survival is 23 weeks and the PFS-6 is 34%. The best response was a CR in one patient, PR in 2 and stable disease in 9. Two patients have died of unspecified causes probably related to treatment. Median overall survival has not been reached; the 12-month and 18 month survivals by Kaplan Meier analysis are 73% and 26% respectively. Grade 3 and 4 toxicities included fatigue (29%), leukopenia (29%), nausea/vomitting (24%), and diarrhea (18%) requiring dose reductions. Two patients had VTE. Conclusions: The preliminary results of this ongoing study suggest that the combination of irinotecan and thalidomide has activity in patients with recurrent anaplastic gliomas; the ongoing assessment of this combination in patients with AG will more definitively define whether the combination can be an effective second line therapy for this population.

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