Comparative effects of the dual metallopeptidase inhibitor, MDL 100,240 and of enalaprilat on regional and on cardiac haemodynamics in conscious, hypertensive, transgenic ((mRen-2)27) rats

1. Heterozygous, male, hypertensive, transgenic ((mRen-2)27) rats (350-450 g) were instrumented for the measurement of regional or cardiac haemodynamics (n = 16, in both groups). Animals were given continuous i.v. infusions of the angiotensin-converting enzyme inhibitor, enalaprilat, or the dual metallopeptidase inhibitor, MDL 100,240 (both at 3 mg kg-1, 3 mg kg-1 h-1; n = 8 for regional and cardiac haemodynamics), for 32 h. Twenty four hours after the onset of infusion of enalaprilat or MDL 100,240, the bradykinin (B2)-receptor antagonist, Hoe 140 (1 mg kg-1, i.v.), was given and measurements were continued for a further 8 h, to assess any possible involvement of bradykinin. 2. Over the first 8 h of infusion, both enalaprilat and MDL 100,240 had significant antihypertensive effects, accompanied by similar regional vasodilatations. However, the blood pressure lowering effect of MDL 100,240 (-54 +/- 9 mmHg) was greater than that of enalaprilat (-38 +/- 4 mmHg), because the former caused a significantly greater reduction in cardiac index. 3. Between 8-24 h after the onset of infusion, there was a reduction in the effect of enalaprilat on blood pressure, because cardiac index rose, with no further increase in total peripheral conductance. In contrast, the antihypertensive effect of MDL 100,240 persisted, in spite of a recovery in cardiac index, because there was further vasodilatation, particularly in the mesenteric and hindquarters vascular beds. 4. There were no apparent haemodynamic changes associated with the injection of Hoe 140, and over the following 8 h, the difference between the haemodynamic effects of enalaprilat and MDL 100,240 persisted; there was little evidence of suppression of the effects of either drug. 5. These results are more consistent with the antihypertensive effects of enalaprilat or MDL 100,240 in transgenic ((mRen-2)27) rats being due to suppression of angiotensin II production, than due to inhibition of bradykinin degradation. The additional effects of MDL 100,240 may be accounted for by inhibition of the degradation of natriuretic peptides reducing cardiac output, initially, and decreasing vascular tone, subsequently. Alternatively, the additional increase in vascular conductance following treatment with MDL 100,240 may represent an autoregulatory response to the reduced pressure.

Rural adolescent pregnancy: a view from the South

An analysis of 1990 census and vital statistics data for eight Southeastern states revealed that the teenage birthrate generally was higher in rural than in metropolitan areas; the exception was among black women aged 15-17. The highest birthrate was 162 births per 1,000 among rural black women aged 18-19. Abortion rates were much lower for rural teenagers than for urban teenagers, regardless of race. For 15-17-year-olds, white women had an abortion rate of 12 abortions per 1,000 in rural counties and 18 per 1,000 in metropolitan counties; black women had rates of 13 per 1,000 and 30 per 1,000 in rural and metropolitan areas, respectively. Similarly, the abortion ratio was lower in rural than in urban areas; for example, 18% of rural white women aged 18-19 who became pregnant had an abortion, compared with 35% of their metropolitan counterparts. Black 15-17-year-olds in metropolitan areas had a higher pregnancy rate (106 per 1,000) than those in rural counties (87 per 1,000). The pregnancy rate of white women aged 15-17 was similar in rural [corrected] and metropolitan areas (about 46 per 1,000). Among rural women aged 18-19, 32% of births to whites and 45% of those to blacks resulted from a second or higher order pregnancy.

Regulation of the taurine transporter gene in the S3 segment of the proximal tubule

Traditionally, bulk amino acid reabsorption in the kidney has been thought to be localized to the early portions of the proximal nephron. Adult Sprague-Dawley rats were fed diets with low, normal, and high taurine content for two weeks. Kidneys were hybridized with an 35S-radiolabeled complementary RNA probe to the rB16a subclone encoding the extracellular and transmembrane domains of the rat brain taurine transporter. Identical fragments were generated by RT-PCR from rat brain and kidneys as confirmed by DNA sequencing. Hybridization was localized to the outer zone of the medulla of all the kidneys. In the normal diet animals, taurine transporter mRNA was localized to the S3 segment of the proximal tubule, to the loop of Henle in the medulla, and to the glomerular epithelial cell layer. With taurine restriction, taurine transporter mRNA expression was up-regulated predominantly in the S3 segment and was virtually absent in this segment in animals supplemented with taurine. These experiments have precisely localized the rat kidney taurine transporter gene, demonstrating regulation that is limited to the S3 segment of the proximal tubule.

Haemodynamic effects of adrenomedullin in human resistance and capacitance vessels

AIMS

The haemodynamic effects of adrenomedullin and calcitonin gene-related peptide (CGRP) were studied in resistance and capacitance vessels of healthy volunteers.

METHODS

Adrenomedullin and CGRP were infused into the brachial artery of eight healthy subjects on two separate occasions at doses between 0.3-30 pmol min(-1). Forearm blood flow was measured using venous occlusion plethysmography. Venodilatation to adrenomedullin and CGRP was assessed in a further eight subjects by infusing the peptides at doses between 0.3-10 pmol min(-1) into a dorsal hand vein preconstricted with noradrenaline. Venodilator responses were measured as percentage reduction in noradrenaline preconstriction.

RESULTS

Adrenomedullin and CGRP at a dose of 30 pmol min(-1), produced an increase in forearm blood flow of 288 +/- 42% and 252 +/- 30% respectively (mean +/- s.e. mean, P<0.001). At doses between 3 and 10 pmol min(-1) adrenomedullin was significantly more potent than CGRP. The vasodilatation to both peptides was of similar duration with a biological half-life of approximately 18 min. Adrenomedullin reversed constriction in dorsal hand veins by 84 +/- 2% (P<0.001) at a dose of 10 pmol min(-1). CGRP produced a similar effect reversing constriction by 72 +/- 12% at the same dose (P<0.01). In veins, adrenomedullin was also more potent than CGRP at doses between 0.3 and 3 pmol min(-1).

CONCLUSIONS

The lowest dose of adrenomedullin producing significant arteriolar dilatation was calculated to produce plasma levels similar to those found in heart failure. These findings suggest that in pathophysiological conditions such as heart failure circulating levels of adrenomedullin may be within a range capable of influencing vascular resistance directly.

Long-term psychological adjustment to witnessing interparental physical conflict during childhood

A retrospective survey of undergraduate students was used to examine the long-term psychological impact of witnessing interparental physical aggression during childhood. Two hundred and three of 1,452 young adults surveyed (14%) reported witnessing as children at least one incident of physical aggression between their parents. Both men and women who witnessed interparental physical conflict reported higher levels of current psychological distress than a comparison group of young adults who never observed physical aggression between their parents. This group difference remained even after controlling for parental divorce, parental SES, physical abuse of the child, parental alcoholism, and nonphysical discord witnessed between parents. Additional analyses found that the negative effect of witnessing interparental aggression was intensified when the aggression was serious enough to warrant some type of outside assistance for the victim and when the parent of the same-sex was seen being victimized. Although these findings provided support for the theory that witnessing interparental physical aggression is a traumatic experience that may have long-term psychological ramifications, we also found that a substantial proportion of the variance accounted for in adult adjustment by interparental physical conflict was mediated through decreased parental caring and warmth during childhood. Implications for these results, limitations of the present study, and directions for further research are discussed.

Regulation of CD28 costimulation in human CD8+ T cells

Optimal stimulation and prevention of anergy in T cells requires signaling through the CD28 molecule. During HIV disease progression, CD28 expression is lost, particularly on CD8+ T cells. Because alterations in cytokine production patterns occur during HIV infection, we determined whether CD8+ T cell phenotype or function was affected by cytokine environment. Treatment of CD8+ T cells with IL-4 decreased levels of both CD28 surface expression and message and increased CD8 expression. Furthermore, CD8+ T cells that had down-regulated CD28 had reduced proliferative capacity. The inhibitory effects of CD28 reduction could be compensated either by increased anti-CD3 or by exogenous IL-2, suggesting that the strength of T cell signaling necessary for the production of IL-2 and subsequent proliferation is negatively regulated by IL-4. CD8+ subpopulations with differential CD28 expression produced different patterns of cytokines, particularly IL-2 and IFN-gamma. Furthermore, CD8+ T cells that had reduced CD28 levels but made their own IL-2 were able to proliferate in response to TCR stimulation. These results suggest that loss of CD28 expression and CD8 T cell function can be regulated by the cytokine environment, which may be altered during HIV disease progression. Whether the dysfunction of CD8+ T cells in HIV infection occurs by such a mechanism is the subject of future investigation.

Regulation of CD28 costimulation in human CD8+ T cells

Optimal stimulation and prevention of anergy in T cells requires signaling through the CD28 molecule. During HIV disease progression, CD28 expression is lost, particularly on CD8+ T cells. Because alterations in cytokine production patterns occur during HIV infection, we determined whether CD8+ T cell phenotype or function was affected by cytokine environment. Treatment of CD8+ T cells with IL-4 decreased levels of both CD28 surface expression and message and increased CD8 expression. Furthermore, CD8+ T cells that had down-regulated CD28 had reduced proliferative capacity. The inhibitory effects of CD28 reduction could be compensated either by increased anti-CD3 or by exogenous IL-2, suggesting that the strength of T cell signaling necessary for the production of IL-2 and subsequent proliferation is negatively regulated by IL-4. CD8+ subpopulations with differential CD28 expression produced different patterns of cytokines, particularly IL-2 and IFN-gamma. Furthermore, CD8+ T cells that had reduced CD28 levels but made their own IL-2 were able to proliferate in response to TCR stimulation. These results suggest that loss of CD28 expression and CD8 T cell function can be regulated by the cytokine environment, which may be altered during HIV disease progression. Whether the dysfunction of CD8+ T cells in HIV infection occurs by such a mechanism is the subject of future investigation.

Enhanced cardiac preconditioning in the isolated heart of the transgenic ((mREN-2) 27) hypertensive rat

OBJECTIVE

Cardiac preconditioning represents an important cardioprotective mechanism which limits myocardial ischaemic damage. The aim of this investigation was to assess the impact of preconditioning in hypertension, which is a major risk factor for ischaemic heart disease.

METHODS

Hearts isolated from male transgenic ((mREN-2)27) hypertensive (TGH) rats, and their normotensive controls (Hannover Sprague-Dawley; SD rats), were perfused at constant flow using the Langendorff technique, and were subjected to either ischaemic preconditioning (3 x 4 min ischaemia) or continuous perfusion. Global ischaemia was then induced for 30 min, followed by 60 min of reperfusion, during which time mechanical performance was assessed (left ventricular developed pressure (LVDP), heart rate, and end-diastolic pressure).

RESULTS

In the absence of preconditioning, mechanical performance was substantially depressed on reperfusion, and there was no difference between TGH hearts and SD hearts (area under the curve (AUC) for the LVDP (LVDP0-60) plot against time for reperfusion = 356 +/- 115 and 296 +/- 206 mmHg.min, respectively). Cardiac preconditioning caused significant protection in both groups, but this was significantly (P < 0.05) greater (3-fold) in the TGH hearts (AUC for LVDP0-60 = 3349 +/- 610 mmHg.min) compared to the SD hearts (AUC for LVDP0-60 = 1153 +/- 527 mmHg.min). In both groups, preconditioning induced significant protection of diastolic function. The enhanced effects of preconditioning on mechanical performance in the TGH hearts were unaffected by the angiotensin AT1-receptor antagonist, losartan (3 microM). However, losartan did partially reverse the beneficial effects of preconditioning on post-ischaemic diastolic function in the TGH hearts.

CONCLUSIONS

The results of the present investigation clearly show that cardiac preconditioning is substantially enhanced in hearts from TGH rats. Furthermore, the beneficial effects of preconditioning on diastolic function, but not mechanical performance, in TGH hearts is partially mediated by AT1-receptors.

Employment status and high blood pressure in women: variations by time and by sociodemographic characteristics

PURPOSE

The association between employment status and high blood pressure in women was examined at two time periods to determine if associations between employment status and high blood pressure varied by time period or by age, race, education, marital status, or parental status.

METHODS

Women participants from the National Health Examination Survey (1960) and the Second National Health and Nutrition Survey (1976-1980) between the ages of 25 and 64 and currently employed or keeping house were included. Logistic regression analysis was used to examine the cross-sectional association between employment status and high blood pressure in each survey, taking into account potential effect modifiers and covariates.

RESULTS

In 1960 employment was associated with a slight, but not statistically significant, elevation in odds of high blood pressure. In 1976-1980, it was associated with a modest but significant reduction in odds of high blood pressure. Variations in associations occurred by marital status (protective associations were limited to unmarried women) and race (associations were of stronger magnitude among African-American women).

CONCLUSIONS

The employment status-high blood pressure relationship shifted across surveys. Changes in the composition of the employed and nonemployed groups account for at least part of the varying relationships.

Insulin-like growth factor (IGF) and IGF binding protein gene expression in multicystic renal dysplasia

Multicystic dysplastic kidney disease is the most common form of renal dysplasia that leads to ESRD in children. This study describes the histopathological changes of multicystic dysplasia that occur from early fetal life to the postnatal period. At 14 wk gestation, early cystic enlargement of various segments of the nephron have been identified, in addition to a displaced metanephric blastema adjacent to zones of normal nephrogenesis. At later stages, the predominant features include cyst enlargement with marked fibromuscular collars, architectural disorganization, and replacement of the interstitium with a disarray of mesenchymal tissue. This study investigated the expression of the mRNA encoding the insulin-like growth factors (IGF) and IGF binding proteins (IGFBP) and have demonstrated IGF-II, IGFBP-2, and IGFBP-3 to be altered. Apart from their expression in the displaced metanephric blastema, both IGF-II and IGFBP-2 were overexpressed in abnormal tissue elements in all kidneys from fetal to postnatal life. IGF-II gene expression was localized to mesenchymal tissue, specifically in the periductal fibromuscular collars. IGFBP-2 mRNA was found to be expressed exclusively in the cyst epithelia of all cysts at all ages studied, whereas IGFBP-3 mRNA was absent from these epithelia. This study details the failure of normal IGF expression in the development of multicystic renal dysplasia and suggests a role for the IGF system in the progressive histopathological changes of this disorder.

An endogenous cannabinoid as an endothelium-derived vasorelaxant

Since the identification of nitric oxide (NO) as an important mediator of endothelium-dependent relaxation, it has become clear that there is an additional endothelial relaxant factor, termed the endothelium-derived hyperpolarizing factor (EDHF). The identity of EDHF has remained elusive, but it is thought to be an arachidonic acid metabolite. We now report that EDHF-mediated relaxations in the rat mesenteric arterial bed are blocked by a highly selective cannabinoid receptor antagonist, SR141716A, consistent with EDHF being a cannabinoid-like substance. Furthermore, in conscious rats,. the NO-independent depressor and regional vasodilator effects of bradykinin were inhibited by SR141716A. The relaxations in the isolated mesentery were accompanied by the accumulation of an arachidonic acid metabolite, which co-eluted on TLC separation with arachidonoylethanolamide (anandamide), an endogenous cannabinoid derived from arachidonate. We further report that anandamide is a potent vasorelaxant in the mesentery, acting via a hyperpolarizing mechanism. These findings suggest that an endogenous cannabinoid is an endothelium-derived vasorelaxant, which may be EDHF.

Temporal differences between the involvement of angiotensin II and endothelin in the cardiovascular responses to endotoxaemia in conscious rats

1. Male, Long Evans rats were instrumented chronically with pulsed Doppler probes and intravascular catheters to allow assessment of regional haemodynamic changes during i.v. infusion of lipopolysaccharide (LPS, 150 micrograms kg-1 h-1). 2. In the presence of the AT1-receptor antagonists, losartan (10 mg kg-1 + 10 kg-1 h-1), the initial (1-2 h) hypotensive and renal, mesenteric and hindquarters vasodilator responses to LPS were enhanced significantly. Thereafter these effects waned, but between 8-23 h after the onset of LPS infusion, a further fall in mean atrial blood pressure (MAP) and increases in renal and hindquarters flows and conductances occurred. All these changes were significantly greater than seen with losartan or LPS alone, and exceeded the sum of their effects. 3. In the presence of captopril (2 mg kg-1 + 2 mg kg-1 h-1), the initial hypotensive and renal vasodilator responses to LPS were enhanced, but less so than in the presence of losartan. However, the effects of LPS in the presence of losartan and captopril together were not different from those in the presence of losartan alone. These observations indicate that the ability of captopril to inhibit the degradation of bradykinin had no additional influence, and the differences between the effect of captopril and losartan on the initial effects of LPS were probably due to more effective suppression of the action of angiotensin II by losartan. 4. In the absence of LPS, co-infusion of losartan and the non-selective endothelin antagonist, SB 209670 (600 micrograms kg-1 + 600 micrograms kg-1 h-1), caused a substantial, progressive hypotension (-25 +/- 2 mmHg at 24 h) accompanied by increases in renal, mesenteric and hindquarters vascular conductances (31 +/- 13, 44 +/- 9 and 45 +/- 12%, respectively), indicating an involvement of angiotensin II and endothelin in the maintenance of normal cardiovascular status in conscious, Long Evans rats. 5. In the presence of losartan and SB 209670, the initial, LPS-induced fall in MAP (-42 +/- 2 mmHg) was not different from that in the presence of losartan (-39 +/- 4 mmHg), and the increases in renal, in mesenteric, and in hindquarters vascular conductances were similar in the two conditions. However, there was no recovery in MAP, and there were persistent renal, mesenteric and hindquarter vasodilatations. 6. In all experiments involving LPS, administration of the V1- receptor antagonist, d(CH2)5-O-Me-Tyr-AVP (10 micrograms kg-1), 23 h after the start of LPS infusion caused additional hypotension and mesenteric vasodilatation, particularly. This effect was most marked in animals pretreated with losartan and SB 209670. 7. The results indicate that the initial (1-2 h) depressor and dilator effects of LPS infusion in conscious Long Evans rats are opposed by the actions of angiotensins II, rather than endothelin. However, between 2-8 h after the onset of LPS infusion the involvement of endothelin develops and that of angiotensin II fades. By 24 h after the start of infusion of LPS, the pressor and vasoconstrictor actions of endothelin wane, and a role of vasopressin is apparent. At no stage is there clear evidence for an involvement of bradykinin in the haemodynamic sequelae of endotoxaemia in this model.

Long-term recording of cardiac output via an implantable haemodynamic monitoring device

Long-term monitoring of central haemodynamics with implanted monitoring systems might be valuable in managing heart failure patients. Such systems offer an opportunity for repeated 'semi-invasive' cardiac output determinations according to the Fick principle. Five patients, four with chronic heart failure and one with chronic pulmonary disease, underwent supine exercise testing during cardiac catheterization at 0, 2, 6 and 11 months after implantation of a right ventricular mixed venous oxygen saturation sensor connected to an implantable haemodynamic monitor. The monitor provided a continuous measure of oxygen saturation via a radio-telemetry link to a metabolic cart capable of measurement of breath-by-breath oxygen consumption. Cardiac output was computed using oxygen consumption, mixed venous oxygen saturation, arterial oxygen saturation by pulse oximetry and haemoglobin oxygen capacity. Biosensor-derived oxygen saturation compared to blood samples from the pulmonary artery showed an excellent correlation over time, r2 = 0.94 (implant), r2 = 0.91 (6-11 months). There was a strong correlation between semi-invasive-determined cardiac output using the biosensor and the invasive technique, which persisted over the entire follow-up period. Repeated semi-invasive cardiac output measurements using an implanted haemodynamic monitoring system in chronic heart failure patients is feasible and the data may be of value for optimizing therapy.

Characterization of fetal ovine renal dysplasia after mid-gestation ureteral obstruction

OBJECTIVE

The etiology and pathogenesis of renal dysplasia are poorly understood. To characterize the histologic changes in fetal renal dysplasia, we studied a fetal ovine model of urinary obstruction.

DESIGN

Animal study.

ANIMALS

Seven fetal lambs, and other lambs of the same gestational age as controls.

INTERVENTIONS

Unilateral ureteral ligation on fetal lambs at approximately 70 days' gestation (term for sheep is 145 days), during nephrogenesis. Kidneys were subsequently collected, examined histologically and characterized by immunohistochemical tests involving cytokeratin antiserum and a monoclonal antibody to alpha-actin.

OUTCOME MEASURES

Histologic changes in ligated fetal lamb kidneys, based on comparison with normal fetal lamb kidneys.

RESULTS

At near term (140 days' gestation), the ligated kidney showed distorted and less abundant renal parenchyma than a normal control kidney. Upon microscopic examination, the ligated kidney displayed marked architectural distortion of the outer cortex, with abundant interstitial fibrosis, primitive ductules and glomeruli, and cysts of varying sizes lined by squamous and cuboidal epithelia and surrounded by a loose mesenchyme. The renal medulla contained differentiated collecting ducts, which were structurally distorted and less abundant than in normal control kidneys. The proximal and distal tubule elements were primitive and markedly underdeveloped. Cytokeratin immunoreactivity was present in the collecting duct epithelium and in the cuboidal epithelium lining many of the cortical cysts. Smooth muscle alpha-actin immunoreactivity was localized in the cortical region of the kidney, which highlighted the abundance and disorganization of the undifferentiated mesenchyme and identified the fibromuscular collars of the primitive ductules of the cortex and the distorted collecting ducts of the medulla.

CONCLUSIONS

These results highlight the histologic changes resulting from unilateral ureteral ligation in fetal lambs. This model is useful in the study of the pathogenesis of fetal obstructive renal dysplasia.

Influence of aminoguanidine and the endothelin antagonist, SB 209670, on the regional haemodynamic effects of endotoxaemia in conscious rats

1. We compared the regional haemodynamic responses to lipopolysaccharide (LPS; 150 micrograms kg-1 h-1, i.v.) in the presence of saline, aminoguanidine (AG; 45 mg kg-1 bolus, 45 mg kg-1 h-1 infusion), or AG and the non-selective endothelin receptor antagonist, SB 209670 (600 micrograms kg-1 h-1), in conscious, chronically instrumented, Long Evans rats (350-450 g; n = 8 in all groups). We used AG because there is evidence that it is a selective inhibitor of inducible nitric oxide synthase (iNOS), although recently it has been claimed AG also inhibits constitutive NOS. 2. Infusion of LPS in the presence of saline caused an early, transient hypotension (1-2 h) and a renal vasodilatation, with a secondary, delayed fall in mean arterial blood pressure (MAP), progressive tachycardia, and renal and hindquarters vasodilatation. 3. AG alone caused a rapid (within 30 s) transient rise in MAP (delta 27 +/- 3 mmHg), accompanied by tachycardia and regional vasoconstrictions, but no reduction in regional flows, indicating the pressor effect of AG was, probably, largely due to an increase in cardiac output. These effects are not consistent with AG inhibiting constitutive NOS. In the presence of AG, LPS still caused an early, transient fall in MAP accompanied by a renal vasodilatation, but thereafter there was a significant rise in MAP (17 +/- 3 mmHg, 3 h after onset of LPS infusion) accompanied by bradycardia and marked mesenteric and hindquarters vasoconstrictions. However, 23 h after the onset of co-infusion of AG and LPS all variables were not different from baseline, except heart rate and renal vascular conductance, which were increased. 4. In the presence of AG and SB 209670, LPS caused progressive hypotension and increases in renal, mesenteric and hindquarters vascular conductances. Hence, SB 209670 prevented the rise in MAP and the regional vasoconstrictions seen with AG and LPS, indicating an involvement of endothelin in these events. 5. In the presence of AG and SB 209670, 23 h after the onset of LPS infusion, the AT 1-receptor antagonist, losartan (10 mg kg-1), and the V 1-receptor antagonist, d(CH2)5-0-Me-Tyr-AVP (10 micrograms kg-1, 10 micrograms kg-1 h-1) caused additional incremental falls in MAP and increases in renal, mesenteric and hindquarters vascular conductances. Under these circumstances, MAP was lower and regional vascular conductances higher than in the other experiments following administration of losartan and d(CH2)5-0-Me-Tyr-AVP. Thus, although the findings are consistent with AG inhibiting iNOS, thereby revealing the pressor and vasoconstrictor actions of endothelin released by LPS, it is clear that LPS activates a very powerful hypotensive/vasodilator mechanism(s) which is resistant to AG, and whose full influence is only unmasked when the actions of endothelin, angiotensin II and vasopressin are inhibited.

Physician directed networks: the new generation of managed care

The external pressure to reduce cost while maintaining quality and services is moving the whole industry into a rapid mode of integration. Hospitals, vendors, MCOs, and now, physicians, are faced with the difficult decisions concerning how their operations will be integrated into the larger health care delivery system. These pressures have forced physicians to consolidate, build leverage, and create efficiencies to become more productive; thereby better positioning themselves to respond to the challenges and the opportunities that lie before them. This initial phase of consolidation has given many physicians the momentum to begin to wrestle back the control of health care and the courage to design the next generation of managed care: Physician Directed Managed Care. What will be the next phase? Perhaps, the next step will be fully-integrated specialty and multi-specialty groups leading to alternate delivery sites. "Everyone thinks of changing the world, but no one thinks of changing himself." - Leo Tolstoy

Health service use among low-risk newborns after early discharge with and without nurse home visiting

BACKGROUND

To examine the potential benefits of routine nurse home visiting after early discharge, we compared health service use among low-risk newborns with and without a nurse home visit and telephone follow-up after short hospital stays.

METHODS

Records of newborns discharged routinely before (n = 83) and after (n = 91) implementation of a universal postpartum home visiting program were reviewed retrospectively. Acute care visits, rehospitalizations, and well-baby visits for newborns up to 74 days of age were compared between the groups.

RESULTS

Acute care visits, rehospitalizations, and missed well-baby visits consistently appeared less likely among newborns receiving home visiting services, in both unadjusted and adjusted analyses. Adjusting for insurance, parity, and breast-feeding, a twofold reduction in acute care visits by 14 days was significant. Although not statistically significant, adjusted analyses of acute care and missed well-baby visits revealed apparently similar patterns at all time intervals. There were too few rehospitalizations for multivariate analysis.

CONCLUSIONS

Despite the limitations of this small retrospective study, the consistency of the findings suggests potentially important benefits of home visiting services after early discharge of low-risk newborns, with substantial implications for clinical and reimbursement policy. Effects could be greater with more vulnerable populations and shorter stays than those in this study.