Effects of perceptual training based upon synthesized voice signals

28 undergraduate students participated in a perceptual voice experiment to assess the effects of training utilizing synthesized voice signals. An instructional strategy based upon synthesized examples of a three-part classification system: "breathy," "rough," and "hoarse," was employed. Training samples were synthesized with varying amounts of jitter (cycle-to-cycle deviation in pitch period) and harmonic-to-noise ratios to represent these qualities. Before training, listeners categorized 60 pathological voices into "breathy," "rough," and "hoarse," largely on the basis of fundamental frequency. After training, categorizations were influenced by harmonic-to-noise ratios as well as fundamental frequency, suggesting that listeners were more aware of spectral differences in pathological voices associated with commonly occurring laryngeal conditions. 40% of the pathological voice samples remained unclassified following training.

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines

BACKGROUND

A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression.

STUDY

Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners).

RESULTS

The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions.

SUMMARY AND CONCLUSIONS

Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Inflammatory cytokines in patients with persistence of the acute respiratory distress syndrome

To determine the relationship between airspace cytokines and cellular inflammatory responses in patients with the acute respiratory distress syndrome (ARDS), we performed bronchoalveolar lavage (BAL) in 82 prospectively identified, mechanically ventilated patients on Days 3, 7, 14, and/or 21 after the onset of ARDS. We studied the relationships between bronchoalveolar lavage fluid (BALF) cell populations and the concentrations of two potent neutrophil (PMN) chemoattractants, interleukin-8 (IL-8) and epithelial cell-derived neutrophil activator-78 (ENA-78); two potent monocyte chemoattractants, monocyte chemotactic peptide-1 (MCP-1) and macrophage inflammatory peptide-1 alpha (MIP-1 alpha); and the early response cytokine interleukin-1 beta (IL-1 beta) and its naturally occurring antagonist, IL-1 receptor antagonist protein (IRAP). We found that all of these cytokines were significantly increased regardless of the duration of ARDS. IL-8 and ENA-78 were the cytokines most strongly and consistently correlated with PMN concentrations in the lung fluids of patients with ARDS, and the correlations were independent of the other cytokines or coexisting lung infection. None of the cytokines tested correlated with macrophage concentrations. MCP-1 was directly correlated with lung injury score on Days 7, 14, and 21. Although neither IL-8 nor ENA-78 was associated with outcome, levels of IL-1 beta measured on Day 7 were associated with an increased risk of death (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.1 to 7.4). These data demonstrate potential molecular mechanisms of the persistent inflammatory process in the lungs of patients with ARDS.

Will uninsured people volunteer for voluntary health insurance? Experience from Washington State

OBJECTIVES

In national and local discussions of health care reform, there is disagreement about whether a national health insurance plan should be mandatory or voluntary. This study describes characteristics of low- income people who were more likely or less likely to be covered by a voluntary plan.

METHODS

Survey data were available from an evaluation of Washington State's Basic Health Plan, which offered subsidized health insurance to low-income residents. For those subjects who were eligible and uninsured at baseline, those who joined were compared with those who did not join on a variety of demographic and health-related characteristics.

RESULTS

There were substantial differences between those who did and did not join the Basic Health Plan. Those who did not enroll were generally less well-off, with less education, lower income, and worse health. Many had never had health insurance.

CONCLUSIONS

If health care reform results in a voluntary plan, additional measures may be needed to ensure that less advantaged citizens have adequate access to health care.

Musculoskeletal Function Assessment instrument: criterion and construct validity

The Musculoskeletal Function Assessment (MFA) instrument, a health status instrument with 100 self-reported health items, was designed for use with the broad range of patients with musculoskeletal disorders of the extremities commonly seen in clinical practice. In this paper, we report on its criterion and construct validity. Criterion validity was tested against physicians' ratings of patient functioning (e.g., upper functioning, lower functioning, daily activities, recreational functioning, emotional adjustment, and overall functioning) and standard clinical measures (e.g., grip strength, walking speed, fine motor skills, knee and elbow strength, and range of motion). Significant correlations (p < or = 0.05) between its scores, physicians' ratings, and clinical measures support the MFA's criterion validity. Construct validity was demonstrated against existing measures of health status (e.g., measures of lower and upper mobility, activity level and satisfaction, health status, social support, pain, emotional status, and quality of life), in accordance with clinical hypotheses about the effect of musculoskeletal disorders on functioning (e.g., type and number of problems, severity of illness or injury, and comorbidities) and by an analysis of demographic characteristics (e.g., sex, education, income, health insurance, and employment) against the MFA scores. Discriminant construct validity was supported in an analysis of MFA scores by patient disease groups (p < or = 0.01).

Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument

Despite an increasing reliance on the use of health status measures to assess and evaluate medical care, no single instrument is currently available for use with the broad range of patients with musculoskeletal disorders of the extremities that is commonly seen in clinical practice. In this paper, we report on the development of the Musculoskeletal Function Assessment instrument, a 100-item self reported health status instrument that is designed to meet this need. The instrument was developed in two phases. During the first phase, items were selected on the basis of interviews with 135 patients and 12 clinicians and from reviews of existing health status instruments. The items then were grouped into categories. During the second phase, the instrument was tested for reliability and content validity using a sample of 327 patients with one of five musculoskeletal disorders of the upper and lower extremities (fractures, soft-tissue injuries, repetitive motion disorders, osteoarthritis, and rheumatoid arthritis). The patients were selected from both community and academic sites. Content validity also was demonstrated, based on a review of item selection procedures, expert opinion, and the distribution of scores on the instrument.

Comparison of the profiles of agonists as stimulants of the beta 3-adrenoceptor in vitro with their gastroprotective effects in the conscious rat

1. This paper compares the activity of a range of agonists as stimulants of the beta 3-adrenoceptor in rat isolated oesophagus with their ability to afford protection against indomethacin-induced gastric damage in the conscious rat. 2. The beta 3-adrenoceptor agonists, CL 316243 and BRL 37344, the non-selective beta-adrenoceptor agonist, isoprenaline and the selective beta 2-adrenoceptor agonist, salmeterol, all evoked concentration-dependent relaxation of precontracted muscularis mucosa from rat oesophagus. The rank order of agonist potency was BRL 37344 > CL 316243 > isoprenaline >> salmeterol. The selective beta 1-adrenoceptor agonist, denopamine, did not relax the preparation. 3. The relaxant responses to all agonists were resistant to blockade by atenolol (10 microM), and ICI 118551 (1 microM) thus suggesting that they were not mediated by either beta 1- or beta 2-adrenoceptor stimulation. In contrast, cyanopindolol and propranolol did inhibit responses to BRL 37344, CL 316243 and isoprenaline, giving pA2 values or pKB estimates which were consistent with an interaction at beta 3-adrenoceptors (i.e. approximately 8.0 and 6.5 respectively). However, responses to salmeterol were resistant to blockade by all the antagonists tested, which suggests that the high (> 1 microM) concentrations of salmeterol used exerted non-specific relaxant effects. 4. The agonist effects of CL 316243 and BRL 37344 on beta 1- and beta 2-adrenoceptors were assessed on guinea-pig right atrium and precontracted trachea respectively. Both agonists had minimal activity as stimulants of heart rate, but did relax trachea, being 380 (CL 316243) and 21 (BRL 37344) fold less potent than isoprenaline. 5. CL 316243 and BRL 37344 were potent inhibitors of indomethacin-induced gastric antral ulceration in the conscious rat (ED50 values = 0.24 and 0.09 mumol kg-1, p.o.) Salmeterol was approximately 100 times less potent than BRL 37344 as a gastroprotective agent and denopamine was without effect. 6. The gastroprotective effects of CL 316243 and BRL 37344 were resistant to blockade by ICI 118551 (10 mg kg-1, p.o.) and propranolol (10 mg kg-1, p.o.). In contrast, both antagonists caused dose-related inhibition of the protective action of salmeterol (10 mg kg-1, p.o.). Cyanopindolol was not assessed as an antagonist in vivo because preliminary experiments revealed that it exacerbated indomethacin-induced gastric damage in its own right. 7. In conclusion, the beta 3-adrenoceptor agonists CL 316243 and BRL 37344 were potent inhibitors of indomethacin-induced gastric antral ulceration in the rat. These data suggest that an agonist which is potent and selective for the human beta 3-adrenoceptor may confer mucosal protection in man.

Enzyme-catalyzed synthesis of poly[(R)-(-)-3-hydroxybutyrate]: formation of macroscopic granules in vitro

A combined chemical and enzymatic procedure has been developed to synthesize macroscopic poly[(R)-(-)-3-hydroxybutyrate] (PHB) granules in vitro. The granules form in a matter of minutes when purified polyhydroxyalkanoate (PHA) synthase from Alcaligenes eutrophus is exposed to synthetically prepared (R)-3-hydroxybutyryl coenzyme A, thereby establishing the minimal requirements for PHB granule formation. The artificial granules are spherical with diameters of up to 3 microns and significantly larger than their native counterparts (0.5 micron). The isolated PHB was characterized by 1H and 13C NMR, gel-permeation chromatography, and chemical analysis. The in vitro polymerization system yields PHB with a molecular mass > 10 x 10(6) Da, exceeding by an order of magnitude the mass of PHAs typically extracted from microorganisms. We also demonstrate that the molecular mass of the polymer can be controlled by the initial PHA synthase concentration. Preliminary kinetic analysis of de novo granule formation confirms earlier findings of a lag time for the enzyme but suggests the involvement of an additional granule assembly step. Minimal requirements for substrate recognition were investigated. Since substrate analogs lacking the adenosine 3',5'-bisphosphate moiety of (R)-3-hydroxybutyryl coenzyme A were not accepted by the PHA synthase, we provide evidence that this structural element of the substrate is essential for catalysis.

Voluntary public health insurance for low-income families: the decision to enroll

A dominant issue in the health reform debate is whether insurance coverage should be voluntary or mandatory. Clearly, the factors that determine who will seek voluntary coverage are relevant to this policy issue. This article uses experience from Washington State's Basic Health Plan to examine the enrollment choices of low-income families in a state-subsidized voluntary insurance plan offered through managed care organizations. We hypothesize that the decision to enroll, which encompasses the decisions to purchase insurance coverage and to select a particular plan, is influenced by four factors: the family's financial vulnerability, their risk perception, the price of coverage, and the transition costs of enrolling. Our enrollment model is supported by the data and has important implications for the design of voluntary programs. Families who choose to enroll are more likely to have a female head of household, young children, and a family member who has a part-time job and some college education. Higher premiums and availability of other insurance coverage decrease the probability of enrolling.

A very short hydrogen bond provides only moderate stabilization of an enzyme-inhibitor complex of citrate synthase

Two extremely potent inhibitors of citrate synthase, carboxyl and primary amide analogues of acetyl coenzyme A, have been synthesized. The ternary complexes of these inhibitors with oxaloacetate and citrate synthase have been crystallized and their structures analyzed at 1.70- and 1.65-A resolution, respectively. The inhibitors have dissociation constants in the nanomolar range, with the carboxyl analogue binding more tightly (Ki = 1.6 nM at pH 6.0) than the amide analogue (28 nM), despite the unfavorable requirement for proton uptake by the former. The carboxyl group forms a shorter hydrogen bond with the catalytic Asp 375 (distance < 2.4 A) than does the amide group (distance approximately 2.5 A). Particularly with the carboxylate inhibitor, the very short hydrogen bond distances measured suggest a low barrier or short strong hydrogen bond. However, the binding constants differ by only a factor of 20 at pH 6.0, corresponding to an increase in binding energy for the carboxyl analogue on the enzyme of about 2 kcal/mol more than the amide analogue, much less than has been proposed for short strong hydrogen bonds based on gas phase measurements [> 20 kcal/mol (Gerlt & Gassman, 1993a,b)]. The inhibitor complexes support proposals that Asp 375 and His 274 work in concert to form an enolized form of acetyl-coenzyme A as the first step in the reaction.

Comparison of prescription and medical records in reflecting patient antihypertensive drug therapy

OBJECTIVE

To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications.

SETTING

Three clinics affiliated with two staff model health maintenance organizations (HMOs).

PARTICIPANTS

Randomly selected HMO enrollees (n = 982) with diagnosed hypertension.

METHODS

Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use.

RESULTS

There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5-8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records.

CONCLUSIONS

In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

Who enrolled in a state program for the uninsured: was there adverse selection?

Managed care plans may hesitate to participate in programs for uninsured persons because they fear adverse selection, whereby only the sickest people or highest users would choose to join the program. We studied this issue in Washington State's Basic Health Plan, a demonstration program that provides subsidized health insurance for families earning less than 200% of the poverty level. We interviewed people in three counties who enrolled in the program, and compared them to people in the same counties who were eligible but did not enroll. There were substantial differences between enrollees and eligibles in education, age, income, employment, race, and insurance status. In spite of these demographic and access differences, health status was remarkably similar for enrollees and eligibles, with the few significant differences favoring the enrollees. In addition, previous and subsequent use of health services was similar or lower for enrollees. The results for health status and utilization were similar across the three counties, even though the counties and the providers were quite different. We conclude that there is no evidence of adverse selection. This is welcome news for the health plans, but suggests that the BHP may not have reached those most in need of insurance.

Functional characterization of three adenosine receptor types

1. The purpose of the present study was to classify adenosine receptors into A1 and A2 subtypes in a wide range of isolated tissues and cell types (rat adipocytes and atria, guinea-pig ileum and atria (A1); guinea-pig aorta, dog coronary artery and human platelets and neutrophils (A2)) using the R- and S-diastereoisomers of N-phenylisopropyladenosine (PIA), N-cyclopentyladenosine (CPA), the novel compound, N-[(1S,trans)-2-hydroxycyclopentyl]adenosine (GR79236), N-[(2-methylphenyl)methyl]adenosine (metrifudil), 2-(phenylamino)adenosine (CV1808), and 2[[2-[4-(2-carboxyethyl)phenyl]ethyl]amino]-N- ethylcarboxamidoadenosine (CGS21680); N-ethylcarboxamidoadenosine (NECA) was used as a standard. 2. Results obtained in all tissue preparations previously reported to contain A1-receptors could be described by a single rank order of agonist potency: CPA > or = GR79236, R-PIA > or = NECA >> S-PAI > or = metrifudil > or = CV1808, CGS21680. 3. In contrast, two distinct rank orders of agonist potency were observed in preparations previously reported to contain A2-receptors. In dog coronary artery, human neutrophils and platelets the rank order of potency was: CV1808, CGS21680 > or = NECA > R-PIA > or = metrifudil > or = CPA > GR79236 S-PIA. However, in guinea-pig aorta the rank order was: NECA > metrifudil > R-PIA, CPA > CV1808, GR79236 > or = S-PIA, CGS21680. 4. The results of this study are consistent with the existence of three types of adenosine receptor: A1-and two subtypes of A2-receptor. The receptor present in dog coronary artery, human platelets and neutrophils, probably corresponds to the A2a subtype, whilst that present in the guinea-pig aorta may be of the A2b subtype.

Suppression of non-esterified fatty acids and triacylglycerol in experimental animals by the adenosine analogue GR79236

1. This is the first description of the metabolic activity of a novel adenosine A1-receptor agonist, GR79236. GR79236 inhibited catecholamine-induced lipolysis in human, rat and dog isolated adipocytes. 2. Oral administration of GR79236 (0.1-10 mg/kg) to fed rats induced minimal changes in the plasma concentration of non-esterified fatty acids and in the blood concentrations of glucose and lactate. 3. Intravenous infusion of GR79236 to fasted pithed rats, or oral administration of GR79236 to fasted conscious rats and dogs, produced time- and dose-dependent decreases in the plasma non-esterified fatty acid concentration. In the fasted rats, doses of GR79236 that lowered plasma levels of non-esterified fatty acids also produced hypotriglyceridaemia and anti-ketotic effects. 4. Only in the pithed rats were acute effects on the plasma glucose and lactate concentrations observed. Hypoglycaemia and hyperlactataemia occurred over the dose range studied (1 x 10(-11)-1 x 10(-8) mol min-1 kg-1). 5. This profile of activity suggests that compounds such as GR79236 might be agents which can be used to define the role of excessive lipolysis in experimental (and human) pathophysiology.

Separate enzymes catalyze the final two steps of coenzyme A biosynthesis in Brevibacterium ammoniagenes: purification of pantetheine phosphate adenylyltransferase

We have discovered that the final two steps in coenzyme A biosynthesis in Brevibacterium ammoniagenes are catalyzed by distinct enzymes, readily separated by DEAE sepharose anion exchange chromatography. This is in contrast to mammalian tissues in which these two reactions are catalyzed by a single bifunctional enzyme (Worrall, D.M., and Tubbs, P.K. (1983) Biochem. J. 215, 153-157) and Bakers yeast in which these two activities have been identified as part of a multifunctional complex (Bucovaz, E.T., Rhoades, J.L., and Tarnowski, S.J. (1980) Fed. Proc. 39 (6), 142). The pantetheine phosphate adenylyltransferase has been purified to homogeneity and found to exist as a trimeric protein of molecular mass approximately 108 kDa. Of other nucleoside triphosphates tested as substrates, only 2'-deoxy-ATP showed measurable activity, being 27% that of ATP.

A validation of the functional independence measurement and its performance among rehabilitation inpatients

The Functional Independence Measurement (FIM) is a new functional status instrument for use among rehabilitation inpatients, but its validity and reliability have been only partially established. Because of its rapid dissemination, we sought further evidence concerning the FIM's internal consistency, responsiveness over time, and construct validity. We examined Uniform Data System (UDS) data on 11,102 general rehabilitation inpatients from the Pacific Northwest. Mean age was 65 and 51% were male. The most common diagnoses were stroke (52%), orthopedic conditions (10%), and brain injury (10%). Internal consistency of the FIM was calculated using Cronbach's alpha. To assess FIM responsiveness, we examined differences between admission and discharge FIM scores. For construct validation purposes, we hypothesized that the FIM would vary with age, comorbidity, discharge destination, and impairment severity. Comorbidity was quantified with the Charlson Comorbidity Index. The FIM had a high overall internal consistency (discharge FIM alpha = .93). The FIM registered significant functional gains during rehabilitation (33% FIM score improvement, p < .001), as do many other functional status indicators. The greatest and least functional improvements were observed for traumatic brain injury and low back pain (53% and 8% FIM score improvement, respectively). The FIM discriminates patients on the basis of age, comorbidity, and discharge destination. Severity differences could be distinguished among spinal cord injury and stroke patients. We conclude that the FIM has high internal consistency and adequate discriminative capabilities for rehabilitation patients. It is a good indicator of burden of care, and demonstrates some responsiveness, but its capacity to measure change over time needs further examination and comparison with competing scales.

Biochemical characterization of programmed cell death in NGF-deprived sympathetic neurons

Young sympathetic neurons die when deprived of nerve growth factor (NGF). Under such circumstances, cell death is appropriate to the developing nervous system and requires RNA and protein synthesis. We have hypothesized the existence of an endogenous death program within neurons that is suppressed by trophic factors. The extent and timing of required changes in the synthetic events that comprise the death program are unknown. In an effort to characterize the biochemical events that mediate the death program further, we performed several experiments on embryonic rat sympathetic neurons in vitro. The death program was blocked with cycloheximide when total protein synthesis was inhibited > or = 80%. When protein synthesis was inhibited within 22 +/- 4 h of NGF deprivation, death was prevented in half the neurons. Hence, we define the commitment point for protein synthesis to be 22 +/- 4 h. Analogously, the commitment point for RNA synthesis was 26 +/- 4 h and that for NGF rescue, 24 +/- 4 h. We tested the ability of a wide variety of chemicals to interfere with the death program. Most compounds tested were unable to prevent neuronal death. Some treatments, however, did save NGF-deprived neurons and were subsequently characterized. These included ultraviolet light and agents that raise intracellular concentrations of cAMP. Finally, we looked for the neuronal expression in vitro and in vivo of genes that have been associated with programmed death in other cell types, including TRPM-2/SGP-2, polyubiquitin, TGF beta-1, c-fos, and c-myc. None of these genes showed significant activation associated with neuronal death.

Stereotactic radiosurgical treatment of brain metastases

In a series of 33 patients with reasonably controlled primary cancers, stereotactic radiosurgery was used to treat 52 brain metastases. After a mean radiological follow-up time of 5.5 months, six lesions (12%) had stabilized in size, 26 (50%) were significantly reduced, and 15 (29%) had disappeared. One large melanoma metastasis progressed relentlessly despite treatment. Five lesions (9%) had decreased in size slightly before enlarging. In two of these lesions, biopsy revealed only necrosis. In almost all cases, treatment was associated with decreased peritumoral edema. However, a group of patients with large metastases and extensive prior brain irradiation has been identified in whom prolonged symptomatic cerebral edema poses a problem. It is concluded that radiosurgery is a viable alternative to surgical resection for some cases of brain metastasis.

The Health of the Public Program at the University of Washington: a new role for academic medical centers

The University of Washington Health of the Public Program has convened a consortium composed of the region's academic medical center, the two largest managed care plans in Washington, and representatives of the state's major private and public purchasers of health care. The consortium's purpose is to test the feasibility of collaboratively collecting cross-system data, assessing variations in practice, and implementing site-specific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortium's initial efforts are described. In today's climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community-wide outcomes of care.

Use of a preferred provider plan by employees of the City of Seattle

Little is known about the use of services in a preferred provider organization (PPO). We studied a preferred provider arrangement between Pacific Medical Center and employees of the City of Seattle. In the second 12 months of this program 8,529 subjects submitted at least one claim; of these, only 420 (4.9%) ever used the preferred provider. Those who used the PPO at least once differed significantly from those who never used it on age, sex, employee/dependent status, and utilization in the previous year. Outpatient and total charges were higher for PPO users than for nonusers before and after control for those characteristics. Those who used the PPO exclusively were similar to those who never used it. People who used both the PPO and other providers were at higher risk for use of services, and had much higher overall utilization, with or without control for other variables. No differences were found between people who obtained only a small proportion of their services at the PPO and those who had most (but not all) of their use at the PPO. Many of these findings can be explained by a self-selection model. It is important for research on PPOs to have an independent manner of assessing who is a PPO user.

Interferon suppresses sympathetic neuronal cell death caused by nerve growth factor deprivation

Cultured rat sympathetic neurons die within 48 h after being deprived of nerve growth factor. Addition of interferons (IFN-alpha/beta or IFN-gamma) prevented the cell death in a dose-dependent manner. Upon longer periods of nerve growth factor deprivation, IFNs failed to maintain survival. Thus, IFNs retarded neuronal death, but did not prevent it. Ligand binding, autoradiography, and cross-linking experiments demonstrated the presence of specific IFN-gamma receptors on sympathetic neurons similar to those seen on other cell types. The possible relationships of the death-suppressing actions of IFNs are compared to the mechanisms of the antiviral or antiproliferative actions of IFNs.

Cytosine arabinoside kills postmitotic neurons in a fashion resembling trophic factor deprivation: evidence that a deoxycytidine-dependent process may be required for nerve growth factor signal transduction

Cytosine arabinoside (AraC) is a pyrimidine antimetabolite that kills proliferating cells by inhibiting DNA synthesis. In this paper we report that AraC kills postmitotic rat sympathetic neurons in a fashion similar to the neuronal death that follows nerve growth factor (NGF) deprivation. Postmitotic rat sympathetic neurons were cultured for 1 week in the presence of NGF and then treated with AraC, still in the presence of NGF. AraC killed neurons after 4 d with an EC50 of 50 microns. The morphological and temporal characteristics of neuronal death that began around 3 d after addition of AraC were indistinguishable from those observed beginning 24 hr after NGF deprivation. Death caused by AraC was prevented by the same agents that prevent the death of NGF-deprived neurons, which included inhibitors of RNA and protein synthesis, a cAMP analog, and depolarizing concentrations of KCl. In contrast, neuronal death caused by ultraviolet irradiation, ricin toxin, and a variety of other toxic insults did not share these morphological, biochemical, or temporal characteristics. Other antimitotic drugs, including adenine arabinoside, thymine arabinoside, fluorodeoxyuridine, hydroxyurea, and aphidicolin, did not kill neurons. AraC caused neurons to behave as if deprived of NGF by interfering with deoxycytidine (dC) metabolism distinct from DNA biosynthesis. dC entirely prevented the neurotoxicity of AraC, even when present at a concentration 1000-fold less than that of AraC. Other deoxynucleosides, and cytidine, did not prevent AraC neurotoxicity. dC could not, however, substitute for NGF and thus is unlikely to be a direct mediator of NGF action. It is hypothesized that dC may participate in a pathway, distinct from DNA synthesis, that is necessary for neurons to respond to exogenous trophic factors.

Effect of a gatekeeper plan on health services use and charges: a randomized trial

A randomized trial was conducted to determine the effectiveness of a health care plan which uses physicians as gatekeepers to control health services use and charges. New enrollees in United Healthcare (UHC), an independent practice association, were randomly assigned to the standard UHC plan requiring a gatekeeper, or to an alternate plan with equal benefits but without a gatekeeper. Individuals in both plans were similar in demographic characteristics, perceived health status, and other health insurance coverage. The gatekeeper plan had 6 percent lower total charges per enrollee than the plan without a gatekeeper. There were minor differences in hospital use and charges. Ambulatory charges were $21 lower per person per year in the plan with a gatekeeper (95% CI = -39.9, -2.1) and these were due to .3 fewer visits to specialists (95% CI = -0.50, -0.10). We conclude that a health plan which incorporates incentives and penalties for physicians to act as gatekeepers can reduce the cost of ambulatory services by limiting specialist visits.

Why do neurons die when deprived of trophic factor?

In this commentary we present circumstantial evidence which supports the hypothesis that neuronal death produced by trophic factor deprivation (i.e., axotomy, target loss, etc.) is not a passive process resulting from a loss of trophic stimulation. Rather, we suggest that it is due to the activation of an endogenous "suicide program" requiring mRNA and protein synthesis. The possible mechanistic relationship of neuronal death to death of other cell types, both in the developing and adult organism, is discussed. If this hypothesis of active death is true, then loss of transcriptional control of this program may be involved in neuronal attrition in aging or neurodegenerative disease.

Role of Ca2+ channels in the ability of membrane depolarization to prevent neuronal death induced by trophic-factor deprivation: evidence that levels of internal Ca2+ determine nerve growth factor dependence of sympathetic ganglion cells

Sympathetic neurons depend on nerve growth factor (NGF) for their survival both in vivo and in vitro; these cells die upon acute deprivation of NGF. We studied the effects of agents that cause membrane depolarization on neuronal survival after NGF deprivation. High-K+ medium (greater than or equal to 33 mM) prevented cell death; the effect of K+ was dose-dependent (EC50 = 21 mM). The protection by high K+ was abolished either by withdrawal of extracellular Ca2+ or by preloading the cells with a Ca2+ chelator. The involvement of Ca2+ flux across membranes in high-K+ saving of NGF-deprived neurons was also supported by experiments using Ca2+-channel antagonists and agonists. The Ca2+ antagonists nimodipine and nifedipine effectively blocked the survival-promoting effect of high K+. The Ca2+ agonists Bay K 8644 and (S)-202-791 did not by themselves save neurons from NGF deprivation but did strongly augment the effect of high K+; EC50 was shifted from 21 mM to 13 mM. These data suggest that dihydropyridine-sensitive L-type Ca2+ channels play a major role in the high-K+ saving. The depolarizing agents choline (EC50 = 1 mM) and carbamoylcholine (EC50 = 1 microM), acting through nicotinic cholinergic receptors, also rescued NGF-deprived neurons. The saving effect of nicotinic agonists was not blocked by withdrawal of extracellular Ca2+ but was counteracted by a chelator of intracellular Ca2+, suggesting the possible involvement of Ca2+ release from internal stores. Based on these findings we propose a "Ca2+ set-point hypothesis" for the degree of trophic-factor dependence of sympathetic neurons in vitro.

Inhibitors of protein synthesis and RNA synthesis prevent neuronal death caused by nerve growth factor deprivation

We have developed an experimental paradigm to study the mechanism by which nerve growth factor (NGF) allows the survival of sympathetic neurons. Dissociated sympathetic neurons from embryonic day-21 rats were grown in vitro for 7 d in the presence of NGF. Neurons were then deprived of trophic support by adding anti-NGF antiserum, causing them to die between 24 and 48 h later. Ultrastructural changes included disruption of neurites, followed by cell body changes characterized by an accumulation of lipid droplets, changes in the nuclear membrane, and dilation of the rough endoplasmic reticulum. No primary alterations of mitochondria or lysosomes were observed. The death of NGF-deprived neurons was characterized biochemically by assessing [35S]methionine incorporation into TCA precipitable protein and by measuring the release of the cytosolic enzyme adenylate kinase into the culture medium. Methionine incorporation began to decrease approximately 18 h post-deprivation and was maximally depressed by 36 h. Adenylate kinase began to appear in the culture medium approximately 30 h after deprivation, reaching a maximum by 54 h. The death of NGF-deprived neurons was entirely prevented by inhibiting protein or RNA synthesis. Cycloheximide, puromycin, anisomycin, actinomycin-D, and dichlorobenzimidazole riboside all prevented neuronal death subsequent to NGF deprivation as assessed by the above morphologic and biochemical criteria. The fact that sympathetic neurons must synthesize protein and RNA to die when deprived of NGF indicates that NGF, and presumably other neurotrophic factors, maintains neuronal survival by suppressing an endogenous, active death program.

Use of ambulatory health care services in a preferred provider organization

The organization of the delivery of health care can have significant cost-saving implications, but few of the available studies have made adequate comparisons of costs across plans. Furthermore, new organizational types such as independent practice associations and preferred provider organizations have not yet been studied in detail. This paper examines ambulatory utilization in a preferred provider organization (PPO) for Uniformed Services beneficiaries at Pacific Medical Center (PMC) in Seattle. The utilization in the PPO is compared with the results of a recently reported study of three other organizationally different Seattle plans: a Blue Cross/Blue Shield plan (BC), a closed-panel health maintenance organization (HMO), and an independent practice association (IPA). The PPO was similar to the IPA and the HMO in having a high percent of patients with any ambulatory use and had standardized ambulatory costs per user which were lower than BC but higher than the HMO. Thus, this particular type of PPO may have cost-saving features, particularly because the Uniformed Services population is known to use more health services than the general population. Methodological issues for future utilization research across organizations are also discussed.

Factors affecting choice of health care plans

The research reported here examined the factors which affected the decision to remain with either Blue Cross of Washington and Alaska or Group Health Cooperative of Puget Sound, or to change to an independent practice association (IPA) in which the primary care physicians control all care. The natural setting allowed examination of the characteristics of families with experience in structurally different plans; a decision not influenced by premium differentials; the importance of the role of usual provider; and a family-based decision using multivariate techniques. An expected utility model implied that factors affecting preferences included future need for medical care; access to care; financial resources to meet the need for care; and previous level of experience with plan and provider. Analysis of interview and medical record abstract data from 1,497 families revealed the importance of maintaining a satisfactory relationship with the usual sources of care in the decision to change plans. Adverse selection into the new IPA as measured by health status and previous utilization of medical services was not noted.

Factors related to the use of ambulatory mental health services in three provider plans

The use of ambulatory mental health (MH) services by adults was studied in three provider plans: Blue Cross (BC), Group Health Cooperative (GHC) and United Healthcare (UHC), an experimental new plan in which a patient's primary care physician managed all of his care. Approximately 8.3% of the enrollees in each plan had some MH use in the 18 months of the study. We studied correlates of MH use (yes/no). Sex was not a significant predictor of MH use. In general, worse health and lower socioeconomic status (SES) were correlated with having at least one MH visit, but better health and higher SES were correlated with a higher quantity of use for those who had some MH use. The three insurance plans did not differ significantly in the proportion of people who had any MH services, but BC users of MH services had 2-3 times more MH visits and higher costs than GHC and UHC users. This suggests that the reliance on primary care providers in UHC and GHC may have changed the nature of MH care as compared to Blue Cross. The effects of income, MH need and symptom sensitivity on MH use were different among the three plans.

Use of outpatient somatic health services by patients who use or need mental health services in three provider plans

A major topic in mental health (MH) research addresses the problem that patients who use mental health services have inappropriately high levels of somatic use, and examines whether provision of mental health services can decrease the inappropriate use (the so-called offset effect). However, the research showing higher somatic use by mental health patients has usually been unable to control for the patients' health status, or for their mental health status. In this paper we examine use of somatic health services by enrollees in three provider plans as a function of both mental health use and mental health need. In two of the provider plans (an HMO and a prepaid independent practice association), MH users used significantly more outpatient somatic services than non-MH patients, after control for age and sex, and after control for the number of chronic conditions they had. People with MH need, however, did not use significantly more MH services than those without MH need. In the third plan, a Blue Cross/Blue Shield type of plan, results were different; MH users did not have significantly higher somatic utilization after control for chronic conditions, and those with MH need did have significantly higher somatic utilization after control for age and sex, but not after control for the number of chronic conditions. These results suggest that the form of inappropriate use of outpatient somatic services, and the nature of an offset effect, may be specific to the type of insurance provided.

Out-of-plan use by Medicare enrollees in a risk-sharing health maintenance organization

In this study, we analyzed the cost and volume effects of a waiver that eliminated lock-in restrictions on out-of-plan use in a health maintenance organization (HMO) with a Medicare risk-sharing contract. We compared out-of-plan cost and number of claims during a 15-month base line period when the lock-in was in effect, with a 24-month waiver period when the lock-in was removed. The results demonstrate that average per capita cost and claims increased significantly for both Medicare Part A (hospital insurance) and Part B (supplementary medical insurance) out-of-plan services during the waiver. Self-referred out-of-plan use normally prohibited by lock-in, accounted for 20 percent of all out-of-plan costs during the waiver and 57 percent of the increase in out-of-plan costs from the lock-in to the waiver. The combination of risk-sharing and lock-in provisions holds promise as a method for reducing expenditures for the Medicare program.

Ambulatory mental health services utilization in three provider plans

This article examines the use of mental health services in three insurance plans: Blue Cross (BC), a health maintenance organization (HMO), and an independent practice association (IPA) in which the primary care physician was to manage all care for an individual. Approximately 7.3% of the enrollees in all three plans used some mental health care in the 18-month study period. The percent of enrollees with mental health utilization was lower in BC than in the other two plans, but the total quantity of mental health care use per enrollee and per user was much higher in BC than in the HMO and the IPA. Use was highest in the 19-44-year-old age group, and there were no significant differences between men and women in use of mental health services. There were substantial differences by race in all three plans: white persons were more likely to use any mental health care and had more visits than nonwhite persons after seeking mental health use. A similar study was conducted in the early 1970s on a poverty-level population enrolled in BC and the HMO. The findings of this study are similar, except that in the low-income study mental health care use was lower, and males used less mental health care than females. These differences might be attributable to the difference in enrollees' socioeconomic status in the two studies or to the increasing acceptability of mental health care utilization, particularly for males.

Use of ambulatory care services in three provider plans: interactions between patient characteristics and plans

A previous study of low-income enrollees in a closed-panel health maintenance organization (HMO) and a Blue Cross/Blue Shield (BC/BS) plan showed that the effect on the use of health services of the age, sex, health status, previous health care use, race, and family size of the enrollees was different in the two plans. We have replicated this study using the same two provider plans but studying a different group of white collar, middle class enrollees. A third plan, an experimental independent practice association (IPA), was also available for analysis. Utilization was defined as use (yes/no) and the quantity of use for those who used services (in standardized dollars). Significant interactions were detected between plan and all of the independent variables but race. The use of services in the HMO was least affected by enrollees' characteristics (age, sex, race, health status, prior use, family size) and use was most sensitive to patient characteristics in BC. In some respects, the IPA was more like the HMO and in other respects more like the BC/BS plan.

Epizootic of parainfluenza-3 virus infection in gibbons

A laboratory-housed breeding colony of white-handed gibbons (Hylobates lar) experienced an epizootic of upper respiratory tract disease characterized by lethargy, anorexia, coughing, and serous rhinorrhea. Signs were more severe in adults than in offspring, and all animals recovered without complications. Base-line, acute, and convalescent sera from the most severely affected gibbons were tested for antibodies against a wide spectrum of infectious agents. For personnel known to have had contact with the gibbons, testing for the same agents was done on base-line sera and sera obtained at the same time as the acute and convalescent sera were obtained from the gibbons. Rising titers against parainfluenza-3 virus were detected in 6 of 7 gibbons tested. An increase in titer was not seen in the sera of personnel.

Serological investigation of an outbreak of simian varicella in Erythrocebus patas monkeys

An epizootic of simian varicella occurring in a colony of Erythrocebus patas monkeys was studied serologically by using radioimmunoassay and neutralization tests against (i) a virus strain isolated from an animal that died during the epizootic, (ii) a simian varicella virus strain from an earlier outbreak of simian varicella-like disease at another facility, and (iii) human varicella-zoster virus. Serological tests detected more cases of infection among the animals exposed to virus during the epizootic than were evidenced by clinical findings; only 6 of the 26 animals with seroconversion developed a rash. Good correlation was seen between antibody responses demonstrated by radioimmunoassay and by the neutralization tests. Specificity of the radioimmunoassay was evidenced by the complete agreement with neutralization results for 17 animals which failed to show an antibody response over the course of the outbreak and were assumed not to have been infected. Thus radioimmunoassay is a reliable, rapid, and relatively economical method which could be used for serological screening of primates entering experimental colonies to identify those which might be potential sources of outbreaks through activation of latent simian varicella virus infection. Close correlation was seen between antibody responses to the virus strain from the current outbreak and the one from another epizootic, indicating that the two outbreaks were caused by antigenically similar viruses. Animals showing neutralizing antibody responses to the simian varicella viruses also showed responses to human varicella-zoster virus, which further substantiates the close antigenic relationship between human and simian varicella viruses.

Interferon prophylaxis against simian varicella in Erythrocebus patas monkeys

Erythrocebus patas monkeys were given placebo or human leukocyte interferon (5 x 10(5) units/kg of body weight per day im) for five days during an epizootic of simian varicella. During the 14 days beginning with the first day of treatment, the attack rate for simian varicella was 14.3% (two of 14) among interferon recipients compared to 70% (nine of 13) among placebo recipients (P less than 0.025). Excluding animals with antibody to simian varicella when the study began, 18% (two) of 11 interferon recipients had symptoms of infection compared to 80% (nine) of 11 placebo recipients (P less than 0.025). The epizootic began in a room housing male animals. The incidence of infection in male placebo recipients was 100% (seven of seven) compared to 14% (one of seven) in male interferon recipients (P less than 0.01). The efficacy of interferon prophylaxis in the simian varicella model supports its continued evaluation for the management of human varicella in high-risk patients.

Cost containment through risk-sharing by primary care physicians: a history of the development of United Healthcare

A new type of independent practice association has been organized to encourage primary care physicians in private practice to become coordinators and financial managers for their patients' medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all specialized care. The primary care physician authorizes payment from his/her own account for hospital and referral care provided to patients. He or she shares any deficit or surplus remaining at the end of the year. This is a background paper detailing the history of development and specific features contained in this new concept of putting the physician in charge and "at risk" for the costs of medical care to his/her patients. The plan has been operating in northern California, Washington, and Utah and has 40,000 members and 750 participating physicians. This historical background paper is part of a large project--State Employees' Insurance Benefits Utilization Study (SEIBUS) being done by the University of Washington School of Public Health to evaluate use and costs of medical care under this innovative plan.

Prevalence of prior hysterectomy in the Seattle-Tacoma area

Hysterectomy is the most common major surgical procedure performed in the United States. The frequency of hysterectomy among women in the general population is of interest because it affects the population at risk for uterine diseases and because the procedure itself carries significant personal and socioeconomic consequences. We studied factors related to the occurrence of hysterectomy by interviewing a representative sample of women ages 35-74 (n= 1087) in two urban Washington counties during 1976-1977.One-third of the women studied had had a hysterectomy. Later birth cohorts were at higher risk. The ageadjusted prevalence of prior hysterectomy was negatively associated with education and age at first childbirth; it was positively associated with parity, history of irregular menses, and history of a variety of other health conditions. Contrary to expectation, income was negatively associated with hysterectomy rates in one county and showed no association in the other. Part of the income effect was due to confounding by age at first childbirth, which was a surprisingly strong predictive factor. WE CONCLUDE THAT: 1) despite economic predictions based on the discretionary nature of the procedure, hysterectomies are not necessarily more common among high-income women; 2) age at first childbirth may be a more important risk factor for uterine disease than previously thought; and 3) estimates of hysterectomy frequency based on clinic populations may be misleading. (Am J Public Health 70:40-47, 1980.)

Disseminated lymphoma in a rhesus monkey: a case report

A rhesus monkey was inoculated with rhesus cytomegalovirus. A leukocyte-associated herpes virus, unrelated to cytomegalovirus, was later isolated from the same monkey. Four years after the virus inoculation, the monkey developed a disseminated lymphoma.

Prematurity and perinatal mortality in the Rhesus (Macaca mulatta): relationship to birth weight and gestational age

While the relative influence of birth weight and gestational age in determining perinatal mortality has not been definitively established, it has been assumed that birth weight makes the predominant contribution to perinatal mortality. The joint effects of birth weight and gestational age were examined by analyzing approximately 2,500 births from timed pregnancies in two rhesus (Macaca mulatta) breeding colonies. Perinatal events in the rhesus are described and shown to be similar to the human. The results demonstrate that gestational age is as important as birth weight in determining perinatal mortality. Since the degree of accuracy in the estimation of rhesus gestational age was much greater than is usually attained in human studies, the estimation of gestational age from the last menses may be too crude to determine the importance of this variable in human perinatal mortality.

Thoracic duct cannulation of the rhesus monkey (Macaca mulatta) for lymphocyte collection: thoracic approach

The thoracic duct of the rhesus monkey (Macaca mulatta) was cannulated with medical grade tubing through a thoracatomy at right interspace 9-10. In 42 monkeys successfully cannulated, a mean of 1.194 x 10(9) lymphocytes was collected in the 70-hour period after surgery. A second collection, 1-3 weeks later, was possible for a shorter period (up to 60 hours) in a portion of these monkeys (15) with a smaller mean yield of lymphocytes (1.076 x 10(9). A third, but still shorter, collection period of up to 48 hours was possible in only five monkeys from which a mean yield of 0.698 x 10(9) lymphocytes was collected. A temporary postoperative weight loss in the monkeys was followed by a return to normal weight several months later.

The Sickness Impact Profile: reliability of a health status measure

This report describes the results of research conducted on the reliability of the Sickness Impact Profile (SIP). The SIP is a questionnaire instrument designed to measure sickness-related behavioral dysfunction and is being developed for use as an outcome measure in the evaluation of health care. The test-retest reliability of the SIP in terms of several reliability measures was investigated using different interviewers, forms, administration procedures, and a variety of subjects who differed in terms of type and severity of dysfunction. The results provided evidence for the feasibility of collecting reliable data using the SIP under these various conditions. In addition, subject variability in relation to reliability is discussed.

The sickness impact profile: validation of a health status measure

The Sickness Impact Profile (SIP), a measure of health status, is being developed as an outcome measure of health care. A preliminary study of the validity of the SIP was conducted on a sample of 278 subjects who were grouped into four subsamples differing in kind and severity of sickness. Selfassessment of health status, clinician assessment of health status, and other measures of dysfunction were used as criteria. SIP scores discriminated among subsamples, and correlations between criterion measures and SIP scores provided evidence for the validity of the SIP. Differences among the correlations obtained for each criterion measure with SIP score are discussed in terms of the need for the development of criterion measures that can be expected to differentially relate to the constructs inherent in the SIP.

Ocular effects of oral contraceptives. II. Studies in the rhesus monkey

Oral contraceptives were administered cyclically to 96 female rhesus monkeys for 5 years. Forty-eight animals received Enovid-E and 48 were treated with Ovulen at doses 1, 10, and 50 times the human dose. Ophthalmic lesions did not occur at any of the dose levels employed. Significant fundic lesions, including papilledema, venous dilatation, venous retinal thrombosis, or arterial retinal thrombosis, did not develop in any of the treated animals.