Market restructuring and pricing in the hospital industry

This paper examines the diagnosis related group-level (DRG) price effects of recent hospital mergers and acquisitions that occurred in Ohio and California. Empirical results indicate that hospital mergers and acquisitions increase prices at the DRG level. Further, price increases are greater in DRGs where the merging hospitals gained substantial market share compared to DRGs where the merging hospitals did not gain significant market share. These results suggest that DRG specific market share plays an important role in a hospital's post-merger pricing strategy.

A study of clinical questions in primary care

This is a prospective study of clinical questions generated in primary care consultations and a comparison of two approaches to answering those clinical questions. Twenty-one doctors in a university-based primary care clinic submitted 78 clinical questions arising from patient consultations during 24 clinic days (0.01 question per patient encounter). These doctors subsequently found answers to 40% of their questions but were satisfied with only 67% of these answers. The investigators were able to provide answers for 95% of the questions asked and the doctors rated these answers as satisfactory in 86% of instances. Answers obtained by investigators had significantly higher satisfaction score than those obtained by doctors' search (p = 0.002). The two main findings of this study are (1) almost all questions arising in clinic setting could be answered by intensive search; (2) answers found by intensive searches were judged to be more satisfactory than those found routinely by doctors. Provision of an information retrieval service in addition to training in the searching and appraisal of medical literature are possible solutions to the information needs of busy clinicians.

Ovine interleukin 12 has biological activity on ovine and human activated peripheral blood mononuclear cells

Interleukin 12 (IL-12) is a heterodimeric cytokine composed of two subunits that form the biologically active p70 molecule, and is a potent inducer of the pro-inflammatory cytokine IFN-gamma. In this study the coding sequence for ovine interleukin 12 p35 and p40 subunits was derived by RT-PCR cloning. Ovine p35 and p40 cDNA sequences show a high level of similarity at the nucleic acid and protein levels when compared to corresponding bovine and human sequences. In particular, cysteine residues and N-linked glycosylation sites are conserved between species. Secretion of the IL-12 heterodimer from CHO cells co-transfected with ovine p35 and p40 cDNA was shown by immunoprecipitation of a 60 and 66 kDa protein from transfectant supernatant. In addition, the supernatant from co-transfected cells augmented the proliferation of Con A-activated ovine peripheral blood mononuclear cells (PBMNC). Cross-species activity was shown by the enhancement of proliferation of human phytohaemagglutinin (PHA)-activated PBMNC. Supernatants from co-transfectants of hu p35/ov p40 and ov p35/hu p40, to generate chimeric heterodimers, also demonstrated stimulatory activity. Human and chimeric IL-12-induced proliferation of activated PBMNC was inhibited using an anti-human IL-12 polyclonal antibody, however this antibody showed minimal inhibition of ovine IL-12. This study suggests that ovine IL-12 has biological properties similar to its human counterpart.

Saccharomyces cerevisiae BUB2 prevents mitotic exit in response to both spindle and kinetochore damage

The spindle assembly checkpoint-mediated mitotic arrest depends on proteins that signal the presence of one or more unattached kinetochores and prevents the onset of anaphase in the presence of kinetochore or spindle damage. In the presence of either damage, bub2 cells initiate a preanaphase delay but do not maintain it. Inappropriate sister chromatid separation in nocodazole-treated bub2 cells is prevented when mitotic exit is blocked using a conditional tem1(c) mutant, indicating that the preanaphase failure in bub2 cells is a consequence of events downstream of TEM1 in the mitotic exit pathway. Using a conditional bub2(tsd) mutant, we demonstrate that the continuous presence of Bub2 protein is required for maintaining spindle damage-induced arrest. BUB2 is not required to maintain a DNA damage checkpoint arrest, revealing a specificity for spindle assembly checkpoint function. In a yeast two-hybrid assay and in vitro, Bub2 protein interacts with the septin protein Cdc3, which is essential for cytokinesis. These data support the view that the spindle assembly checkpoint encompasses regulation of distinct mitotic steps, including a MAD2-directed block to anaphase initiation and a BUB2-directed block to TEM1-dependent exit.

Induction of CTL response by a minimal epitope vaccine in HLA A*0201/DR1 transgenic mice: dependence on HLA class II restricted T(H) response

CTL play a pivotal role in the immune response during viral infections. In this study, the HLA class II restricted T(H) requirement for optimal in vivo induction of HLA class I restricted CTL responses has been investigated. Towards this goal, transgenic mice expressing both HLA class I (A*0201 or A2.1) and class II (DRB1*0101 or DR1) molecules have been derived. Immunization of these mice with an HLA A*0201-restricted and CMV-specific CTL epitope (pp65(495-503)), and either of three different tetanus toxin-derived MHC class II-binding T(H) epitopes, resulted in a vigorous CTL response. CTL specific for the pp65(495-503) epitope were dramatically enhanced in mice expressing both the HLA-DR1 and HLA-A*0201 transgenes. Notably, preinjection of three TT peptides (TT(639-652), TT(830-843), and TT(947-967)) increased the capability of HLA A*0201/DR1 Tg mice to respond to subsequent immunization with the T(H) + CTL peptide mixture. These results indicate that the use of HLA A*0201/DR1 Tg mice constitute a versatile model system (in lieu of immunizing humans) for the study of both HLA class I and class II restricted T-cell responses. These studies provide a rational model for the design and assessment of new minimal-epitope vaccines based on their in vivo induction of a pathogen-specific CTL response.

Structure of the Ser195Ala mutant of human alpha--thrombin complexed with fibrinopeptide A(7--16): evidence for residual catalytic activity

The Ser195Ala mutant of human alpha-thrombin was complexed with fibrinopeptide A(7-22) (FPA) in an effort to describe the (P1'-P6') post-cleavage binding subsites of the fibrinogen-recognition exosite and define more clearly the nature of the Michaelis complex and the scissile peptide bond bound at the catalytic site. The thrombin mutant, however, has residual catalytic activity and proteolysis occurred at the Arg16-Gly17 bond. Thus, the structure of the thrombin complex determined was that of FPA(7-16) bound at the active site, which is very similar to the ternary FPA(7-16)cmk-human thrombin-hirugen complex (r.m.s.d. approximately 0.4 A; Stubbs et al. , 1992). It is further shown by subsidiary experiments that the cleavage is the result of residual catalytic activity of the altered catalytic machinery.

Structure of thrombin complexed with selective non-electrophilic inhibitors having cyclohexyl moieties at P1

The crystal structures of five new non-electrophilic beta-strand-templated thrombin active-site inhibitors have been determined bound to the enzyme. Four co-crystallize with hirugen and inhibitor isomorphously to produce thrombin-hirugen crystals (monoclinic, space group C2), while one co-crystallizes in the hexagonal system, space group P6(5). A 1,4-substituted cyclohexyl moiety is conserved at the P1 position of all the inhibitors, along with a fused hetero-bicyclic five- and six-membered ring that occupies the P2 site. Amino, amidino and aminoimidazole groups are attached to the cyclohexyl ring for recognition at the S1 specificity site, while benzylsulfonyl and diphenyl groups enhance the binding at the S3 subsite. The cyclohexyl groups at the P1 positions of three of the inhibitors appear to be in the energetically favored chair conformation, while the imidazole-substituted cyclohexyl rings are in a boat conformation. Somewhat unexpectedly, the two cyclohexyl-aminoimidazole groups bind differently in the specificity site; the unique binding of one is heretofore unreported. The other inhibitors generally mimic arginyl binding at S1. This group of inhibitors combines the non-electrophilicity and selectivity of DAPA-like compounds and the more optimal binding features of the S1-S3 sites of thrombin for peptidic molecules, which results in highly potent (binding constants 12 nM-16 pM, one being 1.1 microM) and selective (ranging from 140 to 20 000 times more selective compared with trypsin) inhibitors of thrombin. The binding modes of these novel inhibitors are correlated with their binding constants, as is their selectivity, in order to provide further insight for the design of therapeutic antithrombotic agents that inhibit thrombin directly at the active site.

New onset and remission of suicidal ideation among a depressed adult sample

BACKGROUND

Previous research has demonstrated that suicidal ideation often predicts suicide completion.

METHODS

The present study examined clinical and phenomenological variables associated with the presence, development and remission of suicidal ideation among depressed adults. The sample (n = 81) was derived from subjects enrolled in the Duke Clinical Research Center for the Study of Depression in Late Life.

RESULTS

Greater pessimistic thinking at baseline predicted the development of suicidal ideation one year later and the older a person was when he or she first experienced depression, the more likely he or she was to report remission from suicidal ideation one year following onset.

LIMITATIONS

Longitudinal analyses were based on relatively small samples. Variables that were not significant in these analyses might be in a larger sample.

CONCLUSIONS

The longitudinal design of this study mitigates limitations associated with cross-sectional or retrospective designs and advances our understanding of a clinical profile associated with the development and remission of suicidal thoughts.

Correlates of suicidal ideation among an elderly depressed sample

BACKGROUND

Suicidal ideation has been shown to be strongly associated with suicide completion and elders take their own lives more than any other age group.

METHODS

The present study examined clinical and phenomenological correlates of suicidal ideation among an elderly sample (n = 167) derived from subjects enrolled in the Duke Clinical Research Center for the Study of Depression in Late Life.

RESULTS

Bivariate results indicated that clinical variables associated with psychomotor retardation, a history of dysthymia, a previous psychiatric in-patient stay, and being a 'younger' elder were related to greater suicidal ideation. Multivariate analyses indicated that feeling guilty, sinful, or worthless was associated with over six times greater odds of having suicidal thoughts.

LIMITATIONS

Findings are based on correlational analyses, and thus, the direction of causality cannot be inferred.

CONCLUSIONS

This study provides evidence for clinicians of some of the 'red flags' associated with the presence of suicidal ideation among depressed older adults.

Anxiety reduces baroreflex cardiac control in older adults with major depression

OBJECTIVE

Although depression and anxiety predict risk of cardiac mortality, the contributions of depression and anxiety to vagal cardiac control have not been systematically evaluated. The goal of this study was to examine the relationship between state anxiety and vagal control of heart rate in older adults with major depressive disorder (MDD). Older adults (50-70 years old) were selected for this study because of the greater cardiac risk associated with low vagal cardiac control across this age range.

METHODS

Fifty-six men and women with MDD were evaluated. MDD was diagnosed using the Diagnostic Interview Schedule, and severity of depression was measured using the Beck Depression Inventory and the Hamilton Rating Scale for depression. State anxiety was measured using the Spielberger State Anxiety Inventory. Power spectral analysis was used to measure two indices of vagal control: baroreflex control of heart rate (BRC(SPEC)) and respiratory sinus arrhythmia (RSA).

RESULTS

State anxiety was negatively correlated with levels of BRC(SPEC) (r = -0.32, p < .05), whereas depression severity was not related to either RSA or BRC(SPEC). Furthermore, BRC(SPEC) was reduced by approximately 33% in MDD patients with state anxiety scores (ST-ANX) in the highest quartile (ST-ANX > 41, N = 13), compared with patients with ST-ANX scores in the lowest quartile (ST-ANX < 25, N = 14; p < .05).

CONCLUSIONS

Anxiety, but not depression severity, is associated with reduced BRC(SPEC) in older men and women. Future studies are needed to determine whether comorbid anxiety contributes to the increased cardiovascular risk associated with MDD.

A new model of orthotopic penetrating corneal transplantation in the sheep: graft survival, phenotypes of graft-infiltrating cells and local cytokine production

BACKGROUND

Orthotopic penetrating keratoplasty in the sheep was developed as an outbred preclinical model to allow correlation of the cellular infiltrate during graft rejection with local production of cytokine mRNA.

METHODS

Penetrating corneal autografts and allografts were performed in Merino sheep. Graft outcome was followed at the slit-lamp. Corneal infiltrates were examined by immunoperoxidase staining on postmortem specimens. Cytokine mRNA was detected by polymerase chain reaction.

RESULTS

Corneal autografts survived indefinitely. Allografts became vascularized and underwent rejection at a median of 20 days postgraft. Both endothelial and epithelial rejection lines were observed. Immunohistochemical staining of rejecting grafts showed up-regulation of major histocompatibility complex class I molecules on corneal graft epithelium, damaged or absent graft endothelium and a marked, predominantly mononuclear cell infiltrate. CD4-positive T cells were observed in the graft within 2 days of the onset of rejection, followed several days later by CD8-positive T cells. Messenger RNA transcripts for interleukin (IL)-2, tumour necrosis factor (TNF)-alpha and IL-10 (but not for interferon (IFN)-gamma or IL-4) were found in autografted corneas. Proportionately, more allografts than autografts contained transcripts for IL-2 and TNF-alpha, and IFN-gamma was detected in three of four allografts.

CONCLUSIONS

Corneal graft rejection in the sheep is macroscopically and histologically similar to human corneal graft rejection. Allografts become infiltrated by both CD4- and CD8-positive T cells and local production of pro-inflammatory cytokines occurs during graft rejection.

Structure-binding studies of the adrenal AT4 receptor: analysis of position two- and three-modified angiotensin IV analogs

Amino acid substitutions in positions two and three of angiotensin IV (VYIHPF) were carried out to determine which structural features of the side-chains were important for achieving high-affinity binding to bovine adrenal receptors. These studies demonstrated that an activated aromatic ring in the second position side-chain resulted in the highest-affinity binding. Position three required a hydrophobic amino acid to achieve high-affinity binding. Both aliphatic and aromatic side-chains were sufficient to yield high-affinity binding.

Outbreak of nosocomial Acinetobacter baumannii bacteremia in a high risk ward

Acinetobacter baumannii is emerging as a major cause of nosocomial infections particularly in high risk patients. Being resistant to adverse environmental conditions, it can stay for prolonged periods in the hospital environment. We report an outbreak in the medical oncology ward where nine patients suspected of bacteraemia were blood culture positive for A. baumannii from the two samples each, one collected through the i.v. cannula and another through the peripheral veneous puncture. The bacteria was also isolated from the environmental sources from the various samples collected. The biotype, antibiogram, cellular protein profiles on SDS-PAGE and the restriction enzyme analysis patterns of the patient isolates and the environmental isolates were similar. This points to the environment as a source of infection. With reinforcement of proper barrier nursing and use of disposable heparine ampoules it was possible to control the outbreak.

Combined anti-vascular cell adhesion molecule-1 and anti-leukocyte function-associated molecule-1 monoclonal antibody therapy does not prolong allograft survival in an ovine model of renal transplantation

This study investigates the therapeutic efficacy of an anti-vascular cell adhesion molecule (VCAM)-1 monoclonal antibody (mAb), alone or in combination with an anti-leukocyte function-associated-1 mAb, in prolonging allograft survival in an ovine model of renal transplantation. The kinetics of VCAM-1 induction and expression during renal allograft rejection have also been studied. Sheep receiving anti-ovine VCAM-1 antibody demonstrated graft failure at a mean of 8.4 (+/- SD; 0.7) days after transplantation compared with 9.3 (+/- 0.5) days after transplantation for the group given control antibody and 7.7 (+/- 0.3) days after transplantation in the animals given the combined anti-VCAM-1 and anti-leukocyte function-associated-1 mAb therapy. VCAM-1 expression was detected in the allografts at day 1 after transplantation, with peak expression detected by day 5. Tubular expression of VCAM-1 was minimal, with sparse focal staining at the basolateral surfaces. The degree of mononuclear cell infiltrate in the allografts paralleled the progressive increase in VCAM-1 expression after transplantation, and there was no difference in the level of mononuclear cell infiltrate compared with controls.