Getting what you pay for: impact of copayments on physical therapy and opioid initiation, timing, and continuation for newly diagnosed low back pain

BACKGROUND CONTEXT

Physical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common.

PURPOSE

We sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP.

STUDY DESIGN/SETTING

The IBM Watson Health MarketScan claims database was used in a longitudinal setting.

PATIENT SAMPLE

Adult patients with LBP.

OUTCOME MEASURES

The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing.

METHODS

Actual and inferred copayments based on non-nonprimary care provider visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage.

RESULTS

Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days postdiagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] versus 1.07 prescriptions/patient [$50-74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p<.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75-100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887-0.899] and HR=0.905 [95%CI 0.899-0.912], respectively).

CONCLUSIONS

Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Co-pays may impact long-term adherence to PT.

Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses

To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1-11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely.

Opioid Usage in Lumbar Disc Herniation Patients with Nonsurgical, Early Surgical, and Late Surgical Treatments

OBJECTIVE

To assess opioid usage in surgical and nonsurgical patients with lumbar disc herniation receiving different treatments and timing of treatments.

METHODS

Individuals with newly diagnosed lumbar intervertebral disc herniation without myelopathy were queried from a health claims database. Patients were categorized into 3 cohorts: nonsurgical, early surgery, and late surgery. Early surgery cohort patients underwent surgery within 30 days postdiagnosis; late surgery cohort patients had surgery after 30 days but before 1 year postdiagnosis. The index date was defined as the diagnosis date for nonsurgical patients and the initial surgery date for surgical patients. The primary outcome was the average daily opioid morphine milligram equivalents (MME) prescribed. Additional outcomes included percentage of opioid-using patients and cumulative opioid burden.

RESULTS

Inclusion criteria were met by 573,082 patients: 533,226 patients received nonsurgical treatments, 22,312 patients received early surgery, and 17,544 patients received late surgery. Both surgical cohorts experienced a postsurgical increase in opioid usage, which then sharply declined and gradually plateaued, with daily opioid MME consistently lower in the early versus late surgery cohort. The early surgery cohort also consistently had a lower prevalence of opioid-using patients than the late surgery cohort. Patients receiving nonsurgical treatment demonstrated the highest 1-year post index cumulative opioid burden, and the early surgery cohort consistently had lower cumulative opioid MME than the late surgery cohort.

CONCLUSIONS

Early surgery in patients with lumbar disc herniation is associated with lower long-term average daily MME, incidence of opioid use, and 1-year cumulative MME burden compared with nonsurgical and late surgery treatment approaches.

Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain

IMPORTANCE

Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain.

OBJECTIVE

To understand health care utilization in patients with new-onset idiopathic neck pain.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used.

RESULTS

In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were $24 267.55 per surgical patient and $515.69 per nonsurgical patient. Across all health care services, $95 379 949 was accounted for by nonsurgical patients undergoing early imaging who did not receive any additional conservative therapy or epidural steroid injections, for a mean (SD) of $477.53 ($1375.60) per patient and median (IQR) of $120.60 ($20.70-$452.37) per patient. On average, patients not undergoing surgery, physical therapy, chiropractic manipulative therapy, or epidural steroid injection, who underwent either early advanced imaging (magnetic resonance imaging or computed tomography) or both early advanced and radiographic imaging, accumulated significantly elevated health care costs ($850.69 and $1181.67, respectively). Early conservative therapy was independently associated with 24.8% (95% CI, 23.5%-26.2%) lower health care costs.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, early imaging without subsequent intervention was associated with significantly increased health care spending among patients with newly diagnosed idiopathic neck pain. Early conservative therapy was associated with lower costs, even with increased frequency of therapeutic services, and may have reduced long-term care inefficiency.

Profiling Real-Time Aroma from Green Tea Infusion during Brewing

Aroma substances are the most crucial criteria for the sensory evaluation of tea quality, and also key attractors influencing consumers to make the decision for purchasing tea. Understanding the aromatic properties of tea infusion during different brewing time is crucial to control the tea aromatic quality. Here, headspace and direct immersion solid-phase microextraction (HS-SPME and DI-SPME), coupled with GC-MS, were employed to investigate the impact of brewing time on the changes of the volatile features of green tea infusion. Esters, aldehydes, alcohols, fatty acids, and alkaloids were the predominant volatile groups from tea infusions. Two to three minutes was identified as the best duration for the tea brewing that can maximize the abundance of aromatic chemicals in the headspace emitted from the tea infusions. The variation of the key aromatic contributors between the tea infusion and the headspace over the infusion tended to equilibrate during the tea brewing process. This study provides a theory-based reference method by analyzing the real-time aromatic characteristics in green tea. The optimal time was determined for aromatic quality control, and the complementary relationship between the volatiles in the headspace and its counterpart, tea infusion, was primarily elucidated.

OP0059 MAVRILIMUMAB (ANTI GM-CSF RECEPTOR Α MONOCLONAL ANTIBODY) REDUCES RISK OF FLARE AND INCREASES SUSTAINED REMISSION IN A PHASE 2 TRIAL OF PATIENTS WITH GIANT CELL ARTERITIS

Background:

T helper (Th)1 and Th17 lymphocytes play a role in the pathogenesis of giant cell arteritis (GCA). Current treatments primarily target the Th17 axis, possibly leaving residual Th1 activity. Granulocyte macrophage colony stimulating factor (GM-CSF), a mediator of Th1 and Th17 cells, is a pathogenic factor in GCA.

Objectives:

To evaluate the efficacy and safety of the GM-CSF inhibitor mavrilimumab in patients with GCA.

Methods:

Randomized, double-blind, placebo-controlled phase 2 trial enrolling patients with active, biopsy- or imaging-proven new onset (N/O) or relapsing refractory (R/R) GCA. Active disease: GCA symptoms and erythrocyte sedimentation rate (ESR) (>30 mm/hr) and/or C-reactive protein (CRP) (≥1 mg/dL) elevation within 6 weeks from randomization. Corticosteroid-induced remission (resolution of GCA symptoms and CRP <1 mg/dL or ESR <20 mm/hr) was required by baseline. 3:2 randomization to mavrilimumab 150 mg or placebo subcutaneously every 2 weeks and protocol-defined 26-week prednisone taper starting at 20-60 mg/day.

Primary efficacy endpoint: time to first adjudicated flare (ESR ≥30 mm/hr and/or CRP ≥1 mg/dL and GCA symptoms or new/worsening vasculitis on imaging) by Week 26 in all treated patients. Key secondary endpoint: sustained remission through Week 26. Safety up to Week 38 was assessed.

Results:

70 patients (35 N/O, 35 R/R) were enrolled (mavrilimumab [N=42] or placebo [N=28]). Mean (SD) age was 69.7 (7.48) years and 71.4% were female. Flare by Week 26 occurred in 8 (19%) and 13 (46.4%) patients receiving mavrilimumab and placebo, respectively (27.4 percentage points reduction). Median time to flare by Week 26 could not be estimated in the mavrilimumab group due to too few events (Not Estimable) and was 25.1 weeks [95% CI: (16.0, NE)] in the placebo group (HR [95% CI] 0.38 [0.15, 0.92]; p=0.0263) (Figure). Sustained remission at Week 26 occurred in 83.2% of patients receiving mavrilimumab and 49.9% of those receiving placebo (33.4 percentage points increase; p=0.0038). Results were consistent across disease type subgroups (HR for flare: N/O 0.29 [95% CI: 0.06, 1.31; nominal p= 0.0873]; R/R 0.43 [95% CI: 0.14, 1.30]; nominal p=0.1231), although not powered for significance (Table). Adverse events (AEs), mostly mild to moderate, were comparable between groups. There were 5 serious AEs (mavrilimumab 2 [4.8%], placebo 3 [10.7%]), none drug-related. No deaths or vision loss occurred. No adjudicated cases of pulmonary alveolar proteinosis were observed.

Table 1.

Efficacy at Week 26

All Patients [1]SubgroupsN/OR/RMavrilimu-mab (N=42)Placebo (N=28)Mavrilimu-mab (N=24)Placebo (N=11)Mavrilimu-mab (N=18)Placebo (N=17)Patients with Flare, n (%)8 (19.0)13 (46.4)3 (12.5)4 (36.4)5 (27.8)9 (52.9)Time to Flare (weeks) [2]Median, 95% CINE (NE, NE)25.1 (16.0, NE)NE (NE, NE)NE (11.7, NE)NE (16.4, NE)22.6 (16.0, NE)HR (Mavrilimumab vs Placebo), 95% CI [3]0.38 (0.15, 0.92)0.29 (0.06, 1.31)0.43 (0.14, 1.30)P-value [4] [5]0.02630.08730.1231Sustained Remission (%), 95% CI [6]83.2 (67.9, 91.6)49.9 (29.6, 67.3)91.3 (69.3, 97.7)62.3 (27.7, 84.0)72.2 (45.6, 87.4)41.7 (17.4, 64.5)Difference in Proportions (95% CI) [7]33.3 (10.7, 55.8)28.9 (-2.7, 60.5)30.6 (-2.1, 63.2)P-value [5] [7]0.00380.07270.0668

NE = Not estimable. [1] Total mITT population. Stratified by randomization strata. [2] Kaplan-Meier. [3] Cox proportional-hazards model; treatment as covariate. [4] Log-rank test. [5] N/O and R/R subgroups not powered for significance; nominal p values reported. [6] Kaplan-Meier Survival Estimates with standard error. [7] Two-sided p-value for the difference in sustained remission between 2 arms using normal approximation. Placebo arm is reference.

Conclusion:

Mavrilimumab was superior to placebo on the primary and secondary efficacy endpoints of time to flare and sustained remission at week 26 in patients with GCA. Mavrilimumab was well tolerated, and no new safety signals were observed.

Disclosure of Interests:

Maria C. Cid Speakers bureau: meeting attendance support from Roche and Kiniksa, Paid instructor for: educational from GSK and Vifor, Consultant of: consulting for Janssen, GSK, and Abbvie, Grant/research support from: research grant from Kiniksa, Sebastian Unizony Consultant of: consulting for Janssen and Kiniksa, Grant/research support from: research support from Genentech, Lara Pupim Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Fang Fang Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Joseph Pirrello Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Ai Ren Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Manoj Samant Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Teresa Zhou Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, John F. Paolini Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals

Pharmacokinetic study of isatin in dog plasma by liquid chromatography tandem mass spectrometry

AIM

A sensitive and selective method was developed and validated to study the pharmacokinetics of isatin.

METHODS

The blood samples were pretreated by protein precipitation method using methanol. Quetiapine was used as an internal standard. After pretreatment, the samples were assayed by LC/MS/MS method and the pharmacokinetic parameters were calculated by WinNonlin 5.2 using non-compartment model. The separation was performed on a Venusil XBP PH column (5 µm, 2.0×100 mm) with an isocratic mobile phase consisted of methanol-water (containing 50 mM ammonium formate) (65:35, v/v) at a flow rate of 0.3 mL/min. The Agilent G6410B triple quadrupole LC/MS system was operated under the multiple reactions monitoring mode (MRM) using the electrospray ionization technique in positive mode.

RESULTS

The lower limits of quantification (LLOQ) of the analyte of the method was 10 ng/mL. The method was linear with correlation coefficient >0.995. The intraday and interday accuracy and precision of the assay were acceptable.

CONCLUSION

This method has been applied successfully to a pharmacokinetic study involving the oral and intravenous administration of isatin to beagle dogs.

Tigecycline exerts an antitumoral effect in oral squamous cell carcinoma

OBJECTIVE

To explore whether antibacterial drug tigecycline could exert an antitumoral effect in oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

Two OSCC cell lines Tca8113 and KB were used in this study. To investigate the cytostatic effects of tigecycline in OSCC, cell growth was tested by trypan blue staining, MTT assay, and Brdu immunofluorescence staining. Then, the apoptosis proportion was measured by FITC Annexin-V and PI labeling, and cell cycle was determined by PI staining. The expression of caspase 3 (CASP3) and cell cycle regulatory protein was detected by Western blot assay. Finally, the clonogenesis and tumorigenesis capacity were analyzed by soft agar growth and xenograft model.

RESULTS

Here, we showed that tigecycline significantly inhibited cell growth and proliferation in OSCC cell lines Tca8113 and KB. It did not induce cell apoptosis but led to an increase of cells in G0/G1 phase with down-regulation of cyclin E2 (CCNE2) and cyclin-dependent kinase4 (CDK4) protein expression. We also showed that tigecycline inhibited colony formation in soft agar and reduced tumor growth in a xenograft model.

CONCLUSION

Our results suggested that tigecycline might be used as a novel candidate agent for the treatment of OSCC.

Effects of pioglitazone and glipizide on platelet function in patients with type 2 diabetes

OBJECTIVE

Platelet hyper-reactivity is one of the most important causes of accelerated atherosclerosis and increased risk of thrombotic vascular events associated with type 2 diabetes mellitus (T2DM). This study aimed to investigate the effects of different add-on anti-diabetic therapies on platelet function in T2DM patients.

PATIENTS AND METHODS

A three-group parallel study was conducted in 120 patients with T2DM (HbA1c > 7%) undergoing treatment with metformin. Patients were randomly assigned to receive add-on therapy with glipizide or pioglitazone. Markers of PF (platelet PAC-1 binding, p-selectin expression and adenosine diphosphate-induced platelet aggregation) were measured at weeks 0, 4 and 24. Primary outcome was effects of pioglitazone and glipizide on platelet aggregation. Secondary outcome was the related influencing factors of platelet aggregation.

RESULTS

There were no significant differences in baseline characteristics between glipizide and pioglitazone groups. After 24 weeks, fasting blood glucose (p < 0.01) and HbA1c (p < 0.01) were higher in pioglitazone group than those in glipizide group. Fasting insulin (p < 0.01) and HOMA-IR (p < 0.01) were lower in pioglitazone group than that in glipizide group. Markers of platelet function were significantly decreased in both groups at 24 weeks (PAC-1: pioglitazone: -63.3%; glipizide: -45.9%; p-selectin: pioglitazone: -73.9%; glipizide: -54.9%; platelet aggregation: pioglitazone: -24.1%; glipizide: -13.4%; all p < 0.01 vs. baseline), but the decrease in platelet function was more significant in pioglitazone group (p < 0.05). Multiple linear regression analyses showed that platelet aggregation was independently associated with treatment groups (p < 0.001), Triglyceride (p = 0.009) and HDL-C (p = 0.015).

CONCLUSIONS

Add-on therapy with pioglitazone may be more effective than glipizide for inhibiting platelet activation in T2DM.

Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion

OBJECTIVE

To investigate the accuracy of using CT and MRI to characterize lesions of osteonecrosis of the femoral head (ONFH).

METHODS

Coronal CT and MRI scans were performed on 30 femoral head specimens collected from 23 patients who had undertaken hip arthroplasty owing to ONFH. The results were compared with findings from coronal sectional gross specimens. Two radiologists independently measured the volume of necrotic lesions from CT and MR images using computer software, and the results were averaged. The volume of specimens' necrotic lesion was measured using the water displacement method.

RESULTS

There was a high degree of consistency between CT, MRI and the coronal sectional gross specimen on the location, shape and spatial structure of lesions. Differences of the lesion volume measured from CT and MR images were not statistically significant between two radiologists. The necrotic lesion volumes measured from CT and MR images and gross specimens were 22.07 ±5.35, 22.21 ± 5.15 and 21.12 ±4.96 cm(3), respectively, and the differences were not statistically significant (F = 0.396; p = 0.674).

CONCLUSION

For patients with ONFH in Association Research Circulation Osseous stage III or above, CT and MRI can accurately display the characterization of lesion.

ADVANCES IN KNOWLEDGE

The size and location of necrotic lesions are major factors associated with femoral head collapse. CT is superior to MRI in identifying subchondral fracture. CT can help diagnose and predict the prognosis of ONFH.

Caesarean delivery, caesarean delivery on maternal request and childhood overweight: a Chinese birth cohort study of 181 380 children

What is already known about this subject Both rates of caesarean section and childhood overweight have been steadily increasing over the past decade in many parts of the world. Caesarean delivery on maternal request contributes remarkably to the rising trend of caesarean births. A few small-scale studies suggest that caesarean section may be associated with later overweight and obesity, whereas little is known about the impact of caesarean delivery on maternal request. What this study adds Caesarean section is associated with an increased risk of childhood overweight. Children born by caesarean delivery on maternal request are also more likely to be overweight. The strength of the caesarean-overweight association is modest.

OBJECTIVES

To assess the impact of caesarean delivery including non-medically indicated maternal request caesarean delivery on childhood overweight.

METHODS

We conducted a prospective investigation of a Chinese birth cohort involving 181 380 children, who were born during 1993-1996 to mothers registered in a perinatal care surveillance system and whose weight and height were measured in 2000. Information on delivery mode and covariates was obtained from the surveillance system. Overweight was defined according to the International Obesity Task Force body mass index (BMI) cutoffs. Multivariable logistic regression was used to estimate adjusted odds ratios. Stratified analyses were done to test whether the association between caesarean section and overweight persisted across subgroups.

RESULTS

The adjusted odds ratio of overweight for children born by caesarean compared with vaginal delivery was 1.13 [95% confidence interval {CI}: 1.08, 1.18]. The association persisted in subgroups stratified by gender, maternal education, maternal BMI, weight gain during pregnancy and child birthweight (all P values for interaction test ≥0.30). The adjusted odds ratio of overweight for children born by non-medically indicated caesarean delivery compared with vaginal delivery was 1.18 (95% CI: 1.00, 1.41).

CONCLUSION

Caesarean delivery including non-medically indicated maternal request caesarean delivery compared with vaginal delivery modestly increases childhood overweight risk.

Neotyphodium coenophialum-infected tall fescue and its potential application in the phytoremediation of saline soils

The growth response of endophyte-infected (EI) and endophyte-free (EF) tall fescue to salt stress was investigated under two growing systems (hydroponic and soil in pots). The hydroponic experiment showed that endophyte infection significantly increased tiller and leaf number, which led to an increase in the total biomass of the host grass. Endophyte infection enhanced Na accumulation in the host grass and improved Na transport from the roots to the shoots. With a 15 g l(-1) NaCl treatment, the phytoextraction efficiency of EI tall fescue was 2.34-fold higher than EF plants. When the plants were grown in saline soils, endophyte infection also significantly increased tiller number, shoot height and the total biomass of the host grass. Although EI tall fescue cannot accumulate Na to a level high enough for it to be termed a halophyte, the increased biomass production and stress tolerance suggested that endophyte/plant associations had the potential to be a model for endophyte-assisted phytoextraction in saline soils.

Caesarean delivery on maternal request and childhood psychopathology: a retrospective cohort study in China

OBJECTIVE

To prospectively examine the association between mode of delivery and childhood psychopathology.

DESIGN

Retrospective cohort study.

SETTING

Eighteen counties and three cities in China.

POPULATION

A total of 4190 preschool children whose mothers were registered in a perinatal surveillance programme were assessed with the Child Behaviour Checklist (CBCL), an instrument to assess child emotional (internalising) and behavioural (externalising) problems.

METHODS

Differences in CBCL problem scores were analysed both quantitatively and categorically among children born by caesarean delivery on maternal request (CDMR), assisted vaginal delivery (AVD), and spontaneous vaginal delivery (SVD).

MAIN OUTCOME MEASURES

The CBCL total, externalising, and internalising scores.

RESULTS

There were significant differences in the mean scores of total (20.9, 23.0, and 25.0), externalising (7.6, 8.4, and 9.1), and internalising (4.7, 5.2, and 5.6) problems among children born by CDMR, SVD, and AVD, after adjusting for potential confounding factors (P = 0.007, 0.014, and 0.031). Children born by AVD were more likely than those born by SVD to have total (OR 1.43; 95% CI 1.10-1.86), externalising (OR 1.46; 95% CI 1.11-1.92), and internalising (OR 1.41; 95% CI 1.08-1.84) scores in the highest quartile, whereas children born by CDMR were less likely to have externalising scores in the highest quartile (OR 0.64; 95% CI 0.42-0.97). Furthermore, there were significant increasing linear trends on all problem scores, and in the odds of being in the highest quartile, from children born by CDMR to those born by SVD and AVD.

CONCLUSION

The likelihood of childhood psychopathological problems may be the lowest in children born by CDMR, followed by those born by SVD, whereas the highest probability was observed in those born by AVD.

Intensive insulin therapy decreases urinary MCP-1 and ICAM-1 excretions in incipient diabetic nephropathy

BACKGROUND

Nowadays, intensive insulin treatment has been widely used in type 2 diabetics who have poor control of blood glucose, to reduce the risk of chronic complications of diabetes. Recently, some scholars have paid more attention to the pivotal role of inflammation involved in type 2 diabetes and its complications. Monocyte chemoattractant protein-1 (MCP-1) and intercellular adhesion molecule-1 (ICAM-1), which are two important inflammatory chemokines, have been documented to participate in the onset and development of type 2 diabetes and its complications, such as diabetic nephropathy (DN).

DESIGN

In the current study, we recruited 30 type 2 diabetics with microalbuminuria to be treated with multiple insulin injections daily for 2 weeks. Random spot urine samples (corrected for creatinine-Cr) were collected for the examination of urinary MCP-1, ICAM-1 and albumin (Alb) levels before and after the intensive insulin therapy. Changes in their levels were observed to test the hypothesis that type 2 diabetes with microalbuminuria is associated with elevated urinary concentrations of MCP-1 and ICAM-1, and intensive insulin therapy can result in a decline of Alb by reducing the inflammatory reaction.

RESULTS

The urinary MCP-1/Cr and urinary ICAM-1/Cr ratios in type 2 diabetic patients with microalbuminuria were much higher than those in normal controls, and intensive insulin treatment could decrease significantly the urinary MCP-1/Cr, ICAM-1/Cr and Alb/Cr ratios in type 2 diabetics with microalbuminuria.

CONCLUSION

Intensive insulin treatment may protect against renal injury in early DN by reducing the urinary MCP-1 and ICAM-1 excretions.

Low first-trimester hemoglobin and low birth weight, preterm birth and small for gestational age newborns

OBJECTIVE

To examine the relationship between first-trimester hemoglobin (Hb) concentration and risk of low birth weight (LBW), preterm birth and small for gestational age (SGA).

METHODS

Data were obtained from a population-based prenatal care program in China. A total of 88,149 women who delivered during 1995-2000 and had their Hb measured in the first trimester were selected as study subjects.

RESULTS

The prevalence of anemia (Hb<110 g/L) was 22.1% in the first trimester. The risk of LBW, preterm birth and SGA was increased steadily with the decrease of first-trimester Hb concentration. After controlling for confounding factors, women with Hb 80-99 g/L had significantly higher risk for LBW (OR=1.44, 95% CI 1.17-1.78), preterm birth (OR=1.34, 95% CI 1.16-1.55) and SGA (OR=1.13, 95% CI 0.98-1.31) than women with Hb 100-119 g/L. No elevated risk was noted for women with Hb> or =120 g/L.

CONCLUSION

Low first-trimester Hb concentration increases the risk of LBW, preterm birth and SGA.

Sorption and complexation of Eu(III) on alumina: Effects of pH, ionic strength, humic acid and chelating resin on kinetic dissociation study

The effects of pH (pH=2-12), ionic strength (0.01-2 mol/l NaNO(3)) and humic acid on the sorption and complexation of Eu(III) on alumina were investigated by using batch techniques. The experiments were carried out at room temperature and under ambient conditions. The results indicate that the sorption of Eu(III) on alumina is strongly influenced by humic acid. The sorption of Eu(III) on alumina is significantly dependent on pH values and independent of ionic strength. The sorption of Eu(III) on alumina may be attributed to surface complexation. The species of Eu(III) on HA-alumina colloids is dominated by both HA and alumina, and the addition sequences of HA or Eu(III) to the ternary system do not influence the sorption of Eu(III) to HA-coated alumina. Kinetic dissociation of Eu(III) from bare and HA-coated alumina was also studied by using the chelating resin. The result was discussed by a pseudo-first-order kinetics model.

[Safety and immunogenicity of a new inactivated hepatitis A vaccine]

BACKGROUND

To evaluate the safety and immunogenicity of a new inactivated hepatitis A virus (HAV) vaccine.

METHODS

In a randomized controlled trail thirty-one HAV-seronegative adults were enrolled and randomly assigned to either study group or control group. Subjects in the study group were given 1000 units of the new inactivated HAV vaccine, with a booster at 3 months. Subjects in the control group were given 720 ELISA units Havrix, produced by SmithKline Beecham Biologicals, with a subsequent dose at 3 months. Local and systematic reactions and serum response to the vaccines were compared between the two groups.

RESULTS

Mild local reactions were noted in one subject from the study group and two from the control group after primary vaccination. Mild systematic reactions were reported in two subjects from each group after primary vaccination and in one subject from the study group after booster vaccination. Seroconversion rates were 94%, 100%, and 100% in the study group at 1, 3, and 4 (1 month after booster) month, respectively. The corresponding figures were 73%, 80% and 100% in the control group. Geometric mean antibody titers were 139.2 mIU/ml, 137.7 mIU/ml, and 1 066.7 mIU/ml at 1, 3, and 4 months,respectively, in the study group,and 104.3 mIU/ml, 111.3 mIU/ml, and 760.7 mIU/ml in the control group.

CONCLUSIONS

The new inactivated hepatitis A vaccine was safe and highly immunogenic.

An international comparison of the involvement of epidemiology in the most frequently cited publications in the field of clinical medicine

The objectivity, validity and credibility of research in clinical medicine can be enhanced by the appropriate involvement of epidemiology. However, the overall contribution of epidemiology to clinical research, either as a methodology or as a resource for research, has been poorly quantified. We therefore assessed the involvement of epidemiology in influential publications in the field of clinical medicine, and made an international comparison on a quantitative basis. The 500 most frequently cited papers published during 1981-96 in the field of clinical medicine in the US, the UK, and Japan were compared in terms of epidemiological involvement using predetermined criteria. The three criteria were based on the indexing of relevant MeSH keywords, publication types, or the departmental affiliations of the authors. For all three criteria, the proportion of clinical papers with epidemiological involvement was the highest in the US, followed by the UK, whereas it was the lowest in Japan. The difference was almost four-fold between the US and Japan. There was also an increasing trend of epidemiological involvement in publications of clinical medicine over the years, which was more apparent in the US than in either the UK or Japan. These findings may reflect inter-country differences in resources as well as in the stance towards evidence-based health sciences.

[Dynamic changes of serum pro-inflammatory cytokines and anti-inflammatory cytokines in patients with acute infection and the effect of Chinese herbal medicine intervention]

OBJECTIVE

To study the dynamic changes of serum pro-inflammatory cytokines and anti-inflammatory cytokines in patients with acute infection and to explore the effect of 912 compound, a Chinese herbal preparation for intervention.

METHODS

Forty patients with acute infection were randomly divided into 2 groups, 20 in the 912 group and 20 in the control group, and the levels of plasma endotoxin (lipopolysaccharide, LPS), serum pro-inflammatory cytokines, including tumor necrosis factor alpha (TNF alpha) and interleukin-6 (IL-6) and anti-inflammatory cytokines, including soluble TNF-RI, IL-4 and IL-10 were measured before and after treatment by using limulus reagent stroma azo-colored quantitative method and enzyme-linked immunosorbent assay (ELISA).

RESULTS

The level of LPS increased at the early stage of acute infection, the levels of pro- and anti-inflammatory cytokines were all elevated in various degrees, particularly obvious in IL-6, sTNF-RI, IL-4 and IL-10 and the elevations of the two were basically parallel. The TNF alpha, IL-6 and sTNF-RI were positively related with APACHE III scoring. The levels of LPS and inflammatory cytokines reduced to a different extent in accord with the improvement of condition after treatment, the levels of LPS, TNF alpha, IL-6 and IL-10 lowered more significantly in the 912 group than those in the control group (P < 0.05).

CONCLUSIONS

LPS, pro-inflammatory and anti-inflammatory cytokines play important roles in the acute infection process, they were important indexes for evaluating severity of infectious diseases. The Chinese herbal preparation 912 compound could reduce the blood levels of LPS, TNF alpha, IL-6, IL-10 and prevent the decrease of sTNF-RI so as to promote the recovery of patients.

[The relationship between arteriolar pathological changes and brain hemorrhage in primary hypertension cases]

This study was intended to elucidate the relationship between arteriolar pathological changes and encephalorrhagia in the cases of primary hypertension. Gross anatomy and histology of brain were observed in autopsy of 45 cases of primary hypertension. Forty cases of arteriolar hyalinization including 26 cases of brain hemorrhage were found in those 45 cases of primary hypertension. The hyalinized arterioles were divided to two types. One is characterized by the narrow lumen of terminal arterioles, the other by the dilatant lumen of proximal arterioles. Hemorrhage always occurred in the latter type. Besides these changes, 3 cases of acute necrosis and 5 cases of atherosclerosis in arterioles were related to hemorrhage. These data suggest that brain hemorrhage of primary hypertension mainly occur in dilated and hyalinized arterioles, and some cases are probably related to acute necrosis or atheroscleromatous atrerioles.

[Studies of volatile oils from the flowers of Chrysanthemum nankingense and Chrysanthemum indicum]

Chemical constituents of volatile oils from the flowers of Chrysanthemum nankingense and C. indicum were studied by GC-MS. 59, 30 components were identified respectively.

[Pathological morphology of arterioles and main visceal organs in primary hypertension--an analysis of 45 autopsies]

The autopsy materials of 45 cases of primary hypertension were studied retrospectively. The arteriolar lesions were reviewed. The arterioles < 100 microns in diameter were defined as distal arterioles; those > or = 100 microns and < 300 microns in diameter were proximal arterioles. The lesions of arteriolar wall were categorized as plasma infiltration and hyaline degeneration, and according to seriousness, the latter was divided into three degrees: I, II and III. The results revealed that (1) the arteriolar lesions in different areas of the body were at different stages of seriousness; (2) the changes in the distal arterioles were earlier than those in the proximal ones; in brain, the proximal arterioles dilated first, and then occurred the hyline degeneration; (3) hyaline degeneration took place early in the abdominal organs such as kidney, liver and pancreas, but relatively late in brain; (4) different parts of an organ were at different stages of seriousness; and (5) the lesions in different organs led to different consequences. The pathogenesis of arteriolar sclerosis in primary hypertension was also discussed.

[Clinical observation on treatment of bile regurgitational gastritis with danwei capsule]

OBJECTIVE

To evaluate the therpeutic effect of Danwei capsule in treating bile regurgitational gastritis.

METHODS

One hundred and thirty-four patients with bile regurgitational gastritis were divided into two groups. Danwei capsule was used in therapeutic group and Motilium was used in control group.

RESULTS

The total effective rate in therapeutic group was 92.59%, and 71.70% in control group (P < 0.01). The improvement in symptoms, physical findings and bile regurgitation in therapeutic group was better than that of control.

CONCLUSION

Curative effect of Danwei capsule was better than that of Motilium, which should be used widely.

[Pathological analysis of 180 cases of cerebrovascular disorder in autopsy]

OBJECTIVE

To evaluate the ratio of each kind of causes in 180 cases of cerebrovascular disorder(CVD) in autopsy.

RESULTS

In 180 cases of CVD in autopsy: (1)125 (69%) belong to brain hemorrhage including hypertension 36 cases(20%), vascular malformation 28 cases(16%), hemopoitic diseases and blood coagulation disturbances 23 cases(13%), congenital aneurysm and brain tumor 9 cases(5%) each separately. (2) 55 cases (31%) are due to brain infarction, main of them are caused by embolism 29 cases (16%) and thrombosis 17 cases(10%). Thrombosis related to atherosclerosis has 5 cases(3%).

CONCLUSION

In CVD in autopsy, brain hemorrhage is more than infarction, the ratio of them is 2.3:1. More than 50% of cases is due to hypertension and vascular malformation. In infarction, embolism is more than thrombosis, the ratio of them is 1.7:1. Vascular malformation is more than congenital aneurysm, the ratio of them is 3:1.

Occupational lung diseases and global occupational health on the Net

Occupational lung disease is a major area of concern in occupational health, exhibiting a diverse panorama across countries. While pneumoconiosis is deemed to be the most common occupational disease in many developing countries, emphasis is shifting towards asbestos-related lung diseases and occupational asthma in industrialized countries. Following the Occupational Health for All strategies set forth by the World Health Organization, we propose that a model system based upon the Global Health Network can serve as an effective vehicle towards the prevention of occupational lung diseases on a global scale. It has the potential to: (1) enhance transmission of data and collaboration with the primary health care system in disease surveillance; (2) strengthen research and information transfer and (3) promote education and training at all levels of prevention, with a possible application to the interpretation of chest radiograms.

Health status, health habits, utilization behaviour and health care utilization in an actively employed Japanese population

Healthcare utilization data from 1 February 1986 to 31 January 1992 for 18,601 local public service employees were analysed in relation to data on their perceived health status, health habits, health care utilization behaviour and health-related worries which were obtained from a questionnaire survey conducted in 1988. The results showed health care utilization behaviour as defined by the questionnaire responses to be the most important predictor of health care utilization as defined by claim rate and group utilization rate, followed by perceived health status and certain health habits (ie caring about sleep, food and diet, watching body weight). Health-related worries, when used as a group variable, were not an independent predictor of utilization. The co-existence of 'active' utilization behaviour or the above-mentioned health habits with fair/poor perceived health status was associated with the highest health care utilization. The implication of these findings is that if utilization behaviour modification is incorporated into various worksite health programmes that aim at improving employee health and containing health care utilization and costs, greater reduction can be achieved in employee health care utilization and costs.

Health-related worries, perceived health status, and health care utilization

This study examines the association of health-related worries (over cancers, diabetes, work-related stress, heart attack, obesity, general physical fitness, and/or other health conditions) and perceived health status (excellent, good, fair or poor) to the utilization of health care services for 19, 139 Japanese local public service employees. Data on health-related worries and health status were obtained from a self-administered questionnaire survey in 1988 and analyzed in relation to the subsequent 12-month utilization of health care. Results showed that perceived health status was associated with the utilization for almost all medical conditions and so was worry over a specific condition and the subsequent utilization of health care services. The implication of these findings is that measures targeting the relief of an employee's health-related worries, through either health consultation or other health programs, may contribute to the reduction of an employee's health care utilization and costs.

Comprehensive periodic health examination: impact on health care utilisation and costs in a working population in Japan

STUDY OBJECTIVE

To examine the impact of a comprehensive periodic health examination programme on health care utilisation and costs in a working population.

DESIGN

A cohort method was used to observe the trends in health care utilisation and costs for a group of local government employees from 1 February 1986 until 31 January 1992, during which time (in 1988) a comprehensive periodic health examination programme had been introduced. Health care utilisation was measured by a claim rate per employee (number of claims in a year divided by number of employees) and a utilisation rate per 100 employees (number of employees who submitted at least one claim in a year divided by number of employees x 100). Health care costs were measured by claim costs per employee (total cost of claims divided by number of employees). National and prefectural changes in per capita health care costs were used for the adjustment of claim costs. Internal comparisons were made in relation to the intensiveness of the periodic health examinations administered before the introduction of the comprehensive programme.

SETTING

Fukuoka Prefecture, Japan.

PARTICIPANTS

A total of 19,146 local government employees (12,455 men, 6691 women) who worked in small cities, towns, and villages in Fukuoka Prefecture throughout the study period participated.

MAIN RESULTS

Both the claim and utilisation rates showed an increase in 1988 when the comprehensive programme was introduced. After adjustment for the national changes in per capita health care costs and the aging effect of the study participants, substantial increases in claim costs were noted after introduction of the comprehensive programme. The programme had a greater but short term effect of increasing the health care utilisation of those who had received less intensive periodic health examinations before 1988, but no similar effect on claim costs was noted.

CONCLUSIONS

The comprehensive programme had some role in increasing health care utilisation and costs. Its effect on costs was confirmed when the general population or another population was used as a reference. When comparisons were made internally, the comprehensive programme was seen to have had a greater but short term effect of increasing the utilisation of those who had previously received less intensive health examinations to equalise the health care utilisation and costs within the study population.

Hospital use behaviors and associated costs in a health insurance organization, Japan

Physicians are known to play an important role in the rise of health care costs. But patients--the other side of the chain of health care systems--have been given little attention. The present study utilized the outpatient claims (in the belief that the outpatient hospital visits are mainly decided by the patients) from a health insurance organization in Japan (the Fukuoka Prefecture public service mutual aid association for government employees who serve in small cities, towns, and villages) to analyze the employee behaviors in the use of hospital care and the costs associated with these behaviors. Number of diseases diagnosed for an employee, number of claims an employee submitted for one disease, number of hospitals an employee visited, number of claims an employee had from one hospital, and the total number of claims an employee submitted were used to describe the hospital use behaviors. Results showed that some employees exhibited unusual behaviors, characterized by having an extremely large number of diseases diagnosed, visiting a large number of different hospitals, having a large number of claims, etc. Higher medical expenditures were associated with such behaviors. The findings of this study suggest that the patients' role in the rise of health care costs cannot be ignored, and cost-containment strategies targeting modification of patient behaviors in the use of hospital care may prove to be very useful.

[Dietary factors and esophageal cancer: a case-control study]

A hospital-based case-control study of 112 patients with esophageal cancer was conducted to explore the association of dietary factors with cancer of the esophagus. Each case was matched to one non-cancerous patient from surgical department in the hospital of the same sex, age (+/- 5 years), occupation (farmer or nonfarmer), and residence as control. Multivariate conditional logistic regression analysis showed that the consumption of moldy grains (odds ratio (OR), 4.08), pickled vegetables (OR, 2.57), tea drinking habit (OR, 5.65), and hot food consumption (OR, 2.53) were significant risk factors for esophageal cancer. Intake of eggs (OR, 0.30) and higher proportion of flour and rice in the grain ration (greater than 30% vs. less than or equal to 30%) (OR, 0.43) were protective factors. Relations between factors were also discussed in the paper.