A 120-Minute Saline Infusion Test For The Confirmation Of Primary Aldosteronism: A Pilot Study

BACKGROUND

The saline infusion test (SIT) to confirm primary aldosteronism requires infusing two liters of normal saline over 240 minutes. Previous studies raised concerns regarding increased blood pressure and worsening hypokalemia during SIT. We aimed to evaluate the diagnostic applicability of a SIT that requires one liter of saline infusion over 120 minutes.

METHODS

A cross-sectional study, including all patients in a large medical center who underwent SIT from January 1st, 2015, to April 30th, 2023. Blood samples were drawn for baseline renin and aldosterone (t=0) after two hours (t=120 min) and after four hours (t=240 min) of saline infusion. We used ROC analysis to evaluate the sensitivity and specificity of various aldosterone cutoff values at t=120 to confirm primary aldosteronism.

RESULTS

The final analysis included 62 patients. A ROC analysis yielded 97% specificity and 90% sensitivity for a plasma aldosterone concentration of 397 pmol/L (14 ng/dL) at t=120 to confirm primary aldosteronism, and an area under the curve of 0.97 (95% CI [0.93, 1.00], P < 0.001). Almost half (44%) of the patients did not suppress PAC below 397 pmol/L (14 ng/dL) at t=120. Of them, only one (4%) patient suppressed PAC below 276 pmol/L (10 ng/dL) at t=240. Mean systolic blood pressure increased from 140.1±21.3 mm/Hg at t=0 to 147.6±14.5 mm/Hg at t=240 (p=0.011).

CONCLUSIONS

A PAC of 397 pmol/l (14 ng/dL) at t=120 has high sensitivity and specificity for primary aldosteronism confirmation.

Are Unequal Policies in Pre-Exposure Prophylaxis Uptake Needed to Improve Equality? An Examination Among Men Who Have Sex with Men in Los Angeles County

Racial and ethnic minority men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Los Angeles County (LAC), an important epicenter in the battle to end HIV. We examine tradeoffs between effectiveness and equality of pre-exposure prophylaxis (PrEP) allocation strategies among different racial and ethnic groups of MSM in LAC and provide a framework for quantitatively evaluating disparities in HIV outcomes. To do this, we developed a microsimulation model of HIV among MSM in LAC using county epidemic surveillance and survey data to capture demographic trends and subgroup-specific partnership patterns, disease progression, patterns of PrEP use, and patterns for viral suppression. We limit analysis to MSM, who bear most of the burden of HIV/AIDS in LAC. We simulated interventions where 3000, 6000, or 9000 PrEP prescriptions are provided annually in addition to current levels, following different allocation scenarios to each racial/ethnic group (Black, Hispanic, or White). We estimated cumulative infections averted and measures of equality, after 15 years (2021-2035), relative to base case (no intervention). By comparing allocation strategies on the health equality impact plane, we find that, of the policies evaluated, targeting PrEP preferentially to Black individuals would result in the largest reductions in incidence and disparities across the equality measures we considered. This result was consistent over a range of PrEP coverage levels, demonstrating that there are "win-win" PrEP allocation strategies that do not require a tradeoff between equality and efficiency.

Using Microsimulation Modeling to Inform EHE Implementation Strategies in Los Angeles County

BACKGROUND

Pre-exposure prophylaxis (PrEP) is essential to ending HIV. Yet, uptake remains uneven across racial and ethnic groups. We aimed to estimate the impacts of alternative PrEP implementation strategies in Los Angeles County.

SETTING

Men who have sex with men, residing in Los Angeles County.

METHODS

We developed a microsimulation model of HIV transmission, with inputs from key local stakeholders. With this model, we estimated the 15-year (2021-2035) health and racial and ethnic equity impacts of 3 PrEP implementation strategies involving coverage with 9000 additional PrEP units annually, above the Status-quo coverage level. Strategies included PrEP allocation equally (strategy 1), proportionally to HIV prevalence (strategy 2), and proportionally to HIV diagnosis rates (strategy 3), across racial and ethnic groups. We measured the degree of relative equalities in the distribution of the health impacts using the Gini index (G) which ranges from 0 (perfect equality, with all individuals across all groups receiving equal health benefits) to 1 (total inequality).

RESULTS

HIV prevalence was 21.3% in 2021 [Black (BMSM), 31.1%; Latino (LMSM), 18.3%, and White (WMSM), 20.7%] with relatively equal to reasonable distribution across groups (G, 0.28; 95% confidence interval [CI], 0.26 to 0.34). During 2021-2035, cumulative incident infections were highest under Status-quo (n = 24,584) and lowest under strategy 3 (n = 22,080). Status-quo infection risk declined over time among all groups but remained higher in 2035 for BMSM (incidence rate ratio, 4.76; 95% CI: 4.58 to 4.95), and LMSM (incidence rate ratio, 1.74; 95% CI: 1.69 to 1.80), with the health benefits equally to reasonably distributed across groups (G, 0.32; 95% CI: 0.28 to 0.35). Relative to Status-quo, all other strategies reduced BMSM-WMSM and BMSM-LMSM disparities, but none reduced LMSM-WMSM disparities by 2035. Compared to Status-quo, strategy 3 reduced the most both incident infections (% infections averted: overall, 10.2%; BMSM, 32.4%; LMSM, 3.8%; WMSM, 3.5%) and HIV racial inequalities (G reduction, 0.08; 95% CI: 0.02 to 0.14).

CONCLUSIONS

Microsimulation models developed with early, continuous stakeholder engagement and inputs yield powerful tools to guide policy implementation.

An adaptive design to screen, treat, and retain people with opioid use disorders who use methamphetamine in methadone clinics (STAR-OM): study protocol of a clinical trial

BACKGROUND

Methamphetamine use could jeopardize the current efforts to address opioid use disorder and HIV infection. Evidence-based behavioral interventions (EBI) are effective in reducing methamphetamine use. However, evidence on optimal combinations of EBI is limited. This protocol presents a type-1 effectiveness-implementation hybrid design to evaluate the effectiveness, cost-effectiveness of adaptive methamphetamine use interventions, and their implementation barriers in Vietnam.

METHOD

Design: Participants will be first randomized into two frontline interventions for 12 weeks. They will then be placed or randomized to three adaptive strategies for another 12 weeks. An economic evaluation and an ethnographic evaluation will be conducted alongside the interventions.

PARTICIPANTS

We will recruit 600 participants in 20 methadone clinics.

ELIGIBILITY CRITERIA

(1) age 16+; (2) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores ≥ 10 for methamphetamine use or confirmed methamphetamine use with urine drug screening; (3) willing to provide three pieces of contact information; and (4) having a cell phone.

OUTCOMES

Outcomes are measured at 13, 26, and 49 weeks and throughout the interventions. Primary outcomes include the (1) increase in HIV viral suppression, (2) reduction in HIV risk behaviors, and (3) reduction in methamphetamine use. COVID-19 response: We developed a response plan for interruptions caused by COVID-19 lockdowns to ensure data quality and intervention fidelity.

DISCUSSION

This study will provide important evidence for scale-up of EBIs for methamphetamine use among methadone patients in limited-resource settings. As the EBIs will be delivered by methadone providers, they can be readily implemented if the trial demonstrates effectiveness and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04706624. Registered on 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.

Bridging the Gap Between Pilot and Scale-Up: A Model of Antenatal Testing for Curable Sexually Transmitted Infections From Botswana

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections (STIs) associated with adverse outcomes, yet most countries do not test and conduct syndromic management, which lacks sensitivity and specificity. Innovations allow for expanded STI testing; however, cost is a barrier.

METHODS

Using inputs from a pilot program in Botswana, we developed a model among a hypothetical population of 50,000 pregnant women to compare 1-year costs and outcomes associated with 3 antenatal STI testing strategies: (1) point-of-care, (2) centralized laboratory, and (3) a mixed approach (point of care at high-volume sites, and hubs elsewhere), and syndromic management.

RESULTS

Syndromic management had the lowest delivery cost but was associated with the most infections at delivery, uninfected women treated, CT/NG-related low-birth-weight infants, disability-adjusted life years, and low birth weight hospitalization costs. Point-of-care CT/NG testing would treat and cure the most infections but had the highest delivery cost. Among the testing scenarios, the mixed scenario had the most favorable cost per woman treated and cured ($534/cure). Compared with syndromic management, the mixed approach resulted in a mean incremental cost-effectiveness ratio of $953 per disability-adjusted life years averted, which is cost-effective under World Health Organization's one-time per-capita gross domestic product willingness-to-pay threshold.

CONCLUSIONS

As countries consider new technologies to strengthen health services, there is an opportunity to determine how to best deploy resources. Compared with point-of-care, centralized laboratory, and syndromic management, the mixed approach offered the lowest cost per infection averted and is cost-effective if policy makers' willingness to pay is informed by the World Health Organization's gross domestic product/capita threshold.

Informing California's Plan to Enhance HIV Screening in the Ending the HIV Epidemic Initiative

The CDC recommends that everyone have at least one HIV test in their lifetime. However, analyses of California Health Interview Survey data showed that in 2017 only half of Californians had ever received an HIV test. Non-Hispanic Black (64.8%) and Hispanic adults (54.7%) had higher lifetime testing rates than non-Hispanic White adults (48.8%). In multivariable analyses non-Hispanic African American adults had twice and Hispanic adults 1.2 times the odds of lifetime HIV testing as non-Hispanic White adults. The CDC recommends annual HIV testing for higher-risk individuals. Independent of race/ethnicity, heterosexual men with multiple sex partners had lower annual testing rates than other high-risk individuals. Annual testing was unrelated to education level and poverty, but was related to number of doctor visits. HIV screening rates among heterosexual men with multiple partners could be increased by targeting HIV screening to non-medical settings in California's eight Ending the HIV Epidemic counties.

γδT Cells Are Essential for Orthodontic Tooth Movement

Sustained mechanical forces applied to tissue are known to shape local immunity. In the oral mucosa, mechanical stress, either naturally induced by masticatory forces or externally via mechanical loading during orthodontic tooth movement (OTM), is translated, in part, by T cells to alveolar bone resorption. Nevertheless, despite being considered critical for OTM, depletion of CD4⁺ and CD8⁺ T cells is reported to have no impact on tooth movement, thus questioning the function of αβT cells in OTM-associated bone resorption. To further address the role of T cells in OTM, we first characterized the leukocytes residing in the periodontal ligament (PDL), the tissue of interest during OTM, and compared it to the neighboring gingiva. Unlike the gingiva, monocytes and neutrophils represent the major leukocytes of the PDL. These myeloid cells were also the main leukocytes in the PDL of germ-free mice, although at lower levels than SPF mice. T lymphocytes were more enriched in the gingiva than the PDL, yet in both tissues, the relative fraction of the γδT cells was higher than the αβ T cells. We thus sought to examine the role of γδT cells in OTM. γδT cells residing in the PDL were mainly Vγ6⁺ and produced interleukin (IL)-17A but not interferon-γ. Using Tcrd-GDL mice allowing conditional ablation of γδT cells in vivo, we demonstrate that OTM was greatly diminished in the absence of γδT cells. Further analysis revealed that ablation of γδT cells decreased early IL-17A expression, monocyte and neutrophil recruitment, and the expression of the osteoclastogenic molecule receptor activator of nuclear factor-κβ ligand. This, eventually, resulted in reduced numbers of osteoclasts in the pressure site during OTM. Collectively, our data suggest that γδT cells are essential in OTM for translating orthodontic mechanical forces to bone resorption, required for relocating the tooth in the alveolar bone.

Missed Opportunities for HIV Screening of New Enrollees in California's Low Income Health Program

The objective of this study was to measure HIV screening rates and variables associated with screening among new enrollees in California's Low Income Health Program (LIHP). A logit model was used to estimate associations between HIV screening and enrollment, claims, and encounter data for enrollees. HIV prevalence among new LIHP enrollees was 1.2%xd. Among 42,550 new LIHP enrollees with no prior HIV diagnosis, only 27% received screening within 12 months of their first medical evaluation. A total of 350 new HIV diagnoses were identified (incidence rate of 0.8%), exceeding the 0.1% level at which the Centers for Disease Control and Prevention (CDC) recommends routine HIV screening. California reduced screening barriers by removing required written informed consent and pretest counseling; the Affordable Care Act (ACA) eliminated cost-sharing and enhanced access. Removing financial and administrative barriers to HIV screening is necessary, but may be insufficient to reach CDC's recommended screening targets.

Racial, Ethnic, and Nativity Differences in Mental Health Visits to Primary Care and Specialty Mental Health Providers: Analysis of the Medical Expenditures Panel Survey, 2010-2015

Background. Black and Latino minorities have traditionally had poorer access to primary care than non-Latino Whites, but these patterns could change with the Affordable Care Act (ACA). To guide post-ACA efforts to address mental health service disparities, we used a nationally representative sample to characterize baseline race-, ethnicity-, and nativity-associated differences in mental health services in the context of primary care. Methods. Data were obtained from the Medical Expenditures Panel Survey (MEPS), a two-year panel study of healthcare use, satisfaction with care, and costs of services in the United States (US). We pooled data from six waves (14–19) of participants with serious psychological distress to examine racial, ethnic, and nativity disparities in medical and mental health visits to primary care (PC) and specialty mental health (SMH) providers around the time of ACA reforms, 2010–2015. Results. Of the 2747 respondents with serious psychological distress, 1316 were non-Latino White, 632 non-Latino Black, 532 identified as Latino with Mexican, Central American, or South American (MCS) origins, and 267 as Latino with Caribbean island origins; 525 were foreign/island born. All racial/ethnic groups were less likely than non-Latino Whites to have any PC visit. Of those who used PC, non-Latino Blacks were less likely than Whites to have a PC mental health visit, while foreign born MCS Latinos were less likely to visit an SMH provider. Conditional on any mental health visit, Latinos from the Caribbean were more likely than non-Latino Whites to visit SMH providers versus PC providers only, while non-Latino Blacks and US born MCS Latinos received fewer PC mental health visits than non-Latino Whites. Conclusion. Racial-, ethnic-, and nativity-associated disparities persist in PC provided mental health services.

Facilitators and Barriers to Pre-Exposure Prophylaxis Willingness Among Young Men Who Have Sex with Men Who Use Geosocial Networking Applications in California

While correlates of pre-exposure prophylaxis (PrEP) uptake have been explored among older men who have sex with men (MSM), less is known about the facilitators and barriers that encourage uptake among younger MSM (YMSM). This study explores the association between willingness to take PrEP and demographic characteristics, sexual risk, and substance use, and attitudinal factors among YMSM in California who use geosocial networking applications (GSN apps). Based on survey data from YMSM recruited through GSN apps (n = 687), PrEP willingness was positively associated with Hispanic ethnicity [adjusted odds ratio (aOR): 1.73; confidence interval (CI): 1.01-2.98; p = 0.046], concerns about drug effects (aOR: 0.46; CI: 0.33-0.65; p < 0.001), medical mistrust (aOR: 0.71; CI: 0.53-0.96; p < 0.001), and concerns about adherence (aOR: 0.65; CI: 0.49-0.89; p = 0.005). PrEP willingness was positively associated with medium (aOR: 1.87; CI: 1.14-3.07; p = 0.014) and high concern (aOR: 1.84; CI: 1.13-3.01; p < 0.001) about contracting HIV and perceived benefits of taking PrEP (aOR: 2.59; CI: 1.78-3.78; p < 0.001). In addition to emphasizing the benefits of using PrEP, campaigns that address concerns regarding adherence and side effects may increase interest in and demand for PrEP among YMSM. More opportunities are needed to educate YMSM about PrEP, including addressing their concerns about this new prevention strategy. Providers should speak openly and honestly to YMSM considering PrEP about what to do if side effects occur and how to handle missed doses. Outreach using GSN apps for PrEP education and screening may be an effective way to reach YMSM.

Red grape berry-cultured cells reduce blood pressure in rats with metabolic-like syndrome

PURPOSE

Cumulative evidence suggests that moderate red wine consumption protects the cardiovascular system. The effect of cultured cells derived from red grape berry (RGC) on blood pressure (BP) has not been investigated. We therefore studied the antihypertensive effects of oral consumption of RGC in experimental rat model of metabolic-like syndrome and assessed its effect on human umbilical vein endothelial cells (HUVECs).

METHODS

Forty male Sprague-Dawley rats were fed for 5 weeks with either a high fructose diet (HFD) (n = 10) or HFD supplemented, during the last 2 weeks, with different doses (200, 400 and 800 mg/kg/day) of RGC suspended in their food (n = 30). BP, plasma triglycerides, insulin and adiponectin levels were measured at the beginning and after 3 and 5 weeks of diet. RGC effect on vasodilatation was evaluated by its ability to affect endothelin-1 (ET-1) production and endothelial nitric oxide synthase (eNOS) expression in HUVECs.

RESULTS

BP, plasma triglycerides, insulin and adiponectin increased significantly in rats fed with a HFD. The increase in BP, plasma triglycerides and insulin was attenuated by RGC supplementation. Incubation of HUVECs with RGC demonstrated a concentration-dependent inhibition of ET-1 secretion and increase in the level of eNOS, signaling a positive effect of RGC on vasodilatation.

CONCLUSION

In rats with metabolic-like syndrome, RGC decreased BP and improved metabolic parameters. These beneficial effects may be mediated by the cell constituents, highly rich with polyphenols and resveratrol, reside in their natural state.

Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries

A potential impediment to evidence-based policy development on medical male circumcision (MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of arguments used by opponents of this procedure. Here we evaluate recent opinion-pieces of 13 individuals opposed to MC. We find that these statements misrepresent good studies, selectively cite references, some containing fallacious information, and draw erroneous conclusions. In marked contrast, the scientific evidence shows MC to be a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction. Unscientific arguments have been recently used to drive ballot measures aimed at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-income families, and threaten large fines and incarceration for health care providers. Medical MC is a preventative health measure akin to immunisation, given its protective effect against HIV infection, genital cancers and various other conditions. Protection afforded by neonatal MC against a diversity of common medical conditions starts in infancy with urinary tract infections and extends throughout life. Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and mortality from multiple other sexually transmitted infections (STIs) and genital cancers in men and their female sexual partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer at least one foreskin-related medical condition. The scientific evidence indicates that medical MC is safe and effective. Its favourable risk/benefit ratio and cost/benefit support the advantages of medical MC.

Attrition in the RAND Health Insurance Experiment: a response to Nyman

In a prior article in this journal, John Nyman argues that the effect on health care use and spending found in the RAND Health Insurance Experiment is an artifact of greater voluntary attrition in the cost-sharing plans relative to the free care plan. Specifically, he speculates that those in the cost-sharing plans, when faced with a hospitalization, withdrew. His argument is implausible because (1) families facing a hospitalization would be worse off financially by withdrawing; (2) a large number of observational studies find a similar effect of cost sharing on use; (3) those who left did not differ in their utilization prior to leaving; (4) if there had been no attrition and cost sharing did not reduce hospitalization rates, each adult in each family that withdrew would have had to have been hospitalized once each year for the duration of time they would otherwise have been in the experiment, an implausibly high rate; (5) there are benign explanations for the higher attrition in the cost-sharing plans. Finally, we obtained follow-up health-status data on the great majority of those who left prematurely. We found the health-status findings were insensitive to the inclusion of the attrition cases.

ZIP code correlates of HIV-testing: a multi-level analysis in Los Angeles

In this study we examine how individuals' residential areas relate to their HIV-testing, regardless of individuals' characteristics. Data from a 1999 random probability sample of Los Angeles (LA) County adults (n = 5475) was used to conduct a multi-level analysis of HIV-testing among respondents in (1) all 233 ZIP codes and (2) the subset of regions with higher rates of higher-risk sex. Results showed that HIV-testing rates varied across individuals' residential ZIP codes. Throughout LA and in higher-risk regions, residents of areas containing concentrations of African Americans were more likely to test for HIV than residents of White or Latino areas, regardless of individuals' own race/ethnicity or the number of AIDS cases or testing sites in ZIP codes. However, residents of Latino areas were no more likely to test than residents of White areas. This is a concern because of increasing rates of HIV-infection among Latinos. We conclude that opportunities exist to increase testing in Latino higher-risk areas.

Cost-effectiveness of a behavioral intervention for seropositive youth

An intervention for young people living with HIV (YPLH) was effective in reducing the number of partners of unknown serostatus and the number of unprotected sexual risk acts. In this article, we outline new methods to assess the cost-effectiveness of this intervention. Over a period of 3 months, the intervention would avert an estimated 2.02 new infections per 1,000 YPLH. The cost of mounting the intervention was estimated at US 522 dollars/YPLH, with the cost-effectiveness over a 1-year period being US 103,366 dollars/infection averted. Based on standardized estimates of the cost of treating HIV-positive persons and the adjusted quality of life years lost (10.23 for partners of a mean age of 29 years), the cost utility estimate shows that the treatment costs averted exceed the cost of the intervention. Both the methodology of calculating cost-effectiveness and the cost utility of interventions are important for focusing policy makers, clinicians, community providers, and researchers on prevention for persons living with HIV.

Children's use of emergency departments for asthma: persistent barriers or acute need?

Our objective was to explore, in a predominantly Latino inner-city population, why caregivers bring their children with asthma to the ED (emergency department). We conducted bilingual parent surveys and medical chart abstractions of a consecutive ED sample consisting of 234 children with asthma (69% Latino; 54% Spanish-speaking) and their caregivers. Outcome measures included: (1) the acute need for ED services based on objective physiological measures, (2) the extent to which these children experienced barriers to quality primary care for asthma before the ED visit, and (3) the relative importance caregivers assigned to worsening symptoms versus perceived barriers to non-ED care when deciding to bring their child to the ED. Most children had moderate or severe asthma attacks. In the prior month, only 33% went to a primary care provider, 83% had used a bronchodilator, and 63%, an age-appropriate spacer device. Seventy-five percent of caregivers cited perceived acute need, instead of barriers to primary care, as the most important reason for using the ED. This perception of acute need was associated with moderate or severe asthma attacks according to objective physiological measures, after controlling for health and sociodemographic characteristics. Children with asthma who use the ED encounter barriers to primary care, but caregivers' perception of acute need--validated by independent measures of attack severity--dominates caregivers' decision to use the ED. Ensuring continuity of care for children with asthma would involve not only improving various aspects of access to and quality of primary non-ED care--including parent education about early recognition and treatment of asthma attacks--but also providing families with practical low-cost alternatives for 24-hour care and assuring linkages between the ED and sources of primary care.

Spanish-language services assessment for children and adolescents (SACA): reliability of parent and adolescent reports

OBJECTIVE

To assess test-retest reliability of the service utilization screening section of the Services Assessment for Children and Adolescents (SACA) interview among Spanish-speaking parents and adolescents, correspondence between parent and adolescent reports, and the correlation between reliability and participants' demographic and service use characteristics.

METHOD

The English SACA was translated and administered from September 1999 through January 2000 in Los Angeles County, California, on two separate occasions to eligible parents with a child (4-17 years old) who was a client of a local public mental health authority. Adolescents of these parents (12-17 years old) were also interviewed. Reliability was measured by the kappa statistic.

RESULTS

Adult and adolescent reports about lifetime and previous year service setting use exhibited good reliability, but concordance of parents and adolescents did not. Children's service utilization appears to be correlated with reliability of parent reports, and child gender appears to be correlated with reliability of adolescent reports.

CONCLUSION

The SACA appears to be a useful tool for screening Spanish-speaking families about child and adolescent mental health service use. These findings must be considered preliminary until replicated in a larger sample of culturally diverse Spanish-speaking families.

Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study

OBJECTIVE

To employ the behavioral model of health services use in examining the extent to which predisposing, enabling, and need factors explain the treatment of the HIV-positive population in the United States with highly active antiretroviral therapy (HAART).

DATA SOURCE

A national probability sample of 2,776 adults under treatment for human immunodeficiency virus (HIV) infection.

STUDY DESIGN

The article uses data from the baseline and six-month follow-up surveys. The key independent variables describe vulnerable population groups including women, drug users, ethnic minorities, and the less educated. The dependent variable is whether or not a respondent received HAART by December 1996.

DATA COLLECTION

All interviews were conducted using computer-assisted personal interview instruments designed for this study. Ninety-two percent of the baseline interviews were conducted in person and the remainder over the telephone.

PRINCIPAL FINDINGS

A multistage logit regression shows that the predisposing factors that have previously described vulnerable groups in the general population with limited access to medical care also define HIV-positive groups who are less likely to gain early access to HAART including women, injection drug users, African Americans, and the least educated (odds ratios, controlling for need, ranged from 0.35 to 0.59).

CONCLUSIONS

Those HIV-positive persons with the greatest need (defined by a low CD4 count) are most likely to have early access to HAART, which suggests equitable access. However, some predisposing and enabling variables continue to be important as well, suggesting inequitable access, especially for African Americans and lower-income groups. Policymakers and clinicians need to be sensitized to the continued problems of African Americans and other vulnerable populations in gaining access to such potentially beneficial therapies. Higher income, anonymous test sites, and same-day appointments are important enabling resources.

Job continuity among new mothers

In the early 1990s, both state and federal governments enacted maternity-leave legislation. The key provision of that legislation is that after a leave of a limited duration, the recent mother is guaranteed the right to return to her preleave employer at the same or equivalent position. Using data from the National Longitudinal Survey of Youth, we correlate work status after childbirth with work status before pregnancy to estimate the prevalence, before the legislation, of returns to the preleave employer. Among women working full-time before the pregnancy, return to the prepregnancy employer was quite common. Sixty percent of women who worked full-time before the birth of a child continued to work for the same employer after the child was born. Furthermore, the labor market behavior of most of the remaining 40% suggests that maternity-leave legislation is unlikely to have a major effect on job continuity. Compared with all demographically similar women, however, new mothers have an excess probability of leaving their jobs.

Job continuity among new mothers

In the early 1990s, both state and federal governments enacted maternity-leave legislation. The key provision of that legislation is that after a leave of a limited duration, the recent mother is guaranteed the right to return to her preleave employer at the same or equivalent position. Using data from the National Longitudinal Survey of Youth, we correlate work status after childbirth with work status before pregnancy to estimate the prevalence, before the legislation, of returns to the preleave employer. Among women working full-time before the pregnancy, return to the prepregnancy employer was quite common. Sixty percent of women who worked full-time before the birth of a child continued to work for the same employer after the child was born. Furthermore, the labor market behavior of most of the remaining 40% suggests that maternity-leave legislation is unlikely to have a major effect on job continuity. Compared with all demographically similar women, however, new mothers have an excess probability of leaving their jobs.

Variation in inpatient resource use in the treatment of HIV: do the privately insured receive more care?

OBJECTIVE

To estimate the impact of insurance status on inpatient resource use after adjusting for health upon admission and site of care.

DESIGN

Detailed patient information linked to billing records from the AIDS Cost and Service Utilization Survey (ACSUS), a longitudinal analysis of inpatient and outpatient care between March 1991 and August 1992.

SETTING

Hospitalizations of human immunodeficiency virus (HIV) patients from 10 US cities with high incidence of AIDS.

PATIENTS

One thousand, nine hundred and forty nine adolescents and adults at various stages of HIV.

MAIN OUTCOME MEASURES

We estimate inpatient charges, payments and length of stay as a function of patient, and provider and reimbursement characteristics for more than 1,500 hospitalizations to HIV patients. We control for patient characteristics and underlying risk factors including disease stage, CD4 percentage, mode of transmission, discharge status, type of admission, and region. We use hospital-fixed effects to control for unmeasured differences across facilities.

RESULTS

Unadjusted means indicate that uninsured patients or patients covered by public insurance have significantly lower charges and payments than privately insured patients with similar medical conditions. We find that those differences are substantially reduced after controlling for the hospital in which care is received. Further, we find little evidence that "underinsured" patients are discharged sooner on average.

CONCLUSIONS

Inpatient resource use is affected by both the hospital in which care is received and the type of patient admitted. Failure to control for unmeasured differences across hospitals is likely to overstate the impact of insurance substantially.

The policy implications of better structure and process on birth outcomes in Jamaica

BACKGROUND

We investigated if better structural and process elements of prenatal care relate to higher birth weights in the Jamaican population.

METHODS

We used data from two surveys: (1) a national sample of randomly selected households; and (2) a concurrent facility survey of the public health clinics in Jamaica. In the household survey, all women aged 14-50, who had a pregnancy lasting 7 months during the previous 5 years (n = 913) were interviewed. From the household survey, we gathered information on the maternal, clinical and socioeconomic risk factors and on the newborns birth weight (the outcome measure). The facility survey collected data from all public primary care clinics in the country (n = 366). This gave us information on the quality of care (structure and process measures) provided in the clinics.

FINDINGS

Prenatal care in Jamaica, while generally available, provides care to many women who are at particular risk because of parity, age and poverty. Structural measures of the facilities show that clinics are in general disrepair, have only 70% of the basic equipment and are insufficiently stocked with supplies or medication. Many facilities had poor process of care, as measured by assessing the clinical examination and counseling. The average birth weight was 3232 g and 9.8% weighed < 2500 g. The relationships between birth weight and the quality of care were estimated using multiple regression. The biologic and socioeconomic risk factors related to birth weight in the expected direction. None of the structural quality measures were statistically significant. Among the process measures, women who had access to a more complete examination, had infants that weighed an average of 128 g more at birth.

INTERPRETATION

Better quality of care, provided by a more thorough clinical evaluation, has a more powerful effect on birth weight in the population than upgraded facilities or equipment. In developed or developing countries, where resources are limited, policy should focus on education and training to improve birth outcomes.

Effects of the stable prostacyclin analogue iloprost on mesenteric blood flow in porcine endotoxic shock

OBJECTIVE

To determine the effects of the stable prostacyclin analog, iloprost, in a porcine model of endotoxin-induced mesenteric ischemia.

DESIGN

Prospective, experimental, randomized, controlled study.

SETTING

Animal research laboratory at a university medical center.

INTERVENTIONS

Pigs were randomized to receive a constant infusion of iloprost (0.18 microg/kg/min) or an equivalent amount of carrier solution (normal saline) 30 mins before being infused with endotoxin (100 microg/kg over 1 hr). The infusion with iloprost or carrier solution was continued for the duration of the experiment.

MEASUREMENTS AND MAIN RESULTS

Twelve pigs (six per group), weighing between 20 and 22 kg, underwent laparotomy during which a magnetic flowprobe was placed around the superior mesenteric artery and an ileal tonometer was inserted. Thirty minutes before they were infused with endotoxin, the animals were randomized to receive intravenous iloprost or normal saline. Endotoxin was infused centrally over a 60-min period. Animals received normal saline at a rate of 1.2 mL/kg/min which was begun at the start of the endotoxin infusion. Data were measured at the end of the endotoxin infusion (E60) and 1 hr later (E120). Mean arterial pressure was not affected by the dosage of iloprost used in this experiment. After resuscitation, the cardiac output returned to baseline in the iloprost-treated group but remained decreased in the control group (2.6 +/- 0.5 vs. 1.6 +/- 0.4 L/min). Superior mesenteric blood flow increased 34% above baseline levels in animals pretreated with iloprost (from 363 +/- 85 to 485 +/- 81 mL/min). The superior mesenteric PCO2 was significantly higher (53 +/- 9 vs. 40 +/- 5 torr; 7.1 +/- 1.2 vs. 5.3 +/- 0.7 kPa) and the ileal intramucosal pH was significantly lower (7.07 +/- .28 vs. 7.44 +/- .23) in the control group than in the iloprost-treated group.

CONCLUSIONS

Pretreatment with intravenous iloprost effectively increased intestinal blood flow in this model of endotoxin-induced mesenteric ischemia. This action of the drug resulted in an attenuation of ileal intracellular acidosis. Since low-dose iloprost had no effect on mean arterial pressure, it may be a useful adjunct in the treatment of sepsis and septic shock.

Redistributional consequences of community rating

OBJECTIVE

To predict the geographical effects of community rating of health insurance premiums on the amount individuals pay for insurance.

DATA SOURCES

We estimate premiums and health expenditures for a 5 percent sample of Californians from the 1990 U.S. Census (the Public Use Microdata Sample) and use data from Blue Cross of California to adjust for regional price differences in services.

STUDY DESIGN

We use an episodic health simulation model to estimate health expenditures for 975,074 Californians. Because the simulations do not reflect expenditure differences due to price variation in cost of services, we adjust these data for relative price differences by county. This leaves us with a sample of Californians for whom we have estimated health expenditures. We then compute average expenditures within areas of different sizes (all California, two regions, within counties) to estimate community-rated premiums. We then compare these premiums with actual expenditures on a county-by-county basis.

PRINCIPAL FINDINGS

With a single California-wide premium, rural residents pay premiums that exceed their use of care, while urban residents pay premiums that are less than their use of care. These transfers are substantial. Dividing California into regional risk pools at the county level still results in poorer communities providing substantial subsidies to their more wealthy counterparts.

CONCLUSIONS

Mandated community rating of premiums in a heterogeneous state such as California results in large unintended transfers of wealth from poorer, rural communities to urban, wealthier communities. Allowing premiums to vary with the regional cost of medical care would eliminate some of the transfers without sacrificing the benefits of community rating. Subsidies to low-income families could also effectively mitigate this redistribution. UTILITY: This article points out some potentially regressive consequences of geographic community rating and suggests ways to mitigate them.

Comparison of access and costs of Medicaid dental services in a hospital clinic and community practices

OBJECTIVES

This paper reports the results of a three-year evaluation of access to dental care and its associated costs for Aid to Families with Dependent Children (AFDC) beneficiaries enrolled in a hospital-based health maintenance organization (HMO) or a fee-for-service (FFS) option.

METHODS

Medicaid enrollees (n = 3, l655) having a year of eligibility were assigned to either the hospital HMO or FFS care, and their use of dental care and its costs compared.

RESULTS

A higher percent of those beneficiaries enrolled in the FFS option used dental care than those in the HMO plan. FFS enrollees also had more annual visits per person than those in the randomly assigned HMO group. FFS dental patients treated in the hospital had the highest costs of any payment-provider combination studied.

CONCLUSIONS

To understand the mix of utilization rates, visits, and costs, one must take into account the way in which the HMO hospital plan is reimbursed, the way in which the dental department is reimbursed, and the way in which the dental provider is reimbursed.

Continuous fiberoptic arterial and venous blood gas monitoring in hemorrhagic shock

STUDY OBJECTIVE

To compare the performance of continuous fiberoptic blood gas monitoring with standard, intermittent blood gas sampling in the measurement of arterial and central venous blood gases during marked hemodynamic changes.

DESIGN

Prospective, consecutive, enrollment, experimental study.

SETTING

Research laboratory at a university medical center.

PARTICIPANTS

Seven anesthetized, mechanically ventilated pigs.

INTERVENTIONS

Severe shock was induced by hemorrhage in pigs monitored by a pulmonary artery catheter, an arterial line, and two fiberoptic blood gas sensors: one intra-arterial, and the other inserted into the superior vena cava via right internal jugular vein cutdown. Fiberoptic blood gas monitor measurements were compared with standard intermittent blood gas sampling.

MEASUREMENTS AND RESULTS

A total of 184 blood gas samples were compared in seven animals at baseline, during shock, and after resuscitation. The baseline mean (+/- 1 SD) cardiac output decreased from 4.0 +/- 0.9 to 1.2 +/- 0.6 L/min during shock and returned to baseline after retransfusion (3.9 +/- 1.3 L/min). The comparison of continuous fiberoptic blood gas monitoring with intermittent blood gas sampling showed a bias+/-precision of 0.035 +/- 0.047 for arterial pH, 0.021 +/- 0.031 for central venous pH, -4.09 +/- 2.96 mm Hg (-0.55 +/- 0.39 kPa) for arterial Pco2, -3.67 +/- 2.44 mm Hg (-0.49 +/- 0.3 3 kPa) for central venous Pco2, -5.79 +/- 9.64 mm Hg (-0.77 +/- 1.29 kPa) for arterial Po2, and -7.85 +/- 8.52 mm Hg (-1.05 +/- 1.14 kPa) for central venous Po2.

CONCLUSIONS

Continuous fiberoptic blood gas monitoring agrees closely with standard intermittent blood gas sampling during severe hemodynamic shifts and has a comparable accuracy for both arterial and venous blood gas measurements. Changes in venous Pco2 have recently been shown to correlate with changes in global tissue perfusion (eg, changes in cardiac output). Such data, available immediately via continuous venous blood gas monitoring, may be useful for monitoring shock and the response to resuscitation.

Medicaid health maintenance organizations. Can they reduce program spending?

A randomized trial to evaluate the Florida site of the Program for Prepaid Managed Care showed that the plan, a staff model health maintenance organization, was successful in attracting Medicaid enrollees. The evaluation established that the health maintenance organization was able to limit members' utilization. The savings were in the form of lower likelihood of using care. The amount of services received, once care was initiated, was the same in both fee-for service Medicaid and health maintenance organizations. The authors detected no differences in inpatient use or costs. Additionally, they found evidence that the plan attracted sicker than average enrollees, so this reduced utilization translates into Medicaid program savings.

Heritability and selection on body size in a natural population of Drosophila buzzatii

An attempt was made to assess whether the phenotypic differences in body size (as measured by wing length) between wild-caught mating and single Drosophila buzzatii males could be attributed to genetic differences between the samples. Mating males were found to be larger and less variable than a random sample of the population. The progeny of the mating males (produced by crossing to a random female from a stock derived from the same population) were on average larger than those of the single males, but not significantly so (P = 0.063), and less phenotypically variable. This difference in variance between the samples suggests that there are indeed genetic differences between the paternal samples but tests for significant differences in the additive genetic component of variance proved inconclusive. For both samples it was found that while the ratio of additive genetic variation in the laboratory to phenotypic variation in the field yielded estimates of ĥs2(N) congruent to 10% the regression of offspring reared in the laboratory on parents from the wild was not significantly different from zero. In addition, it was found that the average development time of the progeny of the mating males is shorter than that of the random sample.

Explaining Changes in Married Mothers’ Employment over Time

Employment of married mothers with preschool children rose dramatically between 1971 and 1990. Using CPS data, we find that about one-fifth of the increase in labor supply can be attributed to changes in mothers’ demographic characteristics (age, education, and number of children). Changes in the earnings opportunities of new mothers and their husbands explain another one-fifth of the growth in employment. Over the two decades, infants up to three months old became less of a barrier to employment, while women’s labor supply became more sensitive to their own earnings opportunities and less sensitive to those of their husbands.

Explaining changes in married mothers' employment over time

Employment of married mothers with preschool children rose dramatically between 1971 and 1990. Using CPS data, we find that about one-fifth of the increase in labor supply can be attributed to changes in mothers' demographic characteristics (age, education, and number of children). Changes in the earnings opportunities of new mothers and their husbands explain another one-fifth of the growth in employment. Over the two decades, infants up to three months old became less of a barrier to employment, while women's labor supply became more sensitive to their own earnings opportunities and less sensitive to those of their husbands.

Assessing the quality of care for children. Prospects under health reform

The failure to pass federal health reform legislation this year does not mean that the health care crisis has been solved. As we look forward to predictably more incremental efforts to reduce costs, increase access, and improve quality, key issues from the most recent round of deliberations will undoubtedly reemerge. In the last session of Congress, private and public policymakers sent a clear signal that the era of accountability had arrived. In the health reform bills that Congress considered last year, a range of "measurement" strategies were put forth as essential elements for achieving accountability in a reformed health care system. For example, routine monitoring of the quality of care delivered by health plans and health providers was viewed as necessary to balance the impact of policies to control the cost of health care. Each of the major bills that were introduced this past year--Gephardt/Mitchell (S 1757/HR 3600), Cooper/Grandy (HR 3222), Breaux/Durenburger (S 1579), Nickles (S 1743), Chafee/Thomas (S 1770/HR 3704), and Wellstone/McDermott (S 491/HR 1200)--and the mark-up bills that have emerged from Senate and House committees have placed considerable emphasis on evaluating changes in access to health care and quality of care. Although the bills addressed issues related to financing, coverage, and the structure of the delivery system quite differently, they demonstrated much more consensus with regard to quality monitoring.

Adiposis dolorosa (Dercum's disease): 10-year follow-up

Adiposis dolorosa is a disease characterized by painful, subcutaneous fatty tumors. This disorder usually occurs in obese, postmenopausal women and is associated with weakness and mental disturbances such as depression, confusion, lethargy, and dementia. The cause is unknown, and there is no specific treatment. Pain may be relieved by steroids, intravenous lidocaine, or analgesics. Surgical treatment consists of excision or liposuction of the painful masses. We present two cases of adiposis dolorosa in men, with a follow-up of more than 10 years.

Rationing or rationalizing children's medical care: comparison of a Medicaid HMO with fee-for-service care

OBJECTIVES

This paper examines how medical care obtained by children enrolled in a Medicaid health maintenance organization (HMO) differs from that obtained by similar children who receive care from fee-for-service Medicaid providers.

METHODS

In a randomized trial, some Medicaid households were assigned to remain in a traditional fee-for-service arrangement and others were randomly selected to join a Medicaid prepaid plan (an HMO). Participating households recorded data on children's health status and use of medical care.

RESULTS

The prepaid plan members and the fee-for-service recipients received equivalent numbers of checkup visits, but the children in the prepaid plan made significantly fewer acute care visits. This plan appeared to target its services to children with the greatest health care needs. However, the content of health visits in the two systems did not differ, nor did prepaid and fee-for-service enrollees use the emergency room differently.

CONCLUSIONS

It is possible to design a Medicaid HMO that achieves financial savings without reducing services to the most vulnerable patients. However, these findings alone do not provide a basis for widespread policy change in the direction of Medicaid HMOs. Further research is needed to establish whether the children treated in the HMO differed in health outcomes from those treated by fee-for-service care.

A randomized trial to evaluate the effectiveness of a Medicaid HMO

The value of health-care services used by AFDC Medicaid patients receiving care in a voluntary enrollment HMO is contrasted with that of health care services used by Medicaid patients receiving fee-for-service (FFS) care. The randomized assignment of Medicaid recipients to the HMO or to FFS allows the authors to conclude that the apparent lower use of HMO enrollees results from the HMO's selection of patients with lower needs for care rather than from technical efficiency. Patients had lower use while in the HMO, but disenrollees and those who refused enrollment had significantly higher use than FFS participants. In contrast to the effect of HMOs on non-Medicaid populations, the Medicaid HMO studied provided significantly fewer outpatient services, but the same level of inpatient services as the FFS sector. Overall, voluntary enrollment of Medicaid eligibles into the HMO resulted in higher state expenditures for Medicaid because of favorable selection.

Do women's breastfeeding experiences with their first-borns affect whether they breastfeed their subsequent children?

Data on women with at least two children are used to examine how the breastfeeding experience with the first child affects whether subsequent children are breastfed. Our results indicate that women most often repeat with later children the feeding decision they made with their first child. That is, those who breastfed their first child are very likely to breastfeed a later child and those who did not breastfeed their firstborn are unlikely to breastfeed a later-born. Among those who did not breastfeed their first child, education beyond high school increases the likelihood that they will switch to breastfeeding with a later-born. Those who breastfed their first child are less likely to breastfeed a later-born if the first breastfeeding experience was of short duration or was perceived to be unsuccessful or unsatisfactory or if the woman had not gone beyond high school or received anesthesia at the later birth. Hence, educational differences are greater at higher parities than at first parity.

Setting capitations for Medicaid: a case study

This article examines the methodology New York State used to set capitation rates for a Medicaid health maintenance organization. By examining the methods used and the assumptions made in a particular case, some general lessons are drawn about the ratesetting process. Greater reliance on statewide data to assure fair and statistically stable estimates is needed. Although the article focuses on one State and its ratesetting for one particular plan (Health Care Plus), the issues raised have general interest for other plans and for other States concerned with the setting of capitation rates for Medicaid enrollees in prepaid plans.

Substitution between prescribed and over-the-counter medications

Using data from the Health Insurance Experiment (HIE), this article examines use of over-the-counter drugs (OTC) in a general, nonelderly population. Families from six areas of the country were assigned to health insurance plans that varied in the amount of medical care cost sharing. Thus, the out-of-pocket prices of OTC relative to prescription drugs were experimentally varied. The sites were chosen to represent markets with differing access to physician services. Multivariate methods were used to relate OTC use (collected from bi-weekly health diaries) to cost sharing and demographic variables. The empirical results do not support the expectation that people assigned less generous insurance for prescription drugs substitute OTC for prescriptions. People with complete insurance coverage purchased more of both types of drugs, suggesting OTC are an adjunct to formal medical care, rather than a substitute for it. Better educated and more knowledgeable consumers used more OTC drugs and spent more of their drug budget on OTC products. That there was greater OTC drug use in HIE sites with poorer access to formal medical care suggests there was some substitution between formal care and self-care with OTC drugs. Overall, however, better financial access to formal care promotes rather than substitutes for OTC use.

Child care and children's illness

This paper uses nationally representative data from the Child Health Supplement of the 1981 National Health Interview Survey to test the hypothesis that the larger the groups in which children receive care, the more days per year they spend in bed due to illness. We estimate a model of annual bed days for children ages six months to two and one-half years old, and separately for children two and one-half to five years old. Our results show significantly higher numbers of bed days for children in day care centers than for children at home for both age groups, controlling for confounding factors. Children in family day care have significantly more bed days than those at home, but only among the younger sample. The negative effect of family day care is less than that of child care centers. Although the relative effect of group care is to increase annual bed days by 30 to 19 per cent, the absolute effect is modest with children in group care having 1.3 to .6 more bed days per year.

Child care for preschoolers: differences by child's age

Because of the high rates of employment of mothers, a large and increasing number of preschool children receive regular care from someone else. This article develops and tests hypotheses about the choice of child care arrangements for younger and older preschool children, using data from the National Longitudinal Survey of Young Women. We argue that appropriate care depends on the age of the child. It includes care by the mother or a paid provider in the child's home for children aged 0-2 and mother care and nursery school or center care for those 3-5. We estimate models of the mother's employment and choice of child care separately for younger and older preschoolers. Our results show that need for care, presence of substitutes for the mother, financial resources, and preferences all affect both full-time care by the mother and the type of child care chosen by working women, although they affect these two decisions in different ways.

Child care for preschoolers: Differences by child’s age

Because of the high rates of employment of mothers, a large and increasing number of preschool children receive regular care from someone else. This article develops and tests hypotheses about the choice of child care arrangements for younger and older preschool children, using data from the National Longitudinal Survey of Young Women. We argue that appropriate care depends on the age of the child. It includes care by the mother or a paid provider in the child’s home for children aged 0–2 and mother care and nursery school or center care for those 3–5. We estimate models of the mother’s employment and choice of child care separately for younger and older preschoolers. Our results show that need for care, presence of substitutes for the mother, financial resources, and preferences all affect both full-time care by the mother and the type of child care chosen by working women, although they affect these two decisions in different ways.