US Health Care Spending by Payer and Health Condition, 1996-2016

IMPORTANCE

US health care spending has continued to increase and now accounts for 18% of the US economy, although little is known about how spending on each health condition varies by payer, and how these amounts have changed over time.

OBJECTIVE

To estimate US spending on health care according to 3 types of payers (public insurance [including Medicare, Medicaid, and other government programs], private insurance, or out-of-pocket payments) and by health condition, age group, sex, and type of care for 1996 through 2016.

DESIGN AND SETTING

Government budgets, insurance claims, facility records, household surveys, and official US records from 1996 through 2016 were collected to estimate spending for 154 health conditions. Spending growth rates (standardized by population size and age group) were calculated for each type of payer and health condition.

EXPOSURES

Ambulatory care, inpatient care, nursing care facility stay, emergency department care, dental care, and purchase of prescribed pharmaceuticals in a retail setting.

MAIN OUTCOMES AND MEASURES

National spending estimates stratified by health condition, age group, sex, type of care, and type of payer and modeled for each year from 1996 through 2016.

RESULTS

Total health care spending increased from an estimated $1.4 trillion in 1996 (13.3% of gross domestic product [GDP]; $5259 per person) to an estimated $3.1 trillion in 2016 (17.9% of GDP; $9655 per person); 85.2% of that spending was included in this study. In 2016, an estimated 48.0% (95% CI, 48.0%-48.0%) of health care spending was paid by private insurance, 42.6% (95% CI, 42.5%-42.6%) by public insurance, and 9.4% (95% CI, 9.4%-9.4%) by out-of-pocket payments. In 2016, among the 154 conditions, low back and neck pain had the highest amount of health care spending with an estimated $134.5 billion (95% CI, $122.4-$146.9 billion) in spending, of which 57.2% (95% CI, 52.2%-61.2%) was paid by private insurance, 33.7% (95% CI, 30.0%-38.4%) by public insurance, and 9.2% (95% CI, 8.3%-10.4%) by out-of-pocket payments. Other musculoskeletal disorders accounted for the second highest amount of health care spending (estimated at $129.8 billion [95% CI, $116.3-$149.7 billion]) and most had private insurance (56.4% [95% CI, 52.6%-59.3%]). Diabetes accounted for the third highest amount of the health care spending (estimated at $111.2 billion [95% CI, $105.7-$115.9 billion]) and most had public insurance (49.8% [95% CI, 44.4%-56.0%]). Other conditions estimated to have substantial health care spending in 2016 were ischemic heart disease ($89.3 billion [95% CI, $81.1-$95.5 billion]), falls ($87.4 billion [95% CI, $75.0-$100.1 billion]), urinary diseases ($86.0 billion [95% CI, $76.3-$95.9 billion]), skin and subcutaneous diseases ($85.0 billion [95% CI, $80.5-$90.2 billion]), osteoarthritis ($80.0 billion [95% CI, $72.2-$86.1 billion]), dementias ($79.2 billion [95% CI, $67.6-$90.8 billion]), and hypertension ($79.0 billion [95% CI, $72.6-$86.8 billion]). The conditions with the highest spending varied by type of payer, age, sex, type of care, and year. After adjusting for changes in inflation, population size, and age groups, public insurance spending was estimated to have increased at an annualized rate of 2.9% (95% CI, 2.9%-2.9%); private insurance, 2.6% (95% CI, 2.6%-2.6%); and out-of-pocket payments, 1.1% (95% CI, 1.0%-1.1%).

CONCLUSIONS AND RELEVANCE

Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance. Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.

Health Care Spending on Diabetes in the U.S., 1996-2013

OBJECTIVE

Health care spending on diabetes in the U.S. has increased dramatically over the past several decades. This research describes health care spending on diabetes to quantify how that spending has changed from 1996 to 2013 and to determine what drivers are increasing spending.

RESEARCH DESIGN AND METHODS

Spending estimates were extracted from the Institute for Health Metrics and Evaluation's Disease Expenditure 2013 database. Estimates were produced for each year from 1996 to 2013 for each of 38 age and sex groups and six types of care. Data on disease burden were extracted from the Global Burden of Disease 2016 study. We analyzed the drivers of spending by measuring the impact of population growth and aging and changes in diabetes prevalence, service utilization, and spending per encounter.

RESULTS

Spending on diabetes in the U.S. increased from $37 billion (95% uncertainty interval $32-$42 billion) in 1996 to $101 billion ($97-$107 billion) in 2013. The greatest amount of health care spending on diabetes in 2013 occurred in prescribed retail pharmaceuticals (57.6% [53.8-62.1%] of spending growth) followed by ambulatory care (23.5% [21.7-25.7%]). Between 1996 and 2013, pharmaceutical spending increased by 327.0% (222.9-456.6%). This increase can be attributed to changes in demography, increased disease prevalence, increased service utilization, and, especially, increases in spending per encounter, which increased pharmaceutical spending by 144.0% (87.3-197.3%) between 1996 and 2013.

CONCLUSIONS

Health care spending on diabetes in the U.S. has increased, and spending per encounter has been the biggest driver. This information can help policy makers who are attempting to control future spending on diabetes.

Challenges to implementing Gavi's health system strengthening support in Chad and Cameroon: results from a mixed-methods evaluation

Background

Since 2005, Gavi has provided health system strengthening (HSS) grants to address bottlenecks affecting immunization services. This study is the first to evaluate the Gavi HSS implementation process in either Cameroon or Chad, two countries with significant health system challenges and poor achievement on the child and maternal health Millennium Development Goals.

Methods

We triangulated quantitative and qualitative data including financial records, document review, field visit questionnaires, and key informant interviews (KII) with representatives from the Ministries of Health, Gavi, and other partners. We conducted a Root Cause Analysis of key implementation challenges, guided by the Consolidated Framework for Implementation Research.

Results

We conducted 124 field visits and 43 KIIs in Cameroon, and 57 field visits and 39 KIIs in Chad. Cameroon’s and Chad’s HSS programs were characterized by delayed disbursements, significant deviations from approved expenditures, and reprogramming of funds. Nearly a year after the programs were intended to be complete, many district and facility-level activities were only partially implemented and significant funds remained unabsorbed. Root causes of these challenges included unpredictable Gavi processes and disbursements, poor communication between the countries and Gavi, insufficient country planning without adequate technical assistance, lack of country staff and leadership, and weak country systems to manage finances and promote institutional memory.

Conclusions

Though Chad and Cameroon both critically needed support to strengthen their weak health systems, serious challenges drastically limited implementation of their Gavi HSS programs. Implementation of future HSS programs in these and similar settings can be improved by transparent and reliable procedures and communication from Gavi, proposals that account for countries’ programmatic capacity and the potential for delayed disbursements, implementation practices that foster learning and adaptation, and an early emphasis on developing managerial and other human resources.

Electronic supplementary material

The online version of this article (10.1186/s12992-017-0310-0) contains supplementary material, which is available to authorized users.

Factors Associated With Increases in US Health Care Spending, 1996-2013

IMPORTANCE

Health care spending in the United States increased substantially from 1995 to 2015 and comprised 17.8% of the economy in 2015. Understanding the relationship between known factors and spending increases over time could inform policy efforts to contain future spending growth.

OBJECTIVE

To quantify changes in spending associated with 5 fundamental factors related to health care spending in the United States: population size, population age structure, disease prevalence or incidence, service utilization, and service price and intensity.

DESIGN AND SETTING

Data on the 5 factors from 1996 through 2013 were extracted for 155 health conditions, 36 age and sex groups, and 6 types of care from the Global Burden of Disease 2015 study and the Institute for Health Metrics and Evaluation's US Disease Expenditure 2013 project. Decomposition analysis was performed to estimate the association between changes in these factors and changes in health care spending and to estimate the variability across health conditions and types of care.

EXPOSURES

Change in population size, population aging, disease prevalence or incidence, service utilization, or service price and intensity.

MAIN OUTCOMES AND MEASURES

Change in health care spending from 1996 through 2013.

RESULTS

After adjustments for price inflation, annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased by $933.5 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion. Increases in US population size were associated with a 23.1% (uncertainty interval [UI], 23.1%-23.1%), or $269.5 (UI, $269.0-$270.0) billion, spending increase; aging of the population was associated with an 11.6% (UI, 11.4%-11.8%), or $135.7 (UI, $133.3-$137.7) billion, spending increase. Changes in disease prevalence or incidence were associated with spending reductions of 2.4% (UI, 0.9%-3.8%), or $28.2 (UI, $10.5-$44.4) billion, whereas changes in service utilization were not associated with a statistically significant change in spending. Changes in service price and intensity were associated with a 50.0% (UI, 45.0%-55.0%), or $583.5 (UI, $525.2-$641.4) billion, spending increase. The influence of these 5 factors varied by health condition and type of care. For example, the increase in annual diabetes spending between 1996 and 2013 was $64.4 (UI, $57.9-$70.6) billion; $44.4 (UI, $38.7-$49.6) billion of this increase was pharmaceutical spending.

CONCLUSIONS AND RELEVANCE

Increases in US health care spending from 1996 through 2013 were largely related to increases in health care service price and intensity but were also positively associated with population growth and aging and negatively associated with disease prevalence or incidence. Understanding these factors and their variability across health conditions and types of care may inform policy efforts to contain health care spending.

Adjusting health spending for the presence of comorbidities: an application to United States national inpatient data

BACKGROUND

One of the major challenges in estimating health care spending spent on each cause of illness is allocating spending for a health care event to a single cause of illness in the presence of comorbidities. Comorbidities, the secondary diagnoses, are common across many causes of illness and often correlate with worse health outcomes and more expensive health care. In this study, we propose a method for measuring the average spending for each cause of illness with and without comorbidities.

METHODS

Our strategy for measuring cause of illness-specific spending and adjusting for the presence of comorbidities uses a regression-based framework to estimate excess spending due to comorbidities. We consider multiple causes simultaneously, allowing causes of illness to appear as either a primary diagnosis or a comorbidity. Our adjustment method distributes excess spending away from primary diagnoses (outflows), exaggerated due to the presence of comorbidities, and allocates that spending towards causes of illness that appear as comorbidities (inflows). We apply this framework for spending adjustment to the National Inpatient Survey data in the United States for years 1996-2012 to generate comorbidity-adjusted health care spending estimates for 154 causes of illness by age and sex.

RESULTS

The primary diagnoses with the greatest number of comorbidities in the NIS dataset were acute renal failure, septicemia, and endocarditis. Hypertension, diabetes, and ischemic heart disease were the most common comorbidities across all age groups. After adjusting for comorbidities, chronic kidney diseases, atrial fibrillation and flutter, and chronic obstructive pulmonary disease increased by 74.1%, 40.9%, and 21.0%, respectively, while pancreatitis, lower respiratory infections, and septicemia decreased by 21.3%, 17.2%, and 16.0%. For many diseases, comorbidity adjustments had varying effects on spending for different age groups.

CONCLUSIONS

Our methodology takes a unified approach to account for excess spending caused by the presence of comorbidities. Adjusting for comorbidities provides a substantially altered, more accurate estimate of the spending attributed to specific cause of illness. Making these adjustments supports improved resource tracking, accountability, and planning for future resource allocation.

Angular distributions for the inelastic scattering of NO(X2Π) with O2(X3Σg-)

The inelastic scattering of NO(X²Π) by O₂(X³Σ_g^-) was studied at a mean collision energy of 550 cm^-1 using velocity-map ion imaging. The initial quantum state of the NO(X²Π, v = 0, j = 0.5, Ω=0.5, 𝜖 = -1, f) molecule was selected using a hexapole electric field, and specific Λ-doublet levels of scattered NO were probed using (1+1^') resonantly enhanced multiphoton ionization. A modified "onion-peeling" algorithm was employed to extract angular scattering information from the series of "pancaked," nested Newton spheres arising as a consequence of the rotational excitation of the molecular oxygen collision partner. The extracted differential cross sections for NO(X) f→f and f→e Λ-doublet resolved, spin-orbit conserving transitions, partially resolved in the oxygen co-product rotational quantum state, are reported, along with O₂ fragment pair-correlated rotational state population. The inelastic scattering of NO with O₂ is shown to share many similarities with the scattering of NO(X) with the rare gases. However, subtle differences in the angular distributions between the two collision partners are observed.

Spending on Children's Personal Health Care in the United States, 1996-2013

IMPORTANCE

Health care spending on children in the United States continues to rise, yet little is known about how this spending varies by condition, age and sex group, and type of care, nor how these patterns have changed over time.

OBJECTIVE

To provide health care spending estimates for children and adolescents 19 years and younger in the United States from 1996 through 2013, disaggregated by condition, age and sex group, and type of care.

EVIDENCE REVIEW

Health care spending estimates were extracted from the Institute for Health Metrics and Evaluation Disease Expenditure 2013 project database. This project, based on 183 sources of data and 2.9 billion patient records, disaggregated health care spending in the United States by condition, age and sex group, and type of care. Annual estimates were produced for each year from 1996 through 2013. Estimates were adjusted for the presence of comorbidities and are reported using inflation-adjusted 2015 US dollars.

FINDINGS

From 1996 to 2013, health care spending on children increased from $149.6 (uncertainty interval [UI], 144.1-155.5) billion to $233.5 (UI, 226.9-239.8) billion. In 2013, the largest health condition leading to health care spending for children was well-newborn care in the inpatient setting. Attention-deficit/hyperactivity disorder and well-dental care (including dental check-ups and orthodontia) were the second and third largest conditions, respectively. Spending per child was greatest for infants younger than 1 year, at $11 741 (UI, 10 799-12 765) in 2013. Across time, health care spending per child increased from $1915 (UI, 1845-1991) in 1996 to $2777 (UI, 2698-2851) in 2013. The greatest areas of growth in spending in absolute terms were ambulatory care among all types of care and inpatient well-newborn care, attention-deficit/hyperactivity disorder, and asthma among all conditions.

CONCLUSIONS AND RELEVANCE

These findings provide health policy makers and health care professionals with evidence to help guide future spending. Some conditions, such as attention-deficit/hyperactivity disorder and inpatient well-newborn care, had larger health care spending growth rates than other conditions.

US Spending on Personal Health Care and Public Health, 1996-2013

IMPORTANCE

US health care spending has continued to increase, and now accounts for more than 17% of the US economy. Despite the size and growth of this spending, little is known about how spending on each condition varies by age and across time.

OBJECTIVE

To systematically and comprehensively estimate US spending on personal health care and public health, according to condition, age and sex group, and type of care.

DESIGN AND SETTING

Government budgets, insurance claims, facility surveys, household surveys, and official US records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated into 29 conditions). For each record, spending was extracted, along with the age and sex of the patient, and the type of care. Spending was adjusted to reflect the health condition treated, rather than the primary diagnosis.

EXPOSURES

Encounter with US health care system.

MAIN OUTCOMES AND MEASURES

National spending estimates stratified by condition, age and sex group, and type of care.

RESULTS

From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these 155 conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion (uncertainty interval [UI], $96.7 billion-$106.5 billion) in spending, including 57.6% (UI, 53.8%-62.1%) spent on pharmaceuticals and 23.5% (UI, 21.7%-25.7%) spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion (UI, $82.7 billion-$92.9 billion), and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion (UI, $67.5 billion-$94.1 billion). The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion (UI, $47.4 billion-$64.4 billion) and $64.4 billion (UI, $57.8 billion-$70.7 billion), respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4% [UI, 6.4%-6.4%] and 5.6% [UI, 5.6%-5.6%] annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8% [UI, 2.8%-2.8%] and nursing facility care (2.5% [UI, 2.5%-2.5%]).

CONCLUSIONS AND RELEVANCE

Modeled estimates of US spending on personal health care and public health showed substantial increases from 1996 through 2013; with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category. The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control US health care spending.

67 INHIBITION OF 5α-REDUCTASE DURING LATE GESTATION IN THE MARE

During the latter half of pregnancy in the mare, circulating concentrations of progesterone (P4) are low and a major bioactive progestogen, 5α-dihydroprogesterone (DHP), is present in high concentrations. DHP is formed through the activity of 5α-reductase, which converts P4 to DHP. Further metabolites of DHP have been attributed to fetal and myometrial quiescence. The purpose of this study was to examine the effects of a 5α-reductase inhibitor (dutasteride) on P4 metabolism and onset of parturition. Pregnant mares (n = 5) were treated with dutasteride (0.01 mg kg–1; IM), and control mares (n = 4) received vehicle alone from 300 to 320 days of gestation or until foaling. Serum concentrations of P4 and DHP were determined with liquid chromatography/tandem mass spectrometry (LC/MS-MS) daily for 9 days preceding parturition. Endocrine data were analysed with a random effects mixed model with time, treatment (TRT), and time × TRT interaction. Gestational data were analysed with a Wilcoxon test. Although there was a significant effect of time on P4 and DHP, there was no effect of TRT or time × TRT on these progestogens. For the ratio of DHP/P4, there were significant effects of time, TRT, and time × TRT interaction such that the ratio of DHP/P4 was greater in the control than dutasteride-treated mares. Birth weight and gestational length were not different (P > 0.2) between the dutasteride-treated and control mares, although placental weights were greater (P < 0.05) in dutasteride-treated mares. Because the ratio of DHP/P4 was suppressed in dutasteride-treated mares, it appears that dutasteride was active in late gestational mares. Although gestational length and neonatal weights were not different between groups, placentas from dutasteride-treated mares were heavier than those from control mares. The reason for the increase in placental weights was not determined.

174 COMPARISON OF ORAL ALTRENOGEST, CIDR, AND LONG-ACTING PROGESTERONE FOR SYNCHRONIZATION OF ESTRUS IN MARES

Synchronization of oestrus in mares remains a challenge to practitioners using Assisted Reproductive Technologies. The research objective was to compare adverse reactions and reproductive parameters in mares treated with different sources of progestins for oestrus synchronization. Mixed breeds of mares with a mean age of 3 years (range 2–20) were used. Groups were: 1) altrenogest 0.044 mg kg–1 BW PO daily for 10 days (D) (Regumate, Merck, White House Station, NJ, USA) (n = 30), 2) Long-acting progesterone (LAP4) (BET Pharmacy, Lexington, KY, USA) (n = 30) 10 cc IM once in the neck, and 3) Controlled intravaginal drug release (CIDR-B 1.9 g P4; Zoetis, Kirkland, QC, Canada) (n = 15) vaginal insert for 10 days. Mares were randomly assigned to treatment and evaluated using transrectal reproductive ultrasonography on Days 1 (treatment initiation), 5, 10, and daily during oestrus until ovulation (Ov). On Day 10, mares were given 250 µg of cloprostenol (PG) (Estrumate, Merck) IM, and when a follicle (F) >35 mm was detected 2500 IU hCG (Chorulon, Intervet, Millsboro, MD, USA) was administered IM. Adverse reactions were scored as follows: Regumate – any reaction at any time; LAP4 – the injection site was inspected and scored as: 0, no reaction; 1, mild slight raised area; 2, moderate reaction 5 cm; 3, severe reaction 6–10 cm; 4, very severe reaction >10 cm on Day 5 post-injection; CIDR categorical scores were: 0, no discharge; 1, mild vaginal discharge on CIDR at withdrawal; 2, moderate discharge on tail or vulva; 3, severe urine scald or visible discharge; 4, very severe thickened inflamed skin from urine scald or discharge. Chi-squared test at P < 0.05 was used to evaluate the overall frequency of reactions in mares, and the presence of intrauterine fluid. The time from cloprostenol (PG) to F 35, hCG to Ov, PG to Ov, and mm of intrauterine fluid on Days 1–3, was evaluated using the Shapiro–Wilk test and Kruskall–Wallis at P < 0.05. Results of the overall adverse reactions were: Group 1 0/30 (0%), Group 2 9/30 (30%), and Group 3 14/15 (93.3%). The Group 2 treatment resulted in category 0–4 reactions as follows (21/30, 1/30, 5/30, 2/30, 1/30) and for Group 3 category 0–4 (1/15, 13/15, 0/15, 1/15, 0/15), respectively. The overall frequency of adverse reactions was significantly different between groups (P = 0.0000) with Group 2 having the highest rate. Reproductive parameter results were median (quartiles) days from PG to F35 for groups 1–3 respectively: 4 (2.8–6), 5 (0–6), 3 (4–6), hours from hCG to OV: 42(42–42), 42 (42–72), 42 (43–54); and days from PG to OV: 8 (4.5–8), 8 (5–8), 6.6 (4.8–8). Fluid Day 1, Day 2, Day 3 had a median of 0 mm on all days, and on Day 3 mm of fluid was mild 0 (0–0.125) but different between groups (P = 0.0379). The detection of intrauterine fluid on Day 2 (P = 0.005) was different between groups. No follicle wave synchronization was achieved by progestin administration; hence, the main differences noted between groups were the frequency of adverse reactions, rather than the reproductive parameters studied. The cost of the treatment and the frequency of adverse reactions are important considerations when choosing an oestrus synchronization therapy for mares. Research was supported by the Alberta Agriculture Research Institute.

365 THE EFFECT OF ADMINISTERING PROGESTERONE AND ESTRADIOL PRIOR TO eFSH ON THE SUPEROVULATORY RESPONSE OF MARES

eFSH has been used to induce multiple ovulation in cycling mares. However, the response to eFSH is variable. Generally, eFSH is initiated 5 to 7 days after ovulation at a time when the follicular population on the ovaries may be variable. The objective of this study was to determine whether administration of progesterone and estradiol for 10 days prior to eFSH (Bioniche Animal Health, Athens, GA) would enhance the response to eFSH administration. Thirty normal cycling mares were assigned to 1 of 2 groups. Group 1: Control eFSH treatment - mares were examined daily with ultrasonography beginning 5 days after ovulation. Once the follicles in these mares reached 20 to 25 mm in size, eFSH treatment (12.5 mg, i.m.) was administered twice a day. Cloprostenol (Schering-Plough, Union, NJ, USA) treatment (250 �g) was administered on the second day of eFSH treatment. eFSH treatment continued until the majority of the cohort of follicles reached e35 mm. Treatment was stopped and after approximately 36 h hCG (2500 IU, i.v.; Chorulon; Intervet, Millsboro, MD, USA) was administered. Group 2: Injectable progesterone + estradiol (150 mg of progesterone and 10 mg of estradiol; P+E) treatment was initiated in diestrus (5 to 7 days post-ovulation) for 8 mares and in early estrus for 7 mares in this group. Injectable progesterone was continued for 10 days and Cloprostenol (250 �g) was administered on Day 10. Mares were then examined daily with ultrasonography and, once they had acquired 20- to 25-mm follicles, eFSH treatment was initiated. Twice-daily injections of eFSH (12.5 mg, i.m.) were continued until a majority of the cohort of follicles was e35 mm. hCG was administered approximately 36 h later. All mares were inseminated with 1 billion progressively motile spermatozoa from one of two stallions on the day of hCG administration and on the following day with cooled semen (1 billion progressively motile spermatozoa) from the same stallion. Data were analyzed by t-test and Fisher's Exact Test. The number of days of eFSH treatment was similar for the P+E (2) vs. the control (1) group (4.2 � 2.0 vs. 4.9 � 1.3 days, respectively). However, the number of ovulations induced in response to eFSH was greater for mares in the eFSH control (1) group (5.6 � 2.0) than for those in the P+E (2) group (3.0 � 1.9). Embryo recovery per flush was also greater for eFSH control (1) mares (2.7) vs. P+E (2) mares (1.1). Embryo quality was excellent or good for all embryos in both groups. Seventy-three percent of the mares (11 of 15) in both groups gave at least one embryo at each recovery attempt. However, more mares in the eFSH control (1) group gave two or more embryos (60%) compared to those in the P+E (2) group (20%). In summary, treatment of mares with P+E prior to eFSH treatment resulted in fewer ovulations, fewer embryos recovered, and fewer mares providing e2 embryos. Thus, there was no advantage in pretreating mares with P+E prior to eFSH treatment.

Criterion-based validity of an intracarotid amobarbital recognition-memory protocol

PURPOSE

We tested whether the behavioral components of an Intracarotid Amobarbital Protocol (IAP) had criterion validity. It was hypothesized that a recognition-memory test designed for intracarotid injections and used to predict the risk of global amnesia before an elective temporal lobectomy should also identify persons who are severely amnesic due to other neurologic causes. Divergent validity predicts that speech tasks would be unaffected by amnesia. Test-retest reliability also was measured.

METHODS

Fifteen persons with severe amnesia were administered four alternate forms of a yes/no recognition-memory protocol and a speech protocol. No drug injection occurred. Standardized neuropsychological tests were used to divide the amnesic group into those with Global Amnesia (i.e., retain no ongoing memories), Severe Amnesia (i.e., memory impaired), and Amnesia Plus (severe amnesia plus other neuropsychologic deficits).

RESULTS

Two persons with Global Amnesia obtained scores at or below chance (i.e., failed) on the memory protocol. Unexpectedly, 12 of 13 severely amnesic persons obtained near-perfect memory scores. Amnesia had no impact on the speech protocol. Pass/Fail outcomes were highly correlated across all four sets.

CONCLUSIONS

A four-item IAP memory protocol showed good reliability and criterion validity in identifying the rare condition of Global Amnesia, but it was insensitive to other disabling, severe amnesic disorders. This IAP memory protocol might have validity in predicting a postsurgical Global Amnesic disorder, but it did not identify and therefore could not predict other more common severe amnesic disorders.

Ultrasonographic detection of chronic epididymitis in a stallion

Clinical signs of chronic epididymitis in a stallion included recurrent signs of inguinal pain--retraction of the right testis into the inguinal area, resentment of palpation of the right testis, and right-sided scrotal swelling. The tail of the right epididymis was firm and seemed to be adhered to the testis. The tail of the left epididymis felt firmer than normal. Ultrasonographically, the diameter of the head of the epididymis was considered larger than normal, was hyperechoic in relation to the right testis, and had an irregular border. Several bright 1- to 5-mm-diameter echogenic areas that alternated with less echogenic areas were seen in the head of the right epididymis. Ultrasonographic findings were interpreted as fibrosis attributable to chronic inflammation. Unilateral castration (right-sided) was performed, but the prognosis was guarded because of presumed involvement of the left epididymis.

Collaborative clinical laboratory study of a broth-disk test for determination of bacterial susceptibility to beta-lactams in combination with amdinocillin

Methodology for the performance of synergistic antibiotic susceptibility studies has not been standardized. We addressed this problem collaboratively with combinations of amdinocillin and select other beta-lactam antibiotics by using a simple broth-disk test compared with a microdilution approach. Each method used the same drugs singly and in combination. The broth-disk test evaluated each agent and the combinations at concentrations that reflected the breakpoints for each drug; the same ratios of beta-lactam to amdinocillin were used in doubling dilutions with the microdilution method. Initially, each participant studied the same 50 members of the family Enterobacteriaceae; each bacterium was studied on three occasions. Thereafter, 500 representatives of Enterobacteriaceae isolated recently from clinical specimens were studied. Designated strains served as controls. Reproducibility between the two approaches studied in phase 1 of the investigation indicated good agreement between the methods, ranging from 87 to 100%. Agreement between the microdilution and broth-disk tests for the 2,551 clinical isolates ranged from 86 to 95%, with slightly better correlations between combination results than with the single agents. The findings indicate that antibiotic disks used routinely in the clinical laboratory can be used in a simple elution test to determine susceptibility of organisms to beta-lactam antibiotics alone and in combination with amdinocillin.

Interpretation of susceptibility testing of ceftriaxone

Susceptibility of a variety of bacterial isolates to ceftriaxone was determined by Kirby-Bauer assays using 30 micrograms ceftriaxone disks and by microdilution (MIC) assays using standard procedures. The relation between zones of inhibition and MICs was expressed by the following regression equation: zone diameter = 22.98-2.653 In (MIC). Using this regression line and the breakpoints estimated from ceftriaxone concentrations in plasma 12 to 24 hours after 1- and 2-g doses, the susceptibility of a pathogen to ceftriaxone was classified as follows: susceptible-zone 16 mm or greater, MIC 16 micrograms/ml or less; moderately susceptible-zone 13 to 15 mm, MIC 17 to 63 micrograms/ml; resistant-zone 12 mm or less, MIC 64 micrograms/ml or greater. These breakpoints were used to determine the susceptibility of organisms isolated during clinical studies in the United States. The correlation between the in vitro results and the bacteriologic outcomes achieved in the clinical cases was analyzed to assess the suitability of the chosen breakpoints. The results of the disk assays were correctly predictive of bacteriologic responses with 1,388 of 1,513 organisms (91.7 percent), whereas the results of dilution assays correctly predicted the response with 897 of 941 organisms (95.3 percent). The correlation between in vitro results and bacteriologic outcome in patients treated with ceftriaxone was equivalent or superior to that achieved in patients treated with the comparative agents cefamandole and cefazolin. Thus, the chosen cutoff points for indicating susceptibility and resistance to ceftriaxone appear to be suitable and highly predictive of clinical success.

Antimicrobial activity of ceftriaxone: a review

Ceftriaxone possesses potent activity, both in vitro and in vivo, against a broad range of bacteria. MIC50 and MIC90 geometric means were calculated using the results of broth and agar dilution assays performed worldwide. The MIC90 for ceftriaxone overall was 8 micrograms/ml or less for Enterobacteriaceae and 0.024 microgram/ml or less for Neisseria and Hemophilus species. Moderate activity was noted against Pseudomonas and Acinetobacter species (MIC50 12 to 28 micrograms/ml). Ceftriaxone was extremely active against nonenterococcal streptococci (MIC90 0.07 microgram/ml or less) and quite active against methicillin-susceptible Staphylococcus aureus (MIC90 5 micrograms/ml or less). Ceftriaxone generally was inactive against enterococci and methicillin-resistant staphylococci. Activity against anaerobes was good, except for many strains of Bacteroides fragilis and B. thetaiotaomicron (MIC greater than 64 micrograms/ml). Ceftriaxone exhibited excellent stability to beta-lactamases. The effect of medium and inoculum on in vitro testing was minimal. Excellent activity was demonstrated in vivo. Against Enterobacteriaceae, nonenterococcal streptococci, and H. influenzae, the PD50 in mice generally was less than 1 mg/kg. S. aureus strains responded moderately (mean PD50 6.5 mg/kg), whereas against most P. aeruginosa strains, PD50s ranged from 5 to greater than 250 mg/kg. The superior pharmacokinetic profile of ceftriaxone compared with that of other new cephalosporins was demonstrated by use of a prophylactic treatment schedule. The ability of ceftriaxone to penetrate the cerebrospinal fluid and provide excellent therapeutic coverage was confirmed in experimental meningitis models.

Enhanced activity of beta-lactam antibiotics with amdinocillin in vitro and and in vivo

An important advantage of antibiotic combinations which can be determined is the increase in spectrum of activity. Ad hoc combinations of amdinocillin with ampicillin, ticarcillin, piperacillin, azlocillin, cefazolin, cefamandole, cefoxitin, and moxalactam in ratios similar to those in serum after parenteral administration of normal dosages of these agents were tested in vitro against over 200 strains of bacteria, including Staphylococcus aureus, Streptococcus faecalis, representative genera of the Enterobacteriaceae, and Pseudomonas aeruginosa. Independent of amdinocillin's activity, it was possible to show marked enhancement of the spectrum of all the beta-lactam agents tested, except moxalactam, against members of the Enterobacteriaceae. Little or no enhancement or antagonism of activity was seen against gram-positive bacteria or P. aeruginosa. The enhancing activity of amdinocillin on three beta-lactam antibiotics, ampicillin, cefazolin, and cefoxitin, was also demonstrated in experimental mouse infections with gram-negative bacteria.

Late wound separation after cataract extraction

Many years after cataract extraction, blunt trauma ruptured limbal wounds in five eyes. Filtrations followed minor trauma in three patients, and occurred spontaneously in two others. Limbal wounds do not regain the tensile strength of adjacent normal stroma and may be further weakened by tissue incarcerations, vascularization, and other defects. Histologic studies after cataract extraction also reveal minimal collagen bridging of the stromal wound in some human eyes. Diagnosis and clinical significance are discussed.