Humanistic and economic burden of cardiovascular disease related comorbidities and hypoglycaemia among patients with type 2 diabetes in Japan

AIM

This study aims to examine the humanistic and economic burden of cardiovascular disease (CVD)-related comorbidities and hypoglycaemia among respondents with type 2 diabetes (T2D) in Japan.

METHODS

This study used the Japan National Health and Wellness Survey 2016 database. Respondents who self-reported a physician-diagnosed T2D were included. Respondents with or without the condition of interest (CVD-related comorbidities or hypoglycaemia) were compared via generalized linear models in terms of the outcome variables: (1) health-related quality of life (HRQoL), (2) work productivity and activity impairment, (3) healthcare resource utilization and (4) economic costs.

RESULTS

A total of 1478 survey respondents reported a diagnosis of T2D (mean age 63.6 ± 10.6 years, mean HbA1c 6.91 ± 1.1%). Of whom, 804 subjects (54.4%) had at least one CVD related comorbidities, and 369 subjects (29.3%) reported experiences of hypoglycaemia episodes. Patients with CVD-related comorbidities or hypoglycaemia episodes had worse HRQoL, more work and activity impairment, increased health care visits, and higher costs.

CONCLUSIONS

CVD related comorbidities and hypoglycaemia remains a significant humanistic and economic burden in patients with T2D. The findings suggested that appropriate T2D management with proper medication choice are important to control CVD related comorbidities and hypoglycaemia among T2D patients to alleviate the burden.

Influence of late-age births on maternal longevity

PURPOSE

To examine the association between the mother's age at last birth and maternal long-term survival.

METHODS

Data from three national censuses (1972, 1983, and 1995) and national birth and death records (1972-2009) were used to examine the association between age at last birth and mortality while accounting for potential confounders, such as parity. Age-adjusted mortality rates and Cox proportional hazard models were used in the analysis.

RESULTS

A total of 887 women who delivered their last child after 45 years of age were identified from among 178,507 women (1,592,379 person-years). Age-adjusted mortality rates from 55 years of age were highest for childless women (9.2 per 1000) and decreased linearly (P < .001) for parous women with increased age at last birth (5.2 per 1000 for women aged ≥45 years at last birth). In models adjusted for age at first birth and parity, mortality risks were lowest among parous women with late-age births (≥45 years) compared with parous women with their last births before 35 years of age (hazard ratio, 0.58; 95% confidence interval, 0.40-0.86).

CONCLUSIONS

This study provides new empirical evidence that late-age births are associated with maternal longevity, although a direct causal relation cannot be established with the information available.

Influence of background particulate matter (PM) on urban air quality in the Pacific Northwest

Elevated particulate matter concentrations due to Asian long-range transport (LRT) are frequently observed in the free troposphere (FT) above the Pacific Northwest, U.S. Transport of this aerosol from the FT to the boundary layer (BL) and its effect to local air quality remain poorly constrained. We used data collected at the Mount Bachelor observatory (MBO, 2.8 km a.s.l) and from ground stations in the Pacific Northwest to study transport of fine particulate matter (PM) from the FT to the BL. During Asian LRT episodes PM concentrations were clearly elevated above the corresponding monthly averages at MBO as well as at low elevation sites across Washington and Oregon. Also, a clear correlation between MBO and low elevation sites was observed, indicating that LRT episodes are seen in both the FT and BL. In addition, drum impactor measurements show that the chemical composition of PM at MBO was similar to that measured at the BL sites. Using a simple regression model, we estimate that during springtime, when the transport from Asia is most effective, the contribution of Asian sources to PM2.5 in clean background areas of the Pacific Northwest was on average 1.7 μg m(-3) (representing approximately 50-80% of PM). The influence of LRT PM was also seen in measurement stations situated in the urban and urban background areas. However, the fraction of LRT PM was less pronounced (36-50% of PM) due to larger local emissions in the urban areas.

Association between number of children and mortality of mothers: results of a 37-year follow-up study

PURPOSE

To examine the association between parity and long-term, all-cause mortality and mortality owing to specific causes in women.

METHODS

This prospective population-based study included 40,454 mothers who gave birth in Western Jerusalem, Israel, to 125,842 children and were followed for an average of 37 years after the birth of their first child. Cox proportional hazards models were used to evaluate long-term total and specific-cause mortality of women by their parity.

RESULTS

We found a U-shaped relationship between the number of offspring and risk of all-cause mortality in mothers. After adjustment for sociodemographic characteristics and maternal health and obstetric conditions, higher mortality rates were observed for mothers of 1 child (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.04-1.4), mothers of 5 to 9 children (HR, 1.21; 95% CI, 1.09-1.33), and mothers of 10 or more children (HR, 1.49; 95% CI, 1.12-1.99) compared with mothers of 2 to 4 children. Mortality risk from specific causes including coronary disease, circulatory disease, and cancer were increased for multiparous women.

CONCLUSIONS

In this long-term follow-up study, there was an association between number of children and mortality risk for mothers. These findings suggest that maternal pregnancies and postnatal characteristics as reflected by number of children may have consequences for long-term maternal health.

Civilians under fire: evacuation behaviour in north Israel during the Second Lebanon War

This paper seeks to understand evacuation behaviour in a case of spontaneous evacuation. During the Second Lebanon War of 2006, more than one-third of residents in north Israel spontaneously evacuated--the remainder stayed in situ. Using a telephone survey of 665 respondents residing in north Israel, we were able to characterise the behaviour of evacuees and non-evacuees. The main reasons cited for evacuating were fear of injury to self or family, the effect on children, inability to remain in a protective space, and family pressure. The main reasons cited for remaining at home were no suitable alternative, did not perceive a high level of danger, had to go to work, and there is no place like home. There were no significant differences with regard to most socio-demographic characteristics of the population. These findings should aid emergency managers in preparing the population for a future emergency and in engaging in effective dialogue with the population during an emergency on the evacuation option.

Invasive adenoviral infections in T-cell-depleted allogeneic hematopoietic stem cell transplantation: high mortality in the era of cidofovir

BACKGROUND

Adenovirus (ADV) infection occurs in 5-21% of allogeneic hematopoietic stem cell transplants (HSCT). Symptomatic enteritis and hemorrhagic cystitis may be encountered but are seldom fatal. In contrast, mortality rates of up to 75% are reported for adenoviral pneumonia or hepatitis. Cidofovir is currently being increasingly used for treatment of adenoviral infections after HSCT. The efficacy of cidofovir in patients with invasive adenoviral infection is not established.

FINDINGS

We reviewed 687 adult and pediatric patients who received allogeneic HSCT at our institution from 1998 through June 2005. ADV was isolated from 64 (9.3%) patients. Eleven patients received cidofovir for invasive disease occurring at median 39 days (range 3-145) post HSCT. The median age was 40 (range 6-61) years. Seventy-three percent received a T-cell-depleted graft and 18% had grade 3-4 graft-versus-host disease (GVHD) of the gut. Three out of 3 (100%) patients with adenoviral pneumonia died. One patient with hepatitis, cholecysitis, and viremia cleared the infection after 3 months. Two out of 7 (28.6%) patients with hemorrhagic colitis or cystitis died of ADV (1 with extensive GVHD).

CONCLUSION

Mortality rates of ADV pneumonitis after allogeneic HSCT remain high in the era of cidofovir. Clinical trials are needed to evaluate management strategies for this life-threatening infection.

Predictors for persistent cytomegalovirus reactivation after T-cell-depleted allogeneic hematopoietic stem cell transplantation

Cytomegalovirus (CMV) reactivation occurs in up to 60% of CMV-seropositive recipients after allogeneic hematopoietic stem cell transplantation (HSCT). The incidence of CMV disease among T-cell-depleted HSCT patients has been reported from 5-15%. The incidence of reactivation refractory to antivirals in this population is not well studied.

METHODS

In this retrospective study we characterized the outcome of CMV reactivation in a cohort of 255 adult and pediatric patients who underwent T-cell-depleted HSCT at Memorial Sloan-Kettering Cancer Center from September 1999 through August 2004. CMV infection was monitored by the pp65 antigenemia assay (CMV Ag). Persistent reactivation was defined as antigenemia positivity >21 days on antiviral therapy.

RESULTS

Of 118 CMV-seropositive recipients, 69 (58.4%) had reactivated CMV. Twenty of 69 (29%) developed persistent reactivation at first episode of reactivation, and 7 (10%) in subsequent episode. All patients with persistent reactivation received >/=2 antivirals and CMV hyperimmune globulin; 45% received combination antiviral therapy. The median duration of persistent reactivation was 98 days, range 31-256 days. In multivariate analysis, maximum CMV Ag >25 cells/slide was associated with persistent reactivation (odds ratio 16.2%, 95% confidence interval 4-64, P<0.0001). CMV disease occurred in 6/27 (22%) patients with persistent reactivation. Patients with persistent reactivation had lower CD4(+) and CD8(+) lymphocyte counts compared with those with non-persistent reactivation at day +90 post HSCT (P=0.01 and 0.02, respectively).

CONCLUSIONS

Persistent reactivation occurred in 39% of T-cell-depleted HSCT despite treatment with currently available antivirals. Maximum CMV Ag >25 cells/slide was associated with persistent CMV reactivation. More effective treatment modalities are needed for this high-risk population to reduce CMV-associated morbidity and mortality.

Pre- and post-engraftment bloodstream infection rates and associated mortality in allogeneic hematopoietic stem cell transplant recipients

We report on bloodstream infection (BSI) rates, risk factors, and outcome in a cohort of 298 adult and pediatric hematopoietic stem cell transplantation (HSCT) recipients at Memorial Sloan-Kettering Hospital from September 1999 through June 2003. Methods. Prospective surveillance study. BSI rates are reported per 10,000 HSCT days. Date of engraftment is defined as the first of at least 3 consecutive dates of absolute neutrophil count >500/mm(3) after stem cell infusion. BSI severity grades: severe (intravenous antibiotics), life threatening (sepsis), or fatal (caused or contributed to death). Results. The incidence of pre- and post-engraftment BSI was 22% and 19.5%, respectively. Pre-engraftment highest rates were observed for viridans streptococci (58), Enterobacteriaceae (39), and Enterococcus faecium (34). Post-engraftment rates ranged from 0.2 to 2.9 without any predominant pathogen. In multivariate analyses, pre-engraftment BSI was associated with diagnosis of chronic myelogenous leukemia, age >18 years and peripheral blood stem cell graft; post-engraftment BSI was associated with acute graft-versus-host disease, neutropenia, and liver or kidney dysfunction. Attributable mortality was 12.5% and 1.7% for pre- and post-engraftment BSI, respectively. BSI fatality rates were 24% for viridans streptococci, 8% for E. faecium, 11% for Staphylococcus aureus, and 67% for Candida. Conclusions. Pre-engraftment BSI, especially by viridans streptococci and E. faecium, was associated with substantial attributable mortality. Post-engraftment BSI was a marker of post-transplant complications and rarely the primary cause of death.

Alcohol Dehydrogenase Polymorphisms Influence Alcohol-Elimination Rates in a Male Jewish Population

BACKGROUND

Genetic variation in the alcohol dehydrogenase (ADH) enzyme is associated with an aversion to alcohol and a lower risk of alcoholism among Asians. There is growing evidence of a functional role of the ADH2*2 allele in alcohol-drinking patterns among Jews, who have traditionally exhibited low rates of alcoholism and alcohol-related problems. The mechanism by which this allelic effect is mediated is not yet clearly understood. This study examined the effect of ADH2*2 on alcohol-elimination rates (AER) under experimental conditions.

METHODS

Young adult male Jews (N = 109) received an intravenous alcohol infusion; metabolism was measured by using standard breath alcohol concentration tests. A clamping technique was used to achieve and maintain a target breath alcohol concentration of 50 mg/100 ml for a defined time period. The AER at steady state was calculated. The alcohol disappearance rate was also calculated from the descending limb slope. Polymerase chain reaction was used for allelic determination of the ADH2 and ADH3 loci.

RESULTS

The mean AER among ADH2*2 carriers was significantly higher (8.09 +/- 1.4 g/hr) than among ADH2*1 homozygotes (7.14 +/- 1.5 g/hr; p = 0.003). Significance was retained on adjustment for potential confounding covariates. The ADH2 allele explains 8.5% of the AER variance in this population. Little AER difference was observed across ADH3 genotype groups. The slope of the descending limb increased with increasing copies of the ADH2*2 allele.

CONCLUSIONS

The rate of alcohol elimination is significantly associated with the ADH2 genotype of Jewish males. Evidence for variation in alcohol metabolism across ADH genotypic groups provides support for the role of physiologic protective factors in alcohol drinking and suggests that reduced drinking among Jews may be genetically as well as environmentally determined. We believe that application of the novel "Indiana clamp" enhances AER measurement accuracy, allowing for detection of hitherto undetectable differences.

Validity of the Mindstreams™ Computerized Cognitive Battery for Mild Cognitive Impairment

The NeuroTrax Mindstreams computerized cognitive assessment system was designed for widespread clinical and research use in detecting mild cognitive impairment (MCI). However, the capability of Mindstreams tests to discriminate the elderly with MCI from those who are cognitively healthy has yet to be evaluated. Moreover, the comparability between these tests and traditional neuropsychological tests in detecting MCI has not been examined. A two-center study was designed to assess the discriminant validity of tests in the Mindstreams Mild Impairment Battery. Participants were 30 individuals diagnosed with MCI, 29 with mild Alzheimer's disease (AD), and 39 healthy elderly. Testing was with the Mindstreams battery and traditional neuropsychological tests. Receiver operating characteristic (ROC) analysis was used to examine the ability of Mindstreams and traditional measures to discriminate those with MCI from cognitively healthy elderly. Between-group comparisons were made (Mann-Whitney U test) between MCI and healthy elderly and between MCI and mild AD groups. Mindstreams outcome parameters across multiple cognitive domains significantly discriminated between MCI and healthy elders with considerable effect sizes (p < 0.05). Measures of memory, executive function, visual spatial skills, and verbal fluency discriminated best, and discriminability was at least comparable to that of traditional neuropsychological tests in these domains. Mindstreams tests are effective in detecting MCI, providing a comprehensive profile of cognitive function. Further, the enhanced precision and ease of use of these computerized tests make the NeuroTrax system a valuable clinical tool in the identification of elders at high risk for dementia.

Validity of a novel computerized cognitive battery for mild cognitive impairment

BACKGROUND

The NeuroTrax Mindstreams computerized cognitive assessment system was designed for widespread clinical and research use in detecting mild cognitive impairment (MCI). However, the capability of Mindstreams tests to discriminate elderly with MCI from those who are cognitively healthy has yet to be evaluated. Moreover, the comparability between these tests and traditional neuropsychological tests in detecting MCI has not been examined.

METHODS

A 2-center study was designed to assess discriminant validity of tests in the Mindstreams Mild Impairment Battery. Participants were 30 individuals diagnosed with MCI, 29 with mild Alzheimer's disease (AD), and 39 healthy elderly. Testing was with the Mindstreams battery and traditional neuropsychological tests. Receiver operating characteristic (ROC) analysis was used to examine the ability of Mindstreams and traditional measures to discriminate those with MCI from cognitively healthy elderly. Between-group comparisons were made (Mann-Whitney U test) between MCI and healthy elderly and between MCI and mild AD groups.

RESULTS

Mindstreams outcome parameters across multiple cognitive domains significantly discriminated among MCI and healthy elderly with considerable effect sizes (p < 0.05). Measures of memory, executive function, visual spatial skills, and verbal fluency discriminated best, and discriminability was at least comparable to that of traditional neuropsychological tests in these domains.

CONCLUSIONS

Mindstreams tests are effective in detecting MCI, providing a comprehensive profile of cognitive function. Further, the enhanced precision and ease of use of these computerized tests make the NeuroTrax system a valuable clinical tool in the identification of elderly at high risk for dementia.

Atmospheric transport patterns and possible consequences for the European North after a nuclear accident

The main purpose of this study is to examine possible impacts and consequences of a hypothetical accident at the Kola nuclear plant in north-west Russia on different geographical regions: Scandinavia, central Europe, European FSU and Taymyr. The period studied is 1991-1996. An isentropic trajectory model has been used to calculate forward trajectories that originated over the nuclear accident region. Atmospheric transport patterns were identified using the isentropic trajectories and a cluster analysis technique. From the trajectory model results, a number of cases were chosen for examination in detail using more complete transport models. For this purpose, the models MATHEW/ADPIC, DERMA and a newly developed FOA Random Displacement Model have been used to simulate the radionuclide transport and contamination in the case of a nuclear accident and their results have been compared with those of the trajectory modelling. Estimation of the long-term consequences for populations after an accident has been performed for several specific dates by empirical models and correlation between fallout and doses to humans on the basis of the Chernobyl accident exposures in Scandinavia.

Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines

OBJECTIVE

In children <2 years old, minor head trauma (HT) is a common injury that can result in skull fracture and intracranial injury (ICI). These injuries can be difficult to detect in this age group; therefore, many authors recommend a low threshold for radiographic imaging. Currently, no clear guidelines exist regarding the evaluation and management of head-injured infants. We sought to develop guidelines for management based on data and expert opinion that would enable clinicians to identify children with complications of HT and reduce unnecessary imaging procedures. METHODS.

EVIDENCE

References addressing pediatric HT were generated from a computerized database (Medline). The articles were reviewed and evidence tables were compiled. EXPERT PANEL: The multidisciplinary panel was comprised of nine experts in pediatric HT.

CONSENSUS PROCESS

A modified Delphi technique was used to develop the guidelines. Before the one meeting, panel members reviewed the evidence and formulated answers to specific clinical questions regarding HT in young children. At the meeting, guidelines were formulated based on data and expert consensus.

RESULTS

A management strategy was developed that categorizes children into 4 subgroups, based on risk of ICI. Children in the high-risk group should undergo a computed tomography (CT) scan. Those in the intermediate risk group with symptoms of possible ICI should either undergo CT scan or observation. Those in the intermediate risk group with some risk for skull fracture or ICI should undergo CT and/or skull radiographs or observation. Those in the low-risk group require no radiographic imaging.

CONCLUSIONS

We have developed a guideline for the evaluation of children <2 years old with minor HT. The effect of these guidelines on clinical outcomes and resource utilization should be evaluated.

The experience of pet ownership as a meaningful occupation

This qualitative study examined the experience of pet ownership in the everyday lives of seven men with human immuno-deficiency virus or acquired immune deficiency syndrome. Interviews and field observations were analyzed using a grounded theory approach. The findings demonstrate that the experience of pet ownership is both typical of any pet owner and yet profoundly impacted by the illness of the owners. The results of this preliminary study indicate pet ownership can be a highly valued occupation for some, and thus has implications for occupational therapy intervention.

Obtaining HIV test results with a home collection test kit in a community telephone sample

OBJECTIVES

To test the feasibility of obtaining HIV test results by home collection kit from a probability telephone sample of men who have sex with men (MSM).

METHODS

A quota sample of 615 MSM previously interviewed by the Urban Men's Health Study phone survey in Chicago, Los Angeles, New York City, and San Francisco were re-contacted and offered an HIV test using an oral specimen (Orasure) home collection kit.

RESULTS

Eighty percent consented to be mailed a kit, and 84% returned a specimen, for a 67% participation rate. All self-reported HIV-positive persons tested positive (77 of 77); 4 of 266 (1.5%) with a prior negative test and 2 of 69 (2.9%) with no prior positive HIV test result. Participation was associated with self-reported prior HIV test status-HIV-positive (83%), HIV-negative (68%), or no prior HIV test result (54%)-and marginally associated with New York City residence after adjustment for HIV status (odds ratio = 0.7; 95% confidence interval, 0.4-1.1; p =.08).

CONCLUSIONS

These results suggest that urban MSM identified and interviewed by telephone will participate in home collection HIV testing. This methodology could be used to produce population-based estimates of HIV seroprevalence and seroincidence in MSM and could probably be extended to other populations and other viral infections.

Contributions of individual muscles to the submental surface electromyogram during swallowing

Submental surface electromyographic recordings are commonly used in the investigation of swallowing disorders. The measured electromyography is thought to reflect the actions of floor-of-mouth muscles. Although this is a reasonable assumption, to date there have been no investigations to delineate which muscles contribute to this surface recording. The primary goal of this experiment was to determine which muscles contribute most to the submental surface. Electromyography was recorded simultaneously from the submental surface as well as from five individual muscles: mylohyoid, anterior belly of the digastric, geniohyoid, genioglossus and platysma. Three analysis methods were performed to estimate individual muscle contributions: correlation, numeric, and analytic. For the numeric and analytic analyses, a linear model was defined and used to represent the relationship between the surface and intramuscular recordings. Muscles that received a high correlation, numeric and/or analytic value were considered to be primary contributors to the submental recording. Regardless of analysis approach, the primary contributions to the submental surface recording were the mylohyoid, anterior belly of the digastric, and the geniohyoid muscles. Contributions from the genioglossus and the platysma muscles were minimal. Contributions as a function of bolus volume and viscosity are also discussed.

Priorities for research in Emergency Medical Services for Children: results of a consensus conference. EMSC Research Agenda Consensus Committee, National EMSC Resource Alliance

STUDY OBJECTIVE

The study objective was to arrive at a consensus on the priorities for future research in Emergency Medical Services for Children (EMSC).

METHODS

A consensus group was convened using the Rand'-UCLA Consensus Process. The group took part in a 3-phase process. Phase I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics based on the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. They were also asked in the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics reprioritized. The topics were given a rank order and a final ranking was done in Round III.

RESULTS

The panel considered a list of 32 topics and these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care systems organization, configuration and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in EMSC that can be used by foundations, governmental agencies, and others in setting a research agenda for EMSC.

Priorities for research in emergency medical services for children: results of a consensus conference

OBJECTIVE

To arrive at a consensus on the priorities for future research in emergency medical services for children.

METHODS

A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge (2), change behavior (3), improve health (4), decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round III.

RESULTS

The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting research agenda for such services.

Primary care physicians' experience of financial incentives in managed-care systems

BACKGROUND

Managed-care organizations' use of financial incentives to influence the practice of primary care physicians is controversial. We studied the prevalence and effects of these incentives.

METHODS

We surveyed a probability sample of primary care physicians practicing in the largest urban counties in California in 1996. The physicians were asked about the types of incentives they encountered, the amount of income that was keyed to incentives, their experience of pressure in their practices, and the ways in which such pressure affected patient care.

RESULTS

Data were analyzed for 766 physicians involved in managed-care systems. Thirty-eight percent of these physicians reported that their arrangements with the managed-care system included some type of incentive in the form of a bonus. Fifty-seven percent of the physicians reported that they felt pressure from the managed-care organization to limit referrals (17 percent said they believed such pressure compromised patient care), and 75 percent felt pressure to see more patients per day (24 percent believed such pressure compromised patient care). The physicians who reported that their financial arrangements included an incentive based on referrals were more likely than others to have felt pressured to limit referrals in a manner that compromised care (adjusted odds ratio 2.5; 95 percent confidence interval, 1.2 to 5.0), and physicians with an incentive based on productivity were more likely to have felt pressure to see more patients that they believed compromised care (adjusted odds ratio, 2.1; 95 percent confidence interval, 1.2 to 3.8). The physicians whose health care systems used incentives keyed to productivity were less likely than others to be very satisfied with their practices (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.6), whereas those whose systems included incentives related to the quality of care or patients' satisfaction were more likely to be very satisfied (adjusted odds ratio, 1.8; 95 percent confidence interval, 1.1 to 3.0).

CONCLUSIONS

Many managed-care organizations include financial incentives for primary care physicians that are indexed to various measures of performance. Incentives that depend on limiting referrals or on greater productivity apply selective pressure to physicians in ways that are believed to compromise care. Incentives that depend on the quality of care and patients' satisfaction are associated with greater job satisfaction among physicians.

Selection and exclusion of primary care physicians by managed care organizations

CONTEXT

Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory.

OBJECTIVE

To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care.

DESIGN

Cross-sectional mail survey of a probability sample of primary care physicians.

SETTING

A total of 13 large urban counties in California.

PARTICIPANTS

Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice.

MAIN OUTCOME MEASURES

Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts.

RESULTS

Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice.

CONCLUSIONS

Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.

Fatal fungemia resulting from an infected transjugular intrahepatic portosystemic shunt stent

Placement of a transjugular intrahepatic portosystemic shunt is a well accepted treatment in the management of gastroesophageal variceal bleeding. Although morbidity and mortality associated with the use of transjugular intrahepatic portosystemic shunts have dramatically decreased, complications still occur. We report a case of fatal fungemia resulting from an infected transjugular intrahepatic portosystemic shunt stent.

Lovastatin effects on human breast carcinoma cells. Differential toxicity of an adriamycin-resistant derivative and influence on selenocysteine tRNAS

Selenocysteine tRNA[Ser]Sec isoacceptors contain the modified nucleotide i6A immediately 3' to the anticodon. Because synthesis of i6A is expected to be inhibited by lovastatin, the status of tRNA[Ser]Sec isoacceptors was examined in human breast carcinoma cells. As part of the initial characterization of these cells, it was determined that an adriamycin resistant derivative of the MCF-7 cell line exhibited a dramatic increase in the sensitivity to the killing effects of lovastatin relative to the parental MCF-7 cells. When MCF-7Adr cells were incubated with high levels of lovastatin, there was a dramatic perturbation in the distribution of isoacceptors within the selenocysteine tRNA population. Lovastatin may therefore be a useful reagent for both the study of differential killing of drug-resistant tumor cells and selenoprotein biosynthesis.

Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia

Because studies of the treatment of children with occult bacteremia have yielded conflicting results, we compared ceftriaxone with amoxicillin for therapy. Inclusion criteria were age 3 to 36 months, temperature > or = 39 degrees C, an acute febrile illness with no focal findings or with otitis media (6/10 centers), and culture of blood. Subjects were randomly assigned to receive either ceftriaxone, 50 mg/kg intramuscularly, or amoxicillin, 20 mg/kg/dose orally for six doses. Of 6733 patients enrolled, 195 had bacteremia and 192 were evaluable: 164 Streptococcus pneumoniae, 9 Haemophilus influenzae type b, 7 Salmonella, 2 Neisseria meningitidis, and 10 other. After treatment, three patients receiving amoxicillin had the same organism isolated from their blood (two H. influenzae type b, one Salmonella) and two from the spinal fluid (two H. influenzae type b), compared with none given ceftriaxone. Probable or definite infections occurred in three children treated with ceftriaxone and six given amoxicillin (adjusted odds ratio 0.43, 95% confidence interval 0.08 to 1.82, p = 0.31). The five children with definite bacterial infections (three meningitis, one pneumonia, one sepsis) received amoxicillin (adjusted odds ratio 0.00, 95% confidence interval 0.00 to 0.52, p = 0.02). Fever persisted less often with ceftriaxone (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.94, p = 0.04). Although the difference in total infections was not significant, ceftriaxone eradicated bacteremia, prevented significantly more definite focal bacterial complications, and was associated with less persistent fever.

Physicians' attitudes toward the diagnosis and management of fever in children 3 months to 2 years of age

Ninety-seven primary-care physicians, including 73 family physicians and 24 pediatricians, were surveyed in order to ascertain their knowledge and attitudes regarding fever in children 3 months to 2 years of age. A rectal temperature between 37.0 degrees C and 37.9 degrees C was considered to indicate fever by 35% of physicians. Only 17% believed there was no danger from fever, while 12% believed that fever could cause brain damage. Seizures were considered a principal danger of fever by 49% of physicians, and 22% believed that brain damage could result from typical febrile seizures. While 70% chose relief of discomfort as the main purpose of antipyretic treatment, 30% would use temperature alone as an indication for antipyretics. It is concluded that although many physicians have an acceptable attitude toward the diagnosis and management of fever, a significant number still have exaggerated concerns.

Synaptically activated increases in Ca2+ concentration in hippocampal CA1 pyramidal cells are primarily due to voltage-gated Ca2+ channels

Changes in intracellular Ca2+ concentration ([Ca2+]i) in the soma and dendrites of hippocampal CA1 pyramidal neurons were measured using intracellularly injected fura-2. A large component of the [Ca2+]i elevation caused by high frequency stimulation of the Schaffer collaterals was correlated with the Na+ spikes triggered by the excitatory postsynaptic potentials (EPSPs). These spikes were generated in the soma and proximal dendrites and stimulated Ca2+ entry through voltage-gated Ca2+ channels. Suppressing spikes by hyperpolarizing the soma or by injecting QX-314 revealed a smaller nonspike component of Ca2+ entry. A substantial fraction of this component was mediated by the action of the EPSPs on voltage-gated Ca2+ channels, because it persisted in 2-amino-5-phosphonovaleric acid and because it was usually reduced when Ca2+ channel activity was suppressed by hyperpolarization. Ca2+ entry through the N-methyl-D-aspartate receptor channel could not be detected with certainty, perhaps because it was highly localized.

Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis

Nebulized ipratropium bromide is though to be synergistic with albuterol in therapy for acute childhood asthma. Because the efficacy of ipratropium in bronchiolitis is uncertain and some infants with bronchiolitis do not respond to nebulized albuterol alone, the following study was undertaken. In this double-blind, placebo-controlled trial, 69 infants between 6 weeks and 24 months of age who exhibited the first episode of acute bronchiolitis were randomly assigned to receive either nebulized albuterol (0.15 mg/kg per dose) and ipratropium bromide (250 micrograms per dose) (group A, n = 36) or nebulized albuterol and normal saline (placebo) (group B, n = 33) for two doses, 1 hour apart. The two groups were comparable at baseline. Both therapies resulted in clinically significant improvement. However, the addition of ipratropium resulted in no additional benefit with respect to decrease in the respiratory rate (mean decreases 10.6/min vs decreases 8.6/min, P = .86), accessory muscle score (range 0 through 3) (decreases 0.92 vs decreases 0.82, z = -0.44), wheeze score (range 0 through 3) (decreases 0.94 vs 0.85, z = -0.20), oxygen saturation (increases 0.25% vs increases -0.33%, P = .86), or hospitalization rate (17 vs 10). The number of "nonresponders" and "clear responders" was also very similar in both groups. No toxicity was noted. The increase in heart rate was mild and similar in both groups (increases 6.7 vs increases 11.1). The power of the study to detect a difference between the two treatment groups in the respiratory rate change > or = 8/min is greater than 90%.(ABSTRACT TRUNCATED AT 250 WORDS)

NMDA-receptor-independent long-term potentiation

Although NMDA-R-dep LTP in the hippocampus has received much attention, it is clear that many types of LTP do not involve NMDA receptors. While early studies of NMDA-R-indep LTP were done in invertebrates, an NMDA-R-indep LTP is also seen in at least three excitatory pathways of the hippocampus. There would appear to be quite diverse mechanisms of induction of NMDA-R-indep LTP, although in most cases there is evidence, or at least a suggestion, that Ca2+ is involved. At the hippocampal CA3 MF synapse, activation of voltage-gated Ca2+ channels has been proposed as a trigger for LTP induction, and this may also be the case for certain types of LTP at the SC synapse in CA1 (25, 40). The modulation of both MF LTP and Ca2+ channels by beta-adrenoreceptor and muscarinic agonists suggests that specifically the L-type channel is critical for MF LTP induction. L-type Ca2+ channels may also be involved in NMDA-R-indep LTP at SC synapses (6, 40). Clearly more work is needed to test these possibilities. In addition, it will be interesting to discover whether voltage-gated Ca2+ channels play a role in LTP in other areas of the brain such as the cerebral cortex and amygdala (24).

Fluorinated colchicinoids: antitubulin and cytotoxic properties

The synthesis of B-ring and C-ring trifluoroacetamide-substituted colchicinoids and fluoro-substituted colchicineethylamides is presented. The B-ring trifluoroacetamido-substituted analogues exhibit moderate enhancement of potency compared to the nonfluorinated analogues for tubulin assembly inhibition and cytotoxicity toward two wild type cell lines. The C-ring substituted fluoroethylamides have reduced relative potencies in the same systems due to the strong electron-withdrawing effect of the fluoro derivatives. The fluoro colchicinoids are much more cytotoxic toward drug-resistant cell lines than to the wild type cell lines. Their enhanced potency is probably due to an effect of the fluoro moiety on functions specific to resistant cells and/or their higher hydrophobicity that may result in higher intracellular drug content. This finding may suggest the application of designed fluorinated anticancer drugs to overcome acquired resistance which may develop after several regiments of treatment with a nonfluorinated chemotherapeutic agent.

Comparison of ras activation during epidermal carcinogenesis in vitro and in vivo

Mouse epidermal cells have frequently been used to study the role of ras oncogenes in transformation in vivo and in vitro. After initiation with dimethylbenzanthracene (DMBA) in vivo, greater than 90% of the papillomas arising show the same A:T----T:A transversion at codon 61 of the H-ras gene, presumed to be the initiating event. On the other hand, initiation of epidermal cells in culture with carcinogens, followed by selection of initiated cells by resistance to calcium-induced differentiation, does not in general lead to the isolation of clones carrying mutant ras genes. Some other aspects of tumour progression in vivo can be reproduced using epidermal cells in culture: a rare DMBA transformant carrying the codon 61 mutation and expressing a 2:1 ratio of normal to mutant ras alleles gave rise upon transplantation to a more aggressive line in which the ratio of normal to mutant H-ras genes (and p21 products) was reversed. Similar alterations in ras gene dosage have been seen during progression of papillomas to carcinomas in vivo. We conclude that the mechanisms of initiation in vitro may differ substantially from in vivo, and depend on the particular culture conditions used. Moreover, the effects of mutant H-ras expression in mouse epidermal cells are variable depending on the genetic background of the cell.

Staphylococcal sepsis in HIV antibody seropositive psoriasis patients

The cases of three HIV-positive men with generalized psoriasis and staphylococcal sepsis are reported. In each case the skin appeared to be the source of infection. While the patients received antibiotic therapy, the psoriatic plaques resolved despite minimal or no topical treatment.

Emergency management of blunt trauma in children

Apart from the trend to nonoperative treatment of blunt abdominal injuries, based on accurate CT diagnosis, most of the recent and anticipated changes in pediatric trauma are organizational. They include resuscitation and triage before hospitalization, the use of designated trauma centers, resuscitation by trauma teams, noninvasive diagnosis and monitoring, comprehensive pediatric intensive care, the use of objective measures of outcome, and improved rehabilitation programs (Templeton JM: personal communication). The treatment of individual cases is based on simple but well-established principles. The key steps in management are to recognize children with life-threatening injuries (on the basis of the mechanism of injury or a Pediatric Trauma Score less than or equal to 8 or a Revised Trauma Score less than or equal to 11), to support the function of vital organs by establishing and maintaining adequate respiratory gas exchange and circulation, and to identify all important injuries by thorough and ongoing assessment.

Skateboarding injuries in children. A second wave

Motivated by a number of skateboard-related injuries seen in an emergency department, we undertook an investigation of skateboarding injuries in the mid-1980s. We studied US Consumer Product Safety Commission injury frequency estimates, which indicated a resurgence of these injuries: 19,182 in 1984 and 37,180 in 1985. Children 10 to 14 years old were injured with greatest frequency. Nontrivial injuries were more common among children younger than 5 years old, reflecting a larger proportion of head and neck injuries. Boys sustained more frequent and more severe skateboard-related injuries. Observed injury patterns (head and neck injuries in younger children, extremity injuries in older children, and more severe head and neck injuries in older children) probably reflect the role of psychomotor development on both risk exposure and biomechanics. Likely prevention strategies include warnings against skateboard use by children younger than 5 years, prohibition of skateboards on streets and highways, and the promotion of use of helmets and other protective gear.

Induction of long-term potentiation at hippocampal mossy-fiber synapses follows a Hebbian rule

1. The induction of long-term potentiation (LTP) at hippocampal mossy-fiber synapses requires an increase in postsynaptic [Ca2+]i but is independent of N-methyl-D-aspartate (NMDA) receptor activation. Voltage-gated Ca2+ channels have been proposed as one alternative source for raising [Ca2+]i during the induction of LTP. We tested the hypothesis that voltage-gated Ca2+ channel activation could mediate the induction of LTP by examining whether 1) the induction of mossy-fiber LTP was dependent on postsynaptic depolarization and 2) depolarization alone, of a magnitude presumably capable of activating Ca2+ channels, was sufficient to induce LTP. 2. Intracellular recordings were made from rat CA3 pyramidal cells in the hippocampal slice preparation under both current- and voltage-clamp conditions. Mossy-fiber postsynaptic potentials and currents were recorded before and after high-frequency stimulation (HFS) in the presence of 20-50 microM D-2-amino-5-phosphonovaleric acid (D-APV), an NMDA-receptor antagonist. 3. Voltage clamping of CA3 neurons between -80 and -100 mV during HFS reversibly blocked the induction of mossy-fiber LTP. Conversely, HFS paired with depolarizing-current steps under current clamp increased the magnitude of LTP compared with controls. These results indicate that mossy-fiber LTP is dependent on postsynaptic depolarization, and presynaptic activation alone was not sufficient to induce mossy-fiber LTP. 4. Depolarizing-current injections, which presumably depolarized CA3 cells to potentials sufficient to activate voltage-gated Ca2+ channels, had no effect on mossy-fiber synaptic responses. These results suggest that synaptic activation, in addition to postsynaptic depolarization, is required for the induction of mossy-fiber LTP. 5. Single mossy-fiber afferent volleys were also paired with depolarizing-current pulses. In the presence of APV, pairing of single-mossy-fiber excitatory postsynaptic potentials (EPSPs) with postsynaptic depolarization did not potentiate synaptic responses, suggesting that some form of HFS is also required for mossy-fiber LTP. In the absence of APV, however, the contamination of mossy-fiber synaptic responses by CA3-recurrent inputs resulted in some potentiation. 6. These results suggest that the induction of mossy-fiber LTP is dependent on both pre- and postsynaptic activity and thus follows a Hebbian rule for synaptic modification. In contrast to that demonstrated at Schaffer-collateral-commissural synapses, however, the induction of mossy-fiber LTP may require HFS in addition to postsynaptic depolarization.(ABSTRACT TRUNCATED AT 400 WORDS)

Biological and molecular aspects of radiation carcinogenesis in mouse skin

The process of mouse skin carcinogenesis can be operationally subdivided into at least three stages which have been termed initiation, promotion, and progression. Ionizing radiation has been found to be a weak initiator of malignant squamous cell carcinomas (SCCs) when radiation was followed by repeated treatments of the skin with the tumor promoter 12-O-tetradecanoyl-phorbol-13-acetate (TPA). Besides SCCs, ionizing radiation was found to induce, independent of tumor promoters, basal cell carcinomas (BCCs), a tumor histology not normally seen with chemical carcinogens and mouse skin. Fractionated doses of 1 MeV electrons were found to enhance the conversion of chemically induced benign papillomas to malignant SCCs. In addition to the biological studies, questions related to dominant transforming genes and differential gene expression in the radiation-initiated mouse skin tumors have been explored. Distinct non-ras dominant transforming gene(s) have been detected in radiation-initiated, TPA-promoted SCCs. Differences in the expression pattern of tumor-associated genes were seen in comparing chemically to radiation-induced benign and malignant skin tumors. Therefore, ionizing radiation has been shown to be active in the initiation of malignant skin tumors and progression of benign to malignant tumors in the mouse skin. The ability to divide the process of carcinogenesis into multiple stages in the mouse skin model has facilitated mechanistic studies that may elucidate the molecular pathways involved in radiation-versus chemically induced tumor development.

Pediatric emergency medicine fellowships: a survey

A survey of 24 existing pediatric emergency medicine fellowship programs as of December 1987 was conducted in order to characterize the following attributes of training in pediatric emergency medicine: amount of clinical time, required and elective rotations, didactic and research experience, patient volume, and staffing. Time spent in the emergency department varies between three and 10 months annually, with a mean of 34.5 hours per week. Twenty-two (92%) of the programs have required rotations. All responding programs require research and some degree of didactic education. Patient volume varies between 20,000 and 70,000, with a median of 41,000. The data offered should act as a reference for the further development of new and existing programs.

Outcome of patients with human immunodeficiency virus on maintenance hemodialysis

Fifty-one adults with HIV infection, including 20 chronic hemodialysis patients with superimposed HIV infection and 31 patients with HIV-associated nephropathy requiring chronic maintenance hemodialysis were followed to evaluate survival on outpatient dialysis in relation to the clinical stage of the HIV infection. Regardless of when they contracted the infection, AIDS patients who required maintenance hemodialysis had a poor prognosis. All 17 patients who developed AIDS died after a mean of 93 +/- 32 days on hemodialysis (median 30 days; range 2 to 540 days). On the other hand, 12 asymptomatic HIV carriers were alive after a mean follow-up on chronic hemodialysis of 488 +/- 75 days (median 420 days; range 142 to 850 days); and five hemodialyzed patients with ARC were alive after 564 +/- 191 days (median 420 days; range 150 to 1230 days). The data confirm the lack of effectiveness of maintenance hemodialysis for prolonging life in patients with AIDS. This dismal prognosis was evident whether renal failure antedated HIV infection or whether it was HIV-associated. In asymptomatic HIV carriers and in patients with ARC, however, maintenance hemodialysis provides meaningful, long-term life support.