Is perinatal substance abuse falling through the cracks?

OBJECTIVES

Perinatal substance abuse (PSA) is associated with increased risk of prematurity, low birth weight, neonatal abstinence syndrome, behavioral issues and learning difficulties. It is imperative that robust care pathways are in place for these high-risk pregnancies and that staff and patient education are optimized. The present study explores the knowledge and attitudes of healthcare professionals toward PSA to identify knowledge gaps to enhance care and reduce stigma.

METHODS

This is a cross-sectional study using questionnaires to survey healthcare professionals (HCPs) working in a tertiary maternity unit (n = 172).

RESULTS

The majority of HCPs were not confident in the antenatal management (75.6%, n = 130) or postnatal management (67.5%, n = 116) of PSA. More than half of HCPs surveyed (53.5%, n = 92) did not know the referral pathway and 32% (n = 55) did not know when to make a TUSLA referral. The vast majority (96.5%, n = 166) felt that they would benefit from further training, and 94.8% (n = 163) agreed or strongly agreed that the unit would benefit from a drug liaison midwife. Among study participants, 54.1% (n = 93) agreed or strongly agreed that PSA should be considered a form of child abuse and 58.7% (n = 101) believe that the mother is responsible for damage done to her child.

CONCLUSIONS

Our study highlights the urgent need for increased training on PSA to enhance care and reduce stigma. It is imperative that staff training, drug liaison midwives and dedicated clinics are introduced to hospitals as a matter of high priority.

Can Anti-Müllerian Hormone levels predict future pregnancy outcomes in recurrent pregnancy loss?

OBJECTIVE

Serum Anti-Müllerian Hormone (AMH) levels have been shown to be lower among women who have experienced recurrent pregnancy loss (RPL) compared with the general population. However, it is unclear whether it can predict livebirth. This study aims to determine whether AMH can predict the likelihood of a livebirth in women with RPL.

STUDY DESIGN

Prospective analysis of a consecutive cohort of women undergoing investigation for RPL in a tertiary referral centre over a seven year period (August 2014 -December 2021). Analysis was performed using descriptive statistics, chi-square models and logistic regression models adjusting for maternal age and previous livebirth. Exclusion criteria for the regression analysis included abnormal parental karyotype and abnormal pelvic ultrasound scan. Pregnancy outcome was defined as livebirth or further pregnancy loss.

RESULTS

There were 488 women who underwent investigation of RPL during the study period. Of these, 65.2% (n = 318) conceived following attendance at the clinic. The majority of these women (69.4%, n = 221) proceeded to have a livebirth. There were no differences in median AMH levels between the livebirth group and the further pregnancy loss group (11 pmol/L vs 9 pmol/L respectively (p = 0.083). AMH did not affect clinical pregnancy rates (p = 0.77, 95% CI = 0.99 [0.98, 1.01]) or pregnancy outcome (p = 0.30, 95% CI = 1.01 [0.99, 1.04]). Abnormal pelvic ultrasonography (p = 0.04) and an abnormal parental karyotype (p = 0.04) were associated with an increased likelihood of a subsequent pregnancy loss.

CONCLUSION

Although AMH levels may have some utility in counselling of some couples with RPL, these contemporaneous data indicate that low AMH does not negatively influence subsequent pregnancy outcome in women with recurrent pregnancy loss.

Abstract CT072: First in human (FIH) dose escalation studies of intravenous administration of VSV-IFNβ-NIS (Voyager-V1™) in Stage IV or recurrent endometrial cancer

Introduction. VSV-IFNβ-NIS is an oncolytic vesicular stomatitis virus (VSV; Rhabdovirus family) with rapid replication kinetics and potent antitumor activity. VSV-IFNβ-NIS encodes the human interferon beta (IFNβ) gene as a STING agonist and the human sodium iodide symporter (NIS) as a reporter gene for tracking the pharmacokinetics (PK) of virus replication in infected tumors. VSV replicates selectively in cancer cells and has promising preclinical antitumor activity across a broad spectrum of cancer types. We report here the safety and correlative data from an FIH trial of intravenous (IV) administration of VSV-IFNβ-NIS in patients with stage IV or recurrent endometrial cancer (EC).

Methods. There are two ongoing IV FIH trials using VSV-IFN-NIS, in patients with EC (NCT03120624) and one in patients with hematological malignancies (NCT03017820). In EC, it is a classical 3+3 phase I trial, starting at 5x109 TCID50 through 5x1011 TCID50, given as a single IV dose. The primary objective is safety and tolerability; secondary objectives include monitoring the PK of viral replication through SPECT/CT imaging with NIS gene, viremia, virus shedding, preliminary efficacy, changes in the immune profile of peripheral blood leukocytes, and immunohistochemistry for immune cell infiltrates in tumors.

Results. Nine patients have received IV VSV-IFNβ-NIS to date; three with EC and six with hematologic malignancies. The highest dose administered to date is 1.7x1010 TCID50 and dose escalation is ongoing. No DLTs have been observed. Patients experienced the expected infusion related AEs including rigors, chills, nausea, fever, hypotension, and hot flashes. Multiple cytokines increased at 4h post infusion of virus, but most returned to baseline levels by 24h. Viremia was detectable in all patients at the end of infusion, and to varying levels at 30 mins, 1, 2, 4, 24, 48h or 72 hours post virus infusion. No persistent viremia was observed. No infectious virus was recovered in buccal swabs or urine and neutralizing anti-VSV antibodies were present by day 29. Extensive immune phenotyping for T cells, NK, MSDC, myeloid cells performed on peripheral blood cells collected at baseline and at day 3, 8, 15 and 29 post virus infusion showed a trend towards increased PD-1 expression on CD8+ cells. Early IHC data suggests an increase in CD3+ and CD8+ cells in tumor biopsies at day 29 and 3 months in patients with EC treated at the first dose level. Elispot assays for shared EC antigens are pending.

Conclusions. IV administration of VSV-IFNβ-NIS up to doses of 1.7x1010 is safe and well tolerated. There is evidence of T cell activation with increased PD-1 expression in CD8+ T cells in the peripheral blood and increased in CD3+ and CD8+ cells in tumor biopsies. Updated results for the EC study will be reported.

Citation Format: Jamie Bakkum-Gamez, Matthew S. Block, Nanda Packiriswamy, Bethany A. Brunton, Upreti Deepak, Jonathan M. Mitchell, Lukkana Suksanpaisan, Pamela Atherton, Amylou Dueck, Stephen J. Russell, Martha Q. Lacy, Kah-Whye Peng. First in human (FIH) dose escalation studies of intravenous administration of VSV-IFNβ-NIS (Voyager-V1™) in Stage IV or recurrent endometrial cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT072.

First live birth after uterus transplantation in the United States

Uterus transplantation has proven to be a successful treatment for women with absolute uterine infertility, caused either by the absence of a uterus or the presence of a nonfunctioning uterus. We report the first birth of a healthy child following uterus transplantation in the United States, from a recipient of a uterus allograft procured from an altruistic living donor. Two major modifications from the previously reported live births characterized this uterus transplant. First, the transplanted uterus relied upon and sustained the pregnancy while having only the utero-ovarian vein as venous outflow. The implication is a significantly simplified living donor surgery that paves the way for minimally invasive laparoscopic or robot-assisted techniques for the donor hysterectomy. Second, the time from transplantation to embryo transfer was significantly shortened from prior protocols, allowing for an overall shorter exposure to immunosuppression by the recipient and lowering the risk for potential adverse effects from these medications.

Living Donor Uterus Transplantation: A Single Center's Observations and Lessons Learned From Early Setbacks to Technical Success

Uterus transplantation is a vascularized composite allograft transplantation. It allows women who do not have a uterus to become pregnant and deliver a baby. In this paper, we analyze the first five cases of living donor uterus transplantation performed in the United States. The first three recipients lost their uterus grafts at days 14, 12, and 6, respectively, after transplant. Vascular complications, related to both inflow and outflow problems, were identified as the primary reason for the graft losses. Two recipients, at 6 and 3 mo, respectively, after transplant, have functioning grafts with regular menstrual cycles. Ultimate success will be claimed only after a live birth. This paper is an in-depth analysis of evaluation, surgical technique, and follow-up of these five living donor uterus transplants. The lessons learned were instrumental in allowing us to evolve from failure to technical and functional success. We aim to share our conclusions and build on knowledge in the evolving field of uterus transplantation.

An oral carcinogenicity and toxicity study of senna (Tinnevelly senna fruits) in the rat

Senna (Tinnevelly senna fruits), a known laxative derived from plants, was administered by gavage to Sprague-Dawley (Crl:CD (SD) BR) rats once daily at dose levels of 0, 25, 100 and 300 mg/kg/day for up to 104 consecutive weeks. Based upon clinical signs related to the laxation effect of senna, the highest dose (300 mg/kg/day) was considered to be a maximum tolerated dose. Sixty animals per sex were assigned to the control and dose groups. Assessments included clinical chemistry, hematology, full histology (control and high-dose groups; in addition, low and mid dose: intestinal tract, adrenals, liver, kidneys, brain and gross lesions) and toxicokinetics. The primary treatment-related clinical observation was mucoid feces seen at 300 mg/kg/day. When compared to controls, animals administered 300 mg/kg/day had slightly reduced body weights, increased water consumption and notable changes in electrolytes in serum (increases in potassium and chloride) and urine (decreases in sodium, potassium and chloride). The changes in electrolytes are most likely physiologic adaptations to the laxative effect of senna. At necropsy, dark discoloration of the kidneys was observed in animals in all treated groups. Histological changes were seen in the kidneys of animals from all treated groups and included slight to moderate tubular basophilia and tubular pigment deposits. In addition, for all treated groups, minimal to slight hyperplasia was evident in the colon and cecum. These histological changes, together with the changes seen in the evaluation of clinical chemistry and urine parameters, have been shown to be reversible in a previous 13-week rat study of senna. No treatment-related neoplastic changes were observed in any of the examined organs. Based upon these data, it is concluded that senna is not carcinogenic even after daily administration for 2 years at dosages of up to 300 mg/kg/day in Sprague-Dawley rats.

Role of PI 3-kinase and PIP3 in submandibular gland branching morphogenesis

The mouse submandibular gland (SMG) epithelium undergoes extensive morphogenetic branching during embryonic development as the first step in the establishment of its glandular structure. However, the specific signaling pathways required for SMG branching morphogenesis are not well understood. Using E13 mouse SMG organ cultures, we showed that inhibitors of phosphatidylinositol 3-kinase (PI 3-kinase), wortmannin and LY294002, substantially inhibited branching morphogenesis in SMG. Branching morphogenesis of epithelial rudiments denuded of mesenchyme was inhibited similarly, indicating that PI 3-kinase inhibitors act directly on the epithelium. Immunostaining and Western analysis demonstrated that the p85 isoform of PI 3-kinase is expressed in epithelium at levels higher than in the mesenchyme. A target of PI 3-kinase, Akt/protein kinase B (PKB), showed decreased phosphorylation at Ser(473) by Western analysis in the presence of PI 3-kinase inhibitors. The major lipid product of PI 3-kinase, phosphatidylinositol 3,4,5-trisphosphate (PIP(3)), was added exogenously to SMG via a membrane-transporting carrier in the presence of PI 3-kinase inhibitors and was found to stimulate cleft formation, the first step of branching morphogenesis. Together, these data indicate that PI 3-kinase plays a role in the regulation of epithelial branching morphogenesis in mouse SMG acting through a PIP(3) pathway.

Lambda spectra in 11.6A GeV/c Au-Au collisions

E896 has measured Lambda production in 11.6A GeV/c Au-Au collisions over virtually the whole rapidity phase space. The midrapidity p(t) distributions have been measured for the first time at this energy and appear to indicate that the Lambda hyperons have different freeze-out conditions than protons. A comparison with the relativistic quantum molecular dynamics model shows that while there is good shape agreement at high rapidity the model predicts significantly different slopes of the m(t) spectra at midrapidity. The data, where overlap occurs, are consistent with previously reported measurements.

Medicare fees and small area variations in breast-conserving surgery among elderly women

This study used data from Medicare files, the American Hospital Association's Annual Survey of Hospitals, and the 1990 census to investigate whether Medicare fees for breast-conserving surgery (BCS) and mastectomy (MST) affected the rate of BCS across 799 3-digit ZIP code areas in 1994. The full model, which was based on the conceptual framework of the supply of and demand for different treatments, explained 51 percent of the variation in BCS rates. Medicare fees were statistically significant and had the hypothesized effects: a 10 percent higher BCS fee was associated with a 7 to 10 percent higher BCS rate, while a 10 percent higher MST fee was associated with a 2 to 3 percent lower proportion receiving BCS. Other significant economic variables were proximity to a radiation therapy hospital, a teaching hospital or a cancer center, and the percentage of elderly women with incomes below the poverty rate, which were negatively related to the BCS rate. Variations in age, race, and metropolitan populations had small or insignificant effects. The single most important was the percentage of cases with one or more comorbidities.

Ultrasonographic surveillance in red blood cell alloimmunization

OBJECTIVE

This study was undertaken to audit ultrasonographic measurements of fetal liver length and middle cerebral artery peak velocity in cases of red blood cell alloimmunization between 1986 and 1999.

STUDY DESIGN

A total of 200 fetuses at risk for anemia because of red blood cell alloimmunization underwent ultrasonographic measurement of the length of the right lobe of the liver, 45 underwent Doppler recording of middle cerebral artery peak velocity, and 119 underwent fetal blood sampling.

RESULTS

The overall survival was 188 of 200 (94%). Among 69 fetuses found to have anemia, liver length values in 64 (93%) were at the 95th percentile or greater, and the other 5 were in the upper part of the normal range. The middle cerebral artery peak velocity was > or =95th percentile in 15 of the 19 cases of anemia in which this value was measured (79%). Among those measured within 1 week of birth, all liver lengths were at least in the upper part of the normal range, with most >95th percentile, including 1 case with a cord blood hemoglobin concentration <90 g/L.

CONCLUSIONS

All fetuses with anemia identified at fetal blood sampling had enlarged livers with 93% at > or =95th percentile. The peak velocity in the middle cerebral artery was abnormal in most fetuses with anemia.

New molybdenum catalysts for alkyl olefin epoxidation. Their implications for the mechanism of oxygen atom transfer

We report here the design, synthesis, and characterization of new (dioxo)Mo(VI) epoxidation catalysts based on monoanionic tridentate ligands. Two important features distinguish these catalysts from those previously reported. First, their coordination environment remains well-defined during the epoxidation reaction. Second, the ligand design does not permit simultaneous coordination of olefin and alkyl hydroperoxide. Based on the study of these new catalysts, we conclude that direct oxygen atom transfer from coordinated alkyl peroxide to olefin remains the simplest mechanism consistent with the available data. We discuss literature discrepancies in this regard.

Differential access in the receipt of antiretroviral drugs for the treatment of AIDS and its implications for survival

BACKGROUND

Recently published research based on selected samples of patients treated at human immunodeficiency virus clinics documents that use of more intensive antiretroviral drug therapies is responsible for significant declines in morbidity and mortality in persons living with human immunodeficiency virus or acquired immunodeficiency syndrome (PLWHAs). In this study, we evaluate whether receipt of more recently developed antiretroviral therapies varies by sex and race/ethnicity in a large population-based sample of PLWHAs and whether receipt of such drugs has any impact on survival.

METHODS

Analysis of Florida Medicaid eligibility, enrollment, and claims data for PLWHAs for 1993 through 1997. Receipt of 2 nucleoside analogs (TWONUKES) and receipt of 1 protease inhibitor and a nucleoside combination (PI+NUKES) was constructed from claims data. The probability of dying was constructed from eligibility and enrollment data.

RESULTS

The probabilities of receiving TWONUKES and PI+NUKES are 0.16 and 0.09, respectively, lower for women relative to men (P<.01 for both). Blacks are more likely to receive TWONUKES than whites, whereas the reverse is true for Hispanics; this probability is almost 0.04 higher for blacks and 0.03 lower for Hispanics relative to whites (P<.01). In contrast, blacks are significantly less likely to receive PI+NUKES (P<.01). Both drug variables have large statistically significant negative effects on the probability of death. The PLWHAs who received PI+NUKES are 60% as likely to die each month (P<.01). Receipt of TWONUKES lowers the relative hazard of death by close to 66% each month (P<.01). Survival varies significantly by sex and race/ethnicity. Controlling for receipt of drug therapy and diagnosed health throughout the period, women are 56% as likely to die as men (P<.01). Hispanics are almost 14% less likely to die each month relative to whites (relative hazard, 0.87), and blacks are 20% more likely to die than whites (relative hazard, 1.21).

CONCLUSIONS

States need to investigate why women are less likely to receive antiretroviral drug therapies than men and to consider policies that might foster better access to antiretroviral therapies for women with acquired immunodeficiency syndrome because these efforts might yield even further reductions in mortality in women. Given the large reductions in mortality that accompany receipt of antiretroviral therapies, states need to foster policies that promote widespread use of new drug treatment protocols.

Physicians' responses to Medicare fee schedule reductions

BACKGROUND

Relatively little empirical research has addressed physicians' responses to fee changes under the Medicare Fee Schedule.

OBJECTIVES

We analyzed Medicare claims data for ophthalmologists and orthopedic surgeons for the years 1991 through 1994 to evaluate the relative importance of profit-maximizing and target-income theories in determining physicians' supply responses to specific Medicare fee reductions.

RESEARCH DESIGN

This study was designed to estimate the impact of fee reductions for cataract extractions and major joint repair/replacement procedures through pooled cross-section time series data.

RESULTS

The supply function for cataract extractions has both strong own-price and cross-price effects, as well as a highly significant negative income effect. Yet, the magnitude of the income effect is small; thus, the substitution effect dominates the income effect. Similarly, in the supply functions for joint procedures, the own price has the expected positive sign, implying that as the fee declines, orthopedic surgeons will perform fewer joint surgeries. However, the cross-price variable has the correct sign only if treated as exogenous, and the variables measuring the income effect have the wrong sign, although their magnitude is small.

CONCLUSIONS

These results suggest that the Medicare Fee Schedule does have the potential to influence physicians' supply decisions, but these effects may vary by specialty and service.

Measuring the effects of managed care on physicians' perceptions of their personal financial incentives

Using data from the 1997 Resurvey of Young Physicians (N = 1,549), this study examines whether several measures of physicians' contractual arrangements with health plans are associated with their perceptions of overall financial incentives to either decrease or increase the volume of services to patients. Results indicate the following factors were significantly associated with an increased likelihood of reporting an incentive to decrease services: a gatekeeper arrangement with a compensation incentive; the perception of a high risk of plan deselection for physicians with high costs; the perception that referrals received depended on the costs of care provided; communication prohibiting or discouraging the disclosure to patients of the physician's financial relationship with the health plan; receiving capitation payments from at least one plan; and employment in a health maintenance organization. Being compensated on a fee-for-service basis or receiving a salary with incentive or bonus provisions (compared to straight salary) were associated with an increased likelihood of reporting an incentive to increase services to patients. Physicians' overall methods of compensation had a relatively small impact on their perceived financial incentives compared to other statistically significant factors. Our findings suggest that physicians' self-reported, overall personal financial incentives within their practices are a valid summary measure of the heterogeneous mix of specific financial arrangements faced by most physicians.

Effects of case management and new drugs on Medicaid AIDS spending

This study evaluates the effects of Florida's participation in the Medicaid acquired immunodeficiency syndrome (AIDS) home and community-based waiver and the use of recently developed AIDS drugs on spending per Medicaid beneficiary. We find that monthly Medicaid spending for waiver non-participants was significantly higher than was spending for waiver nonparticipants. The major reason for the cost difference is that nonwaiver enrollees incurred significantly higher inpatient costs than did those enrolled in the waiver. Although waiver enrollees had higher drug spending, these represent only a fraction of the higher inpatient costs incurred by nonwaiver enrollees. Thus, it appears that adherence to appropriate medications reduces the need for inpatient care. The case management approach of the AIDS waiver may have similar effects for persons with other chronic diseases.

Physicians' ethical beliefs about cost-control arrangements

BACKGROUND

Although much has been written about the ethics of new methods of health care financing, little is known about the extent to which physicians experience these cost-control arrangements as ethical problems.

METHOD

A cross-sectional telephone survey of 1,549 physicians, 8 to 17 years after residency, randomly selected from 75 US metropolitan service areas (response rate, 74.0%).

RESULTS

Only 17.0% believed that financial incentives to limit services are ethically acceptable. Although 52.9% thought that physicians should try to abide by guidelines discouraging the use of interventions with possible but unproven benefit, only 14.5% thought such guidelines should be enforced by payers. Only 5.7% thought that it was morally acceptable for payers to discourage physicians from telling patients about their personal financial incentives, and only 9.1% found compliance with such restrictions morally acceptable. Changes in the health care system in the past 5 years were believed to have had a negative impact on their own patients' trust in them by 50.6%, and 80.8% believed that changes in the health care system in the past decade have diminished physicians' commitment to an ethic of undivided loyalty to patients. In multiple regression analysis, physicians who reported that the overall personal financial incentives in their practices encouraged them to reduce services were significantly more likely to have ethical objections to such incentives, to believe their own patients' trust in them had diminished, and to believe that the ethic of undivided loyalty to patients had diminished.

CONCLUSIONS

Many of the methods now commonly used to influence medical decision making are considered ethically objectionable by most midcareer physicians. Whether their ethical disquiet about these arrangements is justified cannot be answered from these data.

Quality of life in assisted living homes: a multidimensional analysis

This study examined the impact of four domains upon the quality of life (QOL) of senior residents living in assisted living homes: (a) demographic characteristics and health status, (b) social involvement, (c) facility characteristics, and (d) the social climate. Participants were 201 residents with functional impairments living in 55 different assisted living facilities in California. QOL was measured with three scales of depression, life satisfaction, and facility satisfaction. Bivariate correlations and ANOVAs found significant relations between at least one of the QOL measures and age, health status, social and family involvement measures, facility characteristics, and social climate measures. Social climate measures of cohesion, conflict, and independence had the strongest zero-order correlations. Regression analyses for the three QOL measures found cohesion to be the strongest predictor in all three regressions. Other QOL predictors in the regression analyses were fewer health conditions, participation in social activities, monthly family contact, and an environment low in conflict. Findings suggest that assisted living homes can improve resident QOL by creating a cohesive social environment, and encouraging social participation and family involvement.

Brainstem pain modulating circuitry is sexually dimorphic with respect to mu and kappa opioid receptor function

We have previously shown that activation of kappa opioid receptors within the rostral ventral medulla in lightly anesthetized rats has an anti-mu opioid analgesic action in male rats. Microinjections of the kappa opioid receptor agonist, U69593, attenuated the increase in tail-flick latency produced by activation of mu opioid receptors located within the ventrolateral periaqueductal gray. There are sex differences in the pain modulating potency of opioid analgesics, including kappa opioid agonists. In the present study, we examined whether activation of kappa opioid receptors within the rostral ventral medulla in lightly anesthetized female rats produces an anti-mu opioid analgesic effect similar to that found in males. We found that in the RVM the same dose of kappa opioid receptor agonist that reduces mu receptor-mediated increase in tail-flick latency in male rats produces a moderate increase in tail-flick latency in female rats. Additionally, we discovered that female rats are significantly more sensitive to the mu opioid agonist, DAMGO, injected into the ventrolateral periaqueductal gray. The results indicate that these two brain structures, which mediate the analgesic effects of opioids, are sexually dimorphic with regard to opioid receptor function.

A locus and mechanism of action for associative morphine tolerance

Repeated administration of an opioid in the presence of specific environmental cues can induce tolerance specific to that setting (associative tolerance). Prolonged or repeated administration of an opioid without consistent contextual pairing yields non-associative tolerance. Here we demonstrate that cholecystokinin acting at the cholecystokinin-B receptor is required for associative but not non-associative morphine tolerance. Morphine given in the morphine-associated context increased Fos-like immunoreactivity in the lateral amygdala and hippocampal area CA1. Microinjection of the cholecystokinin B antagonist L-365,260 into the amygdala blocked associative tolerance. These results indicate that cholecystokinin acting in the amygdala is necessary for associative tolerance to morphine's analgesic effect.

HMO penetration and physicians' earnings

OBJECTIVES

The goal of this study is to estimate whether cross-sectional variations in enrollment in health maintenance organizations (HMOs) affected physicians' earnings and hourly income in 1990.

METHODS

Using data from a nationally representative sample of 4,577 younger physicians (<45 years) conducted in 1991, we estimated a partial reduced-form model of physicians annual income and per hour income. We tested whether HMO penetration is endogenous and used the instrumental variables approach to obtain unbiased estimates.

RESULTS

HMO penetration had a negative and statistically significant impact on physicians earnings in 1990. A doubling of the average level of HMO penetration in the market is estimated to reduce annual earnings by 7% to 10.7%, and hourly earnings by approximately 6% to 9%.

CONCLUSIONS

It appears that HMOs were successful in reducing physicians' annual and per hour earnings in 1990, presumably through a combination of fewer visits and lower payment rates for people covered by HMOs. Although these results cannot be generalized to all physicians, the experience of a younger cohort of physicians may still be a good indicator of the future effects of HMOs because younger physicians may be more susceptible to market forces than older and more established physicians. Moreover, these results may be somewhat conservative because they reflect market behavior in 1990, several years before the rapid growth and more aggressive market behavior of HMOs in recent years.

Perceived financial incentives, HMO market penetration, and physicians' practice styles and satisfaction

OBJECTIVE

To estimate the effects of physicians' personal financial incentives and other measures of involvement with HMOs on three measures of satisfaction and practice style: overall practice satisfaction, the extent to which prior expectations about professional autonomy and the ability to practice good-quality medicine are met, and several specific measures of practice style.

DATA SOURCES

A telephone survey conducted in 1997 of 1,549 physicians who were located in the 75 largest Metropolitan Statistical Areas in 1991. Eligible physicians were under age 52, had between 8 and 17 years of post-residency practice experience, and spent at least 20 hours per week in patient care. The response rate was 74 percent.

STUDY DESIGN

Multivariate binomial and multinomial ordered logistic regression models were estimated. Independent variables included physicians' self-reported financial incentives, measured by the extent to which their overall financial arrangements created an incentive to either reduce or increase services to patients, the level of HMO penetration in the market, employment setting, medical specialty, exposure to managed care while in medical training, and selected personal characteristics.

PRINCIPAL FINDINGS

About 15 percent of survey respondents reported a moderate or strong incentive to reduce services; 70 percent reported a neutral incentive; and 15 percent reported an incentive to increase services. Compared to physicians with a neutral incentive, physicians with an incentive to reduce services were from 1.5 to 3.5 times more likely to be very dissatisfied with their practices and were 0.2 to 0.5 times as likely to report that their expectations regarding professional autonomy and ability to practice good-quality medicine were met. They were also 0.2 to 0.6 times as likely to report having the freedom to care for patients the way they would like along several specific measures of practice style, such as sufficient time with patients, ability to hospitalize, ability to order tests and procedures, and ability to make referrals. These effects were generally reinforced by practicing in an area with a high level of HMO penetration and were offset to some extent by having had exposure to HMOs and the practice of cost-effective medicine while in medical training.

CONCLUSIONS

Although financial incentives to reduce services are not widespread, there is a legitimate reason to be concerned about possible adverse affects on the quality of care. More research is needed to investigate directly whether changes in patients' health are affected by their physicians' financial incentives.

Ultrasonographic measurement of liver length in the small-for-gestational-age fetus

OBJECTIVE

Our purpose was to measure fetal liver size in small-for-gestational-age fetuses diagnosed by ultrasonography and to determine whether the small abdominal circumference used to diagnose small for gestational age is the result of a small liver.

STUDY DESIGN

Ninety-eight pregnant women who were diagnosed as having a fetus that was small for gestational age were included. All had a fetal ultrasonographic measurement of abdominal circumference <10th percentile for gestational age. Measurements were made of the length of the right lobe of the fetal liver within 2 weeks of delivery. The liver length measurements were compared with data collected from a normal population that had been previously published by the authors. The group of fetuses with liver length measurements <10th percentile for gestational age were compared with those with liver length measurements within normal limits.

RESULTS

Liver length measurements were >10th percentile in 80 fetuses (82%). Eighteen fetuses (18%) had small liver lengths, and this group had significantly smaller antenatal ultrasonographic measurements of head, abdomen, and femur. They were smaller at birth with smaller placentas and they had a higher perinatal mortality rate.

CONCLUSION

The small abdominal circumference measurement that is the mainstay of ultrasonographic diagnosis of small for gestational age is thought to be a reflection of fetal liver size. This study questions that assumption. The majority of small-for-gestational-age fetuses in this small study did not have small liver lengths. The small abdominal circumference measurement may reflect a reduction in size of other intra-abdominal organs, reduced amounts of fat, or possibly an elevated diaphragm because of poor lung growth.

Validation of the LacTek test applied to spiked extracts of tissue samples: determination of performance characteristics

LacTek tests are competitive enzyme-linked immunosorbent assays intended for rapid detection of antimicrobial residues in bovine milk. In this study, the LacTek test protocol was modified for use with extracts of bovine tissue to detect beta-lactam, tetracycline, and sulfamethazine residues. Test performance characteristics--precision, accuracy, ruggedness, practicability, and analytical specificity and sensitivity--were investigated. Results suggest that LacTek tests can be easily adapted to detect antimicrobial residues in extracts of lean ground beef. However, positive samples may not contain residues at violative concentrations (i.e., Canadian maximum residue limits), and therefore, additional analysis would be required for final confirmation and quantitation (e.g., chromatography).

The contribution of the rostral ventromedial medulla to the antinociceptive effects of systemic morphine in restrained and unrestrained rats

Although there are numerous opioid-sensitive structures in the central nervous system, the contribution of each to the analgesic effect of systemically administered morphine is controversial. One such structure is the rostral ventromedial medulla. In the present study, we tested the hypothesis that the rostral ventromedial medulla is necessary for the full expression of systemic morphine-induced antinociception. Additionally, we examined whether the modulatory effect of the rostral ventromedial medulla on tail-flick latency is dependent on the behavioral state of the animal. In unrestrained rats, inactivation of the rostral ventromedial medulla with either lidocaine (0.5 microl of 4%) or muscimol (50 ng) had no effect on tail-flick latency. In contrast, in restrained rats, inactivation of the rostral ventromedial medulla with either lidocaine (0.5 microl of 4%) or muscimol (50 ng) significantly decreased tail-flick latency. In both conditions, microinjection of morphine (5 microg) into this region significantly increased tail-flick latency. Additionally, in unrestrained rats, muscimol (50 ng) and cholecystokinin tetrapeptide (0.5 ng) infusion into the rostral ventromedial medulla completely reversed systemic morphine-induced analgesia, while lidocaine (0.5 microl of 4%) and cholecystokinin octapeptide (0.25 ng) infusion partially reversed systemic morphine-induced analgesia. These findings demonstrate that the rostral ventromedial medulla does not tonically modulate tail-flick latency in unrestrained rats, but does modulate tail-flick latency when animals are stressed via restraint. These findings also strongly support the hypothesis that the rostral ventromedial medulla is necessary for the full analgesic effects of systemically administered morphine.

Characteristics of the LacTek test as applied to tissue samples: assessment of performance using incurred field samples

The Lactek test, marketed for antimicrobial residue detection in milk, was validated for the detection of antimicrobial residues in tissues. A previous study found that the LacTek test could confidently identify tissue samples spiked with antimicrobial residues. However, the test could not reliably distinguish violative from nonviolative spiked samples relative to Canadian maximum residue limits (MRLs). The objectives of this study were to assess and compare the performance of the LacTek tests for beta-lactams, tetracyclines, gentamicin, and sulfamethazine on samples containing naturally incurred residues by running the test in parallel with the standard microbial inhibition test (MIT) presently used for the routine testing of tissues at our facility and to assess the agreement with high pressure liquid chromatographic (HPLC) determinative methods. Parallel testing with the official MIT found that the Lactek tests could be confidently used for testing tissue samples containing incurred residues. Among 1,008 MIT-positive samples, the LacTek test found that 90% contained beta-lactams and/or tetracyclines. A further 7.3% of violative residues could not be identified to an antimicrobial class. In addition, 9% of samples testing negative on the MIT were found to contain an antimicrobial residue by the LacTek tests. Comparative testing with HPLC methods found that there was very good agreement between the two tests and that most violations were due to penicillin G and oxytetracycline. Although the LacTek test cannot be used to distinguish violative from nonviolative residue levels, it does offer several advantages over the present MIT. These include speed, ease of use, the ability to identify residues to a specific class, and an improved sensitivity at the MRL level for the most commonly found antimicrobials in tissue.

Antimicrobial drug residues in milk and meat: causes, concerns, prevalence, regulations, tests, and test performance

This paper presents a historical review of antimicrobial use in food animals, the causes of residues in meat and milk, the types of residues found, their regulation in Canada, tests used for their detection, and test performance parameters, with an emphasis on immunoassay techniques. The development of residue detection methods began shortly after the introduction of antimicrobials to food animal production in the late 1940s. From initial technical concerns expressed by the dairy industry to the present public health and international trade implications, there has been an ongoing need for reliable, sensitive, and economical methods for the detection of antimicrobial residues in food animal products such as milk and meat. Initially there were microbial growth inhibition tests, followed by more sensitive and specific methods based on receptor binding, immunochemical, and chromatographic principle. An understanding of basic test performance parameters and their implications is essential when choosing an analytical strategy for residue testing. While each test format has its own attributes, none test will meet all the required analytical needs. Therefore the use of a tiered or integrated system employing assays designated for screening and confirmation is necessary to ensure that foods containing violative residues are not introduced into the food chain.

Doppler waveforms from the pulmonary arterial system in normal fetuses and those with pulmonary hypoplasia

Color, pulsed and power Doppler were used to image the fetal pulmonary vasculature in 150 normal pregnancies and ten pregnancies in which the fetus had bilateral multicystic dysplastic kidney disease (MCDK) and associated pulmonary hypoplasia. The normal fetuses had a high resistance pattern in the main pulmonary artery vasculature. There were no significant changes in the resistance of the main pulmonary artery, right pulmonary artery and left pulmonary artery, with increasing gestational age. In the peripheral pulmonary arteries the resistance was less with an increase in diastolic flow, with advancing gestation. All fetuses with MCDK died. This group did not have significantly different Doppler waveforms in the main pulmonary arteries, but Doppler signals from the peripheral pulmonary arteries showed a high resistance pattern quite different from that of normal fetuses. Doppler measurements of the peripheral pulmonary artery may give additional information useful in diagnosing pulmonary hypoplasia.

Breast cancer treatment choice and mastectomy length of stay: a comparison of HMO and other privately insured women

This study uses hospital discharge abstract data from five states (Massachusetts, New York, New Jersey, Maryland, and California) for two years (1988 and 1991) to investigate whether enrollment in an HMO affects nonelderly breast cancer patients' treatment choice (breast-conserving surgery or mastectomy) and hospital length of stay for women who have a mastectomy. Since HMO insurance creates financial incentives that differ from other types of insurance coverage, it is important to assess whether the type of insurance coverage affects the care received by breast cancer patients. Although the results vary from state to state, they suggest that HMO enrollees are less likely to receive breast-conserving surgery (relative odds =.93). However, an unambiguous interpretation of this findings requires better data on patients' opportunity costs and preferences, which also may vary with type of insurance coverage. Among women who had a mastectomy, HMO enrollment was generally associated with a 4.5% shorter average length of stay and a greater likelihood of a short stay (one or two days, relative odds = 1.21-1.29). A much higher proportion of mastectomy patients in California than in other states had a short stay. Follow-up of these women may indicate whether short stays lead to adverse long-term health effects.

Effects of HMO market penetration on physicians' work effort and satisfaction

We investigate whether geographic variations in health maintenance organization (HMO) market penetration are associated with three aspects of physicians' practices: number of hours worked per year, number of patients seen per week, and satisfaction with the current practice. Based on multivariate regression analysis of data for 4,373 patient care physicians (under age forty-five) from a national random sample surveyed in 1991, we estimate that a doubling of the average level of HMO penetration is associated with statistically significant differences of 4 percent fewer annual hours, 13.7 percent fewer patients seen per week, and a 20 percent greater likelihood of not being very satisfied with one's current practice.

Access to bone marrow transplantation for leukemia and lymphoma: the role of sociodemographic factors

PURPOSE

Use of bone marrow transplantation (BMT), a complex, costly treatment for many forms of cancers, has increased significantly in recent years. The increasingly competitive health care marketplace raises concerns about patient access to costly medical procedures such as BMT. We attempted to evaluate patient access to BMT for the treatment of leukemias and lymphomas.

METHODS

We analyzed inpatient hospital discharge data from four states (California, Maryland, Massachusetts, and New York) for 2 years (1988 and 1991) to examine whether the use of BMT for patients with either leukemia or lymphoma varies by sociodemographic characteristics and insurance coverage. We developed a sorting algorithm to collapse the discharge data into patient level records. We used logistic regression to analyze the odds of receiving a BMT stratified by disease type (leukemia or lymphoma).

RESULTS

After controlling for other factors, black patients with leukemia are 51% to 53% as likely as whites, while black patients with lymphoma are 34% to 45% as likely as white patients to undergo a BMT (P < .05). Medicaid, self-pay patients, and Health Maintenance Organization (HMO) enrollees with either leukemia or lymphoma are significantly less likely to undergo a BMT compared with patients with private insurance. Younger patients are significantly more predisposed to undergo a BMT than older patients. The odds of receiving a BMT have increased over time, but the rates of increase vary by state. Consistent with clinical expectations, the relative odds of BMT vary significantly by type of leukemia or lymphoma.

CONCLUSION

Substantial variation exists in access to BMT for patients with either leukemia or lymphoma. Black patients, those enrolled in HMOs, those covered by Medicaid, and self-pay patients were less likely to receive a BMT when admitted for either leukemia or lymphoma. These findings raise concerns about access to cancer treatments for patients in the current health care system.

Expenditures on services for persons with acquired immunodeficiency syndrome under a Medicaid home and community-based waiver program. Are selection effects important?

OBJECTIVES

In 1990, the state of Florida implemented an acquired immunodeficiency syndrome (AIDS)-specific Medicaid waiver program to provide home and community-based services to AIDS patients as an alternative to institutional care. The program is available to Medicaid beneficiaries with AIDS who are at risk of institutionalization. This study examines whether the waiver option was effective in reducing Medicaid expenditures per beneficiary during its first 2 years of operation.

METHODS

The authors used Medicaid claims data and county information on the availability of health services to model the selection of the waiver option by AIDS patients and then to estimate the effect of the waiver on expenditures controlling for nonrandom program selection.

RESULTS

The results indicate that the selection model is highly significant, but that the influence of nonrandom selection on the estimation of the program effects is negligible. More importantly, the regression results indicate that persons with AIDS who use waiver services incur monthly Medicaid expenditures that are on average 22% to 27% lower than otherwise similar nonparticipants.

CONCLUSIONS

These results, based on the first 2 years that Project AIDS Care was operational, suggest that home and community-based care for AIDS patients results in lower expenditures per beneficiary.

Fetal liver length in twin-twin transfusion syndrome

Fetal liver length was measured by ultrasound in 14 pregnancies with twin-twin transfusion syndrome. The liver size was increased above normal values in both the donor (small) and recipient (large) twin. The liver length was significantly greater than in a control group of dichorionic twin pregnancies with discordant growth. Measurement of liver length may be useful in diagnosing twin-twin transfusion syndrome.

A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy

BACKGROUND AND PURPOSE

Access to physical therapy in many states is contingent on prescription or referral by a physician. Other states have enacted direct access legislation enabling consumers to obtain physical therapy without a physician referral. Critics of direct access cite potential overutilization of services, increased costs, and inappropriate care.

METHODS AND RESULTS

Using paid claims data for the period 1989 to 1993 from Blue Cross-Blue Shield of Maryland, a direct access state, we compiled episodes of physical therapy for acute musculoskeletal disorders and categorized them as direct access (n = 252) or physician referral (n = 353) using algorithms devised by a clinician advisory panel. Relative to physician referral episodes, direct access episodes encompassed fewer numbers of services (7.6 versus 12.2 physical therapy office visits) and substantially less cost ($1,004 versus $2,236).

CONCLUSION AND DISCUSSION

Direct access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classified as physician referral episodes. There are several potential reasons why this may be the case, such as lower severity of the patient's condition, overutilization of services by physicians, and underutilization of services by physical therapists. Concern that direct access will result in overutilization of services or will increase costs appears to be unwarranted.

Strategies to promote the use of advance directives in a residency outpatient practice

OBJECTIVE

To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation.

DESIGN

Controlled clinical trial.

SETTING

The internal medicine residents' practice of an urban, university medical center.

PATIENTS/PARTICIPANTS

Medical residents and 250 patients seen at least twice in the 3 months prior to the study.

INTERVENTIONS

We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives.

MEASUREMENTS AND MAIN RESULTS

We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives.

CONCLUSIONS

Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients.

Urinary excretion profiles of 11-nor-9-carboxy-delta 9-tetrahydrocannabinol in humans after single smoked doses of marijuana

Interpretation of marijuana-positive urine tests requires an understanding of the excretion pattern of marijuana metabolites in humans. However, limited urinary excretion data from controlled clinical studies of marijuana use are available. In this study, six subjects smoked a single marijuana cigarette (placebo, 1.75% delta 9-tetrahydrocannabinol [THC], or 3.55% THC) each week while residing on the clinical ward of the Addiction Research Center. Individual urine specimens were collected for 7 days after drug administration and analyzed for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH) by gas chromatography-mass spectrometry (GC-MS) with a limit of detection of 0.5 ng/mL. Substantial intersubject variability in patterns of THCCOOH excretion was noted between subjects and between doses. Mean THCCOOH concentrations in the first urine collections were 47 +/- 22.3 ng/mL and 75.3 +/- 48.9 ng/mL after the 1.75 and 3.55% THC cigarettes, respectively. Mean peak urine THCCOOH concentrations averaged 89.8 +/- 31.9 ng/mL and 153.4 +/- 49.2 ng/mL after smoking of approximately 15.8 mg and 33.8 mg THC, respectively. The mean times of peak urine concentration were 7.7 +/- 0.8 h after the 1.75% THC and 13.9 +/- 3.5 h after the 3.55% THC dose. Mean GC-MS THCCOOH detection times for the last positive urine sample after the smoking of a single 1.75 or 3.55% THC cigarette were 33.7 +/- 9.2 h and 88.6 +/- 9.5 h, respectively, when a 15-ng/mL cutoff concentration was used. An average of 93.9 +/- 24.5 micrograms THCCOOH (range, 34.6-171.6 micrograms) was excreted by each subject during the 7-day period after smoking of a single 1.75% THC cigarette. The average amount of THCCOOH excreted in the same time period after the high dose was 197.4 +/- 33.6 micrograms (range, 107.5-305.0 micrograms). This represented an average of only 0.54 +/- 0.14% and 0.53 +/- 0.09% of the original amount of THC in the low-and high-dose cigarettes, respectively. These data provide a detailed complication of THCCOOH concentrations in urine after administration of marijuana that may aid in the interpretation of urine cannabinoid results.

Detection times of marijuana metabolites in urine by immunoassay and GC-MS

Reports of prolonged drug excretion have provided the basis for the common assumption that cannabinoid metabolites may he detected in urine for a week or longer. The accuracy, sensitivity, and specificity of immunoassays for the detection of cannabinoids and metabolites are unique for a specific assay and may change overtime. it is important that individuals who select assays and those who interpret test results be aware of qualitative and quantitative changes that occur. In the present study, detection times of cannabinoids in urine were determined using cannabinoid immunoassays with 20-, 50-, and 100-ng/mL cutoffs and using gas chromatography-mass spectrometry (GC-MS). Six subjects each smoked a single marijuana cigarette (placebo, 1.75, or 3.55% delta9-tetrahydrocannabinol [THC]) each week while residing on the clinical ward of the Addiction Research Center. Each urine specimen was analyzed under blind conditions by immunoassay according to the manufacturer's instructions. The following cannabinoid reagents were evaluated: EMIT d.a.u. 100, EMIT d.a.u. 50, EMIT d.a.u. 20, EMIT II 100, EMIT II 50, Abuscreen OnLine, and Abuscreen RIA, DRI, and ADx. All urine specimens were also analyzed for 11-nor-9-carboxy-delta9-THC by GC-MS using a 15-ng/mL cutoff. Urinary cannabinoid detection times varied substantially across assays, subjects, doses, and cutoff concentrations. Detection times were shorter than previously assumed. Mean detection times increased from a maximum of 0.5 days after the low dose to 1.5 days after the high dose using the 100-ng/mL cutoff. Mean detection times were less than 1 day following the low dose and less than 2 days following high-dose exposure using the 50-ng/mL cutoff. Mean detection times ranged from 1 to 5 days after the low dose and from 3 to 6 days after the high dose using the 20-ng/mL cutoff immunoassay. GC-MS detection times were approximately twice as long as mean detection times using an immunoassay with a cutoff of 50 ng/mL. Differences in sensitivity and specificity between the available immunoassay products affected the efficiency of detection of marijuana use. These results indicate that recent reductions in cannabinoid cutoffs by military and federally mandated programs will increase detection times and improve sensitivity, as expected. However, monitoring acute marijuana usage with a commercial cannabinoid immunoassay that has a 50-ng/mL cutoff concentration provides only a narrow window of detection of 1-2 days.

Physician ownership of ancillary services: indirect demand inducement or quality assurance?

This paper analyzes two competing explanations for the ownership of ancillary facilities by referring physicians: indirect demand inducement and quality assurance. Consistent with the demand-inducement explanation we find physician-owned clinics treat patients for 50 percent more visits than do independent clinics and the differential is directly related to factors facilitating demand inducement. We find no difference in quality of care across ownership structures, however. In further support of the demand-inducement hypothesis we find that physical therapists are less likely to work in physician-owned clinics in states where therapists are allowed to practice independently.

Short fourth toes in Rett syndrome: a biological indicator

Classic Rett syndrome is now well-known as a non-dysmorphic developmental disorder almost certainly of genetic origin. Short 4th toe (uni- or bi-lateral) is inherited as an autosomal dominant with 27% penetrance and is found also in certain dysmorphic syndromes. Having observed the anomaly in several Rett cases, we examined a cohort of classic Rett people at advisory clinics and all the residents in an adult learning disabled hospital in order to determine the significance of the association. Among the Rett clinic group 28 of 137 showed the anomaly (20%). Among the heterogeneous hospital group it was found in 19 of 526 people, 9 of 206 females (4%) and 10 of 320 males (3%). Rett syndrome was present in 7% of all the women (14 of 206 women). Four of the Rett women showed the toe anomaly (28% of the Rett cases). The anomaly was found in 4 men and 4 women with Down syndrome, representing 16% (8 of 49). Diagnoses in other men with the anomaly included foetal alcohol syndrome, toxoplasmosis, 18/2 translocation and birth injury. The only other woman with the anomaly was profoundly disabled with short limbs. The strong positive association of the anomaly with Rett syndrome and Down syndrome throws new light on the developmental processes affected by these diseases.

Ownership and utilization of MR imagers in the Commonwealth of Virginia

PURPOSE

To assess distribution, operation, and ownership of magnetic resonance (MR) imagers in Virginia in 1991.

MATERIALS AND METHODS

Questionnaires regarding ownership, location, hours of operation, annual throughput, sources and amounts of revenue, and expenses were mailed to identified providers. Data, specifically regarding ownership and location, were analyzed.

RESULTS

Staff from 95% of MR facilities responded. Most facilities were located in and around major metropolitan areas. Population density per imager ranged from one per 76,000 to one per 222,000 persons. Imagers in larger metropolitan areas were operated for longer hours with higher revenues and greater expenses than were those in lower-population-density areas. Imagers owned by physicians in a position to self-refer had the highest patient throughput, the most revenue, and a much lower percentage of revenues from Medicare and Medicaid than did other ownership types.

CONCLUSION

Patient access to MR services in Virginia is inhomogeneous. Important aspects of utilization are location and ownership. Ownership by physicians who can self-refer is associated with higher use, greater overall revenues, and less service to the poor and elderly.

Validity testing of the accuPINCH THC test

Self-contained drug-testing kits are currently being marketed for a variety of drugs of abuse. These tests are designed to provide rapid access to test results without the need for laboratory facilities. This report describes a validity study of the accuPINCH THC test, a self-contained test for cannabinoids in urine. Three healthy male volunteers with a history of marijuana use participated in the clinical study. Each subject smoked one, two, or four marijuana cigarettes (2.6% THC) on each test day. Urine samples were collected and incorporated into a specimen set consisting of 178 clinical samples, 72 urine samples containing known amounts of drug, and 50 drug-free urine samples. The specimen set was randomized and analyzed under blind conditions by the accuPINCH test and by gas chromatography-mass spectrometry (GC-MS) for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH). AccuPINCH results were interpreted independently by three readers as positive at either two calibration points (positive A < 100 ng/mL THCCOOH; positive B > or = 100 ng/mL THCCOOH) or negative. Concordance analysis was performed by comparison of the accuPINCH results with GC-MS. In addition, the effects of changes in sample turbidity, temperature, and assay reading time on test outcome were assessed. For the clinical samples, positive B results were associated exclusively with THCCOOH concentrations greater than or equal to 15 ng/mL, whereas positive A and negative results were obtained at all concentrations. All drug-free urine samples were interpreted as either negative or positive A. The test demonstrated relatively low cross-reactivity with THC and other cannabinoids.(ABSTRACT TRUNCATED AT 250 WORDS)

Florida's Medicaid AIDS waiver: an assessment of dimensions of quality

Some State Medicaid agencies have implemented home and community-based waiver programs targeting acquired immunodeficiency syndrome (AIDS) patients. Under these initiatives, State Medicaid agencies can provide home and community-base services to persons with AIDS (PWA) as an alternative to more costly Medicaid-covered institutional care. This article evaluates quality of care under the Florida Medicaid waiver for PWA along two dimensions: program effectiveness and client satisfaction. Clients are generally satisfied with their case managers and the range and availability of services. Case managers appear to be well trained. Moreover, the probability of turnover is quite low, despite heavy caseloads and high mortality. The major difficulty faced by clients adn case managers relates to the process of becoming Medicaid eligible.

Lowering the federally mandated cannabinoid immunoassay cutoff increases true-positive results

Proposed changes to the Health and Human Services Guidelines for forensic urine drug testing will lower the required cannabinoid immunoassay cutoff concentration from 100 to 50 micrograms/L. We investigated the effect of this change on the sensitivity, specificity, and efficiency of eight cannabinoid immunoassays: Syva Emit d.a.u. 100; Syva Emit II 100; Syva Emit d.a.u. 50; Syva Emit II 50; Roche Abuscreen Online; Roche Abuscreen radioimmunoassay; Diagnostic Reagents; and Abbott ADx. All specimens also were assayed by gas chromatography/mass spectrometry. Lowering the cutoff concentration from 100 to 50 micrograms/L increased efficiencies and sensitivities for all immunoassays, with minor decreases in specificity (1.0-2.6%). There was a 23.2-53.6% increase in the number of true-positive specimens identified. Thus, lowering the cannabinoid immunoassay cutoff concentration from 100 to 50 micrograms/L resulted in detection of a substantial number of additional true-positive specimens, with an accompanying small increase in unconfirmed positive results.

Lowering the federally mandated cannabinoid immunoassay cutoff increases true-positive results

Proposed changes to the Health and Human Services Guidelines for forensic urine drug testing will lower the required cannabinoid immunoassay cutoff concentration from 100 to 50 micrograms/L. We investigated the effect of this change on the sensitivity, specificity, and efficiency of eight cannabinoid immunoassays: Syva Emit d.a.u. 100; Syva Emit II 100; Syva Emit d.a.u. 50; Syva Emit II 50; Roche Abuscreen Online; Roche Abuscreen radioimmunoassay; Diagnostic Reagents; and Abbott ADx. All specimens also were assayed by gas chromatography/mass spectrometry. Lowering the cutoff concentration from 100 to 50 micrograms/L increased efficiencies and sensitivities for all immunoassays, with minor decreases in specificity (1.0-2.6%). There was a 23.2-53.6% increase in the number of true-positive specimens identified. Thus, lowering the cannabinoid immunoassay cutoff concentration from 100 to 50 micrograms/L resulted in detection of a substantial number of additional true-positive specimens, with an accompanying small increase in unconfirmed positive results.

The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women

Polycystic ovaries (PCO) diagnosed by ultrasound have been commonly reported amongst healthy women. The study aimed to determine the prevalence of PCO in a population of women from the community, and to relate it to clinical and endocrinological data. Twelve hundred women chosen randomly from electoral rolls were invited to take part in the study. Two hundred and fifty five women (21%) who met eligibility criteria greed to participate and 183 women 916%) finally completed the study. Seventy two women did not attend. An ultrasound scan and blood tests were taken on day 5-9 of their menstrual cycles. Data about their menstrual periods and reproductive history was collected. The prevalence of PCO was 21% (39 of 183). No differences existed between women with PCO and normal ovaries with respect to uterine size, body mass index, luteinizing hormone levels, serum hormone binding globulin levels and fertility status. Hirsutism (Ferriman Gallwey score > 7), elevated testosterone levels and irregular menstrual cycles were significantly more frequent amongst women with PCO. Mean ovarian volume was larger in women with PCO irrespective of the use of hormonal contraception. Fifty nine per cent of women with PCO had irregular menstrual cycles or elevated Ferriman Gallwey scores or both. There was no detectable effect of PCO on parity or miscarriage although only 70% of women with PCO had evidence of an adequate ovulation compared to 95% of women with normal ovaries.

Transabdominal versus transvaginal ultrasound in the diagnosis of polycystic ovaries in a population of randomly selected women

A study was conducted which compared transvaginal and transabdominal ultrasound in determining the prevalence of polycystic ovaries in a population of women. Women, chosen randomly from electoral rolls, were sent a letter inviting them to take part in a study determining the presence of polycystic ovaries. A transvaginal and transabdominal ultrasound scan was performed on day 5-9 of their menstrual cycles. A total of 187 women (mean age 33 years) took part in the study. The prevalence of polycystic ovaries was 21% (40/187) by transabdominal ultrasound and 27% (36/134) by transvaginal ultrasound. No differences existed between women with polycystic and normal ovaries with respect to uterine size and endometrial thickness. Mean ovarian volume was larger in women with polycystic ovaries irrespective of the use of hormonal contraception or breast feeding. There was no difference in the prevalence of polycystic ovaries diagnosed by transabdominal or transvaginal ultrasound in the group of randomly selected women. However, almost 20% of the women declined a transvaginal ultrasound examination.

Validity testing of the EZ-SCREEN cannabinoid test

Recently, a number of "quick tests" became available for use in on-site drug testing. These tests offer advantages in simplicity, ease of performance, and rapid access to test results. However, there is a paucity of data on the validity of these tests for the detection of drugs of abuse. This report describes a validity study of the EZ-SCREEN cannabinoid test for the detection of cannabinoids in urine. Three healthy, male volunteers with a history of marijuana use participated in the study. Each subject smoked 1, 2, or 4 marijuana cigarettes (2.6% THC) on each test day. Urine samples were collected and incorporated into a specimen set consisting of 178 clinical urine samples, 72 urine samples containing known amounts of drug, and 50 drug-free urine samples. The specimen set was randomized and analyzed under blind conditions by the EZ-SCREEN test and by GC/MS for 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH). Results were interpreted independently by three readers. Concordance analysis was performed by comparison of results of the EZ-SCREEN test with GC/MS. The EZ-SCREEN test was highly sensitive and produced positive results at a standard THCCOOH concentration of 5 ng/mL. While showing high sensitivity to THCCOOH, the assay demonstrated low cross-reactivity with delta 9-tetrahydrocannabinol (THC) and other cannabinoids. No false-positive results were recorded with 50 drug-free urine samples, but one reader recorded eight undecided results. Overall agreement between the three readers for the EZ-Screen results was approximately 80%. Delayed readings and photocopy readings tended to be less accurate than readings obtained at 3 min.(ABSTRACT TRUNCATED AT 250 WORDS)