An economic analysis of adult obesity: results from the Behavioral Risk Factor Surveillance System

This paper examines the factors that may be responsible for the 50% increase in the number of obese adults in the US since the late 1970s. We employ the 1984-1999 Behavioral Risk Factor Surveillance System, augmented with state level measures pertaining to the per capita number of fast-food and full-service restaurants, the prices of a meal in each type of restaurant, food consumed at home, cigarettes, and alcohol, and clean indoor air laws. Our main results are that these variables have the expected effects on obesity and explain a substantial amount of its trend.

Evidence that inactive p42 mitogen-activated protein kinase and inactive Rsk exist as a heterodimer in vivo

Mitogen-activated protein kinases (MAP kinases) are active only when phosphorylated. Here we examine whether the activation of Xenopus p42 MAP kinase might involve changes in its association with other proteins as well as changes in its phosphorylation state. We find that when p42 MAP kinase is phosphorylated and active, it is monomeric, and that when p42 MAP kinase is nonphosphorylated and inactive, about half of it is monomeric and half is a component of a 110-kDa complex. We identify Rsk, an 82-kDa protein kinase that can be phosphorylated and partially activated by p42 MAP kinase, as being specifically associated with inactive p42 MAP kinase. It is possible that the complex of inactive p42 MAP kinase and inactive Rsk acts as a single signal reception particle and that the activation of the two kinases may be better described as a fork in a bifurcating signal transduction pathway than as successive levels in a kinase cascade.

Renal medullary circulation: hormonal control

It is now becoming apparent that the medullary circulation in the kidney can be regulated separately from overall renal blood flow. This characteristic of the medullary circulation plays an important role in the kidney's ability to excrete a dilute or concentrated urine in concert with changes in water and sodium transport in the distal nephron secondary to the action of vasopressin, prostaglandins, the renal nerves, and other hormones without significant other renal hemodynamic changes. There is strong evidence that renal autocoids such as angiotensin II and prostaglandins uniquely affect regional blood flow in the inner medulla because of the special structure and organization of the microvasculature in this region. There is also evidence that this regional blood flow is in part regulated by circulating hormones, such as vasopressin and atrial natriuretic peptide, which are released in response to changes in extracellular fluid volume or osmolality. In addition, data are emerging to suggest that the kallikrein-kinin system, acetylcholine, the renal nerves and adenosine participate in this regulation. In addition to the role of the medullary circulation in the urinary concentrating operation, there are data to suggest that the medullary circulation either directly (by changes in physical forces) or indirectly (by regulating medullary toxicity) may influence sodium excretion in a variety of conditions. In this regard, activation of the renin-angiotensin system locally reduces blood flow in the papilla which may be necessary before sodium retention is fully expressed in salt retaining states. Future research looking at the microvasculature of the medulla and papilla and those factors that control the contractility of these vessels are necessary before a clearer picture emerges. Nevertheless, from the data already available it seems reasonable to suggest that the medullary circulation may be as important to kidney function during physiological and pathophysiological states as is the cortical circulation.

Trimethoprim-sulfamethoxazole induces reversible hyperkalemia

OBJECTIVE

To determine the effect of trimethoprimsulfamethoxazole (Tmp-Smx) on serum potassium concentration.

DESIGN

Retrospective cohort study.

SETTING

An urban teaching hospital.

PATIENTS

Fifty-one persons hospitalized for symptomatic infection with human immunodeficiency virus (HIV). Twenty-five patients who were taking high-dose Tmp-Smx (trimethoprim 20 mg/kg per day; sulfamethoxazole, 100 mg/kg per day) for Pneumocystis carinii pneumonia were the study group. Twenty-six patients who had not received the drug were the control group. Patients who received potassium supplements, those taking medications known to alter potassium homeostasis or renal function, or those with a serum creatinine level more than 186 mumol/L were excluded.

MEASUREMENTS AND MAIN RESULTS

Serum potassium concentration in the study group was 4.1 +/- 0.1 mmol/L (mean +/- SE) and increased by 1.1 mmol/L (Cl, 0.8 to 1.5 mmol/L) (P < 0.0001) 9.8 +/- 0.5 days after starting Tmp-Smx therapy. Patients followed longitudinally showed a progressive increase in serum potassium levels during therapy and a progressive decline after discontinuing Tmp-Smx. Blood urea nitrogen and serum creatinine levels increased mildly from 4.3 +/- 0.5 mmol/L and 85 +/- 6 mumol/L to 6.4 +/- 0.7 mmol/L and 113 +/- 8 mumol/L, respectively. The serum potassium level in the control group was 4.3 +/- 0.1 mmol/L and remained unchanged during hospitalization.

CONCLUSIONS

High-dose Tmp-Smx therapy used for the treatment of P. carinii pneumonia in HIV-infected patients leads to an increase in the serum potassium concentration and may result in life-threatening hyperkalemia. Patients receiving high doses of Tmp-Smx require close monitoring of their serum potassium concentration, particularly 7 to 10 days after the start of therapy.

Hospital ownership and cost and quality of care: is there a dime's worth of difference?

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership.

A Silicon Single-Electron Transistor Memory Operating at Room Temperature

A single-electron memory, in which a bit of information is stored by one electron, is demonstrated at room temperature. The memory is a floating gate metal-oxide-semiconductor transistor in silicon with a channel width ( approximately 10 nanometers) smaller than the Debye screening length of a single electron and a nanoscale polysilicon dot ( approximately 7 nanometers by 7 nanometers) as the floating gate embedded between the channel and the control gate. Storing one electron on the floating gate screens the entire channel from the potential on the control gate and leads to (i) a discrete shift in the threshold voltage, (ii) a staircase relation between the charging voltage and the shift, and (iii) a self-limiting charging process. The structure and fabrication of the memory should be compatible with future ultralarge-scale integrated circuits.

Asymmetric information, ownership and quality of care: an empirical analysis of nursing homes

Theoretically, when asymmetric information exists, nonprofit organizations, due to the attenuation of the property right, provide better quality of service than do the for-profits. Despite extensive theoretical examination of the behavior of nonprofits, there has been very little empirical testing of the plausibility of these theories. This article addresses the effect of ownership type on the quality of service in the nursing home industry, an environment particularly conducive to identifying the existence of asymmetric information. The study shows that the differences between for-profit and nonprofit homes do become manifest when asymmetric information is present.

Pulmonary metastasis of hepatocellular carcinoma associated with transarterial chemoembolization

Recent advances in both diagnosis and treatment of hepatocellular carcinoma have improved the prognosis and changed the clinical significance of the subsequently increasing distant metastases. Pulmonary metastasis of hepatocellular carcinoma associated with transcatheter arterial chemoembolization has rarely been reported.

METHODS

To evaluate whether transcatheter arterial chemoembolization increases the risk of pulmonary metastasis of hepatocellular carcinoma, 230 patients were studied. Among them, 156 received transcatheter arterial chemoembolization with an interval of 12-16 weeks, the remaining 74 cases refused transcatheter arterial chemoembolization and received only conservative treatment. All patients were followed up with chest x-ray films taken before transcatheter arterial chemoembolization, during admission or in the out-patient department. The mean follow-up interval was 3.37 +/- 1.51 months.

RESULTS

Pulmonary metastasis was found in 25.6% (40/156) and 8.1% (6/74) of the patients with and without transcatheter arterial chemoembolization (p = 0.002). The median interval between initial diagnosis and pulmonary metastasis was 3.39 +/- 0.08 and 11.72 +/- 2.91 months among patients with and without transcatheter arterial chemoembolization (p = 0.001). The mean age, sex, existence of cirrhosis, severity of cirrhosis, presence of collateral arterial circulation, amount of lipiodol and agent of anti-cancer drugs were not associated with the development of lung metastasis. However, factors predisposing to lung metastasis included: solitary tumor with tumor size > 10 cm, multiple tumors with main tumor > 5 cm or diffuse hepatocellular carcinoma, intrahepatic portal vein thrombosis, arterioportal or arteriovenous shunt, and the presence of incomplete tumor necrosis after transcatheter arterial chemoembolization (especially combined with necrotic area > 50% main tumor size).

CONCLUSIONS

Pulmonary metastasis associated with transcatheter arterial chemoembolization has a strong adverse impact on patient survival.

Regulation of papillary plasma flow by angiotensin II

We examined in anesthetized dogs the effects of left (L) intrarenal artery infusion of angiotensin II (AII) on renal hemodynamics, urinary concentration and Na excretion, and papillary plasma flow (PPF) (measured by the albumin accumulation technique) in both kidneys. Following AII infusion (0.5 ng/kg/min) into the L renal artery, urinary Na excretion decreased and osmolality increased slightly ipsilaterally, whereas Na excretion did not change significantly and osmolality decreased in the right (R) kidney. PPF was significantly lower in the L compared to the R kidney. When saline loading was superimposed on L intrarenal AII infusion, there was a blunted natriuretic response ipsilaterally with a significantly smaller decrease in urine osmolality compared with the R kidney. PPF increased significantly in the R, but not in the L kidney. Finally, AII blockade with saralasin prior to AII infusion and saline loading prevented the differences between the two kidneys, including PPF. In all groups GFR and renal blood flow did not differ between the two kidneys before or after AII. These data suggest that AII regulates regional blood flow in the medulla, and that the exogenously administered AII induces papillary ischemia, which serves to preserve medullary hypertonicity, preventing an increase in PPF during saline loading, and possibly contributing to the diminished natriuretic response.

Inhibition of c-Jun DNA binding by mitogen-activated protein kinase

Here we demonstrate that partially purified Xenopus p42 mitogen-activated protein (MAP) kinase phosphorylates bacterially expressed human c-Jun at a single site, serine 243. Several lines of evidence argue that this phosphorylation is due to p42 MAP kinase itself rather than some contaminating species. Phosphorylation of serine 243 markedly decreases the binding of c-Jun to oligonucleotides containing the 12-O-tetradecanoylphorbol-13-acetate response element. These findings suggest that MAP kinase may play a role in the down-regulation of c-Jun or in the cycle of transcriptional initiation and elongation.

Parental Education and Child Health: Evidence from a Natural Experiment in Taiwan

In 1968, the Taiwanese government extended compulsory education from six to nine years and opened over 150 new junior high schools at a differential rate among regions. Within each region, we exploit variations across cohorts in new junior high school openings to construct an instrument for schooling and employ it to estimate the causal effects of mother's or father's schooling on infant birth outcomes in the years 1978-1999. Parents' schooling does indeed cause favorable infant health outcomes. The increase in schooling associated with the reform saved almost 1 infant life in 1,000 live births. "The one social factor that researchers agree is consistently linked to longer lives in every country where it has been studied is education. It is more important than race; it obliterates any effects of income." Gina Kolata, "A Surprising Secret to Long Life: Stay in School,"New York Times, January 3, 2007, p. 1.

Hospital ownership and performance: evidence from stroke and cardiac treatment in Taiwan

This paper compares program expenditure and treatment quality of stroke and cardiac patients between 1997 and 2000 across hospitals of various ownership types in Taiwan. Because Taiwan implemented national health insurance in 1995, the analysis is immune from problems arising from the complex setting of the U.S. health care market, such as segmentation of insurance status or multiple payers. Because patients may select admitted hospitals based on their observed and unobserved characteristics, we employ instrument variable (IV) estimation to account for the endogeneity of ownership status. Results of IV estimation find that patients admitted to non-profit hospitals receive better quality care, either measured by 1- or 12-month mortality rates. In terms of treatment expenditure, our results indicate no difference between non-profits and for-profits index admission expenditures, and at most 10% higher long-term expenditure for patients admitted to non-profits than to for-profits.

Pulmonary calcification in hemodialyzed patients detected by technetium-99m diphosphonate scanning

Metastatic pulmonary calcification, a well-known complication in patients with chronic disease, has been demonstrated postmortem in patients with a negative chest X-ray. Recently, scintigrams with bone-seeking radionuclides have been used to detect such subclinical pulmonary calcium deposits. We describe 23 patients on maintenance hemodialysis with no evidence of pulmonary calcification on chest X-ray who were prospectively studied by lung scanning with a bone-seeking radionuclide and pulmonary function testing. Of the 23 patients, 14 (61%) had a positive technetium-99m diphosphonate (99mTc-DP) scan (group 1). These patients were on dialysis 38 +/- 5 months compared with 12 +/- 4 months in 9 patients with a negative scan (group 2) (P less than 0.01). Age, sex, blood pressure, hematocrit, serum calcium, phosphorous, bicarbonate, magnesium, and calcium X phosphorus product, as well as parathyroid hormone level did not differ between the two groups. Of 10 group-1 patients tested, 7 had abnormal pulmonary diffusion capacity compared with non in 5 group-2 patients tested (P = 0.014). Histologic examination of the lung in 1 group-1 patients who expired revealed calcification (amorphous on X-ray diffraction), whereas none was found in 1 group-2 patients autopsied. These observations suggest that in patients on maintenance hemodialysis, pulmonary scanning with 99mTc-DP is a sensitive method for detecting pulmonary metastatic calcification, which may be associated with an abnormality in pulmonary diffusion capacity.

Do bad report cards have consequences? Impacts of publicly reported provider quality information on the CABG market in Pennsylvania

Since 1992, the Pennsylvania Health Care Cost Containment Council (PHC4) has published cardiac care report cards for coronary artery bypass graft (CABG) surgery providers. We examine the impact of CABG report cards on a provider's aggregate volume and volume by patient severity and then employ a mixed logit model to investigate the matching between patients and providers. We find a reduction in volume of poor performing and unrated surgeons' volume but no effect on more highly rated surgeons or hospitals of any rating. We also find that the probability that patients, regardless of severity of illness, receive CABG surgery from low-performing surgeons is significantly lower.

Competition and the impact of online hospital report cards

Information on the quality of healthcare gives providers an incentive to improve care, and this incentive should be stronger in more competitive markets. We examine this hypothesis by studying Pennsylvanian hospitals during the years 1995-2004 to see whether those hospitals located in more competitive markets increased the quality of the care provided to Medicare patients after report cards rating the quality of their Coronary Artery Bypass Graft programs went online in 1998. We find that after the report cards went online, hospitals in more competitive markets used more resources per patient, and achieved lower mortality among more severely ill patients.

Renal actions of endothelin-1 and endothelin-3: interactions with the prostaglandin system and nitric oxide

Endothelins (ET) possess both vasodilatory and vasoconstrictive properties. The renal actions of ET-1 and ET-3, as well as in vivo interactions of these two isopeptides with the prostaglandin and endothelium-derived relaxation factor/nitric oxide systems were studied in anesthetized dogs. The ETs were infused intrarenally at doses not affecting systemic hemodynamics. Both ET-1 and ET-3 induced an early transient renal vasodilation, followed by a prolonged vasoconstriction. Inhibition of nitric oxide synthase with NG-monomethyl-L-arginine completely abolished the renal vasodilation induced by either ET-1 or ET-3 and enhanced the vasoconstriction. Endothelin-1 was associated with an increase in the renal release of prostacyclin, while urinary thromboxane A2 was increased after ET-3 administration. Inhibition of cyclooxygenase (with indomethacin) augmented the renal vasoconstriction induced by ET-1, but inhibition of cyclooxygenase (with meclofenamate) abolished the ET-3-evoked vasoconstriction. Endothelin-1 showed little effects on urinary water and sodium excretion; however, ET-3 displayed significant diuretic and natriuretic effects, which were inhibited by nitric oxide synthase inhibition. These findings suggest that these two isopeptides activate the endothelial endothelium-derived relaxation factor/nitric oxide system, which elicits early renal vasodilation, whereas direct effects on the vascular smooth muscle leads to vasoconstriction. Endothelin-3 causes diuresis and natriuresis, possibly by inducing release of nitric oxide in medullary collecting duct cells.

17Beta-estradiol inhibits oxidized low density lipoprotein-induced generation of reactive oxygen species in endothelial cells

Increase of intracellular reactive oxygen species (ROS) has been proposed to cause endothelial injury, and oxidized LDL (oxLDL) actions are associated with an early increase of ROS. Estrogen protects vascular cells partly via its antioxidant effects and by preventing lipid peroxidation. However, whether it can inhibit oxLDL-induced stimulation of ROS generation in endothelial cells is unknown. We utilized the fluorescent dye (DCFH-DA) to measure ROS generation and compared the stimulant effect of tert-butylhydroperoxide (TBH) and oxLDL in human umbilical vein endothelial cells (HUVECs). We found that TBH, H2O2, and oxLDL rapidly stimulated ROS generation, and in a dose-dependent manner with TBH. A concentration of estrogen effective in preventing lipid peroxidation was employed either by pretreatment of cells 18 h prior to or by direct co-incubation (30 min) with HUVEC and oxLDL. Estrogen (54 microM) pretreatment significantly suppressed both TBH- and oxLDL- induced stimulation of ROS generation. Both 1 and 54 microM concentration of estrogen could directly inhibit oxLDL-induced ROS production in HUVECs. Thus, either 18 h pretreatment or 30 min co-incubation with estrogen reduced stimulated ROS generation, suggesting that both cellular and direct actions of estrogen may be involved.

Occupational hand dermatoses of hairdressers in Tainan City

OBJECTIVES

To determine the prevalence, clinical features, and patterns of hand dermatosis in hairdressers in Tainan, Taiwan, and to examine the associations between patterns of dermatosis and risk factors such as job description, work exposure, and sensitisation to common allergens.

METHODS

Interviews, examinations, and patch tests of the hairdressers from nine hairdressing stores randomly selected from Tainan City. Patch test agents included 41 substances with common allergens, shampoo preservatives, hair dyes, permanent waving and bleaching agents.

RESULTS

98 hairdressers finished the examination, 83% of them had occupational dermatosis and 32% had scissor induced scars or wounds. Most of the dermatoses belonged to either dry metacarpophalangeal dermatitis or eczema of the fingers. 44% of the hairdressers showed positive skin reaction to one or more patch test agents. The patch test results were different from previous reports in that the most common allergens were nickel, thimerosal, Captan, Kathon CG, and fragrance mix, and that the sensitivity to hair dye and permanent wave ingredients were low. The dry metacarpophalangeal dermatitis was associated with exposure to shampoo, and the eczema of the fingers with skin sensitivity to patch test agents.

CONCLUSION

Hairdressers in Tainan City had a high prevalence of dermatoses including traumatic wounds, and allergic and irritant contact dermatitis. The rates of sensitivity to some of the common sensitising agents were different from previous reports.

Acute non-Q wave cocaine-related myocardial infarction

Since our initial report in 1984 of six patients with AMI temporally related to cocaine use, we have observed 19 additional patients in whom ischemic chest pain syndromes occurred shortly after intranasal or IV use of cocaine or after smoking the drug. Seventeen patients (89 percent) developed non-Q wave infarction and two had Q-wave infarction. One patient manifested angina with striking ST-segment elevation. None of the patients had diabetes or hypertension, and all but one were cigarette smokers. The serum cholesterol level was 162 +/- 7 mg/dl. Four of the five patients who consented to coronary angiographic studies displayed normal coronary arteries, and one showed proximal stenosis of the right coronary artery. The cold pressor test was performed in seven patients; none had angina or ECG changes induced by cold stimulation. We conclude that T-wave infarction is a common form of an acute cardiac event related to cocaine abuse, and its pathogenesis may involve that of the cocaine-induced coronary vasospasm.

The cellular and molecular regulation of 1,25(OH)2D3 production

The synthesis of 1,25(OH)2D3 is a critical control point in the regulation of calcium metabolism, and possibly in the growth and differentiation of a number of cell types. This paper reviews our current understanding of the regulation of this process at the cellular and molecular levels, with the emphasis on the mechanisms of feedback control 1,25(OH)2D3 itself, control of parathyroid hormone, the roles of cyclic AMP dependent protein kinase and protein kinase C, and the interaction between the various intracellular regulators of 1,25(OH)2D3 production.

Provider and patient satisfaction with the integration of ambulatory and hospital EHR systems

Objective

The installation of EHR systems can disrupt operations at clinical practice sites, but also lead to improvements in information availability. We examined how the installation of an ambulatory EHR at OB/GYN practices and its subsequent interface with an inpatient perinatal EHR affected providers' satisfaction with the transmission of clinical information and patients' ratings of their care experience.

Methods

We collected data on provider satisfaction through 4 survey rounds during the phased implementation of the EHR. Data on patient satisfaction were drawn from Press Ganey surveys issued by the healthcare network through a standard process. Using multivariable models, we determined how provider satisfaction with information transmission and patient satisfaction with their care experience changed as the EHR system allowed greater information flow between OB/GYN practices and the hospital.

Results

Outpatient OB/GYN providers became more satisfied with their access to information from the inpatient perinatal triage unit once system capabilities included automatic data flow from triage back to the OB/GYN offices. Yet physicians were generally less satisfied with how the EHR affected their work processes than other clinical and non-clinical staff. Patient satisfaction dropped after initial EHR installation, and we find no evidence of increased satisfaction linked to system integration.

Conclusions

Dissatisfaction of providers with an EHR system and difficulties incorporating EHR technology into patient care may negatively impact patient satisfaction. Care must be taken during EHR implementations to maintain good communication with patients while satisfying documentation requirements.

Analysis of hospital length of stay and discharge destination using hazard functions with unmeasured heterogeneity

The hospital length-of-stay and the discharge destination of a Medicare patient are the outcomes of one decision process involving the interests of the patient, the hospital, and the firms offering covered post-hospital care. We use a competing risk hazard estimation procedure and adjust for unobserved heterogeneity with a non-parametric technique to identify significant factors in the decision process. A patient's health and socio-economic characteristics, the availability of informal care, local market area conditions, and Medicare policies influence length-of-stay and discharge destination. The substitution we find between hospital and post-hospital care and among post-hospital care alternatives has policy implications for Medicare.

Reconcile the debate over protective effects of BCG vaccine against COVID-19

While awaiting the COVID-19 vaccines, researchers have been actively exploring the effectiveness of existing vaccines against the new virus, among which the BCG vaccine (Bacillus Calmette-Guérin) receives the most attention. While many reports suggest a potential role for BCG immunization in ameliorating SARS-CoV-2 infection, these findings remain controversial. With country-level COVID-19 outbreak data from Johns Hopkins University Coronavirus Resource Center, and BCG program data from World Atlas of BCG Policies and Practices and WHO/UNICE, we estimated a dynamic model to investigate the effect of BCG vaccination across time during the pandemic. Our results reconcile these varying reports regarding protection by BCG against COVID-19 in a variety of clinical scenarios and model specifications. We observe a notable protective effect of the BCG vaccine during the early stage of the pandemic. However, we do not see any strong evidence for protection during the later stages. We also see that a higher proportion of vaccinated young population may confer some level of communal protection against the virus in the early pandemic period, even when the proportion of vaccination in the older population is low. Our results highlight that while BCG may offer some protection against COVID-19, we should be cautious in interpreting the estimated effectiveness as it may vary over time and depend on the age structure of the vaccinated population.

Surgeon and hospital volume as quality indicators for CABG in Taiwan: examining hazard to mortality and accounting for unobserved heterogeneity

OBJECTIVE

To investigate whether provider volume has an impact on the hazard of mortality for coronary artery bypass grafting (CABG) patients in Taiwan.

DATA SOURCES/STUDY SETTING

Multiple sources of linked data from the National Health Insurance Program in Taiwan.

STUDY DESIGN

The linked data were used to identify 27,463 patients who underwent CABG without concomitant angioplasty or valve procedures and the surgeon and hospital volumes. Generalized estimating equations and hazard models were estimated to assess the impact of volume on mortality. The hazard modeling technique used accounts for bias stemming from unobserved heterogeneity.

PRINCIPAL FINDINGS

Both surgeon and hospital volume quartiles are inversely related to the hazard of mortality after CABG. Patients whose surgeon is in the three higher volume quartiles have lower 1-, 3-, 6-, and 12-month mortality after CABG, while only those having their procedure performed at the highest quartile of volume hospitals have lower mortality outcomes.

CONCLUSIONS

Mortality outcomes are related to provider CABG volume in Taiwan. Unobserved heterogeneity is a concern in the volume-outcome relationship; after accounting for it, surgeon volume effects on short-term mortality are large. Using models controlling for unobserved heterogeneity and examining longer term mortality may still differentiate provider quality by volume.