Trends in the supply of inpatient rehabilitation facilities services: 1996 to 2004

Mallinson TR, Manheim LM, Almagor O, DeMark HM, Heinemann AW. Trends in the supply of inpatient rehabilitation facilities services: 1996 to 2004.

Objectives

Describe the supply of inpatient rehabilitation facilities (IRFs) services in 1996 and examine changes between 1996 and 2004, including the impact of the IRF prospective payment system (PPS) in 2002 on organizational trends.

Design

Retrospective pre-post design.

Setting

Freestanding and subprovider (distinct-part units) IRFs.

Participants

IRFs (N=1424), including 257 freestanding IRFs and 1167 IRF units reported in the Healthcare Cost Report Information System database, from years 1996 to 2004.

Interventions

Not applicable.

Main Outcome Measures

Number of IRF openings, IRF closures, beds, and inpatient days.

Results

The number of IRFs grew from 1037 to 1183 between 1996 and 2001 and grew to 1235 between 2001 and 2004. The likelihood of IRF closures trended lower after PPS, and there was a significant increase in the likelihood of openings when PPS was introduced. For-profit, rural, and small IRFs were more likely to open over the entire period. There was a 12.9% increase in the number of total inpatient days, somewhat less than the 15.7% growth in IRF beds over the period. There was no impact of PPS on beds available but a significant decline in total inpatient days after PPS.

Conclusions

Inpatient days rose under the Tax Equity and Fiscal Responsibility Act and declined after 2002. Yet the likelihood of openings and closures did not appear to respond to these changes, perhaps because they were modest compared with changes in local IRF markets. The IRF PPS did little to affect service distribution in less well-served areas, although we did find growth in rural areas. Occupancy rates in 2004 were close to rates at the start of the period (70%). This observation implies that IRFs were implementing strategies to recruit a sufficient number of patients, even though bed numbers were increasing and length of stay was declining. Consequently, policy that limits the potential of IRFs to increase patient admissions, such as the limits on admissions to IRFs of patients with conditions other than those included in the 75% rule, is likely to produce substantial decreases in total inpatient days.     

A phase 1/2 trial of arginine butyrate and ganciclovir in patients with Epstein-Barr virus-associated lymphoid malignancies

Malignancies associated with latent Epstein-Barr virus (EBV) are resistant to nucleoside-type antiviral agents because the viral enzyme target of these antiviral drugs, thymidine kinase (TK), is not expressed. Short-chain fatty acids, such as butyrate, induce EBV-TK expression in latently infected B cells. As butyrate has been shown to sensitize EBV(+) lymphoma cells in vitro to apoptosis induced by ganciclovir, arginine butyrate in combination with ganciclovir was administered in 15 patients with refractory EBV(+) lymphoid malignancies to evaluate the drug combination for toxicity, pharmacokinetics, and clinical responses. Ganciclovir was administered twice daily at standard doses, and arginine butyrate was administered by continuous infusion in an intrapatient dose escalation, from 500 mg/(kg/day) escalating to 2000 mg/(kg/day), as tolerated, for a 21-day cycle. The MTD for arginine butyrate in combination with ganciclovir was established as 1000 mg/(kg/day). Ten of 15 patients showed significant antitumor responses, with 4 CRs and 6 PRs within one treatment cycle. Complications from rapid tumor lysis occurred in 3 patients. Reversible somnolence or stupor occurred in 3 patients at arginine butyrate doses of greater than 1000 mg/(kg/day). The combination of arginine butyrate and ganciclovir was reasonably well-tolerated and appears to have significant biologic activity in vivo in EBV(+) lymphoid malignancies which are refractory to other regimens.     

Members of the glutathione and ABC-transporter families are associated with clinical outcome in patients with diffuse large B-cell lymphoma

Standard chemotherapy fails in 40% to 50% of patients with diffuse large B-cell lymphoma (DLBCL). Some of these failures can be salvaged with high-dose regimens, suggesting a role for drug resistance in this disease. We examined the expression of genes in the glutathione (GSH) and ATP-dependent transporter (ABC) families in 2 independent tissue-based expression microarray datasets obtained prior to therapy from patients with DLBCL. Among genes in the GSH family, glutathione peroxidase 1 (GPX1) had the most significant adverse effect on disease-specific overall survival (dOS) in the primary dataset (n = 130) (HR: 1.68; 95% CI: 1.26-2.22; P < .001). This effect remained statistically significant after controlling for biologic signature, LLMPP cell-of-origin signature, and IPI score, and was confirmed in the validation dataset (n = 39) (HR: 1.7; 95% CI: 1.05-2.8; P = .033). Recursive partitioning identified a group of patients with low-level expression of GPX1 and multidrug resistance 1 (MDR1; ABCB1) without early treatment failures and with superior dOS (P < .001). Overall, our findings suggest an important association of oxidative-stress defense and drug elimination with treatment failure in DLBCL and identify GPX1 and ABCB1 as potentially powerful biomarkers of early failure and disease-specific survival.     

T cell depleted stem-cell transplantation for adults with hematologic malignancies: sustained engraftment of HLA-matched related donor grafts without the use of antithymocyte globulin

Antithymocyte globulin (ATG) has been used in allogeneic stem-cell transplantation to prevent graft rejection and graft-versus-host disease (GvHD). Its use, however, has been associated with delayed T-cell reconstitution and prolonged susceptibility to opportunistic infections (OIs) especially in patients undergoing T cell-depleted (TCD) transplantation. Recently, a prospective trial was conducted in 52 adult patients (median age, 47 years) with various hematologic malignancies undergoing TCD transplantation from HLA-matched related donors without the use of ATG. The cytoreductive regimen consisted of hyperfractionated total body irradiation (HFTBI), thiotepa, and fludarabine. The preferred source of the graft was peripheral blood stem cells (PBSCs). No additional graft rejection or GvHD prophylaxis was given. All evaluable patients engrafted without any immune-mediated graft rejections. Disease-free survival (DFS) at 3 years was 61% in all patients, and 70% in patients with standard-risk disease. Acute GvHD was limited to grade 2 in 8% and chronic GvHD in 9% of patients. Life-threatening OIs occurred in 3 of 52 patients and was fatal in 1. This study demonstrates durable engraftment with a low incidence of GvHD despite the lack of ATG, as well as the curative potential of this regimen.     

Diagnostic hysteroscopy and saline infusion sonography in the diagnosis of intrauterine abnormalities: an assessment of patient preference

This study was conducted to assess whether women would prefer to undergo saline infusion sonography (SIS) or office hysteroscopy for the investigation of the uterine cavity. In a randomised controlled trial, 100 patients underwent SIS or office hysteroscopy for assessing patients' pain scores. After the investigation, 92 of them were asked to fill out an anonymous questionnaire addressing their preference regarding the method of evaluation and treatment of the uterine cavity. A control group, consisting of 50 women who never underwent SIS or office hysteroscopy, was also asked to complete an identical questionnaire. The questionnaire was completed by 113 women (83.7%). Twenty-four (21.2%) women would opt for SIS, whereas 52 (46.0%) would opt for office hysteroscopy, and 37 (32.7%) had no preference. If therapy would be necessary, 48.7% of the women would opt for an outpatient treatment, whereas 33.0% of the women would prefer treatment under general anaesthesia. Despite the fact that SIS is less painful, the majority of the women prefer office hysteroscopy. Additionally, therapy in an outpatient setting is preferred to a day case setting.     

Identifying characteristics of children requiring sedation for urodynamics

The aim of this study was to identify characteristics of children requiring sedation for urodynamics. Findings suggest children between the ages of 3 and 7 are more likely to require sedation for urodynamics when compared to other age groups.     

Research on couples: are feminist approaches useful?

Title. Research on couples: are feminist approaches useful? Aim. This paper is an exploration of the utility and value of feminist approaches when undertaking narrative‐based research with partner dyads (within both heterosexual and same sex partnerships) and when researching sensitive issues. Background. Adverse life events or conditions experienced by individuals have been found also to have a negative impact on their partners. Most literature addressing partner issues uses quantitative methods, and existing qualitative research on couples has traditionally interviewed only one person in the partnership or coupled partners together. There is little discussion in the literature about the use of feminist research when researching male perspectives and experiences, and even less discussion of the possibilities that feminist research methods bring to the study of couple dyads. Discussion. Qualitative methodologies informed by feminist perspectives, including issues of reciprocity and self disclosure, can be used to unpack structural, personal and political issues related to couples’ experiences. A feminist approach allows us to show that the origin of oppression is not personal but very much about power and that men as well as women, regardless of their sexuality, may experience the effects of oppression. Narrative and story‐telling complements feminist research because of the value it assigns to the storytellers. Conclusion. To care for women effectively, we must also consider the experiences of their partners as the health of one partner has the potential to impact on the other. The concept of oppression is not absent, but indeed is illuminated, in the lives of some men. Gathering stories using feminist perspectives enhances respect and mutuality in the research process.     

Trapping of a nonpeptide ligand by the extracellular domains of the gonadotropin-releasing hormone receptor results in insurmountable antagonism

Drugs that exhibit insurmountable antagonism are proposed to provide improved clinical efficacy through extended receptor blockade. Long-term suppression of the gonadotropin-releasing hormone receptor (GnRHR) is an important therapeutic approach for a number of sex hormone-dependent diseases. In this study, we describe the mechanism and structural components required for insurmountable activity of a GnRHR antagonist. TAK-013 behaves as an insurmountable antagonist at the human receptor (hGnRHR) but as a surmountable antagonist at the macaque receptor (mGnRHR). Mutation of the eight residues that differ between hGnRHR and mGnRHR identified Ser-203 and Leu-300 in extracellular loops (ECL) 2 and 3 of hGnRHR as essential for the insurmountability of TAK-013. Substitution of the corresponding residues in mGnRHR with Ser and Leu (mGnRHR-P203S/V300L) converts TAK-013 to an insurmountable antagonist. In addition, mutation of Met-24 to Leu in the amino terminus of hGnRHR also ablates the insurmountable antagonism of TAK-013. The mechanism of insurmountability of TAK-013 was determined to be governed by its rate of dissociation from the receptor. Although the association rates of TAK-013 to hGnRHR, mGnRHR, and mGnRHR-P203S/V300L do not differ, the dissociation rate half-life correlates closely with the degree of insurmountability observed (169, 9, and 55 min, respectively). Taken together, these data suggest a model of the GnRHR in which ECL2, ECL3, and the amino terminus engage with TAK-013 upon its binding to the transmembrane region of the receptor. These additional interactions form a "trap door" above TAK-013, restricting its dissociation and thus resulting in its insurmountability.     

A retrospective case-control study of the use of hormone-related supplements and association with breast cancer

Hormone-related supplements (HRS), many of which contain phytoestrogens, are widely used to manage menopausal symptoms, yet their relationship with breast cancer risk has generally not been evaluated. We evaluated whether use of HRS was associated with breast cancer risk, using a population-based case-control study in 3 counties of the Philadelphia metropolitan area consisting of 949 breast cancer cases and 1,524 controls. Use of HRS varied significantly by race, with African American women being more likely than European American women to use any herbal preparation (19.2% vs. 14.7%, p=0.003) as well as specific preparations including black cohosh (5.4% vs. 2.0%, p=0.003), ginseng (12.5% vs. 7.9%, p<0.001) and red clover (4.7% vs. 0.6%, p<0.001). Use of black cohosh had a significant breast cancer protective effect (adjusted odds ratio 0.39, 95% CI: 0.22-0.70). This association was similar among women who reported use of either black cohosh or Remifemin (an herbal preparation derived from black cohosh; adjusted odds ratio 0.47, 95% CI: 0.27-0.82). The literature reports that black cohosh may be effective in treating menopausal symptoms, and has antiestrogenic, antiproliferative and antioxidant properties. Additional confirmatory studies are required to determine whether black cohosh could be used to prevent breast cancer.