Managed care and preventable hospitalization among Medicaid adults

OBJECTIVE: The study examines the association between managed care enrollment and preventable hospitalization patterns of adult Medicaid enrollees hospitalized in four states. DATA SOURCES/STUDY SETTING: Hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) database of the Agency for Healthcare Research and Quality (AHRQ) for New York (NY), Pennsylvania (PA), Wisconsin (WI), and Tennessee (TN) residents in the age group 20-64 hospitalized in those states, linked to the Area Resource File (ARF) and American Hospital Association (AHA) survey files for 1997. STUDY DESIGN: The study uses separate logistic models for each state comparing preventable admissions with marker admissions (urgent, insensitive to primary care). The model controls for socioeconomic and demographic variables, and severity of illness. PRINCIPAL FINDINGS: Consistently in different states, private health maintenance organization (HMO) enrollment was associated with fewer preventable admissions than marker admissions, compared to private fee-for-service (FFS). However, Medicaid managed care enrollment was not associated with a reduction in preventable admissions, compared to Medicaid FFS. CONCLUSIONS: Our analysis suggests that the preventable hospitalization pattern for private HMO enrollees differs significantly from that for commercial FFS enrollees. However, little difference is found between Medicaid HMO enrollees and Medicaid FFS patients. The findings did not vary by the level of Medicaid managed care penetration in the study states.     

Physiology: Morphological characteristics of preimplantation stage endometrium in the rhesus monkey

The morphological characteristics of endometrium on day 6 afterovulation of conception (group 1) and non-fecund, menstrual(group 2) cycles have been studied in the rhesus monkey (n =30). A conception cycle was distinguished by the presence ofa developmentally normal, age—stage-synchronized embryo.Thus, 78% of the mated cycles (n = 18) yielding synchronousembryos (12 zona-encased and two zona-free blastocysts) wereused for this study. On day 6 after ovulation, no significantchanges in the serum concentrations of oestrogen and progesteronewere seen in conception cycles (n = 14) compared with the non-mated,normal ovulatory cycles (n = 12). Morphometric analyses revealedthat on day 6 of gestation (n = 8), endometrium differed fromthe corresponding non-mated luteal phase (n = 7) with significantincreases in epithelial mitosis (P < 0.01), height of glandularepithelium (P < 0.05), volume ratio of gland cell to gland(P < 0.03), degree of pseudostratification (P < 0.02),and higher frequency of supranuclear, adluminal accumulationof vacuoles in gland cells (P < 0.05). The degree of stromaloedema was higher (P < 0.02) in fecund cycles but there wasno change in venular diameter. In a separate set of experiments,estimates of tissue vascular response revealed a higher (P <0.02) endometrial extravascular albumin space on the same dayof gestation; there were no differences, however, in endometrialblood volume, or in the number of von Willebrand antigen-positivecapillaries and small vessels between the two groups (group1, n = 6; group 2, n = 5). The overall results of the presentstudy together with our earlier reports support the hypothesisthat differential changes occur in luteal phase endometriumfunctionalis in the presence of preimplantation stage blastocystin the rhesus monkey.     

Permeability of PEUU membranes: their modification towards blood compatibility

An attempt was made to develop haemodialysis membranes using polyether urethane urea synthesised in our laboratory. It was observed that the processing parameters such as precipitation medium, precipitation temperature etc. can influence the porosity of the membrane and subsequently the permeability property. It was also noted that the permeability of the dried membrane was negligible even though it was kept in distilled water overnight before use. The effect of pH on permeability through the membrane was studied by dialysis experiment using mixtures of various components such as urea, creatinine, uric acid, inulin, albumin, NaCl and KCl at various pH. Standard cellulose acetate (CA) membrane was used for comparison. Membranes were also prepared using biomer solution by precipitating in distilled water at room temperature and the monomer, 2-hydroxy ethyl methacrylate (HEMA) was grafted onto it by glow discharge technique. It was found that the permeability was increased by HEMA grafting with some loss of tensile strength and strain. A comparative study of fibrinogen adsorption during dialysis and adsorption by direct exposure of samples to a mixture containing urea, uric acid, creatinine, dextran, fibrinogen and electrolytes like sodium and potassium ions was also done with 125I labelled fibrinogen. Platelet adhesion studies indicated that the number of adhered platelets was less on the HEMA grafted samples which may enhance blood compatibility. Finally, the membranes were subjected to different sterilization processes possible under wet conditions such as glutaraldehyde treatment and autoclaving. The contact angle, permeability, mechanical property and platelet adhesion studies indicated that the sterilization method can affect the performance of the membrane.     

Effects of volatile anesthetics on hippocampal slice metabolism, response to anoxia with and without glucose

Anesthetics attenuate ischemie damage and so are often not used when preparing hippocampal slices for studies of ischemie or anoxic damage. In this study, we tested whether halothane, ether or isoflurane, when used briefly during slice preparation, have persistent effects on slice ATP metabolism, protein synthesis or morphology. We also tested the effects of anoxia with and without glucose on these slices. Five minutes of anoxia without glucose (anoxia-aglycemia) caused a dramatic depletion of ATP to less than 22% of control levels, a persistent inhibition of neuronal protein synthesis to less than 10% of control rates and severe morphological damage. Slices prepared using volatile anesthetics showed the same degree of damage due to anoxia-aglycemia, when compared with untreated tissue. In contrast, 5 min anoxia caused a 40% decrease in ATP levels in untreated tissue, but did not damage protein synthesis or morphology. While isoflurane-treated tissue responded identically to anoxia as untreated tissue, both halothane and ether prevented the anoxic ATP fall. These findings suggest that while halothane and ether may have persistent effects on slice responses to anoxia, isoflurane is a good candidate anesthetic for slice preparation procedures.     

Primary tuberculosis of the tongue: report of three cases

Tuberculosis of the oral cavity is uncommon and poses a diagnostic challenge. We report three patients with primary tuberculosis of the tongue, all of whom responded well to treatment and were cured.     

Assessment of inflammatory response and sequestration of blood iron transferrin complexes in a rat model of lung injury resulting from exposure to low-frequency shock waves

OBJECTIVE: Impact of air blast overpressure waves (OPW), or shock wave, with the body wall or body armor produces two types of energy waves: high-frequency low-amplitude stress waves and long-duration low-frequency share waves. These types of energy waves are characterized by different mechanisms of primary tissue injury that mostly affect lung. Systemic inflammation and resultant acute respiratory distress syndrome are known major secondary causative agents of delayed multiple organ failure and subsequent death after OPW exposure. However, association of each pattern of the blast OPW-produced energy waves with postexposure inflammatory events has not yet been delineated. The objectives of the present research were a) establishment of a rat model for assessment of the inflammatory response following lung injury produced by exposure to medium-amplitude (approximately 120 kPa) low-frequency (260+/-5 Hz) OPWs; and b) assessment of the dynamics of alteration in polymorphonuclear leukocyte counts and expression of CD11b adhesion molecules on the surface of polymorphonuclear leukocytes and status of iron-transferrin complexes in peripheral blood after OPW exposure. DESIGN: This study focused on the OPW effects at different time periods, using a sequential approach to postexposure events. Lung injury in rat was induced by OPW generated in a laboratory shock tube. Animals were exposed to OPW (at peak overpressure of 118+/-7 kPa) that produced "moderate" lung injury. SETTING: Military research institute. SUBJECTS: Twenty-seven CVF Sprague-Dawley rats were subjected to OPW exposures, and 17 sham-treated animals were used as control. INTERVENTIONS: Lung tissue and blood samples were collected at 1, 3, 6, 12, and 24 hrs following OPW exposures and compared with samples collected from nonexposed animals. MEASUREMENTS AND MAIN RESULTS: OPW-induced lung injury caused a 2.7-fold increase in the number of circulatory polymorphonuclear leukocytes as early as 1 hr postexposure, which is indicative of mobilization of the pool of marginated polymorphonuclear leukocytes into the free circulation. Polymorphonuclear leukocyte counts increased through the following 3- and 6-hr periods, when they were, respectively, 5-fold and 3.5-fold higher than in controls. These effects were accompanied by a pronounced expression of CD11b in polymorphonuclear leukocytes and tissue sequestration of blood iron-transferrin complexes during the entire 24-hr period of observations. The increase in circulatory polymorphonuclear leukocytes was accompanied by a decrease in iron-transferrin complex concentrations that apparently reflected implication of blood plasma iron in the inflammatory cell response to OPW-induced injury. CONCLUSIONS: The observed dynamics in polymorphonuclear leukocyte alterations in peripheral blood after OPW exposure were similar to those found recently in clinical observations of nonpenetrating injury and in animal models of infectious insults. Therefore, our data suggest that the main pattern of proinflammatory alterations in the rat model of lung injury induced by exposure to long-duration shock wave is similar to patterns that are characteristic of major trauma. The data further suggest that the expression of polymorphonuclear leukocyte CD11b and the response of iron-transferrin complex can be considered as potential surrogate markers in blood for systemic alterations following OPW-induced injury and, therefore, warrant further investigation in a human pilot study.     

Luteal phase ovarian oestrogen is not essential for implantation and maintenance of pregnancy from surrogate embryo transfer in the rhesus monkey

The aim of this study was to investigate whether luteal phaseovarian oestrogen is required for blastocyst implantation andpregnancy maintenance in the rhesus monkey. Preimplantationembryos were retrieved from naturally ovulated, mated embryodonor monkeys. In group I, developmentally normal, age- andstage-matched embryos were transferred to recipient monkeysshowing naturally synchronized ovulatory cycles. Immediatelyprior to embryo transfer, recipients were subjected to bilateralovariectomy, and following transfer they were treated with i.m.injections of either progesterone (group Ia, n= 4), or oestradiol+ progesterone (group Ib, n= 2). Recipient monkeys of groupIc (n= 4) were subjected to sham ovariectomy and vehicle injection.In group Ia, progesterone supplementation alone led to threepregnancies and live births. In group Ib, there was one livebirth. In the control group Ic, four transfers resulted in twolive births and one abortion on cycle day 58. Analysis of serumprogesterone and oestradiol profiles showed that oestradiolhad declined to undetectable levels within 3–5 days afterovariectomy in group Ia recipients, and the area under the curveof serum oestrogen concentrations during the peri-implantationperiod (days 10–20 after ovulation) were less (p< 0.001)in group Ia compared with group Ic. There were no changes inthe area under the curve among serum progesterone concentrationsin all the subgroups. In group II, long-term ovariectomizedembryo recipients (n= 4) were primed with oestradiol till cycleday 11 of simulated transfer cycle, and received progesteronetreatment from cycle day 10 till the end of the experiment.Of four transfers, live births were recorded in two cases, whilein one case abortion occurred on cycle day 66. Serum oestradiolconcentrations were undetectable during the presumptive peri-implantationperiod of pregnancy cycles in group II recipient monkeys. Noyes‘dating of endometrial samples collected from both groups ondays 5–7 after the oestrogen rise revealed that endometrialhistology synchronized well with those found during days 3–5after ovulation in normal menstrual cycle. We conclude thatluteal phase ovarian oestrogen is not essential for progesterone-dependentendometrial receptivity and response leading to implantationand pregnancy maintenance in the rhesus monkey.     

Epstein-Barr virus-associated gastric carcinoma in southern India: A comparison with a large-scale Japanese series

Epidemiological and clinicopathological features of Epstein-Barr virus (EBV) associated gastric carcinoma was compared in India and Japan, two countries differing markedly in gastric cancer incidence. Using in situ hybridization assay, the presence of EBV-encoded small RNA (EBER) was examined in 215, and 2,011 gastric cancer cases in Kerala, India, and Japan, respectively. Ten cases (5%), all males, in the Indian series were EBER-positive. This frequency was similar to that in the Japanese series (6.2%). As was the case with Japanese series, the EBV-associated gastric carcinoma in the Indian series was observed most frequently in the middle part of the stomach (1 in antrum, 4 in middle part, 2 in cardia, and 3 unknown), and, histologically, the diffuse type Lauren's classification (8 cases) was more common than the intestinal type (2 cases). Virus subtyping by PCR-RFLP revealed that all of the 10 EBV strains isolated from the EBER-positive Indian cases were subtype A, and wild-type F for Bam HI F region. In Bam HI I region, 8 cases were type C and the remaining 2 cases were type D. In either series, there was no significant difference in the frequency of tumors with p53 overexpression between EBER-positive and -negative cases. However, the proportion of cells with p53 overexpression in EBER-negative tumors was significantly higher than that in EBER-positive tumors regardless of histological type in both series. In conclusion, the frequency and major clinicopathological features of EBV-associated gastric carcinoma in south India were similar to those observed in Japanese series although gastric cancer incidence in these two countries differs markedly.