Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality

Although the US health care system is often touted as one of the best in the world, disparities exist in quality of care received by different populations, in different regions, and across different institutions and clinicians. Initiatives to provide access to health insurance have been a major policy tool to ensure that Americans receive high-quality health care. However, availability of insurance coverage does not automatically lead to high-quality care. This article explores points of vulnerability in the US health care system at which the potential to achieve high-quality care can be lost: (1) access to insurance coverage; (2) enrollment in available insurance plans; (3) access to covered services, clinicians, and health care institutions; (4) choice of plans, clinicians, and health care institutions; (5) access to a consistent source of primary care; (6) access to referral services; and (7) delivery of high-quality health care services. Ensuring high-quality health care requires that each of these "voltage drops" be recognized and addressed. JAMA. 2000;284:2100-2107.     

High-density lipoprotein subclasses and esterification rate of cholesterol in children: effect of gender and age

Since the development of coronary heart disease (CAD) is affected by a specific pattern of plasma high density lipoprotein (HDL) effects it may be useful to know whether this occurs already in childhood. In this study we evaluated particle size distribution of HDL by gradient gel electrophoresis and the determination of cholesterol esterification rate (FER_HDL) in plasma depleted of apo B lipoproteins in 221 children (108 boys and 113 girls) aged 4 months to 20 years. Total plasma- (TC), low-density lipoprotein- (LDL-C) and HDL- (HDL-C) cholesterol, HDL unesterified cholesterol (HDL-UC) and plasma triglycerides (TG) were also measured. There were no significant gender and age differences with respect to the plasma TC, LDL-TC and TG but concentration of HDL-TC increased with age. Post-pubertal girls had significantly higher relative concentrations of HDL_2b compared to boys (30.4% vs 17.2%), while HDL_3b,c was lower in post-pubertal girls (8.7% vs. 16.5 %). FER_HDL correlated inversely with HDL_2b and positively with HDL_3b,c particles and was significantly higher in boys of the post-pubertal group compared to girls (16.9%/h vs 12.5%/h). While in girls there was a positive correlation between age and HDL-C, HDL-UC and the relative concentration of HDL_2b no significant correlation were observed in boys. In girls the increase in TC showed a significant correlation with a simultaneous increase in HDL-C, HDL-UC and HDL_2b. In boys TC correlated significantly with changes in TG only. When HDL_2b and HDL_3b,c cholesterol levels are calculated from HDL-C concentration and per cent distribution the differences between males and females are further emphasized. These data indicate that HDL particle size distribution is age- and gender-dependent.     

Hypoglycémie hyperinsulinémique persistante du nouveau-né et du nourrisson

Persistent hyperinsulinemic hypoglycaemia of infancy (PHHI) is the most frequent cause of hypoglycaemia in infancy. Clinical presentation is heterogeneous, with variable onset of hypoglycaemia and response to diazoxide, and presence of sporadic or familial forms. Underlying histopathological lesions can be focal or diffuse. Focal lesions are characterised by focal hyperplasia of pancreatic islet-like cells, whereas diffuse lesions implicate the whole pancreas. The distinction between the two forms is important because surgical treatment and genetic counselling are radically different. Focal lesions correspond to somatic defects which are totally cured by limited pancreatic resection, whereas diffuse lesions require a subtotal pancreatectomy exposing to high risk of diabetes mellitus. Diffuse lesions are due to functional abnormalities involving several genes and different transmission forms. Recessively inherited PHHI have been attributed to homozygote mutations for the beta-cell sulfonylurea receptor (SUR1) or the inward-rectifying potassium-channel (Kir6.2) genes. Dominantly inherited PHHI can implicate the glucokinase gene, particularly when PHHI is associated with diabetes, the glutamate dehydrogenase gene when hyperammonaemia is associated, or another locus.     

依替米星治疗老年肺部感染的疗效和安全性观察

目的观察硫酸依替米星在老年肺部感染性疾病中应用的安全性。方法选择42例年龄大于60岁的老年肺部感染性疾病患者用硫酸依替米星治疗,观察临床疗效,记录用药前后血肝肾功能的变化及用药过程中的临床不良反应。结果依替米星治疗老年肺部感染的临床有效率为85.71%,不良反应的发生率9.52%。结论硫酸依替米星是一个毒性较低、安全有效的氨基糖苷类抗生素,可用于老年肺部感染性疾病。     

Glucocorticoid enhancement of memory consolidation in the rat is blocked by muscarinic receptor antagonism in the basolateral amygdala

Glucocorticoid-induced memory enhancement is known to depend on beta-adrenoceptor activation in the basolateral amygdala (BLA). Additionally, inactivation of muscarinic cholinergic receptors in the rat amygdala blocks memory enhancement induced by concurrent beta-adrenergic activation. Together, these findings suggest that glucocorticoid-induced modulation of memory consolidation requires cholinergic as well as adrenergic activation in the BLA. Two experiments investigated this issue. The first experiment examined whether blockade of muscarinic cholinergic receptors in the BLA with atropine alters the memory-enhancing effects of the systemically administered glucocorticoid dexamethasone. Dexamethasone (0.3, 1.0 or 3.0 mg/kg, s.c.) administered to rats immediately after inhibitory avoidance training produced dose-dependent enhancement of 48-h retention. Concurrent bilateral infusions of the muscarinic cholinergic antagonist atropine (0.5 microg in 0.2 microL per side) into the BLA blocked the memory enhancement. The second experiment investigated whether the BLA is a locus of interaction between glucocorticoid and muscarinic activation. The specific glucocorticoid receptor (GR or type II) agonist RU 28362 (1.0, 3.0 or 10 ng) was infused into the BLA either alone or together with atropine immediately after training. The GR agonist produced dose-dependent memory enhancement and atropine blocked the memory enhancement. These findings indicate that muscarinic cholinergic activation within the BLA is critical for enabling glucocorticoid enhancement of memory consolidation and that enhancement of memory induced by GR activation in the BLA requires cholinergic activation within the BLA.     

Interpreting the improved outcome of patients with central nervous system metastases managed in clinical trials compared with standard hospital practice*

The aims were to determine the median survival and prognostic factors of patients with central nervous system (CNS) metastases managed with whole‐brain radiation therapy (WBRT), and to explore selection criteria in recently published clinical trials using aggressive interventions in CNS metastases. A retrospective audit was performed on patients managed with WBRT for CNS metastases. Potential prognostic factors were recorded and analysed for their association with survival duration. The proportion of patients with these factors was also compared with those of patients managed under three recently reported studies investigating aggressive interventions, such as radiosurgery and chemotherapy for CNS metastases. Seventy‐three patients were treated with WBRT for cerebral metastases over a 12‐month period. The median survival of the population was 3.4 months (95% confidence interval: 2.7–4.1), with 6‐ and 12‐month survival rates of 30 and 18%, respectively. Significant prognostic factors for prolonged median survival were Eastern Cooperative Oncology Group status 0–2 (P = 0.015), Medical Research Council neurological functional status 0–1 (P = 0.006), and Recursive Partitioning Analysis Class 2 versus Class 3 (P = 0.020). On multivariate analysis, younger patient age (P = 0.02) and better performance status (P < 0.01) were associated with improved outcome. When comparing these characteristics with selected published studies, our study cohort demonstrated a higher proportion of patients with poor performance status, a greater number of metastases per patient and a higher incidence of extracranial disease. This reflects the selected nature of patients in these published studies. Central nervous system metastases confer a poor prognosis and, for the majority of patients, aggressive interventions are unlikely to improve survival. The use of potentially toxic and expensive treatments should be reserved for those few in whom these studies have shown a potential benefit.     

Changes in practice of breast cancer radiotherapy 1998–2002: An Australasian survey

In order to assess the impact on radiation oncology practice of the publication of evidence-based guidelines for technical aspects of therapeutic radiation for breast cancer, the Radiation Oncology Expert Advisory Group of the National Breast Cancer Centre conducted two postal surveys of radiation oncologists practising in Australia and New Zealand. Results from a survey conducted in 1998, prior to distribution of the guidelines, have been published previously. This article reports on results from a survey undertaken in 2002 and contains data from 102 respondents who manage women with breast cancer. The results show several important changes in practice since 1998, including increased use of CT scanning in breast cancer treatment planning and increased use of immobilization devices for patient treatment. There is also evidence of increased attention to technical aspects of treatment planning that reduce the potential risk of treatment toxicity. The influence of the guidelines, the wider availability of modern equipment and results from landmark clinical trials on change in radiation therapy practice is discussed.     

Encounters with older lesbians in psychiatric practice

This paper starts from the feminist perspective that the problems experienced by older lesbians need to be understood in their political and socio-cultural context. Given that we live in a society that pathologizes sexual activity beyond the reproductive years and lesbianism at any age, and which labels old people as asexual, lesbians frequently present to practitioners in unorthodox ways. This is perhaps because internalized oppression and fears of being labelled ‘sick’, ‘deviant’, ‘sexless’, and even ‘psychogeriatric’ silence them. Case material is presented in an attempt to illustrate an eclectic basis for practice which reflects the experience of older lesbians. Despite the traditional view that older people are unsuitable for the psychotherapies and respond better to more ‘medical’ therapies (drugs, electroconvulsive therapy, etc.), this paper demonstrates that therapy can be helpful and relevant to older lesbians when the therapist does not construct the patient's lesbianism as a basic problem.     

Early life predictors of adult leisure-time physical inactivity: prospective findings from the 1958 British Birth Cohort

BackgroundLeisure-time physical inactivity has a high prevalence and associated disease burden. Adult inactivity research ignores earlier life factors from which later life influences can originate. We aimed to establish whether early life factors influence adult inactivity.MethodsThe 1958 British Birth Cohort is a nationwide follow-up study of all births during 1 week in March, 1958. The outcome of the present study was leisure-time inactivity, defined as activity frequency of less than once a week, assessed at ages 33 years, 42 years, and 50 years (n=12 776). Early life factors (birth to 16 years) were categorised into three domains (physical, social, behavioural). We assessed stability of inactivity from 33 years to 50 years and associations with adult inactivity using logistic regression of: factors within domains, the three domains combined (ie, multivariable associations), and allowing for adult factors. Missing values were imputed with multiple imputation chained equations.FindingsAt each adult age, about 32% of participants were inactive (31% at 33 years, 34% at 42 years, and 30% at 50 years). 1189 (9%) were inactive at all three ages. In analysis of the three domains simultaneously, factors related to adult inactivity were: short prepubertal stature, poor hand control or physical coordination, and poor cognition (physical); low class at birth, minimal parental education, poor household amenities, parental divorce, and institutional care (social); and inactivity, average or lower sports aptitude, smoking, and externalising and unsociable behaviours (behavioural). Odds ratios for inactivity at age 33 years ranged from 0·86 per SD increase in cognition (95% CI 0·82–0·91) to 1·41 (1·23–1·61) for average or lower sports aptitude. Associations weakened slightly but were mostly maintained after adjustment for adult covariates. After allowing for adult covariates participants with unskilled manual backgrounds had 23% higher odds of inactivity at 50 years than those from professional or managerial backgrounds.InterpretationOur study, based on self-report, focuses only on leisure-time inactivity. However, to have repeat, prospective data on inactivity spanning several decades in adulthood is rare, and leisure-time inactivity is likely to be amenable to modification. Adult inactivity is only moderately stable, providing opportunities for behaviour change. Factors from early life are associated with adult inactivity, allowing for early identification of groups vulnerable to later inactivity.FundingThis work was supported by the Department of Health Policy Research Programme through the Public Health Research Consortium. The Great Ormond Street and University College London Institute of Child Health was supported in part by the Department of Health's National Institute for Health Biomedical Research Centre.