The Changing Landscape of Health Care Financing and Delivery: How Are Rural Communities and Providers Responding?

Rural communities have not kept pace with the recent dramatic changes in health care financing and organization. However, the Medicare provisions in the Balanced Budget Act of 1997 will require rural providers to participate in the new systems. Case studies revealed the degree of readiness for change in six rural communities and charted their progress along a continuum, as reflected in three sets of activities: the development of networking; the creation of new strategies for managing patient care; and the adoption of new methods for contracting with health insurers. Some communities had constructed highly integrated systems, whereas others were just beginning to change their billing practices; a few were signing contracts for capitated care, in contrast to those that were resisting discounts in current fee structures. These six rural areas still have considerable ground to cover before their health care organization and financing reach the levels achieved by urban communities.     

Treatment of herpes retinitis in an animal model with a sustained delivery antiviral drug, liposomal 1-O-octadecyl-SN-glycerol-3-phosphonoformate.

PURPOSE: To evaluate the clinical treatment efficacy of a long-lasting intravitreous injectable anti-cytomegalovirus (CMV) liposomal drug, 1-O-octadecyl-sn-glycerol-3-phosphonoformate (ODG-PFA). METHODS: Sixty-four pigmented rabbits were used for evaluation of the potency and duration of action of ODG-PFA after intravitreal injection using a herpes simplex virus (HSV)-1 retinitis model. For the potency evaluation, liposomal ODG-PFA was injected into rabbit vitreous at the same time that HSV-1 virus was inoculated onto the retina (simultaneous treatment). For the duration evaluation, ODG-PFA was injected days or weeks before inoculation (pretreatment). Retinitis was clinically graded by indirect ophthalmoscopy, and the retinitis scores were compared across the treatment and control groups. RESULTS: Simultaneous treatment study revealed that ODG-PFA was much more potent than its parent compound, foscarnet (P = 0.0027). Pretreatment study indicated that ODG-PFA possesses a much longer antiviral effect (at least 2 weeks) than foscarnet after a single intravitreal injection. CONCLUSION: Liposomal ODG-PFA is a potent long-lasting intravitreal injectable antiviral compound that may be an ideal alternative for treatment of CMV retinitis in patients with acquired immunodeficiency syndrome.     

Removal of silicone oil with vision improvement after rhegmatogenous retinal detachment following CMV retinitis in patients with AIDS

PURPOSE: To report that silicone oil may be safely removed from immuno-recovered patients with acquired immunodeficiency syndrome (AIDS) after instillation for cytomegalovirus (CMV)-related rhegmatogenous retinal detachment. METHOD: We report two patients with CMV-related retinal detachment who had previously been treated with vitrectomy and silicone oil. RESULTS: Six months after removal of silicone oil, the retina remained attached in both patients. Without specific anti-CMV therapy, there was no relapse of CMV retinitis while patients were undergoing highly active antiretroviral therapy. Best-corrected visual acuity improved in both patients. CONCLUSION: It appears to be possible to remove silicone oil safely from patients with AIDS who show immune recovery, thus avoiding side effects of long-standing silicone oil and increasing quality of life. After silicone oil removal, visual acuity was improved.     

Health care reform in the American states: administrative capacity building

As the nation moves to reform Medicare and the health care industry becomes more competitive which will dramatically change the means by which health care is organized and financed, state governments ought to be establishing administrative capacity to administer new systems. This article describes past experiences of states in similar efforts and uses the legislation written in 13 states to analyze in greater detail current state health reform activities. Policies that create new central authorities have the greatest likelihood of building the appropriate administrative infrastructures. Provisions related to establishing data bases, creating regional authorities or advisory committees, establishing uniform claims, and facilitating integrated systems of care are common to several proposals. Previous state experiences with health planning and citizen involvement are evident in the schemes being proposed and enacted.     

Visual performance in the rhesus monkey after exposure to blue light.

Rhesus monkeys trained to perform a visual task (Landolt ring discrimination) were exposed for 1000 sec to known amounts of 441 nm light by means of a 2500 W xenon lamp with narrow bandpass filter. Radiant exposures to the macula of 30 J/cm² did not impair vision, but 60 J/cm² produced a transient loss of 20/20 vision which lasted from 20 to 30 days. A radiant exposure of 90 J/cm² produced a permanent loss of 20/20 vision. These results, in addition to explaining solar retinitis and eclipse blindness, correlate well with the retinal photopathology of the short wavelength photochemical lesion.     

Importance of the Locus coeruleus and involvement of α-adrenergic receptors in the post-decapitation reflex in the rat

The latency, duration, hindlimb kick frequency, and total activity components of the post-decapitation reflex (PDR) were measured in the rat using a movement-sensitive transducer. Reduction of brain and spinal cord norepinephrine (NE) caused by neonatal administration of 6-hydroxydopamine (6-OHDA) or 5,7-dihydroxytryptamine, which also reduced brain serotonin, decreased all components of the PDR. Depletion of serotonin or dopamine alone reduced the vigor of the reflex, suggesting that these pathways can influence the PDR but are not essential for the response. Lesions of neurons in the Locus coeruleus, made electrolytically or with 6-OHDA, decreased the intensity of the PDR, with the 6-OHDA-induced lesion being more effective. Depletion of forebrain NE terminals with 6-OHDA did not alter the PDR, consistent with a critical involvement of spinal noradrenergic fibers. The PDR was also decreased by phentolamine and prazosin, but not by propanolol, suggesting an involvement of -adrenergic receptors in the response. This hypothesis was further supported by the finding that the efficacy of a variety of drugs (such as tricyclic antidepressants, phenothiazines, and antihypertensive compounds) for blocking the reflex was apparently related to their affinity for -adrenergic receptors. Thus, the PDR is dependent on noradrenergic fibers in the spinal cord and may provide a simple screen for drugs with suspected -adrenergic blocking properties or for agents that disrupt the function of central noradrenergic fibers.Bruce A. Pappas was a visiting Professor on sabbatical leave from the Department of Psychology, Carleton University, Ottawa, Canada K1S 5B6     

Three-dimensional intravascular ultrasound imaging of normal and diseased canine and human arteries.

This study reports three-dimensional reconstruction of two-dimensional intravascular ultrasound images obtained along 5 cm vessel segments. Each three-dimensional image was produced by computerized "stacking" of a set of consecutive two-dimensional images (mode 90 images per set; range 32 to 256). Three-dimensional images (n = 26) were obtained from 11 human normal and atherosclerotic arteries (three in vitro and eight in vivo) and five in vivo canine studies. In vivo human examinations included three iliac, one deep, and three superficial femoral arteries and one aortic dissection. Five in vivo canine vessels (three iliac stenoses and two aortic dissections) were imaged before and after intraluminal stent deployment. Images were displayed on a gray-scale monitor, allowing examination of vessel images as complete cylinders or longitudinal hemisections in any user-defined plane. This enabled global examination of vascular segments and identified luminal shape, wall thickness, and distribution and morphology of plaques. Reconstructions of aortic dissections illustrated the extent of the dissection and produced an anatomic picture of the false lumen. Three-dimensional imaging enhanced stent deployment by identifying the site for deployment, dimensions of the vessel lumen, and changes in morphology after stent insertion. There was good correlation in vessel dimensions measured by angiography, two-dimensional intravascular ultrasonography and longitudinal gray-scale reconstructions (r = 0.74 to 0.95; p = 0.34 to 0.001) but poor correlation with measurements from three-dimensional surface-rendered images (r = 0.13 to 0.48; p = 0.42 to 0.87). We conclude that three-dimensional intravascular ultrasound imaging is an innovative new method for identifying the type, extent, and spatial configuration of arterial disease, with promising diagnostic and therapeutic applications.     

Serum α1-microglobulin and β2-microglobulin for the estimation of fetal glomerular renal function

As proteins cannot cross the placenta levels of the microproteins ₁-microglobulin (₁MG) and ₂-microglobulin (₂MG) can be used to assess fetal glomerular renal function. ₁MG, ₂MG and creatinine were routinely determined in cord and maternal blood of 133 newborns [gestational age (GA) 25–42 weeks]. Twenty-nine patients with suspected impaired maternal or fetal renal function were studied separately and two fetuses were studied in utero. The mean fetal ₂MG concentration fell from 3.87±0.56 mg/l in the 25–31 weeks GA group to 2.60±0.50 mg/l in the mature newborn group. ₁MG concentration fell from 3.10±0.51 to 2.25±0.49 mg/dl. In contrast, the mean maternal ₁MG concentration rose from 1.73±0.69 mg/l in the 25–31 weeks GA group to a mean of 1.83±0.48 mg/l in the mature newborn group; ₁MG rose from 3.96±0.58 to 4.33±1.6 mg/dl. Maternal and fetal creatinine levels were identical. Fetal microprotein levels fall during intra-uterine development as glomerular filtration rate (GFR) rises. There is no correlation between cord blood and maternal ₁MG or ₂MG concentrations. In 13 children with urological anomalies only 1 had elevated microprotein levels and he later developed renal insufficiency. Determination of microprotein levels in fetal serum can be used to detect severe renal function disturbances and to estimate GFR independently of maternal renal function.     

Which measure of body fat distribution is best for epidemiologic research among adolescents?

Body fat distribution is a cardiovascular health risk factor in adults. The development of body fat distribution patterns in childhood remains to be explored and the appropriate index and relations of body fat distribution to cardiovascular risk factors in children is not clear. Data are available from the US Health Examination Survey (1966-1970), which included measurements of skinfold thickness, body and limb circumferences, biologic maturity, and risk factors (blood pressure, total cholesterol). Using canonical correlation analysis, the relation between sets of anthropometric variables and risk factors was explored, controlling for age, race, sex, and maturity stage. The relation of various body fat distribution and fatness indices used in adult studies to the risk factors was also explored using stepwise regression and partial correlation analyses. The first canonical correlations were significant between risk factors and both sets of anthropometric variables (skinfolds, 0.36-0.46; circumferences, 0.39-0.54). However, neither method revealed a clear cut pattern suggesting a role of centralized fatness. Rather, body fatness or size appeared to be the major correlate with risk factors in both races (black, white) and sexes and in each maturity status group. In the stepwise regression analysis, a body fatness or "size" variable (e.g., body mass index, hip circumference) invariably entered on step one. Only among the sexually mature did body fat distribution indices enter on the second step in a consistent manner. No one index seemed "better," although indices based on skinfold measures entered more often than the waist/hip ratio.     

Psychosocial disability during the long-term course of unipolar major depressive disorder

BACKGROUND: The goal of this study was to investigate psychosocial disability in relation to depressive symptom severity during the long-term course of unipolar major depressive disorder (MDD). METHODS: Monthly ratings of impairment in major life functions and social relationships were obtained during an average of 10 years' systematic follow-up of 371 patients with unipolar MDD in the National Institute of Mental Health Collaborative Depression Study. Random regression models were used to examine variations in psychosocial functioning associated with 3 levels of depressive symptom severity and the asymptomatic status. RESULTS: A progressive gradient of psychosocial impairment was associated with a parallel gradient in the level of depressive symptom severity, which ranges from asymptomatic to subthreshold depressive symptoms to symptoms at the minor depression/dysthymia level to symptoms at the MDD level. Significant increases in disability occurred with each stepwise increment in depressive symptom severity. CONCLUSIONS: During the long-term course, disability is pervasive and chronic but disappears when patients become asymptomatic. Depressive symptoms at levels of subthreshold depressive symptoms, minor depression/ dysthymia, and MDD represent a continuum of depressive symptom severity in unipolar MDD, each level of which is associated with a significant stepwise increment in psychosocial disability.