The use and cost of health services prior to death: a comparison of the Medicare-only and the Medicare-Medicaid elderly populations.

Lack of data has limited research into the high cost and ethical dilemmas associated with care of the dying elderly. This study is based on a five-year, person-specific file of Medicare and Medicaid use and cost data for residents of Monroe County, New York, over the age of 65. It examines and compares utilization and expenditure patterns of the Medicare-only and the Medicare-Medicaid (dually eligible) decedents in 1988. Examination of reimbursement for nonacute services, not covered by Medicare, reveals that services for the "older old" may be less costly immediately prior to death than for younger decedents. However, when expenses in the year prior to the year of death are also counted, services for the dually eligible, older old decedents appear to be neither more nor less costly than for younger decedents. Distribution of expenses does, however, vary considerably with age. The younger decedents, aged 65 to 74, use 55 percent of their medical resources on hospital care, paid for by Medicare; the older old use 26 percent for hospital services and pay 67 percent for supportive care, reimbursed by Medicaid. The study suggests that medical intervention associated with dying is utilized more often and at a higher cost by younger decedents.     

Effect of basal ganglia injury on central dopamine activity in Gulf War syndrome: correlation of proton magnetic resonance spectroscopy and plasma homovanillic acid levels

BACKGROUND: Many complaints of Gulf War veterans are compatible with a neurologic illness involving the basal ganglia. METHODS: In 12 veterans with Haley Gulf War syndrome 2 and in 15 healthy control veterans of similar age, sex, and educational level, we assessed functioning neuronal mass in both basal ganglia by measuring the ratio of N-acetyl-aspartate to creatine with proton magnetic resonance spectroscopy. Central dopamine activity was assessed by measuring the ratio of plasma homovanillic acid (HVA) and 3-methoxy-4-hydroxyphenlyglycol (MHPG). RESULTS: The logarithm of the age-standardized HVA/MHPG ratio was inversely associated with functioning neuronal mass in the left basal ganglia (R(2) = 0.56; F(1,27) = 33.82; P<.001) but not with that in the right (R(2) = 0. 04; F(1,26) = 1.09; P =.30). Controlling for age, renal clearances of creatinine and weak organic anions, handedness, and smoking did not substantially alter the associations. CONCLUSIONS: The reduction in functioning neuronal mass in the left basal ganglia of these veterans with Gulf War syndrome seems to have altered central dopamine production in a lateralized pattern. This finding supports the theory that Gulf War syndrome is a neurologic illness, in part related to injury to dopaminergic neurons in the basal ganglia.     

Acknowledgment of Ad Hoc Reviewers for Volume 13

Note

Acknowledgment of Ad Hoc Reviewers for Volume 13     

Validity and reliability of a modified qualitative dietary fat index in low-income, overweight, African American adolescent girls

This study evaluated the validity and reliability of a modified qualitative dietary fat index questionnaire (QFQ) in an adolescent minority population. The QFQ was administered to study participants twice over a 2-week period, and data were compared with mean values from three 24-hour recalls. Fifty-seven low-income, overweight, African American adolescent girls, aged 11 to 17 years, were recruited from 7 public housing developments in Atlanta, Georgia. To determine validity, the total QFQ score was compared with the mean values of total fat, percentage of energy from fat, and total energy from three 24-hour recalls within 2 weeks of first administration of the QFQ. Reliability was tested in a subsample (n=22) by comparing total QFQ scores administered 2 weeks apart. total fat was significantly correlated (r=0.31, p<.05) with the QFQ score. Total energy (r=20.23) and percentage of energy from fat (r= -0.23) were not significantly correlated with the QFQ score. The test-retest QFQ scores were significantly correlated (r=0.54, p<.01). The data suggest that additional modifications are needed to make the QFQ more appropriate for low-income, overweight, African American adolescent girls. J Am Diet Assoc. 2000;100;1525-1529.     

Increased Ifng and Il10 Expression Correlate with Disease in Rodent Models Experimentally Infected with Modoc Virus

Flaviviruses present an ongoing threat to global public health, although the factors that contribute to the disease remain incompletely understood. We examined an acute Modoc virus (MODV) infection of two rodent models. Viral RNA was detected in the kidneys, spleen, liver, brain, urine, and sera of experimentally infected deer mice, a reservoir host of MODV, and Syrian hamsters, a known disease model. As expected, clinical outcomes differed between species, and the levels of viral RNA recovered from various tissues demonstrated signs of differential replication and tissue tropism. Multivariate analysis indicated significance in the profile of expressed genes between species when analyzed across tissues and over time (p = 0.02). Between-subject effects with corrected models revealed a significance specific to the expression of Ifng (p = 0.01). the expression of Ifng was elevated in hamsters as compared to deer mice in brain tissues at all timepoints. As the over-expression of Ifng has been shown to correlate with decreased vascular integrity, the findings presented here offer a potential mechanism for viral dissemination into the CNS. The expression of IL10 also differed significantly between species at certain timepoints in brain tissues; however, it is uncertain how increased expression of this cytokine may influence the outcome of MODV-induced pathology.     

Total abdominal hysterectomy after radiation therapy for cervical cancer: use of omental graft for fistula prevention

Abdominal hysterectomy after treatment of cervical cancer by radiation therapy is associated with a significant rate of postoperative vesicovaginal fistulas. In this series, five patients with invasive cancer of the cervix treated by radiation therapy developed new cervical or uterine neoplasms 1 to 27 years after treatment. All underwent abdominal hysterectomy without postoperative fistula formation. Success is attributed to cautious surgical technique and to the use of the omental pedicle graft to bring new vascularity to the vaginal apex and bladder base. The technique of forming an omental pedicle graft is described.     

Risk factors for alcohol hepatotoxicity among male alcoholics

Alcoholic liver cirrhosis is a leading cause of morbidity and mortality in alcohol dependence. A common precursor to cirrhosis is alcoholic hepatotoxicity evident clinically by elevated serum liver enzymes. In this study 50 male patients with significant (greater than two times upper limits of normal) elevation of liver enzymes attending a veterans inpatient alcohol treatment center were matched by age and time since last drink to 50 male veterans without elevated liver enzymes. Patients with elevated liver enzymes were found to be more likely to be daily drinkers, less likely to indulge in binge drinking patterns or have alcoholic blackouts, and showed a trend towards a less severe pattern of alcoholism. Significant gamma glutamyl transferase (GGT) elevations were found in patients consuming an average of 7 beers/day for 5 years, and significant aspartate aminotransferase (AST) elevations were found in patients consuming a threshold of 12 beers/day for 10 years. These findings are consistent with current research suggesting alcoholic cirrhosis is a result of a threshold exposure to alcohol in alcoholics with an additional environmental or genetic risk factor.