Building the case for asthma as a disease management program.

Asthma is a common disease that affects between 5.5% and 7.0% of the population. It is an example of a disease where good guidelines and an accepted model of treatment exist, but have not been fully implemented. In the latter part of 2000, Blue Cross Blue Shield of Minnesota (BCBSM) had existing and successful disease management (DM) programs for diabetes and heart disease and was looking to expand the concept to other diseases. Asthma was one of the conditions under consideration. This study, done in conjunction with PharMetrics, Inc. of Watertown, MA was done to establish the opportunity present to help Blue Cross members with the disease, and to help decide whether developing such a program made sense for the health plan. In addition, if the answer to the second question were yes, the study would lay the groundwork for that program. Using 2 years of BCBSM claims data, the study identified, stratified, and analyzed the cohort of BCBSM members with a diagnosis of asthma according to severity of illness, individual drug or drug combination treatment, emergency room usage, hospitalization, and total episode costs for asthma. Health plan results were bench-marked against the experience of others across the country represented in the (then) 20+ million managed care lives in PharMetrics' Integrated Outcomes Database. The results showed that in some of the recommended guidelines for asthma care BCBSM members led the nation in compliance, but that there was ample opportunity for improvement thus justifying moving forward in developing a disease management program. The results also seemed to validate many of the recommendations for asthma care expressed in the Expert Panel Report 2 on the diagnosis and treatment of asthma from the National Heart Lung and Blood Institute of the National Institutes of Health.     

Swelling of articular cartilage and other connective tissues: electromechanochemical forces

We have measured the relationship between tissue swelling stress and consolidation for bovine articular cartilage and corneal stroma in uniaxial confined compression as a function of bath ionic strength. Our experimental protocol and results clearly demonstrate that two concentration-dependent material properties are necessary to describe the chemical dependence of tissue swelling stress in uniaxial compression over the range of deformations and concentrations explored. A general electromechanochemical model for the swelling stress of charged connective tissues is developed. The model focuses on the role of charged matrix macromolecules in determining the mechanical behavior of the tissue. A constitutive relation for the swelling stress in uniaxial confined compression is formulated and the concentration dependence of the material properties of articular cartilage and corneal stroma is determined. The associated free swelling behavior of cartilage and cornea specimens is computed from these results and is found to compare favorably with data from the literature.     

Immunocytochemical detection of progesterone receptor in breast cancer with monoclonal antibody. Relation to biochemical assay, disease-free survival, and clinical endocrine response

A new immunocytochemical assay for progesterone receptor (PgR-ICA) employing the monoclonal antibody JZB 39 was used to study tumors from two series of patients with breast cancer. In Series 1 assay results were in agreement with those of biochemistry in 76% of 338 cases (P less than 0.001) and in 54% of 101 cases in Series 2 (P less than 0.001). Agreement was better in Series 1 because it included fresher, previously untouched specimens. There were 70 patients in Series 1 with known clinical endocrine response. A negative assay correlated with disease progression in 45 of 57 patients, significantly better than with biochemistry (P = 0.013). In comparing 39 women with rapid disease progression with 39 free of disease at 5.1 years, those with PgR-ICA-positive tumors were over four times more likely to remain disease-free than those with negative results (P = 0.007). Product moment life-table analysis of 79 patients from Series 2 showed a significantly better cumulative survival for those with PgR-ICA-positive tumors (P = 0.047). These findings indicate that PgR-ICA should be of value in planning therapy and predicting disease course in breast cancer patients.     

Substituting diagnostic services. New tests only partly replace older ones

Hospitals' patterns of ancillary service use were examined to determine whether new technologies replace older, more outmoded technologies, and to explore the factors associated with adoption of newer services and abandonment of older services. Annual inpatient use of five pairs of ancillary services was measured for 1978 through 1980 at 63 hospitals in five regions. The diagnostic test pairs consisted of one well-established diagnostic test and one newer service that could largely substitute for the older one and included (1) oral cholecystogram and gallbladder ultrasound; (2) brain scan and computed tomographic head scan; (3) skull roentgenogram and brain scan; (4) bone survey and bone scan; and (5) blood type/cross and type/screen. Use of gallbladder ultrasound increased significantly after its adoption, with small decreases in the use of oral cholecystogram, its paired test. For the other newer tests examined, increased use was not accompanied by significantly decreased use of the paired older service. The strongest predictors of change in patterns of test use were hospital size, number of residencies, occupancy, urban location, and the proportion of specialists on staff. We conclude that diffusion of new diagnostic services occurs gradually and often without concomitant decrease in older, outmoded services; new services generally seem to complement rather than substitute for older ones. Larger hospitals with a greater teaching commitment make a faster transition to the use of new technologies and the abandonment of older ones.     

Paraffin tissue block radiography: adjunct to breast specimen radiography

Radiography of specimens is an essential step in confirming excision of nonpalpable breast lesions. On occasion, however, the pathologist may not identify the lesion histologically. The authors report five cases in which suspicious microcalcifications were included in the excised tissue but were not identified by the pathologist. In all five, paraffin tissue block radiography enabled identification of the specific blocks containing the microcalcifications. The correct tissue blocks were then sectioned again, and the microcalcifications were identified histopathologically. In one case, the initial diagnosis of intraductal hyperplasia was changed to intraductal carcinoma with focal invasion. When the pathologist cannot identify the calcifications on initial histopathologic sections, this technique may assist in identification of the mammographic abnormality.     

Irritable bowel syndrome: The complementary approaches considered

Irritable bowel syndrome is a common problem which, while not fatal, can have a major effect on an individual's quality of life. There is good evidence for the use of relaxation techniques and dietary avoidance, and some evidence for the use of other approaches in this condition. The evidence available is discussed in this article and an overview provided.     

Spontaneous antiidiotypic antibodies to the NZB Coombs autoantibody.

We have further investigated the phenomenon of spontaneous anti-(Coombs) antiidiotypic antibodies in the F1 hybrids of New Zealand black (NZB) and CBA mice. These mice show an age-related increase in incidence of such antiidiotype during the first year of life. There is no difference between males and females in the occurrence of antiidiotype. Reciprocal hybrids are both affected, so that maternal influence from the NZB strain is not critical. The antiidiotype also occurs in spite of the xid gene. We have so far detected such spontaneous antiidiotype only in (CBA X NZB)F1 hybrids and not in hybrids of NZB with two other strains or in a variety of recombinant inbred strains between NZB and C58. Our results to data suggest extensive shared idiotypy among NZB mice and a limited number of total idiotypes.     

Public knowledge and attitudes to AIDS

Three independent cross-sectional surveys of public knowledge and attitudes about AIDS were conducted on a representative sample of people aged 15-54 resident in Wales. 1,303 were interviewed in their homes in February 1987, 683 in September 1987 and 676 in March 1988. The results show that most people knew that having sexual intercourse or sharing needles with people with AIDS represented a high risk of catching AIDS. However there appeared to be considerable misunderstanding about the nature of HIV infection such that one in three thought that a man and woman with a single heterosexual partner was at high or moderate risk of catching AIDS. The high level of concern coupled with considerable confusion appears to have contributed to both unnecessary anxiety and prejudice. One in four people thought that kissing or being spat on by a person with AIDS represented a high or moderate risk, and one in six thought that coughing, sneezing and sharing towels, soap, drinking utensils or lavatory seats were routes of transmission. More than 50% of men and 40% of women said that it was their own fault if homosexuals and drug addicts got AIDS and did not feel sorry for them. It is concluded that action to date to limit the spread of AIDS has informed but not yet adequately educated the public. If unwanted anxieties and prejudice are to be diminished, initiatives by government, health services and others must now concentrate on developing understanding about the nature of HIV infection and its spread through more personal education.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bifid blind-ending ureters

There have been scattered cases of bifid blind-ending ureters reported in the literature. We report 2 cases of unilateral bifid blind-ending ureter, 1 of which was in a bilateral complete duplex system.