Monocyte chemotaxis and chemotactic cytokine release after exposure to hydroxyethyl starch

Hydroxyethyl starch (HES) is commonly used in leukapheresis and infused as an alternative to blood components for the treatment of hypotension due to hemorrhage and trauma. Its prolonged intravascular persistence and retention in tissue raise concerns about possible effects on humoral and cell-mediated immunity and white cell (WBC) locomotion, particularly in volunteer WBC donors or in severely burned individuals with immunologic depression and increased risk for infection. This study evaluated the effect of HES on human monocyte migration and chemotaxis and the production of antigen- and mitogen-induced WBC-derived chemotactic cytokine. A bioassay was developed to quantitate the neutrophil chemotactic activity of a cytokine generated by mononuclear WBCs stimulated in vitro by phytohemagglutinin or tuberculin protein. The time- and dose-dependent generation of the chemotactic cytokine was not affected by the presence of HES. HES by itself did not induce the generation of this cytokine, nor were human monocyte chemotaxis and spontaneous migration significantly changed by exposure to HES. These results, with those of other investigators, suggest that HES is a safe red cell-sedimenting agent for leukapheresis and an alternative to the use of blood components in shock resuscitation.     

Patterns of Enrollment Churn in Medicaid Expansion,Subsequent Insurance Coverage,and Access to Care: A Longitudinal Study

Understand enrollment patterns in Medicaid expansion and how churn and disenrollment affect access to care. We conducted telephone surveys with a cohort of Medicaid expansion enrollees at 3 time points in 2016, 2017, and 2018 (N = 2,608, RR = 89.4%). Surveys measured health, access to care, and insurance status. Respondents who had no HMP/Medicaid enrollment for > 3 consecutive months but re-enrolled (according to state records) were categorized as “churned off/on”; those who had disenrolled from HMP/Medicaid for > 6 months were categorized as “off for > 6 months”; the remainder were categorized as “stayed on.” We used Pearson chi-square tests to compare groups and mixed models with year as a fixed effect to assess changes over time, incorporating weights adjusting for sample design and nonresponse. HMP beneficiaries with ≥ 12 months of HMP coverage in 2016. As of 2018, 74.2% stayed on HMP/Medicaid, 9.8% churned off/on, and 16.0% were off for > 6 months. Going off HMP/Medicaid for > 6 months was more likely for men than women (17.7% vs. 14.6%), those age 19-34 and 35-50 compared to 51-64 (17.1%, 17.0%, and 13.3%), those who were married/partnered compared to those who were not (18.6% vs. 14.3%), those with compared to without a chronic condition (18.9% vs. 14.3%), and those without compared to with a mental health condition or substance use disorder (22.1% vs. 12.6%) (all, P < .05). Employed respondents in 2017 or 2018 were more likely than those unemployed to have gone off HMP/Medicaid for > 6 months (21.7% vs. 5.2%, P < .001)). Employed respondents (11.1% vs. 7.0% not employed), black respondents (14.7% vs. 7.1% white), men (11.7% vs. 7.9% women), those in the youngest age group (14.4% vs. 7.5% for 35-50 and 5.7% 51-64), and those not married/partnered (11.3% vs. 7.3% married/partnered) were all more likely to churn off/on (all, P < .05). More than half (58.9%) of respondents who were off for > 6 months had a period of uninsurance in 2017 or 2018. Respondents who were off > 6 months were less likely than those who stayed on to report having a regular source of care (84.6% vs 93.9%), more likely to report forgone health care for financial reasons (17.0% vs. 3.2%) and more likely to report problems paying medical bills (32.6% vs. 17.5%). Those who churned off/on were also less likely than those who stayed on to report having a regular source of care (83.6% vs. 93.9%) more likely to report forgone health care for financial reasons (7.5% vs. 3.2%) and more likely to report problems paying medical bills (40.4% vs. 17.5%). In a longitudinal study of Medicaid expansion, approximately a quarter of enrollees had either churned off and on HMP/Medicaid or had extended disenrollment over a three-year period. Those who had experienced churn or extended disenrollment were more likely to report forgone health care, not having a regular source of care, and problems paying medical bills. Many Medicaid enrollees who experience churn or disenrollment have difficulty maintaining health insurance and face financial obstacles to care. Michigan Department of Health and Human Services.     

Unmet health needs of uninsured adults in the United States

CONTEXT: In 1998, 33 million US adults aged 18 to 64 years lacked health insurance. Determining the unmet health needs of this population may aid efforts to improve access to care. OBJECTIVE: To compare nationally representative estimates of the unmet health needs of uninsured and insured adults, particularly among persons with major health risks. DESIGN AND SETTING: Random household telephone survey conducted in all 50 states and the District of Columbia through the Behavioral Risk Factor Surveillance System. PARTICIPANTS: A total of 105,764 adults aged 18 to 64 years in 1997 and 117,364 in 1998, classified as long-term (>/=1 year) uninsured (9.7%), short-term (<1 year) uninsured (4.3%), or insured (86.0%). MAIN OUTCOME MEASURES: Adjusted proportions of participants who could not see a physician when needed due to cost in the past year, had not had a routine checkup within 2 years, and had not received clinically indicated preventive services, compared by insurance status. RESULTS: Long-term- and short-term-uninsured adults were more likely than insured adults to report that they could not see a physician when needed due to cost (26.8%, 21.7%, and 8.2%, respectively), especially among those in poor health (69.1%, 51.9%, and 21.8%) or fair health (48.8%, 42.4%, and 15.7%) (P<.001). Long-term-uninsured adults in general were much more likely than short-term-uninsured and insured adults not to have had a routine checkup in the last 2 years (42.8%, 22.3%, and 17.8%, respectively) and among smokers, obese individuals, binge drinkers, and people with hypertension, elevated cholesterol, diabetes, or human immunodeficiency virus risk factors (P<.001). Deficits in cancer screening, cardiovascular risk reduction, and diabetes care were most pronounced among long-term-uninsured adults. CONCLUSIONS: In our study, long-term-uninsured adults reported much greater unmet health needs than insured adults. Providing insurance to improve access to care for long-term-uninsured adults, particularly those with major health risks, could have substantial clinical benefits. JAMA. 2000;284:2061-2069     

Diagnosis-based risk adjustment for Medicare capitation payments

Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula.     

The effects of physician supply on the early detection of colorectal cancer

BACKGROUND: Policymakers question whether there is a relationship between the number and distribution of physicians and the outcomes for important health conditions. We hypothesized that increasing primary care physician supply would be related to earlier detection of colorectal cancer. METHODS: We identified incident cases of colorectal cancer occurring in Florida in 1994 (n = 8,933) from the state cancer registry. We then obtained measures of physician supply from the 1994 American Medical Association Physician Masterfile and examined the effects of physician supply (at the levels of county and ZIP code clusters) on the odds of late-stage diagnosis using multiple logistic regression. RESULTS: For each 10-percentile increase in primary care physician supply at the county level, the odds of late-stage diagnosis decreased by 5% (adjusted odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.92 - 0.99; P = .007). For each 10-percentile increase in specialty physician supply, the odds of late-stage diagnosis increased by 5% (adjusted OR = 1.05; 95% CI, 1.02-1.09; P = .006). Within ZIP code clusters, each 10-percentile increase in the supply of general internists was associated with a 3% decrease in the odds of late-stage diagnosis (OR = 0.97; 95% CI, 0.95 - 0.99; P = .006), and among women, each 10-percentile increase in the supply of obstetrician/gynecologists was associated with a 5% increase in the odds of late-stage diagnosis (OR = 1.05; 95% CI, 1.01 - 1.08; P = .005). CONCLUSIONS: If the relationships observed were causal, then as many as 874 of the 5463 (16%) late-stage colorectal cancer diagnoses are attributable to the physician specialty supply found in Florida. These findings suggest that an appropriate balance of primary care and specialty physicians may be important in achieving optimal health outcomes.     

Bedside filtration of blood products in the prevention of HLA alloimmunization--a prospective randomized study. Alloimmunisation Study Group

To test the efficacy of poststorage bedside leucodepletion of blood products in the prevention of primary HLA alloimmunization and its clinical sequelae, 172 patients with hematologic malignancy requiring intensive red blood cell and platelet support were randomized to receive either standard or filtered red blood cells and platelets. Quality control of bedside filtration was explored by sequential sampling downstream of the filter, but this did not predict the total number of leucocytes transfused. After exclusions, 123 evaluable patients were assessed every two weeks until the end of therapy. HLA antibodies developed in 21 of 56 (37.5%) nonfilter (NF) and 15 of 67 (22%) filter (F) patients (risk ratio estimate, 0.60 [95% confidence interval, 0.34 to 1.05]; P = .07). Patients with acute myeloid leukemia (AML; n = 53) had higher alloimmunization rates in both arms of the study, with a greater effect of filtration (62.5% NF and 31.0% F; P = .025). Bedside filtration did not affect the overall incidence of febrile transfusion reactions (FTRs; 37% NF and 34% F; P = .71) or of platelet refractoriness assessed in 50 patients (30% NF and 26% F), despite an association between broad HLA reactivity and both FTRs and refractoriness. However, FTRs were also seen in 28 patients without HLA antibodies. Five alloimmunized refractory patients (2 F and 3 NF) required HLA-selected platelets. This report, the first prospective study of bedside filtration, has failed to show clear clinical benefit. Methodological limitations may account in part for this failure, notably the difficulties in accurately assessing the number of leucocytes transfused.     

Impact of hospital volume on racial disparities in cardiovascular procedure mortality.

OBJECTIVES: We assessed use of low-volume hospitals by race and ethnicity for major cardiovascular procedures and determined whether hospital volume is an important factor explaining racial and ethnic differences in post-procedure mortality. BACKGROUND: Low hospital volume predicts mortality for cardiovascular procedures and could be a mediator of racial and ethnic differences in procedure outcomes. METHODS: We analyzed data from 719,679 hospitalizations for cardiac artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) from 1998 to 2001 using the Nationwide Inpatient Sample. We used multivariate logistic regression to assess whether race predicts use of low-volume hospitals and the relative contribution of hospital volume to racial disparity in post-procedure in-hospital mortality. RESULTS: Black and Hispanic patients were more likely than white patients to receive cardiovascular procedures in low-volume hospitals. Black patients had greater risk-adjusted mortality than white patients after elective AAA repair (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.20 to 2.84), CABG (OR, 1.19; 95% CI, 1.06 to 1.33), and CEA (OR, 1.56; 95% CI, 1.07 to 2.27), but not PTCA. Hispanic patients did not have higher risk-adjusted mortality than white patients. Adjusting for hospital volume did not substantially reduce the relative risk of death for black patients compared with white patients. CONCLUSIONS: Black and Hispanic patients were more likely to receive cardiovascular procedures in low-volume hospitals, but hospital volume did not explain a large proportion of racial differences in post-procedure mortality. Additional research is needed to determine why black patients have increased mortality after cardiovascular procedures and how these mortality rates can be reduced.     

A simple approach to prenatal diagnosis of beta-thalassemia in a geographic area where multiple mutations occur

We describe a simple approach for detecting beta-thalassemia mutations in geographic areas such as southern China where multiple mutations are known to occur. Segments of the beta-globin gene were amplified in vitro by using the polymerase chain reaction. Dot blot hybridization of the amplified DNA with oligonucleotide probes corresponding to the six mutations found in southern China could directly identify the mutations causing beta-thalassemia in the affected families. The increased number of target sequences after amplification allows the use of 35S-labeled probes, which are reusable for up to 3 months. The mutations can be determined in two days.