Enhancing preventive and primary care for children with chronic or disabling conditions served in health maintenance organizations

Health maintenance organizations serve an estimated 20 percent of the child population, approximately 12 million children, many of whom have chronic conditions or disabling conditions. These children consume a disproportionate share of health resources and represent an important challenge in terms of care management. As HMOs increasingly enroll children with private insurance and Medicaid who have various physical, developmental, behavioral, and emotional disorders, they must find new and innovative ways to provide their care. Almost one third of children are affected by chronic conditions, and a smaller percentage (6 percent) suffer from chronic disabling conditions. Seven design elements for enhancing preventive and primary care for children with chronic conditions are presented in this article with illustrative examples from HMOs and state Medicaid programs.     

The Gastric Bypass for Failed Bariatric Surgical Procedures

Background: Revision of failed bariatric surgical procedures is a significant challenge for every bariatric surgeon. Methods: Evaluated are surgical difficulties, management problems and weight loss in patients with distal gastric bypass as a revisionary procedure. Eighty patients were followed up to 3 years; four were lost to follow-up. Mean age was 43; mean prebariatric surgery weight 134 kg; height 1.65 meters; body mass index 40.1; ideal body weight 62.7 kg; excess weight 70.5 kg; per cent excess weight 214%. A 250 cm stomach-to-ileocecal valve segment of small bowel was used, and the biopancreatic secretions were brought into the terminal ileum 100 cm from the ileocecal valve. Mean pouch size was 63 cc; length of hospital stay 5 days; operative blood loss 616 cc; operative time 130 min. Results: Intraoperative complications included three splenic injuries (without splenectomy). Early complications included one deep vein thrombosis, two marginal ulcers, one GI hemorrhage, one wound dehiscence, one pouch outlet obstruction and one pancreatitis. Late complications included: one death from protein malnutrition/ARDS; 21 hypoproteinemia; six protein malnutrition, and of these, three had hyperalimentation; three cholecystitis; 27 anemia; 22 incisional hernia; two staple-line disruption (reoperated); 26 low serum iron; 11 prolonged (> 6 months) diarrhea; three prolonged frequent vomiting; and two unrelated deaths (chronic myelogenous leukemia and amyotrophic lateral sclerosis). Mean excess weight loss was 83% at 12 months; 89% at 24 months; and 94% at 36 months. Conclusion: The distal gastric bypass is fraught with the operative and immediate post-operative complications experienced in any revisionary bariatric surgery. Distal gastric bypass is very effective in producing long-term weight loss. Nutritional problems are common but usually easily corrected. The most serious nutritional complication is protein malnutrition, which must be identified and corrected early. Success of this procedure is dependent upon patient compliance with proper nutrition and supplements, and regular office follow-up with monitoring of laboratory data. Patients who are noncompliant are at significant risk for complications.     

DRGs: a management control tool in hospitals and multiinstitutional systems

DRGs can be the basis of an effective system of management control because they facilitate comparisons of indicators within and among hospitals.     

Mu and kappa opioid receptor modulation of 5-HT3 and NK-3 receptor-evoked release of acetylcholine from the guinea-pig ileum myenteric plexus

Summary The effects of three different opioid agonists on contractions and [³H]-acetylcholine (ACh) release evoked by 5-hydroxytryptamine₃ (5-HT₃) and neurokinin-3 (NK-3) receptor activation were examined in the guinea-pig ileum longitudinal muscle-myenteric plexus strip (LMMP) preparation. The selective mu ()-opioid receptor agonist (d-Ala²,NMe-Phe⁴,Gly-ol]-enkephalin) (DAMGO; 1 nM–100 nM) and the selective kappa ()-opioid receptor agonist U50488 (10 nM -1 M) inhibited contractile responses to 5-HT and to the selective NK-3 receptor agonist senktide, producing a concentration-related progressive flattening of their concentration-response curves. IC₅₀ estimates for DAMGO and U50488 were somewhat higher for inhibition of 5-HT-evoked as compared to senktide-evoked contractions, and overall lay in the range 6 nM – 51 nM. The selective delta ()-opioid receptor agonist [d-Pen^2,5]-enkephalin (DPDPE) inhibited contractile responses only at the highest concentration used (1 M). ³H-overflow from LMMP preparations preincubated with [³H]-choline was measured as an indicator of [³H]-ACh release. DAMGO (1 nM –100 nM) and U50488 (10 nM -1 M) inhibited the increases in release of [³H]-ACh evoked by 5-HT (10 M) and by senktide (10 nM) in a concentration-dependant manner. IC₅₀ estimates for DAMGO and U50488 were not significantly different for inhibition of 5-HT as compared to senktide-evoked increases in [³H]-ACh release and lay in the range 6 nM –23 nM. DPDPE again only inhibited these responses at the maximum concentration used (1 M). The inhibitory effects of DAMGO, U50488 and DPDPE on contractions and [³H]-ACh release evoked by 5-HT and senktide were completely reversed by naloxone (10 M).These results show that ACh release in the guinea-pig ileum evoked by 5-HT and senktide can be modulated to a similar extent by the opioid agonists DAMGO and U50488, but not by DPDPE. This suggests that the pathways of excitation for 5-HT₃ and NK-3 receptors converge at some level susceptible to opioid inhibition, which may be mediated by - and -, but not -, opioid receptors.     

Rapid elimination of a synthetic adjuvant peptide from the circulation after systemic administration and absence of detectable natural muramyl peptides in normal serum at current analytical limits.

Although it is clear that muramyl peptides are involved in sleep associated with bacterial infection, their role in normal physiological sleep is less certain. It has been speculated that "natural" muramyl peptides, derived from degraded gut flora, may pass into the bloodstream, where they play a role in normal sleep (M. Karnovsky, Fed. Proc. 45:2556-2560, 1986). Muramic acid serves as a chemical marker for muramyl peptides, since it is not synthesized by mammals. After injection of synthetic muramyl dipeptide in rabbits, muramic acid was readily detected (after release by acid hydrolysis) in the circulation; however, levels rapidly decreased. This was an important positive control in assessing circulating levels of natural muramyl peptides. Muramic acid was not found in normal serum (detection limit, approximately 500 pmol/ml), demonstrating the absence of appreciable amounts of circulating natural muramyl peptides. At this time we are unable to provide supportive evidence for Karnovsky's hypothesis.     

The Use of the Biliopancreatic Diversion as a Treatment for Failed Gastric Partitioning in the Morbidly Obese

The dilemma with which every bariatric surgeon is confronted is: What to do with the inevitable failures? In vertical gastric partitioning, revising the gastroplasty results in a high second failure rate. In an effort to improve the Success rate in failed gastroplasty patients who request revisionary surgery, the biliopancreatic bypass (classic Scopinaro procedure) was carried out on 57 patients. They have been followed for up to 10 years. The long-term weight loss has averaged 69.4 lb, which is 87% of the pregastroplasty excess weight. The price paid by these patients, in terms of complications, has been significant. Twenty-two Percent have developed hypoalbuminemia with its accompanying peripheral edema; 24% have required i.v. hyperalimintation because Of malnutrition. Sixteen percent of the patients developed a late post-op bowel obstruction, one resulting in death. Osteomalacia, spontaneous fractures have occurred. The biliopancreatic diversion procedure (BPD) is an effective weight-loss operation in the failed gastroplasty patients, but a significant price must be paid in terms of careful follow-up, nutritional deficiencies, and rehospitalizations.     

Selection and mortality differentials.

The Office of Population Censuses and Surveys Longitudinal Study provides reliable mortality data by a much wider range of characteristics than are available for other national sources. Although it is based on only a 1% sample of the population, it broadens the scope of mortality analysis and permits study of changes in relationships using different aspects of the time dimension. Data from this study have made us increasingly aware of the importance of selection to the interpretation and understanding of observed mortality differentials. Here we focus on that aspect of selection called "health-related mobility," which is associated with the relative health of people acquiring or losing individual characteristics. It is suggested that, for characteristics affected by health-related mobility, mortality differentials would narrow or widen with increased duration of follow-up. One of the basis of this argument the contribution of health-related mobility to mortality differentials by economic position and social class, to regional differentials, and to family and household differentials is investigated. Selection can thus be shown to operate when people change economic position, when they migrate, or when they change marital status. While the effects of these selection processes can be shown to contribute to social class gradients they do not explain regional differentials and contribute only to a limited degree to differentials by marital status. Differentials by household circumstances also reflect the product of selection processes.