Managed Care Organizations and Public Health: Exploring Collaboration on Adolescent Immunizations

ABSTRACT: Managed care organizations (MCOs) joined local and state public health agencies in a pilot effort to improve hepatitis B immunization rates of adolescents in an urban and a suburban/rural school district. The pilot also explored issues inherent in public and private collaboration on population health improvement.
Local public health agencies provided links to schools in their communities, took the lead in implementing school-based immunization programs, and provided health education materials. MCOs contributed financial support necessary for the project. The final cost per fully vaccinated student, not taking into account the work group's planning and coordination time, was little more than the catalog price of the vaccine alone.
Managed care organizations face challenges that complicate their participation and funding of school-based vaccinations: 1) Limited data on health plans of participating students complicate allocation of costs to each MCO; 2) Double-paying occurs for MCOs paying clinics a monthly, per-member rate that already includes adolescent immunizations; 3) When schools provide adolescent immunizations, MCOs lose the "hook" that draws adolescents to clinics for comprehensive health services.
When self-consenting is permitted, schools can achieve a high consent and completion rates for multi-dose adolescent immunizations such as hepatitis B. At the same time, MCOs have the responsibility to provide members with comprehensive care and should continue to examine both internal modifications and external partnerships as opportunities to improve their services to adolescents.     

Down-regulation of c-MYC antigen expression in lymphocytes of Emu-c-myc transgenic mice treated with anti-c-myc DNA methylphosphonates.

In transgenic mice bearing a murine immunoglobulin enhancer/c-myc fusion transgene (Emu-myc), it was found that antisense DNA methylphosphonates targeted against c-myc mRNA inhibited production of c-MYC protein in peripheral lymphocytes. The decrease in protein was measured 3-4 h after i.v. administration of a 300-nmol dose. c-MYC was detected by immunofluorescence of fixed cells stained with an anti-c-MYC antiserum. In addition, DNA methylphosphonates did not induce acute toxicity following i.v. administration of a 300-nmol dose. An identically administered scrambled sequence oligomer did not decrease c-MYC protein or induce toxicity. Finally, recovery of DNA methylphosphonates from the blood plasma of treated mice indicated that the oligomers remained intact up to 3 h, while their concentrations decreased rapidly for the first h, then slowly decreased over the next 2 h. This is the first demonstration of sequence-specific antisense DNA methylphosphonate inhibition of gene expression in the bloodstream of an animal model.     

Practical integration of [18F]-FDG-PET and PET-CT in the planning of radiotherapy for non-small cell lung cancer (NSCLC): the technical basis, ICRU-target volumes, problems, perspectives.

The value of positron emission tomography using [18F]-fluoro-deoxy-glucose (FDG-PET) for pretherapeutic evaluation of patients with non-small cell lung cancer (NSCLC) is beyond doubt. Due to the increasing availability of PET and PET-CT scanners the method is now widely available, and its technical integration has become possible for radiotherapy planning systems. Due to the depiction of malignant tissue with high diagnostic accuracy, the use of FDG-PET in radiotherapy planning of NSCLC is very promising. However, by uncritical application, PET could impair rather than improve the prognosis of patients. Therefore, in the present paper we give an overview of technical factors influencing PET and PET-CT data, and their consequences for radiotherapy planning. We further review the relevant literature concerning the diagnostic value of FDG-PET and on the integration of FDG-PET data in RT planning for NSCLC. We point out the possible impact in gross tumor volume (GTV) definition and describe methods of target volume contouring of the primary tumor, as well as concepts for the integration of diagnostic information on lymph node involvement into the clinical target volume (CTV), and the possible implications of PET data on the definition of the planning target volume (PTV). Finally, we give an idea of the possible future use of tracers other than [18F]-FDG in lung cancer.     

Haemorrhagic shock encephalopathy syndrome in the British Isles.

The aetiopathogenesis of haemorrhagic shock encephalopathy syndrome (HSES) remains unclear and after concern that a novel environmental agent was the cause, the British Paediatric Association and the Public Health Laboratory Service Communicable Disease Surveillance Centre in 1983 initiated surveillance of this condition in the British Isles. After 1986 cases were ascertained via the British Paediatric Surveillance Unit 'active' reporting scheme; this report presents the findings for 1985-8. Sixty five patients were reported, of whom 52 satisfied the criteria for inclusion. Of those whose outcome was known, 24 (46%) died, 18 had severe neurological damage, and six survived apparently intact. Epidemiological features of note were: the median age of 15 weeks (range 3-140); statistically significant clustering of admission times suggesting a peak onset period at night; lack of geographic clusters, of secular trends and, except for a slight excess in winter months, of seasonality. Clinical and pathological features followed a highly consistent pattern, suggesting that HSES is an individual clinical entity distinguishable from conditions with similar presentations, such as septicaemia and Reye's syndrome. There was no microbiological or epidemiological evidence to support the emergence of a novel environmental agent. Many of the features of HSES were, however, the same as those described in heat stroke and we suggest that the two conditions are the same even though there is usually no history of overt overheating.     

What proteins are present in polyethylene glycol precipitates from rheumatic sera?

The proteins present in 4% polyethylene glycol (PEG) precipitates of 10 normal sera and 60 samples from patients with rheumatic diseases were studied. A variety of immunochemical methods were used, including estimation of the percentages of total serum proteins precipitated by PEG, gel filtration analyses of the precipitates, and affinity chromatography with protein A and anti-immunoglobulin columns. Substantial amounts of protein were precipitated from normal sera. Many non-immunoglobulin proteins were precipitated from patients' sera, including fibronectin, haptoglobin, albumin, transferrin, and alpha 1-antitrypsin. Affinity chromatography with anti-immunoglobulin columns bound non-immunoglobulin proteins from PEG precipitates, but the protein A affinity column did not do so. The view that circulating antibody-antigen complexes alone are precipitated by 4% PEG is too simplistic; many non-immunoglobulin proteins are involved. They may either bind to immune complexes or be coprecipitated owing to non-specific protein aggregation.     

COMMUNITY PARTICIPATION OR COMMUNITY MANIPULATION? A CASE STUDY OF THE ILLAWARRA CANCER APPEAL-A-THON

Fashion parades, balls, raffles, and weekly deductions from thousands of workers' pay packets were integral to success of the Cancer Appeal-a-thon in the Illawarra region. In 1986–87 the Illawarra community was induced to contribute $1.5 million in order to purchase a linear accelerator for the Wollongong Hospital. The community agreed that a radiotherapy machine was the number one health service priority for the region. Or did it? Application of Alford's structural interests framework to this case-study reveals how failure to examine power relations between medical monopolizers, health care rationalizers and community participants results in an inability to recognise that alternative community needs — for cancer prevention, domiciliary care, or alternative therapies — might be unarticulated or unobservable, and in an inability to ask whether the community may be mistaken about, or unaware of, its own health needs. Specifically, the paper argues that, ‘community needs’ are easily manipulated or distorted by powerful interest groups and that the political context within which community needs are recognized, articulated and mobilized is the most important issue for community participation in the health policy-making process.     

Bupropion and nicotine patch as smoking cessation aids in alcoholics.

This is a double-blind placebo-controlled study of sustained-release bupropion as a smoking cessation aid in alcoholics undergoing treatment for their alcoholism. Participants (N=58) were enrolled within 1 week of entry into alcohol treatment from community and Veterans Affairs Substance Use Disorder programs. All participants received nicotine patch and were invited to attend a smoking cessation lecture and group. Cigarette smoking and alcohol outcomes were measured at 6 months. Bupropion when added to nicotine patch did not improve smoking outcomes. One third of participants on bupropion reported discontinuing the drug during weeks 1-4. Participants reported cigarette outcomes with nicotine patch that are similar to those seen in the general population. All study participants significantly reduced cigarette use. Comorbid affective disorder or antipersonality disorder did not affect outcomes. Alcohol outcomes were improved in those who discontinued cigarettes.