Healthcare Charges and Use in Commercially Insured Children Enrolled in Managed Care Health Plans in Washington State

Objective: To determine the relative importance of enrollee, physician, medical group, and healthcare plan characteristics as determinants of healthcare use and expenditures in commercially insured children <18 years of age enrolled in managed care health plans. We focused on the effects of age and benefit level, the two most important predictors of cost and utilization in our study of adults. Methods: This study included 67,432 commercially insured children who were between 1 and 18 years of age, and were cared for by 790 primary care physicians, who practiced in 60 medical care groups in Washington State. Plan enrollment and utilization data for 1994 were linked to a survey of medical care groups contracting with three managed care health plans. Benefit level for each enrollee was defined as low, medium, or high and was based on cost sharing by the health plan for hospitalization, outpatient care, and emergency department services. The three outcome measures included estimated total per member per year charges, number of ambulatory visits, and hospital days. Results: In multivariate analysis, enrollee age was the most important determinant of total charges, with younger children incurring higher charges and utilization. For children 5 years and younger, mean total per member per year charges were $617 in the low-benefit category and $878 in the high category (p < .0001). These differences were less apparent for children 6–12 years ($355 versus $420, p = .012), and were not statistically significant for children 13 years and older ($503 versus $552, p = .14). The annual number of visits increased with benefit level for children of all ages. Conclusions: Enrollee age and benefit level were the most important determinants of healthcare use and expenditures in children enrolled in managed care health plans.     

A multilevel time-series model for the incidence of AIDS cases in Spain

OBJECTIVE: The main aim of this research is to study the quantitative evolution of the incidence of AIDS in the 19 Spanish Communities. The hypothesis is that incidence follows a multilevel autoregressive model, where each Community shows random variability around a general process. METHOD: On the basis of official data on the number of existing AIDS cases, an autorregressive multilevel time-series model was developed. RESULTS AND CONCLUSIONS: Analysis shows that the hypothesis is supported, indicating that overall AIDS incidence in Spain has already reached a maximum and has a tendency to remain stable or to decline in future. Long term expected values have become stable in most Communities; a slight increase is expected only in Extremadura. However, this Community has a relatively sparse population, and its contribution on the overall Spanish incidence is small.Long term expected values are estimated to be around 152.99 new cases per million inhabitants per year. This value is slightly smaller than the maximum incidence, observed in 1994 (179.4 cases).     

小鼠肺腺癌体内外生长、运动和侵袭与细胞外基质相关性的研究

利用小鼠肺腺癌（ＬＡ＿（７９５））肾包膜下移植模型，采用间接免疫酶标和间接免疫荧光方法，观察了肿瘤发展过程的不同时期纤维粘连蛋白（ＦＮ），层粘连蛋白（ＬＮ）和ＩＶ胶原的分布情况。结果表明，随着肿瘤移植后时间的延长，间质ＦＮ量不变，ＬＮ和ＩＶ型胶原量增多，且三种成分各自的分布图象在不同时期也存在差异，瘤细胞侵袭基底膜处ＬＮ和ＩＶ型胶原缺失。通过体外实验，观察到ＬＡ＿（７９５）细胞母系有内源性ＦＮ和ＬＮ的产生，无ＩＶ型胶原ｍＲＮＡ的表达，ＦＮ、ＬＮ或ＩＶ型胶原尤其是ＬＮ能促进瘤细胞的运动，ＦＮ或ＬＮ能加快瘤细胞集落的生长，表明ＦＮ、ＬＮ和ＩＶ型胶原与恶性肿瘤的侵袭和转移有关。     

MNNG诱发新生大鼠腺胃癌模型的建立及其在胃癌发病机制研究上的应用

通过给新生Ｗｉｓｔａｒ大鼠连续１０次（每日１次）１－甲基－３－硝基－１亚硝基肌（ＭＮＮＧ）灌胃，成功地诱发出腺胃癌、腺瘤和异型增生等病变。在０．４ｍｇ／只剂量组，这三种病变的诱发率分别为３９％、５０％和１００％，腺胃癌的诱发率与ＭＮＮＧ剂量成正比，雄性大鼠高于雌性（Ｐ＜０．０２），７０％病变发生在胃窦部。本模型具有致癌物用量小、易定量、给药期短、省时省力和不易污染环境等优点。研究还发现６个腺胃癌中有４个ＤＮＡ具有使ＮＩＨ／３Ｔ３发生恶性转化的作用，这种转化表现为对Ｂａｌｂ／ｃ裸鼠有致瘤性，提示在这种腺胃癌ＤＮＡ中存在转化基因。     

Eliciting patients’ preferences for adjuvant chemotherapy in breast cancer: development and validation of a bedside decision‐making instrument in a French Regional Cancer Centre

Introduction

In developed countries, the physician‐patient relationship is moving from a paternalistic model to new decision‐making models that take patient preferences into account.

Objectives

Our aim was to develop a Decision Board (DB) and to test its acceptability in a French Regional Cancer Centre regarding the decision on whether or not to use chemotherapy after surgery in postmenopausal women with breast cancer. This paper presents the development process for this instrument and reports the pretesting phase, as well as the corresponding results.

Methods

A working group was created with oncologists, psychologists and economists. Following the first phase, i.e. the development process, a first version of the instrument was presented to health professionals. Their feedback led to important modifications of the instrument. The DB was then presented to experienced patients, which resulted in slight changes. The second phase consisted of pretesting the comprehension, internal and across‐time consistency of the DB on healthy volunteers.

Results

The DB was pretested in a group of 40 healthy volunteers. Eighteen respondents chose chemotherapy and 22 chose not to have chemotherapy. Comprehension rates were very high (≥87.5%). Internal consistency was assessed considering option attitudes based on outcomes and option attitudes based on process. Women shifted their choices in a predictable way. Across‐time consistency was appraised using the test‐retest method with Visual Analog Scales. The Intraclass Correlation Coefficient was 0.97.

Discussion‐conclusion

Due to cultural differences, the DB developed in our French Cancer Centre is quite different from the DBs previously developed elsewhere. Our instrument showed good comprehension and consistency properties, which are corroborated by the DB literature. Whether our DB is acceptable for patients with breast cancer must still be tested. Patients’ reactions will tell us which type of decision‐making model is at work. Further research is needed in order to explore the shared decision‐making process and clarify the concept.

     

Rabbit model of non-cirrhotic portal fibrosis with repeated immunosensitization by rabbit splenic extract

BACKGROUND: Non-cirrhotic portal fibrosis (NCPF) or idiopathic portal hypertension, a disease of unknown etiology, is a common cause of portal hypertension in developing countries. Attempts to understand the etiopathogenesis of NCPF by developing animal models have been made. We describe a novel approach using repeated injections of rabbit splenic extract that were obtained from a previously primed rabbit, to develop a model of NCPF. METHODS: Twenty-eight rabbits (1.5-2.0 kg) were divided into the control (group I, n = 13) and the experimental (group II, n = 15) groups. The supernatant obtained after centrifugation of a 20% splenic homogenate, containing 6 mg protein/mL, was mixed with Freund's complete adjuvant (1:1 ratio) and injected intramuscularly to the recipient rabbits every 2 weeks for 3 months. Portal pressure was measured by inserting a cannula into the gastrosplenic vein. RESULTS: The mean portal pressure in group II was significantly (P < 0.05) higher than group I at 1 (19.4 +/- 2.9 vs 10.4 +/- 2.2 mmHg), 3 (16.7 +/- 1.1 vs 7.2 +/- 3.6 mmHg), and 6 (20.3 +/- 5.4 vs 10.3 +/- 4.8 mmHg) months. The mean splenic weight in group II was significantly (P < 0.05) greater than group I at 1, 3 and 6 months. Histopathology of spleen showed medullary congestion, hemosidrin laden macrophages and mild fibrosis. Liver showed normal hepatocytes with mild portal lymphocytic infiltrates and Kupffer cell hyperplasia. No significant anomalies were observed in the tests of liver function at 1 and 6 months. CONCLUSIONS: This animal model showed significant splenomegaly, with persistent rise in portal pressure without hepatic parenchymal injury, quite akin to NCPF seen in humans. This study also proposes that repeated immunostimulation may have an important role in the pathogenesis of NCPF.     

Fourier analysis of cytoplasmic texture in nuclear fiber cells from transparent and cataractous human and animal lenses

Comparisons were made of the cytoplasmic textures in electron microscope images of nuclear fiber cells from a variety of human and animal lenses. The goals were to establish the optimal conditions for quantifying the textural features and for relating the extent of roughness with the observed extent of nuclear opacification. Freshly cut Vibratome sections were fixed and processed for thin-section electron microscopy. Normal human donor lenses, human age-related cataracts from surgery, and rat, guinea pig, and canine lenses were analyzed using density linescans, Fourier transforms, and autocorrelation analysis. Normal and control lenses were compared to lenses with varying degrees of scattering including fully opaque nuclear cataract. Images were recorded at 21,000 x, giving structural information in the critical range of 2-300 nm. Human normal and nuclear cataractous lens cytoplasm produce Fourier transforms with relatively high intensity in the range 10-50 nm (equivalent spacing) and relatively low intensity greater than 100 nm. This is consistent with the smooth image appearance, linescans with small fluctuations and autocorrelation functions indicating that the images are nearly homogeneous. Images of the transparent animal lenses were very smooth and produced Fourier transforms that showed less intensity in the range 10-50 nm and less intensity greater than 100 nm compared to the human lenses. Animal lenses with progressively enhanced light scattering showed a strong correlation between increased textural roughness and increased Fourier intensity greater than 100 nm. These analytical image analysis techniques readily documented the wide range of cytoplasmic textural variations in human and animal lenses and cataracts. Consistent comparisons were possible only when well-preserved tissues were examined with high-resolution images. The cytoplasm with the greatest roughness correlated with the greatest light scattering suggests that redistribution and/or loss of cytoplasmic proteins contribute to cataract formation.     

The modulation by xanthines of the DNA-damaging effect of polycyclic aromatic agents. Part II. The stacking complexes of caffeine with doxorubicin and mitoxantrone

Recently accumulated statistical data indicate the protective effect of caffeine consumption against several types of cancer diseases. There are also reports about protective effect of caffeine and other xanthines against tumors induced by polycyclic aromatic hydrocarbons. One of the explanations of this phenomenon is based on biological activation of such carcinogens by cytochromes that are also known for metabolism of caffeine. In the accompanying paper [Kapuscinski et al., this issue] we provide evidence (flow cytometry and the cell cycle analysis) that the cytostatic effects of caffeine (CAF) on two DNA alkylating agents, which do not require the biological activation, depend on their ability to form stacking (pi-pi) complexes. In this study, we use physicochemical techniques (computer aided light absorption and microcalorimetry), and molecular modeling to examine previously published qualitative data. This is published both by our and other group's data, indicates that CAF is able to modify the cytotoxic and/or cytostatic action of the two well known antitumor drugs doxorubicin (DOX) and mitoxantrone (MIT). To obtain the quantitative results from the experimental data we used the statistical-thermodynamical model of mixed aggregation, to find the association constants K(AC) of the CAF-drug interaction (128+/-10 and 356+/-21M(-1) for DOX-CAF and MIT-CAF complex formation, respectively). In addition, the favorable enthalpy change of CAF-MIT (DeltaH=-11.3kcal/mol) was measured by microcalorimetry titration. The molecular modeling (semi-empirical and force field method) allowed us to obtain the geometry of these complexes, which indicated the favorable energy (DeltaE) of complex formation of the protonated drug's molecules in aqueous environment (-7.4 and -8.7kcal/mol for DOX-CAF.5H(2)O and MIT-CAF.8H(2)O complex, respectively). The molecular modeling calculation indicates the existence of CAF-drug complexes in which the MIT molecules are intercalated between two CAF molecules (DeltaE=-29.9kcal/mol). These results indicate that the attenuating effect of caffeine on cytotoxic or mutagenic effects of some polycyclic aromatic mutagens cannot be the result of metabolic activation in the cells, but simply is the physicochemical process of the sequestering of aromatic molecules (e.g. carcinogens or mutagens) by formation of the stacking complexes. The caffeine may then act as the "interceptor" of potential carcinogens (especially in the upper part of digesting track) where its concentration can reach the mM level). There is, however, no indication, both, in the literature or from our experiments, that the xanthines can reverse the damage to nucleic acids at the point when the damage to DNA has already occurred.     

RURAL URGENT CARE MODELS: WHAT ARE THEY MADE OF?

ABSTRACT: The study aimed to identify the elements that constitute rural urgent care systems. Participation in the study was sought from health professionals, welfare and emergency services sectors, and community members. Primary data were collected from informants through interviews and focus groups in five rural communities of different sizes. Twelve common elements to rural urgent care systems were identified and divided into two categories: (i) infrastructure; and (ii) personnel. Infrastructure included organisational support, community support, transport, communication and coordination processes, facilities and equipment, and community knowledge and information. Personnel included nurses, doctors, community leaders, health and welfare professionals, emergency service workers and ambulance officers. The study's major outcome was the recognition that rural urgent care systems consist of a balance of interrelated elements. These elements are context driven, with geographical, social and economic environments having a substantial impact on the ability of rural communities to develop and sustain their urgent care systems.