We enter this century with an unprecedented federal budget surplus-$4.6 trillion over the next 10 years. A substantial portion of the surplus comes from savings in the health care sector. The 1997 Balanced Budget Act cut payments to Medicare providers and raised the premiums for individual beneficiaries, but we overshot the mark. Instead of balancing the budget, we generated a huge surplus. We underestimated the magnitude of Medicare savings. Medicare savings over the period from 1998 to 2007 represent an estimated 15% of the total budget surplus. Fifteen percent of the 10-year budget surplus from 2001 to 2010 comes to $680 billion. We also underestimated the drop-off in Medicaid coverage, as welfare reform took hold. In the year 2000 Medicare and Medicaid outlays were an estimated $104 billion less than projected just 5 years ago-representing an estimated 45% of the budget surplus this year, or about $1 trillion of the 10-year surplus.

Budgets↗

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Oxygen-induced seizures and inhibition of human glutamate decarboxylase and porcine cysteine sulfinic acid decarboxylase by oxygen and nitric oxide.

The recombinant forms of the two human isozymes of glutamate decarboxylase, GAD65 and GAD67, are potently and reversibly inhibited by molecular oxygen (Ki = 0.46 and 0.29 mM, respectively). Inhibition of the vesicle-associated glutamate decarboxylase (GAD65) by molecular oxygen is likely to result in incomplete filling of synaptic vesicles with gamma-aminobutyric acid (GABA) and may be a contributing factor in the genesis of oxygen-induced seizures. Under anaerobic conditions, nitric oxide inhibits both GAD65 and GAD67 with comparable potency to molecular oxygen (Ki = 0.5 mM). Two forms of porcine cysteine sulfinic acid decarboxylase (CSADI and CSADII) are also sensitive to inhibition by molecular oxygen (Ki = 0.30 and 0.22 mM, respectively) and nitric oxide (Ki = 0.3 and 0.2 mM, respectively). Similar inhibition of glutamate decarboxylase and cysteine sulfinic acid decarboxylase by two different radical-containing compounds (O2 and NO) is consistent with the notion that these reactions proceed via radical mechanisms.

Animals↗

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Reimbursement for preventive services: can we construct an equitable system?

This report examines alternative methods of paying for clinical preventive care services. First, the extent of coverage of preventive health care services in public and private health insurance plans is reviewed. Included in this review are Medicare, Medicaid, health maintenance organizations, and private health insurance plans. Second, four alternative methods for paying for preventive care are discussed. These options are: 1) fee-for-service; 2) a periodic preventive health visit fee; 3) capitation; and 4) a preventive services account. The report concludes with recommendations for constructing an equitable system for increasing access to preventive services. A multi-pronged approach is recommended involving improvements in public and private coverage of these services; development of a periodic preventive health visit fee payment mechanism; initiation of additional research and demonstration efforts designed to determine cost-effectiveness of services and payment approaches; and modifications to the current coding system that would lead to a more appropriate method for reimbursement of preventive care services.

Abstracting and Indexing↗

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Controversies in cancer care: hormone replacement therapy after breast cancer: how shall we do no harm?

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Breast Neoplasms↗

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Effects of body temperature on accuracy of continuous cardiac output measurements.

Intermittent measurement of cardiac output is routine in the critically ill surgical patient. A new catheter allows real-time continuous measurement of cardiac output. This study evaluated the impact of body temperature variation on the accuracy of these measurements compared to standard intermittent bolus thermodilution technique. This prospective study in a university hospital surgical intensive care unit included 20 consecutive trauma patients. Data were collected with pulmonary artery catheters, which allowed both continuous (COC) and bolus (COB) thermodilution measurements. The catheter was placed through either the subclavian or internal jugular vein. Measurements for COB were performed using a bolus (10 cm3) of ice-cold saline with a closed-injectate delivery system at end-expiration. Computer-generated curves were created on a bedside monitor, and the average of three measurements within 10% of one another was used as COB. COC was determined as the average of the displayed CO before and after thermodilution CO measurements. Body temperature was measured from the pulmonary artery catheter and was grouped as < or =36.5 degrees C, 36.6-38.4 degrees C, and > or =38.5 degrees C. COB and COC were compared for agreement by plotting the mean of the differences (COB - COC) between the methods. The differences were plotted against the average of each pair and analyzed with linear regression. One hundred seventy-eight paired measurements were made over a period of 1 to 3 days. CO ranged from 3.7 to 15.5 L/min. Eighty-one percent of measurements were at a temperature of 36.5-38.4 degrees C. Approximately 7% of measurements were at a temperature below 36.5 degrees C and 11.2% were in patients with a core temperature above 38.5 degrees C. Correlation between the two techniques was 0.96, 0.91, and 0.82 for temperatures of < or =36.5 degrees C, 36.6-38.4 degrees C, and > or = 38.5 degrees C, respectively. In conclusion, the COC measurements correlate well with COB in trauma patients with a core temperature < or =38.5 degrees C. The accuracy degraded at higher temperatures, which may be related to the smaller signal-to-noise ratio at elevated body temperatures.

Adult↗

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Nature's infant nutrition. Common concerns of mothers who breast-feed.

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Breast Feeding↗

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Clinical and molecular studies in a unique family with autosomal dominant limb-girdle muscular dystrophy and Paget disease of bone.

PURPOSE: To characterize the clinical features and perform linkage analysis of candidate loci in a large Illinois family with autosomal dominant limb-girdle muscular dystrophy (LGMD) and Paget disease of bone (PDB). METHODS: The family includes 11 affected individuals (8 M, 3 F). Clinical, biochemical and radiologic evaluations were performed to delineate clinical features of the disorder. Linkage analysis with polymorphic markers was performed for previously identified LGMD, PDB and cardiomyopathy loci. RESULTS: Onset of PDB is early, at a mean age of 35 y, with classic distribution involving the spine, pelvis, and skull. Muscle weakness and atrophy is progressive with mildly elevated to normal creatine phosphokinase levels. Muscle biopsy in the oldest male revealed vacuolated fibers, however, in others revealed nonspecific myopathy. Affected individuals die from progressive muscle weakness, and respiratory and cardiac failure in their 40s-60s. Linkage analysis excluded autosomal dominant and recessive LGMD, PDB, and cardiomyopathy loci. CONCLUSION: Autosomal dominant LGMD associated with PDB is an unusual disorder. Linkage analysis indicates a unique locus in this family.

Adult↗

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Clinical skin temperature measurement to predict incipient pressure ulcers.

OBJECTIVE: To evaluate temperature differences between areas of erythema and surrounding healthy tissue to determine whether clinical temperature measurement of sites at risk for pressure ulcer development could be used to indicate tissue damage. To validate the temperature portion of the National Pressure Ulcer Advisory Panel's new Stage I pressure ulcer definition. DESIGN: Repeated measures design. SETTING: Acute rehabilitation hospital. SUBJECTS: 65 outpatients and inpatients presenting with pressure-induced erythema at areas at risk for pressure ulcer development. The subjects were primarily non-ambulatory and exhibited a range of skin pigmentation and disabilities, including spinal injury, multiple sclerosis, and lower-limb amputations. MAIN RESULTS: The temperature and appearance of 80 pairs of erythematic and control sites were documented. Sites were considered to have equal temperatures if the difference was within plus or minus 1.0 degree F. Fifteen percent (n = 12) of the erythematic sites were the same temperature as the surrounding tissue, 23% (n = 18) of the erythematic sites were cooler than the control sites, and 63% (n = 50) were warmer. CONCLUSION: Both increased and decreased temperature differences can be used to indicate reactive hyperemia or a Stage I pressure ulcer, but a tissue integrity problem may still exist despite the absence of a temperature difference.

Persons with Disabilities↗

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Elevated alpha 1-antichymotrypsin serum levels in a subset of nondemented first-degree relatives of Alzheimer's disease patients.

A portion of Alzheimer's disease (AD) patients have elevated serum levels of the acute phase reactant alpha 1-antichymotrypsin (A1ACT) compared to age-matched controls. We measured serum levels of A1ACT in AD patients, age-matched controls, Down's syndrome patients, and nondemented first-degree relatives of AD patients. Significantly elevated levels of A1ACT were found in both AD patients and first-degree-relatives. In AD patients, serum A1ACT concentrations decreased with increasing severity of cognitive impairment. These results may suggest that inflammatory phenomena may be an early component of AD pathophysiology.

Age Factors↗

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Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans.

This report addresses diabetes care in the managed care setting and improvement in care brought about by collaboration between 6 Medicare managed care plans (MCPs) and a Peer Review Organization (PRO). The objective was to improve the quality of care of outpatient diabetes patients provided by primary care physicians through the mutual collaboration of 6 Medicare managed care plans and a Medicare Peer Review Organization. The design involved pre-post intervention trial based on 2 random samples, a baseline sample drawn in 1995 and a remeasurement sample drawn in 1996. Medical records of patients in both samples were reviewed by the PRO to determine provision of 14 quality indicator services over a 1-year period. The setting was 6 Arizona Medicare managed care plans comprising approximately 40% of the Arizona Medicare population. Two random samples were drawn from type 2 diabetes patients continuously enrolled in the same managed care plan for at least 1 year. The intervention was comparative feedback of baseline data by the PRO, enabling each plan to compare itself to any other plan on any or all indicators. Each plan developed and implemented its own intervention in response to the 1995 baseline results. The main outcome measures were mean HbA1c, the proportion of HbA1c values below 8%, and positive change in provision of 14 quality indicator services. At postintervention remeasurement, mean HbA1c values fell from 8.9 +/- 2.2 to 7.9% +/- 2.1, and the proportion of patients with HbA1c values below 8.0% rose from 40% to 61.6%. The proportion of the 14 indicator services provided to patients rose from 35% to 55%. The mean number of physician office visits fell 13% and the number of services provided per visit doubled. We conclude that improving the process of care improves glycemic control. Better outpatient diabetes management in competing, capitated managed care plans is an attainable goal when mediated through a neutral third party such as a PRO.

Ambulatory Care↗

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Computer processing of CT images: advances and prospects.

Computerized tomography (CT) images are created by computer and as such are inherently amenable to computer image processing techniques. Advances have been made in the areas of alternative visualization (coronal views, etc.), image enhancement, feature extraction, and computer analysis of the extracted information. Further advances await imaginative application of these techniques and time; others will depend upon necessary advances in image processing methods.

Computers↗

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Universal coverage: building on Medicare and employer financing.

Universal coverage requires a strategy to sever the link between insurance coverage and employment in order to build a more stable insurance base. Universality also will require subsidies to make coverage affordable. Given these realities, the authors evaluate different financing proposals--employer and individual premium mandates and taxes--in terms of equity, affordability, and administrative and political criteria. An expansion of Medicare offers an insurance alternative that takes advantage of existing administrative structures of national scope.

Community Participation↗

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Insurance matters for low-income adults: results from a five-state survey.

Using survey data from 2,000 low-income adult respondents in each of five states, this DataWatch assesses how uninsured, low-income adults differ from low-income adults who have public or private insurance and how Medicaid expansions have affected insurance coverage patterns across states with different eligibility policies. Findings show that the proportion of low-income uninsured adults is two to three times higher in states that have not expanded Medicaid eligibility beyond relatively low welfare levels. Compared with persons who have either Medicaid or private insurance, uninsured persons report more difficulties getting needed care, are less likely to have a regular provider, and rate the care they do receive as lower quality.

Adult↗