Managed care and the treatment of skin disease, 1995. Continued growth and emerging dominance

OBJECTIVE: To document changes in type of financing for office-based visits for the treatment of common skin conditions and to dermatologists. DESIGN: Data from a national survey of visits to office-based practitioners conducted by the National Center for Health Statistics were used. The stratified sampling technique permits estimation of the total number of office visits with specific characteristics in the United States. SETTING: A national probability sample of visits to office-based practitioners occurring in 1995. SUBJECTS: In 1995, 36,875 visits were sampled. Of these, 2121 were for common skin problems to any physician and 1886 were visits for any reason to dermatologists. MAIN OUTCOME MEASURES: The distribution source of payment and presence of managed care arrangements for office visits for common skin problems and to dermatologists. INTERVENTION: None. RESULTS: In 1995, preferred provider and health maintenance organizations provided payment for 34% of all ambulatory care and 38% of office visits for common skin complaints. CONCLUSION: Managed care is already the dominant mechanism of payment for the treatment of skin disease for many patient groups and in many areas of the country. Preferred provider organizations are much more likely to employ dermatologists to provide care of common skin problems than are health maintenance organizations. If the recent trends continue, by year 2000 most patients seen by dermatologists will be seen under the auspices of managed care systems.     

Effect of milk-borne epidermal growth factor on the hepatic microcirculation and Kupffer cell function in suckling rats

A Rehabilitation Information System was created in July 1993 in order to register war victims in need of physical rehabilitation all over Croatia. The system is currently operating and presented data covers the period from July 1991 to July 1995. Approximately 15,000 questionnaires had been completed and returned from medical institutions on in total 8589 disabled war victims in need of rehabilitation. People with severe disabilities comprised about 20% of all in need of rehabilitation. Those reported injured were 3.5 times more than those in need of physical rehabilitation. Most common types of injuries were fractures with a permanent disabling condition (3109 persons), peripheral nerve injuries (1213 persons) and amputations (956 persons). Traumatic brain injuries were registered for 594 and spinal cord injuries for 262 persons. Causes of injuries were explosive devices (such as mines, mortar shell shrapnel, etc.) in 37% of cases, bullets in 22%, accidents in 7%, other (such as fire, blast injuries, etc.) and unknown causes in 34%.     

The cuffed oropharyngeal airway as an aid to fibreoptic intubation

OBJECTIVE: To determine if a structured encounter form for well-child care improves documentation of well-child care. DESIGN: Retrospective medical record review of a before-and-after trial. SETTING: Family practice residency clinic serving a primarily low-socioeconomic urban population. PATIENTS: Children younger than 6 years receiving well-child care visits. INTERVENTION: Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force. MAIN OUTCOME MEASURES: Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form. RESULTS: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form. CONCLUSIONS: The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.     

Characterization of interactions between the anti-apoptotic protein BAG-1 and Hsc70 molecular chaperones

The anti-cell death protein BAG-1 binds to 70-kDa heat shock proteins (Hsp70/Hsc70) and modulates their chaperone activity. Among other facilitory roles, BAG-1 may serve as a nucleotide exchange factor for Hsp70/Hsc70 family proteins and thus represents the first example of a eukaryotic homologue of the bacterial co-chaperone GrpE. In this study, the interactions between BAG-1 and Hsc70 are characterized and compared with the analogous GrpE-DnaK bacterial system. In contrast to GrpE, which binds DnaK as a dimer, BAG-1 binds to Hsc70 as a monomer with a 1:1 stoichiometry. Dynamic light scattering, sedimentation equilibrium, and circular dichroism measurements provided evidence that BAG-1 exists as an elongated, highly helical monomer in solution. Isothermal titration microcalorimetry was used to determine the complex stoichiometry and an equilibrium dissociation constant, KD, of 100 nM. Kinetic analysis using surface plasmon resonance yielded a KD consistent with the calorimetrically determined value. Molecular modeling permitted a comparison of structural features between the functionally homologous BAG-1 and GrpE proteins. These data were used to propose a mechanism for BAG-1 in the regulation of Hsp70/Hsc70 chaperone activity.     

Suspected Brazilian purpuric fever in a toddler with overwhelming Epstein-Barr virus infection

We describe a toddler from Connecticut who developed purulent conjunctivitis, fever, and a morbilliform rash. Blood cultures were positive for Haemophilus influenzae biogroup aegyptius; further investigation was performed to assess the possibility that the illness was consistent with Brazilian purpuric fever, which, to our knowledge, has not been reported in the United States. This isolate shared morphological and some biochemical characteristics with previously studied H. influenzae biogroup aegyptius strains but differed according to slide agglutination testing, plasmid characterization, and ribotyping. Blood and tissue samples obtained during his hospitalization were also positive for Epstein-Barr virus. The child died 8 days after hospitalization. Fifty other cases of invasive H. influenzae infection were identified by active surveillance studies. Of the 49 viable surveillance isolates, 10 were biotype III (two of which had the same ribotype as the strain from our case.     

Minimizing pain for liposuction anesthesia

The publication of the complete genome sequence of Helicobacter pylori and the computer analysis of the genes it contains represents an enormous advance in H. pylori research. Besides providing an overview of H. pylori biology, the genome sequence will aid future research and radically alter the research process. In particular, it will enable a 'top down' approach whereby genes are investigated because of their similarity to genes of known function in other organisms. Other advances in biotechnology will allow all H. pylori genes to be studied simultaneously, proteins to be identified quickly, and potential drug targets to be evaluated efficiently. Progress in H. pylori research should now be rapid, and with the research interest and resources focused on it, H. pylori could become the paradigm for post-genomic research.     

Chromosomal aberrations in soft tissue tumors. Relevance to diagnosis, classification, and molecular mechanisms

In recent years, significant progress has been made in identifying characteristic chromosomal rearrangements associated with several solid tumor types, notably sarcomas, a relatively rare subset of human cancer. Most sarcomas analyzed have been found to be characterized by recurrent chromosome translocations that are specific to histological types. We have reviewed published reports of chromosomal aberrations in benign and malignant soft tissue tumors and found an incidence of specific translocations in these neoplasms that ranged from 20% to 93% within histological tumor types. Identification of recurrent chromosomal abnormalities in benign tumors has resulted in a reappraisal of the general concept that benign tumors have a normal (diploid) chromosome constitution. The variety of recurrent changes present in the different tumor types attests to the cytogenetic diversity inherent in these tumors. The chromosomal rearrangements in each of the tumor types were unique and did not correspond to cancer-associated aberrations known from other solid or hematopoietic malignancies. Cytogenetics thus provides an essential adjunct to diagnostic surgical pathology in the case of malignant soft tissue tumors, which often present substantial diagnostic challenges. In addition, it represents another approach to determine the histogenetic origin of some tumors and identifies sites of gene deregulation for molecular analysis. Indeed, recent molecular analyses of several sarcoma-associated translocations have identified novel genes and novel mechanisms of their dysregulation.     

Maternal viral genotypic zidovudine resistance and infrequent failure of zidovudine therapy to prevent perinatal transmission of human immunodeficiency virus type 1 in pediatric AIDS Clinical Trials Group Protocol 076

Maternal samples were assessed from 96 women enrolled in Pediatric AIDS Clinical Trials Group protocol 076 to determine the prevalence of human immunodeficiency virus type 1 (HIV-1) genotypic zidovudine resistance at entry, if zidovudine resistance developed on study, and the role of zidovudine resistance in vertical transmission of HIV-1 despite zidovudine therapy. Low and high levels of genotypic resistance were assessed by differential hybridization, oligoligation, or direct sequencing of plasma HIV-1 RNA for codons K70R and T215Y/F. None of the women had high-level genotypic resistance to zidovudine at study entry or delivery. For low-level zidovudine resistance, the 95% confidence intervals were 0.3%-6.8% for baseline prevalence and 0.3%-14% for delivery incidence. Low-level zidovudine resistance, adjusted for plasma viral RNA level at delivery, was not strongly associated with an increase in vertical transmission risk (odds ratio, 4.8; 95% confidence interval, 0.2-131; P = .35).