A cost density analysis of benign prostatic hyperplasia.

We assessed the frequency and cost of care for benign prostatic hyperplasia (BPH) among approximately 165,000 subscribers to Fallon Community Health Plan (FCHP), a group model health maintenance organization located in central Massachusetts. We computed rates of episodes of medical services for BPH using automated utilization files, and we estimated costs using Medicare reimbursement schedules and medication average wholesale prices. We identified 3919 men who visited a physician for BPH from January 1, 1991, until December 31, 1994, during which time they contributed 8336 person-years to the analysis. This population comprises approximately 12% of men at least 40 years old at FCHP. From 1991 to 1994, 696 (18%) men received terazosin, 219 (6%) men underwent a prostatectomy, and 41 (1%) men received finasteride. Men averaged 1.66 office visits per year to a physician for BPH. Most office visits (61%) were to a primary care physician, with 39% of the visits to a urologist. Among patients who received terazosin, the frequency of office visits increased slightly after receiving terazosin, from 2.14 to 2.62 visits per year. Among surgery patients, the frequency of visits declined after prostatectomy, from 6.31 visits per year to 1.67 visits. The individual annual cost rate for BPH care ranged from $25.00 to $25,352.00, with an average of $364.00 per person and a median cost of $126.00. The major components of the overall costs were hospital admissions (35%), terazosin dispensings (29%), and physician office visits (19%), with outpatient hospital care and ambulatory procedures accounting for the remaining 17%. Among men receiving terazosin, the average cost was $1190.00 per person-year, and among patients undergoing prostatectomy, the cost was $2630.00 per person-year. The prostatectomy rate declined by nearly 80% during the study period, while the dispensing rate for terazosin doubled, resulting in an overall decline in the total cost of care for BPH from 1991 to 1994.

Negative regulation of interleukin-2 production in primary lymphocytes by 12-O-tetradecanoylphorbol-13-acetate.

Stimulation of quiescent T lymphocytes to proliferate involves a complex series of events both between and within cells. At least 70 genes are known to be induced or activated from the time of the initial stimulation until DNA synthesis. While some of these gene products, e.g., interleukin-2 (IL-2) and IL-2 receptors, are required for proliferation, others, e.g., gamma-interferon and colony-stimulating factor, are ancillary to activated T cell function. Several biochemical signal transductions are among the early events. One of the earliest is phospholipase C-mediated hydrolysis of phosphatidylinositol leading to release of diacylglycerols and inositol phosphates, which in turn activate protein kinase C and elevate intracellular free calcium levels. The discovery that the phorbol ester 12-O-tetradecanoylphorbol-13-acetate (TPA) both enhances proliferation and activates protein kinase C strengthens the evidence for a general role of protein kinase C in proliferation. Yet, the exact consequences of stimulation of protein kinase C in regard to specific proliferation proteins is still not clear. In this study, we present evidence that protein kinase C activation is directed to production of IL-2 but not to IL-2 receptors. Under conditions of TPA treatment in which protein kinase C was chronically reduced in T lymphocytes, IL-2 production was greatly depressed as were the level of IL-2 mRNA and [3H]thymidine incorporation. In contrast, these cells still expressed high affinity IL-2 receptors and proliferated when endogenous IL-2 was added. Because neither phosphatidylinositol metabolism nor Ca2+ flux was affected, the block appeared to be mediated directly or indirectly through protein kinase C.

Molecular mechanisms of homologous and heterologous desensitization mediated by vasopressin in smooth muscle cells.

Arginine vasopressin (AVP) has been shown previously to enhance phosphatidylinositol (PI) turnover and mobilize calcium in the rat aortic smooth muscle cell-line (A10; ATCC CRL 1476) via the V1 receptor (Aiyar, N., Nambi, P., Stassen, F. L., and Crooke, S. T. (1986) Life Sci. 39, 37-45). Exposure of A10 cells to AVP for periods ranging from 5 min to 2 h resulted in 30-40% loss in AVP-binding sites and an inhibition of the production of inositol di- and trisphosphates and the mobilization of calcium when the cells were rechallenged by addition of AVP. We now report that during the same time course AVP induces a dose- and time-dependent decrease in labeled PI, phosphatidylinositol-4-phosphate and phosphatidylinositol-4,5-bisphosphate reaching a minimum after 30 min of incubation. After 2 h of exposure to AVP, the levels of labeled PI, phosphatidylinositol-4-phosphate and phosphatidylinositol-4,5-bisphosphate increased to a new basal level approximately 30% less than the untreated cultures. The decrease in inositol lipid labeling mediated by AVP was inhibited when the V1 antagonist SK&F 100273 was included in the incubations with AVP. No decrease was observed when the V2 agonist 1-deamino, [8-D-arginine]vasopressin was used for pretreatment of the cells. Furthermore, when PI kinase activity was measured in cell extracts from untreated and AVP-treated (2 h) cells a significant decrease (p less than 0.05) was observed in the absence, but not in the presence, of added PI in the AVP-treated cells as compared with the control cells. Thrombin also stimulates PI metabolism and calcium mobilization in these cells and brought about both a prolonged decrease in inositol lipids and inhibition of PI kinase activity. AVP pretreatment affected the release of intracellular Ca2+ induced by AVP, thrombin, and ATP, differently. The time of AVP pretreatment required to induce half-maximal inhibition of intracellular Ca2+ release in response to AVP, thrombin, and ATP was approximately 8, 24, and 30 min, respectively. Consequently, we suggest that the reduction in response to AVP with short term preincubation is due to homologous desensitization as reflected by 30-40% decrease in V1 receptors. Subsequently, a decrease in inositol lipid pools and PI kinase activity results in heterologous desensitization in response to AVP, thrombin, and ATP.

Homologous and heterologous desensitization mediated by vasopressin in smooth muscle cells.

Prolonged exposure of A-10 cells to Arginine Vasopressin (AVP) resulted in the following responses: (a) loss of vasopressin receptors from the cell surface (30-40%), (b) increased basal levels of inositol and inositol monophosphate, (c) decreased inositol di- and trisphosphate production and decreased intracellular calcium release in response to a second challenge with AVP, (d) attenuation of AVP-mediated inhibition of isoproterenol-stimulated cAMP and ANF-stimulated cGMP accumulation and (e) attenuation of thrombin and ATP-mediated increase in inositol di- and trisphosphate accumulation and intracellular calcium release. All the above responses depended on the time of exposure of the cells to AVP with the responses being attenuated as early as 5-10 min of exposure to AVP. The desensitization also depended on the concentration of AVP used with 50% of maximal desensitization for each response being observed at 5 nM of AVP. This concentration of AVP corresponded well with the Kd of vasopressin for binding to these sites. Desensitization of protein kinase C (PKC) by prolonged exposure of the cells to PDBu or addition of the PKC inhibitor staurosporine during pretreatment with AVP did not prevent AVP-mediated desensitization, suggesting that PKC may not be involved in AVP-mediated desensitization in smooth muscle cells. It is concluded that AVP induced both homologous and heterologous desensitization of phosphatidylinositol turnover and calcium release in smooth muscle cells. The desensitization processes did not appear to be mediated by protein kinase C. The possibility that the locus of the heterologous desensitization may be at the level of substrates such as PI, PIP and PIP2 is discussed.

Lectin-induced phosphatidylinositol metabolism in lymphocytes is potentiated by macrophages.

The generation and hydrolysis of phosphatidylinositol 4,5-bisphosphate (PIP2) have been shown to occur early after the stimulation of a variety of cells and to trigger an array of responses, including proliferation in lymphocytes. In this study we examined the requirement for macrophages in the production and metabolism of PIP2 in lectin-stimulated lymph node lymphocytes. When lymph node cells (LNC) were stimulated by the mitogenic lectin, Con A, a two- to threefold increase in [3H]inositol-labeled PIP2 occurred within 15 min, followed by a decrease to the level of unstimulated cells by 30 min. In addition, there was also a two- to threefold increase in the accumulation of [3H]inositol-labeled inositol monophosphate (IP) 30 min after the addition of lectin. However, when the LNC were depleted of macrophages by adherence to plastic and passage over cotton columns before the addition of Con A, the PIP2 response was not seen and the IP accumulation was reduced by 40%. The macrophage-depleted, Con A-stimulated cultures failed to synthesize DNA. [3H]TdR incorporation was only 15% of that of Con A-stimulated unseparated LNC cultures. Soluble IL-2 production was also depressed to 20% of that observed in macrophage-containing cultures. Furthermore, when macrophages (2%) were added to the macrophage-depleted cultures, PIP2 production, IP accumulation, and [3H]TdR incorporation were restored to levels observed in the stimulated unseparated LNC cultures. The addition of IL-1 or the phorbol ester 12-O-tetradecanoylphorbol-13-acetate in combination with Con A also restored both [3H]TdR incorporation and IL-2 synthesis in macrophage-depleted cultures. However, they did so without a detectable increase in phosphatidylinositol metabolism. Collectively, these data suggested that the production and degradation of PIP2 in Con A-stimulated lymphocytes was potentiated by the presence of macrophages.

Phorbol ester circumvents the need for macrophages as well as for mitogenic lectins in the stimulation of lymphocytes with wheat germ agglutinin or the calcium ionophores A23187 or ionomycin.

Numerous biochemical events precede the proliferation of primary lymphocytes stimulated by mitogenic lectins in the presence of macrophages. Various compounds can activate parts of this response. Specifically the tumor-promoting phorbol ester, 12-O-tetradecanoylphorbol-13-acetate, (TPA), can replace the requirement for macrophages, apparently by mimicking the macrophage product interleukin 1 (IL1). Wheat germ agglutinin (WGA), itself a non-mitogenic lectin, is reported to cause a calcium flux, phosphatidylinositol turnover, and enhance interleukin 2 (IL2) synthesis. In spite of these positive responses, WGA inhibits DNA synthesis caused by mitogenic lectins. Nevertheless, in this study, we tested the possibility that together TPA and WGA could complement and bring about DNA synthesis. This prediction turned out to be true. The combination of two non-mitogenic compounds resulted in lymphocyte proliferation. The TPA overcame the inhibitory effects of WGA. Moreover, macrophages were not required. The TPA also synergized with the calcium ionophores A23187 or ionomycin to cause lymphocyte proliferation in the absence of macrophages. WGA and the ionophores together did not cause proliferation, a finding which suggested that they fulfill the same roles. These observations led us to conclude that at least two signals were required for lymphocyte stimulation. One signal caused the mobilization of calcium and the other signal circumvented the need for macrophages or macrophage products possibly by mimicking diacylglycerol, the activator of protein kinase C.

Mitogen and co-mitogen stimulation of lymphocytes inhibited by three Ca++ antagonists.

The Ca++ requirement for in vitro lymphocyte stimulation by lectins is well known and can be demonstrated by the use of Ca++ chelators. In this study, three Ca++ antagonists were examined for their effects on lymphocyte proliferation. [3H]-thymidine incorporation was employed to measure DNA synthesis in several systems. Stimulation and proliferation were achieved by the addition of one of the following: the mitogenic lectin concanavalin A (ConA); the combination of two co-mitogens, the calcium ionophore A23187 and the phorbol ester, 12-0-tetradecanoylphorbol-13-acetate (TPA), neither of which is mitogenic alone; or the non-mitogenic lectin, wheat germ agglutinin (WGA) with TPA. These mitogenic systems were tested for their sensitivity to the Ca++ channel blockers verapamil and nicardipine and the intracellular Ca++ antagonist TMB-8. We found that the ConA and WGA plus TPA treated cells were inhibited approximately 50% by 10 microM verapamil, nicardipine or TMB-8. The stimulation caused by A23187 and TPA was only inhibited by TMB-8 and nicardipine. The inhibitory effects caused by the Ca++ antagonists could not be reversed by the addition of exogenous Ca++ (0.1-1.5 mM), but were reversed by repeated washings in antagonist free media. Using TMB-8 we saw an apparent intracellular Ca++ dependence throughout the G1 phase. Previous studies using Ca++ chelators or Ca++ antagonists suggested an endpoint at about halfway through this period.