The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial.

Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/V(urea), a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive performance, self-reported depression, laboratory markers of nutrition, mineral metabolism and anemia, blood pressure and rates of hospitalization, and vascular access interventions. Patients in the nocturnal arm had improved control of hyperphosphatemia and hypertension, but no significant benefit among the other main secondary outcomes. There was a trend for increased vascular access events in the nocturnal arm. Thus, we were unable to demonstrate a definitive benefit of more frequent nocturnal hemodialysis for either coprimary outcome.

An equine protozoal myeloencephalitis challenge model testing a second transport after inoculation with Sarcocystis neurona sporocysts.

Previous challenge studies performed at Ohio State University involved a transport-stress model where the study animals were dosed with Sarcocystis neurona sporocysts on the day of arrival. This study was to test a second transportation of horses after oral inoculation with S. neurona sporocysts. Horses were assigned randomly to groups: group 1, transported 4 days after inoculation (DAI); group 2, at 11 DAI; group 3, at 18 DAI; and group 4, horses were not transported a second time (controls). An overall neurologic score was determined on the basis of a standard numbering system used by veterinarians. All scores are out of 5, which is the most severely affected animal. The mean score for the group 1 horses was 2.42; group 2 horses was 2.5; group 3 horses was 2.75; and group 4 horses was 3.25. Because the group 4 horses did not have a second transport, they were compared with all other groups. Statistically different scores were present between group 4 and groups 1 and 2. There was no difference in the time of seroconversion between groups. There was a difference between the time of onset of first clinical signs between groups 1 and 4. This difference was likely because of the different examination days. Differences in housing and handling were likely the reason for the differences in severity of clinical signs. This model results in consistent, significant clinical signs in all horses at approximately the same time period after inoculation but was most severe in horses that did not experience a second transport.

Physical and pharmacologic restraints in long-term care facilities.

This study examined the effects of education on the attitudes and practices of long-term care staff toward use of restraints. The intervention, a 1-day educational seminar, used a collaborative team of speakers from the Utah Survey Agency and medical professions. Seminar goals were threefold: first, to provide information about best practices for managing behaviors of individuals with dementia in long-term care settings; second, to provide an explanation of the Omnibus Budget Reconciliation Act regulations pertaining to restraint use; and third, to present alternative strategies to link best practice guidelines to the provision of care. Results showed significant changes in participants' attitudes toward use of restraints. Participants reported replicating the seminar for nursing home staff, revisiting facility policies on restraints, and modifying resident care plans.

Transcriptional pause, arrest and termination sites for RNA polymerase II in mammalian N- and c-myc genes.

Using either highly purified RNA polymerase II (pol II) elongation complexes assembled on oligo(dC)-tailed templates or promoter-initiated (extract-generated) pol II elongation complexes, the precise 3" ends of transcripts produced during transcription in vitro at several human c- and N- myc pause, arrest and termination sites were determined. Despite a low overall similarity between the entire c- and N- myc first exon sequences, many positions of pol II pausing, arrest or termination occurred within short regions of related sequence shared between the c- and N- myc templates. The c- and N- myc genes showed three general classes of sequence conservation near intrinsic pause, arrest or termination sites: (i) sites where arrest or termination occurred after the synthesis of runs of uridines (Us) preceding the transcript 3" end, (ii) sites downstream of potential RNA hairpins and (iii) sites after nucleotide addition following either a U or a C or following a combination of several pyrimidines near the transcript 3" end. The finding that regions of similarity occur near the sites of pol II pausing, arrest or termination suggests that the mechanism of c- and N- myc regulation at the level of transcript elongation may be similar and not divergent as previously proposed.

Initially transcribed sequences strongly affect the extent of abortive initiation by RNA polymerase II.

We investigated transcript initiation and early elongation by RNA polymerase II using templates mismatched between -9 and +3 (bubble templates). Highly purified RNA polymerase II alone was able to initiate transcription specifically on these templates in the presence of dinucleotide primers. The length distribution of abortively initiated RNAs was similar for purified RNA polymerase II on bubble templates and polymerase II on double-stranded templates in HeLa nuclear extracts. Increasing the U content in the initial portion of the transcript caused similar increases in abortive initiation for transcription of bubble templates by pure polymerase and double-stranded templates in extracts. Thus, the level of abortive initiation by RNA polymerase II is at least partly determined by interactions of the polymerase with the transcript and/or the template, independent of the general transcription factors. Substitution of 5-bromo-UTP for UTP reduced abortive initiation on bubble templates, consistent with the idea that transcription complex stability during early elongation depends on the strength of the initial RNA-DNA hybrid. Interestingly, transcription of bubble templates in HeLa extracts gave very high levels of abortive initiation, suggesting that inability to reanneal the initially melted template segment inhibits transcript elongation in the presence of the initiation factors.

Transcriptional pausing at +62 of the HIV-1 nascent RNA modulates formation of the TAR RNA structure.

A strong transcriptional pause delays human RNA polymerase II three nt after the last potentially paired base in HIV-1 TAR, the RNA structure that binds the transactivator protein Tat. We report here that the HIV-1 pause depends in part on an alternative RNA structure (the HIV-1 pause hairpin) that competes with formation of TAR. By probing the nascent RNA structure in halted transcription complexes, we found that the transcript folds as the pause hairpin before and at the pause, and rearranges to TAR concurrent with or just after escape from the pause. The pause signal triggers a 2 nt reverse translocation by RNA polymerase that may block the active site and be counteracted by formation of TAR. Thus, the HIV-1 pause site modulates nascent RNA rearrangement from a structure that favors pausing to one that both recruits Tat and promotes escape from the pause.

Analysis of premature termination in c-myc during transcription by RNA polymerase II in a HeLa nuclear extract.

Transcriptional regulation of the human c-myc gene, an important aspect of cellular differentiation, occurs in part at the level of transcript elongation. In vivo, transcriptional arrest, due to either pausing or termination, occurs near the junction between the first exon and first intron and varies with the growth state of the cell. We have tested the transcription of c-myc templates in HeLa nuclear extracts. We did not observe significant arrest under standard conditions, but we found that a considerable fraction of transcription complexes stopped at the c-myc TII site (just past the first exon-intron junction) when the KCl concentration was raised to 400 mM during elongation. Transcriptional arrest at TII also was observed at KCl concentrations as low as 130 mM and when potassium acetate or potassium glutamate was substituted for KCl. Under these conditions, arrest occurred at the TII site when transcription was initiated at either the c-myc P2 promoter or the adenovirus 2 major late promoter. Further, the TII sequence itself, in forward but not reverse orientation, was sufficient to stop transcription in a HeLa nuclear extract. By separating the TII RNA from active transcription complexes by using gel filtration, we found that arrest at TII at 400 mM KCl resulted in transcript release and thus true transcriptional termination. The efficiency of termination at TII depended on the growth state of the cells from which the extracts were made, suggesting that some factor or factors control premature termination in c-myc.

Medicare expenditures for physician and supplier services, 1970-88.

The trend data in this article focus on Medicare expenditures and allowed charges for physician and supplier services rendered during the period from 1970 through 1988. A brief overview is presented on the provisions of the new Medicare physician payment system mandated by Congress and scheduled to be phased in starting January 1, 1992. The data provide one of the baselines that could be used for measuring and evaluating the impact of the new Medicare payment system for physician services.

Convergent and discriminant validities of the Scales of Independent Behavior and the revised Vineland Adaptive Behavior Scales.

The relation between the Scales of Independent Behavior (SIB) and the revised Vineland Adaptive Behavior Scales (VABS) was examined. Subjects were 53 children ages 3 through 7. A correlation of .83 was found between the SIB Broad Independence Score and the VABS Adaptive Behavior Composite. Campbell and Fiske's criteria for convergent and discriminant validity were applied to six of the scales that were common to both instruments. Results indicated that the most valid subscales were Personal Living Skills, Communication Skills, and Community Living Skills.

Hospital outpatient services under Medicare, 1987.

Presented in this article are data related to hospital outpatient services provided for aged and disabled Medicare beneficiaries during calendar year 1987. Trend data are also presented for selected calendar years 1974-87. Hospital outpatient covered charges and Medicare program payments (in total and per enrollee) are the statistics employed to measure the use of hospital outpatient services. The data contained in this article should provide information to help identify trends and patterns of care for monitoring the Medicare hospital outpatient services.

Use and cost of short-stay hospital inpatient services under Medicare, 1988.

In this article, data are presented on trends in the use of and program payments for inpatient short-stay hospital services to Medicare beneficiaries. The data on the services used by aged and disabled Medicare beneficiaries are presented for the years 1972 through 1988. The discussion is focused on trends in utilization and program payments resulting from the implementation of the Medicare prospective payment system. The State data for 1988 consist of utilization and program payment statistics by the residence of the beneficiaries in urban and rural areas. This is the first time that inpatient hospital data have been presented in this manner.

Leading inpatient surgical procedures for aged Medicare beneficiaries, 1987.

Medicare program data on utilization and charges for short-stay hospital inpatient services are presented. The focus of this article is on trends in total and surgical discharges for selected years (1977-87) and highlights of regional variations in the most frequently reported (leading) surgical procedures performed on aged Medicare hospital insurance beneficiaries during 1987.

Use and cost of physician and supplier services under Medicare, 1986.

There is general consensus that the present Medicare physician payment system and related policies should be revised. Therefore, the Health Care Financing Administration and Congress are examining the physician reimbursement system for potential changes that could reverse the inflationary incentives in the present system and induce greater incentives for efficiency and cost savings. Medicare program data and information are provided to assist health care managers and administrators in the development and analysis of Medicare physician research and policy initiatives. The data may also be helpful in monitoring and measuring the use and cost of Medicare physician and supplier services as related to program performance and administration.

Use and cost of short-stay hospital inpatient services under Medicare, 1986.

This article is part of a continuing effort to monitor the operation of the Medicare program. A synopsis is given of the legislation that implemented the prospective payment system for short-stay hospitals, and the data show the program experience for 1986, the third full year of implementation under prospective payment.

Use and cost of skilled nursing facility services under Medicare, 1987.

The data in this article are focused on the use, covered charges, and Medicare program payments for skilled nursing services during calendar year 1987. Data for the period 1971-87 are included to show trends in the use and cost of skilled nursing facility services under the Medicare program. The impact of the Medicare prospective payment system on skilled nursing facility use is also discussed.

Objective, quantitative measurement of severity of illness in critically ill patients.

Severity of illness must be quantitated in critically ill patients if studies of outcome and therapeutic efficacy are to be meaningful. Objective physiologic indicators of critical illness, such as pertinent laboratory values, can be quantitated using the Therapeutic Intervention Scoring System--TISS. TISS data were obtained for 199 consecutive Class IV critically ill surgical ICU patients and compared to the same data obtained in less critically ill Class II and III ICU patients who served as the control group. For the physiologic indicators of critical illness, a wide range of normal values was established prospectively. The actual values generated by Class IV patients were compared to values of the same indicators as measured in Class II and III ICU patients. Of all objective indicators of critical illness, 55% were either outside the normal range or more than 2 SD away from the mean value of objective indicators for Class II and III ICU patients; 49% were beyond the normal range or more than 3 SD away. Of all TISS indicators, 73% were abnormal, and 36% of all physiologic indicators were still abnormal despite massive therapeutic support when compared to Class II or III ICU patients. Those patients who had more than 40% of their physiologic indicators abnormal were more likely to die. However, the percentage of abnormal TISS indicators did not discriminate between patients who died and those who lived, because almost all patients received massive support.(ABSTRACT TRUNCATED AT 250 WORDS)

Results, charges, and benefits of intensive care for critically ill patients: update 1983.

Objective and quantitative methods were used to measure severity of illness and outcome of intensive care in critically ill patients, in terms of success or failure of therapy within the ICU, survival or death at 1 yr, quality of life in survivors, and utilization of resources. One hundred ninety-nine consecutive Class IV critically ill surgical patients hospitalized between 1977 and 1978 at the Massachusetts General Hospital comprised the study population. Although the mortality rate of 69% was close to the 73% rate we recorded for 1972-1973, the survivors' quality of life was significantly better. Hospitalization costs increased from $15,000 to $22,000 per patient, almost consistent with the inflation rate between 1973 and 1978. Survival rates and quality of life in survivors did not vary with age. The disease process for which the patient was hospitalized was an important determinant of outcome. Intensive care medicine for critically ill surgical patients does prolong life and enable some patients to return to a productive lifestyle; however, the costs of these benefits are extremely high.

Prepaid dental plan offers many benefits.

Prepaid dental care enhances hospital's retention and recruiting positions and reassures employees that management is providing maximum benefits at the least possible cost.