Competing risks analysis of the association between perioperative blood transfusion and long-term outcomes after resection of colorectal cancer.

AIM: Despite numerous reports over three decades, the association between perioperative blood transfusion and long-term outcomes after resection of colorectal cancer remains controversial. This cohort study used competing risks statistical methods to examine the association between transfusion and recurrence and colorectal cancer-specific death after potentially curative and noncurative resection. METHOD: A hospital database provided prospectively recorded clinical, operative and follow-up information. All surviving patients were followed for at least 5 years. Data were analysed by multivariable competing risks regression. RESULTS: From 2575 patients in the period 1995-2010 inclusive, after exclusions, 2334 remained for analysis. Among 1941 who had a potentially curative resection and 393 who had a noncurative resection the transfusion rates were 24.9% and 33.6%, respectively. After potentially curative resection there was no significant bivariate association between transfusion and recurrence (HR 0.93, CI 0.74-1.16, P = 0.499) or between transfusion and colorectal cancer-specific death (HR 1.04, CI 0.82-1.33, P = 0.753). After noncurative resection there was no significant association between transfusion and cancer-specific death (HR 0.93, CI 0.73-1.19, P = 0.560). Multivariable models showed no material effect of potential confounder variables on these results. CONCLUSION: The competing risks findings in this study showed no significant association between perioperative transfusion and recurrence or colorectal cancer-specific death.

Morphological and quantitative changes in paternal brood-pouch vasculature during embryonic development in two Syngnathus pipefishes.

Vascular corrosion casts of Syngnathus floridae and Syngnathus fuscus brood pouches were examined by scanning electron microscopy. Morphological and quantitative data on the vasculature of the paternal brood pouch during each stage of embryonic development were investigated to explore potential changes during brooding, to consider interspecific differences and to provide structural evidence for previously reported functional roles of the brood pouch. The brood pouches of both species are highly vascularized structures with cup-like arrangements of brood-pouch vasculature developing around each embryo shortly after fertilization and breaking down before fry release. The density and size of paternally derived blood vessels in contact with the embryos were found to be consistent for S. fuscus once this structure was established early in development. On the contrary, these vasculature measurements varied with early S. floridae brood stages when the embryo still relied heavily on the yolk sac. Diameter measurements of S. fuscus brood-pouch blood vessels were also comparatively smaller during these early developmental stages, suggesting that the structural stability and opportunity for greater transport via slower blood flow may contribute to greater paternal allocation. This is the first study to document changes in brood-pouch vasculature during specific stages of embryonic development, to show regression of this vasculature before fry release and to provide morphological data for two syngnathid species for which information on brood-pouch physiology is available.

Coordinating care for the dual-eligible population.

Many patients who are eligible for Medicare also are eligible for Medicaid. IDSs that deliver care to these patients, called "dual eligibles," face a challenge of conflicting rules and incentives under existing Federal and state laws governing coverage of these patients. Differences in the Medicare and Medicaid payment rules give IDSs a financial incentive to transfer patients from long-term and postacute to acute care settings in situations in which the patients might receive more appropriate care remaining where they are. Many states are implementing pilot programs to allow IDSs to better coordinate care for dual eligibles. Before states begin implementing pilot or statewide programs, IDSs should be involved in the design of the pilot programs, thereby ensuring that the coordinated funding effectively meets an IDS's requirements for optimum care delivery with adequate payment.

Immune responses and protection induced by mucosal and systemic immunisation with recombinant measles nucleoprotein in a mouse model of measles virus-induced encephalitis.

In this study the immunogenicity of recombinant nucleoprotein (Np) administered intranasally or intraperitoneally, and its ability to support a systemic protective anti-virus antibody response was examined, in a mouse model of measles virus (MV)-induced encephalitis. Although both intranasal and intraperitoneal routes of immunisation resulted in priming Np- and MV-specific T-cell responses, the intraperitoneal route was shown to prime for a predominantly IgG2a serum anti-MV antibody response of high avidity, which confered complete protection following intracranial challenge with a neuroadapted strain of MV. On the other hand, intranasal priming resulted in a mixed IgG1, IgG2a serum anti-MV antibody response of low avidity, and only 43% of immunised mice survived following intracranial challenge with the neuroadapted strain of MV. These findings suggest that the route of immunisation in combination with an appropriate adjuvant could influence the induction of a quality antibody response with protective capacity.

Deconstructing the antigenic profile of a protective epitope from measles virus fusion protein using overlapping peptides.

Three different approaches of using overlapping peptides have been compared to analyse the fine specificity of the antibody response to a protective epitope from measles virus (MV) fusion protein, spanning residues 397-420. Anti-peptide antibodies raised in BALB/c, CBA and C57BL/6 mice were shown to react with the homologous peptide and the MV by ELISA. Results from indirect ELISA using 15mer peptides (overlapping by one residue) as solid phase antigens have shown that anti-peptide antibodies from CBA and C57BL/6 mice recognised the same B-cell epitope(s) located within the 398-414 region, whereas BALB/c mice predominantly recognised epitopes located within the 400-417 region. When the 15mer peptides were used as fluid phase antigens in an inhibition ELISA, peptide 405-419 was shown to be the most effective inhibitor in all three strains of mice. Analysis of serum samples by SPOTs ELISA has shown that the region 407-417 was predominantly recognised by BALB/c mice, whereas antibodies from C57BL/6 mice recognised the 408-420 region. No reactivity was observed with serum samples from CBA mice. Although the majority of the identified B-cell epitopes were shown to overlap by the three methods, the identified boundaries of these epitopes differed, suggesting that the size and the mode of peptide presentation affects their antigenicity.

Can community organization strategies be used to implement smoking and dietary changes in a rural manufacturing work site?

A one-year intervention project was developed and implemented to demonstrate the utility of using community organization methods to mobilize a rural, predominantly minority work site community toward smoking and dietary change. This intervention for smoking and dietary change was conducted in a rural work site (n = 235 at baseline) and guided by employees. It involved activities to change the work site environment and the behaviors of individuals. A community advisory board (n = 15) made up of members of the work site was established, and it met monthly with members from the research team to design and implement nine cancer prevention activities that were targeted to the needs of this community. Activities and information were disseminated to the employees during a nine-month period. Surveys were administered prior to and following the delivery of the intervention. This project was successful in engaging a rural manufacturing work site community in thinking about cancer prevention strategies. Results of this intervention demonstrated significant increases in numbers of smoking cessation attempts, reported fruit and vegetable consumption, self-efficacy for dietary change and perceived risk for cancer. Work site social norms changed as evidenced by employee perceptions of co-worker support of dietary and smoking change (all ts > 1.95, all Ps < 0.05). Other results with marginal statistical significance (P < .015) but potentially useful for future studies include increased intentions to reduce the fat in the diet. In light of the low-intensity and time-limited nature of this community organization intervention, the observed changes in dietary and smoking behaviors are encouraging and support the use of these strategies in rural, culturally diverse work sites.

The closing of a social HMO: a case study.

A social health maintenance organization (SHMO) integrates acute and long-term care and provides an extended-care benefit for elderly who are at risk of institutionalization. This article reports findings from a case study of the termination of the Group Health SHMO in Minnesota. Interviews were conducted with social workers and at-risk elderly who had been receiving long-term care through the SHMO. The case study examines the post-SHMO transition and the process of replacing SHMO care coordination and longterm care services. Most of the elderly and their caregivers indicated they were "losing ground"--that is, they were paying more or getting less care. Some were paying more for less care. Because they tended to switch to private-pay arrangements and to rely more on informal care, it appears that their care system became much less stable after the closing of the SHMO.

Fine specificity of the antibody response to a synthetic peptide from the fusion protein and protection against measles virus-induced encephalitis in a mouse model.

A synthetic peptide representing residues 397-420 from the measles virus (MV) fusion (F) protein was tested for its structure, immunogenicity and protective capacity against intracerebral challenge with a neuroadapted strain of MV. Analysis of the peptide by mass spectrometry showed that it was linear, despite the presence of two cysteine residues in the sequence. Circular dichroism spectroscopy highlighted a weak preference for the peptide to adopt an alpha-helical conformation. The peptide was shown to be immunogenic in BALB/c and C57BL/6 mice after intraperitoneal immunization in Freund's adjuvant, and anti-peptide antibodies from both strains of mice reacted with the MV as a solid phase antigen on an ELISA plate. When the fine specificity of the anti-peptide antibody response was examined using overlapping 8-mer peptides, serum antibodies from BALB/c mice recognized the region between residues 407-417 whereas antibodies from C57BL/6 mice recognized the region 408-420 of the 397-420 peptide sequence. Although anti-397-420 antibodies had no demonstrable neutralizing activity, protection against challenge with a neuroadapted strain of MV was demonstrated following active immunization with peptide in C57BL/6 mice or after passive transfer of anti-peptide antibodies in BALB/c mice. These findings highlight the importance of the 397-420 region in the induction of protective antibodies in the MV encephalitis mouse model, and suggest that this epitope might be a good candidate for inclusion in a future MV synthetic peptide vaccine.

Post-hospital sub-acute care: an example of a managed care model.

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub-acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract. DESIGN: This is a retrospective study of the experiences and outcomes of enrollees who received TCC compared with a like group of enrollees who received customary continuity care through contract services. SETTING: The TCCs are established contractually in five area nursing homes; these facilities keep at least 15 beds available to the health plan for round-the-clock, 7 days per week admissions for sub-acute care. Designated staff from these facilities and designated geriatric nurse practitioners and geriatricians from HealthPartners follow established targeting, admissions, assessment, care planning, and discharge planning procedures to provide team care for these patients at the facilities. PARTICIPANTS: The TCC program is targeted to patients requiring rehabilitation therapy (post-cardiovascular accident, post-fracture/replacement) who are deconditioned, or those with uncomplicated infections (urinary tract infection, pneumonia). A total of 1144 patients participated in the TCC program in the 1-year program under report, and 253 were surveyed in regard to their experience. One hundred HealthPartners physicians were surveyed about the program. RESULTS: Post-acute length of stay in the TCC was substantially lower than that in customary care settings in contract nursing homes (14.3 versus 20.5 days). Rehospitalization rates from these units were comparable to or better than those from other sub-acute units. Patient and primary care physician satisfaction with the units was high. The program provided economic benefit to both partners. The health plan's negotiated rate for the TCC units was 38% less than that paid in noncontractual facilities. CONCLUSION: The TCC partnership provides rehabilitative and geriatric evaluation services in settings more conducive to and less costly than such care usually, and yields improvements in care and utilization outcomes.

A simple tool for designing a database: bridging the communication gaps among health care providers, researchers, and programmers.

As databases are used by a greater variety of people, highly technical methods of designing them are giving way to more human, user-centered approaches. The article describes a human approach to designing a complex, multiuse database with limited resources. The article introduces a simple data modeling tool, the entity-relationship (E-R) diagram, that crosses professional boundaries and enables providers, researchers, and programmers to communicate more easily. Constructing an E-R diagram provides a human description of the social health maintenance organization (S/HMO) multisite demonstration project. This project, now in its tenth year, provides integrated acute and community-based in-home services to allow frail elderly HMO members to stay in their homes. After briefly reviewing the three types of databases and three rules of thumb for designing a relational database, the article shows how a simple E-R diagram can clarify the management and research issues of the S/HMO health care model. The article concludes with a brief discussion of the benefits and limits of housing research-related health data in a relational database.

Psychosocial consequences of postoperative seizure relief.

To address the question of whether complete seizure relief has a positive effect on psychosocial functioning in patients with temporal lobe epilepsy, a follow-up study was conducted at the Montreal Neurological Institute. The approach was one of "before-after" study, with focus on the successfully operated patients, those in whom complete seizure relief was obtained. The Washington Psychosocial Seizure Inventory, specifically developed and validated for use with epilepsy patients, was used for psychosocial assessments. Of 30 surgically treated patients screened for the study, 15 gained complete relief from seizures. At 1-year postoperative follow-up, they showed reductions in their problems scores on all but one of eight psychosocial scales; the average reduction ranged from 24% in Vocational Adjustment to 60% in Adjustment to Seizures. In the areas of Emotional Adjustment and Interpersonal Adjustment reductions were 37 and 48%, respectively. Among the component items, improvement was greatest in ability to concentrate and make decisions, confidence in interpersonal skills, ability to express personal opinions, and perception by others. No appreciable changes occurred in the 15 patients who did not gain complete relief of seizures; indeed, on six of the eight scales they showed a modest increase in their problem scores. This study provides evidence that complete relief from seizures leads to appreciable improvements in psychosocial well-being, manifest as early as 1-year postoperatively, in young adult patients.

Financial performance in the social health maintenance organization, 1985-88.

Since early 1985, four social health maintenance organizations have delivered integrated health and long-term care services to Medicare beneficiaries under congressionally mandated waivers that included shared public-program risk for losses. Three of four sites had substantial losses in the first 3 years, primarily because of slow enrollment and resultant high marketing and administrative costs. After assuming full risk, two of the three showed surpluses in 1988. Service and management costs for expanded long-term care were similar across sites and were affordable within the framework of Medicare and Medicaid reimbursement and private premiums.