The effects of disseminating performance data to health plans: results of qualitative research with the Medicare Managed Care plans.

OBJECTIVE: To assess the information needs and responses of managed care plans to the Medicare Managed Care Consumer Assessment of Health Plans Study (MMC-CAHPS). DATA SOURCES/STUDY SETTING: One hundred sixty-five representatives of Medicare managed care plans participated in focus groups or interviews in the spring of 1998, 1999, and 2000. STUDY DESIGN: In 1998 focus groups were conducted with representatives of managed care plans to develop and test a print report of MMC-CAHPS results. After the reports were disseminated focus groups and interviews were conducted in 1999 and 2000 to identify perceptions, uses, and potential enhancements of the report. DATA COLLECTION/EXTRACTION METHODS: The study team conducted a total of 23 focus groups and 12 telephone interviews and analyzed the transcripts to identify major themes. PRINCIPAL FINDINGS: In 1998 participants identified the report content and format that best enabled them to assess their performance relative to other Medicare managed care plans. In 1999 and 2000 participants described their responses to and uses of the report. They reported comparing the MMC-CAHPS results to internal surveys and presenting the results to senior managers, market analysts, and quality-improvement teams. They also indicated that the report's usefulness would be enhanced if it were received within six months of survey completion and if additional data analysis was presented. CONCLUSIONS: Focus group results suggest that the MMC-CAHPS report enhances awareness and knowledge of the comparative performance of Medicare managed care plans. However, participants reported needing additional analysis of survey results to target quality-improvement activities on the populations with the most reported problems.

Search for promoters for the GARP and rRNA genes of Trypanosoma congolense.

A search was conducted for transcriptional promoters in Trypanosoma congolense. A promoter test plasmid was constructed utilising the luciferase coding region flanked by the intergenic regions of a T. congolense gene encoding GARP, the glutamic acid and alanine rich protein on the surface of procyclic organisms. Using this plasmid, sequences located upstream of an 18S rRNA gene were tested in transient transfection assays for their ability to promote luciferase expression. A rRNA promoter fragment of 377 bp was identified that increases luciferase activity by as much as 35,000-fold above background levels. The rRNA transcription initiation site is located 961 bp upstream of the 18S rRNA gene and immediately downstream of 6 bp imperfect repeats. The plasmid was also used to examine sequences upstream of a GARP gene cluster in two different T. congolense strains for promoter activity. In contrast to the findings of another group, we were unable to detect promoter activity upstream of these GARP genes in either strain. We conclude that the GARP gene promoter, if it exists, has less than 0.03% (1/3000) of the activity of the rRNA promoter in this luciferase-based assay.

Expression of foreign proteins in Trypanosoma congolense.

An expression vector was constructed to express foreign genes in Trypanosoma congolense. The foreign gene and a neomycin phosphotransferase (NPT) gene are flanked by glutamate and alanine rich protein (GARP) gene processing signals and their expression is driven by a ribosomal RNA gene promoter. The plasmid is not maintained as an episome in T. congolense, but the NPT gene permits selection of cells in which the plasmid has integrated into the genome. We used this plasmid to express luciferase, green fluorescent protein and a surface protein of Trypanosoma brucei, glycine-proline-glutamate glutamate threonine procyclic acidic repetitive protein (GPEET PARP). The plasmid-derived GPEET PARP is expressed on the surface of procyclic T. congolense and comigrates on a polyacrylamide gel with native GPEET PARP from T. brucei procyclic cells. We also attempted to use the plasmid to overexpress a previously identified T. congolense cysteine protease. The plasmid-derived cysteine protease mRNA species occurs in the transfected cells, but we were unable to detect increased levels of protein or protease activity.

Median sternotomy for parathyroid adenoma.

Most mediastinal parathyroid tumours lie within the thymus gland and may be retrieved when cervical thymectomy is carried out in the course of neck exploration for primary hyperparathyroidism (HPT). We report 4 patients, each of whom required sternotomy for removal of a true mediastinal parathyroid adenoma. Subtraction isotope scintigraphy suggested the presence of a mediastinal tumour prior to cervical exploration in 2 individuals and prior to re-exploration in a third. When localisation before initial exploration for HPT suggests a parathyroid tumour within the chest, consideration should be given to proceeding to sternotomy, at first operation if a comprehensive neck exploration, including cervical thymectomy, fails to uncover the adenoma. Uniquely, one of our patients underwent sternotomy for HPT when 23 weeks pregnant.

Importance of prostanoids in calcium chelator-induced airway constriction.

To elucidate the mechanism of calcium chelator-induced airway constriction, we examined the relationship between prostanoids and histamine in bronchoalveolar lavage (BAL) fluid and the magnitude of airway constriction in peripheral airways of anesthetized Basenji-Greyhound dogs. A wedged bronchoscope technique was used to measure collateral system resistance (Rcs) before and after aerosol challenges. Sublobar segments were challenged either with acetylcholine or with Na2EDTA in the presence or absence of meclofenamate sodium (3 mg/kg iv) or methylprednisolone (2 mg.kg-1.day-1). After measurements of Rcs, BAL was performed, and the fluid was analyzed for prostanoids with the use of gas chromatography-mass spectrometry. Sublobar segments challenged with Na2EDTA showed increased concentrations of prostaglandin (PG) D2 but no increases in PGE2, PGF2 alpha, 9 alpha,11 beta-PGF2, 6-keto-PGF1 alpha, thromboxane B2, or histamine. There was a strong relationship (r = 0.84, P = 0.005) between changes in Rcs after Na2EDTA and concentrations of PGD2 in BAL fluid. Acetylcholine, which increased Rcs to a similar degree as Na2EDTA did, produced no significant increase in prostanoid concentrations. Changes in Rcs after Na2EDTA and concentrations of PGD2 were reduced in the presence of meclofenamate or methylprednisolone. These data support the idea that the mechanism of calcium chelator-induced bronchoconstriction involves the release of bronchoconstricting prostanoids.

A case report of an Irish family displaying nail-patella syndrome.

This is a case report of an Irish family displaying classical features of Nail-Patella Syndrome--also known as Osteo-onycho Dystrophy--involving four members over three generations. This rare autosomal dominant disorder is well defined with four classical characteristics: dysplasia of finger nails, hypoplastic or absent patellae, hypoplasia of the head of the radius and often the capitulum of the humerus leading to subluxation or dislocation of the radial head and iliac prominences, known as iliac horns which are usually bilateral and symmetrical. Renal dysfunction is also commonly reported. This is the first report of the Nail-Patella Syndrome in an Irish family.

Pasture study of two types of oxfendazole pulse release bolus for controlling nematodes in calves.

One group of first-season calves was dosed with an oxfendazole pulse release bolus at spring turnout (April 30) and on July 15 a second group received the front-loaded oxfendazole pulse release bolus. The objective was to test the boluses for the prophylaxis or control of nematodiasis. The control group consisted of calves to which no bolus was administered. The three groups occupied separate but adjacent plots. For the first five weeks of the trial, three calves, artificially infected with Dictyocaulus viviparus grazed in each plot. Parasitic bronchitis severely affected the control calves, necessitating repeated emergency treatment, whereas administration of the bolus at turnout almost completely prevented this condition. D viviparus infection increased markedly on the control herbage in July and August but was eliminated by the end of June on pasture grazed by bolus treated calves. Treatment in mid-season with the front-loaded bolus brought an outbreak of parasitic bronchitis under control. Gastrointestinal worm egg output was satisfactorily suppressed after the administration of both boluses, resulting in reduced levels of herbage infection. Calves treated with a bolus at turnout gained significantly more weight than either the controls (P less than 0.001) or the calves treated with a front-loaded bolus in mid-season (P less than 0.01). The weight-gain of the calves treated with a front-loaded bolus was slightly but not significantly greater than that of the control calves. On the basis of faecal egg counts, the first pulse released from the standard boluses was delayed and one front-loaded bolus failed to release a dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Prophylaxis of trichostrongylid infection afforded by low-dose phenothiazine given in two successive years to first-season calves on a common area of pasture.

Reduced trichostrongylid infection on herbage and in calves was obtained when first-season calves, grazing a common area of pasture, received low-dosage phenothiazine (PTZ) in two successive years. The average daily dose of PTZ was 7.0 or 10.3 mg kg-1 in the first year and, in the second, between 5.0 and 7.0 mg kg-1. The effect on herbage infection was attributed mainly to ovicidal action. Treatment increased weight gain by 22 and 50 to 60 per cent in the respective seasons. The results suggested a cumulative effect produced by treating calves of successive years. Two calves developed PTZ-induced photosensitivity (corneal opacity) in the first season, and two calves in the second season but in the latter, severe bronchopneumonia was believed to be a predisposing factor. To avoid photosensitivity and still maintain adequate drug activity, the daily intake of PTZ should probably be restricted to around 6 mg kg-1.

Dispersal of Dictyocaulus viviparus larvae from bovine faeces in Ireland.

An involvement of Pilobolus species fungus in the dispersal of Dictyocaulus viviparus third stage larvae from dung to surrounding herbage under Irish conditions was investigated. The presence of Pilobolus kleinii on artificial dung pats containing first stage larvae of D viviparus was associated with a 19-fold increase (P less than 0.05) in numbers of third stage larvae recovered from the surrounding herbage. A subjective examination of natural dung pats showed that the presence of Pilobolus species was significantly correlated with hours of bright sunshine (r = -0.5, P less than 0.01), total rainfall (r = 0.41, P less than 0.05) and the height of herbage surrounding the pats (r = 0.31, P less than 0.001). A multiple regression analysis showed that meteorological parameters and the height of surrounding herbage accounted for 38 per cent of the variation in growth of Pilobolus species on dung pats. The incidence of extensive damage to natural dung pats within five days of deposition, caused by biotic factors, another possible cause of D viviparus third stage larvae dispersal, varied from 0 to 92 per cent of the pats depending on their degree of dryness.

Efficacy of low doses of fenbendazole and its administration via drinking water in the prophylaxis of nematodiasis in grazing calves.

Under experimental conditions, fenbendazole given at doses of 0.4 and 1.0 mg/kg body weight suppressed calves' faecal output of Ostertagia and Cooperia species eggs and Dictyocaulus viviparus larvae. Both dose levels were given in the form of small daily drenches and the higher level showed greater efficacy. In a grazing experiment, medication with fenbendazole at 1.0 mg/kg/day administered intermittently to calves using an automatic dose dispenser almost completely suppressed the output of trichostrongylid eggs. As a result, infection on the pasture and in the calves remained at a low level throughout the grazing season. By contrast, control pasture and control calves showed rather heavy infection from mid-August onwards with significantly lower weight gains and widespread signs of parasitic gastroenteritis. At post mortem examination of representative calves from each group in November, the medicated animals had 99 per cent less Ostertagia species, whether adults or larvae arrested at the early fourth stage, and 95 per cent less Cooperia species compared with controls. Medication in the drinking water suppressed the faecal output of D viviparus larvae for most of the grazing season by comparison with the controls but the medicated calves became infected with this parasite towards the end of the season. Until this problem is overcome, precautions against parasitic bronchitis are advised when this system of medication is adopted.

Low-dosage phenothiazine in the prophylaxis of trichostrongylid infection in calves.

Phenothiazine (PTZ) given indoors to calves artificially infected with Ostertagia ostertagi and Cooperia oncophora showed ovicidal activities of 100, 93, 98 and 85% respectively at daily doses of 9, 8, 7 and 6 mg kg-1. In a grazing study, one group of calves was treated with PTZ via the drinking water, using a "Profel" liquid dispenser. The dispenser was calibrated to add PTZ to the water at a daily dose of 7 mg kg-1, but in practice the dose far exceeded this amount. A dose of 7 mg kg-1 day-1 was given manually to a second group and a third group acted as control, receiving no PTZ. PTZ-induced photosensitivity was widespread in the first group due to over-dosage of medicament by the dispenser and was suspected in one calf in the manually dosed group. PTZ in both treated groups showed marked ovicidal activity and, apparently as a result of this, caused striking reductions in trichostrongylid infection on the pasture and in the calves as evidenced by pasture larval counts, calves' egg counts, pepsinogen levels and live weight gains. Necropsy worm counts showed that the PTZ medication prevented heavy infection by arrested as well as by adult Ostertagia. The reduced infection on the treated calves' pasture was carried over for a second grazing season. Untreated calves grazing the pasture in that season showed lower infection and improved weight gains up to mid-September compared with calves on the control pasture. These effects did not persist for the whole of the second season.

Colonic dysfunction in patients with thoracic spinal cord injury.

Severe constipation is a debilitating concomitant of complete traumatic thoracic spinal cord injury. In order to investigate the pathophysiology of this symptom, we studied colonic compliance, as well as motor and myoelectrical activity, in the fasting and postprandial states and after neostigmine stimulation in 9 patients with clinically and electrophysiologically documented complete thoracic spinal cord injury. Electrophysiologic studies, including nerve conduction velocities, cortical and spinal somatosensory-evoked responses, and bulbocavernosus reflex responses, as well as urinary bladder cystometry, documented normal peripheral somatosensory function, integrity of the distal spinal cord, conus medullaris and cauda equina, and interruption of the somatosensory and descending spinal pathways proximal to the cauda equina. These 9 patients with spinal cord injury demonstrated a decrease in colonic compliance compared with a control group (p less than 0.01). They failed to demonstrate the postprandial increase in colonic motor and myoelectrical activity observed in a control group (p less than 0.01), but did respond to neostigmine with an increase in both motor and myoelectrical activity (p less than 0.02), suggesting an intact myogenic component. In these patients, decreased colonic compliance and absent postprandial colonic motor and myoelectrical activity may be mediated by ablation of outflow from higher centers to the lower spinal cord and may be correlates of visceral neuropathy and severe constipation.

Evaluation of a modified schedule for lungworm vaccination of calves.

The conventional lungworm vaccination schedule, requiring a minimum age of eight weeks, a four-week interval between doses and a further interval of not less than two weeks before turnout, was compared with a modified schedule in which the vaccine was given to calves at six and eight weeks old followed by a turnout immediately after the second dose. The control group consisted of unvaccinated calves, half of which corresponded in age to the conventional and half to the modified vaccination group. All groups were turned out to the same pasture area on May 13 with five calves which were artificially infected with Dictyocaulus viviparus so as to ensure adequate pasture challenge. Challenge caused only mild clinical signs in the vaccinated calves but caused severe husk with two fatalities in the controls. Respiratory rates and faeces larval counts for the vaccinated groups were significantly lower than for the control group and, in the main, not significantly affected by vaccination schedule. The vaccinated groups gained more weight than their respective controls of corresponding age and significantly so for both groups during the period when dictyocaulus infection exerted maximum effect. In this experiment, the modified schedule was as effective as the conventional although delayed challenge precluded a satisfactory test for the effect of turnout immediately after the second dose of vaccine. In a repeat experiment involving apparently a very severe pasture challenge, calves vaccinated at six and eight weeks old showed markedly less resistance than those vaccinated according to the conventional schedule. Probable reasons for the difference in outcome are considered.

Grazing study in Ireland using the morantel sustained release bolus for controlling nematodiasis in calves.

The morantel sustained release bolus was administered at turnout to first-season grazing calves in order to assess its efficacy in the seasonal control of infection by nematode parasites in Ireland. The pastures grazed by control calves showed a marked increase in gastrointestinal trichostrongylid infective larvae by September, while numbers of infective larvae on pasture grazed by bolus-treated calves remained at a low level throughout the grazing season. In consequence, the controls showed significantly higher worm egg counts in late season and significantly higher worm burdens (mainly Ostertagia spp) at necropsy carried out in November on representative number of principal animals selected from each group. These reduced worm burdens were attributed to the suppression of egg output during the early part of the season as a result of treatment with the morantel sustained release bolus at turnout in the spring. Pasture contamination with Dictyocaulus viviparus larvae was present on all treatment pastures. The bolus-treated calves however were subjected to an increase in D. viviparus infection which occurred on their pasture in late season after the active life of the bolus had expired. It was concluded that bolus treatment delayed (rather than prevented) the buildup of D. viviparus infection on the pasture by 60-90 days.

Effect of treatment with levamisole or fenbendazole on primary experimental Dictyocaulus viviparus infection and on resistance in calves.

Based on faecal larval counts, respiratory rates and live-weight gains, the anthelmintics levamisole and fenbendazole were equally efficacious against primary infection with Dictyocaulus viviparus in calves. Calves that were treated with levamisole or fenbendazole resisted the live-weight depressing impact of reinfection. Treatment somewhat impaired resistance to establishment of the secondary challenge as determined at necropsy. However, compared with previously uninfected controls, the treated animals harboured significantly fewer D viviparus, showing that they still strongly resisted reinfecting worms becoming established. The animal responses measured did not demonstrate any difference between levamisole and fenbendazole in relation to efficacy or to effect on resistance.