bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical performance of electronic, head‐mounted, low‐vision devices
Authors: Culham Louise E. , Chabra Anthony , Rubin Gary S.
Published: July 2004

This study compared four electronic head‐mounted devices (HMDs) (Jordy, Flipperport, Maxport and NuVision) with conventional optical low‐vision aids (LVAs). The aim was to determine any performance differences for laboratory‐based clinical measurements and practical visual tasks for patients with macular disease. Possible factors influencing success were explored. Ten patients with early onset macular disease (EOMD) and 10 with age‐related macular disease (AMD) used the four HMDs, habitual spectacles and previously prescribed optical LVAs to complete a range of clinical measurements and everyday visual tasks. The clinical measurements were distance, intermediate and near acuities, and contrast sensitivity. The visual tasks were to read text of three sizes, to write a cheque and to identify grocery items on a shelf. Following the initial evaluation, each subject took home two randomly selected HMD devices for 2 weeks, after which performance measures were repeated. No single HMD stood out as being superior overall. Flipperport and Jordy provided significantly better distance and intermediate acuity than the previously prescribed optical LVAs but near acuity and contrast sensitivity were not consistently better with any of the HMDs. Practice at home provided some improvement in performance with HMDs, nevertheless, optical aids remained the best devices for optimum functioning for the majority of tasks. Younger patients and those with better distance acuity were more likely to benefit from HMDs, particularly when reading small print. In low vision clinics, practitioners should continue to show patients conventional optical aids and demonstrate these electronic HMDs only when appropriate for the individual patient.
Fixation stability and reading speed in patients with newly developed macular disease*
Authors: Crossland Michael D. , Culham Louise E. , Rubin Gary S.
Published: July 2004

Background:  Patients with macular disease and central scotomas must use a peripheral, preferred retinal locus (PRL) in place of their damaged fovea. This paper investigates the development of the PRL, with particular reference to the stability of fixation.

Methods:  Twenty‐five patients with age‐related and juvenile macular disease were recruited. All patients had developed a scotoma in their better eye within the previous 2 weeks. Patients were assessed using a scanning laser ophthalmoscope and an infra‐red gazetracker on four further occasions over the next 12 months.

Results:  A linear relationship exists between reading speed and fixation stability for patients and control subjects. Fixation stability was not related to scotoma size, visual acuity or contrast sensitivity. Changes in fixation stability account for 54% of the variance in change in reading speed over the course of this study.

Conclusions:  The deficit in reading speed in patients with macular disease can be partially attributed to impairments in fixation stability.
Size constancy in visual impairment: a comparison with normally sighted individuals*
Authors: Subramanian Ahalya , Dickinson Christine
Published: July 2004

Size judgements are usually based on size constancy. However, as the number of visual cues decreases, such as by decreasing the field of view, size judgements gradually change from those based on size constancy to those based on the visual angle. The present study investigated whether visually impaired (VI) individuals, most of whom do not have measurable stereoacuity and have visual field defects, might therefore make judgements based on visual angle rather than size constancy. Size constancy was measured on 42 VI and 20 normally sighted subjects. Results indicated that size judgements are similar for both VI and normally sighted individuals at 0.50 m, 1 and 2 m. Statistically significant differences were found at 3 m. Despite this it would appear that VI individuals are able to make judgements based on size constancy rather than the visual angle.
Low vision services in South Devon: a multi‐agency, multi‐disciplinary approach*
Authors: Collins John , Skilton Kate
Published: July 2004

Since 1994, the Low Vision Service in South Devon has been provided by a multi‐agency, multi‐disciplinary team. The team comprises of staff from Devon Social Services Sensory Team, Optima Low Vision Services Ltd, Royal National Institute for the Blind (RNIB) Manor House, Devon and Torbay Special Education Services and South Devon Healthcare Trust. In the 9 years of operation this service has been independently audited twice for patient satisfaction levels and compliance level in the use of low vision aids (LVAs). The results of the most recent service audit questionnaire reveal a high and constant patient satisfaction level with 92% of patients who answered the question reporting that the service was sufficient to meet their needs. The number of patients who used LVAs at least weekly was 88% of those answering the question. Plans for the future expansion of the service include the further development of interdisciplinary working.
Evaluation of a prototype Minified Augmented‐View device for patients with impaired night vision*
Authors: Bowers Alex R. , Luo Gang , Rensing Noa M. , Peli Eli
Published: July 2004

An evaluation was carried out of the first prototype (LV‐3) of a new night vision device, which incorporates visual field expansion through minification (Minified Augmented‐View), to provide feedback for continuing development. Six subjects with night blindness completed visual function measurements and indoor mobility assessments without a device, with the LV‐3 and with a commercially available comparison device (the Multi‐Vision) at light levels representative of well lit and poorly lit streets. Device performance and potential benefits in real‐world situations were evaluated at four outdoor locations (well lit to very dark). Results indicate that the see‐through nature and spectacle‐frame mounting of the LV‐3 address some of the cosmetic and ergonomic disadvantages of currently available devices; however insufficient light sensitivity of the prototype camera limited LV‐3 performance. With improved camera sensitivity and full implementation of the Minified‐Contours Augmented‐View concept in the next prototype, patients might be able to make better use of the novel field expansion and vision multiplexing features to aid outdoor night mobility.
Quality of Health Care: The Views of Homeless Youth
Authors: Ensign Josephine
Published: July 2004

Objective. To develop homeless‐youth‐identified process and outcome measures of quality of health care.

Data Sources/Study Setting. Primary data collection with homeless youth from both street and clinic settings in Seattle, Washington, for calendar year 2002.

Study Design. The research was a focused ethnography, using key informant and in‐depth individual interviews as well as focus groups with a purposeful sample of 47 homeless youth aged 12–23 years.

Data Collection/Extraction Methods. All interviews and focus groups were tape‐recorded, transcribed, and preliminarily coded, with final coding cross‐checked and verified with a second researcher.

Principal Findings. Homeless youth most often stated that cultural and interpersonal aspects of quality of care were important to them. Physical aspects of quality of care reported by the youth were health care sites separate from those for homeless adults, andsites that offered a choice of allopathic and complementary medicine. Outcomes of health care included survival of homelessness, functional and disease‐state improvement, and having increased trust and connections with adults and with the wider community.

Conclusions. Homeless youth identified components of quality of care as well as how quality of care should be measured. Their perspectives will be included in a larger follow‐up study to develop quality of care indicators for homeless youth.
Competing Values of Emergency Department Performance: Balancing Multiple Stakeholder Perspectives
Authors: Tregunno Deborah , Ross Baker G. , Barnsley Jan , Murray Michael
Published: July 2004

Objective.To describe the performance interests of multiple stakeholders associated with the management and delivery of emergency department (ED) care, and to develop a performance framework and set of indicators that reflect these interests.

Study Setting.Stakeholders (1,100 physicians, nurses, managers, home care providers, and prehospital care personnel) with responsibility for ED patients in hospitals in the Canadian province of Ontario.

Study Design.Sixty‐two percent of stakeholders responded to a mail survey regarding the importance of 104 potential ED performance indicators. Descriptive and inferential statistics are used to explore the interests of each stakeholder group and to compare interests across the five groups.

Principal Findings.Emergency department stakeholders are primarily interested in indicators that focus on their role and capacity to provide care. Key differences exist between hospital and nonhospital stakeholders. Physicians mean ratings of the importance on ED performance measures were lower than mean ratings in the other stakeholder groups.

Conclusions.Emergency department performance interests are not homogeneous across stakeholder groups, and evaluating performance from the perspective of any one stakeholder group will result in unbalanced assessments. Community‐based stakeholders, a group frequently excluded from commenting on ED performance, provide important insights into ED performance related to the external environment and the broader continuum of care.
The Relationship of Medicaid Payment Rates, Bed Constraint Policies, and Risk‐Adjusted Pressure Ulcers
Authors: Grabowski David C. , Angelelli Joseph J.
Published: July 2004

Objective. To examine the effect of Medicaid reimbursement rates on nursing home quality in the presence of certificate‐of‐need (CON) and construction moratorium laws.

Data Sources/Study Setting. A single cross‐section of Medicaid certified nursing homes in 1999 (N=13,736).

Study Design. A multivariate regression model was used to examine the effect of Medicaid payment rates and other explanatory variables on risk‐adjusted pressure ulcer incidence. The model is alternatively considered for all U.S. nursing home markets, those most restrictive markets, and those high‐Medicaid homes to isolate potentially resource‐poor environments.

Data Extraction Methods. A merged data file was constructed with resident‐level information from the Minimum Data Set, facility‐level information from the On‐Line, Survey, Certification, and Reporting (OSCAR) system and market‐ and state‐level information from various published sources.

Principal Findings. In the analysis of all U.S. markets, there was a positive relationship between the Medicaid payment rate and nursing home quality. The results from this analysis imply that a 10 percent increase in Medicaid payment was associated with a 1.5 percent decrease in the incidence of risk‐adjusted pressure ulcers. However, there was a limited association between Medicaid payment rates and quality in the most restrictive markets. Finally, there was a strong relationship between Medicaid payment and quality in high‐Medicaid homes providing strong evidence that the level of Medicaid payment is especially important within resource poor facilities.

Conclusions. These findings provide support for the idea that increased Medicaid reimbursement may be an effective means toward improving nursing home quality, although CON and moratorium laws may mitigate this relationship.
The Impact of Medicaid Managed Care on Pregnant Women in Ohio: A Cohort Analysis
Authors: Howell Embry M. , Dubay Lisa , Kenney Genevieve , Sommers Anna S.
Published: July 2004

Objective. To examine the impact of mandatory HMO enrollment for Medicaid‐covered pregnant women on prenatal care use, smoking, Cesarean section (C‐section) use, and birth weight.

Data Sources/Study Setting. Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that implemented mandatory HMO enrollment, and 4 with low levels of voluntary enrollment (under 15 percent). Cuyahoga County (Cleveland) is analyzed separately; the other mandatory counties and the voluntary counties are grouped for analysis, due to small sample sizes.

Study Design. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. County of residence is the primary indicator of managed care status, since, in Ohio, women are allowed to “opt out” of HMO enrollment in mandatory counties in certain circumstances, leading to selection. As a secondary analysis, we compare women according to their HMO enrollment status at the first and second birth.

Data Collection/Extraction Methods. Linked birth certificate/enrollment data were used to identify 4,917 women with two deliveries covered by Medicaid, one prior to the implementation of mandatory HMO enrollment (mid‐1996) and one following implementation. Data for individual births were linked over time using a scrambled maternal Medicaid identification number.

Principal Findings. The effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared to women in voluntary counties. Women residing in all the mandatory counties were less likely to have a repeat C‐section. There were no effects on infant birth weight. The effects of women's own managed care status were inconsistent depending on the outcome examined; an interpretation of these results is hampered by selection issues. Changes over time in outcomes, both positive and negative, were more pronounced for African American women.

Conclusions. With careful implementation and attention to women's individual differences as in Ohio, outcomes for pregnant women may improve with Medicaid managed care implementation. Quality monitoring should continue as Medicaid managed care becomes more widespread. More research is needed to identify the types of health maintenance organization activities that lead to improved outcomes.
The Effect of Benefits, Premiums, and Health Risk on Health Plan Choice in the Medicare Program
Authors: Atherly Adam , Dowd Bryan E. , Feldman Roger
Published: July 2004

Objective. To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan.

Data Source. Individual data from the Medicare Current Beneficiary Survey were combined with plan‐level data from Medicare Compare.

Study Design. Health plan choices, including the Medicare+Choice/Fee‐for‐Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit.

Principal Findings. Premiums have a significant effect on plan selection, with an estimated out‐of‐pocket premium elasticity of −0.134 and an insurer‐perspective elasticity of −4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage.

Conclusions. Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics.
Influenza and Pneumococcal Vaccination Demand Responses to Changes in Infectious Disease Mortality
Authors: Li Ying‐Chun , Norton Edward C. , Dow William H.
Published: July 2004

Objective. To test the hypothesis that individuals are more likely to receive a vaccination against influenza or pneumonia as the perceived disease threat increases.

Data Sources. This study uses two different national datasets. Individual‐level information about the vaccination rates of 38,768 elderly persons are from the Behavioral Risk Factor Surveillance System, 1993–1998. Information on the combined influenza and pneumonia state mortality rates are measured from the Compressed Mortality File.

Study Design. Using both cross‐sectional and state fixed‐effects panel data estimators, we model an individual's probability of having an influenza or pneumococcal vaccination as a function of the lagged state mortality rate. Multiyear lags are specified in order to estimate the duration of the effect of disease mortality on individual vaccination behavior.

Principal Findings. Results support our hypothesis that influenza vaccination behavior responds positively to disease mortality, even after a one‐year lag. We further find that cross‐sectional estimators used in previous work yield downward‐biased estimates, although even for our preferred panel data models, the estimated effects are small.

Conclusions. The findings indicate that behavioral demand responses can help to limit infectious disease epidemics, and suggest further research on how public awareness campaigns can mediate this disease threat responsiveness behavior.
Hospice Use by Hispanic and Non‐Hispanic White Cancer Decedents
Authors: Lackan Nuha A. , Ostir Glenn V. , Freeman Jean L. , Kuo Yong‐Fang , Zhang Dong D. , Goodwin James S.
Published: July 2004

Objective. To investigate rates of hospice use between Hispanic and non‐Hispanic white Medicare beneficiaries diagnosed with cancer using data from a large, population‐based study.

Data Sources. Secondary data from the linked SEER‐Medicare database including the SEER areas of Los Angeles, San Francisco, and San Jose–Monterey, California, and the state of New Mexico. All subjects were Hispanic or non‐Hispanic whites, aged 67 and older, had a cancer diagnosis of breast, colorectal, lung, or prostate cancer from 1991–1996, and died of cancer from 1991–1998.

Study Design. This study employed a retrospective cohort design to compare rates of hospice use between Hispanics and non‐Hispanic whites across patient characteristics and over time.

Principal Findings. Rates of hospice use were similar for Hispanics (39.2 percent) and non‐Hispanic whites (41.5 percent). In a bivariate logistic regression model, Hispanics were significantly less likely to use hospice than non‐Hispanic whites (OR 0.91; 95 percent CI 0.85–0.97). However, after adjusting for age, marital status, sex, educational attainment, income, urban versus rural residence, and type of insurance using multivariate logistic regression analysis, the estimated odds for being a hospice user among Hispanics is similar to the odds of being a hospice user among non‐Hispanic whites (OR 1.05; 95 percent CI 0.98–1.13). Stratified analyses revealed significant differences between ethnic groups in the use of hospice by type of insurance and SEER area, indicating interactions between ethnicity and these variables.

Conclusions. Our findings indicate similar rates of hospice use for Hispanics and non‐Hispanic whites diagnosed with one of the four leading cancers. Additional studies from other national registries may be necessary to confirm these findings.
Tales from the New Frontier: Pioneers' Experiences with Consumer‐Driven Health Care
Authors: Lo Sasso Anthony T. , Rice Thomas , Gabel Jon R. , Whitmore Heidi
Published: July 2004

Objective. To conduct site visits to study the early experiences of firms offering consumer‐driven health care (CDHC) plans to their employees and firms that provide CDHC products.

Data Sources/Study Setting. A convenience sample of three firms offering CDHC products to their employees, one of which is also a large insurer, and one firm offering an early CDHC product to employers.

Study Design. We conducted onsite interviews of four companies during the spring and summer of 2003. These four cases were not selected randomly. We contacted organizations that already had a consumer‐driven plan in place by January 2002 so as to provide a complete year's worth of experience with CDHC.

Principal Findings. The experience of the companies we visited indicated that favorable selection tends to result when a CDHC plan is introduced alongside traditional preferred provider organization (PPO) and health maintenance organization (HMO) plan offerings. Two sites demonstrated substantial cost‐savings. Our case studies also indicate that the more mundane aspects of health care benefits are still crucial under CDHC. The size of the provider network accessible through the CDHC plan was critical, as was the role of premium contributions in the benefit design. Also, companies highlighted the importance of educating employees about new CDHC products: employees who understood the product were more likely to enroll.

Conclusions. Our site visits suggest the peril (risk selection) and the promise (cost savings) of CDHC. At this point there is still far more that we do not know about CDHC than we do know. Little is known about the extent to which CDHC changes people's behavior, the extent to which quality of care is affected by CDHC, and whether web‐based information and tools actually make patients become better consumers.
Employee Choice of Consumer‐Driven Health Insurance in a Multiplan, Multiproduct Setting
Authors: Parente Stephen T. , Feldman Roger , Christianson Jon B.
Published: July 2004

Objective. To determine who chooses a Consumer‐Driven Health Plan (CDHP) in a multiplan, multiproduct setting, and, specifically, whether the CDHP attracts the sicker employees in a company's risk pool.

Study Design. We estimated a health plan choice equation for employees of the University of Minnesota, who had a choice in 2002 of a CDHP and three other health plans—a traditional health maintenance organization (HMO), a preferred provider organization (PPO), and a tiered network product based on care systems. Data from an employee survey were matched to information from the university's payroll system.

Principal Findings. Chronic illness of the employee or family members had no effect on choice of the CDHP, but such employees tended to choose the PPO. The employee's age was not related to CDHP choice. Higher‐income employees chose the CDHP, as well as those who preferred health plans with a national provider panel that includes their physician in the panel. Employees tended to choose plans with lower out‐of‐pocket premiums, and surprisingly, employees with a chronic health condition themselves or in their family were more price‐sensitive.

Conclusions. This study provides the first evidence on who chooses a CDHP in a multiplan, multiproduct setting. The CDHP was not chosen disproportionately by the young and healthy, but it did attract the wealthy and those who found the availability of providers more appealing. Low out‐of‐pocket premiums are important features of health plans and in this setting, low premiums appeal to those who are less healthy.
Evaluation of the Effect of a Consumer‐Driven Health Plan on Medical Care Expenditures and Utilization
Authors: Parente Stephen T. , Feldman Roger , Christianson Jon B.
Published: July 2004

Objective. To compare medical care costs and utilization in a consumer‐driven health plan (CDHP) to other health insurance plans.

Study Design. We examine claims and employee demographic data from one large employer that adopted a CDHP in 2001. A quasi‐experimental pre–post design is used to assign employees to three cohorts: (1) enrolled in a health maintenance organization (HMO) from 2000 to 2002, (2) enrolled in a preferred provider organization (PPO) from 2000 to 2002, or (3) enrolled in a CDHP in 2001 and 2002, after previously enrolling in either an HMO or PPO in 2000. Using this approach we estimate a difference‐in‐difference regression model for expenditure and utilization measures to identify the impact of CDHP.

Principal Findings. By 2002, the CDHP cohort experienced lower total expenditures than the PPO cohort but higher expenditures than the HMO cohort. Physician visits and pharmaceutical use and costs were lower in the CDHP cohort compared to the other groups. Hospital costs and admission rates for CDHP enrollees, as well as total physician expenditures, were significantly higher than for enrollees in the HMO and PPO plans.

Conclusions. An early evaluation of CDHP expenditures and utilization reveals that the new health plan is a viable alternative to existing health plan designs. Enrollees in the CDHP have lower total expenditures than PPO enrollees, but higher utilization of resource‐intensive hospital admissions after an initially favorable selection.
Percutaneous ethanol injection treatment of severe hyperparathyroidism in maintenance dialysis: Risks and benefits
Authors: Guebre‐Egziabher Fitsum , Easy Firas , Juillard Laurent , Valette Pierre‐Jean , Fouque Denis
Published: July 2004

Renal hyperparathyroidism is one of the main and serious complications that occur in chronic kidney disease and particularly during long‐term maintenance dialysis. Several recent trials indicate that a high calcium phosphorus product is correlated with high cardiovascular morbidity and mortality and poor outcome. Thus, it is important to improve the control of hyperparathyroidism in chronic renal failure patients. Several methods have been reported for treating severe hyperparathyroidism resistant to medical therapy. Total parathyroidectomy and transplantation or excision of tumor is considered as the treatment of choice. More recently, interventional methods with percutaneous ethanol or calcitriol injection have been developed. These latter techniques have been reported as an alternative to surgical treatment for patients with high perioperative risk. We report the occurrence of laryngeal recurrent nerve palsy, vocal fold paralysis, and hemiplegia after a successful injection of ethanol in a left parathyroid adenoma in a maintenance hemodialysis patient and discuss the restrictions of the procedure and alternative treatments in view of the available studies.
Serum matrix metalloproteinase‐3 in hemodialysis patients with dialysis‐related amyloidosis
Authors: Ishizaki Makoto , Matsunaga Tomohito , Adachi Kuniaki , Miyashita Eishi
Published: July 2004

Background:  Matrix metalloproteinase‐3 (MMP‐3) has been linked to osteoarticular destruction in rheumatic arthritis. To investigate the role of MMP‐3 in dialysis‐related amyloidosis (DRA), we determined serum MMP‐3 in long‐term hemodialysis (HD) patients with and without clinical manifestations of DRA.

Methods:  Thirty‐three subjects (63% female, 3% diabetic) enrolled in the study between September 2001 and June 2003. All patients underwent standard HD three times per week, using high‐flux dialyzers. Four patients had active DRA complications (DRA patients), whereas the others (n = 29) had no evidence of DRA. We determined serum concentrations of MMP‐3, C‐reactive protein (CRP), β2‐microglobulin (β2M), and interleukin‐6 (IL‐6). We also studied the effects of hemodiafiltration (HDF) on inflammatory measures by transferring the DRA patients from regular HD to predilution HDF.

Results:  The DRA group had been on dialysis significantly longer than the control group. Significant positive correlations were observed between MMP‐3 and IL‐6 (R2 = 0.5143, p < 0.0001) and MMP‐3 and CRP (R2 = 0.6492, p < 0.0001). IL‐6 levels increased after a single dialysis treatment, but this effect was minimal with predilution HDF (the increment of IL‐6 levels did not exceed 10 pg/mL). Serum MMP‐3 levels decreased in parallel with the decrease of IL‐6.

Conclusions:  MMP‐3 serum levels increase in accordance with clinical manifestations of DRA and elevated circulating levels of IL‐6. For the evaluation of the pathophysiologic state of DRA, serum MMP‐3 may be a useful predictor indicative of chronic inflammation and osteoarticular disorders in DRA patients.
Timely referral to the nephrologist: Essential to optimizing patient outcomes
Authors: Sułowicz Władysław , Stompór Tomasz P.
Published: July 2004

Annual mortality on renal replacement therapy is about 10% in Western Europe and reaches 20% in the United States. The reasons responsible for this excess mortality include among others advanced age, high prevalence of diabetes and comorbid conditions, susceptibility to infections, and cancer. An additional cause that should be considered is late referral to overall renal care and for renal replacement therapy. It has been demonstrated recently that early referral may provide many advantages for the patient, such as prevention of organ damage secondary to uremia and even delay the onset of end‐stage renal disease. These benefits prompted numerous recommendations for timely referral, both for dialysis and for long‐term renal follow‐up. Despite available guidelines for nephrology referral the current practice is still suboptimal, resulting in delayed initiation of dialysis and clinical outcomes that are not ideal. There is an urgent need in the renal community to change the current practice of referral. Beyond the benefits for patients, society may also expect potential cost effectiveness from early renal care.
Erythropoietic agents, iron and hemoglobin—What happens beyond the trial setting: Observational data from the ANZDATA Registry
Authors: McDonald Stephen P , Marshall Mark R , Kerr Peter G , Russ Graeme R
Published: July 2004

Background:  The issues surrounding anemia management in patients receiving dialysis therapy are complex and widely debated. Although numerous trials have been published, clinical practice patterns may differ, particularly in the presence of uncertainty about the optimal management of anemia in this setting.

Methods:  We examined data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) regarding use of erythropoietic agents (EA), hemoglobin, and ferritin concentrations and transferrin saturation in 8476 prevalent dialysis patients in Australia and New Zealand during the 6 months preceding March 31, 2001. From this cross‐sectional survey, we examined the distribution of reported hemoglobin concentration, transferrin saturation, and ferritin concentration. Among hemodialysis patients, other predictors of hemoglobin examined included urea reduction ratio (URR), age, sex, and the presence of comorbidities.

Results: In Australia, 87% of dialysis patients received an EA; in contrast, only 42% of New Zealand patients received an EA. Hemoglobin concentrations were significantly higher in Australia, where 16% of reported values were <100 g/L, compared to New Zealand where 37% reported values were <100 g/L. Transferrin saturation and serum ferritin concentrations were significantly correlated, but less strongly among those receiving EA than those not receiving these agents. Both transferrin saturation and serum ferritin were significantly and independently associated with hemoglobin concentration, as were age and sex. The association with ferritin was inverse: higher serum ferritin concentrations were associated with lower hemoglobin concentrations. There was poor agreement (κ = 0.15) between categories of low transferrin saturation (<20%) and low ferritin concentrations (<200 ng/mL). Among the Australian hemodialysis patients, there was no significant variation in Hb between categories where reported URR was ≥65%, whereas the group with a reported URR <65% had a significantly lower hemoglobin concentration.

Conclusions:  There was a wide variation in reported hemoglobin concentrations in this population. Potential contributing factors include variable patient responsiveness to EA and iron, differing regulations in Australia and New Zealand regarding government subsidy of EA, and the lack of consensus among physicians regarding hemoglobin target values. Although a cross‐sectional study cannot directly address the predictive value of iron indices for iron deficiency, it appears likely that transferrin and ferritin have different relationships with hemoglobin, and measurement of both may have greater clinical utility than either parameter alone.
The advanced practice nurse–nephrologist care model: Effect on patient outcomes and hemodialysis unit team satisfaction
Authors: Harwood Lori , Wilson Barbara , Heidenheim A Paul , Lindsay Robert M
Published: July 2004

The tertiary care nurse practitioner/clinical nurse specialist (NP/CNS) is an advanced practice nurse with a relatively new role within the health‐care system. It is stated that care provided by the NP/CNS is cost‐effective and of high quality but little research exists to document these outcomes in an acute‐care setting. The clinical coverage pattern by nephrologists and NP/CNS of a hemodialysis unit in a large academic center allowed such a study. Two NP/CNS plus a nephrologist followed two of three hemodialysis treatment shifts per day; only a nephrologist followed the third shift. The influence of this care pattern of patients was examined using a cross‐sectional review of outcomes such as adequacy of delivered dialysis, anemia management, phosphate control, hospitalizations, etc. In addition, the level of satisfaction of the dialysis team and perceptions of care delivered with the care models was assessed. The care model staff‐to‐patient‐number ratio was similar in both groups (1:27 for NP/CNS plus nephrologist; 1:29 for nephrologist alone). Patient demographics were similar in both groups but the NP/CNS–nephrologist group had patients with more comorbidities. No statistically significant (p < 0.05) differences existed between the groups in patient laboratory data, adherence to standards, medications, inter‐ and intradialytic blood pressure, achievement of target postdialysis weights, and hospitalizations or emergency room visits. Significantly more adjustments were made to target weights and medications and more investigations were ordered by the NP/CNS–nephrologist team. Team satisfaction and perceptions of care delivery were higher with the NP/CNS–nephrologist model. It is concluded that the NP/CNS–nephrologist care model may increase the efficiency of the care provided by nephrologists to chronic hemodialysis patients. The model may also be a solution to the problem of providing nephrologic care to an ever‐growing hemodialysis population.
Early readmission and length of hospitalization practices in the Dialysis Outcomes and Practice Patterns Study (DOPPS)
Authors: Lopes Antonio Alberto , Leavey Sean F , McCullough Keith , Gillespie Brenda , Bommer Juergen , Canaud Bernard J , Saito Akira , Fukuhara Shunichi , Held Philip J , Port Friedrich K , Young Eric W
Published: July 2004

Background:  Rising hospital care costs have created pressure to shorten hospital stays and emphasize outpatient care. This study tests the hypothesis that shorter median length of stay (LOS) as a dialysis facility practice is associated with higher rates of early readmission.

Methods:  Readmission within 30 days of each hospitalization was evaluated for participants in the Dialysis Outcomes and Practice Patterns Study, an observational study of randomly selected hemodialysis patients in the United States (142 facilities, 5095 patients with hospitalizations), five European countries (101 facilities, 2281 patients with hospitalizations), and Japan (58 facilities, 883 patients with hospitalizations). Associations between median facility LOS (estimated from all hospitalizations at the facility and interpreted as a dialysis facility practice pattern) and odds of readmission were assessed using logistic regression, adjusted for patient characteristics and the LOS of each index hospitalization.

Results:  Risk of readmission was directly and significantly associated with LOS of the index hospitalization (adjusted odds ratio [AOR] 1.005 per day in median facility LOS, p = 0.007) and inversely associated with median facility LOS (AOR = 0.974 per day, p = 0.016). This latter association was strongest for US hemodialysis centers (AOR = 0.954 per day, p = 0.015).

Conclusions:  Dialysis facilities with shorter median hospital LOS for their patients have higher odds of readmission, particularly in the United States, where there is greater pressure to shorten LOS. The determinants and consequences of practices related to hospital LOS for hemodialysis patients should be further studied.
Evolution of pigment cell regression in the cavefish Astyanax: a late step in melanogenesis
Authors: McCauley David W. , Hixon Ernest , Jeffery William R.
Published: July 2004

Summary
Pigmentation and eyes are often lost in cave‐adapted animals. Although the mechanisms of eye degeneration are beginning to be understood, little is known about the evolutionary and developmental processes involved in pigment cell regression. In teleost embryos, a population of neural crest cells migrates into the body wall and differentiates into melanophores, xanthophores, and iridophores. All three pigment cell types are present in the eyed surface‐dwelling form (surface fish) of the teleost Astyanax mexicanus. However, melanophores are absent or substantially reduced in number in various derived populations of the conspecific blind cave‐dwelling form (cavefish). We show here that tyrosinase‐positive melanoblasts are present in cavefish. DiI labeling revealed a population of trunk neural crest cells in cavefish embryos that migrate to locations normally occupied by differentiated melanophores. We also discovered a cell population in cavefish embryos and adults resembling melanoblasts in several features, including the ability to synthesize melanin when supplied with the tyrosinase substrate l‐dopa. DiI‐tyrosinase double‐labeling and neural keel explant experiments showed that the tyrosinase‐positive cells are derived from the neural crest. The number of melanoblasts varies in different adult cavefish populations relative to the extent of melanophore reduction. Although cavefish melanoblasts can synthesize melanin from exogenous l‐dopa, they are unable to convert exogenous l‐tyrosine to l‐dopa and melanin. We conclude that pigment cell regression in cavefish is mediated by an evolutionary change late in melanogenesis that may involve an impediment in the ability to convert l‐tyrosine to l‐dopa and melanin.
Evolution of regulatory elements producing a conserved gene expression pattern in Caenorhabditis
Authors: Wang Xiaodong , Greenberg Jennifer F. , Chamberlin Helen M.
Published: July 2004

Summary
Natural selection acts at the level of function, not at the logistical level of how organisms achieve a particular function. Consequently, significant DNA sequence and regulatory differences can achieve the same function, such as a particular gene expression pattern. To investigate how regulatory features underlying a conserved function can evolve, we compared the regulation of a conserved gene expression pattern in the related species Caenorhabditis elegans and C. briggsae. We find that both C. elegans and C. briggsae express the ovo‐related zinc finger gene lin‐48 in the same pattern in hindgut cells. However, the regulation of this gene by the Pax‐2/5/8 protein EGL‐38 differs in two important ways. First, specific differences in the regulatory sequences of lin‐48 result in the presence of two redundant EGL‐38 response elements in C. elegans, whereas the redundancy is absent in C. briggsae. Second, there is a single egl‐38 gene in C. briggsae. In contrast, the gene is duplicated in C. elegans, with only one copy retaining the ability to regulate lin‐48 in vivo. These results illustrate molecular changes that can occur despite maintenance of conserved gene function in different species.
Clinical isolation and functional characterization of cord blood CD133+ hematopoietic progenitor cells
Authors: Bonanno Giuseppina , Perillo Alessandro , Rutella Sergio , De Ritis Daniela Giovanna , Mariotti Andrea , Marone Maria , Meoni Franco , Scambia Giovanni , Leone Giuseppe , Mancuso Salvatore , Pierelli Luca
Published: July 2004

BACKGROUND:  Human cord blood is a relevant source of CD133+ HPCs. Clinical‐scale isolation of human umbi‐lical cord blood (UCB) CD133+ HPCs using immunomag‐netic microbeads and the CliniMACS clinical cell isolator is reported. CD133+ HPCs isolated after large‐scale pro‐cessing were functionally characterized.

STUDY DESIGN AND METHODS:  Closed disposable sets were used to process nine different samples of RBC‐reduced UCB nucleated cells. In‐vitro hematopoietic assays and human xenografts in NOD/SCID mice were performed to assess the functional properties of isolated CD133+ cells. Different mixtures of human cytokines were tested for the ability to expand nascent CD133+ HPCs. Furthermore, freshly isolated CD133+ cells were conditioned in culture medium specifically tested to support in‐vitro myogenesis or osteogenesis.

RESULTS:  Isolation procedures yielded the recovery of an average of 2.53 × 106 CD133+ HPCs with a mean recovery of 96 percent (referred to as RBC‐reduced samples) and a final sample purity of 82 percent. Purified CD133+ cells had high cloning efficiency, had relevant long‐term activity, and were capable of repopulating irradiated NOD/SCID mice. In 10‐day stroma‐free cultures, a 2‐fold and 8.3‐fold expansion of colony‐forming cells (CFCs) and extended long‐term culture‐initiating cells, respectively, was obtained. Freshly isolated CD133+ cells differen‐tiated into large nucleated cells expressing either myosin D or osteopontin (as revealed by RT‐PCR and immuno‐cytochemistry), with a protein/mRNA expression compar‐able to or even higher than that observed in UCB CD133– nucleated cells in identical culture conditions.

CONCLUSION:  Collectively, clinical‐scale isolation of UCB CD133+ cells provides a relevant amount of primi‐tive HPCs with high hematopoietic activity and in‐vitro mesenchymal potential.
Interleukin 1 beta and tumor necrosis factor levels in stored platelet concentrates and the association with gene polymorphisms
Authors: Addas‐Carvalho M. , Origa A.F. , Saad S.T.O.
Published: July 2004

BACKGROUND:  Cytokines (IL‐1β and TNF) generated by WBCs during storage of PLT concentrates have been associated with febrile nonhemolytic transfusion reactions.

STUDY DESIGN AND METHODS:  This study was undertaken to investigate whether there is an association between the polymorphisms of IL1B ‐511C/T and +3953C/T, IL1RN intron 2 VNTR and TNFA‐308G/A genes and the increase of cytokines during the storage of PLT concentrates produced by plasma‐rich PLTS (PRP‐PC) or apheresis PLTs.

RESULTS:  Thirty PRP‐PCs were studied and a pro‐gressive increase of IL‐1β and TNF during storage was revealed. IL1‐β and TNF levels were inversely correlated with the content of PLTs in PRP‐PCs detected on Day 3 (p = 0.004) and Day 5 (p = 0.019), but not on Day 7. There was association of IL1B‐511T polymorphism and IL‐1β levels (Day 5, p = 0.063, only tendency and on Day 7, p = 0.038, significant). There was no association of the other polymorphisms (IL1B+3953C/T, IL1RN intron 2 and TNFA‐308G/A) with their respective cytokines.

CONCLUSION:  The great variation of cytokine levels in the plasma of PLT concentrates (PCs) during storage may also be caused by cytokine gene polymorphisms, as well as WBC contamination, material that the bags are made of, and storage time, as previously described.
Visual assessment of hemolysis in red blood cell units and segments can be deceptive
Authors: Janatpour K.A. , Paglieroni T.G. , Crocker V.L. , DuBois D.J. , Holland P.V.
Published: July 2004

BACKGROUND:  Blood components that appear hemo‐lyzed are discarded. However, visual inspection is subjec‐tive and criteria for excessive hemolysis are poorly defined.

STUDY DESIGN AND METHODS:  Packed RBCs (10 CPDA‐1, 10 Adsol) were collected. Half of each unit was leukoreduced. Plasma Hb was measured and compared in segments and units by three methods: 1) a HemoCue Plasma/Low Hb Photometer system; 2) a tetramethyl‐benzidine (TMB) chemical method, and 3) a free Hb visual comparator.

RESULTS:  Visual assessment tended to overestimate hemolysis. Chemical methods were comparable (r2= 0.894; HemoCue = 0.043 +[0.770]× TMB; n = 400; range, 0.01‐0.5 g/dL), although the mean plasma Hb (g/dL) for the HemoCue method was higher than that of the TMB method (0.12 vs. 0.10 g/dL, respectively; p < 0.001). No units would have been discarded based on a hemolysis level of at least 0.6 g/dL (approx. 1%) if measured by a chemical method. However, 50 percent of CPDA‐1 and 10 percent of Adsol units would have been discarded if only visual criteria were used. Leukoreduction did not increase plasma Hb levels. Discrepancies in plasma Hb levels were noted between units and their corresponding segments.

CONCLUSION:  Visual assessment of hemolysis can result in unnecessary wastage of blood components. HemoCue offers an alternative, objective method to assess plasma Hb in the setting of blood collection and processing facilities for routine quality control and process validation, and may aid in the development of objective criteria for excessive hemolysis in blood components.
Ceftriaxone causes drug‐induced immune thrombocytopenia and hemolytic anemia: characterization of targets on platelets and red blood cells
Authors: Großjohann Beatrice , Eichler Petra , Greinacher Andreas , Santoso Sentot , Kroll Hartmut
Published: July 2004

BACKGROUND:  Ceftriaxone, a third‐generation cephalosporin, has been reported to occasionally cause fatal drug‐induced immune hemolytic anemia (DIHA). A clinical and serologic analysis of the first two patients with severe drug‐induced thrombocytopenia (DITP) due to ceftriaxone and one patient with fatal DIHA is reported.

STUDY DESIGN AND METHODS:  Sera were assessed by the IAT, EIA, glycoprotein (GP)‐specific immunoassay, flow cytometry, and immunoprecipitation using trans‐fectants expressing GPIIb/IIIa and GPIb/IX and with different cephalosporins.

RESULTS:  Sera from Patients 1 and 2 reacted strongly with PLTs in the presence of the drug, but not with RBCs. The binding sites of the drug‐dependent antibodies (DDAbs) could be localized to GPIIb/IIIa and GPIb/IX, respectively. Inhibition studies indicated that DDAbs recognized epitopes residing on the GPIIb/IIIa complex and on the GPIX subunit, respectively. No cross‐reactivity was observed with other cephalosporin derivatives. Serum 3 showed strong agglutination with RBCs of Rhnull phenotype in the presence of ex‐vivo metabolites of ceftriaxone, but no cross‐reactivity with PLTs.

CONCLUSIONS:  The first two cases of severe DITP and a third patient with DIHA are reported. DDAbs from all patients showed individual reaction patterns and clear cell lineage specificity. In addition, the DDAbs were dependent on the substitution at position 3 of the ceftriaxone molecule. Epitopes on GPIIb/IIIa and GPIX were involved on PLTs. The Rh protein was not the only target of DDAbs on RBCs.