Efflux and target mutations as quinolone resistance mechanisms in clinical isolates of Streptococcus pneumoniae

The aim of this study was to characterize quinolone resistance mechanisms in strains of Streptococcus pneumoniae with increased MICs of ofloxacin. These strains were also tested for their susceptibility to a battery of quinolone antimicrobial agents, including gemifloxacin. Of the S. pneumoniae isolates used, 27 were susceptible to ofloxacin, 18 intermediate and 48 resistant (ofloxacin MIC <4, 4 and >4 mg/L, respectively). In general, the ofloxacin-susceptible strains had no amino acid substitutions in GyrA, GyrB, ParC or ParE. Moderate increases in MIC were associated with substitutions in the quinolone resistance-determining region (QRDR) of ParC, while the highest MICs were found for strains that also had substitutions in the QRDR of GyrA. The most common substitutions were Ser79-->Phe in ParC and Ser81-->Phe in GyrA. Other substitutions were identified within the QRDR of ParC and outside the QRDR of ParC and ParE; these did not appear to affect susceptibility. The effects of antimicrobial efflux pumps were studied by determining MICs of a range of quinolones in the presence and absence of reserpine, an inhibitor of Gram-positive efflux pumps. Our results indicated that high-level resistance, caused entirely by efflux, was seen in a minority of ofloxacin-resistant S. pneumoniae strains. Testing the susceptibility of quinolone-resistant strains to gemifloxacin, ciprofloxacin, norfloxacin, ofloxacin and trovafloxacin revealed that gemifloxacin was least affected by this large variety of resistance mechanisms and was the only quinolone with MICs of < or =0.5 mg/L for all strains in this study. These results suggest that gemifloxacin is highly potent against S. pneumoniae and may also be effective against strains resistant to other quinolones.

In vitro activity of gemifloxacin against a broad range of recent clinical isolates from the USA

The antibacterial potencies of gemifloxacin (SB-265805) and 13 comparator compounds were determined by broth microdilution against a panel of 645 Gram-positive and 995 Gram-negative organisms collected from various USA sites. Time-kill studies were performed and postantibiotic effect (PAE) was determined for several organisms using trovafloxacin and ciprofloxacin as comparator compounds. Based on MIC(90)s, gemifloxacin was the most potent compound tested against Gram-positive isolates: Streptococcus pneumoniae (MIC(90) 0. 016 mg/L), Streptococcus agalactiae (0.03 mg/L), Streptococcus pyogenes (0.03 mg/L), viridans streptococci (0.12 mg/L), methicillin-susceptible Staphylococcus aureus (0.03 mg/L), Staphylococcus epidermidis (2 mg/L), Staphylococcus saprophyticus (0. 016 mg/L) and Enterococcus faecalis (2 mg/L). Against Gram-negative isolates, the potency of gemifloxacin was equal to that of levofloxacin and ciprofloxacin and generally better than that of ofloxacin, grepafloxacin, trovafloxacin and nalidixic acid. MIC(90)s for gemifloxacin were: Haemophilus influenzae (</=0.008 mg/L), Moraxella catarrhalis (0.008 mg/L), Escherichia coli (0.016 mg/L), Klebsiella pneumoniae (0.25 mg/L), Klebsiella oxytoca (0.25 mg/L), Enterobacter cloacae (1 mg/L), Enterobacter aerogenes (0.25 mg/L), Proteus spp. (4 mg/L), Serratia spp. (1 mg/L), Citrobacter freundii (2 mg/L), Morganella morganii (0.12 mg/L), Pseudomonas aeruginosa (8 mg/L), Stenotrophomonas maltophilia (4 mg/L) and Acinetobacter spp. (32 mg/L). Gemifloxacin was bactericidal for all organisms studied at 2 and 4 x MIC. The PAE for most strains was in the range 0.7-2.5 h at 2 and 4 x MIC, although longer PAEs were observed with H. influenzae, P. aeruginosa and Proteus vulgaris (>6 h at 4 x MIC) and shorter PAEs with E. faecalis (0.1-0.6 h) and K. pneumoniae (0.1-0.2 h). In conclusion, gemifloxacin is a novel quinolone with a broad spectrum of antimicrobial activity. It has substantially improved potency against Gram-positive organisms, especially streptococci, for which gemifloxacin is generally at least eight- to 16-fold more potent than other quinolones tested. It retains the good Gram-negative activity seen with ciprofloxacin and levofloxacin and shows good bactericidal activity and prolonged PAEs.

Use of the entire width of the flexor carpi radialis tendon for the ligament reconstruction tendon interposition arthroplasty does not impair wrist function

Although the original technical description of the ligament reconstruction tendon interposition arthroplasty as treatment for osteoarthritis at the base of the thumb included use of one half of the width of the flexor carpi radialis (FCR) tendon, it has been recommended that the entire width be used to simplify harvest and provide a larger piece of tissue for ligament reconstruction. The objective of this study was to evaluate preoperative and postoperative wrist motion and flexion strength, subjectively and objectively, to identify whether the use of the entire width of the FCR tendon results in decline or weakness. Our findings show neither subjective nor objective impairment of wrist motion or flexion strength at 1-year follow-up; 6 months after the procedure, strength had returned nearly to baseline.

Limb loading activity of adult horses confined to box stalls in an equine hospital barn

OBJECTIVE

To determine a range of limb loading activity for healthy adult horses confined to box stalls in an equine veterinary teaching hospital and determine the effects of hospital environmental factors on load rates and daily limb loading patterns.

ANIMALS

6 mature healthy horses of various ages, breeds, and sexes, and 1 horse with a repaired metatarsal fracture.

PROCEDURE

Step monitors were placed on 2 limbs of adult horses confined to box stalls. Relocation steps and weight shifts were recorded, as loading events, for 24 hours. Influence of forelimb versus hind limb and environmental factors on load rate (loading events per hour) were assessed with repeated-measures ANOVA.

RESULTS

Loading activity was greater for the forelimb than the hind limb and was greater during the day than the night. Loading activity differences were not associated with daytime environmental factors.

CONCLUSIONS AND CLINICAL RELEVANCE

Horses with normal locomotor activity appear to have higher load rates for forelimbs compared with hind limbs and higher load rates during the day compared with night. Knowledge of influence of environmental factors and mechanical restraint on limb loading activity may be useful in management of horses with musculoskeletal disorders. This information may also be used for in vitro simulation of in vivo loading of limbs during cyclic biomechanical investigations.

The EGF/TGFalpha response element within the TGFalpha promoter consists of a multi-complex regulatory element

Autocrine TGFalpha is an important growth effector in the transformed phenotype. Growth stimulation of some colon cancer cells as well as other types of cancer cells is effected by activation of the epidermal growth factor receptor. Importantly, this receptor activation leads to further stimulation of TGFalpha transcription and increased peptide synthesis. However, the molecular mechanism by which TGFalpha transcription is activated is poorly understood. In this paper, we describe the localization of a cis-sequence within the TGFalpha promoter which mediates this stimulation. This region contains parallel cis-acting elements which interact to regulate both basal and EGF-induced TGFalpha expression. The well differentiated colon carcinoma cell line designated FET was employed in these studies. It produces autocrine TGFalpha but requires exogenous EGF in the medium for optimal growth. Addition of EGF to FET cells maintained in the absence of EGF resulted in a 2 - 3-fold increase of both TGF promoter activity and endogenous TGFalpha mRNA at 4 h. This addition of EGF also stimulated protein synthesis. The use of deletion constructs of the TGFalpha promoter in chimeras with chloramphenicol acetyl transferase localized EGF-responsiveness to between -247 and -201 within the TGFalpha promoter. A 25 bp sequence within this region conferred EGF-responsiveness to heterologous promoter constructs. Further use of deletion/mutation chimeric constructs revealed the presence of at least two interacting cis-elements, one binding a repressor activity and the other, an activator. Gel shift studies indicate the presence of distinct complexes representing activator and repressor binding, which are positively modulated by EGF. The type and amount of complexes formed by these proteins interact to regulate both the basal activity and EGF-responsiveness of the TGFalpha promoter. The interaction of an activator protein with an EGF-responsive repressor may serve to regulate the level of this progression-associated, transforming protein within tight limits.

Shyness and boldness in pumpkinseed sunfish: individual differences are context-specific

Natural selection often promotes a mix of behavioural phenotypes in a population. Adaptive variation in the propensity to take risks might explain individual differences in shyness and boldness in humans and other species. It is often implicitly assumed that shyness and boldness are general personality traits expressed across many situations. From the evolutionary standpoint, however, individual differences that are adaptive in one context (e.g. predator defence) may not be adaptive in other contexts (e.g. exploration of the physical environment or intraspecific social interactions). We measured the context specificity of shyness and boldness in a natural population of juvenile pumpkinseed sunfish, Lepomis gibbosus, by exposing the fish to a potentially threatening stimulus (a red-tipped metrestick extended towards the individual) and a nonthreatening stimulus (a novel food source). We also related these measures of shyness and boldness to behaviours observed during focal observations, both before and after the introduction of a predator (largemouth bass, Micropterus salmoides). Consistent individual differences were found within both contexts, but individual differences did not correlate across contexts. Furthermore, fish that were scored as intermediate in their response to the metrestick behaved most boldly as foragers and in response to the bass predators. These results suggest that shyness and boldness are context-specific and may not exist as a one-dimensional behavioural continuum even within a single context. Copyright 1998 The Association for the Study of Animal Behaviour.

Teaching hospital costs: implications for academic missions in a competitive market

CONTEXT

As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions.

OBJECTIVE

To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME).

DESIGN

Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds).

SETTING AND PARTICIPANTS

A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals.

MAJOR OUTCOME MEASURES

Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case.

RESULTS

In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity.

CONCLUSIONS

The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.

Aberrant regulation of transforming growth factor-alpha during the establishment of growth arrest and quiescence of growth factor independent cells

Autocrine transforming growth factor alpha (TGFalpha) is an important positive growth effector in malignant cells and plays a significant role in generating the growth factor-independent phenotype associated with malignant progression. However, the molecular mechanisms by which TGFalpha confers a growth advantage in progression is poorly understood. The highly tumorigenic cell line HCT116 up-regulates TGFalpha mRNA expression during growth arrest, whereas the poorly tumorigenic growth factor-dependent FET cell line down-regulates TGFalpha mRNA expression as it becomes quiescent. We have identified a 25-bp sequence at -201 to -225 within the TGFalpha promoter which mediates the differential regulation of TGFalpha expression during quiescence establishment in these two cell lines. This same sequence confers TGFalpha promoter responsiveness to exogenous growth factor or autocrine TGFalpha. The abberant upregulation of TGFalpha mRNA in quiescent HCT116 cells may allow them to return to the dividing state under more stringent conditions (nutrient replenishment alone) then quiescent FET cells (requires nutrients and growth factors). Antisense TGFalpha approaches showed that the dysregulated TGFalpha expression in quiescent HCT116 cells is a function of the strong TGFalpha autocrine loop (not inhibited by blocking antibodies) in these cells.

Regulation of transforming growth factor alpha expression in a growth factor-independent cell line

Aberrant transcriptional regulation of transforming growth factor alpha (TGF alpha) appears to be an important contributor to the malignant phenotype and the growth factor independence with which malignancy is frequently associated. However, little is known about the molecular mechanisms responsible for dysregulation of TGF alpha expression in the malignant phenotype. In this paper, we report on TGF alpha promoter regulation in the highly malignant growth factor-independent cell line HCT116. The HCT116 cell line expresses TGF alpha and the epidermal growth factor receptor (EGFR) but is not growth inhibited by antibodies to EGFR or TGF alpha. However, constitutive expression of TGF alpha antisense RNA in the HCT116 cell line resulted in the isolation of clones with markedly reduced TGF alpha mRNA and which were dependent on exogenous growth factors for proliferation. We hypothesized that if TGF alpha autocrine activation is the major stimulator of TGF alpha expression in this cell line, TGF alpha promoter activity should be reduced in the antisense TGF alpha clones in the absence of exogenous growth factor. This was the case. Moreover, transcriptional activation of the TGF alpha promoter was restored in an antisense-TGF alpha-mRNA-expressing clone which had reverted to a growth factor-independent phenotype. Using this model system, we were able to identify a 25-bp element within the TGF alpha promoter which conferred TGF alpha autoregulation to the TGF alpha promoter in the HCT116 cell line. In the TGF alpha-antisense-RNA-expressing clones, this element was activated by exogenous EGF. This 25-bp sequence contained no consensus sequences of known transcription factors so that the TGF alpha or EGF regulatory element within this 25-bp sequence represents a unique element. Further characterization of this 25-bp DNA sequence by deletion analysis revealed that regulation of TGF alpha promoter activity by this sequence is complex, as both repressors and activators bind in this region, but the overall expression of the activators is pivotal in determining the level of response to EGF or TGF alpha stimulation. The specific nuclear proteins binding to this region are also regulated in an autocrine-TGF alpha-dependent fashion and by exogenous EGF in EGF-deprived TGF alpha antisense clone 33. This regulation is identical to that seen in the growth factor-dependent cell line FET, which requires exogenous EGF for optimal growth. Moreover, the time response of the stimulation of trans-acting factor binding by EGF suggests that the effect is directly due to growth factor and not mediated by changes in growth state. We conclude that this element appears to represent the major positive regulator of TGF alpha expression in the growth factor-independent HCT116 cell line and may represent the major site of transcriptional dysregulation of TGF alpha promoter activity in the growth factor-independent phenotype.

Humanized mAb H22 binds the human high affinity Fc receptor for IgG (FcgammaRI), blocks phagocytosis, and modulates receptor expression

About 10-15% of patients with immune thrombocytopenic purpura (ITP) cannot be controlled by corticosteroid therapy and splenectomy. For these patients treatment with high-dose IVIgG induces partial or complete responses. The clinical benefits of IVIgG could be due to blockade of Fc receptors for IgG (FcgammaR), because several model systems clearly show that functional FcgammaR are essential for establishment of ITP and related diseases. However, the specific contributions of the three individual classes of FcgammaR remain to be more completely defined. Recently monoclonal antibody (mAb) H22, which recognizes an epitope on FcgammaRI (CD64) outside the ligand binding domain, was humanized by grafting its complementarity determining regions onto human IgG1 constant domains. Because FcgammaRI has a high affinity for human IgG1 antibodies, we predicted mAb H22 would also bind to FcgammaRI through its Fc domain and block FcgammaRI-mediated phagocytosis. These studies demonstrate that mAb H22 blocked phagocytosis of opsonized red blood cells 1000 times more effectively than an irrelevant IgG. Moreover, cross-linking FcgammaRI with mAb H22 rapidly down-modulated FcgammaRI expression on monocytes without affecting other surface antigens. We conclude that because mAb H22 is a humanized mAb that blocks the FcgammaRI ligand binding domain and down-modulates FcgammaRI expression, it is a particularly good candidate for evaluating the role of FcgammaRI in patients with ITP.

A novel polymorphism of FcgammaRIIIa (CD16) alters receptor function and predisposes to autoimmune disease

A novel polymorphism in the extracellular domain 2 (EC2) of FcgammaRIIIA affects ligand binding by natural killer (NK) cells and monocytes from genotyped homozygous normal donors independently of receptor expression. The nonconservative T to G substitution at nucleotide 559 predicts a change of phenylalanine (F) to valine (V) at amino acid position 176. Compared with F/F homozygotes, FcgammaRIIIa expressed on NK cells and monocytes in V/V homozygotes bound more IgG1 and IgG3 despite identical levels of receptor expression. In response to a standard aggregated human IgG stimulus, FcgammaRIIIa engagement on NK cells from V/V (high-binding) homozygotes led to a larger rise in [Ca2+]i, a greater level of NK cell activation, and a more rapid induction of activation-induced cell death (by apoptosis). Investigation of an independently phenotyped normal cohort revealed that all donors with a low binding phenotype are F/F homozygotes, while all phenotypic high binding donors have at least one V allele. Initial analysis of 200 patients with SLE indicates a strong association of the low binding phenotype with disease, especially in patients with nephritis who have an underrepresentation of the homozygous high binding phenotype. Thus, the FcgammaRIIIa polymorphism at residue 176 appears to impact directly on human biology, an effect which may extend beyond autoimmune disease characterized by immune complexes to host defense mechanisms.

Ethnicity and use of acute psychiatric beds: one-day survey in north and south Thames regions

BACKGROUND

Previous studies have shown higher rates of psychiatric admissions, compulsory admissions, and diagnosed schizophrenia in Black ethnic groups compared with other population groups.

METHOD

In a point-prevalence study, demographic and clinical data were collected for adult acute and low-level secure psychiatric in-patients in all National Health Service and seven private psychiatric units in North and South Thames regions on 15 June 1994.

RESULTS

A total of 3710 adult acute and 268 low-level secure psychiatric patients were surveyed; 75% of the patients were White, 16% were Black, and 4% were Asian. Analysis reveals that a high proportion of the Black population were admitted to a psychiatric unit; that Black patients are more likely to be admitted under Section; to be located in locked wards; have an inpatient diagnosis of schizophrenia; and not be registered with a general practitioner.

CONCLUSIONS

These findings demonstrate the over-representation of Black ethnic groups within current psychiatric provision. The complement of services to all minority ethnic groups should be examined in terms of access, appropriateness and quality of care. Racism awareness and staff training need to be incorporated into mental health service provision as a matter of priority.

A preliminary study of the analysis of Cannabis by supercritical fluid chromatography with atmospheric pressure chemical ionisation mass spectroscopic detection

A rapid method is described for the analysis of Cannabis products by supercritical fluid chromatography (SFC) coupled to atmospheric pressure chemical ionization-mass spectroscopic (APCI-MS) detection. The method had a shorter analysis time than GC-MS methods, without the need for derivatization prior to analysis. It was also faster than HPLC methods, with better resolution and definitive identification. Linearity of detector response to cannabidiol, delta 8-tetrahydrocannabinol, delta 9-tetrahydrocannabinol and cannabinol was established, the detection limits for mass on column being 0.55 ng, 1.20 ng, 0.69 ng and 2.10 ng respectively. The technique offers a means by which Cannabis products can be definitively identified in a single chromatographic run. Application to casework samples is described.

Why are you waiting? Formulating an information pamphlet for use in an accident and emergency department

The provision of information to patients and relatives reduced their anxiety and leads to greater understanding of what is happening to them and around them. Supplying information verbally has been shown to be at times fragmented and haphazard, particularly when dealing with worried and anxious patients in a hospital setting. The anxiety generated by injury or illness leading to attendance at Accident and Emergency (A & E) Departments does not lend itself to the use of verbal information. To overcome this an information leaflet was developed to supplement verbal information. It describes the working and geography of the A & E department, in an attempt to improve patients' understanding of how the department works and why they may have to wait. The introduction of the leaflet is to supplement verbal communication. Its use has had a positive effect, dovetailing with verbal communication to improve patients' understanding of why they may have to wait.

Prognostic value of morphometric features and the callender classification in uveal melanomas

PURPOSE

Cytomorphometric analysis of uveal melanoma has focused on nucleolar characteristics, although nuclear measurements are easier and more reproducible. In this study, we examine a restricted set of nuclear and nucleolar cytomorphometric variables in the search for the most quantifiable and reproducible prognostic parameter among these and discover a means of assessing the malignancy of tumors within the different Callender subgroups.

METHODS

Uveal melanomas from 94 patients with a minimum follow-up of 5 years underwent nuclear and nucleolar morphometric analysis using a digitized interactive video overlay system. Statistical analysis included univariate and multivariate survival analysis on morphometric variables and classic prognostic parameters (such as Callender cell type, size, etc.).

RESULTS

Univariate analysis of cytomorphometric parameters showed the standard deviation of nuclear area (NASD) to be the most significant variable (P < 0.0001: Mantel-Cox, 15.2). This was followed by the difference between nuclear and nucleolar areas (P < 0.002; Mantel-Cox, 9.5), the standard deviation of nucleolar area (SDNA) (P < 0.01; Mantel-Cox, 6.4), and the standard deviation of the shortest nuclear axis (P < 0.02; Mantel-Cox, 6.4). There was a trend for significance with the mean of the ten largest nucleoli (P < 0.07). Multivariate analysis of clinical and cytomorphometric variables showed improvement of prognostic prediction with a combination of the NASD, largest tumor dimension, and glaucoma (P < 0.0001; Mantel-Cox, 26.3). Callender cell type was strongly correlated with the NASD (P < 0.0002), the mean axis ratio of the nuclear area (P < 0.0007), and the mean of the ten largest nucleoli (P < 0.0007).

CONCLUSION

Cytomorphometric analysis of uveal melanoma should include nuclear area and may identify tumors of differing malignancy within the same Callender class.

Clinical-based vs insurance-based recommendations for substance abuse treatment level

An exploratory study of 250 patients was conducted at three treatment facilities in Western Pennsylvania, USA, to determine: 1) the extent of disagreement between clinical-based [using American Society of Addiction Medicine (ASAM) criteria] and insurance-based [using Managed Care Organization (MCO) criteria] recommendations for treatment levels, and 2) the extend of ASAM recommendations that become the actual treatment. Cross-tabulations showed: 1) ASAM and MCO recommendations were the same for 85% of the cases, and 2) ASAM recommendations became the actual treatment in 93% of the cases. The exceptionally high level of ASAM-MCO agreement suggests a convergence in ASAM and MCO criteria and a deference to ASAM criteria in practice.

No way out: the delayed discharge of elderly mentally ill acute and assessment patients in north and south Thames regions

We examined the characteristics of patients occupying elderly-mentally-ill acute and assessment beds in all mental health units within North and South Thames Regions; the proportion of patients defined as no longer requiring acute care (inappropriately located); and the unmet need for alternative service provision these patients required. Of the 1510 patients surveyed, 24.4% (n = 368) were defined as inappropriately located. For inappropriately located patients unable to be discharged home most (52.8%, n = 154) required residential care or nursing-home provision. A large proportion of these patients were very elderly (aged 85+ years), had dementia, and required high levels of supervision. This study indicates that purchasers, mental health service managers and social services departments should devise a more appropriate mix of inpatient and community provision. Particular emphasis needs to be placed on the greater provision of residential care and nursing homes with an appropriate skill-mix to care for this complex care group.

Use of acute psychiatric beds: a point prevalence survey in North and South Thames regions

BACKGROUND

Concerns have been expressed, particularly in inner cities, about the growing pressure on acute psychiatric beds, evidenced by increased occupancy rates, difficulties in accessing beds, and increasing use of private beds by health authorities. This study investigated these concerns by conducting a census of psychiatric patients occupying acute beds. The proportion of patients who no longer required acute care and their needs for alternative provision were determined, together with bed occupancy rates.

METHODS

A point prevalence survey of acute psychiatric patients in all National Health Service acute psychiatric units and seven private psychiatric units in North and South Thames regions was conducted on 15 June 1994. Sociodemographic, diagnosis and admission characteristics data were collected. Patients who no longer required acute care were identified and the alternative service provision required for these patients was determined. Bed occupancy rates were calculated.

RESULTS

A total of 3710 psychiatric patients (including those on leave) were ennumerated. More than one in five (23.2 per cent) were defined as inappropriately located. The main alternative services required for inappropriately located patients who could be discharged to the community were professional support in patient's home (71.5 per cent), and housing or more appropriate housing (61 per cent). For inappropriately located patients who could not be discharged into the community, the main alternative services required were group home (29.3 per cent) and in-patient rehabilitation (20.8 per cent). Bed occupancy rates were high on the day of the survey (95 per cent).

CONCLUSION

Best use is not being made of acute psychiatric beds in the Thames regions. A high proportion of patients occupying beds are those who no longer require acute care, but for whom alternative services are unavailable.

Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses

Researchers at The Johns Hopkins University (JHU) developed two new diagnosis-oriented methodologies for setting risk adjusted capitation rates for managed care plans contracting with Medicare. These adjusters predict the future medical expenditures of aged Medicare enrollees based on demographic factors and diagnostic information. The models use the Ambulatory Care Group (ACG) algorithm to categorize ambulatory diagnoses. Two alternative approaches for categorizing inpatient diagnoses were used. Lewin-VHI, Inc. evaluated the models using data from 624,000 randomly selected aged Medicare beneficiaries. The models predict expenditures far better than the Adjusted Average per Capita Cost (AAPCC) payment method. It is possible that risk adjusted capitation payments could encourage health plans to compete on the basis of efficiency and quality and not risk selection.