A43 LONG-TERM EFFICACY AND SAFETY OF OBETICHOCLIC ACID IN PRIMARY BILIARY CHOLANGITIS: RESPONDER ANALYSIS OF OVER 5 YEARS OF TREATMENT IN THE POISE TRIAL

Background

Obeticholic acid (OCA), a potent farnesoid X receptor agonist, is approved as second-line treatment for primary biliary cholangitis (PBC) in patients with an incomplete response or intolerance to ursodeoxycholic acid.

Aims

We evaluated the effect of OCA in PBC patients enrolled in the POISE trial, comparing those who did or did not achieve the POISE response criteria.

Methods

The phase 3, randomized, double-blind, 1-year POISE trial evaluated the efficacy and safety of OCA 5 and 10 mg vs placebo in patients with PBC; a 5-year open-label extension followed in which all patients received OCA. This analysis evaluated longer-term efficacy and safety in patients who achieved the POISE primary endpoint of alkaline phosphatase (ALP) <1.67 × upper limit of normal (ULN), total bilirubin <ULN, and ALP decrease >15% from baseline after 1 year of OCA and in patients who were incomplete responders.

Results

The analysis included 86 patients who achieved the POISE primary endpoint at year 1 of OCA treatment and 107 incomplete responders (mean baseline ALP, 268 vs 356 U/L, respectively; P<0.0001). Mean change from baseline in ALP at year 5 was –101 U/L for responders and –121 U/L for incomplete responders (P<0.0001; Figure). Median (Q1, Q3) baseline GLOBE 10-year risk of event scores were 16 (11, 23) for responders and 25 (15, 43) for incomplete responders. Change from baseline in median (Q1, Q3) GLOBE 10-year risk of event at year 1, which includes age and thus increases with time, was –2 (–4, 2) for responders and –2 (–6, 4) for incomplete responders; at year 5, these changes were 2 (–2, 7) and 4 (–4, 11), respectively. Median (Q1, Q3) baseline UK-PBC 10-year risk of event scores were 5 (3, 8) for responders and 8 (4, 16) for incomplete responders. Change from baseline in median (Q1, Q3) UK-PBC 10-year risk of event at year 1 was –1 (–3, 0.2) for responders and –1 (–3, 1) for incomplete responders; at year 5, these changes were –0.8 (–2, 0.2) and –0.05 (–2, 2), respectively. The most frequently reported AEs among responders and incomplete responders were pruritus (67%, 86%) and fatigue (35%, 31%).

Conclusions

OCA treatment improved key biochemical markers of PBC, regardless of achieving the POISE primary endpoint after 1 year of OCA treatment. Changes in biochemical parameters over time were often similar between groups.

Funding Agencies

Intercept Pharmaceuticals

COVID-19-Associated Carotid Atherothrombosis and Stroke

We present a radiology-pathology case series of 3 patients with coronavirus disease 2019 (COVID-19) with acute ischemic stroke due to fulminant carotid thrombosis overlying mild atherosclerotic plaque and propose a novel stroke mechanism: COVID-associated carotid atherothrombosis.

Effects of obeticholic acid on lipoprotein metabolism in healthy volunteers

The bile acid analogue obeticholic acid (OCA) is a selective farnesoid X receptor (FXR) agonist in development for treatment of several chronic liver diseases. FXR activation regulates lipoprotein homeostasis. The effects of OCA on cholesterol and lipoprotein metabolism in healthy individuals were assessed. Two phase I studies were conducted to evaluate the effects of repeated oral doses of 5, 10 or 25 mg OCA on lipid variables after 14 or 20 days of consecutive administration in 68 healthy adults. Changes in HDL and LDL cholesterol levels were examined, in addition to nuclear magnetic resonance analysis of particle sizes and sub-fraction concentrations. OCA elicited changes in circulating cholesterol and particle size of LDL and HDL. OCA decreased HDL cholesterol and increased LDL cholesterol, independently of dose. HDL particle concentrations declined as a result of a reduction in medium and small HDL. Total LDL particle concentrations increased because of an increase in large LDL particles. Changes in lipoprotein metabolism attributable to OCA in healthy individuals were found to be consistent with previously reported changes in patients receiving OCA with non-alcoholic fatty liver disease or non-alcoholic steatohepatitis.

Adaptive response to hypoxia and remote ischaemia pre-conditioning: a new hypoxia-inducible factors era in clinical medicine

Transient ischaemia leads to tolerance to subsequent protracted ischaemia. This 'ischaemia pre-conditioning' results from the induction of numerous protective genes, involved in cell metabolism, proliferation and survival, in antioxidant capacity, angiogenesis, vascular tone and erythropoiesis. Hypoxia-inducible factors (HIF) play a pivotal role in this transcriptional adaptive response. HIF prolyl hydroxylases (PHDs), serving as oxygen sensors, control HIFα degradation. HIF-mediated ischaemic pre-conditioning can be achieved with the administration of PHD inhibitors, with the attenuation of organ injury under various hypoxic and toxic insults. Clinical trials are currently under way, evaluating PHD inhibitors as inducers of erythropoietin. Once their safety is established, their potential use might be further tested in clinical trials in various forms of acute ischaemic and toxic organ damage. Repeated transient limb ischaemia was also found to attenuate ischaemic injury in remote organs. This 'remote ischaemic pre-conditioning' phenomenon (RIP) has been extensively studied recently in small clinical trials, preceding, or in parallel with an abrupt insult, such as myocardial infarction, cardiac surgery or radiocontrast administration. Initial results are promising, suggesting organ protection. Large-scale multi-centre studies are currently under way, evaluating the protective potential of RIP in cardiac surgery, in the management of myocardial infarction and in organ transplantation. The mechanisms of organ protection provided by RIP are poorly understood, but HIF seemingly play a role as well. Thus, Inhibition of HIF degradation with PHD inhibitors, as well as RIP (in part through HIF), might develop into novel clinical interventions in organ protection in the near future.

Mechanically Tunable Hollow Silica Ultrathin Nanoshells for Ultrasound Contrast Agents

Perfluoropentane (PFP) gas filled biodegradable iron-doped silica nanoshells have been demonstrated as long-lived ultrasound contrast agents. Nanoshells are synthesized by a sol-gel process with tetramethyl orthosilicate (TMOS) and iron ethoxide. Substituting a fraction of the TMOS with R-substituted trialkoxysilanes produces ultrathin nanoshells with varying shell thicknesses and morphologies composed of fused nanoflakes. The ultrathin nanoshells had continuous ultrasound Doppler imaging lifetimes exceeding 3 hours, were twice as bright using contrast specific imaging, and had decreased pressure thresholds compared to control nanoshells synthesized with just TMOS. Transmission electron microscopy (TEM) showed that the R-group substituted trialkoxysilanes could reduce the mechanically critical nanoshell layer to 1.4 nm. These ultrathin nanoshells have the mechanical behavior of weakly linked nanoflakes but the chemical stability of silica. The synthesis can be adapted for general fabrication of three-dimensional nanostructures composed of nanoflakes, which have thicknesses from 1.4-3.8 nm and diameters from 2-23 nm.

Neural HO-1/sterol interactions in vivo: implications for Alzheimer's disease

BACKGROUND

Up-regulation of heme oxygenase-1 (HO-1) and altered cholesterol (CH) metabolism are characteristic of Alzheimer-diseased (AD) neural tissues. We previously provided evidence of significant HO-1/sterol interactions in vitro (cultured rat astroglia) and in post-mortem human AD brain (Religious Orders Study).

METHODS

The current experiments were designed to further delineate these interactions in vivo by comparing the behavior of HO-1/sterol interactions in two mouse models; (1) a novel HO-1 transgenic mouse (GFAP.HMOX1) engineered to selectively express human HO-1 in the astrocytic compartment and (2) the previously described triple transgenic AD mouse (3xTg-AD). In samples of frontal cortex, total CH, CH precursors and relevant oxysterols were quantified by gas chromatography-mass spectrometry (GC-MS) and HO-1 protein expression was assessed by ELISA. The relationships of HO-1 expression to total CH, CH precursors and total oxysterols were determined for both mouse models using linear regression analysis.

RESULTS

HO-1 expression is increased in GFAP.HMOX1 mice relative to wild type and in 11-12-month-old 3xTg-AD mice (with AD-like phenotype) relative to control mice and 5-6-month-old 3xTg-AD mice (no AD-like phenotype). Total oxysterols significantly decreased as HO-1 expression increased in GFAP.HMOX1 mice expressing high levels of HO-1, whereas total oxysterols increased as HO-1 expression increased in aged 3xTg-AD mice. Total CH and total CH precursors increased as HO-1 protein expression increased in 11-12-month-old 3xTg-AD mice relative to 5-6-month old 3xTg-AD mice.

CONCLUSIONS

Our findings indicate a differential impact of HO-1 on patterns of brain sterol and redox homeostasis that is contingent on the presence or absence of AD-like neuropathology. These data provide fresh insight concerning the regulation of sterol homeostasis within the aging and degenerating CNS which may inform the development of novel therapeutic and preventive strategies for the management of AD and related conditions.

Sitagliptin reduces plaque macrophage content and stabilises arteriosclerotic lesions in Apoe (-/-) mice

AIMS/HYPOTHESIS

Inhibitors of dipeptidyl peptidase-IV (DPP-IV), such as sitagliptin, increase glucagon-like peptide-1 (GLP-1) concentrations and are current treatment options for patients with type 2 diabetes mellitus. As patients with diabetes exhibit a high risk of developing severe atherosclerosis, we investigated the effect of sitagliptin on atherogenesis in Apoe (-/-) mice.

METHODS

Apoe (-/-) mice were fed a high-fat diet and treated with either sitagliptin or placebo for 12 weeks. Plaque size and plaque composition were analysed using Oil Red O staining and immunohistochemistry. Furthermore, in vitro experiments with the modified Boyden chamber and with gelatine zymography were performed to analyse the effects of GLP-1 on isolated human monocyte migration and metalloproteinase-9 (MMP-9) release.

RESULTS

Treatment of Apoe (-/-) mice with sitagliptin significantly reduced plaque macrophage infiltration (the aortic root and aortic arch both showing a 67% decrease; p < 0.05) and plaque MMP-9 levels (aortic root showing a 69% and aortic arch a 58% reduction; both p < 0.01) compared with controls. Moreover, sitagliptin significantly increased plaque collagen content more than twofold (aortic root showing an increase of 58% and aortic arch an increase of 73%; both p < 0.05) compared with controls but did not change overall lesion size (8.1 ± 3.5% vs 5.1 ± 2.5% for sitagliptin vs controls; p=NS). In vitro, pretreatment of isolated human monocytes with GLP-1 significantly decreased cell migration induced by both monocyte chemotactic protein-1 and by the protein known as regulated on activation, normal T cell expressed and secreted (RANTES) in a concentration-dependent manner. Furthermore, GLP-1 significantly decreased MMP-9 release from isolated human monocyte-derived macrophages.

CONCLUSIONS/INTERPRETATION

Sitagliptin reduces plaque inflammation and increases plaque stability, potentially by GLP-1-mediated inhibition of chemokine-induced monocyte migration and macrophage MMP-9 release. The effects observed may provide potential mechanisms for how DPP-IV inhibitors could modulate vascular disease in high-risk patients with type 2 diabetes mellitus.

Diabetes technology and the human factor

When developing new technologies for human use the developer should take into consideration not only the efficacy and safety of the technology but also the desire and capabilities of the potential user. Any chronic disease is a challenge for both the patient and his/her caregivers. This statement is especially true in the case of patients with type 1 diabetes mellitus (T1DM) where adherence to therapy is crucial 24 hours a day 365 days a year. No vacation days are possible for the T1DM patient. It is therefore obvious why any new technology which is developed for helping patients cope with the disease should take into consideration the 'human factor' before, during and after the production process starts. There is no doubt that technology has changed the life of patients with T1DM in the last few decades, but despite the availability of new meters, new syringes, new sophisticated insulin pumps and continuous glucose sensors and communication tools, these technologies have not been well utilised by many patients. It is therefore important to understand why the technology is not always utilised and to find new ways to maximise use and benefits from the technology to as many patients as possible. The present chapter will review papers published in the last year where the patient's ability or willingness was an important factor in the success of the technology. We will try to understand why insulin pumps, glucose sensors and self-monitoring of blood glucose (SMBG) are not used enough or appropriately, whether there is a specific group that finds it more difficult than others to adopt new technologies and what can be done to overcome that issue. For this chapter we chose articles from a Public Medicine review of the literature related to human factors affecting the outcome of studies and of user acceptance of continuous glucose monitoring, insulin infusion pump therapy. We also searched the literature in the field of psychology in order to accurately define the problems that the users of technology are facing (such as adherence, quality of life, motivations, executive functioning etc.) Those articles that had the most important contributions to understanding human factors as well as those highlighting the interface between technology and psychology, were chosen for this review, with emphasis on articles that provide insight into future studies and acceptance of emerging technologies for glycemic control.

The media's perspectives of health care fraud and abuse--an objective assessment

The media make it seem that greedy health care professionals are perpetrating a widespread conspiracy to defraud the Medicare trust fund of billions of taxpayer dollars. However, the media often underreport another side to the health care fraud and abuse issue-the flawed, inordinately complex, and ill-equipped Medicare payment system itself. It is difficult to quantify the purported loss of billions of dollars to fraud or estimate the costs to the U.S. health care system of the advocated increased controls. However, this discussion serves to divert attention from key health care issues--the many Americans who are uninsured, underinsured, or lack access to care and the system's administrative complexities.

Effects of Dietary Restriction and Metal Supplementation on the Accumulation of Iron-Laden Glial Inclusions in the Aging Rat Hippocampus

The mechanisms responsible for the pathological deposition of iron and other redox-active metals in the aging and degenerating mammalian CNS remain poorly understood. We previously demonstrated that normal aging and pharmacological (oxidative) stressors promote the transformation of astroglial mitochondria to iron-laden, diaminobenzidine (DAB)-positive cytoplasmic inclusions in sub-cortical regions of the rat brain. In the current study, we demonstrate that (1) numbers of DAB-positive glial granules in the rat dorsal hippocampus, an area implicated in learning and memory, progressively increase between 3, 12 and 22 months of age; (2) dietary restriction (40%), a manipulation that attenuates many mammalian aging processes, has no effect on the age-related accumulation of these gliosomes in the rat hippocampus; and (3) the latter can be accelerated by dietary supplementation of iron and copper. Our data support the view that dietary exposure to iron and/or copper in adult life can impact the sequestration of redox-active metals in aging hippocampal astroglia.

Screening colonoscopy in the asymptomatic 50- to 59-year-old population

BACKGROUND

In an effort to decrease the death rate from colorectal cancer, a multitude of medical societies and task forces recommend routine screening for colorectal cancer beginning at age 50. Yet, there is no consensus as to the best and most cost-effective screening method. Medicare now pays for screening colonoscopies for its average risk beneficiaries [3]. Many insurance companies, however, will not cover this test in younger patients. We therefore reviewed our institution's colonoscopy experience with asymptomatic 50- to 59-year-olds, with negative fecal occult blood tests and negative family histories.

METHODS

Between January 1999 and January 2002, 4779 colonoscopies were performed at our institution. The charts for 619 persons 50-59 years of age were retrospectively reviewed, with 91 patients meeting the strict requirements of this study. We defined polyps with high-grade neoplasias as those with villous or tubulovillous components, and cancerous lesions included those with carcinoma in situ. The distal colon was defined as the rectum and sigmoid colon.

RESULTS

There was a 58% incidence of neoplastic polyps in this younger asymptomatic population. More than 4% of our subjects had high-grade neoplasias or cancerous lesions. In the absence of any distal findings, flexible sigmoidoscopy would have missed up to 38% of these polyps.

CONCLUSIONS

The findings generally support the recommendations by the American College of Gastroenterology for average-risk patients to preferentially undergo a screening colonoscopy at age 50 in lieu of other methods.

Role of heme oxygenase-1 in the biogenesis of corpora amylacea

Corpora amylacea (CA) are glycoproteinaceous inclusions that accumulate in the human brain during normal aging and to a greater extent in Alzheimer's disease. We previously demonstrated that, in cultured rat astroglia, cysteamine (CSH) upregulates heme oxygenase-1 (HO-1) and promotes the transformation of normal mitochondria into CA-like inclusions. In the current study, primary cultures of neonatal rat astroglia were exposed to 880 micro M CSH for three months in the presence or absence of dexamethasone, a suppressor of HO-1 gene transcription. Cells were double-labeled with periodic acid-Schiff reagent (PAS) and antisera against ubiquitin, HO-1, or a mitochondrial epitope. CA were quantified and their immunostaining characteristics analyzed using confocal microscopy. HO-1 immunofluorescence was more abundant in cultures exposed to CSH alone relative to untreated control cultures and cultures exposed to both CSH and dexamethasone. Mature CA appeared as large (5-50 microM), spherical or polygonal, intensely PAS-positive inclusions within glial cytoplasm or deposited extracellularly. The inclusions manifested intense rim and, less commonly, homogeneous or stippled patterns of immunoreactivity for ubiquitin, HO-1, and the mitochondrial marker. Monolayers exposed to CSH exhibited 660% more CA relative to untreated controls (P < 0.05). Numbers of CA in cultures exposed to CSH were diminished by co-administration of 50 microg/ml dexamethasone (P < 0.05 relative to CSH alone) or 100 microg/ml dexamethasone (P < 0.05 relative to CSH alone). Numbers of CA in cultures co-treated with CSH and 50 microg/ml dexamethasone or 100 microg/ml dexamethasone were not significantly different from untreated control values. Up-regulation of HO-1 may contribute to the formation of CA in aging astroglia.

Ambulatory surgery outcomes: a survey of office-based delivery

Due to a few well-publicized stories about patient injury and death, office-based ambulatory surgery has recently been thrust upon the forefront of current discussions about clinical outcomes. This has stimulated interest among ambulatory surgery stakeholders, including physicians, patients, and elected officials. An analysis of medical office-based surgical facilities in Florida indicates that office-based surgeons tend to work independently, with limited peer oversight, although as a whole, they professionally subscribe to a high level of ethical standards and offer patients an expected high quality level of clinical expertise. The results did not definitively indicate a relationship between unaccredited medical offices and unacceptable surgical procedures. The paper concludes by offering fifteen medical office standards that can aid in developing office surgery oversight policies.

Constructive engagement: an integrative method of involving students in the learning process

Providing a meaningful learning environment for each student represents a constant and ongoing challenge for faculty. This objective can be facilitated by active student participation in class interactions. The authors have developed the Constructive Engagement Method (CEM), an integrative method for actively involving students in the learning process. CEM permits students to hone interpersonal skills through the development of interrelated practical applications of critical listening and peer evaluation. The CEM approach introduces a method of student performance evaluation that has been judged as fair and equitable by almost all student participants. CEM fully involves all students, even in classes with very large enrollments. CEM as a teaching strategy utilizes a modified debate format that begins with a period of student preparation followed by a debate between two competing teams. The debate is followed by an evaluation period, during which the non-participating students practice the all-important task of determining the value of each team's investment in the process. CEM comprises five stages as follows: Phase 1--Preparation; Phase 2--Opening Statements; Phase 3--Intense Interaction; Phase 4--Closing Statements; and Phase 5--Evaluation. The CEM methodology has enjoyed strong support among graduate and undergraduate students.

Marketing in today's health care environment

The application of health care marketing is seen as a relatively recent phenomenon. Marketing is discussed as a sophisticated managerial tool that includes five critical components: product, price, place, promotion, and partners. The triumvirate of health care decision makers (i.e., patients, insurance organizations, and employers) are examined vis-à-vis these five components.

Proinflammatory cytokines promote glial heme oxygenase-1 expression and mitochondrial iron deposition: implications for multiple sclerosis

Proinflammatory cytokines, pathological iron deposition, and oxidative stress have been implicated in the pathogenesis of multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE). HO-1 mRNA levels and mitochondrial uptake of [(55)Fe]Cl(3)-derived iron were measured in rat astroglial cultures exposed to interleukin-1beta (IL-1beta) or tumor necrosis factor-alpha (TNF-alpha) alone or in combination with the heme oxygenase-1 (HO-1) inhibitors, tin mesoporphyrin (SnMP) or dexamthasone (DEX), or interferon beta1b (INF-beta). HO-1 expression in astrocytes was evaluated by immunohistochemical staining of spinal cord tissue derived from MS and control subjects. IL-1beta or TNF-alpha promoted sequestration of non-transferrin-derived (55)Fe by astroglial mitochondria. HO-1 inhibitors, mitochondrial permeability transition pore (MTP) blockers and antioxidants significantly attenuated cytokine-related mitochondrial iron sequestration in these cells. IFN-beta decreased HO-1 expression and mitochondrial iron sequestration in IL-1beta- and TNF-alpha-challenged astroglia. The percentage of astrocytes coexpressing HO-1 in affected spinal cord from MS patients (57.3% +/- 12.8%) was significantly greater (p < 0.05) than in normal spinal cord derived from controls subjects (15.4% +/- 8.4%). HO-1 is over-expressed in MS spinal cord astroglia and may promote mitochondrial iron deposition in MS plaques. In MS, IFN-beta may attenuate glial HO-1 gene induction and aberrant mitochondrial iron deposition accruing from exposure to proinflammatory cytokines.

An RBRVS Approach to Financial Analysis in Health Care Organizations

Resource-based relative value scales (RBRVS) have altered the outpatient reimbursement system of America's health care system and established a method of standardization whereby the efficiency of medical practices of varying size and complexity can be compared using a standard (the cost conversion factor) for analysis. This article compares the utility of RBRVS with earlier systems of reimbursement and concludes with a brief speculative assertion regarding the emergence of the next stage of ambulatory care reimbursements through ambulatory payment classifications.

Stakeholder management in a hyperturbulent health care environment

The fast-paced change in today's health care environment presents an unsettling organizational climate within which managers must make important decisions that affect key stakeholders. This ambiguousness has resulted in the proliferation of health care organizations that are bundling together to find a sense of environmental stability in which they can achieve common goals. This means that health care managers need to view stakeholders as parts of larger bundles rather than only as individual organizations.

Medical care program compliance--a year 2000 recipient perspective of Medicare claims

This article provides a brief assessment of patient and provider views and concerns regarding reimbursements under the Medicare program. Specifically targeted is the payment of pharmaceutical claims. Also addressed are the ongoing and respective responsibilities of individual clinical providers, associated hospitals, and recipients of care. A summation of significant results of direct interviews and follow-up discussions with 10 Medicare recipients also is provided.

Employee assistance programs: a prevention and treatment prescription for problems in health care organizations

Employee assistance programs (EAPs) are a by-product of community-based mental health services--making behavioral care available in an outpatient ambulatory setting. This manuscript outlines an application of EAPs to health care workers and the multiplicity of challenges they must confront and describes the importance of timely intervention and support.

Professional liability insurance for health care organizations--several significant considerations

The purchase of professional liability insurance coverage represents one of the more important financial and administrative decisions in terms of managing a health services organization. This manuscript outlines a decision process for evaluating and determining the most viable option(s). Also addressed are some significant caveats in assessing the strengths and weaknesses of various coverage options.

Objective employee assessments--establishing a balance among supervisory evaluations

Objectivity, predictability, and consistency in a supervisor represent character traits that are recognized and appreciated by employees. When evaluating employees, these attributes assume added significance. This article outlines a methodology, the Quartile Rating Index (QRI), for objectively addressing disparities in the rating habits of various supervisors when evaluating the work of employees under their supervision.

Pre-employment decision trees: job applicant self-election

Human resource administration is an instrumental factor in determining the degree of organizational success. This is especially true in the labor-intensive health care industry, which uses teams of health care providers to deliver treatment and services. A key function of human resource management is recruiting, since the quality of health care treatment is positively correlated with the quality of employees. Therefore, the recruiting function can consume a disproportionate share of organizational resources. This article discusses how managers can reduce the amount of resources spent dealing with inappropriate job applicants by using the Pre-Employment Decision Tree, which directs pre-applicants to self-elect to apply or not apply, given the degree of fit between the pre-applicant and the organization.

Pathologists' roles in clinical utilization management. A financing model for managed care

In ancillary or laboratory utilization management, the roles of pathologists have not been explored fully in managed care systems. Two possible reasons may account for this: pathologists' potential contributions have not been defined clearly, and effective measurement of and reasonable compensation for the pathologist's contribution remains vague. The responsibilities of pathologists in clinical practice may include clinical pathology and laboratory services (which have long been well-defined and are compensated according to a resource-based relative value system-based coding system), laboratory administration, clinical utilization management, and clinical research. Although laboratory administration services have been compensated with mechanisms such as percentage of total service revenue or fixed salary, the involvement of pathologists seems less today than in the past, owing to increased clinical workload and time constraints in an expanding managed care environment, especially in community hospital settings. The lack of financial incentives or appropriate compensation mechanisms for the services likely accounts for the current situation. Furthermore, the importance of pathologist-driven utilization management in laboratory services lacks recognition among hospital administrators, managed care executives, and pathologists themselves, despite its potential benefits for reducing cost and enhancing quality of care. We propose a financial compensation model for such services and summarize its advantages.

Health care alliances and alternative dispute resolution: managing trust and conflict

The U.S. health care industry has entered an unprecedented era of alliance activity. These alliances involve medical groups and hospitals, as well as many of the newer health care entities such as managed care organizations and integrated delivery systems. The increase in organizational collaboration has resulted in an increase in organizational conflict. Alternative dispute resolution (ADR) techniques can serve as a valuable tool for mitigating this type of conflict. The role of ADR is to refocus partners' attentions away from an adversarial posture and toward a complementary existence. This will permit the partners to realize the intended outcomes of the collaboration.

Managed care evolution--where did it come from and where is it going?

The emergence and development of managed care has been and will continue to be a major force in America's health care delivery system. Specifically reviewed in this article are those legislative initiatives that contributed to the formation of this system of reimbursement and utilization management. Also addressed are responsibilities that can be ascribed to all stakeholders in necessitating this system as well as the adjustments required to make the system more responsive to the needs of higher-risk populations. This article concludes with a series of recommended actions that will be required of all individual citizens in assuring the future economic viability of this nation's health care programs.

Behavioral contract management: a prescription for employee and patient compliance

A health care manager's responsibilities of offering efficient service while ensuring effective outcomes is hampered frequently by both employees and patients whose unacceptable behaviors are detrimental to one or both of these mandates. Behavioral contracts offer a structured method that allows both patients and employees to self-actualize the required behavioral changes. When noncompliant behavior is diagnosed, behavioral contracts are the prescription that places the responsibility for corrective action squarely on the shoulders of the offending individual.

Alternative dispute resolution programs in health care: a study of organizational utilization

The hyperturbulence in today's health care environment acts as a primer that escalates the frequency and severity of business conflicts. Several alternative dispute resolution (ADR) programs are described, with ADR suggested as a viable approach in assisting organizations in resolving conflicts. The data indicate that all of the health care organizations surveyed utilize some form of ADR to resolve conflict. The most common conflict resolution objective found is win/win, and respondents felt that ADR effectively met intended objectives. While the data gathered for this study are from a limited geographic region in Central Florida, the results can likely be generalized to many socially and ethnically diverse regions of the country.

Alleged abuses in health care in the 1990s: a critical assessment of causation and corrections

Allegations of fraud in the health care field are being directed at a multitude of providers. This article, which follows an earlier one published in The Health Care Supervisor (16:2), seeks to address three questions surrounding the issue: what manner of fraud has occurred in the health care industry; which methods are being employed by our nation's legal system to address the problem, and, in the growing number of instances in which culpability is unclear, how alternative dispute resolution can be utilized to both address and resolve problems that arise.

Neural heme oxygenase-1 expression in idiopathic Parkinson's disease

Heme oxygenase-1 is a cellular stress protein expressed in brain and other tissues in response to oxidative challenge and other noxious stimuli. In the present study, immunohistochemistry was used to assess HO-1 expression in various postmortem human brain specimens derived from PD and control subjects. In the substantia nigra of both PD and control specimens, moderate HO-1 immunoreactivity was consistently observed in neuromelanin-containing (dopaminergic) neurons. Lewy bodies in PD nigra neurons exhibited intense HO-1 immunostaining in their peripheries. In both PD and control specimens, neuronal HO-1 staining was faint or nondetectable in the other brain regions surveyed. The fraction of GFAP-positive astroglia expressing HO-1 in PD substantia nigra (77.1 +/- 12.3) was significantly greater than that observed in the substantia nigra of control subjects (18.7 +/- 7.1; P = 0.0015). In the other regions examined, percentages of GFAP-positive astroglia coexpressing HO-1 were relatively low and did not differ significantly (P > 0.05) between control and PD specimens. Upregulation of HO-1 in the substantia nigra of PD subjects supports the view that the affected tissue is experiencing chronic oxidative stress. In addition, excessive cellular levels of heme-derived free iron and carbon monoxide resulting from HO-1 overactivity may contribute to the pathogenesis of PD.

Alternative dispute resolution: a conflict management tool in health care

This article focuses on methods of resolving conflict either within or between health care organizations using an alternative dispute resolution (ADR) strategy. After identifying the principal sources of contemporary disagreements within health services settings, the authors describe the basis of ADR. This is followed by a discussion of some common obstacles to settling a dispute. The principal communication guidelines and stages of a mediation session are presented. An alternative dispute resolution framework is proposed that includes an Office of Dispute Resolution (ODR). Also provided is a series of attributes that together comprise the core of mediation as a discipline.

Responsibilities of health care supervisors and employees: seven recommended tenets

This article proposes seven tenets of responsibility for health care managers and the employees under their supervision. The damaging consequences of workplace misbehavior are chronicled, and the importance of establishing forthright supervisor/employee relationships is documented. Seven recommended tenets of responsibility are proposed as guideposts for managers and employees alike.

Estrogen induction of glial heat shock proteins: implications for hypothalamic aging

In the aging mammalian hypothalamus, a unique subpopulation of glial cells accumulates peroxidase-positive cytoplasmic inclusions distinct from lipofuscin. In adult rodents, this senescence-dependent glial granulation is accelerated by administration of estradiol valerate. In the present study, brain sections derived from male rats given 3 monthly intramuscular injections of estradiol valerate (0.2 mg or 2.0 mg) were immunostained for heat shock proteins and glial fibrillary acidic protein to determine whether a glial stress response is implicated in estrogen-induced granulation. Our findings indicate that estrogen elicits a heat shock response and subsequent granulation in astrocytes residing in estradiol receptor-rich brain regions including the arcuate nucleus and the wall surrounding the third ventricle but not in estradiol receptor-deficient regions such as the striatum and corpus callosum. The heat shock proteins induced by estrogen, namely, the 27, 72, and 90 kDa stress proteins, are upregulated in astrocytes in response to oxidative challenge supporting our hypothesis that estrogen mediates senescent changes in the rodent hypothalamus through oxidative mechanisms.