Managed Care for Elderly People: A Compendium of Findings

Although managed care seems to serve well the in terests of non-elderly enrollees and their payers, elderly people face more risks. Chronic conditions, multiple prob lems, and more limited resources make them more vul nerable, whereas multiple payer sources make them more complicated to cover. This synthesis of managed care de livered in Medicare and Medicaid demonstration projects serving elderly beneficiaries shows that managed care plans either select or attract enrollees who suffer fewer frailties than those served in fee-for-service settings, ex hibit reluctance to enter rural markets, provide a broad range of elderly-specific services, offer more compre hensive coverage and services, and result in greater per ceived access problems, particularly for vulnerable subgroups. Plans operate more cheaply by using fewer resources, even after adjusting for case mix differences. Managed care enrollees tend to be more satisfied with financial and coverage aspects, whereas fee-for-service enrollees report higher satisfaction on other dimensions. In acute care settings, process of care findings were mixed, whereas clinical and self-reported outcome indi cators were no better and in some instances worse in managed care. Long-term care enrollees, in the few stud ies reported, consistently faired worse in both the processes and outcomes of care. These findings suggest that further research on the effects of managed care in its rapidly changing incarnations is needed, particularly with respect to how to improve the quality of acute and long-term care delivered to elderly people and the proper role of government and other key actors in the health care system.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66514/2/10.1177_106286069801300304.pd

Human polyomavirus JC replication and non-coding control region analysis in multiple sclerosis patients under natalizumab treatment

The occurrence of progressive multifocal leukoencephalopathy (PML) caused by Polyomavirus JC (JCV) in patients affected by multiple sclerosis (MS) treated with natalizumab has raised concerns about the safety of this drug. In this study, we performed a JCV-specific quantitative PCR on biological samples collected at the enrollment (t0) and every 4 months (t1, t2, t3) for 1 year and in the second year of treatment (t4, t5). Then, specific PCR products for JCV NCCR and VP1 sequences were analyzed. Moreover, JCV-specific antibodies were assessed by STRATIFY JCV® in serum at t0 and t3. After 1 year of natalizumab treatment, results showed a significant association between patients with JC viruria and positive STRATIFY JCV® with respect to those patients with no JCV-specific antibodies (p=0.0006). Moreover, at t4 the JC viremia was prevalently observed rather than JC viruria (p=0.04). Regarding NCCR sequence analysis, in peripheral blood mononuclear cells of patients STRATIFY JCV® positive at t3 and treated with 12 natalizumab infusions, NCCR sequencing revealed the presence of rearranged sequences. Finally, VP1 sequence analysis showed the prevalence of the genotypes 1A, 1B and 4. In conclusion, testing JC viruria seems to be useful to identify patients who harbor JCV with an undetectable specific humoral immune response. It may also be important to study the JCV NCCR rearrangements since they could generate neuro-invasive viral variants increasing the risk of PML onset

Fluid flow through the sedimentary cover in northern Switzerland recorded by calcite-celestite veins (Oftringen borehole, Olten)

Abundant veins filled by calcite, celestite and pyrite were found in the core of a 719 m deep borehole drilled in Oftringen near Olten, located in the north-western Molasse basin, close to the thrust of the Folded Jura. Host rocks are calcareous marl, argillaceous limestone and limestone of the Dogger and Malm. The delta O-18 values of vein calcite are lower than in host rock carbonate and, together with microthermometric data from fluid inclusions in vein calcite, indicate precipitation from a seawater-dominated fluid at average temperatures of 56-68A degrees C. Such temperatures were reached at the time of maximum burial of the sedimentary pile in the late Miocene. The depth profile of delta C-13 and Sr-87/Sr-86 values and Sr content of both whole-rock carbonate and vein calcite show marked trends towards negative delta C-13, high Sr-87/Sr-86, and low Sr content in the uppermost 50-150 m of the Jurassic profile (upper Oxfordian). The Sr-87/Sr-86 of vein minerals is generally higher than that of host rock carbonate, up to very high values corresponding to Burdigalian seawater (Upper Marine Molasse, Miocene), which represents the last marine incursion in the region. No evidence for internally derived radiogenic Sr (clay minerals) has been found and so an external source is required. S and O isotope composition of vein celestite and pyrite can be explained by bacterial reduction of Miocene seawater sulphate. The available data set suggests the vein mineralization precipitated from descending Burdigalian seawater and not from a fluid originating in the underlying Triassic evaporites