Determining the cost of obesity and its common comorbidities from a commercial claims database.

What is already known about this subject Obesity is highly prevalent and costly in the US. Obesity often leads to other comorbid conditions, including diabetes and hypertension. Obesity prevention efforts can reduce healthcare costs. What this study adds Obesity combined with other comorbidities significantly increases healthcare costs per patient visit. The combination of obesity and depression exacerbates costs. The most expensive series of chronic conditions in this study included obesity, diabetes, hypertension and depression. Our objectives were to determine payments made by commercial healthcare providers in the US for adults diagnosed with obesity, and those comorbid with any combination of selected chronic conditions. Using a commercial claims and encounters database (n = 3,562,717), we evaluated an adult study population that had at least one in-patient visit, outpatient visit or emergency department visit, and received a primary or secondary diagnosis of obesity. Persons were categorized by one or more comorbid diagnoses for diabetes mellitus, hypertension, depression or congestive heart failure. We adjusted for age and gender, and calculated the mean total net expenditures (in 2012, $US) for each combination of comorbid conditions based on individual visits to an in-patient, outpatient or emergency department setting. Among 50,717 claims with diagnosis of obesity, the mean net expenditure for in-patient and outpatient services was $ 1907 per patient per visit. Persons diagnosed with obesity and other comorbidities observed an increase in total net expenditures. Obesity and congestive heart failure observed the highest increase among single comorbidities at $ 5275. For persons with obesity and two other comorbidities, diabetes mellitus and depression was the highest at $ 15,226. The most expensive condition was obesity, diabetes mellitus, hypertension and depression at $ 15,733. Compared with average medical claims, persons diagnosed with obesity and other common chronic conditions experience significant increases in medical costs. These costs are often driven higher by time spent as in-patients. By controlling and reducing the prevalence of obesity, we may see significant decreases in medical expenditures.

Ketamine anesthesia during the first week of life can cause long-lasting cognitive deficits in rhesus monkeys.

Previously our laboratory has shown that ketamine exposure (24h of clinically relevant anesthesia) causes significant increases in neuronal cell death in perinatal rhesus monkeys. Sensitivity to this ketamine-induced neurotoxicity was observed on gestational days 120-123 (in utero exposure via maternal anesthesia) and on postnatal days (PNDs) 5-6, but not on PNDs 35-37. In the present study, six monkeys were exposed on PND 5 or 6 to intravenous ketamine anesthesia to maintain a light surgical plane for 24h and six control animals were unexposed. At 7 months of age all animals were weaned and began training to perform a series of cognitive function tasks as part of the National Center for Toxicological Research (NCTR) Operant Test Battery (OTB). The OTB tasks used here included those for assessing aspects of learning, motivation, color discrimination, and short-term memory. Subjects responded for banana-flavored food pellets by pressing response levers and press-plates during daily (M-F) test sessions (50 min) and were assigned training scores based upon their individual performance. As reported earlier (Paule et al., 2009) beginning around 10 months of age, control animals significantly outperformed (had higher training scores than) ketamine-exposed animals for approximately the next 10 months. For animals now over 3 and one-half years of age, the cognitive impairments continue to manifest in the ketamine-exposed group as poorer performance in the OTB learning and color and position discrimination tasks, as deficits in accuracy of task performance, but also in response speed. There are also apparent differences in the motivation of these animals which may be impacting OTB performance. These observations demonstrate that a single 24-h episode of ketamine anesthesia, occurring during a sensitive period of brain development, results in very long-lasting deficits in brain function in primates and provide proof-of-concept that general anesthesia during critical periods of brain development can result in subsequent functional deficits. Supported by NICHD, CDER/FDA and NCTR/FDA.

The effects of chronic methylphenidate administration on operant test battery performance in juvenile rhesus monkeys.

Methylphenidate (MPH) is an amphetamine derivative widely prescribed for the treatment of attention deficit-hyperactivity disorder. Recent concern over its genotoxic potential in children [11] spurred a study on the effects of chronic MPH treatment in a nonhuman primate population and the studies reported here were conducted in conjunction with that study in the same animals. Here, the focus was on the ability of juvenile rhesus monkeys to learn how to perform a battery of operant behavioral tasks while being treated chronically with MPH. Performance of the National Center for Toxicological Research (NCTR) Operant Test Battery (OTB) was used to quantify the learning of tasks thought to model specific aspects of cognitive function including learning, motivation, color and position discrimination, and short-term memory. The OTB tasks designed to assess these specific behaviors included Incremental Repeated Acquisition (IRA), Progressive Ratio (PR), Conditioned Position Responding (CPR), and Delayed Matching-to-Sample (DMTS), respectively. Juvenile males (n=10/group) pressed levers and press-plates for banana-flavored food pellets. Subjects were treated orally, twice a day, five days per week (M-F) for 66 weeks with escalating doses (0.15 mg/kg initially, increased to 2.5 mg/kg for the low dose group and to 12.5 mg/kg for the high dose group) and tested in OTB tasks 30 to 60 min after the morning dose. The findings indicate that MPH at doses up to 2.5 mg/kg twice per day were well tolerated (performance was no different than controls) but at doses of 12.5 mg/kg twice per day there was a significant decrement in OTB performance, characterized by decreases in both percent task completed and response rates for all tasks. These effects of MPH seem primarily due to decreases in motivation to perform for food, which is not surprising given the well known appetite suppressing effects of amphetamine-like stimulants. Thus, the current data do not strongly suggest cognitive impairments following chronic MPH administration.

Effect of chronic MK-801 and/or phenytoin on the acquisition of complex behaviors in rats.

The purpose of the present experiment was to assess the effects of chronic MK-801 (an N-methyl-D-aspartate receptor antagonist) and/or phenytoin (a sodium channel blocker) treatment on behavioral acquisition and performance in rats. Learning, audio/visual discrimination and motivation were modeled using incremental repeated acquisition (IRA), audio/visual discrimination (AVD) and progressive ratio (PR) tasks, respectively. MK-801 and/or phenytoin were administered daily, 7 days/week by orogastric gavage beginning just after weaning on postnatal day (PND) 23 and continuing until PND 306. Monday through Friday behavioral assessments began on PND 27 and continued until PND 430. Throughout treatment, subjects in the high dose MK-801 (1.0 mg/kg/day) and the high dose drug combination (1.0 mg/kg/day MK-801+150 mg/kg/day phenytoin) groups exhibited decreased body weight gains compared to control subjects. For these two affected groups, response rates were also decreased in all tasks. Task acquisition, as evidenced by an increase in response accuracy, was decreased for both these groups in the AVD task, but only for the high dose MK-801 group in the IRA task. The data suggest that chronic MK-801 treatment adversely affects the acquisition of IRA and AVD task performance and that the inclusion of phenytoin in the MK-801 dosing regimen blocks some of the adverse effects of chronic MK-801 treatment on IRA task acquisition. These findings are in marked contrast with those observed in nonhuman primates and suggest important species differences associated with chronic exposure to compounds that block NMDA receptors and/or sodium channels.

Beamline Performance Simulations for the Fundamental Neutron Physics Beamline at the Spallation Neutron Source.

Monte Carlo simulations are being performed to design and characterize the neutron optics components for the two fundamental neutron physics beamlines at the Spallation Neutron Source. Optimization of the cold beamline includes characterization of the guides and benders, the neutron transmission through the 0.89 nm monochromator, and the expected performance of the four time-of-flight choppers. The locations and opening angles of the choppers have been studied using a simple spreadsheet-based analysis that was developed for other SNS chopper instruments. The spreadsheet parameters are then optimized using Monte Carlo techniques to obtain the results presented in this paper. Optimization of the 0.89 nm beamline includes characterizing the double crystal monochromator and the downstream guides. The simulations continue to be refined as components are ordered and their exact size and performance specifications are determined.

Assessing the potential toxicity of MK-801 and remacemide: chronic exposure in juvenile rhesus monkeys.

The present experiment examined the effects of chronic exposure to either 0.1 or 1.0 mg/kg MK-801 [a selective N-methyl-D-aspartate (NMDA) receptor antagonist] or 20.0 or 50.0 mg/kg remacemide (an NMDA receptor antagonist which also blocks fast sodium channels) in juvenile rhesus monkeys. Endpoints were monitored to provide a general index of subjects' health and included measures of clinical chemistry, hematology, ophthalmology, spontaneous home-cage behavior, and peak drug plasma levels. In general, both drugs were well tolerated and produced no treatment-related effects during 2 years of dosing and assessment. Periodic plasma drug level determinations provided limited evidence that both compounds may induce their own metabolism. The present results contrast sharply with previously reported effects of long-lasting impairments in the acquisition of incremental learning and in the development of color and position discrimination in these same subjects. These observations highlight the importance of collecting a broad range of toxicology data, including tests of cognitive function, to make comprehensive assessments of new drug safety. In the present case, the less obvious effects of these drugs on cognition defined the toxicologic response.

Differential effects of two NMDA receptor antagonists on cognitive-behavioral development in nonhuman primates I.

The present experiment examined effects of chronic exposure to remacemide (an N-methyl-D-aspartate [NMDA] antagonist which also blocks fast sodium channels) or MK-801 (which blocks NMDA receptors, exclusively) on learning and motivation in young rhesus monkeys. Remacemide (20 or 50 mg/kg/day) or MK-801 (0.1 or 1.0 mg/kg/day) was administered every day to separate groups of animals via orogastric gavage for up to 2 years. Immediately prior to dosing, 5 days per week (M--F), throughout the 2-year dosing period, an incremental repeated acquisition (IRA) task was used to assess learning and a progressive ratio (PR) task was used to assess motivation. The results indicate an effect of 50 mg/kg/day remacemide to impair learning (IRA) which persisted even after drug treatment was discontinued. MK-801 had no effect on learning but transiently increased motivation. Because the effects of remacemide occurred independently of changes in motivation or response rates, they are likely due to specific cognitive impairments and are not due to an inability of subjects to fulfill the motoric requirements of the task. The fact that MK-801 did not alter learning suggests that NMDA antagonism alone may be insufficient to produce learning deficits in young monkeys and that such deficits may rely on the ancillary blockade of fast sodium channels.

Differential effects of two NMDA receptor antagonists on cognitive--behavioral performance in young nonhuman primates II.

The present experiment examined the effects of chronic exposure to remacemide (an NMDA antagonist that also blocks fast sodium channels) or MK-801 (which blocks NMDA receptors more selectively) on the acquisition of color and position discrimination and short-term memory behavior in juvenile rhesus monkeys. Throughout the 2-year dosing period, a conditioned position responding (CPR) task was used to assess color and position discrimination and a delayed matching-to-sample (DMTS) task was used to assess memory. Chronic exposure to high doses of either drug delayed the acquisition of accurate color and position discrimination without altering response rates. In the case of MK-801, these effects abated within 6 months of the start of treatment. In the case of remacemide, the effects persisted for 17 months of dosing. Neither compound significantly altered performance of the short-term memory task at any time point or at any dose tested. The fact that the effects of remacemide on behavioral performance were more persistent than those seen for MK-801 suggests that tolerance may develop to the behavioral effects of MK-801, which does not develop to the effects of remacemide. Alternatively, these results may suggest that the concurrent antagonism of NMDA receptors and fast sodium channels may have more profound consequences for behavior than does the antagonism of NMDA receptors alone.

Neuropathic pain in the cancer patient.

Cancer presents itself in numerous ways, adding to the complexity of any pain syndrome with which it is associated. Neuropathic pain, unlike many other pain syndromes, is difficult to treat even in the absence of cancer. The combination results in a heterogeneous group of patients with a complex set of symptoms. This makes the assessment of pain, classification of syndromes, and clinical study a challenge. If the disease is nonprogressive, general principles of care are essentially the same as in those without cancer. In patients with progressive disease and more refractory painful conditions, spinal anesthetic and neurosurgical therapies must often be considered. Under such circumstances, caregivers are forced to carefully balance uncertain benefits and risks, often without the luxury of time. More careful observation and controlled trials in these patients help facilitate this challenging process.

Commissural myelotomy for intractable cancer pain: report of two cases.

PATIENTS: We describe two patients with cancer-related low back and bilateral lower extremity pain that failed pharmacologic treatment. RESULTS: In both cases, commissural myelotomy provided significant pain relief. The role of myelotomy in the management of cancer pain is discussed.

The effect of chronic cocaine exposure during pregnancy on the acquisition of operant behaviors by rhesus monkey offspring.

To explore possible long-term effects of gestational cocaine exposure in a nonhuman primate model, pregnant rhesus monkeys were treated from about 1 month of gestation until term with either 0 (N = 3), 0.3 (N = 3), 1.0 (N = 3), or escalating doses up to 8.5 (N = 3) mg/kg (IM), three times per day, 5 consecutive days per week. Despite these differences in cocaine exposure, the experimental groups did not differ significantly with respect to the postnatal growth of offspring over an 18-month period following birth. Beginning at 6 months of age, the behavior of offspring was monitored using an operant test battery that included five food-reinforced tasks designed to model aspects of learning, color and position discrimination, time estimation, short-term memory and attention, and motivation. Although the acquisition of each operant behavior by offspring progressed significantly during training between 6 and 18 months of age, this acquisition was not differentially affected by gestational cocaine exposure. It was concluded that, in a rhesus monkey model, chronic cocaine exposure during pregnancy had no significant effect on the offsprings' acquisition of operant behaviors.

Acute behavioral effects of phencyclidine on rhesus monkey performance in an operant test battery.

The effects of phencyclidine (PCP; a noncompetitive NMDA antagonist) were assessed in rhesus monkeys using performance in an operant test battery (OTB) consisting of five food-reinforced tasks thought to engender responses dependent upon aspects of time estimation, short-term memory, motivation, learning, and color and position discrimination. End-points included percent task completed (PTC), response rate or latency, and response accuracy. Testing occurred 15 min after IV injections of PCP (0.00, 0.003, 0.01, 0.03, 0.1, 0.13, 0.18, and 0.3 mg/kg). PCP disrupted performance of all tasks at 0.30 mg/kg. PTC was significantly decreased in the time estimation, motivation, and learning tasks at doses > or = 0.13 mg/kg. PTC for the short-term memory and color and position discrimination tasks was significantly decreased at 0.18 mg/kg and above. Response rate was significantly decreased at 0.13 mg/kg and above in the motivation and learning tasks and at 0.18 mg/kg and above in the time estimation, short-term memory, and color and position discrimination tasks. Response accuracy was significantly decreased in the time estimation, short-term memory, and learning tasks at doses > or = 0.13 mg/kg, while accuracy in the color and position discrimination task was decreased only at 0.30 mg/kg. PCP's effects on OTB performance were generally nonspecific, in that the time estimation, short-term memory, learning, and motivation tasks were all equally sensitive, with the color and position discrimination task being the least sensitive. These results are different than those obtained from earlier studies on the effects of MK-801, a more selective noncompetitive NMDA antagonist.

Behavioral and neurochemical effects of chronic methylenedioxymethamphetamine (MDMA) treatment in rhesus monkeys.

Effects of chronic treatment with the putative serotonergic neurotoxicant MDMA were assessed in rhesus macaques using behavior in an operant test battery (OTB) designed to model aspects of time estimation, short-term memory, motivation, learning, and color and position discrimination. After an initial acute dose-response assessment, escalating doses of MDMA (0.10-20.0 mg/kg, im, twice daily, for 14 consecutive days at each dose) were administered, followed by three additional acute dose-response assessments. In general, tolerance to MDMA's acute effects was evident in all OTB tasks by the second week of repeated exposure to each individual MDMA dose and as doses escalated. Baseline OTB performance after chronic treatment was not significantly altered. Residual behavioral tolerance to MDMA's acute effects, however, was evident in all OTB tasks but was least pronounced in the motivation task. Monkeys were sacrificed (21 months after chronic treatment) and brains were dissected into several regions for neurochemical analyses. Serotonin (5-HT), 5-hydroxyindoleacetic acid (5-HIAA), dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), and homovanillic acid (HVA) were analyzed via HPLC. Although MDMA-treated monkeys tended to have lower 5-HT concentrations in the frontal cortex, chronic MDMA treatment had no significant effects on 5-HT concentrations in any brain area sampled. Hippocampal 5-HIAA concentration, 5-HT uptake sites, and turnover of 5-HT of MDMA-treated monkeys were significantly lower than control values. DA concentrations in the CN of MDMA-treated monkeys were significantly greater than control values. No significant effects on DA concentrations were noted in any other brain area sampled. The absence of significant decreases in 5-HT and the general increase in DA concentrations are dissimilar to neurochemical effects reported after a short course of MDMA treatment at relatively high doses. These data suggest that chronic administration of gradually increasing doses of MDMA results in long-lasting tolerance to the drugs acute effects on the complex brain functions modeled in the OTB. It is uncertain, however, if such tolerance is related to the observed decreases in uptake sites and turnover of 5-HT in the hippocampus of these monkeys.

Prenatal ethanol exposure in rats: long-lasting effects on learning.

Pregnant Sprague-Dawley rats were fed a liquid diet containing either 0% (group C), 18% (group L), or 36% (group H) ethanol-derived calories (EDC) from gestational day 1 to 20. Male offspring were assessed under a conditioned taste aversion paradigm (PND 35-45), in a complex maze (PND 68-80), and for operant behavior (temporal response differentiation and motivation to work for food, PND 140-198). Although conditioned taste aversion was fully acquired by all groups, retention of the conditioned taste aversion response was impaired in group H animals. Importantly, deficits in the acquisition of timing behavior were found in group H (group L not tested), confirming that this operant task is quite sensitive in detecting prenatal drug effects and demonstrating that neurological effects of prenatal ethanol exposure persist into late adulthood.

Acute effects of methylenedioxymethamphetamine (MDMA) on several complex brain functions in monkeys.

The effects of MDMA were assessed in rhesus macaques using behavior in an operant test battery (OTB) consisting of five food-reinforced tasks designed to model aspects of time estimation, short-term memory, and attention, motivation, learning, and color and position discrimination. Testing occurred 30 min after intramuscular, injections of MDMA (0.0, 0.1, 0.3, and 1.0 mg/kg). The behavioral endpoints monitored included percent task completed, response rate or latency, and response accuracy. Percent task completed was significantly decreased in the time estimation, learning, and motivation tasks at 1.0 mg/kg as compared to saline controls. Response accuracies in the time estimation and learning tasks were also decreased at 1.0 mg/kg. Response rate was decreased at 1.0 mg/kg in the motivation task but was not significantly affected in any other tasks. No behavioral endpoints were significantly affected in the short-term memory and attention and color and position discrimination tasks at any dose tested. Results indicate that time estimation, motivation, and learning are more sensitive to the acute effects of MDMA than are short-term memory and attention and color and position discrimination.

The interpretation of pain relief and sensory changes following sympathetic blockade.

A comparative study of the effects of sympathetic blockade by stellate ganglion block (SGB) and intravenous phentolamine infusion (PhI) was carried out in 24 patients with presumed sympathetically maintained pain of an upper extremity. A total of 15 SGBs and 16 PhIs were performed, with seven patients undergoing both procedures. All patients developed a Horner's syndrome with SGB and nasal stuffiness and cardiovascular changes with PhI. Similar pain relief was obtained with SGB and PhI in six of the seven who underwent both procedures. Pre-procedure patient characteristics including age, sex, duration of pain, historical and physical examination features suggestive of the reflex sympathetic dystrophy syndrome, and sensory disturbances such as allodynia and hyperpathia did not predict pain relief from either procedure. Changes in skin temperature following the sympatholytic procedure did not correlate with pain relief. For PhI, pain relief correlated with the magnitude of decrease in systolic blood pressure. After SGB, changes in quantitative thermal sensory testing (QST) suggestive of a partial deficit in thermal sensation correlated with pain relief. In 20 normal controls, water bath immersion to cool the hand passively by 7 degrees C and warm the hand passively by 4 degrees C had small and selective effects on thermal QST thresholds, but did not produce a general impairment in thermal sensation. In conclusion, the diagnosis of sympathetically maintained pain based on the history and physical examination alone cannot be made with confidence and therefore a sympatholytic procedure is necessary. When SGB produces pain relief but PhI does not, systemic absorption of local anaesthetic and/or sensory blockade by spread to somatic nerves may be the reason. Thus, PhI appears to be a less sensitive but more specific test than SGB. These two procedures provide complementary information and both may be needed to establish the diagnosis of sympathetically maintained pain.

Acute behavioral effects of MK-801 in rhesus monkeys: assessment using an operant test battery.

The acute effects of MK-801, a selective, noncompetitive NMDA receptor antagonist, were assessed using an operant test battery (OTB) of complex food-reinforced tasks that are thought to depend upon relatively specific brain functions such as motivation to work for food (progressive ratio, PR), learning (incremental repeated acquisition, IRA), color and position discrimination (conditioned position responding, CPR), time estimation (temporal response differentiation, TRD), and short-term memory and attention (delayed matching-to-sample, DMTS). Endpoints included response rates (RR), accuracies (ACC), and percent task completed (PTC). MK-801 (0.003-0.075 mg/kg, IV), given 15 min pretesting, produced significant dose-dependent decreases in measures of IRA and TRD performance at doses > or = 0.03 mg/kg. In both tasks, MK-801 produced significant decreases in accuracy at doses lower than those required to affect response rate. MK-801 also produced statistically significant decreases in PR, CPR, and DMTS measures, but only at higher doses (> or = 0.056 mg/kg) that caused significant decreases in both response rates and accuracies. These results indicate that, in monkeys, performance of operant tasks designed to model learning and time estimation is more sensitive to the disruptive effects of MK-801 than performance of tasks that model motivation, color, and position discrimination, and short-term memory and attention.

Study of sodium saccharin co-carcinogenicity in the rat.

A co-carcinogenicity experiment was conducted with female Sprague-Dawley rats in which the effects of short-term sodium saccharin dosing and initiation with a direct-acting carcinogen were examined in the urinary bladder. All initiated animals were administered 0.5 mg N-methyl-N-nitrosourea (MNU) by instillation into the bladder at 8 wk of age. The animals were also given saccharin at one of four levels in the diet (0, 1.0, 2.5 or 5%) for 4 wk either (1) just before treatment with MNU (4-8 wk of age), (2) centred on treatment with MNU (6-10 wk of age) or (3) after MNU treatment (8-12 wk of age). Additionally, a group of animals was exposed to saccharin through the milk for 3 wk by dosing the mothers, starting on the day of parturition. The animals were held on control diet until interim killing of 20 animals per group at about 590 days of age, removal for morbidity, or terminal killing of the remainder of 60 animals per treatment around 780 days of age. A histopathological examination was made of the urinary tract and the relationship of saccharin dose to bladder tumour prevalence analysed statistically. A consistent increase (with very weak statistical significance) in tumour rate at interim killing, and for the pathology data overall, was shown by the 2.5% dose group given saccharin from 8 to 12 wk of age. Tumour prevalences of 47.6 and 40.7% v. control prevalences of 21.1 and 25.4% were observed for the two time periods (P values < 0.076 and < 0.0853, respectively). All groups given saccharin neonatally showed increased tumour prevalence for both time periods, but none of the differences was statistically significant at the 95% confidence level. No consistent increase in tumour prevalence was seen in the groups given saccharin from 4 to 8 or 6 to 10 wk of age; thus, these data suggest that saccharin does not act as a strong co-carcinogen in the MNU-treated rat bladder.

Acute effects of caffeine on several operant behaviors in rhesus monkeys.

The acute effects of 1,3-trimethylxanthine (caffeine) were assessed using an operant test battery (OTB) of complex food-reinforced tasks that are thought to depend upon relatively specific brain functions, such as motivation to work for food (progressive ratio, PR), learning (incremental repeated acquisition, IRA), color and position discrimination (conditioned position responding, CPR), time estimation (temporal response differentiation, TRD), and short-term memory and attention (delayed matching-to-sample, DMTS). Endpoints included response rates (RR), accuracies (ACC), and percent task completed (PTC). Caffeine sulfate (0.175-20.0 mg/kg, IV), given 15 min pretesting, produced significant dose-dependent decreases in TRD percent task completed and accuracy at doses > or = 5.6 mg/kg. Caffeine produced no systematic effects on either DMTS or PR responding, but low doses tended to enhance performance in both IRA and CPR tasks. Thus, in monkeys, performance of an operant task designed to model time estimation is more sensitive to the disruptive effects of caffeine than is performance of the other tasks in the OTB.