Paying the piper: the crisis in chronic care.

The current article reviews the broad outlines of the crisis in chronic care with emphasis on Southern California, a region where the powerful forces buffeting health and long term care have reached gale force intensity. The article argues that a partial solution to the crisis lies in flexible local partnerships among patients, families, providers, and payers focused on helping the chronically ill cope with the tasks of daily life. Such partnerships would emphasize supportive care, prevention, family preservation, assistive devices, and family income supplementation through facilitation of productive work, aspects of chronic care neglected by current financing and service delivery practices. A case example, the Southern California-based Partners in Care Foundation's Family Care Network, illustrates these essential components of a revitalized, responsive chronic care system.

Development of human cochlear active mechanism asymmetry: involvement of the medial olivocochlear system?

To study the functional development of the medial olivocochlear system, transient-evoked otoacoustic emission suppression experiments were conducted in 73 ears of 38 pre-term and 11 full-term neonates. The continuous contralateral stimulation was a broad band white noise, presented at 70 dB SPL. Efferent suppression was determined by subtracting the without-contralateral stimulation condition from the with-contralateral stimulation condition. Across this population, a mean suppression effect of contralateral stimulation on transient-evoked otoacoustic emissions was found, with most of the suppression effect observed after 8 ms. The amount of suppression is linearly, positively correlated with the conceptional age. In the subgroup of bilaterally tested neonates, the suppression of transient-evoked otoacoustic emissions is similar in the right ear and the left ear in subjects whose conceptional age is less than 36 weeks and significantly higher in the right ear than in the left ear in older neonates. This last observation was seen at frequencies where transient-evoked otoacoustic emission amplitudes became higher in the right ear than in the left ear as the conceptional age increased, a finding already reported in adults. This study shows that the functional adult pattern of the medial efferent system, probably involved in the detection of signals in noise such as speech sounds, seems to appear gradually in neonates and represents one of the several arguments in favor of functional auditory lateralization in humans, with a right ear advantage.

Mutations in the connexin 26 gene (GJB2) among Ashkenazi Jews with nonsyndromic recessive deafness.

BACKGROUND: Mutations in the GJB2 gene cause one form of nonsyndromic recessive deafness. Among Mediterranean Europeans, more than 80 percent of cases of nonsyndromic recessive deafness result from inheritance of the 30delG mutant allele of GJB2. We assessed the contribution of mutations in GJB2 to the prevalence of the condition among Ashkenazi Jews. METHODS: We tested for mutations in GJB2 in DNA samples from three Ashkenazi Jewish families with nonsyndromic recessive deafness, from Ashkenazi Jewish persons seeking carrier testing for other conditions, and from members of other ethnic groups. The hearing of persons who were heterozygous for mutations in GJB2 was assessed by means of pure-tone audiometry, measurement of middle-ear immittance, and recording of otoacoustic emissions. RESULTS: Two frame-shift mutations in GJB2, 167delT and 30delG, were observed in the families with nonsyndromic recessive deafness. In the Ashkenazi Jewish population the prevalence of heterozygosity for 167delT, which is rare in the general population, was 4.03 percent (95 percent confidence interval, 2.5 to 6.0 percent), and for 30delG the prevalence was 0.73 percent (95 percent confidence interval, 0.2 to 1.8 percent). Genetic-linkage analysis showed conservation of the haplotype for 167delT but the existence of several haplotypes for 30delG. Audiologic examination of carriers of the mutant alleles who had normal hearing revealed subtle differences in their otoacoustic emissions, suggesting that the expression of mutations in GJB2 may be semidominant. CONCLUSIONS: The high frequency of carriers of mutations in GJB2 (4.76 percent) predicts a prevalence of 1 deaf person among 1765 people, which may account for the majority of cases of nonsyndromic recessive deafness in the Ashkenazi Jewish population. Conservation of the haplotype flanking the 167delT mutation suggests that this allele has a single origin, whereas the multiple haplotypes with the 30delG mutation suggest that this site is a hot spot for recurrent mutations.

The impact of managed care on cancer care. Review and recommendations.

PURPOSE: The authors review the opportunities and challenges to quality cancer clinical care presented by the rise of managed care. OVERVIEW: The impact of managed care is apparent in every aspect of cancer care: research and clinical trials, practitioner training, prevention and early detection, treatment decisions, palliation and psychosocial support, and timely referral to hospice. The little research that has been done indicates that the transformation wrought by managed care has resulted in mixed consequences for oncology healthcare providers and patients alike. CLINICAL IMPLICATIONS: Whether cancer care will deteriorate or will improve in response to the advent of managed care depends largely on the oncology community's response. The opportunities for betterment include agreement on the quantifiable definition of excess care and the curbing of practices falling within that definition; greater emphasis on palliation and psychosocial support; flexible provider roles that may improve continuity of care and fit between patient and family need and practitioner behavior; reallocation of research dollars to reward innovation and reduce project duplication; and a diffusion of medical education into community settings.