Variations and Determinants of Hospital Costs for Acute Stroke in China

Background

The burden of stroke is high and increasing in China. We modelled variations in, and predictors of, the costs of hospital care for patients with acute stroke in China.

Methods and Findings

Baseline characteristics and hospital costs for 5,255 patients were collected using the prospective register-based ChinaQUEST study, conducted in 48 Level 3 and 14 Level 2 hospitals in China during 2006–2007. Ordinary least squares estimation was used to determine factors associated with hospital costs. Overall mean cost of hospitalisation was 11,216 Chinese Yuan Renminbi (CNY) (≈US$1,602) per patient, which equates to more than half the average annual wage in China. Variations in cost were largely attributable to stroke severity and length of hospital stay (LOS). Model forecasts showed that reducing LOS from the mean of 20 days for Level 3 and 18 days for Level 2 hospitals to a duration of 1 week, which is common among Western countries, afforded cost reductions of 49% and 19%, respectively. Other lesser determinants varied by hospital level: in Level 3 hospitals, health insurance and the occurrence of in-hospital complications were each associated with 10% and 18% increases in cost, respectively, whilst treatment in a teaching hospital was associated with approximately 39% decrease in cost on average. For Level 2 hospitals, stroke due to intracerebral haemorrhage was associated with a 19% greater cost than for ischaemic stroke.

Conclusions

Changes to hospital policies to standardise resource use and reduce the variation in LOS could attenuate costs and improve efficiencies for acute stroke management in China. The success of these strategies will be enhanced by broader policy initiatives currently underway to reform hospital reimbursement systems.     

3H]thymidine uptake in cells of rat condylar cartilage

Weanling rats were injected intraperitoneally with [3H]thymidine and sacrificed from 5 min to 20 days later. Their mandibular condylar cartilages were examined histologically, by thin-layer autoradiography, and by using liquid scintillation and microscopic counting methods. Labeled DNA appeared in some of the chondrocytes of the resting zone as early as 10 min postinjection, and reached the proliferative zone by 24 hr and the hypertrophic zone by 4 days. The labeling pattern in the last zone was more disperse, being oriented toward the periphery of the cells as they became hypertrophic. The maximum number of labeled chondrocytes was reached by 2 hr postinjection. These amounted to approximately 11% of the total chondrocyte population, the majority of which were located in the resting zone (73%). It is concluded that, over this period, the mitotic index for these cells is 50-60 per thousand resulting in approximately 100 labeled chondrocytes. In addition, some of the chondroclasts at the erosion front contained labeled DNA as early as 5 min after [3H]thymidine administration. By 10 min, 65% of these cells exhibited one or more labeled nuclei, and the ratio of labeled cells remained high through 20 days. Chondroclasts were seen to contain a diffuse label within their cytoplasm after 5 days. This label was similar to that seen in hypertrophic chondrocytes that had reached the erosion front by that time. Clearly, chondroclasts exhibit nuclear division and do not form from fusion of hypertrophic chondrocytes, although which specific mononuclear cells may act as chondroclast progenitors is not clear. In addition, these multinucleate resorbing cells are capable of ingesting or phagocytizing nuclear remnants from hypertrophic chondrocytes at the eroding face of cartilage.     

Phospholipid molecular species of bronchoalveolar lavage fluid after local allergen challenge in asthma

Electrospray ionization mass spectrometry was used to quantify phosphatidylcholine (PC) and phosphatidylglycerol (PG) molecular species in bronchoalveolar lavage fluid (BALF) from control and mild asthmatic subjects after local allergen challenge. BALF was obtained from 5 control and 13 asthmatic subjects before and 24 h after segmental allergen and saline challenge. There were no differences in the ratio of total PC to total PG or in the molecular species composition of PC or PG between the asthmatic and control groups under basal conditions. Allergen challenge in asthmatic but not in control volunteers caused a significant increase in the PC-to-PG ratio because of increased concentrations of PC species containing linoleic acid (16:0/18:2 PC, 18:0/18:2 PC, and 18:1/18:2 PC). These molecular species were characteristic of plasma PC analyzed from the same subjects, strongly suggesting that the altered PC composition in BALF in asthmatic subjects after allergen challenge was due to infiltration of plasma lipoprotein, not to catabolism of surfactant phospholipid. Interactions between surfactant and lipoprotein infiltrate may contribute to surfactant dysfunction and potentiate disease severity in asthma.     

Interaction of rabbit skeletal muscle troponin T and F-actin at physiological ionic strength

Troponin T has been shown to interact significantly with F-actin at 150 mM KC1 by using an F-actin pelleting assay and 125I-labeled proteins. While troponin T fragment T1 (residues 1-158) fails to pellet with F-actin, fragment T2 (residues 159-259) mimics the binding properties of the intact molecule. The weak competition of T2 binding to F-actin, shown by subfragments of T2, indicates that the interaction site(s) encompass(es) an extensive segment of troponin T. The extent of pelleting of troponin T (or T2) with F-actin is only marginally altered in the binary complex troponin IT (or T2), indicating that the direct interactions either of troponin T (or T2) or of troponin I, or both, with F-actin are weakened when these components are incorporated into a binary complex. The binding of troponin T (or T2) is moderately (-Ca2+) or more extensively reduced (+Ca2+) in the presence of troponin C. The pelleting of Tn-T seen in the presence of Tn-C (-Ca2+) and Tn-I was further reduced when either Tn-I or Tn-C (-Ca2+) was added, respectively, to form a fully reconstituted Tn complex. As noted by others, whole troponin shows little sensitivity to Ca2+ in its binding to F-actin (-tropomyosin). These and other observations, taken together with the restoration of troponin IC (+/- Ca2+) binding to F-actin by troponin T, implicate a role for the interaction of troponin T and F-actin in the thin filament assembly.     

Polymorphisms of the glucocorticoid receptor gene in laboratory and wild rats: steroid binding properties of trinucleotide CAG repeat length variants

The polyglutamine tract, beginning at codon 75 in the N-terminal modulatory domain of rat glucocorticoid receptor (rGR), was analyzed in 61 inbred strains and 155 wild caught Rattus norvegicus. A discontinuous distribution of repeat lengths was found (7, 17–23 repeats). To investigate the possible significance of this distribution, full-length rGR cDNAs with 7, 18, 20, and 21 CAG repeats were expressed in CV-1 cells, and the resulting GR protein analyzed by Western blots and extensive Scatchard analyses. The quantity and steroid binding capacity of GR, together with the binding affinities for dexamethasone and corticosterone, were found to be indistinguishable for the four repeat alleles. From the sequencing of four inbred strains CAG repeat variants were found to be flanked by silent allelic substitutions at nucleotide positions 198, 531, and 711. The four variable sites extended over 471–519 bp of coding sequence, forming six Grl haplotypes. The results are discussed in the light of genetic studies on the Milan hypertensive and normotensive strains of rat. Codon sequence of rat GR required amendment at the following residues: D98, G226, D260, P600, and F602. Received: 30 May 1997 / Accepted: 21 October 1997     

Polarized Growth of Fungal Hyphae Is Defined by an Alkaline pH Gradient

Robson, G. D., Prebble, E., Rickers, A., Hosking, S., Denning, D. W., Trinci, A. P. J., and Robertson, W. 1996. Polarized growth of fungal hyphae is defined by an alkaline pH gradient. Fungal Genetics and Biology 20, 289-298. Polarized cell growth is exhibited by a diverse range of eukaryotic and prokaryotic cells. The events which are responsible for this growth are poorly understood. However, the existence of ion gradients may play an important role in establishing and driving cell polarity. Using a pH-sensitive, ratiometric fluorescent dye to monitor intracellular pH in growing fungal hyphae, we report a gradient at the extending hyphal tip that is up to 1.4 pH units more alkaline than more distal regions. Both the magnitude and the length of the pH gradient were strongly correlated with the rate of hyphal extension and eradication of the gradient-arrested growth. These results suggest that alkaline pH gradients may be integral to hyphal extension in fungi.     

Orientation acuity estimated with simultaneous and successive procedures.

Orientation discrimination thresholds for medium contrast sinewave grating stimuli were estimated by a forced-choice procedure for the two principal, and the two main oblique axes. The results obtained for simultaneous presentation with a centre/surround stimulus arrangement are compared with the threshold estimates obtained when the two stimuli to be discriminated do not overlap in time. We find that orientation acuity depends on the temporal relationship of the discriminanda. Estimates of orientation threshold with simultaneous presentation are lower on all axes tested than those obtained with successive presentation; the greatest difference in orientation acuity was found at obliques. The data support the hypothesis that the meridional anisotropy in orientation discrimination that is found with conventional, two-interval forced-choice methods is not entirely attributable to anatomical and physiological changes at the level of the striate cortex.     

Isometric force development, isotonic shortening, and elasticity measurements from Ca(2+)-activated ventricular muscle of the guinea pig

Isometric tension and isotonic shortening were measured at constant levels of calcium activation of varying magnitude in mechanically disrupted EGTA-treated ventricular bundles from guinea pigs. The results were as follows: (a) The effect of creatine phosphate (CP) on peak tension and rate of shortening saturated at a CP concentration more than 10 mM; below that level tension was increased and shortening velocity decreased. We interpreted this to mean that CP above 10 mM was sufficient to buffer MgATP(2-) intracellularly. (b) The activated bundles exhibited an exponential stress-strain relationship and the series elastic properties did not vary appreciably with degree of activation or creatine phosphate level. (c) At a muscle length 20 percent beyond just taut, peak tension increased with Ca(2+) concentration over the range slightly below 10(-6) to slightly above 10(-4)M. (d) By releasing the muscle length-active tension curves were constructed. Force declined to 20 percent peak tension with a decrease in muscle length (after the recoil) of only 11 percent at 10(-4)M Ca(2+) and 6 percent at 4x10(-6)M Ca(2+). (e) The rate of shortening after a release was greater at lower loads. At identical loads (relative to maximum force at a given Ca(2+) level), velocity at a given time after the release was less at lower Ca(2+) concentrations; at 10 M(-5), velocity was 72 percent of that at 10(-4)M, and at 4x10(-6)M, active shortening was usually delayed and was 40 percent of the velocity at 10(-4) M. Thus, under the conditions of these experiments, both velocity and peak tension depend on the level of Ca(2+) activation over a similar range of Ca(2+) concentration.