Day 3 morphology is a poor predictor of blastocyst quality in extended culture

OBJECTIVE

To determine how the quality of blastocysts formed on day 5/6 of extended culture compares with their morphology on day 3.

DESIGN

Retrospective observational study of IVF laboratory records.

SETTING

Private assisted reproduction clinic.

PATIENT(S)

101 IVF cycles in which 5 to 25 embryos were produced. The average maternal age was 33.1 years.

INTERVENTION(S)

Embryos were individually cultured in vitro in sequential media for an extended time to enable use of blastocysts for fresh transfer or cryopreservation.

MAIN OUTCOME MEASURE(S)

Comparison of embryo quality for putative ET or cryopreservation on day 3 with quality of embryos used for actual ET and cryopreservation on day 5/6.

RESULT(S)

Of 1,263 cleaving embryos, 559 were judged to have been suitable for use on day 3; 355 would have been used for ET (average per ET, 3.5) and 204 would have been frozen (equivalent to 44% utilization). In actuality, 471 blastocysts were used on day 5/6, of which 234 were transferred (average per ET, 2.3), and 237 were frozen (equivalent to 37% utilization). Only 48% embryos that would have been chosen for ET and/or cryopreservation on day 3 were eventually used in such a manner at the blastocyst stage. Historically, the rate of viable pregnancy from day 3 transfers was 30.5% per transfer; this rate increased to 45% with routine day 5/6 transfers.

CONCLUSION(S)

Extended culture of human embryos seems to increase discrimination of potential embryonic viability. Criteria for embryo selection on day 3 seem to be inadequate. Extended in vitro culture may therefore be an effective means of optimizing IVF clinical success.

Ten misconceptions physicians have about marketing

Negative attitudes about marketing abound in medicine and largely arise from 10 common misconceptions. This article describes each and offers remedies.

Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS

OBJECTIVE

To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998.

MAIN OUTCOME MEASURES

Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition.

MAIN RESULTS

Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema.

CONCLUSION

Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant

It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Initial field testing of an instrument to measure: observable indicators of nursing home care quality

The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

Death and readmission in the year after hospital admission with cardiovascular disease: the Hunter Area Heart and Stroke Register

OBJECTIVES

To compare outcomes one year after hospital admission for patients initially discharged with a diagnosis of acute myocardial infarction (AMI), other ischaemic heart disease (other IHD), congestive heart failure (CHF) or stroke.

DESIGN

Cohort study.

SETTING

Hunter Area Heart and Stroke Register, which registers all patients admitted with heart disease or stroke to any of the 22 hospitals in the Hunter Area Health Service in New South Wales.

PATIENTS

4981 patients with AMI, other IHD, CHF or stroke admitted to hospital as an emergency between 1 July 1995 and 30 June 1997 and followed for at least one year.

MAIN OUTCOME MEASURES

Death from any cause or emergency hospital readmission for cardiovascular disease.

RESULTS

In-hospital mortality varied from 1% of those with other IHD to 22% of those with stroke. Almost a third of all patients discharged alive (and 38% of those aged 70 or more) had died or been readmitted within one year. This varied from 22% of those with stroke to 49% of those with CHF. The causes of death and readmission were from a spectrum of cardiovascular disease, regardless of the cause of the original hospital admission.

CONCLUSIONS

Data from this population register show the poor outcome, especially with increasing age, among patients admitted to hospital with cardiovascular disease. This should alert us to determine whether optimal secondary prevention strategies are being adopted among such patients.

Setting thresholds for quality indicators derived from MDS data for nursing home quality improvement reports: an update

BACKGROUND

Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument.

SETTING THRESHOLDS

In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results.

REPORTING MDS QIS FOR QUALITY IMPROVEMENT

The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret.

SUMMARY AND CONCLUSIONS

As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.

Nursing home care quality: a multidimensional theoretical model integrating the views of consumers and providers

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The seven dimensions of the consumer multidimensional model of nursing home care quality are: staff, care, family involvement, communication, environment, home, and cost. The views of consumers and families are compared with the results of a previous study of providers of nursing home services. An integrated, multidimensional theoretical model is presented for testing and evaluation. An instrument based on the model is being tested to observe and score the dimensions of nursing home care quality.

Synthesis, physicochemical properties, anticonvulsant activities, and GABA-ergic and voltage-sensitive calcium channel receptor affinities of alpha-substituted N-benzylamides of gamma-hydroxybutyric acid. Part 4: Search for new anticonvulsant compounds

In a search for new anticonvulsant compounds, two series of N-benzylamides of alpha-(benzylamino)-gamma-hydroxybutyric acid (series A) and alpha-(2-phenylethylamino)-gamma-hydroxybutyric acid (series B), were investigated in maximal electroshock (MES), subcutaneous metrazole, and rotorod toxicity assays. The most potent anticonvulsant compounds were alpha-(benzylamino)-gamma-hydroxybutyric acid N-benzylamide (3) and N-(2-chlorobenzylamide (4) with median effective (ED50) doses 63.0 mg/kg and 54.0 mg/kg, respectively. alpha-(4-Phenylpiperazinyl)-gamma-hydroxybutyric acid N-(4-methylbenzyl)amide (17) and alpha-(benzylpiperazinyl-gamma-hydroxy-butyric acid N-(4-methylbenzyl)amide (18) were also tested for their ability to potentiate [3H]-muscimol binding and to inhibit [35S]-TBPS binding (as indices of GABA-A receptor potentiation). Amide 17 exhibited activity at the GABA-A complex which may be the mechanism by which the anticonvulsant effect of this compound is mediated. The N-benzylamides of alpha-(benzylamino)-gamma-hydroxybutyric acid (3-9) were also evaluated for their ability to displace [3H]-nitrendipine from voltage-sensitive calcium channel (VSCC) receptors isolated from rat cortex.

Are Sarcocystis neurona and Sarcocystis falcatula synonymous? A horse infection challenge

Equine protozoal myeloencephalitis (EPM) is a debilitating neurologic disease of the horse. The causative agent. Sarcocystis neurona, has been suggested to be synonymous with Sarcocystis falcatula, implying a role for birds as intermediate hosts. To test this hypothesis, opossums (Didelphis virginiana) were fed muscles containing S. falcatula sarcocysts from naturally infected brown-headed cowbirds (Molothrus ater). Ten horses were tested extensively to ensure no previous exposure to S. neurona and were quarantined for 14 days, and then 5 of the horses were each administered 10(6) S. falcatula sporocysts collected from laboratory opossums. Over a 12-wk period, 4 challenged horses remained clinically normal and all tests for S. neurona antibody and DNA in serum and cerebrospinal fluid were negative. Rechallenge of the 4 seronegative horses had identical results. Although 1 horse developed EPM, presence of S. neurona antibody prior to challenge strongly indicated that infection occurred before sporocyst administration. Viability of sporocysts was confirmed by observing excystation in equine bile in vitro and by successful infection of naive brown-headed cowbirds. These data suggest that S. falcatula and S. neurona are not synonymous. One defining distinction is the apparent inability of S. falcatula to infect horses, in contrast to S. neurona, which was named when cultured from equine spinal cord.

Type 2 diabetes: evidence for linkage on chromosome 20 in 716 Finnish affected sib pairs

We are conducting a genome scan at an average resolution of 10 centimorgans (cM) for type 2 diabetes susceptibility genes in 716 affected sib pairs from 477 Finnish families. To date, our best evidence for linkage is on chromosome 20 with potentially separable peaks located on both the long and short arms. The unweighted multipoint maximum logarithm of odds score (MLS) was 3.08 on 20p (location, chi = 19.5 cM) under an additive model, whereas the weighted MLS was 2.06 on 20q (chi = 57 cM, recurrence risk,lambda(s) = 1. 25, P = 0.009). Weighted logarithm of odds scores of 2.00 (chi = 69.5 cM, P = 0.010) and 1.92 (chi = 18.5 cM, P = 0.013) were also observed. Ordered subset analyses based on sibships with extreme mean values of diabetes-related quantitative traits yielded sets of families who contributed disproportionately to the peaks. Two-hour glucose levels in offspring of diabetic individuals gave a MLS of 2. 12 (P = 0.0018) at 9.5 cM. Evidence from this and other studies suggests at least two diabetes-susceptibility genes on chromosome 20. We have also screened the gene for maturity-onset diabetes of the young 1, hepatic nuclear factor 4-a (HNF-4alpha) in 64 affected sibships with evidence for high chromosomal sharing at its location on chromosome 20q. We found no evidence that sequence changes in this gene accounted for the linkage results we observed.

Climatic and environmental patterns associated with hantavirus pulmonary syndrome, Four Corners region, United States

To investigate climatic, spatial, temporal, and environmental patterns associated with hantavirus pulmonary syndrome (HPS) cases in the Four Corners region, we collected exposure site data for HPS cases that occurred in 1993 to 1995. Cases clustered seasonally and temporally by biome type and geographic location, and exposure sites were most often found in pinyon-juniper woodlands, grasslands, and Great Basin desert scrub lands, at elevations of 1,800 m to 2,500 m. Environmental factors (e.g., the dramatic increase in precipitation associated with the 1992 to 1993 El Niño) may indirectly increase the risk for Sin Nombre virus exposure and therefore may be of value in designing disease prevention campaigns.