1987 to 1991 cost and utilization of Class IV HIV patients

The 1987 to 1991 direct medical costs and service utilization of Class IV Human Immunodeficiency Virus (HIV) patients cared for at a Group Health Cooperative of Puget Sound (GHC) are described and compared across four time periods: 1987-'88, 1989, 1990, and 1991. Cost and utilization information for an age- and sex-matched control group of GHC enrollees not having Class IV HIV conditions are also compared to those of the Class IV HIV group. Data are presented on pharmacy, inpatient care, outpatient visits by physician specialty, laboratory, radiology, home health/hospice and other costs. The costs of the Class IV HIV population are, on average, 20 times those of the control group. The percent distribution of the control group's costs did not experience much change from 1989 to 1991. Conversely, the Class IV HIV group experienced a shift in costs from the inpatient to outpatient setting from 1987-'88 to 1989. This shift was temporary, as the locus of care shifted back to the inpatient setting over the following 2 years. Anecdotal evidence suggests that antiretroviral treatment may have led to a period in which patients required less intensive settings to manage their illness. Inpatient costs may have increased as the initial benefit of zidovudine treatment began to wane. The Class IV HIV population had greater percent of total expenses in pharmacy, laboratory, radiology, and home health/hospice services, and lower percent of total expenses in outpatient primary and specialty care than the control group.

Activity analysis of sterile products technicians

Work sampling techniques were used to determine the amount of time sterile products technicians spent performing predefined activities. Twenty-two predefined activities were divided into three major categories: admixture preparation techniques, total parenteral nutrition preparation techniques, and other activities. The total time spent by all sterile products technicians revealed the greatest amount of time consumed preparing sterile products in minibags (362.2 minutes), whereas drug manufacturers piggyback (DMPB) doses required 65.8 minutes. Preparation of these small volume parenterals took approximately 1.3 minutes per dose, whereas syringes consumed 123.5 minutes, or approximately 1.8 minutes per dose. Preparation of miscellaneous products required 57.7 minutes, or 1.9 minutes per dose. TPN consumed 240.7 minutes in total, or 5.5 minutes per bottle. Other activities included paperwork (154.8 minutes), communication (169.1 minutes), and sorting prepared intravenous solutions by nursing unit and time of administration (102.5 minutes). Work sampling was effective in quantifying activities performed by sterile products technicians.

Cystogenesis of the ovarian antral follicle of the rat: ultrastructural changes and hormonal profile following the administration of dehydroepiandrosterone

Immature 27-day-old female Sprague-Dawley rats were administered daily subcutaneous injections of dehydroepiandrosterone (DHEA, 5 mg/100 g BW) to induce the formation of ovarian follicular cysts. Groups of rats were killed on days 0, 10, 15, 20, 25, and 30. Ovaries from each group of rats were processed for light and electron microscopy and for follicular or cystic fluid hormone analysis. Normal antral follicle fluid, PMSG-treated preovulatory follicular fluid, and cystic fluids were analyzed for progesterone (P), estrone (E1), estradiol (E2), testosterone (T), delta 4-androstenedione (delta 4-A), 5 alpha-dihydrotestosterone (DHT), luteinizing hormone (LH), follicle stimulating hormone (FSH), and prolactin (PRL). DHEA induced anovulation, acyclicity, and the formation of follicular cysts. In certain antral follicles, there was a dramatic increase in the quantities of smooth endoplasmic reticulum (SER) in the granulosa cells and many mitochondria had tubular cristae. Further depletion of granulosa cell number was associated with intense blebbing of the cytoplasm into the follicle antrum. Formation of the ovarian follicular cyst was completed when the entire cyst was lined by a single layer of transformed granulosa cells in contact via adhering, gap, and tight junctions. These cells had little cytoplasm, mitochondria with lamellar cristae, vast basal and apical bands of microfilaments, and an extensive array of smooth-surfaced endocytotic invaginations on the basal plasma membrane. These endocytotic pits may subsequently form smooth-surfaced vesicles and thereby serve as one mechanism for moving fluid from the ovarian interstitium into the cyst. Theca interna cells were rarely observed in the peripheral regions of the cyst. Abundant smooth muscle cells were located beneath the basement membrane of the epithelial cells comprising the cyst wall. These acquired morphological and physiological features may ensure persistence of the ovarian cyst and thus potentiate a chronic pathological condition. In this study it was also shown that progesterone, estrone, and estradiol as well as androgen concentration increased in the follicle after PMSG treatment. With DHEA treatment, the follicular cystic fluid concentrations of these steroids progressively increased to extremely high levels concurrent with the development of the follicular cysts.(ABSTRACT TRUNCATED AT 400 WORDS)

X-ray laser microscopy of rat sperm nuclei

The development of high brightness and short pulse width (< 200 picoseconds) x-ray lasers now offers biologists the possibility of high-resolution imaging of specimens in an aqueous environment without the blurring effects associated with natural motions and chemical erosion. As a step toward developing the capabilities of this type of x-ray microscopy, a tantalum x-ray laser at 44.83 angstrom wavelength was used together with an x-ray zone plate lens to image both unlabeled and selectively gold-labeled dried rat sperm nuclei. The observed images show approximately 500 angstrom features, illustrate the importance of x-ray microscopy in determining chemical composition, and provide information about the uniformity of sperm chromatin organization and the extent of sperm chromatin hydration.

Demonstration of x-ray microscopy with an x-ray laser operating near the carbon K edge

High-brightness and short-pulse-width ( approximately 200 ps) x-ray lasers offer biologists the possibility of high-resolution three-dimensional imaging of specimens in an aqueous environment without the blurring effects associated with natural motions. As a first step toward developing the capabilities of this type of x-ray microscopy we have used a tantalum x-ray laser (lambda = 4.483 nm) together with an x-ray zone plate lens to image a test pattern. The observed image shows a detector-limited resolution of approximately 75 nm and paves the way to three dimensional biological imaging with high spatial resolution (20-30 nm).

Accuracy in staging of renal cell carcinoma involving vena cava

Accurate preoperative staging of renal cell carcinoma is necessary to determine patient prognosis and surgical approach, particularly when tumor thrombus invades the vena cava. The pathologically-confirmed tumor stage was compared with the radiographic preoperative stage in 44 patients undergoing surgery for renal cell carcinoma invading the vena cava (T3cNxMx). Nine patients (20%) were upstaged as the result of extracapsular tumor extension. Twelve patients (27%) were upstaged due to unrecognized regional lymphadenopathy, and 1 patient was downstaged. Only 1 patient was upstaged as the result of unrecognized metastases. The level of tumor thrombus extension for surgical approach was accurately determined in all but 2 patients. Overall, 15 patients (34%) were upstaged as a result of pathologic studies, 28 patients (64%) were correctly staged, and 1 patient was downstaged. Radiographic staging of extracapsular tumor extension and regional lymphadenopathy is unreliable, but current radiographic techniques delineate the level of thrombus extension for surgical approach with high accuracy.

Spinal epidural abscess as a complication of Fournier's gangrene

Fournier's gangrene is a rare, multi-organism infection of the perineum. The disease is most often confined to the groin area with distant spread being extremely unusual. A ase of spinal epidural abscess as a complication of Fournier's gangrene is presented. The infection appears to have spread by the hematogenous route. The patient had several symptoms, including fever, which could have provided an early diagnostic clue. Multiple fever workups were negative, however, and the diagnosis was not made until quadriplegia developed. A lumbar puncture as part of the fever workup might have allowed for an earlier diagnosis and more prompt surgery.

Changes in ovarian morphology and serum hormones in the rat after treatment with dehydroepiandrosterone

This investigation was designed to study ovarian and hormonal changes in the rat after treatment with dehydroeplandrosterone (DHEA). We identified a heterogeneous experimental group of animals with respect to ovarian histology: group I, corpora lutea (Cls) + cysts; group II, CLs + no cysts; group III, no CLs + cysts; group IV, no CLs + no cysts. Histological sections of these ovaries showed healthy and atretic follicles in different stages of cytomorphosis and degeneration. The aforementioned histological groups were also heterogeneous according to their hormonal profiles. Serum androgens, estrogens, and prolactin concentrations are significantly increased in DHEA-treated animals as compared with controls. There was no significant difference in follicle stimulating hormone between rats with cysts and rats without cysts after DHEA treatment. After 20 days of DHEA treatment, rats with CLs have very high levels of luteinizing hormone. Luteinizing hormone and prolactin levels are significantly higher in rats with cysts than in rats without cysts after 10 days of DHEA treatment. As has been shown in this inquiry, androgens and estradiol levels in rats with cysts after DHEA treatment are higher than those in rats without cysts after DHEA treatment. Therefore, this study suggests that the ovarian cystic condition developed after DHEA treatment in rats, is associated with higher levels of circulating androgens, estradiol, and prolactin.

Abnormal responses to orthostatic testing in children and adolescents with recurrent unexplained syncope

Syncope in the pediatric age group is a frequent event. Most often the cause is readily apparent--i.e., orthostatic hypotension or a vasovagal event. However, there are a large number of children with frequent recurrent unexplained syncope. Neither history, physical examination, nor standard testing reveals a cause. One hundred four consecutive patients were evaluated by orthostatic testing after standard methods found no cause for the recurrent syncope. Forty-seven (44%) of these 104 patients had syncope produced by orthostatic testing. Twenty-six of the 47 (55%) became syncopal within 5 minutes of testing initiation and 21 of the 47 (45%) after 5 to 11 minutes of testing. These patients had an average decrease of 81.5 mm Hg in blood pressure and a 25 beat/min decrease in heart rate. Of 12 control subjects, none lost consciousness with standing times as long as 14 minutes. Pacing was ineffective in preventing syncope, as two patients with a previously implanted normally functioning pacemaker had recurrent syncope clinically. Syncope was also induced by orthostatic testing, with the pacemaker showing a normal response with pacing as the patient became bradycardic. The syncopal event produced by orthostatic testing occurred with a downward blood pressure trend and a narrowing of the pulse pressure without a significant increase in heart rate. This was followed by a sudden drop in blood pressure and then by bradycardia. There is a group of children and adolescents with recurrent unexplained syncope due to abnormal orthostatic control mechanisms. Orthostatic testing appears helpful in identifying these patients.

Oral contraceptive (OCP) use increases proliferation and decreases oestrogen receptor content of epithelial cells in the normal human breast

The effect of ingestion of oral contraceptives (OCP) on cell proliferation and oestrogen (ER) and progesterone receptor (PR) expression of the epithelial cells of the normal human breast was compared with findings in controls not taking OCPs. Histologically normal breast tissue was removed during operation for fibroadenoma or reduction mammoplasty in 216 women whose mean age was 28.1 +/- 8.5 years (+/- SD range 14-53 years). During natural cycles the mean proportion of cells expressing ER was 3.94 +/- 3.71 (% mean +/- SD, range 0-20.8, n = 51), while of those expressing PR it was 12.1 +/- 7.1% (range 3.0-36.1, n = 47). There was a significant decline in ER during the menstrual cycle [p = 0.001 by multiple linear regression (MLR)], but there was no significant change in the proportion which expressed PR. The mean proportion of proliferating cells (LI) was 2.50 +/- 2.42 (range 0-11.5, n = 147). There was a significant increase of LI during the cycle (p = less than 0.001, MLR) and a significant inverse relationship between LI and ER (r = -0.29, p less than 0.01). Use of the OCP significantly reduced the number of cells which expressed ER and increased the LI earlier in the cycle. No effect of OCP use on the number of PR+ cells was detectable. We conclude that significant changes in the proportions of ER+ and proliferating cells occur during natural menstrual cycles. These changes are perturbed by ingestion of OCPs, so that there is greater suppression of ER and a longer period of high proliferation during the menstrual cycle. These results may explain the relationship between OCP use and the possible risk of breast cancer.

Flow cytometric analysis of granulosa cells from developing rat follicles

Immature rats were treated with diethylstilboestrol (DES) or pregnant mares' serum gonadotropin (PMSG) and forward angle light-scatter (FALS) and 90 degrees light-scatter (90 degrees LS) signals were used to measure the size and the granularity (internal organization) of the granulosa cells, respectively. The results confirmed the presence of two major populations of granulosa cells in the ovaries of both groups of rats, with the same percentage of larger cells in both treatments (52.3% in DES, 49.5% in PMSG). Since DES treatment brings about granulosa cell growth while PMSG treatment causes growth and differentiation, it is evident that there is heterogeneity in granulosa cell sizes during different states of growth and differentiation. There was also heterogeneity in sizes of granulosa cells harvested from follicles of small (less than 210 microns), medium (210-420 microns) and large (greater than 420 microns) diameter. Quadrant analysis of granulosa cells in various fractions collected from Percoll gradients suggested an increase in granularity in the small and large granulosa cell populations. Cell cycle analysis of small and large granulosa cell populations collected from large follicles of rats treated with PMSG indicated that each population was distributed in G0/G1, S and G2/M phases. These results demonstrate that populations of small and large granulosa cells exist in rat ovarian follicles during various stages of growth and differentiation.

Heterogeneity in granulosa cells of developing rat follicles

The present study was designed to characterize the granulosa cell subpopulations derived from rats in which ovarian growth was induced by diethylstilbestrol (DES) or in which growth and differentiation was induced by pregnant mare's serum gonadotropin (PMSG). In the DES model, immature rats were given two separate injections of 2 mg DES/rat s.c. on 25 and 26 days of age and were killed 24 hr after the second injection. In the PMSG model, rats on day 28 were given 8 IU of PMSG s.c. and were killed 54 hr later. Granulosa cells were isolated from the ovaries, separated on a continuous Percoll density gradient, and divided into 12 fractions. The cells in each fraction were cultured in the presence of androstenedione with or without 20 ng/ml of follicle-stimulating hormone (FSH) and estradiol and progesterone in the incubation medium were measured. In DES-treated rats, granulosa cells in fractions 4 and 5 and fractions 9 and 10 contained about 30-40% of total cell yield and showed high steroidogenic potential. Granulosa cells from fractions 6, 7, and 8, which represent 55-60% of total cell yield, produced relatively low amounts of steroids on a per-million-cell basis. FSH was required for the stimulation of steroidogenesis. In granulosa cells from the PMSG treated rats, aromatase activity appeared maximally induced and incubation with FSH in vitro did not bring about any further increase. However, in vitro incubation with FSH was required for progesterone production. Furthermore, the granulosa cells from the PMSG treated rats also showed much more active estradiol and progesterone synthesis in fractions 9-12 as compared with lower density fractions.(ABSTRACT TRUNCATED AT 250 WORDS)

Nurses' knowledge of breastfeeding

The purpose of this study was to survey nurses' knowledge of breastfeeding and to assess whether nurses' education, clinical experience, or personal experience predicted their breastfeeding knowledge. Results suggest that nurses have limited knowledge of breastfeeding, although no variable consistently predicted breastfeeding knowledge. Clinical experience produced the most consistent results, implying that leadership, variety in maternal and newborn nursing experiences, and years of experience result in nurses having more knowledge about breastfeeding.

Surgical management and prognosis of renal cell carcinoma invading the vena cava

A total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection. Of these patients 27 had primary tumor confined within Gerota's fascia, negative lymph nodes and no distant metastases (stage T3cN0M0). Patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69% 5-year survival rate (median 9.9 years) but patients with tumor thrombus directly invading the vena cava had a 26% 5-year survival rate (median 1.2 years), which improved to 57% (median 5.3 years) if the involved vena caval side wall was resected successfully. Of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension, regional lymphadenopathy or distant metastases, and the 5-year survival rate was less than 18% in all groups (median survival less than 0.9 years). Prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension. Patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer, positive lymph nodes or distant metastases. However, when partial venacavectomy establishes negative surgical margins then survival markedly improves.

Platelet-derived growth factor receptor alpha-subunit gene (Pdgfra) is deleted in the mouse patch (Ph) mutation

Platelet-derived growth factor receptors are composed of two subunits (alpha and beta) that associate with one another to form three functionally active dimeric receptor species. The two subunits are encoded by separate loci in humans and other species. In this study, we used conventional interspecific backcross mapping and an analysis of a deletional mutation to establish close linkage between the alpha-subunit gene (Pdgfra) and the dominant spotting (W) locus on mouse chromosome 5. Further, by analyzing the restriction fragment length polymorphisms in interspecific F1 hybrids, we were able to demonstrate that the closely associated patch (Ph) locus carries a deletion in Pdgfra. This observation was confirmed by both DNA and RNA analysis of 10.5-day fetuses produced from crosses between Ph heterozygotes. Out of 16 fetuses analyzed, Pdgfra genomic sequences were absent and no mRNA for the receptor was detected in 6 fetuses that were developmentally abnormal (the presumptive Ph homozygotes). We also determined that the deletion associated with the Ph mutation does not extend into the coding sequences of the adjacent Kit gene, by analysis of the genomic DNA from both the interspecific F1 hybrids and the presumptive Ph homozygotes. The absence of Pdgfra genomic sequences and the lack of detectable message associated with the Ph mutation should make this mutant a valuable asset for understanding the role of the receptor alpha subunit during mammalian development.

Swelling-induced changes in electrophysiological properties of cultured astrocytes and oligodendrocytes. II. Whole-cell currents

Using whole cell patch-clamp recordings we have found that swelling cultured cerebrocortical astrocytes or mouse spinal cord oligodendrocytes by perfusing them with hypotonic medium induced inward currents at the normal resting potential of -60 mV. The currents in the oligodendrocytes were always less than for astrocytes. We examined the reversal potentials of these responses by rapidly jumping the holding potential to different values and measuring the currents. We found that the hypotonic medium-induced conductance increase was always preceded by a conductance decrease in the case of oligodendrocytes, but only sometimes preceded by a conductance decrease in cultured astrocytes. The reversal potential of the conductance increase for astrocytes was around -40 mV, while the conductance decrease had a more negative reversal potential of -60 mV or less. For oligodendrocytes the reversal potential for the conductance increase was around -50 mV while the conductance decrease had a reversal potential of -90 mV or less. This suggests that K+ conductance decreased in the initial phase, while the conductance increase was due to additional channel openings. Ion substitution experiments in the case of the astrocytes showed that the reversal potential was shifted to a more positive value when medium K+ was increased, but was unaffected when Na+ was substituted by N-methyl-D-glucamine or Cl- by D-glucuronate, when corrected for liquid junction potential changes. Thus, the channels opened in these cells are likely to include non-specific cation channels. It is of interest that the two cells show a difference in their responses, and in the case of astrocytes these are likely to be involved in the regulatory volume decrease processes documented in these cells.

Oximetry in children recovering from deep hypothermia for cardiac surgery

Although pulse oximetry is a potentially useful diagnostic tool in the treatment of children after major open heart surgery, there are concerns regarding its reliability for measuring oxygen saturation (SaO2) in hypothermic or low perfusion states. To test pulse oximeter reliability in children under these conditions, our study compared 187 SaO2 pulse oximeter readings (Biox 3700) with simultaneous hemoximeter (OSM2, Radiometer) readings from 56 children rewarming after open heart surgery. Ages ranged from 4 months to 18 yr; temperatures ranged from 23.5 degrees to 38 degrees C (toe) and 31.3 degrees to 40.8 degrees C (core). The mean pulse oximeter SaO2 reading was 94.90% (SD 7.18, range 54% to 100%), mean hemoximeter reading was 96.07% (SD 7.06; minimum 54%; maximum 100%). The correlation between the readings was high (r = .88, p less than .005), and was not affected by low core temperature. When oximeter and cardiac monitor pulse rates coincided, the oximeter SaO2 value was within +/- 5% (p less than .05). We conclude that the Biox 3700 oximeter is reliable for noninvasive SaO2 monitoring in mild to moderately hypothermic children after open heart surgery, particularly when oximeter and cardiac heart rates coincide. Further studies are needed to confirm our findings in children with core temperatures less than 31.3 degrees C, and when other oximeters are used.

CT scanning and surgical treatment of 1551 head injured patients admitted to a regional neurosurgical unit

Computed tomographic (CT) scans of 1551 recently head injured patients transferred to a regional neurosurgical unit (NSU) were reviewed. Some 90% of first scans were done outside normal working hours. More than a third of first scans were normal including a fifth of the patients who were in deep coma. Haematoma was found in 50%, contusion 28%, shearing injuries 13% and general swelling in 9%. In 22% the first scan led to urgent surgical evacuation of an intracranial haematoma. More than one scan was done in 41% of patients and more than two in 10%, making 2608 scans in all. Repeat scans were more often done when the first scan was abnormal. In only five of 554 patients (1%) whose first scan had been normal were contusions or haematomas seen on subsequent scans, and in none of these was surgery required. Of 997 patients whose first scan had been abnormal a new lesion (contusion, haematoma and/or infarction) was seen on a subsequent scan in 103 cases (10%). Surgery was required (for the first time), in 57 patients whose abnormal first scans had not indicated the necessity for surgery at that time. The implications of these and other findings for the scanning of recently head injured patients in general hospitals, as scanners become more widely available, are discussed in our accompanying paper on p. 88.