Assessing the influence of payment on motivations of women participating as oocyte donors

We report on the motivations of potential ovum donors entering an assisted reproduction program and discuss the potential ramifications of escalating payments to donors. From July 1995 to July 1998, recruitment of ovum donors was directed at healthy women between 21 and 34 years of age. Financial remuneration for services rendered was USD 2,500 from July 1995 through March 1998 and increased to USD 5,000 after that. Donors were screened and consented according to established SART guidelines. The demographic background of the women was similar for women paid USD 2,500 to those receiving USD 5,000. The financial motivation was greater in those receiving USD 5,000 (68%) than USD 2,500 (39%). Some form of expressed altruism was similarly present in both groups (USD 5,000 90%, and USD 2,500 91%). However, altruism expressed as the sole motivation occurred more in those receiving USD 2,500 (61%) compared to USD 5,000 (32%). Financial reimbursement has escalated for the services of ovum donors in order to maintain the increasing demand. While money has become a dominant factor motivating ovum donors, its seductive nature requires even greater attention to adequate informed consent. Young donors may be unable to adequately weigh the risks of ovarian hyperstimulation and oocyte retrieval against the monetary reward.

Surgery after downstaging of unresectable hepatic tumors with intra-arterial chemotherapy

BACKGROUND

This retrospective study was performed to assess the outcome among patients who underwent hepatic resection or tumor ablation after hepatic artery infusion (HAI) therapy down-staged previously unresectable hepatocellular carcinoma (HCC) or liver metastases from colorectal cancer (CRC).

METHODS

Between 1983 and 1998, 25 patients with HCC and 383 patients with hepatic CRC metastases were treated with HAI therapy for unresectable liver disease. We retrospectively reviewed the records of 26 (6%) of these patients who underwent subsequent surgical exploration for tumor resection or ablation.

RESULTS

At a median of 9 months (range 7-12 months) after HAI treatment, four patients (16%) with HCC underwent exploratory surgery; two underwent resection with negative margins, and the other two were given radiofrequency ablation (RFA) because of underlying cirrhosis. At a median postoperative follow-up of 16 months (range 6-48 months), all four patients were alive with no evidence of disease. At a median of 14.5 months (range 8-24 months) after HAI therapy, 22 patients with hepatic CRC metastases underwent exploratory surgery; 10 underwent resection, 6 underwent resection and RFA or cryotherapy, and 2 underwent RFA only. At a median follow-up of 17 months, 15 (83%) of the 18 patients with CRC who had received surgical treatment had developed recurrent disease; the other 3 died of other causes (1 of postoperative complications) within 7 months of the surgery. One patient in whom disease recurred underwent a second resection and was disease-free at 1 year follow-up.

CONCLUSIONS

Hepatic resection or ablation after tumor downstaging with HAI therapy is a viable option for patients with unresectable HCC. However, given the high rate of recurrence of metastases from CRC, hepatic resection or ablation after downstaging with HAI should be used with caution.

Intraoperative lower extremity compartment pressures in lithotomy-positioned patients

PURPOSE

Measurement of anterior leg compartment pressures in eight patients (16 limbs) who were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery.

METHODS

Anterior leg compartment pressures were measured in eight patients (16 limbs) by using a slit catheter, whereas subjects were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery.

RESULTS

Compartment pressures had minor elevations after initial lithotomy positioning, and gradually increased over time. Levels elevated to 30 mmHg at an average of five (range, 3.5 to 6) hours. The maximum recorded leg compartment pressure was 70 mmHg. The addition of Trendelenburg positioning was noted to consistently increase compartment pressures. All pressures returned to less than 10 mmHg shortly after removing the limb from the stirrups and placing the limb supine. No patients developed clinical evidence of compartment syndrome.

CONCLUSIONS

Leg anterior compartment pressures rise when limbs are placed in the lithotomy position for prolonged periods of time. The rise in pressure is increased with the addition of Trendelenburg positioning. Anterior compartment pressures reached a threshold of 30 mmHg at an average of five hours. The results of this study suggest that lithotomy positioning of the lower extremities has the potential to initiate leg compartment syndrome when the period of positioning approaches five hours. Removing the limbs from the stirrups and placing them in the supine position allows the pressure in the compartments to return to normal.

Adenovirus-mediated expression of a ribozyme to c-myb mRNA inhibits smooth muscle cell proliferation and neointima formation in vivo

Smooth muscle cell (SMC) proliferation is an important component of restenosis in response to injury after balloon angioplasty. Inhibition of proliferation in vivo can limit neointima hyperplasia in animal models of restenosis. Ribozymes against c-myb mRNA have been shown to be effective inhibitors of SMC proliferation in vitro. The effectiveness of adenovirus as a gene therapy vector in animal models of restenosis is well documented. In order to test the utility of ribozymes to inhibit SMC proliferation by a gene therapy approach, recombinant adenovirus expressing ribozymes against c-myb mRNA was generated and tested both in vitro and in vivo. This adenovirus ribozyme vector is shown to inhibit SMC proliferation in culture and neointima formation in a rat carotid artery balloon injury model of restenosis.

Flexion and traction effect on C5-C6 foraminal space

OBJECTIVE

To determine the effects of cervical flexion and traction on foraminal volume and isthmus area at the C5-C6 foraminal space in cadavers.

DESIGN

This study evaluated the foraminal space at C5-C6 in cadaver specimens during flexion and traction of the cervical spine.

SETTING

An orthopedic biomechanics laboratory and department of radiology of a university medical center.

PATIENTS OR OTHER PARTICIPANTS

Nine cadaver cervical spines, C1 through T3, were used in the study. Superficial tissues were dissected, preserving the ligaments.

INTERVENTIONS

Proximal and distal portions of the cadaver spines were potted using bone cement. Spines were mounted and imaged with computed tomography in neutral position, 15 degrees of flexion, and maximum flexion with and without 25lbs of axial traction.

MAIN OUTCOME MEASURES

The areas and volumes of the foramen were measured and calculated.

RESULTS

Flexion alone significantly increased the foraminal volume and isthmus area at C5-C6. Traction resulted in little additional change.

CONCLUSIONS

For cervical spines with mild to moderate degenerative changes at C5-C6, cervical flexion with or without traction produces significant increases in foraminal volume and area at the foraminal isthmus.

Value-based formulas for purchasing. Pursuing value in Medicaid managed care: access to care and enrollee information management

Medicaid and other publicly funded health coverage programs face special challenges in managed care purchasing. This article discusses two of those challenges based on the state of Minnesota's experience: how to develop, evaluate, and communicate access to care; and how to manage the transfer of enrollee eligibility and health status information.

Phase II trial of hepatic arterial infusion of fluorouracil and recombinant human interferon alfa-2b for liver metastases of colorectal cancer refractory to systemic fluorouracil and leucovorin

PURPOSE

To determine the toxicity, response rate, and survival in patients treated with hepatic arterial infusion (HAI) of fluorouracil (5-FU) plus recombinant human interferon alfa-2b (rIFN-alpha 2b) (Intron-A; Schering-Plough, Inc, Kenilworth, NJ) for colorectal carcinoma (CRC) liver metastases refractory to systemic 5-FU plus leucovorin (LCV).

PATIENTS AND METHODS

Forty-eight patients were given a 6-hour HAI of rIFN-alpha 2b 5 MU/m2 followed by an 18-hour HAI of 5-FU, 1,500 mg/m2 daily for 5 days. Twenty-nine patients were treated through percutaneously placed catheters and 19 through implantable infusion pumps (Shiley Infusaid Inc, Noorwood, MA). Treatment cycles were repeated every 28 to 35 days.

RESULTS

There were three (6.6%) complete remissions (CRs) and 12 (26.6%) partial remissions (PRs), for a CR plus PR rate of 33.3% among 45 assessable patients (95% confidence interval [CI], 20% to 49%). The median response duration was 7 months, while median survival duration was 15 months. Grade 3 to 4 treatment-related toxic effects included mucositis (40%), neutropenia (42%), and thrombocytopenia (12%). No hepatobiliary toxicity was encountered in any of the patients. Treatment was discontinued because of progressive liver disease in 23 patients and extrahepatic progression in 16, while six patients continue treatment through an infusaid pump.

CONCLUSION

HAI of 5-FU plus rIFN-alpha 2b is well tolerated, devoid of hepatobiliary toxicity, and can produce a response rate of 33.3% among patients refractory to bolus intravenous (IV) 5-FU plus LCV. The lack of hepatobiliary toxicity may permit salvage HAI with floxuridine (FUDR) in patients whose liver tumors fail to respond to HAI of 5-FU plus rIFN-alpha 2b. Because diarrhea was not a common side effect of HAI of 5-FU plus rIFN-alpha 2b, it would be of interest to investigate whether alternating HAI of 5-FU and rIFN-alpha 2b with systemic irinotecan (CPT-11) will decrease the incidence of both hepatic and extrahepatic disease progression.

Judgements and processes in care decisions in acute medical and surgical wards

The decisions which health care professionals make are the basis of treatment and care given. In order to evaluate effective care it seems logical to suggests that an awareness of the decisions which health care professionals make and how they make them is needed. This study examines the processes nurses use when making decisions about the health care needs of acutely ill patients. In stage one, 104 qualified nurses were interviewed to identify how they decide health care needs. In stage two, a 'think aloud' technique was used with patient simulations to obtain verbal protocols from a further 55 qualified nurses to identify the information strategies they used when making these decisions. The results suggest that nurses base their health care decisions mainly on their assessment of qualitative patient states or conditions. Initial indications are that the processes used differ from those characterized in the diagnostic reasoning model, with the context in which decisions are made being an important influence together with nurses' experience. It is suggested that, in order to develop effective predictive models and clinical guidelines which aid decision making, more research into the nature of health care professionals' decision making is carried out.

Overview and critique of judgement and decision making in health care: social and procedural dimensions

This paper presents an outline of the scope for the application of decision theory to health care. Firstly, the main approaches to and assumptions of decision theory are discussed. Secondly, health care decision making is reviewed. It is noted that decision theory can be applied to either the health care professional or to the lay person. Applications of decision theory to clinical practice, to the management of care and to resourcing are considered. Thirdly, some areas which would repay further research are identified. These include social processes in individual and group decision making, the temporal distribution of outcomes and the development of techniques capable of dealing with the complex and dynamic features of decisions. On the basis of the foregoing, some conclusions are drawn.

Comparison between the Health Belief Model and Subjective Expected Utility Theory: predicting incontinence prevention behaviour in post-partum women

A small-scale study was undertaken to test the relative predictive power of the Health Belief Model and Subjective Expected Utility Theory for the uptake of a behaviour (pelvic floor exercises) to reduce post-partum urinary incontinence in primigravida females. A structured questionnaire was used to gather data relevant to both models from a sample antenatal and postnatal primigravida women. Questions examined the perceived probability of becoming incontinent, the perceived (dis)utility of incontinence, the perceived probability of pelvic floor exercises preventing future urinary incontinence, the costs and benefits of performing pelvic floor exercises and sources of information and knowledge about incontinence. Multiple regression analysis focused on whether or not respondents intended to perform pelvic floor exercises and the factors influencing their decisions. Aggregated data were analysed to compare the Health Belief Model and Subjective Expected Utility Theory directly.

NMR studies of muscle glycogen synthesis in insulin-resistant offspring of parents with non-insulin-dependent diabetes mellitus immediately after glycogen-depleting exercise

To examine the impact of insulin resistance on the insulin-dependent and insulin-independent portions of muscle glycogen synthesis during recovery from exercise, we studied eight young, lean, normoglycemic insulin-resistant (IR) offspring of individuals with non-insulin-dependent diabetes mellitus and eight age-weight matched control (CON) subjects after plantar flexion exercise that lowered muscle glycogen to approximately 25% of resting concentration. After approximately 20 min of exercise, intramuscular glucose 6-phosphate and glycogen were simultaneously monitored with 31P and 13C NMR spectroscopies. The postexercise rate of glycogen resynthesis was nonlinear. Glycogen synthesis rates during the initial insulin independent portion (0-1 hr of recovery) were similar in the two groups (IR, 15.5 +/- 1.3 mM/hr and CON, 15.8 +/- 1.7 mM/hr); however, over the next 4 hr, insulin-dependent glycogen synthesis was significantly reduced in the IR group [IR, 0.1 +/- 0.5 mM/hr and CON, 2.9 +/- 0.2 mM/hr; (P < or = 0.001)]. After exercise there was an initial rise in glucose 6-phosphate concentrations that returned to baseline after the first hour of recovery in both groups. In summary, we found that following muscle glycogen-depleting exercise, IR offspring of parents with non-insulin-dependent diabetes mellitus had (i) normal rates of muscle glycogen synthesis during the insulin-independent phase of recovery from exercise and (ii) severely diminished rates of muscle glycogen synthesis during the subsequent recovery period (2-5 hr), which has previously been shown to be insulin-dependent in normal CON subjects. These data provide evidence that exercise and insulin stimulate muscle glycogen synthesis in humans by different mechanisms and that in the IR subjects the early response to stimulation by exercise is normal.

A phase I evaluation of chronotropic delivery of floxuridine by hepatic arterial infusion in patients with metastatic colorectal cancer

Hepatic arterial infusion (HAI) of floxuridine is often used for metastatic colorectal cancer, though this is associated with dose-limiting hepatobiliary toxicity. A phase I trial was initiated to determine if circadian-patterned HAI floxuridine would reduce toxicity. Twenty-one patients were enrolled, and they received a continuous 14-day HAI of floxuridine, with 90-95% of the drug delivered over the same six-hour period daily. The therapy was tolerable, but there was no reduction in hepatobiliary toxicity. The response rate of 33% (1 complete and 6 partial responses) was similar to that of regimens that do not utilize circadian timing. HAI floxuridine chronotherapy for metastatic colorectal cancer cannot be recommended.

Information sources used in decision making: considerations for simulation development

Simulation tasks, together with think aloud techniques are often used to research the cognitive processes individuals go through when making a decision or solving a problem. They have been utilised to a certain degree within nursing. A study was carried out to try and identify the sources of information nurses in acute medical and surgical wards used to make assessment judgements. A sample of 114 nurses were interviewed, and their responses analysed using content analysis. Four main sources of information were identified, with verbal interaction being the source of information most frequently mentioned by the subjects. The content of material presented in simulations is normally tested using techniques such as expert panels. However, this paper suggests that of equal importance may be the form of presentation or source of that information. It is suggested that in order to increase the validity of information obtained from simulation tasks, the form of presentation of information to the subject should also be considered.

The cognitive component of nursing assessment: an analysis

This paper presents an analysis of the cognitive component of nursing assessment, complimenting the growth in knowledge of other important aspects of assessment. The purpose of the paper is to provide a framework for understanding how nurses structure assessment problems and the types of judgements they make. The thrust of the analysis is based on a comparison between nursing assessment and medical diagnosis, since the cognitive component and judgements formed in medical diagnosis have been more fully articulated. The results suggest that there may be similarities between the cognitive strategies used in nursing assessment and those used in medical diagnosis, particularly in relation to the gathering and organization of information. But the purpose of the information search appears to be different. In medical diagnosis the aim is to establish an explanation for the patient's presenting problem. In nursing assessment, on the other hand, the aim appears to be to provide an accurate picture of the patient's current condition or situation. The assessments formulated fit the definition of a judgement and, in common with medical diagnoses, include some form of prediction. Unlike the medical diagnoses, however, which usually remain stable throughout treatment, the assessments need to change as the patient's condition changes. The cognitive component of assessment has significant implications for nurse education and clinical practice. Further understanding of how nurses structure assessment problems and formulate judgements is therefore needed. The findings may also help to clarify the meaning of nursing diagnosis.

Hepatic arterial infusion of floxuridine, leucovorin, doxorubicin, and cisplatin for hepatocellular carcinoma: effects of hepatitis B and C viral infection on drug toxicity and patient survival

PURPOSE

To conduct a pilot trial of hepatic arterial infusion (HAI) of floxuridine (FUDR), leucovorin, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and cisplatin (FLAP) in nonresectable hepatocellular cancer (HCC) confined to the liver and assess the effects of hepatitis B (HBV) and hepatitis C (HCV) viral markers on toxicity, response to treatment, and patient survival.

PATIENTS AND METHODS

Of 31 HCC patients, 13 were HBV- and HCV-nonreactive, and 18 had evidence of either current or prior HBV and/or HCV infection. Treatment was delivered through percutaneous hepatic arterial catheters, and Infusaid pumps (Shiley Infusaid, Norwood, MA) were placed in responding patients. Cisplatin (100 mg/m2) and Adriamycin (30 to 35 mg/m2) were administered on day 1, followed by a continuous 24-hour HAI of an admixture of floxuridine (60 mg/m2) and leucovorin (15 mg/m2) daily for 4 days. Treatment was repeated every 5 weeks.

RESULTS

Twelve (41%) of 29 assessable patients had a partial response (PR), with a median time to disease progression of 13 months. Six (50%) of 12 HBV-negative (HBV-)/HCV-negative (HCV-) and six of 17 (35%) HBV-positive (HCV+) and/or HCV-positive (HCV+) patients achieved a PR. Eight patients have been maintained in remission for a median duration greater than 15.5 months. The median survival duration of all 31 patients was 15 months, 7.5 months among HBV+ and/or HCV+ patients, and significantly longer among hepatitis-non-reactive patients (P = .007). (A median has not yet been reached.) Granulocylopenia (< 0.1 x 10(3)/microL), thrombocytopenia (< 25 x 10(3)/microL), and hospitalizations for infectious complications were significantly more common among HBV-HCV-reactive than -nonreactive patients: 56%, 50%, and 67% versus 15%, 15%, and 8%, respectively (P < .05 for all).

CONCLUSION

HAI of FLAP has induced long-term PR and has palliated extensive nonresectable HCC. Positive hepatitis serology appeared to increase bone marrow susceptibility to myelotoxic drugs. Conceivably, one or both viruses may have a direct inhibitory effect on bone marrow progenitors and thereby contribute to the observed myelotoxicity.

Reduction of systemic drug exposure after hepatic arterial infusion of doxorubicin with complete hepatic venous isolation and extracorporeal chemofiltration

BACKGROUND

Hepatic arterial infusion of doxorubicin has produced tumor response in hepatic malignancies; however, the limited success of these treatments is related in part to dose-limiting systemic toxicities. The purpose of this study was to determine whether a novel venous isolation-chemofiltration system could limit systemic exposure to doxorubicin after hepatic arterial infusion.

METHODS

Doxorubicin (1 or 3 mg/kg) was infused in the hepatic arteries of domestic pigs after complete hepatic venous isolation was achieved with a dual-balloon vena cava catheter. The hepatic vein effluent was pumped through an extracorporeal carbon chemofiltration circuit. Doxorubicin levels were measured in prefilter (hepatic vein), postfilter, and systemic serum at intervals up to 1 hour after drug infusion.

RESULTS

Complete hepatic venous isolation with extracorporeal chemofiltration significantly reduced (> 90%) the postfilter and systemic levels of doxorubicin compared with prefilter levels (p < 0.01). At the time animals were killed 7 days after infusion of doxorubicin (3 mg/kg), tissue levels of doxorubicin in the liver showed a 16-fold increase compared with levels in the heart (p < 0.01).

CONCLUSIONS

For chemotherapeutic drugs like doxorubicin with a low first-pass extraction by the liver, the novel system described herein achieved significant reduction in systemic drug exposure. This system will allow dose intensification of doxorubicin administered by hepatic arterial infusion to treat hepatic malignancies.

Biosynthesis and endocrine control of the production of the German cockroach sex pheromone 3,11-dimethylnonacosan-2-one

The biosynthesis and endocrine regulation of sex pheromone production in the female German cockroach (Blattella germanica) were determined. Radio-TLC and radio-GLC were used to demonstrate the metabolism of 3,11-dimethylnonacosane, a major cuticular lipid component, to the corresponding alkan-2-ol and methyl ketone. [11,12-3H2]-3,11-Dimethylnonacosan-2-ol was efficiently metabolized to the methyl ketone, and radio-GLC showed that the methyl ketone product from both experiments was coeluted with a methyl ketone standard. A comparison of the metabolism of the labeled dimethylalkane and dimethylalkan-2-ol by age and sex showed that both males and females from day 1 through day 9 after adult emergence readily metabolized the alcohol to the corresponding methyl ketone, whereas only females of 5-9 days postemergence efficiently converted the labeled dimethylalkane to the corresponding methyl ketone. Application of the juvenile hormone analog hydroprene induced significant increases in the conversion of the labeled hydrocarbon to the methyl ketone in starved adult females as well as in females fed a protein-free diet, conditions under which endogenous juvenile hormone biosynthesis is nearly undetectable. These data show that the methyl ketone sex pheromone is formed by the hydroxylation and oxidation of the 3,11-dimethylalkane at the 2 position, show that the age- and sex-specific step in this process is the conversion of 3,11-dimethylnonacosane to 3,11-dimethylnonacosan-2-ol, and provide evidence that juvenile hormone regulates sex pheromone production in the German cockroach.

Comparison of pregnancy rates following in vitro fertilization-embryo transfer between the donors and the recipients in a donor oocyte program

Our in vitro fertilization (IVF) program provides a unique opportunity to evaluate influences of hormonal milieu on pregnancy outcome, by using a shared pool of oocytes obtained by donors (in exchange for financial assistance). The study presented herein evaluated 38 retrieval cycles (28 oocyte donors/22 recipients). No difference in mean number of embryos transferred was seen (2.7 in the donors vs 2.8 in the recipients). However, a statistically significant difference was seen in the pregnancy rates per retrieval (10.5% donors vs 29% recipients) and per transfer (4/35, 11.1%, vs 11/34, 32.3%). Abortion rates were similar (25% donor, 27.2% recipients). These data suggest that other reports of higher pregnancy rates from donor oocyte programs may not be due exclusively to better-quality oocytes. Possibly a negative effect of hyperstimulation or adverse endometrial environment of the donor (possible chronic endometritis) may explain these data.

Restriction endonuclease and genetic mapping studies indicate that the vegetative genome of the temperate, Salmonella-specific bacteriophage, epsilon 15, is circularly-permuted

Data from physical and genetic mapping studies show that the vegetative genome of the temperate, Group E 1 Salmonella bacteriophage, epsilon 15, is circularly-permuted. Preliminary evidence suggests that the circular permutation of the epsilon 15 genome is non-random.