Asthma quality of life in a Southern practice: towards a new paradigm

BACKGROUND

Quality of life (QOL) surveys are increasingly recognized as part of state-of-the-art asthma assessment. Disease-specific surveys quantitate total QOL and subscale domains which, along with changes in these measures, suggest asthma severity and effects of intervention.

OBJECTIVES

This study was conducted to (1) compare regional variation in QOL and change in QOL in an allergy practice in the South and (2) to examine if one or a set of questions relating to asthma severity could estimate QOL thereby obviating the need for a complete survey.

METHODS

Fifty-eight patients were administered an asthma specific quality of life (AQOL) questionnaire, the Marks et al Asthma Quality of Life survey, at baseline and surveyed in follow-up at 1 and 6 months. Additional questions were asked concerning bronchodilator use in a day and 1 week, missed work/school days, nocturnal wakening in 1 week due to asthma, emergency room visits in the previous month, and past hospitalizations in the last year. Spirometry was performed at each visit.

RESULTS

Baseline AQOL is significantly (P < .05) related individually to nocturnal wakening, bronchodilator use in a day, work or school days missed, and hospitalization during the past year. A model combining these factors explains 49% of the variance, r2 = .49. The AQOL score between baseline and the first month shows a significant improvement (P < .0001) and this improvement is related (P = .002) to the reduction in nocturnal wakenings during that same time period.

CONCLUSIONS

Specialty care intervention affected QOL similarly in the Southern practice compared with other regions/countries. Nocturnal wakening, bronchodilator use in a day, workdays missed, and hospitalization in the past year were all significantly correlated with AQOL. Number of nocturnal wakenings and bronchodilator use in a day may not only stratify asthma severity, they roughly stratify AQOL. The wide scatter of AQOL scores for a given indicator of asthma severity makes a limited combination of questions an indicator but not yet a reliable predictor of AQOL.

Neurite-outgrowth regulating functions of the amyloid protein precursor of Alzheimer's disease

Many studies have shown that breakdown of the amyloid protein precursor (APP) to produce the amyloid protein is an important step in the pathogenic mechanism which causes Alzheimer's disease (AD). However, little is known about the normal function of APP. Developmental studies show that APP expression increases during the period of brain development when neurite outgrowth and synaptogenesis is maximal. APP is expressed highly within growing neurites and in growth cones, and purified APP has been shown to stimulate neurite outgrowth from cells in culture. Thus APP may regulate neurite outgrowth or synaptogenesis in vivo. APP is actively secreted from many cells, and the C-terminally secreted APP has been shown to associate with components of the extracellular matrix, such as the heparan sulphate proteoglycans (HSPGs). Two putative heparin-binding domains on APP have been reported. Binding of HSPGs to an N-terminal heparin-binding domain (HBD-1) stimulates the effect of substrate-bound APP on neurite outgrowth. In the mature nervous system, APP may play an important role in the regulation of wound repair. It is highly likely that studies on the normal functions of APP will shed further light on aspects of the pathogenesis of AD.

Experience measuring performance improvement in multiphase picture archiving and communications systems implementations

When planning a picture archiving and communications system (PACS) implementation and determining which equipment will be implemented in earlier and later phases, collection and analysis of selected data will aid in setting implementation priorities. If baseline data are acquired relative to performance objectives, the same information used for implementation planning can be used to measure performance improvement and outcomes. The main categories of data to choose from are: (1) financial data; (2) productivity data; (3) operational parameters; (4) clinical data; and (5) information about customer satisfaction. In the authors' experience, detailed workflow data have not proved valuable in measuring PACS performance and outcomes. Reviewing only one category of data in planning will not provide adequate basis for targeting operational improvements that will lead to the most significant gains. Quality improvement takes into account all factors in production: human capacity, materials, operating capital and assets. Once we have identified key areas of focus for quality improvement in each phase, we can translate objectives into implementation requirements and finally into detailed functional and performance requirements. Here, Integration Resources reports its experience measuring PACS performance relative to phased implementation strategies for three large medical centers. Each medical center had its own objectives for overcoming image management, physical/geographical, and functional/technical barriers. The report outlines (1) principal financial and nonfinancial measures used as performance indicators; (2) implementation strategies chosen by each of the three medical centers; and (3) the results of those strategies as compared with baseline data.

Thromboembolic complications of cardiac radiofrequency catheter ablation: a review of the reported incidence, pathogenesis and current research directions

INTRODUCTION

Radiofrequency catheter ablation (RFCA) has become established as an effective therapy for the treatment of many cardiac tachyarrhythmias. The principle limitation of conventional RFCA continues to be the risk of thromboembolism. This risk is of particular concern for the ongoing development of the catheter maze procedure for the treatment of atrial fibrillation, which currently involves the creation of extensive linear lesions in the left atrium.

METHODS AND RESULTS

A Medline search of the literature over the last ten years was performed. Focused review of the reported thromboembolic complications of RFCA indicates an overall incidence of 0.6%. However, the risk is increased when ablation is performed in the left heart (1.8% to 2%) and for ventricular tachycardia (2.8%). It is of concern that intravenous heparin and the use of temperature feedback to control radiofrequency current do not eliminate the risk of thromboembolic events.

CONCLUSION

The thromboembolic complications of RFCA are not eliminated by the treatment of intravenous herapin and mode of temperature control during ablation. Potential approaches to further reduce the risk of thromboembolism include the adjunctive administration of specific inhibitors of platelet activation and aggregation, intraprocedural intracardiac echocardiography, irrigated radiofrequency ablation, and cryoablation catheter systems.

Comparison of endemic and exotic entomopathogenic nematode species for control of Colorado potato beetle (Coleoptera: Chrysomelidae)

We compared the efficacy of 2 endemic strains of entomopathogenic nematodes isolated from Hermiston, OR, with that of 3 exotic nematode species for control of Colorado potato beetle, Leptinotarsa decemlineata (Say). In laboratory experiments, the exotic Heterorhabditis species were more pathogenic to Colorado potato beetle than were the endemic Heterorhabditis strains. Exotic Steinernema species were less pathogenic to Colorado potato beetle than the exotic Heterorhabditis species. No Colorado potato beetle adults emerged from soil treated with H. marelatus Liu & Berry, a new species collected from Seaside, OR. Nematode pathogenicity was detected up to 14 wk after application in Galleria mellonella (L.) in soil taken from field plots treated with endemic and exotic nematode species.

Evaluation of bivalent live attenuated influenza A vaccines in children 2 months to 3 years of age: safety, immunogenicity and dose-response

1126 children, 2 months to 3 years old, received a single intranasal dose of 10(4), 10(6), or 10(7) TCID50 of cold adapted (ca) A/Kawasaki/9/86 (H1N1) and A/Beijing/352/89 (H3N2) or placebo, in a double blind, placebo-controlled, safety and immunogenicity trial. No reactogenicity attributable to vaccine was demonstrated. A single bivalent 10(6) or 10(7) dose produced high rates of seroconversion to H1N1 (77%) and H3N2 (92%) in seronegative children > 6 months old; serologic responses were lower to H1N1 (P < 0.001) and H3N2 (P = 0.01) in younger infants. A single 10(6) dose of bivalent ca influenza A vaccine can be immunogenic in children, but response is age dependent.

Developing strategic plans for academic general internal medicine

There is an increasing need to train more primary care physicians. Therefore, it would be advantageous for academic general internal medicine (GIM) to develop strategies to meet these demands. Our GIM division developed a strategic planning process with the participant groups being the division faculty, a pertinent literature review (the surrogate expert), and selected medical administrators. The IDEALS systems design provided the conceptual framework for the strategic planning process. This process used the Delphi technique to develop the theoretically ideal work system based on the division's vision for its future role, and the Nominal Group Process Technique to create the recommended work system, using the Delphi results. The strategic planning process was economical and division faculty agreed that it was useful.

Detection of Epstein-Barr viral DNA in serum using rapid-cycle PCR

Our study describes the comparison of a rapid nested PCR assay to standard serology techniques for the detection of Epstein-Barr virus (EBV) in serum. The sera of 81 patients with suspected EBV infection were analyzed; 54 were positive for one or more of the standard serology markers, i.e., IgM viral capsid antigen (VCA), IgG-VCA, Epstein-Barr nuclear antigen 1 (EBNA-1), and early antigen (EA), and 27 were negative for all serology markers. The sera from 15 normal healthy blood donors were also included. No EBV DNA was detected in any of the 15 blood donor samples or in any of the 27 samples with negative serology results. Eleven samples (20%) of the 54 with positive EBV serology results were positive for EBV DNA. Of these samples, 9 were EBV IgM-VCA positive and anti-EBNA negative, suggesting acute infection. One of the 11 samples had high titers of IgM-VCA, IgG-VCA, anti-EBNA, and anti-EA. The last of the 11 samples was from a patient with acute infectious mononucleosis without sufficient sample volume for EBV serology testing. Seventeen of the total 96 samples from the study were IgM-VCA positive and anti-EBNA negative and 9 of these 17 samples (53%) tested positive for EBV DNA. These data suggest that the detection of EBV DNA by PCR in serum may be a useful indicator of active infection rather than latent virus.

Epidemiology and clinical impact of parainfluenza virus infections in otherwise healthy infants and young children < 5 years old

Over a 20-year period in a population of otherwise healthy children, respiratory viruses have been cultured from nasal wash specimens from each child with a clinically significant respiratory illness. Since efforts are underway to develop vaccines for prevention of illness due to parainfluenza virus (PIV) type 3, the epidemiologic characteristics of PIVs were reviewed, and the population size necessary to demonstrate vaccine efficacy was estimated. A population of 1429 children was followed through early childhood. PIVs were isolated from 286 samples, 17.4% of positive viral cultures. PIV-3 was the most common: 10% of the children had at least one symptomatic, culture-proven PIV-3 infection. PIV-3 was endemic during the study period, while the other two PIVs, PIV-1 and -2, caused biennial flu epidemics. Only four PIV-related hospitalizations were seen. The efficacy of a PIV-3 vaccine could be demonstrated in a trial of 600 carefully monitored children vaccinated by 3 months and followed to 15 months of age.

Effects of extracorporeal shock wave lithotripsy to one kidney on bilateral glomerular filtration rate and PAH clearance in minipigs

PURPOSE

This study examined the acute time course of effects of extracorporeal shock wave lithotripsy (ESWL) on renal hemodynamics in anesthetized minipigs with and without pretreatment with verapamil.

MATERIALS AND METHODS

We applied ESWL (2000 shocks, 24 kV, unmodified Dornier HM3), to the right kidneys of isoflurane-anesthetized female pigs. Urine flow and renal hemodynamics were monitored from each kidney via ureteral balloon catheters. Arterial blood pressure and bilateral urine flow, glomerular filtration rate (GFR, insulin clearance) and renal plasma flow (RPF, para-aminohippurate clearance) were monitored for 45 minutes before ESWL, and at 1, 4 and 24 hours after ESWL.

RESULTS

Treatment with ESWL consistently caused unilateral hematuria and subcapsular renal hematomas in the shocked kidneys and significantly reduced GFR and RPF in those kidneys at 1 and 4 hours after ESWL. Urine flow was reduced through 24 hours in the shocked kidneys. Renal plasma flow, but not GFR, was significantly reduced in the contralateral (unshocked) kidneys at 1 and 4 hours after ESWL to the other kidneys. Verapamil blunted the ESWL-induced reductions of urine flow, GFR and RPF in the shocked kidneys and eliminated the reduction of RPF in the unshocked kidneys.

CONCLUSIONS

These experiments demonstrate that ESWL to 1 kidney acutely impaired hemodynamics in both kidneys and that verapamil attenuated the response in the shocked kidneys and eliminated it in the contralateral unshocked kidneys.

Recombinant baculovirus influenza A hemagglutinin vaccines are well tolerated and immunogenic in healthy adults

In a prospective double-blind trial, the reactogenicity and immunogenicity of recombinant baculovirus influenza A vaccines containing purified full-length hemagglutinin (HA) were compared with standard trivalent inactivated vaccine (TIV). The recombinant baculovirus influenza A vaccines (rHA0) were monovalent (containing 45 micrograms of A/Beijing/92[H3] and 15, 45, and 135 micrograms of A/Texas/91[H1]) and bivalent (containing 45 micrograms of both A/Beijing/92 and A/Texas/91). The bivalent rHA0 vaccine produced fewer local side effects than the TIV (50% vs. 88%, P = .003). The hemagglutinin inhibition (HAI) responses (defined as a > or = 4 increase in HAI) to A/Beijing rHA0 in the monovalent A/Beijing/92, the bivalent vaccine, and the TIV were 68%, 76%, and 46%, respectively (P = .086). Increasing doses of A/Texas rHA0 (15 micrograms [60%], 45 micrograms [69%], and 135 micrograms [76%]) and bivalent HA (76%) gave better immunologic responses to H1 than did TIV (31%; P = .003).

Parameters associated with adverse perinatal outcome in hypertensive pregnancies

BACKGROUND

Hypertensive disorders are a major contributor to perinatal morbidity and mortality. As all hypertensive pregnancies do not have a bad outcome, we sought to identify clinical and laboratory parameters associated with adverse perinatal outcome in hypertensive pregnancies.

METHODS

We analyzed the clinical course of 271 hypertensive patients delivered at a tertiary center. Adverse perinatal outcome included: (1) perinatal death; and (2) perinatal morbidity due to hypertension-related prematurity and uteroplacental vasculopathy. In our analysis, we sought to compare good and adverse perinatal outcome groups of hypertensive pregnancies. Two sample t-tests were used for continuous variables and chi 2-tests were performed for categoric variables. Blood pressures (BP) were analyzed by multivariate analysis for four time periods (P, I through IV) defined by gestational age in weeks: I, 10-19; II, 20-24; III, 25-29; and IV, 30-36.

RESULTS

There were 96 cases of adverse perinatal outcome due to hypertension (mortality, n = 6; morbidity, n = 90) in this series. Two clinical factors had a significant association with adverse perinatal outcome: (1) the need for prenatal treatment with antihypertensives (P < 0.0001); and (2) early onset of hypertension during the pregnancy (P < 0.008). The adverse outcome group had higher systolic (S) BP as early as 10-19 weeks (P < 0.01). This group had higher systolic and diastolic (D) BP as early as 20-24 weeks' gestation (P < 0.004-0.0001). Serum uric acid of > or = 6 mg/dl had a relative risk of 4.2 for adverse perinatal outcome (95% CI, 2.0-8.9; P < 0.0001).

CONCLUSIONS

Our study suggests that the increased severity and longer duration of hypertension may be the primary pathophysiologic mediator of adverse perinatal effects in these pregnancies. Elevated serum uric acid may be a clinically useful predictor of perinatal mortality and, more importantly, of perinatal morbidity in hypertensive pregnancies.

A visual guide to PACS

Picture archiving and communication systems (PACS) is a complex and vast subject, about which much has been written. A Visual Guide to PACS is an overview of the subject presented as an efficient reference for hospital and department administrators planning for and implementing PACS. A Visual Guide to PACS is adapted from presentation materials developed by Integration Resources/GORCA to capsulize issues relating to PACS. The authors aim to communicate the broad parameter and some of the complexity of the subject.

Angiotensin IV inhibits neurite outgrowth in cultured embryonic chicken sympathetic neurones

Angiotensin IV (Val-Tyr-Ile-His-Pro-Phe) is reported to enhance apomorphine induced stereotypy and to improve memory recall through actions on specific binding sites in the central nervous system. In the present study, 10 nM angiotensin IV or angiotensin II inhibited neurite outgrowth from cultured E11 chicken paravertebral sympathetic neurones by 25%. The effects of both peptides were inhibited by a 1 microM concentration of the angiotensin IV analogues. WSU 4042, Nle1-Y-I-amide or Nle1-AIV, but not by the avian angiotensin II antagonists, [Sar1,Ile8]Ang II or CGP 42112, suggesting that the inhibition of neurite outgrowth by both peptides is mediated by the angiotensin IV binding site. These results suggest that angiotensin IV may be involved in neurite modelling and may therefore have an important role in neuronal development.

A novel action of angiotensin peptides in inhibiting neurite outgrowth from isolated chick sympathetic neurons in culture

There is increasing evidence that neuropeptides have trophic functions during embryogenesis. We examined the ability of angiotensin II, substance P, somatostatin-28 and luteinising hormone-releasing hormone to influence neurite outgrowth from embryonic chick sympathetic neurons in culture. Nanomolar concentrations of angiotensin II inhibited neurite outgrowth, whereas the other peptides had no effect at similar concentrations. The effect of angiotensin II on neurite outgrowth is likely to be mediated by an atypical angiotensin receptor, as it was only weakly inhibited by [sar1,ala8]angiotensin II, and was not inhibited by losartan, an inhibitor of mammalian AT1 receptors, or PD123319, an AT2 inhibitor. Neurite outgrowth was also inhibited by angiotensin III and angiotensin IV but not by angiotensinogen I1-14. The study provides further evidence that angiotensin peptides, like classical neurotransmitters, may have trophic functions during embryogenesis.

Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children

Obesity and low levels of physical and metabolic fitness are risk factors for cardiovascular disease and diabetes. The purpose of this investigation was to attenuate obesity and improve physical and metabolic fitness in elementary school children. Schools have the opportunity, mechanisms, and personnel in place to deliver nutrition education, fitness activities, and a school food service that is nutritious and healthy. Cohorts from grades 3 to 5 in two school districts in rural Nebraska (Intervention/Control) participated in a 2-year study of physical activity and modified school lunch program. Data collection for aerobic capacity, body composition, blood chemistry, nutrition knowledge, energy intake, and physical activity was at the beginning and end of each year. Int received enhanced physical activity, grade specific nutrition education, and a lower fat and sodium school lunch program. Con continued with a regular school lunch and team sports activity program. At year 2, Int lunches had significantly less energy (9%), fat (25%), sodium (21%), and more fiber (17%). However, measures of 24-hour energy intake for Int and Con showed significant differences for sodium only. Physical activity in the classroom was 6% greater for Int compared to Con (p < 0.05) but physical activity outside of school was approximately 16% less for Int compared to Con (p < 0.05). Body weight and body fat were not different between schools for normal weight or obese children. No differences were found for cholesterol, insulin, and glucose; however, HDL cholesterol was significantly greater and cholesterol/HDL was significantly less for Int compared to Con (p < 0.05). It appears that compensation in both energy intake and physical activity outside of school may be responsible for the lack of differences between Int and Con.

The role of elective operation in the treatment of portal hypertension

Variceal bleeding is associated with a high rate of rebleeding and death if left untreated. Operative therapy is an important modality for managing portal hypertension in patients unsuitable for, or who fail, sclerotherapy. Review of 41 patients undergoing 42 surgical procedures for portal hypertension since 1988 revealed 22 elective procedures with a 4.5 per cent operative mortality. Ten emergent procedures were undertaken for patients actively bleeding, resulting in a 40 per cent mortality rate. Minor rebleeding not related to portal hypertension occurred in 2 of the 35 patients who survived long term, and long-term shunt patency was 97 per cent. These 41 patients were compared with 35 patients undergoing transjugular intrahepatic portosystemic shunts (TIPS) at Vanderbilt University Medical Center, whom we have previously reported. Five patients underwent shunt procedures after TIPS failure. Attempts to decompress portal hypertension using TIPS placement have met with limited success because of early thrombosis (12%), stenosis (41%), and a high rebleeding rate. Our data suggest that elective operative shunting procedures for the treatment of portal hypertension in Child's class A or B patients are associated with low rates of mortality, encephalopathy, and rebleeding. Moreover, the encephalopathy rate that occurred after TIPS or operative total shunt was higher than that observed in patients undergoing selective distal splenorenal shunt. Therefore, we advocate the elective operation rather than TIPS in the management of portal hypertension in patients with good liver reserve. TIPS is better suited for the patient with active bleeding, poor liver reserve, transplant candidates, or in patients with prohibitive operative risk.

The role of heparan sulfate proteoglycans in the pathogenesis of Alzheimer's disease

The hallmark of Alzheimer's disease (AD) is the deposition of amyloid plaques and neurofibrillary tangles in the brain. The relationship between amyloid deposition and the cognitive deficit is still unclear. The amyloid beta A4 protein is produced by proteolytic cleavage of the amyloid protein precursor (APP). Very little is known about the normal function of APP and the role the protein may play in pathogenesis. Several studies have shown that APP is important for the regulation of neurite outgrowth. Our studies support these findings and indicate that the neurite outgrowth-promoting effects of APP are stimulated by an interaction between APP and specific proteoglycans. Using site-directed mutagenesis, a heparan sulfate binding site which mediates this effect has been mapped to the N-terminus of APP (residues 96-110, HBD-1). A peptide homologous to HBD-1 blocks the trophic effects of APP in cell culture. To purify specific proteoglycans which stimulate the action of APP, an affinity column was constructed using a biotinylated peptide homologous to HBD-1 coupled to streptavidin-agarose. Two proteoglycans were isolated from a crude brain cell conditioned medium by affinity chromatography. The purified proteoglycans bound APP saturably with high affinity and stimulated the action of APP on neurite outgrowth from chick sympathetic neurons. Digestion of the proteoglycan fraction with heparitinase I or chondroitinase ABC demonstrated the presence of two major proteins, a heparan sulfate proteoglycan with a core protein of 63-67 kD molecular mass and a chondroitin sulfate proteoglycan with a core protein of 100-110 kD molecular mass. The results demonstrate that APP binds to at least two proteoglycans and that this interaction may regulate the trophic effects of the protein. The interaction of specific APP-binding proteoglycans with amyloid plaques may disturb the normal function of APP and contribute to the neuritic degeneration that is commonly seen around the amyloid plaque cores.

Importance-performance analysis as a guide for hospitals in improving their provision of services

As a result of the 1990 National Health Services Act, hospitals now compete with one another to win service contracts. A high level of service quality represents an important ingredient of a successful competitive strategy, yet, in general, hospitals have little external information on which to base quality decisions. Specifically, in their efforts to win contracts from fundholding general practitioners, hospitals require information on that which these purchasers deem important with respect to quality, and on how these purchasers assess the quality of their current service performance. The problem is complicated by the fact that hospital service quality, in itself, is multi-dimensional. In other areas of economic activity, the information problem has been resolved by importance-performance analysis and this paper reports the findings of such an analysis conducted for hosptials in the Trent region. The importance and performance service quality ratings of fundholders were obtained from a questionnaire survey and used in a particular variant of importance-performance analysis, which possesses certain advantages over more conventional approaches. In addition to providing empirical data on the determinants of service quality, as perceived by the purchasers of hospital services, this paper demonstrates how such information can be successfully employed in a quality enhancement strategy.