Costs of care associated with high-dose therapy and autologous transplantation for non-Hodgkin's lymphoma: results from the University of Nebraska Medical Center 1989 to 1995

The purpose of this paper was to (1) comprehensively analyze transplant-related costs for predicted temporal cost shifting and (2) to evaluate whether previous findings of decreasing costs of care persisted using a cost analysis of 353 NHL patients who received autologous stem cell transplantation (SCT) at the University of Nebraska Medical Center. All transplant-related costs between the patient's initial consult and program dismissal were obtained and inflated to constant 1995 dollars. Homogeneous resources were categorized into six cost-drivers and subdivided into outpatient, transplant, and additional inpatient time periods in order to evaluate resource utilization and cost shifting patterns. Between 1989 and 1991 both the average length of stay and comprehensive costs decreased 4.9 days and 14%, respectively. By 1995 additional decreases of 25.7 days and 51% led to an overall 7 year cost decline of 65%. Percent contributions of the six cost-drivers remained similar demonstrating uniformed suppression in transplant-related resource consumption. In contrast, the timing of resource utilization changed dramatically, with transplant hospitalization costs accounting for 83% of the overall costs in 1989, 71% by 1992, and only 45% in 1995, while total outpatient's contribution was 14%, 26% and 49%. Before 1991 ebbing costs were likely related to the development of new technologies such as hematopoietic growth factors and peripheral SCT, while the three-fold larger improvement in costs reported by 1995 are presumably associated with learning curve effects such as organizational changes, increased use of coordinated outpatient facilities, and the more cost-effective use of laboratory tests and pharmaceuticals.

An evidence-based analysis of the effect of busulfan, hydroxyurea, interferon, and allogeneic bone marrow transplantation in treating the chronic phase of chronic myeloid leukemia: developed for the American Society of Hematology

Because there are differing opinions regarding treatment of patients in the chronic phase of chronic myeloid leukemia (CML), the American Society of Hematology convened an expert panel to review and document evidence-based benefits and harms of treatment of CML with busulfan (BUS), hydroxyurea (HU), recombinant interferon-alpha (rIFN-alpha), and bone marrow transplantation (BMT). The primary measure for defining efficacy was survival. Analysis indicated a survival advantage for HU over BUS. Observational studies of rIFN-alpha suffer from numerous biases including sample size, variations in study populations, definitions of hematologic and cytogenetic remissions, and dose. That rIFN-alpha is more efficacious than chemotherapy is demonstrated by 6 prospective randomized trials. For patients with favorable clinical features in chronic phase, compared to HU and BUS, rIFN-alpha improves survival by a median of about 20 months. Most evidence suggests that rIFN-alpha is most effective when combined with other drugs and when given during the earliest stage of the chronic phase. Adding cytarabine to rIFN-alpha adds further survival benefit but increases toxicity. Limitations for evaluating the long-term benefits of allogeneic BMT include the retrospective nature of most studies, incomplete documentation of the clinical characteristics of the patients, paucity of the details on patient selection, lack of control groups, and limitations of survival calculations. Survival curves for BMT show that at least half of the patients transplanted remain alive 5 to 10 years after treatment, whereas similar curves for rIFN-alpha show a continuous relapse rate over time with the curves crossing at about 7 to 8 years. Estimates of long-term survival may be confounded by the selection biases mentioned and the analytic methods used. The magnitude of the incremental increase in benefit with BMT must be weighed against the potential serious harm and death that may accompany the procedure in the short term. The best results with BMT have been obtained when it is performed within 1 to 2 years from diagnosis. Since each treatment option involves tradeoffs between benefit and harm, patient choice must be based on the examination of facts presented in an unbiased fashion. Newly diagnosed younger patients and older patients who are candidates for BMT should also be offered information about IFN-based regimens, the tradeoffs involved, and, if possible, share in the treatment decision. Hopefully this analysis will provide the stimulus for evaluation of other important aspects of CML.

A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study

OBJECTIVE

To evaluate a family-focused asthma intervention designed for inner-city children 5 to 11 years old with moderate to severe asthma.

STUDY DESIGN

Randomized, multisite, controlled trial to minimize symptom days (wheeze, loss of sleep, reduction in play activity) measured by a 2-week recall assessed at 2-month intervals over a 2-year follow-up period. The intervention was tailored to each family's individual asthma risk profile assessed at baseline.

RESULTS

Averaged over the first 12 months, participants in the intervention group (n = 515) reported 3.51 symptom days in the 2 weeks before each follow-up interview compared with 4.06 symptom days for the control group (n = 518), a difference of 0.55 (95% CI, 0.18 to 0.92, P =.004). The reduction among children with severe asthma was approximately 3 times greater (1.54 d/2 wk). More children in the control group (18.9%) were hospitalized during the intervention compared with children in the intervention group (14. 8%), a decrease of 4.19% (CI, -8.75 to 0.36, P =.071). These improvements were maintained in the intervention group during the second year of follow-up, during which they did not have access to the asthma counselor.

CONCLUSIONS

We demonstrated that an individually tailored, multifaceted intervention carried out by Masters-level social workers trained in asthma management can reduce asthma symptoms among children in the inner city.

Silicone filled breast implants and the risk of fibromyalgia and rheumatoid arthritis

OBJECTIVE

The symptoms of what has been called silicone implant associated syndrome (SIAS) and fibromyalgia (FM) are similar. It has been hypothesized that silicone (filled) breast implants (SBI) might be causally related to the development of FM. This hypothesis was investigated by comparing 508 patients with FM with 1228 control subjects. We also studied the relationship of SBI to the subsequent development of rheumatoid arthritis (RA).

METHODS

Utilizing a longitudinal databank, implantation status was determined in 464 patients with RA, 508 with FM, 261 with osteoarthritis (OA) of the knee or hip, and in 503 randomly selected community controls. We obtained data on the type of implant and its temporal relationship to the onset of FM and RA.

RESULTS

No association between SBI and RA was found (OR 1.66, 95% CI 0.33, 8.23, p = 0.538). No association between prior SBI and subsequent FM was found (OR 1.22, 95% CI 0.30, 4.89, p = 0.781). But one-third of the SBI in FM occurred after development of the syndrome. When all implants regardless of temporal relationship were considered, the overall relationship between any implant and the diagnosis of FM was significant at p = 0.095 (OR 2.45, 95% CI 0.86, 7.03).

CONCLUSION

No relationship between prior SBI and the subsequent development of FM or RA was noted. But implants appear to be more common in patients with than in those without FM (p = 0.095). A common, predisposing set of psychosocial characteristics may be shared between those who have FM and those who undergo SBI.

Gender-related differences in vascular smooth muscle cell proliferation: implications for prevention of atherosclerosis

Premenopausal women have a significant reduction in coronary artery disease compared to age-matched males. Little is known about the mechanism underlying this cardioprotective effect of estrogen. Contradictory evidence has been published and our lack of basic understanding of hormone interactions and bioavailability of different estrogens prevents definitive interpretation of these data. We demonstrate gender-specific effects in the proliferation of coronary artery vascular smooth muscle cells obtained from a sexually mature animal model. Vascular smooth muscle cells are an integral component of the atherosclerotic plaque, and inhibition of cell proliferation by estrogen may be one mechanism by which estrogen exerts its cardioprotective effect. Various types of estrogen may also have different mechanistic actions on the vascular system. No differences are demonstrated in overall estradiol binding in vascular smooth muscle cells obtained from male or female animals: however, differences in c-jun, c-fos and TIEG gene expression were gender related. Inhibition of vascular smooth muscle cell proliferation may have important implications in the prevention of atherosclerotic disease and these studies may provide evidence for the cardioprotective effect of estrogen.

A rapid chromatographic strip test for the pen-side diagnosis of rinderpest virus

Rinderpest is a contagious viral disease of cloven-hoofed domestic and wild animals. Eradication of the virus following outbreaks depends on rapid and accurate diagnosis of infection and the implementation of control measures. Reporting and confirmatory diagnosis precede the implementation of control measures. A number of techniques have been used for diagnosis such as agar gel immunodiffusion, enzyme-linked immunosorbent assay (ELISA), molecular biological techniques such as polymerase chain reaction (PCR) and virus isolation in tissue culture. Many of these methods are both time consuming and require skilled personnel. The development of a rapid pen-side test for the detection of rinderpest virus (RPV) antigen in lachrymal fluid of cattle is described using the Clearview chromatographic strip test technology (Unipath, Bedford). Optimum conditions for binding monoclonal antibody to nitrocellulose and latex microspheres were determined and a prototype device was developed. The device detected viral antigen in lachrymal fluids from experimentally and naturally infected cattle and showed no cross-reactivity with other related viruses. A field trial was carried out at the Landhi Cattle Colony (LCC), Pakistan, to assess the performance of the rinderpest test under field conditions. Ninety-seven animals, some of which were showing various clinical signs, at LCC and neighbouring colonies were sampled and tested at the pen-side by Clearview and later by immunocapture ELISA (IC-ELISA) at IAH, Pirbright. Nineteen animals were positive by Clearview and/or IC-ELISA. Seventeen out of 19 rinderpest positive animals were positive by Clearview and 15 out of 19 were positive by IC-ELISA. Reverse transcription polymerase chain reaction (RT-PCR) confirmed the 19 animals to be rinderpest positive. This simple, rapid, specific test allows for the first time, accurate pen-side diagnosis of rinderpest.

Increased cytotoxicity and decreased in vivo toxicity of FdUMP[10] relative to 5-FU

The efficacy of treatment with 5-Fluorouracil (5-FU) is limited, in part, by its inefficient conversion to 5-Fluoro-2'-deoxyuridine-5'-O-monophosphate (FdUMP). We present data indicating that FdUMP[10], designed as a pro-drug for intracellular release of FdUMP, is cytotoxic as a consequence of uptake of the multimeric form. FdUMP[10] is stable in cell culture medium, with more than one-half of the material persisting as multimers of at least six nucleotides after a 48 h incubation at 37 degrees C. FdUMP[10] is more than 400 times more cytotoxic than 5-FU towards human colorectal tumor cells (H630). FdUMP[10] also has decreased toxicity in vivo, with doses as high as 200 mg/kg/day (qdx3) administered to Balb/c mice without morbidity, compared to a maximum tolerated dose of 45 mg/kg/day for 5-FU using the same protocol. FdUMP[10] shows reduced sensitivity to OPRTase- and TK-mediated drug resistance, relative to 5-FU and FdU, respectively, and is much more cytotoxic than 5-FU towards cells that overexpress thymidylate synthase. Thus, FdUMP[10] is less susceptible to resistance mechanisms that limit the clinical utility of 5-FU. The increased cytotoxicity, decreased toxicity in vivo, and reduced sensitivity to drug resistance of FdUMP[10], relative to 5-FU, indicates multimeric FdUMP is potentially valuable as an anti-neoplastic agent, either as a single agent, or in combination with 5-FU.

Dundee step test: a simple method of measuring the blood pressure response to exercise

The exercise systolic blood pressure (BP) response provides prognostic information over and above that of resting clinic BP in both normotensive and hypertensive individuals. We have developed a 3-min step test as a method of measuring the exercise systolic BP. Healthy volunteers and patients referred for assessment of hypertension took part in validating this exercise test. We assessed the reproducibility of the exercise systolic BP response, and this was compared with that obtained using the cycle ergometry at an equivalent workload. We also compared the baseline characteristics, BP profiles and exercise systolic BP responses in different subject groups. The intra-observer coefficient of variation assessed in 25 subjects was 5.9% with a mean difference of 1.8 mm Hg. The values for between observer were 8.3% and 2.5 mm Hg respectively. Exercise systolic BP measured with the step test correlated with that of cycle ergometer (n = 37, r = 0.93, P < 0.01). Exercise systolic BP data from healthy volunteers (n = 107) showed a normal distribution. An exercise systolic BP of >/=180 mm Hg was greater than 2 standard deviations from the mean and was taken as an abnormally high BP during exercise. There was a positive correlation between exercise BP and increasing age in healthy volunteers (r = 0.57, P < 0.01). This was also present in hypertensive subjects (n = 46, r = 0.48, P = 0.001), however the slope of this relationship was twice as steep as in the normal subjects. Hypertensive subjects with high exercise systolic BP had significantly higher clinic BP, ABPM and a greater BP rise during exercise. The Dundee step test is quick, reproducible and may be prognostically useful.

Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital

OBJECTIVE

To investigate the nature and duration of clinical instability (i.e., abnormalities in simple physical observations or laboratory test results) in hospital patients before a "critical event" (i.e., a cardiac arrest or an unplanned admission to intensive care).

DESIGN

Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population.

SETTING

A 300-bed metropolitan teaching hospital with a seven-bed ICU.

PATIENTS

All patients having CEs over a 12-month period (January to December 1997).

MAIN OUTCOME MEASURES

Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients.

RESULTS

There were 122 CEs in 112 patients (median, 1; range, 1-4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0-9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0-432 hours), and in that time a median of two (range, 0-13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19,853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU.

CONCLUSIONS

Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

Surveillance of construction worker injuries: the utility of trade-specific analysis

Construction is a dangerous industry, with high rates of both fatal and nonfatal injuries. To learn more about the causes of nonfatal construction worker injuries, and to identify injury cases for further work site-based investigations or prevention programs, we established an emergency department-based surveillance program in November 1990. This article describes circumstances of injury, diagnoses, and demographic characteristics of injured construction workers for 2,791 cases identified through mid-August, 1997. Lacerations and strains and sprains were the most frequent diagnoses; cutting and piercing objects were the leading causes of injury among all construction workers, followed by falls and overexertion. Because of the variety of work performed in this industry, more detailed injury descriptions, by trade, are most useful for thinking about injury prevention. To illustrate this, we profile injury patterns among workers from four specific trades: carpenters, electricians, plumbers, and ironworkers. Areas of concern highlighted by the trade-specific analyses include eye injuries among plumbers; falls from ladders among electricians and plumbers; slips, trips, and falls on the same level among ironworkers; electrical exposure among electricians; and, amputations among carpenters.

Correlation of cytokine elaboration with mononuclear cell adhesion to platelet storage bag plastic polymers: a pilot study

The basis for many febrile nonhemolytic transfusion reactions associated with platelet transfusion therapy is cytokine elaboration and accumulation in the storage bag, which correlate with the leukocyte content and the length of platelet storage. We propose that a possible additional variable in the elaboration and accumulation of cytokines is the differential adhesion of mononuclear cells to the plastic substrate of the platelet storage bag. We hypothesize that mononuclear cell adhesion-induced cytokine release is greater in random-donor platelet bags composed of the polyolefin polymer compared to the single-donor apheresis platelet bags composed of the polyvinyl chloride polymer with the tri-(2-ethylhexyl) trimellitate (TEHTM) plasticizer. For four blood donors, we demonstrate preferential mononuclear cell adhesion, in vitro, to discs of polyolefin polymer versus discs of polyvinyl chloride polymer with the TEHTM plasticizer. Scanning electron microscopy corroborates this. In addition, proinflammatory cytokine (interleukin 1beta [IL-1beta] and tumor necrosis factor alpha [TNF-alpha]) levels are greater in culture wells containing discs of polyolefin polymer than in those containing discs of polyvinyl chloride polymer with the TEHTM plasticizer, and even more so in storage bags containing polyolefin polymer versus polyvinyl chloride polymer with the TEHTM plasticizer (IL-1beta, TNF-alpha, IL-6, and IL-8). This study suggests, for the first time, that differential plastic substrate mononuclear cell adhesion may contribute to cytokine release during platelet storage. This may represent an additional variable in the pathophysiology of febrile nonhemolytic transfusion reactions in patients receiving stored platelet units.

Solubility of various forms of strontium titanate in lungs: in vitro and in vivo studies

At the In-Tank Precipitation Facility of the Savannah River Site, strontium and other radionuclides are removed from high-level radioactive waste and sent to the Defense Waste Processing Facility. Strontium removal is accomplished by adsorption using a slurry that includes monosodium titanate, which forms strontium titanate with unknown lung solubility characteristics. The purpose of this study was to determine the solubility of strontium titanate in the form created at the In-Tank Precipitation facility. An in vitro dissolution study was done with a slurry simulant and with several types of strontium titanate, and the results were compared. An in vivo study was also performed with high-fired SrTiO3 in rats. Strontium and titanium were measured by inductively-coupled plasma/atomic emission spectrometry. The data from both studies were used independently to assign the compounds to an absorption type based on criteria specified in ICRP 71. Results of the in vitro studies showed that the Defense Waste Processing Facility simulant should be assigned to Type M and the strontium titanate should be assigned to Type S. Results of the in vivo study verified that SrTiO3 should be assigned to Type S. Lung clearance data of SrTiO3 from rats showed that 85% cleared within the first 24 h and the remaining 15% cleared with a half-time of 130 d. The initial rapid clearance is attributed to deposition in airways as compared to the alveolar region.

GCD14p, a repressor of GCN4 translation, cooperates with Gcd10p and Lhp1p in the maturation of initiator methionyl-tRNA in Saccharomyces cerevisiae

Gcd10p and Gcd14p were first identified genetically as repressors of GCN4 mRNA translation in Saccharomyces cerevisiae. Recent findings indicate that Gcd10p and Gcd14p reside in a nuclear complex required for the presence of 1-methyladenosine in tRNAs. Here we show that Gcd14p is an essential protein with predicted binding motifs for S-adenosylmethionine, consistent with a direct function in tRNA methylation. Two different gcd14 mutants exhibit defects in cell growth and accumulate high levels of initiator methionyl-tRNA (tRNAiMet) precursors containing 5' and 3' extensions, suggesting a defect in processing of the primary transcript. Dosage suppressors of gcd10 mutations, encoding tRNAiMet (hcIMT1 to hcIMT4; hc indicates that the gene is carried on a high-copy-number plasmid) or a homologue of human La protein implicated in tRNA 3'-end formation (hcLHP1), also suppressed gcd14 mutations. In fact, the lethality of a GCD14 deletion was suppressed by hcIMT4, indicating that the essential function of Gcd14p is required for biogenesis of tRNAiMet. A mutation in GCD10 or deletion of LHP1 exacerbated the defects in cell growth and expression of mature tRNAiMet in gcd14 mutants, consistent with functional interactions between Gcd14p, Gcd10p, and Lhp1p in vivo. Surprisingly, the amounts of NME1 and RPR1, the RNA components of RNases P and MRP, were substantially lower in gcd14 lhp1::LEU2 double mutants than in the corresponding single mutants, whereas 5S rRNA was present at wild-type levels. Our findings suggest that Gcd14p and Lhp1p cooperate in the maturation of a subset of RNA polymerase III transcripts.

Comparative cytotoxicity of fumonisin B1 in two cell lines derived from normal human bronchial epithelial cells using four distinct bioassay techniques

This study focuses on the cytotoxic effects of fumonisin B1 (FB1) on both immortalised and immortalised and subsequently transfected normal human bronchial epithelial (NHBE) cells of human origin using four bioassays. While the MTT, Neutral Red and hexosaminidase colorimetric assays showed little difference between the toxic effects on the two related cell lines, the clonogenic assay, measuring cell survival and proliferation, indicated that FB1 had a more toxic effect on the nontransfected cells. This kind ofin vitro approach using cells which retain many characteristics of normal cell growth and differentiation can go some way to developing evaluation models for food safety in the case of mycotoxin contamination without resorting totally to whole animal testing. Nevertheless, one or two cytotoxicity tests may be inadequate for a complete appraisal of toxic potential: rather, as wide a range of methodologies as feasible should be employed initially before meaningful conclusions may be drawn.

Cardiovascular disease and treatment outcomes with osseointegration surgery

STATEMENT OF PROBLEM

The frequency of prescription of implant-supported prostheses demands increased scrutiny of systemic health condition on treatment inclusion and exclusion criteria. The risks of an impaired healing response in patients with certain types of cardiovascular diseases (CVD) suggest a possible risk for implant failure in such patients.

PURPOSE

This preliminary study surveyed implant treatment outcome of patients with cardiovascular diseases.

METHODS

A retrospective analysis of 246 consecutively treated patients was conducted. The patients comprised a CVD interest group of 39 patients, and control subgroups of 98 healthy and 109 patients with a history of other systemic disease.

RESULTS

Differences in implant failure rates between the groups were not found to be significant. Though the sample size is small, these results suggest that CVD may not be a risk factor for successful osseointegration.

The efficacy of lamotrigine in rapid cycling and non-rapid cycling patients with bipolar disorder

BACKGROUND

Patients with bipolar disorder (BD) who have rapid cycling features are often treatment refractory. Clear and conclusive evidence regarding effective treatments for this group is not available.

METHODS

Patients with diagnoses of refractory bipolar disorder who were currently experiencing manic, mixed, depressive, or hypomanic episodes were treated with lamotrigine as add-on therapy (60 patients) or monotherapy (15 patients). We compared the efficacy of lamotrigine in the 41 rapid cycling and 34 non-rapid cycling patients with BD.

RESULTS

Improvement from baseline to last visit was significant among both rapid cycling and non-rapid cycling patients for both depressive and manic symptomatology. For patients entering the study in a depressive episode, improvement in depressive symptomatology was equivalent in the two groups. Among patients entering the study in a manic, mixed, or hypomanic episode, those with rapid cycling improved less in manic symptomatology than did non-rapid cycling patients. Among rapid cycling patients with initial mild-to-moderate manic symptom severity, improvement was comparable to that in non-rapid cycling subjects; however, the subset of rapid cycling patients with severe initial manic symptomatology had little improvement in mania. Rapid cycling patients had earlier onset and more lifetime episodes of mania, depression, and mixed mania.

CONCLUSIONS

Lamotrigine was generally effective and well tolerated in this group of previously non-responsive, rapid cycling bipolar patients.