Inhibition by the anti-mitotic drug doxorubicin of platelet-activating-factor-induced late eosinophil accumulation in rats

Platelet-activating factor (PAF) has been shown, in the rat model of pleural inflammation, to induce the generation of an intermediate proteic factor able to cause eosinophil proliferation in vitro. This study was undertaken to investigate the effect of the anti-mitotic compound doxorubicin on PAF-induced eosinophilia in rats, in order to evaluate the contribution of local cell proliferation to this phenomenon. The late eosinophil infiltration caused by another chemoattractant leukotriene B4 was used for comparison. We observed that local treatment with doxorubicin (20 and 40 microg/cavity), given 6 h after PAF (1 microg/cavity), suppressed the eosinophil accumulation within 24 h, whilst only the higher dose was effective when the drug was given 12 h post-PAF. An effect on chemotaxis was ruled out, since local doxorubicin (40 microg/cavity) failed to modify the eosinophil migration noted 24 h after leukotriene B4 (0.5 microg/cavity) and the neutrophil/eosinophil infiltration noted at 6 h after PAF injection. Transfer of the pleural fluids collected 6 h after PAF from donors to recipient rats caused significant eosinophil accumulation in the recipient rats, an effect which was inhibited by the co-administration of doxorubicin (40 microg/cavity). No inhibitory effect was noted when the drug was given 6 h after the pleural fluids were transferred. We also found no change in the number of blood or bone marrow eosinophils after PAF stimulation. We conclude that doxorubicin selectively impaired the late eosinophil accumulation triggered by PAF in the pleural cavity of rats, clearly indicating that local cell proliferation seems to contribute to the development of this inflammatory response.

Assessing the availability of casemix information in hospital database systems in Rio de Janeiro, Brazil

OBJECTIVE

This article considers the possibility that using secondary diagnoses extracted from hospital medical records of patients would modify the diagnosis related groups (DRG) allocated to a case and the Charlson comorbidity index (CCI) calculated from data in the Brazilian hospital information system.

DESIGN

This study used two databases: the administrative database of the Brazilian health care system which consists of claim forms abstracted from medical records and is primarily linked to reimbursement, and the medical records that correspond to a sample of claims forms of which the first data source is composed. Changes in DRG were tested by analyzing percent of agreement and the kappa index. Logistic regression was employed to evaluate the impact of using CCI scores.

SETTINGS AND PATIENTS

This study is based on a sample of claim forms and medical records (n = 1331) from a number of private acute-care hospitals which had contracts with the municipality of Rio de Janeiro in 1986.

RESULTS

Use of information on comorbidity shown in medical records caused changes both in the classification of cases into DRG and in the scores of the CCI. The impact of restrictions on the number of secondary diagnoses in the Brazilian administrative database is comparatively more important for the CCI than for DRG allocation since the Charlson method is based on an additional model where every case of comorbidity is taken into account cumulatively for the final score.

CONCLUSION

These findings indicate the importance of taking a number of measures to improve the quality of information systems in order to increase their potential role in the evaluation of Brazil's health services.

Tennessee's failed managed care program for mental health and substance abuse services

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.

Addressing a state's physician workforce priorities through the funding of graduate medical education: the TennCare model

TennCare is Tennessee's innovative program that replaces the state's Medicaid program with a health care system based on managed care and designed to cover the vast majority of the state's poor and uninsured. The program provides health care benefits not only to those eligible for Medicaid, but also to the uninsured poor who do not qualify for Medicaid and those who are uninsurable because of existing medical conditions. This article describes the allocation of TennCare graduate medical education funding, which is designed to address the state's physician workforce priorities regarding specialty mix and practice location. Under the new TennCare graduate medical education funding design, funds flow to the state's 4 medical schools and then to the sites of the residents' training. Allocation to the medical schools is based primarily on the number of primary care residents in residency programs under sponsorship of each.

[A clinical case of restrictive myocarditis due to senile-type amyloidosis]

We describe the case of a patient with restrictive cardiomyopathy due to primary amyloidosis associated with aging. The patient had a complex myocardial function. A brief review is made of the etiology, diagnostic procedures and therapy of this clinical entity, which is an important rare cause of cardiac death in elderly patients.

Long-term effects of potassium citrate therapy on the formation of new stones in groups of recurrent stone formers with hypocitraturia

OBJECTIVE

To compare stone formation rates before (as total rates and during remote periods) and after therapy with potassium citrate in patients with hypocitraturia.

PATIENTS AND METHODS

The study comprised 15 patients with hypocitraturia only (Group I) and 12 patients with hypocitraturia associated with other abnormalities (Group II), all of whom were recurrent stone formers. Their urine chemistry, including citrate, was measured before and after treatment.

RESULTS

In both groups, the urinary citrate concentration increased significantly to within normal limits during therapy with potassium citrate (P < 0.005). The rate of total stone formation in patients in Group I decreased significantly from 0.7/year before to 0.13/year after treatment (P < 0.005). The corresponding remote stone formation rate before (0.88/year) was significantly greater than the rate after treatment (0.13/year; P < 0.005; follow-up 4.6 +/- 1.9 years). Patients in Group II showed a similar striking decrease in total stone formation rate, from 1.2/year to 0.08/year after treatment (P < 0.005). The corresponding remote stone formation rate (1.66/year) before was significantly greater than that after treatment (0.08/year; P < 0.005; follow-up 4.1 +/- 1.6 years). There was a remission rate of 93% for stone formation over the complete follow-up.

CONCLUSION

Potassium citrate appears to be the drug of choice in the long-term treatment of patients with hypocitraturia as it not only decreases the rate of stone formation but also maintains normal citrate levels in the urine.

The efficacy of individual computer heart rate indices in detecting acidemia at birth in growth-restricted fetuses

OBJECTIVE

To determine the efficacy of individual fetal heart rate (FHR) indices, as determined by computer analysis of the FHR tracing, in detecting fetal acidemia at birth in growth-restricted fetuses.

METHODS

The study population consisted of 38 growth-restricted fetuses at 26-37 weeks' gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. The 1-hour FHR tracing was analyzed by computer within 4 hours of cesarean birth before the onset of labor. Umbilical artery cord blood was collected at birth, and pH was determined within 5 minutes of collection.

RESULTS

On linear regression, the duration of episodes of low variation in minutes (r = -0.77, r2 = 0.59) and short-term (r = 0.72, r2 = 0.52) and long-term (r = 0.69, r2 = 0.47) variation in milliseconds were significantly related to umbilical artery pH at birth, and more so than the number of accelerations of ten (r = 0.57, r2 = 0.32) and 15 (r = 0.38, r2 = 0.14) beats per minute. There were significant differences in computer measurements of FHR accelerations and variation between the umbilical artery pH categories of acidemia (pH less than 7.20), preacidemia (7.20-7.25), and nonacidemia (greater than 7.25). Stepwise regression revealed that episodes of low variation best described the model for predicting umbilical artery pH at birth (P < .001), with no improvement provided by the addition of other computer-analyzed FHR characteristics.

CONCLUSION

In this population of growth-restricted fetuses delivered by elective cesarean, the computer indices of duration of episodes of low variation and short-term and long-term variation were significantly associated with umbilical artery pH and predicted umbilical artery acidemia at birth.

[Exertion syncopal crisis in the young, associated with idiopathic long QT syndrome]

The cases of two young patients with repetitive syncopal attacks due to idiopathic long QT syndrome (ILQTS) are reported. Both had been primarily misdiagnosed for seizures. In one of the cases the QT interval in the ECG at rest was normal. The same patient had a previous episode of cardiac arrest with ventricular fibrillation. The treadmill stress test was of great value, revealing polymorphic ventricular tachycardia induced by exercise, and evaluating the efficacy of beta-blocking therapy in the follow-up. The ILQTS should be considered a possible etiology in any patient presenting with new onset seizures, especially in the young. The treatments were different in both cases. In the first one, the treatment with nadolol (100 mg od) revealed to be very effective with total remission of symptoms. The treadmill stress test performed 15 days after the beginning of treatment did not show any ventricular arrhythmias, and it was assumed that the patient was effectively protected against ventricular arrhythmias. After 4.5 months of follow up, no syncopal episodes occurred. In the second case due to young age, the frequency, and the severity of the attacks (cardiac arrest with ventricular fibrillation), and the inefficacy of beta-adrenergic-blocking agents, the implantable cardioversor-defibrillator was the treatment chosen, although the beta blocking therapy was maintained to reduce the number of arrhythmic events. The ILQTS is a rare anomaly related to sudden cardiac death. The ILQTS is characterised by the association of several distinctive electrocardiographic features, among which prolongation of the QT interval is the best known. Life-threatening arrhythmia occurs usually under conditions of physical or psychological stress. Relatively effective therapies do exist and are represented by antiadrenergic interventions: beta-adrenergic-blocking agents are the treatment of choice. When they fail, left sympathetic denervation or the automatic implantable cardioversor-defibrillator have also proved to be effective.

Twinning in the Palestinian population of Jerusalem and the West Bank

Although it is currently believed that the Palestinian population has relatively high twinning rates, to our knowledge no specific studies on this have yet been conducted. Therefore, and as a first step in our institutional program to develop medical and social care, as well as research programs specifically directed to twins in this area of the world, a number of observations have been conducted in order to gather estimates of twinning rates in the Palestinian population of East Jerusalem and the West Bank of the Jordan. This corresponds to the regions of Judea and Samaria, largely composed of small villages where most of the population lives, as well as a number of more important centers, such as Jenin, Nablus, Ramallah, Bethlehem, and Hebron.

Although we have, unfortunately, been unable to obtain vital statistics on the entire Palestinian population of the West Bank from the administrative offices of Judea and Samaria, information on total maternities and twin maternities by sex, for the period 1984-1988, was kindly provided by all Arab hospitals and maternity clinics in Jerusalem, and also by the United Nations Refugees World Agencies (UNRWA) with respect to the refugee camps.

The population we have studied, therefore, is limited to the Palestinians of East Jerusalem and the West Bank refugee camps, and corresponds to about one-third of the entire Palestinian population of the area. However, it does include both an urban setting (East Jerusalem) as well as a rural one (the refugee camps), and both Moslems and Christians, so it can be safely considered as representative of the entire Palestinian population. As for the period considered, we elected to limit our survey to the five-year period 1984-1988 because the records for then are considered to be more reliable than they had been previously, when little, if anything, was known on statistics, particularly on twin statistics relating to the West Bank population.

[Atresia of the common pulmonary vein]

A case of common pulmonary vein atresia is presented, in which all pulmonary veins drain into a venous confluence without outlet. The criteria helpful in differentiating this condition from other forms of anomalous pulmonary disease in the neonatal period are discussed.

Caudal block for analgesia after paediatric inguinal surgery

Two hundred and eleven children aged 1-5 years were studied after undergoing herniorrhaphy or orchiopexy. In 111 cases a caudal block was used for postoperative analgesia. This was administered immediately after induction of anaesthesia, using bupivacaine 0.25% plain (0.7 ml/kg lean body mass), and was successful in 100 patients. A mean analgesic level (+/- SE) of T9.9 +/- 0.47 was achieved (range L2-T6). In 5 cases no block occurred and in 6 the level was below T12. The other 100 children acted as controls. Behaviour patterns were more restful in the caudal block group on awakening and less opiate was required during the first 5 postoperative hours. No complications resulted.

[Occlusive adenoids causing cor pulmonale and pectus excavatum in a child (author's transl)]

In a Child respiration was impaired already during infancy by occlusive adenoids causing pectus excavatum, cardiomegaly with signs of right ventricular and right atrial hypertrophy, hepatomegaly and dystrophy. The child showed psychological injury as well. After adenectomy these symptoms gradually disappeared. The cardiorespiratory syndrome by obstruction of the upper airways demands active surgical therapy since it may lead to right ventricular failure and pulmonary edema.

[A contribution to the closing of perforations of the nasal septum (author's transl)]

A method of closure of septal perforations is described. A wide pedicled flap of mucoperichondrium based by the inferior margin of the perforation is raised and having been rotated and drawn through closes the perforation on the one side. The defect is further patched by a composite retro-auricular graft, the cartilage of which is shaped to fit the perforation. During the past 2 years, 7 large perforations have been closed in this hospital by this method. Apart from one posterior defect, which at operation could not be covered the other perforations were closed.

[Presentation and treatment of stapes dislocation and subluxation (author's transl)]

The symptomatology, especially vestibular, and the surgical findings in traumatic dislocation of the stapes into the oval window are described in 2 patients, one of whom seen 1 3/4 h after the accident and the other after 12 days. The main indication for exploratory tympanotomy was change of the spontaneous nystagmus from an irritative to a paretic type. Special attention should be given to positional nystagmus, which increases on turning onto the affected side, the mechanism for which is apparently similar to the positional vertigo of labyrinthine fistulae. Hearing was preserved in both patients. In one patient, vestibular function recovered considerably whilst in the other, there remained considerable impaired function.