Impact of managed care on obstetrician-gynecologists' practice: the providers' perspective

The American College of Obstetricians and Gynecologists' 1998 Socioeconomic Survey of Fellows included questions, developed in collaboration with the Jacobs Institute of Women's Health, to assess the impact of managed care on respondents' practices and patients. Participation in managed care is extensive among obstetricians and gynecologists (ob/gyns), especially in commercial managed care plans. The greatest areas of dissatisfaction for physicians were administrative workload, external review of clinical decisions, and promptness of payment. More research is needed to determine the impact of administrative burdens, restrictions on access to ob/gyns, and denial of coverage on women's receipt of timely and appropriate services.

Validation of conductance catheter system for quantification of murine pressure-volume loops

The purpose of this study was to define the validation methods and outcomes of a conductance catheter system specifically for in vivo murine cardiac hemodynamic analysis. To express the relationship between conductance and blood volumes, we used an in vitro model to derive a volume-conductance line. The volume-conductance line was used to compute raw volume from the modified conductance signals. The parallel volume was calibrated with hypertonic (15%) saline injected from extrajugular vein. The ventricular volume was computed by raw volume minus parallel volume. The accuracy of conductance volumetric measurements was validated with a static in situ infusion of calibrated volumes of whole blood injected into arrested left ventricles. In vivo dynamic measurements were performed with 24 C57B1/6 mice, 6 months old; for comparison of established values. The in situ model showed that after calibration, the experimental coefficient, alpha, was equal to 1 and the measured volume by conductance catheter was equal to the true volume of the left ventricle (y = 0.982x + 0.513, p < .0001). For the in vivo models, the end-diastolic volumes and the stroke volumes and cardiac output determined with the conductance catheter system were 17.3 +/- 1.0 microL, 10.6 +/- 0.9 microL, and 6.0 +/- 0.5 mL/min, respectively. We validated the relationship between measured volume by conductance catheter and the true volume and demonstrated the accuracy of the volume-conductance line for conversion of conductance to volume.

The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics

OBJECTIVE

This investigation assessed the detection and treatment of psychiatric disorders and at-risk substance use among pregnant women in the obstetric sector.

METHOD

The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and modified CAGE questionnaires were used to assess current psychiatric disorders and at-risk substance use among 186 women receiving prenatal care. Medical records were reviewed for evidence of obstetrical providers' recognition of psychiatric and substance use symptoms and diagnoses and initiation of evaluations and treatments. The associations between patient characteristics and chart-documented evaluations and treatments were ascertained.

RESULTS

Seventy (38%) of the women met screening criteria for psychiatric disorders or substance use. Among women who screened positive, symptoms were recorded in 43% of the charts, diagnoses in 18%, evaluations in 35%, and treatments in only 23% Patients who screened positive for psychiatric disorders and/or substance use were significantly more likely to have a documented mental health evaluation if they were less well educated, had inadequate prenatal care, or had longer hospital stays at delivery.

CONCLUSIONS

A substantial number of women treated in obstetrics have unrecognized and untreated psychiatric disorders and substance use. Given the potential impact of antenatal mental disturbances on maternal and infant outcomes, further investigations into the psychiatric evaluation and treatment of pregnant women in the obstetrical sector are required.

A differential outcomes effect using biologically neutral outcomes in delayed matching-to-sample with pigeons

The differential outcomes effect (DOE) pertains to enhanced conditional discrimination performance if each correct stimulus-choice sequence is always followed by a different outcome (e.g., food vs. water) compared to when each correct sequence is followed equally often by either outcome. The present experiments sought evidence of a DOE in pigeons, using biologically neutral outcomes. Experiment 1 replicated findings with rats demonstrating that a DOE can occur when one outcome is a biologically neutral light and the other is the absence of that light. Experiment 2 extended these findings by demonstrating a DOE when two biologically neutral outcomes of similar sensory and associative properties were employed.

MLC3F transgene expression iniv mutant mice reveals the importance of left-right signalling pathways for the acquisition of left and right atrial but not ventricular compartment identity

Abstract Transcriptional differences between left and right cardiac chambers are revealed by an nlacZ reporter transgene controlled by regulatory sequences of the MLC3F gene, which is expressed in the left ventricle (LV), atrioventricular canal (AVC), and right atrium (RA). To examine the role of left-right signalling in the acquisition of left and right chamber identity, we have investigated MLC3F transgene expression in iv mutant mice. iv/iv mice exhibit randomised direction of heart looping and an elevated frequency of associated laterality defects, including atrial isomerism. At fetal stages, 3F-nlacZ-2E transgene expression remains confined to the morphological LV, AVC, and RA in L-loop hearts, although these appear on the opposite side of the body. In cases of morphologically distinguishable right atrial appendage isomerism, both atrial appendages show strong transgene expression. Conversely, specimens with morphological left atrial appendage isomerism show only weak expression in both atrial appendages. The earliest left-right atrial differences in the expression of the 3F-nlacZ-2E transgene are observed at E8.5. DiI labelling experiments confirmed that transcriptional regionalisation of the 3F-nlacZ-2E transgene at this stage reflects future atrial chamber identity. In some iv/iv embryos at E8.5, the asymmetry of 3F-nlacZ-2E expression was lost, suggesting atrial isomerism at the transcriptional level prior to chamber formation. These data suggest that molecular specification of left and right atrial but not ventricular chambers is dependent on left-right axial cues.

Salmonella prosthetic valve endocarditis

We report the case of a 69-year-old man with an aortic valve bioprosthesis in whom a diagnosis of Salmonella typhimurium prosthetic valve endocarditis was made. During the prolonged hospital admission early aggressive antibiotic therapy and early valve replacement surgery were the deciding factors enabling him to survive this otherwise lethal condition.

Multiple transcriptional domains, with distinct left and right components, in the atrial chambers of the developing heart

During heart development, 2 fast-conducting regions of working myocardium balloon out from the slow-conducting primary myocardium of the tubular heart. Three regions of primary myocardium persist: the outflow tract, atrioventricular canal, and inflow tract, which are contiguous throughout the inner curvature of the heart. The contribution of the inflow tract to the definitive atrial chambers has remained enigmatic largely because of the lack of molecular markers that permit unambiguous identification of this myocardial domain. We now report that the genes encoding atrial natriuretic factor, myosin light chain (MLC) 3F, MLC2V, and Pitx-2, and transgenic mouse lines expressing nlacZ under the control of regulatory sequences of the mouse MLC1F/3F gene, display regionalized patterns of expression in the atrial component of the developing mouse heart. These data distinguish 4 broad transcriptional domains in the atrial myocardium: (1) the atrioventricular canal that will form the smooth-walled lower atrial rim proximal to the ventricles; (2) the atrial appendages; (3) the caval vein myocardium (systemic inlet); and (4) the mediastinal myocardium (pulmonary inlet), including the atrial septa. The pattern of expression of Pitx-2 reveals that each of these transcriptional domains has a distinct left and right component. This study reveals for the first time differential gene expression in the systemic and pulmonary inlets, which is not shared by the contiguous atrial appendages and provides evidence for multiple molecular compartments within the atrial chambers. Furthermore, this work will allow the contribution of each of these myocardial components to be studied in congenitally malformed hearts, such as those with abnormal venous return.

A T-cell-selective interleukin 2 mutein exhibits potent antitumor activity and is well tolerated in vivo

Human interleukin 2 (IL-2; Proleukin) is an approved therapeutic for advanced-stage metastatic cancer; however, its use is restricted because of severe systemic toxicity. Its function as a central mediator of T-cell activation may contribute to its efficacy for cancer therapy. However, activation of natural killer (NK) cells by therapeutically administered IL-2 may mediate toxicity. Here we have used targeted mutagenesis of human IL-2 to generate a mutein with approximately 3,000-fold in vitro selectivity for T cells over NK cells relative to wild-type IL-2. We compared the variant, termed BAY 50-4798, with human IL-2 (Proleukin) in a therapeutic dosing regimen in chimpanzees, and found that although the T-cell mobilization and activation properties of BAY 50-4798 were comparable to human IL-2, BAY 50-4798 was better tolerated in the chimpanzee. BAY 50-4798 was also shown to inhibit metastasis in a mouse tumor model. These results indicate that BAY 50-4798 may exhibit a greater therapeutic index than IL-2 in humans in the treatment of cancer and AIDS.

Choice biases in delayed matching-to-sample duration with pigeons: Manipulations of ITI and delay illumination

Two experiments investigated the effects of similarity between intertrial interval (ITI) and delay illumation on the choose-short effect. Different groups of pigeons learned to match "short" (2 s) and "long" (6 or 8 s) food samples to green and red test stimuli in a matching-to-sample procedure with a 5-s training delay. Subsequent 10- and 20-s delay tests revealed choose-short effects if the ITI and delay were both illuminated (i.e., group ON-ON), if the ITI and delay were both dark (i.e., group OFF-OFF), and if the ITI was illuminated and the delay was dark (i.e., group ON-OFF). In addition, either a choose-short effect or a choose-long effect was observed if the ITI was dark and the delay was illuminated (i.e., group OFF-ON). Results are incompatible with the confusion/instructional failure view of the choose-short effect.

Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team

BACKGROUND

Male circumcision is associated with reduced HIV acquisition.

METHODS

HIV acquisition was determined in a cohort of 5507 HIV-negative Ugandan men, and in 187 HIV-negative men in discordant relationships. Transmission was determined in 223 HIV-positive men with HIV-negative partners. HIV incidence per 100 person years (py) and adjusted rate ratios (RR) and 95% confidence intervals (CI) were estimated by Poisson regression. HIV-1 serum viral load was determined for the seropositive partners in HIV-discordant couples.

RESULTS

The prevalence of circumcision was 16.5% for all men; 99.1% in Muslims and 3.7% in non-Muslims. Circumcision was significantly associated with reduced HIV acquisition in the cohort as a whole (RR 0.53, CI 0.33-0.87), but not among non-Muslim men. Prepubertal circumcision significantly reduced HIV acquisition (RR 0.49, CI 0.26-0.82), but postpubertal circumcision did not. In discordant couples with HIV-negative men, no serconversions occurred in 50 circumcised men, whereas HIV acquisition was 16.7 per 100 py in uncircumcised men (P = 0.004). In couples with HIV-positive men, HIV transmission was significantly reduced in circumcised men with HIV viral loads less than 50000 copies/ml (P = 0.02).

INTERPRETATION

Prepubertal circumcision may reduce male HIV acquisition in a general population, but the protective effects are confounded by cultural and behavioral factors in Muslims. In discordant couples, circumcision reduces HIV acquisition and transmission. The assessment of circumcision for HIV prevention is complex and requires randomized trials.

Blood cell lead, calcium, and magnesium levels associated with pregnancy-induced hypertension and preeclampsia

This study compares the red blood cell (Rbc) levels of lead (Pb), calcium (Ca), and magnesium (Mg) in relation to blood pressure in 39 pregnant women in the third trimester of pregnancy. The study population included 20 women with normal pregnancies, 15 with mild hypertension, and 4 with severe hypertension and preeclampsia. The mean +/- SD for each group was calculated and the difference between the means of the normotensive and the other groups were compared by analysis of variance. Significant differences from normal to the preeclamptic pregnancies were in (1) elevated Rbc Pb (p < or = 0.001), (2) lower Rbc Ca (p < or = 0.001), and (3) lower Rbc Mg/Pb ratio (p < or = 0.0001). Pearson's rank correlation between blood pressure showed a direct relation to the Rbc Pb level (p < or = 0.01) and an inverse relation to the Rbc Ca and Mg/Pb ratio (p < or = 0.004, < or = 0.007). Apparently, prenatal blood pressure is directly proportional to Rbc Pb content and related or modified by Rbc Ca and Mg.

Contribution of increasing CO2 and climate to carbon storage by ecosystems in the United States

The effects of increasing carbon dioxide (CO2) and climate on net carbon storage in terrestrial ecosystems of the conterminous United States for the period 1895-1993 were modeled with new, detailed historical climate information. For the period 1980-1993, results from an ensemble of three models agree within 25%, simulating a land carbon sink from CO2 and climate effects of 0.08 gigaton of carbon per year. The best estimates of the total sink from inventory data are about three times larger, suggesting that processes such as regrowth on abandoned agricultural land or in forests harvested before 1980 have effects as large as or larger than the direct effects of CO2 and climate. The modeled sink varies by about 100% from year to year as a result of climate variability.

Geranylgeranyltransferase I of Candida albicans: null mutants or enzyme inhibitors produce unexpected phenotypes

Geranylgeranyltransferase I (GGTase I) catalyzes the transfer of a prenyl group from geranylgeranyl diphosphate to the carboxy-terminal cysteine of proteins with a motif referred to as a CaaX box (C, cysteine; a, usually aliphatic amino acid; X, usually L). The alpha and beta subunits of GGTase I from Saccharomyces cerevisiae are encoded by RAM2 and CDC43, respectively, and each is essential for viability. We are evaluating GGTase I as a potential target for antimycotic therapy of the related yeast, Candida albicans, which is the major human pathogen for disseminated fungal infections. Recently we cloned CaCDC43, the C. albicans homolog of S. cerevisiae CDC43. To study its role in C. albicans, both alleles were sequentially disrupted in strain CAI4. Null Cacdc43 mutants were viable despite the lack of detectable GGTase I activity but were morphologically abnormal. The subcellular distribution of two GGTase I substrates, Rho1p and Cdc42p, was shifted from the membranous fraction to the cytosolic fraction in the cdc43 mutants, and levels of these two proteins were elevated compared to those in the parent strain. Two compounds that are potent GGTase I inhibitors in vitro but that have poor antifungal activity, J-109,390 and L-269,289, caused similar changes in the distribution and quantity of the substrate. The lethality of an S. cerevisiae cdc43 mutant can be suppressed by simultaneous overexpression of RHO1 and CDC42 on high-copy-number plasmids (Y. Ohya et al., Mol. Biol. Cell 4:1017, 1991; C. A. Trueblood, Y. Ohya, and J. Rine, Mol. Cell. Biol. 13:4260, 1993). Prenylation presumably occurs by farnesyltransferase (FTase). We hypothesize that Cdc42p and Rho1p of C. albicans can be prenylated by FTase when GGTase I is absent or limiting and that elevation of these two substrates enables them to compete with FTase substrates for prenylation and thus allows sustained growth.

Presentation and outcome of sacral agenesis: 20 years' experience

The underlying risk factors, presenting features, and outcome of 22 children with sacral agenesis and associated neuropathic bladder were studied retrospectively. The age of children at presentation was bimodally distributed, with peaks below 1 year and between 4 and 5 years of age. Ten patients presented after 1 year. The oldest was diagnosed at 12 years of age. In 12 children there was maternal diabetes, orthopaedic anomalies in 14, skin defects in 11, and anorectal/tracheooesophageal anomalies in three. Most children had persistent dribbling of urine on presentation associated with frequency, urgency, recurrent urinary tract infections, failure to respond to medication, and/or constipation. Twenty-one children had abnormal neurology in the lower limbs. Videourodynamics showed neuropathic vesicourethral dysfunction in all children and vesicoureteric reflux in 10. Nineteen had a history of urinary tract infections. Seven had renal scarring, with renal impairment in three at presentation. Clean intermittent catheterization was recommended for 20 of the children. Bladder or bowel surgery has been carried out in seven and neurosurgery performed in two. Twenty of the 22 children underwent operative procedures. Ten operations were performed before sacral agenesis was diagnosed. Over a third of the children have required psychological support. The combination of urinary symptomatology and any of the above risk factors should give rise to a high level of suspicion and low threshold to perform investigations to exclude sacral agenesis. All these children have abnormal bladder and urethral function which not only causes incontinence but puts the kidneys at risk. Early detection allows effective multidisciplinary input specifically aimed at continence, preservation of renal function, and adequate psychological support.

Contribution of vaporization and boiling to thermal-spike sputtering by ions or laser pulses

Here we consider what, in our terminology, we designate as normal vaporization, normal boiling, and phase explosion. In the case of vaporization, one is dealing with the emission of particles (atoms or molecules) from the extreme outer surface of either a solid or liquid for any temperature exceeding 0 K. In the case of boiling, one is (at least ideally) dealing with heterogeneously nucleated bubbles which diffuse to the outer surface of a liquid or solid and then escape, the latter being possible for temperatures equal to or exceeding the boiling temperature (T(b)). In the case of phase explosion one is dealing with the consequences of what happens when a liquid approaches the thermodynamic critical temperature (T(tc) or T(c)), and massive homogeneous nucleation takes place. Although these three mechanisms have been reviewed in reasonable detail in recent work, we will here present evidence, apparently not previously considered, that boiling, whether the distance scale is atomically small (5-15 nm, as for laser-pulse impact on a metal in the absence of thermal diffusion) or much larger, has a prohibitive kinetic obstacle because it requires bubble diffusion if the bubbles are formed other than at the outer surface. That is to say, boiling will never be a significant process whether with ion or laser-pulse impact. This leaves vaporization and phase explosion as the only possible thermal-spike processes capable of expelling material from an ion- or laser-pulse bombarded surface in a significant quantity. But even with vaporization it can be shown that a kinetic obstacle, although not as severe as for boiling, will enter. The final result is that only phase explosion will normally be relevant for sufficiently short time scales.

Medical restrictions to driving: the awareness of patients and doctors

The study was set up to investigate the awareness of elderly patients and medical doctors of medical restrictions to driving. Separate questionnaires were completed by patients and doctors. All were interviewed face-to-face, without prior warning and their immediate answers were recorded. In total, 150 elderly patients from the acute elderly care wards, rehabilitation wards and day hospital, and 50 doctors (including all grades from consultant to junior house officer) were interviewed. The main outcome measures were numbers of patients currently driving and previously driving; patients' awareness of how their medical condition affected their ability to drive; doctors' spontaneous knowledge of medical conditions which restrict driving, current licensing policy, and restrictions for five specific medical conditions (epilepsy, myocardial infarction, stroke, 5-cm abdominal aortic aneurysm, and diabetes). Only 21 patients were current drivers, and six of these should not have been driving. While 103 perceived themselves eligible to drive, 46 had medical restrictions to driving. Seventeen of the 47 patients who perceived themselves not eligible to drive possibly did not have restrictions to driving. Doctors' knowledge of the current licensing policy and action to be taken if a patient was not eligible to drive was very poor. Knowledge of medical restrictions to driving was scanty, with few doctors giving the correct driving restrictions for the five specific conditions. We recommend that education of doctors regarding medical restrictions to driving should begin at an undergraduate level and be continued throughout their postgraduate career.

Outflow uropathy: occupational disorder?

This paper alerts physicians, health care workers, and employers to a probable connection between voluntary, infrequent voiding and urinary dysfunction. The dysfunction includes abnormal uroflow patterns, increased urethral resistance, abnormal post-void residuals, chronic trigonitis, and urethrovesical inflammatory polyps. A review of intermittent uroflow and obstructive uroflow patterns reveals that all females in this study worked long hours without voiding.