Cyclic supraventricular tachycardia in the parturient: to treat or not to treat?

Cardiac arrhythmias are more common in pregnant women than in non-pregnant women. In the asymptomatic pregnant patient with a stable fetus, watchful waiting might be the best strategy. Herein, we describe the first reported case of a pregnant patient who developed cyclic supraventricular tachycardia during labor. No treatment was prescribed, with a good maternal and fetal outcome.

Cost of injuries from a prospective cohort study of North Carolina high school athletes

OBJECTIVE

To estimate the economic cost of injuries in a population of US high school varsity athletes.

DESIGN AND SETTING

The North Carolina High School Athletic Injury Study, conducted from 1996 to 1999, was a prospective cohort study of injury incidence and severity. A two-stage cluster sampling technique was used to select athletic teams from 100 high schools in North Carolina. An injury cost model was used to estimate the economic cost of injury.

PARTICIPANTS

Varsity athletes from 12 sports: football, girls' and boy's soccer, girls' and boys' track, girls' and boy's basketball, baseball, softball, wrestling, volleyball, and cheerleading.

MAIN OUTCOME MEASURES

Descriptive data were collected at the time of injury. Three types of costs were estimated: medical, human capital (medical costs plus loss of future earnings), and comprehensive (human capital costs plus lost quality of life).

RESULTS

The annual statewide estimates were $9.9 million in medical costs, $44.7 million in human capital costs, and $144.6 million in comprehensive costs. The mean medical cost was $709 per injury (95% CI $542 to $927), $2223 per injury (95% CI $1709 to $2893) in human capital costs, and $10,432 per injury (95% CI $8062 to $13,449) in comprehensive costs. Sport and competition division were significant predictors of injury costs.

CONCLUSIONS

Injuries among high school athletes represent a significant economic cost to society. Further research should estimate costs in additional populations to begin to develop cost-effective sports injury prevention programs.

Making a difference in differences for the health inequalities of individuals

Policy interventions should focus on the degree to which health conditions are persistent, avoidable, and treatable. Assistance should be targeted to people who are at greater risk for such conditions amid the most pronounced gaps between their available resources and likely economic needs. The highest-yield interventions should address prenatal and early childhood care and reformation of destructive lifestyle practices. Improving outreach, education, convenience of access, and service delivery represents a more important factor than expanding the level and scope of insurance coverage. Vulnerable people are better served by more pluralistic social processes that facilitate, but do not mandate, more effective choices and trade-offs.

One week of esomeprazole triple therapy vs 1 week of omeprazole triple therapy plus 3 weeks of omeprazole for duodenal ulcer healding in Helicobacter pylori-positive patients

In this randomized, double-blind, multicenter study, H. pylori-positive patients with an active duodenal ulcer (DU) received esomeprazole, 20 mg twice daily (bid), or omeprazole, 20 mg bid, with amoxicillin, 1000 mg bid, and clarithromycin, 500 mg bid, for 1 week (EAC and OAC, respectively). Patients received an additional 3 weeks of either placebo or omeprazole, 20 mg once daily (od), in the EAC and OAC groups, respectively. The intent-to-treat population included 374 patients (EAC, 186; OAC, 188). Four-week DU healing rates were similar in the EAC+placebo and OAC+omeprazole groups: 74% and 76%, respectively. DU healing rates at 8 weeks were 87% for EAC+placebo and 88% for OAC+omeprazole. H. pylori eradication rates were 75% and 79% for EAC and OAC, respectively. Both regimens were well tolerated. A 1-week regimen of esomeprazole-based H. pylori eradication triple therapy was as effective for DU healing and eradication of H. pylori as omeprazole-based triple therapy followed by an additional 3 weeks of monotherapy.

A phase I/II study of galiximab (an anti-CD80 monoclonal antibody) in combination with rituximab for relapsed or refractory, follicular lymphoma

BACKGROUND

Galiximab is a monoclonal antibody that targets CD80, a costimulatory molecule constitutively expressed on follicular and other lymphomas. Modest single-agent clinical activity and tolerability were demonstrated in a phase I study in relapsed or refractory, follicular non-Hodgkin's lymphoma (NHL). A phase I/II study was conducted to evaluate galiximab in combination with a standard course of rituximab. Safety, pharmacokinetics, and efficacy were evaluated.

PATIENTS AND METHODS

Patients with follicular NHL who had relapsed or failed primary therapy were enrolled. Rituximab-refractory patients (no response or a response with time to progression <6 months) were excluded. Patients received 4 weekly i.v. infusions of galiximab (125, 250, 375, or 500 mg/m(2)) and rituximab (375 mg/m(2)). International Workshop Response Criteria (IWRC) were used to evaluate response.

RESULTS

Seventy-three patients received treatment. All had received at least one prior lymphoma therapy; 40% were rituximab naive. Infusions were delivered in an outpatient setting and were well tolerated. The most common study-related adverse events (AE) were lymphopenia, leukopenia, neutropenia, fatigue, and chills. The overall response rate at the recommended phase II dose of galiximab (500 mg/m(2)) was 66%: 19% complete response, 14% unconfirmed complete response, and 33% partial response. The median progression free survival was 12.1 months. Combination therapy did not appear to alter pharmacokinetics.

CONCLUSION

These results indicate that galiximab can be safely combined with a standard course of rituximab. This doublet biologic approach offers the potential to avoid or delay chemotherapy or to integrate with other lymphoma therapies. A phase III, randomized study evaluating clinical benefit of rituximab versus the combination has been initiated.

Incidence and lifetime costs of injuries in the United States

BACKGROUND

Standardized methodologies for assessing economic burden of injury at the national or international level do not exist.

OBJECTIVE

To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses.

METHOD

The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000.

MAIN OUTCOME MEASURES

Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism.

RESULTS

More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of 406 billion dollars; 80 billion dollars for medical treatment and 326 billion dollars for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0-44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase.

CONCLUSIONS

These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

Coherent Electronic Fringe Structure in Incommensurate Silver-Silicon Quantum Wells

Atomically uniform silver films grown on highly doped n-type Si(111) substrates show fine-structured electronic fringes near the silicon valence band edge as observed by angle-resolved photoemission. No such fringes are observed for silver films grown on lightly doped n-type substrates or p-type substrates, although all cases exhibited the usual quantum-well states corresponding to electron confinement in the film. The fringes correspond to electronic states extending over the silver film as a quantum well and reaching into the silicon substrate as a quantum slope, with the two parts coherently coupled through an incommensurate interface structure.

[Predictive validity of the Scale of Prodromal Symptoms (SOPS)]

INTRODUCTION

We conduct an exploratory factor analysis with the Scale of Prodromal Symptoms (SOPS) items, to determine its psychometric characteristics and construct validity, as well as we analyze criterion or predictive validity of its clinical subscales in the conversion of high mental risk subjects from prodrome to psychosis in a 1 year follow-up period.

METHOD

The subjects were 30 patients referred for evaluation with the Structured Interview of Prodromal Syndromes (SIPS), which includes the SOPS, because of a suspected psychosis prodromal syndrome, a factor analysis with varimax rotation was carried out: Cronbach internal coherence indices were obtained, and predictive validity of the subscales comprising this instrument were analyzed using logistic regression.

RESULTS

Three first-order factors were found, one of them was a homogeneous component made up of negative symptoms, consistent with previous studies, and higher scores were observed in negative, disorganized and general symptoms in males. Cronbach's alpha indices were 0.880, in the recruitment phase of risk patients, and 0.952 one year later. With an incidence rate of psychosis of 26.67 % in the sample studied, during the 1 year follow-up period, an excellent positive predictive value of the SOPS subscales was found, with negative symptoms having the best specificity (95.5 %) and sensitivity (100 %) indices.

CONCLUSIONS

Diagnostic criteria based on the SIPS/ SOPS make it possible to identify persons at high risk of psychosis, and to make an accurate prediction of medium term psychotic episodes. It is a valid, economical and easy to use instrument in primary health care systems.

Umklapp-mediated quantization of electronic states in Ag films on Ge(111)

We employ angle-resolved photoemission to study the electronic structure of atomically uniform films of Ag grown on Ge(111). A new kind of quantum well state is observed near a specific emission direction away from the surface normal. In contrast with the usual quantum well state arising from electron confinement by specular reflections at the surface and interface of the film, the new kind involves retroreflections, or umklapp reflections, at the interface. It requires four reflections, instead of the usual two reflections, to complete a coherent interference path.

Iris ring melanoma: fine needle biopsy

AIMS

To delineate the diagnostic accuracy of fine needle biopsy in iris ring melanoma and determine the tumour related mortality of this neoplasm.

METHODS

A retrospective analysis of 22 patients with iris melanomas that involve the entire 360 degrees of the anterior chamber angle.

RESULTS

Iris ring melanomas were correctly diagnosed in all cases. In 11 of 16 cases (69%) a fine needle biopsy performed 180 degrees away from the main mass was positive for an iris ring melanoma. The tumour related mortality in iris ring melanoma cases was four of 22 patients (18%). Actuarial survival analysis showed a 10 year mortality (Kaplan-Meier) of 15%.

CONCLUSION

A fine needle aspiration biopsy can be used to diagnose an iris ring melanoma. Iris ring melanomas have significant mortality compared with focal tumours.

Peripheral neuropathies in Waldenström's macroglobulinaemia

OBJECTIVE

We sought to determine the prevalence, clinical features, and laboratory characteristics of polyneuropathies in Waldenström's macroglobulinaemia (WM), a malignant bone marrow disorder with lymphocytes that produce monoclonal IgM.

METHODS

We prospectively studied 119 patients with WM and 58 controls. Medical history was taken, and neurological examinations, electrodiagnostic tests, and serum studies were performed by different examiners who were blinded to results except the diagnosis of WM.

RESULTS

Polyneuropathy symptoms, including discomfort and sensory loss in the legs, occurred more frequently (p<0.001) in patients with WM (47%) than in controls (9%). Patients with WM had 35% lower quantitative vibration scores, and more frequent pin loss (3.4 times) and gait disorders (5.5 times) than controls (all p<0.001). Patients with IgM binding to sulphatide (5% of WM) had sensory axon loss; those with IgM binding to myelin associated glycoprotein (MAG) (4% of WM) had sensorimotor axon loss and demyelination. Patients with WM with IgM binding to sulphatide (p<0.005) or MAG (p<0.001) had more severe sensory axon loss than other patients with WM. Demyelination occurred in 4% of patients with WM with no IgM binding to MAG. Age related reductions in vibration sense and sural SNAP amplitudes were similar ( approximately 30%) in WM and controls.

CONCLUSIONS

Peripheral nerve symptoms and signs occur more frequently in patients with WM than controls, involve sensory modalities, and are often associated with gait disorders. IgM binding to MAG or sulphatide is associated with a further increase in the frequency and severity of peripheral nerve involvement. Age related changes, similar to those in controls, add to the degree of reduced nerve function in patients with WM.

Modification of surface states in ultrathin films via hybridization with the substrate: a study of Ag on Ge

The Shockley surface state of Ag(111) develops unusual band dispersion relations for Ag films of decreasing thicknesses on Ge(111), as observed by angle-resolved photoemission. Its parabolic dispersion in the thick-film limit shifts toward higher binding energies and splits into multiple bands with dispersions that reflect the valence band structure of Ge including the heavy-hole, light-hole, and split-off bands. The results are explained in terms of a hybridization interaction between the Ag surface state and the Ge substrate states.

Massachusetts: More Mirage Than Miracle

Enactment of the Massachusetts health reform plan stemmed primarily from several factors unique to the state. They were augmented by a questionable rationale that this latest version of health reform would forestall even greater threats ahead to the interests of the state's business community, private insurance policyholders, and taxpayers. The plan's foremost achievement involves development of a "Connector" mechanism to facilitate pooling and purchasing beyond the workplace. However, its successful implementation will be challenged by the complexities of enforcing an individual mandate and changing the long-standing course of an overregulated and high-cost health market.

Correlation between initial and early follow-up CT perfusion parameters with endoscopic tumor response in patients with advanced squamous cell carcinomas of the oropharynx treated with organ-preservation therapy

BACKGROUND AND PURPOSE

Current organ-preservation regimens for upper aerodigestive tract squamous cell carcinoma (SCCA) require endoscopic procedures under general anesthesia to evaluate the tumor response. The purpose of our study was to determine whether CT perfusion (CTP) parameters correlate with response to induction chemotherapy as assessed by endoscopy under general anesthesia.

METHODS

Nine patients with advanced (stage 3 or 4) SCCA of the oropharynx were enrolled in a nested phase 2 prospective trial in which induction chemotherapy was used to assess the tumor response. Patients underwent direct laryngoscopy and CTP before and 3 weeks after one cycle of induction chemotherapy. The outcome variables were the surgeon's estimate of tumor volume during endoscopy with biopsy under anesthesia and CTP parameters (capillary permeability (CP), blood volume (BV), blood flow (BF), and mean transit time (MTT)). Wilcoxon rank sum analysis was used to correlate the baseline values of BF and BV with response to induction chemotherapy. Comparison of agreement between the reduction in tumor volume and change in CTP parameters was performed by using kappa estimates.

RESULTS

Seven of 9 patients demonstrated > or =50% tumor volume reduction, representing positive response to induction chemotherapy. In the responder group, the following changes in mean pre- and postinduction chemotherapy values were noted: mean BF, 114.2 mL/100 g /min (preinduction) to 45.1 mL/100 g/min (postinduction); mean BV, 5.11 mL/100 g to 3.1 mL/100 g; mean CP, 25.6 mL/100 g /min (preinduction) to 18.3 mL/100 g / min (postinduction); mean MTT, 4.9 seconds (preinduction) to 8.0 seconds (postinduction). In the nonresponder group, the following changes were noted: mean BF, 56.9 mL/100 g/min to 75.9 mL/100 g/min; mean, BV 2.7 mL/100 g to 4.71 mL/100 g; mean CP, 24.1 mL/100 g/min to 23.7 mL/100 g/min; mean MTT, 4.3 seconds to 5.34 seconds. Higher baseline (pretherapy) values of BV showed significant correlation with endoscopic tumor response (P < .05). Reduction in the BV (by >/=20%) on follow-up studies also showed substantial agreement with clinical response as assessed with endoscopy (kappa = 0.73). The agreement between decreased BF, decreased CP, and increased MTT and clinical response was fair (kappa = 0.37).

CONCLUSION

These preliminary results show that deconvolution-based CTP technique offers potential for noninvasive monitoring of response to induction chemotherapy in patients with oropharyngeal cancers. Percentage reduction of BV is significantly correlated to endoscopic response to induction chemotherapy, though we acknowledge that the data correspond to short-term outcomes and long-term durability of response cannot be established. Nevertheless, validation of the use of deconvolution CTP parameters as predictors of tumor response may permit replacement of an invasive diagnostic procedure conducted under anesthesia currently used to assess response with noninvasive perfusion CT imaging.

Controlling the thermal stability of thin films by interfacial engineering

The quantized electronic structure in Pb films on Si(111) varies substantially as the film thickness increases. The changes in electronic energy cause the thermal stability of the films to oscillate with an approximate bilayer period. The phase of the oscillations can be controlled by interfacial engineering. Comparison of Pb films prepared on Si(111) terminated by In, Au, and Pb as interfactants reveals a phase reversal. For , films made of odd numbers of atomic layers (5, 7, and 9) are more stable than the even ones. This trend is reversed for the other two cases.

Functional architecture of the mammalian striatum: mouse vascular and striosome organization and their anatomic relationships

To determine whether the general architecture of striatal vessels and mu opioid receptor-rich striosomes is similar, we investigated 3D reconstructions of coronal sections in 10 FVB mice. The sections were stained for striosomes using a mu opioid receptor antibody (MOR1). We used computerized procedures to detect striosomes and vessels and to calculate volume, number and colocalization of striosomes and vessels. The results showed a lattice-like pattern of striosomes similar to, and often surrounding, blood vessels. Furthermore, co-localization calculations suggested that the striosomes are more vascular than the matrix. Vessel volume was 5.0+/-1.3% per microm3 in striosomes versus 3.6+/-0.9%microm3 in matrix (p=0.01). The findings emphasize the probable importance of a grid- or lattice-like structure as an organizing principle of striatal anatomy and function. In addition, the greater vascularity of the striosomes compared to the matrix suggests a unique function of this compartment in relation to humoral signals and neurotropic drugs.

Comparison of injury case fatality rates in the United States and New Zealand

OBJECTIVE

To compare injury case fatality rates in the United States (US) with New Zealand (NZ) to guide future information collection, research, and evaluation.

DESIGN

Using NZ (1992-96) and US (1996-98) mortality censuses, NZ national 1992-96 hospital discharge censuses, and US 1996-98 National Hospital Discharge Survey data, the authors compared case fatality rates by mechanism and intent of injury and age group. The analysis was restricted to severe injuries (AIS> or =3).

SUBJECTS

NZ (1992-96) and US (1996-98) populations.

MAIN OUTCOME MEASURES

Ratio of case fatality rates in NZ versus the US (RCFR(NZ:US)).

RESULTS

Overall, among cases meeting the study criteria, unintentional injuries were 1.57 times more likely fatal in NZ and intentional assault injuries were 1.14 times more likely to be fatal in the US. Firearms were involved in 50% of US assaults versus 8% of NZ assaults. By mechanism, cutting/piercing injuries were 1.86, firearm injuries were 1.41, and motor vehicle injuries were 1.44 times more to be likely fatal in NZ. Natural/environmental injuries (RCFR(NZ:US) = 0.57), unintentional poisonings (RCFR(NZ:US) = 0.26), and unintentional suffocations (RCFR(NZ:US) = 0.67) were significantly more likely to be fatal in the US.

CONCLUSIONS

Possible reasons for the observed results include: differences in geography and proportion of population in rural areas, trauma system differences, road design and vehicle types, seat belt use, larger role of firearms in US assaults, coding practices, policies, and environmental factors. Disparities evoke hypotheses to test in future research that will guide priority setting and intervention.