Should fewer premature infants be screened for retinopathy of prematurity in the managed care era?

OBJECTIVE

To determine appropriate upper limits for gestational age and birth weight when screening infants for retinopathy of prematurity (ROP).

DESIGN

Retrospective survey.

SETTING

Tertiary neonatal intensive care nursery.

PATIENTS

Seven hundred seven infants born July 1, 1990 to June 30, 1996 and screened for ROP according to the 1988 to 1996 American Academy of Pediatrics guidelines.

OUTCOME MEASURES

Maximum stage of ROP with respect to birth weight and gestational age.

RESULTS

No ROP more than Stage 1 was observed in infants with gestational ages >/=32 weeks or birth weights >/=1500 g. All cases of threshold and Stage 4 ROP were confined to infants with gestational ages </=30 weeks or birth weights <1200 g.

CONCLUSIONS

The latest American Academy of Pediatrics screening guidelines for ROP are discretionary for infants with birth weights >1500 g or gestational ages >28 weeks. If ROP screening is limited to infants with birth weights of </=1500 g, 34.2% fewer infants would require screening compared with the previous <1800 g recommendation, while missing no cases of ROP more than Stage 1. A gestational age cut-off of </=28 weeks, however, is less desirable, and could potentially miss several infants with more advanced retinopathy (including Stage 4). If ROP screening criteria were instead modified to include infants of gestational ages <32 weeks, the number of patients requiring screening could be reduced 29.1% compared with the previous recommendation of <35 weeks, again without missing any cases of ROP more than Stage 1. Use of such a screening strategy (birth weight <1500 g or gestational age <32 weeks) is predicted to save in excess of 1.5 million dollars annually in the United States, while missing no cases of ROP more than Stage 1.

Voting with their feet: public hospitals, health reform, and patient choices

OBJECTIVES

This study identified public hospital patients' preferences under managed care and health reform.

METHODS

A cross-sectional survey of 348 ambulatory public hospital patients was conducted.

RESULTS

Patients reported a high degree of loyalty to the public hospital given several hypothetical reform scenarios. Those patients who stated they would remain at the hospital increased (from 74.2% to 85.5%) when care elsewhere required copayment for medications and physician visits.

CONCLUSIONS

Patients at one public hospital reported a high likelihood of remaining in the public system, and this likelihood increased when copayment for services was required elsewhere.

Accelerated Alzheimer-type phenotype in transgenic mice carrying both mutant amyloid precursor protein and presenilin 1 transgenes

Genetic causes of Alzheimer's disease (AD) include mutations in the amyloid precursor protein (APP), presenilin 1 (PS1), and presenilin 2 (PS2) genes. The mutant APP(K670N,M671L) transgenic line, Tg2576, shows markedly elevated amyloid beta-protein (A beta) levels at an early age and, by 9-12 months, develops extracellular AD-type A beta deposits in the cortex and hippocampus. Mutant PS1 transgenic mice do not show abnormal pathology, but do display subtly elevated levels of the highly amyloidogenic 42- or 43-amino acid peptide A beta42(43). Here we demonstrate that the doubly transgenic progeny from a cross between line Tg2576 and a mutant PS1M146L transgenic line develop large numbers of fibrillar A beta deposits in cerebral cortex and hippocampus far earlier than their singly transgenic Tg2576 littermates. In the period preceding overt A beta deposition, the doubly transgenic mice show a selective 41% increase in A beta42(43) in their brains. Thus, the development of AD-like pathology is substantially enhanced when a PS1 mutation, which causes a modest increase in A beta42(43), is introduced into Tg2576-derived mice. Remarkably, both doubly and singly transgenic mice showed reduced spontaneous alternation performance in a "Y" maze before substantial A beta deposition was apparent. This suggests that some aspects of the behavioral phenotype in these mice may be related to an event that precedes plaque formation.

Novel liposaccharide conjugates for drug and peptide delivery

Sugar-lipid conjugates with general structure 1-4 were prepared by coupling amino sugars with N-Boc-protected lipoamino acids and oligomers. Conjugates with general structure 5 were also prepared from glucuronic acid and methyl 2-aminohexadecanoate. The physicochemical properties of the conjugates were modified by varying the nature and number of sugars or the number of lipoamino acids or their alkyl chain length. The ability of the liposaccharides to aggregate was examined. These preliminary experiments have demonstrated the ability of the liposaccharides to form particulate systems per se and also their ability to be incorporated into conventional liposomal systems. The structure of the respective liposaccharides and the molar ratio of liposaccharide to dimyristoyl lecithin and cholesterol were found to have a profound effect on the type of colloidal systems produced.

Programme budgeting revisited: special reference to people with learning disabilities

The recent reorganization of community care in the UK removed many of the perverse incentives identified in the previous system. However, the organization of care for many people is still divided across several agencies in the public and independent sectors. As purchasing and providing agencies in both the National Health Service and local authority personal social services attempt to coordinate policy objectives and the means to achieve them, the total resources available and their allocation across different care groups and among people in the same care groups from a consistent focus of attention. The principles and practice of programme budgeting provide important lessons for planning and monitoring expenditure. This paper rehearses such principles in the specialized area of policies for people with learning disabilities and draws on the experience of mapping expenditure on relevant services in a survey over 10 local authorities in England.

Tumor necrosis factor-alpha enhances antitumor effects of radiation against glioma xenografts

Long-term control of high-grade brain tumors is rarely achieved with current therapeutic regimens. The aim of this study was to determine if low doses of tumor necrosis factor-alpha (TNF-alpha) could augment the effects of radiation in a glioma xenograft model and to evaluate hematological and other parameters that might indicate treatment-related toxicity. Nude mice were injected subcutaneously with C6 rat glioma cells and randomized into groups. Two different time-dose protocols were employed using intravenous human recombinant TNF-alpha and radiation beginning within 24 h after tumor cell implantation. The administration of radiation as a single agent slowed tumor progression, whereas TNF-alpha alone had no effect. However, TNF-alpha, especially when given twice per week before radiation for a total of four doses each, significantly increased the efficacy of the radiation. Low leukocyte counts were associated with combination treatment, whereas transforming growth factor-beta 1 levels were depressed in all treated groups. TNF-alpha did not modulate radiation-induced inhibition of C6 cell proliferation in vitro. The data show that TNF-alpha at relatively nontoxic doses can significantly enhance the antitumor effects of radiation against a rapidly growing glioma. This effect was more than additive, because TNF-alpha alone did not slow tumor progression.

St. Louis Integrated Immunization Information System

The immunization rate for St. Louis, Missouri, children age two and younger is only 49 percent, below the statewide rate of 64 percent and far below the estimated national rate of 75 percent. In response to this crisis, the St. Louis Integrated Immunization Information System (SLIIIS) was designed to establish an on-line immunization information system, identify barriers to immunization among health care providers and the client population, and implement methods for removing these barriers. Available to both public and private health care providers, SLIIIS uses a population-based approach to monitoring and improving immunization levels in the Eastern Missouri Region. SLIIIS was initiated by a partnership of an academic center with community agencies and institutions. Review of initial development efforts and system design may be valuable to others involved in creating regionally integrated information systems.

Psychological distress among informal supporters of frail older people at home and in institutions. The Resource Implications Study Group of the MRC Cognitive Function and Ageing Study

OBJECTIVE

Investigate presence of psychiatric morbidity in informal carers using 30-item General Health Questionnaire (GHQ) and examine which factors best predict psychiatric morbidity.

DESIGN

Two-year longitudinal, panel survey of informal supporters of frail elderly subjects, using semi-structured interview schedules. Subjects were those defined as frail after screening stratified random sample of people aged 65 or over.

SETTING

Informal supporters of frail elderly subjects residing in private households or residential or nursing homes in four UK districts.

RESPONDENTS

623 informal supporters of subjects living at home, 129 regular visitors of those in long-term care.

MEASURE

30-item GHQ (cross-sectional analysis).

RESULTS

Stepwise multiple regression indicated main predictors of high GHQ scores in key supporters were: subjects had at least three problems of behaviour (b = 1.56, 95% CI 1.25-1.94); supporters had to alter working hours (b = 1.70, 95% CI 1.15-2.51); supporters were female (b =1.26, 95% CI 1.06-1.50). The following variables predicted low GHQ scores: supporters able to leave subject all day (b = 0.71, 95% CI 0.64-0.80); subjects never wandered (b = 0.78, 95% CI 0.62-0.99); supporters were 'other relatives' or friends of subject (b = 0.74, 95% CI 0.59-0.91). For visitors, spouses were most likely to have high GHQ scores (b = 2.46, 95% CI 1.32-4.57).

CONCLUSIONS

Results suggest the need for greater collaboration between formal and informal care. Little work has been carried out to ascertain which interventions are most effective in alleviating carer stress: a series of randomized controlled trials to determine long-term effectiveness of various interventions for different groups of carers is required.

Activation of phosphatidylinositol 3-kinase by interleukin-13. An inhibitory signal for inducible nitric-oxide synthase expression in epithelial cell line HT-29

The human colonic epithelial cell line HT-29 can be induced by a combination of the cytokines interleukin (IL)-1alpha, tumor necrosis factor alpha, and interferon-gamma to express the inducible form of nitric-oxide synthase (iNOS; Kolios, G., Brown, Z., Robson, R., Robertson, D. A. F., & Westwick, J. (1995) Br. J. Pharmacol. 116, 2866-2872). IL-13 is a potent inhibitor of cytokine-induced iNOS mRNA expression and nitric oxide generation in HT-29 cells via an unknown mechanism. We report here that in HT-29 cells, IL-13 induces a concentration and time-dependent increase in the formation of the lipid products of phosphatidylinositol (PtdIns) 3-kinase, namely phosphatidylinositol (3,4)-bisphosphate and phosphatidylinositol (3,4,5)-trisphosphate. IL-13 also induces a parallel concentration and time-dependent increase in the in vitro lipid kinase activity present in immunoprecipitates of the p85 regulatory subunit of PtdIns 3-kinase. In addition, we also demonstrate that IL-13 stimulates the tyrosine phosphorylation of the adaptor molecule insulin receptor substrate 1, which may facilitate receptor coupling to PtdIns 3-kinase. Both the increases in D-3 phosphatidylinositol lipids and the increased in vitro lipid kinase activity of p85 immunoprecipitates were inhibited by wortmannin and LY294002. Inhibition of the PtdIns 3-kinase activity was paralleled by a reversal of the ability of IL-13 to inhibit iNOS mRNA expression and nitrite generation in HT-29 cells. These data demonstrate that the activation of PtdIns 3-kinase by IL-13 is a key signal that is responsible for the inhibition of iNOS transcription in activated epithelial cells.

Ethiodized oil emulsions in hepatic microcirculation: in vivo microscopy in animal models

RATIONALE AND OBJECTIVES

The authors' purpose was to define the stability and drug-carrying and drug-releasing capacity of ethiodized oil emulsions in the hepatic circulation.

METHODS

Emulsions prepared in various ratios of a nonionic contrast material containing doxorubicin to ethiodized oil were injected into the hepatic arteries of normal and tumor-bearing livers in rats or mice. In vivo microscopy was used to observe the dynamic distribution of the emulsions in the hepatic circulation.

RESULTS

A solution of less water mixed with more oil formed water-in-oil (w/o) phase emulsions, whereas oil with more water formed oil-in-water (o/w) emulsions. The oil in the emulsions carried the water in the blood circulation. The w/o emulsions exhibited significantly higher carriage capacity and longer release time for the drug solution than did the o/w emulsions (P < .01).

CONCLUSION

The delivery of w/o emulsions is superior to that of o/w emulsions. Further studies about preparation methods and delivery capability of emulsions in the liver are warranted.

Generalization of independent response model for toxic mixtures

Interaction between toxic compounds has long been known to researchers. Attempts to model this interaction have been based on two basic paradigms--termed additivity and independence (1, 2). Previous models based on these assumptions focused on measuring the interaction between the compounds and then classifying the type of interaction as synergism, antagonism, additivity or independence (3, 4). The aim of this work is to present a generalization of the independent action hypothesis that is quantitatively capable of describing deviations regardless of the underlying single component dose response models. The mathematical framework of copulas is employed. This approach is then tested against data sets with both human health and ecological risk applications.

Pilot study of continuous-infusion 5-fluorouracil, oral leucovorin, and upper-abdominal radiation therapy in patients with locally advanced residual or recurrent upper gastrointestinal or extrapelvic colon cancer

PURPOSE

The purpose of this study was to develop a satisfactorily tolerated regimen of radiation therapy, continuous infusion 5-fluorouracil, and leucovorin in patients with locally advanced upper-abdominal gastrointestinal cancer.

METHODS AND MATERIALS

Patients with locally advanced or locally recurrent gastric, pancreatic, or extrapelvic colon cancer were eligible for this study. Radiation therapy consisted of 45 Gy in 25 fractions to the tumor and regional lymph nodes, followed by 5.4-9 Gy in three to five fractions to the tumor. Treatment with leucovorin, 10 mg orally daily, and continuous infusion 5-fluorouracil was initiated on the first day of radiation therapy. 5-Fluorouracil was administered at an initial daily dose of 125 mg/m2, with dose escalation planned in 25-mg increments, depending on patient tolerance.

RESULTS

Twenty-one evaluable patients participated in this study. Six were treated at the initial daily 5-fluorouracil dose of 125 mg/m2. One patient experienced Grade 4 anorexia and nausea. No other Grade > or = 3 toxicity was observed at this dose. Fifteen evaluable patients were entered at a planned 5-fluorouracil dose of 150 mg/m2 daily; 6 of them experienced Grade 3 toxicity, and none experienced Grade > or = 4 toxicity. Grade 3 toxicities and the number of patients who developed each were: vomiting (three patients); nausea (two patients); diarrhea (two patients); and skin toxicity, hand-foot syndrome, catheter-related infection, and stomatitis in one patient each. Four of the six patients who experienced Grade 3 toxicity developed more than one type of Grade 3 toxicity.

CONCLUSIONS

In patients with upper-abdominal gastrointestinal cancer, continuous infusion 5-fluorouracil (150 mg/m2 daily), leucovorin (10 mg orally daily), and radiation therapy (50-54 Gy) resulted in a 40% rate of severe toxicity but no life-threatening toxicity. This clinical trial excludes, with 90% confidence, a 20% risk of Grade 4 toxicity with this combination. The 40% rate of severe toxicity suggests that this combination of agents is near the maximal tolerated dose.

Baroreflex sensitivity in patients with vasovagal syncope

BACKGROUND

In the present study, we tested the hypothesis that baroreflex sensitivity is reduced in patients with vasovagal syncope compared with normal control subjects.

METHODS AND RESULTS

We investigated 30 patients with vasovagal syncope (mean age, 43.6 +/- 16.7 years; 14 men and 16 women) and 32 normal control subjects (mean age, 41.8 +/- 17.0 years; 24 men and 8 women). Cardiopulmonary baroreceptor sensitivity was assessed by measuring the change in forearm vascular resistance during subhypotensive lower body negative pressure (LBNP). Carotid baroreflex sensitivity was assessed by measuring the change in RR interval during the manipulation of carotid transmural pressure. Phenylephrine baroreceptor sensitivity was assessed on the basis of the linear regression slope of the RR interval versus systolic blood pressure during the increment in blood pressure after intravenous administration of phenylephrine. In patients with vasovagal syncope, during the application of -10 mm Hg LBNP, forearm vascular resistance decreased by 0.7 +/- 11.6 U versus an increase of 8.3 +/- 6.2 U in control subjects (P = .002). Phenylephrine baroreceptor sensitivity was 11 +/- 7 ms/mm Hg in patients versus 14 +/- 6 ms/mm Hg in control subjects (P = NS). Carotid baroreflex sensitivity was 4 +/- 6 versus 4 +/- 2 ms/mm Hg in patients and control subjects, respectively (P = NS).

CONCLUSIONS

In patients with vasovagal syncope, during the application of subhypotensive LBNP, there is impaired forearm vasoconstriction or paradoxical forearm vasodilation. This suggests impaired cardiopulmonary baroreceptor inactivation or paradoxical activation of these receptors and is consistent with reduced cardiopulmonary baroreceptor sensitivity.

Psychiatric morbidity in medical and surgical patients evacuated from the Persian Gulf War

Acute treatment records of all medical and surgical patients evacuated to Walter Reed Army Medical Center in Washington, D.C., from the Persian Gulf theater (N = 161) were examined to better understand the relationship of injury to psychiatric symptoms. A total of 110 (68 percent) sustained a traumatic injury. They were significantly more likely to have an axis I disorder or psychiatric symptoms of concern than participants in the Persian Gulf War who did not sustain traumatic injuries but who were evacuated for medical conditions. The results indicate that traumatically injured veterans are at greater risk of psychiatric symptoms than veterans who are not injured and that they should be referred for psychiatric evaluation.

Rapid recovery of a functional MDR phenotype caused by MRP after a transient exposure to MDR drugs in a revertant human lung cancer cell line

Prior studies have shown that, in some human tumour cells, increased expression of the multidrug resistance gene MDR1 can be induced in response to certain stress conditions such as a transient exposure to cytotoxic agents. Little is known about the possibility of increasing the expression of the recently cloned multidrug resistance-associated protein (MRP) in response to a transient exposure to cytotoxic drugs. In order to examine this possibility, we have used sensitive assays (RT-PCR, flow cytometry) and the sensitive large cell lung cancer cell line, COR-L23/P, and the revertant line (COR-L23/Rev), generated by growing the doxorubicin-selected, MRP-overexpressing resistant variant COR-L23/R without drug exposure for 24-28 weeks. COR-L23/Rev overexpresses MRP, but to a lesser extent than COR-L23/R. COR-L23/Rev rapidly recovered similar levels of MRP mRNA, protein expression, resistance and drug accumulation deficit as COR-L23/R after a 48-72 h exposure to cytotoxic concentrations of doxorubicin or vincristine but not cisplatin. The increase in MRP mRNA could only be detected 3 to 4 days after the transient exposure to drugs. However, when the parental line, COR-L23/P, was exposed to equitoxic doses of doxorubicin, vincristine or cisplatin, no increase in the levels of MRP mRNA could be observed at higher doses (5- to 10-fold the IC50) of doxorubicin or vincristine (but not of cisplatin), we detected a transient increase in the levels of MDR1 mRNA immediately after short-term exposure. In conclusion, we have shown that a human revertant lung cancer cell line (COR-L23/Rev) has the ability to recover quickly, similar levels of MRP expression and resistance as COR-L23/R after a transient exposure to the MDR-drugs doxorubicin and vincristine.

An association between precocious puberty and fragile X syndrome?

STUDY OBJECTIVE

To determine the FMR1 gene status in a 10-year, 10-month-old girl with a history of precocious puberty and a family history of fragile X syndrome.

DESIGN

Case report.

SETTING

The outpatient facility of the Division of Adolescent Medicine and the Division of Genetic and Metabolic Disorders at Children's Hospital of Michigan and the Medical Genetics and Birth Defects Center of Henry Ford Hospital, Detroit, Michigan.

PARTICIPANT

A 10-year, 10-month-old girl with a history of precocious puberty.

INTERVENTION

Evaluation for menorraghia, DNA extraction, and fragile X gene analysis of blood samples from the patient and her mother.

MAIN OUTCOME MEASURES

Identification of a full mutation in the FMR1 gene.

RESULTS

Southern blot analysis of the FMR1 gene identified a full mutation in the daughter with approximately 750 repeats of the CGG sequence. Methylation studies showed that the full mutation was completely methylated. FMR1 DNA studies on her mother identified a premutation of approximately 100 repeats.

CONCLUSIONS

This report identifies a young girl with a history of precocious puberty and fragile X syndrome. It is also the first report of molecular genetic FMR1 studies in a female with precocious puberty. A possible association between the two conditions is suggested and warrants further investigation.

A further presenilin 1 mutation in the exon 8 cluster in familial Alzheimer's disease

Recent studies suggest that mutations in the presenilin 1 gene, which encodes a polypeptide predicted to be a multispanning membrane protein, are responsible for the majority of cases of early onset, autosomal dominant Alzheimer's disease. Here we describe a further mutation in the presenilin 1 gene (R269G) in a family with early onset Alzheimer's disease. This mutation is in exon 8 which appears to be a favoured region for pathogenic mutations. In the presenilin protein the region coded for by this exon is likely to comprise a domain located on the membrane surface. We discuss the likely effects of the exon 8 mutations on the structure of the exon and in the pathogenesis of the disease.

A regional integrated information system to assure maternal-child health services: a progress report

Priorities for improving the health of our nation include rebuilding the public health infrastructure through increasing assessment, policy development, and assurance capacities in our communities. Capacity building necessitates formalizing and strengthening public health practice linkages to achieve Year 2000 objectives. Determining progress in achieving objectives requires development of public health infrastructure surveillance and data system capabilities. The Tracking Center of Tracking and Outreach Program for St. Louis (TOPS), through unique collaboration among academic and practice partners, laid the foundation for a Regional Integrated Information System (RIIS) by developing a centralized maternal-child health data base for prenatal and pediatric care providers. The RIIS model provides an example of a capacity building system designed to provide public health surveillance, assessment, planning, and evaluation capabilities. Medical Subject Headings (MeSH): health information systems, prenatal care, immunization, maternal-child health care, public health surveillance.

Complete analysis of the presenilin 1 gene in early onset Alzheimer's disease

The presenilin 1 gene has recently been identified as the locus on chromosome 14 which is responsible for a large proportion of early onset, autosomal dominantly inherited Alzheimer's disease (AD). We have elucidated the intron/exon structure of the gene and designed intronic primers to enable direct sequencing of the entire coding region (10 exons) of the presenilin gene in a large number of families. This strategy has enabled us to find a further two novel mutations in the gene. We discuss the distribution of mutations and the proportions of autosomal dominant AD with a mean age of onset below 60 years caused by mutations in this gene.