The characteristics of patients with possible familial hypercholesterolemia-screening a large payer/provider healthcare delivery system

BACKGROUND

Familial hypercholesterolemia (FH) is an under-diagnosed condition.

AIM

We applied standard laboratory criteria across a large longitudinal electronic medical record database to describe cross-sectional population with possible FH.

METHODS

A cross-sectional study of Clalit Health Services members. Subjects who met the General Population MED-PED laboratory criteria, excluding: age <10 years, documentation of thyroid, liver, biliary or autoimmune diseases, a history of chronic kidney disease stage 3 or greater, the presence of urine protein >300 mg/l, HDL-C>80 mg/dl, active malignancy or pregnancy at the time of testing were considered possible FH. Demographic and clinical characteristics are described at time of diagnosis and at a single index date following diagnosis to estimate the burden on the healthcare system. The patient population is also compared to the general population.

RESULTS

The study cohort included 12 494 subjects with out of over 4.5 million members of Clalit Health Services. The estimated prevalence of FH in Israel was found to be 1:285. These patients are notably positive for, and have a family history of, cardiovascular disease and risk factors. For most of them the LDL-C levels are not controlled, and only a quarter of them are medically treated.

CONCLUSIONS

By using the modified MED-PED criteria in a large electronic database, patients with possible FH can be identified enabling early intervention and treatment.

Trends in outpatient antibiotic use in Israel during the years 2000-2010: setting targets for an intervention

PURPOSE

The abundant use of antibiotics (Abs) in the community plays a major role in inducing Ab resistance, but the literature concerning patterns in outpatient Ab use is limited. This study aims to lay the foundations for future policy and interventional programs to address the rise in Ab resistance by looking at long-term trends in Ab usage in Israel.

METHODS

Defined daily doses per 1,000 inhabitants per day (DID) of total Ab use, consumption in different age groups, and of different Ab preparations were calculated for the years 2000, 2005, and 2010 in the eight districts of Israel. Data were collected from the pharmacy registries of "Clalit Health Services", the largest Health Maintenance Organization (HMO) in Israel, covering 4 million patients, representing 53 % of the population. Trends in use over time were analyzed.

RESULTS

The overall Ab usage in Israel has remained constant in the last decade. Three significant trends were identified in this study: an increase in the consumption of expensive, broad-spectrum Abs, paralleled by a reduction in narrow-spectrum Abs; an increase in Ab consumption among the elderly, counteracted by reduced usage among children; large regional variations in the overall and specific use of Ab agents.

CONCLUSIONS

Our main findings of increased broad-spectrum Ab consumption, primarily among the adult population in Israel, and a wide variability in Ab use between the regions in Israel, can focus our future studies on searching for the factors behind these trends to aid in constructing interventional methods for decreasing outpatient Ab overuse.

Biological function of the soluble CEACAM1 protein and implications in TAP2-deficient patients

Interactions of natural killer (NK) cells with MHC class I proteins provide the main inhibitory signals controlling NK killing activity. It is therefore surprising to learn that TAP2-deficient patients suffer from autoimmune manifestations only occasionally in later stages of life. We have previously described that the CEACAM1-mediated inhibitory mechanism of NK cytotoxicity plays a major role in controlling NK autoreactivity in three newly identified TAP2-deficient siblings. This novel mechanism probably compensates for the lack of MHC class I-mediated inhibition. The CEACAM1 protein can also be present in a soluble form and the biological function of the soluble form of CEACAM1 with regard to NK cells has not been investigated. Here we show that the homophilic CEACAM1 interactions are abrogated in the presence of soluble CEACAM1 protein in a dose-dependent manner. Importantly, the amounts of soluble CEACAM1 protein detected in sera derived from the TAP2-deficient patients were dramatically reduced as compared to healthy controls. This dramatic reduction does not depend on the membrane-bound metalloproteinase activity. Thus, the expression of CEACAM1 and the absence of soluble CEACAM1 observed in the TAP2-deficient patients practically maximize the inhibitory effect and probably help to minimize autoimmunity in these patients.

The mechanisms controlling the recognition of tumor- and virus-infected cells by NKp46

The destruction of viral-infected and tumor cells is mediated in part via the lysis receptor of natural killer (NK) cells, NKp46. The nature, however, of its lysis ligands expressed on target cells is poorly defined. Recently, we have identified a novel functional interaction between the lysis receptors NKp46 and NKp44 and the hemagglutinin of influenza and hemagglutinin-neuroaminidase of Sendai viruses. This recognition depends on the sialylation of NKp46 and NKp44 receptors. In this study, we expand the significance of these observations by demonstrating a conserved pattern of NKp46 and NKp44 recognition by various hemagglutinins derived from different viral strains. We further establish that this recognition is direct and mainly mediated via alpha2,6-linked sialic acid carried by NKp46. In addition, we demonstrate that the ability of NKp46 to recognize target cells is confined to the membrane proximal domain, and largely relies on the highly conserved sugar-carrying residue, Thr 225. This residue plays a critical dual role in NKp46 interactions with both viral hemagglutinins and the unknown tumor ligands via different mechanisms. These results may explain the ability of NK cells to kill such a broad spectrum of viral-infected and tumor cells.

Enhanced recognition of human NK receptors after influenza virus infection

The NK cell cytotoxic activity is regulated by both inhibitory and activating NK receptors. Thus, changes in the expression levels and in the affinity or avidity of those receptors will have a major effect on the killing of target cells. In this study, we demonstrate that the binding of NK-inhibitory receptors is enhanced after influenza virus infection. Surprisingly, however, no change in the level of class I MHC protein expression was observed on the surface of the infected cells. The increased binding was general, because it was observed in both the killer cell Ig-like receptor 2 domain long tail 1 and leukocyte Ig-like receptor-1. The increased binding was functional, was not dependent on the interaction with viral hemagglutinin-neuraminidase, was not dependent on the glycosylation site, and was not abolished after mutating the transmembrane or cytosolic portions of the class I MHC proteins. Confocal microscopy experiments showed increased binding of NK receptor-coated beads to infected cells expressing the appropriate class I MHC proteins. In addition, specific cell-free bead aggregates covered with class I MHC proteins were observed only in infected cells. We therefore suggest that the influenza virus use a novel mechanism for the inhibition of NK cell activity. This mechanism probably involves the generation of class I MHC complexes in infected cells that cause increased recognition of NK receptors.

CD66a interactions between human melanoma and NK cells: a novel class I MHC-independent inhibitory mechanism of cytotoxicity

NK cells are able to kill virus-infected and tumor cells via a panel of lysis receptors. Cells expressing class I MHC proteins are protected from lysis primarily due to the interactions of several families of NK receptors with both classical and nonclassical class I MHC proteins. In this study we show that a class I MHC-deficient melanoma cell line (1106mel) is stained with several Ig-fused lysis receptors, suggesting the expression of the appropriate lysis ligands. Surprisingly, however, this melanoma line was not killed by CD16-negative NK clones. The lack of killing is shown to be the result of homotypic CD66a interactions between the melanoma line and the NK cells. Furthermore, 721.221 cells expressing the CD66a protein were protected from lysis by YTS cells and by NK cells expressing the CD66a protein. Redirected lysis experiments demonstrated that the strength of the inhibitory effect is correlated with the levels of CD66a expression. Finally, the expression of CD66a protein was observed on NK cells derived from patients with malignant melanoma. These findings suggest the existence of a novel class I MHC-independent inhibitory mechanism of human NK cell cytotoxicity. This may be a mechanism that is used by some of the class I MHC-negative melanoma cells to evade attack by CD66a-positive NK cells.

Recognition of haemagglutinins on virus-infected cells by NKp46 activates lysis by human NK cells

Natural killer (NK) cells destroy virus-infected and tumour cells, apparently without the need for previous antigen stimulation. In part, target cells are recognized by their diminished expression of major histocompatibility complex (MHC) class I molecules, which normally interact with inhibitory receptors on the NK cell surface. NK cells also express triggering receptors that are specific for non-MHC ligands; but the nature of the ligands recognized on target cells is undefined. NKp46 is thought to be the main activating receptor for human NK cells. Here we show that a soluble NKp46-immunoglobulin fusion protein binds to both the haemagglutinin of influenza virus and the haemagglutinin-neuraminidase of parainfluenza virus. In a substantial subset of NK cells, recognition by NKp46 is required to lyse cells expressing the corresponding viral glycoproteins. The binding requires the sialylation of NKp46 oligosaccharides, which is consistent with the known sialic binding capacity of the viral glycoproteins. These findings indicate how NKp46-expressing NK cells may recognize target cells infected by influenza or parainfluenza without the decreased expression of target-cell MHC class I protein.

The Primary Care Assessment Survey: tests of data quality and measurement performance

OBJECTIVES

The authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that operationalizes formal definitions of primary care, including the definition recently proposed by the Institute of Medicine Committee on the Future of Primary Care.

METHODS

The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Data from a study of Massachusetts state employees (n = 6094) were used to evaluate key measurement properties of the 11 PCAS scales. Analyses were performed on the combined population and for each of the 16 subgroups defined according to sociodemographic and health characteristics.

RESULTS

The 11 PCAS scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. Tests of scaling assumptions for summated rating scales were well satisfied by all Likert-scaled measures. Assessment of data completeness, scale score dispersion characteristics, and inter-scale correlations provide strong evidence for the soundness of all scales, and for the value of separately measuring and interpreting these concepts.

CONCLUSIONS

With public and private sector policies increasingly emphasizing the importance of primary care, the need for tools to evaluate and improve primary care performance is clear. The PCAS has excellent measurement properties, and performs consistently well across varied segments of the adult population. Widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

Multiple dorsal dislocations of the metacarpophalangeal joints: a case report and review of the literature

A case of multiple dorsal dislocations of the metacarpophalangeal joints is presented with a review of literature. Prompt recognition of the dislocation type is essential, followed by trial of closed reduction under proper anesthesia; open reduction is sometimes required. A short period of immobilization is needed, followed by intensive rehabilitation.

[Propofol anesthesia for craniotomy in patients who are awake]

During craniotomy, the patient's cooperation is needed during procedures in which continuous neurological examination and mapping of crucial regions close to the area to be resected area are required. We report our experience in 9 patients who underwent such procedures under intravenous propofol as the main sedating agent. This short-acting hypnotic was administered prior to and during the painful stages of the procedure. Patients were fully asleep when the skull was opened and the dural flap raised or excised. During the rest of the operation patients were lightly sedated but remained responsive and cooperative. This enabled precise intra-operative mapping of the brain and surgery-related neurological deficits were avoided. Respiratory depression or hemodynamic compromise were not encountered. All patients were comfortable during the operation and there were no additional neurological deficits after operation. We believe that propofol should be the main sedating agent used for these procedures.

New monitors of intravascular volume: a comparison of arterial pressure waveform analysis and the intrathoracic blood volume

OBJECTIVE

Two new monitoring techniques, the analysis of arterial pressure waveform during mechanical ventilation and the determination of intrathoracic blood volume, were evaluated for preload assessment in a model of graded hemorrhage.

DESIGN

8 anesthetized dogs bled of 10, 20, and 30% of their blood volume, then retransfused and volume loaded with plasma expander. Central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac output, parameters of the arterial pressure waveform analysis [systolic pressure variation (SPV) and delta down (dDOWN)], and intrathoracic blood volume (ITBV) were measured at baseline and after each stage of hemorrhage and volume expansion.

RESULTS

The stroke volume index decreased significantly from 1.3 +/- 0.4 ml/kg at baseline to 0.7 +/- 0.2 ml/kg at 30% hemorrhage and then increased after retransfusion and volume loading. The changes in the filling pressures during the various stages of hemorrhage were in the range of 1-2 mmHg. CVP decreased from 5.5 +/- 0.9 to 3.1 +/- 1.7 mmHg and PCWP from 8.0 +/- 0.8 to 5.1 +/- 1.2 mmHg at 30% hemorrhage. Both filling pressures responded significantly to retransfusion; PCWP also changed in response to a volume load. SPV and dDOWN (expressed as percent of the systolic blood pressure during a short apnea) increased significantly from 6.7 +/- 1.7 and 5.6 +/- 3.2%, respectively, at baseline, to 9.7 +/- 2.6 and 8.1 +/- 2.9% after 10% blood loss and to 13.1 +/- 3.9 and 11.1 +/- 3.8% after 30% hemorrhage. ITBV decreased significantly from 29.7 +/- 4.5 to 26.8 +/- 5.3 ml/kg after 10% blood loss and to 23.1 +/- 3.0 ml/kg after 30% hemorrhage. ITBV, SPV, and dDOWN responded significantly to retransfusion and volume load. Significant correlations were found between the degree of volume change and dDOWN (r = 0.93), SPV (r = 0.96), ITBV (r = 0.95), CVP (r = 0.82), and PCWP (r = 0.90).

CONCLUSIONS

The parameters of arterial pressure waveform analysis (SPV and dDOWN) and ITBV were sensitive estimates of cardiac preload during the early stages of hemorrhage. Measurement of SPV and dDOWN, being both sensitive and relatively noninvasive, has advantages over other methods of preload assessment but is limited to patients on controlled mechanical ventilation. ITBV, which supplies quantitative information about cardiac preload, is more invasive but can also be used in patients who are breathing spontaneously or who are on partial ventilatory support.

Asian-American patient ratings of physician primary care performance

OBJECTIVE

To examine how Asian-American patients' ratings of primary care performance differ from those of whites. Latinos, and African-Americans.

DESIGN

Retrospective analyses of data collected in a cross-sectional study using patient questionnaires.

SETTING

University hospital primary care group practice.

PARTICIPANTS

In phase 1, successive patients who visited the study site for appointments were asked to complete the survey. In phase 2, successive patients were selected who had most recently visited each physician, going back as far as necessary to obtain 20 patients for each physician. In total, 502 patients were surveyed, 5% of whom were Asian-American.

MAIN RESULTS

After adjusting for potential confounders, Asian-Americans rated overall satisfaction and 10 of 11 scales assessing primary care significantly lower than whites did. Dimensions of primary care that were assessed include access, comprehensiveness of care, integration, continuity, clinical quality, interpersonal treatment, and trust. There were no differences for the scale of longitudinal continuity. On average, the rating scale scores of Asian-Americans were 12 points lower than those of whites (on 100-point scales).

CONCLUSIONS

We conclude that Asian-American patients rate physicians primary care performance lower than do whites, African-Americans, and Latinos. Future research needs to focus on Asian-Americans to determine the generalizability of these findings and the extent to which they reflect differences in survey response tendencies or actual quality differences.

Use of flumazenil for intraoperative arousal during spine fusion

The intraoperative arousal test is used to detect potential damage to the spinal cord during spine fusion. We determined whether a continuous midazolam infusion, the effects of which are antagonized by flumazenil when the arousal test is needed, is associated with good control of the timing of arousal and with no adverse reactions. In a randomized study of 20 patients (10 in each group), we compared arousal with flumazenil during midazolam-narcotic anesthesia with an arousal test done during halothane-nitrous oxide anesthesia, both under conditions of controlled hypotension. Motor responses to verbal command were obtained 39.1 +/- 36.0 s (mean +/- SD) after the injection of flumazenil in eight patients. Two patients form this group awoke spontaneously 6 and 8 min after terminating the administration of nitrous oxide and midazolam but remained sedated up to the time of the test itself. In the halothane group, arousal occurred 26 +/- 8.3 min after halothane administration was terminated and 10.1 +/- 3.3 min after nitrous oxide was stopped. Two of the patients in this group moved, owing to early arousal 5 and 8 min before the scheduled time and needed reinstatement of anesthesia. In four patients in the halothane group, we had to wait 3-11 min after the scheduled time before satisfactory arousal was achieved. One of the patients in the halothane group showed a motor deficit of the lower limbs during the wake-up test that disappeared after decreasing the spine correction. There were no adverse reactions except for occasional shivering in the recovery period.(ABSTRACT TRUNCATED AT 250 WORDS)

Urokinase does not prevent abdominal adhesion formation in rats

Damage to the fibrinolytic system preventing the resolution of temporary fibrinous adhesions was repeatedly mentioned as an etiological factor in the process of adhesion formation. We experimentally induced abdominal adhesions in rats by gentle scraping of the entire small bowel. Severe adhesions, sometimes accompanied by intestinal obstruction, developed in all of the control animals. Urokinase, a commonly used and potent fibrinolytic agent and a known plasminogen activator, was administered intragastrically, intraperitoneally, or intravenously at various doses ranging from 5,000 to 100,000 U/kg. Urokinase had no effect on the prevention of abdominal adhesions, nor did it reduce the severity or frequency of adhesion formation.

Pilocytic astrocytoma of the optic nerve with hemorrhage and extreme cystic degeneration

Juvenile pilocytic astrocytoma of the optic nerve (glioma of childhood) usually grows slowly. Rapidly evolving proptosis is rare and reflects the accumulation of mucinous or hemorrhagic material within the tumor. Rapid proptosis is more common in those patients beyond the first two decades of life who have long-standing tumors. We studied a 26-year-old woman with rapid proptosis caused by a large blood-filled cyst in a pilocytic astrocytoma of the optic nerve. The cyst was surgically removed along with the intraorbital portion of the optic nerve.