Exploring kidney dialysis costs in the United States: a scoping review

AIMS

The increasing prevalence of end-stage renal disease (ESRD) in the United States (US) represents a considerable economic burden due to the high cost of dialysis treatment. This review examines data from real-world studies to identify cost drivers and explore areas where dialysis costs could be reduced.

METHODS

We identified and synthesized evidence published from 2016-2023 reporting direct dialysis costs in adult US patients from a comprehensive literature search of MEDLINE, Embase, and grey literature sources (e.g. US Renal Data System reports).

RESULTS

Most identified data related to Medicare expenditures. Overall Medicare spending in 2020 was $29B for hemodialysis and $2.8B for peritoneal dialysis (PD). Dialysis costs accounted for almost 80% of total Medicare expenditures on ESRD beneficiaries. Private insurance payers consistently pay more for dialysis; for example, per person per month spending by private insurers on outpatient dialysis was estimated at $10,149 compared with Medicare spending of $3,364. Dialysis costs were higher in specific high-risk patient groups (e.g. type 2 diabetes, hepatitis C). Spending on hemodialysis was higher than on PD, but the gap in spending between PD and hemodialysis is closing. Vascular access costs accounted for a substantial proportion of dialysis costs.

LIMITATIONS

Insufficient detail in the identified studies, especially related to outpatient costs, limits opportunities to identify key drivers. Differences between the studies in methods of measuring dialysis costs make generalization of these results difficult.

CONCLUSIONS

These findings indicate that prevention of or delay in progression to ESRD could have considerable cost savings for Medicare and private payers, particularly in patients with high-risk conditions such as type 2 diabetes. More efficient use of resources is needed, including low-cost medication, to improve clinical outcomes and lower overall costs, especially in high-risk groups. Widening access to PD where it is safe and appropriate may help to reduce dialysis costs.

Accelerating Solutions for the Overdose Crisis: an Effectiveness-Implementation Hybrid Protocol for the HEAL Prevention Cooperative

Given increasing opioid overdose mortality rates in the USA over the past 20 years, accelerating the implementation of prevention interventions found to be effective is critical. The Helping End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is a consortium of research projects funded to implement and test interventions designed to prevent the onset or escalation of opioid misuse among youth and young adults. The HPC offers a unique opportunity to synthesize and share lessons learned from participating research projects' varied implementation experiences, which can facilitate quicker integration of effective prevention interventions into practice. This protocol paper describes our hybrid approach to collecting and analyzing information about the implementation experiences of nine of the HPC research projects while they maintain their focus on assessing the effectiveness and cost-effectiveness of prevention interventions. To better understand implementation within this context, we will address five research questions: (1) What were the context and approach for implementing the prevention interventions, and how was the overall implementation experience? (2) How representative of the target population are the participants who were enrolled and retained in the research projects' effectiveness trials? (3) For what purposes and how were stakeholders engaged by the research projects? (4) What are the adaptable components of the prevention interventions? And finally, (5) how might implementation of the prevention interventions vary for non-trial implementation? This work will result in intervention-specific and general practical dissemination resources that can help potential adopters and deliverers of opioid misuse prevention make adoption decisions and prepare for successful implementation.

SLE mortality remains disproportionately high, despite improvements over the last decade

Despite a marked improvement in 10-year survival for systemic lupus erythematosus (SLE) patients over the past five decades, mortality rates from SLE remain high compared to those in the general population. SLE was also among the leading causes of death in young women in the United States during 2000-2015. However, it is encouraging that SLE mortality rates and the ratios of SLE mortality rates to non-SLE mortality rates have decreased every year since the late 1990s. Despite this improvement, disparities in SLE mortality persist according to sex, race, age, and place of residence. Furthermore, demographic and geographic variables seem to modify the effect of each other in influencing SLE mortality, leading to interactions between sex/race/ethnicity-associated factors and geographic differences. In other words, individuals of the same sex/race/ethnicity had differences in SLE mortality depending on where they lived. These observations highlight SLE as an important public health issue. The recognition of SLE as a leading cause of death in the general population might spur targeted public health programs and research funding to address the high lupus mortality.

Double-blind randomized clinical trial of percutaneous endoscopic gastrostomy versus radiologically inserted gastrostomy in children

Background

The aim of this RCT was to determine whether radiologically inserted gastrostomy (RIG) in children is associated with more complications than percutaneous endoscopic gastrostomy (PEG).

Methods

Children at a single tertiary children's hospital requiring a primary gastrostomy were randomized to PEG or RIG. Patients were followed by assessors blinded to the insertion method. Complications were recorded, assigned a severity score, and analysed by zero-inflated Poisson regression analysis on an intention-to-treat basis, adjusting for length of follow-up.

Results

Over a 3-year period, 214 children were randomized (PEG, 107; RIG, 107), of whom 100 received PEG and 96 RIG. There was no significant difference in the number of complications between PEG and RIG groups (P = 0·875), or in the complication score: patients undergoing RIG had a 1·04 (95 per cent c.i. 0·89 to 1·21) times higher complication score than those who underwent PEG (P = 0·597). Only age had an independent significant effect on complication score, with older patients having a 0·97 (0·95 to 1·00) times lower complication score per year.

Conclusion

PEG and RIG are both safe methods of gastrostomy insertion with a low rate of major complications. Registration number: NCT01920438 (http://www.clinicaltrials.gov).

Economic Burden of Attention-Deficit/Hyperactivity Disorder among Pediatric Patients in the United States

OBJECTIVES

To determine the adjusted incremental total costs (direct and indirect) for patients (aged 3-17 years) with attention-deficit/hyperactivity disorder (ADHD) and the differences in the adjusted incremental direct expenditures with respect to age groups (preschoolers, 0-5 years; children, 6-11 years; and adolescents, 12-17 years).

METHODS

The 2011 Medical Expenditure Panel Survey was used as the data source. The ADHD cohort consisted of patients aged 0 to 17 years with a diagnosis of ADHD, whereas the non-ADHD cohort consisted of subjects in the same age range without a diagnosis of ADHD. The annual incremental total cost of ADHD is composed of the incremental direct expenditures and indirect costs. A two-part model with a logistic regression (first part) and a generalized linear model (second part) was used to estimate the incremental costs of ADHD while controlling for patient characteristics and access-to-care variables.

RESULTS

The 2011 Medical Expenditure Panel Survey database included 9108 individuals aged 0 to 17 years, with 458 (5.0%) having an ADHD diagnosis. The ADHD cohort was 4.90 times more likely (95% confidence interval [CI] 2.97-8.08; P < 0.001) than the non-ADHD cohort to have an expenditure of at least $1, and among those with positive expenditures, the ADHD cohort had 58.4% higher expenditures than the non-ADHD cohort (P < 0.001). The estimated adjusted annual total incremental cost of ADHD was $949.24 (95% CI $593.30-$1305.18; P < 0.001). The adjusted annual incremental total direct expenditure for ADHD was higher among preschoolers ($989.34; 95% CI $402.70-$1575.98; P = 0.001) than among adolescents ($894.94; 95% CI $428.16-$1361.71; P < 0.001) or children ($682.71; 95% CI $347.94-$1017.48; P < 0.001).

CONCLUSIONS

Early diagnosis and use of evidence-based treatments may address the substantial burden of ADHD.

Early demographic and clinical predictors of developing acute kidney injury in snake bite patients: A retrospective controlled study from an Indian tertiary care hospital in North Eastern Uttar Pradesh India

Aims:

This study was conducted retrospectively to define early demographic and clinical predictors for acute kidney injury (AKI) among snake bite patients at the time of hospital admission.

Materials and Methods:

We analyzed 138 cases with a poisonous snake bite. Patients were classified into two groups according to the presence and absence of AKI. The data regarding clinical features and demographic profile of these patients were collected from the hospital records in a prestructured pro forma and statistically compared.

Results:

Of the 138 patients of venomous snake bite, 62 developed AKI (44.92%). Patients who developed AKI were older in age. Moreover, prolonged bite to anti-snake venom (ASV) time had a significant relationship in developing AKI (P < 0.05). Among the clinical features, there was an independent positive association of AKI with abdomen pain, tenderness and vomiting, cellulitis, bleeding tendencies, myalgia, and black or brown urine (P < 0.05). Neurological features were inversely associated with renal involvement.

Conclusion:

We found that marked abdominal pain, tenderness and vomiting, myalgia, black or brown urine, bite site cellulitis, bleeding tendencies, and prolonged (>2 h) bite to ASV time were significantly associated with the development of AKI in snake bite patients.

Impact of FDA Black Box Warning on Psychotropic Drug Use in Noninstitutionalized Elderly Patients Diagnosed With Dementia

Background:

The study seeks to investigate the impact of Food and Drug Administration's black box warning (BBW) on the use of atypical antipsychotics (AAP) and nonantipsychotic psychotropic alternatives in noninstitutionalized elderly population diagnosed with dementia.

Method:

The Medical Expenditure Panel Survey (2004 through 2007) was utilized as the data source. Medication use in elderly patients (≥65 years) was defined as taking at least 1 medication for dementia. We performed a statistical comparison of prewarning (2004-2005) and postwarning (2006-2007) periods with respect to AAP and nonantipsychotic psychotropic use to examine the impact of labeling changes.

Results:

A bivariate analysis did not yield statistically significant change in either the AAP or nonantipsychotic psychotropic use, pre- versus postwarning. However, multivariate logistic-regression analyses revealed greater odds for antidementia (odds ratio [OR] = 1.976, P = .0195) and benzodiazepine (OR = 3.046, P = .0227) medication use in postwarning period compared to the prewarning period.

Conclusion:

The regulatory warnings and labeling changes regarding off-label use of AAPs in dementia treatment showed minimal impact on their actual use in noninstitutionalized populations. A corresponding increase in the use of nonantipsychotic psychotropics explains that BBW might have resulted in a compensatory shift in favor of benzodiazepines and antidementia medications. Additional research should be conducted to examine the long-term impact of BBW on antipsychotic prescribing changes.

Outcome of Twin Deliveries at a Tertiary Care Centre of Eastern Nepal

BACKGROUND

Twins, compared to singletons, have higher perinatal mortality and morbidity. The aim of this study was to describe the twinning rate, epidemiological variables and hospital outcome of twin deliveries and to find out ways of better management of twins in our part.

METHODS

A retrospective evaluation of the outcome of 92 twin pregnancies during one year study period (1st January 2014 to 31st December 2014) was conducted at BPKIHS. Twins delivered within the institution were included but cases less than 28 weeks gestation were excluded. Maternal and neonatal data were retrieved and analysed.

RESULTS

The twinning rate was 9.2/1000 (92/10,031). The mean birth weight was 1636.30 ±339.21 grams and mean gestational age 34.31±2.67 weeks(28 - 40 weeks). One hundred eighty-two babies (98.9%) were low birth weight (LBW) while 32.1% were small for gestational age (SGA). There was mild, moderate and severe growth discordance in 63 (68.5%)22 (23.9%)and 7 (7.6%) respectively. Three (3.26%) of 92 pairs had twin-to-twin transfusion syndrome. The hospital mortality rate was 10.87% (20/184) and 69 (37.5%) babies had complications. The clinical causes of death were hyaline membrane disease in 7 (3.3%), severe birth asphyxia in 5 (2.7%), congenital malformations in 3(1.6%) and sepsis in 3 (1.6%) babies.

CONCLUSIONS

Twin deliveries are common in this hospital and have poor hospital outcome with more complications and mortality. Hence there is a need for further studies with long term follow-ups to plan for better management of twins in our part.

Adherence to Anticoagulant Therapy in Pediatric Patients Hospitalized With Pulmonary Embolism or Deep Vein Thrombosis

Objectives:

The American College of Chest Physicians recommends anticoagulant therapy for at least 3 months in children hospitalized for venous thromboembolism. The objectives of the study were to evaluate the medication utilization patterns and predictors of adherence to anticoagulant therapy in pediatric population.

Methods:

Texas Medicaid medical and prescription claims from September 1, 2007 to December 12, 2012 were extracted for children (<18 years) hospitalized for pulmonary embolism (PE) or deep vein thrombosis (DVT). The index date was defined as the date of the first prescription of an anticoagulant given within 14 days of discharge. Proportion of days covered (≥80% vs <80%) was used to assess adherence to anticoagulants while controlling for demographics, cause of hospitalization, history of nonsteroidal anti-inflammatory drug use, anticoagulant use, malignancy, drug type, and Charlson comorbidity index (CCI).

Key Findings:

The patients (n = 60) had a mean (± standard deviation [SD]) age of 14.2 (±4.8) years, were primarily female (56.7%), African American (55.0%), enoxaparin users (58.3%), and had a mean (±SD) CCI of 18.3 (±37.7). The mean (±SD) adherence rates for warfarin and enoxaparin were 85.5% (±22.7%) and 78.7% (±27.8%), respectively. Overall, 66.7% were adherent (≥80%) to anticoagulant therapy. Logistic regression showed that increasing age was significantly associated with adherence to anticoagulant therapy, after controlling for other covariates (odds ratio = 1.5, 95% confidence interval = 1.13-1.85).

Conclusion:

Nearly one-third of the pediatric patients on anticoagulant therapy after discharge from PE or DVT were still nonadherent. Further research is needed to highlight the factors responsible for nonadherence in pediatric patients.

Clinico-epidemiological study of low birth weight newborns in the Eastern part of Nepal

Low birth weight (LBW) remains an important cause of newborn morbidity and mortality. A hospital based prospective and descriptive study was conducted at Paediatric wards, Nursery, Neonatal intensive unit (NICU) and Post natal ward during period of June to October 2010 to note the clinico-epidemiological profile of Low Birth Weight (LBW) newborns. Incidence of the LBW babies in our hospital was 14.45%; more than four fifth (82.2%) baby's mothers were primigravida. Eighty two percent mothers had unbooked pregnancies. Twenty and half percent LBW babies were twins. The mean duration of hospital stay of the subject was 7.4 (± 5.5) days. The mean birth weight of LBW babies was 1648 (± 344) grams. Clinical sepsis, non physiological jaundice and hypoglycaemia were the three most common complications of LBW babies. Antibiotics, oxygen and phototherapy were the three commonest modes of therapy. Majority of children (82.0%) improved and were discharged. Birth weight and gestational age were significantly different between survivors and babies who expired. Primigravida and lesser antenatal visits were important risk factors for Low birth weight babies. Birth weight, gestational age, apnoea and mechanical ventilation were the predictors of outcome.

Mid- to late term hypoxia in the mouse alters placental morphology, glucocorticoid regulatory pathways and nutrient transporters in a sex-specific manner

Maternal hypoxia is a common perturbation that can disrupt placental and thus fetal development, contributing to neonatal impairments. Recently, evidence has suggested that physiological outcomes are dependent upon the sex of the fetus, with males more susceptible to hypoxic insults than females. This study investigated the effects of maternal hypoxia during mid- to late gestation on fetal growth and placental development and determined if responses were sex specific. CD1 mice were housed under 21% or 12% oxygen from embryonic day (E) 14.5 until tissue collection at E18.5. Fetuses and placentas were weighed before collection for gene and protein expression and morphological analysis. Hypoxia reduced fetal weight in both sexes at E18.5 by 7% but did not affect placental weight. Hypoxia reduced placental mRNA levels of the mineralocorticoid and glucocorticoid receptors and reduced the gene and protein expression of the glucocorticoid metabolizing enzyme HSD11B2. However, placentas of female fetuses responded differently to maternal hypoxia than did placentas of male fetuses. Notably, morphology was significantly altered in placentas from hypoxic female fetuses, with a reduction in placental labyrinth blood spaces. In addition mRNA expression of Glut1, Igf2 and Igf1r were reduced in placentas of female fetuses only. In summary, maternal hypoxia altered placental formation in a sex specific manner through mechanisms involving placental vascular development, growth factor and nutrient transporter expression and placental glucocorticoid signalling. This study provides insight into how sex differences in offspring disease development may be due to sex specific placental adaptations to maternal insults.

Randomized Control Trial of Kangaroo Mother Care in Low Birth Weight Babies at a Tertiary Level Hospital

Introduction: This study was conducted to compare the effect of Kangaroo Mother Care (KMC) and conventional methods of care on weight gain, occurrence of hypothermia and apnea and duration of hospital stay among Low Birth Weight (LBW) babies. Materials and Methods: It was a randomized control trial conducted at a tertiary level hospital for a period of one year from June 2009 to May 2010. Total 126 stable LBW babies weighing less than 2000 gm and fulfilling inclusion criteria were included in the study. Neonates enrolled for the study were allocated to either KMC or control group using random number table. KMC group was subjected to Kangaroo mother care of at least six hours per day in not more than four sittings. In control group, babies were adequately clothed, covered and kept with their mother and if required were kept under radiant warmer. Recording of temperature in KMC group was done before, during and after KMC. In control group temperature was taken every 4 hours. Weighing of baby was done twice daily on electronic weighing scale. Results: Median daily weight gain (IQR) was 10 (6- 20) gm in KMC group as compared to 7 (0-10) gm in control group (p<0.001). Mean weight gain was 12.11±9.04 gm in KMC group as compared to 3.29±15.81 gm in control group (p<0.001). Incidence of hypothermia was more in control group (12.6%) as compared to KMC group (3.1%) (p=0.048). Duration of hospital stay was less in control group as compared to KMC group (p=0.015). Conclusion: LBW babies less than 2000 gm who receive KMC show better weight gain and have less incidence of hypothermia than those who do not receive KMC. DOI: http://dx.doi.org/10.3126/jnps.v34i1.8960   J Nepal Paediatr Soc 2014;34(1):18-23

Intrinsic hyporesponsiveness of invariant natural killer T cells precedes the onset of lupus

Patients with systemic lupus erythematosus (SLE) display reduced numbers and functions of invariant natural killer T (iNK T) cells, which are restored upon treatment with corticosteroids and rituximab. It is unclear whether the iNK T cell insufficiency is a consequence of disease or is a primary abnormality that precedes the onset of disease. To address this, we analysed iNK T cell function at different stages of disease development using the genetically lupus-susceptible NZB × NZW F1 (BWF(1)) model. We found that iNK T cell in-vivo cytokine responses to an iNK T cell ligand α-galactosylceramide (α-GalCer) were lower in BWF(1) mice than in non-autoimmune BALB/c and major histocompatibility complex (MHC)-matched NZB × N/B10.PL F1 mice, although iNK T cell numbers in the periphery were unchanged in BWF(1) mice compared to control mice. Such iNK T cell hyporesponsiveness in BWF(1) mice was detected at a young age long before the animals exhibited any sign of autoimmunity. In-vivo activation of iNK T cells is known to transactivate other immune cells. Such transactivated T and B cell activation markers and/or cytokine responses were also lower in BWF(1) mice than in BALB/c controls. Finally, we show that iNK T cell responses were markedly deficient in the NZB parent but not in NZW parent of BWF(1) mice, suggesting that BWF(1) might inherit the iNK T cell defect from NZB mice. Thus, iNK T cells are functionally insufficient in lupus-prone BWF(1) mice. Such iNK T cell insufficiency precedes the onset of disease and may play a pathogenic role during early stages of disease development in SLE.

Distribution and ethnic variation of â-thalassemia mutations in Nepal

This is the first study characterizing spectrum of beta-thalassemia mutations in Nepalese population. Mutations were analyzed in 22 patients using 10 sets of allele-specific primers. Five of the mutations, namely F.S 41/42 (--TCTT), IVS1 nt5 (G-->C), IVS1 nt1 (G-->T), 619 bp deletion and F.S 8/9 (+G), were found to constitute 87.82% of total alleles studied. F.S 41/42 (--TCTT) was the commonest mutation. -88 (C-->T), Codon 16 (--C) and Codon 15 (G-->A), had a combined frequency of 12.18%. Distribution of mutations causing beta-thalassemia in different ethnic Nepalese groups was analyzed. The mutational profile in Nepal share several similarities with that from the two neighboring countries, India and China. Detection of more than one mutation in three cases of thalassemia trait raises the likelihood of existence of multiple mutations in cis in Nepalese thalassemic carriers. Such possibility has to be carefully considered while developing prenatal screening program for Nepalese population.

Disparate effects of depletion of CD1d-reactive T cells during early versus late stages of disease in a genetically susceptible model of lupus

Some T cells react with lipid antigens bound to antigen-presenting molecule CD1d. Numbers and functions of a subset of such lipid-reactive T cells are reduced in patients with systemic lupus erythematosus (SLE) and their relatives, as well as in genetically susceptible and chemically induced animal models of lupus-like disease. We have reported that the germline deletion of CD1d exacerbates lupus, suggesting a protective role of these cells in the development of lupus. The use of a knockout mouse model in this study, however, did not allow examination of the role of these cells at different stages of disease. Here, we describe an approach to deplete CD1d-dependent T cells, which allowed us to investigate the role of these cells at different stages of disease in genetically lupus-prone NZB/NZW F1 (BWF1) mice. Repeated intravenous injections of large numbers of CD1d-transfected cells resulted in ∼50-75% reduction in these cells, as defined by the expression of CD4, NK1.1 and CD122, and lack of expression of CD62 ligand. TCR γδ (+)NK1.1(+) cells were also reduced in the recipients of CD1d-transfected cells as compared with control recipients. Such depletion of CD1d-reactive T cells in preclinical BWF1 mice resulted in disease acceleration with a significant increase in proteinuria and mortality. In older BWF1 mice having advanced nephritis, however, such depletion of CD1d-reactive T cells resulted in some disease improvement. Taken together, these data as well as our published studies suggest that CD1d-reactive T cells protect against the development of lupus in animal models. However, these cells appear to be unable to suppress established lupus nephritis in these animals, and might even play a disease aggravating role in late stages of disease.

Induced Dwarf Mutant in Catharanthus roseus with Enhanced Antibacterial Activity

Evaluation of an ethyl methane sulphonate-induced dwarf mutant of Catharanthus roseus (L.) G. Don revealed that the mutant exhibited marked variation in morphometric parameters. The in vitro antibacterial activity of the aqueous and alcoholic leaf extracts of the mutant and control plants was investigated against medically important bacteria. The mutant leaf extracts showed enhanced antibacterial activity against all the tested bacteria except Bacillus subtilis.

Activation of the p53 pathway by the MDM2 inhibitor nutlin-3a overcomes BCL2 overexpression in a preclinical model of diffuse large B-cell lymphoma associated with t(14;18)(q32;q21)

p53 is frequently wild type (wt) in diffuse large B-cell lymphoma (DLBCL) associated with t(14;18)(q32;q21) that overexpresses BCL2. Nutlin-3a is a small molecule that activates the p53 pathway by disrupting p53–MDM2 interaction. We show that nutlin-3a activates p53 in DLBCL cells associated with t(14;18)(q32;q21), BCL2 overexpression and wt p53, resulting in cell cycle arrest and apoptosis. Nutlin-3a treatment had similar effects on DLBCL cells of activated B-cell phenotype with wt p53. Cell cycle arrest was associated with upregulation of p21. Nutlin-3a-induced apoptosis was accompanied by BAX and PUMA upregulation, BCL-XL downregulation, serine-70 dephosphorylation of BCL2, direct binding of BCL2 by p53, caspase-9 upregulation and caspase-3 cleavage. Cell death was reduced when p53-dependent transactivation activity was inhibited by pifithrin-α (PFT-α), or PFT-μ inhibited direct p53 targeting of mitochondria. Nutlin-3a sensitized activation of the intrinsic apoptotic pathway by BCL2 inhibitors in t(14;18)-positive DLBCL cells with wt p53, and enhanced doxorubicin cytotoxicity against t(14;18)-positive DLBCL cells with wt or mutant p53, the latter in part via p73 upregulation. Nutlin-3a treatment in a xenograft animal lymphoma model inhibited growth of t(14;18)-positive DLBCL tumors, associated with increased apoptosis and decreased proliferation. These data suggest that disruption of the p53–MDM2 interaction by nutlin-3a offers a novel therapeutic approach for DLBCL associated with t(14;18)(q32;q21).

Laparoscopic vascular relocation: alternative treatment for renovascular hydronephrosis in children

AIMS

The standard treatment for pelviureteric junction obstruction (PUJO) has been dismembered pyeloplasty. The open surgical, Hellström procedure in which crossing polar vessels are relocated, has been an option in adult urological practice. We present our experience with laparoscopic vascular relocation in children.

METHODS

Data were retrospectively gathered on all patients who underwent laparoscopic relocation of lower pole vessels (LRLPV) at our institution between July 2004 and March 2008. Follow-up ultrasounds and MAG3 were obtained.

RESULTS

LRLPV was performed in 10 boys and 9 girls. Patients were between 5.8 and 15.25 years (median 9.9 years). They presented with recurrent abdominal pain (n = 17), urinary tract infections (n = 7) and haematuria (n = 3). On ultrasound, MAG3 and retrograde studies they had hydronephrosis, obstructed drainage and a normal calibre ureter with a sharp cut-off. They were further assessed at laparoscopy and were found to have aberrant lower pole crossing vessels. All underwent laparoscopic mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and relocating them superiorly onto the anterior wall of the pelvis. The median operating time was 120 min (range 60-240 min). The median hospital stay was 2 days (range 1-3 days). They were followed up for a median period of 12 months (range 6-36 months). All patients have remained asymptomatic. Ultrasound done at 6 months showed decreased hydronephrosis. MAG3 study showed improved drainage in 17, while 1 had poor drainage. This patient remains symptom free and is under regular follow up.

CONCLUSION

Laparoscopic vascular relocation is an unconventional technique in carefully selected patients with PUJO. It obviates disrupting an intrinsically normal PU junction and treats the cause rather than the effect. Our intermediate-term results are encouraging and further long-term assessment is needed.

Hedgehog signaling pathway is activated in diffuse large B-cell lymphoma and contributes to tumor cell survival and proliferation

Hedgehog (HH) signaling is important in the pathogenesis of several malignancies. Recently, we described that HH signaling proteins are commonly expressed in diffuse large B-cell lymphoma (DLBCL); however, the functional role of HH pathway in DLBCL has not been explored. Here, we assessed the possibility that HH pathway activation contributes to the survival of DLBCL. We found that HH signaling inhibition induces predominantly cell-cycle arrest in DLBCL cells of germinal center (GC) B-cell type, and apoptosis in DLBCL cells of activated B-cell (ABC) type. Apoptosis after HH signaling inhibition in DLBCL cells of ABC type was associated with downregulation of BCL2; however HH inhibition was not associated with BCL2 downregulation in DLBCL of GC type. Functional inhibition of BCL2 significantly increased apoptosis induced by HH inhibition in DLBCL cells of both types. We also showed that DLBCL cells synthesize, secrete and respond to endogenous HH ligands, providing support for the existence of an autocrine HH signaling loop. Our findings provide novel evidence that dysregulation of HH pathway is involved in the biology of DLBCL and have significant therapeutic implications as they identify HH signaling as a potential therapeutic target in DLBCL, in particular for those lymphomas expressing the HH receptor smoothened.

Genotoxicity of cadmium on root meristem cells of Allium cepa: cytogenetic and Comet assay approach

Cytogenetic and DNA damaging effects of cadmium (Cd) were examined through chromosome aberrations (CA) and Comet assay on the root meristem cells of Allium cepa. Root meristem cells were exposed to Cd (10, 20, and 40 μM) for 24h and also left in water for 24h recovery. Exposure of Cd revealed significant (P<0.001) inhibition of mitotic index (MI), induction of CA, mitotic aberrations (MA), and micronucleus (MN) formation. Similarly, at 40 μM significant increase in the tail length (85.70 ± 9.40 μm) and tail moment (58.75 ± 5.30 μm) was observed as compared to control 4.50 ± 0.76 and 0.86 ± 0.03 μm, respectively. However, cells examined at 24h post-exposure showed concentration-dependent decline in all the endpoints. Findings of this study confirms the root meristem cells of A. cepa are suitable model for detecting both the environmentally induced CA as well as DNA damage analyzed by Comet assay.

MTA1-mediated transcriptional repression of BRCA1 tumor suppressor gene

Metastasis-associated tumor antigen 1 (MTA1), a component of the nucleosome remodeling and deacetylating (NuRD) complex is routinely upregulated in several cancers. In the present study, we investigated the potential role of MTA1 in BRCA1 transcriptional repression and subsequent chromosomal instability. MTA1-NuRD complex was found to negatively regulate BRCA1 transcription by physically associating with an atypical estrogen-responsive element (ERE) on the BRCA1 promoter. Moreover, MTA1 and HDAC complex recruited to the ERE of BRCA1 promoter in an ER alpha-dependent manner. Accordingly, BRCA1 protein levels were enhanced by silencing of either MTA1 expression or by treatment with the specific histone deacetylase inhibitor trichostatin A. MTA1's strong repressive effects on BRCA1 expression was supported by our observation that cells stably overexpressing MTA1 showed centrosome amplification which has been long implicated as a phenotype for BRCA1 repression. Accordingly, overexpression of BRCA1 in cells stably over expressing MTA1 resulted in restoration of normal centrosome numbers. Together, these findings strongly implicate MTA1 in the transcriptional repression of BRCA1 leading to abnormal centrosome number and chromosomal instability.

Self-organized ZnSe quantum dots: synthesis and characterization

Self-organized ZnSe quantum dots (Q-ZnSe) were grown on indium tin oxide substrate using wet chemical technique without or in presence of copper and manganese dopants. The structural, morphological and luminescence properties of the as grown Q-dot films have been investigated, using X-ray diffraction, transmission electron microscopy, atomic force microscopy and optical and luminescence spectroscopy. Composition of the samples were analyzed using atomic absorption spectroscopy. The quantum dots have been shown to deposit in a compact, uniform and organized array on the indium tin oxide substrate. The size dependent blue shift in the experimentally determined absorption edge has been compared with the theoretical predictions based on the effective mass and tight binding approximations. It is shown that the experimentally determined absorption edges depart significantly from the theoretically calculated values. The photoluminescence properties of the undoped as well as doped Q-ZnSe have also been discussed.

Surgical treatment of the failing heart

Heart failure is one of the leading causes of hospitalization worldwide. Currently, most therapeutic strategies are aimed at resolving the acute exacerbation of failure, resulting in a high readmission rate. Despite significant advances in the medical treatment of heart failure, the results are far from perfect. Mortality remains high and hospitalization costly. Surgical management is still required for patients with end-stage heart failure. Unfortunately, its evolution has occurred in a less structured fashion. In addition to transplantation, strategies for the treatment of heart failure currently under investigation include implantation of pacemakers, left ventricular reconstruction, mitral valve repair, coronary revascularization, cardiomyoplasty and mechanical circulatory support. In the end however, the surgical management of patients with heart failure rests on the type of underlying cardiomyopathy. Hence, care must be taken to accurately diagnose these patients as either having dilated or ischemic cardiomyopathy.

Traumatic pseudoaneurysm of the internal carotid artery presenting with oculosympathetic palsy

BACKGROUND

Blunt internal carotid artery (ICA) injury is rare but undiagnosed can have disastrous clinical consequences.

AIM

To report a late presentation of blunt ICA injury in a young male following a road traffic accident.

RESULT

A 16-year-old male presented 11 days following a head injury with a unilateral Horner's syndrome. Imaging confirmed a pseudoaneurysm of the ICA. The patient was treated with anticoagulant therapy.

CONCLUSION

Diagnosis of ICA injury requires a high index of suspicion and presentation with unusual neurological signs following blunt trauma to the head and neck requires prompt investigation.

Current Diagnosis and Management of Blunt Internal Carotid Artery Injury

BACKGROUND

Blunt carotid artery injury (BCI) is a rare but potentially devastating injury. When undiagnosed it can result in severe disability or death.

METHODS

A Medline-based literature search was performed using key words 'blunt carotid injury' and cross-referenced with further original papers obtained from the references from this search.

RESULTS AND CONCLUSIONS

The incidence of BCI is very low. However, given the serious consequences of a missed injury, recent efforts have focussed on targeted screening for this injury in trauma patients. Conventional angiography remains the investigation of choice but may be superceded in the future by non-invasive methods such as magnetic resonance angiography or CT angiography. Operative intervention is rarely required and anti-coagulation remains the treatment of choice where dissection or pseudoaneurysm is diagnosed. The role of anti-platelet therapy is currently being investigated. Endovascular management using stents has been described but medium to long term results are not yet available.

Neutrophilic eccrine hidradenitis mimicking cutaneous vasculitis in a lupus patient: a complication of cyclophosphamide

Neutrophilic eccrine hidradenitis (NEH) is an unusual self-limited skin disorder characterized by an inflammatory cell infiltrate in the deep dermis involving the eccrine sweat glands, commonly presenting as painful cutaneous nodules. NEH occurs most frequently in patients receiving chemotherapy for haematologic malignancies. We report a case of NEH masquerading as cutaneous vasculitis in a woman receiving cyclophosphamide for lupus nephritis. The association of NEH and the use of cytotoxic agents for SLE or other autoimmune diseases has not been reported previously. NEH must be considered in lupus patients receiving cytotoxic agents to avoid inappropriate use of corticosteroids or antibiotics in this self-limited condition.

Defining small bowel strictures

BACKGROUND

Strictures of the intestine can be difficult to detect despite current radiological techniques.

AIM

To review our experience with a new Foley catheter technique.

METHOD

Three cases are reviewed in which a Foley catheter was used to identify a fibrous stricture.

RESULTS

A Foley catheter with an inflated 10ml balloon inserted through an enterotomy successfully identified the site of stricture in three cases of fibrous stricture obstruction.

CONCLUSION

A Foley catheter inserted through an enterotomy is a useful method of identifying fibrous strictures.

Comparative study between IMRT with NOMOS BEAK and linac-based radiosurgery in the treatment of intracranial lesions

A comparative study was undertaken to examine intracranial irradiation using intensity-modulation radiation therapy (IMRT) and linear accelerator-based radiosurgery. The IMRT was examined using the Peacock system with a BEAK attachment. A clinical case involving a metastatic brain lesion, treated with 3 radiosurgery isocenters, was planned for IMRT. The radiosurgery was planned using the Leibinger planning system. The IMRT was planned using the CORVUS planning system. The CORVUS planning system uses an inverse planning algorithm, a recent development in radiotherapy. Isodose distributions and dose volume histograms were generated and compared. Analysis of the dosimetry shows that the dose conformity and homogeneity within the target using the RTOG guidelines are superior for IMRT. The advantages of IMRT using inverse planning system include the ease of planning and execution of treatment, especially for cases that involve concave targets that require multiple isocenters using radiosurgery.

In vitro high frequency regeneration of plantlets of Vigna mungo and their ex vitro growth

Of the five explants of V. mungo var. T9 used, the excised shoot tips gave best response with regard to offshoot formation followed by the embryonal axis explants. While a treatment comprising 0.5 mgL(-1) BAP, 0.5 mgL(-1) 2iP and 0.1 mgL(-1) NAA induced differentiation of an average 10 offshoots in shoot tip explants, only 3 offshoots were formed in the explants of embryonal axis in a treatment containing 0.5 mgL(-1) BAP and 0.1 mgL(-1) NAA, found optimum for them. Multiple shoots differentiated when explants with earlier regenerated and growing offshoots were first cultured in a treatment containing 0.1 mgL(-1) BAP, 0.25 mgL(-1) IAA and 5 mgL(-1) CCC and then subcultured in the same treatment but having only 1 mgL(-1) CCC. The isolated shoots rooted in 0.5 mgL(-1) IAA resulted in the formation of complete plantlets of an average height of 15 cm in 20 days. The in vitro-regenerated plants grew normally under field conditions and came to flowering as well.

Statistical mechanics of prion diseases

We present a two-dimensional, lattice based, protein-level statistical mechanical model for prion diseases (e.g., mad cow disease) with concomitant prion protein misfolding and aggregation. Our studies lead us to the hypothesis that the observed broad incubation time distribution in epidemiological data reflect fluctuation dominated growth seeded by a few nanometer scale aggregates, while much narrower incubation time distributions for innoculated lab animals arise from statistical self-averaging. We model "species barriers" to prion infection and assess a related treatment protocol.

Designing a medical Web site

BACKGROUND

A web site is a valuable shop window for any medical unit with something to sell or something to say.

AIMS

The aim of this report is to outline the basic steps of web page design for the individual or unit with limited financial resources.

METHODS

There are two ways of designing a web site. A reputable web design company can be employed, but this is usually expensive. Alternatively, a web site can be designed in-house using commercial software, following a few simple steps. The basic requirements are a personal computer, software that is available on most computers and access to a few peripheral items of hardware. An outline of the page design should first be put down on paper. This can be transferred to a computer file using a web page design program. This file is then sent to a server for publication on the World Wide Web (WWW).

CONCLUSION

Designing and publishing a web page can take time and effort, but the rewards can be great and the results will reflect the message and motto of the unit.

Dosimetric study of the narrow beams of 60Co teletherapy unit for stereotactic radiosurgery

This study explores the possibility of using a telecobalt unit for radiosurgery. A dosimetric study was performed for the narrow beam of Cobalt 60 (60Co) unit with circular radiation fields in diameters of 11, 17, 20, 27, 32, 35, 40, and 44 mm. Percentage depth dose and off-axis ratio were measured with ion chamber and radiographic film. The tissue air ratio values derived from measurements agreed well with the calculated values for all cone sizes and depths, ranging from the depth of maximum ionization of 24 cm in water. A quantitative evaluation of treatment plans with 60Co and 6-MV photon beams was carried out. The penumbra of the narrow beam of 60Co was larger than that of the 6-MV beam by 1.3 mm on average. This difference in penumbra can be attributed to the large source size of 60Co units. The feasibility of using narrow-beam 60Co for stereotactic radiosurgery/radiotherapy is discussed.

Treatment with a consensus peptide based on amino acid sequences in autoantibodies prevents T cell activation by autoantigens and delays disease onset in murine lupus

OBJECTIVE

To test the hypothesis that an artificial peptide, based on an algorithm describing T cell stimulatory sequences from the VH regions of murine IgG antibodies to DNA, is an effective tolerogen in vivo in the (NZB/NZW)F1 (BWF1) mouse model of systemic lupus erythematosus.

METHODS

Using proliferative T cell responses to 439 Ig peptides, an algorithm was constructed that describes the amino acid sequences likely to stimulate BWF1 T cells. Stimulatory (pConsensus [pCONS]) or nonstimulatory (pNegative [pNEG]) peptides were synthesized. Groups of 10-week-old (healthy) or 20-week-old (diseased) BWF1 mice received monthly intravenous injections of 1,000 microg of peptide or saline. Ex vivo splenic T cell responses and in vivo clinical effects were measured.

RESULTS

Tolerance was induced by pCONS, but not by pNEG, with respect to ex vivo T cell proliferation and T cell help for antibodies to DNA. T cell help for IgG anti-DNA was impaired not only after T cell stimulation by pCONS but also after stimulation by some peptides from nucleosomal and Ro antigens. Treatment with pCONS significantly delayed the onset of nephritis and inhibited increases in the plasma levels of total IgG, IgG antibodies to DNA, nucleosome, cardiolipin, interferon-gamma, and interleukin-4. In contrast, antibody responses to an exogenous antigen were not impaired. Survival was significantly prolonged in both healthy and diseased mice treated with pCONS.

CONCLUSION

Induction of immune tolerance in response to treatment with pCONS in autoreactive T cell helper populations is highly effective in delaying the appearance of multiple autoantibodies, cytokine increases, and nephritis in BWF1 mice, and dramatically prolongs survival. A striking effect is the ability of the peptide to tolerize T cell help for anti-DNA that is induced by multiple, structurally unrelated self antigens.

High-energy magnon dispersion and multimagnon continuum in the two-dimensional Heisenberg antiferromagnet

We use quantum Monte Carlo simulations and numerical analytic continuation to study high-energy spin excitations in the two-dimensional S = 1/2 Heisenberg antiferromagnet at low temperature. We present results for both the transverse (x) and longitudinal (z) dynamic spin structure factors Sx,z(q,omega) at q = (pi,0) and (pi/2, pi/2). Linear spin-wave theory predicts no dispersion on the line connecting these momenta. Our calculations show that in fact the magnon energy at (pi,0) is 10% lower than at (pi/2, pi/2). We also discuss the transverse and longitudinal multimagnon continua and their relevance to neutron scattering experiments.

Strong-coupling expansions for multiparticle excitations: continuum and bound states

We present a new linked cluster expansion for calculating properties of multiparticle excitation spectra to high orders. We use it to obtain the two-particle spectra for systems of coupled spin-half dimers. We find that even for weakly coupled dimers the spectrum is very rich, consisting of many bound states. The number of bound states depends on both geometry of coupling and frustration. Many of the bound states can only be seen by going to sufficiently high orders in the perturbation theory, showing the extended character of the pair attraction.

The potential use of peptides and vaccination to treat systemic lupus erythematosus

Studies in humans and mice with systemic lupus erythematosus (SLE) suggest that the development of autoantibodies and disease is dependent on T helper (Th) cells. This review highlights recent efforts to identify the antigens that activate such autoreactive Th cells. Various laboratories are using different approaches to identify the autoantigenic epitopes, which appear to be derived from diverse sources such as nucleosome core histones, ribonucleoproteins, and immunoglobulin variable regions. Identification of the putative autoantigenic epitopes has raised the possibility of peptide-specific vaccination as therapy for SLE. Indeed, vaccination of prenephritic lupus-susceptible mice with such peptides delays the development of autoantibodies and nephritis, and prolongs survival. Recent data suggest that peptide treatment can also influence established disease in older lupus mice. These studies offer new hope for a similar treatment approach in patients with SLE. Studies have begun to identify T cell epitopes in human disease.

Exact demonstration of magnetization plateaus and first-order dimer-Neel phase transitions in a modified shastry-sutherland model for SrCu2(BO3)(2)

We study a generalized Shastry-Sutherland model for the material SrCu2(BO3)(2). Along a line in the parameter space, we show rigorously that the model has a first-order phase transition between dimerized and Neel-ordered ground states. Furthermore, when a magnetic field is applied in the dimerized phase, magnetization plateaus develop at commensurate values of the magnetization. We also discuss various aspects of the phase diagram and properties of this model away from this exactly soluble line, which include gap-closing continuous transitions between dimerized and magnetically ordered phases.

Evidence for multiple mechanisms of polyclonal T cell activation in murine lupus

Individuals with systemic autoantibody-mediated diseases such as lupus have polyclonal T and B cell activation. Yet, autoantibody production is restricted to certain autoantigens. The mechanisms underlying this phenomenon remain unclear. We propose three potential mechanisms by which autoreactive helper T cell responses diversify to become polyclonal, yet are restricted to certain antigens. First, using a model where self-Ig peptides spontaneously activate T cells and modulate disease in lupus mice, we demonstrate that the numbers of autoantibody-augmenting T helper peptides increased across the Ig molecule as mice aged ("intramolecular determinant spreading"). Secondly, a single T cell hybridoma established from a (NZB x NZW)F1 mouse immunized with one self-Ig peptide recognized several Ig-derived determinants, which had little sequence homology with the immunizing peptide. Such determinant degeneracy can lead to polyclonality. To explore a mechanism for restriction to certain autoantigens, a protein database search was done for homologies with sequences of selected stimulatory Ig peptides. Identical sequences of such determinants were not found in murine proteins other than Ig. These occurred infrequently in nonautoantibody Ig, but quite commonly in lupus-related autoantibodies such as antibodies to DNA, cardiolipin, and erythrocytes. Thus, determinant spreading and degenerate recognition in T cells coupled with recurring use of T cell determinant sequences among autoantibodies result in polyclonality that is restricted to certain autoantigens.

Self Ig peptides that help anti-DNA antibody production: importance of charged residues

Young NZB/NZW F1 (BWF1) mice develop T cell repertoires that are spontaneously stimulated by peptides derived from the VH regions of BWF1 J558-encoded autoantibodies (autoAb) to DNA, but not to VH region peptides of a J558-encoded antibody to an exogenous antigen. Immunization of young BWF1 mice with selected Ig-derived peptides accelerates anti-DNA production and nephritis, and immune tolerance induction to a combination of these determinants delays anti-DNA production and disease onset. To further characterize this immunoregulatory circuitry, we asked whether this phenomenon of spontaneous T cell activation by VH region peptides is restricted to anti-DNA Ab of the VH J558 family, and what are the charge and structural attributes of these T cell determinants? We studied spontaneous T cell proliferative responses to peptides derived from an autoAb to DNA constructed from VH 7183 and found that it contains several T cell determinants. Both charge and size of certain amino acids (AA) within each peptide seemed to be important. Peptides containing arginine (R) or glutamic acid (E) were more likely to be T cell determinants than peptides without those AA; replacement of charged AA with uncharged AA abolished T cell recognition of a peptide. We previously reported that some Abs to DNA are enriched in R in their VH; pathogenic BWF1 IgG anti-DNA are enriched in positively and negatively charged AA in VH regions. Therefore, we speculate that peptides from natural IgM autoAb may initially activate BWF1 T cells, and as somatic mutations of Ig occur, charged AA introduced into V regions increase the number of T cell determinants, thus favoring upregulation of pathogenic Ab subsets. Therefore, in predisposed individuals, the ability of T cells to recognize more charged T cell determinants in autoAb may be one mechanism promoting development of disease.

Reciprocal T-B determinant spreading develops spontaneously in murine lupus: implications for pathogenesis

Recent work from several laboratories has shown that, in contrast to the widely held notion that one autoimmune disease is caused by one or a few related autoantigenic determinants, autoimmunity is fundamentally a continuously evolving process. The autoimmune responses shift, drift and diversify with time not only to other determinants in the original antigen but also to other antigens. We have described a form of determinant spreading--reciprocal T-B determinant spreading--where the induction of first T cells by peptides from an autoantibody molecule could lead to help provided to a variety of B cells displaying a cross-reactive version of the original determinant. The response spreads in this way by reciprocal T-B stimulation until large cohorts of T and B cells have expanded. Such spontaneous expansion must be important in clinical disease, since tolerance induction to a limited set of T-cell determinant peptides derived from an anti-DNA antibody VH region delayed the appearance of IgG anti-dsDNA antibodies and onset of lupus nephritis in the NZB/NZW F1 mouse model of systemic lupus erythematosus. Understanding the diversification patterns in autoimmune responses has enormous implications in developing peptide-targeted therapies.

Effect of potash alum (aluminium potassium sulphate) on human semen and sperm

25 normal and healthy human volunteers were engaged in this investigation. The different concentration of potash alum solution have different effects on sperm, motility/death and fructose level of the semen. Higher concentration have higher effects.

Solitary fibrous tumor of urinary bladder: report of two cases

The clinical and pathologic features of two cases of solitary fibrous tumor arising from urinary bladder wall are described. To our knowledge, solitary fibrous tumors have not been previously reported at this site. Both tumors showed typical histologic features of solitary fibrous tumor, were CD34 immunostain positive and pursued a benign clinical course on short term follow-up.