O033 Video tuition of intracavernosal alprostadil injection for management of erectile dysfunction

Introduction

Intracavernosal injections (ICI) are the second line treatment of erectile dysfunction (ED). To reduce the risk of complications, primarily priapism, the first administration has traditionally required face-to-face appointments. With a move to remote working, the safety and feasibility of an instructional video for the first self-administration of ICI was assessed.

Methods

Two centres recruited patients, with participants receiving a pack comprising a written instruction leaflet and a Viridal Duo prescription, followed by an email with our instructional video. Patients were given a specific time to self-administer their ICI (Alprostadil 2.5 micrograms), when our CNS was available for support. The same CNS would follow up two hours later via telephone to assess the experience using a Likert scale semi-structured interview.

Results

Thirty-nine patients were recruited between two centres, with 35 continuing to injection. The median age was 63 years (range 34–78). The most common ED aetiology was post-prostatectomy (18/35). Thirty-four (97%) recruits found the video instructions clear, with it being watched a mean 2 (range 1–8) times. Only 1 patient (3%) required telephone support. At the 2.5mcg dose, the mean erection hardness score was 2 (range 1–4) after an average of 5 minutes. No patients reported significant bruising at the injection site and there was no priapism. Thirty-three patients (94%) were very or extremely likely to recommend this method for starting ICI therapy.

Conclusion

Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

Take-home message

Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

P1646Do Extracellular Vesicles repair chronic ischemic heart disease by replenishing the cardiomyocyte pool?

Introduction

Extracellular Vesicles (EV) seem to mediate the benefits of cell therapy for ischemic heart failure. Although their mechanism of action remains poorly understood, one hypothesis is that they might trigger the generation of new cardiomyocytes.

The doubly transgenic fate-mapping MerCreMer/ZEG mice model was thus used to distinguish whether these putative new cardiomyocytes originated from the division of preexisting ones (GFP+, Troponin T [TnT+], EdU+) or differentiated from endogenous progenitors, in which case they would stain positive for TnT+/EdU+ but negative for GFP.

Methods

Myocardial infarction was induced in 35 MerCreMer/ZEG mice by permanent occlusion of the left anterior descending coronary artery. Three weeks later, the surviving mice (n=18) with a left ventricular ejection fraction (LVEF) ≤45% received transcutaneous echo-guided injections in the peri-infarct myocardium of either EV (from 1.4 million human iPS-derived cardiovascular progenitor cells; 10 billion particles, n=9) or PBS (n=9); osmotic pumps were implanted to deliver EdU for 7 days in order to track the proliferation of new and native cardiomyocytes. Four-6 weeks after treatment all mice were evaluated by echocardiography (n=9 per group) and MRI (7 in each group), and then sacrificed for histological assessment, blindly.

Results

Based on echocardiography (MRI data pending), EV improved LVEF by 16% relative to baseline while a decrease of 4% was observed in the PBS group (p=0.46).

The number of new cardiomyocytes (TnT+/EdU+/GFP+) did not significantly differ between the EV-treated hearts and the controls, and averaged 0.54% of the total heart cell content in infarct, peri-infarct and remote areas. However, EV treatment better preserved preexisting GFP+/WGA+/TnT+ cardiomyocytes in the peri-infarct area as their number was greater by 5.15% compared to PBS (32 sections analyzed for each mouse). Compared to the PBS control group, EV delivery was also associated with a 2.5% decrease in fibrosis, a reduction of infarct size by 14.9%, and an increase in angiogenesis in the peri-infarct area (with a between-group absolute difference of 71 capillaries, on the basis of isolectin staining).

Conclusions

EV secreted by iPS-derived cardiovascular progenitors improve the function of chronically infarcted hearts. Preservation of the existing cardiomyocyte pool and limitation of adverse remodeling and scarred tissue, likely favored by increased neoangiogenesis, are the main mechanisms mediated by the EV, while fate mapping allowed to exclude the generation of new cardiomyocytes.

The cost of diabetic foot ulcers and amputations to the National Health Service in England

AIM

To estimate the healthcare costs of diabetic foot disease in England.

METHODS

Patient-level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014-2015.

RESULTS

The cost of health care for ulceration and amputation in diabetes in 2014-2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration.

CONCLUSIONS

Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one-third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.

Progress of the Healthier You: NHS Diabetes Prevention Programme: referrals, uptake and participant characteristics

AIMS

To describe early progress of the Healthier You: NHS Diabetes Prevention Programme, a behavioural intervention designed to prevent or delay onset of Type 2 diabetes in people in England already identified to be at high risk, to assess numbers of referrals received by Programme providers and the proportion that attended the initial assessment, and to identify the factors associated with attendance rates.

METHODS

These analyses examine the data for referrals received between June 2016 and March 2017.

RESULTS

There were 43 603 referrals received, 16% higher than expected. Of those referred, 49% attended the initial assessment, higher than the 40% modelled uptake. Of those referred, there was no significant difference in uptake by sex (P=0.061); however, attendance per 100 000 population varied significantly by sex, age group, ethnicity and deprivation; it was significantly lower for men (P<0.001), higher as age increased (P<0.001) and higher for individuals from Asian, Afro-Caribbean, mixed and other ethnic groups compared with individuals from white European groups (P<0.001). There was significant interaction between attendance rates by ethnicity and deprivation (P<0.001) such that attendance rates were significantly higher in the most deprived quintile vs the least deprived quintile for Asian, Afro-Caribbean, mixed and other ethnic groups but not significantly different for white European ethnic groups.

CONCLUSION

The analyses show that referral numbers and percentage uptake are in excess of prior modelled values. Characteristics of attendees suggest that the programme is reaching those who are both at greater risk of developing Type 2 diabetes and who typically access healthcare less effectively.

Equating scores of the University of Pennsylvania Smell Identification Test and Sniffin' Sticks test in patients with Parkinson's disease

Background

Impaired olfaction is an important feature in Parkinson's disease (PD) and other neurological diseases. A variety of smell identification tests exist such as “Sniffin’ Sticks” and the University of Pennsylvania Smell Identification Test (UPSIT). An important part of research is being able to replicate findings or combining studies in a meta-analysis. This is difficult if olfaction has been measured using different metrics. We present conversion methods between the: UPSIT, Sniffin’ 16, and Brief-SIT (B-SIT); and Sniffin’ 12 and Sniffin’ 16 odour identification tests.

Methods

We used two incident cohorts of patients with PD who were tested with either the Sniffin’ 16 (n = 1131) or UPSIT (n = 980) and a validation dataset of 128 individuals who took both tests. We used the equipercentile and Item Response Theory (IRT) methods to equate the olfaction scales.

Results

The equipercentile conversion suggested some bias between UPSIT and Sniffin’ 16 tests across the two groups. The IRT method shows very good characteristics between the true and converted Sniffin’ 16 (delta mean = 0.14, median = 0) based on UPSIT. The equipercentile conversion between the Sniffin’ 12 and 16 item worked well (delta mean = 0.01, median = 0). The UPSIT to B-SIT conversion showed evidence of bias but amongst PD cases worked well (mean delta = −0.08, median = 0).

Conclusion

We have demonstrated that one can convert UPSIT to B-SIT or Sniffin’ 16, and Sniffin’ 12 to 16 scores in a valid way. This can facilitate direct comparison between tests aiding future collaborative analyses and evidence synthesis.

•

Need to harmonise olfaction tests (UPSIT and Sniffin’ Sticks) for meta-analysis.

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Use of Item Response Theory and equipercentile methods to convert scores.

•

Validation shows high concordance and little bias between true and converted scores.

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New age and gender corrected centiles for impaired olfaction from Sniffin’ scores.

Finding out what matters: validity of quality of life measurement in young people with ASD

BACKGROUND

  Compared with other conditions there has been a lack of focus on quality of life (QoL) as an outcome measure for children and young people with Autism Spectrum Disorder (ASD). This pilot study aimed to evaluate the validity of existing QoL questionnaires for use with children with ASD aged 8-12 years.

METHODS

  A literature review (1990-2011) identified the PedsQL (Pediatric Quality of Life Inventory) and Kidscreen as robust measures used with children with neurodevelopmental disorders. These measures were completed by 10 children and 11 parents. In addition semi-structured interviews were conducted with 10 parents and four children to explore their experience of completing the QoL questionnaires.

RESULTS

  Young people with ASD, and their parents, report lower child QoL compared with a normative sample. Framework analysis of the data highlighted six key themes which may affect the validity of generic QoL measures when administered within an ASD sample and which warrant further investigation.

CONCLUSIONS

  Our results indicate that a new condition-specific measure of QoL, grounded in ASD children's own perspectives of their lives, is needed and that such a measure should assess experiences of anxiety and access to special interests when measuring QoL of children with ASD. Active involvement of young people and their families is critical for the development of a theoretical framework for QoL within ASD, and any future development of an ASD-specific measure.

The case for re-evaluating the upper limit value for selenium in drinking water in Europe

Selenium is an essential trace element for life, which can be toxic for humans when intakes reach a certain amount. Therefore, since the margin between healthy intake and toxic intake is narrow, the selenium concentration of tap water is a parameter that must be monitored because of its potential for increased intake. The present work gives an overview of the different approaches used to calculate safe limits for selenium. As recommended by WHO, the guidelines for drinking water form the basis of national legislated standards for drinking water. Before setting a maximum acceptable level in drinking water, it is necessary to take into account the total intake of selenium in both food and beverage. The limit value of 10 microg l(-1) for drinking water laid down in the European regulations for all countries should be adapted depending on geographic area, as previously recommended by WHO.

Essential role of the unfolded protein response regulator GRP78/BiP in protection from neuronal apoptosis

Neurodegenerative diseases are often associated with dysfunction in protein quality control. The endoplasmic reticulum (ER), a key site for protein synthesis, senses stressful conditions by activating the unfolded protein response (UPR). Here we report the creation of a novel mouse model where GRP78/BiP, a major ER chaperone and master regulator of UPR, is specifically eliminated in the Purkinje cells (PCs). GRP78 depleted PCs activate UPR including induction of GRP94, PDI, CHOP and GADD34, feedback suppression of eIF2α phosphorylation and apoptotic cell death. In contrast to current models of protein misfolding where abnormal accumulation of ubiquitinated protein is prominent, cytosolic ubiquitin staining is dramatically reduced in GRP78 null PCs. Ultrastructural evaluation reveals that the ER shows prominent dilatation with focal accumulation of electron-dense material within the ER. The mice show retarded growth and severe motor coordination defect by week 5 and cerebellar atrophy by week 13. Our studies uncover a novel link between GRP78 depletion and reduction in cytosolic ubiquitination and establish a novel mouse model of accelerated cerebellar degeneration with basic and clinical applications.

Using the DREEM-Italian Version to Evaluate the Recovery-Orientation of Pavia Rehabilitative Services

We assessed the recovery-orientation of the Pavia Rehabilitation Services using an Italian Version of the DREEM (Developing Recovery Enhancing Environment Measure). A preliminary Italian Version of the DREEM was translated by the first author (MB) and a back-translation was carried out by a trained translator (MT). A third member of the research team (JS) resolved disagreements between the two versions by discussion and consensus with MB and MT. The final version was administered to the patients of the rehabilitation services of Pavia. 15 patients out of a possible 21 (71.4%) participated in the first interview. Demographic information including gender (53% male, 47% female), age range (26-35 years: 27%, 36-45 years: 33%, 46-55 years: 27%, 56-65 years: 6%, 66 years and over: 7%), ethnicity (Italian: 100%) was collected. 20% had been using mental health services for between 5 and 10 years, and 80% for more than 10 years. The section “elements of recovery and recovery enhancing services” scored 1.2 for “importance ratings for recovery elements” and 2.4 for “staff performance”, with a performance gap of 1.2. Mean scores for “organizational climate” and “recovery markers” were 2.3 in both sections. The mean score of 1.2 on the importance ratings shows that patients have a good understanding of recovery elements. The other scores reveal a fairly good recovery orientation of the service, but with a wide margin for improvements as indicated by the performance gap. The Italian version of the DREEM is useful; the results can promote reflections, discussion and learning within the staff.

Palliation for suspected unresectable hilar cholangiocarcinoma

AIM

The aim of this study was to evaluate the outcome of different techniques of palliation for patients with hilar cholangiocarcinoma.

METHOD

All patients treated with palliative intent between 1988 and 2004 at the Royal Infirmary of Edinburgh were reviewed. Patients were analysed on an intention to treat basis. Demographics, procedure and outcome (including re-admissions) were recorded.

RESULTS

Two hundred and thirty-three patients underwent palliative treatment for suspected hilar cholangiocarcinoma. The diagnosis was confirmed histologically in 109 patients. The procedure related morbidity and mortality was 54/225 and 18/207 respectively. Seventy-one patients required re-admission. Twenty patients underwent surgical biliary bypass for jaundice. Those undergoing surgical palliation had a longer median (95% CI) time to re-admission (16 (0-36) vs.7 (2-12) weeks, p=0.001). Endoscopic retrograde cholangio-pancreatography (ERCP) and stenting was only successful in 28 patients and was associated with a significantly higher re-admission rate compared to patients in whom ERCP was not performed (60/179 vs. 4/27, p=0.050). The overall median (95% CI) survival was 145 (124-185) days.

CONCLUSION

Current options for palliation of hilar cholangiocarcinoma provide good short term success but are all associated with significant early and late morbidity. Due to its low success and association with an increased re-admission rate, ERCP for definitive palliation should not be used in the first line staging and management of these patients.

Novel growth factors involved in the pathogenesis of proliferative vitreoretinopathy

AIMS

To determine whether hepatocyte growth factor (HGF) and connective tissue growth factor (CTGF) are expressed in human specimens of proliferative vitreoretinopathy (PVR) and to propose a model of PVR pathogenesis based upon the known activities of these growth factors. Methods Immunohistochemical methods (ABC Elite) were used to demonstrate the presence of HGF and CTGF in cryostat sections of five human PVR membranes.

RESULTS

In each of the five PVR membranes, stromal cells were immunohistochemically positive for both HGF and CTGF. Based upon this information and the known actions of these growth factors, a model of PVR pathogenesis was developed. In this model, injury of the retina induces an inflammatory response that upregulates HGF expression inducing the formation of multilayered groups of migratory retinal pigment epithelial cells (RPE). These RPE, present in a provisional extracellular matrix, come in contact with vitreous containing TGF-beta. The TGF-beta is activated, upregulating expression of CTGF. Under the influence of TGF-beta and CTGF, RPE become myofibroblastic and fibrosis ensues. Retinal traction induces further detachment continuing the cycle of retinal injury.

CONCLUSIONS

HGF and CTGF are expressed in PVR membranes and may play important roles in the pathogenesis of PVR. The expression and function of these growth factors should be critically examined in human PVR specimens, in in vitro cultures of RPE, and in animal models of PVR.

Synthesis and biological evaluation of destruxin A and related analogs

This report describes the development of an efficient solid-phase synthesis protocol and adaptation of reported solution phase procedures for the synthesis of the cyclic depsihexapeptide destruxin A and related analogs. The solid-phase method described is based on standard Fmoc peptide chemistry, including a new synthetic method for the assembly of the depsi bond-containing unit. In order to select analogs of destruxin A for synthesis and evaluation of insecticidal activity, the work of Hellberg et al., describing a set of Z-descriptors for amino acid side-chains comparing their physicochemical properties, was utilized. Destruxin A and 27 different analogs with structural variations in four residues were synthesized and insecticidal activity was evaluated via injections into tobacco budworm (Heliothis virescens) larvae. Several destruxin A analogs were found to be at least as potent as the native compound.

Zinc nasal gel for the treatment of common cold symptoms: a double-blind, placebo-controlled trial

Effective treatment for the common cold have been difficult to develop because so many different types of virus are responsible for this condition. Oral zinc has been studied as a possible means of preventing or alleviating symptoms, with mixed results. We studied a new approach to zinc therapy--an over-the-counter nasal gel formulation (Zicam)--to independently evaluate its efficacy as a treatment for the common cold. Our study was conducted at four sites over a 5-month period. The study group consisted of 213 patients with recent-onset(< or = 24) cold symptoms; 108 patients received zinc therapy, and 105 reviewed placebo. Symptom charts were used to track the duration and severity of each patient's symptoms. At study's end, the duration of symptoms was 2.3 days (+/-0.9)in the zinc group and 9.0 days (+/-2.5)in the control group--a statistically significant difference (p <0.05). These results provide evidence that zinc nasal gel is effective in shortening the duration of common cold symptoms off when taken within 24 hours of their onset.

FGF-2 facilitates binding of SH3 domain of PLC-gamma1 to vinculin and SH2 domains to FGF receptor in corneal endothelial cells

PURPOSE

To determine the cellular localization of the Src homology (SH)2 and SH3 domains of PLC-gamma1 and their cytoplasmic binding partners, living corneal endothelial cells were microinjected with the fusion proteins containing SH domains.

METHODS

Fusion proteins were prepared from plasmid vectors, and the fusion proteins containing SH2-SH2 [(SH2)2], SH2-SH2-SH3 [(SH2)2-SH3] or SH3 were isolated using affinity chromatography. Following microinjection, immunolocalization was analyzed using confocal laser microscope.

RESULTS

Microinjected SH domains were targeted to the subcellular location following stimulation with FGF-2: the SH3 domain appeared to be targeted to cytoskeleton; the (SH2)2 domain showed a dual localization in cytoplasm and plasma membrane; the (SH2)2-SH3 domain was predominantly localized at membrane and perinuclear sites. In the absence of stimulation by FGF-2, the microinjected fusion proteins remained at the injection sites. When cytoplasmic binding partners were determined by double-staining, the SH3 domain demonstrated colocalization with vinculin: the staining profile of the SH3 domain was identical to that of vinculin, which demonstrates characteristic punctated profiles. The punctated staining of SH3 disappears toward the basal membrane, while that of vinculin remains in all confocal optical sections. On the other hand, some fraction of the (SH2)2 domain was colocalized with FGF receptor at the membrane site. When PLC-gamma1 and F-actin were double-stained, the endogenous PLC-gamma1 demonstrated a diffuse cytoplasmic staining and/or perinuclear staining, while phalloidin staining demonstrated that all cells have filamentous cytoplasmic distribution of F-actin.

CONCLUSIONS

These findings indicate that the SH3 domain directs PLC-gamma1 to bind to vinculin and that the SH2 domains may mediate the binding of PLC-gamma1 to receptor tyrosine kinase. Furthermore, they suggest that phosphorylation is not required for targeting of PLC-gamma1 to membrane or cytoskeleton sites.

Vascular basement membrane pathology and Alzheimer's disease

We have previously demonstrated that the capillary vascular basement membrane (VBM) is pathologically altered in Alzheimer's disease (AD). This microangiopathy is highlighted by the immunocytochemical localization of the three principal intrinsic VBM components: heparan sulfate proteoglycan, collagen type IV, and laminin. These three VBM components also immunolable amyloid deposits and senile plaque-associated glial processes. The present study examines the ultrastructure of the VBM in one brain region severely affected (temporal gyrus) and one relatively spared (cerebellum) from the lesions of AD in both AD and neurological control cases. The cross-sectional area as well as the width of the VBM were found to be greater in AD cortical capillaries. In addition, we found ultrastructural evidence for the activation of microglial-related perivascular cells, and their apparent extravasation through the VBM, findings consistent with the hypothesis that these cells are being recruited as part of a disease-related immune response. The recruitment of these "resting" microglial-like cells from their intra-VBM location to plaques and tangles in AD may explain (1) the thickening and vacuolization of the VBM; (2) the specificity of this VBM alteration to brain regions where there are plaques and tangles; and (3) the source of some of the large number of activated microglia in these affected areas. Thus, while VBM alterations may not be specific to AD, these changes appear to be specifically related to the disease process.

Retinal nerve fiber layer thickness in normal human eyes

PURPOSE

To measure the histologic thickness of the retinal nerve fiber layer (RNFL) in normal human eyes.

METHODS

Human eyes were obtained at autopsy within 6 hours postmortem. The retina was dissected into four quadrants and serially sectioned in historesin. The RNFL thickness was measured histologically in all four quadrants at the disc margin and at regular intervals from the disc margin. Measurements of the RNFL thickness also were obtained at the fovea and in the retinal periphery.

RESULTS

Ten eyes of ten white individuals were studied. Age (mean +/- standard deviation) was 53.1 +/- 19.6 years (range, 18-76 years). For the eyes studied, the disc area (mean +/- standard deviation) and cup:disc ratio (mean +/- standard deviation) were 1.92 +/- 0.1 mm2 and 0.3 +/- 0.08, respectively. Mean superior, inferior, nasal, and temporal RNFL thickness at the disc margin was 405, 376, 372, and 316 microns, respectively. In all four quadrants, the RNFL thickness decreased with increasing distance from the disc margin. The average superior and inferior RNFL thickness was inversely related to age (P = 0.033, P = 0.097, respectively). The average RNFL thickness was not related to disc area. The average RNFL thickness just superior, inferior, nasal, and temporal to the foveola was 27, 34, 26, and 12 microns, respectively. The average RNFL thickness just posterior to the ora serrata in the superior, inferior, nasal, and temporal retinal periphery was 8 to 11 microns.

CONCLUSION

The peripapillary RNFL thickness in humans is thicker than that seen in nonhuman primates. The thinnest peripapillary RNFL is in the region of the papillomacular bundle. These data can be used to determine the accuracy of NFL analyzers in obtaining in vivo RNFL thickness measurements.

Characterization of ORG 20241, a combined phosphodiesterase IV/III cyclic nucleotide phosphodiesterase inhibitor for asthma

The pharmacological profile of a novel cyclic nucleotide phosphodiesterase (PDE) inhibitor, Org 20241, has been characterized. The compound selectively inhibits PDE IV (pIC50, 5.2-6.1) and PDE III (pIC50, 4.4-4.6) from animal and human tissues. Org 20241 relaxed preparations of bovine trachea (pD2, 5.9 and 5.4), guinea pig trachea (pD2, 6.2 and 4.9) and human bronchi (pD2, 5.3 and 4.7) for histamine and methacholine-induced contractions, respectively. Rolipram and Org 20241 inhibited leukotriene B4-induced thromboxaneB2 (IC50, 0.3 and 1.4 microM, respectively) and H2O2 (IC50, 2.1 and 0.4 microM, respectively) production in guinea pig eosinophils. In phenylephrine (0.3 microM) precontracted rabbit aorta preparations, the PDE III inhibitor Org 9935 (pD2, 6.3 and 6.1 in the presence and absence of endothelium, respectively) was the most effective relaxant, whereas Org 20241 (pD2, 5.3 and 5.4 in the presence and absence of endothelium, respectively) was more effective than rolipram (pD2, 4.6 and 4.1 in the presence and absence of endothelium, respectively). Org 20241 relaxed rabbit aorta preparations and airway preparations at similar concentrations. In electrically stimulated rabbit cardiac papillary muscles, Org 20241 had little effect on contractility at concentrations up to 30 microM. Lower concentrations (10 microM) potentiated the inotropic effect of Org 9935. Whereas the PDE III inhibitor milrinone (1-100 microM) enhanced the rate of repolarization of guinea pig papillary muscles and shortened the effective refractory period, Org 20241 and rolipram (1-100 microM) did not reduce the action potential duration. In the presence of Org 20241 or rolipram, isoproterenol did not produce a greater increase in the rate of repolarization or reduction in the effective refractory period than in the absence of these PDE inhibitors. Org 20241 is a dual PDE IV/III inhibitor with some PDE IV selectively. This compound relaxes airways smooth muscle and inhibits eosinophil activation. The data indicate that such PDE IV/III inhibitors may be effective for the long-term therapy of asthma.

Getting it all together. Systems should link their strategic and financial planning

Foreseeing dramatic changes in healthcare delivery, the leaders of the Franciscan Health System (FHS) decided in the early 1990s to more closely link their strategic and financial planning. Though this cooperation was tentative at first, by 1993 both our planners and our chief financial officers shared certain assumptions about the future--above all, that the coming delivery model was managed care provided by integrated delivery systems (IDSs). Having agreed on our assumptions, we translated them into a vision statement, from which we derived four strategic goals: Advance the healing mission of our sponsors; Create a culture of continuous improvement in leadership, quality, innovation, cost-effectiveness, and measurable customer value; Create an environment that values and empowers those with whom we work; Develop, through partnering, an IDS that provides affordable care to our communities; Our goals established, we charted what we call a "crosswalk" between the strategic and financial aspects of our budgeting. We found that we had to think in a new way about capital. For example, we began investing as heavily in "soft" items like research, partnerships, and new services as in the traditional "bricks and mortar." This process is new for us, and developing it has not always been comfortable. But we believe it has helped us to more wisely allocate FHS's resources and thus give our system greater stability.

Developing a model for technology assessment. A system helps its facilities prepare for technological change

In 1991 the Franciscan Health System (FHS), Philadelphia, created a Technology Assessment Task Force to support specific goals and strategies in the FHS strategic plan and to help prepare its members for technological change. Because FHS is a large and diverse system, with facilities in seven states both on the East Coast and in the Pacific Northwest, the task force needed to develop flexible recommendations with broad applicability. The task force recommended a time-phased approach for changing the way technology is identified, acquired, and used in FHS organizations. Key recommendations included (1) creating a standing FHS technology steering committee, (2) implementing a technology assessment model for selected technology activities, (3) sponsoring systemwide technology conferences, and (4) reviewing FHS technology actions, revising as appropriate. The system and hospital leadership adopted the task force's recommendations and are now implementing them.

Effects of Org 7797 on early, late and inducible arrhythmias following coronary artery occlusion in rats and dogs

1. The class Ic steroidal antiarrhythmic agent, Org 7797, was compared with two other Ic agents, flecainide and propafenone for intravenous activity against ischaemia-related cardiac arrhythmias and for electrophysiological actions in vivo. In addition the haemodynamic effects of Org 7797 were assessed in greyhounds. 2. Org 7797 (0.5 mg kg-1) significantly reduced the expected incidence of early ischaemia-induced ventricular fibrillation (VF) in rats and greyhound dogs and at doses of 0.5-1.0 mg kg-1 antagonized reperfusion-induced arrhythmias. Comparative studies in rats showed Org 7797 to be 2-4 times more potent than flecainide or propafenone. 3. Org 7797 (0.5 mg kg-1) slowed intracardiac conduction in anaesthetized beagles and again was at least 2-4 times more potent than flecainide or propafenone. 4. Org 7797 (0.5 and 2.0 mg kg-1), flecainide (1.0 and 2.0 mg kg-1) or propafenone (0.5 and 2.0 mg kg-1), did not significantly prevent induction of tachyarrhythmias (VT) in dogs with 5-6 day old myocardial infarcts although all 3 drugs appeared to prevent induced VF. All 3 drugs (notably flecainide) did however reduce the VT rate. 5. All 3 drugs (1-2 mg kg-1) suppressed spontaneous tachyarrhythmias in conscious beagle dogs with 1-2 day old infarcts. Propafenone was the least effective. 6. In an antifibrillatory dose (0.5 mg kg-1), the major haemodynamic effect of Org 7797 was a 10% increase in peripheral vascular resistance. Stroke volume, cardiac output and coronary blood flow were unchanged. In therapeutic doses, Org 7797 was also less negatively chronotropic than flecainide.7. It was concluded that Org 7797 is a potent antifibrillatory agent which is haemodynamically well tolerated. Higher doses are required to suppress late ischaemia-induced tachyarrhythmias which suggest that its antifibrillatory effects are the consequence of an action other than, or in addition to, sodium channel block.

Putting the poor first. A system's assessment project identifies community needs

To enhance its mission of promoting compassionate and high-quality holistic healthcare to all people, especially the poor and underserved, Franciscan Health System (FHS), Aston, PA, launched the Service Area Needs Assessment (SANA) project in 1990. The project focused on population segments who live in the most economically deprived ZIP codes within member hospitals' service areas. SANA coordinators surveyed FHS hospitals about their programs and services for the poor and underserved and documented the programs' scope, value, and benefit to the community. When hospital personnel learned the results of the survey, they felt encouraged to interact with one another and learn more about their facilities' contributions to care for the poor and underserved in their communities. SANA coordinators and team members then interviewed community agency representatives, physicians, other service providers, and community residents. The agencies and healthcare providers identified several unmet needs that residents verified. However, the interviews revealed a gap between what providers think the problems of the poor are and what these individuals themselves believe their problems to be. As a result of these interviews, several hospitals have established programs to meet the identified needs. Of the 33 initiatives proposed, 16 represent new activities, 10 represent expansion of existing activities, and 7 represent collaboration with other organizations on new and existing programs. FHS believes the SANA project is just the beginning of a renewed commitment to caring for the poor and underserved.

Effects of amiodarone on cardiac electrophysiology and inducibility of arrhythmias in chronically infarcted dogs: late arrhythmias, haemodynamics, and sympatholytic actions

The electrophysiological and antiarrhythmic effects of acute (2 and 10 mg/kg i.v.) and chronic (400 mg/day p.o. for 28 days) amiodarone (AM) treatment were compared in anaesthetised dogs with 5-6-day-old myocardial infarcts. Intravenous AM prolonged the RR interval, sinus node recovery time, the PR interval, and atrial to His conduction time by 36, 33, 25, and 36%, respectively. Corresponding increases after oral amiodarone were 50, 57, 12, and 26%. Atrial and His-Purkinje conduction times were unchanged. Atrial and ventricular refractory periods were increased especially after oral treatment. Oral AM additionally prolonged QRS, QT, and paced QT (by 4, 34, and 19%, respectively). Effects of oral AM on ventricular repolarisation and on the fast inward sodium current were confirmed in vitro. Both modes of AM administration protected against inducible arrhythmias, an effect that was more marked during normal sinus rhythm than during pacing in orally treated dogs. Oral amiodarone failed to protect against spontaneous late arrhythmias 24 h after infarction whilst both modes of administration noncompetitively inhibited isoprenaline-induced tachycardia. Oral AM reduced blood pressure (13%) and LV dP/dt/P (24%) whereas cardiac output was maintained by an increase in stroke volume. It was concluded that oral AM is haemodynamically well tolerated and that prolonged ventricular repolarisation enhanced by bradycardia together with sympatholytic actions may be important mechanisms for antiarrhythmic efficacy, whereas the mechanisms involved in i.v. efficacy are less clear but may depend, at least partly, on sympatholytic actions and perhaps (tentatively) on sodium channel block in Purkinje tissue.

Morphologic association between microglia and senile plaque amyloid in Alzheimer's disease

Alzheimer senile plaques are comprised of extracellular deposits of beta-amyloid. The cell type responsible for the secretion of this amyloid, however, is unknown. In the present study, compact amyloid 'stars' and the cellular elements directly apposed to them were examined at the ultrastructural level. In many cases, amyloid fibrils were closely interdigitated with the plasma membrane of cells with dark cytoplasm, dense bodies and distinctive nuclei. These cells were morphologically identified as microglia, the resident macrophages of the brain. Previous work has described an identical morphologic association between macrophages and several types of systemic and cerebral amyloidoses. Taken together, these data suggest that beta-amyloid may be secreted by microglia.

Measurements of regional cerebral blood flow and cognitive performance in Alzheimer's disease

Single photon emission computed tomography (SPECT) with 99mTc-HMPAO was used to image 26 patients with dementia of the Alzheimer type (DAT) and 10 healthy controls. Regional cerebral blood flow (rCBF) data indicated a relative sparing of the occipital regions in DAT. Normalisation to occipital flow illustrated highly significant CBF deficits in a number of cortical regions, particularly in the left and right posterior--temporal cortex in DAT compared to controls. The cognitive performance of DAT patients was measured using a clinical cognitive assessment procedure (CAMCOG) and numerous correlations between these scores and rCBF were obtained. The implications and value of this investigative technique are discussed.

Developing a market research survey

This is the fourth in a series on a systemwide geriatric-care marketing initiative. Other articles outlined gaining voluntary involvement of internal marketing segments and detailed putting out a request for proposal to market research vendors. This article explores the development of a market research survey that meets the needs of the system's membership.

Evaluating researchers for the project

This is the second in a series on a system-wide geriatric-care marketing initiative undertaken at Franciscan Health System, Chadds Ford, Pa. In the first article, the author outlined the process of gaining the voluntary involvement of internal market segments. In this article, the author details the process of putting out a request for proposal to market-research vendors.

Gaining internal support for a marketing effort

Franciscan Health System, Chadds Ford, Pa., developed a systemwide marketing initiative to assure positive participation from its internal market segments. In the first of a series, the author outlines the goals, objectives and positioning of the marketing mix used to achieve voluntary involvement from these segments.

Comparative antiarrhythmic and electrophysiological effects of drugs known to inhibit calmodulin (TFP, W7 and bepridil)

The potential antiarrhythmic and electrophysiological actions of drugs known to inhibit calmodulin, i.e. trifluoperazine (TFP) and N-(6-aminohexyl)-5-chloro-1-naphthalene sulphonamide (W7) have been compared with bepridil, whose antiarrhythmic actions have previously been ascribed to blockade of the fast inward sodium current in cardiac tissue. Like bepridil, both TFP and W7 reduced the severity of arrhythmias evoked by 30 min of coronary artery occlusion in the anaesthetized rat. TFP (2.5-10 mg kg-1, i.v.), W7 (2.5-10 mg kg-1, i.v.) and bepridil (1-5 mg kg-1, i.v.) also antagonized the development of ventricular fibrillation induced by 5 min of occlusion followed by reperfusion. All three drugs also reduced mortality. TFP and bepridil also reduced the incidence of reperfusion-induced ventricular tachycardia whilst all 3 drugs reduced its duration. Although TFP was shown to possess alpha-adrenoceptor blocking properties, the classical alpha-blocker, phentolamine, failed to reduce significantly the incidence or severity of reperfusion arrhythmias. In contrast to bepridil (2-20 microM), which markedly reduced the maximum rate of depolarization (Vmax) of guinea-pig isolated papillary muscle, W7(5-50 microM) showed only weak effects on Vmax and was at least 10 times less potent than bepridil whilst TFP only reduced Vmax in high concentrations (40-100 microM) which lowered resting membrane potential. Unlike bepridil, neither TFP (4-40 microM) nor W7 prolonged the absolute refractory period. The results suggest that drugs which inhibit calmodulin confer protection against both ischaemia-and reperfusion-induced arrhythmias in the rat. Although the electrophysiological actions of bepridil would adequately account for its antiarrhythmic activity, the same cannot be said of W7 and especially TFP. In conclusion, calmodulin antagonism may constitute a mechanism of antiarrhythmic activity.

Ambulatory surgery offers quality, savings

A hospital's ambulatory surgical center has eased census pressures on inpatient units and has offered patients and third-party payers substantial cost savings for high-quality care.

Puromycin resistance in Chinese hamster cells: genetic and biochemical studies of partially resistant, unstable clones

Resistance to 10 microgram/ml of puromycin has been analyzed in V79 Chinese hamster cells. Clones that were isolated in 10 microgram/ml of puromycin and subsequently cultivated in its absence consistently lost their resistance. One clone was analyzed in detail by recloning in the presence and absence of puromycin, and it was found that non-puromycin cultivated subclones also lost their resistance and regained inhibition profiles similar to the V79 parent. Reconstruction experiments between sensitive and resistant cells demonstrated that the yield of mutants was not affected by metabolic cooperation. The mutation rate was calculated to be 1 x 10(-7) per cell generation, and was the same within the limits of statistical error in a colchicine-produced polyploid derivative of the V79 line. Although a number of resistant clones were found to have polyploid karyotypes, the polyploid V79 lines was not more resistant to puromycin, nor did it possess a higher frequency of puromycin resistant cells. Studies employing radiolabeled puromycin established that resistance was due to a lowered uptake of puromycin and that an inverse relationship existed between resistance level and uptake rate.

Spontaneous mutation rate to thioguanine resistance is decreased in polyploid hamster cells

The mutation rate to thioguanine resistance was 3.11 X 10(-6) in a near diploid V79 hamster cell line and 7.58 X 10(-8) in a near tetraploid derivative produced with colchicine. The specific activities of glucose-6-phosphate dehydrogenase and phosphoglycerate kinase of the tetraploid line were greater than that of the diploid which suggests that twice the number of active X chromosomes were present in the tetraploid. These results are compatible with the hypothesis that spontaneous variants resistant to thioguanine arise through mutation and chromosomal segregation, as has been suggested for induced mutations in tetraploid hamster cells.