Sex related differences in the characteristics and outcomes of heart failure: A sub analysis of heart failure disease management study

Aims

This is a sub-analysis of a randomized controlled trial on heart failure (HF) disease management (DM) in which patients with HF (N = 1,360; 27.5% women) were assigned randomly to DM (N = 682) or usual care (UC) (N = 678). Study intervention did not significantly affect the rate of hospital admissions or mortality. This study evaluates sex-related differences in baseline characteristics, clinical manifestations, adherence to treatment and outcomes among the study cohort.

Methods

Association between sex and hospital admissions and mortality was tested in multivariable models adjusted for the patients’ baseline characteristics. The primary composite outcome of the study included time to first HF hospitalization or all-cause mortality. Secondary composite outcome included number of hospital admissions and days of hospitalization, for HF and all other causes.

Results

Compared to males, females recruited in the study were on average 3 years older [median age 72 (62, 78) vs. 75 (65, 82), p = 0.001], with higher prevalence of preserved left ventricular function (LVEF ≥50%) and lower frequency of ischemic heart disease (IHD) (p ≤ 0.001). Females had shorter 6-min walking distance and worse quality of life and depression scores at baseline (p < 0.001). The proportion of patients receiving HF recommended medical treatment was similar among females and males. During a median follow-up of 2.7 years (range: 0–5), there were no significant differences between females and males with respect to the time elapsed until the study primary endpoint and its components in univariate analysis [557 (56.5%) males and 218 (58.3%) females were hospitalized for HF or died for any cause; p > 0.05]. Multivariable analysis showed that females were significantly less likely than males to experience the primary outcome [adjusted hazard ratio (HR) = 0.835, 95% CI: 0.699, 0.998] or to die from any cause [adjusted HR = 0.712; 95%CI: 0.560, 0.901]. The sex-related mortality differences were especially significant among patients with non-preserved EF, with IHD or with recent HF hospitalization. Females also had lower rates of all-cause hospital admissions [adjusted rate ratio = 0.798; 95%CI: 0.705, 0.904] and were more likely to adhere to HF medical therapy compared to males.

Conclusion

Females with HF fare better than men. Sex related differences were not explained by baseline and morbidity-related characteristics or adherence to medical treatment.

Disease Management plus Recommended Care versus Recommended Care Alone for Ambulatory Patients with Chronic Obstructive Pulmonary Disease

Rationale: The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain.Objectives: To study the effect of disease management (DM) added to recommended care (RC) in ambulatory patients with COPD.Measurements and Main Results: In this trial, 1,202 patients with COPD (age, ≥40 yr), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists, inhaled long-acting bronchodilators and corticosteroids, smoking cessation intervention, nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and by remote contacts with the patients between these visits, included patient self-care education, monitoring patients' symptoms and adherence to treatment, provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 patients (47.2%) in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95% confidence interval, 0.77-1.08).Conclusions: DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory patients with COPD.

Maccabi proactive Telecare Center for chronic conditions - the care of frail elderly patients

Background

In 2012, Maccabi Healthcare Services founded Maccabi Telecare Center (MTC), a multi-disciplinary healthcare service providing telemedical care to complex chronic patients. The current paper describes the establishment and operation of the MTC center, from the identification of the need for the service, through the design of its solution elements, to outcomes in several areas of care.

We analyze the effects of the program on elderly frail patients, a growing population with complex and costly needs.

Methods

Observational quasi-experimental analyses using propensity score matching was used to assess the effect of MTC’s operation on utilization outcomes including direct costs.

Results

Results for frail elderly patients with complex chronic conditions show significant reductions in hospitalization days and hospitalization costs. MTC interventions also entailed lower overall average monthly costs in frail patients.

Conclusion

We conclude that a proactive telehealth service for complex chronic patients using education, empowerment to self-management, and coordination of care is a cost-effective means of improving quality care and health outcomes in frail elderly patients.

Electronic supplementary material

The online version of this article (10.1186/s13584-017-0192-x) contains supplementary material, which is available to authorized users.

Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial

BACKGROUND

The efficacy of disease management programs in improving the outcome of heart failure patients remains uncertain and may vary across health systems. This study explores whether a countrywide disease management program is superior to usual care in reducing adverse health outcomes and improving well-being among community-dwelling adult patients with moderate-to-severe chronic heart failure who have universal access to advanced health-care services and technologies.

METHODS

In this multicenter open-label trial, 1,360 patients recruited after hospitalization for heart failure exacerbation (38%) or from the community (62%) were randomly assigned to either disease management or usual care. Disease management, delivered by multi-disciplinary teams, included coordination of care, patient education, monitoring disease symptoms and patient adherence to medication regimen, titration of drug therapy, and home tele-monitoring of body weight, blood pressure and heart rate. Patients assigned to usual care were treated by primary care practitioners and consultant cardiologists. The primary composite endpoint was the time elapsed till first hospital admission for heart failure exacerbation or death from any cause. Secondary endpoints included the number of all hospital admissions, health-related quality of life and depression during follow-up. Intention-to-treat comparisons between treatments were adjusted for baseline patient data and study center.

RESULTS

During the follow-up, 388 (56.9%) patients assigned to disease management and 387 (57.1%) assigned to usual care had a primary endpoint event. The median (range) time elapsed until the primary endpoint event or end of study was 2.0 (0-5.0) years among patients assigned to disease management, and 1.8 (0-5.0) years among patients assigned to usual care (adjusted hazard ratio, 0.908; 95% confidence interval, 0.788 to 1.047). Hospital admissions were mostly (70%) unrelated to heart failure. Patients assigned to disease management had a better health-related quality of life and a lower depression score during follow-up.

CONCLUSIONS

This comprehensive disease management intervention was not superior to usual care with respect to the primary composite endpoint, but it improved health-related quality of life and depression. A disease-centered approach may not suffice to make a significant impact on hospital admissions and mortality in patients with chronic heart failure who have universal access to health care.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00533013 . Trial registration date: 9 August 2007. Initial protocol release date: 20 September 2007.

Disease management programs: barriers and benefits

OBJECTIVES

The healthcare system in Israel faces difficulties similar to those of most industrialized countries, including limited resources, a growing chronically ill population, and demand for high quality care. Disease management programs (DMPs) for patients with a chronic illness aim to alleviate some of these problems, primarily by improving patient self-management skills and quality of care. This study surveyed the opinions of senior healthcare administrators regarding barriers, benefits, and support for implementing DMPs.

STUDY DESIGN

Cross-sectional survey.

METHODS

A 21-item questionnaire was self-completed by 87 of 105 (83%) healthcare administrators included in the study. Participants were 65.5% male and 47% physicians, 25.3% nurses, 17.3% administrators, and 10.3% other healthcare professionals.

RESULTS

The main perceived benefit of DMPs among all respondents was improving quality of care. Other benefits noted were better contact with patients (81.6%) and better compliance with treatment (75.9%). Efficient long-term utilization of system resources was perceived as a benefit by only 58.6%. The main perceived barriers to implementing DMPs were lack of budgetary resources (69%) and increased time required versus financial compensation received (63.2%).

CONCLUSIONS

The benefits of DMPs were patient oriented; barriers were perceived as financial and limiting professional autonomy. Information regarding long-term benefits (better patient outcomes) that ultimately provide better value for the system versus short-term barriers (increased costs and expenditures of time without compensation) might encourage the implementation of DMPs in countries faced with a growing population of patients with at least 1 chronic illness.

Chronic obstructive pulmonary disease: diagnosis and management

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. However, despite being one of the most common causes of hospital admission, COPD has been a neglected respiratory condition. Nurses working in all care settings can make an important contribution to the care of patients with COPD. This article discusses assessment, diagnosis and management of COPD. Reference is made to recent policy developments, emphasising the importance of transforming care, and improving quality of life and health outcomes for patients.

Oncoplastic surgery for breast cancer based on tumour location and a quadrant-per-quadrant atlas

BACKGROUND

The majority of published techniques for oncoplastic surgery rely on an inverted-T mammoplasty, independent of tumour location. These techniques, although useful, cannot be adapted to all situations. A quadrant-per-quadrant atlas of mammoplasty techniques for large breast cancers was developed in order to offer breast surgeons a technique dependent on tumour location, which reduces the risk of postoperative complications and delay to adjuvant therapy.

METHODS

From 2005 to 2010, a series of eligible women with breast cancer were treated by quadrant-specific oncoplastic techniques. All complications and any delay to adjuvant treatment were recorded prospectively, along with local and distant cancer recurrences. Cosmetic outcome was evaluated using a five-point scale.

RESULTS

A total of 175 patients were analysed. The median tumour size, after histological examination, was 25 (range 4-90) mm. Twenty-three patients (13.1 per cent) had involved margins. Seventeen of these patients were treated by mastectomy and three had a re-excision. Complications occurred in 13 patients (7.4 per cent), which led to a delay to adjuvant treatment in three (1.7 per cent). After a median follow-up of 49 (range 23-96) months, three patients had developed a local recurrence. The mean score after cosmetic evaluation was 4.6 of 5.

CONCLUSION

A quadrant-per-quadrant approach to oncoplastic techniques for breast cancer was developed that tailors the mammoplasty for each tumour location. This panel of techniques should be a useful guide for breast surgeons, and extends the possibilities for breast conservation for large or poorly limited cancers, with a low complication rate and good cosmetic results.

Adipose-tissue grafting to the post-mastectomy irradiated chest wall: preparing the ground for implant reconstruction

INTRODUCTION

Breast implant reconstruction after radiotherapy carries a high risk of failure and complication. Nevertheless, it may be the only alternative for patients who are not suitable for autologous reconstruction or who refuse this option. As clinical and experimental studies have demonstrated that grafting adipose tissue (lipofilling) in an irradiated area improves the quality of the skin, we made the assumption that preliminary fat grafting of the chest wall might reduce the complication and failure rates of implant reconstruction by improving the implant coverage.

PATIENTS AND METHODS

From 2007 to 2009, 28 patients had fat transfer to the chest wall, prior to implant reconstruction. All patients had had mastectomy and irradiation for breast cancer. Lipofilling was initiated 6 months after the end of radiotherapy. The mean number of fat-grafting sessions was 2 (range 1-3). An average volume of 115 cc (70-275 cc) was injected each time. Once the chest wall's skin seemed to have gained enough thickness, implant reconstruction was performed.

RESULTS

The mean follow-up period was 17 months. Three minor complications occurred. Implant explantation was performed in one case for exposition. The cosmetic results were good and very good in >80% of the cases.

CONCLUSION

This study points out the benefits of fat grafting to the irradiated chest wall prior to implant placement and demonstrates that lipofilling prepares the ground to implant breast reconstruction. This approach could be considered as an alternative to flap reconstruction for selected patients.

Inhaled bronchodilators for chronic bronchitis and emphysema

The article discusses the pharmacology of oral bronchodilators and their role in the management of chronic obstructive pulmonary disease (COPD). Management of acute exacerbations and the importance of follow up and review are considered briefly. The article includes a description of the damage to the airways caused by COPD.

Recent advances in the study of candidate genes for adolescent idiopathic scoliosis

We used a microarray approach to evaluate gene expression profiles in human AIS osteoblasts, and to identify genes that are differentially expressed following estrogen exposure in non-AIS and AIS human osteoblasts. We found that more than one gene is likely responsible for AIS. Furthermore, some of these genes are estrogen-regulated, suggesting a possible role of estrogens in the etiology of scoliosis.

The pathogenesis of dermatophyte infections in human skin sections

AIM

A novel ex vivo model for the study of adherence and invasion of dermatophytes to the stratum corneum was developed.

MATERIALS AND METHODS

A skin of full epidermis thickness was infected by spores of Trichophyton mentagrophytes and examined after various periods of time by scanning and transmission electron microscopy.

RESULTS

After 12 h of inoculation a tenacious adherence between the spores and the stratum corneum was observed. There was a time dependent increase in the number of spores adhered to this surface. By 24 h, germination had commenced. The initial growth of germ tubes occurred extracellularly to the corneocytes. Three days after inoculation, the most prominent feature was proliferation of fungal hyphae and penetration of mycelium through the outer keratinocyte layer which is followed by invasion of the outer stratum corneum.

CONCLUSION

The model introduced in the present study may contribute to a better understanding of the nature of the interaction between dermatophytes and skin cells in dermatophytosis process.

Mites in fungal cultures

Recently all existing Trichophyton mentagrophytes colonies within our laboratory, which had originally appeared normal, rapidly and at an early stage became perforated. Therefore the aims of this study were to expose the cause of these major morphological changes and to find out if this phenomenon may occur in other fungal cultures. Microscopic examination of specimens taken from the damaged colonies showed many mites at different developmental stages, which were subsequently identified as the acarus, Tyrophagus putrescentiae. The laboratory experiments demonstrated that mites feed on the spores and hyphae of all the dermatophytes, moulds and yeasts tested. For the time being Tyrophagus putrescentiae is an unpleasant pest which damages fungal cultures but future use of the acari in biological control may be considered.

Molecular epidemiology of preterm delivery: methodology and challenges

Preterm delivery (PTD) appears to be a complex trait determined by both genetic and environmental factors. Few studies have examined genetic influence on PTD. The overall goal of our study is to examine major candidate genes of PTD and to test gene-environment interactions. Our study includes 500 preterm trios, including 500 preterm babies and their parents and 500 maternal age-matched term controls. We will perform the transmission/disequilibrium test (TDT) on candidate genes thought to be important in each of the four biological pathways of PTD: (1) decidual chorioamionotic inflammation: interleukin 1 (IL-1), IL-6, and tumour necrosis factor (TNF); (2) maternal and fetal stress: corticotropin-releasing hormone (CRH); (3) uteroplacental vascular lesions: methylenetereahydrofolate reductase (MTHFR); and (4) susceptibility to environmental toxins: GSTM1, GSTT1, CYP1A1, CYP2D6, CYP2E1, NAT2, NQO1, ALDH2, and EPHX. We will also perform standard case-control analyses on the 500 preterm cases and 500 term controls to examine gene-environment interactions. The major environmental, nutritional and social factors as well as clinical variables known or suspected to be associated with PTD will be used to test for gene-environment interactions. This study integrates epidemiological and clinical data as well as genetic markers along major pathogenic pathways of PTD. The findings from this study should improve our understanding of genetic influences on PTD and gene-environment interactions.

Efficacy of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors for prevention of stroke

OBJECTIVE

To determine if 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) are effective in preventing fatal and nonfatal strokes in patients at increased risk of coronary artery disease.

DESIGN

Meta-analysis of randomized controlled trials. Clinical trials were identified by a computerized search of MEDLINE (1983 to June 1996), by an assessment of the bibliographies of published studies, meta-analyses and reviews, and by contacting pharmaceutical companies that manufacture statins. Trials were included in the analysis if their patients were randomly allocated to a statin or placebo group, and reported data on stroke events. Thirteen of 28 clinical trials were selected for review. Data were extracted for details of study design, patient characteristics, interventions, duration of therapy, cholesterol measurements, and the number of fatal and nonfatal stroke events in each arm of therapy. Missing data on stroke events were obtained by contacting the investigators of the clinical trials.

MAIN RESULTS

Among 19,921 randomized patients, the rate of total stroke in the placebo group was 2.38% (90% nonfatal and 10% fatal). In contrast, patients who received statins had a 1.67% stroke rate. Using an exact stratified analysis, the pooled odds ratio (OR) for total stroke was 0.70 (95% confidence interval [CI] 0.57, 0.86; p =.0005). The pooled OR for nonfatal stroke was 0.64 (95% CI 0.51, 0.79; p =.00001), and the pooled OR for fatal stroke was 1.25 (95% CI 0.71, 2.24; p =.4973). In separate analyses, reductions in total and nonfatal stroke risk were found to be significant only for trials of secondary coronary disease prevention. Regression analysis showed no statistical association between the magnitude of cholesterol reduction and the relative risk for any stroke outcome.

CONCLUSIONS

The available evidence clearly shows that HMG-CoA reductase inhibitors reduce the morbidity associated with strokes in patients at increased risk of cardiac events. Data from 13 placebo-controlled trials suggest that on average one stroke is prevented for every 143 patients treated with statins over a 4-year period.

Disulfide bond reduction: A powerful, chemical probe for the study of structure-function relationships in the hemocyanins

The copper-containing hemocyanins are a class of oxygen-transport proteins whose structures differ in arthropods and molluscs. Crystal structure analyses and amino acid sequence comparisons show that disulfide bonding is a common feature in both arthropod and mollusc hemocyanins. Reduction of the disulfide bonds of a representative set of arthropod and mollusc hemocyanins results in complete loss of their oxygen-binding capacities. Thus, retention of the disulfide bonds is essential to the functional integrity of the oxygen-binding sites in the subunits of this class of oxygen carriers, despite the very different architectures of the arthropod and mollusc molecules. Depending upon the specific hemocyanin, partial to virtually complete restoration of the oxygen-binding capacity occurs when the disulfide-bond reductant is removed by dialysis. The rate at which the functional, active-site geometry is lost and the extent to which it can be restored varies markedly with hemocyanin type, aggregation state, and experimental conditions. Consequently, a comparison of these differences provides a simple, but powerful, way to probe internal and environmental factors that govern physiologically important structure-function relationships in this entire class of oxygen-transport proteins.

Commissioning: the community nurse's role

This article examines the proposal in the White Paper The New NHS (DoH 1997) that community nurses will be involved in commissioning health care and highlights nurses' absence from the commissioning arena in the past. The important contribution nurses can make to commissioning and their interpersonal and communication skills are considered. Factors that may constrain commissioning and strategies to overcome these are also discussed.

Sterilisation of married couples: husband versus wife sterilisation

Sterilisation has been increasing in the United States in recent decades. Using the National Survey of Families and Households, this paper examines sterilisation among married couples using event history techniques, viewing husband and wife sterilisation as competing risks. Wives are more likely to experience sterilisation and at shorter durations of marriage. Number of children has a curvilinear effect on sterilisation, increasing and then decreasing its likelihood. Wives who are older than their husbands are more likely to get sterilised themselves. Black and Hispanic husbands are more likely to undergo sterilisation.

Nurse practitioners in general practice: an expanding role

At a time when the government is proposing to allow nurses to become equal partners with GPs and a consultative report commissioned by the NHSE found that nurse practitioners provide cheaper and better services for patients (NHSE 1996), this article describes the role of a nurse practitioner working in a GP fundholding practice in the UK. The author considers issues of autonomy and accountability surrounding the development of the role. Its relationship to the development of nursing and caring is examined in the light of some doctors' and nurses' scepticism and ambivalence. The benefits to patients are presented to highlight the value of a properly structured nurse practitioner role integrated into primary care provision.

Hospitalization of patients infected with active TB in New York State, 1987-1992: the effect of the HIV epidemic

Hospital discharge records were used to study the relationship between human immunodeficiency virus (HIV) epidemic and hospitalized patients with tuberculosis in New York State from 1987 through 1992. The discharges of patients coinfected with HIV and tuberculosis increased by 270%, rising from 1,573 in 1987 to 5,825 in 1992. This constitutes an increase from 19.8 to 49.1% of all discharges of patients with tuberculosis. Discharges of tuberculosis patients who were not infected with HIV decreased slightly during this time, going from 6,359 to 6,039. Postdischarge treatment plans, HIV prevention, HIV testing, and HIV educational programs for the tuberculosis population require special consideration, given the significant rise of HIV in the tuberculosis-infected population.

Teenage sexual attitudes in China

Not much is known about the sexual attitudes of Chinese teenagers. In this article we endeavor to address this void by examining the sexual attitudes of Chinese teenagers with survey data collected in Sichuan Province in 1988. Our analysis has two goals: first, to describe aggregate attitudes toward premarital sexual practices; and second, to identify the principal factors that influence these attitudes. To accomplish the second goal we estimate several regression equations with predictor variables known to influence teen sexual attitudes. Our analysis reveals major differences and similarities between China and the United States and indicates that China's teenagers are somewhat strongly opposed to teen sexual contact, but seem to be more understanding of others who so engage, despite strike laws and public morality forbidding it.

Costs of triplet pregnancy

OBJECTIVE

Our purpose was to describe the total costs involved in the delivery, prenatal, and neonatal care for triplet pregnancies.

STUDY DESIGN

Twenty triplet pregnancies were born at our institution over the 1-year period between July 1, 1992, and June 30, 1993. Total charges for prenatal care, physician fees, antepartum admissions, delivery, postpartum inpatient and outpatient care, and neonatal inpatient and outpatient care were extracted from the hospital billing computers.

RESULTS

Our 20 triplet pregnancies were delivered of 54 live born infants at an average gestation of 30.2 weeks. Mothers averaged 16.7 inpatient hospital days. Total cost of prenatal care, outpatient laboratories and ultrasonography, delivery, and maternal inpatient care averaged $27,491. Neonates averaged 13.7 hospital days. Total neonatal costs for the inpatient stay and short term-postpartum (< 6 week) outpatient period was $36,856 per family. Total average cost per family was $64,347.

CONCLUSION

Combined maternal and neonatal costs per individual baby delivered was approximately $21,000. Although expensive, this cost is far from prohibitive, even in times of close attention to health care expenditures.

Clean shots

Jon Stuen Parker and Andrew Hoffman, son of radical Abbie Hoffman, won their battle with the City of Chicago when a judge acquitted them of charges that they knowingly broke Illinois law by participating in the illicit act of needle exchange. Illinois is one of only nine states that prohibit the distribution of sterile syringes by non-medical personnel. Parker, founder of the AIDS Brigade, has been arrested 43 times for distribution and possession of hypodermic needles, and has been found not guilty in 41 of the 43 cases. Shared needles and paraphernalia are leading factors in the spread of HIV and AIDS among injection drug users. Several Federal government agencies and national drug abuse organizations support needle exchange programs on the basis that they do not increase drug use, are effective in reducing the spread of AIDS, and serve as a bridge to drug treatment and services to needle exchange clients. Still, fewer that 50 needle exchange programs operate today. Syringe exchange could cut new infections by half, if Illinois would revamp its syringe law.

Effect of interleukin-1 beta on ovulation in the in vitro perfused rabbit ovary

Interleukin-1 (IL-1), a prominent 17-kilodalton member of a group of immune mediators referred to as cytokines, is secreted by a variety of immuno- and nonimmunocompetent cells. As IL-1 is an established mediator of inflammation, and ovulation may constitute an inflammatory-like reaction, consideration may be given to the possibility that IL-1 may play an intermediary role in the ovulatory process. Such a hypothesis is supported by the recent demonstration of the gonadotropin-dependent preovulatory induction of IL-1 transcripts at the level of the murine and human ovary. To date, however, the direct effect of IL-1 beta on the ovulatory process has not been examined. The objective of this study was to investigate the potential role of IL-1 beta in ovulation, oocyte maturation (nuclear and cytoplasmic), and subsequent fertilizability of in vitro ovulated oocytes. Rabbit ovaries perfused in vitro were used for these experiments. Ovarian arteries were cannulated in situ, and the ovaries were excised and perfused in vitro with or without IL-1 beta (18 ng/ml). The ovulatory efficiency of 18 ng/ml IL-1 beta-treated ovaries was 73.1%, similar to that of hCG (71.2%). Recovered oocytes were examined for their maturation and were inseminated in vitro to investigate fertilization, cleavage, and embryonic development. The fertilization rates of the 18 ng/ml IL-1 beta-treated and hCG-treated groups were 65.8% and 95.8% (P < 0.01), respectively. Cleavage rates of the IL-1 beta-treated and hCG-treated groups were 50% and 83.3% (P < 0.01), respectively. Most of the cleaved embryos from the IL-1 beta-treated group arrested at the four-cell stage, and only 2.6% of the fertilized embryos developed into the morula stage, whereas 54.2% of the hCG-treated group developed to the morula stage (P < 0.01). A cytotoxic effect of IL-1 beta is unlikely in this model. A more likely explanation is the induction of other factors by IL-1 beta, which may inhibit cytoplasmic maturation. Taken together, our findings demonstrate that in the absence of an ovulatory gonadotropic trigger, IL-1 beta can induce ovulation and oocyte maturation, facilitate fertilization, and influence subsequent embryonic development. Although fertilization and embryonic development occurred after IL-1 beta treatment, these rates were lower than those after hCG treatment. These observations give credence to the possibility that IL-1 may play an intermediary role in the ovulatory process.

The role of protein kinase-C in gonadotropin-induced ovulation in the in vitro perfused rabbit ovary

Tumor-promoting phorbol esters are believed to affect ovarian granulosa cell progesterone and prostaglandin (PG) production and possibly ovulation by activating protein kinase-C (PKC). The effects of phorbol esters and PKC inhibitors on ovulation, progesterone, and PG production were examined in an in vitro perfused rabbit ovary. The effect of tranexamic acid, an inhibitor of the conversion of plasminogen activator to plasmin, on phorbol ester-induced ovulation was also examined. Phorbol 12,13-dibutyrate (PdBU), a PKC stimulator, induced ovulation in a dose-related manner in the absence of gonadotropins (56%, 200 nM PdBU; 0%, 0 nM PdBU; P < 0.05). Perfusate progesterone levels were increased only after 600 nM PdBU treatment, and perfusate PGF2 alpha, PGE2, and 6-keto-PGF1 alpha were increased in a dose-dependent fashion (P < 0.05). Staurosporine, a potent inhibitor of the catalytic domain of PKC, and calphostin-C, a specific inhibitor of the diacylglycerol-binding region, inhibited hCG-induced ovulation in a dose-related manner. Gonadotropin-induced ovulation decreased from 73% without staurosporine to 19% with 1.0 microM staurosporine (P < 0.01). Calphostin-C reduced ovulatory efficiency from 60% to 24% (P < 0.01). However, neither inhibitor decreased progesterone or PGF2 alpha production by ovaries exposed to hCG. hCG-induced oocyte maturation was also unaffected by exposure to either staurosporine or calphostin-C. Tranexamic acid reduced phorbol ester-induced ovulatory efficiency from 67% to 37% (P < 0.05). These findings demonstrate that the calcium-dependent PKC pathway is instrumental in gonadotropin-mediated follicular rupture in the rabbit. Although PGs may play an important role in ovulation, they do not appear to be directly responsible for PKC-mediated follicular rupture.

Evaluation of the sorbent suspension reciprocating dialyser in the treatment of overdose of paracetamol and phenobarbitone

Poisoning with paracetamol (acetaminophen) and phenobarbitone is a common occurrence in the United States and Europe. The removal efficiency of these drugs by a sorbent suspension reciprocating dialyser (SSRD) has been investigated. The SSRD is a parallel plate dialyser with a reciprocating blood flow and free mobile sorbent suspension composed of charcoal and zeolites. This arrangement provided a system with minimal sorbent saturation. High performance liquid chromatography was used for the quantification of the drugs in aqueous and serum fluids. The in-vitro removal efficiency of the dialyser was studied by dialysing a large volume of the drug in solution for 12 to 16 h. The removal efficiency remained relatively constant up to 10 h of dialysis. The in-vivo dialysis studies were performed using normal dogs. Large doses of the drugs were administered orally or intravenously to achieve high blood levels. The clearance values obtained from these studies were comparable with, or in excess of, the values reported in the literature for conventional dialysers. The major advantage of the SSRD is the ability of the unit to be used for prolonged dialysis and to provide a system with minimal sorbent saturation due to mixing and interchange of sorbent granules next to the membrane surface.

Immunological profile of chest x-ray-negative, asymptomatic asbestos workers

Several immunologic parameters, both humoral and cellular, were studied in the serum and peripheral blood lymphocytes derived from chest x-ray-negative, asymptomatic asbestos workers. All humoral and cellular parameters were intact, except the con-A-induced T cell suppressor activity and T cell division in autologous mixed lymphocyte reaction, which were significantly elevated in the asbestos plant workers. The significance of these increased T cell activities in asbestos exposed people is not clear, and further clinical and immunological follow-up is warranted.

Computer-assisted individualized lidocaine dosage: clinical evaluation and comparison with physician performance

The performance of a computerized dosing aid in achieving a target serum concentration of lidocaine in the middle of the recommended therapeutic range (3.5 mg/L) was evaluated in 63 patients treated for acute ventricular arrhythmias. In all patients a serum concentration measurement was obtained shortly after starting lidocaine infusion. In 22 patients a microcomputer program based on a Bayesian forecasting technique was used for dosing recommendations, whereas in 41 the serum concentration was interpreted and the dose was adjusted by the unaided physician. Both groups were similar with respect to the average concentration achieved (control: 3.8 +/- 1.13 [SD] mg/L, computer-aided: 3.5 +/- 0.59 mg/L). However, the interindividual variability was significantly larger in the control group (95% confidence interval: 1.5 to 6.1 mg/L vs 2.3 to 4.7 mg/L [p less than 0.01]). Nine of the 41 patients in the control group had a lidocaine concentration outside the recommended therapeutic range of 2 to 5 mg/L compared to only 1 of 22 in the computer-aided group. Lidocaine concentrations greater than 2 mg/L were associated with significantly more effective suppression of ventricular arrhythmias (p less than 0.05). The results show that Bayesian forecasting outperforms the physician in early adjustment of lidocaine dosage based on serum concentration measurements.

Familial, balanced insertional translocation of chromosome 7 leading to offspring with deletion and duplication of the inserted segment, 7p15 leads to 7p21

We report an uncle and niece with duplication and deletion, respectively, of segment 7p15 leads to 7p21 originating from a balanced, intrachromosomal insertion in their mothers. The proposita had prenatal and postnatal growth deficiency, retarded psychomotor development, microcephaly, wide cranial sutures, ocular hypertelorism, small palpebral fissures, apparently low-set and malformed ears, cleft palate, congenital heart defect, hypoplasia of the distal phalanx of first fingers, rocker-bottom feet, persistent cloaca, and imperforate anus. She died at three months. Her maternal uncle has duplication of this segment and is alive at 32 years. He has severe mental deficiency, but normal growth; communicating hydrocephalus was diagnosed at three months.